THE squadron in the Mediterranean in 1864 consisted of twenty-six vessels, of which two were iron-clads; one was a first-rate line-of-battle ship; two were line-of-battle ships of the second rate, and one of the third rate. There were five frigates, three of them being of the fourth rate, and two of the sixth; five sloops; three steam-vessels; four gun-vessels; one gun-boat; one surveying vessel, and one receiving ship permanently stationed at Malta. The mean force corrected for time was 7,920, and the total number of cases of disease and injury entered on the sick-list, 10,791, being in the ratio of 1362·4 per 1,000 of mean force. Of these, 291 were invalided, and sixty-two died, the invaliding rate being 36·7, and the ratio of mortality 7·8 per 1,000 of mean force. All these ratios are much below those of the preceding year. Twenty-one of the vessels were on the station during the whole year, and the returns from the remainder are for periods varying from three to eleven months. Of the vessels employed on the ordinary duties of the station, and from whom the returns are either for the whole year or very nearly so, the lowest sick-rates were in the Marlborough, the Surprise, and the Magicienne; the highest in the Cossack, Royal Oak, and the Gibraltar.
The daily loss of service from fevers, including the eruptive fevers, was equal to about twenty-four men, or in the ratio of 2·9 per 1,000; from diseases of the brain. and nervous system, about four men; of the respiratory organs, the ratio per 1,000 of daily loss of service was 5·4; of the heart and blood-vessels, ·5; of the alimentary canal, 1·5; of the genitourinary organs, 4·7; from rheumatism, 3·9; diseases of the bones and joints, ·2; of the special senses, ·4; of the skin and cellular tissue, 18, of which 12·2 was from abscesses and ulcers alone; from dyspepsia and headache, 1·1; dropsy, ·2; and wounds and injuries of various kinds, 8. The total number daily sick from all causes was equal to about 356 men, or in the ratio of 45 per 1,000 of mean force, which is 8·3 per 1,000 below the daily sick-rate of the preceding year.
Fevers.- There were 611 cases of fever of a continued or remittent type; 114 of intermittent fever; nine of smallpox; twenty-four of measles; and seventeen of scarlatina, entered on the sick-list during the year; and of these, ten of continued or remittent fever, and one of scarlatina, proved fatal.
Continued and Remittent Fevers.- There were eight cases of primary fever in the Caradoc. They occurred during the midsummer quarter, when the vessel was at Galatz in the Danube, and the average duration of each case on the sick-list was about eleven days.
In the Chanticleer, there were only three cases of primary fever, but of these one proved fatal. They all appear to have been of considerable severity. The fatal case occurred in the person of a boy, and the type was from the first decidedly enteric. On the seventh day there was profuse haemorrhage from the bowels, causing a state of collapse, from which he was with difficulty recovered. Subsequently the lungs became involved, diarrhoea assumed an urgent form, and he sank on the 13th day after being placed on the sick-list. The disease was contracted at Malta. The following report of the post-mortem examination of the body, and remarks, are by the assistant surgeon (Assistant Surgeon Richard Whish Brigstocke) of the ship:
"On opening the chest, the heart was seen lying over the middle line, with its apex to the right of the sternum. This abnormal position did not appear to be due to any morbid phenomena, for there was no effusion in the left pleura, but the left lung was larger than ordinary, as compared with the right. Both lungs were congested; but with the exception of part of the posterior lobe of the right, which was in a state of red hepatization, their texture was firm and crepitant; but on being squeezed, a frothy sero-sanguineous fluid issued from the cut surface. On opening the pericardium, it was seen to contain an abnormal quantity of fluid. There were no adhesions, but over the left ventricle were two small patches of recently deposited lymph. The right ventricle was filled with a soft coagulum, the left was empty. The general texture of the heart was pale and flabby; the cavities and valves appeared perfectly healthy. The liver, kidneys, and supra-renal capsules were also healthy. On the outer surface of the lower edge of the spleen were two small white spots, which, on being cut into, resembled tuberculous matter. The centre of one was beginning to soften. The pancreas was of natural size, but very hard, creaking like cartilage when cut with a knife, and of a pearly whiteness. The jejunum was congested in two or three spots. The ileum was much congested in its lower third. Peyer's patches were prominent, and swollen, being clearly discernible to the naked eye, the glands having a black dotted appearance. None, however, were found to be ulcerated. The solitary glands, however, were more especially affected, and near the ilio-coecal valve were several circular ulcers, some as large as a sixpenny piece. In every instance, the ulcer was situated about midway between the attachment of the mesentery and the point opposite. These ulcers had well-defined margins of thickened freely moveable mucous membrane, and their bases were generally formed by the muscular coat, which was completely bare. In one spot, the ulcerative process had extended to the peritoneal coat, which formed a transparent centre, limited by a ring of muscular tissue, while beyond, the thickened mucous membrane formed the margin of the sore. The coecum and ascending colon were much congested, but below the gut appeared healthy. The mesenteric glands were much enlarged.
“The general symptoms, particularly the diarrhoea and intestinal hemorrhage, were clearly diagnostic of typhoid fever; and the state of the ileum after death confirmed this opinion. The characteristic eruption was never seen, but it is possible that being scanty and evanescent, it may have escaped observation, though looked for daily, or, death having occurred within the second week, it may not have appeared. The period of incubation must have been ten days or more, as we sailed from Malta on the 5th, and on the 15th the boy was placed on the sick-list. During our short stay at Malta, twenty-four hours' leave was given to each watch, and this poor boy was among those who took advantage of it. Much sickness was said to prevail on shore at the time, but chiefly in the form of a slight eruptive fever, resembling rubeola notha. The case occasioned no particular anxiety, though the subject of it was a pale, slight, delicate lad, until the occurrence of the haemorrhage, which completely prostrated him, and from that moment scarcely any hopes were entertained of a favourable termination."
In the Gibraltar there were only five cases of primary fever. Three of these were of a severe character; one proved fatal. This occurred at the Piraeus, in the person of a marine artilleryman, and was of the enteric type. He was placed on the sick-list on the 30th of June; on the 7th of July the characteristic eruption appeared on the abdomen, and on the 11th he died. Diarrhoea was not a prominent symptom in this case. Seven days after his death a seaman who was under treatment for an obstinate skin disease to which he had been long subject, was seized with acute febrile symptoms, and from the diarrhoea, the red tongue, and the protracted illness, this case also seems to have been of the enteric type. On the twenty-second day a doubtful eruption appeared upon him. He was discharged to hospital on the vessel's arrival at Malta, at which time he was progressing favourably. Four days after the above patient was taken ill, a seaman was placed on the sick-list with somewhat sharp febrile symptoms, the duration of which was very short, however. Convalescence in this instance was accompanied with a peculiar state of the pulse. He was placed on the sick-list on the 20th of July, and discharged to duty on the 1st of August. The surgeon (Surgeon C. M'Shane) of the Gibraltar says, with reference to this case: "The symptoms at first were very severe, and on the fourth day there was some abdominal tenderness. On the next day this had disappeared, and he was comparatively well, and on the 1st of August he was discharged to duty. In this case the sudden depression of the pulse without any apparent cause was remarkable. On the morning of the 20th it was 120, by the evening it had fallen to 90; on the 21st it fell to 50, and on the 23rd to 45; next day it rose to 50, and on the 26th to 76. During all this time he was taking carbonate of ammonia and chlorate of potass draughts, and from the 22nd soup and wine." The other two cases in this ship occurred in November, and were of an ephemeral character.
There were twenty-five cases of primary fever in the Hibernia, of which one proved fatal. This occurred in a man who was brought on board from the Corradino prison, where he had been taken ill, and in which he had been confined for twenty-eight days. The fever was of the enteric type, being accompanied with purging, severe abdominal pain, excessive deafness, and wandering delirium. He was at once discharged to the naval hospital, where he died four days afterwards. All the other cases of fever were ephemeral, averaging between five and six days on the sick-list, and were chiefly prevalent in the autumn. With reference to them the surgeon (Surgeon T. Russel Pickthorn) says: "These febriculae were not, as in former years, accompanied by eruptions on the skin, and in my dockyard practice the number of cases presenting eruptions was very small. Yet, in Valetta, I was told by the medical practitioners, that eruptive fevers were very common, more so, indeed, than in former years."
There were eight cases of primary fever in the Hydra, the majority of which occurred at Corfu about the end of July, in the persons of men who had been much exposed to the sun's rays while on detached boat service, surveying. They appear to have been of a somewhat tedious character, the duration of each case on the sick-list being on an average upwards of three weeks.
