A REVIEW OF THE DISEASES CONTRACTED 
IN THE CUBAN CAMPAIGN OF 1898 
BY 
HENRY JACKSON, M.D. 
ASSISTANT VISITING PHYSICIAN, BOSTON CITY HOSPITAL 
REPRINTED FROM THE MEDICAL AND SURGICAL REPORTS OF THE BOSTON CITY HOSPITAL 
TENTH SERIES, 1899 
BOSTON 
Municipal Printing Office 
1899 A REVIEW OF THE DISEASES CONTRACTED 
IN THE CUBAN CAMPAIGN OF 1898 
BY 
HENRY JACKSON, M.D. 
ASSISTANT VISITING PHYSICIAN, BOSTON CITY HOSPITAL 
REPRINTED FROM THE MEDICAL AND SURGICAL REPORTS OF THE BOSTON CITY HOSPITAL 
TENTH SERIES, 1899 
BOSTON 
Municipal Printing Office 
1899 A REVIEW OF THE DISEASES CONTRACTED IN THE 
CUBAN CAMPAIGN OF 1898. ONE HUNDRED 
AND TWENTY-THREE MEN. 
Henry Jackson, M.D. 
From the twenty-third of August to the first of October 
between four and five hundred men were admitted to the 
Boston City Hospital, most of whom had served in Cuba; a 
few had been in camp at Chickamauga, or in some of the 
camps situated in Florida. One hundred and twenty-three 
of these men were entered on the first medical service. 
Great interest attaches to these cases from a medical point 
of view, in that they offered us the first opportunity to study 
in a large number of cases, the various phases of malaria of 
the estivo-autumnal type. 
Taken as a whole, these men presented many interesting 
phenomena. They were all dark, their skins having a pecul- 
iar yellow or brownish color, sometimes with a tinge de- 
scribed as muddy; many hardly looked like Anglo-Saxons, 
resembling rather the Armenians. The color was apparently 
dependent upon several factors ; first, sun-burn, which of 
course was an important factor, hut by no means the only 
cause of the color, as in many of the men a similar, though 
less marked, discoloration was seen all over the body, which 
had been protected by the clothing; destruction of the blood 
pigment evidently played quite an important part in produc- 
ing the color noted, as the tint was similar to that seen in 
some blood diseases, as pernicious anemia, where there is 
destruction of blood pigment. Finally, anemia, present in a 
large number of the men, was important in producing the 
color; the anemia was evidently severe in grade, though 2 
unfortunately the stress of work made exact counting of 
the corpuscles in many cases impossible ; in the cases where 
a red count was made the number was reduced by one-half. 
Almost invariably they were thin, the few exceptions only 
proving the rule, while many can be described only as ema- 
ciated ; their eyes were sunken and lustreless, their cheeks 
hollow, and their bones were alarmingly prominent. In these 
men described as emaciated not only was there no fat tissue, 
but the skin had lost its elasticity and the muscles were re- 
duced to the smallest possible size. 
It was noteworthy that very few showed any evidence of 
skin diseases due either to neglect of proper care in washing 
or to vermin; in a few cases only was there edema of the 
legs and feet not dependent upon kidney disease. 
Mentally they were marked by extreme apathy; one was 
not impressed that they suffered and repressed their pain, 
but rather that they were indifferent to pain and discomfort. 
Also in small ways many seemed unbalanced, almost childish 
in their opposition to minor hospital rules or in their wish to 
do things considered by the physicians as inadvisable or abso- 
lutely harmful. I dwell especially upon these changes in 
their mental balance because the same characteristics were 
noted by Dr. Prescott at Montauk and by a man, not a 
physician, who had charge of a station at Long Island City, 
where large numbers of troops were fed and cared for while 
en route from Montauk to various points in New York and 
the West. Dr. Prescott has said that this lack of mental 
balance was a source of much trouble, in that men who had 
been furloughed insisted upon leaving camp when they 
were not actually sick, and yet not well enough to travel 
alone. Actual delirium or wandering was seen in several 
cases where there was no fever sufficient to cause such a dis- 
turbance ; it was dependent apparently simply upon weak- 
ness, and in each instance passed off in a few days. 
There has been much discussion as to whether the sickness 
amongst the troops could be directly traced to carelessness 
or negligence on the part of the officers ; after careful con- 
sideration it seems to me that in only a few instances could 
the diseases be traced to any source than the climatic 3 
conditions of Cuba. Theoretically the fourteen cases of dysen- 
tery and the twenty-one cases of typhoid should have been 
prevented, but these diseases played but a small part in 
causing the sickness in comparison with the large number of 
cases of malaria. It cannot and should not be denied that 
improper and insufficient food was an important factor in 
causing the debilitated condition of the men. 
The cases may be classified as follows: 
Malaria ..... 
46 cases. 
Typhoid fever .... 
18 « 
Typhoid fever and malaria 
5 “ 
Dysentery ..... 
6 “ 
Dysentery and malaria . 
7 “ 
Amebic dysentery .... 
1 case. 
Debility, convalescents, etc. 
. 87 cases. 
Convalescence from yellow fever 
2 “ 
“ Collapse ” . 
1 case. 
Total ..... 
123 cases. 
In al] of the cases classified as malaria there was fever of 
a greater or less degree after they entered the hospital, those 
who had no fever after arriving from Cuba being classified 
as convalescents. Plasmodia were found in only twenty- 
nine cases; in eleven no blood examination was made; in 
eight no plasmodia were found. Several reasons may be 
brought forward to explain the apparent absence of plasmodia 
in well-marked cases ; most of the men had taken quinine, 
some in large doses, so that it is probable that but few 
organisms were present; many left the hospital after a short 
time, going to various outlying hospitals to convalesce. In 
proof of the latter statement, in three cases where no plas- 
modia were found when the first examination was made, the 
organisms were abundant when the men returned after a 
considerable interval with a renewal of the fever. And 
lastly the large amount of work of a necessary character 
made frequent examinations impossible when the treatment 
of the case was not dependent upon the finding of the plas- 
modia. The men were so sick that in no case did I dare to 4 
delay in giving large doses of quinine at once, so that failing 
to find the organisms on the first examination a second 
opportunity might not present itself in another rise of tem- 
perature. The organisms found were of the estivo-autumnal 
type in twenty-four cases, hyaline intra-corpuscular forms 
and crescents or ovoid bodies ; occasionally pigmented forms 
were seen in which the granules were larger and less numer- 
ous than in the tertian plasmodia, these forms resembling 
rather the quartan organisms. The crescents were often 
present in large numbers, two, three, or more being often 
seen in a single field of the microscope. In three cases the 
tertian plasmodia were found, and these cases differed essen- 
tially from the majority in the mild character of the dis- 
ease, and the readiness witli which the fever yielded to 
quinine. 
