Cornell University Library The original of this book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924086055088 COHNELL UNIVERSITY LIBRARY 1924 086 055 088 In compliance with current copyright law, Cornell University Library produced this replacement volume on paper that meets the ANSI Standard Z39.48-1992 to replace the irreparably deteriorated original. 1999 ^-...£ THE GIFT OF ..."\^vvvxxV>jct-vv^ "/Hi A....l\«.5'.5^.. 678-2 SURGICAL MEMOIRS WAR OF THE REBELLION. COLLECTED AND PUBLISHED UNITED STATES SANITAEY COMMISSION. I. ANALYSIS OF FOUR HUNDRED AND THIRTY-NINE RECORDED AMPUTATIONS IN THE CONTIGU- ITY OF THE LOWER EXTREMITY. BY STEPHEN SMITH, M. D. II. INVESTIGATIONS UPON THE NATURE, CAUSES, AND TREATMENT OF HOSPITAL GANGRENE, AS IT PREVAILED IN THE CONFEDERATE ARMIES, 1861-1865. BY JOSEPH JONES, M. D. PROFESSOR OP CHEMISTRT DT THE MEDICAL DEPARTMENTS OP THE UNIVERSITr OP LOUISIANA, NEW ORLEANS ; PORUBRLT SURGEON IN THE PROVISIONAL ARUZ OP THE CONFEDERATE STATES. EDITED BY Prof. FRANK HASTINGS HAMILTON. NEW YORK: PUBLISHED FOR THE U. S. SANITARY COMMISSION, BY HURD AND HOUGHTON. CamBritjge: iUitJetiSilJc ^tc00, 1871. Entered according to Act of Congress, in the year 1871, by the United States Sakitart Commission, in the Office of the Librarian of Congress, at Washington. KIVERSIDE, CAMBRIDGE: STEREOTYPED AND PRINTED BY H. O. HOnOHTON AND COMPANY. JUNITED STATES SANITARY COMMISSION. Rev. H. W. Bellows, D. D. . . Alexander Dallas Bache, LL. D. William H. Van Buren, M. D. . WOLCOTT GiBBS, M. D * Egbert C. Wood, M. D., U. S. A. t George W. Cullum, U. S. A. . J Alexander E. Shiras, U. S. A. Samuel G. Howe, M. D. ... Elisha Harris, M. D Cornelius R. Agnew, M. D. . . George T. Strong, Esq. . . . John S. Newberry, M. D. . . . Frederick Law Olmsted, Esq. Et. Rev. Thomas M. Clark . . Horace Binney, Jr., Esq. § Hon. R. W. Burnett . Hon. Mark Skinner . . § Hon. Joseph Holt . . Rev. James H. Heywood II Fairman Rogers, Esq. J. Huntington Wolcott, Esq. Charles J. Still]6, Esq. Ezra B. McCagg, Esq. . C. New York Washington, D. New York Cambridge, Mass. D\T£ OF APPOINIMBKT. June 9, 1861. Boston, Mass. New York . New York . New York . Cleveland, O. New York . Providence, R. I. Philadelphia, Pa. Cincinnati, O. . Chicago, 111. Washington, D. C, Louisville, Ky. . Philadelphia, Pa. Boston, Mass. . Philadelphia, Pa. Chicago, m. June 12, 1861 June 13, 1861 June 14 1861 June 20, 1861 July 30, 1861 July 30, 1861 Dec. 5, 1861 Dec. 7, 1861 Jan. 23, 1863 Jan. 23, 1863 Feb. 6, 1863 June 13, 1863 Jan. 15, 1864 Mar. 9, 1864 * Resigned, December, 1864. f Resigned, February, 1864. t Resigned, December 17th, 1864. § These gentlemen never tool^ their seats. II Resigned, 1864. COI^rTEN"TS. ANALYSIS OP FOUR HUNDRED AND THIRTY-NINE RECOV- ERED AMPUTATIONS IN THE CONTIGUITY OF THE LOWER EXTREMITY. BY STEPHEN SMITH, M. D. Former Opioions as to the Value of Amputations in Military Surgery. — Fallacy of the Reasoning. — Effect of Conservative Measures. — Absolute Necessity of Ampu- tations in Military Surgery. — Position of the Various Questions relating to Ampu- tations at Commencement of the War. — Amputations formerly regarded as Mutila- tions. — Compensative Appliances. — Direction in which we are to look for Im- provements during the War. — Scope of this Article. — Table of One Hundred and Fiftj'-eight Cases of Recovered Amputations of Thigh. — Table of Two Hundred and Eighty-seven Cases of Recovered Amputation of the Leg. — Comparative Frequency of Amputation of Right and Left Leg. — Frequency of Right and Left Leg Amputations in the French Army. — Comparative Frequency of Amputation in Various Regions of Thigh and Leg. — Missiles. — Missiles which inflicted Wounds requiring Amputa- tion of Thigh and Leg in French Army in Crimea. — Proportion of Amputations for Wounds and Fractures. — Location of Fractures. — Comparative Table from French Statistics. — Period of Amputation. — Nature of the Injury. — Missiles. — Methods of Amputation. — Antero-posterior Flaps most frequent in the Thigh, and Circular in the Leg. — Other Methods. — Flaps of Skin and Circular of Muscles. — Testi- mony of Surgeons as to Value of Different Methods. — Assistant-Surgeon Powers. — Assistant-Surgeon Meachcr. — ■ Surgeon Deming. — Suigeon Bailhache. — Surgeon Collamore. — Surgeon Batwell. — Surgeon Manfred. — Surgeon Kneeland. — Sur- geon Robbins. — Surgeon Field. — Surgeon Walton. — Surgeon Chaddock. — Sur- geon . — Surgeon . — Surgeon Williams. — Surgeon Potts. — Assistant- Sur- geon Moon. — Surgeon Levis. — Surgeon D. P. Smith. — Circular Operation more frequent in Upper Third of Thigh. — Flap Operations most firequent in Middle Third. — Methods of Operation in the Confederate Service. — Circular Method preferred in all Parts of Thigh. — Methods of Operation in the Leg. — Period of Operation after Injury. — Importance of a New Division of the Periods of Amputation. — Various Divisious of Periods of Amputation. — Hamilton's Division of Periods. — Period before Shock. — A Fifth Period recognized. — Periods should designate the Condi- tion of the Patient — New Names of Periods. — Propriety of Amputations in each Period. — Propriety of Immediate Amputation. — Results of Immediate Amputation. Amputation during Shock. — Success of Amputation within Six Hours of Injury. Period of Reaction. — Intermediary Period. — Secondary Amputations. — General Conclusions in Regard to Success of Amputation at Different Periods — Atrophy of Stump. — Proximal Atrophy not increased by Inflammation. — Distal Atrophy in Thigh and Leg. — Conclusions in Regard to Atrophy. — Influence of Method of Am- putation upon Atrophy. — Influence of Various Methods of Amputation upon Nour- ishment of the Stump. — Efliects of Circular and Flap. — Rectangular Flap. — Skin Flap and Circular of Muscle. — Eflect ot Various Methods in the Leg. — Effect of Transportation. — Surgeon Walton. — Surgeon Bailhache. — Surgeon Deming. — Surgeon Batwell. — Surgeon Kneeland. — Influence of Different Methods of Amputa- tion on Healing. — Sources of Error. — When a Patient is cured. — Surgeon Hodgen on Treatment of Retracted Flaps. — Artificial Limbs. — Question to be answered by Mechanical Surgeon 4 Viu CONTENTS. AMPUTATIONS AT THE ANKLE JOINT IN MILITARY SUR- GEEY. BY STEPHEN SMITH, M. D. Frequency of the Operation. — Its Estimate in Civil Practice. — Objections to tliis Op- eration. — An Operation of Expediency. — Comparative Success of Anltle-joint Am- putation. — Comparative Frequency of Reamputation. — Frequency of Sloughing and Necrosis. — Serviceableness of Stump. — Amputation of Leg does not give Direct Support. — Patient has Power over Muscles of Calf in Anltle-joint Amputations. — Adaptation of Stump for an Artificial Limb. — Advantages of Stump at Ankle. — Conclusions. — Experience of late War. — Causes of Failure. — Surgeon David P. Smith on Causes of Failure. — Sloughing of Flaps. — Contusion of Soft Parts. — Lia- bility to amputate in Injured Parts. — Heel most exposed to Injury. — Possibility of Baving Flaps. — Extensive Destruction of Soft Parts; Lateral Flaps. — Flap from Dorsum of Foot. — Moulding of Stumps by Adhesive Strips. — Destruction of Nutri- tious Arteries in Operation. — Necrosis in Syme's Amputation. — Necrosis after Piro- goffs Amputation. — PirogofTs Remarks. — Mr. Busk's Remarks. — Mr. Croft's Experience. — Dr. Hewson's Comments. — Reamputation for Necrosis in PirogoflTa Amputation. — The Bone will unite under most Unfavorable Conditions. — A Second Unfavorable Case terminating in a Good Recovery. — Hewson's Case. — Sensitive- ness of Stamp. — Hewson's Experience. — Fergusson's Opinion. — Quain's Opinion. — Erichsen's Opinion. — Opinion of Dr. Hudson of New York. — Bad Effects of Scabs on Cicatrix. — Sensitiveness not a Sign of Permanent Disability. — Displace- ment of Heel Flap backward. — Within the Control of the Surgeon. — Case where there was no Support. — Value of Dressing. — Displacement of Flap in Pirogofifs Stumps. — Failure due to After Treatment. — Not adapted to Transportation. — Ne- cessity of Proper Dressings. — Prince's Modification. — Comparative Value of Syme's and PirogofTs Methods. — Comparative Mortality. — Comparative Frequency of Re- amputation. — Advantages of Method of Operation. — Mr. Croft's Remarks. — Mr. Syme's Objections. — Hancock's Statistics of British Surgery. — Comparative Ser- viceableness of Stump. — Value of Length of Limb. — Endurance of Stump. — Adap- tation of an Artificial Limb. — Syme's Stump most favorable. — PirogofTs Last Statement 99 INVESTIGATIONS UPON THE NATURE, CAUSES, AND TREAT- MENT OP HOSPITAL GANGRENE, AS IT PREVAILED IN THE CONFEDERATE ARMIES, 1861-1865. BY JOSEPH JONES, M. D. INTRODUCTION. History of Investigations on Hospital Gangrene. — Gunshot Wounds treated in Au- gusta, Georgia, during the Spring and Summer of 1862. — Moist Gangrene of Rare Occurrence during the Earlier Periods of the War for Confederate Independence. — The First Case which came under the Obsen-ation of the Author at all resembling Hospital Gangrene, occurred in the Month of July, 1862. — History of this Case. Investigations upon this Disease, instituted during the Months of August, September, and October, 1863, in the Confederate General Hospitals at Summerville, Charleston, and Columbia, South Carolina, and in Richmond, Gordonsville, Charlottesville, and Lynchburg, Virginia.- Effects of Incessant Labors, Excitement, Fatigue, Bad Wa- ter, and Foul Air upon the Confederate Soldiers defending the Earthworks on Morris Island, and the Ruins of Fort Sumter in Charleston Harbor. — Observations upon the Moist Gangrene which prevailed amongst the Confederate Wounded who crowded tlie General Hospitals in Augusta, Georgia, after the Battle of Chickamauga. — In- quiries instituted in the Field and in the Hospitals, and amongst the Medical Officers of the Army of Tennessee during the Months of June and July, 1864. — Outline of Labors submitted to Surgeon-General. — Clinical Investigations and Post-mortem CONTENTS. ix Examinations instituted amongst tlie Federal Prisoners at Camp Sumter, Anderson- ville, Georgia, and in the General Hospitals at Macon and Vineville, September, October, and Noyember, 1864. — Objects and Results of these Labors upon Hospital Gangrene and Small-pox. — Form of Circular containing Inquiries on Hospital Gan- grene, addressed to Confederate Surgeons. — Method of presenting the Results of these Investigations. — Definition of Certain Terras. — Form of Confederate Reports of Sick and Wounded. — New Form of Sick Report Remarks upon the Classifica- tion of Diseases. — Division of Gangrene into Gangrsna Sicca, Humida, and Phage- dsena Gangrsenosa. — Use of the Terms Mortification, Gangrene, and Sphacelus, by Various Authors, as Galen, Fabricius, Hildanns, Samuel Sharpe, Fercival Pott, John Hunter, John Pearson, Samuel Cooper, John Syng Dorsey, John Abernethy, Charles Bell, Sir Astley Cooper, John Thomson, Baron Boyer, Baron Larrey, Mr. Guthrie, Chelius, R. Carswell, and Copland. — Observations upon the Method of Investiga- tion and Classification of the Phenomena of Mortification : 1. Mortification arising trom Mechanical Injuries, and the Local Action of Physical and Chemical Agents ; 2. Mortification arising from and following Inflammations of Important Organs and Structures, without any External Injury; 3. Mortification arising from Constitutional Derangements, and Alterations in the Circulatory Apparatus, without any Local In- jury or Internal Inflammation; 4. Mortification arising from the Action of Special Poisons, either developed within the System or introduced from without, through the Alimentary Canal, Respiratory System, or Skin, or through the Blood, or through Wounds and Ulcers. — Notes upon the History of Hospital Gangrene. — Records of the Ancients furnish only Negative Testimony. — State of Medical Science amongst the Assyrians and Padaeans. — Armies of the Ancients subject to very much the same Diseases as the Modem Armies; Examples: Pestilence in Grecian Army; in the Army of Xerxes; amongst the Hebrews. — Scurvy known to the Ancients. — Very few Wounded survived the Ancient Battles. — Homer*s Description of the Bat- tles between the Grecians and Trojans. — Time at which regular Army Surgeons were first employed. — Hebrews; Moses; Homer's Account of the Wounding of Menelaus; Darius; Alexander; Roman Annies. — History of the Establishment of Hospitals. — Authors who have treated of Hospital Gangrene, Pliny, Parie, Lamotte, Pouteau, Leonard Gillespie, and others 143 CHAPTER FIRST. OtTTLINE OF THE SYMPTOMS AND CHANGES CHARACTERISTIC OF HOSPITAL GAH- ORENB, AS TT HAS MANIFESTED ITSELF IN THE CONFEDERATE ARMIES. Outline of the Symptoms and Changes characteristic of Hospital Gangrene, as it has manifested itself in the Confederate Armies, i — Constitutional Disturbances amongst the Earliest Symptoms of Hospital Gangrene. — DifBculty of determining whether the Fever was the Resultant or the Cause of the Early Changes in the Wound. — Observations of Dr. Rollo in the Artillery Hospital at Woolwich. — Views of Mr. Blackadder, who held that Hospital Gangrene was only communicated by the Direct Application to a Wounded Surface of the Infectious Matter, and that the Local Symptoms precede the Constitutional. — Views of various other Writers upon the Relations of the Local and Constitutional Symptoms of Hospital Gangrene; of Del- pech. Baron Boyer, Dr. Thomas Trotter, Thomas Moffat, John Thomson, Henuen, Thomas Clark, James Copland, H. B. Macleod. — In its Mode of Origin, Hospital Gangrene may be viewed in Four DiflTerent Ways: 1. As a Local Disease, communi- cable only by Contact with Animal Matter in a Certain Stage of Change or Decom- position; 2. As a Constitutional Disease; 3. As both Local and Constitutional in its Origin ; 4. The Disease may arise from the Action of a Specific Poison, which acts in a Manner similar to that of Small-pox, Measles, or Scarlet Fever. — Hospital Gan- grene may arise in those exposed to the Exhalations from Gangrenous Wounds, without any Abrasion of the Surface. — Illustrative Cases. — Observations of Dr. Trotter. — Hospital Gangrene can be communicated through the Atmosphere to Wounded Surfaces without any Direct Application of the Matter. — Extensive Prev- alence of the Disease amongst the Wounded sent to Augusta, Ga., after the Battle of Chickamauga. — Effects of Crowding and Bad An-. — Testimony of Surgeon D. J. 1 X CONTENTS. Roberts, of 20th Tennessee Regiment, Tyler's Brigade, with Reference to the Origin of Hospital Gangrene amongst the Confederate Wounded captured by the Federals after the Battle of Jonesboro'. — Case related by Surgeon E. N. Covey. — In some Cases after the Wounds hare been subjected to the Action of the Cause of Hospital Gangrene, a considerable Period of Time elapses before the Disease appears ; Illus- trative Cases. — Case reported by Assistant-Surgeon F. A. Anderson. — RapidAction and Spread of Hospital Gangrene amongst the Dejected, Diseased, and Filthy Pris- oners crowded into the Foul Prison and Hospital at Andersonville. — Period of the Incubation of Hospital Gangrene not fixed. — Views of Mr. Blackadder, of Baron Boyer, and Thomson. — The Establishment of the Facts that the Poison of Hospital Gangrene has no Definite Period of Incubation, and that it may arise de novo at any Time, and that it may be communicated either through the Atmosphere, or by Direct Contact, is of Importance in its Bearings upon the Theory and Classification of the Disease. — Death resulting from the Rapid Poisoning of the System before the Local Disease has progressed to any Extent. — Observations of Mr. Gutlirie and Macleod. — Character of the Local Changes. — Illustrative Cases 218 CHAPTER SECOND. MICROSCOPICAL AND CHEMICAL INVESTIGATIOKS DPOS HOSPITAL GAKGRENE. Microscopical Examination of the Gangrenous Matter. — Consists of the Various Struc- tures in a Disorganized State, together with the Products of the dead Disorganizing Tissues. — The Pus Globule absent in the Gangrenous Mass. — The Appearance of the Pus Globule in Hospital Gangrene a Favorable Sign. —Animalcules present in considerable Numbers in the Gangrenous Matter. — The Results of these Microscop- ical Observations clearly sustain the View that Hospital Gangrene is due to the Action of an Irritant Organic Poison, which, after the Manner of a Ferment, is capable of inducing such Decomposition in the Tissues and in the Blood, that all Development of the Cellular Elements of the Liquor Sanguinis into Cells or Fibres, or into Pus, is arrested. — Chemical Examination of the Gangrenous Matter. — Observations of Surgeon Jackson Chambliss, of Camp Winder Hospital. — First Chemical Examina- tion of Gangrenous Matter by Mr. Cruikshank, Chemist of the Royal Artillery Microscopical Examination of the Pus secreted by Wounds, after the Removal of Hos- pital Gangrene. — Changes of the Blood in Hospital Gangrene. — Illustrative Cases. Analysis of Blood. — These Investigations tend to establish that the Action of the Poison of Hospital Gangrene is attended with both Local and Constitutional Symp- toms of Inflammation, and that the Changes excited both locally and constitutionally by the Gangrenous Poison, are such that the Products and Phenomena of the Dis- ease vary to a certain Extent from those of Ordinary Inflammation . . . .265 CHAPTER THIRD. Variations of the Temperature and Circulation in Hospital Gangrene. — Marked Daily Variations of the Temperature, also Marked Variations between the Temperature of the Trunk and Extremities. — Daily Variations of the Pulse. — The Observations upon the Variations of the Pulse and Temperature, of Importance in their Bearing upon the Nature and Treatment of this Disease. — Hospital Gangrene is especially characterized by the Great Difference which frequently exists between the Tempera- ture of the Central Organs and that of the Extremities. — Whilst the Trunk presents the Heat of a Warm Fever, the Extremities will in many Cases feel cold, and in Fact the Temperature be not higher in Degree than that of a Regular Chill. — The Symp- toms of Open Sthenic Inflammation are in general wanting in this Disease As a General Rule, the Respiration in Cases of Ordinary Severity is not disturbed to any Great Extent either in Character or Frequency; in this Respect the Febrile Excite- ment of Hospital Gangrene presents a Slarked Difference from that of Malarial Fe- ver.— Changes of the Urine in Hospital Gangrene. — Increase of Coloring Matters, of Urea and Uric Acid, Free Acid, Phosphoric and Sulphuric Acids. — Decrease of Cliloride of Sodium. — When Pyajmia supervenes upon Hospital Gangrene, the Urine assumes a most beautiful Pink Color, from the Great Destruction of the Colored CONTENTS. XI Blood Corpuscles, induced by the Presence of Pus in the Blood. — Cases illustrating the Changes of the Temperature, Circulation, and Urine, in Hospital Gangrene . 300 CHAPTER FOURTH. Progress of Hospital Gangrene to Recovery. — Cases illustrating the Slow Convales- cence which follows in Cases in which the Constitution has been extensively in- volved. — Disability resulting from Hospital Gangrene. — Number of Men disabled by Hospital Gangrene in the Array of Tennessee during the Months of July and August, 1864. — Causes of Death in Hospital Gangrene, and Results of Post-mortem Examinations. — 1. Progressive Failure of the Powers under the Action of the De- pressing and Irritating Effects of a Large and constantly Increasing Wound, and of the Derangement in the Constitution of the Blood and of the Nutrition, induced by the Absorption of the Gangrenous Matter and its Products. — 2. Hemorrhage from the Blood-vessels exposed and eroded by the Gangrene. — 3. Entrance of Air into Veins eroded and opened by the Ravages of Hospital Gangrene. — 4. Opening of Large Joints by the Gangrene. — 5. Formation of Large Bed-sores during the Prog- ress of the Disease, and the Appearance of Gangrene in them. — 6. Diarrhoea result- ing from the Irritant Action of the Poison of Hospital Gangrene upon the Intestinal Mucous Membrane. — 7. Extensive and Rapid Disorganization of the Tissues around the Original Wound, beneath the Sound Skin, accompanied by Absorption of the Gangrenous Matters, great Nervous and Muscular Prostration, and Obstinate Diar- rhoea. — 8. Mortification of Internal Organs, induced by Gangrenous Matter ab- sorbed by the Local Disease. — 9. The Invasion of Organs essential to Life, by the Direct Destruction of Intervening Structures. — 10. Pysemia; Investigations upon the Changes of the Temperature, Pulse, Respiration, and Urine in Pyaemia, illus- trated by Cases. — 11. Phlebitis. — 12. Various Sequelae 371 CHAPTER FIFTH. CAUSES OF HOSPITAL OANGBENE. Causes of Hospital G«ngrene. — 1. A Debilitated and Cachectic State of the Constitu- tion. — Such Derangement of the Solids and Fluids as favor the Production of Hos- pital Gangrene, may be the Result of Exposure, Fatigue, Bad Diet, and Impure Water, and also of the Rapid and Slow Action of a Special Poison in a Low, Humid, and Miasmatic Atmosphere. — Illustrative Observations, by Various Observers. — Effects of Climate and Malaria in predisposing to Ulcers and Hospital Gangrene. — Effects of the Climate of the West Indies upon the Health of English Troops. — 2. The Air of Crowded Hospitals, Tents, and Ships, loaded with Animal Exhala- tions. — Hospital Gangrene may at any time arise de nmo, when Sick and Wounded Soldiers are crowded together in badly Ventilated Houses, Filthy Hospitals, Close Box Cars, or on Shipboard. — Hospital Gangrene will arise most readily under these Circumstances, when the Soldiers have been on Scanty and Poor Food, and have been exposed to Fatigue, Loss of Rest, the Constant Excitements of Battle, and the Unhealthy Atmosphere of Crowded, Filthy Camps, and Beleaguered Cities. — Illus- trative Observations. — 3. The Contact of the Gangrenous Matter with Diseased and Wounded Surfaces, as in using Unclean Sponges, Bandages, Wash-bowls, and Sur- gical Instruments. — Hlustrative Observations. — Origin and History of Hospital Gangrene amongst the Federal Prisoners confined in Camp Sumter, Andersonville, Georgia 452 CHAPTER SIXTH. Treatment of Hospital Gangrene. — Measures for the Prevention of the Disease Im- portance of Ventilation in Hospitals. — Danger of crowding Wounded into Box Cars. — Value of Disinfectants. — Importance to Wounded Men of Good, Nutritious Diet, and Cleanliness of Person and Clothing. — Constitutional Treatment of Hospital Gangrene; Principles upon which this should be based. — The Indications in the xii CONTENTS. Treatment of Hospital Gangrene; first, to remove the Patient from all Causes which depress the System and deteriorate the Blood j second, to eliminate the Deleterious Agent; third, to restore the System to such a Condition that Healthy Nutrition, Reparation, and Inflammation may take place; fourth, to induce such Changes in the Injured Parts as will lead to a Complete Separation between the Diseased and Dead Structures; fifth, to destroy all Poisonous Matters in the Diseased Parts; sixth, the Stimulation of the Capillaries and Structures around the Seat of Local Disease to Healthy, Active, Inflammatory Action. — Value of Quinine, Tincture of Sesquichlo- ride of Iron, and Alcoholic Stimulants in the Constitutional Treatment of Hospital Gan- grene. ^-Importance of Concentrated and Nutritious Diet: Milk, Beefsteak, Mutton, Soft-boiled Eggs. — Local Treatment of Hospital Gangrene. — Importance of clear- ing out all Dead Gangrenous Masses and Tissues. — Value of Nitric Acid ; Method of its Application. — Mode of using Poultices. — Stimulating Applications, Oil of Turpentine, Tincture of Iodine, etc. — Value of Arsenical Applications in the Treat- ment of Hospital Gangrene. — Testimony of Ancient and Modem Writers. — Vari- ous other Remedies: Sulphates of Copper, Zinc, and Iron; Acid Nitrate of Mercury, Nitrate of Silver, Chloride of Zinc, etc. — Testimony of Ancient and Modern Sur- geons 548 EXPLANATION OF THE PLATES. PLATE I. Gangrenous Ulcer of Finger of Confederate Soldier. Case VII. W. J. Black, pp. 248-250. At the time of the appearance of the gangrene, the patient was act- ing as a nurse in the Gangrene Hospital, at Vineville, near Macon, Georgia. A small blister appeared upon the third finger of the right hand, which gave much pain, assumed a dark gray and greenish color, and was surrounded by a purplish and blue border in the skin. Con- centrated nitric acid did not arrest the progress of the gangrene ; and this failure of the local treatment appeared to be due to the gradual poisoning of the system during the continued residence of this nurse in the infected atmosphere of the gangrene hospital. The drawing was executed on the thirteenth day after the appearance of the gangrene. The gangrene spread progressively along the borders, under the blue discolored skin. Notwithstanding the comparatively small surface in- volved, the constitutional symptoms in this case were well marked. PLATE n. General Appearance and Extent of Gangrenous Wound of Thigh of Confederate Sddier. Case VIII. Thomas Paine, pp. 250-256. This patient was wounded on the 17th of August, 1864, at Atlanta, Georgia. A fragment of lead weighing about one pound projected from a rifle shell, struck the middle of the left thigh, upon the external sur- face, and lacerated the parts, but did not fracture the bone. Gangrene attacked the wound on the tenth day. The drawing was executed on the thirty-first day after the appearance of the gangrene, and at this time the wound in the thigh was about eight inches in diameter, nearly circular, deeply and irregularly excavated, and coated with dark greenish gray and bluish and brown matter. No healthy pus was discernible ; but in its stead the wound discharged a foetid sanious fluid. The large muscles of the thigh were exposed, and could frequently be observed quivering, especially after the application of nitric acid, which caused intense pain. Patient restless and nervous, with trembling hands and quivering distressed eyes. EXPLANATION OF THE PLATES. PLATE m. ' General Appearance of Wound of Thigh of Thomas Paine, afler the Disappearance of Hospital Gangrene. Case VIII. pp. 250-256. This drawing was executed twenty days after Plate No. 2. At this time the wound was improving, presenting a bright red granulating sur- face, and discharging healthy pus. By a comparisou with the drawing of the wound during the state of gangrene (Plate No. 2), it will be seen that the parts surrounding the wound have greatly diminished in size, and that with the disappearance of the gangrene, and the improvement of the wound, the swelling and eflfusion have also disappeared. PLATE IV. Appearance of Internal Surface of Portion of Femoral Vein in Case of Pycemia. Case XLVI.^ Ira Parker, Confederate Soldier, pp. 415-439. The femoral vein was distended with thick yellow pus. Many of the venous branches were in like manner filled with yellow pus. The pop- liteal vein and its branches, the anterior and posterior tibial veins, were traced to the disorganized tissues, and were in like manner distended with thick, cream-like yellow pus. At various intervals, but chiefly at the junction of the large vessels with the main trunk, and also in the region of the semi-lunar valves, clots of blood were found mingled with the pus, and firmly attached to the sides of the veins. At such points the walls of the veins appeared to be discolored by the coloring matter of the blood, and to be more softened than in those positions where no clots had been formed. The veins were traced directly to the disorgan- ized tissues of the calf and leg ; and in the diseased, broken-down dif- fluent tissues and pus, the walls of the veins were rotten, and gave way upon the slightest touch. The femoral vein, near where it is continuous with the popliteal, and where several branches were received, and where there were semi-lunar valves, was much distended, and presented upon its exterior a dark blue gangrenous appearance. This portion of the femoral vein is represented in the Plate by 1, 2. The remnants of the coagula at the mouths of several vessels, and also attached to the semi- lunar valves, were here visible. The internal surface of this portion of the vein was covered with a tenacious fibrinous exudation, of a greenish yellow and bluish gray color, as represented in the Plate (1, 2), which adhered with tenacity. When this was scraped off, the walls of the vein presented a grayish-blue and black color, and evidently appeared to be gangrenous. The odor of the pus as well as of this portion of the vein was similar to that of tissues affected with hospital gangrene. 1 The Plate is incorrectly numbered Case XLIV. EXPLANATION OF THE PLATES. PLATE V. Microscopical Appearance of Dark Gray, Green and Black Portions of the Exudaiion upon Surface of Femoral Vein in Case of Pytemia. Cass XL VI. Ira Parker, p. 425. Exhibiting granular masses, with dark masses of the altered haematin of the blood, together with pus globules and masses of fibrous tissue, broken capillaries and fragments of muscular tissue : many of the par- ticles of coloring matter presenting a smooth angular fracture, as if they were crystallized. ANALYSIS OP FOUR HUNDRED AND THIRTY-NINE RECOVERED AMPUTATIONS IN THE CONTINUITY OF THE LOWER EXTREMITY. BT STEPHEN SMITH, M. D. ANALYSIS OF RECOVERED AMPUTATIONS. GENERAL REMARKS. Amputations have been the subject of more discussion than any other branch of military surgery. At one period Former nil 11 1 lie opinions as "we nnd them regarded as the true method or treatment to the value n -111 ini •" 1 of amputa- ot every considerable wound of the extremities, and at "ona in mii- another period they have been rejected altogether, and gery. the injured Hmbs have been left to the rude appliances of the time. Their value has generally been estimated by the mortality that has followed, and this has varied with nearly every campaign. Hence have arisen those remarkable fluctuations of opinion which are recorded in the earlier history of military surgery. It is but a century since that Bilguer, the Surgeon-General of the Prussian army, alarmed at the great fatality of amputations in the wars of that age, prohibited them altogether, preferring to leave the wounded to the then almost unaided efforts of nature. The re- sults of this expectant plan of treatment, or non-operative inter- ference, as reported by him, were so favorable when compared with amputations, that professional opinion for a long period fa- vored an adoption of the expectant method. The fallacy of the reasoning of Bilguer, and of those who advo- cated his practice, is now very apparent. They made no raiiacy of -i... f. I'll ■ the reason- distinction as to the time at which the amputation was ing. performed after the receipt of the injury. Nor were the circum- stances relating to the patient and his subsequent surroundings duly considered. "When at a later period the causes of the fatality of amputations began to be more thoroughly understood, and the time of the operation more judiciously selected, the mortality was much reduced, and the operation again became the popular method of treating severe wounds of the extremity. But the great advance in practical surgery within the last quarter of a century, has again modified the opinions of Effectofoon- surgeons as to the necessity and value of amputations for measures. gunshot wounds. Compound fractures are now treated with a 8 NECESSITY OF AMPUTATIONS. success formerly unknown, and many limbs are saved that a cen- tury ago were incontinently sacrificed. The remarkable success which has attended exsections for gunshot injuries of bone, both in saving life and in securing a useful limb, has rescued another large class of cases formerly condemned to amputation. Every campaign has enlarged the experience of military surgeons in the application of conservative measures, and thereby limited more and more the field of amputations. The Crimean and Schleswig- Holstein wars gave a powerful impulse to conservatism in mihtary surgery, the former by its fi-ightfiil mortality after amputations, and the latter by the great successes which attended conservative meas- ures, especially exsections. But notwithstanding these great improvements in the treatment Absolute ne- of gunshot wouuds of the extremities, whereby many amputations Hvcs and limbs are saved that were formerly sacrificed, it in military i t . i t • -n "nrgery. cannot be denied that amputations must stul occupy an important place in modern military surgery. The liability of the extremities to wounds and injuries is rather increased than dimin- ished by the improved methods of warfare, while their severity is greatly enhanced by the destructive nature of the missiles em- ployed. These facts may be illustrated by the records of the late war; of 87,822 wounds and injuries classified by the Surgeon- General from official returns, 55,245, or nearly two thirds, were located in the extremities, and from the same source it appears that of 17,125 operations of various kinds, 13,397, or about three fourths, were amputations. While it may be true that many of these amputations might have been avoided by the judicious em- ployment of conservative means, it is nevertheless equally certain that in a vast majority of cases the wounds were amenable to no other form of treatment than amputation. We can scarcely be- lieve it possible that a campaign will ever again be inaugurated with an of&cial order from the chief medical officer prohibiting all amputations. The position of the various questions relating to amputations at Position of *^® commencement of the late war can be stated only in quMH?M"re- general terms. Many questions which had hitherto di- l^pltSiona vided surgeons were now definitely settled. There was ^M^ient no longer any doubt as to the success of primary when of the war. compared with sccoudary amputatious. A broad distinc- tion was very properly drawn between amputations in the upper and lower extremities, based upon the difference in their functions. Every possible effort was advised to save the upper limb by con- COMPENSATIVE APPLIANCES. 9 servative measures. Exsection was well adapted to preserve the functions of the upper extremity, and was strongly recommended at any of its articulations involved in a gunshot injury in prefer- ence to amputation. Lesions of the shafts of the long bones were also treated conservatively to the utmost practicable limit. In the lower extremity far less importance was attached to conservative measures ; exsection here became a formidable operation, and not only imminently endangered life, but at best its results were doubt fill as regarded the serviceableness of the resulting limb. Gun- shot fractures of the long bones, especially when severe, were gen- erally condemned to amputation unless occurring under the most favorable circumstances for treatment. The propriety of amputation at the articulations of the upper extremity was well established ; but the same operation in the lower extremity was regarded with little favor. Amputation at the ankle- joint had attracted some attention, but in general surgeons pre- ferred amputation through the leg, and practiced the old routine. The point of amputation was still determined by the old rule of operating as far from the trunk as possible, or certain points of election were selected, originally fixed by circumstances or condi- tions long since become obsolete. The methods of operation were altogether unsettled, the preference being generally given to the circular and the flap. Formerly amputations were regarded as veritable mutilations. They were the dernier ressort, the only alternative of AmputouoM which was death. The operation was repugnant alike to ^la'^"" surgeon and patient, as by it the latter seemed reduced ""»'"«'«""^- to an almost helpless condition. No appliance could compensate for the loss of either an upper or lower extremity. For a hand nothing had yet been invented which even preserved the form, while the clumsy peg-leg was a substitute only in length.. But in our time limb-making has been carried to such a state of perfection that both in form and function they so completely resemble the natural extremity that those who wear them pass unobserved and unrecognized in walks of business and of pleasure. The conservatism of artificial appliances has, therefore, become a most important department of both civil and military ^ompensa- surgery. Amputations are no longer to be regarded as ances. mutilations, especially in military surgery, as the government, in its munificent care of its soldiers, gratuitously furnishes every form of artificial substitutes for lost parts. In this respect amputations have become eminently a conservative measure. The surgeon has 10 SCOPE OF THIS ARTICLE. not only to consider the probabilities of saving life by his opera- tion, but also the possibilities of giving his patient a better limb with an artificial appliance than he would have if the injured limb were retained. From this statement it is apparent that there was ample room Direction ^°^ improvement in this field of operative surgery, and Lreto'ioor we readily perceive in what direction we are to look for SenSZr the results of the experience in the late war. In the first iDgthewar. ^^a.^^ we should expect to have all the circumstances and conditions which determine a resort to conservative measures, rather than to amputation, more accurately defined. When ampu- tation becomes the alternative, the period after the injury best adapted to secure successful results, as regards the mortality, would be thoroughly investigated and definitely fixed. The old land- marks which defined the boundary between primary and secondary amputations could scarcely fail of being removed, and others more discriminating established. Again, the much disputed question in regard to the propriety of amputation at the articulations would now find a practical solution. Not only should we expect to have the general question as to the comparative dangers of these opera- tions settled, but equally should we have a fixed value placed upon amputation at each individual articulation. Another and not less important subject is the determination of the influence which the point of amputation and the methods of operation has upon the' usefulness of the stump in the final adjustment of artificial appli- ances. This is a new question and of the greatest importance to the future happiness and comfort of the patient. How far the reasonable anticipations of the profession of the final settlement of the various questions relating to amputations have been realized by the vast experience of the late war, we are not in a position to decide. These final conclusions will be devel- oped only when the accumulated facts of the entire surgical ser- vice are reduced and systematized by the Central Official Bureau. The following paper is a contribution to our knowledge of the Scope of this Tcsults of amputation in the lower extremity. It is based "^'''°- upon the careful study of the stumps of patients when prepared for the application of artificial limbs. Many of them came under our own observation at the U. S. General Hospital, at Central Park, New York. This hospital was, for upwards of two years, the rendezvous of soldiers who had lost their limbs by ampu- tation, and, while inmates, large numbers were supplied with arti- ficial limbs by Dr. E. D. Hudson, of New York, who held a DK. HUDSON'S OBSERVATIONS. 11 government commission for the manufacture and adjustment of appliances to compensate for losses, deformities, etc., resulting from the service. In the practice of mechanical surgery, Dr. Hudson combines the learning and experience of an educated prac- tical surgeon, with a high degree of mechanical skill and ingenuity. In the adjustment of artificial limbs his observations have extended beyond the mere mechanics or art of his profession, and he has made car«ful studies of subjects relating to stumps, of great practi- cal interest to surgeons. The records from which the following tables are compiled, were made by Dr. Hudson upon blanks at the bedside of each patient preparatory to the adjustment of each limb. The measurements were all made with great care, and with that accuracy which only a mechanic after long experience can attain to, and they may be relied upon as nearly absolutely correct. While the view which we take of amputations must necessarily be quite limited, it nevertheless involves some points which are novel and of very great importance. Never before have we had an opportunity of studying on a large scale the final results of am- putation. These tables enable us to estimate with great precision the absolute and relative value of the various methods of operation, and of the stumps in different parts of the limb, and of the service- ableness of artificial limbs under every varying condition of stump. 12 ONE HUNDRED AND FIFTT-EIGHT CASES TABLE OF ONE HTINDBED AND FrFTT-EIOHT 0ASE3 Nahk. Begiment Occupa- tion. Limb. Point of Operation. Method. "Where per- formed. Length of Time after Injury. Cause. T.D. 7th Conn. Siulor L. lEddle third Anterior flap At Post Hos- pital One hour Fragment orsheU KB. 9thr.8. C. T. Farmer B. Lower third Lateral skin flaps and circular On the field • Four hours ^ffi' C.H.8. MN.T.A. Farmer B. Middle third Circular On the field Three hours Fragment oPsheU J.C. UthConn. Farmer 1. Lover third Leterfll flaps On the field Imme- diately Solid shot O.B.F. I4«i N. T. Vols. JjlU.S.A. Teamster R. Lower third Circular On the field One day Mlnle-ball E.7. Farmer L. Lower third Ant post flaps On the field One hour Fragment of sheU S. C. T. 169lhN.T. Vols. Clerk L. Lower third Ant post flap On the field Twenty-fo'r hours Rifie-baU B.B. ISOthN.T. Vols. Farmer L. Middle third Circular On the field Six hours Fragment ofiheU W.C. Q.S. B.A. 14th U.S. Infantrv i«tu. S. Farmer Laborer Military L. L. B. Lower ttiird Lower third Lower third Circular Ant post flap Ant post flap On the field On the field On the field Six hours One hour Five hours Minle-ban Minie-ball Musket-ball A.H. Urn UUWt^LO ethHuirlB Cavahy 4th XT. L Cavaliy Carpenter L. Lower third Circular On the field Nine hours Minie-baU J. McO. Laborer L. Middle third Ant poet flaps State Hospi- tal, Colum- bus, Go. Two weeks Piece of eheU H.E.P. rthVerm't Vols. Machinist B. Lower third Ant post flap On the field Thirty h'rs SoUd shot T.P. aothlnd. Cooper B. Lower third Ant post flap Rebel camp Twenty-fo'r hours Musket-ball J. F. E. V. S. S. C. Clerk L. mddle third Ant post flaps On the field Twenty h'rs Rifle-ball CJ.O'B. Mth N. T. Vols. Tinman B. Middle third Circular Field hospi- tal ' In Frederick Hospital, Md. Two hours RIfle-baU A. Q.I. 9thN.Y.M. None B. Middle third Circular — Mnsket-baU T.P. N.A.U. JthU.S.A. 48aiN.T. Vols. Laborer Militaiy E. Middle third Lower third Ant post flap Bilateral flaps On the field On the field Imme- diately One and a half hour Solid shot Minie-ball B.B. IT. S. Navy Landsm'n L. Middle third Ant post flap U. S. gun- boat Twenty-fo'r houn - J.D. G.D. 69th N.T. Vols. Slit N.T. Carpenter Laborer B. L. Middle third Lower third Ant post flap Ant post flap Frederick Citv Hosp'l Field hosp'l, St Josepfi's, Governor's Thirty-sev- en days Twenty-fo'r hours Minie-ball Shell A.T. T.W.D. 9th N.T. 8MN.Y. Joiner Clerk R. L. Upper third Upper third Ant post flap Ant post flap Island Fahnouth On the field Twenty-fo'r Three days Grape-«hot SheU H.D. aSthMoflfl. TaCor R Lower third Post flap On the field, 2d Staunton Hospital Eight days Minie-liall 2d time, in- suffic'ntflap OF KECOVERED AMPUTATIOIir OF THIGH, 13 OP REOOVBRED AMPUTATION OP THIGH. Description of In- jury. Gomponnd com- minuted fVacture of knee-joint Deatructloa of foot and ankle-joint Comp'nd commi- nutfract. of low- er third of thigh Comp'nd conuoi- nufed, fracture of knee-joint and condvLes of fem'r Comp'd fract low- er third of ttugh DeatrucU'n of knee and leg . . . Comp'd com. fract of middle leg, knee uninjnred Nearly dlssevenng limb atknee-^''"^ ■j'int Comp'd com. frac- ture of knee-Vint Onnp'd com. frac- ture of knee^^'int Comp'd com. {net. low. th'd of thigh Comp'd com. frac- ture of knee-j'int Muscular tis. of leg. entirelT denuded fir. anlue to knee Comp'd com. fract low. th'd of fem'r Comp'd_ fracture of knee-joint. . . Wound of knee . Comp'd fracture of kneejoint. . . "Wonna of knee- joint .... BatUe. Fort "Wag- ner, S. C. Chapin'a Blutf or Farm, Va. Chancel- lorsTille Antietam, Hd. Port Hud- son, I Fort Hud- Bon, La. PoTt Hud- son, La. Destruct of knee- joint Comp'd com. frac- ture of knec^'int Comp'd com. frec- tnrexif tibia, fibu- la, and femur . Wonnd of lower tiiird of tbigh . Deatmc low. third of leg occasioned by sloughing. . Acorn, fract of the knee, thigh, &leg Comp'd com. fnic. of upper third of legandknee-j'nt Comp'd fracture of knee-joint and head of tibia Peters- burg, Va, Deep Bot- tom, Va, Deep Bot- tom, To. BuUBun, Va. Colum- April 16, bua, Ga. 1865 Date. Oct 8, U63 Sept. 29, 1664 May 1^ Sept. 17, June L 1864 May 1^ Ma72r, 186S Spanish FortMd, Fair Oaks, Va. Fur Oaks, Va. Antietam, Md. Antietam, Md. Port Hud- son, Miss. Wilming- ton, N.t;. Wilming- ton, N. C. Antietam, Md. Freder'ks- burgfVa. FredcrTcs- bui|r,Va. Freder'kfl- burgjVa. Freder'ks- burgtVa. July 28, iSm Aug. 15, 1%4 Aug. 29, M'ch29, June 25, Sept. 17, 1862 Sept. 17, May 29, 1863 Feb.aL 1865^ Sept. Sept 17, U62 Dec. 18, Dec. IS, 1862 Dec. 13, Length of time from Amputa- tion to Exami- nation. ISmofl. 9mos. 7mos. 6mo3. 9mos. 4moE. 5moa. ISmos. 8moa. 8mos. 6mos. 8 moB. ft lyear 8mo8. lyear £moB. 9moB. 6m08. 6mos. 5moB. Length of time from Amputa- tion to Applica- tion. Length of Stump. 6moB. 10 mos. 14 mos. 10 mos. 15 mos. 7 mos. 11 mos. 6 mos. I year ft II mos. 9 mos. 9moB. 16 mos. 7 mos. II mos. 9 mos. 71 inches II inches Atrophy. 7 inches 9f inches 12} inch. 6^ inches 10 inches 93 inches ^ inches lOi inch. 7i inches 11 inches 10 inches 9| Inches 7 inches 6} inches 6 inches 9 inches 7} Inches 7 inches 8} Inches 7 mos. 11 mos. Proximal Portion. Diital PorUon. None 2 inches ^incli 2 inches J inch linch 1} inches None linch 2 inches liacli 8 inches linch finches None iinch Beuabks, Generally made at Time of Applica- tion of Amflciai Limb. 9 mos. . 41 inches 8 inches 121 inch. 21 inches None iinch 8 inches linch 2 inches 8 inches 1^ inches iinch None 31 inches linch mcrease S inches linch finches None {inches 2 inches None 2 inches 3 inches 21 inches 2 inches 3 inches {inches None None linch linch 8 inches increase {inches increase { inches Stump healed, very welifonned, effi- cient Very good, com- pact, weU fonned, healed by the flnt intention. Stump not healed, end of femur not well covered. Good, sm'th stump, well cicatrized. Well healed. Stump well covered by anterior flap, posterior flap re- dundant, flaccid. Stump diseased, ec- zema. Stump muscles retracted, femur protrudea, not en- tirely healed, or- dered bandt^ing from above down- ward. Considerably atro- phied, very good. Healed, very good. Healed, veiy good. Stump healed. Iinured by necrosis, bone removed.nos entirely healed. Not yet sound, ni- cer and fetid dis- charges. Diseased, herpes, enlarged. Stump unBonnd,re- tracuon musclea, bone exposed, ne- crosis^ exfolia- tions m process. Healed in good or- der. Some tluckening of the periosteum. Damaged by extr. sloughs along front and half the stump. Extensive cicatris- ation. Not healed. Stump very short and flexed upon the body. Cicatrization exten- sive, stump un- necess'ly long for thigh amputation. 14 ONE HUNDRED AND FITTY-EIGHT CASES TABLE OF ONE HUNDRED AND FIBTY-EIOHT CASES Kuci. Regiment Occnpa- tion. Limb. Point of Operation. Method. "Where per- formed. Length of Time after Injury. Cause. l.K. rSthN.T. MachinUt R. Lower third Circular On the fleld Two hours ^fTeu' •W.M. Mth W.Va. VoU. ISSdFs. VolB. Sirrsmlth L. Middle third Circular On the fleld Six days Piece of sheU MUUe-baU RH. Farmer L. Lower third Ant poBt flap 11th Corps hospitaf Four days C.H.Q. None L. Middle third Ant post flap On the fleld Twenty-fo'r hours One hour Rifle-ball A.C. - Printer L. Middle third Ant poBt flap - Minie-baU P.McA. iBltT. S.A. Laborer R. Lower third Anterior flap On the fleld Five hours Fragment ofshell B.T. E.C.II. 2dN. T. VoU. 12th XJ. S. Intantrv 11th MeTne Fanner Captain 1. L. Middle third Middle third Ant post flap Circular Field hospitl On the fleld Two hours and a half Twenty-fo'r hours ■ Two hours MuBket-ball Minle-ban C.H.B. Farmer L. Lower third Ant post flap On the fleld Bifle-baU J. P. l«d N. T. VoU. Farmer L. Lower third Ant post flap On the fleld Three hours Minie-ball C.B. 7th N.T. VoU. Butcher H. Ulldie third Anterior flap On the fleld Imme- diately Piece of SheU K.T.W. 76th Fenn. Farmer L. Lower third Ant post flap - Two days Blfle-baU C.LF. Sth N. T. Cayalty AjiBUtant ABBeesor B. Lower third Circular On the fleld Half an ho'r SoUdBhot A.A.H. 9lh N. T. Cavaliy Farmer B. Middle third Circular On the fleld Eight hours Miide-ball J.B. 79Ui N. T. Flae:stone- catter L. Middle third Circular On the fleld Twenty-one hours Minle-baU A.H. U.P. 7th N. T. H. ArtUl'iy VenezuTn Army Glazier B. K. Middle third Lower third Ant post flaps Circular On the fleld Forty-eight hours Five m'nths Minie-baU MuBket-baU Q.I,.E. 16th Conn. Vols. 24th N. T. ■ Vola Farmer L. Middle third Circular _ Two hours Grape-shot J. a. Surreyor R. Lower tiiird Ant post flaps Field hoBpifl Forty-eight hours Five days Twenty d'ys RL. J.B. 176th N.T. VoU. 6lhMo. VoU. Tailor None R. L. Lower third Middle third Ant post flaps On the fleld Beaufort, B.C. Fragment of BheU Fall of tree B.B. 22dN.T. VoU. Boatman R. Middle third Ant post flaps Field hospit'l Tlirec hours Piece of BheU J.W. 3.8. 13rth,or 139th N. Y. VoU. SdN. T. Vols. Carpenter Cigat- maker R. K. Lower third Middle third Ant post flap On the fleld On the field Eighteen hours Twenty-fo'r hours Musket-ball Minie-baU E.T. «hVa. VoU. Farmer B. Lower third Circular On the fleld Thirty-Blx hours Seventeen houra Musket-baU G.W. MthMJue. VoU. Farmer R. Middle third Circular On the field Minie-baU A.K. 8. D. S. 1624 N. Y. VoU. 7th N.H. Sash and blindmak. Farmer E. L. Lower third Upper third Rectangular flap Circular On the field Confederate hoBpital, C. 8. c! Twelve h'rs Forty hours SheU Grape-flhot OF RECOVERED AMPUTATION OF THIGH. OF KBCOVERED AMPUTATION OF TEIGU. — (Continued.) 15 Length of time from Length of time from Atrophy. Kemaeks, Deacriptionoflia- BatUe. Date. Amputtt- :ioa to Amputar tion to Length of Stump. Generally made at Time of Applica- tion of Axtificial Exami- AppUcar Proximal Distal nation. tion. Portion. Portion. Limb. SeBtruction of leg Gettys- July 1, lOmos. ISmoB. ^ inches 3 inches 31 inches Not healed, stump burg, Pa. not well covered. Comp'd com. frac- Shenan- Aug. 22, 1^ 9moB. 10 moB. 81 inches 21 inches 3 inches Very good. ture of knee-rlnt Comp'd com. nac- doah Val. Gettys- '%'• 14moB. 15 mofl. lOiinch. 8 inches 8 inches Healed, extensive tmc of knee-j'int burg, Pa. contrac. of flex- or muscles. Comp'd fracof low. Fair Oaks, June 18, 7moa. 11 mos. Giinclies 2 inches 2 inches Gangrene, convar third of femur . Vo. 1862 increase lescing. Comp'd com. fhic- Bermuda June 29, 5mo8. 6 mos. 8 inches None None Healed m good con- turc of thigh Hundred 1864 dition. above knee . . Comp'd com. frac- Bayou April 12, ^moB. 10 moB. 9 inches 2 inches 3 inches Stump good pro- porfiona, ant. flap well cicatrized. ture of upper half of leg and knee- Teche, Ia. 1863 joint . .... stump well cov- ered, smooth. Comp'd fVactlower Fair OakB. June 25, 6moB. — 6\ inches None 41 inches — third of femur . Va. W62 Comp'd com. frac- Wilder- *s/- 7moB. 10 moB. 7i inches 11 inches 2i inches Creditable though ture of thigh. . nesB, Va. scanty covering. Comp'd com. frac- Deep Bot- ^%^'- 6moB. 7 mos. lOi Inch. 11 inches 2} inches Very good. ture of knee-j'int Comp'nd fracture of knee-joint. . tom, Va. Benton- Mch. 19, 7moB. 7 mos. 9 inches 2 inches 2 inches Not pr'perly heal'd. viUe,N.C. 1865 otherwise good. Comp'd com. fract Newport Mch. 8, IZmoe. 19 mos. 9} inches 3 Inches 2i inches Stump well healed, finely covered, cicatrix weUb'ck, apper third of leg NewB 1662 clean front, a neat stump, full size. Comp'd com. frac- Focotali- Oct 22, 6moB. 11 moB. U inches iinch linch — ture of the thi^h go, S. C. i86r mtitB lower third and knee-joint Deetruction of leg "Winches- ter, Va. Sejtl9, 10 mos. lyear 9 inches 8 inches 2 inches Very good, hack of end damaged by sloughing. Comp'd com. frac- Stevens- Oct 11, 8mo8. 10 mOB. 9i inches None 2 inches Healed, badly dam- ture of knee . , burg, Va. 1863 aged by Blough- ings, eczematous. Comp'nd commi- Blue Oct 10, 4 mos. 7 mos. 8 inches J inch linch St'mp healed, some nuted fracture of Springs, 1863 increase increase angular pouting in front. femur .... E. Tenn. June 3, Comp'd com. frac- Coal Har- 1864' 6moa. 7 mos. 6.J inches linch li inches Healed, very good. ture of low. third Comp'd com. frac- bor, Va. 1861 4 years 4 years lOi inch.- 'I inch 2 inches Healed, insufficient ture of upper increase integumental third of leg . . covering. Comminuted frac- Sufiblk. Sept 17, 1863 5moa. 6moB. 4 inches linch 2 inches Healed. ture of knee-joint Comp'd com. frac- Va. Antietam, lyear ISmoB. linch linch Well healed and ture of knee-i'int Comp'd com. tract. Md. Fisher's 10 mos. lyear 10 inches J inch 4 inches sound. Ordinary, healed. 4 inch, bel* w knee Simple oblique fracture of thigh Hill,Va. Beaufort, 6.C. 10 moB. - 5 inches increase None None Lack of extcnaion, became ah'rtened and limited. Comp'd com. fhws- Antietam, Sept 17, f862 4m0B. 4 mos. 5 inches None 11 inch — tureof low. ttilrd MdT^ Com. Itact of up- Xiookout o°L?' Smos. 6 mos. 101 inch. linch 3 inches Stump not healed. per third of leg Valley, Tenn. Drury'B Bluff 1663 Comp'd com. fiiac- •^516. 7moB. 9 mos. 7 inches Jincli 3i inches Healed, very good. ture of low. third of thigh. . . . Comp'nd fracture of knee-joint . . Comp'd com. frac- Cedar Oct 19, Smos. 4 mos. 11 inches IJ inch linch Healed, very good. Creek.Vft. Winchcfl- 1864 4moB. fimoB. 9 inches linch linch Healed, very thin- ly covered by cic- atrix, caused, by retraction. ture of low. third of thigh . . ■ ter.Va. Comp'd com. frac- Port Hud- June 14, Smos. 16 mos. 10 inches linch linch - ture of knee-j'int ■ Compound com- of thigh . . . FortVag- ner, S. C. 1863 7 mos. 9 mos. 2i inches 3 inches U inches Hemorrhage arreat- ed by a cord he had in his pocket, 24h'rainetrench, st'mp ins'fficient- ly covered .owing to aloughing, ex- foliation, and re- traction. 16 ONE HUNDRED AND FIFTY-EIGHT CASES TABLE OF ONE HUNDItED AND FEFTY-EIGHT OASES P.S. P.D. E.J. D.W.B. J.C. J.UcL. C. T. D. G.W.F. Begiment. 100th N. Y. VolB. 17th Mich. Volfl. nth N. T. Cavalry U.S. Navy 46th N. T. Volfl. SdN.T. Cavalry U7th N. Y. VoIb. 150th N.Y. Volfl. 14Ui Maine U. 8. Inf y 20th Ind. Volfl. 3d Maryl'd Volfl. Iflt V. H. ArtiUeiy F.M. T.F. J.J. E.W. H.M.C. C. McD. •W.A.K:. W.S. M.H. J.L. P.K, 11th Vt Vola. SdN.Y, Vola. U. S. Navy Ordinary seaman TJ. B. Navy Coolpaas'r H.D. T.McC. Occupa- tion. Seaman Landsm'n Cahinet- maker Shoe- maker. Stone-ma- son Farmer None Fanner 10th Conn. Volfl. 2d U.S. ArtUlery 4th B.L Vols. Freedm'n's Bareau 76th N. Y. Volfl. 6th Conn. Vola. S7th N. Y. Vols. 79th N. Y. Volfl. Srth N. Y. Vols, Gardener Bor-tend'r S^or Flogser Brick- layer Point of Operation. Ixiwer third Middle third Middle third Middle third Upper tWrd Upper third Lower third Iiower third Lower third Lower third Upper third Middle third Lower third Middle third Middle third Middle third Middle tiUrd Lower third Lower tiiird Middle third Middle third Lower third Middle third Middle third Anterior flap Circnlor Ant. post, flap Circolflr Circular Circular Circular Circular Ant. poBt flaps Ant. post, flap Circular Circular Ant post flaps Ant post flaps Circular Ant post flaps Circular Ant post flaps Ant post flap Circular Circular Ant post flap Anterior flap Ant post flap Ant post flap Where per- fonned. Morris Island On the fleld U. S. HoBp., Norfolk, Va. On the field On the field On the field On the field In hospital David's Ifll- and HoBpIt'l, Cul pepper C. U. Armoiy Sq. General Hos- pital Length of Time after Injuiy. Eighteen hours Twenty-fo'r hours For^-eight days Six hours Two hours Seven hours One hour Seven hours Five months ondaliaif Thi«e days Thirteen days Twenty-fo'r hours Fragment ofsheU Minie-ball Fragment oTflheU Muiie-ball Musket-ban Grape-ehot Minie-ball Musket-baU Musket-baa Minie-baU Minie-ball On the fleld Twelve h'rs Hospltl ship. Ft Jackson Gunboat Ft Jackson On the fleld On the fleld On the field On the fleld MIddletown Hospiti, Md. Fortress Monroe In 3d Army Corps field hospital Steam'r Dan- iel Webster Twenty-fo^ hours Twenty-fo'r hours Imme- diately Twenty-fo*r hours Four hours Two hours Four days 2d time One year Forty-eight hours fifteen days Imme- diately Twenty-fo'r hours Three days Canister- shot Minie-ball Cannon-bail Musket-ban Mlnie-baU Keceof BheU Gunshot Minie-ball Bifle-ban Minie-ball' Musket-baU iUfle-baU OF RECOVERED AMPUTATION OF THIGH. OF RECOVERED AMPUTATION OF TSiaa.—{CotUinued.) 17 Length of time fVom Length of time from Atrophy. Reuabks, DeMiiption of In- jury. Amputa- tion to Amputa- tion to Length of Stump Generally made at Time of Applica- Battle. Date. Exami- Applica- Proximal Distal tion of Artiflcial nation. tion. Portion. Portion. Limb. DcBtruct. of knee- joint Fort Wag- ner, S. C. ^%^. 7moB. 9 mos. 10 inches linch 2 Inches Stump healed, ten- der, posterior flap atrophied, bone covered. Comp'd fracture of South Sept 14, &62 9mOB. 11 mos. ^ inches jinch linch Stump sound. thigh at middle Mountain, smooth, efficient third Va. Comp'd com. frac- West June 14, 5moB. 6moB. 7 inches ^ inches 2} Inches Healed, very good. toxe of thigh . . Louisiana 1664 Comp'd com. fhict. of upper third of Gunboat Mendota '"-iki'' — 7 mos. 6J Inches )inch 1| inches End not well cov'd, retraction of mus- leg r. . . . cles, leaving bone exposed. Healed, very short, Comp'und fracture Peters- 'i^- gmoa. 7 mos. 3} inches {inch None of middle third burg.Va, imperfect of thigh . . . Comp'und fracture Rich- "304"' 7mo8. 9 mos. 5 inches llnch linch Healed, poorly cov- of thigh . . . mond, Ya. ered. Destmct of knee- Fort Fish- '•&''• 9mos. 10 mos. 103 inch. Increase 5J inches Very good, consid- erably Injured by joint er, N. C. 8 inches two other shots. Comp'und commi- Gulps June 29, 13mOB. 14 mos. 9 inches }inch 5 inches Very good, nine nuted fracture of F'rms, Ga. 1864 inches of seques- upper third of leg Comp'und commi- tia. Baton ^Ji/- lOmos. 11 mos. U inches linch ^ inches Scanty covering. nuted fhicture of Rouge, increase extensive cica* knee-joint. . . La. trices adhering to bone. Comp'und fhicture of head of tibia . David's Dec. 6, 4moB. dmofi. 2 inches 2 inches Length excessive, Island ' 1862 erysipelatous In- flammation, ab- scesses, nlcerSjCtc Comp'und firact of Cedar Mt., ^?^'' £moB. — 4J inches None None Gangrene, not low. third of thigh Va. ready. Comp'und commi- nuted fracture of knee-joint, com- plicated with compound frac- ture of left leg . Coal Har- June 1, Ijeax :^moe. 7( inches 2} inches 2J inches Very fhlr, bone well covered, 41 inches of bone necrosed, removed whole shaft, periphery, new bone formed, leg bowed, from bor, Va. 1864 • poatcrior olough. Very good, exten- sively cicatrized. Comp'und commi- CoalHaiv June 1, lyear 18 moa. 9i inches 3 Inches 4i inches nuted fracture of tor, Va. 1864 lower third of femur .... Comp'und fhicture of lower third of thigh .... Manassas Gap, Va. '%^' 7mos. Idmoe. 9i inches 11 inches 3 inches Stump ulcerated on posterior and up- per angle, indica- tions or exfoliat'n, will be efiicient Comp'und commi- nuted fracture of Fort Fish- er, N. C. '"a5^ 4m08. 6 mos. 7 inches None None Not healed, on furlough ten days. Excellent knee-joint . . . Comp'und comnu. Fort Fish- Jan'y IS, 2mos. 4moB. 8 Inches 22 inches iinch fracture of lower third of thigh . Destruction of leg er, N. C. 1*5 Newbem, March _ _ 5) inches None None — ■Wound of knee- N. C. San Au- 14,1862 __ _ 6 inches 2 inches 4 inches Healthy. joint Comp'd com. frac- Sntietam! Sept ir, fi62 14 mos. 16 mos. 9 inches S inches S inches Stump sound and ture of kneM'int Comp'd com. fract. of leg and knee Comp'd com. fract middle of leg. 2d Md. 9mos. 9 mos. 10 inches 8} Inches 5i inches vigorous. Excellent South Mountain, 17 mos. 2d time 20 mos. 2d time 8 inches li inch 3 inches St'mp healed near ly, not well cush- ioned. Healed. necrosis of femur "Wound of knee- Va. Chester fimoB. 5mofl. 8 mos. 6 mos. 8\ inches 2 inches 3^ Inches joint Fiact're of the low- er part of the fe- Station Chancel- lorsville 7 mos. lyear 7 inches Hinch iinch Stump pretty fairly cov'd, not healed perfectly, will be mur ' good, habits not good, ulcers on other ankle, sore Comp'und fracture of knee and leg Blue Oct 10, 4 mos. 7mofl. lOi inch. None IJ inches Walked with assist- ntipn hnir n mil A Springs, £. Tenn. 1863 st'mp not healed, some granulated w'lU be efficient Comp'und fracture Fair Oaks, ■May 81, 1&2 8 mos. 10 mos. 8 inches J inches 11 inches — of knee-joint. . Comp'und fracture of knee-joint. . Va. Fair Oaks, Va. 7 mos. k 24 days 10 mos. 8 Inches 2 inches 2 inches 18 ONE HUNDRED AND FIFTY-EIGHT CASES TABLE OP ONE HDNDRBD AND FIBTY-EIGHT OASES NjUIZ. Begimeut. Occupa^ Hon. Limb. Point of Operation. Method. "Where per- formed. Lenethof Timeaiter Injury. Cause. Q. 8. F. 24th Mius. Vols. Shoe- maker B. Upper third Circular On the fleld Eight houra Mhiie-ball W. S. SdArta- 4th°l[^6l- ment SdN.Y. Artilleiy 4th N. Y. Vols. Farmer B. Lower third Ant post flaps Hospital Tliree days Minie-ball F. O'B. J.H.D. J.S. Cart-dri- ver Carpenter & joiner Brewer L. B. R. Middle third Upper tliird Middle third Lateral flaps Ant post flap Ant post, flap Acad. Q. H., Newb'n.N.C. On the fleld Four weeks Thirty-Bli hours Cut with an axe Mueket-baU Mrnie-ball U.M. 69th N.Y. VolB. Carpenter B. Middle third Ant post flap On the fleld Three days Bifle-baU D.C. O.S. 25th N. Y. Vols. 169th N. Y. Volu. L'ngBh're- man TeamBter B. Upper third Middle third Circular Ant poBt flap On the fleld On the fleld One hour Two houra Solid shot CanUter- shot a. 8. 11th Conn. VoU. Hatter ij. Middle third Ant post flap On the fleld Two hours Minie-ball F. 8. rithN.Y. Vols. Sth N.J. VoU. Sth Wis. VoU. «8th N. Y. VoU. aerk L. Middle third Ant post flap Field Three days Bifle-baU J.H. - L. Upper tliird Circular On the fleld Six days Minie-ball I.e. Farmer L. Middle third Ant post flaps David's Isl- and Hospit'l Field Fifteen days Musket-baU T.B. Sailor B. Middle third Ant post flaps Six hours Minie-ball LB.B. 26th Iowa VoU. Farmer B. Lower third Ant post flap Field Two houra Minie-baU D.McO. 2dMasi. VoU. Shoe- maker B. Lower third Ant. post flap U. S. Oenerl Hosp. N. H. Thirteen months Fragment opBheU F.L B.W.G. 2d N.J. VoU. 84lh N. Y. 6.M. Black- smith Painter L. B. Middle third Lower third Anterior flap Ant post flap On the fleld in corps Hospital Infield hos- pital Eighteen hours Thirty hours Canister- shot Minie-baU O.M. 40th N. Y. VoU. VamUher R. Lower third Bcctan^lar flap On the fleld Second day BheU J.T. 14th N. Y. VoU. Broker L. Lower third Circular On the fleld Twenty-fo'r hours Minie-baU T.H.W. 13th N. J. VolB. Batter L. Lower third Ant post flap On the field Three hours Minie-baU J.A. Mth N. Y. VoU. SaUor L. Middle third Ant post flap At fleld hos- pital Eight days Iifinie-haU necrosis J.C. 104th N. Y. VoU. None L. Upper third Circular Four days Minle-baU OF RECOVEEED AMPUTATION OP THIGH. 19 01' BEOOTESBED AMPUTATION OJ THIGH. -(anlim«i«.) Length of Length of Atrophy. Rbhasks, time from timefrx)m Description of In- Battte. Date. Amputa- tion to Amputa- ^on to Length of Stump. Gienerally made at Time of Appiica- Exami- Applica- Proximal Distal tion of Artificial nation. tion. Portion. Portion. Limb. Gomp'und commi- nuted fracture of Seabrook April 11, 4moB. 8 mos. 4} Inches ^inch linch Stump not entirely healed, perioste- Island, 1863 the middle of the S. C. um, some thick- thigh .... ened, short, and "Wound of knee- Washing- ton, N. C. Baltim'rc, Sept 9, — 11 mos. )} Inches 2 inches 3 inches Stump healed. joint Wound of knee . March, 14 moB. 15 mos. 7 inches 2} inches 3 inches inflammation and Hd. 1862 gangrene ensued. Comp'd com. firac- Kinaton, Dec. 14, 4mos. ' 8 mos. 4^ Inches 2} Inches 2 Inches Stump not healed. ture of femur N. C. 1862 increase increase Comp'und Iracture Antietam, Sept. 17, 9mos. 11 mos. 8 inches linch 2 inches St'mp uneven, hav- Md. 1662 ing sloughed, cicatrices large, small ulcers re- maining. Comp'und commi- nuted fracture of Antietam. Sept. 17, 7mos. lyear 8 inches None linch Secondary hemor^ Md. 1862 rhage ensued. lower tUird of the femoral arteiy 11- femur .... gated, Bt'm p near- ly healed, and pathological con- ditions &ir. exc'pt cicatrix extensive on anterior part Destruct of knee- Antietam, Sept. 17, 1862 June 1, 1864 7moB. 9 mos. S} inches None iinch — joint, etc. . . . Comp'und fracture lower third of thigh Md. Coal Har- bor, Va. 5mos. 6 mos. 6} Inches 2i inches 2 inches Damaged by gan- grene, healed, bone covered by cicatrix only. Comp'Tind commi- nuted fracture of Blnff,Va, "S^^ lyear A: 14 mos. lyearft 5mos. 6 inches 2^ inches ^ inches Very good, some damaged by gan- f^mur .... Comp'und fract. of Williams- ""&'' 8 moa. lyear 7i inches U inch increafle linch grene. Not ready. lower 3d of femur burg. Va. Williams- increase Comp'und fracture of knee-joint. . Comp'd fy-act. low- er third of femur Comp'und fracture of thigh . . . June 20, 8 mos. 8 mos. 41 inches linch None Beady. burg, Va. WilRamB- 7 mos. lyear 5^ inches 2 inches }inch _ burg,Va. Antietam, Md. 1862 Sept. 17, 1862 7 moa. 11 mos. 7 inches increase 2J inches 23 inches St'mp nearly ready, not liealed, ball >aaaing obliquely rom the anterior ater'lheadoftlb- a, making its ex- t above the inter- nal condyles of femur, up the left leg, striking the ricKt thigh mid- dle lower third of femur, causing comp'nd fracture. Comp'und commi- nuted fract. low- er third thigh . . Lovejoy Station, Oa. Se^4, 11 mos. 18 mos. 8i inches S inches 3i inches Damaged by gan- grene, tranapYted one mile, then 4, then 130, not dressed for4dayi, diet very poor. Destruction of ham Cedar Mountain, ^?8^"- 8 mos. lyear 10 inches linch 3i inches Nearly h^ed, some eczema, angula- Comp'und fracture knee and leg. . Va. Gettya- burg. Pa. '%'■ 6 mos. 9 mos. 82 inches 2 Inches 2 inches Stump irregularly covered, healed, efficient Comp'und commi- nuted fracture of knee Comp'und commi- nuted fracture of upper third of leg and knee . Comp'und commi- nuted fracture ol Gettys- burg, Pa. Gettya- buig, Pa. Gettys- burg, Pa. fimoa. 3 mos. 6 mos. 7 mos. 6 mos. 8 mos. 10 inches lOJ inch. 10| inch. 3 inches None 21 inches 2 inches linch 2 inches Stump admirable, finely cov'red and proportioned. Stump favorable, clean In front healed and aer- Ticeable. Stump healed, effi- cient knee-joint. . . Comp'und commi- nuted fracture of Gettys- burg, Pa. «• 6 mos. 9 mos. 11 Inches 21 inches 21 inches Stump well Scaled, round, smooth, well covered, ex- knee-joint . . tensively cica- trized, stitches sloughed out Comp'und commi- nuted fracture of lower third of leg Comp'und fracture of Oie middle of thigh .... Gettys- burg, Pa. Gettys- burg, Pa, July J, 1863 1 year. 2d time 11 mos. Umoa. 14 mos. 2d time 13 mos. lyear 8 inches 2 inches None 1} inches increase 1| inches None Damaged by sloughing, main- Some hypertrophy, healed scanty, in- tegumentary cov- ering, some ul- ceration. 20 ONE HUNDRED AJSD FIFTY-EIGHT CASES TABLE OP OWE HUNDRED AND FIFTY-EIGHT CASES Nahe. Regiment. Occnpa- Uon. Limb. Point of OpemSon. Method. "Where per- form ea. Length of Time after Injury. Cause. C.K. 20th N.T. 8. II. Fumer B. Upper third CircuUr Hospital at Get^sburg, Hospital Seven days Minie-baU H.B.E. lethN.T. Farmer L. Lover third Circular Ten days Gunshot C. UcD. imhN.T. VolB. Clerk R. Lower third Ant, post, flap On the field Twenty minutes Musket-ball W. 8. O.W.8. Ifth Ind. BatleiT Mth Conn. Vol». Psinter Salesman L. B. Lower third Lower third Ant post flap Rectangular flap Field Field Twenty-fo'r houn Tw'nty-one hours Minie-baU Minie-ball a.B. 2d N.T. M.B. 7th Wis. srth N. T. Vols. Laborer R. Lower third Ant post flaps On the field One hour Musket-ball G.T. D.B. Fur-trap- None R. R. Lower third Lower third Ant irost flap Ant poet flap On the field On the field Twenty-fo'r hours Tw'nty-one hours Fragment of shell MusketrbaU an. P. 7th Wis. Carpenter B. Upper third Ant post flap On the field Twenty hours Forty-eight hours HInie-baU J.U. 107th N. Y. VolB. Farmer L. Middle third Rectangular flap On the field Grape-shot P.T. /. 0. C. J. B. S4th Mich. 7th Md. VoLi. 4th B. I. Lumber- man Hmcr Carpenter R. L. L. Lower third Lower third Lower third Circular Circular Anterior flap Hospital at Gettysburg, On the field On the field Tlueedays ^^ Four hoars Seven hours Minie-baU Minie-ball Grape-shot If. 8. G. P. 8. 183d Penn. 2lBt Conn. Vols. 5th Conn. Vols. ^"^ot^- None Farmer R. R. Lower third Middle third Circular Ant post flap Douglas's Hospital On the field Six days Foot hours Minie-baU Minie-baU ■W.K.S. Merchant a Lower third Ant poet flaps On the field Twelve h'rs SheU T.K. Laborer L. Lower third Ant post flap - Tw'nty-one hours Kfle-baU J.H.V. lorth N. Y. ■Vols. Farmer L. Lower and middle third Ant post flap On the field Seven days 2d time Tw'nty-one days Rifle-boU. 2d time Extensive sloughings and de- n'ded bone W.M.V. aw. P. 26th N. T. Vols. 2l8tN.J. Vols. Cigar- maker Book- keeper R. R. Lower third Middle third Circular Circular On the field On the fleld Five days Six days Minie-baU Muaket-boU J.McW. 20th Conn. Vols. Student L. Lower third Circular Acqnia Cr. Hispital Twenty- three days Minlo-baU J. S.I/. Jth N. J. Vols. 8th N. J. Vols. 16th Conn. Vols. - L. Lower third Ant post flaps Potomac Hospital Armory So. H'spilaI,D.C. At his home Four days Minie-baU J.H. J. E. C. Silver- plater Farmer B. L. Lower third Middle third Circular Circular Six weeks Four weekB Minie-baU Minie-baU H.S. 26th N. Y. Vols. Farmer B. Lower third Anterior flap On the fleld Thirty ho'ra Minie-baU J.Q. 88th N.T. Vols. B'nk-note printer L. Middle third Lateral flap On the fleld five days Minle-baU BrLB. 63d N.T. Vols. Shoe- maker B. Upper third Ciicubir On the fleld Forty-eight hours Rifle-baU J. P. esth N. T. Vols, srth N. Y. Vols. 25th N. T. Vols. 1st Berdan 8. Shootera Soldier E. Upper third Circular - — _ J. O.W. Salesman B. Lower tliird Lateral flap At home 107 daya Gunshot J.C. C.I-. Lather B. L. Upper third Lower Uilrd Ant l>ost flaps Ant post flaps Incamphos- pittS On fho fleld Five days Two hours Rifle-baU Orape-shot OF RECOVERED AMPUTATION OF THIGH 21 OF RECOVERED AMPUTATION OF TSIQU. —(Continued.) DeBCription of In- jury. Compound Fracture middle third of thigh Comp'd com. frac- ture of patella. . Comp'und commi- nuted fracture of knee-joint . . Comp'd com. fract low.third of thigh Comp'und commi. fracture of knee- joint Comp'd com. frac- ture knee-joint . Comp'd com. fmcL of lep near knee Comp und commi- nuted fracture of knee and lee . . Comp'd com. met. middle of thigh Comp'd com, frac- ture of knee- joint Comp'und fracture c'ndyle of femur, knee involved . Comp'd com. frac- ture knee-joint Compound com- minuted fracture knee-joint . . Comp'd com. frac- ture knee-joint Comp'd com. frac- ture knee-joint Destruc. upper p'rt of leg and knee Com p^nd commi- nuted fracture knee-joint. . . Compound com' minuted fracture knee-joint . Comp'd com. frac- ture knee-joint Compoand com- minuted fracture knee-joint. . Compound com- minuted fracture knee-joint. . . Fracture .... Comminuted frac- ture knee^oint . Comp'und rract're knee-joint .' Getty»- July 7, burg, Pa. If" Freder'ka- burgf Va. Peters- burg, Va. Peters- burg, Yb. Peters- burg, Va. Peters- burg, Va. Peters- burg:, Va. Peters- burg, Vo. Peters- burg, Va. DalUs. Ga. Gettys- burg, Pa. Comp'd com. frac- ture of the upper third of leg . . Comp'und commi- nuted fracture of lower third of femur .... Comp'd com. fract. of lower and middle third of thigh .... Comp'd fracture of femur .... Comp'd fract mid- dle third of leg . Comp'd fract low- er third of femur Comp'd fr'ct knee; destruction of leg Peters- burg, Va. Peters- burg, Vo. Peters- burg, Va. Peters- burg, Va. Chanccl- lorsville Chancel- lors ville Chancel- May 3, lorsville 1863 Mays, 18G3 July*, June 18, 1864 Sept. 30, 1864 July 17, 1^ June 18, 1864 June, 18C4 M'ch 31, 1865 May 25, 1^ 1^ July 30, 1%4 M'ch 81, 1865 June 25, 1864 May 3, 1863 Length of time from Amputa^ tion to Exami- nation. Cbancel- lorsville Chancel- lorsville Chancel- lorsTilte Chancel- lorsville Chancel- lorsville Antietam, Md. Freder'ks- burg, Va. Frcdcr'kiS- bui:g, Va. Antietam, Md. Bull Run, Va. Ball Run, Vo. Hanover C. H., Va. Hanover C. H., Va. 8mofl. 8moB. 9mo8. 6mos. 4mo8. £mos. fimos. 8mo8. lOmos. 6mo8. 6moB. 8moB. 8moB. SmoB. 13 mos. llmoB. 11 moB. 11 mos. Length of time from Amputa- tion to Applica- tion. 13 mos. 11 moB. Umos. 8 mos. Length of Stump lyear 11 mos. 7 mos. 7 mos. 10 mos. 14 mos. 14 mos. 15 mos. Kone )J inches 9 inches 12 inches 10 inches 11^ inch. 10 inches 6 inches 9} inches 7J inches 9 inches 9 inches 9j inches 6^ inches 9 inches 10 inches 8} inches 10} inch. 5£ inches Atrophy. Proximal Distal Portion. Portion. ^^'■ 11 mos. Sept n, 1862 8 mos. 8moti. 11 mofl. Dec. 13, 1662 lyear Dec. 13, 1862 fimos. Sept. 17, f862 13 mos. 1861 July 21, 1»11 3 years June 2, 1862 Mav2r, 1862 7 moB. 8 mos. 1} inches None 23 inches 1} inches 3 inches 2 inches 2J inches j inch Jinch 3J inches 2 inches 2 inches' 2} inches 4 inches 1 inch li inches 3 inches 3} inches linch 11 mos. 10 inches 14 mos. 9i inches 11 mos. 7} inches lyearft 20 days 9 inches 14mo6. 12i inch. 7 mos. 8 inches 15mofl. 4 inches _ 3} Inches 3 years & 2 mos. 10 mos. 10 inches % inches 9 mos. 8 inches 3 inches linch 4^ inches }inch None 3 inches None {inch linch 2} inches li inches 3 inches 2 inches 3 Inches None _ linch increase 6} inches li inches 4 inches 3 inches 2 inches 2 inches { inches 4 inches 4 inches 1} inches 2j inches Bkmarks, Generally mode at Time of Applica- tion of Artificial Limb. 3) inches 4J inches 3 inches 4 inches linch None SI inches ^inch 2J inches Healed, very sfaoit, imperfectly cov- ered. Stump damaged by sloughing. Very good, some damaged by sloughing. Very good, not per- fectly healed. Very good. Healed very good. Nearly welL Healed, very well composed. Very good. Excellent covering, excellent Indications of mor- tification, stump ulcerated, will be well shaped. Healed very good. Heal'd, very good* except injury. Very good. Very good. Not healed. Nearly healed, eome periostitis, necrosis. Stump mainly healed, ulcer on the inferior pos- terior part, badly cicatrized by sloughing ana exfoliations. Healed. Healed, periosteum some thickened, some teDdcrness, an tenor and infe- rior part, cicaM- zation. Stump fair, eeantly covered, tenderly healed, will prove effScient Mortificati'n fourth day after injury. Stump healed, good coodition. Bone protrudes, covered only with skin, muscles re- tracted, stump well, secondary. Stump Imperfectly healed, excessive- ly long. Stump ulcerated over the end of bone, ports gran- ulating, hae sloughed badly. Stump short, well healed, will prove vigorous. Gangrene. Good. Gangrene, conva^ lesccnt Stump poorly rounded. 