All the febrile cases in the Icarus were of an ephemeral character.
There were 139 cases of primary fever in the Liffey. Of these two are returned as cases of continued fever, ninety-eight as remittent, and thirty-nine as ephemeral. Ninety-seven of the cases of remittent fever occurred during the Lady quarter of the year when the vessel was at anchor off Beyrout; and, with regard to this epidemic, the surgeon of the ship (Dr. Robert Hastings) gives the following history:-
"The ship arrived at Ayas Bay on the 29th of December 1863, where we remained at anchor until the 21st of January. During this time the weather was dry, cold, and bracing, with the wind from the North to N.E. The lowest temperature recorded was 29°; it generally froze during the night, and the surrounding and distant hills were covered with snow. Our sick-list during this time did not exceed 5 per cent., chiefly catarrhal, rheumatic, and febrile cases. Three out of the four cases of pneumonia, were here put on the sick list, and several of febricula and remittent fever. On the 21st of January we passed over to Alexandretta, and remained at that place until the 27th. The temperature there was considerably milder than at Ayas, being more sheltered from the prevailing winds. The sick list here remained of much the same extent and character, three or four cases of febricula having been put on the list. On the 27th we sailed for Larnaka with a sick-list of twenty-eight, but only remained there about twenty-four hours. The wind was blowing into the Bay; some officers landed for a few hours. On the 29th of January we left Larnaka for Beyrout, where we arrived on the 31st of the same month, and anchored in St. George's Bay. During the few days that intervened between our leaving Alexandretta and our arrival at Beyrout, four cases of fever of a distinctly remittent, but of a mild character, appeared.
"I have been thus particular in describing our movements, and the state of the sick-list, up to the time of our arrival at Beyrout, as from that day, cases of remittent fever appeared so rapidly, that by the 10th of February, our sick-list had reached 100, its maximum. On the 1st of February, four cases appeared; on the 2nd, six; on the 3rd, sixteen; on the 4th, sixteen; on the 5th, nine; on the 6th, seven; on the 7th, four; on the 8th, eight; on the 9th, nine; and on the next day the list reached 100. After this the cases were few, and of a milder character; in fact, more of the intermitting type. In consequence of my representation, we sailed on the 10th from Beyrout for the southward, as far as Kaiffa, where we arrived the same day. After this, only a few cases appeared, and that over the next three or four days. On the 13th of the same month, our sick-list was again reduced to thirty, and we returned to Beyrout, anchoring off the town.
"This fever was preceded by the ordinary premonitory symptoms of fevers in general, but of shorter duration. Usually there were chills, alternating with flushes of heat for a day or two before presentation, at which time the patient was found in a high state of fever, which continued for several hours, ending in perspiration, and a remission. At this stage, and generally continuing more or less through the disease, there was complained of, and often very much, a pain, weight, or constriction about the praecordium, or in either hypochondriac regions, in some with nausea and vomiting; and not only in these regions, but also in many there was pain and constriction in the chest, with a dry cough. In one case the pain was so excruciating, over the region of the spleen, that it was thought necessary to apply the cupping-glasses, and take blood to eight ounces.
"The exacerbations generally came on in the afternoon, or first part of the night, sometimes preceded by chills, and after a longer or shorter time, moderated more or less in sweating, which continued through the night. Thus the fever went on for a few days, and what were remissions now became more intermissions, the paroxysms coming on in the evening or first part of the night, and the remission and sweating continuing through the night. In some of the more severe cases this night sweating continued for some time, even during convalescence, without any chills or febrile symptoms.
"The cases which presented themselves at the commencement of this fever, say for the first four or five days, were the worst, and they gradually became milder as they went on, until at last they assumed more of an irregular intermittent character, of one or perhaps two paroxysms, and of short duration. In fact, in a few cases it was difficult to form any certain diagnosis as to which was remittent and what was intermittent. The longest case on the list was nineteen days. The treatment was at first, until the intermissions or remissions were well defined, opening and saline medicines, then quinine. In many eases counter-irritation to the praecordial and pectoral regions was necessary, in consequence of the symptoms above mentioned.
"If this fever, as we are bound to believe, is caused, like intermittent fever, by local malarious influence, I am at a loss to know when, or at what particular place, the ship was subjected to the conditions necessary to produce it. We arrived on the coast of Syria, at Beyrout, from Corfu, on the 22nd of November (1863), and a week after went to the southward as far as Jaffa, returning to Beyrout, by Kaiffa, on the 14th of December. The two cases before mentioned, as returned under the head of Continued Fever, were no doubt cases of remittent. At Ayas Bay there were two or three cases of fever of the same character, but very mild. At Alexandretta, where we remained about a week, and where, as I have before mentioned, the weather was much as at Ayas, but a little milder; a few cases under the head of Febricula were entered on the list, but none under that of Remittent. Here the town is built in and upon the edge of a low marsh or swamp, which stretches to the southward for some distance, and to this place, at any other season of the year, might be put down the fever which afterwards showed itself. But with such a low temperature, and with a dry northerly wind, not blowing over any neighbouring marshy ground that I know of, I do not exactly understand the development of a malarious influence, as I was under the impression that it required the very opposite conditions; viz., a temperature, say of about 60°, not less, and moisture, and these continued for some time. I am disposed, however, to refer the fever to this place, even under the circumstances, as, from the day we arrived at Alexandretta, until what I may call its first appearance in St. George's Bay, Beyrout, was a period of nine days, a fair time for incubation. It is a strange fact, that of all those who landed at that place, and they were, I may say, all the officers, many of them to shoot through the marsh daily, watering parties, boats' crews, &c., only one man had the fever afterwards.
"The extreme cold to which the men were often exposed in washing decks in the early morning, in the Bay of Iskenderoon, in the month of January, I have no doubt contributed in some measure to the production of this fever, by rendering the men more susceptible of an exciting cause. And why also may not this cause have produced its effect at an earlier period than that for which I have given it credit, viz., at Alexandretta, but lain dormant, or been kept in a state of incubation by the cold, until it had been favoured by the milder temperature of St. George's Bay, at Beyrout?"
The average duration of each of these cases was between eight and nine days, and no case terminated fatally.
There were fourteen cases of primary fever in the Magicienne, nine of which were of the remittent type, the average duration of each case on the sick-list being about fifteen days; and the remainder ephemeral, the treatment of each case only averaging four or five days. There was nothing worthy of comment in connection with these cases.
There were seventy-five cases of primary fever in the Marlborough, of which two proved fatal. They occurred chiefly in the Midsummer and Michaelmas quarters of the year, and in the Quarterly Return for the latter period the Surgeon (Dr. Wm. Duirs) says:-
"Very many of them were simple febriculae, but some have run a long and tedious course, attended by great debility and by a peculiar nervous irritability, particularly those of the month of September, admitting of no kind of exertion or excitement. The later cases, cases are also accompanied by rheumatism. I find it impossible in these cases of fever to keep up the distinction between remittent and continued. Some have had evening exacerbations for a few nights, and then for many weeks they have gone on precisely like the others that have never had any periodicity at all. The characters of remittent fever have not been present in many cases, and when they did show themselves it was irregularly and temporarily, so that I am inclined to class them all as continued fevers."
Elsewhere the following observations are made by the same officer:-
"With July there came a marked increase of temperature, and the character of the cases put under treatment underwent a corresponding change. The febrile affections were both more numerous and more severe, and a considerable proportion of them were accompanied by pneumonia in one or both lungs, which complicated the cases to an embarrassing degree. These were the worst cases in the list; and I may remark that in other ships of the squadron at Malta, and also among patients on shore, the same chest affections accompanied cases of fever about the same time . . . . In August the ship was still at Malta, and, though the heat was perhaps a little greater, and made more oppressive by the sirocco winds, which were not much felt earlier in the season, there was very little in the sick-list to distinguish this from the preceding month; excepting in some of the characteristics of the fevers indeed, there was no sensible difference. In the fevers of July chest affections were not uncommon accompaniments; but in August we lost sight of these altogether, and in their stead came typhoid symptoms occasionally, and rheumatism more frequently. The convalesence, as might be expected, was longer and more frequently interrupted, particularly in those cases in which rheumatism was concerned. It affected the knees most frequently, the wrists and shoulders in other instances, and it was always accompanied by great muscular debility and extreme sensitiveness to atmospheric changes; the approach of a sirocco was felt by the patient with painful distinctness, and while it blew he was depressed and prostrated extremely.