The type of the fever was varied; in one class there was 
a mild fever for a few days, gradually falling to normal, and 
without subsequent rise in temperature; in others an irreg- 
ular temperature with daily rise and fall continuing for a 
week or so, these cases probably representing a type depend- 
ent upon the cycle of development of a single set of plas- 
modia. Many cases represented the typical remittent form 
of malaria, or at least one period of the remittent fever was 
developed and carried through in the hospital, suggesting 
that the patient had previously passed through similar periods 
of fever. In others, there was a continued type of fever 
closely resembling the course of the temperature in an 
average case of typhoid fever; these two latter types being 
of the variety which has given rise to the name “ typho- 
malaria;” and, firstly, three cases representing the virulent 
type of malaria called “ pernicious.” 
The type of the fever was independent of the treatment, 
as all of the cases were treated alike with large doses of 
quinine. Investigation of recent years makes it probable 
that the long-continued malarial fevers are dependent upon 
the presence of many sets of plasmodia, each reaching matu- 
rity at a different time and giving rise to a continuous, or 
almost continuous, type of fever. 
Twenty-one cases with fever of short duration. 5 
None of these men showed the emaciation so marked in 
those who had more severe types of malaria; some were in 
very good condition, but as a rule they were thin, anemic, 
and had the color seen in the majority of the cases previously 
described. 
In general in all the various forms of malaria similar 
accounts were given of their previous condition. Fever had 
been present for periods varying from four to six weeks 
with intervals of comparative health; the periodicity of the 
fever differed in the various cases, but apparently bore no 
relation to the type presented when they entered the hospital. 
In some the sickness began with chills followed by fever 
and sweating, and the fever continued but without repeti- 
tion of the chills; in others the chills recurred every day, 
every other day, every three days, or once a week. Many 
of them were quite exact in their statements as to the height 
of the fever, saying that their temperature had been 104° or 
105° on many succeeding days. In many cases the so-called 
chills were not true rigors with shaking, but rather a sensa- 
tion of chilliness or cold followed by periods of fever; in 
others true rigors were accurately described, rigors of great 
severity and long duration. A medical student, who acted 
as hospital steward in one of the hospitals, tells me that he 
saw true rigors in only a comparatively small number of the 
men who had malaria. While in the hospital very few men 
had rigors, certainly not more than half a dozen; in many 
the rise of temperature was not accompanied by sensations 
of cold, while in others, probably the majority, the men felt 
uncomfortable, rather cold and wanted to draw the blankets 
up over the shoulders. When rigors appeared at all they 
were of great severity and long continued. The absence of 
rigors accompanied by rapid pulse and great constitutional 
disturbance was in marked contrast to the usual picture in 
the tertian forms of malaria seen in this neighborhood. 
Diarrhea Avas a prominent feature in most of the cases ; 
many had from five to twenty movements daily while in 
Cuba, the dejections being large, watery, and occasionally 
mixed with blood. Vomiting Avas frequently described, but 
not often of long continuance. Headache, dizziness and 
blurring of the sight were present in many of the cases. 6 
I give a few histories as types: 
Case I. — Man, 23 years, 9th Mass. Vols. Well nourished, 
anemic. Entered the hospital September 10. About the middle 
of August, while in Cuba, he had pains in the hips, back and legs, 
with slight fever but no chills; there was headache and blurring of 
the vision; some diarrhea with large, watery dejections, not accom- 
panied by abdominal pain. 
Hyaline intra-corpuscular plasmodia were found. He seemed very 
sick upon entrance, but improved rapidly. Quinine was given sub- 
cutaneously on entrance. 
Case II. —Man, 41, 9th U.S. Cavalry. Well nourished. Entered 
September 13. Early in August he had fever, with headache and 
vomiting of greenish matter; no chills. He also had cough with 
white expectoration. During the week previous to entrance he 
had felt chilly every other day. He was weak upon entrance to 
the hospital but improved rapidly. Plasmodia found on Septem- 
ber 16. 
Case III.—Man, 28, 2d Mass. Yols. Anemic, thin and very 
weak. Entered hospital August 30. Towards the end of July he had 
chills and fever; later he was delirious, vomited a great deal and 
had large watery movements. He was then up and about his 
regular work; for some days before entrance to the hospital he 
was weak and had headache and diarrhea. On September 2 many 
crescents were found and a few hyaline bodies. He improved 
rapidly. 
Ten cases of fever of irregular type, with intermissions. 
These men were in general more seriously sick than the 
preceding class. 
Case I. Man, 25, 9th Mass. Yols. Anemic, thin, very weak, 
and on entrance somewhat delirious. He entered September 6. 
While in Cuba he had two chills, followed by fever and 
sweating, and since then there had been fever, but no chills. 
He had ten or twelve movements daily, the dejections being large 
and watery, Avitli some blood ; there had been abdominal pain and 
tenderness, but without tenesmus and no vomiting. Ho plasmodia 
were found until September 15. The temperature Avas marked by 
sharp remissions Avith rapid, irregular rise in the fever, but there 
were no chills ; quinine Avas given in large doses from the day of 
entrance. He improved gradually, and was sent to a convalescent 
hospital in tAvo weeks. 
Case II. Man, 20, 9th Mass. Yols. Emaciated and anemic. 
He entered the hospital on August 30. Six weeks previously he was 
taken suddenly with great Aveakness and general prostration, having 
pains all over the body ; he then had chills, fever, and sweating 7 
daily. He had diarrhea continuously, the dejections averaging ten 
a day, of a watery character. He went to his home September 2, 
and remained there for a month. During his first stay at the hos- 
pital his temperature was normal, and no plasmodia were found. 
While at home he was weak, and was in bed much of the time. In 
the last week of September he had a chill and iater a sensation of 
chilliness, with fever and sweating every other day. When he 
re-entered he was pale, had a peculiar yellow color, and the sclera 
were also a lemon yellow. The heart was enlarged in all directions,* 
and a soft systolic murmur was heard at the apex and over the pul- 
monic valves. The spleen was very hard, and extended by meas- 
urement to a point one and a half inches above the umbilicus. 
Hyaline intra-corpuscular plasmodia were found. For nearly two 
weeks he had rise of temperature every third day, but no rigors. 
He improved gradually, but remained in the hospital for many 
weeks on account of great weakness and anemia ; when discharged 
the spleen was much reduced in size, being just palpable ; he was 
fat and in good general health. 
Case III. Man, 25, U.S. Regular 10th Cavalry. Fairly well 
nourished, anemic. Entered hospital August 21. He went to 
Cuba in June, took part in the battle of San Juan, July 1 and 
3, and in the bombardment of Santiago, July 10 ■ and 11. 
About the middle of July he had chills and fever, the chills recurring 
almost daily until July 25. After an interval the chills recurred, 
and he left Cuba August 2. The spleen was felt three inches 
below the margin of the ribs, and was sensitive to pressure. 