22 ONE HUNDRED AND FIFTY-EIGHT CASES TABLE OP ONE HUNDRED. AND PrFTI-EIGHT CASES NAMK. Begiment. Occupa- tion. Limb. T. G. R.C. 36th N. y. Vols. 23d Veto •n.IlL Laborer Builder L. P.B. SdB.r Artilleiy laborer K. L. D. P. Slh N. T. Vols. Sailor B. A. 8. P.M. 4lhN.H. Vols. 100th N. Y. Vols. Teamster Farmer L. R. M-K. Ist Vt ArtUleiy Farmer L. T.B. lOOth N. y. Vols. Farmer B. Q.C. J. F. -W. 3dTJ. B. A. A. Sailor Soldier SoUor B. L. K.O. U. S. NaTy SaUor R. ICB. E.K. SdN.J. Vols. Black- smith Moulder L. R. O.P.K. J.B. U.Q. 10th Penn. Reserve rth Ind. ft ISth N. Y. esth N. y. Vols. Carpenter MflChinist Laborer R. B. L. P.H. «)lh N. y. Vols. Butcher B. J.M.B. J.M.T. M.S.M. eth N. y. Artillery 36th nu lafantiT Slat N. Y. Vols. Seaman Lieuten- ant Fumace- man R. L. L. M.J. C. MSlhPenn. None E. J. H. Ist Texas Cavalry None L. J.H.C. C.W. 4lh N. Y. Vols. '"*ot^- Teamster Tinsmith B. L. C.H.M. 69lh N. Y. Vols. Waiter K. Point of Operation. Middle third Lower third Iiower third Middle thiid Kiddle third Middle tliird Jliddle third Middle third Middle thiitl Middle third Middle third Lower third Middle third Lower third Lower third Middle third Lower tiiird Lower third Middle third Middle third Lower third Middle third Middle third AsL post flaps Ant post flaps Bilateral flaps Bcctangular flap Lateral flaps Circular Bilateral flaps Ant post flaps Ant post, flap Ant post flaps Ant post flap Circular Ant post flap Ant post, flaps Bilateral skin- flapa and circular Anterior flap Anterior flaps Ant post flaps Ant post flap Ant post, flaps Ant post flap , Circular Circular Ant post flaps Where per* formed. On the field On the field In field hos- pital, Morris Island, S. C. Bebel hospi- tal On the field On bo'rd reb- el transport, Ctiarleston On the field Charleston, S. C. BellcTue Hospital Onhosp.ship Louisiana Hampton Hospital On the field Armory Sq. Hosp., D. C. On the field On the field Marine Hoa- pital, N. O. Ebenezer Church Frederick City Hospitl Length of Time after Injury. Three hours Three hours Two hours and a half Twenty-fo'r hours Twenty-fo'r hours Five days One yr. and nine months Six days One month Sixty-eight days Imme- diately Fifteen days Thirty ho'rs Three hours Soon after injury Thirty-six hours Five m'nths Six months and a half Grape-shot Monle-hall Explosion of forpedo Miuie-ball Fragment of BheU Grape-shot Fragment of shell Grape-shot Bifle-baU Gunshot Gunshot FIstol-shot Bifle-baU Bifle-ball Upsetting caisson Minle-ball With axe Gunshot Mlnie-ball Fragment of shell Shell Kific-baU OF RECOVERED AMPUTATION OF THIGH. 23 OF EEOOVERED AMPUTATION OP THIGH — {Continued.) Description of In- jury, Comp'd com, firact. low. third femur Compound com- minuted fracture upper third leg ... . Destruction of leg at knee-joiut . Compound com- minuted fracture of knee-joint Comminuted frac- ture of knee . . Entire leg badly comminuted to knee. ... Destruct of knee- joint .'.... Compound com- minuted fracture of middle of leg Wound of knee- joint Comp'd com. frac- ture knee-joint . Comp'und fracture lower third of femur . . Comp'und fracture of ankle-joint . Comp'und fracture of isnee-jomt Destmct of knee Great toe, erysipe- las, gangrene . Comp^d fracture of knee-joint. . . Compound com- minuted fracture of lower tiiird of thigh. . . Malvern Hill, Vo. Peters- burg, Va. Morria Island Pelers- but:g, Va. Morris Isl- and, 8. C. FoptWae- ner, S. C. Port Hud- son ,La. Fort Wag- ner, S. C. TTtah Ter- ritory Ft. Donel. & Philip Ft, DoneU & Philip Hartford, Conn. Gainef*! Mill, Vs. Gaines'i Mill, Va. Torkt'wn, Va. White Oak Swamp N. Anna Kiver Comminuted frac- ture of knee- W'oint ound of popliteal artery .... Comp'd com. fract. of entire leg . . Comp'und fracture of knee-joint Comp'd {tRct up- per third of leg and knee . . Julyl, 1862 April 2, A;^i8, Sept 17, fees July 19, lees May 27, ims July 18, 1863 June 4, 1860 1S62 1862 Bee. 26, 1861 June 27, 1863 June 27, 1862 April 30, ISBi June 27, HudBon City, La. FrederlcB- Buuhun, Va. Antietam, Ud. May 27, 1^ May 26, 18S4 May 9, 18M Oet.14, ^?S Sept 17, 1862 Length of imcfrom Amputa- tiou to Exami- nation. Length of time from Amputa- tion to Applica- tion. Length of Stump. Atrophy. Proximal Portion. Distal Portion, 6mo8. 3mos. 8]| moE. 4mo8. 8^ inches 12 inches 2 inches iinch linch increase Uinch 5moB. 7mo8. 81 inches iinch None 5m.0B. — 8 inches linch increase None 4moB. 7mo8. 8 inches 2 inches linch lOmos. lyear 6i inches 1} inches S inches 8mo8. 3mos. 10 mofl. 7moB. 6 inches 9 inches 2) inches increase linch 3 inches linch 2 years* 6mo8. — 7i Inches linch 2 inches - 7 inches None None - - 4 inches 2 inches 2 inches - - 9^ inches linch linch 2 years 7moa. 3 years* 4moB. 18 moa. 8J inches 8i inches 21 inches None 3 Inches None 7mos. 9moB. 10 inches 13 inches linch 6moB. 9J inches Uinch 2i inches 6mos. 8 moa. 9J inches 2 inches 2 Inches 6moB. 7moB. 9J inches 2| inchei S inches 8mo8. 8moB. 12 inches linch Uinch Smos. 10 moE. 8 inches linch 3 inches 8mo8. lyear 7 inches liinch 1} inch 7mos. 10 mos. 8 inches 2 inches 8 inches Smos. lyear lOJinch. 2i inches S inches 10 moB. lyearft 26 days 8 inches S inches linch llmoB. lycarfc 1 month 10 inches liinch 8 inches Rbuabes, Generally made at Time of Applica- tion of Artificial Limb. Disc very good, should hare [>een disarticulation. Stimip not healed, will be round and efficient. Finely formed end covered, swelling on anterior mi^f die of stump, white, painlesB, size indicative of some disease, 4x3. Stump not healed, willbe efficient. Healed, poorly cov- ered, damaged by sloughing. Stump heSed, well covered. Stump healed, pe- riosteum some thickened. Stump not healed, will DC very good. Not healed. Healed very good- Atrophy of muBCle about union of the flaps, front and end smooth, tak- en prisoner to Richmond ; two months on board Sanitary Ship, then to City Hos- pital. N, Y. Not quite healed, some thickening and exfoliation. Nearly healed. Healthy, united by first intention. Extensive necrosis, healed, extensive- ly cicatrized, ex- cessive incisiona. Healthy. Stump healed. some irregular, efficient. Stump healed. Stump bruised, ul- ceratedjgood con- dition, habits in- temperate, leg badly cedematoua Stump not perfect- ly healed. 24 TWO HUNDRED AKD EIGHTY-SEVEN CASES TABLE OF TWO HONDRED AND EIGHTT-SEVEN CASES L.H. ■W.E.S. O.K. P.D. P. B. 8.B.D. H.P. J.M. "W.R. B.G. W.C. F.F. E.D,N. B.A. N.D, P. 8. G.W.M. P.B. J.L. B.M. J.F.M.B T.P. D.0'8. Regiment 10th U. S. Infantiy 14th V. 8. Infanti7 140th N. T. Vohu irOth N. T. Vols. S9th N. T. Volfl. ISth N. T. Vols. 69th N.Y. Vols. 8thMfl£B. Voli. 10th N. T. Volfl. 10th U. B. Infimtry 82dN.T. Volfi. 82d N. Y. Vols. fith N. Y. H.ArtlU'ry fith N. Y. VoU. nth Conn. VolB. 14th n. S. Iniiuitiy eiBt N. Y. Vohi. 122dN.Y. VolB. 74th N. Y. Vols. 69th N. Y. Vols. 108th N. Y. VolB. ISth N. C. C. S.A. adN.Y. 8. AL 8dU.8. Infkntiy Jth N. Y. VoU. Occapa- tion. Farmer Soldier Brick- layer Bhick- smith Former Fanner 8hlp-car- penter Brick- layer None Tinman TeamBtei Fanner Mechanic Fanner French- man Z«aborer Fanner Student Ifilltaty Hatter Point of Operation. Lower and middle third let, low. third 2d, middle Sc upper third Upper and middle Upper and middle third Middle and upper third Lower third Lower third let, lower and middle third 2d, middle third Lower third Middle third Upper third Upper Qilrd Upper and middle third Upper and Middle third Upper and middle third Middle third Middle third Middle and upper third Lower and middle third Middle and upper third IjOwer third Middle and lower third I)wer and middle third Ist. ampnta. lower third 2d,amputa. upper third Upper third Junction of middle and lower third Upper and middle third Upper third Upper and middle third Circular BiUterol flaps Posterior flap Ant. post flaps Posterior flap Ant post flaps Ant post flaps Circular Ant poet flap Ant post flap Ant post flap Ant post flaps Circular Ant post flap Circular Ant post flap 2d, circuUr Circular Circular Ant post flap Posterior flap Posterior flap Bilateral flaps Posterior flap Ant post flap Circular "Where per- formed. On the field On the field On the field On the field Brooklvu CoU'ge Hosp. On Uie fleld Uarrisbarg, Va. Port Royal, 8. c: On gnnboat JohnT. Jack- Spring Hos- pital, Md. Bellevuo Hospittd On the field 2d, Central Park Winchester Church On the fleld On the fleld On the fleld 2d. Freder- ick City Ship IsUnd, MUs. In post hos- pital Charleston Hosp., S. C. On the field Length of Time after Injury. Five hours Six hours Twenty-fo'r hours Twelve h'rs Six hours Seventeen days Twenty-fo'r hours Thirty-five days Thirteen days Seventeen hours 2d, 8 weeks Four days Sev'n^-sev- en hours Six hours 2d, three months Sixty days Five days Half hour Musket-ball Minie-ball Minie-ball Solid shot Kailroad cars Grape-shot Musket-baU Blfle-baU Shot Piece of BheU Bifle-ball Bifle-ball Cannon-ball Gunshot Minie-ball 2d,exfortioa and necrosis Musket-baU Grape-shot Conical-ball Musket-baU 3d, exfolia- tions Explosion of torpedo Bifle-ba21 Piece of shell Rusty nail OF KECOVERED AMPUTATION OF THE LEG. 29 OS REOOTBRBD AMPUTATION Of THE JJEQ.— {Continued.) Length of Length of Atrophy. Bbhabks, time from t me from Dewriytion of In- Battle. Date. Amputa- tion to Amputa- t on to Length of Stump. Generally made at Time of Applica- tion of Artificial Exami- Applica- Proximal Distal nation. tion. Portion. Portion. Limb. Comp'd com. frac- Coal Har- June 1, 7mo9. 8 mos. 6 inches 1| inch 1^ inches Good, well healed. ture of ankle Vint Comp'd com. frac- bor, Va. Coal Har- 1864 June 3, 6moB. 7mo9. 14 inchcB iinch 2 inches Healed, good. ture of ankle j'int bor, Va. 1864 Comp'd com. fmcL Coal Har- June 3, lycar 13 mos. 3 inches None None Indifferent, dam- of middle upper bor, Va. 1864 aged by g'ngrcnc. third of leg . . knee support. Disrupt and carry- Coal Hai^ June 2, 11 mos. 13 mos. 10| inch. 11 inch 2 inches Excellent ing away entire foot PflSBing over ankle joint bor, Va. 1864 Brooklyn, N.Y, Dec., 1862 4moa. 6 mos. 8| inches linch ^ inches - Comp'd fract. mid- Chantilly, ^tkf' Smoa. 7 mos. ^ inches None None — dle third of leg . Va. Comp'und fracture Cro8S June 25, 7 mos. 7moB. lOJ inch. linch 4) inches — of ankle joint . Keys, Va. 1862 Shattering ankle joint Taking off foot, at Port Roy- al, S. C. June, 1862 — — 9 inches None None — VickBb'rg, June 28, — — — None None — the same time Minn, 1863 wounding other foot . .^. . . DisBevering exter- Antletam, Sept. ir, 1862 lyear lyear* 7 inches linch 2} inches Stump in good coin nal malleoluB,not Md. 9 mos. dition. injuring foot nor the tibia and as- tragalus at artic- ulation,8o that he walked with the aid of a rifle. Comp'und fracture Malvern July 1, 1862 5 mos. — 10 inches linch 4 inches Clean, well formed of ankle joint . HiU,Va. stump, tibio-as- tragaloid articu- lation, artificial Ena of stump ir- Comp'und fracture of the middle of Malvcm JulTl, 1862 4 mos. _ 4 inches None 2 inches Hm,Va. regular, flap ob- lique. Cicatriza. healthy. "Wounding soft Malvern Julyl, 4 mos. _ SJ inches 3 inch 12 inches parts, lower parts of belly, gastroc- Hill, Va. 1862 well, even, quite efficient, walked nemii .... to Harrison's Landing, thence to Bellevue per transport, walked about till amputa- tion, secondary hemorrhoee. Stump good, knee I^ower third of leg Malvern July 1, lyearft fimoa. 1 year & 2 inches None None severed .... Hill, Va. 1862 5 mos. support. Ankle joint and Malvern July 1, 6 mos. 9 inches None None Taken prisoner at foot HiU, Va. 1*2 Malvern Hill, Va. Comp''und commi- Winches- Sept. 19, 1864 9 mos. lOmoB. 7 inches {inch 8 inches Very good, cover- nuted fracture of ter, Va. ing angular. ankle joint . . Comp'und commi- Winches- Sej^l9, Smoa. 9 mos. 9i inches None 4 inches Very good, end ex- nuted fracture of ter, Va. posed by slough- anklejoint . . Comp'und coDuni- Winches- SeftlS. 7 mos. 8mo8. 2i inches None None ing. Excellent for knee nuted fracture of middle of leg . Comp'und commi- ter. Va. support, flexed. Winches- Sept. 19, 7moa. 8mofl. 61 inches None Scinches Very feir, stump d'maged by sl'gh- nuted fracture of ter, Va. ower middle of ing. Comp'und commi- Antietam, Sept 17, 1862 UmOB. 14 mos. fi inches linch 8 inches Stump damaged by exfoliations and nuted fracture o1 Md. 8 mos. Umos. 3J effect ankle joint, ab- sloughinga. Bcesses, etc. . . Comp'd com. iract. of lower third of East Pas- Aprils, 7 mos. 14 mos. ^ inches IJlnch U inches St'mp some flexed. "IS"' 1863* S eff'ctive Increase healed, will be ef- BesCru'ction of low- ficient FtWae- ner, S. C. Sept 19, 1863 10 mos. Umos. finches None 8 inches Healed mainly er third of leg, eastrocnemiiand biceps badly hic- some exfoliation stump flexed hanutrings rigid. crated .... Comp'und commi- Ft. Wae- ner, S. C. July 18, 1863 9 mos. lyear 42 inches J inch 2} inches Some atrophied. nuted fracture of healed, irregular, ankle joiat . . not well com- posed. Healed, flexed. Comp'und fracture Ft. Wag- ner, S. C. July 21, H moa. 13 mos. S^incheB linch 8i inches of middle of leg 1863 rather short Completely carry- ing away the leg Shftrps- burg, Md. Sept.l9, 8 mos. 10 mos. ^ inches iinch 4 inches — at itfl middle, , Punctured wound, _ 1859 4 years 4 years 6i inches None 2 inches _ Inflammation . 30 TWO HUNDRED AND EIGHTY-SEVEN CASES TABLE OF TWO HXTNDKED AND EIGHTY-SEVEN CASES u.uca. J. D. T. E.T. CM. P. E.B. P. B. C. W. S. I..H.M. £.LeO. J.K. C.W.R H.A.G. A.C. E. O. F.U.J. jr.L. H.O. A. A. Re^meat 27th Hau. Vols. 23d Moss. VolB. «th N. T. Vols. 11th N. T. Vola. 14lh N. T. Militia 1st Elts- worth Zouaves 22dN.T. Vols. 20th Conn. Vols. lBtB.L A. lUh Vt Vols. Ut U. S. Artillery lit La. In- fimtry ISlstN.T. Vols. 187th Penn. Vols. 89th HI. Infantrv CMN. Y. Vols. U. S. Navy I42d N. T. Vols. Ji6th N. T. Vols. lorth N. Y. Vols. lOCth N. Y. Vols. Occupar tion. Limb. None R. None L. Farmer R. Lieuten- ant L. Farmer L. aerk L. Black- smith Butcher L. L. _ L. Shoe- maker Farmer L. R. Carpenter L. Fireman L. Faimer L. Shoe- maker L. Negro dri- ver a Carpenter R. Railroad Conduct'r R. Railroad Mana^r Pianoforte maker R. L. Boat- swain's mate R. House- punter L. Carriage- maker R. None R. Farmer L. Point of OperaUon. Middle third Junction of middle and upper third Upper and middle third Middle and upper third Upper and middle thltd Upper third Upper third Lower third Upper third Upper third X/Ower and middle third Lower and middle tlilrd Upper third Lower and middle third Junction of middle and upper third Upper third Upper and middle third lot, extreme lower third 2d,junct. of low. mid. 3d June, of u^- per and mid- dle of Ice Middle and lower third Lower and middle third Circular Fosteiior flap Bilateral flaps Foaterior flap Ant post flap Ant. poat flap Circular Foaterior flap Ant, poet, flap Ant poBt. flap Foaterior flap Ant poat flaps Circular Foaterior flap Anterior flap Ant poat flaps Ist Circular 2d, Bilateral flap Bilateral and Circular Ant poet flap Where per- formed. In fleld hos- pital Reeidence, New York Clifbome Hospital Kebel hoap., Bichmond Bellevue Hospital Oa the field On the field Portamouth Grove Hos- pital McDougal U. S. Ocncr'l Hospital On the field On the fleld In the fleld hoapitol On the field On board ahlp On the fleld 2d, Central Park On the fleld On the fleld On the field Length of Time after Injury. Eight daya Half hour Twenty-one months Eight daya Four days Eighteen boura Eleven months For^-eight hours Three daya Eighteen hours Half hour Seven weeks Twenty-fo'r hours Eighteen hours Seven months Seven and a half months Ten hours Three to four hours Canister- shot Grape-shot Union gun while in rifle-pita Rifle-ban Bifle com- bustible ball Minie-ball Bifle-boli Shot Minle-ball Fragment of sheU Fr^mcnt of shell Grape-shot Canister- shot Erysipelas from cut Grape-shot Caught In turret Piece of sheU Canister- shot Musket-boll Fragment of shell OF RECOVEKED AMPUTATION OF THE LEG. 81 OP EBOOVBRED AMPUTATION OP THE "LEQ. -^{Continued.) Peacription of Li- Comp'und commi- nuted ftuct. low- er third of leg Comp'und firacture^ of lower purt of leg and ankle . Comp'd com. fracL lower third of leg, and flesh wound of calf of the other leg . . . Corap'unafroct of fibula, tibia split, Comp'und commi- nuted fracture of middle of leg. Comp'und commr nuted fVocture of middle third . . Comp'd fract, low- er part of leg . Compound uac- Comp^d com. fract of middle third . Destruction of log at lower third . Boring a hole in the tibia antero- posterior without fracture .... Comp'und commi- nuted fracture of 4thanddth meta- tarsal bones, of internal and ex- ternal cuneiform and calcis . . . Comp'd com. fiact of lower third . Severing leg at its middle and lower third Comp'und commi- nuted ftacture of middle third of leg ... Newbem, N.C. Newbem, N.C. Port Hud- son, La. 2dBuU Run, Va. Bull Run, Va. Bull Run, Va. Bull Run, Va. Bull Run, Va. Bull Run, Va. Chancel- lomville Chancel- lonviUe Fred'icks- burg, Va. Iiodged in foot, en- tering back ex- ternal malleolus^ making a circuit offoot . . . Middle of leg Tarsus metatarsus flundered . . . Comp'd com. fract. of fbot, ankle joint, and lower tliird of tibia . . Comp'd com. frac- ture of fbot, heel, and , ankle joint uninjured . . Entire destruction of ankle joint, subsequent dis- ease or bone . . Comp'und fracture of upper middle of leg .... Compound com- minuted firacture ankle joint . . Comp'd com. frac- ture of ankle . Length of timefirom Amputa- tion to Exami- nation. Fred'icfcs- burg, Vo. March 14, 1862 March 14, 1862 June 2T, 1863 May 18, 1864 July, 1861 July 29, 1862 July 21, 1861 July 21, 1861 April 29, 1863 May 8, 1863 Dec. 3, 1863 Mays, Coal Har- bor, Va. Port Hud- son, La. Port Hud- son, La. Port Hud- son, La. W. Point, Va. James Rirer, Va. DUbyt'wn Dingle's MUl, S. C. ■Winches- ter, Va. lyear SmoB. € weeks 7moB. 7moe. 16 moB. 8moB. 9mos. June ], 1864 May2r, June 18, 1864 Mays, 1^2 Nov. 28, 1864 Oct. 2r, 1864 April 9, 1865 M'ch 16, 1865 8mOB. 6moB. Length of time fVom Amputa- tion to Applica- tion. Length of Btump, 10 mOB. 6moB. 11 mos. 8 mot. 5moa. 6mOB. 4mOH. 13 moa. 9 mos. 4moB. 9mOfl. lyear ft 4 mos. 11 mos. 13 mos. Proximal Distal Portion. Portion. 9 mos. 10 mos. dmoB. 7mo3. 7 mos. 6( Inches 5} inches 4 J inches 5^ inches 4| inches 9 Inches 5} inches 8 inches 8} inches 4i inches Atrophy. {inch 4^ inches 1} inches 3^ inches None linch None 1} inches I inch IJ inches jinch (inch 4 inches 2^ effect- ive 10 inches 6 Inches 9| inches ll|inc:i. 9} inches 4 inches 9] inches 9 inches Bbhakks, Generally made at Time or Applica- tion of Artificial Limb. Has been wearing a leg with rotatoiy motion at ankle joint, unreliable and unsatisfac- tory. Healed. Stump in bad con- dition,exfbliation, flap not united, ulceration, etc. linch 3 inches None 2 inches 31 inches 2 inches Healing. Retracted, flexion more than angle of 45 degrees. Stump rigorous, well healed. None 2 inches None }lnch 1) inches Unch increase linch increase }iuch 2) inches None 43 inches 2^ inches Fine stump. Stump healed and efficient. St'mp healed, some damaged by sloughing. Stump healed, flop redundant] pend- ulous two inches. Stump smooth, neat, efficient, thoro'ly healed. Well healed, excel- lent Stump well healed, will be vigorous, is well formed. Flap redundant, cicatrices exten- sive, angles pout- ing, healed, scab- by, will do pretty good service. Stump bad, necro- sis of tibia, BCT- eral ulcers, livid, hypertrophied. Medium size, swol- len, paxtially healed. Good. Stump not healed, subsequent in- jury, delay. Very fine, healed primarily. Two and one half inches reampu- tated,not entirely healed, sluggish. Excellent. Excellent Healed good. 32 TWO HUNDRED AND EIGHTY-SEVEN CASES TABLE OF TWO HUNDRED AND EIGHTY-SEVEN CASES CO. B. M.AL J.H.H. J.A.H. E.T. H.B. J.B. O.C. J.Y. J.S. B. C. C. Be^ment U. 8. Navy isrth N. T. VoU. 4th V. S. .InfantiT £th N. H. VoU. SSth U. S. Artillery 11th Maine 17th Conn. VoU. 85th Fenn. VoU. 100th N. Y. VolB. 63d N.Y, Vols. Occupa- tion. Stone- cutter Fanner Farmer Fanner SaUor Fanner BUck- omith Cabinet- maker Laborer P.P. B-W. B. F.H.B. T.McQ. J. G. N. F. O.F. 63d Fenn. Tola. 93d Fenn. VoU. 67th N. Y. VoU. 45th N. Y. VoU. U. 8. L. Artillery 48th N. Y. VoU. 69th N. Y. VoU. Powder boy 163d N. Y. VoU. 4th N. Y. VoU. Farmer None Farmer Cabinet- maker Fireman irunbo't Diana Farmer Lock- smith Uphol- sterer FoiDt of Operation. Ist, just ab've malleoli, 2d, junct. lower & mid. third Iiower and middle third Lower third Irf>wer third Upper third Junction of lower and middle third Lower third liOwer and middle third Jiower and middle third Ix>wer and middle third Upper third Middle and upper Uiird Upper third Upper and middle third Junction of lower and middle third Middle third Upper mid- dle Lower and middle third Lower and middle Uiird Where per- formed. Bilateral flaps Circular Circular Anterior flap Circular Ant post flaps Circular Circular Circular Circular Posterior flap Circular Ant post flap Iiength of Time after Injury. Cause. On ^nboat 2d, at Mem- phis On the field On the field On the field On the field In the field hospital Beaufort General Hos- pital Hosp., Mor- ris island Frederick City Posterior flap Ant post flap Ant post flaps Circular Circular Circular Ant post flap Lateral flaps Ten min'tes 2d, Twenty- two days One hour Five hours Three hours Five hours One hour Three days One hour One month AnnapolU Hospital Id a farm- house, Woodstock, Va. General Hos- pital, Newbem, N. 0. Fatterson- Tille, La. Portsmouth Hospitid U. S. Hospi- tal, Baltim're In field hos- pital Field hospi- tal Five days Four hours 8ix weeks Grape-shot Minie-ball Musket-ball Minie-ball Fragment of sheU Fragment ot shell SheU Musket-boll Nine hours Two days Three moB. Twelve hours Four hours Six hours Three hours Musket-boll Minie-ball Minie-baU 6heU Minie-baU Mnsket-baU Bidlroad cars Gunshot SheU Solid ahot OF KECOVEKED AMPUTATION OF THE LEG. 33 OF EECOVEEED AMP0TATION OF THE LEQ. — (ContiniKd.) length of Length of Atrophy. Rehabeb, time from time from DeBcription of In- jury. BatUe. Date. Amputa- tion to Amputa- tion to Length of Stump Generally made «t Time of Applica- Exami- Applico^ Proximal Distal tion of Artificial nation. tion. Portion. Portion. Limb. Comp'd com. fract. of tarso-metatai- flua Bed River Au^^. Umos. lyear 9 inches jinch 11 inches Nearly ordinary very good, hardy. Compound com- Poplar Sey^SO, 9mos. lyear 8 inches Kone None Not healed, three minuted fracture Grove,Va. quarterH of an inch of necrosis, ankle joint aud Destruction of 'an- bone removed. Anttetam, Sepl. 17, 1862 llmos. lyearft 9 inches 11 inches 4 inches Stump healed. kle joint . . . Comp'd com. ftact of ankle joint . Md. 2 mos. Deep Bot- tom, Va. ■'"(L^' 10 mos. llmos. 101 inch. linch 2} inches Excellent. Comp'd com. tract, middle third leg Deep Bot- V 11 mos. — 3i inches iinch 2 inches ExceUent. tom, Va. Comp'undfractui-e Deep Bot- Aug. 14, 5 mos. 7 mos. 10 inches linch 21 inches Good, well except sUght nicer. of ankle joint . tom, Yo, 1*4 Comminuted frac- Morris Isl- ^&^^' 6 mos. 8 mos. li inches Kone 3 inches Stump heeled. ture lower third and, S. G. of leg . . . . Comminuted an- Morris Isl- Aug. 29, 1863 5 moB. 13 mos. ISiinch. linch 2 inches Stump long, redun- kle joint and foot and, S. C. dant, some in- flamed, ulcerated, wiU be efficient. ScTcring leg at an- kle Morris Isl- and, S. C. Aug. 31, ma 4 mos. lyear 12 inclieG Jinch 21 inches Stump not healed, will be efficient. Striking leg at ^unction of lower Antietam, Sept. 17, f862 9 mos. 11 mos. 8i inches 2i inches 8 inches A model stump, Md. healed by first in- third, Bhatterine the bone, exit at tention, cicatrix hardly percepti- ble, silver liga^ the heel . . . Rtures, slump right proportions. Comp'und fk«cture Fur Oaks, June 1, U moB. 1 year & 9 inches None S inches Stump healed. lower third of Va. 1862 £mo8. some damaged leg nMs':'"^- Comp'd fracture of ankle and lower third of leg . . Comp'd com. fmct. Fair Oaks, May 81, 1862 14 moB. lyeaxSt 10 mos. 9} inches linch 4^ inches Va. Fair Oaks, May 31, llmofl. 1 year & 8 inches 11 inches 21 inches Ulcer on end. of aukle joint. Va. 1802 5moB. ball entering back of internal malleoU, and ex- it at anterior lat- eral portion for- ward of external malleoU. . . . Comp'd com. frac- ■Wood- Junes, 16 mos. l9moB. 4inclLe8 Jinch 13 inches Stump healed. ture middle ot stock, Va. 1863 increase 1^ by accidental discharge of m u£- ket Comp'd com, frac- ture of tarsuB, en- Sondy Ridge April 17, 1863 6moB. 8 mos. 13 inches linch 31 inches Stump smooth, well healed, le? trance tareo- me- dundant; query, tatarsus, exit could parts hav^ posterior exter- been secured nal malleolus . . from Syme's at ankle, vastly «u- perior. Entirely severing leg ai its middle Berwick M'ch28, 8 mos. _ — Bay en- 1863 Uurd gagement Compound com- Drury'B Bluff, Vft. M'^l". 8-moa. 9 mos. 61 inches None 2 inches Healed, excellent, minuted fracture compact, firm. of Bukle joint . Compound frac- Drury's Bluff,Va. «i^w. 7 mos. 8 mos. 9 inches Jinch 3 inches Healed, some dam- ture of ankle aged by exfolia- joint Comp'd com. fract. of foot and lower I>art of leg . . . tions. Baltim're, 'ii?- 2 years & 8 mos. 3 years 71 inches iinch linch Md. Gen. Por- June, _ 9 inches linch linch ter's staff 1861 Comminuted frac- Fort St ^fi^' 10 mos. 10 mos. £ inches linch None ture of lower Philip 8c third of leg . . Jackson At ankle joint, low- Frededks- Dec. 13, 4moB. 8 mos. 7 inches Jinch 3^ inches — er third of leg. buig, Va. 1862 severing the foot from the leg save a few shreds of tiftsuea .... Severing the foot Freder'ks- Dec. 13, 4 mos. — 81 inches linch 11 inches "Sd. ■""" from the leg at butg,Va. lfi62 the lower tliird. ■ave bv some 34 TWO HUNDRED AND EIGHTY-SEVEN CASES TABLE OF TWO HUNDEBD AND EiaHTT-SEVEN CASES J.H. Q.W. P. F. A.G. M.W. ■W.B. ■W.G.B. B. 3. B. H.B. KS. J.R. H-W. l.B. A. D. D. B. I.e. lata Ma (H. LO. J.B. RE.W. 7. UcC. I. L. S. D.B. C. K. s. s. J. c. W.H.H. J.N. Begiment. 3Slh N. T. Vols. 9th N. T. Vols. SOlhN.T. Mllitis 75th N. Y. Vol». U4lhN. Y. Vola. 9th N.J. Vola. U. 8. Navy 137th N. T. Vols. 16th BL Vols. 10th Ohio Cavaliy TJ. 8. Navy U. S. Navy V. S. Navy IJth N. Y. Heavy Ar- tillery 97lh N. Y. Vola. 83d N.y. Vola. Omaha Indian Uth N. H. Vols. 9th N.Y. Vola. l«lh N. Y. Vola. 1st D. C. Vola. 4th Mich. 1st Fcnn. 1st Penn. BcBOrvo 142d N. Y. Vola. 55th N. Y. Vola. lat Md. Vols. U. 8. Navy Occupa- tion. Limb. Clerk B. E. Cabinet- maker Farmer L. L. ArtUt B. Foundry I.. Boat- K. swain Farmer E. Brick- layer L. Farmer R. Ordinary Seaman K. Ordinary seanuin L. Sailor R. Oerk L. UiUer R. Cooper L. - - Farmer & I.. currier Farmer Ij. Carpenter L. Farmer L. None L. Farmer a. None B. Fanner L. Farmer L. Farmer L. Seaman L. Point of Operation. Upper third Ixiwer Rnd middle third Upper third Junction of middle and lover third Upper third Lower and middle third Lit, middle third 2d, extreme upper third Middle third Middle third Upper third l/ower end middle third Lower and middle third Liower third Lower third Upper third Upper and middle third Lower third Upper third Upper third Middle third Lower third Extreme of upper third Middle and upper tliird Upper third Ant post flap Circular FoBterior flap Ant post flaps Bilateral flaps Circular Circular Ant post flap Circular Posterior flap Bilateral skin- flaps and circular Ant post, flap Lateral flaps Bilateral skin flaps and circular Bilateral flaps Ant post flap Ant post flaps Flap Circular Ant post flap Flap Flap Circular Circular Circular Bilateral skin flaps and circular "Where per- formed. Field hospi- tal On the fleld On the field General Hos- pital, Baton Bouge Hospital On the field Naval Hos- pital, Pen- sacolo, Fla. On the field 2d, in general hospital On the field U. S. gun- boat General Jackson Norfolk U. S. Hospital Ship Kara- tan za In Falmouth Hospital Union Chap- el Hospital Oo tiie field At Savage's Station On the field lu fleld hos- pital De Camp Hospital On the field On Montauk, U.S. gunboat Length of Time after lujury. Five hours 2d operation eleven days Twenty-one hours Thirty days Half hour Sev'nty-two hours Two hours 2d, twenty- three days Twenty-one hours Sixteen days Istj one hour __, caused by slo'gliing One day Fifteen hours Six days Half hour Three days Three hours Thirty-six hours Twenty-fo'r hours Three days Fifteen days Three noun Twenty hours One hour Cannon-ball Extensive sloughings simultatve- ous with 1st dressing Minie-Difdl Fragment of shell Minie-ball Musket-baU Solid shot Explosion of torpedo Piece of shell Musket-ball Minie-ball Shell Minie-baU Grape-Bhot Grape-«hot Canlster- Bhot Fragment of shell Grape-shot Bifle-ball Minie-ball Bifle-ballft buck-shot Minie-ball Solid shot OF RECOVERED AMPUTATION OF THE LEG. 36 OP RBCOVBEEB AMPUTATION OF THE LEa.—( Conlimied.) Length of Length of Atrophy. Beuabks, time from time from DeBcripdoit of In- Battle. Date. Amputa- Amputa- Length of Stump. Generally made at Time of Applicor tion of Artificial jury. tion to tion to Exami- Applica- Proximal Dibtal nation. tion. Portion. Portion. Limb. Comp'd com. frac- Frcder'ks- Dec. 13, 4moB. 5moa. Si inches None 13 inches ture lower half burg.Va. 1863 of leg, 2d, expos- ure of tibia, Bome exfoliations . . Comp'und commi. Freder'ka- Dec. 18, 4mos. 4mos. 9 inches tlnch 2i inches fract. lower third burg, Va. FretTer'ka- burg, Va. 1S63 Bevering leg at low- er third. . . , Dec. 13, 1862 5mofl. 7moB. 3 inches None None Stumjp spread, ad- heuion. Comp'und fracture Baton 1&' 7mofl. 9moB. 9 Inches 11 inches 3 inches Stump mainly healed, pretty of tibia, astrag- Bouge aluB, etc. . . . good covering end ehanc, crCEt cicatrized, ab- scesBea, etc., wi I prove very good. some oedema. Near ankle joint . Cleaning gun June 25, 1865 7moB. 13 mos. "*" 2 inches 3 inches Healed by first in- tention, finely composed. Severing the leg Goldsb'ro, Dec. 17, 9mos. lyear {inch None 2} inches Stump healed. at lower third . N. C. 1662 sound. Comp'd com. frac- Mobile M'ch 29, fimofu 9 inches 1} inches None Very ccdcmatoua. ture of ankle Bay, Ala. 1865 increase healed, system joint and foot . debilitated. Comp'd com. fract of tower third . Atlanta, '•^• 9moH. 11 mos. 9 inches None None Very fair, stump flexed for knee Ga. 8moB. 10 mos. 2} inches ^JS.'^' support Comp'und commi- Savannah, Dec. 13, 3moa. 5 mos. 7 inches None 13 inches Very good, scan^ nuted fracture of Ga. 1864 covering. lower third of leg Comp'd com. fract. of leg and ankle Macon, Nov. 19, 4mos. 7 mos. 7 inches None None Will be good, not Ga. 1864 well cicatrized. Joint . .... Wound of posterior Ft Fisher JanVlS, 18&> 2mos. 5 mos. 3 inches None None Not healed, doing tibial artery, no N.C. well, flexed for fracture . . . knee support. Baa, poorly cov- Compound com- Fort Fish- Jan'y IS, 6moa. 9mo6. 8 inches None linch minuted fracture er, N. C. 1865 ered, damaged by of ankle joint . filoughe. Comp'und fracture of lower third of Fort Fish- Oct 11, 5moa. 5 mos. 6^^ inches 3 inches 8 inches er. N. C. 1862 kg Nov. 6, 1862 4mos. 4 mos. Comp'und commi- Hatcher's Mnr. 31, 5moB. 6 mos. 8 inches linch 21 inches exfol'd, sloughed. nuted fracture of Bun, Va. 186S mcreaac anklejoint . . Comp'und commi- Hatcher's reb'vS, 4moB. fmos. 83 inches finch 23 inches Very long, com- nuted fracture of Run, Va. 18&> ahea^d!"-^ anklejoint . . Comp'und commi- nuted fracture of Dallas, Ga. ^Jsf- 7mos. 8mo6. 10 inches (inch 1| inches Healed, very good. tarsus .... Suppuration, in- filtration, and — — — — _ ^ — — mortification . . Comminuted frac- Bappa- Dec. 13, Tmos. 16 mos. S inches J inch 21 inches Stump extremely ture of lower third of leg . . Canying away the hannock 1862 cicatrized. Roanoke ^'iS*- 16moB. 17 mos. 3) inches None None Stump flexed. leg. except a few fibres from upper Island, tif^ly anchytoaed. N.C. middle third. . Comp'd com. frac- Falls Ch., Not. 29, Smos. 10 mos. 6 inches None 3 inches _ ture of tibia . . Va. 1862 Entirely destroy- Rich- Sept. 29, l864 5m08. 6moB. lOJ inch. linch 3 inches Finely healed, ex- ing the taniUB . mond, Va. cellent Comp'd com. fract. Gaines's June 28, 9mos. 10 mos. 4i inches J inch 3 inches of middle of leg Mills, Va. 1862 3| effect Comp'und fracture WhiteOak June 30, 5mo8. _ 3| inches i inch 33 inches Stump fair, short. of anklejoint . Swamp, Va. 1862 defective, prison- er at Richmond. Comp'und fracture WhiteOak June 30, 1 month 5m0B. 7 inches None 2i inches Stump sloughed. lower third of leg Swamp 1862 exfoliation. Comp'd com. fract City "l-sSf- 7mo8. 9moB. 10 inches jinch 4incheB Very good, weU formed. of anklejoint . Point, Va- Hcridian, Comp'und commi- Feb. 15, 11 moG. lyear linch None None Very good, neat. nuted fracture of middle of leg . Comp'd com. frac- Miss. 11164 good knee sup- port Healed. Mon'cacy, '"l^'- 5moa. 6 mos. 3} inches linch 3 inches ture of low. third ofleg . . . . Destroying leg at middle ttiird . Md. Stono, 8. C. "&'' £moa. 6 mos. 3i inches None None Swollen, not entire- ly healed, rigidly flexed at right angles, knee sup- port. 36 TWO HUNDRED AND EIGHTY-SEVEN CASES TABLE OP TWO HUNDRED AND EIGHTY-SEVEN CASES IIaAi. Bcgiment Occapa- tion. Limb. D. T. «MN.Y. Vols. Printer L. F.RK. 66lhN. T. Vols. Barber K. C.B. J.W. UlstN.Y. Vols. eethN. Y. Vols. Butcher Cabinet- maker L. L. M.W. 16M N. Y. Vols. Seaman K. C.A.B. Mth N. Y. Vols. Railroad R. P.B. 100th N.Y. Vols. Cigar- maker R. A-W. GthConn. GUder L. }.M. 76th Pcnn. Volji. Carpenter L. M.S. F.K. 100th N. Y. Vols. 7th Conn. Laborer Railroad laborer R. L. R.H.T. 4th B. I. Vols. Boatman L. S.C.R. J.H.B. 2d F«nn. H.ArtiU'ry SdU.S. C. T. Moulder Sidlor B. R. C.B. IstU S. C. T. Honse- serrant R. M.L. 123th N. Y. Vols. Livery R. W. T. 20th Mich. Farmer R. G.B. 97th Pcnn. Clerk R. M.M. 6th Wis. Vols. 2d Lieu- tenant R. U.F. S. Mth N. Y. Vols. - B. W.T.M. 48th N. Y. Vols. Seaman L. H.G. 1st Maine Heavy Ar- tillery Farmer L. J.K. 7th N.Y. Artillery Potter L. R.D.P. T.B. 9th N. Y. Artniory «h N. Y. H.ArttUery Farmer L. L. Point of Operation. Middle and upper third Upper and miadle third Upper third Uppei' and middle third Junction of lower and middle tliird Upper and middle Ziower and middle thiid Upper third Upper third Upper third Upper tWrd Upper third Lower and middle third Iiowdr and middle third Lower and middle third Upper third Upper third Ijower third Middle third Middle third Upper and middle third Upper third Upper third Lower and middle third Ant. post flaps Lateral flaps Ant. post flap Latere flaps Bilateral flaps Ant poet flap Circular Ant post flap Circular Circular Ant. post flap Circular Ant. post flap Circular Bilateral aVin flaps and circular Bilateral flaps Ant post flaps Long post flap Ant post flap Ant. post flap Ant post flaps Where per- formed. Ill fleld hos- pital In fleld hos- pital In field hos- pital On the fleld Beaufort General Hos- pital Charleston, S. C. Charleston, S, C. On the fleld Confederate hospital, Charleston, S.C. McDougal Hospibil On the field On the field Portsmouth U. S. Hoap'l On the fleld On the fleld Knights Hospital, N. H. liewtown Hospital, Gettysburg On the field On the fleld On the field length of Time after Injury. Tw'nty-two days Twenty-fo'r hours Two hours Two hours Three hours Four days Twenty-fo'r hours Forty-eight hours One hour Ten hours Eighty-eev- cn days Three hours Five hours Ser'nty-two hours Three hours Three hours Twenty-fo'r hours Twenty-fo'r hours Sixteen days Twenty-fo'r houiB Twenty-fo'r hours Forty-eight hours Cause. Piece of sheU MusLet-boll Kfle-ball I^^men't of SheU Piece of SheU Grape-shot Two can- is ter-Bhot» SheU Grape-shot Fragment of shell Fragment of SheU Gra^e-shot Piece of SheU Mlnic-bdl Musket-boll Piece of ■heU Grape-Hhot Minie-boU Minie-baU OF RECOVERED AMPUTATION OF THE LEG. 37 OF RECOVERED AMPUTATION OF THE liEQ.^i Continued.) Beecii^tion of In- jury. Comp'und {Vacture of upper middle third of lefi: . . Comp'd com. frac- ture of low. third of lee .... CQmn'uad fracture mid. third of leg Comp'und fracture of lower third of Destroying foot at tarsus .... CJomp'd com. fract. almost deetrVing low. third oileg Entrance head of first metatarsal bone, exit be- neath external malleolus, corap. com. fracture of tare us metatar- sus, ankle joint not injured . . Comp'd com. frac- ture of ankle and middle third of leg Comp'd com. frac- ture of leg a1 middle third. . Dis&eTering leg; at its middle tMrd Comp'd com. frac- ture of middle third of leg . Comp'und fiacture of tibia, wound of tibial artery . . Comp'd com. fract, of ankle joint . Compound com. fracture of ankle joint Comp'und commi- nuted fracture of ankle joint . . Comp'd com. frac- ture of middle of leg Comp'und fracture of middle third of tibia .... Comp'd com. frac- ture metatarsus, subsequent gan- grene . .... Comp'und commi- nuted fracture of ankle joint Comp'd fracture of ankle joint Nearly destroying leg at junction of lower and middle third . Comp'd com. frac- ture iunction of middle and low er third . , . Comp'd com. fract of middle of leg Comp'd com. fract. of middle of leg Comp'd com. fract. of lower third of leg , . . Antietom, Md. Antietam, Md. Antietam, Md. Antietam, Md. Deep Bot- tom, Ya. Winches- ter, Va. net, jrE Ft. Wag ner, S.C Ft Wag- ner, S. C. Ft. Wag- ner, S. C. Ft Wag- ner, S. C. Peters- bui^, Va, Fetere- burg, Va. Petera- burg, Va. Petera- buig, Vo. Peters- burg, Va. Peters- burg, Vo. Peters- burg, Vo. Getlys- burg. Pa. GettyB- burg. Pa. Peters- burg, Va. Peters- burg, Vo. Peters- burg, Va. Coal Har- bor, Va. Coal Har- bor, Va. Length of time from Amputa- tion to Exami- nation. Sept 6, 1662 July 2r, 1&64 Sept 19, 18G4 July 18, 1863 July July 18, uses July 11, 18(33 Julys, 1861 June 21, 1861 June 15, 1864 June 17, 1864 June 18, 1864 Jan'y 17, 1^ July 2, July 19, 1863 July 80, 1864 June 16, 1864 June 17, 1664 June 8, 1864 June 1, 1864 7nlofl. 6moB. JSmoB. 5 moB. 6moB. 15 moB. 4mos. SmoB. Smoa. 6 mos. 7mo8. 8moB. 8 mos. 8moB. 11 moB. 10 moB. 10 mos. 8mofl. 9 mos. 18 mos. 14 moB. Length of time from Amputa^ tion to Applica- tion. Length of Stump. lycar& 6 mos. 8 mos. 7 mos. 8moB. 8 mos. lycar 9 mos. 9 mos. 19 moB. lycar lycar 10 moB. 10 mos. 6J inches 6 inches 6 inches dj inches 3J inches 9 inches S inches 2J effect 4 inches 3 inches 9J inches 9} inches 9i inches 3 inches 3 inches minch. 8 inches 8 inches 6 inches 32 inches J inches I inches Atrophy. Proximal Portion. Distal Portion. None None iinch 3 inches 3 inches 8 inches None 2 inches None 2 Inches None None Iinch 3 inches None 21 inches None None {Inch increase Iinch increase Iinch IJ inches None None None llnch (inch 3 inches None - None None None None None li inches (inch 4 inches Iinch S inches iinch li inches None None None None None None iinch S inches Rbuabes, generally mode ft Time of Applica- tion of Artificial Limb. Stump healed. Ligatures removed, crest of tibia prominent Healed very good, model etump. Some angles of flaps ; in very good condition. Stump not healed, damaged by gan- grene. Tibia shortest, fit'mp well healed, will prove efll- cient St'mp yet ulc'rated, enlarged, semi- flexed, knee sup- port, fine stump, highly creditable. Stump not yet healed. Stump healed, tumefied, cica- trices on the crest by exfoliation^ one finger ofi, arm fr;actured, inferior maxilla fractured. Very good, knee flejced for knee support. Not healthy, eo- zematous. Healed first rate. Above diBeased part unhealthy, exfoliations. Healed irregular, posterior petty flap. Very good, healed, knee, support. Not entirely heal'd, some indications of exfoliation, too long. Eight inches, ordi- n'te,finely formed, healthy, fi"*j7 cicatrized, em- cient. Healed, cicatrized, well formed. Pretty good, re- dundant flap, not strongly cica- trized. Strongly cicatrized, flbula spread, prominent crest Very good, smooth, make good knea support Very good. Very good. 38 TWO HUNDRED AND EIGHTY-SEVEN CASES TABLE OP TWO HUNDRED AND EIGHTT-SETEN CASES N.J. E. C. L. J.B. J. 0*B. O.W.G. J. D. P. F.H. O. P. C. J.W. W.C. H.McG. W.i>. A. J. A. J.D. T.C- Regiment. F.H. T. S. nth N. Y. H. Artill'ry 8th N. J. 66th N. T. Vols. 6th Md. Volfl. 148th N. Y. Volfl. 8th N. Y. U. Artillery let Moss. Heavy Ar- tillery 47th Pean. VolB. 1st Excele'r Brigade 17th N. Y, • Vols. 120th N. Y, Vols. 59th N. Y, Voh>. rSthN.Y. Vols. 145th N. Y. Vols. 29th N. Y. Vols. 73d N.Y. Vols. 62dN. Y. Vols. 5rth N. Y. Vols. 3d U.S. Infiuitry fith Mass. Vols. 2dVt. VoU. Occupa- tion. Fanner Farmer Operative Shoe- maker Dry-gooda clerk Farmer Wool carding Coverlid weaver None Laborer Shoe- maker Brick- layer Water- man Hemp- dtesser Carriage- painter Point of OperaUon. Upper and middle third Liower and middle third l/ower and middle third Upper and middle tliird Lower and middle third Lower third Upper third Upper third E Brand e third' Upper third Lower third Upper and middle third Upper third Lower and middle tliird Upper third Lower and middle third Middle third Middle third Middle and upper third Ist, middle third 2d,uj Bilateral skin flaps and circular Circular Anterior flaps Ant post flaps <^rcular Bilateral akin flaps and circular Bilateral flaps Posterior flap Ant poBt flap Ant post flap Circular Posterior flap Ant. post flaps Circular Posterior flap Posterior flap Circular Posterior flap Posterior flap Circular Circular Circular Where per- formed. On the field On the field On the field Forty-eight hours Two hours and a half On the field Four hours Length of Time after Injury. Two hours On the field On the field On the field On the field At hospital Hilton Head Hospital SteomerVon- derbilt, June 7tk On the field On the field On Uie field Ist on the field 2d,Fitzhugh Uospil shugE litaf In field hos- :reek pitaL Acq.uia Ci ' In field hos- pital On ihe field On the field On the field On the field Ist on the field 2d^t Mount Pleasant Hospital Twenty-fo'r hours Five hoars Four hours One hour Two m'n&B Three days Seven days Twenty-fo'r hours Thirty hours Twenty-fo'r hours Three hours Two hours Eighteen days Fourteen days Eight days Twenty-fo'r hours Nine hours Two hours Eight hours Two hoUTH 1st, Twenty- four hours 2d, Thirty- four hours Minie-ball Minie-boll Fuse shell Minle-ball Minie-hall Minie-ball Musket-ball Grape-shot Minie-ball Canister- shot Bifie-baU Piece of shell Minie-ball Gunshot Minie-ball IstPiag- m'nt of shell 2d, bone ex- posed by ex- tr'me slo'gh- ing Rifle-baU & extensive suppurati'n after 14 d'ys on the field Minie-ball Minie-ball Mu6ket-baU Minle-ball Piece of , shell Solid shot 1st, BheU 2d, slough- ing and pro- trusion of bone * Syme's mode at ankle joint, slongbcd. OF RECOVERED AMPUTATION OF THE LEG. 39 OP EBCOTBRED AMPUTATION OF THE LEG. — (Condnued.) Peacription of In- jury. Gomp'd com. fmcL of ankle joint . Comp'd com. fract. of ankle joint . Destruct. of leg at low.* mid. third Compound coninii' nuted iracture of leg ... . Comp'd com. frac- ture of leg and ankle joint Comp'd com. fract of middle of leg. Comp'd com. fract. of ankle joint . Comp'd com. fract. of ankle joint . Slight flesh wound middle of leg, gangrene. Comp^d com. fract lower third of leg .... Comp'und fracture of tarso and met- atarsal bones . , Deetruction of leg at ankle joint , Removed the foot, ankle joint not Etined . . . Comp'und commi- nuted fracture of leg .... Comp'und commi- nuted fracture . Comp'd com. fract oflow. part ofleg and ankle joint Comminuted frac- ture lower third ofleg . . . Comp'nnd commi- nuted fhu:ture of middle third of leg ... , Comp'd com. frac- ture ankle joint Comp'd com. fract of middle of leg Comp'und commi- nuted fracture of middle of leg Comp'd com. frac- ture of middle third of leg . . Comp'und commi- nuted fracture of foot and lower part of leg . . Deetruction of leg at lower third . Nearly severing leg at its lower Petcra- bure, Va. Peters- burg, Va. Peters- burg. Va. Peters- burg, Va. Peters- burg, Va. Peters- burg, Va, Peters- burg, Vo. Peters- burg, Va. Peters- burg, Va. Pocotali- go, S. C. Fair Oaks, Va. Blue ' Springs, E. Tenn. Chancel- lorsville, Va. Chancel- lorflvillc, Va. Chancel- lorsvitle, Va. Chancel- lorsville ClmnceL- lorsville, Va. Chancel- loreville, Vu. Chanccl- lorsvillc, Va. Chancel- lorBville, Va. Fred'icks- burg, Va. July 30, 1804 July 30, April 2, 1865 May 10, 18t>4 June 22, 1864 June 22, 1864 June 18, imi June IG, 1864 June 16, 1861 Oct 22, 1862 June 1, 1862 M'ch 17, 1865 Oct 28, 1864 Aug. 15, 18(» June 22, 1864 Oct. 10, 1863 May 2, Mays, 1863 May 2, 1863 Mays, 1863 May 3, 1863 Mays, 1863 May 2, 1£^ Length of time from Amputa- ;ion to Exami- nation. Length of time from Amputa- tion to Applica- tion. 16 mos. — 15 moB. 16 mos. 5 mos. 6 mos. lyearft 3 mos. 16 mos. 13 mos. 15 mos. Umos. 14 mos. lyear 13 mos. 11 mos. lyear 10 mos. lyear 4 mos. 6 mos. 7 mos. - 6moa. — Umos. lyear 13 mos. 14 mos. - 15 mos. 4 mos. 10 mos. Umos. lyear 6 mos. 14 mos. 5 mos. 18 mos. 8 mos. 10 mos. fimos. Umos. 4moe. 7" mos. 4 mos. 6 mos. 4m»8. 6 mos. U mos. 15 mos. length of Stump. 15 inches 10 inches 3 inches 7 inches 9 inches 4j inches 10) inch. Hi inch. 3 inches 49 inches 2i effec- tive 3J inches lOJ inch. 6 inches 2 inches 9 inches 7 inches 82 inches 5 inches 2J effect Knee support 73 inches 3 inches 2 effect. Atrophy. Projcimal Portion. Diatol Portion. None 2i inches linch 5 inches None None 3 inch 31 inches iinch iinch 2i inches 2 inches linch 2i inches linch 2 inches None None None 3 inches -> iinch 3 inches iinch _ li inch ^ inches None None None 2^ inches J inch 1^ inches None None Unch increase None iinch 3 inches Sinch 2} inches None 12 inches None None linch linch None 2 inches iinch increase None Bekareb, Generally made at Time m Applica- tion of Artificial Limb. Considerably atro- phied, excellent Very good. Some atrophy, four inches of seques- tra removed, | shaft ot bone cased, new bone* very good. Very good, poste- rior some re- tracted. Very good. Some atrophy, very good. Some atrophy, ex- cellent Very good. epi- Exfoliation, demic. flap post, redun- dant, adhesions now broken up. Normal, very good. A prisoner three months in Peters- burg, one month in Richmond, st'mp firm, heard. Bad by sIoughLngs, gangrene, ecze- ma. Knee flexed for knee support, very good. Stump not healed, ulcerated. Stump healed, flap ftendulous, exfo- iotions, extensive cicatrization. Stump damaged by sloughing. Stump not yet healed, will result fovorably. Stump healed, effi- cient Stump ill condi- tioned, flap pen- dulous, extensive cicatrization, mainly healed. Stump healthy, condition flexed, clean, good knee support. Stump healed and well prop'rtioned. Stump contracted, caused by flesh wound of nip, In- volving the flexor muscles of leg, healed. Parts nearly healed, badly damaged by abscessea and sloughings below and above knee, stump pretty vig- orous. 40 TWO HUNDRED AND EIGHTY-SEVEN CASES lASLE OP TWO HDNBRED AOT) EIGHTY-SEVEN CASES »AKK. Begiment Occnpfi^ flon. Limb. Point of Operation. Method. "Where per- formed. LengOiof Time after Injury. Cause. G.A.F. 14th Conn. Vols. Fanner L. Lower and middle third Circular On the fleld Jonr days Minle-baU J.B. 36th N.Y. Vols. Laborer B. Upper and middle third Circular On the fleld Half hour Piece of sheU O. Z. rth N. T. VoU. Joiner L. Upper third Circular On the fleld Five days Musket-ball W.W.M. 20th N. T. Voli, 2dVt. VoU. _ R. Lower third Circular On the fleld Three days Minie-baU J. H. M. Farmer L. Upper third Ant post flap In hospital, Frederick Two hours Minie-ball 8.T. }.yr. 29th N.,Y. Vol«; 22dN. T. VoU. IMthN.T. VoU. None Sawyer underman Farmer B. L. B. Middle third Upper and miaSe thiid Lower third Ant post flaps Posterior flap Ant. post flaps City Inflrm'ry H., Wash., D. C. In fleld hos- pital On the fleld Twenty-fo'r hours Three hours Seven hours FaU Canister- shot ^tf^eU* H.C.B. 8th Conn. Baggage- master Hartford Bailroad Operative B. Lower and middle third Ant post flaps WiUow Spring^Hos- Six weeks - w.at 8th Conn. L. Lower third Circular In the fleld hospital Three weeks Minie-baU F.B. <9th N. Y. VoU. Painter B. Upper third Ant post flap On the fleld Eighteen hours Bifle-baU F.H.M. SlhN.T. VoU. Clerk L. Upper third Circular In fleld hos- pital, Fal- mouth, Vo. Eighteen hours Musket-baU B.W. S.H.G. 9th N.Y. VoU. 18th Conn. Printer Laborer B. L. Middle and lower third Upper third Circular 2d,Bilatena flaps Posterior flap Stone Hos- pital 2d,llewYork On the field Nine weeks ^.sev'nteen months Five hours Minie-baU Minie-bcOi Vr.H.M. SlBtHUs. VoU. Farmer L. Lower third Ant post flaps On the fleld Three hours Minie-boU B.B. F.W. 74th N. Y. VoU. 49th Bcgt. Farmer Sailor L. L. Middle third Lower and middle third Ant post flaps Ant post flaps General Hos- pital, New- Orleans Lee's Mills Hospital Eighty-one days Minie-baU Kifle-baU H.ILD. U4lh N. y. VoU. Farmer L. Upper third Bilateral skin flaps and circular Campbell Hospital Fourteen days Minie-baU J.U. H.P.D. 7th Conn. VoU. 12th N.H. Brick- layer Shoe- maker L. B. 1st, middle third, 2d, up- per third Upper third 2d, ant post. flaps Ant post, flap U. S. Hos- pital At Jarris Hospital, Baltimore Eighteen hours Ten months Twenty- seven days Grape-shot Mlnle-ball F.B. E.K. 2l)thBeet. JjiTalit Corps 12th U. S. In&ntiy Laborer B. L. Lower third Upper third Ant post flaps Circular On the field On the fleld Three hoois Twelve hours Minie-baU Canister- shot C.W. 4Sth N. Y. VoU. Printer L. Lower and middle third Circular Octtysburs Hospital Tw'nty-two hours Fragment oPsheU P.J.M lBtB.1. L. ArtiU'ry Hotter B. Middle third Posterior flap On the field Twelve hours Musket-boll OF RECOVERED AMPUTATION OF THE LEG. OF EECOVBEED AMPUTATION OF THE LEG. — (Coi«tm«i.) 41 Length of Length of Atrophy. Kbharks, timefVom time from JjMcripHon of In- juiy. Battle. J>atc. Amputa- Amputa- Length of Generally made at tion to tion to Stump. Time of Applica^ tion of Artificial Exami- Applica- Proximal Difitel nation. tion. Portion. Portion. Limb. Comp'd com. fhict. of lower third of Fred'icka- Dec. 13, 10 mos. 14 mos. 8 inches linch 2 inches Stumpsmooth.well modeled, neural- burg, Va. 1862 leg . .... gia, an teriortibial nerve morbidly Bcneitive. Comp'und commi- nuted fracture of Fied'icka- Mays, 5mofl. Smos. 51 inches Kone linch Stump Bome dam- aged by exfolia- tion, will be effi- cient Stump all available burg, Va. 1863 lower tliird of les Comp'd com. fract Fred'icka- Dec. 13, 10 moa. 13 mos. 21 inches None 3 inches of middle third of burg, Va. 1862 though abort ul- Coiflp'dcom.finict. cers on the end. Fred'ickB- Dec. 13, — lyear 7j inches 2 inches 2f inches Healthy. of ankle joint . burg, Va. FreJ'icka- 1862 Comp'd com. frac- ''lis'- 4 mos. 7moB. 3J inches None 2J inches Stump not healed. ture of middle of burg, Vn, will prove effi- ICR cient. Comp'und fracture Mason'i Oct. 2, — — 9 inches Jinch 11 Inches lower third of leg Comp'd com. fract. of lower third . Hill 1861 South Sept. 14, f862 ZmoB. 9 mos. 4i inches None U inches — Mountain Entire, deetruction Antietam, Sept. 17, 18 mos. 21 moa. 9 inches li inches 4i inches Stump healed, of the ft>ot at Md. 1862 scarcely sufficient tibia BstragoiuB cicatrix. articulation . . Antietam, Md. Sept. 17, 1862 18 mos. 21 moa. 9 inches 1^ inches 2i inches Stump nearly well, circulation filug- giBh, cold,bluiBh. Through ankle Joint Antietam, Md. Sept. 17, 15 mos. 19 moB. - - _ Stump entirely healed, but look- ing very blue and tender, general health good. Comp*nnd commi- Fred'ickB- W- 3 mos. 7 mos. 3i inches J inch linch Stump tumefied, nuted fracture of burg, Va, increase partially .fiexed, middle and low- rigid atan angle of 45*, cicatriza- tion extensive. er third oi leg . Comp'und commi- Fred'icks- Dec. 13, 7 mos. lyear & fimoB. 3| inches None None Stump ulcerated, diathefiis scrofu- nuted fracture of bure, Va. 1862 ' middle of leg . lous, absccsaes, general syetem impaired, notdit- eosed. Comp'und commi- Fwd'icks- Dec. 13, 7 mos. 20mo8. 8i inches iinch jinch Stump good, tume- fied, hard, three nuted fracture of burg, Va. 1862 ankle and tibia . ulcers on end. Comp'd com. fract of lower third of Piedmont, June E, 9 mos. 10 moB. 2^ inches None None Not good, very an- gular and redun- daut Va. 1864 leg Comp'und commi- McDon- Nov. 16, Smoa. 4 moa. 12 inches None 2 inches "Well cicatrized, nuted fracture of ald, Ga. 1864 very good, ex- ceaEively long. tarsua anterior to medto-tarsal line Comp'und fracture Teche, *^^- lyear 14 mos. 7} Inches linch 3 inches Stump healed, ^ of ankle joint . La. come latter part of May. Comp'd fract. mid- Torkfwn, «J^5^' 7 mos. 7 mos. 9 inches 23 inches 2| inches dle of leg, parts Va. ab'venot injured Comp'und commi- Peters- June 22, 7 mos. 9 moa. S inches None None Healed, flexed, nuted fracture of burg, Va. 1864 ham-atringa rigid, middle of leg . otherwise good, wishes knee sup- port Excellent Comp'd com. fract of lower third of Peters- "t^"' 14moB. 15 mos. 4 inches iinch 2} inches burg, Va. 3 avail- able leg Comp'd com. fract. GettyB- '%'• 9 mos. lyear 3i inches None None St'mp healed, dam- of external ankle burg, Pa. aged by abscesses, aloughings, exfo- and tar&ue exclu- sive of calcane'm liations. Comp'und commi- nuted fracture of Gettys- '^' 8 mos. _ Hi inch. li inches 3 inches Stump neatly burg, Pa. formed, healed by ankle joint . . Comp'und comml- nuted fracture ol Gettys- '%'' 7 moa. llmoB. 3J inches None 2i inches first intention. Stump healed. burg, Pa. spread by infil- middle of leg . tration, and long angles of cicatri- zation. of lower third of leg Gettya- burg.Po. Julyl, 1^ 7 moa. 10 mos. 8i inches iinch 3 inches Stump healed, in pretty good order, damaged by ab- BCeasea and exfo- liation a alone line of tibia. Comp'und fracture of lower third ol Chancel- T&'- 13 moa. 14 mos. 6^ inches li inches SJ inchea Healed, badly com- lorHville, posed, efficient. leg Va. 1 42 TWO HUNDEED AND EIGHTY-SEVEN CASES TABLE OF TWO HUNDKED AND EIGHTY-SEVEN CASES Naki. Segiment Occupa- tion. Limb. Point of Operation. Method. ■Where per- formed. Length of Time after iDJuiy. Cause. &W. 68lh N. T. Tola. l^abOTCrin houae a Upper third Circular On the field Six days Fragment of shell J.H.P. 20th Conn. 66th N. T. Vol«. Gunsmith Cabinet- maker L. a Middle and upper thinl 2$, middle third Middle of leg Posterior flap Circular 1st, hospital, Gettysburg, 2d,Pro?'rost, New York On the field Thirty-four d^s 2d, Four months Forty-eight hours Rifie-ball 2d, seques- trum from dead bone Mlnie-ball H.D. SZdN.Y. Fanner L. Lower and middle third Lower third Circular On the field Three hours Grape-shot D.K. lit N. T. VoU. Iron- worlcer a Circular On the field Five houra Musket-ball J.W.C. J.C. SZdN.T. 10th N. T. VoU. Moulder Laboier a Lower third Lower third CircuUr Bilateral flaps On the field One hour end a half One hour Minie-baU Musket-ball a.E.o. 122dN. T. VolB. Canienter and joiner L. Lower thini Circular Hospital, d: c. Five weeks Fragment of sheU T.C. 42dni. Infiintiy Mth Mnas. VoU. Fanner Mechanic I,, a Middle and upper third Upper tliird Circular Circular Field hospi- tal Two hours One hour Musket-baU Fragment of BheU B.vr.B. aethN.T. VoU. Hatter a Upper third Ant post flaps Portsmouth Hospital, Va. Sii weeks Musket-baU O. 8. 9th Vt. VoU. Fanner 1. Upper third Anterior flap Field hospi- tal Twenty-fo'r houra Minle-baU J1.B. B. MeD. W.H.R. {SHiFenn. Vols. 6th N. T. U. A. l«th N. T. VoU. Farmer Hotel Uborer Fanner 1. a a Upper third Lower third Upper third Posterior flap CircuUr Ant post flap On the field On the field On the field Six houra Two houra Twenty-fo'r houra Piece of shell Minie-ball Minie-ball P.O'K. 7th N. T. H.A. Clothes- cutter L. Upper third Circular Douglass Hospital Six daya Bifle-ball O.W.E. Uth Fenn. Infantnr «h Vt VoU. Shoe- matEcr Farmer L. Upper tliird Circular On the field Twenty-fo'r houra Seven days Mlnle-baU B.A.B. li. Upper third Posterior flap Field Minle-baU G.F.T. 10th N. T. VoU. Captain L. Middle third Circular On the field Seven houra Mlnie-baU A.H. 49th N.T. VoU. Farmer a Lower and middle third Circular On the fleld Two houra Fragment of BheU J. IT. U. S. Navy Lando- man a Upper third BiUteral flaps Onboard Boney Twenty-fo'r houra Musket-ball P.E. Uth IIois. Vols. 724 N. T. Vol.. 20th N.Y. VoU. Spinner L. Upper third Ant post flap On the field Twenty-fo'r houra Twenty-five Four houra Musket-ball A.W. Ciga^ maker Jewel cases L. Middle third Ant post flap Ant post flap On Knick- erbocker On the field Musket-baU Kifle-bali aw. _ Farmer — Middle third _ — _ Cannon- baU J.G. 7th Mich. Laborer a Middle third Ant post flap Field hospi- tal " Nary Hospi- tal, Baltim'ie Twenty- eight houra E.P.S. Printer L. Upper and middle thiid Lateral flaps Bound mua- OF RECOVERED AMPUTATION OP THE LEG. 43 OP RECOVERED AMPUTATION OF THE V&Q.— (Continued.) Length of Length of Atrophy. Remarks, time from time from SeacripUon of In- jury. Battle. Amputa- tion to Amputa- tion to Length of Stump. Generally made at Time of Applica- tion of Artificial Date. Exami- Applica- Proximal Distal nation. tion. Portion. Portion. Limb. Cora minuted fmct. Gettys- "X'' 7mos. 11 mos. None None None Stump flexed at an- of ankle joint and lower tibia ; ex- burg, Pa. gle 35", not en- tirely hcaled.creat tensive extrava- angular by ulcer- sation, mortifica- ation, cicatriza- tion tion will afford knee base of sup- port. Flap very good, healed, stump Comminuted finct. Gettys- Julys, fimos. 9 mos. 4} inches Jinch 2 inches of ankle jointand burg, Pa. 1863 2d time 2d time lower port of tibia 2moa. 6 mos. flexed. 45°. Comminuted low- Gettys- Julys, 6mos. 9 mos. 6^ inches linch jinch Stump insufficient- er leg . ... burg, Pa. 1863 ly covered from sloughing, heal'd, tender, will be effective. Disrupture of leg Coal Har- June 3, Smos. 4 mos. 8 inches None None Healtliy, well com- poKcd. at ankle joint . Compound com- bor, Va, 1864 Coal Har- June], 2mo8. 4 mos. 101 incl»- linch linch Beautiful stump, very best, healed by first intention. Some atrophy, nearly healed. minuted fracture bor, Va. 1864 of ankle joint . Comp'dcoin. fract. of root and ankle Coal Har- June .3, Smoa. Smos. 12 inches 1^ inches 2 inches bor, Vo. 1864 Comp'und fracture Rapidau reb. 6, 2mos. 5 mos. 12 inches None 31 inches Some atrophied, healed, well formed, etc. of ankle joint . 186i Metatarsua only . Rappa- hannock Dec., 1863 ~ 18 mos. 15 inches inordi- nate linch S inches Swollen, ulcerated parts inflamed, some exfoliation. Comminuted fract Murfrees- Dec. SI, 20mos. 22 mos. 5 inches linch 21 inches Healed, well com- of ankle joint . boro'.Ten. 186i posed. Comminuted frac- ture of lower Morris Isl- Aug. 19, 10 mos. 13 mos. 3 inches None None Some ulcerated, and, S. C. lSi3 eczematoua. part of leg . . Comp'und fracture Fair Oaks, Miy 31, 1862 7 mos. & 10 mos. 21 inches None None of upper middle of leg .... Comp^ind commi- Va. 24 days Chapin's 'Ik^' 10 mos. lyear 2 inches None None Vei7 smooth, and nuted fracture of Farm, Va, even surfaces. middle of leg . Disrupture of low- Chapin's Sept. 29, 1864 6 mos. Smos. 41 inches linch linch Very fair. er half of leg . Comp'd com. fract. Farm, Va. increase Chapin's Oct. 7, 4 mos. 6 mos. Ul inch. linch 2j inches Much atrophied. of ankle joint . Comp'und commi- Farm, Va. 1S64 excellent. Wilder- Mays, 6 mos. 7 mos. 21 inches None None Healed, short, ir- nuted fracture of ness Va. 1864 regular. middle of leg . Comp'und commi- ■Wilder- May 31, 1^ 13 mos. 14 mos. 3 inches None None Very good, dam- nuted fracture of ness, Va. aged some, fibula middle of leg . spread, knee sup- port. Good, not straight Comp'und commi- "Wilder- Mays, lycar 14 mos. 31 inches None None nuted fracture . Comp'und commi- ness, Vo. Wilder- 1864 Mays, 11 mos. 13 mos. 6 inches None 2% inches Damaged by neg- nuted frw;ture of ness, Va, im 3 avail- lect middle of leg . Comp'd com. irac- Wilder- ^^4^' 10 mos. lyear able 8i inches iinch 2} inches Veiy good, dam- ture of ankle, ness, Va, aged somewhat lower third . . Comp'und commi- ^ilder- May 6, 8moB. 9 mos. 7% inches None 2 inches hy sloughing. Very good and effi- cient, has psoas nuted fracture of nesa, Va. \m ankle joint . . . abscess of right femoral region. Comp'und fracture lower third both Maudm're River, Va. T^=' 1 year Sc Smos. lyear* lOmoB. 3 inches None 11 inches Letl leg fractured, not healed, right legs healed, sloughed. partial uae.wo'nd- ed leg not flexi- ble at knee more than 45 degrees. Comp'nnd fract. of Antietam, Sept. 17, 1862 Sept. 17. 4 mos. 7 mos. 3 inches jincli None — ^ the middle of leg Comp'und fracture Md. Malvern 7 mos. Smos. 7 inches increase linch 3 inches — of ankle joint . £ntering under in- HiU, Va. Antietam, 9 mos. lyear 71 inches 3 inch 4i inches Good st'mp, sound, ternal malleoli. Md. 1862 some cicatrices by exit at low. mid- abscesses, exfolia- dle of leg . . . Comminuted fract. So. Moun- Sepl. 14, 9 mos. 1 year 61 inches 3 inch \\ inches tions. through knee . Com p'a fracture of tain, Va. Antietam, 1862 Sept. 17, 1862 7 mos. 10 mos. 7 inches linch 21 inches Not healed. lower third of leg Fracture of ankle joint Md. Gaines's MUls.Va. 4 mos. 4moa. 7i inches Jinch 3 j inches Artificial leg ap- plied, semitendi- nosus and eemi- membranosufl bi- ceps contracted. improving. 44 TWO HUNDRED AND EIGHTY-SEVEN CASES TABLE OF TWO HUNDRBD AND EIGHTY-SEVEN CASES Naki. Beglment. Occnpa- tion. Limb. 1.0. T.E. 18lh N. Y. Vols. 105th N. Y. VoU. Butcher Laborer K. L. J.L 1st Fenn. ArtUleiy Laborer R. CL. Sth Penn. Carpenter R. W.F.B. Mth N. T. Vols. Ship-ear- pcnter L. li. W.V. 6th Haine Farmer L. A.L. MILL VoU. BUck- smith S. A. I.. 9lhN.Y. S. MUitia Ship- joiner L. H.C.B. Sth Maine Farmer L. T.I,. 48Hi N. Y. VoU. Laborer R. I-.A.F. Mthlliiss. Hack- driver L. E. F. B. W.N. 76th Penn. Vols. 6th Kansas VoU. Tinsmith Farmer L. >L. E.B. iBtN. Y. M.B. None R. E.B. tr. 8. gun- boat Lands- man L. W.H.S. 9lh Penn. CavaUy Saddler I/. I/.H.G. 6th Vt Vols. Cabinet- maker L. 8. J. aboter Clerk L. B. W.W. SthUaine VoU. Farmer K. J.B. a. U4th N. Y. Voln. Captain L. P.H. «th N . Y. Vols. Boiler- maker L. J. P. C. IlSth N. Y. Vols. <2d Fenn. Ifason L. J.M. Farmer I.. J.G.8. 7th N.U. Farmer B. •W.H.B. 4th N. H. Shoe- maker L. H.S. 8th N. Y. Caviliy None iM Folat of Operation. Lower third 1st amputa- tion Lower and middle third Lower and middle third Middle and upper third Upper third Middle thiid [Tpper and middle third 1m Lower third Lateral ftapa Same's mode Posterior flap Circular Lateral flaps Posterior flap Posterior flap Ant. post flap Ant. poBt. flap Ant post flap Where per- formed. On the field On the field In field hos- pital Stone Hospi- tal, Waehlng- ton, D. C. In liOBpital In field hos- pital In Lincoln Hosp., D. C. Length of Time after Injury. 1st, 24 hours 2d, seven months Six days Six hours Twenty-fo'r hours Twenty-fo'r hours Twelve hours Two hours Eight days Solid shot sloughing ft want of care Piece of BheU Piece of ■heU Minie-ball Minlc-boU Fragment of shell Bifle-baU Frafl;ment of shell Explosion of torpedo Carbine- baU OP RECOVERED AMPUTATION OF THE LEG. OF RECOVERED AMPUTATION OF THE LEG. — (C5jn(mi«rf.) 47 Length of i Length of Atrophy. Bbmabks, time from time from Description of In- Battle. Date. Amputa- Amputa^ tLon to IT^nptTi t}f\ Generally made at Time of Applica- tion of Artificial jury. tion to Stump. Exami- Applicor Proximal Distal nation. tion. Portion. Portion. Limb. Bhattering the Antietam, Sept 17, B62 9mos. lyear I2i inch. linch S inches ®&ed. ""*''^ phalanges and Md- 2d,3mos. 2d, 5 moB. metataraal bones offoot .... Comp'd com. fract of ankle joint . Antictam, Md. Sept. ir, B62 9moB. — 7i inches 3i inches 3) inches Stump well cica- trized, neuralgia. Not entirely hefl'd, four inches of ne- Injury of foot through tareuH James River Oct. 22, 18G4 7mo8. 8mos. Scinches None 3 Inches croued fibula re- moved, March 12. 1865, June 1? healed. Comp'd com. frac- Jackson- March fimos. 7mofl. m ittch linch 3 inches Some necrosis, ul- ture of the tarsus ville, Flo. 26,1863 cers will recover and end of tibia soon, stump well healed, model shape, excess of Compound comml. fracL lower third of leg .... Comp'd com. frac- ture of low. third - B^f^IO, Sraoa. 7mos. £i inches }inch 21 Inches length. Some atrophied, very good. — Mi^' 5mos. 7moa. 4 inches None Scinches Good stump, flexed. of leg .... Comp*dcom.fract of foot and ankle — ^1'^^- 6mos. 9mofl. 7i inches None Jinch Very good. Comp'und commi- WUUams- ^^^^ 22mos. 2 years & Imonth 5J Inches iinch 2 inches Stump healed, cic- nuted fracture of buig, Va. atrices extensive, lower third of leg owing to ulcera- tion, fibula long- est Destruction of leg at lower third . On picket d^ity %.'^ 4mo8. 6moB. 5 inches linch S inches Stump healed, pos- terior part pend- ulous. Comp'd com. frac- Onnicket d^ity Sept. 8, 5mos. 8moa. 10 inches li inches 4 inches Stump healed, vig- ture of tibia, as- 1863 orous. tragalus, articu- Comp'und fracture of tarsus . . . Beverly Ford, Va. June 9, 1863 8mo3. Umos. Scinches linch 8 inches St'mp healed, good. 48 LIMB AMPUTATED. I. LIMB AMPUTATED. Comparaave The following table gives the frequency of amputa- of amputa- tion of the limb, whether right or left, in an aeereeate of Con of right f i-u- u J 1 . .■ 6S S and left leg. 445 cases 01 thigh and leg amputations : — Limb. Right. Left. Total. Thigh .... I*g 92 134 66 153 158 287 Totals . 226 219 445 From this table it would appear that there is a difference in the liability of the two lower extremities to those accidents or injuries which necessitate amputation of the thigh or leg in military prac- tice. In a gross number, comprising both thigh and leg amputa- tions, this difference, though not very great, is in favor of the right limb. When, however, we separate the thigh from the leg ampu- tations, we find this discrepancy becomes very marked in regard to both classes of cases. In the thigh amputations the right limb required removal in more than half of the total number of cases ; while in the leg the left limb amputations considerably exceed the right. Nor is this pecuharity in the relation of thigh and leg amputa- Frequency tious to the right and left side accidental ; for, on re- wulg'am-"' ferring to other collections of cases, the same difference tho'*Frenli^'' is traceable. For example, in an aggregate of 484 ampu- "™^' tations in the thigh and leg, collated by Chenu^ from the records of French surgery in the Crimea, the following com- parative results are deducible : — Limb. Bight. Loft. Total. Thigh 73 169 61 181 134 350 Totals . . 242 242 484 In this table we have results strikingly similar to those which were obtained from the records of American military surgery. Of 1 Sapport au Conseil de Sanle des Armies. COMPARATIVE FREQUENCY IN THIGH AND LEG. 49 the aggregate amputations in the lower extremity, the operation falls about equally on both limbs. But this result is found not to be due to an equality of amputations throughout the entire limbs, but to the fact that an excess of right thigh amputations is counter- balanced by an excess of left leg amputations in a given number of all amputations impartially collated. This result is not vitiated by the statement that the total number of leg amputations greatly exceeds that of the thigh amputations, for the same ratio holds true whether we diminish or increase the number of each. II. FKEQUENCY OF AMPUTATION IN THE SEVERAL REGIONS OF THE THIGH AND LEG IN 439 RECOVERED CASES. The comparative frequency of amputation in the various SqSy™ regions of the thigh and leg in a given number of re- tfon^n"^ covered cases, is illustrated by the following table : — ortwfhMd Begion. Thigh. Leg. 15 66 74 103 ^ Middle third Totals . . 155 284 In regard to thigh amputations, we should infer from this table either that a much less number of amputations are performed in the upper than in the middle third, and in the middle than in the lower third, or that the same number being performed in each division, the proportion of recoveries are largely increased as we pass from above downwards. Both of these inferences are true, as will appear from the following statistical table : — British Army, in Crimea. Confederate Army., Sherman's Campaign. (Andrews.) Begion. Eeo'd. Died. Kec'd. Died. Eeo'd. Died; Upper third .... Middle third. . . . Lower third .... 5 26 26 34 39 34 50 87 143 61 87 126 5 13 61 15 16 36 Totals 57 107 280 274 79 67 Grand totals . . . 164 554 146 50 COMPARATIVE MORTALITY. This table sustains the inferences drawn from the preceding table, that while amputations in the upper third of the thigh are much less frequent than in either of the other divisions of the thigh, they are also largely more fatal. In the British army in the Crimea, the amputations in the upper third of the thigh were but 23.8 per cent, of the total thigh amputations, while the fatal cases of amputation in this region equal nearly one third of the total mortality of thigh amputations. In the Confederate service, the amputations in the upper third of the thigh were 20 per cent, of the total thigh amputations, and the mortality was 22.2 per cent, of the total mortality. In Sherman's campaign,^ the amputations in the upper third were but 13.7 per cent of the thigh amputa- tions, but the mortality was in nearly the same ratio to the total mortality as in the British and Confederate service, being 22.2 per cent. Passing from the upper to the middle third, we find these statis- tics establish the fact that there is not only a larger gross number of amputations than in the upper third, but that tliere is a dimin- ished rate of mortality. The fatal cases in the middle third do not greatly exceed the cases of recovery, being 46 per cent., while in the upper third the fatal cases are very largely in excess. In regard to amputations in the lower third, these tables show that the number in general equals the total number in both of the other regions, with a still further reduction of the proportionate mortality, the successful considerably exceeding the fatal cases, except in the records of the British army. Applying these facts to the first table, which consists of only re- covered cases, and we may safely conclude that the 15 cases of recovery after amputation in the upper third represent a much larger number of fatal cases, and that the 66 amputations in the middle third represent about an equal number of fatal cases, while the 74 amputations in the lower third represent a less number of fatal cases, in the same regions respectively. In regard to amputation of the leg, the above table gives the largest proportion of recoveries in the lower third, and the least in the middle third ; the upper and lower third being nearly equal in numbers, while the middle third furnishes but a little more than one fourth the total number of cases. It is stated in the Surgeon- General's Report,^ that the majority of cases of amputation of the 1 StaUsUcs of Sherman's Campaigns, by E. Andrews, M. D., p. 64. 2 Circular No. 6. NATURE OF MISSILES. 51 leg was in the upper and middle third. In that cage this collection shows a partial selection, and most favorable to amputation in the lower third. If, however, we compare it with the following other group of cases in which both the fatal and successful cases are recorded, we shall find a confirmation of the above conclusions : — FRENCH ARMY.i Re^on. B«cOTered. Died. 259 U 21 84 Middle third 3 26 III. NATURE OF MISSILES. The following table comprises the various missiles with which the wounds were inflicted in 429 cases of amputation of , Missiles. the lower extremity : — Missile. Minie-ball Musket-ball Rifle-ball Shell Grape-shot Canister-shot Solid shot Gunshot Torpedo Pistol-shot Cut with an axe Fall of a tree ...... Injury by overturning of caisson Cannon-ball Railroad injury Injured in a turret Kxplosive ball Burn Fall Rusty nail thrust into foot . . Totals Grand total Tliigli. 429 Leg. 58 84 22 52 18 29 26 56 10 20 3 9 7 _ 6 5 4 — 1 1 _ - 3 - 5 - 1 - 1 - 1 - 1 "* 1 155 274 Nearly two thirds of the injuries which required amputation of the lower extremities, in a total of 429 recovered cases, were I Legoueat. 52 NATURE OF MISSILES. inflicted by the missiles of the infantry, namely, the minie, musket, and rifle balls. Of these, the minie-ball was used much more frequently than both the musket and rifle balls, or was much more destructive, the proportion being, minie-balls 142, musket and rifle balls 121. The difierence between the recovered cases of amputa- tion after injuries inflicted upon the thigh and leg by these various missiles is considerable. In the thigh the amputations for injuries inflicted by the minie-ball are 68, and by the musket and rifle balls 40 ; while in the leg the minie-ball injuries are 84, and by the mus- ket and rifle balls 81. Recovery from amputations after injuries inflicted by shell are more frequent in the leg than in the thigh, in the following propor- tion : recovered thigh amputations about one sixth, and recovered leg amputations more than one fifth, of the total number of thigh amputations. It is noticeable that the solid shot gives a number of recovered -amputations of the thigh and none of the leg, while the torpedo furnishes more recovered cases of leg amputation than of the thigh. We may compare the nature of the missiles with which severe wounds of the lower extremities were inflicted, as appears in the above table and in the records of the Crimean War : — NATURE OP THE MISSILES WITH WHICH THE WODNDS WERE DTFLICTED IN 466 KECOTERED AMPnTATIONS OF THE LOWER EXTREMITY, IN THE FRENCH ARMY IN THE CRIMEA. Limb. BaU. Boulet. ^lats de Projectiles • BIscalen. Thigh I*g 26 109 18 35 86 192 Totals 135 53 278 Misalles which in- flicted wounds re- quiring am- putation of thigh and leg in French army la Orimea. It is apparent from this table that in the Crimean campaign, which partook of the nature of a siege, the most destructive wounds were inflicted by artillery. Both tables show a preponderance of recovered leg amputations in about the same proportion. NATURE AND LOCATION OF INJURIES. 58 IV. NATDEE AND LOCATION OF THE INJURIES BY VARIOUS MISSILES IN 423 RECOVERED CASES OF AMPUTATION OF THE LOWER EXTREMITY. Thioh. Les. Fractoies. Wounds. Fractures. Wounds. •a 1 i 5 i i M 2 i i 49 M a •< 25 9 2 i 4 O Minie-ball . . . 24 23 Husket-ball . . 9 7 1 1 2 1 25 17 7 1 1 _ KiBe-ball . . . 7 7 _ _ 2 1 18 7 3 1 _ SheU .... 1 14 6 1 _ 4 34 15 7 _ _ _ Grape-shot . . 3 6 2 _ _ - 11 7 2 _ _ _ Canister-shot . 2 1 _ - - 8 1 _ _ _ _ Solid-shot . . 1 3 1 _ _ - 6 1 3 _ _ _ Gunshot . . . - 3 1 _ - 4 1 - _ _ _ Torpedo . . . - 1 - - - - 2 2 - - - _ Railroad injury - - - - - - 3 1 - - _ - Cannon-ball . . - - - - - - 2 - 1 - _ Cut by axe . . _ - _ - _ - - _ _ 1 _ „ Fall of tree . . - - _ - - - - 1 - _ - Injured in turret - - - - - - - 1 - - - Explosive ball . - - - - - - 1 - - - - - Burn .... — — _ — — — _ — — _ _ 1 Fall .... _ _ _ _ - 1 _ _ _ _ _ Nail, wound by f - - - - - - - - - 1 - - Totals . . . 47 65 16 2 6 6 164 78 33 6 1 1 Thigh amputation for firactures . 128 Thigh amputation for wounds . 14 lieg amputation for fractures . . 