"Early in September the ship left Malta for a more extended cruise to Palermo and the Bay of Naples. At the time of our departure a large proportion of the sick-list consisted of fevers; not all severe cases, but amongst them were several patients who had been long confined to bed in a state of great debility. There were several officers in the number. They seemed to have no power of rallying, and the extent of nervous depression and irritability was remarkable. A few steps across the deck were enough to produce fatigue and tremulousness, and a few minutes' conversation was followed by a sense of weariness and confusion. With all this, a fair amount of sustenance could generally be taken with relish, and most of them slept tolerably well. Rheumatism was a very troublesome concomitant, not usually intense nor general over the body, but causing tenderness and swelling of the knees or wrists, and completely disabling the limb for the time.
"I hoped that the change to Italy from Malta, where we had been all through the summer, would do much good to my fever patients; it did improve most of them certainly, but not at all to such an extent, nor so rapidly, as I anticipated. One good result of our departure from Malta was, that very few new cases of fever came on after we left, and there was undoubtedly a higher standard of health generally in the ships during our absence.
"A few days after our return to Malta, in the end of September, cases of fever began to come in again. They had ceased during our absence, and now they presented themselves with some grave complications - abdominal tenderness, and diarrhoea, and complete prostration, with deafness and persistent wakefulness. One of the first of these, a young seaman, applied four days after our return, and soon showed typhoid symptoms, so that he was sent to hospital. Others followed, with symptoms of the same character more or less developed, and the ship put to sea, to return to England, on the 13th of October, having five beds occupied with such cases, all recent attacks. One of them died, having taken on the typhoid symptoms very distinctly.
"The concomitant symptoms of fever during this year have varied as the season advanced, and this in a very marked degree as shown, but whether the same variations are equally apparent in other seasons I am not in a position to decide. I observe, however, as I did last year at Athens, that the worst cases of fever did not occur in the extreme heat of the summer, but after the season had begun to change into temperate. There were more cases in this ship this year than there were last, and certainly a greater number of serious cases, though the general average of days' sickness does not differ much till late in the season.
"It is remarkable that towards the end of this last summer a larger proportion of officers than usual have been on the sick list, and mostly with fever. One-fourth of the whole number of sick on board for a considerable period was composed of ward-room and gun-room officers. I can give no satisfactory explanation of the fact; in one case there was perhaps more exposure to the sun than was prudent, but in none of the others could that cause apply, and many of the men, I am quite sure, were much more in the sun without suffering any inconvenience.
"I may here take occasion to remark with regard to exposure to the sun, that while labourers and artisans work hard all day in the open air without the least shade, people who are not similarly employed always seek the shade; and Maltese who have lived all their lives on the island - the officers of the native regiment for example, and others in a like condition of life - say that they cannot expose themselves with impunity to the sun to such an extent as many of ourselves habitually do. It might seem that the ready explanation is in the habit of exposure, and that use makes it harmless; but again we find that cricket parties will play their game for hours in an August afternoon under a hot sun without bad effect, our soldiers do so frequently, and naval men occasionally are rash enough to join them. It seems to me that exertion or excitement during exposure to the sun prevents to a great extent the bad effects of it whether the person is accustomed to it or not, and that those suffer who are comparatively inactive, and who are not much in the sun usually."
Both the fatal cases on board this ship were of the enteric type, and the disease was contracted at Malta.
There were fifty cases of primary fever in the Meeanee, but with one or two exceptions they were of an ephemeral character. One of the exceptional cases was of the enteric type, and occurred in the person of a young officer who appears to have contracted the disease at the Piraeus.
There were fifteen cases of primary fever in the Orlando, two of which proved fatal: one of these occurred in the person of a young officer who, while on a boating pleasure excursion at Tunis, was exposed for a whole day to a very hot sun and for some time to most offensive emanations from the mud of a lagoon where he remained for some tine in charge of the boat. Four days afterwards he presented himself for treatment, stating that he had been more or less unwell since his exposure in the lagoon. The attack was principally characterised by great and progressive debility, from which there was never the least effort to rally. The fever appears to have been occasioned by the continued influence of marsh miasm and insolation. The other fatal case was that of a marine who died in Malta Hospital. He had passed through a very severe attack of fever, and was apparently convalescing when he suffered a relapse of aggravated intensity attended with double pleuro-pneumonia, under which he sank. In consequence of the invaliding of one medical officer from this ship, the death by drowning of another, and the temporary charge held by two others, the medical returns are somewhat interrupted in their character. One of the officers (Dr. H. N. MacLaurin) in temporary medical charge of the ship, however, has availed himself of the opportunity furnished him in his journal, of giving a very excellent description of what is ordinarily termed Malta fever, although there were no cases of that form of disease in the Orlando during the period of his charge. He says:-
"Of the disease commonly known among naval surgeons as Malta fever, I have not had occasion to return any cases in my reports; as, however, I had several opportunities of seeing it in a very well-marked form, I think it may not be out of place to give a short description of it here. This affection commences with the symptoms of an ordinary ephemera, usually not very severe. There are often rigors, always considerable diminution of strength, and usually headache, with general pains. The appetite is commonly diminished and capricious, and the pulse is generally though not always a little accelerated. The case is of course looked on as one of ordinary febricula, but instead of its tending to recovery, the patient gets into a low state of health with great and progressive emaciation, which may continue for months without improvement. As the disease advances different classes of symptoms become more prominent in different cases; thus in five cases which were once under my observation together, two were chiefly marked by regular daily rigors, profuse night sweats and cough, with wandering pains in the chest; other two by great emaciation and intense pains in the loins and larger joints, with night sweats; and the fifth by loss of appetite, with weakness of the lower limbs, and intense dislike to anything which could cause exertion, so much so that the patient could not even bear to see visitors; in this case the pulse never exceeded 64. Now all these cases, although apparently so dissimilar, began in the same way, and when seen simultaneously they impressed one's mind with an idea of their connection, whose grounds it is very difficult to explain. All were benefited by similar means.
"I think it as well that I should here mention in detail the different symptoms which this singular disease may present, in order to give a correct notion of its multifariousness.
"The pulse is commonly accelerated, and differently at different periods of the day; usually it numbers about 80 in the morning, and 96 in the evening; but if the patient is subject to febrile accessions, we then commonly find the rigor coming on about noon, or a little after, with the pulse about 84; the hot and dry stage about midnight, with the pulse about 120; and the sweating stage about three in the morning, with return of the pulse to its former frequency. It must be noted also that incomplete febrile accessions often occur; thus a patient may have a rigor followed by sweating without the hot stage, and so with respect to the other stages; but the most frequent is that the sweating occurs without the patient's having observed either of the other stages. And it must be noticed that the times at which these phenomena occur seldom vary; thus I have never seen the rigor after 5 p.m., nor the hot stage before 10 p.m. As I have already mentioned, in one case there was no acceleration of the pulse; here there were no rigors, but occasionally there were night sweats. Sometimes fainting fits occur, but they are not common. In one case there were frequent attacks of bleeding at the nose, with a difficulty in stanching slight wounds.
"As a rule, the respiratory system is not very prominently affected in this disorder. I have, however, seen some cases in which there was occasional severe cough, with mucous expectoration. The mucous membrane of the fauces is generally congested, and there is often irritation of the larynx, with a tickling sensation at the bifurcation of the trachea.
"Patients become anxious and low spirited, and there is a great aversion to and incapacity for mental exertion. The temper is sometimes singularly changed: thus I have seen a man of ordinarily hot and uncertain temper bear his illness with the utmost patience, his original disposition returning as his health improved; while another patient at the very same time who was of any exceedingly mild and agreeable disposition, became so irritable and peevish that one could hardly venture to speak to him. There is occasionally headache, more frequently pain and tenderness of the scalp; a sense of heat and pain in the eyes is very common, pains are also complained of in the loins, hips, knees, and ankles. As I said before, the strength is very much diminished; one of our patients was unable to walk a couple of steps without assistance, and had to be carried whenever he wished to go more than a few yards.
"The tongue was seldom or never clean; usually it was covered with a brown coat, occasionally with a grey fur. The appetite was sometimes very much diminished, sometimes normal, and sometimes extremely capricious; thirst was not increased excepting during the hot stage of a febrile paroxysm. There was no nausea nor vomiting; occasionally a little flatulent distention of the stomach after meals. If the appetite continued good, the process of digestion was often attended by an unusual somnolency; the sleep which it produced was by no means refreshing, the patient usually waking with a foul dry tongue, and considerable thirst. At first the bowels were generally constipated, soon, however, they became tolerably normal in action; in some cases there was a decided tendency to diarrhoea, which was generally associated with defective or capricious appetite.
