others occurred among the assistant physicians, orderlies and nurses in the hospital, which were as well marked by pathognomic signs throughout their whole course; nor could they be discriminated in their symptoms, stages, or duration, from those direct from the ships. In the latter examples it is evident that the malady originated from the pestilential atmosphere generated within our walls, which was sufficiently potent at one time to become both the remote and the exciting cause, the same identical agency being sufficient to produce the predisposition, and afterwards develope the fever.

Nor is there the slightest foundation for the suspicion of any specific contagion in the case, as is seen in the fact that no new instances of the fever have occurred in the premises, since the cleansing, purification, and ventilation of the establishment has been effected; so that the rationale of the infection which was undoubtedly endemic here, and had become epidemic in the vicinity, must be obvious; and is precisely the same as that existing on ship-board in the instances of sickness and death which have become so lamentably notorious. The want of pure air, of wholesome food, and of pure water, are privations which by a physical necessity generate disease. In a crowded hospital, as well as in a crowded ship, filthy apartments, ill-ventilated wards, and the confined air resulting from such untoward cir cumstances, have from time immemorial been known to be such violations of hygenic laws, as will develope pestilential fever. All who inhale such an atmosphere for any length of time become sick, and each sufferer by the morbid exhalations from his skin and lungs, contributes to augment the infection, and increase the sources of danger to himself and others. Still worse, if amid such a crowd there be, as is too often the case, a neglect of personal cleanliness, and a failure to remove the morbid excretions, which, if allowed to remain, vastly add to the intensity of the atmospheric poison. Such are the precise circumstances under which, in certain latitudes and given temperatures, ship-fever, jail-fever, and hospital-fever have been generated and perpetuated. Such a pestilence may be manufactured to order; and may be arrested with equal facility by obeying the laws of hygeine, instead of violating them. So much for the contagiousness of the ship-fever. As to the figment of "contingent contagion," it is only contingent nonsense.

Those who have imagined that in this much dreaded "ship-fever," there has been any distinctive or specific character constituting it a new disease, or in any sense sui generis, must have had very limited opportunities for observing it. Nor is there anything in its pathology or treatment contradistinguishing it from the family of congestive fevers, of which it is a familiar variety, modified, however, by differ ent causes, but always characterized by the same type. Indeed, this identical fever has been annually observed to greater or less extent on board ships, in our hospitals and in other crowded apartments of our city, inhabited by a degraded population; and it has often appeared in jails, prisons, etc., in various sections of our country.

The symptoms, course and type of the ship-fever here, have been

identical with those of that form of malignant disease denominated "Typhus Petechialis," modified in different examples by age, sex, temperament, habits of living, etc., but all bearing the impress of the same cause, proving their absolute identity in nature, though differing in degree. Always congestive, often inflammatory, and very fre quently both the one and the other, constituting the mixed fever of modern writers.

In the example which came under our observation sufficiently early to allow of recording and discriminating its premonitions and development, there was found very great uniformity. The earliest and most prominent symptoms of an attack, have been sudden loss of strength, soon followed by a sense of overwhelming debility, while as yet there was no appreciable functional disturbance. A disinclination for food and an inability to sleep supervened, often with great rapidity. The tongue and eyes usually presented the first distinct morbid appearances, the former becoming coated and the latter red and watery, while no manifest febrile symptoms, properly so called, were discoverable. At this period a slight chilliness was often complained of, though not always cognizable. A full chill did occasionally occur, but it was but very seldom. Nausea was very often present, and in a few rare cases vomiting, with or without diarrhea, seemed to designate the development of the fever. The skin remained dry, and slightly elevated in temperature, while the pulse indicated the presence of indirect debility, though differing in frequency very little from the natural standard for several days, when it usually became accelerated somewhat, and in bad cases soon fell below 70 in the minute.