275 Leg amputation for wounds Total 8 Total 4 03 22 From the preceding table it appears that amputations for fractures are more frequent, in a given number of re- Proportion covered cases, than foi; wounds, in the proportion of 18 tations for to 1. And this difference is found, on inquiry, to be far fractures. the greatest in the leg. In the thigh the amputations for fractures are to amputations for wounds in the ratio of about 8 to 1, while in the leg amputations the ratio of fractures to wounds is as 34 to 1. The location of fractures is found in the amputations of the thigh, in largest number involving the knee, and in am- Lo<^ti„„ „f putations of the leg, involving the bones of the leg. The '"«'"»=• 54 NATURE AND LOCATION OF INJURIES. largest number of fractures into the knee were produced by the minie-ball, and the next largest by shell. The fractures of the leg necessitating amputation were produced in largest numbers by the minie-ball, and next in frequency is the shell. Injury to the ankle joint was not as frequently the cause of amputation of the leg, in proportion to the total amputations of the leg, as injury to the knee the cause of thigh amputations in proportion to the entire number of amputations in that part. Fractures of the leg were followed by comparatively few amputations of the thigh, being in the ratio of eight amputations for fractures in the knee and thigh to one of the leg. Nearly the same ratio obtains between amputations of the leg for fractures involving the foot, and amputations for fractures of the ankle and leg. The following table, compiled from Chenu,^ affords a comparison Comparative betwccn the abovc collection and the French statistics of ft«noh°Bto- til® army in the Crimea, as to the frequency of amputa- *''''"■ tion of the thigh and leg for fractures in certain regions in recovered cases : — Region. Fracture of femur . . . Destruction of thigh or leg . Fracture of knee . . . . Fracture of leg Fracture of foot . . . . Destruction of leg . . . Totals AMPUTATION OP Thigli 1 Leg. 48 _ 13 - 24 - 43 196 1 57 — 29 129 282 This table presents a striking contrast with the preceding, so far as relates to thigh amputations. In the former, compound frac- ture of the knee was the form of injury necessitating amputation in nearly half the recovered cases, while in the latter this injury occurred in but about one fifth of the total cases. We are not able to determine to what this discrepancy is to be attributed, as we are not able to give the mortality in the Federal army ; but it is probable that there was a much greater mortality among the French, as the percentage of fatal cases in amputations for this injury was thirty-seven. 1 Rapport au Comeit de Sante des Armees. DISTRIBUTION OF INJURIES. 55 V. DISTRIBUTION OF INJURIES REQUIRING AMPUTATION OF THE LOWER EXTREMITY IN RECOVERED CASES. (a) One hundred and forty-one Amputations of Thigh. Compound fracture of femur 10 Compound fracture of middle third .... 7 Compound fracture of lower third .... 27 Simple fracture of femur 1 Compound fracture of knee 59 Compound fracture of knee and upper third of leg . 12 Destruction of leg 6 Compound fracture of leg — upper third ... 3 Compound fracture of leg — middle third ... 5 Compound fracture of leg — lower third ... 9 Destruction of ankle 2 Fracture 1 Wound of thigh 2 Wound of knee 5 Wound of leg 1 Wound of popliteal artery 1 Gangrene of toe 1 Total 141 (h) Two hundred and eighty-seven Amputations Comminuted fracture of the upper third Comminuted fracture of the middle third Comminuted fracture of the lower third Comminuted fracture of the ankle joint Fracture involving the ankle joint Destruction of leg .... Destruction of ankle joint Destruction of foot .... Destruction of calcaneum Compound fracture of calcaneum Wound of posterior tibial artery Woi^nd of soft parts of leg Gangrene following a burn Injury of tibia without fracture . Injury of knee and patella Injury of knee (?) . of Leg. 3 67 75 57 2 20 14 •8 Total 287 56 INJURIES REQUIRING AMPUTATION OF THE THIGH. Injuries requiring Amputation of the Thigh. — Of the injuries of the thigh requiring amputation, in a given number of recovered cases, compound fracture of the lower third is by far the most fre- quent; comprising nearly two thirds of all the cases. We have already alluded to the proof that a less number of amputations are performed in the middle and upper third of the thigh, and that they are more fatal in these regions. This fact will account in part for the great discrepancy which this table shows between the total recovered amputations in these different regions. The injury which necessitates the largest number of amputa- tions of the thigh is seen to be compound fracture of the knee. The total number of these injuries, including those which im'olve also the upper third of the leg, comprises about one half of all the causes of amputation of the thigh. This subject is deserving of. a more critical examination. At the period of making his Report,^ the Surgeon-General states that 1,183 cases' of gunshot wounds of the knee joint, with or without fracture of the patella, or of the epiphyses of the femur or tibia, had been recorded. Of these, 770 had terminated, and the results were known. The following statement of the treatment and its results, so far as ascertained, is given in the 1,183 cases of knee-joint injury reported : — Treatment. No. of Cases. Recovered. Died. Undetermined. Ampatation .... Excision Conservative measures 718 11 454 121 1 50 331 9 258 266 I 146 Totals . . . 1,183 172 598 413 It would appear from these facts that in a little less than two thirds of the wounds of the knee joint amputation was resorted to, and a mortality of 73.23 per cent, occurred in the determined cases. In the 11 cases submitted to exsection the mortality was 90 per cent. In a little more than one third of the total cases, conserva- tive measures were adopted, with a mortality in the terminated cases of 83.76 per cent. We may safely conclude that in this collection of cases' amputa- tion was resorted to in the severest form of injuries, as when the joint was freely opened, with or without fractures of the extremi- ties of bones entering into the joint ; while conservative measures were adopted in slighter forms of injury, and when there was 1 Circular No. 6. AMPUTATION FOR WOUNDS OP KNEE JOINT. 57 doubt whether the cavity of the joint was involved. And this opinion is confirmed by the Surgeon-General, who states that, " with six or eight exceptions, the fifty recoveries without amputa- tion, classified with gunshot wounds of the knee joint, were exam- ples of fracture of the patella, in which the evidence that the joint was opened was not unequivocal." It is evident, therefore, that amputation was the acknowledged method of treatment in severe gunshot injuries of the knee joint, during the war. And the comparative results of this treatment justify the rule now so firmly established in military surgery. The mortality was ten per cent, less than when conservative measures were employed, and nearly twenty per cent, more favorable than excision. If we take into consideration the remark of the Sur- geon-General that all the successful cases treated conservatively, except six or eight, were so slight as to be of a doubtful character, the comparative results of amputation in grave injuries of the knee joint are far more favorable. Professor Chisholm, of the Medical College of South Carolina, a surgeon to the insurgent forces, gives statistics^ of the con- servative treatment of gunshot wounds of the knee joint which are altogether more favorable than those compiled by the Sur- geon-General. Of 103 cases treated, 50 recovered, and 53 died ; the mortality per cent, being but 52. In answer to the objection that many of these cases must have been of a trivial character, and could not have implicated the cavity of the articulation, he refers to the duration of treatment in the successful cases, which gives an average of 166 days, in proof of the severity of the wounds. The shortest period of treatment was 96 days. He concludes, therefore, that they were cases of the perforation of the joint by balls without the crushing of bones being detected. This comparison does not invalidate the general conclusion that amputation of the thigh shoxild be the rule of practice in severe gunshot injuries of the knee. The following tables are instructive, as they illustrate the condi- tion of stump in an amputation at different points of the thigh after gunshot wounds of the knee joint. 1 Medical Times and Gazette. London, December 29, 1S66. 58 AMPUTATION FOR INJURIES OF KNEE JOINT. XIIIRTY-THREB CASES OS KECOVERBD AMPUTATIONS OF THE THIGH IN THE LOWER THIRD, FOR GUNSHOT INJURIES OP THE KNEE JOINT. MlSSILK. No. 25 8 Method. No. 19 6 7 1 Result. Good. Imperfect. Unknown. Minie, rifle, and musket ball . . Cannon-ball, shell, grape, torpedo (Flap ( Circular (Flap [ Circular 16 6 5 1 1 1 2 1 In these 33 cases it -will be observed that amputation was suc- cessfully performed in the lower third of the thigh in 8 cases of wound of the knee joint by shells, by cannon-ball,' by grape- shot, and by torpedo. These were doubtless very grave forms of injury, and attended with more or less destruction of the soft parts. In some instances it is noticed that the limb was nearly severed at the knee. The fact that they still admitted of success- ful amputation at a point so near the seat of injuiy is instructive, as it proves that in the severest gunshot wounds of the knee we may still select the most favorable point in the thigh for amputa- tion with a fair prospect of success. Another fact is noticed, namely, that in all of these cases of am- putation for wounds of the knee by shell and solid shot but one, the flap method was preferred. This is the more remarkable as the circular method is generally considered especially adapted to the lower third of the thigh, and to wounds attended with great destruction of the soft parts. Of these 88 cases, 26 were performed by the flap, and 7 by the circular methods. The results of these cases are more favorable to the circular method, all of which gave good stumps. TWENTT-NINE CASES OF RECOVERED AMPUTATIONS AT THE JUNCTION OF THE MID DLB AND LOWER THIRD OF THIGH. Missnj!. No. 20 9 Method. No. 9 11 8 1 RjSSOLT. Good. Imperfect. Verj poor. Unknown. Musket, minie, and rifle ball Shell, solid, and grape shot (Flap Circular Flap Circular 5 5 4 1 2 6 3 I 1 1 In this table we have a larger proportion of cases of wounds AMPUTATION AT MIDDLE THIKD OP THIGH. 59 by shells, solid, and grape shot. The ratio of these missiles to the musket, rifle, and minie balls is nearly that of one third. From this it appears that as a rule surgeons amputate higher than the lower third in wounds of the knee joint by these destructive missiles. But the most interesting feature of this table is the compara- tively large proportion of circular operations, and the comparatively unfavorable results of this method, when practiced at the junction of the middle and lower third of thigh after knee-joint injuries. Of the 12 circular amputations, 6, or one half, gave imperfect stumps, while of the flap operations 9, or more than one half, gave good results. The difference between the results in this and the preceding table is striking : in the former the final results of all the amputations were very favorable, and especially of the circular method ; in the present table both methods failed of giving gen- erally good results, the circular being the most unsuccessful. NINETEBN CASES OE RBCOVEKED AMPUTATIONS AT THE MmDLB THIRD OF THIGH. Missile. No. Method. No. Result. Good. Imperfect. Very poor. Unknown. Minie,- musket, and rifle ball Shell, grape, canister, can- non, and solid shot . . 10 9 (Flap ( Circular Flap 6 4 8 3 3 7 1 1 1 2 In this table we find a still greater proportion of injuries of the knee joint by the larger form of missiles ; 9 of the 19 cases being injuries by shells and solid shots. We have here still further evidence of the destructive character of the wounds of the knee which called for amputation, and the necessity which frequently existed of amputating at a distance from the wounds. We have noticed in the preceding tables that amputations in the lower third of the thigh gave good results, while those performed at the junction of the middle and lower third gave much more un- favorable results. In the middle third we find the table reversed, and both forms of amputation are again highly successful as regards the final results. The proportion of circular to flap amputations is about the same as in the first table. 60 AMPUTATION FOR INJURIES OF KNEE JOINT. FIVE CASES OP AMPUTATION AT THE JUNCTION OF THE UPPER A?ID MIDDLE THIRD OF THE THIGH. No. Method. No. Eesdit. Good. Imperfect. Very poor. Shell and grape shot Musket-ball 3 2 Flap Circular Flap ( Circular 3 2 2 1 1 1 FOUR CASES OF AMPUTATION IN THE UPPER THIRD OF THIGH. Missile. No. 3 1 Method. No. 2 1 1 Result. Good. Imperfect. Very poor. Solid and grape shot, and shell . Minie-ball (Flap j Circular (Flap 1 Circular 1 1 1 1 In amputation at the junction of the middle and upper third of the thigh the larger number of v^ounds v?ere inflicted with solid shot. It is remarkable that in every case the circular operation was performed in preference to the flap method. The result, how- ever, was not favorable in the majority of cases. Of the four amputations in the upper third, but one was per- formed for wound by a minie-ball. From this fact we infer that, in general, wounds of the knee joint by a rifle-ball admit of ampu- tation in the lower part of the thigh, and rarely necessitate the removal of the limb high up. It is also apparent that in a given number of cases of amputation in the upper third of the thigh for gunshot wound of the knee, a large majority will be necessitated by the larger and more destructive missiles. The results of the two methods prove the value of the circular method. From these tables it would appear that in a total number of cases of recovery after amputation of the thigh, for gunshot injury of the knee joint, the operation was performed in the lower third in more than one third of the cases ; at the junction of the middle and lower third in a little less than one third of the cases ; in the mid- dle third in about one fifth of the cases ; and above this point in PERIOD OF AMPUTATION. 61 a little less than one thirteenth of the cases. The total amputa- tions at and below the junction of the middle and the lower third of the tliigh comprise more than two thirds ef all the cases. It is evident, then, that in gunshot injuries of the knee joint suc- cessful amputation is far more frequently performed below than above the middle of the thigh. The comparative mortality of this operation, according to the Surgeon-General, was very small. Of 243 amputations in the lower third of the thigh for wounds of the knee, 112 died, being a mortality of 46 per cent.^ The Confed- erate army reports give the following statistics of this operation : total number of amputations in the lower third of the thigh for wounds of the knee, 269, of which 126 died, being a mortality of 46 per cent.^ We have here a striking coincidence in the success of a given operation for the same cause. It would be interesting to note also the comparative mortality of amputation at other points in the thigh for these wounds, but we have not the data. The period at which the operation was performed after the injury, in the majority of cases, proves not only the se- perfoaof verity of the wound, but the importance of early ampu- """P"**'"""- tation to insure a successful result. In more than one third of the cases the operation was performed within six hours of the injury, and in nearly one fourth of the cases it occurred between the 6th and 24th hour. In other words, within twenty-four hours of the injury about two thirds of the operations were performed. It should also be noticed that 67 or more than two thirds of the operations were performed on the field. These facts prove both the severity of the original injury, and the necessity of an early operation ; for it must be remembered that this is a record of successful cases. If there were any doubt as to the severity of the wounds which led to amputation in these cases, it would be dispelled Nature of by a reference to the record of the nature of the inju- *' taj>"y- ries. In all but 13 cases there existed a fracture, generally com- minuted ; in the remaining cases the joint was freely opened, and the leg nearly dissevered at this point. Of the missiles with which the wounds were inflicted, in 59 cases the minie, rifle, or musket ball was employed ; in 17 it was a fragment of a shell ; in 13 it was a solid shot. It follows that the wound must, in one third of the cases, have been of the severest character. 1 Keport of the Surgeon-General (Circular No. 6.) s Chisholm, London Medical Times and Gazette, December 29, 1865. 62 OPINIONS OF SURGEONS. The following opinions of surgeons sustain the conclusions drawn from the preceding statistics, and are worthy of record in this connection. Professor A. C. Post gives the result of his observations in regard to gunshot wounds of the knee joint as follows : — " Gunshot wounds penetrating the knee joint are generally fatal, unless the limb be amputated. This is especially the case when, in addition to the wound of the joint, there is extensive fracture of the articular extremity of the femur or tibia. " The practical rule which I would recommend in gunshot wounds of the knee is this, to amputate in all cases where the ball has passed through the centre of the joint, or where the inferior articular ex- tremity of the femur or the superior articular extremity of the tibia has been fractured, but to make an attempt to save the limb where the ball has not penetrated deeply into the joint, and when the patella only has been fractured. In the class of cases in which I have recommended an attempt to save the limb, the attempt will always be attended with some danger to the life of the patient." Surgeon George A. Collamore, 100th Ohio Vols., speaks of the causes of thigh amputation as follows : — " In gunshot fractures of the femur, amputation will depend on the location of the injury. If the fracture occur in the upper third, I should prefer to trust the case to nature, with such aid from position, splints, etc., as could be obtained. In fractures affecting the lower two thirds of the limb, I should amputate so as to remove the fractured por- tion. Gunshot wounds involving the knee joint invariably demand amputation, if possible, just above the condyles and below the medul- lary canal. Gunshot fractures of the tibia, involving much comminu- tion and laceration of the muscles, usually require amputation. It would be a very unusual case that I would attempt to preserve. In my opinion conservative surgery should not be carried too far in gunshot fractures of the lower extremities, admitting amputation. Extensive fractures of the tarsal bones, involving the malleoli or articulation, re- quire amputation at the ankle. Fractures of the fibula do not usually require amputation, as this bone is but slightly instrumental in the sup- port of the body.'' Professor Paul F. Eve, of the Confederate service, makes the following communication in regard to the success of amputation of the thigh during the war, as compared with the same operation in former wars : — " Ribes examined four thousand veteran soldiers in the Hotel des Invalides in Paris, and found not one who had undergone amputation of the thigh, or who had sustained an injury of the femur by a shot. Pro- PROFESSOR EVE'S REMARKS ON AMPUTATIONS. 63 fessor Malgaigne of Paris, with whom I was associated in the war, makes the same report of all similarly wounded during the Polish campaigns of 1831. At the close of the Mexican War in 1847, Dr. McSherry of the United States navy, on detached duty, was permitted to accompany General Scott's army, and declared that, although he remained in the city of Mexico eight months after the battles, and walked the hospitals, he did not see one soldier restored to health after a gunshot wound of the thigh, involving its fracture. Of an almost similar import were my communications to the Nashville Journal of Med. and Surg., after the late Italian campaign. Writing from Turin, July, 1859, it was stated that while the results were good after injuries in the upper ex- tremities, the reverse was true of those involving the inferior, with or without amputation, whenever a compound fracture existed. Dr. Sal- leron, chief surgeon of the military hospital ef that city, assures me that the nearest he came to saving a patient thus wounded, was a Zouave shot in the Crimea, who remained seven months in a hospital at Constantinople before attempting to return to France, and when he did so, finally died of pyaemia. In Milan I took notes of five cases of compound fractured thighs, which were all I saw there, fifty-six days after being wounded : in three there was little or no hope of recovery ; another had had the limb amputated above the knee, and was doing well ; while the fifth was the only one expected to recover with the limb. " In amputations of the thigh in the Crimean War, sixty-four in every one hundred died ; in the Paris hospitals seventy-five per cent., and in the Polish and Mexican wars one hundred per cent, or every one op- erated on, died. Of twenty-one disarticulations at the hip-joint, every one was fatal, and eighty-six per cent., according to McLeod, of ampu- tations in the upper third of the thigh died. As late as 1861, Mr. Thomas Bryant, surgeon to Guy's Hospital, one of the best ap- pointed and managed of these institutions in London, reported seven- teen cases of thighs requiring treatment. Ten were amputated, seven of them died ; seven were attempted to be saved, four died ; thus, of the seventeen cases eleven died. The most favorable return ever made, is that of Jules Roux, naval surgeon at Toulon, who saved four of six he amputated at the hip-joint ; being by far the best success ever ob- tained by any one, though the circumstances were very propitious under which he operated. He mentions having seen twelve of these dreadful disarticulations ; seven died. He also states that there were twenty-one cases of consolidated fractures of the thigh passing through his hospital from Italy. As Toulon was the only door through which the maimed could reach home (for Marseilles is a commercial and not a military port), it is highly probable that of all the two hundred and fifty thou- sand men who went to aid the Sardinians, these twenty-one constituted the whole number of all those wounded through the thigh bone who once more returned to la belle France with two legs. 64 INJURIES REQUIRING AMPUTATION OF LEG. " In the late terrible civil war our profession has nobly performed her duty, and America has reason to honor her surgeons. With pride and gratulation we point to the hundreds and thousands saved by their skill, even in compound fractures of the femur. Lieutenant-General Ewell survives an amputation through the upper third of the thigh ; and so does Lieutenant-General Hood, performed by Professor Richardson of New Orleans, on the battle-field of Chicamauga. They so fully re- covered, as is well known, that subsequently each commanded army corps in person on the field. I have seen as many as three soldiers con- versing together in the streets of Augusta, Ga., each having lost a limb above the knee. I think I had two successful amputations of the thigh in Atlanta, and about the same number left under treatment in Co- lumbus, Miss. I regret not having access to my ofiicial reports, but there must have passed under my supervision over one hundred of these amputations during two years and a half of hospital service. It is right, however, to say here that the majority of these were fatal. " Primary amputations did decidedly best, and, if not before, this question ought now to be considered definitely settled. The majority of those who recovered after injury of the femiur were operated on in the field, or before infiammation and its results had ensued. To this rule we have the single exception in those requiring disarticulation at the hip-joint. In these cases it is now ascertained that few constitutions can bear in quick succession such shocks as, first, the injury requiring this operation, and then, secondly, that produced by its performance'. The statistics of McLeod in the Crimean War already referred to, giv- ing twenty-one primary operations, followed by twenty-one deaths, con- trasted with Eoux's four successful out of six consecutive, or secondary amputations is determinate on this point." Injuries requiring Amputation of the Leg. — The largest per- centage of recoveries after amputatiou of the leg, occur from inju- ries in the lower third, and in this respect resemble the recoveries after amputation of the thigh. It is interesting to notice three recoveries after amputation of the leg for compound fractures in the upper third, the amputation being in the immediate vicinity of the injury. Amputation for compound fracture of the middle third gives also a large percentage of recovered cases. Injuries of the ankle joint led to amputation of the leg in about one fourth of the total cases. Injuries of the foot veould seem to have been very rarely followed by amputation of the leg, but in the French army in the Crimea it was a frequent operation, there being fifty- seven amputations of the leg for wounds of the foot in a total of two hundred and twenty-five amputations of the leg, or about one foui'th. METHOD AND FREQUENCY IN THIGH AND LEG. 65 VI. METHODS OF OPERATION, AND THE FREQUENCY WITH WHICH THEY WERE PERFORMED IN THE THIGH AND LEG. The following table comprises the various methods of amputa- tion in the thigh and leg, and shows how frequently they Methods of were performed in each division of the extremity : — amputation. Circular Antero-posterior flaps .... Posterior flap Anterior flap Lateral flaps Rectangular flap Skin flaps and circular of muscles Thigh. 54 78 10 6 5 2 155 Leg. 115 93 45 2 21 8 284 It is apparent that the amputations of the thigh and leg were performed either by the circular method or by some modification of the flap. Of the flap operations that which was generally pre- ferred was the antero-posterior flap ; the anterior, posterior, and lateral flaps being but seldom performed, with the exception per- haps of the posterior flap in the leg. Of the two principal methods, the circular and antero-posterior flap, we notice that the antero-posterior flap was preferred Antero-pos more frequently in the thigh, and the circular in the leg. most'&i^ In the thigh the antero-posterior flap method comprises ?hi|h, Lnd ° half the operations, while the circular exceed but little the leg. one third. In the leg these methods are nearly reversed, the circular amputations amounting to nearly three sevenths, and the antero- posterior amputations to but about one third. Of the remaining methods the anterior, posterior, and lateral flaps have long been occasionally practiced, but without q^^^^ „^y, any definite results. The rectangular flap of Teale "**• seems to have been performed in a few instances in the thigh. The method by flaps of skin and circular of muscles was per- formed in ten cases, two in the thigh and eight in the naps of skin ^ . and circular leg. This method seems to have become very popu- of muscles. lar with many military surgeons, especially with those who were compelled to transport their patients long distances. The surgeons in General Sherman's army came to prefer this operation to all 5 66 VALUE OF DIFFERENT METHODS. others. Their method of operating was to make lateral flaps of the skin and a circular incision of the muscles ; the lateral flaps brought in apposition gave a cicatrix running vertically on the face of the stump. In dressing the stump the ligatures w^ere all brought out at the lower angle of the wound, and the drainage was perfect, leaving the upper portions of the wound dry. Accord- ing to the testimony of many surgeons who had great experience in the transportation of the recently amputated, these stumps required dressing much less frequently than other forms, and union by first intention throughout three fourths of the wound was an almost constant result. In some cases it is stated that the stumps would remain so dry that the dressings would not require renewal in four or five days. TESTIMONT OF SURGEONS AS TO THE VALUE OF DIFFERENT METH- ODS OF AMPUTATION. Tesamonyof The various opinions of surgeons in regard to the spe- to value of cial merits of the different methods may be gathered from different , n ^^ ■ J b methods. the tollowmg extracts. Assistant-Surgeon Powers, U. S. Army, says : — " If the patient is obliged to be removed soon after amputation, I pre- Asdstant- fer the circular operation, as the parts are steadier, and keep Powers. their place better ; otherwise I generally use the flap opera- tion." Assistant-Surgeon N. A. Meacher says : — " I saw a great deal of trouble with stumps, on account of the flesh Assistant- sloughing and leaving the end of the bone protruding, and I Meaoiier. think the circular operation more liable to that trouble than the ' Listen flap,' which I prefer, unless it is in operating near the wrist or ankle." Surgeon C. E. Deming, 28th Ohio Vols., prefers the flap only in certain locations, as foUows : — " In amputations of the arm, angle, and upper two thirds of the leg, Surgeon ^ prefer the flap operation to the circular. The preference I Deming. jjave for the flap over the other is on several accounts ; a more perfect covering is secured for the bone ; the integument is only disturbed in the line of the incision, while in the circular the muscles are rarely ever cut close up to the retracted integument ; the flap has less cutting and is speedier done, and the size of the flap can always be proportionably estimated to the size of the limb ; in the circular it is TESTIMONY OP SURGEONS. 67 more or less guess-work. In the circular again the second cut is .never exac% close up to the retracted skin; the third cut more or less haggles or cuts off the ends of the divided muscles of the second cut ; the skin when brought over the end of the bone more or less gaps, and the cut ends of the muscles double in over the sawed end of the bone. It suppurates more and is usually longer in healing than the flap. " At the lower third of the leg the circular is the best." Surgeon P. H. Bailhache, 14th Illinois Cav., says : — " In amputations I prefer the double flap (posterior and anterior) for the arm and thigh, and the ' combination ' or ' semi-lunar and g^^^^ flap ' for the leg and fore-arm. I am of opinion that the Baiihache. ' circular ' amputation injures the integuments by frequent lesion of its nutritious vessels, which is done while dissecting it back upon itself — hence the flabby, waxy appearance of the parts in many instances. Some hold that there is less discharge of pus from a circular than from a flap operation ; this may or may not be so ; but even were such the case there is no advantage gained, as the drain upon the system is no greater, and the union of the flap is as speedy and as perfect. It is also said there is danger of transfixing or splitting the blood-vessels or nerves ; this is mere theory, not substantiated by facts or experience, besides which ordinary care and a knowledge of the parts obviates the risk of doing so. Again, in the circular operation it is almost always necessary to split the integuments on one or both sides before they can be turned back and .dissected sufficiently high to prevent the bone from protruding ; so it is eventually ' two flaps ' without the advantage of 'time' and at the expense of more or less injury to the integuments ; if the muscles are not required as a cushion for the bone they can be readily cut out afterward without destroying the areolar structure," etc. Surgeon George A. CoUamore, 100th Ohio Vols., expresses nearly the same opinion. Although he formerly em- g„rgeon ployed the circular method, he now prefers the flap, <'<'ii»™<«»- believing that it " allows more perfect approximation of the sur- faces, and union by the first intention sometimes will take place, but never, so far as I have known, in the circular operation." Surgeon E. Batwell, 14th Michigan Vols., draws the following distinctions between the flap and circular : — "From close observation, I am unable to give preference to either as far as regards healing, both depending on the constitution of g^^. your patient, and bpth healing with equal facility. Hemor- Batweii. rhage took place more frequently in circular operations, owing doubt- less to vessels of large size retracting more readily when divided straight across, than those cut slanting, as in flap amputation. As soon 68 VALUE OF DIFFERENT METHODS. as full reaction set in, these vessels poured out blood, and very fre- quently necessitated the opening of the stump to secure the bleeding artery. Anterior and posterior flaps healed more kindly than lateral ones, notwithstanding the latter possessed less tendency to accumula- tion of pus, and the sutures held the lips of the flaps together better ; but the nervous twitchings of the stump made the bone protrude through the edges of lateral flaps more readily, and tore the newly organized plastic lymph. Any modifications of the above operations, or a combination of both, healed slowly and unsatisfactorily, invariably leaving painful stumps. Short anterior, with long posterior flaps made the process of healing very tedious, always leaving so painful a stump that a secondary amputation became necessary ; I have thought that the nerve got under the bone, and was thus pressed on. The above observations were made from a similar number of flap and circular operations, with a view of deciding in my own mind the relative merits of each. I have measured the exposed surface, and was much aston- ished to find a larger extent on a circular than on a flap. In making the second sweep with the Catlin, I found that by inclining the edge of the knife towards the patient's bod)', so as to have the bottom of the incision an inch and a half or two inches higher up than the external, forming a hollow cone, a far nicer looking stump was formed, and one far better adapted for an artificial limb." Surgeon W. Manfred, 22d Kentucky Vols., is of opinion that the flap method is more successful than the circular : — " I generally prefer the flap to the circular operation ; it makes a Surgeon better Stump, and there is less waste of muscle in making Manfred. tjjg flaps, except in certain exceptional cases, when the cir- cular operation is probably the best, as when the muscle is very thick, or when it is injured by the ball so as to make the flap operation inadmissible. Moreover, my flap cases have been uniformly more suc- cessful than the circular." Surgeon B. T. Kneeland, — New York Cav., says : — " I prefer flap amputations always, which have the advantage of Surgeon Saving time both in the operation and in the recovery, and as KneeUnd. giving better results in every respect." Surgeon H. C. Robbins, 101st Illinois Inf., says : — " I prefer flap operations in the arm and thighs as more likely to Sureeon cover the bones and aflford a soft cushion for an artificial EobWna. limb. In the fore-arm and leg I would use the circular operation for similar reasons." Surgeon N. Field, 66th Maryland Vols., says : — TESTIMONY OF SURGEONS. 69 "I prefer the flap method, because, as I believe, it makes a better covering for the end of the bone. The circular requires care g„,geoii to prevent trouble afterwards.'' ^'='''' Surgeon J. C. "Walton, 21st Kentucky Vols., prefers the flap, but believes that if the patient is transported any considerable dis- tance there is danger that the flaps vi'ill separate : — " I have generally performed the ' flap ' operation, except in cases where there was much loss of the soft parts, or much contu- s„„eon sion. It is most conveniently performed, and in healthy sub- Wa'toi- jects frequently heals more rapidly. It makes a better covering for the stump, and a softer cushion for an artificial limb. The only objection to this method is that it gives more suppurating surface, — provided the patients are kept quiet, and are not required to be moved from place to place ; but should the case require transportation several miles over rough roads the flaps are apt to gap open." Surgeon Chaddock, 7th Michigan Vols., says : — " I prefer the flap ; it gives greater mechanical neatness, less exposure of wound to air, and the chances of healing by first inten- s„„j„„ tion. I am also satisfied that the cut surface is less with the Chaddook. flap mode of operating, if well made, than it is in the circular." Surgeon , , says : — " In the arm and thigh I invariably performed the flap operation ; making in all cases where practicable antero-posterior flaps, g^ My reasons for this method are several : 1st The operation is more easily and quickly performed. 2d. The flaps are not so liable to slough as when they are made by the circular method. In the latter the skin and areolar tissue are dissected up to the extent of from two to four inches, cutting off", to a certain degree, their supply of blood ; hence lowering their vitality, and making them more liable to slough. In the former, the skin and cellular tissue retain their connections with the more deep-seated tissues, and their vascular supply is not interfered with. 3d. In the flap operation the stump heals more quickly and with less suppuration, because -the parts are brought more perfectly in ap- position than they can be when the circular method is used. 4th. Because (and this follows as a corollary from the two preceding reasons) the flap method is less liable to be followed by pyaemia, erysipelas, or gangrene. 5th. Because this method gives stumps better adapted to artificial limbs than the other method : the end of the bone is more thickly covered. " These reasons, which I think will be found to be good ones, cer- tainly show the immeasurable superiority of the flap over the circular method. Even in the fore-arm and leg, I consider the flap the better operation." 70 VALUE OF DIFFERENT METHODS. Surgeon , — ■ , writes : — " I prefer the flap in large thighs, because I can judge more nearly Surgeon *^^ exact amount of covering I will have on the end of the bone, and that there will be less likelihood of sloughing and of protrusion of the bone. There will usually be a better covering for the bone than after circular operations, and the skin will not be so ex- tensively detached from its normal relations to the muscular tissues, and it will not become so pale and so liable to ulcerate and slough where the edges come together over the bone. I believe that in gunshot wounds, particularly of the femur, the operation should generally be made by cutting from without, i. e. the antero-posterior, or lateral flaps, as the case may permit, should be made of proper size and shape, and with even edges through the skin and areolar tissue down to the muscles, either with a large scalpel or with the point of an amputating knife, and then the muscular portions of the thigh be quickly and freely divided down to the point where the femur is to be divided. In this way the flaps will be evenly made, the detached pieces of bone will not be caught upon the edge of your knife, as is so very often the case in transfixion, the flaps will come in exact coaptation, and the stump will be of the proper size and shape, and will have every inducement to par- tially adhere by primary adhesion. I look upon this plan of operating, in the army particularly, as worthy of attention, and can recommend it as having come into favor with those whom I have known to perform it I have operated in this manner occasionally during the last two years." Surgeon J. W. Williams prefers a covering without any muscle, and to secure this end he dissects off all muscle from the flap. He says : — " I think it is new, and better than the common flap method. In the Surgeon common antero-posterior flap operation in the lower third, wuuama. the anterior flap is narrow, not equal to its fellow, and in con- sequence of the constant tendency of the thigh to evert, the end of the bone is apt to protrude at the inner angle of the narrow flap. And further, I have found that where the flaps were well relieved of mus- cle, the healing process was more rapid and kind, and that in all of the stumps I have seen, no muscle whatever covered the end of the bone, however niuch was left by the operator. Hence in these cases I left no muscle with the flap, which for the anterior was made from half the diameter of the thigh by cutting from without inward, making a semi- lunar flap of integument and fascia only, and the posterior by trans- fixion. " These cases at the time of operation were very low with gangrene and pyjemia, yet three of them healed in less than three weeks with very little discharge, and a heavier covering than I had ever seen over TESTIMONY OF SURGEONS. 71 the end of the stump. The fourth one died of pyaemia in about two weeks, the stump being nearly healed." Surgeon George J. Potts, 23d North Carolina Inf., prefers the circular operation : — " I prefer the circular in all parts of the femur and humerus, the flap in the lower thirds of fore-arm and leg ; and why ? because g„„jo„ when dividing the muscles in the thigh and arm the retrac- ^°"^- tions are often so forcible that they assist the surgeon in forming a coni- cal cavity for the covering of the stump. The grand aim in any opera- tion is to save integument enough to cover the muscle, and muscle enough to cover the bone, and not to scrape off the periosteum. I think that there is less difficulty in seizing the arteries in the circular opera- tion for the ligature, and that the surgeon is not so liable to ligate a nerve, or branches or twigs of nerves, as in the flap operation. I do not think that the oblique or straight division of the arteries, in either flap or circular, has anything whatever to do with the weight of testimony in favor of one or the other mode of operation." Assistant-Surgeon W. P. Moon prefers the oval of skin and circular of muscles : — " In the majority of my amputations of arm, fore-arm, and leg, I adopted the oval of skin with circular of muscle from an impression Assistant- that there was more muscular tissue to heal, and I thought I Moon. observed more resultant inflammation in the flap operation of my own and other cases. " The only advantage in the ' oval ' over the ' circular,' I conceive to be, that it is a handsome operation, and permits of more expedition. In opposition to this it requires more care and greater precision in mak- ing our initial incisions." Surgeon R. J. Levis thus condemns in emphatic language the circular method : — "Having had, during the war, under my observation probably a larger number of stumps of a defective character than any „ one else, I do most emphatically condemn the circular opera- i*™- tion as being the method most frequently followed by stumps most tardy in healing, liable to leave an attenuated and tender cicatrix attached to the bone, and least suited to the adaptation of artificial limbs." Surgeon David P. Smith, United States Vols., makes the following observations in regard to the method of amputation of the leg : — " Experience in many cases during this war has shown that the usual methods of amputating the leg in continuity are ex- ceedingly faulty and often lead to deplorable results. The '^- ^- smith. 72 METHODS OF AMPUTATION. leg, being merely a means of progression, and its removal being more nearly compensated for than any other part of the body, will always be condemned to amputation more readily than any portion of the upper extremity. It behooves us therefore to employ the very best manual procedure possible. " The mechanical difficulties to be avoided, are, — " 1. Protrusion of the spine of the tibia. " 2. Tender stump. " 3. Redundance of posterior flaps ; in some instances forming a pendulous mass, and interfering greatly with adaptation of artificial limb. " Protrusion of the spine of the tibia has occurred in every instance that came under the writer's notice during the war in which the posterior flap operation had been performed upon the field of battle. Transpor- tation of the patient is sure to cause this. When we look at this form of operation and carefully observe all its defects, it seems amazing that it should ever have been practiced. The circular and the lateral flap methods are each of them superior to it in every respect. " On account of the facility of execution, the complete freedom from all and any tension, the ready exit of pus, the freedom from pressure of all the important vessels and nerves, and the impossibility of any drag- ging of the flap against the spine of the tibia, the anterior flap method should, in the opinion of the writer, be preferred in all amputations of the leg in its continuity. It is best done in the following manner : — " Standing on either side, transfix the limb one inch below the point at which you intend to saw the bones, passing the knife just behind the tibia and fibula, grazing both ; then, keeping the flat of the blade closely applied to the bones, cut downwards for about five inches. Next, bring- ing the knife back to its first position, as when transfixing, cut downwards through the muscles of the calf, forming a flap of two inches in length. Now, carrying the disengaged knife over the front of the limb, connect the two lower extremities of the longitudinal transfixing cut by a curved incision, convexity downwards. Then dissect up the anterior flap from the bones and interosseal membrane, guarding against injury of ante- rior tibial artery by using the thumb-nail, or handle of the scalpel, to detach the muscle in its neighborhood. Use a small scalpel to cut around the bones and divide the periosteum, which do leisurely. Lastly, put on the retractor, and, as it is tightened, with your thumb- nails scrape upwards from the bones and all around the bones all the periosteum and muscular tissue, so that when the section is made, the same surfaces may be well covered with the one as well as with the other. Divide the bones on exactly the same level, remembering to saw off a very little from the upper and inner angle of the shin. It will now be seen that your anterior flap falls over the stump as naturally as the eyelid over the eye, and the pus finds as ready an exit as the tears. DISTRffiUTION OP METHODS. 73 " Acupressure needles can be used to control the hemorrhage in this amputation as well as in any other, but, inasmuch as they ought to be removed by some one entirely conversant with the subject at as early a period as possible, the carefully tied ligature, in battle-field surgery at least, is most applicable. Metallic sutures, and not plasters, should be used to close the wound. " In some instances it may not be practicable to give the length herein recommended to the anterior flap. In such instances the poste- rior flaps can be made of greater length. The peculiar advantages of this form of operation are preserved if the anterior is two inches longer than the posterior flap. " Many experiments upon the cadaver abroad before the commence- ment of the late struggle, showed that this was a most facile procedure, and experience in hospitals and on the field since then demonstrate its benefit to the patient." It is the opinion of Assistant-Surgeon Leale that patients having amputation of leg suffer more than those who have had the thigh amputated. He " The patients as a rule with amputations through the tibia sufier more pain than those with amputated femurs, taking those at present in hospital as a guide." DISTRIBUTION OF THE VARIOUS METHODS OE AMPUTATION IN THE DITFERENT REGIONS 01 THE THIGH AND LEG. Upper third. Middle third. Lower third. Thigh. teg. Thigh. Leg. Thigh. I*g. Circular Antero-posterior flaps Posterior flaps Anterior flaps 10 5 33 3T 2? 1 3 4 22 35 4 3 2 27 24 17 7 20 .37 1 4 3 9 50 34 6 1 11 4 Rectangular flaps Skin flaps and circular of muscles Totals 15 103 66 75 74 106 We learn from this table that the circular operation vs^as more frequently performed in the upper third of the thigh, in a given number of thigh amputations which recovered, than the flap. According to these statistics the former exceed the latter in the ratio of two to one. The number of cases is too few to establish the fact that the circular method gives a greater proportion of recoveries in this region, and we merely Circular operation more fre- queDt in up- per third of thigh. 74 DISTRIBUTION OF METHODS. chronicle the record as an interesting, and perhaps important, con- clusion presented by these statistics. In the middle of the thigh the proportion of circular to flap Flap opera- Operations materially changes, and we find the latter pre- fi^ue"un dominating, and in the lower third this proportion is middle third, increased both by the increase of the flap operations and the diminution of the circular operations. This last result is quite unexpected, for the circular operation is generally regarded as especially adapted to the lower third of the thigh. We must either conclude that the circular operations more frequently proved fatal, or that this method was not so generally adopted at this point as the flap. The following table of thigh amputations performed by Southern surgeons during the war is of interest in this connec- tion : — Methods of operation in the Confed- erate Borrice. AMPUTATIONS OF THE THIOH IN THE CONFEDERATE SERVICE (CHISHOLM). Method. Circular Flap . . Upper Third. Middle Third. Lower Third. Eec'd. Died. Rec'd. Died. Keo'd. Died. 21 10 18 5 40 18 28 19 54 40 48 16 209 108 The number of cases of amputation by the circular and flap operations in the upper third of the thigh which recovered, are in nearly the same proportion in this table as in the table already given. But we have also added the fatal cases, and in this collec- tion the circular method gives a large excess of deaths. If this latter table correctly illustrates the comparative mortality after the two operations, the flap is far the most successful method of ampu- tation in the upper thii-d of the thigh. This excess of fatal cases of circular amputations we must consider as exceptional until fiirther investigations prove it more definitely. It appears from this table that in the Confederate service the cir- circniar cukr method was preferred to the flap method in all parts fe^ in all of the thigh. In Baer's consohdated tables,^ we find parts ofjQf, p i_i • t thigh. 106 cases ot thigh amputation recovered, of which 116 were the circular, and 67 the flap operation. These operations were distributed as follows : — 1 Chisholm's Military Surgery, 3d ed. p. 395. DISTRIBUTION OF METHODS. 75 lilfethod. Upper Third. Middle Third. Lower Third. Total. Circular Flap 22 9 40 18 54 40 116 67 Totals 31 58 94 183 The influence of the method of operation upon the mortality does not appear in our tables. From the consolidated table quoted from the statistics of the insurgent service, however, the following comparison may be instituted between 134 fatal cases, and the 183 recovered cases above tabulated : — Ittethod. Upper Thttd. Middle Third. lower Third. Total. Circular Flap 18 5 28 19 48 16 94 40 Totals 23 47 64 134 These tables, properly reduced, give the following as the relative frequency of the two operations in the different parts of the thigh in the recovered and fatal cases, as reported by the Confederate surgeons : — Recovered Oases. Fatal Gases. MKTHOI). Upper Third. Middle Third. Lower Third. Upper Third. Middle Third. Lower Third. Circular Flap 1 in 5.2 1 in 7.3 1 in 2.9 1 in 3.7 1 in 2.1 1 in 1.6 1 in 5.2 lin8 1 in 3.3 1 in 2.1 1 in 1.9 1 in 2.5 The almost exact correspondence of the proportion of circular and flap operations in the different regions of the thigh, both in the recovered and fatal cases, would seem to prove conclusively that the mere method of operating did not affect the mortality in the slightest degree. Of the remaining amputations of the thigh, the anterior and lateral flaps seem to have been adopted in several cases in the mid- dle and lower third. The rectangular flap of Teale was per- formed five times, twice in the middle third, and three times in the lower third. The operation by flaps of the skin and circular of 76 PERIOD OF AMPUTATION. the muscles was performed but twice in the thigh, and on each occasion in the lower third. Passing to the leg, we find the rival operations are the circular Methods o/ and an tcro-posterior flaps. The circular, in every region °Eg.°° '" of the leg, however, presents the larger number of recov- ered cases. In the upper and middle third the difference in num- bers between the two operations is not very marked; but in the lower third the preponderance of circular over the flap cases is very decided, and emphatically asserts the greater frequency of that operation. We find here a large number of posterior flap amputations, lim- ited principally to the upper and middle thirds of the leg. This operation is undoubtedly closely allied to the antero-posterior method in the leg, the anterior flap being short, and the posterior flap very long. The method by lateral flaps was performed in twenty cases, the largest number being in the lower third of the leg. In this operation we recognize the method by skin flaps and circular of the muscles, or an operation resembling it, owing to the nature of the tissues and part in which it was performed. VII. PERIOD OF AMPUTATION AFTER INJURY. We have, in this collection, the period of operation fixed with Period of great precision in 155 cases of thigh amputation, and in ^"i^ary. 276 cascs of leg amputation, making a total of 431 cases of amputation in the lower extremity. We will first group them into primary and secondary operations according to the usual plan : — Umb. Primary. Secondary. Thio-h U3 ' 186 42 T.PP- 90 Totals . . 299 132 This table, in a striking manner, confirms the now well-estab- lished fact that primary amputations in military surgery are far the most successful. In a given number of recovered cases, taken in- discriminately, we find the primary amputations exceed the second- ary more than two to one. That this statement may be accepted NEW DIVISION OP PERIODS. 77 as a general truth is proved by the following statistics, which are gathered from various sources, and represent only recovered cases : Thigh. Leo. Secondary. Primary. Secondary. Above collection Sherman's campaign (Andrews) . . Confederate army British army (in Crimea) Hospitals on Bosphorus 113 53 224 53 36 42 26 56 6 6 186 60 96 61 30 90 7 18 4 4 479 136 433 123 Primary amputations 77.8 per cent, of recovered cases of thigh. Primary amputations 77.8 per cent, of recovered cases of leg. This table furnishes not only the strongest possible evidence of the success of primary amputations over secondary, but we find in it also a singular coincidence between the results of the primary and secondary amputations in the thigh and leg. It is found on reduc- ing this large collection of cases that there is precisely the same per- centage of primary amputations in both the thigh and leg, and that the percentage is more than three fourths of the recovered cases. But while the success of primary over secondary amputations has been definitely determined, and the principle that the former should always be preferred to the latter has been incorporated as a maxim into military surgery, there has been a growing disposition manifested to study more thoroughly the influence of periods upon the results of amputation, and by a wise discrimination establish new and more practical subdivisions than those hitherto importance ■^ of a new di- known as primary and secondary. It has long been ap- Tision of the parent to careful observers that, after the receipt of a amputation, severe gunshot injury of an extremity, the patient passes through several well marked stages or periods, in which his general con- dition and the wound undergo very material changes. At first he suffers from the shock or ehranlement ; this is followed by reac- tion ; then succeeds the preliminary stages of inflammation ; and finally the inflammatory stage with suppuration supervenes, and the progressive changes through which wounds pass to recovery. The first period can last but a few hours ; the second may extend to twenty-four or forty-eight hours ; the third may continue several days before the fourth is established ; and the fourth may continue 78 OLD DIVISIONS OF PERIODS. an indefinite period. Competent observers describe still another stage, namely, that which intervenes between the receipt of the injury and the commencement of the shock. Writers on military surgery have variously divided these periods, Various di- ^^^ '" general they have added only one subdivision, JfricSsof and that has been intermediate between the primary amputation. ^^^ secondary periods. Boucher, followed by Alcock, made the following distinctions, namely, the primary, the intermedi- ate, and the secondary. H. Larrey distinguished three periods, as follows : the immediate or primitive, the consecutive, and the ulte- rior. Legouest made three divisions, namely, the immediate, the mediate, and the ulterior. 3. Roux gave the following titles to his subdivisions, namely, the immediate ot primitive, the mediate or secondary, and the ulterior or consecutive. In these new divis- ions the period which intervenes between the commencement of the inflammation and the commencement of suppuration was re- garded as intermediary, consecutive, or mediate. These distinc- tions have for the most part been made by French writers. Le- gouest thus defines the meaning and application of the terms which he employed, namely, immediate, mediate, and ulterior : an amputation is immediate when it is practiced before the devel- opment of infiammatory phenomena ; it is mediate when made during the inflammatory period ; and it is ulterior when practiced at the time that the lesion becomes local, and may be regarded as a chronic affection. It will be perceived that Legouest overlooks altogether the period of shock, and the same is true of the other authors quoted. Professor Hamilton, of New York, has made a new classification of the periods of amputation, in which he divides the primary period of Boucher, and the immediate period of Legouest, into the immediate and primary. He remarks of this division : ^ " These Hamilton's pcrfods are divided somewhat arbitrarily into immediate, periods. primary, intermediate, and secondary, which arbitrary divisions have relation to certain supposed physical conditions of the patient during these periods. It is assumed that the condi- tions correspond, therefore, to certain divisions of time with some degree of accuracy. It being assumed that in a certain proportion of cases within the first six hours the patient is in a condition of shock, this is called the ' immediate ' period. It being assumed that after the lapse of six hours, and before forty-eight, reaction ensues, but not inflammation, this is called the ' primary ' period, 1 Sfed. Record, September 15, 1866. AMPUTATIONS BEFORE SHOCK. 79 or period of reaction. It having teen observed that after the lapse of forty-eight hours, and before the interposition of suppuration, which is usually completed by the seventh day, there is inflamma- tory action or a congestion of the limb, this is called the period of inflammation or of congestion, or the ' intermediate ' period, as being intermediate between the primary and secondary. And it being assumed that suppuration takes place, or is pretty well de- veloped, by the seventh day, the period extending from this time on is called the ' secondary ' period. This latter period is indefi- nite as to its extent, and is also called the period of suppuration." In these several classifications of the periods into which we may divide the stages of progress of gunshot wounds of the penoabe- extremities, no notice is taken of that still eariier period '"re'tock. which intervenes between the receipt of the injury and the shock, to which we have already referred. Those writers who recognize this period regard the shock as delayed, giving, thereby, a period more important, with reference to the operation, than any which follow. Par^ alluded to this period, though perhaps without recognizing the absence of shock, and urged that amputation should be made while the wounded were in sight of the battle-field. Wiseman refers to it in this emphatic language : " If you decide to operate, do so at once, while the soldier is in heat and in mettle." Larrey recognized it, and declares that amputation should be per- formed at once. Hutchuison,^ a distinguished British naval sur- geon, proves by a large experience that there was a distinct interval between the injury and the occurrence of shock. His observations were made on shipboard, where he had an opportunity to see the patient from the moment of injury. Quarrier,^ also a naval sur- geon, speaking of a naval action in which he was engaged, says : — " All our amputations were performed immediately, without waiting for reaction ; and it may be necessary to observe, that though many of the men were carried down with their limbs torn from them, others with the most severe lacerations and fractures, .... yet in no instance could we perceive the dreadful perturbation and constitutional shock so frequently described by authors on gunshot wounds, until some time after the injury was received." He adds : — " I have every reason to conceive, that amputation having so promptly followed the wound, was the only effectual means of saving many from its baneful influence." 1 Practical Observations in Surgery. * Med. Chir. Transact. toI. vjii. 80 A FIFTH PERIOD GIVEN. Surgeon Lidell, an accurate observer, and in charge of a large military hospital during the late war, believes that the shock is generally delayed, giving a period favorable for the operation. Surgeon C. J. Walton, 21st Kentucky Vols., says : — " In some cases there is a period of time sufficiently long between the reception of the injury and the ' shock.' Beyond all doubt this is the most favorable time for an operation. The patient then only receives one ' shock,' and the recovery is rapid, and almost invariably successful." Surgeon D. F. Leavitt, 3d Massachusetts Cav., writes : — " Shock after severe injuries has not been frequent under my obser- vation. Two cases only among many hundred severe injuries have suffered in a marked degree from shock — one a compound comminuted fracture of head of tibia by large grape-shot ; the other, compound com- minuted fracture of femur at trochanter by small grape-shot. Both died without hemorrhage. No operation was performed." Finally, we have the evidence of McLeod, not only as to the existence of this stage, but as to its importance vsdth reference to the operation. He says : ^ — " I know of several well authenticated cases which occurred during the siege, in which the perfect absence of all constitutional prostration after an accident so severe as the carrying off of a limb, and the non- appearance of such shock for some considerable time after, went to prove the same position." In view of such testimony it seems important to recognize a fifth A fifth pe- period, which becomes truly that of the immediate ampu- nized. tation, namely, the period which intervenes between the receipt of the injury and the shock. This period would not ordi- narily extend beyond an hour. It may be stated here that these divisions of time cannot be fixed in any given case. They depend upon physical conditions that change with individuals and with surrounding circumstances. Inflammation may occur within twelve hours of the injury, or by treatment it may be delayed three or four or more days. The Periods periods that have been fixed, and the terms that have natotheoon- been employed to designate changes, are arbitrary, and patient. are to be taken in the most general and liberal sense. In the redivision of these periods terms ought to be adopted that clearly define the meaning of those who use them in every individual case. The old terms primary and secondary, though 1 Notes on tke Surgery of Crimeon War. AMPUTATIONS IN DIFFERENT PERIODS. 81 applied to two very well understood divisions of time which em- braced certain conditions of the local injury, were rarely so em- ployed as to convey a definite meaning. The science of our day demands more positiveness in the nomenclature of diseases. It would be far better, therefore, in making a new classification of periods, to select terms which explain the existing condition of the patient or wound, and which are not arbitrary. We propose for the purposes of discussion in this paper to so divide the periods as to include all hitherto described, and under such titles „ JNew names as more nearly explain the condition of the patient or "' p™o'1»- part. We name five periods, as follows : before shock (one hour or less) ; during shock (one to six hours) ; during reaction (sixth to forty-eighth hour) ; primary inflammation (forty-eighth hour to seventh day) ; secondary inflammation (after seventh day). The first two periods relate to the condition of the patient, and the last two to the condition of the wound. Much difference of opinion exists among writers as to the pro- priety of amputations in these different periods. This propriety of question can be correctly settled only on the basis of the ™^w^° comparative, mortality in each. The preceding collection "'"'• of cases furnishes us the materials for forming correct conclusions upon this much debated subject. We are able to fix the time of operation in each case with so much exactness that we are enabled to determine the proportion of recoveries, in the different periods, to the total recoveries, and thus determine the most favorable period for the operation. We will first present an analysis according to the divisions of Hamilton. NUMBER or CASES IN FOUIt HUNDRED AND THmiT-ONB RECOVERED AMPUTATIONS IN THE IMMEDIATE, PRIMARY, INTERMEDIATE, AND SECONDARY PERIODS, AND THE PER CENT. IN EACH PERIOD OP TOTAL AMPUTATIONS IN THE THIGH AND LEG. Immediate. Primary. Intermediate. Secondary. Thigh, 52, or 33.5 per ct. 49, or 31.6 per ct. 18, or 11.6 per ct. 36, or 23.2 per ct. Leg, 104, or 37.6 per ct. 82, or 29.7 per ct. 35, or 12.6 per ct. 55, or 19.9 per ct. 156 131 53 91 SUMMARY. Immediate, 156, or 36.2 per ct. of total. I Intermediate, 53, or 12.3 per ct. of total. Primary, 131, or 30.4 per ct. of total. | Secondary, 91, or 21.1 per ct. of total. If we divide the cases included in the immediate period into those occurring within one hour, and those occurring between the 82 PROPRIETY OF IMMEDIATE AMPUTATION. first and the sixth hour, we should separate those operated upon before, from those operated upon during the shock, or nearly so, as follows : — Before shook. During shock. Thigh 18, or 11.6 percent. 34, or 21 .6 per cent. Leg 24, or 8.6 per cent. 80, or 28.7 per cent. 42, or 9.7 per cent, of total. 114, or 26.5 per cent, of total. In regard to the propriety of amputation immediately after the Propriety of occurrencc of the injury, or before the shock is of any l^puSn. considerable intensity, as within one hour from the gun- shot, various opinions are held. Par6 and "Wiseman evidently approved of immediate amputation in the sense in which we speak of it, namely, lefore the shock. Larrey advocated with great ear- nestness immediate amputation, and affirms that he lost a great number of patients by delay. He speaks of being most success- ful in cases where the operation was peu d'instans apres le coup. McLeod, speaking of the period which intervenes between the wound and the shock, says : " If this precious moment could be seized at all times, and that operation performed under chloroform, which assists so much in warding off the ebranlement we fear, how much more successful would our results prove than under any other circumstances they ever can be ! " Hutchinson says : " The operation ought not to be deferred one moment ! " Guthrie says : " There can be no doubt that if the knife of the surgeon could in all cases follow the ball of the enemy, or the wheel of a railway carriage, and make a clean, good stump, instead of leaving a contused and ragged wound, it would be greatly to the advantage of the sufferer." He approves, in general, of imme- diate amputation in the arm or below the knee, remarking : " These operations may be done at any time from the moment of infliction until after the expiration of twelve or twenty-four hours, without any detriment being sustained by the sufferer with regard to his recovery." In those cases where the injury renders ampu- tation in the upper third of the thigh or at the hip joint necessary, he is in doubt as to the propriety of immediate amputation, and thinks the subject demands further investigation. Hamilton^ believes that the occurrence of delayed shock is rare, and would approve of immediate amputation only in extreme cases, "as, for example, when a limb is nearly torn off", and a dangerous hemorrhage, which cannot be arrested, is occurring ; or when spicula of bone, such as neither the forceps nor fingers can 1 Med. Record, September 15, 18GG. AMPUTATION DUKING SHOCK. 83 extricate, are causing intense suffering." He would also favor immediate amputation " in a considerable number of cases of injuries to larger limbs, when it is clearly seen that the patient is not faint, or depressed, or suffering under great nervous agitation." The above table shows that amputation was successfully per- formed during the late war within a period after the Kesuits of injury which implies either that shock had not super- amputation vened, or that it was as yet but slight. In many cases the opera- tion is reported to have been performed immediately, and some of these we know were immediately, in the true sense of the word, but a few minutes having elapsed between the receipt of the injury and the operation. It may be stated in regard to the compara- tively few cases reported, that they prove that a large mortality must have occurred, or that but few operations were performed. We incline to believe the latter is the true explanation. The opportunity to perform an amputation within an hour after the injury, occurs but infrequently compared with the cases which offer for amputation at subsequent periods. Various opinions are advanced by military authorities in regard to amputation during the existence of shock. Larrey Amputation went so far as to contend that the nervous " commo- ehlck. tion " was rather an indication of the propriety of the operation, because its effects " far from being aggravated, diminish and disap- pear insensibly after the operation." McLeod, quoting this state- ment of Larrey, says : ■ " But even although that constitutional disturbance which is the result of injury is present, is it always necessary to wait its subsidence before operating ? If it be very decidedly marked, and the patient thus much prostrated, such delay may certainly be called for ; but it is an opinion often stated by those who must be well informed on the subject, that such delay is not always advantageous, but manifestly the reverse." Hamilton decidedly condemns amputations during the stage of shock. He remarks that his experience has been, " after at least twenty years of observation in hospital practice, and after a pretty large experience upon the field, that amputations of large limbs, made after severe injuries and before reaction has fairly been established, have in most cases resulted speedily in the death of the patients." The cases to which Larrey refers, in which the nervous commotion is diminished by an operation, he explains to be those in which the broken bones, fragments of shell, splinters, clothing, or some other foreign substance lying in the track of the wound, are causing pain, and perpetuating the irritation. 84 AMPUTATION DURING PERIOD OF REACTION. The preceding table would seem to definitely settle the question Success of of the advantages of amputation within six hours of the ■within six injury. And this period includes the limits set by Ham- jury. ° '"' ikon to the stage of shock. Thirty-six per cent, in a total of four hundred and thirty recovered amputations, embracing all periods after the injury, were performed within six hours of the receipt of the wound. These statistics prove that immediate (Hamilton) amputations of the thigh and leg, that is, those per- formed before and during shock, are six per cent, more successful than those performed after reaction comes on and before inflamma- tory symptoms appear ; three times as successful as those performed in the intermediate period, or in the stage of primary inflammation ; and, finally, nearly twice as successful as the secondary operations. Comparing the thigh and leg amputations, it will be seen that the largest percentage of recovered cases in the immediate period occur in the leg. If we analyze the immediate amputations by dividing this period into two, the first of one hour, and the second from one to six hours, or into the amputations before the shock, and during the shock, we find that 9.7 per cent, were performed in the first period, and 26'.5 per cent, in the second period. It is to be noted also that amputations before the shock were three per cent, more favor- able in the thigh than in the leg. The period of reaction extends from the sixth to the forty-eighth Period of re- hour. During this time the wound remains in a com- "''°°" paratively quiescent state. The patient rallies and re- covers his normal general condition, and seems to be in a proper state for an operation. But these tables prove that the success of amputations in this period is not as great as before, or during the shock, or rather that in a given number of recovered cases the largest percentage occurs in the earlier periods. From this fact we learn that primary amputations are successful in proportion to the number that are performed before the stage of reaction com- mences. Heretofore the period of primary amputations has in- cluded the three periods above designated, namely, that before, and during the shock, and the stage of reaction ; and the general opin- ion of surgeons was that the successfiil amputations mostly fell in the third period, or were performed in the stage of reaction. By this discrimination of time, and the more careful designation of the periods within which operations were performed, we learn that the real value of primary amputations depends upon whether they were performed before the stage of reaction. GENERAL CONCLUSIONS IN REGAED TO SUCCESS. 85 The great fatality of amputations performed in the " interme- diary " period, or during the excitement which precedes intermediary suppuration, is strikingly illustrated in these tables. By ^'"'^■ far the smallest percentage of recoveries are reported for this period. This unfavorable result is not so much due to the condi- tion of the wounded parts, as to the general condition of the patient. The system is now suffering from the first onset of inflammatory fever, and there is necessarily a high degree of vas- cular and nervous excitement. The temperature of all the tissues of the body is raised by the blood surcharged with heat from the inflamed parts, and there is consequently an exalted tissue sensi- bility. The shock which follows an operation under these circum- stances is always most profound, and reaction correspondingly difficult and uncertain. The inflammation which supervenes is also more destructive of tissue, and exhaustive of the patient. These circumstances combine to render the intermediary period more dangerous than any preceding. The secondary period, which includes all operations performed after the seventh day, is seen to give a larger percentage Secondary of recoveries than the intermediary period, but the results tions. are not as favorable as in either of the two earliest periods, namely, before, and during the shock. We have in this result only the general conclusions of military surgeons, long since established, that the secondary amputations are more fatal than the primary ; but we had not before so discriminated the divisions of the stages through which the patient passes, included in the primary period, as to determine at what precise time the least and greatest mor- tality occurred. We now discover that secondary amputations are not as successful as primary amputations at any period within the first forty-eight hours. We may conclude in regard to the success of amputa- General eon- T/v. "1 n 11 elusions in tions at the different periods as tollows : — regard to . . /. J I J. success of 1. Immediate amputations, or those pertornaed before amputation ' . .,, at different the shock, give good results m military surgery. periods. 