Hyaline plasmodia and crescents were found. He was discharged 
August 27, and told to consult a doctor, which he did not do. 
One week after leaving the hospital he had a chill, and at irregular 
intervals subsequently he had fever, until he re-entered the hospital 
on October 6. 
When he re-entered he was pale, the red corpuscles numbering 
2,168,000; the spleen was hard, and was felt four inches below the 
ribs. Plasmodia were found. The temperature rose to 104.5° the 
day after entrance, but there was no chill; subsequently the temper- 
ature was normal. 
Four cases of fever of remittent type. 
In addition to these four cases there was a fifth who had 
dysentery associated with the malaria, the case being re- 
ported in the class of dysentery and malaria. 
These men were all very sick. 
Case I. — Man, 24, 9th Mass. Yols. He entered the hospital 
September 6. He was very sick, emaciated, pale and sallow in 8 
color; on entrance he was delirious, and for many days his condition 
was critical; for three weeks he was unable to leave the bed, and was 
not discharged from the hospital for two months. 
Early in August he was taken suddenly with chills and fever, 
marked by great prostration; the fever and sweating continued at in- 
tervals up to the time 
of his entrance to the 
hospital. Diarrhea, 
vomiting and severe 
headache marked the 
course of his sick- 
ness. 
The right side of 
the heart was en- 
larged ; the spleen was 
hard and felt one inch 
below the ribs. Many 
crescents were found 
in the blood. Diar- 
rhea continued in the 
hospital. He had 
fever of an irregular 
type, marked by re- 
missions without in- 
termission for ten 
days; quinine did not 
check the fever, 
though under its use 
there was a steady improvement in his general condition. The 
delirium was present only during the high fever at entrance and did 
not recur, though he was extremely apathetic for a long time. 
Case II. —Man, 23, 9tli Mass. Vols. Fairly well nourished. En- 
tered September 16. In August he had, in Cuba, chills and fever, 
but improved after leaving Cuba, and was fairly well until a few days 
before entrance, when he had headache, chilly sensations, with fever 
and sweating. No diarrhea, but occasional vomiting. 
Hyaline plasmodia were found. The spleen was not very large. 
He was at no time critically sick and convalesced rapidly after the 
temperature reached normal. 
Case III.—Man, 22, 9th Mass. Vols. Thin, anemic, weak. En- 
tered the hospital September 6. On July 15 he had severe head- 
ache, delirium, no chills or fever; later occasional chills came on 
accompanied by fever and sweating. In August had diarrhea; lost 
twenty-five pounds; crescents were found in the blood. While 
in the hospital he had high fever but no chills; his only complaint 
was of weakness. He was discharged to a convalescent hospital 
I DAYS OF 
MONTH, 
UAVSOP 
1 DtStASE.1 
TEMPERATURE. 
PULSE. 
REMITTENT TYPE 9 
September 20. He re-entered the hospital October 6; he had been 
in bed for two days on account of fever and sweating; on the day 
of entrance he had a chill. The spleen was felt half-way between 
the margin of the ribs and the umbilicus; in this case purpuric spots 
were found scattered over the legs and thighs; they were not 
observed in any other case; there was a severe general bronchitis; 
plasmodia were found; Widal negative. In a week he improved 
rapidly. 
Six cases of fever of continued type like typhoid. 
Case I. Man, 34, 7th U.S. Regulars. Emaciated, anemic. 
Entered the hospital September 13. From July 21 to August 12 
he had fever and headache ; was then all right for two weeks, when 
he again had fever, headache and diarrhea; no chills. Since the 
end of August he had had no fever, but constant diarrhea and a 
good deal of abdominal pain. 
On September 15, hyaline plasmodia were found, and on the 
17th crescents ; Widal negative. For three weeks the fever con- 
tinued, and during this time he was very weak and had diarrhea 
most of the time ; crescents were again found on the 28th of Sep- 
tember. He was confined to his bed for six weeks on account of 
weakness, but his convalescence, though slow, was steady. 
Case II. Man, 21, U.S. Regulars. Was pale, weak and thin. 
He entered August 30. Early in August he had general pains in 
the bones, chills followed by fever and sweating, which recurred 
every three days, and profuse diarrhea. Plasmodia were found. 
He had fever but no chills after entrance; he improved rapidly in 
spite of the continued fever. 
In the latter two classes the differential diagnosis from 
typhoid was extremely difficult; the type of fever was the 
same as in the cases of combined typhoid and malaria. No 
single sign was characteristic of either disease ; several symp- 
toms pointed more strongly towards one disease than the 
other. The spleen in malaria was less hard and smaller; 
the tongue often dry and glazed, but not coated with a thick 
dirty pasty coat so common in typhoid. The hebetude and 
stupor of typhoid were not seen in malaria; delirium in mala- 
ria was apparently associated with the high fever, and when 
this passed off the men were often apathetic, but did not pre- 
sent the mental condition usually seen in typhoid. Rose 
spots when seen were important. 
Three cases of pernicious malaria fever. 10 
To these might be added a fourth classified under the 
head of malaria and dysentery, as it was complicated by the 
latter disease, but the severity of the disease and the death 
of the patient seemed dependent rather upon the malaria than 
the dysentery. 
TTaYSDF 
MONTH, 
DAYS OF 
DISEASE. 
TEMPERATURE. 
REPRESENTING A CONTINUED TYPE OF MALARIAL FEVER. 
The term pernicious is applied to these cases because of 
the severity of the acute symptoms produced by the malaria. 
One man entered the hospital in the height of an attack, 
while in the other two the symptoms came on after 
entrance to the hospital. They had very high fever, 
105° or over, they were unconscious, cyanotic, with cold and 
clammy skin ; the pulse was rapid, feeble, and in fact, hardly 
perceptible at the wrist. 
Case I. — Man, 22, 4th Artillery U.S.A. Anemic, sallow, ema- 
ciated. Entered the hospital August 23. He was unconscious 
upon entrance, but later the following history was obtained : About 
the middle of July he had chills and fever, the chills recurring every 
day for a week; he then had fever for a longtime, but no chills; 
he complained of weakness, dizziness, and said he had vomited 
occasionally ; he was given cold baths, stimulants freely, and qui- 
nine subcutaneously, and soon recovered consciousness, though he 
was delirious for several days. 
As shown by the chart there was a gradual but steady fall in the 
temperature and great improvement in his general condition. 
Case II.—Man, 23, 20th U.S. Infantry. Was very pale, thin, 
but not emaciated, sallow in color. He was conscious upon en- 
trance, though wandering at times. The first of August he had 
chills and fever, the chills recurring regularly every other day for 11 
two weeks. While in hospital at Santiago he was delirious, had 
severe headache, general muscular pains, and, during the last part of 
August, pain, redness' and swelling in the knees. There had been 
profuse diarrhea with a few intervals of constipation. 