The most constant characteristics of this fever were great apathy, and apparent indifference to life; sudden and continued deafness; a mental torpor which could not be roused to sensibility, and the absence of all pain, or at least of all complaining, except of weakness, which was universally present throughout the whole course of the disease. Petechia, though not invariably present, were very generally so, occasionally over the entire body, but more frequently upon the neck, chest, and abdomen, in which situations they usually were most visible and most numerous. In general, these appeared about the seventh day, but often earlier, sometimes on the third day; and I have seen them in great numbers as late as the seventeenth day of the disease, with and without sudamina, especially over the abdomen, The tongue presented very variable appearances, sometimes continuing white and thickly coated throughout, more frequently, however, becoming dry, brown, and even black, with occasional sordes, but the latter very rare, even in fatal cases. Delirium was very generally present after the seventh day, followed after a few days by coma, stertorous breathing, and subsultus tendinum, but these latter symptoms were not frequent.

In most of the cases, prior to the occurrence of delirium, a diarrhoea to greater or less extent was present, which was difficult to control by the usual remedies, when the excretions were biliary in their

character; while it readily yielded under other circumstances, to a single dose of castor oil and laudanum. When this diarrhoea ceased, either spontaneously or as the result of medication, if at the same time the skin was open, convalescence was usually rapid, and a favourable prognosis might be safely made.

Relapses were frequent, even after entire convalescence, but most generally the result of some error in diet. In these the worst cases were those in which diarrhoea recurred, or erysipelatous inflammation exhibited itself. The latter cases were numerous, and sometimes fatal. Extensive suppurations of the parotid and other glands were among the worst sequelæ, and these mischiefs were observed especially with the intemperate, who were so numerous as to greatly augment the mortality of the hospital.

In respect to the treatment of this fever, there could be but very little difference of opinion among practical men, in reference to the majority of those patients received into this hospital, arriving, as they very generally did, in the later periods of the disease. So plainly was blood-letting contra-indicated, that, with the exception of a single instance, it was never resorted to by myself or assistants, nor was it even proposed by any of my medical friends who visited us, after inspecting the patients. Cupping was used in a few examples for the relief of local complications, and then always with advantage. But in general the aspect of the case forbade any depletory measures, or other active treatment. Even a single drastic purge was inadmissible, nor could it be given with impunity.

The successful means adopted by us may be thus detailed. A mild laxative was prescribed, if necessary, in the beginning, after which a dose of the Sp. Mindereri, with or without a grain of Ipecacuana, was given every hour or two, according to the urgency of symptoms, and this course steadily pursued until free perspiration was induced. Meanwhile nutritious drinks were used, such as oat-meal gruel, rice or barley water, arrow root and milk, beef tea, and the like. Ice and iced water were freely used, and when much heat was present, the head, neck, and body were sponged with ice water. Mustard plasters and blisters were used when diarrhoea or delirium supervened, or any indications were present of local lesions, or increased debility. So soon as any flagging of the pulse appeared, milk punch, wine whey, or brandy and ainmonia were resorted to, and continued so long as stimulation was called for. These latter agencies had to be used to a very great extent in many cases, and with the best results. Such was the general course of treatment, modified as circumstances demanded. When the diarrhoea became threatening, injections of nitrate of silver, a drachm to the pint, were found of great value. Dysenteric symptoms were arrested by calomel, opium, and ipecacuana, with injections of iced water. Erysipelatous complications were treated chiefly with quinine, and mercurial ointment, and occasionally by blisters and nitrate of silver. And so of local lesions, which but rarely occurred, the principles of rational medicine being our guide. The limits assigned me forbid greater particularity or amplification.

The pathological results of this fever, as shown by dissection, will soon be given to the profession in the forthcoming report of the Committee of the New York Academy of Medicine, from the notes of our excellent friend, Dr. Sabine, who, as one of the committee, has been pursuing that branch of inquiry. I may be pardoned, therefore, for the present, in only indicating what will then appear, viz.: that effusion in the ventricles of the brain was discoverable in almost every fatal case, and this for weeks together, while the autopsies were daily made. The absence of the intestinal ulcerations, which characterize the Dothinenteritis of the French writers, proved that our endemic, at least, has been called Typhoid fever by a misnomer, while the cerebral mischiefs so constantly observed, identify this fever with the other varieties of Typhus fever, being the petechial species of the genus; its malignity and danger having been the result of causes already indicated as accompanying its origin and prevalence.