2. Amputations performed between the first and sixth hour after the injury, or during the shook, are more successful than when performed at a later period, but are not probably more successful than when performed immediately. 3. Amputations performed between the sixth and forty-eighth hour, or in the period of reaction, are more successful than at any subsequent period, but are not nearly as successful as amputations performed previously to the sixth hour. 86 OPINIONS OF SURGEONS. 4. Amputations performed between the forty-eighth hour and seventh day, or in the intermediary period, are more fatal than at any time prior or subsequent to that period. 5. Amputations performed after the seventh day, or in the secondary period, are more fatal than amputations performed at any time prior to the forty-eighth hour after the receipt of the injury. TESTIMONY OF SURGEONS AS TO THE PEEIOD AT WHICH AMPUTA- TIONS SHOULD BE PERFORMED. Surgeon D. F. Leavitt, 3d Massachusetts Cav., says : — " Amputation immediately after injury I think affords the best chance of recovery. If the patient is suffering from shock, I think sulphuric ether should be administered whether operation is required or not, it being, so far as I have observed, the best treatment for that condition. If time for primary operation has passed, and there are no urgent rea- sons for early secondary operation, such operation need not be per- formed until sufficient reasons aside from the ultimate usefulness of the limb exist. In capital operations such a course affords most chances of recovery. Other things being equal, a late secondary operation fur- nishes better chances of recovery than an early one performed while inflammation is acute, and the system has not had time to adapt itself to the burden it already has to bear." Surgeon C J. Walton, 21st Kentucky Vols., says : — " The earlier an amputation is performed after the injury is received, the more successful will it be, unless the ' shock ' is too great to justify operating immediately ; then, of course, we should wait for reaction.'' Surgeon P. H. Bailhache, 14th Illinois Cav., says : — " Primary amputations are almost always successful, while interme- diary and secondary are generally fatal, particularly in general hospital practice. Of some thirty-five primary operations only two deaths occurred, one of these from malarial poison ; while of ten cases of secondary amputation eight died." Surgeon B. W. Avent writes : — " I have for many years advocated the immediate procedure in un- complicated shock. The experience afforded during the last few years has greatly strengthened my former convictions. The principle which controls me in this selection is not alluded to by yourself or those to whom you refer ; nor have I been able to find it elsewhere. Larrey INFLUENCE OP PLACE UPON ATROPHY OF STUMP. 87 may mean something of the kind, when he speaks of loss of patients, because his operations were, in some instances, too long deferred ; but his language is not explicit. In the limits of a letter I can merely mention the grounds upon which I act. The premises may be untrue, but the results have been more satisfactory, as a general rule, than in either the primary or secondary selection. I give it as follows : — " 1. Shock, following gunshot wounds, or other injuries of a kindred character, is purely nervous. 2. The impression is both local and con- stitutional. 3. Susceptibility to further impression is suspended pro- portionally to the recognized manifestation upon the subject 4. Loss of blood is not essential to the production of nervous shock, but to a limited extent may be regarded as remedial in its effects. 5. Anaes- thesia may be employed with entire safety during any period of shock, though in many instances where the operation is near the wound, owing to the absence of sensation, this agent might be dispensed with. " I never adopt the immediate procedure when there has been serious loss of blood. Many of the failures incident to it, in my judgment, are referable to a want of discrimination at this point. The respective conditions from shock and loss of blood are so entirely dissimilar that but little experience is required to detect them. They are, however, often overlooked. "I remarked just now that loss of blood when limited is remedial in shock. I think there is no principle in surgery more conclusive." VIII. INFLUENCE OF THE PLACE OF AMPUTATION UPON THE AMOUNT OF ATROPHY OF THE STUMP. Among the final results of amputations, atrophy of the stump must be regarded as of the first consideration. Next in Atrophy „f value to a firm and durable covering to the stump is °'"™'' a well nourished extremity. If the stump undergo progressive atrophy, the artificial limb requires much more care to maintain its adaptation. The constant shrinkage of the extremity renders the appliance loose, and hence it requires readjustment by continuous padding of the socket. This padding of the socket is not required when the limb maintains its full dimensions. The accompanying tables enable us to determine how far the method of operating, and the point of the limb at which the ampu- tation is performed, influence the subsequent nourishment of the stump. The measurements were made when the stump was healed, and prepared for the final adjustment of the artificial limb. The first or proximal measurement was made, in the thigh, at the high- 88 COMPARATIVE ATKOPHY. est point where the circumference could be taken, and in the leg, immediately below the knee. The second, or distal measurement, was made directly around the extremity of the stump, at a point where the margins of the flap begin to incline towards the cicatrix. The figures entered in the tables under the head " atrophy," ex- press the difference in inches and fractions of an inch between the measurement at the points above indicated of the mutilated and uninjured limb. COMPARATIVE AMOUNT OF ATROPHY OF STUMPS IN THE UPPER, MIDDLE, AND LOWER THIRDS OF THE THIGH AND LEO, IN AN AGGREGATE OF 430 OASES. (In inches and fractions of inches.) LntB. Upper Thiid. Middle Third. Lower Third. Proximal. Distal. Proximal. Distal. Proximal. Distal. Thigh I*g 0.45 0.97 1.05 1.70 1.56 0.71 1.70 1.42 1.34 0.57 2.08 2.26 It must be borne in mind that the proximal measurements in the thigh are all made at the same point ; and the same is true of the leg. It would appear from this table that the point of amputation exercises a very marked influence upon the degree of atrophy of the stump, both in the thigh and leg. In general, the amount of atrophy progressively increases as we recede from the trunk, an exception, however, being noticed in the middle third of both the leg and thigh, which we shall presently notice. In the thigh the proximal atrophy is least in amputation in the upper third, and greatest in amputations in the middle third. In amputations in the lower third of the thigh, the proximal atrophy is slightly less than in those performed in the middle third, but still it is three times as great as after those in the upper third. This fact proves a progres- sive proximal atrophy as the point of amputations in the thigh re- cedes from the trunk. In the leg this rule is reversed, and the proximal atrophy diminishes as the point of amputation recedes. And this atrophy diminishes in regular order, being least in ampu- tations in the lower third of the leo;. It must not be supposed that the proximal atrophy is influenced Proximal by the amount of inflammatory thickening subsequent to atrophy not - . „ . , , , ® , increaMd by the Operation, tor in that case the degree of atrophy would toflamma- . ,, , ,, ..„, tion. in general depend upon the proximity of the amputation to the point of measurement. But this is by no means the case. INFLUENCE OF METHOD UPON ATROPHY. 89 Amputations in the middle third of the thigh, near the point of measurement, are followed by a greater amount of atrophy than those in the lower third, remote from that point ; while in the leg the largest amount of atrophy is in amputations near, and the least in amputations remote from the point of measurement. The distal atrophy, or that which occurs at the extremity of the stump, has in the thigh a progressive increase as we j,-^^^ proceed from the trunk, being about twice as great in the ^l^iai lower as in upper third. In the leg, on the contrary, the ^'^' least distal atrophy occurs in the middle third, while that of the lower extremity is not so great compared with that of the upper extremity, as was found existing between the upper and lower thirds of the thigh. Comparing the atrophy of the stumps in thigh and leg amputa- tions, we notice that the proximal atrophy is greater in amputations in the upper third of the leg than in the same region of the thigh, while in the middle third it is more than twice as great in the thigh as in the leg, and in the lower third the excess of atrophy is greater in the thigh in proportion than in the leg. The distal atrophy varies very markedly as follows, namely : in the upper third it is greater in the leg ; in the middle third it is greater in the thigh ; and in the lower third it is greater again in the leg. These facts may be stated in general terms as follows : — 1. In the thigh, the farther amputation is performed conclusions ^ ^ ^ * in regard to from the trunk the greater will be the atrophy of the atrophy, entire stump. 2. In the leg, the farther amputation is performed from the trunk the greater will be the atrophy of the extremity of the stump, and the less the atrophy of the body of the stump. IX. INFLUENCE OF THE METHOD OF AMPUTATION UPON THE ATROPHY OF THE STUMP. We next proceed to inquire as to the influence of different methods of amputation upon the nourishment of the influence of . ,, . ,. ., . r. method of stump. The following; table contains a distribution ot amputation ST o upon the several methods of amputation in the thigh and leg, atrophy, with a computation of the average amount of atrophy following each : — 90 INFLUENCE OF METHOD UPON ATROPHY. COMPARATIVE AMOUNT OF ATKOPHY OF STUMPS AFTER AMPUTATION BY VARIOUS METHODS IN THE UPPER, MIDDLE, AND LOWER THIRDS OF THE THIGH AND LEG. (In inches and /Tactions of an inch,) THIGH. ( Total number of stumps, 167.) Upper Third. Middle Third. Lower Third. Method. Proximal. Sistnl. Distal. Proximal. Distal. Circular 0.7 0.7 1.4 1.9 1.6 2.5 Antero-posterior flaps . 0.2 1.4 1.1 1.6 1.6 2.4 Lateral flaps .... - - 1.8 1.8 1.6 2.3 Anterior flap .... _ - 2.5 2.2 1.3 2.4 Rectangular flap . . . - - 1.0 0.0 2.0 2.8 Skin flaps and cir. mascles _ _ - - 0.6 1.5 Posterior flap .... — — — — 0.7 0.7 LEO. (Total number of slumps, 287. ) Circular Antero-posterior flaps . Posterior flap .... Lateral flaps .... Skin flaps and circular . 1.1 1.5 1.0 2.3 0.5 1.1 1.3- 0.4 1.1 0.1 1.3 1.1 0.5 2.2 1. 0.4 2.9 1.0 1.0 0.7 - - - - 0.5 2.3 2.7 2.6 2.6 1.1 This table illustrates in a very striking manner the influence of Influence of the various methods of forming the covering of the stump methods of upou the nourishment of its cicatricial tissue. The dif- upon nour- fercnce in the amount of atrophy of the distal extremity the stump, evidently depends upon the extent to which the arterial supply has been sacrificed. In the thigh the arteries which are distributed to the muscles are principally in the upper third, from the femoral branches immediately below Poupart's ligament, and in the middle and lower third from the profunda. In the upper third of the thigh, therefore, a circular amputation Effects of would divide the branches of the femoral at a higher point circular and . n . i . i flap- than an antero-posterior nap, — in which the posterior flap is usually longer than the anterior, — and hence the atrophy would be greater in a stump formed by a circular than in one formed by an antero-posterior flap. The same rule would apply to these operations in other parts of the thigh, though perhaps not so markedly. The method of operation by lateral flaps does not differ mate- rially, in respect to the degree of atrophy, from the circular, and the results of the two are seen to be very similar. INFLUENCE OF METHOD UPON ATROPHY. 91 The method of operation by making an anterior and a rectangu- lar flap, differs in this important respect from the preced- i^ctangaiar ing methods, namely, that the flap is made wholly from ^''• the anterior part of the limb, while the tissues are completely divided to the bone in a perpendicular direction on the posterior aspect of the limb. By these methods the principal covering of the stump is poorly supplied with nourishment, and hence atrophy would be more likely to occur. This is seen to be the case especially in the anterior flap method in the middle third, and the rectangular flap in the lower third. The methods which give the least atrophy of the stump, both in its proximal and distal portions, are the skin flaps and swn Bap circular of the muscles, and the posterior flap. It is not ofmuscie. difficult to understand why the posterior flap method gives results so favorable ; it leaves quite intact the full vascular supply to the entire covering of the stump. In this respect it might well be regarded as the best method of operation in the thigh, but these advantages are so counterbalanced by the tendency of the flap to retain pus, its heavy and unsuitable position for transportation, etc., that it has but few advocates. The method by skin flaps and cir- cular of the muscles gives results nearly as favorable as the poste- rior flap, and much more favorable than any other of the preceding methods. It is greatly preferable to the posterior flap method, both on account of the facility of drainage, and the neat apposition and lightness of the flaps, thus adapting it to transportation. The influence of the various methods of operation upon the nourishment of the stump is not so well marked in the leg ^g^^. „f as in the thigh. This is unquestionably due to the pecul- ^JJSs in iarity of the arterial distribution. The larger trunks are *^^^^- numerous, and are deeply situated in immediate relations with the bones. They are not, therefore, liable to division until the opera- tion is about to be completed. There would therefore be but little difference among these operations as regards the vascular supply of the flaps, except so far as the extent of the flap should modify the ultimate distribution of arteries. A long flap would necessarily have less supply than a short flap, and would be more liable to immediate death and future atrophy. Of the different methods it will be noticed that the skin flaps and circular of the muscles gives the least atrophy in the leg as well as in the thigh. Many of the disastrous results of amputation in the lower extrem- ities have been attributed to immediate transportation. Effect of To this cause have been referred sloughing of flaps, gaping tim?*" 92 EFFECTS OF TRANSPORTATION. of wounds, protrusion of bone, etc. There is, undoubtedly, some truth in this very prevalent opinion, and yet the statement must undergo certain modifications. There were innumerable instances in which men suffering from recent amputations of the lower ex- tremity, had their wounds so imperfectly dressed and supported, were so crowded and confined, and were so rudely transported, that the most unfortunate consequences ensued. But unfavorable results under such circumstances are not justly due to simple transportation, but rather to that want of care in the preparation of the patient, and the conditions surrounding him, which mihtary exigencies necessitate or which are the result of negligence. There are abundant facts to prove that the transportation of recent amputations, when judiciously managed, is attended with the most happy results. During the long marches of Sherman's army from Atlanta to Savannah, and from the latter place north- ward, an opportunity was offered of determining the effects of transportation upon recent amputations. As soon as the amputa- tion was performed, and the wound properly dressed, the patient was placed in the ambulance or army wagon, and there remained until the army reached its destination. It is the testimony of sur- geons who had the care of these men, that their wounds healed with but little suppuration, sloughing did not occur, and scarcely a case proved fatal. Most of the amputations, made on the first, second, or third day's march, were entirely healed when the army reached Savannah. It should be stated that the army marched through a pleasant country, and with good roads ; the men were in good physical and mental condition, and the supply of fresh food of every description was abundant. The following testimony of surgeons upon the question of the dangers of transportation to the recently amputated is impor- tant : — Surgeon J. C. Walton, 21st Kentucky Vols., says : — " My observation proves that soldiers laboring under wounds not involving fracture of the long bones, or who have undergone Wditon. amputation, bear transportation remarkably well, and often express themselves as feeling improved, after being moved several miles over rough roads." Surgeon P. H. Bailhache, 14th Illinois Cav., writes : — "It is surprising with what ease recent cases of amputation bear transportation. I have witnessed little or no bad effects there- Surgeon r „ , . „ Baiihacho. from in some twenty-five or thirty cases. EFFECTS OF TRANSPORTATION. 93 Surgeon Charles E. Darning, 28th Ohio Vols., says : — " In nothing have I been more astonished than the very inconsidera- ble injurious effects of transportation upon recent amputa- surgeon tions of the inferior extremities. I have seen men with am- ^™™s- putated thighs, legs, and arms, transported sixty or seventy miles over the roughest of roads, in wagons, without producing any very serious consequences. Care should be taken to keep the stump constantly wet with cold water by an attendant, whose duty it should be to steady the limb when passing over very uneven places. " Wagons filled with hay afford the best means of transportation over roads ; ambulances jolt and rock too much." Surgeon E. Batwell, 14th Michigan Vols., says : — " No point of practice was so difficult to decide as the treatment of gunshot fractures. On one side we had what seemed to be a g^^. ^^ simple compound fracture, with no great apparent comminu- Batweii. tion or laceration of the soft tissues, whilst on the other, we had statis- tical evidence of the fatality arising from endeavoring to save the limb. Out of six cases of compound fracture arising from gunshot wounds, after the battle of Jonesboro', but one recovered, and that too under the most favorable circumstances. The transportation to Atlanta was over a level sand road, and the dressing of the wounds was performed by skillful and efficient surgeons, regidarly every day. Every requisite was furnished to mitigate suffering or to afford comfort, by the Sanitary Commission ; but the result proved that if the limbs had been removed, a very different state of things would have followed ; for out of thirty- five cases of amputation but four proved fatal, and two of these were secondary operations. Such success in operation we consider unprece- dented, and we feel some just pride at the results gained. " I look on immediate transportation as not productive of half the danger to a patient as if necessity required us to remove them at a later period. The request I would myself make, if 1 had received a compound fracture from a gunshot wound, would be to have immediate amputation performed. " When Sherman swung his army to the south of Atlanta, a man was brought to hospital, and his left leg taken off at the upper third of the thigh, and before he was well out from the influence of chloroform, he was put into an ambulance, and continued to move with the army daily for seven days. He improved rapidly, and his wound was almost united ou arriving at Atlanta, and in sixteen days he was sitting up, and in twenty was on crutches. « When obliged to move cases of amputation of the lower extremi- ties, I placed the stumps in slings suspended from the top of the ambu- lance ; by this all jolting was lessened, and the patients could save themselves much agony by holding and raising themselves ; besides, they 94 INFLUENCE OF METHOD ON RAPIDITY OF HEALING. could move and change position with far greater facility, and turn on their side without hurting or knocking the stump. I found that in our stationary hospitals this same plan, carried out by a simple frame across the cot, afforded the very greatest ease to our patients, both as regards facility of movement and dressing ; besides, the wounds were very easily protected from flies, and the subsequent effects of maggots were thus obviated. Tou also had a better chance of applying cold water without drenching the bed, or any other application deemed necessary." Surgeon B. T. Kneeland, New York Cav., says : — " My experience in transportation of those who have suffered arapu- Surgeon tations is limited to army wagons, and I was frequently sur- Knceiand. prised to witucss the improvement of patients when thus removed, often exceeding that of patients confined to hospitals." X. THE INFLUENCE OF DIFFERENT METHODS OF AMPUTATION IN THE SEVERAL REGIONS OF THE THIGH AND LEG, ON THE RAPIDITY OF THE HEALING PROCESS. There is an opinion very prevalent among surgeons, both in Influence of civil and military practice, that there is a marked differ- different . .,.^ . , , . , . tit methods of ence in the rapidity with which amputation-wounds heal, amputation , ,. ^1 -.i.ii on healing, dependmg upon, 1st, the region in which the operation is performed ; and, 2d, the method employed. It is necessary, of course, in estimating this difference, to discriminate carefully the cases selected, and place them upon precisely the same basis as regards, their condition. K two operations are compared in this particular, the patients must be equal quantities in every respect, otherwise our conclusion will be vitiated by a preponderance of favorable or unfavorable conditions. Nothing would be more difficult than to select two patients thus equally balanced. It is quite impossible to determine whether any, and what, difFer- Sources of Guccs exist in the healing of these wounds, except as we error. ^]jg ^^^ avcragcs of large numbers situated under nearly the same circumstances ; and even then our deductions can only approximate the truth. In this collection we are able to group together a large experience in amputations of the lower extremity, and determine in a somewhat definite manner the period of healing of the amputationrwounds. It is true that there are many circum- stances incident to the healing of wounds in military surgery, which tend to vitiate our conclusions, such as injurious transporta- tion, insufficient food, sloughing of flaps from gangrene, necrosis, etc., etc. But in grouping together a large number of cases, all WHEN A PATIENT IS CURED. 95 having been subjected to the same untoward influences in a greater or less degree, the average results are rendered in a cer- tain degree truthful. Amputations are frequently pronounced cured when the wound is not completely closed, the surgeon having reference wheiua pa- rather to the safety of the patient and his ability to leave cured, his bed than to the actual condition of the stump. But in the sense in which we are to regard the patient as cured, the condition of the stump alone is to be considered. No stump can, in this connection, be pronounced cured when the wound is not healed, and the cicatrix is not so far perfected as to admit the adaptation of an artificial limb. In the preceding tables a note is made of two examinations of the stump, the first, when the patient first came under observation, and the second, when the stump was ready for the adjustment of the artificial leg. In regard to the first examination, it should be stated that in general it was made when the surgeon discharged the case as cured, and when the stump was thought to be suffi- ciently healed for the proper measurements for the artificial limb. In many instances the wound was already completely cicatrized when the patient first presented himself for examination. In such cases the date of the completion of the cure is not stated. This column gives, therefore, merely approximate results. We can learn from it only that within given periods a certain number of stumps were completely cicatrized, and that a certain other number were not healed. The condition of the stump is generally noted, and the causes which led to its non-cicatrization are briefiy speci- fied. In the second column the date of the application of the artificial limb is given. At this period the stump was healed and in a con- dition suitable for use. This period did not always mark the exact date of the perfection of the cure, as in some instances the stump had been healed for a considerable time. But in general it may be assumed that the date of the adjustment of the artificial limb marks the period of the completion of the cure, and the final dis- charge of the patient. The following table contains the results of a computation of the average periods of the healing and non-healing of stumps in various parts of the thigh and leg, and by different methods. Although the deductions are necessarily imperfect and want that scientific accuracy that is desii-able, still, considering the large number of cases, they are worthy of record. 9P> AVERAGE PERIODS OP HEALING. AVERAGE PERIODS OP HEALING AND NON-HEALING OF AMPUTATION WODNDS OF THIGH AND LEG. Eeoiok ash Method. XJPPEB THIKD. Antero-posterior flaps . . . Circular Posterior flap Upper and middle thibd. Antero-posterior flaps . . . Circular Posterior flap Middle thibd. Antero-posterior flaps . . . Circular Posterior flap Middle and lower thibd. Antero-posterior flaps . . . Circular Posterior flap LOWEB THIRD. Antero-posterior flaps . . . Circular Posterior flap Thiss. Healed. J, Av. No. * months. 7 II H 9 "i 22 9 9 llf J, Ay. No. 8J 8 10 8 "A H 12f 13 Lua. Healed. „„ At. No. ^j^ No- months. '^''• "A 10^ 10 lOf lOf 10| 10* H 13 At. No. months. 6J 10 10 lOf 12f lOf 13^ In regard to retracted flaps, so frequently noticed, Surgeon Hodgen makes some practical observations. He states that he " has observed a great number of cases of Surgeon retracted flaps, following almost every variety of amputa- trrataent of tion, and givcu the subject some study. Most of them hav- flaps. ing been transported in ambulances, army wagons, rail- road cars, and steamboats, were so often disturbed that there was little chance for a speedy union, and every possible facility ofiered for retraction of the soft parts, and the protrusion of bones. Amputa- tions are performed during anaesthesia. The muscular tissue, which forms a larger part than any other element of the covering of the bones after amputation, is completely relaxed, and the dressing is ADAPTATION OF COMPENSATIVE APPLIANCES. 97 performed before the anaesthetic influence passes off; and when it does pass off, the muscles, resuming their original tonicity and irri- tability, contract, thus retracting the flaps, and either forcing the bone between the flaps or so firmly against them that ulceration rapidly follows, and the bone protrudes. Another cause is the manner of dressing stumps ; thus, strips of adhesive plaster are heated and applied, one end on one surface of the limb, and the flap is drawn by this strip, which is carried firmly over the end of the stump, and the remaining end fixed tightly to the highest pos- sible point upon the opposite surface of the limb, and so on, one after another, until a sufficient number of strips is applied to hold the lips of the wound together. It is apparent to any thinking man that these freshly cut surfaces are pressed tightly against the bone, and this is favorable to ulceration. Perhaps the most fre- quent cause of protruding bones is careless handhng in applying dressings after the first dressing. The surgeon observes a limb requires dressing, for the bandages are saturated with pus. The bandages are removed, and perhaps also the adhesive strips, without having the parts properly supported by a competent assistant, so that newly formed attachments are broken up and the flaps fall asunder, allowing the bones to protrude." He recommends a method of treatment which he has followed with success, namely, extension of the retracting flaps by adhesive strips with a weight. His rule is — when flaps are to unite by granulation, apply extension ; when the bones protrude, apply extension ; and when the cicatrix is tense and firm and slow to heal, apply extension. Never saw off protruding bones in these cases. XI. ADAPTATION OF COMPENSATIVE APPLIANCES. In the adaptation of an artificial limb to the stump we have the final results of amputation in the lower extremity. Sec- Artmoiai ond only in importance to the life of the individual is the '™'"' value of the stump for compensative appliances. The great aim of the surgeon now is, when the first question is answered and the safety of the patient is duly considered, at what point and by what method shall amputation be performed to secure a stump most favorable to the application of the best form of artificial limb. We have no longer the rich and poor man's stump ; these artificial aids are now brought within the means of every man ; the poorest soldier and sailor, through the wise munificence of government, 98 QUESTION FOE MECHANICAL SURGEON. are entitled to all the benefits which art can bestow in remedying the physical defects and deformities resulting from war. Even in civil life the poorest person, in anticipation of the charities of the benevolent, or his own providence and success in business, may demand that his limb shall be so amputated as to give him a stump adapted to the best artificial appliance. The question here proposed is to be answered, not by the oper- Qaesdon to ^ting surgcon, but by the skilled and scientific mechan- by^ll'i^ ical surgeon. It is his province to deal with the stump icai surgeon, g^fjgj. jj. j^g^g passed from the hands of the operator, and to test its substantial merits as a means of locomotion. AMPUTATIONS AT THE ANKLE JOINT IN MILITARY SURGERY. BY STEPHEN SMITH, M. D. AMPUTATIONS AT THE ANKLE JOINT. Amputation at the ankle joint seems to have been a compara- tively infrequent operation during the late war. In a Frequency total of 9,705 amputations, but 67 ankle-joint amputa- tion/"'*"" tions have as yet been fully ascertained at the Surgeon-General's office. The record is, however, stated to be far from complete. Whatever may prove to be the total number of these operations, we are satisfied that ankle-joint amputations, by any of the recog- nized methods, were not regarded with favor by the surgeons of either the Federal or insurgent armies, at the close of the war. On a very extensive personal inquiry of army surgeons of large experience, there was found to be great unanimity of opinion in the total rejection of these operations from military surgery. At the commencement of the war, amputation at the ankle joint was considered a legitimate procedure in civil practice, its es«mate In some one of the several methods of operation it was practice. almost universally regarded not only as free from danger as any amputation in that vicinity, but as yielding admirable results as respects the future usefulness of the limb. So much importance was attached to this amputation at that time that one of the oldest and most experienced army surgeons, 0. S. Tripler, instructed the surgeons of the division of the army of which he was then medical director (the Army of the Potomac),to amputate at the ankle joint by PirogofF's method in preference to amputation through the leg, when practicable.^ The objections of army surgeons to ankle-joint amputations are various. In the experience of some, sloughing of the flap is the chief source of mischief; others allege that exten- objections to n « ,1 . this opera- sive suppuration, or necrosis, generally toUow, necessi- tion. tating reamputation ; while a few did not regard the stump as the most serviceable, and rejected it without trial. Considering the importance which civil surgeons generally attach to these opera- tions, both on account of their comparative safety and the value of the stump for future usefulness, it becomes a matter of considerable 1 Consult Tripler's order. 102 COMPARATIVE SUCCESS. importance to determine on what grounds the unfavorable opinion of army surgeons is based, and what should be the status of ankle- joint amputations in military surgery. It must be observed, in limine, that amputation at the ankle joint is always an alternative operation. It is selected in preference to An opera- an amputation at a point higher up in the limb. It should pediency. also be added that it is an operation of expediency. It is not a dernier ressort. If it fails of success the surgeon may still, with rare exceptions, perform the alternative amputation through the leg with the prospect of as favorable results as when the latter is the first operation. In determining the value of ankle-joint amputations, therefore, the following questions naturally arise for our consideration : — I. The comparative success of this amputation. (a.) As regards mortality. (5.) As regards the necessity of reamputation. (e.) As regards the comparative frequency of sloughing, ne- crosis, etc. II. The comparative serviceableness of the resulting stump, (a.) As regards the ability for unaided locomotion. (J.) As regards the adaptation of the stump for an artificial limb. COMPARATIVE SUCCESS OF ANKLE-JOINT AMPUTATIONS. (a.) Comparative Mortality. — From the Surgeon-General's Re- comparative Port ^ wc Icam that in a total of 67 amputations at the InX^oin' ankle joint, 9 proved fatal, and 58 recovered. This state- amputation. ^^^^ gj^^g ^ mortality in this operation of 13.43 per cent. From the same source it appears that in 2,348 amputa- tions of the leg, 611 proved fatal, and 1,737 recovered, being a mortality of 26.02 per cent. Again, the total amputations of the lower extremities, including the toes, partial amputations of the foot, etc., were 6,058, as reported to the Surgeon-General, and of this number 34.55 per cent, proved fatal. The results of amputation in the British army during the Crimean war do not differ materially from those given above. Amputation at the ankle joint proved fatal in about 18 per cent, of the cases operated upon, while amputations of the leg gave a mor- tality of 36 per cent.^ 1 Circular No. 6, Surgeon-General's office. * Medical and Surgical History of the British Army, etc. FREQUENCY OF REAMPUTATION. 103 The surgical records of the insurgent armies furnish some col- lateral evidence. A consolidated table of amputations from June 1, 1862, to February 1, 1864, is published,^ from which it appears that ankle-joint amputations were fatal in 20 per cent., and ampu- tations of the leg were fatal in 27 per cent, of the cases operated upon. From these statistics it appears that amputation at the ankle joint is 50 per cent, less fatal than the alternative amputation through the leg. Compared with the mortality after the total am- putations of the lower extremity, including the most trivial, it is but a little more than one third as fatal. If we were to decide the merits of this operation, then, by its comparative fatality, or by the dangers to life which it involves, we should give it the prefer- ence, unhesitatingly, over all other forms of amputation of the leg. But the absolute value of an amputation cannot be decided alone by its mortality. We have to consider, also, — (J.) The Oom/parative Frequency of Reamputation after Ampu- tations at the Ankle Joint. — It is difficult to determine comparatire with any considerable degree of accuracy the frequency relmpuS-"' of reamputation in any given class of cases. We are able, ''°''- however, to arrive at approximative results, which indicate very clearly how in general the question is to be decided. In 31 cases of ankle-joint amputation, 4 required reamputation, or about 12.9 per cent. ; in 65 amputations of the lower third of the leg, reampu- tation was required 6 times, or in about 9.2 per cent, of the cases. It is evident from these facts that reamputation after ankle-joint amputations was more frequent than after amputations in the leg. In examining as to the causes which led to reamputation we find that in ankle-joint amputations it was performed once on account of retraction "of the flaps, and three times on account of sloughing and necrosis. In amputations in the lower third of the leg ream- putation was practiced five times on account of sloughing and necrosis ; one case cause unknown. (e.) Comparative Frequency of Sloughing and Necrosis. — Slough- ing of the flap after Syme's amputation, and necrosis of piequency the adapted portion of the calcaneum after Pirogoff's am- "^a^^^J^s putation, are alleged to be the chief sources of failure "^' after ankle-joint amputations. The following collection of cases gives a total of 23 ankle-joint amputations by Syme's method, and 1 A Manual of Military Surgery, etc., by J. Julian Chisholm, M. D., third edition, Colom- bia, S. C, 1864. 104 SERVICEABLENESS OF STUMP. 10 by Pirogoff 's method. Of the 23 cases of Syme's amputation, 4 are reported to have been followed by sloughing of the flaps, and 3 by necrosis. In other words, 7 in 23 cases were followed by sloughing and necrosis, or 30.4 per cent. Of the 10 cases of Piro- goff 's amputation, 2 are reported to have been followed by necrosis, in one case the os calcis necrosed, and in one the posterior part of the lower extremity of the tibia was involved. It is noticeable that in two cases of sloughing after Syme's operation the stumps healed and ultimately became serviceable. It cannot be alleged, however, that the comparative difference between these two operations is sufficient to decide the question as to the point of election. If ankle-joint amputations present any very considerable advantages in other respects over leg amputa- tions, no prudent surgeon would regard this slightly greater liability to sloughing and necrosis as a sufficient reason why he should be deterred from selecting the former. Before determining the question, we must consider the compar- ative value of the stumps resulting from these different opera- tions : — II. COMPAKATIVE SERVICEABLENESS OF THE RESULTING STUMP. (a.) As regards Locomotion. — Ankle-joint amputations differ Serrtccabic- from amputatious in the leg in this essential particular, stump. namely: in the former the support is taken directly upon the extremity of the stump, and in the latter upon the sides of the limb. In model stumps of each class it will be found that the one which takes direct support upon the extremity is not only capable of enduring a much larger degree of service, but the per- son suffers fer less inconvenience. Direct pressure upon the heel flap may be endured as long in Syme's stump as similar pressure upon the natural heel. And the same is true of stumps following Pirogoff's method. Patients with these stumps have frequently been known to walk successive days twenty and thirty miles with only the simple covering or protection of the heel of a common shoe or boot. Mr. Syme stated in a clinical lecture that " Patients who had suffered the operation, were able to stand, walk, and even run, without any covering or protection of the stump ; and a gen- tleman present, having had his attention accidentally directed, a few days before, to some boys who were amusing themselves on a slide in the street, discovered that one of them had undergone am- putation at the ankle joint." Professor Van Buren, of New York, AMPUTATION FOR ARTIFICIAL LIMB. 105 recently met at his clinic the third person on whom Mr. Syme performed this operation, sixteen years hefore, who stated that he had walked thirty miles in a day without inconvenience from his stump. These are by no means exceptional cases. Surgeons who have been accustomed to meet with the results of this operation most frequently, uniformly testify to the ease with which patients betake themselves to the stump with only such covering as they can rudely adjust. Of the stumps left by Syme's and Pirogoff's operation, the latter has the greater length, and thus requires less compensation. Amputations through the leg, at whatever point, and however skillfully performed, never furnish stumps which take Amputation direct support. The limb is useless for locomotion by not°|i-re^- any simple means of compensation ; it is only when an "*' support, artificial limb is accurately and skillfully adjusted that it serves the purpose of even simple progression. Again, in amputation at the ankle joint the patient retains power over the muscles of the calf which are essential to the act pa,tjeiit has of running. It is extremely rare that a patient who has m^4,'e7of suffered amputation of the leg can make even the pretense jrint°a^pit' of running upon his artificial limb. The muscles, espe- •*'"""• cially of the calf, have shrunken from disuse, and progressive, per- manent atrophy of the parts below the knee ensues. In ankle- joint amputations, however, the tendons of all the muscles employed in locomotion retain their former, or acquire new attachments, and are immediately and constantly exercised in the movements of the limb. It is true this movement of the muscles is more limited than in the normal limb, but it is nevertheless suflBciently great to preserve much of their activity, and consequently their nutrition is but partially impaired. The importance of preserving the functions of the muscles of the leg is seen in the perfection of gait which persons with anlde-joint amputations soon acquire. They can not only run, often with great ease and facihty, but they acquire the power of leaping, dancing, etc., to such perfection that their disability frequently passes unrecognized. (b.) As regards the Adaptation of the Stump for an Artificial Limb. — As previously stated, the stump after ankle-joint Adiiptation amputation takes direct support upon the extremity. Mr. an°^ciS' Quain thus .speaks of the advantages of direct support, ""*"■ in referring to Syme's amputation: "It is free from any valid objection, and, what is more important, the result in practice has been found to be good. A person who has undergone this opera- 106 CONCLUSIONS. tion is enabled to bear his whole weight upon the end of the stump without inconvenience ; and on this account the facility of progres- sion is, with a proper apparatus, decidedly greater than when the amputation is performed at any higher part of the limb." The advantages of the ankle-joint stump over those of the leg Advantages for the adaptation of an artificial limb, are admitted by ankle"''* the most Competent mechanical surgeons to be of the most undoubted character. In Syme's amputation the patient walks upon the end of the stump with ease and grace, can run, leap, and dance, and is capable of enduring fatigue little short of that of the sound limb. We speak now of successful cases. No results at all comparable with this are attainable with any form of stump above the ankle. This review of the comparative merits of ankle-joint and leg amputations as exhibited by statistical evidence authorizes the following conclusions : — 1. Ankle-joint amputations are fifty per cent, less fatal Conclusions. , , . than leg amputations. 2. Ankle-joint amputations are three per cent, more liable to be followed by reamputation than leg amputations. 3. The stumps left after ankle-joint amputations are far more serviceable than those resulting from leg amputation for unassisted locomotion. ' 4. An artificial limb can be far more usefully applied to an ankle-joint than to a leg stump. It may be stated in general terms that the experience of the Experience ^^^'^ '^^'^ ^^^ established the fact that ankle-joint amputa- of late war. ^^ovts are Icss fatal than leg amputations, but that slough- ing and necrosis are more likely to occur in the former than in the latter ; that the resulting stump in ankle-joint amputations is much more favorable for unaided or aided progression than in leg ampu- tations. The correct inference from these conclusions is that ankle-joint amputations should be recognized as occupying an important place among the legitimate operations of military sur- gery. It remains to consider the causes of failure in ankle-joint ampu- Cansesof tations as illustrated in this collection of cases, the reme- aiiure. jjj^j measures adapted to prevent or mitigate such causes, and, finally, the comparative value of the methods of operation proposed by Syme and Pirogoff. CAUSES OF FAILURE. 107 CAUSKS OF FAILURE IN ANKLE^OINT AMPUTATIONS. The striking difference in the success of ankle-joint amputations in civil practice from that in military practice, depends upon causes not difficult to determine and appreciate. Surgeon David P. Smith, United States Vols., who has had a large experience, and is a warm advocate of the operation, says : — " "When done in our army for gunshot wound, the results have not, by any means, been uniformly successful. It appears, however, Surgeon that the failures can hardly with justice be attributed to the Smith on form of operation. From much conversation with army sur- mu^. geons upon this topic, and from no inconsiderable personal experience, it is believed, first, that the operations have been generally too long delayed, and at last done when, from the undermining of tissues by the burrowing of pus, there could be no reasonable hope of success ; and, secondly, that the manual performance was faulty in the ex- treme.'' He illustrates the failure of the operation from the first cause by his own experience : — " The four cases of ankle-joint amputation occurring at Fairfax Sem- inary General Hospital, were performed upon wounded removed at a late date from the disastrous field of the second Bull Run battle, where they had undergone much privation and hardship. The tissues were undermined with pus. Had I not witnessed Mr. Synie's own practice, and heard him detail his experience of constant success under the most adverse circumstances, I should have preferred amputation in the con- tinuity of the leg in these cases, so great was the suppuration about the ankle above the point of section. Mr. Syme's procedure was strictly followed in all four cases. " One recovered, and left the hospital with a good firm stump. " One, apparently the most suitable of all for this operative procedure, succumbed to pyaemia. In this case no section of bone was made, even the malleoli being suffered to remain. " Two, on account of sloughing of flap and protrusion of bone, were obliged to submit to amputation of the leg." The various causes of failure of this operation may be considered under the following heads : — I. Sloughing of the Flaps. — In the early history of ankle- joint amputations, especially by the method of Syme, sioughingof sloughing of the flaps was a frequent accident. Many ^'^■ surgeons were led to discard the operation altogether after repeated failures from this complication. Experience proves, however, that 108 SLOUGHING OF FLAPS. sloughing cannot be regarded as a necessary or even a frequent result of this operation. It occurred but four times in twenty- three cases as we have already shown. There are apparently two principal causes of sloughing of the flaps, namely : (a.) Contusion of the soft parts entering into ike flaps ; (6.) Destruction of the nutritious arteries of the flap in the operation. (a.) Contusion of the Soft Parts. — It not unfrequently happens Contusion of that in the accident that caused the injury for which soft parts, amputation is performed, there is a much larger destruc- tion of the soft parts than at first appears. Especially is this true of railroad injuries, gunshot wounds, etc. The sudden and ter- rible violence of the impinging body not only destroys the vitality of the part which it encounters by direct contact, but the same destructive effects are manifested in contiguous tissues after several days over a surface often surprisingly extensive. And this decep- tion is rendered the more complete by the apparent accuracy with which we may at first limit the destroyed parts. The line of demarcation seems well defined by the discoloration which borders the upper limit of the lesion of tissues. But within a day or two the fallacy of this observation becomes unpleasantly apparent. Parts that at first were believed to be uninjured become cold, -the purple discoloration of incipient gangrene extends, and the slough that forms proves that the skin and subjacent tissues were devital- ized by the shock far beyond the bounds that had been set. Hence, it not unfirequently happens that the surgeon called to Liability to perform an immediate amputation afl;er railroad and gun- i^ured''* '° s^ot injuries, of the severe class, is deceived as to the ^'^' extent of the actual destruction of the vitality of the soft parts, and, in his anxiety to save as much of the limb as possible, makes the whole or considerable portions of the flaps of tissues which are already destroyed and must slough. This result is often seen in civil practice after severe railroad injuries, and the same is true of military practice, especially where the injury has been in- flicted by a missile of large size, as a cannon-ball, grape-shot, etc. In no part of the lower extremity are we as liable to meet with Heel most this accideut as at the heel. The crushing of the foot by exposed to injury. railroad cars, or by missiles used in war, not unfre- quently impairs the vitality of the soft parts about the heel and ankle to such a degree, that when they are subjected to the neces- sary bruising of an amputation, sloughing to a given extent en- sues. ILLUSTKATIVE CASE. 109 It is evidently no fault of the operation that in such a case sloughing of the flap occurs. Sloughing doubtless to the same extent would follow any form of amputation which involved tissues similarly injured. The error is in the judgment of the surgeon ; amputation should have been originally performed where it was subsequently. But this error is not always reprehensible, for the most experienced and judicious surgeon cannot foresee always the extent of the injury. Where there is a rational doubt, the facts embodied in this paper will, we think, authorize the operator to decide in favor of ankle-joint amputation, as in general preferable to leg amputation, and holding the latter in reserve. There is a practical point, illustrated by this collection of cases, bearing upon the question of amputation when the soft parts about the heel have suffered severe contusion and laceration, which deserves the most serious consideration. If the tissues of the heel have been destroyed, the surgeon should not at once possibmtyof decide that this precludes amputation at the ankle joint, "^""^ ^''- as might be inferred from the preceding remarks. Important as are the tissues of the heel for the covering of the stump where it is to take direct pressure, it is nevertheless true that the tissues of the sides of the ankle and the dorsum of the foot wiU soon become sufficiently dense to bear readily the weight of the body. If therefore the operator is convinced that on general prin- ciples an ankle-joint amputation is preferable to a leg amputation, he should consider well before he rejects the former, if it is not possible to secure sufficient flap tissue around the ankle. The following case illustrates this point : — Case I. Wound of the Ankle hy the Fragment of a Shell ; Extendve Destruction of the Soft Parts ; Amputation hy Lateral Flaps ; Slough- ing; Final Cicatrization and a Useful Stump. — C. D. was wounded June 24, 1864, by the fragment of a shell, which struck the Extensivo sole of the foot just anterior to the heel, lacerating the soft ormftp^. parts extensively, and injuring the tarsal and metatarsal '***"^' ^v^- bones. He was removed to the Mower U. S. General Hospital, where amputation was performed on the third day by Acting Assistant-Sur- geon W. P. Moon. Owing to the laceration of the soft parts, a com- plete posterior flap could not be made from the heel. Flaps were, therefore, dissected from the sides of the ankle and foot, and particu- larly from the sole on the external part. For a few days the case progressed favorably ; sloughing then oc- curred to a small extent, and finally a small fragment of bone sepa- rated ; abscesses also formed, one being of considerable size. The 110 LATERAL FLAPS. wound at length completely cicatrized, and the stump assumed a good shape, though it was somewhat tender. Case IL Wound of the AnEe Joint hy a Spiral Case-shot ; Destruc- tion of the Heel ; Formation of Lateral Flaps; Recovery with a Useful lArnb. — A. L. T., private, 20th Regiment Massachusetts Vols., was wounded at Fredericksburg, Va., May 2, 1863, by a spiral case-shot which passed through the ankle joint, destroying the articulation and the soft parts about the heel. Amputation was performed about four hours after the receipt of the injury. Notwith- standing the destruction of the heel, it was decided to amputate at the ankle joint, and make the flaps from such uninjured tissues in the neighborhood as could be brought to cover the stump. A suflicient amount of tissue was accordingly dissected from the lateral parts of the ankle to cover the stump, and disarticulation was performed. "With the exception of several abscesses which formed from time to time, the wound progressed favorably, and at the end of three months cicatriza- tion was complete, and he could bear his weight upon the stump. The only unpleasant sensation experienced was a prickling. At the end of five months an artificial limb was applied by Hudson, of New York, which enabled him to walk " with ease and comfort.'' Case IIL Extensive Laceration of the Tissues of Foot and Heel hy Fragment of a SheU ; Amputation at AnTde Joint with Lateral Flaps ; Recovery with a Useful Limh. — H. H. C, private, 100th Regiment New York Vols., was wounded at Drury's Bluff, Va., in May, 1864, by the fragment of a shell striking the left foot The soft parts of the foot and heel weijs so extensively lacerated as to pre- clude the formation of a flap from the heel, if amputation were per- formed at the ankle joint It was, therefore, determined to amputate at the ankle joint, with flaps formed from the sides of the ankle. The operation was performed by Surgeon Kettinger, United States Army, and flaps were made from the lateral aspects of the ankle. The case progressed favorably, although the patient suffered at the same time an amputation of the other foot by Chopart's method. The cica- trix became firm and healthy, and the patient could bear his weight upon it with comparative ease. An artificial limb was subsequently applied by Hudson, of New York, with the most satisfactory results. Equally good results may be obtained by taking the principal flap from the dorsum of the foot, as is seen in the following case: — Case IV. Amputation of the Ankle Joint for an Old Railroad In- Jury ; Principal Flap taken from the Dorsum of the Foot on Account of Ulceration of the Tissues of the Heel; Sloughing of the Extremity of the Flap; Final Cicatrization of Wound ; Useful Stump. — This case was FLAP FROM DORSUM OF FOOT. Ill treated in Bellevue Hospital, and the history is talcen from its records : " B. T. K. Regiment New York Vols., was admitted to Flap from Bellevue Hospital in March, 1864. About two years before, foot. his left foot was caught under a rail-car wheel and severely crushed. He had on the foot a very stout boot, with an unusually thick and firm sole, which saved it from being entirely destroyed. The wheel traversed the foot from the heel to the toes, passing diagonally along the dorsum from the external malleolus to the great toe, fracturing the tarsal, met- atarsal, and phalangeal bones in its course. An attempt was made to save the foot. Suppuration was established throughout the foot, with sloughing of the contused integument. Fragments of bone were removed, involving the tarsal and metatarsal bones, but the wound both on the dorsum and palmar surfaces finally completely cicatrized, and he was discharged. " On entering Bellevue Hospital, about two years from the time of the injury, the foot was so completely crippled that he was unable to walk except with crutches. It was so twisted upon itself by the cicatrix on the sole as to assume the position of a talipes varus. An ulcer existed upon the heel, and the tissues of this region were for the most part cicatricial. The cicatrix upon the dorsum was not very firm or adher- ent, except over the metacarpal bone of the great toe. " Amputation at the ankle joint by any of the ordinary methods was impossible ; but it was determined to make the flap from the dorsum, and take the risk of sloughing in the line of the cicatrix. The opera- tion was performed by Dr. Stephen Smith. A sufScient flap was readily secured, which, turned backward, effectually covered the whole surface of the stump. As was feared, the extremity of the flap where the cicatrix was most dense, sloughed off, but the remainder rapidly united. The stump was moulded by adhesive strips, and assumed a very fine appearance. The patient left the hospital able to walk with comparative ease." The following case illustrates still more strikingly the value of an ankle-joint amputation : — Case V. Bony Anchylosis of Tarsal and Anlde Joints ; Extreme Thick- ening and Degeneration of Soft Parts ; Sloughing of a Portion of Anterior Flap ; Successful Moulding of the Stump by Adhesive Strips ; Recovery ■with a Wellformed and Useful Stump. — The following history Moulding of is taken from the records of Bellevue Hospital, where the case ^'Ji"!'^''^ was treated : Patrick Connelly, corporal, 70th Regiment New strips. York Vols., was wounded at Bristow's Station, Va., August 29th, 1862, by a minie-ball. The point of entrance was the posterior part of the left heel, and it was removed from beneath the integument on the dor- sal face of the tarsus, having completely traversed the tarsal bones. The limb was at first condemned to immediate amputation, but subse- 112 MOULDmG BY ADHESIVE STRIPS. quently efforts were made to save it. Suppuration soon became estab- lished throughout the tarsus, the foot, and ankle ; sinuses formed in various directions, and portions of bones from time to time escaped from the various sinuses. At the end of a year the inflammation had so far subsided that he was able to walk about on crutches. He obtained his discharge from the army, and returned to his business of a mechanic. He was able at length to bear considerable weight upon the foot, but he was finally obliged to seek more permanent relief. On entering the hospital his foot was a large, shapeless mass, the swelling and puriform appearance extending from above the ankle to the toes. On the posterior part of the heel was the depressed cicatrix of entrance, and upon the centre of the tarsal region in front was the open extremity of a sinus which corresponded with the point of exit. There was no apparent motion at the ankle or tarsal joints. A probe passed into the sinus came in contact with uncovered bone. His gen- eral health was good. A consultation decided in favor of amputation of the leg. The question of amputation at the ankle joint was discussed, but the soft parts were so thickened and unhealthy, that it was believed that an operation which involved such tissues would necessarily prove a failure. Subsequently Dr. Stephen Smith amputated at the ankle joint. On incising the soft parts, they were found of the consistence and appear- ance of fat pork, and so thick and dense that it was impossible to turn the flaps back for the purposes of dissection. The ankle joint being fixed by bony anchylosis, it was sawn through. So thick and unyield- ing were the flaps, that it was found impossible to unite them, and they were left unadjusted. On the following day a slough began to form around the old sinus, which finally involved two square inches of surface. It was very soon noticeable that the infiltrated tissue began to soften and disappear, melt down apparently, and the flaps became more thin and pliable. Adhesive strips, cut very narrow, were now applied very accurately to the flaps, and the stump rapidly took a round and symmetrical form. Owing to the sloughing, a large cicatrix remained drawn somewhat across the face of the stump. This cicatrix was slow in healing, scabs forming of large size. He experienced con- siderable inconvenience for a time from this unhealed junction of flaps, but at length the cicatrix was perfectly formed, and he walked with ease with the heel of a boot for his support Dr. E. D. Hudson, of New York, applied an artificial limb to the stump, which eventually served him perfectly. He continued under observation for several months, as gate keeper at the hospital, and always expressed himself as able to do his duties with little or no incon- venience from the stump. DESTRUCTION OF ARTERY. — NECROSIS. 113 (J.) Destruction of the Nutritious Artery of the Flap during the Operation. — Mr. Syme remarks upon this cause of Destruction failure : " That the flap may and probably will still °^,t?fa"' occasionally slough, is unhappily too true ; but that this "p""^"''""- result is always owing to an error in the mode of performance, I think does not admit of any question. For as the integument, being detached from its subjacent connections, can derive nourish- ment only from the anastomosing vessels, it is evident that if scored crossways, instead of being separated by cutting parallel to the surface, the flap must lose its vitality." In his early practice of Syme's operation, Mr. Ferguson, of London, committed the error above alluded to, and so frequently did he meet with sloughing of the flaps that he rejected the operation altogether. Subsequently, however, he became one of its strongest advocates, stating : " In so far as I can judge, it is one of the greatest improvements in modern surgerj' as regards the subject of amputations." That there is great danger of wounding the posterior tibial artery in making the principal dissection from above downward, and from before backwards, is a demonstrable fact, and there is no doubt that it is one source of failure of this operation. While we are not able to determine how frequently this accident happens, we know that among army surgeons the erroneous method of operation alluded to by Mr. Syme was occasionally practiced. We feel authorized, therefore, to attribute to this cause a certain percentage of the failures of ankle-joint amputations from slough- ing of the flaps. II. Necrosis. — It cannot be seriously alleged against Syme's amputation that the small amount of necrosis which occa- Necrosis in sionally results to the extremity of the tibia or fibula is a putation. valid objection to its performance. It is stated to have occurred four times in twenty-three cases, and in three of these the necrosis does not seem to have interfered with the final success of the case ; one was still under observation. It is extremely rare that the necrosis is of any considerable extent, or so complicates the recovery as to necessitate reamputation. The opponents of Pirogoffs amputation urge the dangers of necrosis with great pertinacity, although experience de- Necrosis after cidedly disproves the correctness of their logic. Theo- amputation, retically the argument is strong and almost conclusive against the operation. It is essentially a resection of bones with an attempt to obtain union by placing the fragments in simple contact. It 114 EXPERIENCE OF SURGEONS. cannot be denied that the section of the calcaneum does occasion- ally undergo necrosis, and finally separates from the flap, but it must now be considered a rare accident, and dependent rather upon the imprudence of the operator in his effort to excise the bone, than upon any intrinsic fault of the method itself. Pirogoff remarks : — " Notwithstanding the suppuration and considerable gravitation of pus PiroKoff's re- ^^^ *^® ^^P ^^ *^^ third case ; notwithstanding the softness marks. and fatty degeneration of the os calcis, which could be cut with the knife, in the second case ; and lastly, notwithstanding the bleeding fungous excrescences which formed on the bones, also in the second case ; still the remains of the os calcis united firmly with the tibia and fibula. Lastly, one of the cases, the third, proves that the exarticulation at the ankle joint after my method — at least in children and young people — may be undertaken even in cases of diseased ankle joint, provided disorganization has not extended too far over the soft parts about the articulation. In the boy in the second case, I found pus in the capsule during the operation, the cartilages softened and decayed, the ends of the bones also softened and in a state of fatty degeneration, yet the result was most successful." Mr. Busk, of London, says : — " Some have feared that the section left of the calcaneum would not „ _ . , readily unite with the extremity of the tibia ; but this fear is remarks. groundless. In the last operation performed by Mr. Tudor, union was found to be quite firm on the twelfth day In my first case the man could support his whole weight on the stump within a fortnight" Mr. Croft, of the Dreadnought hospital ship, London, gives the experience of the surgeons of that ship in six cases, as follows : — " Six times the operation has been performed, and in four instances . ., with most perfect success ; but in the two remaining death experience, rcmovcd the subjccts of operation before cure was completed — in the first instance by granular disease of the kidneys, and in the second instance by secondary deposits of pus in various joints. In two of the six cases in which cure was completed, the operation was per- formed for the removal of scrofulous disease of the articulation between the tarsal bones, and in the two others the operation was for frost-bite of the anterior part of the foot. Progress towards health was marked by suppuration along the tendons of the tibialis anticus and posticus, and the peroneal tendons in each of the cases, but not by exfoliation of bone. The posterior part of the os calcis was united firmly with the DK. HEWSON'S COMMENTS. 115 tibia, generally in about three weeks ; but in one instance ^— the last in which the operatiou was performed — union was good at the end of twelve days." He thus expresses his confidence in the union of the bones under the most unfavorable conditions : — " Although the os calcis may be diseased at and about its articulation in instances of scrofulous disease of the joints of the tarsus, it is rarely that the posterior part is rendered too unhealthy to be made use of in the formation of a stump." Hewson, of Philadelphia,^ has operated five times, and makes the following comments, bearing upon the question of necrosis of the OS calcis : — " In all a cure followed rapidly. In two especially, the result was least to be expected. These were the adults, one of whom ^^ Hewson'i was a seaman advanced in years, and who had been leading ooinmeits. an exceedingly intemperate life ; and the other a soldier, who had been wounded in a battle after long and tedious marching in pursuit of the enemy, and who was operated on four weeks after receiving his wound, in a military hospital where gangrene was prevailing to a very great extent at the time. How much the firm and speedy union of the bones in all these cases was the result of the expedient resorted to, namely, the strip of adhesive plaster and the weight, to prevent the contraction of the muscles attached to the tendo Achillis, is a question which we are not prepared to answer. The possibility of such a union not taking place, has been the only theoretical objection apparently of any impor- tance advanced against the operation. But how far such an objection has been realized in the experience of others we have not been able to ascertain. Our own experience certainly points to its being of little, if any, value. For surely there could not be found two more unpromising cases for any operation than those of the adults here reported, and it is against the operation in adults especially that this objection would seem to have greatest force. The very perfect character of the union which took place between the bones in Bowers' case, as is to be seen in the specimen which we had the good fortune to obtain after his death, fur- nishes as strong a refutation as a single instance could of this theoret- ical objection." Of the ten cases of amputation at the ankle joint by PirogofTs method, reported in the following tables, but one was attended with necrosis of sufficient amount to necessitate reamputation. I The American Journal of Medical Sciences, July, 1864. 116 ILLUSTRATIVE CASES. The patient was a Confederate soldier, and the case is reported by James M. Holloway, M. D., Professor of Anatomy, Louisville, Ky.i Case VI. Pirogoff's Amputation at the Ankh Joint ; Necrosis of the Section of the Os Calcis and of the Tibia ; Jieamputation of Leg. — Heamputa- A. B., Soldier, was wounded at Chattanooga, Tenn., in 1863. tioQ for ne- . ° crosia in Amputation at the ankle joint by Pirogoirs method was per- ampatation. formed a few days after the injury. The reporter first saw the case in January, 1864. The flaps had united, but a number of sinuses communicated with the coaptated surfaces of the os calcis and tibia, at the bottom of which denuded bone could be felt upon the introduction of the probe. In addition to these, other sinuses situated on the lateral aspects of the lower third of the leg, communicated with the sheaths of the tendons. These latter, so far as could be learned from the patient, appeared subsequently to those leading to the carious bones. The integuments overlying and adjacent to the diseased bone and inflamed sheaths of tendons, presented a remarkably healthy appear- ance ; so much so that the true condition of the stump did not transpire until a more thorough examination was made, while the patient was under the influence of chloroform. Such was the complete disintegra- tion of the OS calcis and the end of the tibia that amputation of the leg was found to be necessary. The following cases illustrate most forcibly the fact that the segment of the os calcis will become united to the tibia under the most unfavorable circumstances : — Case VII. Wound of the AnMe Joint ; Pirogoff's Amputation ; Feeble Condition of Patient ; Attack of Erysipelas ; Symptoms of Pycemia ; Convalescence ; Recovery with a Useful lAmb? — Lieutenant W. C. W., Thebonewiii Co. I, 5th Michigan Cav., was wounded April 1st, 1865, at the unite under « -r,. x-i i i - i i i most un- battle of Five Forks, by a conoidal musket-ball, which passed oonditioDB. through his left ankle joint. He was immediately carried to the hospital at City Point, and amputation at the ankle was performed on the same day by Surgeon St Clair, 5th Michigan Cavalry ; the artic- ulating surfaces of the tibia and calcaneum were removed, and the cut surfaces were brought into apposition. On April 16th, 1865, the patient was transferred to Armory Square Hospital, at Washington. On admission he was in a feeble condition. An erysipelatous blush extended above the knee on the injured side, an abscess had formed in the lower part of the leg, and no union of the flap had taken place. With the employment of stimulants and nutritious diet, with emollient applica- 1 Am. Journal Medical Sciences, January, 1866. 2 Circular No. 6, Surgeon-General's office. GOOD RECOVERY IN UNFAVORABLE CASE. 117 tions to the limb, there was a gradual improvement, until April 28th, 1865, when symptoms of pysemic infection supervened. Rapidly recur- ring chills, an icteroid coloration of the skin and conjunctiva, anorexia, and a frequent feeble pulse, suggested the gravest prognosis. Ener- getic treatment was adopted. An ounce of brandy was given every two hours, and quinia, sesquichloride of iron, and beef tea were freely administered. On May 6th, the grave symptoms began to subside, and, by the end of the month, the patient was fairly convalescent. On June 26th, he was pronounced well. The os calcis had firmly united to the tibia, and there was a good solid stump. Case VIII. Amputation at the Ankle Joint by Pirogoff's Method on the Battle-field at Malvern Sill ; Patient taken Prisoner, and conveyed in an Army Wagon to Richmond ; neglected and exposed to Great Hard- ships for Several Days ; exchanged, and conveyed to Oity Point withovi Care or Support in extremely Hot Weather; transported to Fortress Monroe before Proper Dressings were applied ; Perfect Union of Hard and Soft Parts without the Slightest Necrosis or Sloughing; Useful Limb. — H. B., private, 5th New York Art., was wounded by a shell at the a second un- battle of Malvern Hill, July 1, 1862. The injury was inflicted Sl^^^;. principally in the metatarsal and tarsal regions, producing a gMd?ecoT- corapound comminuted fracture of the bones of the foot, with '"^■ the exception of the astragalus and calcaneum. Chloroform was admin- istered, and amputation by PirogofTs method performed. He was imme- diately after taken prisoner, and placed in an army wagon and conveyed to Richmond. The weather was extremely hot, and he had no means of supporting or protecting the stump. He remained at Richmond several days, during which he was crowded together with other prisoners, with- out care, his limb remaining undressed. He was finally exchanged and conveyed to City Point, a distance of twenty-six miles, most of the dis- tance on the railroad, the remainder in an ambulance, but the entire distance he was compelled to take his chances with the crowd. From City Point he was conveyed to Fortress Monroe, where he had the first proper dressings applied. No sloughing or necrosis occurred ; the bone united promptly, and the flaps adhered as if union had taken place by first intention. He came under observation at Central Park Hospital several months after, when the stump was in the most perfect condition. It had the appearance of having healed by first intention, throughout. He bore his weight upon it, walked easily with a cane, but complained of slight tenderness. An artificial limb was applied by Hudson, of New York, and he was discharged in a condition to be able to follow almost any ordinary employment. The tv(fo following cases were reported by Adinell Hewson, M. D., surgeon to the Pennsylvania Hospital : ^ — 1 Am. Jaur. Med. Sci., July, 1864. 