On the day after entrance his temperature rose suddenly to 105°, 
his pulse was rapid and thready, and he was absolutely unconscious; 
for two days the temperature was normal, when it began to rise and 
continued to do so daily in spite of large doses of quinine. During 
the second attack of fever he was not unconscious, but was delirious 
during a part of the time; his only complaint was of headache; no 
chills were seen while he was in the hospital. Ilis convalesence 
was slow. 
Case III. — Man, 23, 2d U.S. Regulars. Anemic, emaci- 
ated, and very weak upon entrance. He entered the hospital on 
September 6. • About the first of August he had headache, pains all 
over the body and great weakness; he had fever with much sweating 
but no chills ; mentally he was sluggish, but not delirious. A few 
hours after entrance he became comatose, was deeply cyanotic, the 
skin was cold and clammy and the pulse could hardly be felt at the 
wrist. For two days he remained practically in the same condition, 
though the coma was less marked; on the fourth day he recognized his 
brother, and spoke to the doctor. On September 12th he did not seem 
so well, areas of consolidation were found in both lungs, though his 
condition was so serious as to make a complete examination im- 
possible. He died the next day, and the account of the post-mortem 
examination follows: Autopsy, three hours post-mortem. 
Clinical Diagnosis Malaria. Body well developed and nourished; 
length, 179 cm; pupils slightly dilated; slight rigor mortis; over 
the anterior aspect of the right leg, just below ankle there were two 
areas with loss of epithelium, and several small blebs filled with clear 
serous fluid. 
Abdomen: Large intestine much distended; a few slight adhe- 
sions between cecum and coils of small intestine; mesenteric 
glands normal ; diaphragm fourth rib each side. 
Pleurae: Both pleurae contained a slight amount of yellowish 
watery fluid; surface of both lungs were covered with a thin yellow- 
ish white fibrinous exudate; this was more marked over the middle 
and lower lobes of the right lung and over the lower lobe of the left 
lung; over the middle lobe of the right lung it formed a firm, 
thick, yellowish, false membrane. Pericardium normal. Heart 
weight, 355 grammes. Measurements: Tricuspid valve 12.5 cm. 
Pulmonary valve 6.5 cm.; Mitral valve 11 cm.; aortic valve 6.5 cm.; 
thickness of left ventricle 1.8 cm.; of right ventricle 0.6 cm.; valves 
and cavities normal; fresh preparation of myocardium shows no fat. 
Right lung: Upper lobe distended, cushiony, and along the 
edges are seen distended air vesicles; middle lobe almost completely 12 
solidified; beneath the thick false membrane, previously described, 
the lung is exceedingly firm, elevated above the rest of the lung sub- 
stance and on section shows two portions distinctly marked off from 
one another; the outer portion of the pleurae, about 2 cm. in width, 
is composed of a dark red, glistening, slightly granular, firm tissue; 
while the inner portion, which makes up the rest'of the consolidated 
area, is grayish white in color, very granular, firm, and has a slightly 
foul odor; fresh section of this preparation shows the dark red 
area to have an exudate composed of considerable fibrin and few 
ceils, while the gray area is almost entirely cellular; the lower por- 
tion of the upper lobe and the posterior portion of the lower lobe, 
dark red in color; rather firm; exceedingly edematous, slightly 
granular, but glistening, very much injected, and a portion removed 
sinks in water. 
Left lung: Beneath the pleura of the upper lobe are many very 
fine hemorrhages; here and there scattered through this lobe are a 
few firm, dark red areas about \ cm. in diameter, raised above the 
surface of the lung. In the lower portion of this lobe is an area of 
solidification, 6 by 3£ cm., exceedingly firm; on section grayish red 
in color, and in the centre is a small cavity, cm. in diameter, filled 
with soft yellowish puriform fluid, smears from which show many 
pus cells, epithelial cells and a variety of organisms, among which 
are distinguished a long, thin bacillus, a spore-bearing bacillus, elon- 
gated diplococci and flattened diplococci occurring in short chains; 
lower lobe shows a lax consolidation of same nature as that in the 
lower lobe of right lung; it involves two-thirds of the lung, and is 
sharply marked off from the normal lung tissue at the base; mucous 
membrane of bronchi injected; cut ends of bronchi show consider- 
able muco-pus; bronchial glands enlarged, pigmented. 
Spleen, weight, 245 grammes. Capsule smooth; surface of a dark 
slate color; on section the surface is dark brown in color, glistening, 
and relieved here and there by very few minute whitish points — the 
Malpighian bodies; on scraping no pulp is removed; frozen section 
shows a large amount of black pigment. 
Stomach: Mucous membrane normal, except in the cardiac end, 
where there is a small irregular whitish area, about 1 by cm., with 
firm, indurated base; the mucous membrane over this area is 
smooth (suggestive of healed ulcer). 
Liver, weight, 1960 grammes. Capsule smooth, dark brown in 
color, firm; on section markings indistinct; here and there are seen 
minute reddish specks, between which the substance is of a slate 
color; fresh section shows central fat, dark pigment, particularly in 
Kupfer’s cells. 
Gall bladder distended, contains about 40 c.c. of very dark yellow- 
ish fluid with exceedingly mucoid material and granular sediment. 13 
Ividneys, weight, 355 grammes. Capsule peels easily; on section 
cortex, pale; relations between cortex and pyramids normal; 
fresh section shows no fat. Aorta, normal. Bladder, prostate and 
testicles normal. Bone marrow, dark red in color, firm. Head not 
opened. 
Smears from pleurse and lungs show a variety of organisms, 
among which is the lanceolate diplococcus. 
Anatomical Diagnosis: Acute lobar pneumonia; acute broncho 
pneumonia; abscess of lung; acute fibrinous pleurisy; pigment in 
liver and spleen; healed gastric ulcer. 
In all these cases plasmodia were found, and the Widal reaction 
was negative. Quinine was given in large doses both by mouth and 
subcutaneously; baths were used to reduce the temperature, but 
without any practical result; strychnine was given subcutaneously as 
a stimulant, also alcohol in large doses. It is noticeable that the 
spleen was not very large in any of these men. 
uaySToT’ 
MONTH, 
DAYS OF 
DISEASE. 
1)ayS of 
MONTH, 
DAYS OF 
DISEASE. 
TEMPERATURE. 
TEMPERATURE. 
PULSE. 
PULSE. 
Three cases of tertian infection. 
In three men the tertian organisms were found ; the men 
were not much sick, were not emaciated, though thin, and the 
fever ceased after the exhibition of a single large dose of 
quinine. 
PERNICIOUS MALARIA. 