"The urine is often clear and normal; sometimes, however, it deposits abundant lithates. As I have already stated, there is always emaciation, and in some cases it proceeds to a really remarkable degree. Sweating is very common, especially at any time that the patient may drop off to sleep. I have occasionally seen a painful enlargement of bursae, such as that over the patella.
"This disease usually occurs in summer or autumn; it is, however, occasionally met with in spring. In two cases which I saw, the patient referred his illness to exposure to the sun on a definite occasion; but in most cases it is impossible to refer the disease to any special cause. The course of the disorder is slow, and it generally terminates in complete recovery. In one or two cases it has seemed to me to lay the seeds of phthisis.
"Change of air is the only measure in the way of treatment from which we can expect good results. When patients go anywhere to the north of Malta, but especially when they return to England, recovery is generally remarkably speedy. Pains disappear rapidly, digestion is much improved, if there be diarrhoea it is very soon checked, and the patient soon recovers his original weight. If it be inconvenient to send the patient home, we must then content ourselves with treating cases. It might be expected that where the disease assumes a periodic form, quinine would exercise a decidedly beneficial influence. Such, however, in my experience, is not the case. In one case where the patient had a rigor every day about half-past twelve o'clock, quinine was ordered in full doses, so much so as at last to produce cinchonism. It had not, however, the least effect in stopping or even deferring the return of the rigor. It was consequently abandoned after several weeks' careful trial. Alcoholic stimulants are well borne, excepting at the beginning of the disease, and appear to me to produce more benefit to the patients than any other remedies. Where bleeding at the nose is a frequent symptom, the preparations of iron seem to be very useful. Beyond this we can merely treat symptoms as they arise; anodynes and local applications are useful in allaying pain, and astringents temporarily check diarrhoea. As I said, however, before, the great means of treatment is change of air, but especially removal from the station."
There were seven cases of primary fever in the Pelican. Of these one is returned as a case of continued fever, and was nineteen days on the sick-list; four as remittent fever, the average duration of each case being about twenty-five days; and two as ephemeral fever, the average of each case being six days. The cases of remittent fever occurred in the month of October on the coast of Tunis. All those affected were stokers, and the surgeon (Dr. J. C. Messer) of the Pelican has considerable difficulty in assigning a cause for the disease, as for several weeks previously none of the men had been nearer the land than a mile and a half. "None of these men had ever previously suffered from ague, and only one had ever any disease attributable to a malarious origin, namely, dysentery, which he contracted in China about four years ago, but which has not since troubled him. This man was attacked with the remittent fever suddenly while on deck, without any exposure. Of the other two men one got wet in the copper punt, the other by heavy rain, immediately before becoming ill." The fourth case was a relapse in one of these men. The case of continued fever appears to have been an example of what is termed Malta fever, as described above by the acting surgeon of the Orlando. The symptoms came on three days after leaving Malta, and the attack was characterised by excessive lassitude and nervous depression, and the degree of debility and emaciation was very considerable.
There were fifty-two cases of primary fever in the Phoebe, of which three are returned as of the continued type, the average duration of each on the sick-list being, however, only seven days; fifteen were of the remittent type, with an average duration to each case of seventeen days; and thirty-four were cases of ephemeral fever, three or four days sufficing for their treatment, as a rule. The ship was much employed on the coast of Syria during the year, and the cases of remittent fever were doubtless attributable to exposure there. Some of them were of considerable severity, being complicated with pneumonia and other affections, but they all did well.
There were eight cases of primary fever in the Psyche, all of an ephemeral character.
In the Resistance there were thirty-four cases of fever of a continued, and three of a remittent type. One of the cases of continued fever proved fatal in Malta hospital. It was of the enteric type, and the disease was contracted at Malta. Twenty-one of the cases of continued fever occurred during the Midsummer quarter of the year, and eleven during the Michaelmas quarter. A very large proportion of these case were ephemeral in their nature.
There were only four cases of primary fever in the Revenge, and of these only one was of any importance. In that instance the patient, a young officer of a delicate habit of body, was attacked at Malta with what appeared at first to be the peculiar fever of that locality, and as the vessel was about to proceed to Tunis, it was thought advisable that he should go in her for change of air. He rapidly convalesced on getting to sea, and appeared to be going on most favourably, when he had what is termed a bilious attack, ushering in a severe attack of fever of a continued type, which lasted twenty-one days; a remission then occurred, and subsequently for some time he had regular daily attacks of ague. These passed off, and he again rallied wonderfully; but, as the vessel had now returned to Malta, it was thought desirable that he should leave the station, and he was accordingly discharged for a passage to England, having been sixty-three days under treatment. Subsequently, it appears, on reaching Gibraltar, he had an alarming attack of syncope, which was succeeded by another after leaving that place, from which he never rallied. The average duration on the sick-list, of the other cases in this vessel, was four days.
There were fifty-one cases of primary fever in the Royal Oak. Twenty-five of these were of a continued character, each case being on an average between thirteen and fourteen days on the sick-list; and twenty-six were ephemeral, six days being their average duration. Nineteen of the continued and twenty-one of the ephemeral cases occurred during the Christmas quarter of the year. With reference to the cases of fever, as they occurred in the Royal Oak, the surgeon (Surgeon John Jack) remarks:-
"One case of continued fever remained by last return, and twenty-five were added during the year. There were also twenty six of an ephemeral character added during the same period; in all, fifty-one febrile attacks. Only one of these occurred in England, that, namely, remaining from last return, and was probably, from the combination of symptoms, rather a case of enteric or typhoid fever in a very mild form, there being diarrhoea and other symptoms of that disease. It was most likely contracted by contagion on shore. The first case added during the year occurred at Malta, on the 22nd of February; the second at Corfu, on the 12th of March; the third on the 14th of March, and the fourth on the 15th, both at Corfu. After the 15th of March no case of fever occurred until the 18th of August, and no case under the head of continued fever until the 2nd of September - a period of between five and six months, and comprising the hottest period of the year, besides being the time of a daily rising temperature. The first case of fever in the autumn was entered on the list on the 18th of August. It was of an ephemeral nature; but from this time until late in December cases continued to occur, the greater number, however, being entered in October. These febrile attacks, then, form a very distinct and continuous group, occurring at the "fall" of the year, a term which, in many respects besides its derivative meaning, seems very appropriate. They commenced in the first instance at Malta, continued during a cruize to the coast of Italy, and were added in greater numbers on the return of the ship to Malta. Although these cases are entered under two heads, viz., those of continued and those of ephemeral fever, I know of nothing by which they could be distinguished from each other except in severity and duration; and I believe them to have been absolutely identical. The fever itself, even in its severer forms, was characterised generally by very slight febrile movement, often throughout; viz., some heat and dryness of the skin, quick pulse, furred tongue, pain in the head and notably in the loins, with thirst, want of appetite, lassitude, and debility, often giddiness; these three latter symptoms being often present when there was very little otherwise to denote fever, and these were sometimes the worst and most protracted cases. Without delirium or other head symptom, except a headache at the commencement; without diarrhoea or other abdominal complication; without, as a rule, cough or chest affection; without even, excepting late in the disease, any great depression, this fever, with perhaps occasional slight remissions and exacerbations, persisted for weeks without any perceptible change from day to day, but ending, when long continued, in great debility, which, like the fever, was most persistent; and ending also, in a considerable number of cases, in rheumatic attacks. In several cases cough was present from bronchitis, and in two cases phthisis resulted, it is presumed, from tubercle having been already deposited, or the predisposition to it, at least, been present. The great peculiarity in the disease, however, seemed to be its tendency to result in rheumatic fever, or sub-acute rheumatism. There seemed, indeed, to be a very close connection between the two, fever and rheumatism; for in some of the cases decided rheumatic fever set in early, the other having only declined, while in others it came on afterwards, during convalescence, or before the health was thoroughly re-established. It is further to be noted, that several severe cases of rheumatic fever occurred independently at the same time. Nevertheless, the connection between the two probably amounted to no more than this, that contemporaneously with the fever, rheumatism prevailed also, and that it found its victims in those already weakened by illness, since, until decided rheumatism supervened, the fever cases had no resemblance to that disease. Notwithstanding its apparent mildness, it has resulted in the invaliding of at least five persons; viz., one for rheumatism and extreme cachexia; two for phthisis, in hospital. The other two were invalided from this ship after their return from hospital, and are not shown in this return, the invaliding having been in the beginning of January."