118 HEWSON'S CASES. Case IX. Foot crushed hy the Recoil of a Gun-carrictge ; Attempt to save the Foot ; Great Distortion of Foot ; Amputation at the Ankle Joint hy Pirogoff's Method ; Prompt Union of Bone ; Recovery with a Useful lAmb. — Tom Bowers, a tall, thin, but well-formed seaman, aged Hewson'B forty-eight years, applied for admission to the Pennsylvania '^°- Hospital, on the 3d of March, 1863, on account of distortion of his right foot, the result of an injury received on board of one of the Mississippi gunboats in the attack on Vicksburg, in the month of June previous. The foot had then been crushed by the recoil of a gun- carriage, and the bones of the metatarsus had evidently — according to the patient's account — been much comminuted, with great contusion of soft parts, but no great amount of laceration of integument. Attempts had, therefore, been made to save the foot Extensive phlegmonous inflammation ensued, and extended up the leg, which bore the marks of the free incisions which had been made for the escape of the pus. The foot itself was distorted by the conglomeration of the bones, through the callus thrown out for their repair, and by a large mass of cicatricial tissue on the plantar surface, all of which combined to draw the toes down and prevent the patient walking on the sole. It was thus only by a very forced elevation of the forepart of the foot, and throwing the whole weight on the back of the heel, that he could get along on the limb. For this deformity he applied at the hospital, desir- ing to have the leg amputated. It was evident that a partial amputa- tion of the foot was the only remedy for him. The cicatricial mass on the sole would not allow of a Lisfranc tarso-metatarsal disarticulation, or of a Chopart inter-tarsal. It was, therefore, determined to make a Pirogoff amputation Some symptoms of delirium tremens manifested themselves on the following day, and these were soon devel- oped into a well-defined attack of that disease. The operation was consequently delayed until the 28th of the month (March), when it was performed Owing to the rigidity of all the tissues of the foot, considerable difficulty was experienced in effecting sufficient dislocation at the ankle to saw off the os calcis at the proper angle. Indeed, this was found impossible without injuring the soft parts. The bone had consequently to be broken after it was partly sawn through. No dressing was applied over the wound. The stump was put in a fracture-box, and the weight of a brick, about four and one half pounds, was applied by means of a long and broad strip of adhesive plaster on the back of the leg to overcome all tendency to displacement of the os calcis, by contractions of the muscles attached to the tendo Achillis. The healing took place very slowly. Still the patient was well enough to be discharged on the 25th of May, eleven weeks afler the operation. The OS calcis was noted to be firm to the tibia on the twenty-sixth day. Case X. Wound of the Ankle Joint; Suppuration in the Joint; SENSITIVENESS OF STUMP. 119 Amputation by Pirogoff's Method on the Twenty-eighth Day ; Subsequent Necrods of Fibula ; Rapid Union of Os Galcis and Tibia ; Recovery with a Useful Limb. — 0. C, aged twenty, private, 7th "Wisconsin Regiment, was wounded on the first day of the battle of Gettysburg (July 1, 1863)) by a bullet in the right foot. From the battle-field he was sent to the United States Military Hospital, Philadelphia, where he arrived on the 6th. The wound did not appear at first to be a serious one, and our attention was not called to it until some time after his admission, when the foot and ankle had become very much swollen and inflamed. On probing the wound it was found that the ball had passed through the astragalus, and must have consequently implicated the ankle joint It was, therefore, determined to amputate the foot, and, as the tissues of the heel ap- peared sound, it was decided to attempt a Pirogoff, which was done on the 28th of the month (July). On opening the joint it was ascertained that the malleoli had both become considerably denuded by the suppu- ration which had been going on in the joint, so that it became necessary to remove the ends of both the tibia and fibula an inch above the joint The denudation of the bones led us to form a rather unfavorable prog- nosis for the operation. The inflamed condition of the tissues, espe- cially of those composing the anterior flap, caused delay in the process of union, which took place, however, throughout by granulations, and the portion of os calcis was found to be firmly adherent to the tibia on the twenty-eighth day after the operation. When the cicatrization of a greater part of the flaps had been accomplished, it was discovered that two suppurating points, one quite on the front of the leg, and the other behind the line of the fibula, communicated by sinuses with a large piece of necrosed bone evidently belonging to the fibula, and which had pushed the OS calcis somewhat to the inside before it had become firm to the tibia. These sinuses were dilated by sponge tent, and this portion of bone detached without even disturbing in the least the union between the tibia and os calcis. The patient is now just beginning to throw his weight on the stump, which has been entirely healed for about a month. He ran with ease on the end of the stump before the members of the college at the meeting at which this communication was made." III. Sensitiveness of Stump. — But it is frequently alleged that the stump after ankle joint amputations is very sensuireness liable to be tender, and will not tolerate direct pressure. °' °*'"°''- In this case we not only lose all the advantages claimed for direct support, but from the shape of the stump it is difficult to obtain sufficient lateral support of the limb to render the artificial appliance useful. This objection cannot, however, be founded on a very large experience. In the thirty-one cases in the accom- panying tables, tenderness of the stump of a degree sufficient to interfere with the application of an artificial Kmb is not once men- 120 TESTIMONY OF SURGEONS. tioned. Hewson, of Philadelphia, speaking of the ease with which patients walk who have PirogofF's stump, says : — " No such results as these have ever been obtained from the Syme Hewson'8 Operation — for not more than one half of the cases which expenenco. jj^ve applied to Mr. Palmer for artificial limbs have been able to bear any pressure whatever on the end of the stump, and that a long time after they were entirely healed. The only case of a Syme ampu- tation of which we have had the opportunity of seeing the results was unable to bear his weight on it a year after it was made." This statement is in direct opposition to the experience of sur- geons of large experience. Fergusson, of London, who has re- peatedly operated by this method, says : — Fergusson's " In SO far as I can judge, it is one of the greatest improve- opuuon. nients in modern surgery as regards the subject of amputa- tion." Quain, of London, says it is — " Free from any valid objection, and what is more important, the Quain'8 result in practice has been found to be good. A person who opinion. ^las undergone this operation is enabled to bear his whole weight upon the end of the stump without inconvenience ; and, on this account, the facility of progression is, with a proper apparatus, decidedly greater than when the amputation is performed at any higher part of the hrab." Erichsen, of London, confirms the above estimate of Syme's am- putation. He says it — "Constitutes one of the greatest improvements of recent date in Eriotisen's Operative surgery, as by its performance amputation of the opinion. j^g ^^^^ often be avoided, and the patient being left with an exceedingly useful stump, the covering of which being ingeniously taken from the heel, constitutes an excellent basis of support." But the strongest and most important testimony as to the entire Opinion of serviceablcoess of Syme's stump is given by Hudson, of of New York. Now York, who states that in fifty cases to which he has applied artificial limbs he has not met with a single instance where the stump did not, afler proper preparatory treatment, take the direct pressure without inconvenience, and invariably give a most happy result. This treatment consisted in removing scabs from the cicatrix, healing superficial indolent ulcers, etc. We need only add that in a large collection of cases from civil practice DISPLACEMENT OF HEEL FLAP. 121 tut one Syme's stump was found sensitive. It is very important that the surgeon should examine the cicatrix occasionally Bad esecto after the cure seems to be complete, to insure a firm dcatni. closure of the wound. If a small space is left over which scabs form, these incrustations become so thick before the patient re- moves them that they take the whole pressure when the stump is placed upon the floor, and the violence is expended upon the small ulcerated surface on which they rest. I have frequently seen stumps which have been pronounced tender, found capable of sustaining the weight of the body, and enduring great fatigue when these incrustations were removed. It is the duty of the surgeon not only to remove these constantly recurring scabs, but to heal by appropriate treatment the chronic, indolent ulcer from which they spring. Surgeons have mistaken the early sensitiveness of the wound for a permanent disability. A certain degree of tenderness sensiavencss must necessarily exist for a time as the result of so con- pemanlat"' siderable a wound, but as cicatrization progresses the sen- *'*'''"'y- sitiveness generally gradually subsides, and ultimately ceases to give the patient any trouble IV. Tendency to Displacement of the Heel Flap back- ward BY the Action of the Muscles of the Calf. — Dispia«e- A final cause of failure is alleged to be due to the action aa^'b^k^' of the muscles of the calf, which so act upon the heel, or ■"""'• posterior flap, as to bring the cicatrix upon the most dependent part of the stump, and expose it to injury in walking. The ob- jection is based upon clinical experience, and this result has led to reamputation in some cases. We have reason to believe, however, that this posterior displace- ment of the flap is due to circumstances entirely within within the the control of the surgeon. The remedy is found in the the surgeon. after treatment. Displacement will never take place to an extent sufficient to interfere with complete usefulness of the stump, either in Syme's or Pirogoff''s stump, when the posterior flap is well sup- ported and proper traction is made upon the calf. Surgeons too frequently leave the flap entirely unsupported, so that even its weight displaces it. The natural tonicity of the muscles of the calf under such circumstances leads to their abnormal contraction, and hence to the permanent displacement of the flap. The fol- lowing case illustrates this displacement from want of support : — 122 VALUE OF DRESSING. Case XI. Amputation at Ankle Joint by Syme's Method ; no Support Case where given to the Posterior Flap ; Great IHsplacement bachward. — there waa no -^ support. I. M., 46th Georgia Vols., was wounded March 25, 1865, by a rifle-ball which passed through the ankle joint. Amputation by Syme's method was performed twenty-four hours after the injury. When examined forty days after the operation the wound was healed, but two or three sinuses discharging gave indications of the presence of dead bone. The stump was placed on a pillow, with the extremity projecting over it, without the slightest support to the flaps. The large posterior flap hung pendulous from the end of the stump, its own weight being sufiicient to displace it completely from the face of the tibia. No effort had been made to adjust and retain it with adhesive strips." This case had been pronounced a failure by those v^ho had it in charge, and reamputation was recommended with great unanimity. But no one who has witnessed the benefits of the proper application of adhesive strips in moulding a stump can doubt that the displace- ment was entirely due to the lack of proper dressings. In Cases IV. and v., the flaps were of the most unpromising character. Value of heing large, thick, and infiltrated, but they were moulded to *'*™'°^- the stump with great ease, and formed a conical extremity of great perfection. In no form of amputation do we regard the kind of dressings and their method of application of so great importance as in amputation at the ankle joint. From the very first there should be proper support given to the posterior flap, and the best form of support is by means of narrow adhesive strips. In the later stages of the treatment, this dressing is of great value in giving proper shape to the stump. When early and thoroughly applied, the strips fix the posterior flap upon the extremity of the limb, and retain it there so firmly that the flexor tendons form attachments to its anterior part, and effectually counteract the contractions of the muscles of the calf. In a well-formed Syme's stump the patient has power to move the heel flap anteriorly as well as posteriorly, showing that the flexors of the foot have become attached to it. In regard to the displacement of the flap in PirogofFs stump, it Bispiace- ^^ ®^'^^ more evident that the fault is in the after treat- ta'pirogoff? ment. That serious results follow its displacement is stumps. proved by those cases in which reamputation was the only remedy hj which the defect was overcome. But it is evident that in these cases little effort could have been made to counteract the contraction of the muscles of the calf, during the period of ossific union of the extremity of the os calcis and the tibia, for when that union was once complete, all farther tendency to dis- ADAPTATION TO TRANSPORTATION. 123 placement ceases. This fact is proved by Hewson's cases, IX., X., in which this contraction was immediately counteracted by proper dressings, and the bones united symmetrically, giving a very useful stump. We must attribute, therefore, the failure to secure a good apposi- tion of the heel flap in either Syme's or Pirogoif 's am- Failure due to after putation at the ankle to the neglect of proper after treat- treatment, ment. V. Not adapted to Transpoktation. — It is very generally alleged against ankle-ioint amputations, that owing to Not adapted ,, ? ^. „,, \ ■ a J V • e ^ totranspor- tne large size or the posterior nap and its imperiect nour- tation. ishment, the stump will not endure transportation. We have not a sufficient amount of accurate and reliable information on this subject to determine how far this objection is worthy of serious consideration. The accompanying collection of cases contains several instances of patients who had undergone ankle-joint ampu- tations, and were subsequently subjected to transportation long distances without inconvenience. Case IX. proves that Pirogoff 's stump, the most liable to be seriously affected by transportation of the two, may not only be transported, but even subjected to much rough handling, without interrupting the process of ossific union. This must undoubtedly be considered an exceptional, per- haps an extraordinary case, but still it must be accepted as proving that the character of the operation does not preclude transporta- tion, even under the most unfavorable circumstances. Without sufficient facts to decide this question as to the power of ankle-joint stumps to endure transportation, we would Necessit? of suggest that much must depend upon the manner in ings. which dressings are applied. If they are carefully adapted so as to thoroughly support the parts, we doubt if the inconvenience will be greater than in an ordinary flap stump. We may in this place notice a so-called modification of Syme's amputation, performed by Surgeon David Prince, United States Vols., who reports the following case : — Corporal W. P. Everett, Co. H., 9th Alabama Vols., received a musket-shot on the inner side of the tarsus, in the battle of prince's Williamsburg, May 5, 1862. There was no counter opening, "'""fi'^"™- and it seemed probable that the ball had lodged among the tarsal bones. No ball, however, was found, from which it follows that it must have come out at the same opening at which it went in, or that the injury had been occasioned by some other substance. The operation was commenced by making an exploratory incision in 124 COMPARISON OF SYME'S AND PIROGOFF'S METHODS. the course of the tendon of the tibialis anticus, discovering numerous fragments which were successively removed, when it was found that all the bones of the tarsus were fractured ; and on this account it was re- solved to amputate the metatarsus, and exsect the tarsus. A transverse incision was made over the scaphoid and cuboid bones. The separation of the bones was prosecuted by Liston's large cutting forceps, and the soft parts on the plantar surfaces cut in the manner of a flap. The exsection of the tarsus was prosecuted with Fergusson's large gouging forceps, removing the whole of the astragalus and nearly the whole of the calcaneum. As the fragments of bone were pulled away from their attachments, a considerable amount of periosteum and some shells of bone were left for the formation of new bone. The mal- leoli were cut off by the bites of the forceps, so as to present a tolerably smooth surface to receive subsequently the plantar integument. No other opening was made in the integument than that in front. The parts were kept somewhat in position by a roller bandage, without sutures or any close approximation. The wound must heal and contract by granulation. The theory of this operation is to preserve the circulation in the plantar integument, without cutting off its supply by dividing the tissues, as is necessary in the manner of cutting the lateral ligaments of the ankle joints. These ligaments are left in connection with the surround- ing parts, unless accidentally pulled away by the traction upon the bones to which they are attached. The bones should not be cut away from their attachments, but pulled away, in order to leave as much as possi- ble of the periosteum. - The patient went from under my observation, and I have not since heard from him. AS APPRECIATION OF THE COMPARATIVE VALUE OF THE METHODS OF AMPUTATION AT THE ANKLE JOINT BY SYME AND PIROGOFF. Although an important feature of Syme's original operation was ComparatiTo the formation of the principal flap from the heel, we shall, Syme's and in this Comparison, include as Syme's amputations all methods. cases in which the os calcis was completely removed with the other tarsal bones. PirogofF's method is distinguished by an excision of the posterior portion of the os calcis, and the union of the retained fragment with the tibia. A comparison of these two methods involve for the most part a consideration of the same points as in the comparison of leg and ankle-joint amputa- tions. 1. Comparative Mortality. — It is difficult to determine witli any comparatiTe degree of certainty the mortality from these operations, mortauty. That patisnts died after amputations at the ankle joint is FREQUENCY OF REAMPUTATION. 125 evident ; but it does not appear to what extent this mortality is attributable to the operation. Taking these collected cases as the only basis of comparison, we have the following comparative results : In thirty-seven cases of Syme's amputation, there were four deaths, or a mortality of 10.8 per cent. In ten cases of PirogofTs amputation, there was one death, or 10 per cent. This difference in mortality is so slight that it is safe to conclude that there is no appreciable difference in the mortality of the two methods. 2. Comparative Frequency of Reamputation. — Of thirty-seven cases of Syme's amputation, six were subjected to ream- comparative putation, or 16.6 per cent. Of ten cases of PirogofFs reXpa°i°' amputation, one case submitted to reamputation, or 10 per **"°' cent, of the cases operated upon. In this comparison PirogofFs am- putation would seem to be the more successful. In examining the causes of reamputation it appears that the most frequent cause in Syme's amputation is sloughing of the flaps ; retraction of the flaps is given in one case, and necrosis of the tibia in one case. In the single case of reamputation of a PirogofFs stump, necrosis of the OS calcis and tibia had occurred. We cannot consider these figures as conclusive. We need a detailed history of the individual cases, the circumstances attending the first operations and the subsequent history, before the question can be satisfactorily settled. Too frequently, as we have elsewhere stated, the flap sloughs, and the bone undergoes necrosis, or caries, as the result of an unscientific and unskillful operation, or insuffi- cient after-treatment. Still we give them a certain weight of evidence, and as such consider them an approximation to the truth. In any case they prove tliat there is but.little difference in these amputations as regards primary results, and, therefore, that it is in the final serviceableness of the stumps we are to find points of contrast, if any exist. 3. As regards the Operative Procedure. — Pirogofi" claims for his operation the following advantages : (1.) The tendo Advantages Achillis is not divided, and we avoid all the disadvantages operation. connected with its injury. (2.) It also follows that the base of the posterior flap is not thinner than its apex, while the skin on the base of the flap remains ununited with the fibrous sheath of the tendo Achillis. (3.) The posterior flap is not cup-like, as in Syme's method, and its form is therefore less favorable to a collection of pus. (4.) The leg is longer. 126 ADVANTAGES OP METHOD OP OPERATION. Mr. Croft also says : " The advantages of this operation over Mr. Croft's ' Svme's ' (the only operation with which it can be com- remarks. pared) are, that it may be performed more rapidly as to time, leaves a more vascular flap, forms a larger stump, and pro- duces a firmer pad for the subject to walk upon. Less time is occupied in the operation, for the somewhat troublesome dissection of the skin of the heel from the os calcis is avoided, and the os calcis sawn through instead. Greater vascularity of the flap is secured, for the plantar arteries are divided in the hollow of the foot." Mr. Rusk, of the same hospital, confirms these statements, and claims " greater facility and rapidity of execution ; less dis- turbance of the natural relations of the parts which are to form the cushion of support ; a solid instead of a hollow flap," in PirogoflPs method. Syme denies the correctness of these assertions. He states that his operation can be performed in less than a minute. The cup- shaped form of flap which is liable to collect pus is remedied by perforating it, and thus allowing the free and direct escape of its contents. That the vitality of the flap is not materially affected by a proper dissection is proved by the promptness with which union of the flap generally takes place. Professor Van Buren, of New York, reports a case occurring in his own practice in which there was union by first intention. These objections to Syme's amputation cannot, therefore, be regarded as well founded. On the contrary, Mr. Syme charges that Pirogoff^s amputation Mr. Syme's " deprives his of all its advantages, by rendering it com- objections. plicated instead of extremely simple ; by impairing its constitution ; by retaining a portion of the osseous tissue justly liable to the suspicion of relapse ; and finally by not being applica- ble to all cases requiring amputation at the ankle." The objections of Mr. Syme are refuted by the experience of competent surgeons whose opinions we have already quoted. Like the objections of Pirogoff', above given, they are entirely theo- retical, and ample experience has decided them unworthy of credi- bility. In regard to the operative procedure, we may conclude that these two methods have equal advantages, and one cannot justly claim superiority over the other. Mr. Hancock publishes the following table, showing the com- ^SsaMof P^'i'ative results of Syme's and Pirogofl's operation in British sur- gritish civil practice : ^ — gcry. ^ 1 Lancet, August 11, 1866, p. 144. COMPARATIVE SERVICE ABLENESS OP STOMP. 127 Of 219 of Syme, Suppuration specially mentioned in 4. Sloughing of flap, 16. Died, 16 (or 7|| per cent.). Secondary amputation, 13 (or 6 per cent.). Recovered, 185 (or 84 per cent.). Results not stated, 5. Period of recovery in 40 cases varied from 3 to 52 weeks. 29 were cured within 12 weeks. 34 were cured within 16 weeks. 37 were cured within 24 weeks. The remaining 3 between 33 and 52 weeks. Of 58 of Pirogoff. Suppuration specially mentioned in 11, Sloughing of the flap, 1. Died, 5 (or 9^%- per cent.). Secondary amputation, 5 (or 9^ per cent.). Recovered, 45 (or rather more than 75 per cent.). Period of recovery in 13 cases varied from 6 to 69 weeks. 11 were cured within 12 weeks. 1 was cured within 24 weeks. 1 was cured within 40 weeks. 1 was cured within 61 weeks. 1 was cured within 69 weeks. COMPARATIVE SEEVICEABLENESS OF THE STUMP. (a.) As regards Unaided Locomotion. — In comparing leg and ankle-joint stumps, we stated that the latter had far comparative greater advantages than the former, because the stump nera'^'''°" resulting from an ankle-joint amputation was longer and ^'""p- took direct support on its face. In comparing now two ankle-joint stumps in unaided locomotion, — by which we mean that no artifi- cial limb is applied, and only such covering is employed as a patient applies, — we have to consider, (1) The value of length of limb ; and, (2) The power of endurance of the different stumps. 1. The Value of Length of lAmh in Progression. — Pirogoff states that in his operation " the leg appears an inch and a half vaiue of (sometimes even more) longer than in the three other umb. operations (Syme, Baudens, Roux), because the remnant of the OS calcis left in the flap, as it unites with the inferior extrem- ities of the tibia and fibula, lengthens them by an inch and a half." Mr. Croft remarks : " The length of the stump is a very im- portant point ; it (Pirogoffs stump) is longer than in Syme's operation, by the portion of the os calcis left on the flap, which should be quite one inch and a quarter. In the four instances mentioned, the difference in length between the foot operated upon and the sound foot, was never more than three eighths of an inch." We cannot doubt that the additional length of stump in Piro- gofTs operation gives it some advantage over that of Syme, pro- vided the patient has no artificial aid. It requires less compensative 128 ADAPTATION FOR ARTIFICIAL LIMB. appliance to make up the deficiency of length between the sound and amputated limb. The almost direct pressure which PirogofTs stump makes upon the surface over which the patient walks, gives greater steadiness in his gait. 2. Enduranee of the two Stumps. — It is claimed for PirogofTs Endurance Operation, that the stump having the extremity of the os of stump. ca]cis as its base of support, must be capable of greater endurance than the stump in Syme's operation, which is simply a flap resting directly upon the newly cut surface of the tibia. There are no facts, we believe, to sustain this conclusion. The alleged tenderness of Syme's stump, we have already shown, is not based on experience, and hence must be regarded as theoretical. In all the trials that have been made with these stumps in simple unaided locomotion, no marked advantages could be claimed by one over the other. And, again, there is no necessity of cutting off the extremity of the tibia ; the articular surface is found to unite firmly to the flap. (6.) Adaptation for an Artificial Limb. — We have already Adaptation Stated that the real test of the usefulness of a stump is its flciai limb, adaptation to an artificial limb. Judged by this standard, we find a marked contrast between the two stumps under exam- ination. The advantages of greater length yielded to Pirogoff's stump when employed in locomotion without aid, prove to be disadvantages when a proper artificial limb is adjusted. In constructing a useful artificial foot, it is very important that Symo'8 there be space for an ankle joint which shall have full feTorabie. play. In Pirogoff's stump the base of support is so near the floor that the joint must necessarily be on a much lower plane than that of the sound limb, and have but limited movements. This is a practical difficulty which has not been overcome by any mechanical contrivance. In Syme's stump, on the contrary, the base of support is on the same plane as the original ankle joint ; and this space enables the mechanical surgeon to construct a joint which acts with as long a leverage and as free motion as the natural joint. In this respect Syme's stump has a real and per- manent advantage over that of Pirogoff. We cannot better conclude this paper than by the insertion of the following recent letter by Pirogoff to Mr. Hancock, of London, in regard to his experience in this method of amputation. It will be seen that, so far from abandoning it, as reported, he is its strongest advocate : — PIROGOFF'S LAST STATEMENT. 129 " As to my osteoplastic operation, I reckon, nearly one hundred cases in Russia alone, for accident or disease. My pupil. Dr. Pirogoeps Dzemickeritch, was the first who introduced it into the mili- ment. tary practice at Odessa, in the case of a soldier wounded at the Alma ; and his patient walked, with the assistance of a stick, in about two months. In the Crimea it was practiced principally during the first six months of the siege ; and I have registered sixty cases. In December, 1855, when I inspected the military hospitals at Chersow, Eckerterino- slaw, and CharkofF, I found fifteen patients who had been transferred from the Crimea since the date of their operation. The condition of the whole fifteen was satisfactory, notwithstanding nearly half of them had received other injuries. Thus two had undergone also amputation of the fore-arm. In one my operation had been performed upon both his feet One had the metatarsal bones of his other foot removed. In one the opposite leg, and in another the opposite thigh, had been amputated. Two already walked upon crutches, and two even with a stick only. " A year after the war, I learned that two of the wounded admitted into the hospital at Sympheropol, having submitted to my operation on both feet, still walked on crutches. I ordered them shoes and steel supports. I only know with certainty of seven deaths ; and also of one case wherein the flap sloughed, which necessitated amputation of the leg. Secondary hemorrhage occurred in several. " These are the results of this operation in my military practice ; and, judging from the number of patients so operated upon whom I saw subsequently, the mortality could not have been great The best proof of this is, that among those who have survived, some had the operation performed on both feet ; some had at the same time undergone ampu- tation of the other leg and of the other thigh. To be impartial, I will not speak myself of all the advantages offered by this operation with respect to the functions of the limb ; but I will repeat what has been communicated to me by surgeons who have adopted it " During the year 1863, I visited nearly twenty hospitals and various universities of Germany ; and in five of these I was shown patients operated upon according to my method. The whole walked, even without sticks. But the most remarkable case was in the hospital at Heidelberg, under the care of Professor Chelius. A young woman, aged twenty-five,, had club-feet from birth. She had tried all sorts of orthopedic treatment without benefit; and Chelius performed my operation upon both feet When this patient returned from the city to the hospital, I could not discover what she wanted. She walked with- out a stick, and wore shoes with lateral steel supports. "Upon subsequently examining the feet operated upon, I have inva- riably found the portion of the os calcis grown together with the epiphysis of the tibia. In two cases only have I detected a little move- 130 PIROGOFF'S LAST STATEMENT. ment, which, however, did not prevent the use of the limb. Neverthe- less, many French and English surgeons doubt even the possibility of such an operation, and find faults discovered by themselves only. This, doubtless, arises from the fact that this ' osteoplastique ' operation did not originate with themselves. Thus, Syme pronounces it as an indication of reckless. surgical principles. Syme would speak more courteously if he only knew how I had supported his operation of disar- ticulation when the late Dr. Arnold, inspector of hospitals at St. Peters- burg, would have forbidden its employment. " Another celebrated English surgeon asserts that I have myself abandoned my operation. Whence he learned this, God only knows. Could he have arrived at this conclusion from one of my letters to a surgeon in London, who applied to me for the results of this operation ? ' I have not made up my mind,' I replied ; ' time will show whether it is worth anything or no.' Malgaigne repeats what he has read in Fer- gusson, and, probably never having tried my operation, frightens the reader of his ' Operative Surgery,' about gangrene of the flap, the impossibility of adhesion or coalescence, fistulas, and the pain expe- rienced by the patient in walking. Exactly what never takes place. The contemporaneous school, however, of Germany has treated me much more impartially. Langeubeck, Linhault, Neudorfen, Chelius, Busch, Beliott, and others, have frequently performed my operation with success. 0. Weber has enumerated forty cases, and has defined the rate of mortality at 15 per cent. (He found the same rate of mortality in one hundred and one cases of Syme's operation.) In seven cases the wound healed completely in one month. Dr. Kestnor, of the penal hospital at Strasburg, presents also sixteen cases. Of these, the results of six as to functions of the foot remain at present doubtful ; in the other ten only one failed as to walking, and in four fistulse remained. We might suppose that Malgaigne could not have ignored these results, described by his countrymen in a dissertation in the French language ; but he assumes to himself the credit of being the inventor of the sub- astragaloid amputation, although it is due entirely to his countryman Legnerolles. Hence the reason why, at all hazards, he vaunts the advantages of his operation at the expense of others. On the other hand, Hyrth, from purely anatomical considerations, rejects Malgaigne's operation altogether. As to myself, I will not treat it unjustly, but will say in its favor that it preserves a little increased length to the foot, but that it is much more difficult to perform. " I do not fear the result of my operation ; its importance does not consist in the method of amputating, but in a novel osteoplastic prin- ciple. My whole merit consists in irresistibly demonstrating by my proceeding that a portion of one bone remaining, naturally connected with soft parts, readily unites with another, and at the same time serves to lengthen the limb and increase its utility. But few military surgeons PIROGOFF'S LAST STATEMENT. 131 have tried my operation. Stroraeyer, without any reasons, doubts its success ; and in Chenu's report we cannot make out whether, during the Crimean campaign, the French and English surgeons made any distinction between my operation and that of Syme. Of forty-eight operations, twenty-one proved fatal, or 44 per cent. ; but with the English, of twelve, only two died, or 16 per cent. During the Italian campaign, Denne saw Neudorfer perform my operation at Verona three times ; all three patients recovered. According to Stromeyer's report, during the Holstein campaign four patients, who submitted to Syme's amputation, died." 132 AMPUTATION AT ANKLE JOINT. AMPUTATION AT ANBXE JOINT, W. C. N. Lieu- tenant Begiment fith Mich. Cavalry SdN.H. Vols. April 1, 1885 June 10, 1864 Five Forks Co- noidal musket ball Chatta- Boo^or MiBsion- ary Bidg^ PeterB- burg, Va. Passing through hia left ankle joint Injury. Amputa- tion at the ankle was performed. Pirogoff'fl method. The articu- lating 8ur- feces of the tibia and calcaneum removed, and the cut surfaces bro't Into appoaition Injuring right foot PirogoflF'a amputa- tion, a few da^s after iiyury Amputa- tion at tho ankle joint byPiro- goff'i method Ampu- tation of leg early in month of Feb- ruary Where performed and Sut^ geon. Surgeon St Clair, at City Point Hos- pital Prof Paul Eve, of Nashville, Tenn. Or. Rich- ard Tay- lor, of Memphis, Tenn AMPUTATION AT ANKLE JOINT. PIROGOFF'S METHOD. 1S3 Carried to the hospi- tal at City Point, April 16, 1865) the patient was traneferred to Ar- mory Square Hospital, "WaBningtoD, D. C. "With the employment of stimulants and nu- tritious diet, with emollient applications to the limb, there was a gradual Improve' ment . . ProgreBB of Case. On admission to Ar- mory Square Hospital he was in a feeble con- dition. An eryaipela' tous blush extended over the knee on the injured side; an ab- scess had formed in the lower part of the leg, and no union of the flap had taken place. April 28, 1865, symp- toms of pysamic infec- tion supervened; rap- idly recurring chills; an icteroid coloration of the skin and con- junctiva, anorexia, and a frequent feeble pulse suggested the gravest prof^osis. On Mny 6th, the grave symp- toms began to disap- pear, and by the end of the month the pa- tient was fairly conva- lescent. On June 6th, pronounced well; the 08 calcis liad firmly united to the tibia, and there was a good solid stamp Cose seen for the first time by the reporter, James M. Holloway, M. D., of Louisville, Ky., in the latter part of January, 1864. The flaps bad united, but a number of einuses communicated with the coaptated surfaces of the calcis and tibia, at the bottom of which denuded bone could be teitupon the intro- duction of the probe. In addition to these, other sinuses situated on the lateral aspects of the lower third of leg communicated with the sheaths of the ten- dons. These latter, as tar as he could judge from the statement of the patient, appeared subsequent to those leading to the carious bones. Tbc integu- ments overlying and adjacent to the diseased bone, and inflamed condition of sheaths of tendons presented a re- markably healthy ap* pearance, so much so that the true condition of the stump did not transpire until a more thorough examination was made, while the patient was under the mflucoce of chloro- form. Such was the complete disintegra- tion of the calcis and the end of the tibia that amputation of the leg was necessary . . - The case progressed favorably, and termi- nated in a veiy useful stump .3 . 1.1 PS A good solid stump. MARXB. Avery useful stump , (Spec. 2298. A. M. M. and Photo. 75 in se- ries.) Cir- cular No. 6, Surgeon General's Office, p. 47. Reported by James M. Hollo- way, M.D. Prof, of Anat, of Louisville, Ky.,Amer. Jour. Med. Sci., Jan., 1866, p. 85. 134 AMPUTATION AT ANKLE JOINT, AMPUTATION AT ANKLE JOINT, Nake. g •a O .5 Regiment, 11 Battle. MiiEUe. Injury. h "Where performedf and Sur- geon. - - - - - - - - Pirogoff'B amputa- tion - - aw.H. «thN.Y. Vols. "%'■ Cliancel- lorsville, Va. PirCffloff'B ampu&- tioa P.B.C. - - IMiN.T. Vols. 1^10, Near SpottsjI- vanU C't House - - Pirogoff's amputa- tion, July 20, 71 days after injury - - P.L. - - 48th N. T. Vols. ^1^'^ Ft Wag- ner, S. C. ment of ■heU Commi- nuting tar- Bo-metatar- 8UB except calcia PirogofTs amputa- tion per- formed - U. 8. Hos- pital.Hil- ton Head, six daya after in- jury, by Surgeon Applegata B.B. Kh N. T. ArtiUery Malvern Hill BheU Compound fracture of tareo-meta- tarsal bones except as- tragalus andcalca^ neum Pirogoff'B amputation AMPUTATION AT ANKLE JOINT. PIROQOFF'S METHOD.— (Confiitued.) 135 Lo-wer portion of tibia exsected, and an> terior portion of calca- neum; integumente and posterior portion of calcLB brought up ; united to tibia . . . ProgrcBB of Coae. Patient progrceEcd very unfavorably, and eubecquently Bank and died Upon examination on the 8th of July, 1864, fourteen months afterwards, found the stump healed, but the pai-ts were stilt swollen and (edematous; un- able to walk without two crutches ; heel drawn upwards, and cicatrix of flap thrown downwards and for- wards, BO that during locomotion it came in contact with the floor. No trace of the exist- ence of inflammation of the sheaths of the ten- dons remained, and the bones seemed to be sound The soldier was able to proceed to his home in Geor^B, though the stump had not entirely healed, and consider- able tumefaction of the stump and leg stiU ex- isted. The heel was drawn up and the ten- der cicatrix constituted a portion of the sole of the stump .... Stump much en- larged generally; exfo- liation from posterior portion of tibia; prog- nosis highly favor- able; leg tumefied ; cedematoug, cicatrized ; almost entire weight borne upon the end . Stump compact, fine- ly formed, but the por- tion of calcaneum use- less and embarrassing; artificial appliance or- dered; to begin to use a boot OB base of sup- port linch below patella, Xln.; at calf, 4 in., at end of stump, S of in. Walk'd with crutch- Be- UABE8. Beported by Prof. Jae. M. Hollo way, op. cit. Beported by Jas. M. Holloway, M. D., op. cit. Beported by Jas. M. Holloway, M. D., op. ciu 136 AMPUTATION AT ANKLE JOINT. AMPniATION AT ANKLE JOINT, A. J. Regiment Gray, Maine New Eng. Corp'l Lawy'r 45th Ga. Vols. IMth N. T. Vols. M O 8th Minn. Vols. 70lh N. T. Vols. 5th N.Y. Vola. Dec. 9, 1864 July, 1861 M'ch 25, 1865 May 18, 1^ IfitBuU Run Musket ball Rifle- ball Dec. 7, 1864 Spottsyl- vania, Ct. House Murfreea- boro, Tenn. Bristow'a Station, Va. Gainca'a Mills Minie- baU Minie- baU Ipjnry. Paesing through the tarsus Passing thro' the right tar- sus, frac- turing the tarsalDoncs Passing thro' the ankle joint Striking the right foot 1^ Amputa- tion at an- kle joint (Syme's), Jan. 20, 1865 Amputa- tion, ankle, Syme's method Amputa- tion at an' kle joint, Syme'a method, 24 hours after injury Passing thro' the tarsus from the dorsum to the heel, making a clean track, and caus- ing a com- pound frac- ture of tar- sal bones Entering the posteri- or part of left heel, and was rc- mov'd from beneath the integu- menlof the dorsal face of the tar- sus ; it com- pletely traversed the tarsal bones Paasing Aug. 1st, through Syme'a the tarsal operation bones performed 11 ■So -II Where performed, and Sur- geon. Dr. Buck, at St. Luke's Hospital, N.Y. Assistant Sui^eon Gouley, at Wash, Inflrnuuy. Amputa- tion per- formed 9 hours after injury, by Syme's method Amputa- tion of an- kle joint, Syme's method Amputa- tion at an- kle joint, by Syme's method Amputa- tion at an- kle joint, Syme's method, two years after gun- shot wound Feb. 12, 1865, Dr. Mott ream- putated 3 inch's above ankle joint, by the circular method Dr. Briee^ Confed. Surgeon XT. S. Genl Ho8pital,at Murfrees- boro, Surg. Turner Bellevue Hospital, N.y.,by Dr. Ste- phen Smith Dr. Bar tholoT AMPUTATION AT ANKLE JOINT. STMB'S METHOD. 18T Patient taken to Jack- Hon Hospital, Rich- mond, Va. The limb ■was placed upon a pil- low without the sh'ght- cat support to the flaps, bv means of dressing. The large posterior flap dragged down by its own weight, formed a large, pendulous, BUp- puraung mass . . . Patient removed to the XJ. S. General Hos- pital, Murfreesboro', and ten days after in- jury amputation was pcrfomlea . . . The ankle joint be- ing anchylosed, the tibia was sawn through above the malleoli, and the foot removed; so thick and firm were the flaps that it was quite impossible to place them in immedi- ate apposition. By care in the adjustment of strips the irregular margins of the flaps were moulded Into shape Was moved at once to Savage Station, af- terwards to Richmond. Cold - water dressings were kept applied. He was sent with the other paroled prisoners to Progress of Case. The case did well with a shortening of Hmb Stump healed kind- ly, leavmg a service- able extremity; artifi- cial limb applied at the end of one year and two months .... The case processed unfavorably, with ex- foliation of bone and suppuration. When examined forty days after the amputation, there was still consid- erable discharge from several points . . . The flap sloughed. Patient taken to Rich- mond on the third day Has been healed, but now open in conse- quence of on injuiy . The posterior flap was short and became subsequently enlarged, but by care, union be- came Arm, and the stump sound and reli- able. He walks about with a boot leg, having a thick sole, without inconvenience . . The proprcfls of the case to ultimate recov- ery was most satisfac- tory. The portion of the flap which con- tained tne opening and track of the sinus sloughed, but left a healthy granulating surface ; the thickened and infiltrated tissues were rapidly reduced, and the flaps were brought together. The stump assumed a per- fectly rounded and symmetrical form.with tne cicatrix on the ex- tremity. Dr. Hudson adapted an artificial foot to the stump, which after a little use enabled him to walk with ease and but a a slight limp . . • The flaps came to- gether perfectly well. The wound began to heal up rapidly; about two weeks alter the operation, the wound being healed, eryeipe- I SHght Pretty fair 2Jin. Firm and useful An effi- cient and useful stump Walks well Walks well Walks well Walks well Rb- UABKS. D'bt- ful 138 AMPUTATION AT ANKLE JOINT, AMPUTATION AT ANKLE JOINT, E^ g Nake. a 1 1 Begiment If Battle. Missile. Injury. Where performed and Sur- geon. 1 s d o $Ss F.J. LtCoL 1st Mich. ''&''■ Spottsyl- vauiaCt. Kinte- Compound Amputa- - f S. Shooters baU comminut- tion at an- House, ed wound klejoint, by Syme's me&od Va. of left tar- %- sus B.L. mhMflss. Sept 17, 1863 Antietam, Solid Carrying Amputa- Dr. How- VolB. Md. ehot away the tion at an- ard, on the field im- phalanges klejoint. by Syme's meuiod and meta- mediately tarsus, and after in- shattering jury the tarsus H.E. — - nth V. S. Infimtry Not. li 1864 Snicker's Gfap - Amputa- tion at an- kle joint, Syme's method - - T. D. S9C«m- — l8t Excele'r June 1, Fair Oaks, Rifle- Causing a Amputa- Ream- Surgeon Lewis, at ron St. Brigade 1861 Va. baU compound tion at an- puta- N. Y. Vols. fracture of the tarsus and metatarsal bones kle joint performed by Surg. Lewis, Syme's tion Savage's Statiou J.C. Altoo- n.,Pa. Laborer r6th Penn. July 10, 1863 Ft. ■Wag- ner, S. C. Musket Causing method Amputa- Reom- AtFoit Voifl. baU compound tion of an- puta- Schuyler- N/V. comminut- klcjoint, by Syme's tion ed fracture thro' of tarsus method. 24 Sept1?I hours after J. C. U.8.N. Cox- Bwain V. 8. N. May 31, 1*4 Appomat- tox River, - Compound comminu- AJmpula- tion at an- 1863 Asa'tSurg, Va. ted fracture kle joint of the tarsal performed bonea, with 1 hour after laceration the Injury, of soft parts Syme's of left foot. method J. E.U. _ __ 8th N. T. ^■ffi"' Funka- Rifle- Entered Ampntat'n performed by Syme's method, _ _ Cavolry town,Md, baU the left foot at the junc- tion of the tarso, metar at ankle tarsal joint, 9 h'rs bones, and after the in- emerg'd be- hind the jury was received external malleolus ■W.B. Kirk- Stu- 69lhN. T. W' Chancel- Unex- Comminut- Amputa- On the land. dent Vols. lorsviUc. ploded ing the phalanges. tion of the field by Va. sheU ankle joint Surteon Wo healing up and doing well, except the part corresponding with the fibula; took a number of detached pieces of bone out . Aug. rth, doing well, healing. Aug. 21st, ab- scess formed on the In- ternal side of foot ; opened. Sept. 3d, do- ing well, and soon in a condition to be dis- missed Case did well, and the stump was sound and serviceable though the flaps were com- posed of tissues from the lateral parts of the anklej the same patient sufffer'd a Chopart's am- putation of the right foot, which did well. A Blight necro- sis of the lower end of tibia oc- curred An in. below the knee, J of an inch; at calf,3j inches i at the end of stump, J of an inch 5iin a . II Be- UABX8. Good when wound- ed Aug.l4, general health good Stump very service- able Walks well with artifi- cial limb* After the necrotic part of the fibula is resected, the wound will un- doubtedly he&l fa«t 2Jin. Useful limb INVESTIGATIONS THE NATURE, CAUSES, AND TREATMENT OF HOS- PITAL GANGRENE, AS IT PREVAILED IN THE CONFEDERATE ARMIES, 1861-1865. JOSEPH JONES, M. D. PBOFESaOR OF CHEMISTKY IN THE MEDICAL DF.PARTMENT OF THE CKIVEESITT OP liOmSIANA, KEW OBLEAHS, FOKMERLY SURGEON IN THE PKOVISIGNAL ARMY OF THE CONFEDERATE STATES. INTRODUCTION. History of Investigations on Hospital Gangrene. — Gunshot Wounds treated in Augusta, Georgia, during the Spring and Summer of 1862. — Moist Gangrene of Rare Occurrence during the Earlier Periods of the War for Confederate Independence. — The First Case ■which came under the Observation of the Author at all resembling Hospital Gangrene, occurred in the Month of July, 1862. — History of this Case- — Investigations upon this Disease, instituted during the Months of August, September, and October, 1863, in the Confederate General Hospitals at Summerville, Charleston, and Columbia, South Caro- lina, and in Bichmond, Gordonsville, Charlottesville, and Lynchburg, Virginia. — Effects of Incessant Labors, Excitement, Fatigue, Bad Water, and Foul Air upon the Confederate Soldiers defending the Earthworks on Morris Island, and the Ruins of Fort Sumter in Charleston Harbor. — Observations upon the Moist Gangrene which prevailed amongst the Confederate Wounded who crowded the General Hospitals in Augusta, Georgia, after the Battle of Chickamauga. — Inquiries instituted in the Field and in the Hospitals, and amongst the Medical Officers of the Army of Tennessee during the Months of June and July, 1864. — Outline of Labors submitted to Surgeon -General. — Clinical Investigations and Post-mortem Examinations instituted amongst the Federal Prisoners at Camp Sumter, Andersonville, Georgia, and in the General Hospitals at Macon and Vineville, September, October, and November, 1864:. — Objects and Results of these Labors upon Hospital Gangrene and Small-pox. — Form of Circular containing Inquiries on Hospital Gangrene, addressed to Confederate Surgeons. — Method of presenting the Results of these Investigations. — Definition of Certain Terms. — Form of Confederate Reports of Sick and Wounded- — New Form of Sick Report. — Remarks upon the Classification of Diseases. — Division of Gangrene into Gangrsena Sicca, Humida, and Phagedsena Gangrsenosa. — Use of the Terms Mortification, Gangrene, and Sphacelus, bj' Various Authors, as Galen, Fabricius, Hildanus, Samuel Sharpe, Percival Pott, John Hunter, John Pearson, Samuel Cooper, John Syng Dorsey, .lohn Abernethy, Charles Bell, Sir Astley Cooper, John Thomson, Baron Boyer, Baron Larrey, Mr. Guthrie, ChcliuSf R. Carswell, and Copland. — Observations upon the Method of Investigation and Classifi- cation of the Phenomena of Mortification: 1. Mortification arising from Mechanical Injuries, and the Local Action of Physical and Chemical Agents; 2. Mortification arising from and following Infiammations of Important Organs and Structures, without any External Injury; 3. Mortification arising from Constitutional Derangements, and Altera- tions in the Circulatory Apparatus, without any Local Injury or Internal Inflammation; 4. Mortification arising from the Action of Special Poisons, either developed within the System or introduced from without, through the Alimentary Canal, Respiratory System, or Skin, or through the Blood, or through Wounds and Ulcers. — Notes upon the Histor3^ of Hospital Gangrene. — Records of the Ancients furnish only Negative Testimony. — State of Medicfil Science amongst the Assyrians and Padaians, — Armies of the Ancients subject to very much the same Diseases as the Modern Armies; Examples: Pestilence in Grecian Army; in the Army of Xerxes; amongst the Hebrews. — Scurvy known to the Ancients. — Very few Wounded survived the Ancient Battles. — Homer's Descrip- tion of the Battles between the Grecians and Trojans. — Time at which regular Army Surgeons were first employed. — Hebrews; Moses; Homer's Account of the Wounding of Menelaus; Darius; Alexander; Roman Armies. — History of the Establishment of Hospitals. — Authors who have treated of Hospital Gangrene, Pliny, Par^, Lamotte, Poiteau, Leonard Gillespie, and others. The following Report on Hospital Gangrene was drawn up for the use of the Medical Department of the Confederate States of 10 146 HISTOKY OF INVESTIGATIONS America. In the investigations and discussions, the author en- deavored to follow the inductive method. Whilst striving to present the results of his labors amongst the Confederate soldiers in field and hospital, it has also been his earnest desu'e to present as full and as just views of the labors of others as possible, during a period of desolating war, in a country convulsed with a mighty revolution, sparsely settled, without large libraries, and cut off from the surrounding world. The military surgeon is prone to attach great importance to mere operative surgery ; but we would rather join a distinguished English surgeon in saying, " How to obviate and remove the most common causes of military or civil diseases, is with me a more momentous consideration than to aim at setting off my own importance by filling the reader's mind with matters of mere spec- ulation, or to detain him with subjects which can come before him but very rarely." On the other hand it may be said, that a disease ■which is comparativelj' rare except in army and navy hospitals is interesting chiefly during a season of war, and can have but little interest to the civil practitioner. Apart from the large amount of original matter presented in this report, and the interest which it may possess from the time and circumstances of its production, it is worthy of consideration, that hospital gangrene was almost unknown upon the American Continent up to the time of the recent gigantic contest ; and as we have no reason to believe that the military operations of the American people will cease with this age, we are led to hope that the experience now recorded ■will prove of value in the conduct of future wars. During the spring and summer of 1862, I examined and treated History of in the general hospital in Augusta, Georgia, many cases t^^Mo^os- of gunshot wounds from Virginia and the coast of South II^Do^'rho Carolina. As this was the only hospital at this post, and rare occur- as it vTSiS locatcd upon the direct line of railroad travel ae eiriier"^ from Virginia, the number of transferred and furloaghed th"war.° wounded soldiers who applied for medical aid was by no means inconsiderable ; and from the previous fatiguhig travel to which the wounded had been subjected, this was a favorable point for the examination of the origin of hospital gangrene. Although in many cases the wounds had not been dressed for several days, from the time that the soldiers had left the battle-field or hospital in Virginia until they reached Augusta, in no case did I observe ON HOSPITAL GANGRENE. 147 any appearance of moist gangrene. In some ca?es the wounds contained living maggots, generated during the passage from Rich- mond in the cars, and in others erysipelas had made its appear- ance, and the parts were swollen and red ; but still, in these earlier periods of the war, as far as my observation extended, the gunshot wounds discharged well-formed pus, and were free from moist gangrene. This observation was also true of a number of gunshot wounds from the battle of Secessionville (June 16, 1862), which came under my treatment. The first case at all resembling hospital gangrene which came under my notice, occurred in the month of July, Theflrstcasa 1862. A young soldier belonging to one of the regi- "„s™teigL- ments of Florida volunteers, was stabbed in a rencounter ^™e under in a drinking saloon. The slender dirk entered the tiin'S'thr' anterior and superior portion of the scrotum, on the right TnaM in the side, near where it united with the integuments of the ^°=t»'='i- abdomen, and following very nearly the track of the spermatic cord for about half an inch, passed towards the left side, grazing the root of the penis. One or more blood-vessels appear to have been severed, although at the subsequent examination, when the parts were swollen and infiltrated with blood, it was impossible, without enlarging the wound, to discover the ends of the vessels. This unfortunate young soldier was brought to the Confederate hospital eight hours after the reception of the wound. The scro- tum was distended with blood, and resembled in color, and in its distended purplish and blackish skin, a Guinea squash or egg-plant. After carefully probing the wound with the finger, and after care- ful examination, although the severed ends of the vessels were not secured, still it was ascertained that the hemorrhage had ceased. The lips of the wound were drawn together, the enlarged scrotum was suspended and elevated by a bandage, and cloths saturated with ice-water applied. Upon the third day, finding that the scrotum had not diminished, but had rather increased in size, sev- eral free incisions were made into the most dependent portions. Blood was effused and coagulated throughout the cellular tissue. Nothing but bloody serum issued from the incisions. The size of the tumor was diminished somewhat by this loss of fluid. The weather was very warm, and in the course of a few days it was evident that the effused blood in the scrotum was undergoing decomposition ; bright lines of inflamed lymphatics shot up from the scrotum on both sides towards the abdomen, and the skin of the groin and lower portions of the abdomen presented an 148 HISTORY OF INVESTIGATIONS inflamed reddish, purplish, and greenish discolored appearance. The marks of inflammation and disorganization progressed most rapidly on the uninjured (left) side, no doubt because the veins and lymphatics were not severed on this side ; and the left thigh, groin, and lower portion of the abdomen on this side soon presented a swollen green, purplish, grayish, and in parts blackish look, as if the parts were undergoing rapid decomposition. The odor from the scrotum became insupportable ; chlorine, nitric acid, and tar fumigations only partially mitigated the stench. The abscess, or rather gangrenous mass upon the left groin and lower portion of the abdomen, progressively increased, and the inflamed lym- phatics and black distended veins could be seen radiating from it in all directions. When I plunged my lancet into this elevated purplish and greenish putrid-looking mass, it encountered no resistance ; the integuments and tissues appeared to be completely dissolved, and a dark greenish and purplish, horribly offensive matter, mixed with numerous bubbles of air, poured out in large quantity. The entire mass of coagulated blood and infiltrated tissues now sloughed off, and left the white and apparently healthy testicles entirely exposed. The skin of a large portion of the penis also sloughed off. During these changes, the whole complexion assumed a sallow, unhealthy, leaden hue. Death closed this dis- tressing case in less than seven days after the reception of the wound. This case presented several points of interest. 1. It was evident that death was not caused by the severity of Death in the the wound, for uo vital organ was injured, and the ofBorotiim, hemorrhage was inconsiderable. Death was evidently caused by the ^ i i ■ i • n^ n i -i absorption due to the absorptiou and poisonous effects of the prod- and poison- />ii i iiii. oas effects of ucts of the Qecoinposed gangrenous blood and tissues. the products „ rni i • i of the decern- 2. The ccrebro-spinal nervous system presented but grenoua few cvideuces of disturbance. The patient retained his blood and . n i i tissues. senses to within a few moments of death, and was at no period restless. The low, muttering delirium, as well as the twitchings of the muscles and tendons characteristic of adynamic fevers, were at no time present. No active pain was suffered, and the patient appeared to be insensible to his distressing condition ; he expressed no fears of death, did not complain of the horrid stench, and although fully warned of his true situation, and in- formed that every hope of life had vanished, he actually traded for a watch two or three hours before his death. 3. The pulse, previous to the gangrene of the scrotum and the formation of the gangrenous abscess, was full and soft ; after these ON HOSPITAL GANGRENE. 149 evidences of the disorganization of the tissues and blood, it became rapid and feeble. The heat of the body was somewhat elevated, but not to the degree common in idiopathic fevers. The skin felt relaxed and moist, and the sweat gave a sticky, clammy, unpleas- ant feeling to the hand. Throughout the tongue was clean, moist, and relaxed. 4. The complexion assumed a leaden hue, and the marks of death were discoverable in the pinched nose, sunken eyes, hollow temples, the rough, dry, tense skin of the forehead, and the dull leaden eye, for thirty-six hours before death. 5. No case of gunshot wound had ever been treated in the small room in which this patient lay. Several cases of typhoid fever, and quite a number of other diseases, as malarial fever and measles, had been treated in this and the adjoining room, from the foundation of the hospital ; but for a week or ten days before the entrance of this patient there had been no serious cases of disease, and the two rooms had been cleansed. 6. The poisonous matters causing the gangrenous abscess were evidently generated within the injured structures of the patient, and were not derived from any extraneous source. The passage of the scrotum into the gangrenous state was due, not to the introduction of a special poison from without, but to the preexistent state of the constitution, and the decomposition of effused blood in this hot climate, in a dependent organ, and in tissues of low vitality. During the months of August, September, and October, 1863, I visited the sick and wounded in the general hospitals in Sum- merville, Charleston, and Columbia, South Carolina, and in Rich- mond, Gordonsville, Charlottesville, and Lynchburg, Virginia, and instituted investigations and inquiries upon hospital gangrene and other diseases. The trials and sufferings of the brave defenders of the Confed- erate earthworks on Morris Island, and of Fort Sumter gaectsof in Charleston harbor, were of no ordinary character. In bomb-proofs the history of warfare, troops were never subjected to a MMdTunon severer ordeal than that endured for days and nights by ^"»""*«*- the gallant defenders of Batteries Wagner and Gregg. Shut up upon the end of a barren sand island, in two small sand forts, with no navy to assist them, the Confederate soldiers were almost encircled by the land batteries and iron-clads of the enemy, armed with the heaviest and most effective ordnance known to modern warfare. During the severe and incessant bombardment in this 150 HISTORY OF INVESTIGATIONS intensely hot weather, the Confederate soldiers were compelled to remain in the bomb-proofs. With more than one thousand soldiers crowded into these sub- terranean passages, with necessarily imperfect ventilation, the atmosphere became loaded with noxious and oflFensive exhalations. In addition to all this, it was impossible to convey water and pro- visions to the forts, except during the night, and the water of the island was hot, brackish, and nauseous. The meat and food kept in the bomb-proofs rapidly spoiled, through the action of the foul emanations from confined living beings. The effects of the hot, foul air, continuous labors, and excitement upon the men, were marked, and hundreds were incapacitated for duty by sheer exhaustion, or by severe bowel affections resulting from these causes, and especially from bad water and food, or by malarial fevers arising from the exhalations of the island, the sandy surface of which was underlaid by an ancient salt marsh. The wounded especially suffered from these causes, and the gunshot wounds assumed in many cases an unhealthy appearance, even before leaving the bomb-proof hospital. The only ameliorating agent was the stimulating ozone of the sea air, which tended to counter- act the effects of the other deleterious influences. I embraced the opportunity of comparing the Confederate and Effectaofex- Federal wounded in the general hospitals in Charleston Srd"water°'' ^^'^ Columbia, South Carolina. The wounded Federals proEreM°of captured during the assaults upon Battery Wagner, who loun^' received similar attention with the Confederate soldiers, ^"o°f 'the'"' recovered more rapidly from their wounds than the bS'ia^ Confederate soldiers. The difference in the healing of chariMtoD t^® wounds appeared to be due to the fact, that the Fed- ®' '^- eral soldiers wounded and captured in these attacks had been brought in a high state of health from the most salubrious localities in the outer range of sea islands, immediately into action, without being subjected to the action of malaria and the excite- ment and fatigue of incessant bombardment and the foul air of bomb-proofs, which resembled more nearly caverns in the earth. The extensive Confederate hospitals in Richmond, Charlottes- LarBehoB- villc, and Lyuchburg, Virginia, presented a wide and KiSaaRbrd- important field for the investigation of hospital gangrene, fitidforthe The hospitals were visited, and the most interesting cases of bospM"" subjected to critical observation, the gangrenous matter gangrene. carefully examined under the microscope, drawings exe- ON HOSPITAL GANGRENE. 151 cuted of the microscopical appearances at different stages of the disease, and the effort made to excite and direct the attention of the surgeons to the careful investigation and record of cases, and to the determination of important questions, as the local or consti- tutional, and the contagious or non-contagious nature of the dis- ease ; and experiments with the gangrenous matter were proposed and instituted upon living animals. During these labors I was enabled to determine that pus is not formed in the truly gangrenous matter, and that its appearance is one of the most important signs of improvement in the wound ; and further, that constitutional symptoms almost invariably accompany the progress of the local disease. Upon my return to Augusta, the Confederate hospitals were found crowded with wounded from the bloody battle of Effects of Chickamauga. One thousand and fifty sick and wounded "^^1^1* soldiers, about nine hundred of whom were recently receded*™ w^ounded, were sent from the battle-field of Chickamauga g"5"^ to Augusta. The majority of the wounds were slight, ^f cucSL and of the extremities. Mp^nW The battle of Chickamauga was fought September 18- lf^^^„ 20, and the wounded were not received in Augusta until g'ngren?" the 26th-28th, or from eight to ten days after the recep- ^ OTcr-*"" tion of the wounds. l^I^^'^^i Not only were these soldiers much crowded in the cars, yentnlted'^ and without the proper dressing and attention to their •'"^p"*''- wounds during the tedious journey of near three hundred miles, but many of them lay out in the railroad depot, with little or no accommodation or attention to their wounds, for from forty to eighty hours after arriving in Augusta. The hospital accommoda- tions were wholly inadequate to the proper treatment of this num- ber of wounded, and they were crowded into houses and churches, the hygienic conditions and arrangements of which were defective. Thus the Second Georgia Hospital, with a capacity, according to the regulations, in cubic feet, of only 165, received 273 sick and wounded ; the Third Georgia Hospital, first division, with a capac- ity of 130, received 220 ; second division of the Third Georgia, with capacity for 162, received 370 sick and wounded soldiers. The capacity of the Presbyterian Church, impressed as a hospital, was only 112 ; nevertheless 240 wounded men were crowded into it ; the pews were not removed, the seats were converted into bunks, and the wounded men laid in the pews. The capacity of the Catholic Church was only 50, and yet it 152' mSTORY OF INVESTIGATIONS received 130 wounded. Hospital gangrene appeared first in the Presbyterian Church, a few days after the crowding of the wounded into the imperfectly ventilated building, surrounded by a dense and damp shade of large oak-trees. Not a single wounded soldier escaped gangrene in this building. The upper portion of the church was more imperfectly ventilated than the lower, and in addition to this the heated air, loaded with the exhalations from the lungs and putrid wounds, ascended ; and the cases of gangrene in the gallery were, as a general rule, severer than those treated below on the first floor. The disease next appeared in the Catholic Church, and here also all the wounded were attacked ; and finally the wounded of the Second and Third Georgia Hospitals (proper) were visited, and a number of cases terminated fatally. The most interesting cases were selected, and careful observations made upon the changes of the secretions, excretions, temperature, pulse, and respiration, and upon the pathological alterations after death. During the months of June and July, 1864, I visited the Army of Tennessee, in Northwestern Georgia, and instituted amongst the medical officers a series of inquiries upon the history of various diseases, and especially upon typhoid fever and hospital gangrene. The prolonged occupation by the Confederate forces of Kenesaw Mountain, and of the heights around Marietta, afforded a favorable opportunity for the examination of the experience of the Medical Director, and of many of the chief surgeons of the corps, divisions, brigades, and regiments. I was able to ascertain, by these inqui- ries both amongst 'the field and hospital surgeons, that but few cases of moist gangrene had appeared amongst the Confederate wounded after the battle of Chickamauga. The number of cases of hospital gangrene appeared to increase in proportion to the distance which the wounded were transported from the battle-field. Thus, in the hospitals of Dalton, Rome, Cassville, Kingston, and Marietta, very few cases were reported, and the number was greater in Atlanta. The origin and remark- able spread of the disease amongst the wounded transferred to Augusta, appeared to be due to the transportation of the wounded for near three hundred miles in close cars, with little or no atten- tion to the wounds ; to the crowding of the hospitals far beyond their capacity ; and to the sudden change of climate, from the salubrious regions of Northern Georgia, elevated one thousand feet and over above the level of the Atlantic Ocean ; to the malarious climate and low basin of Augusta, elevated only about one hun- dred and fifty feet above tide-water, and surrounded with hills. ON HOSPITAL GANGRENE. 163 In response to the direction of the Surgeon-General, I prepared in the month of August, 1864, a brief report upon hos- invesUga- pital gangrene, giving the general results of the labors Juted'"'"' up to that time ; and immediately after this was for- '"""a?"'"' warded, I repaired to Camp Sumter, Andersonville, FeTerafW Georgia, and instituted a series of investigations upon fl°eia™ the diseases of the Federal prisoners. The field was of ^e^And™' great extent, and of extraordinary interest. There were o™"""'-*'*- more than five thousand seriously sick in the hospital and stockade, and the deaths ranged from ninety to one hundred and thirty each day. From the establishment of this prison, on the 24th of Feb- ruary, 1864, to the 1st of October, over ten thousand Federal prisoners died ; that is, near one third of the entire number per- ished in less than seven months. I instituted careful investiga- tions into the condition of the sick and well, and performed numerous post-mortem examinations, and executed drawings of the diseased structures. The medical topography of Anderson- ville and the surrounding country was examined, and the waters of the streams, springs, and wells around and within the stockade and hospital carefully analyzed. Diarrhoea, dysentery, scurvy, and hospital gangrene were the diseases which have been the main causes of the extraordinary mortality. The origin and causes of the iiospital gangrene which prevailed to such a remarkable degree and with such fatal effects amongst the Federal prisoners, engaged my earnest consideration. The scorbutic condition induced by salt meat and farinaceous food, without fresh vegetables, modified the course of every dis- ease, poisoned every wound, however slight, and lay at the foun- dation of those obstinate and exhausting diarrhoeas and dysenteries, which swept off thousands of these unfortunate men. Such was the state of the solids and fluids in systems debilitated by long confinement, despair, and poor diet, that slight injuries, abrasions, and scratches of the surface, and even the bites of small insects, were in many cases followed by such rapid and extensive gan- grene as to destroy extremities and even life itself After the conclusion of the labors amongst the Federal prisoners at Andersonville, a series of inquiries and investigations invosHga, were instituted upon the hospital gangrene, which pre- tuted in the vailed to so great an extent amongst the hospitals con- pitaisoftho nected with the Army of Tennessee during the recent nessee. disastrous campaign in Northwestern Georgia, and especially after the evacuation of Atlanta. The doubtful if not dangerous and 154 HISTORY OF INVESTIGATIONS. disastrous policy of collecting the cases of hospital gangrene into one hospital devoted exclusively to its treatment, was inaugurated amongst the general hospitals of the Army of Tennessee located in and around Macon, and three hundred and eiglity-five cases of hospital gangrene were treated at the Empire Hospital, in Vine- ville, near Macon, during the months of August, September, and October. Sixty-five cases of gangrene terminated fatally during these months at the Empire Hospital ; that is, during this short space, one sixth of all the cases proved mortal. The gangrene hospital was located in a depression covered with small scrub oaks, just ■where the Vineville road meets the railroad, and directly opposite to the Confederate States Laboratory. The effects of location, and change of climate, and the crowding of the gangrene patients into hospitals devoted specially to its treatment, was examined ; and numerous examinations and analyses of the blood and excre- tions were made, and life-like drawings executed of the gangrenous parts, illustrating not only the appearances presented by the wounds at the different stages of the disease, but also the perma- nent disability which gangrene produces by the contraction of the injured muscles. The origin and causes of this disease in the Army of Tennessee were investigated, the hospital records examined and consolidated, and numerous inquiries relating to hospital gan- grene addressed to the various medical officers. One of the wards of the Empire Hospital was devoted to the treatment of small-pox, and several cases occurred in which variola appeared in patients who had but recently suffered with hospital gangrene, and whose wounds were still extensive and in an un- healthy condition. The two diseases, small-pox and hospital gangrene, were inves- tigated side by side in the same manner, and the results of the analyses of the excretions and of the post-mortem examinations compared, in order that the difference between the actions of two poisons of animal origin might be determined. This comparison ■was peculiarly interesting, because in the one case the action of the animal poison produced specific effects which altered the entire constitution, and could not be repeated, whilst in the other the animal poison produced no specific alteration of the system, and so far from affording any immunity, rather tended to render the sys- tem affected more liable to its action. The following form of the inquiries which I drew up and addressed both in person and by circular to a large number of the INQUIRIES UPON HOSPITAL GANGRENE. 