TERTIAN MALARIA. 14 
As a striking picture, in sharp contrast to the irregular 
charts of the preceding cases of malaria of the estivo- 
autumnal type, I give the chart of a case of ordinary tertian 
malaria, which represents the course of the fever seen in 
cases having their origin in this neighborhood. Note the 
rapid pulse associated with the rigor and rise of tempera- 
ture. 
Spleen : The great hardness of the spleen was noticeable 
in all the cases ; in all cases it was enlarged, and in many 
enormous, reaching nearly to the umbilicus. Where the 
spleen was very large there was usually a good deal of ten- 
derness ; one man complained of great pain in the left side, 
the only explanation being found in a greatly enlarged spleen, 
which extended almost to the umbilicus, and practically filled 
the lower left axillary region. The great enlargement seemed 
to be associated rather with a long continuance of a moderate 
fever than with excessively severe types of fever. In one 
case, on another service, autopsy showed a spleen weighing 
760 grammes. 
Under the treatment by quinine and the subsequent use of 
iron and arsenic the spleen diminished rapidly in size. 
Treatment: Alcohol was given to all cases where the 
pulse showed any tendency to weakness, and this was often 
re-enforced by strychnine or digitalis. Quinine was given in 
large doses, always in capsule; pills are unreliable, and solu- 
tions are hard to take when such large doses are necessary. 
In many instances dilute sulphuric acid was given after the 
capsules. Bromide of ammonium or small doses of morphine 
checked the disagreeable ringing in the ears. In most of the 
cases twenty grains of quinine were given after the tempera- 
ture had fallen one degree from the acme, and later five 
grains were given three times a day; in a few cases larger 
doses were given. In other cases the method of Dock was 
employed, giving twenty grains after the temperature fell a 
degree, and then giving fifteen or twenty grains every seven 
days for four weeks. This treatment was employed only 
in the cases where the temperature was normal the second 
day and remained so subsequently. In certain instances 
quinine was given subcutaneously, the preparation used 15 
being the bisulphate dissolved in a weak solution of tartaric 
acid. 
Quin, bisulphat. . . . G-r. Y 
Ac. tartarici .... Gr. V 
Aq 3 j. 
M. 
Quinine is not the quick and satisfactory specific in estivo- 
autumnal malaria that it is in tertian malaria; the men 
usually improved after quinine was given, often markedly, 
but in many instances, as shown by the charts published, 
the fever continued in unabated force. The continuance of 
the fever I believe to be due to the co-existence of many 
sets or crops of the plasmodia, each crop giving rise to fever 
when it reaches maturity. A single large dose of quinine 
appears to kill all organisms that have reached a certain stage 
of development; this I think is shown in the cases where 
after a long interval of normal temperature a sharp rise 
occurs, the “Dock ” method is employed and subsequent rapid 
convalescence follows without further attacks. 
Eighteen cases of typhoid fever: Five of the men had 
been stationed in the southern camps; thirteen were in Cuba. 
Two of the men died; one was extremely sick upon entrance, 
was constantly delirious, had incessant vomiting, and died 
upon the third day. The men who came from the southern 
camps were not so emaciated as the men that came from 
Cuba, but they had a typhoid of a more severe type. As 
a rule the cases were not very severe, some being convales- 
cent, in whom the diagnosis was made by the Widal reaction. 
Most of them had diarrhea, headache, weakness and gen- 
eral pains for several weeks before they were admitted to the 
hospital; in two or three instances there had been one or 
more chills. By the history, therefore, it was impossible to 
form any accurate opinion as to the diagnosis, as many of the 
cases of malaria gave a similar history, though in the latter 
disease chills were usually a more important factor. ’In 
many cases analysis of the blood alone made an accurate 
diagnosis possible. The chief points in favor of typhoid may 
be stated as follows: lethargy or stupor without very high 16 
temperature; disturbance of the mental condition was seen 
in the malarial cases only when the temperature was very 
high, as in the so-called pernicious forms. A tongue heavily 
coated, or with a moist pasty coat. In typhoid the spleen 
was not so large or so hard as in the malaria cases. Abdom- 
inal tenderness and rose spots when present. The pulse in 
typhoid was relatively to the temperature lower and often 
dicrotic. Herpes was common in the malarial cases and not 
found in the typhoid cases. The Widal serum reaction was 
absolutely positive in fourteen cases, doubtful in one case; 
negative in one case that died very shortly after entrance, so 
that only one examination was made. It was negative in 
two cases classified as typhoid; in these two cases the history, 
the mental condition, the dejections, the course of the fever, 
all pointed to typhoid fever, and therefore this diagnosis was 
made; in each case repeated examinations failed to show the 
presence of plasmodia. 
Two charts are given, one illustrative of a mild typhoid, 
the other a severe case, complicated by a large intestinal 
hemorrhage. 
In five cases there was a mixed infection, malaria and 
typhoid fever. These cases are reported in detail by Dr. 
Withington in another article in this volume, and I will only 
say here that the course of the typhoid fever was apparently 
unmodified by the malaria; the malaria making itself mani- 
fest by a sharp rise in temperature late in convalescence. 
Dysentery, fourteen cases : One case amebic dysentery; 
seven cases of dysentery with malaria, four ending fatally; 
six cases of dysentery without malaria, one ending fatally. 
One case of amebic dysentery: A man of about forty years, 
entered August 30. He was thin, having lost a great deal of flesh, 
as was shown by a photograph taken when he enlisted, but he was 
not emaciated, as were many of the men who had other forms of 
dysentery; he was very weak. About the middle of July he was 
taken suddenly with fever, general pains, severe headache and was 
much prostrated; for two weeks he had profuse diarrhea, but con- 
tinued on duty and lived on army rations. He took quinine, which 
had no effect upon his trouble. He entered the field hospital 
August 1, for ten days; in the hospital he had continuous fever, but 
no chills or sweating. During this time his movements were large* 17 
watery, greenish, with blood and mucus; he did not have much 
pain; when discharged he was very weak, the diarrhea continued, 
and he had occasional vomiting. On entrance he complained 
especially of great weakness, and his appearance certainly cor- 
responded with his feelings. 
The liver and spleen were not enlarged; the abdomen was flat, 
tympanitic, not rigid and somewhat tender. His movements were 
small, accompanied by pain, hut without marked tenesmus; they 
consisted of bloody mucus, with the addition of a small amount of 
fecal matter. Amebse were found in the mucus; they were large, 
actively motile bodies, with nucleus and vacuoles. No doubt was 
felt by many observers who saw these bodies as to the correctness 
of the diagnosis. The temperature was elevated on the day of 
entrance, hut fell to normal the following day and remained so 
during his stay in the hospital; throughout his sickness his pulse 
was between 70 and 80. 
Five grains of quinine were given by mouth three times a day; 
the lower bowel was irrigated with a solution of quinine, twenty 
grains to the quart, the irrigations being given every six hours. 