The influences operating in the production of these fevers he considers to be in some measure, particularly in Malta, of a local character, referable to the contaminated state of the harbour from the large quantity of sewage. which is constantly being poured into it, and for which there is no outlet. He thinks that the great and depressing heats of summer predispose persons to any evil influences which may prevail in any locality in which they may be placed at a later season of the year, and that the decomposition of organic remains having reached its climax by the end of summer, the emanations arising thence are more concentrated in the autumn.
With regard to treatment in such cases, he states that quinine seemed to have no good effect whatever, and that in some cases it positively seemed to increase the fever. Neither in the debility following the febrile condition, had it any good influence in restoring strength.
There were five cases of primary fever in the Surprise, four of which were of a slight character. The fifth was, however, of a more serious nature, and the recovery was exceedingly tedious. He was fifty-six days under treatment. The type appears to have been remittent; debility set in at a very early period of the attack, and there was such great prostration of strength, that the surgeon (Surgeon J. E. Dyas) says, "Were it not for the free use of stimulants, and the great attention paid to the administration of food at frequent intervals, the patient must have died. The quantity of food and beef tea consumed by this man in twenty-four hours, was almost incredible."
There were four cases of primary fever in the Trident, and nine in the Wanderer, all of which, with the exception of one in the latter vessel, were of an ephemeral nature. In the exceptional case, the type was remittent, and the patient was sixty-two days under treatment.
There were eighteen cases of primary fever in the Weser, sixteen of which were ephemeral in type, and two remittent. Of these latter, one died. The medical officer (Dr. James Middleton) of this vessel says, with reference to the ephemeral cases, that they apparently owed their origin in most instances to exposure or excesses, that their average duration was from three to four days, and that in no case did they exceed seven days. With regard to the fatal case of remittent fever, he says:-
"The subject of this attack was a leading stoker who bore a most excellent character for steadiness and sobriety. Before coming on this station, he had served for four years on the West Coast of Africa, during which time, according to his own account, he had never had a single day's sickness. But whether due to his prior service, or that in the Danube, there was at least ample evidence to show that climatic agencies had exercised a most injurious influence upon his general health. He was unequal to much bodily exertion; was often low spirited; his complexion was sallow, and his general appearance was that of a man who had become prematurely old. l am the more inclined to believe that the severity of this case was due to the above causes, inasmuch as others occurring at the same time, both on board, and among the townspeople of Galatz, partook more of the ephemeral character, or at most of a mild form of remittent . . . . . . It is by no means uncommon for trading vessels whose crews have during their stay in the Danube, either suffered very slightly, or been entirely exempt from the prevailing fevers of the locality, to find themselves short-handed soon after leaving the river. Influenced by this consideration, I administered the sulphate of quinine with an extra allowance of rum, and in the manner directed by the "Instructions," during the passage from Sulina to Syra (i.e., during a period of nine days after leaving the river), to the engineers and stokers, whose duties as well as perhaps their habits, appear to render them most susceptible of such noxious influences. The result was that no new cases presented themselves until some time after our return to Malta, and these in all probability owed their origin to unavoidable exposure to the sun while the ship was refitting."
Intermittent Fever.- The vessels in which there were the largest number of cases of ague, were the Liffey, the Orlando, and the Phoebe. In the Liffey and the Phoebe, the disease appears in every instance to have been contracted on the coast of Syria; and in the Orlando it was referable to previous service on the coast of Mexico. One hundred and fourteen cases altogether were under treatment in the squadron during the year, but in many instances two or three attacks occurred to one person, so that the number of persons affected was by no means so great as the number of cases would seem to imply. The ratio of cases was upwards of one-third less than that of the preceding year, but they occasioned a loss to the service of three men by invaliding, while there was no loss from this cause in 1863.
Eruptive Fevers.- There were nine cases of small-pox; twenty-four of measles, and seventeen of scarlatina in the squadron during the year. Of these, one case of scarlatina proved fatal.
Small-pox. There were six cases of small-pox in the Cossack. The disease appears to have been contracted at Malta, where general leave had been given to the ship's company, at a time when small-pox was prevailing on shore. All the persons affected had been previously vaccinated, and in all the disease was exceedingly modified in character.
In the Royal Oak, a case of eruptive fever of a somewhat doubtful character was sent to hospital from its resemblance to modified small-pox. In hospital, the case remained doubtful for several days, but ultimately was pronounced to be varicella.
There were two cases of small-pox in the Trident. One of these occurred in a man who presented no marks of previous vaccination. It was of the confluent variety, exceedingly severe in its symptoms; and for several days the patient was in an exceedingly critical condition. He ultimately recovered, however. In the other case, there was a very satisfactory vaccination cicatrix, and the attack was of a modified character. In both instances, the disease was contracted at the Piraeus, where it was prevailing extensively amongst the inhabitants on shore.
Measles.- There were twenty-four cases of this disease during the year, of which, fifteen occurred in one vessel. Many of these, however, appear to have been examples of a spurious form of measles, which prevailed extensively in Malta, and elsewhere, in 1864, and to which it has been proposed to apply the term Rubeola notha.
In the Firefly there was one case, apparently, of this nature. The surgeon (Surgeon James Flanagan) says, "I was at first puzzled to name it nosologically, as it had a great deal the appearance of scarlatina; the tongue was not characteristic of this latter disease, but the form of the eruption was not in crescentic patches, as described in true measles. I believe the case to have been one of Rőtheln, a disease first noticed in Germany." The patient was nineteen days under treatment.
Two cases of measles, running their course simultaneously, appeared in the Meeanee, in the latter part of November, at Malta. The surgeon (Dr. William Ross) says, "In both, the usual catarrhal symptoms were present, but in one, persistent headache, referred chiefly to the occiput, followed, with occasional vertigo. These symptoms were not dispelled until a blister had been applied to the nape of the neck, followed by a seton, the douche, and the exhibition of quinine. During the months of November and December, measles prevailed among the European children in Malta; as also did a spurious form of the complaint among the adult natives."
There were two cases of spurious measles in the Pelican, in the month of November, when the vessel was lying in Sleima creek, Malta. The average duration of each case was three days and a half. At the same time and place, also, there were four cases of the same form of disease in the Phoebe, the average duration of each of which was nearly four days.
There were fifteen cases of measles in the Royal Oak; eleven of these occurred in the Lady quarter of the year, when the disease appears to have been introduced into the ship by a boy who had been received as a supernumerary from the Implacable, at Plymouth. The disease developed itself at Lisbon, and the boy was immediately landed at the naval hospital there. No other case occurred until twelve days afterwards, when the ship was at Malta, where all the rest of the cases, with one exception, occurred, and were successively discharged to the hospital there. The last case occurred at Corfu, and was a continuance of the same outbreak. Four cases of spurious measles occurred at Malta in the month of November. The average duration of each case of the spurious disease was about four days.
Scarlatina.- In the Statistical Report of the Health of the Navy, for the year 1863, it was noted that two cases of scarlatina had appeared in the Gibraltar, shortly after she left Malta for the Piraeus; that one of these had proved fatal, and that, at the same time, cynanche of a very suspicious character became prevalent in the ship. One of the cases of scarlatina that occurred at that time was still on the sick-list at the end of the year; and during the Lady quarter of 1864, eight cases of scarlatina were added to the sick-list, while the vessel lay at the Piraeus, and 102 cases of cynanche. The surgeon says, in his report on these cases:-
"In the journal of last year, it was mentioned that two cases of scarlatina had occurred, that one had terminated fatally on the 28th of November, and the other was, on the 31st of December, convalescent. On the 4th of January a seaman was attacked; desquamation commenced on the 13th, and on the 8th of February he was discharged to duty. On the 8th of January, a midshipman was put on the sick list, with febrile symptoms, and on the next day the rash of scarlatina appeared. This was a more severe case than the two last, and was followed by rheumatic pains in the fingers, arms, and shoulders; it was also attended by delirium; sclerotitis also was present. Desquamation commenced on the 16th, and he was discharged to duty on the 10th of February.
"The next case was that of a boy who had had a severe attack of cynanche in the beginning of December, soon after scarlatina appeared in the ship; the tonsils have ever since been in a state of chronic enlargement. The rash appeared on the 16th, and desquamation commenced on the 23rd. In this case the symptoms were very contradictory; the tongue, from the commencement, being dry and brown, and yet, after the first day, there was scarcely any general disturbance.