155 medical officers of the Confederate army, is now presented, as it gives an outline of the general method pursued by me in the investigations upon hospital gangrene recorded in this volume. INQUIRIES UPON HOSPITAL GANGRENE. Augusta, Ga., August — , 1864. Surgeon , Army of Tennessee. Sir, — I respectfully call your attention to the following order of the Surgeon-General : — Confederate States op America, J Surgeon-General's Office, War Department, > Richmond, Va., August Sth, 1864. ) Surgeon Joseph Jones is directed to institute an extended investigation upon the causes, pathology and treatment of fevers, and the relations of inquiries , ., ,. uponhos- climate and sou to disease. piui gan- Surgeon Joseph Jones will visit those parts of the Confederate dresred by States, and prosecute his investigations in those cities, armies, and ?;""i°j'°, regimental and general hospitals, wliich he may deem necessary, as surgeons. affording suitable fields for the establishment of the results indicated in this order. Medical directors of the field and hospital, and chief surgeons of corps, divisions, districts, and brigades, and surgeons and assistant-surgeons of regi- ments and general hospitals, will afford every facility to Surgeon Jones to carry out these instructions, and will respond as far as possible to his inquiries by letter and circular, and will furnish him with copies of all field and hospital reports which he may deem necessary for the illustration of the various sub- jects of inquiry indicated in this order. Surgeon Jones will embody the results of his labors relating to the diseases of the Confederate army in substantial volumes, and will deposit them in the Surgeon-General's office, for the use of the medical department of the Confed- erate army. (Signed) S. P. MOOEE, Surgeon- General C. S. Army. In the prosecution of these inquiries, the inductive method has been followed, and individual facts have been observed and recorded, and general principles established by the analysis, comparison, classification, and combination of the facts and phenomena. In an inquiry into the causes, pathology, and treatment of different diseases, the first and most essential labor consists in the accurate delineation of the symptoms and phenomena (natural history) of diseases, and the effects of remedies, based upon the critical observation and record of the symptoms during life, and the pathological alterations after death. The entire period of a long and active life would be insufficient for the full execution in this manner of the labors indicated ; and in truth such extended investigations could be thoroughly conducted only by a large corps of zealous and intelligent observers, laboring in concert systematically, and supplied with the materials and instruments of 166 INQUIRIES UPON HOSPITAL GANGRENE. modern chemical, physiological, and pathological science. " The diffi- culties of medical observation and inquiry can be adequately conceived," as Sir Henry Holland most truly remarks, " by the medical man alone. Neither those accustomed to legal evidence only, nor such as have pur- sued physical science in its more simple material forms, can rightly apprehend the vast difference made by the introduction of the principle of life ; or yet more, of the states and phenomena of mind, in connection with bodily organization. We have here a new world of relations, occult and complex in their nature, to be reasoned upon and resolved, with a principle of change, moreover, ever operating among them, and deviations from nature, under the forms of disease, which render all conclusions liable, in a thousand ways, to error." No lengthy argument is necessary to prove that experiments and instrumental aids are necessary characteristics of the inductive method, and that observation by the uuaided senses, and induction by the unaided intellect would fail to advance the cause of medicine much beyond the state in which it was left by the ancient Greek school of medicine. Bacon has well said that " the unassisted hand, and the understanding left to itself, possess but little power. Effects are pro- duced by the means of instruments and helps, which the understanding requires no less than the hand. And as instruments either promote or regulate the motion of the hand, so those that are applied to the mind prompt or protect the understanding." In like manner the cautions of Lord Bacon against too hasty generalizations, even when experiment is used, are well worthy of the consideration of the medical investi- gator. " Even when men build any science and theory upon experiment, yet they almost always turn with premature and hasty zeal to practice, not merely on account of the advantage and benefit to be derived from it, but in order to seize upon some security in a new undertaking of their not employing the remainder of their labor unprofitably; and by making themselves conspicuous, to acquire a greater name for the present. Hence, like Atalanta, they leave the course to pick up the golden apple, interrupting their speed, and giving up the victory. But in the true course of experiment, and in extending it to new effects, we should imitate the divine foresight and order. For God in the first day only created light, and assigned a whole day to that work, without creating any material substance thereon. In like manner we must first, by every kind of experiment, elicit the discovery of causes and true axioms, and seek for experiments which may afford light rather than profit." From the complicated nature of the phenomena demanding investi- gation, as well as from the peculiarities of the struggle in which we are now engaged with a powerful enemy, who has blockaded our ports, and cut us off from those implements and materials of research so valuable in modern pathological inquiries, many embarrassments have arisen, and great expenditures of health and strength have been necessary in the prosecution of these investigations. INQUIKIES UPON HOSPITAL GANGRENE. 157 Generalizations upon the Iiistory, origin, and causes of diseases, and their relations to climate and soil, cannot be perfected without testi- mony from various competent medical observers viewing the same dis- eases under varied circumstances. Thus, such important questions as the contagious or non-contagious nature of typhoid fever and hospital gangrene, the settlement of which would be of interest to the public as well as to the profession, can be determined by no process apart from testimony. Whilst my entire time and strength will be devoted to the labors in- dicated in this order of the Surgeon-General, and whilst it shall be, as it has been, my earnest effort to explore in person the most extensive and important fields of investigation, at the same time I desire the cooperation of the medical staff, and cheerfully throw my reports open to the carefully recorded observations of the medical officers of the Confederate army upon the phenomena and relations of diseases. You can afford valuable assistance by recording observations upon the following disease, and by a careful investigation of the subjects of inquiry now proposed. Even if you should find time from your mani- fold and pressing official labors, to do nothing more than to faithfully record a single case according to the method here indicated, through the whole course of the disease, it may prove a useful and valuable con- tribution to medical science ; and the discussion of any one of the questions proposed may throw light upon important points in the prac- tice as well as in the theory of medicine. HOSPITAL GANGRENE. A. General description op the origin, progress, and char- acters or hospital gangrene as it has prevailed in the HOSPITAL, regiment, CORPS, OK DIVISION, OB ARMT TO WHICH TOU HAVE BEEN ATTACHED. 1. What is the date of the first case of hospital gangrene that came under your observation, or to your knowledge ? General de- 2. Has hospital gangrene increased or diminished since th" orf^n"' the commencement of the war ? Md^hwae- 3. Has hospital gangrene increased in severity since the t^""' i">»- commencement of the war ? grene. 4. Is it possible to trace any relations between the appearance and spread of this disease and the previous exposures, hardships, and changes of climate to which the Confederate soldiers have been sub- jected ? A general outline of the epidemics of hospital gangrene through which each hospital has passed since the commencement of the war, together with observations upon the effects of climate and soil, water, food, exposure, privations, and severe labors, would prove of great value. Such experience would prove of service in the conduct of future wars. 158 INQUIRIES UPON HOSPITAL GANGRENE. B. Careful reports op cases studied and recorded through THE whole course OP THE DISEASE AT THE BEDSIDE. All the phenomena should be carefully observed and noted. The Method of following general plan should be followed in each case : — undre^rto" 1. General Description of Case. — Name, age, company, o cases. regiment, native place, and occupation, color of eyes and hair, ofcase. complexion and temperament. First symptoms of the dis- ease; time and nature of wound; treatment to which the patient has been subjected ; previous exposures ; habits and diseases of the patient. All general observations bearing upon the origin and progress of the disease, such as upon the diet, climate, change of climate, hard- ships in camp and hospital, crowding in cars or badly ventilated rooms and tents, possess value, and should be carefully recorded. 2. Daily Record of Symptoms. — Date of observation ; month ; day of Miy record month ; hour of day ; general appearance of the patient; con- toms. dition of intellect ; posture in bed ; the grasp of the hand, whether it be strong or weak, uncertain or tremulous ; the expression of the countenance, whether it be calm or anxious, or listless, or dis- turbed ; the sound of the voice, whether it be full, firm, or cheerful, or weak, hesitating, and tremulous ; the character of the complexion, whether it be healthy, clear, or florid, or pale, sallow, anaemic, or dusky ; the state of the nutrition of the body, whether the limbs are full and soft, or full and muscular, or reduced and skeleton-like ; the manner of respiration, and the characters of the pulse, should be noted not merely as matters of form, but as of vital importance in furnishing a general outline of the condition of the nervous, circulatory, respiratory, and muscular sys- tems, and of the blood and nutrient energies, and as affording that knowledge which is essential to correct diagnosis and treatment GompUxion. — The chemical and physical characters of the blood are altered in various diseases, and these alterations are fre- quently manifested in the change of the color of the blood and its mode of circulation through the capillaries. These changes are especially marked when the process of oxygenation is interfered with, or when certain excrementitious matters, as the coloring matter of the bile, are not eliminated. Changes in the complexion, that is, variations in the color and mode of circulation of the blood in the capillaries of the skin may therefore be important signs of disease, which, if properly understood, enables the sagacious practitioner to determine quickly and clearly the nature of the disease, and the best mode of treatment. Condition of the Wound. — Careful description of the size and appear- of ^"'^^ ^^ ^^^ wound and surrounding parts. The reaction of wouQd. the wound should be carefully tested from time to time. In this experiment it is essential that no foreign fluid or body be present- Thus, if the reaction be determined shortly after the wound has been INQUIRIES UPON HOSPITAL GANGRENE. 159 touched with nitric, acetic, or pyroligneous acids, the reaction will in- variably be acid. A sour farinaceous poultice also would give an acid reaction. Microscopical examinations should, if possible, be made of the dead tissues and discharges of the wounds, and careful drawings executed. Appearance of Tongue. — Clean or coated ; pale or red ; moist or dry. The appearance of the tongue should be described most minutely. Pulse. — Number of beats to the minute ; full or small in volume ; forcible or feeble ; rapid or slow. Respiration. — Number of respirations to the minute ; character of respiration ; full or feeble ; thoracic or abdominal ; natural , . . Respiration. or labored. Temperature. — Temperature of hand ; temperature under the tongue, or in the axilla. If it is possible to secure an accurate ther- lempera- mometer with the bulb exposed, the temperature of the ex- *>™- tremities and of the trunk should be determined with the greatest possible accuracy. The hand should completely surround the bulb of the thermometer, every avenue for the entrance of air being closed. It is well to surround the hand with some non-conducting cloth, and to hold the palm and fingers closely around the bulb of the thermometer. The instrument should be allowed to remain until it ceases to rise or fall. When the bulb is placed in the axilla, the arm should be held close against the side and chest so as to surround the stem of the ther- mometer completely with the naked skin ; and the instrument should not be removed for at least half an hour. Condition of Skin. — Dry or moist ; soft or harsh ; warm or cold ; hot or cool. Condition of Bowels. — Character of evacuations ; number, , . J Bowels. color, consistence. Urine. — Color ; clear or turbid ; appearance of deposits. ''"™- Microscopical Character of D^osits. — Amount, abundant or scant. The more recent volumetric method of analyzing the urine, not only yields more accurate results, but is much more rapidly executed than the older and less reliable methods. In the present war we are unfor- tunately cut off from those countries, as Germany, from which both instruments and reagents could be derived. This is unfortunate, as the field now opened for pathological investigation is more extensive than that ever known to medical oflScers ; and from the very extent of this struggle, which has almost completely emptied the Southern Confed- eracy of its male population, such an opportunity for investigation will never again be affbrded during this generation at least. The importance of examining the excretions of the kidneys cannot be overestimated. As the poisons producing the phenomena of different diseases vary in their chemical constitutions, and in their reactions, relations, and affini- 360 INQUIRIES UPON HOSPITAL GANGRENE. ties with the elements of the various fluids and tissues, the accurate determination of the amount and characters of the excrementitious compounds resulting from the changes excited by these poisons during different periods of diseases, is of great importance in affording that knowledge by which we may determine not only the tissues specially involved in the pathological changes, but the extent of these changes and their relations to the muscular and nervous disturbances, and to the elevations or depressions of temperature, and thus establish the marked characteristics of different diseases, and aid in the foundation of a phil- osophical classification of diseases. To those narrow-minded and ignorant physicians who affect to de- spise such examinations as unnecessary, disagreeable, and as tending to excite ridicule, we reply in the language of Lord Bacon : — " With regard to the meanness or even the filthiness of particulars, for which (as Pliny observes) an apology is requisite, such subjects are no less worthy of admission into natural history than the most magnificent and costly ; nor do they at all pollute natural history, for the sun enters alike the palace and the privy, and is not thereby polluted. We neither dedicate nor raise a capi- tol or pyramid to the pride of man, but rear a holy temple in his mind, on the model of the universe, which model therefore we imitate. For that which is deserving of existence is deserving of knowledge, the image of existence. Now the mean and splendid alike exist. Nay, as the finest odors are some- times produced from putrid matter (such as musk and civet), so does valuable light and information emanate from mean and sordid instances. But we have already said too much, for such fastidious feelings are childish and efieminate.'' JBIood. — In case of hemorrhage, the color and mode of coagulation, form and tenacity of clot, should be carefully observed and noted. Both chemical and microscopical examinations should be instituted. In hospital gangrene it is especially important to deter- mine the proportion of fibrine. Each case under critical examination should be investigated at least twice during the twenty-four hours, and oftener if possible. It is important that the variation of the pulse, tem- perature, and respiration should be determined at different periods of the day. I recommend that observations instituted with a view to determine the law of these variations be made at 2 a. m., 8 a. m., 2 p. m., and 8 p. m. If only two observations be made during the day, I would recommend the hours 8 A. m. and 8 p. ir. Dr. Thomas Laycock, in his " Lectures on the Principles and Meth- ods of Medical Observation and Research," ^ has given the following interesting observations on horary meteorological, physiological, and pathological changes, which are well worthy of an experimental exam- ination and extension : — " The hours of the twenty-four in which pathological and physiological changes take place are, in the order of their importance, — 1 Page 127. INQUIRIES UPON HOSPITAL GANGRENE. 161 " (a.) From 4 to 6 a. m., when the consumption of oxygen by dj. i^ycock the organism is at the minimum ; the thermometer low ; the o" ^njeof atmospheric pressure low. Death is most frequent at this period ; regular ob- and attacks of epidemic cholera, diarrhoea, ague, and the like, most stated likely to occur. 1"=™'^- " (J.) From 8 to 10 A. M. are favorable hours for the health, and the oppo- site, therefore, to the early morning hours. " (c.) The night hours are appropriate to sleep ; and it is during these that diseases seated in the nervous system, or originating there, are the more fre- quent. The hour of falling asleep is marked by a state of the sensorial system closely analogous to that of morbid states ; there is a quasi-delirious condition, predisposing to those paroxysmal diseases which are usually associated with an abnormal circulation of the blood through the brain. It is at this hour that delirium begins in fever and insanity, and that epileptic attacks occur. " (d.) The hour of profound slumber, usually from 1 to 2 A. M., is also char- acterized by a state predisponent to paroxysmal diseases, but more especially to those in which interrupted excretory function acts on the nervous system ; to this group spasmodic asthma, the spasmodic neuralgia, and gout especially belong." Tables drawn off after the form given upon the next page, will be found useful for the rapid record of the cases. Each medical officer will find it difficult thus to observe critically and record more than two or three cases each day, together with the regular discharge of his official duties. In endeavoring thus to investigate and record the phenomena or natural history of any disease, the medical observer will do well to fol- low the advice of Dr. Thomas Sydenham, in the preface to his cele- brated work on " Acute and Chronic Diseases " : — " In writing, therefore, a history of diseases, every philosophical hj'pothesis which hath possessed the writer in its favor, ought to be totally laid aside, and then the manifest and natural phenomena of diseases, on the meth- however minute, must be noted with the utmost accuracy, imitating "caMuvesti- in this the great exactness of painters who in their pictures copy the 8*"™- smallest spots or moles in the originals ; for it is difficult to give a detail of the numerous errors that spring from hypothesis, whilst writers, misled by false appearances, assign such phenomena for diseases as never existed but in then- own brains ; whereas they ought to appear clearly if the truth of their favorite hypothesis, which they esteem incontestable, were well established. Again, if any symptom, properly suiting their hypothesis, does in reality belong to the disease they are about to describe, they lay too much stress upon it, as if noth- ing more was wanting to confirm it ; whereas, on the contrary, if it does not agree with their hypothesis, their manner is either to take no notice at all of it, or barely to mention it, unless they can, by means of some philosophical sub tlety adjust it thereto, and bring it in some measure to answer their end." And the medical observer should receive in a like spirit the advice of John Huxham, who more than a century ago drew such faithful por- traits of typhus and typhoid fevers, as that modern writers on these 11 162 TABLE FOR EAPID EECORD OF CASES. Name of Patienti Company and ^giment; Date of ■Wound! Date of Entrance into Hospital Nature of Wound; Age of Patient; Weight, Heigliti Com- plexion, Temperament, Color of Eyes and Hair. Day of Month. 1 Hour of Observation. Condition of Wound; Size of Wound; Color, Chai- actera of Discharge; Gangrene Increasing or De- creoaing! Painful or otherwise, etc. General Appearance of Patient; Wasted or other- wUe; Complexion Clear or Sallow} Posture in Bed; Expreflsion of Countenance, etc. State of Intellect Condition of Nervous Syatem; Quiet or otherwise. Sleep, Quiet or Disturbed. Appetite. Appearance of Tongue. Condition of Bowels, and Character of Stools. Pulse, Number of Beats to Minute; Full, Soft, Fee- ble, etc. Kespirations per Minute. Temperature of Hand. Temperature of Asillo. Temperature under Tongue. 1 State of Skin, Moist or Soft, Diy or Hot. 1 Amount of Urine excreted during Twcnty-foui 1 Hours. Color of Urine. 1 Specific Gravity of Urine. 1 Characters of Deposits in TJrine. 1 Reaction of Urine, Acid or Alkaline. 1 Urea excreted during Twenty-four Hours. 1 Uric Acid excreted during Twenty-four Hours. I Free Acid excreted during Twenty-four Hours. PhosphoricAcid excreted during Twenty-four Houra. 1 Sulphuric Acid excreted during Twenty-four Hours. Chlorine excreted during Twenty-four Hours. 1 Equivalent, Chloride of Sodium. 1 Soda. 1 Potassa. 1 Lime. 1 Lactic Acid. 1 Ammonia. 1 Creatine. 1 Creatinine. 1 Albumen. 1 Extractive and Coloring Matters. Characters of Blood ; Proportion of Fibrine, etc. 1 Treatment. 1 Itemorks, INQUIRIES UPON HOSPITAL GANGRENE. 163 diseases have added but little either to his description of the symptoms during life, or to the principles of treatment which he laid down. In the preface to his " Essay on Fevers," after recommending the study of the works of the ancients, and especially of Hippocrates, and after extolling the ancients not only as men of vast genius but of the greatest diligence and unwearied application, who kept their eyes steadily fixed on what they would describe, and thus gave us the true picture and naked truth of things, which is infinitely more beautiful than all the affected daubery and flourishes of a modern luxuriant imagination, Huxham forcibly remarks : — " The more just the description, always the more excellent. What is a portrait good for, that is not like the original ? As Nature herself, the more accurately viewed, is the more admired, so he that gives us the truest copy of her face will ever be deemed the greatest master. In this, Hippocrates so greatly excelled, that he had the united applause of the nations around him, nay, they even paid him divine honors ; for by this he was enabled to heal as well as to know and describe diseases. I am fully persuaded, had his method been strictly followed by succeeding physicians, the art of healing would have long ere this time been carried to a much greater height than it is at present, which hath by no means kept pace with the many and great discoveries that have been made since, especially within this and the last century, in natural philosophy, anatomy, the materia medica, and chemistry. Indeed, as man is by nature mortal, it is impossible that art can make him immortal ; but surely it is very possible it may supply something more exact and determinate than we have at present." The following questions demand careful investigation : — C. Is HOSPITAL GANGRENE A LOCAL OK CONSTITUTIONAL DISEASE ? 1. Do fever and constitutional disturbances invariably pre- uogpii^i cede hospital gangrene ? S'oTotu- 2. Do fever and constitutional disturbances invariably ac- BUtutionaL company hospital gangrene ? 3. Is hospital gangrene ever strictly local in its effects without any constitutional disturbances ? These questions can be best decided by keeping a careful record of all the phenomena, and especially of the changes of temperatm-e and urine, throughout the whole course of the disease. The investigation should, if possible, be commenced before the appearance of the gan- grene. The effects of amputation in arresting the disease or otherwise, should be carefully noted, as bearing directly upon the definite settlement of the question of the local or constitutional origin of the disease. D. Is HOSPITAL GANGRENE CONTAGIOUS? It is difficult to settle the question of contagion, and it is still more diflScult to define its laws. 164 " CONTAGION." It is incumbent upon those who assert the contagious or non-conta- QuesHon as g}0\is nature of hospital gangrene, to give the cases and facts tofion oT upow which their belief rests. Mere opinion can possess but hospital ijttie value in the determination of complicated que,stions. Points to be In attempting to isolate patients in the same hospital, it is observed in .... . i i jr this discus- almost impossible to avoid the numerous sources oi contagion, and strictly isolate the wounded under observation and exper- iment : the basins, the towels, the water, the rags, the mingling of the bed- clothes in washing, or even the flies, may one or all be sources for the transmission of gangrenous matter from one patient to another. Then there is the medium of the atmosphere for the transmission of various gases. In the crowded wards of the hospital, the atmosphere may become poisoned by the exhalations of the lungs and skin, and of the urinary and intestinal excretions ; and the general system of all the patients be affected by the absorption of these poisons. The cases of typhoid fever and other diseases are rendered more severe and fatal by these depressing agents, whilst the general health of the wounded is affected by the blood poisoning, and the most marked and dangerous effects are manifested in the place of injury. In hospitals crowded with wounded, the oxygen, and especially that active state of this element known as ozone, may be consumed to such an extent, that the wounds may assume an unhealthy appearance from the imperfect oxygenation of the blood, and the consequent derange- ment of the chemical and physical constitution of the blood and nutri- tion of the tissues. It is a matter of importance to determine how far hospital gangrene may be due to changes in the physical and chemical properties of the atmosphere apart from the introduction into the surrounding medium of poisonous agents. The direct effects of different gases, as hydrogen, nitrogen, sulphureted hydrogen, and ammonia, upon gunshot wounds, apart from any action through the general system, should be carefully investigated ; and we may reasonably look to the results of such an in- vestigation as likely to establish valuable principles, both for the treat- ment and the prevention of hospital gangrene. I have used the word contagion in its most general acceptation, and "Contagion" as synonymous with infection; that is, the communication of moft'gemrai disease in any way from one person to another without refer- S'S°'sy°-"' ^^'^^ *■*' *^™^' °'' medium of communication. Literally con- wit'h £fe"- tagion ^ means a touch or touching, and hence the attempt by ""■»■ some writers to confiiie the meaning of this word to the com- munication of disease by contact. Infection ° means to thrust in, and may, without doing any violence to the derivation and literal meaning, be made to signify the direct infu- 1 Lat. contagio, from the root of canlingo, tango, primarily (ago, to touch. 2 Lat. inficio, in/ectus, in anifacio. OBSERVATIONS ON CONTAGION. 165 sion into a healthy body of some virus 'or morbid matter from a- dis- eased body, or the infusion into the body of some deleterious miasmata from the surrounding medium. The poison of some diseases, as syphilis, can be infused into the healthy body only by direct contact, whilst in others, as measles and small-pox, the poison may be infused into the surrounding air and the healthy body brought under its influence, and the original disease be communicated and reproduced, without direct contact with the living body. Literally, therefore, infection is a generic term embracing both the idea of the communication of disease by con- tact (contagion), and the transmission of disease through the surround- ing medium. As the word contagion is destitute of the verbal form, the phrases to infect, or to be infected, become convenient modes of expression. It is evident, therefore, that it would be entirely arbitrary to limit the meaning of infection to the communication of disease from the sick to the healthy, by a morbid miasm or exhalation diffused in the air. Neither are we justified in limiting the term contagion to the com- munication of disease by the actual touch of diseased and healthy bodies ; for the atmosphere is a porous form of matter, as well as the clothing of the sick, and besides this the water diffused in the form of vapor through the air, becomes a medium for the absorption and direct application of morbid matters to the surface of healthy bodies. The use of the words contagion and infection as synonymous should not lead to confusion, but should rather lead to farther investigation ; and when the laws of the transmission of diseases are better understood, we shall have increased accuracy of description, expression, and a more perfect nomenclature ; and it will be seen by the succeeding inquiries that we desire by the employment of these terms in the most general sense, to avoid the chief fault of distinctions drawn between infection and contagion, which have generally been based upon preconceived, nar- row, and erroneous views of their nature and operation. The observations of Sir Henry Holland upon the "Method sirH^nry of Inquiry as to Contagion," in the third chapter of his Se'method « Medical Notes and Reflections," ' are worthy of the most ^ ^'lonta- careful consideration of those who may seek to determine its eion- laws : — " I believe it may be assumed, that in every instance of communicated dis- order of the same kind (except the ambiguous case of certain nervous com- plaints, when other principles are concerned), there is a materies morbi, — a material cause, — whatsoever and howsoever subtle its nature and manner of transmission, which is directly concerned in the communication. This assump- tion, though large, is justified by observation as far as it goes ; hy strict analogy and probability, when observation cannot be had. It is likely that future re- search will rather augment than lessen the number of instances when such miasma or material cause of contagion may be presumed to exist. And it is further probable, that we shall hereafter acquire more intimate knowledge of 1 Pages 58-62. 166 SIR HENRY HOLLAND ON CONTAGION. the nature of these morbid matters ; of their relations to each other, and the manner in which they are transmitted so as to propagate disease. The course of modem inquiry directs through many channels to these important results. "Looking singly, however, to the principle just stated, and admitting its truth, we shall find basis in it for aU reasoning on the laws and anomalies of contagion ; that is to say, for all the conditions which determine and modify the communication of disease from one person to another. A disease is com- municated by some morbid matters, thrown off from the first, and capable of producing like symptoms in the second, when conveyed either by inoculation, by simple contact, or indirectly through some medium of transference. Here, then, three main conditions present themselves, each open to many variations, and in their combination capable of producing the numberless varieties and apparent anomalies in the laws of contagion. These conditions are, — first, the state of the person giving the infection ; secondly, the state of the person receiving it ; thirdly, the condition of the medium through which the transfer- ence is made. I believe that reflection will show the whole subject to be comprised under these three heads ; and that we are bound to refer to them severally in all particular questions or instances which come before us for solu- tion. " The first is very important, inasmuch as it includes all that relates to the varying quantity and intensity of the virus itself. This forms a part of the con- dition of the patient giving the infection, and the most essential part ; one, however, by no means duly appreciated in the ordinary methods of viewing the subject. Though we have no present method of estimating either the absolute quantity, or the energy of quality, of the material cause, or the relation which these conditions bear to one another, this does in no wise lessen the certainty that variations exist in different cases, and have effect, directly or indirectly, in every example of infection. In the case of inoculated disease, we have evi- dence as to this point, from the influence of dilution in altering or annulling the effects of the virus employed. The modifications arising from the particular period of the disorder, from idiosyncrasies of constitution in those affected, and especially from the variety of the part or textures through which communi- cation takes place, are all concerned in this view, and have severally their in- fluence iu determining the power of the virus, and the course of propagation of the disease. " Under the second head, namely, the state of the person receiving the infection, we have modifications derived from the previous condition of tem- perament and general health, from the actual health at the time, and particu- larly from the presence or absence of other specific disorder, counteracting or modifying the virus received ; and from the state of the organ or tissue first or most intimately affected by it. All these circumstances needfully enter into a just and complete view of the subject ; but none of them, as I think, are suffi- ciently regarded in our common methods of dealing with it. The latter point in particular has been almost wholly kept out of view, from the great difficulty of reaching it by any distinct proofs. Yet we cannot for a moment doubt that the condition of the part which habitually or casually receives any given in- fection, must determine the degree of the effects produced, and probably in many other ways modify their character and course. " Under the third head, of medium of transmission, still more numerous variations may be presumed to exist. Putting aside the obvious cases of inocu- CONTAGION. 167 lation, and contact of surfaces, and looking to the atmosphere as the medium in the great majority of instances, we have here the endless variety arising from changes of weight, temperature, humidity, electrical state, and direction of currents, — circumstances ever fluctuating in themselves, constantly chang- ing in their combinations with each other, and capable therefore of modifying infinitely the action of any virus thus conveyed, even without regard to the chemical changes which it may possibly undergo during transmission. And further under this head, we have the case of fomites or virus thrown off from diseased surfaces, imbibed by porous bodies, and again emitted — occasionally, as some assert, in a more concentrated form, from this previous absorption. " Duly considering these several points, they will be found, I think, to show adequate cause for all the strange and perplexing appearances of contagious disease. So far from being difficult to explain why a given disorder should occasionally appear infectious, at other times not; why it should spread rapidly and virulently in some localities, and not at all in others ; why it should affect some persons, and leave others free ;. why the cases should be violent at one period, mild at another, — it is rather, perhaps, matter of wonder that the circumstances are not still more varied and irregular than we find them to be. When there are such numerous and ever-changing elements of difference, the combinations of these may well give scope to every assignable variety of result. It is clear that very many of the contradictions of opinion and statement, as to the contagious nature of certain diseases, may be solved by a reference to these considerations. In all common reasoning on the sub- ject, and even in what has been written upon it, infection is too much regarded as a simple and uniform act, and the virus transmitted as the same in quantity and intensity. Such views, however, carry error into every part of the discus- sion. If we can dilute the matter of small-pox, so that it is no longer capable of giving the disease by inoculation, equally may the effluvia of certain fevers, capable of communicating the disorder in one degree of concentration, be so diluted in other cases, — either in their original emissions from the sick body, or by distance, or from the state of the atmosphere, or by the intervention of other matters, — that tbey lose their power of reproducing disease in its com- plete and specific form. Accordingly we find that in these fevers, as well as in diseases more undoubtedly and actively contagious, the proofs of infection mul- tiply in proportion as the causes exist which are likely to concentrate, or give direction to infectious matter ; as stagnant air, want of cleanliness and fresh clothing, proximity of place, particular currents of air, etc. And what is true as to these disorders, will equally apply to many other doubtful or anoma- lous cases in the history of disease. " In erysipelas, for example, though its occasional contagious nature is suffi- ciently proved, the instances of this are comparatively so rare that it occurs in the light of an anomaly to common observation. The controversy still existing as to infection in puerperal fever, may probably best be solved by a close regard to the circumstances stated above. Nor can I doubt (having seen cases which go far to prove it) that a patient laboring under genuine measles may be pres- ent to another, perfectly susceptible of the infection, without the latter receiv- ing the disorder, in default of the quantity or other peculiar state of the virus, needful for its passage through the intervening air. And this point receives farther illustration from those singular cases where an imperfect and irreo-ular evolution seems to occur of an infectious disorder, the actual nature and pres- 168 TRANSMISSION OF HOSPITAL GANGEENE. ence of which cannot be doubted. These various conditions can in no way be so well explained as by looking to the difference in quantity or concentration of a given virus, and to the manner of its introduction into the system ; diversi- ties which must be of constant occurrence, and can never occur without some change of effect. " It is another and frequent mistake, in reasoning upon contagion, to con- sider that the infectious nature of a disease may be disproved, by showing that it has been spread without any obvious communication through man or human means. The two conditions brought into the question, instead of being op- posed, are, in fact, perfectly compatible with each other. If a virus can be transmitted from the body through a few feet of air, we are not entitled, from the partial experiments hitherto made, to set any limit to the extent to which, under favorable circumstances, it may be conveyed through the same or other medium. " This virus, as already stated, must in every case be regarded as a material agent, and, as such, susceptible of various influence and modification. Com- mon reason here concurs with our actual experience of the transmission of the virus of certain diseases in various ways, and to remote distances." E. If hospital gangrene be contagious, how is it trans- mitted — through the atmosphere, or by direct contact AND inoculation ? In the determination of such questions, all cases where healthy nurses Question and surgeons have been inoculated by the gangrenous mat- modeof° ^^i should be carefully recorded. Each case of inoculation ofh'ospuai"' ''y gangrenous matter should be considered as a valuable gangrene. experiment. 1. "Will hospital gangrene appear in healthy men with only slight wounds, who are exposed only occasionally and at short intervals to the atmosphere of the patients suffering with the disease ? 2. Can hospital gangrene be communicated to a strong, healthy man, simply by inoculation, the subject of the experiment being removed entirely from the atmosphere of the hospital ? 3. Does the constant inhalation of the atmosphere of a hospital pre- dispose to hospital gangrene ? 4. Can the general system be influenced, by the atmosphere of wards crowded with patients suffering with hospital gangrene, to such an extent that the disease may appear without any known local injury, manifesting itself in sound parts ? 5. Does hospital gangrene ever arise spontaneously in a well-ven- tilated room or tent, removed entirely from all other collections of human beings ? Thus, does hospital gangrene ever arise when only a single wounded man occupies a well-ventilated house, where there are no other sick and wounded, and no collection of living beings ? CONDITIONS AND CAUSES OF GANGRENE. 169 F. What are the essential conditions and causes of hospital GANGRENE ? 1. Do previous exposure, bad diet, and fatigue predispose to the disease ? 2. Will hospital gangrene arise spontaneously amongst men Questions as crowded, as prisoners are, into confined spaces, and subjected ^*coS'° to various depressing influences, as mental distress, bad diet, pS^n-™' foul air, and filth ? bi^°«- 3. Does the transference of the wounded after battles, in close cars to a great distance, predispose to hospital gangrene ? 4. Has climate any influence in the origin and spread of the disease ■* Is a low, malarious climate favorable to its origin and spread ? Has moisture any connection with the origin and spread of the disease ? Can any connection be traced in hospitals between the condition and changes of the gangrenous wounds and the changes of the weather ? These questions open a wide and interesting field of inquiry, and the discussion might be rendered important and interesting by a sketch of the campaigns, the hardships, exposures, and depressing influences and changes of climate to which the soldiers have been subjected previous to the prevalence of hospital gangrene. The inquiry respecting the influence of climate upon the production and modification of hospital gangrene, should embrace, — First, Investigations into the chemical constitution of the air. The proportions of ozone, carbonic acid gas, sulphuretted hydrogen, am- monia, and of all noxious gaseous admixtures, should be carefully deter- mined. Second, The changes of weight or density. Third, The changes of temperature. Fourth, The hygrometric state. Fifth, The electrical state and changes. Sixth, The physical and chemical actions of the rays of the sun, not merely upon the atmosphere during their transmission, but upon living vegetables and animals, and upon dead animal and vegetable matters. Thus it is a well-established fact that there is a greater proneness to diseases, especially of a low form, in those parts of crowded buildings, such as barracks, from which the light is excluded ; and Dr. Reid, of Edinburgh, has inferred from experiment that the effects produced by an atmosphere loaded with the excess of carbonic acid, are more speedily removed when the patient is placed under a strong light, than when merely brought into fresh air. G. Are there any lesions eeoognizable after death which ARE characteristic OF HOSPITAL GANGRENE? This question can be settled only by careful post-mortem examina- tions. 170 TKEATMENT OF HOSPITAL GANGKENE. 1. In each examination, we should dissect the parts in and around Questions as ^^^ wound most Carefully, and examine with special minute- teruticlffiS^s" ^^^^ ^^^ blood-vessels and nerves. The contents of the of hospital blood-vessels, with the characters of the fluids, pus or blood, gangrene. _ which they contain, should be carefully noted. 2. Is the diarrhoea which so often appears in the latter stages of hos- pital gangrene, dependent upon any uniform alteration of the mucous membrane of the intestinal canal ? 3. Is the spleen enlarged and softened in fatal cases of hospital gan- grene ? 4. Is pyaemia more common in patients suiTering with gangrenous wounds than in ordinary wounds free from hospital gangrene ? In all iatal cases of pyaemia, careful examinations should be instituted of the blood-vessels in and around the diseased parts. 5. Do the blood-vessels ever contain pus in pyaemia ? 6. When the veins contain pus in pyasmia, is its progress towards the heart barred by the formation of clots, where the pus and blood meet? The points of interest to be determined in such caseS are, — First, The contents of the veins and arteries. Second, If they contain blood, is this invariably coagulated near and in the diseased structures ? What are the characters of the coagula — coagulated blood, or fibrin devoid in great measure of its colored cor- puscles ? Third, In cases of pyaemia, do the veins entering the diseased struc- tures contain pus ? When they contain pus, is it secreted by the veins, or absorbed directly from the diseased structures through the eroded and open coats of the veins ? H. What is the best mode op treating hospital gangrene ? 1. What is the relative value of nitric acid, and the actual cautery in the treatment of the disease ? Qneshons as „ . i i t r* ' to the treat- 2. Value of turpentine, and method of application ? pitai gan- 3. Can Severe cases of hospital gangrene be treated suc- ^™°' cessfuUy without local treatment ? 4. What is the best method of constitutional treatment ? 5. Can hospital gangrene be treated strictly as a constitutional dis- ease, without any local application, with success ? In the determination of this question, no local application should be used. 6. Can hospital gangrene be treated with success, strictly as a local disease, without any constitutional measures, especially in the crowded hospital, and in the present condition of the Confederate troops ? 7. Is the combination of local and constitutional treatment the best method ? 8. What have been the results of amputation in hospital gangrene ? BEST METHOD OF TREATMENT. 171 9. Does amputation ever arrest hospital gangrene, and what are the conditions of the constitution most favorable to its arrest by amputa- tion? 10. What are the conditions which warrant amputation in hospital gangrene ? 11. "What is the best method of arresting hemorrhage in this disease ? What are the conditions in which ligation is preferable to the applica- tion of styptics ? As a general rule, what is the best point for ligation in hospital gangrene — within the wound, or in the sound parts ? Has pressure any value in the arrest of hemorrhage in hospital gangrene ? When the patient survives the hemorrhage, is it generally followed by improvement in the gangrenous wound ? 12. Are limbs ever restored, so as to be capable of active service in the field, in which gangrene has made extensive ravages ? What is the proportion of cures to the permanently disabled in this disease ? 13. What is the best form of diet in the treatment of hospital gan- grene ? All these questions are open for discussion and investigation, and can be settled only by the most careful study and record of the cases. It would be best when hospital gangrene is prevailing, to examine carefully the phenomena presented by all the wounded, whether suffer- ing from the disease or not. In this way alone could the question of the constitutional or local origin be determined. Experiments with the gangrenous matter might be instituted upon animals and even upon man. Allow me to assure you that I will take great pleasure in considering carefully any observations which you may record and forward me upon these various subjects of inquiry, and in presenting in your name the cases and facts of interest in my reports to the Surgeon-General. And in conclusion I would again, in the language of Bacon, express my belief in the great value of careful observations over mere dogmatic expressions of belief and opinion, unsupported by facts, although such assertions may be dignified by the title of extensive experience : — " They who have presumed to dogmatize on nature, as on some well-investi- gated subject, either from self-conceit or arrogance, and in the professional style, have inflicted the greatest injury on philosophy and learning. For they have tended to stifle and interrupt inquiry exactly in proportion as they have prevailed in bringing others to their opinion ; and their own activity has not counterbalanced the mischief they have occasioned by corrupting and destroy- ing that of others. " The human understanding resembles not a dry light, but admits a tincture of the will and passions, which generate their own systems accordingly ; for man always believes more readily that which he prefers. He therefore rejects the difliculties for want of patience in investigation ; sobriety because it limits his hope ; the depths of nature from superstition ; the light of experiment from 172 DEFINITION OF CERTAIN TEEMS. arrogance and pride, lest his mind should appear to be occupied with common and varying objects ; paradoxes from a fear of the opinion of the vulgar ; in short, his feelings imbue and corrupt his understanding in innumerable and sometimes imperceptible ways. " There is no small difference between the idols of the human mind and the ideas of the divine mind ; that is to say, between certain idle dogmas and the real stamp and impression of created objects, as they are found in nature. " Man, as the minister and interpreter of nature, does and understands as much as his observation on the order of nature, either with regard to things or the mind, permit him, and neither knows nor is capable of more." Very respectfully, Your obedient servant, JOSEPH JONES, Surgeon P. A. C. 8. In the present volume, the results of observations upon more than one thousand cases of hospital gangrene will be recorded. The subjects of investigation will be presented under the following general divisions : — First, The description of the phenomena of the disease, em- bracing the local and constitutional changes, the microscopical appearances of the gangrenous matter at different periods, the con- stitution and changes of the blood and urine, the variations of the pulse, respiration, and temperature. Second, The causes of death, and the pathological changes. Third, The causes of hospital gangrene, embracing an examina- tion into the relations of foul air, exposure, diet and climate, to the origin and progress of the disease. Fourth, An effort to form such a theory of the disease as will embrace the known facts. Fifth, Relations of hospital gangrene to various diseases. Sixth, Treatment. Each of the preceding divisions will be illustrated by cases. Seventh, The views and labors of Confederate surgeons upon hospital gangrene. DEFINITION OF CERTAIN TERMS. From the commencement of the war for the independence of the Definition of Confederate States of America to the middle of 1864, terms" the form of '' Reports of the Sick and Wounded " was similar to that employed in the old United States service. The term gangrene does not appear in this classification of dis- impoBsibie cases. A new form of sick report, containing a different from'th™ °° classification of diseases, was issued about the middle of DEFINITION OP CEKTAJN TERMS. 173 1864 (the first reports upon this new form returned from confederate the general hospitals of the Army of Tennessee were for thJS"^ the month of July, 1864) ; and gangrene appears for the "Se?of first time in the Confederate list of diseases. ^"^gan-""" It is impossible, therefore, to determine from the sick ^'''""'" reports of the Confederate armies, either the date of the origin, or the number of cases of gangrene. In the new classification, under the general division of " Non- inflammatory Diseases, but frequently attended by In- obserrationa flammation during their Course," and under the subdi- S'flX vision « Diseases with their Seat in the Skin and Cellular SscatL Tissue," we find the terms gangrmna sicca, gangrcena adopted by humida, a,nd phagedcena gangrcenosa, laid down as if they depa^tamt were three distinct and specific diseases, in immediate federate*"'' connection with, and under the same general division "'°^' and subdivision with scabies, eczema, impetigo, psoriasis, urticaria, lepra, herpes, anasarca, ulcers, and fistula in ano. It is thus implied, if not directly asserted, that gangrcena sicca, gangrcena humida, and phagedcena gangrcenosa are not only three distinct specific diseases, but also that their seat is in the skin and cellular tissue, that they are essentially local diseases, as certain skin affections and fistula in ano, and that they are not necessarily accompanied with inflammation ; or more accurately, that these forms of gangrene, as well as the long list of diseases included under the same general division, are in their nature " non-inflam- matory, but frequently attended with inflammation during their course." Upon a still farther examination, it will be seen that " erysipe- las traumaticus " is included under the same general division of " Non-inflammatory Diseases, but frequently attended by Inflam- mation during their Course," and is classed under the subdivision " Accidents, Injuries, etc.," alongside with " contusio, vulnus inci- sum, vulnus laceratum, vulnus punctum, vulnus sclopeticum, luxatio simplex, luxatio composita, fractura simplex, fractura com- posita, sub-luxatio, prolapsus ani, hernia inguinalis, hernia femo- ralis, concussio cerebri, compressio cerebri, suicidium, asphyxia, hanging, drowning, irrespirable air, military execution," whilst on the other hand " erysipelas idiopathic " appears under the head of " continued fevers, the seat of which is referred to the blood, as febris cont. simplex, febris typhoides, typhus, febris typhus icter- odes, rubeola, variola, varioloides, scarlatina simplex, scarlatina anginosa, and scarlatina maligna." 174 DEFINITION OF CERTAIN TERMS. We might dwell upon the fact that the seat of the various forms of malarial fever is in this classification referred exclusively to the nervous system, whilst it is now well established that the blood is more thoroughly altered in its physical and chemical constitution in malarial fever than in any other form of disease, except per- haps in pyemia, which is preeminently a blood disease, and which resembles in many of its phenomena so nearly certain forms of malarial fever ; and we might notice, still further, the omission of the most common of all army diseases, dysentery, acute and chronic (it is true that colitis acuta and chronica appear in the classification, but these terms should not include the more generic name of dysentery, as in this last disease other organs besides the colon may be both primarily and secondarily involved) ; but we desire merely to present such facts as indicate the necessity of the careful definition of such terms as mortification, gangrene, spha- celus, dry gangrene, moist gangrene, hospital gangrene, gan- grenus phagedena. A correct idea of the meaning of mortifica- tion, gangrene, sphacelus, dry gangrene, and moist gangrene, will best be obtained by a brief examination of the manner in which these terms have been employed by some of those systematic writers whose works may be taken as exponents of the state of medical science at the period at which they were written. Galen defined gangrene to be a mortification not actually Galen's defl- formed, but forming, being the intermediate stage be- gangrene. twcon the height of inflammation and the state of spha- celus, or complete death. Various writers, as Fabricius Hildanus, John Baptist Morgagni, Mode in Matthcw BailHe, William Cullen, John Abernethy, and termra'DCTene Charlcs BcU, have employed the terms gangrene and p^yeTby'ro^ sphacclus in pretty much the same sense in which they riouBwrltera. ^gj.g j,gg^ j^y Qalen. In the treatise of Samuel Sharpe, " On the Operations of Sur- gery," the tenth edition of which was published in London in 1782, it is affirmed that inflammations from all causes have their ways of terminating, either. by dispersion, suppuration, or gan- grene; and the terms gangrene and mortification are used as synonymous. Percival Pott, in his " Chirurgical Works," uses the term mor- tification in a generic sense, and applies it to the entire phenomena of gangrenous inflammation and death of parts. John Hunter divided mortification into two kinds, the " one without, the other with inflammation." JOHN HUNTER ON MORTIFICATION. 175 "The effects of life are preservation and action; death is the loss of both. Life may exist in the whole, or only in a part, but it john Hunter must always be in a vital part. Other parts may be dead, trndatio "in-" without aflfecting materially the machine. The immediate thrjne''i"ith- cause of death in a part would appear to be a loss of circula- °"^*t^'in!''' tion ; this may arise in various ways, but it must be the effect fl»mni»«on. of some cause. Mortification is very different from universal death ; the Joss of natural life arises from some universal action having taken place, the same structure still remaining ; but it is altered in mortified parts, all is blended in one mass of animal matter, and cannot possibly be injected. " Partial death, or mortification, arises from various causes ; yet there is probably in all of them some cause which may be called specific. There are many others which may be considered as immediate and remote causes, as happens in the gout, which may be produced by many causes, .yet the specific cause has a peculiar mode of action in this as it has in other diseases. Mortification is commonly attended with great pain, characterized by burning, and, if it is in view, the stagnation of blood in the vessels always produces a livid color. The same burn- ing sensation takes place from pressure, if carried sufHciently far to produce mortification, and is familiar in people's heels after lying long in bed. " There are two kinds of mortification, one without, the other with inflammation. " The first arises from causes less visible than the other ; that is, there is no increased action or sensible heat, although the burning pain is considerable. What the predisponent cause is I cannot tell ; I have suspected something like a spasm of the small vessels, but I cannot be certain ; we know spasm will sometimes threaten mortification, as we see in priapism, by Which I have seen mortification produced in a dog. When the disposition is present, the action goes on ; as we see in sores, some parts being of a purplish hue, and going on in this way, while health is in the other parts. In some of these cases a part withers and dies, and does not stimulate the living parts, so as to produce separa- tion, for a long time ; but I have seen too few of these cases to judge of them accurately. The second kind seems to arise from a change taking place before death. Inflammation seems to be the immediate cause ; but this inflammation has two remote causes, of which one is weakness, which is the common cause of mortification ; but the other, or that which produces carbuncle, is not well known. " Inflammation sometimes depends upon an increased action, with increased power of the vessels ; but in mortification it must depend on an increased action with diminished power ; in all cases where this kind of mortification takes place, we have evidently a deficiency of the animal powers. In young people, mortification is generally preceded by fever, 176 JOHN HUNTER ON MORTIFICATION. in old by debility ; and the weakest parts generally give way first, as the toes. But debility alone does not produce mortification, if there hap- pens to be strength in the part sufficient fisr the action which is induced ; debility, therefore, is only a predisposing cause. We see this in scari- fying anasarcous legs, in weakness from accident in weakened parts, in bruises, in frost-bitten parts, or wherever action is produced beyond what the powers of the part or system are able to sustain. But the increased action is not necessarily inflammation ; it may be a salutary endeavor of the part to restore itself, which salutary action the powers of the part cannot support, and hence it gives way and dies. When frost-bitten parts are exposed to heat, the debility is increased by the necessary action, which action the strength of the part cannot bear. Heat is congenial to life, but it should be proportioned to the degree of life, or otherwise it will increase the debility. On this principle it is that cold air is so serviceable to people weakened by disease. In frost-bitten parts, for example, the living principle is much dimin- ished by the previous cold, and heat must be gradually applied, in pro- portion to the quantity of life which remains, but as the manifestations of life increase, so should the heat be increased also ; otherwise, by applying a degree of heat at once too great in proportion to the life, the part will mortify, which is invariably the case in man and all other animals, for warmth induces a more than ordinary exertion of the living powers, which may even be so considerable as to destroy the powers themselves. " Parts which have been weakened, seem much disposed to take on the continued sympathy ; and the parts, finding this disposition, become irritable, and are easily inflamed, which inflammation produces death oftener than any specific inflammation. Mortification, however, is neither peculiar to weakened habits nor accidents, but is often conse- quent on common inflammation, as in compound fractures. In a state of health, the powers are much greater than the action ; but when this state does not exist, either the powers or the action must be predomi- nant. Thus in mortification the powers are too weak for the action ;• but this weakened power is produced by various causes, such as old age, accident, or erysipelas. The skin of such as take on this irritable action, is generally opaque, and looks withered even in the young subject." * Mr. Hunter, therefore, viewed inflammation as an increased action of that power which a part is naturally possessed of; and in those inflammations which he denominated healthy, this in- creased action is attended with an increase of power ; but in inflammations which result in mortification, there is no increase 1 The Works of John Hunter, F. R. S., with notes; edited by James F. Falmer. London, 1837. Vol. i. " Lectures on the Principles of Surgery," p. 602. JOHN PEARSON ON THE CAUSES OF GANGRENE. 177 of power, but on the contrary, a diminution of power, wiiicli, joined to an increased action, became the cause of mortification, by destroying the balance which ought to subsist between the power and action of every part. John Pearson, whose " Principles of Surgery " were published in 1788, about five years before the death of John Hun- John Pear- •' /.111. son taught ter, whilst adopting the definition of the older writers, that there , , . .« . was not a that " a gangrene, strictly speaking, is a mortification necessary not actually formed, but approaching, being the interme- between gan- ■, n • n . 11 greneandin- diate state between the height of inflammation and spha- flammation. celus," at the same time dissents from the custom of many writers to enumerate gangrene as a third mode in which inflammation fre- quently terminates, and affirms that there is not a necessary con- nection between the two diseases. " Gangrene does indeed some times supervene to inflammation, but this order is not absolute and immutable, for it very often originates from causes which imply a state of the system that is the reverse of inflammation." This writer used the term mortification as synonymous with sphacelation, and drew a clear distinction between this last word and gangrene. Thus : — " As a gangrene most commonly terminates in sphacelation, there is some propriety in treating both of them under one head ; yet the dif- ference between a gangrenous and mortified part is so very consid- erable that the terms ought never to be employed as synonymous ones. " A part of the body that is afflicted with gangrene, does not imme- diately lose its sensibility ; the fluids continue to circulate in their vessels, and within certain limits the part is capable of being restored to its former offices in the animal economy. Sphacelation implies the total loss of life in the part ; an absolute derangement of its structure ; the ablation of all its functions, and an utter incapacity of its being restored to any service in the animal economy." Amongst the remote causes that have a powerful influence in producing gangrene, Pearson enumerates, — 1. The application of severe stimuli to a diseased or debilitated part, as in the effects of lightning, intense inflammation, erysipelas, the action of aerial substances, poisons, fractured bones, etc., and strong stimulants applied to dropsical or paralytic limbs. 2. Obstruction to the due transmission of blood, especially when there is an increased action in the blood-vessels ; as in strangu- lated hernia, tight bandage, compression of large blood-vessels by tumors. 12 178 SIR ASTL'EY cooper ON GANGRENE. 3. A sudden diminution of sensibility and repression of action in a diseased part, by the improper application of repellant reme- dies, as is sometimes seen in erysipelas, etc. This author again divides the causes which may induce spha- celus into four divisions : — 1. Whatever destroys the organization of a part, so that it becomes incapable of carrying on its natural functions, as in large wounds, when the most considerable blood-vessels of a part are divided, violent contusion, by which the contexture of a part is subverted, and the contents of the vessels are either effused or rendered incapable of being circulated. 2. Total obstruction to the motion of the blood in a principal artery, as in some cases of aneurism, ossification of arteries, com- pression from tumors, etc. 3. Certain changes induced upon the living solids and fluids, by cold, heat, actual and potential, and also from the use of unwhole- some food. 4. Sphacelation sometimes appears suddenly, without any evi- dent procatarctic cause. The previous state of the general system has very extensive influence in determining the action of the remote cause to the production of gangrene or sphacelus, as previous fever, dropsy, paralysis, and languid action of the extreme blood-vessels, as in old The division of mortification into two kinds, " the one without ThediTjsion and the other with inflammation," proposed by John «on into two Huutcr, was adopted by various systematic writers on John 'Hun- surgcry, as Samuel Cooper, in his " Dictionary of Prac- bjTarious tical Surgcry," and John Syng Dorsey, in his " Elements writers. of Surgcry," and John Abemethy, in his " Surgical Works " and " Lectures on Surgery." Charles Bell, in his " Sys- tem of Operative Surgery founded on the Basis of Anatomy," affirms that he had not seen gangrene the consequence of high inflammatory action : " it should rather be called high irritation, which disorders and overcomes the inflammatory action, and is followed by mortification." Sir Astley Cooper, in his " Lectures on the Principles and Practice of Surgery," uses the term gangrene in a generic sense, and defines it to be a partial death, — the death of one part of the body, while the other parts retain their natural powers. 1 PHna'ples of Surgery, for Ike Use of Oiirurgieal Students, by John Pearson, Surgeon. London, 1788. Part I. pp. 108-112. THOMSON ON GANGRENE. 179 " We find that when inflammation is extremely violent, it occasions the destruction of the vital power of the part. At other times, sir Aatiey when there is a less degree of inflammatory action, but the theTti^ powers of the part are feeble, life will still be destroyed ; so f^So " that gangrene is produced either by an excess of inflam- 8<"^^- matory action, where the powers are natural, or by a less degree of inflammation, where the powers of a part are feeble The nature of gangrene, as far as dissection enables me to judge of it, is this : the excessive action of the part kills the blood-vessels, and the blood contained in dead vessels becomes coagulated." As the term gangrene was found to be not sufficiently expres- sive of the different varieties of mortification, it was fur- Gangrene ther subdivided by several of the authors just referred to, S^aesinto and by many others, into idiopathic, chronic, or dry gan- mois'°or grene, when the death of the part has been preceded by ''™"'*- little or no deposition of fluids in it, and followed by a drying and hardening of the part with few signs of putrefaction ; and humid gangrene, when the death of the part has been preceded by a great deposition of fluids in it, and followed by rapid and general putre- faction. John Thomson, in his " Lectures on Inflammation," employed mortification as a generic term, comprehending the whole johuThom- series of phenomena which occur in any inflamed texture pioycd mor- or organ, fi-om the first apparent diminution of its vital generic term, ,. ,, 1 .. . comprehend- powers to their total and complete extmction. As a ingthcwhoie considerable interval of time often elapses, and many phenomena , IIP* which occur marked events may occur, between the state oi apparent in my in- p 1 • 1 p • n ^ 1 flamed teit- dimmution or the vital powers or an inflamed part and ure or organ, .,_,.„, , fromthefirst the complete extinction or lire, the term gangrene has diminution been employed by Thomson and many others to express powers to that stage of mortification in inflamed parts which pre- extinction, cedes the death of the part, and the word sphacelus to denote the complete death or mortification of a part. As thus employed, gan- grene relates to the stage in which there is a diminution, but not a total destruction of the powers of life ; in which the blood appears to circulate through the larger vessels ; in which the nerves retain a portion of their sensibility ; and in which, perhaps, the part affected may still be supposed to be capable of recovery ; and sphacelus denotes that state in which the blood ceases to circulate, the sen- sibility of the nerves is lost, and the powers of life have become extinct, whether the dead or mortified part has or has not become actually putrid, or shown any tendency to separate and fall away from the living and sound parts. 180 BARON BOYER'S DEFINITION OF GANGRENE. Putrefaction, or the spontaneous decomposition of the animal tissues, has been regarded by many writers as an accidental, and not a necessary effect of the state of mortification ; because the period at which it occurs, as well as the extent to which it pro- gresses and the rapidity of its progress, are regulated by the struc- ture and morbid conditions of the dead tissues, and by external circumstances, as the temperature and humidity of the atmos- phere. Baron Boyer, in his " Treatise on Surgical Diseases," employs gangrene as synonymous with sphacelus, or complete death of the part, and local asphyxia for that condition in which the parts are in a state of suspended animation, and are consequently susceptible of resuscitation ; thus : — " Gangrene is the death of a part of the body ; that is, the perfect Baron Boyer abolition of its sensc, motion, and organic action. This last gMfgreue as Condition is essential to a definition of gangrene ; for all sense yrith'^tace- ^°"^ motion of a part may be destroyed, and yet its life pre- 1"?. "■■J* ap- served, as we see in paralysis, a disease in which the organic term local motion of the vessels is not destroyed. that condi- " Gangrene ought not to be confounded with local asphyxia, the parts are Or the State of apparent death of a part ; for, in the last dis- susp^^ed"^ ease, the life only being suspended, may be again restored, animation, "pims gangrene is to local asphyxia what death is to general asphyxia. There are some examples of local asphyxia in which the heat, sensibility, and motion, the pulsation of the arteries, in fine, all the phenomena of life, after having appeared annihilated for some days, are gradually reanimated, and resume all their vigor. " De La Mothe relates the case of a billiard-table boy, whose right hand was so asphyxied by a blow of a stick on the external part of the arm, that it appeared dead for ten days ; but at the end of this time the heat returned gradually, the pulsation of the arteries was perceived, and the hand restored to its natural state. " When the principal artery of a limb is tied, it has been believed by some that it was deprived of life, because below the ligation it showed neither sensation, motion, nor pulsation of the arteries. However, it often happens that, after having remained in this state some time, it revives by degrees. " It is important to distinguish this state of local asphyxia from gan- grene, because otherwise we should be inclined to amputate a limb capable of being restored to life, or perform operations which would be followed by results more or less injurious. We shall avoid this serious mistake, if we observe that in the case of a limb apparently deprived of life, the article is not detached, as in gangrene ; and we do not find that putrid dissolution nor the fetid odor which is peculiar to this dis- ease. BAKON BOYER'S DEFINITION OF GANGRENE. 