In a few days he improved, but had a good deal of pain when the 
bowels moved for the first week; after ten days the dejections were 
yellow and partially formed. He had two subsequent attacks of 
looseness of the bowels. 
His improvement was rapid, and when he left the hospital on 
October 18 he had almost regained his former weight and appeared 
well. 
This is the only case of amebic dysentery that has come 
under my observation early in the disease, the other cases 
that I have seen belonging to the class pf cases called clini- 
cally “chronic diarrhea;” it seems possible that the early 
treatment of this case by quinine injections may have 
destroyed the amebrn before any extensive ulcerations had 
taken place. 
This man re-entered the hospital in March, 1899, with a 
recurrence of dysentery. 
Seven cases of dysentery and malaria: On entrance all 
of these men were emaciated to the last degree. In most 
of them the skin seemed to be tightly stretched over 
their bones, and the atrophy of the muscles was as marked 
as the entire absence of subcutaneous fat tissue. I have 
never seen cases showing such marked emaciation, except 
occasionally in cancer, where the disease has been so 18 
situated as not to interfere directly with life, so that the 
individual could live as long as the heart had strength 
enough to beat. The mental condition was even more 
alarming than the physical condition; in all there was 
delirium during a part of the day and in two there was con- 
stant delirium till death. But more alarming than the deli- 
rium was the persistent and marked apathy; the men barely 
spoke unless questions were asked; they often hardly com- 
plained of pain when they were having constant bloody 
dejections and took no interest in what was going on about 
them. No pen can describe the impression made upon me by 
these men ; several had weighed 175 pounds or more at the 
opening of the campaign and lay in their beds mere skele- 
tons, with minds as weak as their bodies. Three recovered. 
Case I.—Entered August 23. He was a man of large frame, 
very pale, emaciated, apathetic, with occasional periods of mild 
delirium. For several days there was edema of the lower extremi- 
ties, with a good deal of pain if the legs were extended, so that he 
lay in bed with the thigh flexed. The pulse was weak and thready. 
About the first of August he had a chill, followed by fever, and 
the fever had continued since then, but without the recurrence of 
chills. For two weeks his moveriients had been small, fre'quent, 
with blood and mucus. There was tenderness all over the abdomen, 
most marked along the course of the colon. The spleen was en- 
larged to percussion and the edge was easily felt. 
For the first few days the movements were small, loose, very 
frequent, bright green*in color, and mixed with blood and mucus. 
Vomiting occurred but rarely after he entered the hospital, though 
he was able to take but a small amount of food; from day to day 
death seemed imminent, but the pulse remained at a fair rate, rising 
only once to 120, and in the course of three weeks he was really 
convalescent. 
In this case, after, and perhaps because of, the exhibition of large 
doses of ipecac, the stools soon lost their green color, the blood dis- 
appeared and in a few days they were simply soft yellow discharges. 
An air bed added greatly to his comfort. When he gradually 
recovered from the profound collapse present on entrance, he 
complained of great abdominal pain, which was controlled by 
morphine. 
No plasmodia were found until the fifth of September, during the 
second rise of temperature, when organisms of the estivo-autumnal 
type were found. The chart is given on page 19. 19 
On September 28, when it was first possible to weigh him, his 
weight was 127 pounds; October 14, he weighed 160 pounds. 
“DAYS OF 
MONTH, 
DAYS OF 
DISEASE. 
TEMPERATURE. 
PULSE. 
MALARIA AND DYSENTERY. 
Two other cases recovered; in both there was a history 
of chills, fever and sweating recurring daily, or every other 
day for a long time. Though they both had fever of a 
moderate degree in the hospital, plasmodia were not found 
in either case. One of them had a herpes zoster extending 
over a large area on the right flank, abdomen and thigh, 
which caused far more pain and distress than the dysentery. 
In this case a long-continued diarrhea followed the dysen- 
tery, and for weeks the man remained about as thin as upon 
entrance, though he gradually improved and in six weeks 
was discharged well. 
In neither of these cases was the mental condition so seri- 
ous as in the fatal cases ; they were not delirious, and their 
condition mentally may be described rather as one of apathy 
and weakness. 
Four cases died, three living less than a week, and one 
living, or rather existing, for three weeks. 20 
In one the entry of “ no history ” speaks more eloquently 
of his condition than any words; he was so weak and so 
delirious that it was impossible to get any account of his 
previous condition. 
In two of the cases there was a history of a chill some 
three weeks before entrance to the hospital, followed by fever 
and sweating, but without rigors; in each instance there was 
abdominal pain with great tenderness and many movements, 
green in color, with blood and mucus. They were delirious 
upon entrance and remained so throughout their sickness, 
developing subsultus tendinum before death. Vomiting was 
constant from the first, vomiting without nausea, rather 
regurgitation of all food taken, which absolutely prevented 
all attempts at giving nourishment. 
In the fourth case there was a post-mortem examination 
and, therefore,. I give the history and course of the disease in 
detail. 
A man of thirty-six years, 9th Mass. Vols. Entered the hospital 
August 30. Since the early part of July he had had profuse 
diarrhea, the dejections varying in number from fifteen to thirty 
daily. At first the dejections were light in color and watery, later 
becoming more scanty and dark or reddish in color. There was 
a good deal of abdominal pain, which was relieved by the move- 
ments ; the feces had a very foul odor. 
He was markedly emaciated, with sunken cheeks and deep 
hollows under the eyes ; the mental condition was one of profound 
weakness and apathy, with mild wandering at times. 
Examination of the heart, lungs, liver and spleen showed nothing 
abnormal. The abdomen was lax, tympanitic, and was somewhat 
tender all over, especially so over the descending colon. Ho amebse 
were found in the stools. The bowels moved frequently, the 
dejections being small in size, with blood, mucus and greenish 
matter. As in the other cases the number of dejections marked 
upon the chart gives no adequate idea of their frequency, as often 
he was for a long time upon the bed-pan before it was removed. 
On September 6 many crescents were found in the blood and a 
few hyaline forms. 
At first he was able to take only a very small amount of food ; for 
several days he retained only somatose in broth. 
On September 10 lie was decidedly better, could take more food, 
and the blood had disappeared from the dejections; improvement 
continued for a week, when on September 17 he passed a considerable 21 
amount of pure blood, and from this time failed gradually to his 
death on September 24. After the hemorrhage he was almost pulse- 
less, all food was vomited, and up to the time of his death he 
retained only teaspoonful doses of peptonized milk. 
Autopsy three-fourths of an hour post mortem. Clinical diagnosis: 
Dysentery. Body was still warm; no rigor mortis; body length, 169 
cm., slim, extremely emaciated. Abdomen retracted so that the 
umbilicus rests on the lumbar vertebrae. Eyeballs deeply sunken 
in sockets. The right pupil dilated more than the left. 