Should this desultory letter serve your present purpose, written as it has been amid pressing avocations here, you may shortly hear from me again on the same topic, when more leisure shall be allowed me. For any measure of success which has accompanied my exertions in this hospital, I am greatly indebted to the diligence and toil of my assistants, Drs. O'Neil, Wendel, Mott, and Davis, who, with myself, providentially escaped the disease, while all the rest were visited by one or more attacks of fever. I am likewise under many obligations to Dr. F. Campbell Stewart, and Dr. A. V. Stout, who, at the most critical period, volunteered their valuable services and spent weeks with me in the hospital. Many others of my professional brethren, by their frequent visits, their counsel and sympathy in the trying duties to which I have been called, might be worthily mentioned, for all are gratefully remembered. Happily, none of my medical assistants fell victims to the fever, though eight of them were sick, and some of them suffered severe and dangerous attacks. In their treatment, Drs. Chalmers, Cheesman, Johnson, and others of the profession, rendered unremitting and valuable aid. You will forgive me for thus alluding incidentally and gratefully to these "friends in need," though writing for a Medical Journal, for I should do violence to the impulses of my heart, should I refrain. Their kind offices merit a better memorial, and serve to make us prouder of our noble profession. With great respect, I remain,

Your obedient servant,

Prof. C. A. Lee, M. D. Aug. 28th, 1847.

D. M. REESE, Resident Physician.

A Case of Vesico Vaginal Fistula remedied by Caustic. By ELAN W. HARRIS, M. D., of Elm Wood, Cape Girardeau county, Mo.-Mrs. C., a married lady, aged 30 years, presented herself to me early in February last, laboring under the unfortunate, painful, and disgusting infirmity of vesico-vaginal fistula. Her garments were constantly wet; the vaginal cavity, labia and thighs bathed with urine,

in an erysipelatous condition, and exquisitely tender. The complaint had existed for five years, and occurred seven or eight days after a tedious first labor, and violently severe manipulations of her midwife. In addition to the soreness caused by the irritation of the urine, she suffered violent pain in the bladder, which often prevented sleep whole nights; she sometimes passed urine the natural way for a day or two at a time, but always with great pain, and if, during her monthly periods, the urine is discharged through the urethra it is mixed with the catamenial fluid, just as it is when the urine passes through the fistula and vagina.

The parts being too sore to attempt any exploration, recumbency, aperients, fomentation, and tepid lotions were enjoined. In a few days, her condition being much improved, the finger was introduced into the vagina, the walls of which felt hard and irregular, presenting to the finger the sensation of cicatrices. No os tincæ or neck of the womb could be felt. The vaginal speculum was now carefully inserted into the vagina, which terminated in a round sack-like cavity without anything like the neck of a womb projecting into it. Instead of an os tincæ, a small opening was found large enough to admit a silver probe which entered the uterus; about three quarters of an inch from this aperture, in the anterior wall of the vagina, was found an oblique fistulous opening into the bladder (five lines in extent), through which the urine could be seen flowing. The bladder was then sounded, and I soon convinced myself of the existence of a calculus. The patient was informed that the only relief that could be afforded was by extracting the stone, and that there was barely a hope that the fistula might be healed, and thereby relief obtained from the troublesome and disgusting incontinence. She replied that she would willingly submit to any operation rather than remain in her miserable condition.

On the second day after the examination, a long delicate pair of forceps was introduced through the meatus urinarius, with a bistoury at hand to make the proper incision if found to be necessary for the extraction of the stone. By gently and gradually opening the chaps of the forceps, the urethra was sufficiently dilated in about twelve minutes, (with very little pain), to enable me to take hold of the stone. In endeavoring to get a firm grasp, this was crushed to pieces, which I considered a fortunate occurrence; the fragments were removed with the forceps and syringe, at a sitting of a few minutes each day for five days, when no more could be found. Some of the particles passed through the fistula and were washed out of the vagina with a syringe. I weighed four drachms and six grains of gravel saved, and there was fully as much lost. No unpleasant symptom occurred, and she was permitted to walk about, expressing great gratification on account of freedom from pain.

The incontinence was still annoying, and on the sixth day after the removal of the last of the gravel, the speculum was again introduced, and a piece of solid lunar caustic made fast by a thread in the same forceps used for extracting the stone, was carried up through