181 " Nevertheless, putrid dissolution and gangrene are not to be regarded as identical. In fact, mortification always precedes the putrid dissolu- tion, or that kind of fermentation which destroys the organic structure of a part affected with gangrene, and disengages several of its elements in the form of gases of a fetid odor. " It is true that in many instances of gangrene, the affected part is so speedily separated by sloughing, that the symptoms of putrefaction ap- pear almost as soon as those of mortification ; but we ought not the less to distinguish these two states, which have been confounded by several authors. We observe them well marked and regular in succession ; in the gangrene which results from tying the principal artery of a limb, and that produced by cold; for in these two cases we evidently see that life is extinct in the part, some time before the development of the phenomena of putrefaction. " When gangrene is confined to the common integuments, and to the subcutaneous cellular tissue, it receives the name of gangrene simply. It takes the name of sphacelus, when it affects the flesh, the vessels, and the bones themselves ; and in a word, when a limb is mortified throughout its whole thickness. But gangrene and mortification are, in fact, but two degrees of the same affection, and the distinctions which several authors have made between them, are not founded on good grounds. In fact, gangrene is the absolute death of the part which it affects. If the life of a part be not entirely destroyed, it may be re- called, and no gangrene exist. Thus the name of gangrene, which has been given to that state of the parts in which the weakness of the vital powers only threatens mortification, is evidently misapplied. " When the cause of gangrene drives to the part affected a large quantity of fluids, swelling precedes mortification, and the humors con- fined there soon run into putrefaction. The gangrene is then called humid. " If, on the contrary, the cause of the disease hinders the approach of the fluids from the beginning, if it affect a part which contains only its natural quantity of them, as the cause then acts by coagulating the liquids and the solids, the member diminishes in size, the flesh shrinks like tanned leather, and is harder to cut than a living part. In this case the gangrene takes the name of dry gangrene." '^ Baron Boyer separated the varieties of gangrene into two grand divisions : — I. Gangrene from external causes. The external causes which may produce gangrene were referred by this author to inflammation, contusion, slow compression, 1 A Treatise on Surgical Diseases and the Operations suited to them, by Baron Boyer, Member of the Legion of Honor, etc. Translated by A. H. Stevens, M. D. New York, 1815. Vol. i. pp. 57, 58. 182 BARON LARREY'S DIVISION. burning, congelation, and the interception of the course of the fluids. II. Gangrene from internal causes. First, gangrene produced by the malignity of the cause of in- flammation ; second, that which supervenes in the course of a malignant or putrid fever ; third, that whicli has received the ap- pellation of dry gangrene. Baron Lar- Baron Larrcy, in his " Memoir on Traumatic Gan- gan^ne'* grene, or Gangrene produced by Wounds," published in taM^us and ^^^ " Mcmoirs of Military Surgery," divided gangrene Md endSv- ^"^o spontaueous and traumatic, and endeavored to found rnjes'fo?™* Hiles for amputatiou upon the distinctions which he drew u^n toi"" between these varieties of mortification. difiOnction. Under the former, he included dry gangrene, pro- duced by an internal cause, or by the abstraction of heat from a part, as in congelation or gangrene from frost. Under the latter he included moist gangrene, arising from me- chanical injuries and hospital gangrene. According to Larrey, in spontaneous gangrene, the part affected Spontaneous turns black, and instead of puffing up as in traumatic Larroy. gangrene, shrinks, dies, and sometimes hardens like horn : a well-defined inflammatory line appears, separates the sound from the gangrenous parts, and prevents the propagation of the gan- grenous principle towards the centre of life, in consequence of the obstruction produced by inflammation in the mouths of the vessels in the cellular substance, and in the lymphatic system. In this form of gangrene, therefore, he affirms that no inconvenience can ensue if we choose to wait when amputation is indicated, until the mortification be defined. Traumatic or moist gangrene, on the other hand, arising from Tranmatioor external and mechanical causes which directly injure the S^nc of °" vitality of the parts, is always preceded by an inflamma- ^^^^- tory obstruction, erethismus, and rupture of more or less of the capillary system. Tiie parts are tumefied by their vital action, which is not yet extinct ; the epidermis is separated, and forms phlyctsena, filled with a serum that should have been dis- charged by transpiration ; the cutis grows soft, becomes black, and putrefies ; the cellular substance is decomposed, with all the mem- branes ; a redundant quantity of fluid, which has escaped from the vessels and adipose substance, is found in the parts, and hence the name, moist gangrene. Yet in the centre of this sphacelus, more especially when the BARON LARKEY ON GANGRENE. 183 destruction of the limb is not complete, or the injury has not been uncommonly violent, may be found muscles, arteries, and nerves possessed of life. Such also is the fact in the hospital sore, or sphacelus, which decomposes and melts down all the adipose sub- stance, while the muscular fibre and the arterial tubes remain of a red color in the midst of dissolution. Spontaneous gangrene generally appears in those parts farthest removed from the heart, or in such as are debilitated or have their vital power diminished, as the feet, the nose, the ears, and the fingers ; and the absorption of the gangrenous matter is effected with difficulty, the disease remains latent for an indefinite time, and it is not unusual to see the sphacelus or necrosis separated from the living parts by the power of nature alone, without a change in the general functions ; while on the other hand, trau- matic gangrene can take place in any wounded part, and may prop- agate itself rapidly and in succession through the parts from one limb to another, seize on the trunk, infect the organs of life, and destroy the patient. In addition to the local and gradually ex- tending inflammation, a metastasis of the gangrenous principles to the brain is induced either through the cellular substance or vas- cular system, and the most alarming symptoms ensue. The intel- lectual faculties are disturbed, and the animal functions impaired, paleness of the face, anxiety, delirium, and all the symptoms of ataxia make their appearance, and if this infection continues the patient must soon expire. From this view of the subject. Baron Larrey concludes, not merely that there is an essential difference between the traumatic • or moist gangrene, from external causes, and the spontaneous or dry gangrene, from internal causes, but also that in the first species of gangrene it would be dangerous to wait until it had become defined by the reddish circle or line, because putrefaction advances without any opposition, not only by contagion, but by absorption or transmission from the part first affected ; there should, therefore, be no hesitation to perform immediate amputa- tion, when once the necessity of it is well established. Larrey still further affirms that we need not fear that gangrene will attack the stump, as in spontaneous mortification which is not defined ; for traumatic gangrene, after being produced by a local cause, is propagated or extended by absorption. Amputation, therefore, first removes the contagious matter when performed above the parts in a state of real gangrene ; the nerves and vessels are set at liberty when divided by a sharp instrument, and they 184 ME. GUTHEIE'S DISTINCTION. are thus relieved from fluids that are in a state of stagnation, their action is reestablished ; and far from performing the part of syphons by absorbing heterogeneous principles, they are enabled to expel these principles, and the fluids they contain, and subsequently to relieve the principle of life. Guthrie, in his " Treatise on Gunshot Wounds," has criticised OiiticUm of t^® division of gangrene by Baron Larrey, and the prac- Swdwisioa ti^^^ deductions from the character and relations of the by^aron^^ two spccies, ou the ground that neither the state of ^'^'y- constitution, nor of parts, nor the surgical treatment, are at all times alike, and because they may even differ most essen- tially in a very short space of time. Mr. Guthrie makes an additional distinction of constitutional Mr. Guthrie and local gangrene, including the humid and the dry makes anad- .,°°..,,° ..*' dittonai dis- under Cither, as it might happen that the constitution tinctionof P,, J,'^ . . ,. ,. conatita- was or was uot materially aiiected. According to this local gan- author, the terms constitutional humid and dry gan- ciuding the grenc do not mean only gangrene which has originated humid and ?,. , . ,, , , • ,■? i . . the dry, un- idiopathically, but that in which the constitution or system der either as /^ . •" », , . ., , ., it might hap- at large is, or has been afrected primarily or secondarily. pen that 'ho " ^ •' •' constitution By local humid and dry gangrene, on the other hand. ^as or was notinToived. should be uudcrstood a state of disease of a particular part, by which the constitution or system at large has not been implicated, or only sympathizes in a degree which is not felt to be generally detrimental to its powers of originating and maintaining action, which may be subsequently required for the safety of the whole. Mr. Guthrie affirms that traumatic gangrene may, in opposition to the opinion of Baron Larrey, be of two kinds, humid and dry, ■ or both species may obtain in a limb at the same time, but under particular circumstances.^ It is evident, therefore, that if both varieties of gangrene can arise from the same cause, exist at the same time in the same per- son and even in the same limbs, the terms humid and dry gan- grene, however comprehensive and apparently useful, are never- theless based upon arbitrary distinctions, and must be abandoned as generic terms in a perfect system of classification. The term mortification has been objected to, on the ground that Term gan- it is uot technically explicit, and has been vaguely and flammation indiscriminately used ; and the term gangrenous inflam- ^Ters. ^ mation has been employed by Mr. Travers as indicating 1 A Treatise on Gunshot Wounds, on Inflammation, Erysipelas, and Mortification, on Injuries of Nerves, etc., by G. J. Guthrie, F. K. S., etc. 3d edition, London, 1827, pp. 115, 116, 125. CHELIUS. — CAESWELL. — COPLAIJD. .185 the stages of recoverable and irrecoverable, threatened and devi- talized texture. This author substitutes gangrene for sphacelus, and designates by the former substantive term a state of utter death, in which the part becomes subject to chemical changes, as if severed from the body. Chelius, in his " System of Surgery," defines mortification to be the passage of inflammation into partial death, and the Deflmtion of subjection of the mortified part to the general chemical by Cheiius. laws. Under the name mortification, Chelius distinguishes two conditions, namely, the hot mortification, in which the living power is not perfectly extinguished, and in which it may be re- stored to its natural action ; and the cold mortification, in which the part is actually dead. The hot mortification of Chelius corresponds therefore with the gangrene of Thomson and many other writers, and with the gangrenous inflammation of Travers ; and the cold mortification of Chelius is synonymous with the sphacelus of Galen and others, and with the gangrene of Travers. Two of the most recent and able English authorities upon this subject, although employing pretty much the same divis- j,, caraweii ions and method, have used the words mortification and tSm morua- gangrene each in a different manner. Thus Dr. R. geMrio"* Carswell employs the term mortification in the generic ""'^°' sense as it has been most generallj' employed by English writers, constituting a generic sign of the disease of which gangrene and sphacelus indicate particular stages. Dr. James Copland, on the other hand, employs the word ^^ Copland gangrene in a generic sense, as has been customary with ™rd°^n^° continental writers, and applies the term mortification to f^^l^^ ° the last result or termination of the morbid state. ^'^"■ This examination of the modes in which this subject has been treated, and of the different ways in which important terms have been employed, might be greatly extended, but it is believed that these examples will not only illustrate the necessity for a more accurate classification of the varieties of gangrene than that now employed in the Confederate " Sick and Wounded Reports," but will also constitute an excuse for the attempt on our part to indi- cate the method which we believe to be the best for the investiga- tion and classification of this subject. In the following observations upon the method of investigation and classification of the phenomena of mortification, this term will be used as a generic sign of the disease of which gangrene and 186 METHOD OP INVESTIGATION AND CLASSIFICATION sphacelus indicate particular stages, after the manner of Thomson and other English physicians. OBSERVATIONS UPON THE METHOD OF INVESTIGATION AND CLASSI- FICATION OF THE PHENOMENA OF MORTIFICATION. The classification of the varieties of mortification should be based Methodofin- npon the knowledge of the causes producing the degen- andciaasifl- eratioH and death of the tissues or organs, and of the phenomena nature and relations of the physical, chemical, and nutri- tion, tive changes of the affected tissues in health and during the different stages of disease and mortification ; and upon the knowledge of the effects of the changes and their organic products upon the surrounding tissues, and upon the vegetable and animal ftinctions. The correct comprehension of the complicated phenomena of any case of gangrene includes a knowledge of — 1. The physical and chemical constitution and physiological functions of the tissue, structure, or organ involved ; the physical and chemical constitution and relations of the blood circulating through the affected part ; and the relations of tlie tissue, struc- ture, or organ to the respiration and circulation, and to the cerebro- spinal and sympathetic nervous system. 2. The condition of the general system at the time of the ap- pearance of the symptoms of mortification. It is well established that certain modes of life and certain sub- Certain stances taken as food, induce such a state of the system as modes of life , „ - , , . . « . ^ and certain is favorable to the origin of gangrenous inflammation upon foodinducea the reception of trivial injuries, or they may even induce Btateofthe .o . . i , , . . ''_•', system &- mortification without any local iniury. In such cases we Torableto •' , . the origin of need something more than a mere description of symp- gangienous ipi . /», J r Inflammation, toms and of the progressive appearances of the gangrenous parts ; and we cannot claim a thorough knowledge of this phenome- non until we understand the changes of nutrition during the progres sive degeneration of parts. This subject is involved in numerous and great if not insurmountable difficulties. In most cases of gan- grene it is difficult if not impossible to determine the point at which the tissues commence to degenerate ; and even after it has been well established that the nutritive and vital fijnctions are defective, it is almost impossible to distinguish between degeneration and death. Thus a part may degenerate to death, whilst the surrounding tis- sues, although greatly degenerated and altered, may still present signs of life, and neither be cast off or absorbed ; so also while a CHEMICAL RESULTS OP PUTREFACTION. 187 certain diminution of arterial blood may lead only to deranged nutrition and degeneration, a greater diminution may lead to death ; and a certain degree of inflammatory action has always a defective nutrition and consequent degeneration, whilst in an increase of the inflammation the death of the same part may ensue. 3. The nature of the cause producing gangrene ; if mechanical, the nature and extent of the injury ; if chemical, the properties of the substance, and its actions upon and chemical and physical rela- tions with the living tissues ; if a mineral, vegetable, or animal poison, its chemical affinities and relations, not merely to the tis- sues or organs involved, but to the circulatory, respiratory, and nervous systems, and to the vegetable and animal functions. 4. The chemical constitution of the various products formed at the different stages of the mortification, and the effects of these organic compounds upon the constitution of the blood, upon the nutrition of the surrounding tissues and of the system generally, and upon the actions of the circulatory, respiratory, and nervous systems. The organic compounds formed during the putrefaction of animal matters removed from the living body, must, without Different or- doubt, differ in chemical constitution and physiological IJSncis™" action from those formed during mortification in the liv- fn™hepu-" ing body. Putrefaction under these different conditions Smai'ma? must necessarily yield different products from the differ- ^ " diaS- ences of temperature, and the presence of surrounding or- tSm alS' ganized living tissues and fluids in the one case, and their *s™ts. absence in the other. In like manner the products formed will vary with the different varieties of mortification. When inflamed parts, with a large amount of exudation, pass into mortification from a loss of vitality or from the obstruction of the circulation caused by the exudation, or from both causes combined, the products formed during the death and decay of the moist distended tissues will diflfer from those formed when the parts undergo little or no inflammation, and simply die, shrivel up, and become black, as in senile gangrene. The rapidity of the putrefaction of organic sub- stances is in general in proportion to the degree of temperature, and the supplies of oxygen and water. The character of the com- pound formed will vary with the manner in which these essential conditions are fulfilled. If the supply of oxygen be deficient, an excess of carbon and carbonaceous compounds will be found in the dead mass, which otherwise would have been transformed and 188 INFECTION OF THE GENERAL SYSTEM. removed chiefly in the form of carbonic acid gas. Some of these compounds, formed under peculiar circumstances both without and within the living body, are capable of acting the part of ferments and of exciting decomposition in neighboring masses. We can in this manner find an explanation of the rapid and progressive destruction of the surrounding tissues in hospital gangrene, can- crum, oris, noma, and some other malignant forms of mortifica- tion. The extent to which the general system will suffer from the The extent iufectioD of the dead matters and poisonous compounds, ^MrSVi"-" ^'^^^ depend in great measure upon the condition of the tofeotSi'b5° constitution, and surrounding tissues. When the constitu- Sy'n'gi"'? ^^^ '^ robust, and the vascular system well developed and in'igS* active, with rich, healthy blood, active inflammation is ex- raX'coS cited around the dead part, and an effusion of coagulable «institutim° lymph surrounds and limits the local disease, and tends rountog to protect the general system from infection. In those *'°°"^' cases in which the mortification is thus circumscribed, the predominant symptoms will be those of inflammation and inflamma- tory fever ; but if the constitution be primarily enfeebled, and the blood be defective in its constitution and vital properties, or if the forces be secondarily depressed, and the nutrition impaired, and the blood deteriorated during the progress of the inflammatory fever, the general system will suffer from the absorption of the poisonous compounds. The absorption of the poisonous animal matters will be announced by the increased feebleness and frequency of the pulse, the pallidity and duskiness of the complexion, the distressed, anxious countenance, with collapsed, pinched features, cold sweats, the dry or clammy, brown-coated tongue, restlessness and agita- tion, low muttering delirium, hiccough, fetid diarrhoea, coma or syncope, and death. The rapidity with which the products of mortification will be absorbed and affect the system, depends not only upon the condition of the blood and forces, and of the general constitution, but also upon the organ or tissue involved, the ab- sorption being, as a general rule, most rapid and deleterious in its effects when the dead part is in the interior of the body in some vital organ, and surrounded by an extensive vascular net-work. 5. The relations of the different stages of mortification to the different stages of other diseased actions, as the stages of inflam- mation and fever. 6. The processes by which nature limits or arrests the destruc- tive progress of mortification. MORTIFICATION FROM MECHANICAL INJURIES. 189 It is evident that the thorough investigation of the relations of mortification here pointed out, would not only necessitate im- mense labor, but also the discovery and invention of methods of experiment, and of tests and apparatus unknown to pathological science. The varieties of mortification may be arranged under the fol- lowing heads : — I. — MORTIFICATION ARISING FROM MECHANICAL INJURIES, AND THE LOCAL ACTION OF PHYSICAL AND CHEMICAL AGENTS. As severe mechanical iniury, great heat, or powerful Morttscation J J ^ G r ^ arising from chemical agents may kill the structures and contained mMhanicai . . 1. . n • injuries, and blood at once, without any precedmg mflammation, we tiic locai are lustified in classing this as the most simple and un- physical and 1 . IP /. . ^ . cliemical complicated form of mortification. agents. When, however, these agents are applied in smaller measure, they may fail to cause mortification directly, but may excite an inflammation which, added to the damage that the part has sus- tained, may result in an indirect or secondary mortification. This first division may be subdivided into mortifications result- ing from — (a.) Mechanical injury of blood-vessels. (6.) Mechanical injury of nerves. (e.) Mechanical injury of the entire structure. (cZ.) Effects of heat. (e.) Effects of cold. (/.) Effects of destructive corrosive chemical agents, as the mineral acids, etc. The extent and character of the mortification arising from me- chanical injuries, and the local action of physical and t^^ extent chemical agents, will depend not merely upon the nature JJ^of^hT' of the injury, but in a large degree upon the condition of SStag°from the constitution. Sii;;^?^"?^ iqjunes, and Thus slight injuries, not sufficient to excite gangrenous ^tton ^ inflammation in healthy persons, will be attended with chemS""* extensive and even fatal mortification in habitual drunk- a|™J^' ^[ ards, and in the enfeebled, depressed state of the system "Sfenltare ° often found in old age, and after long continued fevers. jj^'"'iiut in The rapid destruction of tissue in parts exposed to pres- p^'^^n"" sure (bed-sores) following fevers of a low type, appears of th^"con-™ to be due to the depressed state of the forces, and to im- ^'''"''™- perfect nutrition, as well as to the action of morbific agents. 190 MORTIFICATION FOLLOWING INFLAMMATION. An excess or deficiency of blood, as well as variations in the constitution and relative proportions of the constituents of this fluid, will influence the extent and character of the inflammation and mortification following local injuries. Although mortification arising from the action of mechanical and physical causes may at first appear to be strictly local, at the same time the constitution, even in the most simple and favorable cases, is more or less involved. Thus, if the life of a large portion of the tissues in the middle of the leg be destroyed by a cannon-ball, which fractures the bone, divides the arteries, or renders them incapable of carrying on a sufficient circulation for the nutrition of the tissues which they supply, mortification may take place in the injured tissues or in the foot imperfectly supplied with blood, immediately ; or there may be first an inflammatory action estab- lished in the parts above and around the injured tissues, and at the same time an imperfect manifestation of the phenomena of inflam- mation in the foot. As soon as inflammation is established in any part, either in the parts in and around the wound, or in the foot imperfectly supplied with blood, the action of the circulation and respiration is increased, the chemical changes become more active, the temperature of the entire body is elevated, the appetite fails, the urine becomes high-colored, the nervous system manifests signs of sympathetic derangement, and the constitution is involved. After the parts pass into the gangrenous state, various abnormal organic products result from their decomposition, which, entering into the circulation, disorganize the blood, derange the nutrition of the surrounding parts and of the body generally, depress and derange the actions of the circulatory and nervous systems, and still further aggravate the constitutional systems. II. — MORTIFICATION ARISING FROM AND FOLLOWING INFLAMMATIONS OF IMPORTANT ORGANS AND STRUCTURES, WITHOUT ANT EXTER- NAL INJURY. The extent and character of this variety of mortification, will MorHfi ' tt i » • i o /. i em amies, and Homer opens the " Ihad with an account or a fatal pestilence in the camp of the Achaeans, which sent many gallant souls of heroes to Hades, and made their carcasses a prey to dogs and birds of prey. Herodotus relates that during the hasty retreat of Xerxes from Mardonius, in Thessaly, to the Hellespont, a large portion of his army perished from hunger, dysentery, and pesti- lence. Pliny, in his " Natural Historj'," refers to a disease called by AccorSin to medical men stomacace and sceloturbe, characterized by Irn^'of^" loss of the teeth and total relaxation of the joints of the fe^ w«h knees, which afflicted the army of Cassar, in his German scurry. campaign, and which, from its cause, symptoms, and method of cure, appears to have been the scurvy. This disease appeared in a Roman camp beyond the river Rhenus, near the sea. The water was brackish, and the only fresh water to be obtained was from a spring in the vicinity of the sea. The habit- ual use of this water for two years, caused the loss of the teeth, and general 'debility. A remedy was discovered in the plant known as the britannica, which Sprengel and Desfontaines identify with the Rumex aquations, and Lee with the Inula britannica of Linnffius. It is probable that the Romans were not unacquainted with scurvy, and with the best means of preventing this disease ; for they are said to have constantly carried vinegar and wine in their fleets and armies, and even the common soldier and sailor daily partook of both. These facts are of interest, for in modern fleets and armies scurvy has often been associated with the most dangerous forms of hospital gangrene. We might multiply these examples by reference to the pestilential fevers which afflicted the Grecian and Roman armies at various times, but we will reserve the consideration of such facts to the examination of the origin of typhus and typhoid fevers. The silence of many of the ancient w^riters with reference to the origin and spread of contagious diseases in armies and crowded cities, may be due to several causes. Thus, it has been said that amongst the ancients the dread of poison was the continual alloy of successful ambition, and the object of medicine was rather to discover antidotes, than to record the symptoms of disease and dis- cover remedies. Many of the older writers, as has been remarked by Fracastorius and some others, were thought to have been unacquainted with contagious diseases, or rather with the mode of CONTAGIOUS DISEASES AMONG THE ANCIENTS. 197 origin and communication of those infectious disorders which arise from a mere tainted atmosphere, in consequence of the too close accumulation of diseased subjects ; and yet there are observations which render it probable that the danger of the intercourse with the sick in certain diseases was so well known to the historians of the classical age, that the physicians thought it unnecessary to dwell upon an established and widely admitted fact. Mr. Adams, in his work on " Morbid Poisons," has well remarked, that conta- gious diseases were less attended to than in the present day, because of the greater separation of the different classes of man- kind, and the prevalence of contagious diseases chiefly amongst the poorest classes. " The different classes of mankind were more separated, and the destruction of thousands of slaves, or the plebeian race, was a matter little felt by the higher ranks. In the plague described by Homer, it does not appear that any of the chiefs suffered ; but the lessened num- ber in the ranks at last became an object of consequence, and the hero who first thought this calamity worth notice, is throughout the poem described as particularly attentive to his myrmidons. In the siege of Syracuse, the Carthaginian generals, having no advantage above the privates, all perished ; but considerable as the mortality was among the Romans, all the generals escaped. For the most part in war, and still more in peaceable times, famine was the forerunner of pestilence, and the rich generally escaped both. The disease ceased with the cause which produced it, and the individuals who fell were scarcely known, except by their nearest connections In military expedi- tions, it was of more consequence ; and it is worthy of remarking that in proportion as a nation became more martial, all the means of avoid- ing the causes of such diseases became a part of their discipline. "Who can possibly forget the lively description of a Hebrew camp (Num. xxiv. 5), given by an enemy during the military period of that once warlike nation, or of Leonidas' troops, when waiting the assault from the largest army the world had ever seen — some exercising themselves and others combing their hair. Among the Roman historians, ' corpus curari ' is an expression which perpetually occurs in describing the progress of armies. Add to this, their clothing was more simple, and the want of linen rendered frequent bathing an indispensable custom. When the severity of the service obliged them to dispense with these habits, we have seen that they suffered like modern armies." The strongest argument against the ancient existence of hospital gangrene lies in the fact which is well established by the The strong- writings of the Hebrews, of Homer, Herodotus, Csesar, ^S™™' Plutarch, and others, that notwithstanding the immense Km of 198 ANCIENT BATTLES. hospital armies of the ancients, and the immense slaughter which lies in the took place in their battles, the dead being numbered by fact that r , , 1 ,. , 1 r .1 J.- compara- tens and even hundreds oi thousands, at the same time wounded there were few or no wounded who survived the imme- cient battles, diate conflict. The contending armies of the ancients came to close quarters, and engaged in desperate hand-to-hand fights. In such contests it was difficult, if not impossible, to remove the wounded from the field of battle ; and as soon as an adversary had wounded or disabled his antagonist, he followed up his advantage, and did not desist until his victim was slain and robbed of his armor. The qualifications of the ancient warrior were very different from those considered essential in modern times. The rigid discipline and mechanical movements of modern armies were unknown in ancient times, and the success of the warrior depended chiefly upon his strength and presence of mind, personal bravery, experience in the use of weapons, bodily strength, and agility. The eye of the ancient warrior acquired an animation, his countenance an expression of fierceness and eagerness, and his voice a power and variety of cadence, and his whole frame a degree of athletic force and energy unknown amongst the comparatively sluggish and mechanical masses of modern armies. Thus, Homer describes the Trojans as advancing to battle with Description ^ clamor and a shout, like the scream of cranes when batura^by %!"§ ^o™ wiutor and excessive rains they wing their Homer. ^^^ ^^^j. j.jjg floods of Occanus, Carrying death and destruction to the pygmies, while the Grecians moved on in silence, breathing forth valor ; and, as the south wind spreads a mist upon the brow of a mountain, by no means agreeable to the shepherd, but to the robber better than night, in which a man sees as far only as he can cast a stone, so rose the troubled dust under the feet of the hostile hosts as they rushed across the plain. When Alexander advanced in front of the Trojans with the skin of a panther on his shoulders,, and shaking two brazen pointed spears, challenged the chief of the Grecians to meet him in mortal combat, Menelaus, perceiving his adversary advancing with long strides, rejoiced like a hungry lion who lights upon a huge carcass, and, burning with revenge, leaped from his car to the ground. Again, in the second meeting of the hostile armies. Homer compares the advance of the columns of the Grecians to the rushing of waves upon a resounding shore, which, 'rising in the deep water and urged on by the winds, are dashed against the land, roaring and swelling and curling around the rocks. When advancing on both HOMER'S DESCEIPTION OF CONFLICTS. 199 sides the armies meet, the spears, and hossed shields, and brazen corselets are dashed together, the earth flows with blood, and the shriek and shout of the slaughtering and slaughtered warriors mingle together, as when the torrents of winter, rolling down the steep mountain from their vast sources, pour together their foaming waters into some lake within the hollow glen. The description by Homer of the personal conflicts of the indi- vidual warriors, still more forcibly illustrates the deadly and fero- cious nature of ancient battles, and explains the reason of the disparity bet^yeen the wounded and the slain. The Grecian Anti- lochus was the first who slew a Trojan warrior ; his brazen spear struck the cone of the helmet crested with horse-hair, of Echepolus, and pierced the helmet and bone within. Elephenor, the leader of the Abantes, seized Echepolus by the feet as he fell, and dragged him from amongst the weapons, that he might plunder him of his armor ; but his eager efforts were short, for Agenor, seeing him dragging the body, thrust his brazen spear into his side, which was uncovered by his shield as he stooped. Over the dead body of Elephenor, the Trojans and Grecians rushed upon each other like wolves, and engaged in deadly strife. Here the Telamonian Ajax, with his spear, struck upon the breast, near the right pap, Simoeis- ius, a noble and vigorous youth, and the brazen spear went to the opposite side, through the shoulder. Antipus, a son of Priam, then hurled his sharp javelin at Ajax, and, missing him, wounded Leucus, the brave comrade of Ulysses, as he was dragging the body of the youthful warrior to the other side, and the body dropped from his hands, and he fell upon it. Then Ulysses, enraged on account of the slain, armed in glittering brass, ad- vanced amongst the foremost combatants,' and, looking around, threw his shining spear, which struck Democoon, a bastard son of Priam, upon the temple, and his armor rang upon him as he fell with a crash. Hector and the foremost warriors then giving way, the Argives loudly shouted, dragged away the dead bodies for plunder, and rushed forward. After the Trojans had been rallied by Apollo, who had been looking on from the citadel of Troy, the battle was renewed with increased fury. Perios, the leader of the Thracians, hurled a large, rugged stone, which struck the right leg of Diores, near the ankle, and crushed the tendons and bones. As Diores fell in the dust, with both hands stretched out to his comrades, Perios rushed upon him and plunged his spear into his bowels, so that all his entrails gushed out upon the ground. Thoas, the iEtolian, rushed upon Perios, and drove his spear 200 HYGIENIC LAWS OF MOSES. through his breast into his lungs, and jerking the spear from his breast and drawing his sharp sword, plunged it into his belly, and in turn deprived him of life. But he did not strip his fallen foe of his armor, for the Thracians, closing over it, drove back Thoas. And in a similar manner Homer describes the fierce and bloody contest of many other Grecian and Trojan heroes, and has thus given a most graphic, and, as far as the testimony of other ancient writers extends, a most truthful picture of ancient battles. It appears, therefore, that in the battles of former times, few or no wounded survived, and the prisoners which were captured were either immediately destroyed or sold as captives. In the wars carried on between the Israelites and the surrounding nations, persons of rank were frequently reduced to the most degrading slavery ; some prisoners were put under saws and harrows of iron, and made to pass through the brick-kiln ; others were beheaded, or mutilated in various ways ; mothers were murdered with their children; pregnant women were ripped up, and infants were dashed against the stones. And amongst the Romans, prisoners were frequently sold to the infamous schools for gladiators. The time at which regular army surgeons were first employed, 5^5 ^t as well as the date of the establisliment of hospitals for u^ari^^" the treatment of the wounded and sick generally, are waet^t points of interest in the discussion of the origin of hospital weu'as to'e°^ gangrene. With the Hebrews, as well as among the ushinent of Egyptians, the art of healing was committed chiefly to pofntfof in- the priests. Moses, who was reared in the court of the diMusBioi''" prince of Egypt, and instructed in all the knowledge of of hospS"' the wise men, and of the learned Egj'ptian priesthood, wfto the has left a most valuable monument to the history of med- j^^ians,"'* icine. The writings of this great lawgiver and statesman hMU^ Mm- contain hygienic rules of the highest sagacity, designed Siiefly to the to regulate not only the intercourse of the sexes, but also SrSt value to prevent the origin and spread of contagious diseases gieniciaws amougst the hosts of Israel. As the Hebrew priests ''^' accompanied the armies to battle, it is probable that their ministrations to the wounded were of a physical as well as of a spiritual nature. The careful precepts of the Hebrews regarding personal cleanliness in all, whether healthy or diseased, as well as the free use of oil and wine upon wounded surfaces, would appear to have been eminently calculated to favor the speedy recovery of the wounded, without the supervention of the diseases which so often infest modern military hospitals. The instructions of Moses THE PHYSICIAlirS OF ALEXANDER. 201 regarding the signs of tlie leprosy and of other contagious dis- eases, and the measures to be adopted to prevent their origin and spread amongst the people, are certainly most accurate and minute. Many of the expressions of the sacred writers indicated that they were acquainted with unhealthy and even gangrenous sores and wounds ; and some of these descriptions would apply with force and accuracy to the severest forms of hospital gangrene. Whatever doubts may be entertained concerning the knowledge of profane writers, it is evident that the divine legislation made ample provision against the danger of contagion, as appears not only by the many laws against any communication with those afflicted with diseases, and especially sores and ulcers, . deemed unclean, but also by the extreme caution with which all inter- course was prevented with other nations. That physicians frequently accompanied and ministered to the leaders of armies at an early period, may be established ^ . ^ , , la ancient by many facts. Thus Homer, in his account of the times physi- J J ' Clans fre- wounding of Menelaus by the barbed arrow of Pandarus, aoentiy m- o -J ' companiea represents the king Agamemnon as calling for a surgeon ^^^^jj,' to probe the wound, and apply medicaments to allay ^^f"^"^ pain. Machaon, son of the famous ^sculapius, who, in ^u^'o'^' response to the call of Agamemnon, extracted the arrow, MeneS"'^ squeezed out the blood, and sprinkled upon the wound g^ai'swiroir soothing medicaments which Chiron of old had kindly Machaon. given to his father, is presented by Homer in the light of a warrior and hero as well as of a surgeon. According to Plutarch, Alexander the Great was assisted in the study of physic by Aristotle, and not only loved the Alexander theory, but also the practice, and prescribed for his friends ^^l^^*' medicines and a proper regimen. And it is evident from "'d wS^io- the account given by the historian of the illness of the i„"i^°ira great conqueror, in Cilicia, supposed to have been caused appS"'^ by bathing in the cold waters of the river Cydnus, that p'^^™'*'"- Alexander was accompanied by regularly appointed physicians. The physicians are represented as consulting together, fearing to administer medicine to the king in his dangerous illness, lest in case of a fatal termination they should be accused of poisoning ; and the life of Alexander was said to have been saved by the bold and timely ministrations of Philip, the Acarnanian physician. The fears of the physicians appear to have been well founded ; for Alexander himself crucified the physician Glaucus, after the death 202 DEMOCEDES. — ^SCULAPIUS. of Hephsestion, a favorite soldier and officer, who, when sick of a fever, took the opportunity, whilst Glaucus was gone to the theatre, to eat a roasted fowl and drink a flagon of very cold wine, in con- sequence of which he grew worse, and died a few days after. It is Darius kept clcar, also, from Herodotus, that Darius kept around him the most the Hiost Icamed physicians of foreign countries. Shortly siciansof after the overthrow of Oroetes the Persian, Darius, in couutries. leaping from his horse while hunting, twisted his foot with such violence that the ankle joint was dislocated. Thinking that he had about him those of the Egyptians who had the first reputation for skiU in the healing art, Darius made use of their assistance ; but, by twisting the foot and using force, the Egyptian physicians made the evil worse, and the pain was so great that he lay seven days and nights without sleep. On the eighth day, as the king still continued in a distressed state, some one who had before heard of the skill of Democedes the Crotonian, made it known to Darius, who ordered him to be brought as' quickly as possible. This physician, by using Grecian medicines, and applying lenitives after violent remedies, caused the king to sleep, and in a little time restored him to health, though he had before despaired of ever recovering the use of his foot. The surgical skill of Democedes was still further attested by the cure of Atossa, daughter of Gyrus and wife of Darius, who had a tumor on her breast, which after some time burst and spread con- siderably. As long as it was small, she concealed it, and from delicacy informed no one of it ; when it became dangerous, she sent for Democedes. In Greece and Asia Minor, physicians were held in high esteem ; for, not to mention the divine honors paid to -^sculapius, who was considered as the father of the healing art, there was a law at Athens that no female or slave should practice physic, and in one of the states a law was enacted, that if any one during his illness should drink wine contrary to the orders of his physician, even if he should recover, he should be put to death for his disobedience. At various times medals were struck off in honor of different per- sons belonging to the medical profession ; and it appears that the same honors were conferred upon Hippocrates by the Athenians, as had before been given to Hercules ; he was voted a golden crown, publicly initiated into the Eleusinian mysteries, and main- tained in the Prytaneum at the state's expense. Under the Roman emperors, we find the term Archia'ter, which has been ROMAN ARMIES. 303 interpreted to signify either the " chief of the physicians " or the " physician to the prince." Without entering into any in the ro- discussion as to the real signification of the word, or into epeci™phy- any critical examination of the offices of the two classes had attained of Archiatri (^Archiatri sancti palatti, who were supposed rank in their to attend the emperor, and Archiatri popular es, who at- were chosen tended on the people), it appears that special physicians, emperors. who had attained the highest rank in their profession, were chosen to attend the emperors, and were distinguished with special privi- leges and great honors. It would appear that at a comparatively remote period, the Roman armies were furnished with regularly appointed The Roman physicians, with determinate duties. Medieus cohortes nSed^tL and medieus legioni are said to appear in ancient inscrip- aMotatfa tions ; and Salmasius, in noticing a passage ahout an St^'^^^"!" army physician, exercitus medieus, in the work of Achilles ^^o^°^^ Tatius, who lived about the third century of the Chris- '*'"°*' tian era, says that each cohort had in general a physician. In the sixth century, the emperor Mauricius had attached to his army depvtati, who were distributed amongst the cavalry, and were obliged to carry off those wounded in battle. They had on the left side of the saddle two stirrups, in order that they might more easily take up the wounded behind them ; and for every person thus saved, they obtained a certain reward. They were also obliged to carry a bottle containing water, for the purpose of reviving those who might have fainted through loss of blood. The emperor Leo VI., in the ninth century, mentions, besides the offi- cers necessary for each band or company of a regiment, the depu- tati, physicians, and attendants on the sick. We know but little beyond the bare fact that the Roman armies were provided with a medical staff, and little or nothing of the diseases of the sick and wounded soldiers who fell to their care. The employment of appointed physicians in armies appears to have fallen into disuse with the decline of the Roman j^e empioy- power, and the first Christian armies of the Middle Ages pol°M pgy appear to have been without any medical organization ; ^^°' j.°^ the various celebrated physicians who were present at the Ijl^the^de. battles and sieges of those times appear to have served, Roman^*" not in an official capacity as army surgeons, but as J"™'"- soldiers. It was not until the fifteenth century that the attempt was made 204 TEMPLES OP -2ESCULAPIUS. to furnisli some of the European armies with medical organiza- in the 15th tions. In fact, notwithstanding the efforts of the Ger- century the ^ - _--_ _^ - _, , attempt was mans, and ot Henry V. ot England, and of Ferdinand nish some of and Isabella of Spain, no very efficient organization was the European itii 'ii • n r~A armies with established until the time or Grustavus Adolphus, who medical or- • i /» i . t ' ganizatioDB. appointed tour surgeons to each regiment, which he re- duced from the number of two or three thousand, first to twelve hundred, and afterwards to one thousand and eight. We cannot look to the barber surgeons to whom these armies were intrusted for any very accurate accounts of the various diseases. As far as our knowledge extends, there were no organizations No organiza- for the treatment of sick and wounded soldiers, and of the treatment of sick generally amongst the ancient Greeks and Romans, wouDded corresponding to the military and civil hospitals of the amongst the _ ttti i • i • i ancient prcsent day. W hen the sick were carried to certain tem- Roman«,cor- ples, Es that of iEsculapius, they looked chiefly to super- to the civil natural means for restoration. The Asclepiadse or priests and military . i-r-ni* p hospitals of attached to the worship of ^sculapius, formed a particu- the prescDt , _ , ™- Mr. Blackadder, who believed that hospital gangrene was only communicable by the direct application to a wounded sur- According to „ , . „ . 1 1 T 1 ■ . Mr. Black- face of the infectious matter, declared that in no instance adder, the ,.,,-, . « 1 . TIT coQStitation- which he had an opportunity or observing, did the con- aidiaturt- ^ *■ "^ ° ^ ances always stitutional symptoms or gangrenous phagedsena precede follow the the local, unless the case be held an exception, in which ifestations. the stump became affected after amputation had been performed on account of the previous effects of the disease. According to. this author, the period at which the constitution begins to exhibit symp- . toms of irritation is extremely irregular, sometimes as early as the third or fourth day, and sometimes even as late as the twentieth. Mr. Blackadder, from numerous cases of this disease observed at Passage, in Spain, drew the following conclusions : — 1. That the morbid action could almost always be detected in the wound or sore previous to the occurrence of any constitu- tional affection. 2. That in several instances the constitution did not become affected until some considerable time after the disease had mani- fested itself in the sore. 3. That when the disease was situated in the inferior extremi- ties, the lymphatic vessels and glands in the groin were observed to be in a state of irritation, giving pain on pressure, and were sometimes enlarged before the constitution showed evident marks of derangement. 4. That the constitutional affection, though sometimes irregular, was in many cases contemporary with the second, or inflammatory stage. 5. That all parts of the body were equally liable to become affected with this disease. 6. That when a patient had more than one wound or sore, it 222 BARON BOYER'S STATEMENT OF SYMPTOMS. frequently happened that the disease was confined to one of the sores, while the other remained perfectly healthy, and that even when they were at no great distance from each other.^ The opinion is here clearly announced by Mr. Blackadder, that hospital gangrene is at first a local disease, which is not necessarily preceded or in the first stages accompanied by any constitutional derangement. Delpech, in like manner, testified that the constitutional symp- Deipech ex- toms occurrcd always after the establishment of the local presses sim- , . ^ i p ^ i uar views. discase, and were therefore a consequent and not a cause of the local derangement. Baron Boyer, whilst giving as causes of hospital gangrene the Baron Boyer situatioD of the hospital in low, marshy ground, the coDsMution- vicinity of sinks, the filth of personal uncleanness, un- last in the wholesome food, crowded or unventilated wards, and in cession. fact everything which destroys the purity of the air of the place where the patients are collected, — for air thus affected, he aflSrms, brings on this disease, even in the most simple wounds, by its effect not only on the surface of the wound, but also on the whole system, — at the same time places the constitutional . symptoms as the last in order of succession. Thus, according to Baron Boyer, — " The first symptoms of hospital gangrene are, pain in the wound, and a white, viscid coat on the surface of the granulations, which be- come paler, and present several grayish spots, resembling venereal ulcers, or apthee. Commonly, these points of ulcerations in different ■parts of the primitive sore extend and unite, so that the whole mass assumes a grayish ash color, more or less hard, and sometimes bleed- ing; a purplish red color next forms on the adjacent skin, which becomes oedematous, and extends. Sometimes, when the patient is healthy, the disease goes no further, it may even affect only a part of the ulcer, but oflener its progress is extremely rapid and frightful ; the edges of the wound become hard and everted ; the granulations are raised and puffed up by the elevation of a large quantity of gas, with which they seem to be entirely filled, then they fall off by sofl, reddish eschars, very like the putrid brain of a foetus ; the surface of the ulcer becomes putrid, and furnishes an abundance of sanious pus, extremely fetid. Until it be arrested, it extends either in superficies or depth, so that aponeurosis, muscles, blood-vessels, nerves, tendons, periosteum, and the bones themselves become its prey. As soon as the disease has reached a certain height, the patient loses his appetite ; the tongue is covered with a white coat ; a fever appears ; the pulse is small, hard, and 1 Observations on Phagedaena Gangrarmsa, p. 19. DK. TROTTER ON NATURE OP HOSPITAL GANGRENE. 223 irregular ; his agitation becomes general ; he is anxious, sleepless, and disturbed." On the other hand, Dr. Thomas Trotter, in the second and third volumes of his " Medicina Nautica," denies the infectious nature of this disease, which he calls malignant ulcer, and refers its existence to a peculiar state of the constitution : — " The operation of any specific contagion, either generated or im- ported, leaves us equally in the dark. If there had been such Dr. Trotter a cause, the mode of its application is beyond scrutiny ; if it SSSn^ of could act without actual contact, it must be of too subtle a "icera'to'a nature to become familiar to our senses, and renders every iK'o/the attempt at explanation nugatory. The analogy of some other constitution. contagions, such as lues venerea, elephantiasis, lepra, psora, etc., cannot apply ; for these have each their peculiar action, and their source is easily traced. Ulcers produced by punctures of dissecting instruments, and proving fatal, may be added to this account Whether, therefore, a morbid poison, or a contagious matter, or any other cause, may be considered as producing this ulcer, it is clear from the history given in our ships, that there is a condition of body, at the time, which renders it susceptible of the noxious power, if this condition of the body be not of itself fully adequate for the whole That there is a species of ulceration peculiar to a scorbutic diathesis, is a fact as well ascertained as any in the history of disease. That it is produced at sea, by a concurrence of causes, but chiefly by a deficiency of recent vegeta- ble matter, we believe to be equally well established. This peculiar kind of ulceration in a scorbutic disposition does not always require the exciting power of external injury to begin it. "We have seen and have been told that the cicatrix of an old sore breaks out afresh, and the callus of bones formerly broken is dissolved. Like the ulcer of our inquiry also, the disposition and character of the scorbutic sore are often engrafted on fresh wounds and old ulcers, from whatever cause, till in the end they occupy the whole ulcerated surface, and exhibit their own features only. A scrofulous disposition excites first inflammation, and then ulcers of its own kind. The secondary ulcers of the venereal virus are also produced by a habit of body beginning the diseased action. But the disposition to cancer, the most formidable of all ulcers, is first latent in the habit, and only in its latter stage appears with the charac- ter of an open sore. " With all these analogies, therefore, before us, why should we deny that a disposition of body may not also be the main cause of one species of ulcer, and that the fresh wound, as in phlebotomy, the blister, the scald, and burn, with the common sore, were only so many diseased spots, where its action could be more easily put in motion than on the sound part of the constitution, that retained the preservative powers of 224 DR. THOMSON ON HOSPITAL GANGRENE. health to secure them against it. Dr. RoUo has told us that the morbid poison was first perceived in the edges of healing sores, as a distinct little ulcer, of a darkish color, its edges jagged, its bottom unequal and rugged, and discharging a thin matter, having a peculiar smell. Dr. Browne, in the ' Royal Sovereign,' remarked sores nearly cicatrized, displaying on the inner edge of the cicatrix a watery bladder, with a dark-brown or black spot in the middle. He emphatically adds, this was the focus whence the flame spread. Thus these accurate observers give similar evidence, in first detecting the beginning embryo ; but this black or brownish spot, it is plain, must have undergone previous inflammation to make it appear in that color ; and the fetid smell per- ceived, showed that the seat of it was now undergoing decomposition. We do not, therefore, find that there was any need of a foreign poison to excite this inflammation in a sore or wound, with constitutions in such high states of excitement as our patients have been found. The future progress of the ulcer, till the sloughing and fever are finished, is only this course on a large scale. It seems in its genius as an ulcer, what the epidemic of the West Indies is as a fever ; the stages of high excitement and exhausted sensorial power follow one another so quickly that we have scarcely time to mark where the one finishes and the other begins." ' Mr. Thomas Moffat, in a communication to Dr. Trotter relating to the malignant ulcer, or hospital gangrene, dated on board the Triumph, at sea, 1798, states that — " For some days after the wound or other injury was inflicted, every Views of Dr. thing went on well ; when suddenly a violent fever came on. Trotter 8U3- ° „ , . , . , . , . tainedbythe generally towards evening, and continued without any inter- obserrationa . . « ^ ^, , ,, i .1 ofMr.Moffat. missiou lor two Or three days, sometimes a week, the sore meanwhile becoming inflamed and livid for a considerable distance around, throwing off" very deep and fetid sloughs, of a grumous appear- ance, till the sore was twice its former size, with a ragged surface, as if gnawed by a dog, and high reflected edges. As it ceases to cast off sloughs, the fever subsides, and frequently both are over in two nights. After a length of time, more or less in different cases, when the sore had been brought to a healing state, it has frequently run the same course over again for several times successively." ^ Dr. John Thomson, in his " Lectures on Inflammation," favors the vievv' that the constitutional symptoms precede the local in hospital gangrene. « We know as yet, it is true, but little of the laws by which this con- Dr. Thomson tagiou is commuuicated, or the distance to which it extends ■view that the from the focus of infection. It would seem, however, to be 1 Medicina Nautica, an Essay on the Diseases of Seamen, by Thomas Trotter, M. D. Sec ond edition, 1804, vol. ii. pp. 211-215. 2 Ibid., vol. ii. p. 184. DR. HENNEN ON HOSPITAL GANGRENE. 225 capable of being communicated through the medium of the constitu- air ; for it passes along the wards of an hospital, and attacks ^m prMede patients placed at some distance from one another. Nor is hosp'S gM- the time at which the disease begins to show itself, after the sre™- infection has been received, better ascertained. I think that I have re- peatedly seen it attack patients in less than three days after they have been exposed to its influence, but of this I would not be very positive. We are also ignorant whether this poison can act immediately on the sores which it attacks, without being absorbed, or whether, like most other poisons, it must first be absorbed, and produce its effects afterwards, only through the medium of the general constitution. " The symptoms by which malignant ulcer, or hospital gangrene, is characterized, are partly of a local and partly of a constitutional nature. These two classes of symptoms are not invariable in the order of their appearance, for sometimes the one and sometimes the other class seem to occur first in the order of succession. According to the result of my own observation, the constitutional symptoms usually precede the local. In the cases in which they have appeared to succeed the local, may not the constitutional symptoms, though they actually existed, have been so mild as to escape observation ? In the progress of the constitutional symptoms, a general uneasiness is felt before any visible changes take place in the wound or sore which is attacked with hospital gangrene ; the tongue becomes foul, with a sensation of bitterness in the mouth ; the appetite decreases, and the patient begins to loathe food ; the pulse becomes very quick, but is in general rather weak than strong ; the skin feels hot, and the patient, in the progress of the disorder, becomes afflicted with great anxiety and restlessness." ^ Dr. Hennen regarded the disease in its origin as constitutional, as well as local, and he appears to have placed more reli- Dr. neniea ance upon internal remedies than upon external applica- disease in its lions. According to this author, the disease, as it pre- constuu- 1 n ■ iL p tionat as well vailed at Bilboa, commenced generally, m the case ot as'iocai. wounds, with a sudden attack of severe pain in the head and eyes, tightness about the forehead, want of sleep, loss of appetite, a quick pulse, and other febrile symptoms, while the wound, which had been healthy and granulating, at once became tumid, dry, and painful, losing its florid color, and assuming a dry and glossy coat. If the incipient stage was overlooked, the febrile symptoms very soon became aggravated ; the skin around the sore assumed a hio-hly florid color, which shortly became darker, then bluish, and at last black, with a disposition to vesicate ; while the rest of the 1 Lectures on Inflammation, by John Thomson, M. D., etc. American edition. Philadel- phia, 1817, pp. 364, 385. 15 226 DR. CLARK- ON HOSPITAL GANGRENE. limb betrayed a tendency to oedema. All these threatening appearances occurred within twenty-four hours ; and at this period also the wound, whatever might have been its original shape, soon assumed the circular form. The sore now acquired hard, promi- nent edges, giving it a cup-like appearance, with particular points of the lip of a dirty yellow hue, while the bottom of the cavity was hned with a flabby, blackish slough. The gangrene still advancing, fresh sloughs were rapidly formed ; the increasing cup-like cavity was filled up and overtopped by them, and the erysipelatous liver and vesication of the surrounding skin gained ground, while chains of inflamed lymphatics could be traced from the sores to the adjoining glands, there exciting inflammation and suppuration, which often furnished a new nidus for £;angrene. The face of the sufferer assumed a ghastly, anxious appearance ; his eyes became haggard, and deeply tinged with bile ; his tongue covered with a brownish or blackish fur ; his appetite entirely failed, and his pulse feeble and accelerated. In this stage the weakness and irritability of the patient was such that the slightest change of posture put him to torture, increased by his inability to steady the limb, which, if lifted from the bed, was seized with tremors and spasmodic twitches.-' Dr. Thomas Clark records the observation that the hospital gan- grene which seized the English troops in the West Indies was ushered in with fever : — " In the beginning of July, 1794, several hundred wounded men were According to received into the general hospital from Guadaloupe. For Dr. Clark, some time after admission, the generality of the wounded the gangreoe o ^ which Bcized seemed to do very well. Speedily, however, the ereater nart the Knglish . , . , , ,. troops in the of them were seized with more or less fever. The sores then was ushered assumed an unfavorable aspect; a violent inflammation gener- nwi ever, ally took place, and was very often Succeeded by mortification of the neighboring parts, of various degrees of extent in different instances. Upon the cessation of fever, the inflammation generally abated, and the mortification stopped. A separation of the dead from the living parts soon' afterwards took place ; and the sores now, though generally very much increased in dimensions, again put on a healthy appearance, and continued to mend until another attack of fever hap- pened. A renewal of the phenomena lately mentioned then took place, generally more violent than at first, and necessarily left the patients' constitutions much impaired. In these climates, when men are reduced to a certain degree of debility, feverish attacks are very common, and 1 Hennen's Military Surgery^ second edition, pp. 214r-216. DR. COPLAl^D ON CAUSES OF HOSPITAL GANGRENE. 227 the condition of ulcers generally correspond with the other symp- toms." 1 Dr. Clark affirms that during his stay in the West Indies there was not a single instance, that fell under his observation, of a com- plete x'ecovery after amputation, and, as far as he could learn, but one perfect recovery was effected in the general hospital, under like circumstances. All of the patients either died or were put on board hospital-ships for England. Hospital gangrene appears to have been one of the chief causes of this extraordinary mortality. One of the most learned and able medical writers of the present day affirms, that although the fluids of the diseased part j,^ j^^^ will produce hospital gangrene when they come in con- ^"f^^'J^j^t tact with an abraded surface, or possibly even when hospital ^ r J gangrene is they are for any time applied to the sound skin, yet it J^S^rfth is chiefly owing to the solution of putrid animal miasms ^,^"^^13 in the humidity of the surrounding air that the disease is ^es by" communicated in the wards of a hospital ; the close and ^™^'on^° foul air generated by the discharges from suppurating or ^n™^^"^ gangrenous surfaces will favor the production of gan- CJi^rare- grene in injured parts, by lowering vital power and dete- JJentfebrfi'J riorating the circulating fluids, and thereby inducing a *y™p'°™8- state of system similar to that in which putro -adynamic fever origi- nates, or by which it is characterized. Hospital gangrene is always attended by adynamic fever ; and in the circumstances just alluded to, it is often preceded by more or less depression of nervous and vital power, although rarely by prominent febrile symptoms. Derangement of the digestive fimc- tions, sometimes diarrhoea, a quick and feeble pulse, and physical and mental depression, generally usher in and attend the early progress of this gangrene.^ Dr. Copland enumerates the following causes of this dis- ease : — 1. A cachectic and debilitated state of constitution, generally connected with disorder of the digestive canal and liver. 2. A low, humid, and miasmatous atmosphere, and a damp and an ill-ventilated place of residence. 3. Insufficient or unwholesome food, and the use of impure water. 1 Oiservations on the Nature and Cure of Fevers, and of the Diseases of the West and East Indies, and of America, etc., by Thomas Clark, Surgeon; 1801, pp. 118-120. > " A Dictionary of Practical Medicine, etc., by James Copland, M. D., etc. New Tork 1855, vol. ii. pp. 18, 20. 228 AUTHOR'S VIEWS ON HOSPITAL GANGRENE. 4. An air loaded with putrid miasms or animal exhalations, as that of crowded hospitals, camps, ships, and transports ; and — 5. The contact of animal matter or of diseased secretions or dis- charges, as in using unclean sponges, etc. From what Dr. Copland has seen of the disease in foreign hos- pitals, he inferred that although the fourth and fifth of these are . the most common exciting causes, the others are often more or less influential, either in predisposing to it or in directly producing it, especially after severe injuries and operations, or when aided by the depressing passions; and that tlie causes commonly giving rise to typhoid or putro-adynamic fever will often occasion it, espe- cially in crowded surgical wards of hospitals. A recent writer on military surgery, in noticing the hospital gangrene which appeared amongst the English troops in the Crimea, states that — " The attendant fever was uncertain in its development ; sometimes it preceded, sometimes it accompanied, and sometimes it fol- rr. Macieod, lowed the local outbreak. Often there was little if any consti- gangreneof tutional disturbance, and occasionally the fever was of a low wa° aMom- typhoid type. The most generous diet was always necessary ; feTe'r^mne'- for though it may be true, as was the case in the Peninsula, cShiVsome. ^^'^^ ^** antiphlogistic treatment is at times necessary, it can times accom- jjg gQ only in strong, healthy men, who derived the disease sometimes from infection. With us the depression of the powers of life following the local out- was so marked, and appeared to exercise so strong an influ- ence, as predisposing to its outbreak, that in place of lower- ing remedies, the most strengthening, including stimulants, and above all, fresh air, were absolutely required, and were alone of any use. Those who had suffered in camp from diarrhoea, and whose strength had thus been much reduced, more especially those whose constitutions were strongly impregnated with scurvy, were most liable to be attacked ; and in all our cases, so far as I saw, the development of the disease resulted from a lowered general health more than from specific causes. It was, in many cases, a veritable ' child of the typhus.' " ^ These examples are sufficient, we believe, to represent truly the views of the best writers, and at the same time to present impar- tially the question of the local or constitutional origin of the dis- ease. In its mode of origin, hospital gangrene may be viewed in four different ways : — 1 Notes on the Surgery of the War in the Crimea, with Remarks on the Treatment of Gun- thot Wounds, by George H. B. Macieod, M. D., etc. AUTHOR'S VIEWS ON HOSPITAL GANGEENE. 229 1. As a Local Disease, communicable only by Contact with Ani- mal Matter in a Certain State of Change or Decomposition, views of the — Whatever constitutional disturbances arise, they are the mode of always consequent to and upon the changes in the wound hospital itself, and arise chiefly from a propagation of the de- Thoentiii rangement by nervous sympathy. If this proposition be scnted in true, amputation would be one or the most certam meth- propositions. ods of removing the disease. 2. As a Constitutional Disease. — The constitutional disturbance manifesting itself in gangrenous inflammation in any wounded sur- face may be produced either by previous exposure and bad diet, or by the constant inhalation of an atmosphere deprived of its active oxygen and electrical fluid, and loaded with carbonic acid gas and sulphureted hydrogen, and other deleterious gases and animal matters. According to this view, when the constitution is deranged, the blood altered, and the forces depressed by such agencies, the disease may appear in any wounded surface apart from any direct application of poisonous animal matter. 3. As both Local and Constitutional in its Origin. — Animal matter, in a certain state of decomposition, is capable of acting upon a wounded surface and of developing gangrenous inflamma- tion ; or the system may be so depressed by the action of gases and foul air inhaled, and by previous exposure and diet, that this form of inflammation may result from the depression of the forces, the derangement of nutrition, and the consequent degeneration of wounded parts. If the disease arise locallj'', the absorption of the gangrenous matter commences as soon as it is applied to any wounded surface, and goes on continuously as long as any gan- grene is present ; and the decomposing matters entering the blood derano-e its composition and the nutrition of the body, and depress the forces. In this way the constitutional derangements may be manifested before the local changes are evident to the senses, without at all standing in the relation of cause and effect. The admission of its local and constitutional characters at the same time, is not at all contradicted by the fact that we may have in the same patient one gangrenous wound and another entirely free from the disease. Neither does it follow that because the absorbed matters disturb the nutrition and the composition of the blood, and derange to a certain extent the forces, therefore amputation will not arrest the disease. Whether or not the severing of the gan- grenous mass from the body will arrest the disease, will depend not upon the mere fact of the absorption of the gangrenous 230 AUTHOR'S VIEWS ON HOSPITAL GANGRENE. matter, but upon the extent to which it has deranged nutrition and depressed the forces. Thus, the poison of the rattlesnake produces death of the immediate parts into which it is injected, and at the same time that portion which is absorbed alters the blood, acts upon the heart, deranges the nutrition, disturbs the circulation and respiration, and depresses the nervous and muscu- lar systems. If the limb poisoned and rendered gangrenous by the poison of. the rattlesnake be amputated in the sound parts, it does not follow that because the constitution has been affected by the poison absorbed, that therefore the stump must also become gangrenous. Neitlier does it follow that because the gangrene was not reproduced in the stump, therefore the poison of the rattle- snake did not act constitutionally. In the case of amputation for a gangrenous wound, the reap- pearance of gangrene in tlie wound will depend on the amount of the matter absorbed from the local source, and the extent to which it has deranged the system. 4. The Disease may arise from the Action of a Specific Poison, which acts in a Manner similar to that of Small-pox, Measles, and Scarlet Fever. — After the introduction of the poison, either through wounded surfaces or through the skin and lungs, certain constitutional changes are excited which precede the manifestation of the local symptoms, and are connected intimately with, if not in the relations of cause and effect with, the local manifestation. In other words, tlie specific cause of hospital gangrene may induce such changes in the constitution of the blood, and so modify the nutrition of the body, and so depress the forces, that however the poison may have been received by direct contact to the wound or through the atmosphere, all local inflammations may manifest its specific gangrenous action. The third proposition expresses most nearly our views, for it ,is capable of demonstration. First, That hospital gangrene may arise in those exposed to the exhalations fi-om gangrenous wounds, without any abrasion of the surface, "this will be illustrated by the following observations : — Case I. Empire Hospital, Vineville, Ga. ; George N. Tippin, Com- CaM I. pany H, 1st Florida Regiment. Native of the southern por- thauiofpitai t'"" ^^ Alabama, near the Florida line. Entered this hospital gaogrene ^jj], ^j,j,|- ^^g g^id to be tvphoid fever, on the 10th of Sep- may arise in j r ^ sr those ex- tember, 1864, and was treated in a tent containing several posed to the ' ' , i i i exhalations cases of hospital gangrene, and surrounded by other tents grenoua containing numerous cases of this disease. The attack of DR. TROTTER'S ACCOUNT OF MALIGNANT ULCER. 