"The next case was that of an officer, which was attended for a day or two by hallucinations; they disappeared, however, and the case progressed favourably. Desquamation commenced on the 22nd of January, and on the 9th of February he was discharged to duty. On the 19th of January a seaman was placed on the list; the rash was seen on the same evening. He stated that he had not been well on the previous day. Desquamation commenced, to a slight extent, on the 24th. This was a severe case, and attended by foul ulceration of the right tonsil. No other case occurred until the 1st of February, when a seaman was attacked. This case was very mild; on the 10th, slight desquamation had commenced.
"The next case was that of a midshipman. It was so slight that it would not have been recognised as scarlatina, had not desquamation been observed seventeen days after he was put on the list. He was entered on the sick-list on the 8th of February, and discharged to duty on the 2nd of March; and the last case which happened was also in the person of a midshipman, the fourth gun-room officer, attacked by this complaint. This was a very severe case. He was put on the sick-list on the 22nd of February, and removed on the following day to sick quarters on shore, a house on the beach, close to the ship. On the 28th, desquamation had commenced. This case was attended by extensive suppuration of the cervical glands on both sides of the neck. He continued in a very weak state until the arrival of the ship at Malta on the 20th of March, and on the next day he was sent to hospital.
"The epidemic of cynanche, and the cases of anasarca which occurred at this time, may now be noticed, as both seemed to be so intimately associated with the outbreak of scarlatina. Indeed, it seems difficult to account for the appearance of the second case of scarlatina on the 20th of December, unless by supposing that some of these cases of cynanche, which appeared so soon after the death of the first man attacked, were masked forms of the infectious disorder; the men did not belong to the same mess; the man who died had been separated from the crew from the day he was put on the list till his death, and twenty-two days intervened between the death of the first and the appearance of the second case. Moreover, these cases of cynanche were attended by one of the sequelae of scarlatina, viz., anasarca. A seaman, who had been on the sick-list with cynanche on the 17th, and again on the 25th of December, was again put on the list with oedema of the ankles, which disappeared under the influence of a few doses of compound jalap powder; the next case, that of a marine, also a very mild one, was put on the list on the 24th of March, suffering chiefly from disordered state of the stomach, but for two days there was decided oedema of the legs, and puffiness of the face. He had been on the list on the 11th, and again on the 15th of the same month, with cynanche. The third case was that of a seaman, who had had cynanche in December and again in January, on both occasions very slightly. On the 24th of January he was put on the sick-list for diarrhoea, and on the 27th oedema of the legs and general anasarca accompanied by sudden and urgent dyspnoea appeared."
"Several other cases of anasarca, one of which proved fatal, and another was subsequently invalided for albuminuria, appear also to have been dependent in great measure on the morbific influence that was prevailing in the ship at this time. There can be little question that all the cases of cynanche that occurred at this time on board the Gibraltar, were dependent on the action of the scarlatinal poison.
A case of scarlatina appears in the returns from the Liffey. It was of a very doubtful character, however, and presented more of the character of spurious measles than of true scarlatina. There was no sore throat, and no subsequent desquamation. He was sixteen days on the sick-list.
There were four cases of scarlatina in the Marlborough, and as there were some points of interest in connection with them, their history is perhaps better given in the words of the surgeon of the ship.
"A case of scarlatina showed itself in January, the first one in the ship, and the only one at that time. It occurred in the person of a gun-room officer. It had no trace of an infectious origin, for although the disease was known to exist in a sporadic way about Malta, this patient was not aware of having been near anyone who had been affected with it, nor could I discover anything to warrant a suspicion of infection. His hammock was berthed at the foot of the cockpit ladder, where he might have caught catarrh or sore throat; and when he first came on the sick-list my belief was that his symptoms arose from sleeping in an exposed place. Accordingly, he was put to bed in the sick bay without suspicion of scarlatina, till more than two days afterwards, when the eruption began to show itself, and he was then sent to hospital. There were several cases of cynanche, as I have said, about that time; some of them were accompanied, too, with more or less fever, but there was no further appearance of scarlet-fever eruption for more than three months afterwards.
"On the 23rd of January, however, only two days after this officer was removed to hospital, a case of sore throat was put on the sick-list, whose subsequent history is a remarkable one as showing characteristic sequelae of scarlatina after what appeared to be a very ordinary case of sore throat, without any attendant eruption or even fever. The patient was five days on the list with sore throat, and four days after he was discharged cured he presented himself with albuminuria and general dropsy. I cannot charge myself with overlooking any of the symptoms which accompanied the sore throat in this case, and which would have induced me to enter it as scarlatina; for having just sent a case of that disease to the hospital, I was on the watch for suspicious signs in every throat affection that presented itself, and while this man was first on the list, his skin was repeatedly examined for marks of eruption. Desquamation could hardly be looked for where there was no eruption; there was none, but that it was an exanthem, though not fully developed, I have no manner of doubt; and perhaps others of the sore-throat cases of less importance were of the same nature. It is at all events satisfactory to know that it did not spread in the ship as a formidable disease . . . . . On the 30th of April a gun-room officer presented himself with scarlatina; and was immediately landed at the hospital; this was at an interval of three months after the last appearance of scarlatina in the ship, so that the two could have had no connection with each other. Nor does this young gentleman, any more than the last one, seem to have been within the influence of infection on shore, although it is true that sporadic cases have been met with in Valetta for some time before; he had indeed visited the Royal Oak in the harbour, and a case of scarlatina had been sent to hospital from her about a week before; that also occurred in a gun-room officer, but the two patients never came in contact until they met at the hospital, and I cannot see that the two cases could have had any connection. Early in May, a week after the gun-room officer was sent to hospital, a seaman of the Afterguard was taken with the same disease, and also sent to the hospital, and that was the last case in the ship, until she was paying off in Portsmouth in the month of November. Febricula in a very slight form and sore throats of a mild kind were pretty common in the ship about the time, but these were the only cases of exanthem. All the men were warned of the necessity of showing themselves in the sick bay at once, if they should find their throats in the least sore, and they came in considerable numbers, but none of them had anything characteristic of scarlatina, and very few required even to be excused from their duties."
The last case that occurred in this ship was in a gun-room officer at Portsmouth, a few days before the ship was paid out of commission. It is surmised that the disease may have been contracted on shore, as doubtless it was; and there can be as little doubt that the first three cases were due to infection at Malta.
There were two cases of scarlatina in the Revenge, one of which proved fatal. This happened in the person of a young gun-room officer, and the disease assumed such virulence that death took place within forty-eight hours. He was placed on the sick-list on the 20th of January complaining of sickness, headache, and a feeling of faintness, which continued during the day and were followed by diarrhoea and vomiting. On the following morning these symptoms had given way to general feverishness, but he appeared comfortable and made no complaint. On the morning of the 31st, however, on being seen in his hammock in the cockpit, a very grave set of symptoms were found to have set in, and he was said to have been incoherent during the night. There was an exceedingly quick pulse (120); the breathing with the mouth open indicated a swollen and inflamed condition of the throat; the tongue was furred with a dry central patch; the pupils were contracted, and there was a tremulous motion of the eyeballs, with a fixity of stare; he did not answer questions to him. He was immediately removed from his hammock to a cot on the main deck, and there an eruption was observed on his chest which somewhat increased, and he became more coherent and spoke. The throat was observed to be much inflamed and swollen. He continued during the forenoon in this condition, with the pulse very struggling, weak, and increased to 150, with the eruption showing but faintly, and the respiration becoming gurgling from the increased tenacious discharges from the throat. Subsultus tendinum set in, there was a dusky appearance of the body, and the face became livid and puffy. Sinapisms were applied to the chest, and stimulants vainly attempted to be administered. Violent muscular paroxysms now supervened, and in one of these he expired on the afternoon of the 31st. Immediately on his death, another young gun-room officer whose hammock had been side by side in the cockpit with his, made his appearance labouring under febrile symptoms, which proved to be dependent upon the same disease, he was immediately landed and placed in sick quarters, where, although the case was a severe one, it had a favourable termination.
Both these cases occurred at the Piraeus, and the surgeon of the Revenge is of opinion that the disease was contracted on shore by the officer who died, he having been employed for some weeks previously in charge of a watering party at a thickly-peopled part of the Piraeus, where both scarlatina and small-pox were prevailing.
Two cases of scarlatina occurred in the Royal Oak; one in the person of a boy, who it is supposed may have contracted the disease in England; and the other, three months afterwards, at Malta, in a young officer. In neither case could the source of infection be satisfactorily traced.