Abdominal cavity. Intestines contracted to the size of a finger, 
lying on each side of the vertebral column. Almost no sign of fat 
in omentum or mesentery. Bladder moderately dilated. 
The diaphragm fifth rib left side; fourth space right side. 
On opening thorax lungs contracted to a considerable degree. 
They were downy, of a pale pinkish-white color with very little 
pigmentation. USTo adhesions. 
Heart small, weight, 185 grammes. Flabby. Valves and cavities 
normal. Blood in cavities fluid, but coagulated soon on exposure 
to air. On fresh examination no fatty degeneration present. 
Left lung apparently normal. The bronchi of the right lung con- 
tained yellowish mucoid, purulent material, not very abundant. In 
the lower lobe were several pale grayish, but fairly translucent, 
solidified areas, from which on section th,in pus could be squeezed. 
Spleen, weight, 95 grammes. The anterior edge much lobulated. 
Color of a greenish black. On section the cut surface showed the 
same dark greenish black color. Microscopically much black pig- 
ment was present in cells. 
Gastro-intestinal tract. Stomach contracted down so as to be 
almost tube-like in shape. Its length along lesser curvature was 
15.5 cm. Along the greater curvature, 20.5 cm. Its circumference 
at the cardiac end was 11.5 cm. At the pyloric end, 7 cm. The 
wall felt thick; probably due to contraction. On opening it the 
stomach was empty. The mucous membrane drawn into longitudi- 
nal folds, which in places were somewhat injected. The small 
intestine was practically empty throughout its entire length. Wall 
thickened from contraction. Mucous membrane pale. Peyer’s 
patches not visible. In large intestine, beginning at the anus 
and extending almost to cecum, the mucous membrane showed 
many ulcerations extending down to the muscular coat. The ulcer- 
ations varied in size from 2 to 3 mm. to several cm. in diameter. 
They were irregular in shape. The mucous membrane was much 
undermined, and many of the ulcerations communicated with each 
other beneath bridges of mucous membrane. The mucous mem- 
brane which was left was swollen, and in places rather deeply in- 
jected. In other places it was of a grayish color. A very little soft 
yellowish fecal material was present. On the whole, the ulcerations 22 
were more extensive in the rectum and in the descending colon and 
less abundantly marked in the upper portion of the ascending colon. 
No mucus or blood could be found in the contents of the large 
intestine. Examination of the material from the surface of the 
mucous membrane and at the base of the ulcers beneath the mucous 
membrane was negative for amebse coli. 
Liver, weight, 930 grammes. Greenish black in color. On sec- 
tion presented the same dark color. Lobules easily made out. On 
fresh examination much black and reddish brown pigment present, 
particularly in the peripheries of the lobules. 
Kidneys, combined weight, 245 grammes. Capsule peeled with 
difficulty. Surface slightly granular. On section cortex about nor- 
mal in thickness; pale, rather translucent; markings not distinct. 
Reaction for amyloid negative. Microscopical examination of fresh 
section showed much fatty degeneration. Very small amount of 
light yellowish crystals in tubules. 
Aorta. Intima practically normal. Only in places could a few 
yellowish specks be made out. Testicles normal. Bladder normal. 
Adrenals normal. Pancreas normal. 
Anatomical diagnosis: Ulcerative colitis (amebic?) ; acute bron- 
chitis and broncho-pneumonia; malarial pigmentation of spleen and 
liver; chronic diffuse nephritis. 
Cultures: Heart and spleen, sterile. Liver and kidney, colon 
bacillus. Lung, micrococcus lanceolatus. 
Six cases of dysentery in which there was no proof of 
malaria, either from the history or from the physical exam- 
ination ; two died, one shortly after entrance, the dysentery 
being complicated by pulmonary tuberculosis, and the other 
after a lingering illness of nine weeks. Two of the men 
were fairly well nourished, while four were much emaciated. 
Mentally they were bright, were not delirious with the ex- 
ception of the case rapidly fatal and did not show the apathy 
so marked in the cases of dysentery associated with malaria. 
In three the temperature was normal and the pulse not very 
rapid; in one there was a temperature very suggestive of 
malaria, though there had been no history of chills, fever, or 
sweating, and no plasmodia were found. 
In the case that lived for nine weeks there was through- 
out irregular fever with one sharp rise and during the last 
few days of life a temperature with extreme variations simi- 
lar to the charts seen in, sepsis. During seven weeks the 
pulse did not rise above 110 or fall below 100. The 23 
abdomen was tender, rigid, and the stools at first consisted 
almost entirely of bloody mucus; there was a gradual 
improvement in his general condition, the dejections were 
yellow and infrequent, he was bright and cheerful, with a 
good appetite, but the loose movements returned, and he 
succumbed. 
Treatment: In the cases with malaria, quinine was given in 
large doses as has been described in the report of the malarial 
diseases ; where vomiting was present it was given subcutane- 
ously, though without effect. Hot boric acid or alkaline in- 
jections were given in all cases and they seemed at least to 
afford temporary relief. Morphine was given to most of the 
cases, especially when pain was a prominent symptom, but 
without any apparent effect in checking the frequency of the 
dejections. Bismuth alone or in combination with salol was 
used in large doses, this drug being more useful in checking the 
dejections than morphine. The only astringent that appeared 
to me useful was tannigen, given in ten-grain doses. I rarely 
used large and continued doses of salines to wash out the 
bowels as all of the men were in a very weak condition, and 
in none of them on entrance did 1 dare to run the risk of the 
possible debilitating effect of large watery dejections. In a 
good many cases I gave the treatment used so extensively in 
India and China, ipecac and morphine; in two cases “ post ” 
and perhaps “propter” there was an almost immediate 
change in the character of the dejections. The green color, 
the blood, and the mucus disappeared, and in two or three 
days the stools were yellow. No vomiting was caused and 
there was no depressing effect even in the men who were 
very sick. The method employed was to give one-sixth of a 
grain of morphine subcutaneously, and half an hour later to 
give twenty grains of powdered ipecac in capsules; this 
treatment was repeated every six hours. 
In giving rectal injections in dysentery great care must be 
taken not to distend the large intestine; I have seen a large 
intestine from a case of amebic dysentery that was ruptured 
in several places; the man collapsed immediately after a 
rectal injection and died in a few hours. 24 
Convalescent men : Thirty-seven cases were in the hospital 
for a few days only, awaiting transference to their homes or to 
other neighboring hospitals where convalescents were re- 
ceived; nineteen passed but one day at the City Hospital. 
These men, like the others who were more seriously sick, 
showed marked evidences of the diseases and hardships from 
which they had suffered; eighteen had lost much flesh and 
many of them were weak on entrance; three were “emaciated;” 
one was in such a debilitated condition that in spite of his 
having no fever he was delirious for the first few days. 