Diseases of the Brain and Nervous System.- One hundred and forty-seven cases appear under this head, of which thirty were invalided and seven proved fatal. The ratio of cases is much in excess of that of the preceding year, but the invaliding rate is lower. There is a trifling increase in the ratio of mortality. Sixteen of those invalided were epileptic subjects, and five were insane.
A case of disease of the brain terminated fatally in Malta Hospital, in the person of a seaman of the Liffey. When admitted he was found to be labouring under otorrhoea of both ears, with ulceration extending into the tympanum. There was also an abscess in the right tonsil, with purulent discharge. There was no fever present. He was admitted on the morning of the 5th of April. His condition remained unchanged until the morning of the 12th, when he was found in a state of stupor with delirium, and great dyspnoea with moaning respiration. From this time he gradually sank; and died on the morning of the 13th. On post-mortem examination of the body, a large abscess was found involving the whole of the middle lobe of the right hemisphere of the brain.
There was also a fatal case of abscess of the brain in the person of a bandsman of the Royal Oak, which is of much interest as showing how grave a lesion of the brain-substance may exist without any proportionate symptoms during life. The case is detailed by the surgeon of the ship, and is as follows:
"About 6 p.m. of the 2nd of February he was brought into the sick berth in a state of partial insensibility, having fallen down on the main deck whilst crossing over to smoke. The right pupil was contracted, the left dilated, but both sensible to light. There were no convulsions. In a few minutes all these symptoms passed off, but he remained somewhat confused. From all that could be gathered he had had no previous attack of the kind, nor had he complained of being ill, except that on the previous day he had taken a laxative for constipation. From his confused state, little could be gathered from himself, and as the symptoms might be supposed to be those of a partial and first attack of epilepsy, he was in meantime merely directed to be kept quiet. About 7.30 p.m., having continued lying down in a drowsy state, he had another similar attack without convulsions, which also soon passed off, leaving him drowsy and confused. About nine it was reported that he was suffering from a ’fit,’ and when seen was now in a state of perfect coma, with stertorous breathing, and dilated and insensible pupils. The pulse was full and soft; the legs rigidly fixed, with the toes turned inwards; the right arm rigid; the left arm flaccid, but not paralysed; and there were occasional convulsive movements. As these symptoms persisted, and the breathing was becoming hurried and somewhat convulsive, and the pulse beginning to flag, a turpentine enema was ordered to be administered, and sinapisms applied to the legs and feet; but before they had time to act effectually, the breathing became more convulsive - then suddenly intermitted, the pulse small and thready. Ammonia being applied to the nostrils, breathing, after a time, heavy and laboured, recurred; and the pulse regained more strength, but it again soon became suspended; the pulse became extremely small and thready, and after a few more convulsive efforts at breathing, both respiration and pulse ceased, and life was extinct.
"On post-mortem examination the head only was opened. The membranes appeared healthy, but there was some venous congestion. The brain itself generally seemed healthy, but somewhat firmer than natural, until, on slicing the anterior part of the left hemisphere of the cerebrum, a pretty large abscess, containing about a dessert spoonful of well-formed but greenish and fetid pus, was found. It was close to the surface and with thin firm walls, the brain for a short distance round only being somewhat softened - beyond this quite firm and white. There was effusion into the ventricles, but small in quantity.
"On questioning his messmates minutely, it was elicited that for about a week or ten days previously he had seemed out of sorts, and sometimes complained of slight indisposition, and more especially had exhibited great loss of memory, suddenly halting in the middle of a sentence, unable to complete it. The abscess was most probably strumous, and, from its particular position, seems to have given rise, till the last, to very little irritation. He had always a pale, rather delicate appearance, but had continued at his duty till the evening of his death."
Twenty-two cases of delirium tremens occurred in the squadron during the year, and of these three proved fatal. The subjects of this degrading disease were five Petty officers, two leading seamen, thirteen able seamen, one leading stoker, five stokers, and five marines. The rating of one person cannot be ascertained.
Diseases of the Organs of Respiration.- There is a considerable decrease in the ratio of cases of all forms of disease coming under this head, as compared with the preceding; but this is altogether dependent on the less prevalence of common catarrhs. The ratio of inflammatory diseases of the lungs, of phthisis, and of cynanche are almost precisely the same as obtained in 1863. There is a reduction, however, in the invaliding and death-rates from inflammatory disease and from phthisis.
There is very little to be said respecting these diseases. In the Gibraltar, as has been before noticed, catarrh and cynanche were epidemic at a period when cases of scarlatina were occurring in the ship, and there can be little doubt that many of the cases of sore throat were attributable to the scarlatinal poison. The same may probably be said of many of the cases of cynanche that occurred in the Marlborough. The surgeon of the Royal Oak says also, "Tonsillitis, with sharp fever, was very prevalent in the intense cold of January in the Hamoaze. In some of the cases ulceration and slight sloughing took place, and the cases had much the appearance of being propagated by contagion, some being attacked in the sick berth while suffering from other complaints. Except in one case of scarlatina, there was no eruption in these attacks, but the fever and sore throat were very similar to that of scarlet fever."
Diseases of the Heart and Blood-vessels.- There is a slight increase in the ratio of cases coming under this head, as compared with the preceding year; but there is a reduction in the ratio of invaliding. The death-rate in both years is precisely the same.
There were two deaths from disease of the heart in the Gibraltar. One of these, a case of pericarditis, died in Malta Hospital. The patient, a seaman, had been admitted on the sick-list, labouring under symptoms of what appeared not unlike enteric fever. There was considerable pyrexia, general muscular pains, and diarrhoea. The pulse was 120. The diarrhoea was checked, but the febrile symptoms continued, with abdominal and thoracic pain. When admitted into hospital there was dulness on percussion on both sides of the chest, with friction sound and well-marked crepitation on the right side, and on the left side coarse crepitation. There was a loud rasping to-and-fro sound audible all over the pericardium. He died twelve days after his admission to hospital. Urgent dyspnoea had set in as the to-and-fro sound diminished; and ultimately there was orthopnoea with livid countenance and cold extremities. On post-mortem examination of the body a good deal of effusion was found about the pectoral muscles. The pericardium was thickened and distended by three pints of fluid, rendered turbid by pus and shreds of lymph. The outer surface of the heart was completely enveloped by a dense mass of semi-organized lymph, as was also the pericardium. The endocardium was slightly inflamed. There was no deposit in the valves. The left lung was slightly hepatized in the lower lobe. On the right side there were extensive recent adhesions of the pleura to the walls of the chest and diaphragm, and the whole lung was in a state of grey hepatization. Under the microscope the deposit on the exterior of the heart was observed to contain the first rudiments of filamentous tissue.
The other fatal case in this ship occurred in the person of a petty officer, who had never made any complaint referable to the heart until he presented himself with anasarca of both legs, puffiness of the face, and dyspnoea. No abnormal sounds could be detected in the cardiac region. He died seven days after being placed on the sick-list. The following is the report of the post-mortem examination of the body:-
"Body pale, muscular; legs oedematous. On opening the cavity the chest, about a quart of fluid was found. Both lungs were compressed and infiltrated to some extent with frothy mucus. The heart nearly filled the pericardium, being enlarged to more than double its natural size. The thickness of the walls of the left ventricle was in unison with the increased size of the heart; but the walls of the right ventricle were much attenuated and anaemic, and the cavity was filled with coagulated blood. The valves showed no abnormal appearance. The liver was found to be enlarged, unnaturally firm in texture, and its section having a nutmeg appearance; the peritoneum was readily pulled off. The gall-bladder was much thickened in texture, and contained about half an ounce of inspissated bile; the duct was almost impervious. Both kidneys were much enlarged, lobulated, very firm; and there was much congestion about the apices of the pyramids. The veins of the intestines were turgid."
In the Orlando, a sudden death took place in the person of a seaman, who while at sail-drill, and when at his station on the maintop-gallant-yard, complained of sudden pain in his chest, and descended into the maintop; he there complained of pain in the right side of his chest, and inclination to vomit, which he attempted to do, but without effect. He was lowered down from the top, but expired before he reached the sick bay. The appearances found on post-mortem examination of the body were not of a very decided character. The only approach, indeed, to any morbid lesions were a somewhat enlarged condition of the heart and slight dilatation from the commencement to the arch of the aorta, with spots of induration in its coats, from incipient ossification. From these latter appearances it was considered that death was occasioned by syncope, induced by suspension of the circulation.
A petty officer of the Psyche died of disease of the heart in Malta Hospital. He had long been delicate, and had several times applied for relief for cough, pains in the chest, and other symptoms. Physical examination of the chest showed mitral valve disease, but the sounds were scarcely distinguishable. His most urgent symptom was dyspnoea. The pulse was intermittent. The right side was enlarged, he remained constantly in a sitting position, and cough and dyspnoea were more urgent at night. The limbs were anasarcous. He died two days after his admission to hospital, and on post-mortem examination of the body, all the serous cavities of the trunk, but especially the pericardium; were found to be immensely distended with fluid. The lungs were in a state of intense passive congestion. The heart was flabby, and excentrically hypertrophied; the mitral valve was ossified, the ossification extending for some distance down the chordae tendineae. The other valves were healthy. The liver was much enlarged, greasy, and presented a highly marked nutmeg-like appearance.
A case of sudden death is reported to have occurred in the person of a petty officer of the Surprise, a man of somewhat irregular habits. Death is attributed to disease of the heart; but upon this point there can be no certainty, as the body was not examined in consequence of the stormy state of the weather. A month or two before his death, he had been on the sick-list for rheumatism, and on that occasion his chest had been examined, and the heart's action found perfect in force and sound.
Diseases of the Alimentary Canal.- There is a reduction in the ratio of cases coming under this head, as compared with the preceding year, equal to 43·5 per 1,000 of mean force. The ratio of mortality is also much below that of 1863, but the invaliding rate is precisely the same.
A seaman of the Liffey was placed on the sick-list, labouring under symptoms of acute inflammation of the bowels. The abdominal pain was very severe, and accompanied with obstinate vomiting. The day after being seized with these symptoms, he was sent to Malta Hospital, being in a state of extreme prostration at the time, and there he died in less than an hour after admission. The post-mortem examination of the body is as follows:- "Abdomen greatly distended with flatus, which escaped with a noise resembling the retort of a pistol when the incision was made, and was followed by an immense discharge of feculent fluid from the peritoneal sac. Perforation of the large intestines was discovered in the vicinity of the caecum, the surrounding bowel being of a dark claret colour." A fortnight previous to this man's fatal attack, he had been placed on the sick-list for colic and diarrhoea, and was only discharged to duty seven days before his last illness set in. For two days previous to his discharge on that occasion, however, he had been entirely free from any complaint.
A seaman of the Royal Oak was sent to Malta Hospital, labouring under obstinate constipation attended by severe colic and dyspepsia. He had had enemata in various forms, but without effect. He invariably vomited medicine and solid food. The abdomen had become tympanitic. After much suffering in hospital for eight days, he expired; and on post-mortem examination of the body the following appearances were observed. The intestines generally were somewhat congested, especially the large, and enormously distended. Near the angle of junction between the transverse and descending colon, there was a constriction of the intestines for the space of about two inches. The intestinal coats involved in the stricture were congested, excessively thickened and cartilaginous, and the thickening had encroached on the calibre of the intestine so much as to reduce its transverse diameter to less than half an inch. Its structure under the microscope presented the character of epithelioma. Above the constriction there was a great accumulation of feculent matter. The kidneys and other organs were healthy.
These were the only two deaths from disease of the alimentary canal that occurred in the squadron during the year.
Diarrhoea.- There were 166 cases of this complaint in the Cossack, sixty-nine of which occurred during the Michaelmas and fifty during the Christmas quarter of the year. Little or no information whatever is given in connection with these cases, but the average duration of each was between five and six days.
There were seventy-seven cases of diarrhoea in the Gibraltar, twenty of which occurred in the month of June. They were not of much importance as a rule, but in some instances they appear to have been connected with the presence of tape-worm. The Liffey and Orlando were the only other vessels which suffered much from this disease; and in them also it presented no features calling for any comments.
Diseases of the Genito-Urinary Organs.- The ratio of cases of all classes of disease coming under this head is slightly below that of the previous year, but there is an increase under the head of syphilis to the extent of 6·2 per 1,000 of mean force. The ships which suffered most from this disease were the Gibraltar and the Royal Oak. In the former vessel all the cases that occurred in the first quarter of the year were contracted in England; and those subsequently, at the Piraeus, Corfu, or Naples, where surveillance of prostitution is either imperfectly or not at all carried out. In the Royal Oak the Surgeon says:-
"Some of the cases under the head of syphilis were secondary affections following disease contracted in England. The cases contracted on this station have been few and comparatively mild, and in no case has secondary symptoms followed; and yet I cannot say that the sores were very different in appearance from those so followed. There can be no doubt, incomplete as it may be, that the surveillance now exercised over this disease at Malta exercises a most salutary influence, and the Royal Oak has certainly largely gained in that respect by coming to this station from England; the cases there being both numerous and virulent. It is to be fervently hoped that the new act will be extended, and firmly acted on at home, in such a way as to allow of an easy prosecution of those knowingly propagating the disease."
The Surgeon of the Liffey, in which vessel there were twenty-two cases of syphilis, says:-
"Venereal diseases have been three times as numerous this year as last, although they are still not very numerous. Corfu, Zante, and the Piraeus of Athens gave them their origin: all Greek. Four or five cases of syphilis showed themselves at Malta, but these were contracted from prostitutes who had emigrated from Corfu on our giving up the Ionian Islands. I do not know that I can put down one case of this disease to the credit, or rather I should say, to the discredit of Malta. I have often seen general leave given at this place (Malta) without one man being put on the sick list afterwards for venereal diseases of any kind, so well does the supervision in these matters appear to be carried out. The Piraeus above all other places to which I have been in the Mediterranean, is the worst for these diseases."
Rheumatism.- Six hundred and fifty-two cases of rheumatism were under treatment during the year, which is in the ratio of 82·3 per 1,000 of mean force, being a reduction, as compared with the preceding year, of 13·3 per 1,000. There is an increase, however, to the extent of 1·3 in the ratio of invaliding occasioned by it. There was no mortality from this disease. The largest number of cases that occurred in any ship was in the Gibraltar, in which 100 cases were under treatment. A large majority of these occurred during the first two quarters of the year, when the vessel lay chiefly in Salamis Bay, where, during the Lady quarter, the crew had been much exposed to cold bleak winds and tempestuous weather.
There were also a good many cases of rheumatism in the Liffey, but the surgeon says they were of a slight and uninteresting nature. The average treatment of each case in this vessel was under ten days. The total day's sickness on board ship and in hospital, of all cases under treatment in the squadron, during the twelve months was 11,367, which gives an average to each case of between seventeen or eighteen days. Thirty-one men were, on an average, daily on the sick-list for this complaint, which is in the ratio of 3·9 per 1,000 of mean force.
Wounds and Injuries.- Four men were killed by falling from aloft, and one of these in his descent struck another man and threw him into the hold, whereby he was killed. One man was accidentally shot by another during rifle practice. A man in going down the fore-hatchway from the lower deck to the store-room slipped his foot, and fell into the forehold, sustaining fatal fracture of the skull; and a man while lying asleep close to the main hatchway was struck by a large iron bar or carline which crosses the hatchway, and which had been accidentally dislodged in sending up a spare main topsail. The bar, which weighed seventy-five pounds, struck first the combing of the hatchway and then glancing off struck him as he lay on his back, just below the umbilicus. He staggered to his feet, fell helpless, and was dead in a few minutes. On post-mortem examination of the body it was found that the abdominal aorta was very extensively ruptured.
Seven officers and four men were drowned by the capsizing of a ship's boat, while away on a pic-nic; one man was drowned while bathing; and two were drowned by falling overboard. One man died asphyxiated from congestion of the lungs following upon long-continued immersion. The total number of deaths in the squadron was sixty-two, of which thirty-nine were from diseases of various kinds, and twenty-three of wounds and injuries and drowning. The death-rate from disease was 5 per 1,000 and from casualties 2·8, making a total of 7·8 per 1,000 of mean force, which is 1·7 below the ratio of mortality of the previous year.
Invalided.- Eleven men were invalided for the sequelae of fever; thirty for diseases of the brain and nervous system, of whom sixteen laboured under epilepsy; seventy-two for diseases of the organs of respiration, sixty of whom were phthisical; twenty-six from functional or organic disease of the heart; three for chronic diarrhoea; sixteen for diseases of the genito-urinary organs; forty-five for rheumatism; seven for diseases of the bones and joints; thirteen for diseases of the special senses; twenty-eight for diseases of the skin and cellular tissue, twenty of whom were labouring under ulcer; fourteen for dyspepsia; one for inveterate headache; twenty for wounds and injuries of various kinds, and five for hernia; making a total of 291, or in the ratio of 36·7 per 1,000 of mean force, which is a reduction of 6·1 per 1,000 as compared with the previous year.