Eleven of the men were in fairly good condition, suffering 
only from general weakness which prevented them from 
walking. They none of them had any fever during their stay 
in the hospital. Perhaps the most marked physical sign, 
apart from loss of flesh, was the great apathy noted in most 
of the men. 
None of the men were in the hospital sufficiently long to 
enable us to make an exact diagnosis, but judging from their 
history most of them were convalescing from malaria. Un- 
doubtedly many had relapses after leaving the hospital. 
The following table gives the symptoms complained of: 
Chills and fever ..... 
Chills and fever. Diai’rhea 
Chills and fever. Diarrhea. Vomiting. 
Chills and fever. Insolation . 
Diarrhea ....... 
Diarrhea. (Nephritis) .... 
Weakness 
Jaundice ....... 
Syphilis 
. 10 “ 
4 “ 
2 “ 
4 “ 
1 case. 
5 cases. 
. 1 “ 
Total 
The two cases having respectively nephritis and jaundice 
gave no evidence in their history of a preceding malaria. 
Those who had diarrhea in Cuba described a most severe 
form, many of them having had eighteen to twenty move- 
ments a day. Some of the cases had true rigors, with general 
shaking; more of them described their chills as a sensation 
of cold, followed by sweating, but without shaking. The 
attacks of fever lasted a few days, were followed by a period 
of weakness, when the fever again returned. 25 
Two cases convalescent from yellow fever. 
Both were members of the 2d Mass. Vols. They entered 
the hospital on August 30. They were well-developed 
men; the one in fair general condition and the other thin, 
poorly nourished and anemic. 
Case I.—About the first of August he was taken suddenly sick, 
having at this time severe headache and backache; two days later 
vomiting came on and on one occasion was described as being 
brown. The attack lasted about a week, and apparently was not 
severe. 
For two days there was fever, but later it -was normal. No 
plasmodia of malaria were found. 
Case II. —Towards the end of July he was taken suddenly with a 
severe chill, and for the next two weeks remembered nothing of 
what occurred. He was told that during this time he was very sick 
and had frequent large involuntary dejections. During convales- 
cence he was fairly comfortable, suffering only from a moderate 
diarrhea and weakness. 
On entrance to the hospital he was weak, anemic, and his com- 
plexion had a peculiar, muddy color; the color of the skin was 
different in tone from that seen in the majority of the men who had 
been in Cuba, and who had suffered from malaria. 
There was no fever. The patient had a moderate bronchitis, 
"vthich cleared up rapidly. The spleen was enlarged, the edge being 
easily felt. 
In both of these cases there was a marked discoloration of 
the finger nails that Dr. McCollom said was suspicious, and 
frequently seen in yellow fever; namely, at the root of the 
nail was a pinkish crescentic area marking the growth of the 
nail since the sickness; the older part of the nail had a deep 
yellow, almost saffron, color. In the two cases observed, 
this yellow discoloration of the nail was very different from 
the dirty brownish-yellow discoloration of the nails which 
was seen in the majority of the cases of malaria returning 
from Cuba. 
I draw especial attention to this phenomenon, as, so far as 
I know, it is not mentioned in any printed article upon yellow 
fever; yet Dr. McCollom considers it of importance in the 
diagnosis. Both the men convalesced rapidly, and left the 
hospital in a few days. 26 
Case of collapse. Acute gastro-enteritis : 
A man of twenty-eight years, fine physique and fairly well 
nourished, was brought to the hospital late at night in an unconscious 
condition. He was a member of the 1st Maine Yols. and was 
en route from Chickamauga to Maine. On the train he was sud- 
denly seized with vomiting and diarrhea, and when he reached 
Boston was so weak that he could not stand. We later found out 
that he had had diarrhea at Chickamauga for several weeks. 
On entrance he was cold, cyanotic, at first absolutely unconscious, 
later partially conscious; his temperature was 97°, and the pulse 
rapid and scarcely perceptible; there was constant vomiting and 
small involuntary movements. His condition appeared so critical 
that he was quickly wrapped in blankets without removing his 
clothes; strychnine, atropia, and brandy were given subcutaneously. 
Nothing was given by mouth for several hours, and then he was 
given small doses of very hot water before any attempt was made to 
add nourishment. The following day he recovered consciousness 
and from this on made an uninterrupted recovery. 
I give in detail this case, because, though it does not represent 
any type of a definite disease, it was to me the most remarkable 
instance of severe collapse due to exhaustion in a man previ- 
ously perfectly healthy. I think my house officer, Dr. 
Stevens, made the correct diagnosis when he called the con- 
dition “ Collapse of cholera infantum.” 
His temperature was 100° on the morning after entrance, 
later normal. 
Examination of the heart: In view of the various dis- 
turbances of the heart seen in the soldiers of the rebellion, 
it is interesting to consider what conditions were found 
in the soldiers who returned from the Cuban campaign. 
It is as yet too early to form any opinion as to what the 
ultimate result will be, and most of the cases seen at the 
City Hospital were seriously ill. In the war in Cuba 
most of the men suffered from disease, insufficient diet 
and the tropical climate, whereas in the rebellion the severe 
physical strain involved in prolonged marches was considered 
as the most probable factor in causing the so-called “soldier 
heart.” Few of the men in Cuba were subjected to physical 
strain from arduous or prolonged labor. As has been previ- 
ously stated most' of the men were anemic and many were 27 
profoundly so, and it seems probable that the anemia played 
a more prominent part than strain in such disturbances of 
the heart as were found. The following data are collected 
from the physical examination of the heart in the 123 
soldiers: Not abnormal, 69; enlarged, 18; no enlargement, 
murmurs, 36. Total, 123. 
In the cases showing enlargement of the heart the sounds 
were clear in eight; in one there was a pulmonic murmur, 
and in one a murmur at the apex. In eight cases there was 
a murmur at the apex and over the pulmonic valve. In one 
case the enlargement was limited to the left side, in six to 
the right side, while in eleven cases both sides of the heart 
showed enlargement. 
In thirty-six cases murmurs were heard in which percus- 
sion showed no enlargement of the heart; in eighteen the 
murmur was at the apex, in thirteen over the pulmonic area 
and in five at the apex and pulmonic area. In these latter 
cases the murmurs were undoubtedly hemic in origin. 
None of the men complained of palpitation, distress in the 
cardiac region, or shortness of breath. Rapid or irregular 
action of the heart was found only in those seriously ill. As 
a matter of fact not only was no weakness or failure of the 
heart observed, but perhaps the one most prominent factor in 
these cases was the resistance offered to severe disease by 
men who were emaciated to a degree and yet showed a 
vitality that kept them alive as long as life was possible. 
The saddest and yet the most encouraging feature in these 
•cases was the action of the heart, sad because it showed what 
their health and strength must have been before they 
were reduced by disease; encouraging because it enabled 
these men to live as long as life was possible, considering the 
diseased conditions of organs other than the heart.