231 fever, which had been of some standing before entering: this wounds, . , . , , , ,. , , , . without any hospital, was said to nave been shght, and the patient was abrasion of convalescent in the course of ten days. On the 28th, the patient complained of a painful swelling on the margin of the perinaeum and left buttock. On the 31st, I examined the affected spot, and found the surface for the space of near one half an inch in diameter of a bluish, grayish color, as if the skin was dead. The lancet passed readily through the dead integuments and tissues, and a large quantity of dark, grumous, tar-like, gangrenous matter, of a most offensive smell, flowed out. The odor was so offensive that it was almost impossible for the attendants to remain in the tent. After the evacuation of the dark, fetid matter, the structures within presented the general appearance of hospital gangrene, and not of an ordinary abscess. The edges of the wound became inverted, and were surrounded by a purplish border in the skin, and the destruction of tissue progressed rapidly. The wound was freely cauterized with nitric acid, and the patient placed upon tincture muriate of iron and quinine, and nutritious diet. This treat- ment appeared to be productive of much good, and the gangrenous sur- face in the course of a week assumed a more healthy appearance, and in the course of ten days the gangrene appeared to be entirely removed. This patient was not, however, isolated by removal from the gangrene ward ; and the disease reappeared, and advanced with increased power, and denuded a large portion of the muscular structures of the peri- naeum and left buttock. On the 6th of November, the gangrene was burrowing extensively around the anus, and exposing the muscles of the perinaeum and the bulb of the urethra ; the complexion was of a leaden hue ; the expression of the countenance was distressed and haggard ; nervous system irritated and weak ; pulse feeble and rapid ; appetite entirely gone ; and the recovery of the patient doubtful. Dr. Trotter, in his account of the malignant ulcer, — hospital gangrene, — has recorded similar observations : — " Although for the most part these ulcers spring from some external injury, yet we have met with a number of cases where neither similar ob- . -til .11 serratlona wound, puncture, scab, or contusion could be said to have recorded by first taken place. A small, circumscribed red spot would be Trotter. first perceived, scarcely to be felt ; but in a few hours rising to a pim- ple, becoming black in the centre, and inflamed round the edges, till it increased in size, swelled, and assumed every characteristic symptom, with concomitant fever, and subsequent ulceration, sloughs, and fetid discharge." * " Some cases we have also met with where no previous injury had been offered to even the cuticle, that could be suspected or discov- ered ; these began on the fleshy part of the leg and fore-arm, and 1 MecUcina Nautica, vol. ii. p. 177. 232 TRANSMISSION OF HOSPITAL GANGRENE. ■were followed with the separation of nearly the whole integuments and muscular parts of the limb." '■ These cases of Dr. Trotter occurred in the crowded and badly ventilated ships, lying idly in port. We are justified by the preceding case, and by these observa- tions of Dr. Trotter, in drawing the conclusion that the poison inducing hospital gangrene is capable of entering the system through the pulmonary and cutaneous systems, and of exciting gangrene in parts which were perhaps in a state of defective nutri- tion, degeneration, or inflammation, or of depressed vitality ; but which, as far as known, were not exposed in any manner to the direct action of the poisonous matter, and over which the integu- ments were, until they were involved by the gangrene from within, in an unbroken and uninjured state. Second, That hospital gangrene can be communicated through the atmosphere to wounded surfaces, without any direct applica- tion of the matter. Thus, in the large numbers of wounded which, after the battle of Chickamauga, were crowded into the hospitals at Augusta, the disease appeared simultaneously in a large number of wounds which were, as far as the bandages, and utensils, and nurses were concerned, separated from each other. The common medium into which the effluvia from the wounds and the exhalations from the lungs, skin, and urinary and intestinal excretions were poured, was the atmosphere , and we are justified in concluding that through it the poison was transmitted. The following interesting communication from Surgeon D. J. Roberts illustrates in a still stronger manner the possibility of the transmission of the poison of hospital gangrene to a large number of wounds entirely through the atmosphere. Many of these wounds, from the time of their reception to the appearance of the gangrene, had not even been dressed, and in many the original dressings after amputation had not been removed : the suspicion of the transmis- sion of the poison from one to the other by contact, cannot there- fore be entertained. 20th Tennessee Regiment, Tyler's Brigade, ) Bates' Division, Army of Tennessee, Near Lovejot Station, Ga., September 8lh, 1864. J Sdegeon Joseph Jones, C. S. A., Augusta, Ga. Sir, — I beg leave to make the following statement of cases of hos- Obserrations pital gangrene that have come under my observation within BototoT'o. the past few days. 1 Medidna Naviica, p. 210. CASE m. — HOSPITAL GANGRENE. 233 About two hundred of our wounded were left at Jonesboro', s. a., upon the ongia of Ga., on the 1st inst They fell into the hands of the Fed- hospital , gangrene erals, who deprived them of the greater portion of their amongst the attendants, and some of the surgeons left with them, — so I wounded ■ « J after the am informed. battle of The enemy having fallen back north of Jonesboro', they •'»"'»'"'"'• were sent for on the 7th inst. They were found collected together in two houses, never before used as hospitals. They had received very little med- ical or other attention — some none — since the first dressing of their wounds ; very few if any of their wounds having been dressed or even washed since they had left the field hospitals. A large proportion of the wounds were amputations ; the others, all severe cases. Nearly every case presented well-marked symptoms of hospital gangrene ; some in an incipient stage, others more advanced, and some full and well developed cases. The disease was produced, in my opinion, by want of cleanliness, and closely crowding together a large number of severely wounded in a small space. These men were freshly wounded, just from the battle-field, and placed in a house that had never before been used as a hospital. There was, therefore, no opportunity of the disease being produced by con- tagion from previous cases. I am, sir, most respectfully, Your obedient servant, DEERING J. ROBERTS, Surgeon 2Qlh Tennessee Regiment. The transmission of the gangrenous poison through the atmos- phere was still further illustrated by a case related to me by Surgeon E. N. Covey, Medical Inspector District of Virginia, Tennessee, and Georgia : — Case II. A medical officer, connected with one of the general hos- oitals of the Army of Tennessee, was attacked with sore o>isen. o , . 1 TT" Related by throat whilst attending upon cases of hospital gangrene. His surgeon e. symptoms becoming alarming, a careful examination was c.'s. a. ' made, and the throat was found to be affected with hospital gangrene. Third, In some cases, after the wounds have been subjected to the action of the cause of hospital gangrene, a certain period of time elapses before the disease appears. The following case illustrates the truth of this proposition : — Case III. John Kemp, sergeant 11th Regiment Tennessee Vols. Age, twenty ; height, six feet ; brown hair ; grayish-blue eyes ; florid complexion in health; weight in health, one hundred and sixty 234 CASE m. — HOSPITAL GANGRENE. EtotSng pounds- Wounded 19th of September, 1863, at battle of ?' 'h'°u' Chickamauga, in right foot ; minie-ball entered about two some cases af- and a half inches below the external malleolus, and passing ter the wounds -, ^ t ^ i < t < 'a. i. have been around the bones ot the mstep, or tarsus, made its exit at a the''Mtion of similar distance from the internal malleolus. The bones of the ho'spuaf* °' tarsus do not appear to have been seriously injured. Re- ferS^'"'' " niained at the field infirmary from the reception of the wound ttoe'eia'^ses *° ^^^ '^^^^ °^ September, when he was sent to Atlanta, where before the jje remained in general hospital until the 28th inst, when he disease ap- or pears. was transferred to Augusta. Arrived at the car-shed in Augusta at six o'clock a. m., September 29th, and remained there until one o'clock, p. m., and was then received into the Catholic Church, second division. Third Georgia Hospital. After remaining in this crowded ward for several days, was transferred to the Presbyterian Church, where he remained, together with some three hundred other wounded soldiers, many of whom were suffering with gangrenous ■wounds, until October 15th. At this date (October 15th), although he had been exposed to a foul atmosphere in these badly ventilated churches, crowded with wounded suffering with ill-conditioned and gangrenous wounds, his wound looked healthy, and appeared to be healing. From the fearful increase of gan- grene, this patient was transferred to private quarters, in a house situ- ated at the corner of Broad and "Washington streets. The wound continued to improve, and was nearly healed up, when, on the 4th of November, near twenty days after his transfer from the infected atmos- phere of the hospital, the wound felt very painful, as if thousands of needles were pricking the injured surface. The patient was unable to sleep during the succeeding night, and was feverish and restless. The wound commenced to swell, and the edges became ragged and everted, and the parts around assumed a red, inflamed appearance. Loss of appetite, nervous depression and irritation, and fever accompanied these symptoms. Nitrate of silver was applied freely to the diseased surface, which now commenced to emit a disagreeable, fetid odor. The application of the caustic relieved the pain to a considerable extent, but it did not check the progress of the disease. November 7th, the patient was transferred from private quarters back to the Catholic Church. At this time the external wound of entrance was healed. The wound at the point of exit of the ball was one inch in diameter, swollen and raised above the surrounding surface of the instep, with everted edges, and surrounded by an inflamed, purplish areola. Surface of the wound covered with a moist, gray, and brownish and greenish slough. Odor nauseous and putrid. Upon the recommendation of Dr. L. A. Duo-as, Professor of Surgery in the Medical College of Georgia, nothing was applied to the diseased mass but common salt. Whiskey fjiss, and tincture muriate of iron, m. xv., were administered three times a day. CASE m — HOSPITAL GANGRENE. 235 November 8. — Gangrene extending. The salt which covered the wound caused much pain, and appeared to exert no beneficial effect Pulse, 94 in the morning and 98 in the evening. Treatment con- tinued. November 9 Gangrene continues to spread. Treatment continued. November 10. — Five o'clock p. m. Pulse, 100 beats to minute. Tem- perature of hand, 85° F. Temperature under tongue, 102° F. November 11. — Gangrene spreading. Eight o'clock A. M. Pulse, 98. Temperature under tongue, 100° F. Temperature of hand, 90° F. Treatment continued. November 12. — Nine o'clock a. m. Hectic flush on cheek. Eyes present an excited, restless look. Complains of the pain in the wound, and manifests great nervous excitement whenever the limb is moved. Tongue pale, clear, and moist, and but slightly furred. Bowels regular, and have been so up to the present time. Skin warm, moist, and soft. The wound is now about two inches in diameter, with ragged, everted edges. It resembles some forms of ulcerated, fungous cancer. The borders are elevated above the surrounding parts, whilst there is a depression in the centre. The surrounding skin presents a red and purplish inflamed border, about two inches in diameter, and the parts around are swollen. Yesterday a considerable slough separated from a portion of the gangrenous mass, and the parts beneath presented a more florid and natural color than the gray and greenish gangrenous structures ; and from this portion of the ulcer a little pus row issues. Up to the time of the separation of this slough no pus has been visible. The muscles of the calf of the leg are swollen, and very tender and painful to the touch. The parts immediately around the gangrenous ulcer feel hotter than those at a little distance. These facts indicate that this form of gangrene resembles in a measure inflammation ; but it is an imperfect form of inflammation. Pulse, 100. Temperature of hand, 93.5°. Temperature under tongue, 100.5°. Four and one half o'clock p. m. Pulse, 120. Temperature of hand, 103°. Temperature under tongue, 103.5°. The actual cautery was applied to the wound, and the treatment with tincture muriate of iron and whiskey continued, together with nutritious diet. November 13. — The marks of inflammation around the wound have increased, and this appears to be attributable to the effects of the actual cautery. Charcoal poultices are now applied to the wound. Nine and one half o'clock a. m. Pulse, 102. Temperature of hand, 93.5°. Temperature under tongue, 102°. Bowels continue regular. Ap- petite still poor. Hectic flush of cheeks and the nervous irritability also continue. 236 CASE m. — HOSPITAL GANGRENE. Examination of Urine. — Amount of urine passed during twenty-four hours, from November 13, 4 p. m., to November 14, 4 p. m., grains, 23,496.79 (1,465 cubic centimetres). Specific gravity, 1,018.5. Reaction strongly acid. Color of urine deep orange, with a decided tinge of red. Very slight deposit at the end of thirty-four hours. ANALYSIS or TIRINB, NO. 1. Amount of urine collected during twenty-four hours. November 13, 4 p. M., to November 14, 4 p. M. . Urea Uric acid Free acid Phosphoric acid ... Equivalent of phosphorus in phosphoric acid . . . Sulphuric acid Equivalent of sulphur in sulphuric acid . . . , . Chloride of sodium Equivalent of chlorine in chloride of sodium .... Urine collected during 24 hours, contained grains 23,496.79 609.14 16.14 23.68 40.60 17.81 37.68 15.07 130.85 79.29 1,000 parts of urine con- tained 25.92 0.68 1.007 1.72 0.71 1.13 0.64 5.56 3.03 November 14. — A portion of the dead tissues in the wound have been thrown off. Concentrated solution of blue-stone (sulphate of copper) has been applied, and followed by charcoal poultices. Four o'clock p. M. Pulse, 120. Temperature of hand, 99° F. Temperature under tongue, 102° F. Hectic flush in cheeks, and nervous excitability con- tinue. Urine, deep orange red. November 15. — Ten and one half o'clock a. m. Pulse, 100. Tem- perature of hand, 85° F. Temperature under tongue, 99° F. Skin moist and soft. Bowels regular. Tongue clean. Appetite improving. The red border in the skin around the wound is paler than heretofore, and the swelling of the surrounding parts appears to be subsiding. The pain in the wound, as well as the general nervous excitability and de- pression, have also to a great extent disappeared. Treatment con- tinued. November 16. — The red color of the surface around the wound has disappeared. The swelling in the surrounding parts has in a great measure subsided, and the edges of the wound are not prominent and everted. All the dead tissues have come away or been removed by the knife and forceps, and the surface of the wound has a red and healthy look. Eight and one half o'clock a. m. Temperature of hand, 92° F. Temperature under tongue, 100° F. Five o'clock p. m. Temperature of hand, 96° F. Temperature under tongue, 99.5° F. PERIOD OF INCUBATION IN HOSPITAL GANGRENE. 237 November 17. — Swelling has subsided. Wound is filled with granu- lations. Nine and one half o'clock A. m. Pulse, 100. Tempei'ature of hand, 98° F. Temperature under tongue, 100° F. November 18. — The wound is now about two inches in diameter, and presents a florid, healthy look, with numerous granulations, and has lost the ragged and everted appearance of the edges. The skin adja- cent to the ulcer presents a light purplish color. November 27. — Up to this time the wound has continued to improve, and it is now not more than one inch in diameter. The peculiar color around the wound has daily grown paler, and now has nearly disap- peared. Tongue clean and natural. Pulse, 92. Skin warm and soft. Bowels regular, and have been so throughout the entire case. The nervous excitability, irritation, and depression, have disappeared. The treatment has been continued up to the present time, vrith the exception of the discontinuance of the sulphate of copper, and the substitution of simple cerate for the charcoal poultice. This case presents many points of interest which will be exam- ined hereafter. We will notice at the present time only those results which bear upon the present inquiry. The wound con- tinued to improve after this case was removed from the foul atmosphere of the hospital, and hospital gangrene did not appear for near twenty days after this patient had been exposed to the infection. Baron Boyer has recorded a similar observation, and he affirms that it is certain that a patient who has received a germ of this disease in a hospital, cannot prevent it by any precaution what- ever ; and still further, that he has seen it appear among wounded men who fled from the epidemic to elevated situations, where the air was pure. Dr. Taylor, in his report on the diseases of the 29th Regiment in the Crimean war, says : — " It is to be observed, as illustrating the possibility of gangrene infec- tion lying dormant for some days, or of a fomites of the disease hanging about the clothing of the men, that wounded men discharged fit to rejoin their regiments, were, in several instances, returned from camp to hospital with hospital gangrene." It is also worthy of note, that during the period that our patient Kemp was exposed to the cause of the disease, and during the period that the poison appeared to be latent in his system, cases exposed to precisely the same infection were constantly arising. Whilst in this case twenty days elapsed between the exposure to the causes of hospital gangrene and the actual manifestation of the 238 CASE IV. — HOSPITAL GANGRENE. disease, on the other hand, the wounds of the Confederate soldiers who fell into the hands of the Federals at Jonesboro' became gan- grenous in the course of less than one week after their removal from the battle-field. The following case, reported for me by Assistant-Surgeon F. A. Anderson, will show that under certain circumstances and under certain conditions of the constitution, particularly when the sys- tem has been depressed by disease and by the exhalations of the hospital and especially of gangrenous wounds, the direct contact of the gangrenous matter with a wounded surface may be followed by the development of the disease in the course of a very short period. Case IV. Ocmulgee Hospital, Macon, Ga. John W. Hollingsworth, Case TV. ^^^ Grcofgia Reservcs, Company B ; age, twenty-two ; previous When the occupation, farming. Was admitted into ward No. 7, October system has . been de- 30, 1864, with pneumonia, the disease involving only the right disease and lung, and in the second stage. Expectoration free. Consid- haiations of crable blood in the sputa. Treatment, blister, ipecac, and andespSSi- opium. Patient improved rapidly until oth of November, gren'o?^''" whcn symptoms of pneumonia appeared in left lung. A little direc°''^'on-° ^"^ t^oddy was administered, and the patient placed on pul. ^ugrenou's 'Pecac, grs. ii., pul. opii, grs. i., every four hours. matter with November 6. — Blister applied to right side. Patient im- a wounded . a i o surface may prOVmfif. be followed by the de- On the evening of the 7th of November, the nurse, through tte°diTOlse'' mistake, applied, in dressing his blister, a cloth that had been o°aTery""* used upon. Or in dressing a phagedaenic wound ; and on the short penod. morning of the next day, November 8th, there were unmis- takable symptoms of the disease having attacked the whole blistered surface. Offensive sanious discharge ; the parts of a dark gray or purple color. The blistered surface was dressed with dilute nitric acid (foi. to 5iv. water), which in a very short time corrected the disordered condition. Patient complained of no pain. Pulse, 130 ; respiration, 28 to 30, but easy. Morning of the 9th of November, symptoms augur a speedy fatal termination. Abdomen and thorax tympanitic ; dusky complexion ; brilliancy of eyes ; pulse, 140 to 150. Respiration rather slower, but apparently voluntary. Marked anxiety. He died about four o'clock p. M., 9th of November. Post-morlem Examination, Six Hours after Death. — Upon opening the thorax, escape of gas, and a considerable quantity of serum. The anterior edges of both lungs almost normal. Small spots of extrava- sated blood. Upon removing the lungs and heart, for careful examina- tion, the right lung was found to be in the third stage ; the left in the second stage, or that of hepatization. The disease was very extensive, HOSPITAL GANGEENE AT ANDERSONVILLE. 239 involving all but the extreme anterior part of the lungs. The right lung appeared to be merging into the suppurative stage, and its condi- tion was somewhat different from what is generally observed in this stage. A diffusive infiltration is very rare, the pus for the most part not being readily discovered because of its thorough sanious admixture ; and this was the condition in this case. Upon the surface of both lungs, particularly of the lower lobes, there were numerous dark, softened spots. When immersed in water, the whole lungs sank. Amongst the dejected, debilitated, diseased, and filthy Federal prisoners crovifded into the foul prison and hospital at At Ander- AndersonviUe, Ga., 1 observed that after amputation pitaigan- hospital gangrene almost invariably returned, if it had turned after , , ^ •' amputation been before present, and, it the wound was a recent one, forthedis- attackedthe exposed surface in many cases within as short m recent , 1 1 . -1 rni IIP T ' 1 "wounds at- a period as thirty-six hours. The day before I arrived at tacked the Andersonville, in the month of September, 1864, a train fece withia of cars, convej'ing Federal prisoners to Charleston, South hours. Carolina, ran off the track and was dashed against the side of a hill. The engine and several cars were completely wrecked, and a number of Federal prisoners were killed and wounded. I observed these wounded as well as other amputations and wounds in the Confederate military prison hospital at Andersonville, and noted the first appearance of the gangrene. Case V. In the case of an amputation in the middle of the leg, from a compound comminuted fracture of the foot and leg case v. received at the time of the railroad accident, the lips of the J^arSfnce'ana wound did not unite at all; and although the patient was a ho°spitaigfii- stout Irishman, and had never been in the hospital before this f^^g^j" ■ accident, and although he appeared to be in good health, in o"^"- the course of twenty-four hours a blue line appeared along the edges of the flaps in the skin, which presented an inflamed and blistered appear- ance. The sutures came away (tore out), the edges of the wound gaped open, the stump assumed a grayish, and greenish, and bluish color, and in a few days the bones of the leg were denuded, and projected nearly two inches, so rapid had been the destruction of tissue. In another case, when the cap of the knee was simply cut to no great depth longitudinally, gangrene appeared in fifty hours, and progressed rapidly ; and in another case of amputation, hospital gangrene appeared in twenty-four hours. These observations tend to establish the fact that the period of incubation of the poison of hospital gangrene is not period of the fixed, but varies with the condition of the system, with o°'theVo°isoa 240 PERIOD OF INCUBATION OF HOSPITAL GANGRENE. ^n'^^ene'"^ the length of the period of exposure to the causes capa- not fixed. ^jg Qf producing the disease, and with the concentration and mode of introduction of the poison. This proposition may be still further supported by the state- ments of various writers. Thus, Mr. Blackadder affirms that when the morbific matter is Testimony of inserted into a punctiire or scratch, the first progress of ^tera as to t^^^s disease bears a resemblance to that of a part inocu- [n:uS;n°' lated with vaccine matter. of the poison. According to this experienced writer, the primary in- flammation in gangrenous phagedsena commences at the end of the second or early on the third day ; the inflammation is at its height about the sixth. When the scab begins to form in one disease, phagedenic ulceration begins in the other, and, when allowed to proceed, soon affords sufficient proof of the non-identity of the two diseases. When the disease attacks a recent gunshot wound, remarks this observer, the discharge, two or three days after infec- tion, is found to be lessened, and to have become more of a sanious than purulent nature. The sore has a certain dry and rigid appearance ; its edges are more defined, somewhat elevated and sharpened ; the patient is sensible of a change in the usual sensa- tion in the sore, and complains of the occasional stinging sensation, resembling that produced by the sting of a gnat. At this period, but sometimes a day or two later, the integuments at the edge of the sore become inflamed, and the surface of the sore itself assumes a livid or purple color, and appears as if covered with a fine pel- licle, such as is formed on a coagulum of blood.-' Boyer, who adopts the view of Pouteau and of many other writers, that hospital gangrene may be communicated to a wound or a simple ulcer of a person of the most healthy constitution, breathing the purest air, merely by the contact of linen or lint infected with the leaven of the disease, believes that this inocula- tion is the more to be dreaded, and is more speedy and certain in its effects, when patients have already been exposed to the action of causes capable of producing the disease, and whose constitutions favor its development. Dr. Thomson admitted that the time at which the disease begins to show itself after the infection has been received, was not posi- tively ascertained, and expressed the belief that he had repeatedly seen hospital gangrene attack patients in less than three days after they had been exposed to its influence. 1 On Phagedcena Gangrccnosa^ p. 33. MR. GUTHRIE ON RAPID ABSORPTION OF THE POISON. 241 The establishment of the facts that the poison of hospital gan- grene has no definite period of incubation, and that it The foots ° . ^ . 1 1 1 1- that hospital may arise de novo at any time, and that the disease may gangrene has , . 1 • 1 , , 1 , •'no definite be communicated either through the atmosphere or by p«"at it may ,, n,... oi ^jjgg ^g novo classincation or this disease. at any time, ihus, certain diseases, as syphilis and cow-pox, are maybocom- 11, , „.„. municated communicated only by actual contact ot intectious mat- eiuier 1-1 1 1 1 1 I • 1 ,1 ttiToagh the ter, while on the other hand, hospital gangrene, small- atmosphere 1 1 • , 1 • 1 , 1 or by direct pox, measles, whooping-cough, scarlatina, and typhus and contact, of ^ ' . , „ ^ * . , , , , importance typhoid leyer, are communicated not only by actual con- in their bear- tact, but also by the transmission of an effluvium from theciassifl- , . . 1 „ . » . ,. ™ cation of this the original source of infection through the medium of disease, the air. Certain diseases, as syphilis, small-pox, and measles, are, as far as the knowledge of diseases extends, never spontaneously generated, but appear to be always propagated by animal matter, transmitted in succession from one person to another. On the other hand, typhoid fever, and hospital gangrene, and typhus fever, may, under certain circumstances, arise de novo without any pre- vious exposure to infection. Fourth, In some cases, poisonous matters are so rapidly absorbed from the infected atmosphere of the crowded wards, and Rapid poi- .. I'l 1 ' f f soning of the the diseased action is propagated with such rapidity from system in , ^ . . . hospital gau- the local injury to the central organs, m constitutions grene. broken down by bad diet, exposure, and by the influence of the foul emanations from the wounded and sick crowded into badly ventilated hospitals, that death results from the effectual and almost immediate poisoning of the system, before the local disease has progressed to any extent. This proposition is well sustained by some observalions recorded by Mr. Guthrie, in his " Treatise on Gunshot Wounds : " — " I wish now to draw attention to a state of gunshot wound which I have not often seen, but which is highly dangerous, infinitely observations more so than those I have been noticing, in which the inflam- Guthrie, matory stage runs on to the suppurative. It will, perhaps, be the'^w^ best explained by a case. KylLl."' "After the battle of Albuhera, Mr. Curby, Assistant-Sur- insomecasea , /. "^^ hospital geon of the 29th Regiment, drew my attention to the case of gangrene. a man, as something peculiar, whom I had seen with him the day before, with a shot through the thigh, and who died after a short illness the following morning. In the evening he had complained of pain, which had increased so much on the last visit as to demand par- 16 242 MR. GUTHRIE ON RAPID ABSORPTION OF THE POISON. ticular attention, and fomentations and an opiate were ordered. The pain, it was reported, continued during the night, and in the morning, early, he died. The body was carried away, and no examination was made. " On the retreat of the army from Fuerte Guinaldo, in 1812, a smart affair took place at the Convent of Saca Farte, between the advance of the French and the cavalry and the fourth division of the British army, under Sir T. Cole, to which I belonged. The wounded accompanied me to Sabugal, on the heights near which we offered battle. Among them was a man, a stout, handsome soldier, who had been shot through the right thigh, the ball entering below the femoral artery, passing through and outwards close to the bone. This wound went on remark- ably well for near a fortnight, so much so that the man had actually got up and walked about I saw him at one o'clock, and, as he was stand- ing, desired him to keep himself quiet ; he answered, he felt quite well. In the evening, Mr. Mahoney, now Surgeon of the Fusileers, who occu- pied the same quarters with me, reported, that the man was suffering some pain, and that he had ordered him an opiate and a poultice. He died early in the morning, having complained a good deal in the night, but not sufficiently to induce the orderlies to call Mr. Mahoney, until symptoms of approaching death alarmed them. I examined the limb carefully, within twenty-four hours of the man's being in comparative health. On the day previous to his death, the wound looked favorably, there was little or no inflammation, the limb was soft, and he was capa- ble of walking, and conceived himself comparatively well. Inflamma- tion came on in the night, internally, deep, and hardly affecting the skin with redness ; on dissection, the thfgh appeared swelled, although not particularly so ; but on cutting deeply through the fascia in the course of the wound, the whole thigh seemed so stuffed, or gorged with blood, that the texture of the parts, muscular as well as cellular, was soft, and readily giving way to a moderate pressure of the fingers ; I can only compare it to tlie appearance of a part just falling into a state of gan- grene. " I lost a French prisoner precisely in the same way, after the battle of Salamanca ; and Mr. Knight, late Inspector-General of the medical department of the army, informs me that at the Helder, in 1799, his attention was drawn to a case of the same nature, which terminated fatally ; and, on dissection, the appearances gave him the idea of a part which had fallen, or was immediately about to fall, into a state of gan- grene. It is not easy to say with precision, when a case of this descrip- tion, which is so exceedingly rapid in its course, is cured, or rather prevented ; I am almost certain I have lost others, and I think I have saved some. In either way, the cases are very rare. After the battle of Toulouse, where the strictest attention was paid to everything pecul- iar, there was not one. It would appear that this attack, which runs MR. GUTHRIE ON RAPID ABSORPTION OP THE POISON. 243 so rapid a course, is one of inflammation of the most acute kind, tend- ing to gangrene, and the means of relief must be proportionately active." ^ Mr. Guthrie, in his observations upon erysipelatous inflamma- tion, notices a form of disease v^hich I think is closely allied to that just described, and the fatal termination, without any marks of extensive local injury, appears to be due to the rapid poisoning of the general system. The following are the observations of Mr. Guthrie : — " There is an inflammation which I have seen several times occur in gunshot wounds, which I do not perfectly understand, and which, as it is attended by peculiar and fatal circumstances, deserves particular attention. It is not common, seldom more than one or two cases occur in a hospital of a thousand men, and they generally take place after the first ten days. My attention was first drawn to it after the battle of Albuhera, in consequence of losing three men very suddenly, whose death I did not expect, having seen them in the evening ; and in all the three cases, on finding their places vacant in the morning, was informed on inquiry, that they had died during the night, and had been carried away. The death of the first did not attract my attention ; that of the second left an impression which made me attend more particu- larly to the third, and to consider the affection as something peculiar. Two cases occurred after the battle of Salamanca, and one at Toulouse. I did not see a case among the wounded at the sieges of Ciudad Rodrigo, Badajos, or Burgos ; the wounded at the battles of the Pyrenees only came under my direction at a period later than I have known it occur ; neither did I see one at Brussels or at Antwerp, after the battle of Waterloo. It is very possible some may have occurred which escaped my observation. " This inflammation makes its appearance after the first ten days in every case ; and in all that I have seen, the injury was in the upper extremity. The wound, from being only a simple one without fracture, begins to swell and to become painful, and the swelling increases. The redness, which is of a pale color, more resembles the phlegmonous than the erysipelatous inflammation, whilst t'.ie skin has a shining, glossy appearance, and the tumefied parts retain, in slight degree, the impres- sion of the finger, although the accomplishment of it gives great pain, and to a certain extent is resisted by the firmness of the parts below. The pain is not greater than in other cases of inflammation, and is rather burning than throbbing. The constitution sympathizes at first only in a moderate degree. The swelling and shining appearance con- tinue to extend up to the axilla. The patient can sit up and wash his own arm (in two instances they walked about), and neither his coun- 1 Treatise on Gunshot Wounds, third edition. London, 1827, pp. 96, 97. 244 MR. GUTHRIE ON RAPID ABSORPTION OF THE POISON. tenance nor pulse indicates the near approach of dissolution, which in five or six cases took place a few hours after the last visit, when the appearances were such as I have described. In the five fatal cases, I could only learn that they got worse during the night, that is, the pain increased, difiiculty of breathing came on, and death. In all, this took place the day after the swelling had reached the axilla ; and in the fifth case, the result appeared to me so certain at the same period of time, that I desired the orderly to take care that if the man died during the night, he should not be removed. This direction seemed to surprise the orderly, who had no suspicion that the man would die ; but his first salutation at half past five in the morning, when I came into the hos- pital, was, ' Sure, sir, the man is dead.' I relate the case in this man- ner to draw the attention more strongly to the impression it had made on my mind, that the complaint may not be overlooked on future opportunities offering themselves, and that it may not too hastily be considered as a common case of erysipelatous or oedematous inflamma- tion. The three first cases were not examined after death. In the fourth, I could discover nothing particular beyond inflammation of the veins, especially those leading to the axilla, the axillary vein being also inflamed, to which I attributed the man's death, without considering it very peculiar, being of frequent occurrence iu fatal cases afl«r amputa- tion. In the fifth, the man died of eff'usion into the chest on the same side as the injury of the arm, the whole of which was much enlarged, and had been highly inflamed ; but the great veins were not affected as in the former instance. " The sixth case occurred after the battle of Toulouse, in the Caserne de Calveti hospital, under the direction of Staff-Surgeon Bontflower, and in the immediate charge of Mr. Franklyn, now Surgeon of the 37th Regiment, to whom I pointed it out at its commencement as of very dangerous tendency ; and it was from that moment an object of particu- lar attention. The man was bled, purged, vomited, and diaphoretic remedies were administered, composed of calomel, antimony, and prin- cipally opium. Poultices were applied to the wound, and cold applica- tions to the remainder of the limb. The arm swelled nearly up to the axilla, and I fully expected it would have taken the same course as the others, but it did not do so ; the inflammation gradually subsided ; the arm diminished, and resumed its usual appearance ; the exact time I cannot mention, having lost the particulars of the case. During this process the man's health declined, he suffered an attack of fever, became afterwards jaundiced, and died under symptoms of diseased liver. There was nothing wrong at his death about the arm which had been inflamed. " It is from the termination that I have been induced to give the caution not to mistake the disease for a common case of unhealthy or diffused cellular inflammation ; and even admitting that it should be MACLEOD ON RAPID AND FATAL GANGRENE. 245 hereafter proved to be so, there will still be something very peculiar in it, and deserving investigation. I am disposed to hazard a conjecture, that it was effusion in the chest which carried off the first three patients ; that the inflammation of the veins of the arm in the fourth was an acci- dental occurrence, although of this I am by no means positive. The treatment to be adopted should be that which was made use of in the last case, and which proved successful in removing the inflammation, although the patient subsequently died from fever and visceral dis- ease." 1 Macleod, in his " Notes on the Surgery of the War in the Crimea," has recorded the following interesting observations on a most rapid and fatal form of gangrene : — " In the Crimea, during the heat of the summer of 1855, after the taking of the Quarries, and the assault on the great Redan in obserrationa June, not a few amputations of the thigh were lost, from moist onara^'wand gangrene of a most rapid and fatal form. In the case of a JJ^Lta™ "' few who lived long enough for the full development of the gangrene- disease, gangrene in its most marked features became estsjblished ; but most of the men expired previous to any sphacelus of the part, over- whelmed by the violent poison which seemed to pervade and destroy the whole economy. This form of the disease occurred in four cases under my own charge, in men who had had a limb utterly destroyed by round-shot or grape. In all, the knee joints were crushed, the collapse was deep and prolonged, and the operation performed primarily in the middle third of the thigh. Three of the four were of very intemperate habits. All these cases took place about the same time, at midsum- mer, when many other similar cases occurred in camp. The wards, though full, were not overcrowded, and could not from their construc- tion be freely ventilated. The weather was sultry, and cholera was in the camp. The atmosphere was surcharged with electricity, and the dreaded sirocco prevailed. Wounds generally assumed an unhealthy aspect for days, when this pestilential wind blew. The cases of all those who died in my wards seemed to be doing perfectly well up to sixteen hours, at the furthest, before death. Three of them were seized on the eighth day after amputation, just as suppuration was being established. The fourth died in the fifth day. The seizure and conse- quent symptoms were indicated in them all. In recording one case, I relate all. " During the night previous to death, the patient was restless, but did not complain of any particular uneasiness. At the morning visit, the expression seemed unaccountably anxious, and the pulse was slightly raised. The skin was moist, and the tongue clean. By this time, the 1 Gunshot Wounds, pp. 111-114. 246 APPEARANCE AND CHARACTERS OF LOCAL CHANGES. stump felt, as the patient expressed it, heavy like lead, and a burning, stinging pain had begun to shoot through it. On removing the dress- ings, the stump was found slightly swollen and hard, and the discharge had become thin, gleety, colored with blood, and having masses of mat- ter like gruel occasionally mixed with it. A few hours afterwards the limb would be greatly swollen, the skin tense and moist, and marked along its surface by prominent blue veins. The cut edges of the stump looked like pork. Acute pain was felt. The constitution by this time had begun to sympathize. A cold sweat covered the body ; the stomach was irritable, and the pulse weak and frequent The respiration be- came short and hurried, giving evidence of great oppression, of which the patient so much complained. The heart's action gradually and surely got weaker, till, from fourteen to sixteen hours from the first bad symptom, death relieved his suflferings. All local and constitutional remedies which could be thought of were equally powerless ; nothing could relieve the system from the weight which seemed to crush it, or enable it to support the severe burden. Strong stimulants were the only remedies which appeared to retard the issue for a moment Post- mortem examination, instituted shortly after death, showed the tissues of the limbs, and in many cases those of the internal organs also, to be filled with gas and loaded with serous fluid. The vessels leading from the stump were healthy, and in only one case had there been any actual mortification previous to death. The intestines, in two of the four cases, were much diseased. " Was the cause which gave rise to this affection referable to ' weak- ness or defective powers of action,' arising from the patient's bad state of general health, or excessive irritability or disposition to act, from their being of intemperate habits ? or was it excessive irritation or excitement to act, arising from the severity of the injury sustained ? After the taking of the city in September, the same form of disease again appeared, especially among the Russians who had been operated on, and was so deadly that in no case which I could hear of did recovery follow." ^ APPEARANCE AND CHAKACTEES OF THE LOCAL CHANGES. In many cases of gunshot wounds which subsequently became Appcaranco gangreuous, the attention of the wounded men was first tors of the Called to the injured parts by severe and darting pains in changes. the wounds. ThesB pains were sometimes compared by in the incep- the Confederate soldiers to the pricking of thousands of disease. needlcs. In other cases the early stages of the disease were announced by a stinging or itching sensation ; whilst in 1 Notes on the Surgery of the War in the Crimea, vrith Remarks on the Treatment of Gun- shot Wounds, by George H. B. Maeleod. CASE VI. — HOSPITAL GANGRENE. 247 some cases there was little or no change in the sensation of the part. In some cases, in the earliest stages the wounds presented a dark-red glazed surface ; the granulations became altered Eariy in appearance, and rapidly disappeared ; the discharge of the mmd. healthy pus disappeared, and was followed by a reddish and green- ish sanious fetid discharge. The parts around the wound became painful and swollen, and frequently a well-defined red and purpKsh indurated border in the sound skin surrounded the wound. The wound itself rapidly assumed a swollen, ragged appearance (the gangrenous matter often rising several lines above the surrounding tissues), with swollen, ragged, everted edges. With this infiltra- tion of the diseased structures, and the consequent elevation of the surface and eversion of the edges of the wound, the glazed, dark- red appearance of the wound disappears, and the gangrenous mass presents a greenish and grayish color. When the wounds were extensive, the gangrene would fre- quently appear in one or more circumscribed spots, of a in extensive dark gray and greenish color, and gradually spread over ^^g^ne""* the entire surface, and destroy the surrounding tissues, q^enajtp- I have seen extensive ulcerated surfaces in which the ^i^^ gangrenous parts remained almost stationary, whilst the '•"''■ surrounding portions of the wound presented a bright florid ap- pearance. Case XLV. aifords a good illustration of this appear- ance of a gangrenous mass in the midst of a large florid wound. In cases of amputation in patients whose systems were depressed and deranged by bad food and foul air, as the Federal indebmtated . , „, , , , , ... . , systems the prisoners m the falthy and crowded military prison hos- first symp- • 1 » 1 -ii /~i • 1 • 1 n toms of hos- pital at Andersonville, (jeorgia, hospital gangrene tre- pitaigan- Quentlv made its appearance in the wounds in from manifested ^ •' ' '^ , . in the ab- twentv-rour to seventy-two hours ; and m such instances eence of any the first symptoms of the disease were manifested in the effusion, absence of any adhesive effusion or inflammation, the swelling of the flaps, the rapid tearing out of the sutures, and the appearance of a deep blue and purplish discoloration of the skin around the edges of the wound. We have before described the first symptoms of the disease, in the case of the Irishman (Case V.) whose leg was amputated in consequence of a compound comminuted fracture received in a railroad accident near Andersonville. Case VI. In another case in which the leg was amputated at the upper third, on account of the extensive ravages of a gangrenous wound, following a slight injury of the foot by a splinter, gangrene appeared in 248 CASE Vn. — HOSPITAL GANGRENE. twenty-four hours ; and at the end of forty hours the stump presented a deep blue and purplish mottled appearance beyond the knee joint, and the constitutional symptoms were of the gravest character. During the active stages of hospital gangrene, the surrounding Biarkedcon- pa^^ts are swollen and infiltrated with serum, and the tem- Moundthe perature of the parts immediately around the diseased ^S"""" structures is elevated somewhat above that of the parts fettoof h™- beyond. As far as my observations extend, the serous orrhage. £^j(j infiltrating the tissues is liquor sanguinis, and is capable of coagulation. The blood-vessels surrounding a gan- grenous wound are always engorged with blood, as if the capilla- ries had lost their power to contract ; and if an incision be made around the wound in the unbroken skin, these distended vessels bleed freely. I have noticed in several cases of severe gangrene, that after serious hemorrhage the recovery of the patient was very rapid, as if the emptying of the surrounding engorged vessels had contributed to the rapid improvement of the wound. The deep purple and blue color of the skin surrounding gangrenous wounds which are spreading rapidly appears to be due to the want of oxygenation in the blood, and also to the fact that this blood is altered and contaminated, and in fact poisoned by the neighboring gangrenous matter. The deep blue and purple color in the sur- rounding skin is one of the most infallible signs of the active prog- ress of the disease. After the disappearance of the gangrene, the blue and purple border either disappears entirely or else fades away. The following cases will still further illustrate this subject : — Case VII. Empire Hospital, Vineville, Ga. W. J. Black, Com- Casevii. pany G, Lee's Invalid Battalion; age, forty-six. Native of niustraMng Troup County, Ga. Farmer by occupation. Height, five feet tomsandap- nine inches ; weight in health, one hundred and sixty pounds ; hospital gan- black hair and eyes ; florid complexion. Has been in Con- oTinMuia- federate service three years and three months. Served two of foul at- years with Stonewall Jackson. Was wounded about one year "roTu ol^g" ago in Maryland ; lost the first joint of the second finger ; and the disease, jj^g jjj,j. ]jgg^ j^j ggj J service since. Eelieved from active ser- vice in the field by a board of physicians, on account of feeble health, and what was supposed to be an affection of the kidneys. The patient says that he often sufiers with pain in his back, in the region of his kidneys. Acted as a nurse in Atlanta, at the Empire Hospital, and moved with it to Yineville, near Macon, Ga. Has been acting as a nurse in this hospital for the past two months, since the conversion of this institution into a gangrene hospital. During this time has been inoculated with CASE Vn. — HOSPITAL GANGRENE. 249 hospital gangrene twice. The first attacic was caused by tlie prick of a pin on the side of the hand, received in dressing a gangrenous wound. The prick of the pin became painful almost immediately ; and in the course of two days the injury commenced to inflame, and the surface around assumed a purplish and bluish color. The disease spread from the centre of infection, and the slough presented a grayish and greenish color. The inflamed and gangrenous parts were freely cauterized with strong nitric acid. By this means the gangrene was arrested before the ulcer had exceeded one quarter of an inch in diameter. This occurred in the beginning of September, about one month ago. The constitution did not appear to suffer, and the wound healed readily, and the patient resumed his labors as a nurse to the gangrene pa- tients. Had not been engaged in dressing the gangrenous wounds more than two or three days before a small blister appeared upon the third finger of his right hand, which gave much pain, and, in the language of the patient, " throbbed as if a bone was breaking loose." The blistered surface assumed a gray and greenish color, and was surrounded with a purplish and blue halo in the skin. The gangrene commenced to spread rapidly. Concentrated nitric acid was immediately applied three times a day, but it did not arrest the gangrene. It appears that in the first inoculation, the system was not specially involved, and the local treatment arrested the disease. But the continued residence in this infected atmosphere, and the constant attention upon the gangrenous wounds, gradually poisoned the system of this faithful nurse to such an extent that in the second attack the local treatment did not arrest the disease. In this view, this case presents points of great interest in their bear- ings upon the history of the disease. On the 3d of October, 1864, just twelve days after the commence- ment of this second attack of hospital gangrene, I executed the accom- panying drawing. The gangrene is progressing along the upper border under the blue discolored skin of the third finger of the right hand. The color of the skin in this portion of the wound, where the gangrene is progressing most rapidly, was of a most remarkable deep-blue. The lower portion of the ulcer appears to be improving somewhat, and now discharges a little pus. The constitutional disturbances, notwithstanding the comparatively small surface involved, are well marked. Pulse accelerated, and feebler than in health. Face flushed. During the execution of the sketch of his right hand, suffered much pain from the confined position of the hand ; was very restless and nervous, and was very much nauseated, and attempted several times to vomit. Hands tremble from the nervous irritation. No appetite. Tongue of a purplish, bluish, leaden color. 250 CASE Vni. — HOSPITAL GANGRENE. Has fever in the evenings, which declines towards the morning. Feels weak, nervous, feverish, and depressed. On the 5th of October, when the appearance of the wound, as well as the general symptoms, were very much the same, I instituted the fol- lowing analysis of the urine of this patient : — Amount of urine collected during twenty-four hours, October 4, 5 o'clock, p. M., to October 5, 5 o'clock, p. m., 490 cubic centimetres = grains 7915.6. Specific gravity, 1,028. Deep-brown, inclining to blackish-red color. ANALYSIS OF UKINE, NO. 2. Elements. Amount of urine collected during twenty-four hours . Urea Uric acid Free acid Pliosphoric acid . . Equivalent of phosphorus in phosphoric acid . . . Sulphuric acid Equivalent of sulphur in sulphuric acid . . • , Chloride of sodium . Equivalent of chlorine in chloride of sodium . . . Urine collected during 24 hours, contained grains 1,000 parts of urine con- tained 7,915.60 369.75 46.71 5.88 0.74 26.41 3.33 33.20 4.17 14-57 1.84 29.30 3.70 11.72 1.48 7.54 0.95 4.56 0.57 The following is the treatment adopted in this case, which is recorded here simply in its relations to the analysis of the urine : October 1. — Tincture muriate of iron, gtts. xv. ; sulphate of quinia, grains v., three times a day. October 4. — Treatment continued. October 5. — Treatment continued. On the 7th of October, it wis decided to furlough this patient, although his finger was still in a gangrenous condition. It was believed that his recovery would be very tedious, if not doubtful, in this poisoned atmosphere. Case VIII. Empire Hospital, Vineville, Ga. Thomas Paine, pri- Casevni. vate. Company B, 1st and 4th Missouri Regiments, Stewart's gangrene. corps ; native of Bates County, Missouri. Occupation previous to entering the army, farming. Has been in Confederate service near four years. Age, twenty-two ; height, five feet ten inches ; weight in health, one hundred and fifty pounds. Brown hair ; grayish-black eyes ; fair freckled complexion. Has been generally healthy, and has had no sickness except the measles, since entering service. Has never been wounded before. Was wounded on the 17th of August, 1864, at Atlanta, Ga. A piece of lead, weighing about one pound, from a rifle shell, struck the middle of the left thigh, upon the external surface, and CASE Vm. — HOSPITAL GANGRENE. 251 lacerated the parts, but did not fractsre the bone. "Was taken to one of the brigade hospitals in Atlanta, where he remained five days, and was then transferred to the Ocmulgee Hospital. From the account of this patient, it appears that gangrene attacked his wound four days after entering the Ocmulgee Hospital in Macon. On the 27th of August, says that he experienced no special pain in the wound when the gangrene appeared. Entered the Empire Hospital on the 2d of September. His attend- ant physician, Assistant-Surgeon V. T. Perry, who assisted me in the determination of the temperature in this case, informed me that up to the time of my examination, the general treatment consisted of stimu- lants, tincture muriate of iron, and opiates when necessary ; and the local, of the daily application of strong nitric acid, the wound being afterwards dressed with lint or cotton saturated with turpentine or tinc- ture of iodine. The actual cautery was upon one occasion substituted for the nitric acid. Under this treatment no amendment has been observable. September 30. — "Wound in the thigh about eight inches in diameter, nearly circular, and deeply and irregularly excavated ; edges everted, and the surface coated with a dirty grayish, purplish, and dark bluish leaden color. No healthy pus was discernible, but in its stead the wound discharged a most fetid, irritating, sanious fluid. Tongue clean, red, and dry. Pulse, 120, quick and feeble. Respiration, 20. Tem- perature at three o'clock p. m., in hand, 40.9° C. (105.6° F.) ; in axilla, 41.1° C. (106° F.). Skin hot and dry ; bowels constipated ; urine scant and high colored. October 1. — Eight and one half o'clock A. m. Pulse rapid and feeble, 105. Eespiration, 16. Temperature of axilla, 39.2° C. (102.6° F.). Temperature of hand, 38.8° C. (101.8° F.). Skin moist. Bowels con- stipated ; urine high colored. Wound of a dark greenish, gray and bluish color. The large muscles of the thigh are exposed by the gan- orenous excavation, and they frequently can be observed quivering, especially after the application of nitric acid, which causes intense pain. Patient nervous and restless. Hands tremble, and the eyes present a nervous, restless, distressed expression. Whenever the patient sleeps, appears to be disturbed by visions, and talks constantly, and sometimes calls out aloud. Treatment continued. Eight o'clock p. M. Pulse, 134. Respiration, 21. October 2. — Eight o'clock a. m. Tongue clean, moist, and red. Pulse, 116. Respiration, 22. Temperature of axilla, 38.2° C. (100.7° F.). Temperature of hand, 29.5° C. (85.1° F.). Skin of extremities feels cool, soft, and moist. Bowels moved once through the night ; the foecal matters were said to be natural in color and consistence. The drawing, Plate No. 2, was executed by myself on this day, and presents a general idea of the appearance and extent of the wound. 252 CASE Vm.— HOSPITAL GANGRENE. Examination of Urine. — Amount of urine collected during the past twenty-four hours, 1,500 CC. = grains 23,891. Specific gravity, 1011.5. Bright red color. Strong effervescence in the urine, upon the addition of concentrated nitric acid. At the end of forty-eight hours, the urine gave an alkaline reaction, and let fall a heavy light-yellow deposit of triple phosphate, oxalate of lime (dumb-bell and octahedral crystals), globular and acicu- lar crystals of the urates of soda and ammonia, mucous corpuscles and vegetable cells. ANALYSIS OF UKINB, NO. 3. Amount of urine collected during twenty-four hours . Urea Uric acic Free acid Phosphoric acid Equivalent of phosphorus in phosphoric acid . . . Sulphuric acid Equivalent of sulphur in sulphuric acid Chloride of sodium Equivalent of chlorine in chloride of sodium . . . Urine collected duriDg 24 hours, contained grains 1,000 parts of arine con- tained 23,891.63 635.25 26.58 3.00 0.125 24.25 1.01 50.82 2.12 22.30 0.93 32.72 1.302 13.08 0.58 110.88 4.64 73.15 3.06 Eight o'clock p. M. Tongue dry and red. Pulse, 114. Respiration, 22. Temperature of axilla, 40° C. (104° F.). Temperature of hand, 39.7° C. (103.5° F.). Two operations of bowels during the day. October 3. — Eight o'clock A. Ji. Tongue clean, dry, and red. Pulse, 106. Respiration, 24. Temperature of axilla, 38.2° C. (100.8° F.). Temperature of hand, 34° C. (94.3° F.). Bowels moved oiice during the night Eight o'clock p. M. Tongue clean, red, and moist. Pulse, 101. Respiration, 17. Temperature of axilla, 38.2° C. (100.8° F.). Temper- ature of hand, 38° C. (100.4° F.). October 4. — Condition of patient the same, except that bowels are loose. Examination of Urine. — Reaction alkaline at the end of forty-eight hours. Heavy yellow deposit, consisting of triple phosphates (prismatic crystals), dumb-bell and octahedral crystals of oxalate of lime, granular and acicular crystals of the urates of ammonia and soda, and numerous vegetable cells. Amount of urine collected during the past twenty-four hours, 650 CC. = grains 10,322.4. The bowels of this patient have been running oflF, and a portion of the urine has been lost. Deep orange color. Heavy light deposit and alkaline reaction at the end of the collection of the urine passed during the preceding twenty-four hours. Patient CASE VIII.— HOSPITAL GANGRENE. 253 complains of pain and difficulty in passing his urine. Specific gravity, 1,012. ANALYSIS OF URINE, NO. 4. Urine collected during 24 hours, contained grains Amount of urine collected during twenty-four hours . Urea Uric acid Free acid Phosphoric acid Equivalent of phosphorus in phosphoric acid' . . . Sulphuric acid Equivalent of sulphur ifi sulphuric acid Chloride of sodium Equivalent of chlorine in chloride of sodium . . , 10,322.40 210.21 1.30 alkaline 6.00 2.62 8.47 3.38 40.04 26.42 1,000 parts of urine con- tained 20.36 0.12 alkaline 0.58 0.25 0.82 0.32 3.86 2.55 October 5. — Eight o'clock a. m. Tongue moist and red. Pulse, 112. Eespiration, 26. Temperature of axilla, 40° C. (104° F.). Tempera- ture of hand, 39° C. (102.2° F.). Eight o'clock p. M. Pulse, 104. Eespiration, 20. Temperature of axilla, 39° C. (102.2° F.). Temperature of hand, 37.3° C. (99.2° F.). Bowels unmoved through the day. Examination of Urine. — Amount of urine collected during twenty- four hours, October 4, 8 p. m., to October 5, 8 p. m., = 850 CC. Spe- cific gravity, 1,015. Bright reddish orange color. Heavy light-yellow deposit, aramoniacal odor, and alkaline reaction at end of twenty-four hours. ANALYSIS OF UMNE, NO. 6. Elements. Amount of urine collected during twenty-four hours . Urea Uric acid Free acid Phosphoric acid . . . Equivalent of phosphorus in phosphoric acid . . . Sulphuric acid Equivalent of sulphur in sulphuric acid Chloride of sodium . . . . Equivalent of chlorine in chloride of sodium . . . Urine collected 1,000 parts of during 24 hours. unne con- contained grains tained 13,601.00 347.65 25.56 4.25 0.31 alkaline alkaline 18.32 1.34 8.03 0.59 8.47 0.62 3.38 0.24 19.63 1.44 12.95 0.95 October 6. — Eight o'clock a. m. Tongue clean, dry, and red. Pulse, 112. Eespiration, 24. Temperature of axilla, 38.6° C. (101.5° F.). Temperature of hand, 34.5° C. (94.1° F.). 254 CASE VIIL — HOSPITAL GANGRENE. Eight o'clock p. M. Pulse, 126. Respiration, 21. Temperature of axilla, 40.4° C. (104.8° F.). Temperature of hand, 40.2° C (104.4° F.). Two operations from bowels during the day, which were said to be natural in consistence and color. Up to this date, the appearance of the wound remains unchanged, notwithstanding the daily application of nitric acid. The wound has not, however, spread to any great extent October 7. — Condition of the patient the same. OctoJer 8. — Eight o'clock p. M. Pulse, 164. Eespiration, 20. Tongue pale and moist Bowels moved once during the preceding night. Eight o'clock p. M. Pulse, 124. Respiration, 20. Bowels moved once during the day. Operation natural. October 10. — Eight a. m. Pulse, 130. Respiration, 20. Eight p. M. Pulse, 122. October 11. — Eight A. M. Pulse, 124. Eight p. m. Pulse, 122. October 12. — Eight a. m. Pulse, 132. Eight p. m. Pulse, 116. October 13. — Eight A. m. Pulse, 116. Eight p. m. Pulse, 124. October 14. — Eight p. m. Pulse, 136. October 15. — Eight A. m. Pulse, 128. October 16. — Eight A. m. Pulse, 128. October 17. — Eight a. m. Pulse, 102. The appearance of the wound was almost uniform until the 11th of October, when it gradually assumed a healthy appearance. In the course of six days from the 11th, all traces of gangrene left the wound. The use of nitric acid was abandoned on the 9th, by Assistant-Surgeon Perry, not because any amendment was observed, but for the reason that it appeared to accomplish but little good. Instead of the acid, the attendant physician substituted a cerate of the following constitution : Resin cerate lb. ^ ; oil of turpentine, fsiii; tincture of iodine, fSiss. The bowels of this patient have generally been in good order, and the only medicine administered for their regulation was one small dose of castor-oil. Up to the present time, the appetite of this patient has been generally pretty good. October 18. — Eleven o'clock a. m. Patient doing well. Appetite good. He is still, however, nervous and excitable, and easily disturbed. When I first entered the ward, his pulse was 120, and in a few moments it fell to 116. The surface of the wound presents a bright red color, and is covered with granulations and secretes pus. Examination of Urine. — Amount of urine passed during twenty-four hours, from October 17, 11 a. m., to October 18, 11 a. m., 1,725 CC. = grains 27,479.4. Specific gravity, 1,014. Light orange color. At the end of seventy-two hours, the urine was turbid, with a heavy white deposit of granular urates, prismatic crystals of the phosphates, and octahedral ci-ystals of oxalate of lime. Reaction at the end of seventy-two hours alkaline. CASE Vm.— HOSPITAL GANGRENE. 255 ANALYSIS OP URINB, NO. 6. Elements. Urine collected during 24 hours, contained grains 1,000 parts of urine con- tained Amount of urine passed during twenty-four hours . Urea 27,479.40 664.12 8.28 13.28 19.12 8.39 27.21 10.88 172.67 104.63 24.31 Uric acid , . 0.301 Free acid 0.48 0.69 Equivalent of phosphorus in phosphoric acid . . . 0.305 99 Equivalent of sulphur in sulphuric acid Chloride of sodium . 0.39 6 28 Equivalent of chlorine in chloride of sodium . . . 3.86 Oetoier 19. — Patient continues to improve. Appetite good. Bowels regular. "Wound clean, and bright red, with healthy granulations. Examination of Urine. — Amount of urine passed during the past twenty-four hours, 890 CO. = grains 14,353.24. Specific gravity, 1,024.5. With the diminution in the amount of urine, the specific gravity has increased. The weather is cool, with light frosts in the mornings. After standing over the cool night, the urine threw down a very light deposit. Light orange color. Carefully tested, together with a number of other specimens of urine collected from patients in various stages of hospital gangrene, for grape sugar ; neither in this nor in any of the other specimens was any trace of the substance found. At the end of forty-eight hours the urine was still slightly acid, and a light yellow, almost white deposit had fallen. Under the microscope this deposit was found to consist of innumerable crystals of oxalate of lime, chiefly of the octahedral variety, granular and crystalline phosphates and urates, and round, irregular, orange colored masses. ANALYSIS OF URINE, NO. 7. Amount of urine passed during twenty-four hours . Urea Uric acid Free acid (twenty-two hours after collection of urine) Phosphoric acid Equivalent of phosphorus in phosphoric acid . . . Sulphuric a«id Equivalent of sulphur in sulphuric acid Chloride of sodium Equivalent of chlorine in chloride of sodium . . . Urine collected during 24 hours, contained grains 1,000 parts of urine con- tained 14,353.24 438.59 30.35 10.14 70 17.28 1.20 22.47 1.56 9.86 0.61 28.20 1.97 11.28 0.78 61.67 4.29 37.37 2.63 256 GENERAL CONCLUSIONS FROM CASE VIIL October 2L — Wound still improving. Presents a bright red, granu- lating surface, and discharges healthy pus. The gangrene dissected the muscles, and separated entirely the cellular tissue. Upon this day I executed the sketch, Plate No. 4 ; which gives a general idea of the appearance and size of the wound. By a comparison with the drawing of the wound during the state of gangrene, it will be seen that the parts surrounding the wound have greatly diminished in size. With the dis- appearance of the gangrene, and the improvement of the wound, the swelling and effusion have also disappeared. October 2i. — Ten o'clock a. m. Pulse, 104. Temperature of axilla, 38.2° C. (100.8° F.). Appetite good. Bowels regular. Tongue clean. Spirits of the patient excellent. Eight o'clock p. M. Temperature of axilla, 38.2° C. (100.8° F.). Temperature of hand 37.4° C. (99.3° F.). We observe, amongst many other interesting points illustrated Tempemtare in this case, that the temperature returns to the normal returns to i i i i t i . . the normal standard, and the diurnal variations cease, as soon as the standard as i i i i ■ t soon as the wound Essumes a healthy appearance : the unne also wound as- ./a * sumesa retums to the normal standard, and loses its high healthy ap- <= pearancc. COlor. It is worthy of note, that when the temperature and the excre- tions returned to the normal standard, the wound was as extensive as during the active progress of the gangrene, when the constitu- tional symptoms were most marked, and the perturbations in the temperature greatest. And notwithstanding the nervous sensi- bility of the wound was as great if not greater after the removal of the gangrene, still the constitutional symptoms disappeared almost entirely. It is fair to conclude that the derangement of nutrition, secre- tion, and excretion, and the depression of the nervous and muscu- lar forces, and the perturbations of temperature during the active stages of the disease, arose in great measure, if not wholly, ft-om the absorption of the poisonous matter causing the gangrene, and of the various altered products resulting from the decay of the tissues. When the system has been thoroughly poisoned by the absorp- when the tion of the gangrenous matter from a large wound, and been thor- by the coustaut inhalation of the foul atmosphere of the soned by the crowdcd ward, I have in a number of instances observed of the gan- parts pemovcd from the immediate wound, but generally gronousmat- ^ t i i i ' n ter, various upou the samc limb, take on the gangrenous iniiamma- portioDB of.*^ ,, ., i 1 the system tiou, and that too Without any apparent cause, such as removed from the pressure. GENERAL CONCLUSIONS PROM CASE VIH. 257 In such cases, a purple or blue spot is first perceived, ™°''* ™»y or the color might more properly be termed in some cases grenoas in- ■• , ^ '' flammation. an ash gray or leaden hue. The cuticle is sometimes character of J , , the gaDgrene raised, and contams serum below. The rapidity of the thus arising. progress of the gangrene in such spots will depend chiefly upon the extent to which the system has been poisoned by the absorp- tion of the deleterious matters. I have seen the skin in the affected spot melt away in twenty-four hours into a grayish and greenish slough, whilst a deep blue and purple, almost black areola, surrounding the dead mass, spread rapidly in ever increasing cir- cles ; whilst the skin and tissues within, over which it had just passed, changed rapidly to the ash gray, and green and bluish hue characteristic of this form of gangrene. This is witnessed most generally in the worst and fatal cases. In some cases the gangrenous slough presents a black, hard crust, which can only be removed by poultices. As long as the crust remains, the case progresses unfavorably ; and in fact, as far as my experience extends, these are amongst the most inveterate and obstinate cases. Hospital gangrene destroys the cellular and adipose tissues most rapidly ; the muscles, nerves, large blood-vessels, and the Relative ra- bones, resist its action for a greater length of time. It is which Sn- not uncommon to see large surfaces of muscles and even ftroTs the of bones exposed, the skin and cellular tissue having been tusu'™ completely dissected away by the disease. The blood-vessels yield more readily in hospital than in the forms of dry gangrene ; and hence in the former, hemorrhage, both venous and arterial, is very common, and in some cases both directly and indirectly becomes a cause of death. From this cause it happens that the gangrenous tissues frequently present a mottled appearance, from the hemor- rhages of limited extent taking place from the smaller vessels destroyed in the ravages of the disease. Whilst there is a ten- dency to the coagulation of the blood in the vessels passing into and through the gangrenous mass, still the tendency is less and the coagulation far less perfect than in dry gangrene. This difference may be due to the more rapid progress of the disease as well as to differences in the constitution of the blood, and especially to differ- ences in the quantity and quaUty of the fibrous element in the dif- ferent forms of gangrene. As far as my observations extend, the bones do not yield readily to hospital gangrene ; and even when exposed, and in part sur- rounded by the disease, with the exception of slight exfoliation of 17 258 GENERAL CONCLUSIONS FROM CASE Vin. the outer table, little or no erosion or death takes place ; and when the disease is arrested, granulations spring up rapidly and cover the exposed surface of the bones. Several instances have come under my observation, in which gangrene existed in structures beneath an apparently sound skin. Thus, in the case of a Federal prisoner, who received a slight wound upon the external portion of the left thigh, just above the knee joint, at the battle of Chickamauga, and who suffered for several days before death with an abscess in the groin of the injured limb, from which sanious fetid matter issued, and who died apparently from the exhaustive effects of colliquative diar- rhoea, resulting probably from the absorption of the products of the disorganizing tissues ; the skin over the injured thigh and but- tocks appeared sound, wiiilst the cellular and muscular tissues of the thigh and buttock were in a state of gangrene, presenting blue and green and greenish gray disorganized matter. In this case the muscular structures were so disorganized that they were crushed by the slightest pressure. Under the microscope, the muscular substance and structures appeared to be almost com- pletely disorganized, and nothing but the fibrous tissue remained. Innumerable granules and granular masses, crystals of the color- ing matter of the blood, prismatic crystals of the phosphates of ammonia, magnesia, and hme, altered blood corpuscles, detached masses of cellular tissue and of muscular fibres, in which the strise were fast disappearing, together with oil globules, all pervaded by a fetid greenish sanious fluid, constituted the mass of the gan- grenous muscles. The disorganized structures were strongly impregnated with ammonia, one of the products of the disintegration of the nitrogen- ized constituents ; and the normal acid reaction of healthy muscu- lar structures was changed to a strongly alkaline reaction. In another case, where the operation of ligating the brachial artery was performed, to arrest hemorrhage from a gangrenous wound in the fore-arm, involving structures around the elbow joint, the cellular tissue surrounding the artery was found to be in a gangrenous state, although no suspicion was entertained of the existence of gangrene before the operation was performed. It is probable that in this case the spread of gangrene had been very rapid along the fibrous tissue surrounding the great vessels and nerves. I have frequently seen a narrow strip of apparently sound skin passing between two gangrenous wounds, and even passing across CASE IX.— HOSPITAL GANGRENE. 259 a large gangrenous mass. This observation is well illustrated by the following case : — Case IX. David Shelton, Company G, 12th and 47th Regiments Tennessee Vols., private. Has been in Confederate service caso ix. since the 16th of December, 1861. Age, thirty-four. Native J"elSten?e of Kentucky. Stout, well-built man. Sandy hair and beard, bit""™ two" Scraggy beard and moustache. ''•''e^ em- °°'' grenous Wounded on the 1st of September, 1864, at Jonesboro', wounds. Georgia. The ball passed directly through both eyes and through the nose, leaving the bridge of the nose untouched. The patient says that when the ball struck his eyes, he perceived a vivid flash of light, and then all was darkness, as if he had been suddenly shut up in a dungeon under ground. The knees gave way somewhat, but the wounded soldier did not fall ; and he says that he immediately put his hand to the wound and passed his finger through the places formerly occupied by the eyes, and through the round hole in the bridge of his nose, and felt a gelat- inous mass of torn flesh and blood. He then knew that both eyes were gone, and quietly sat down in the trenches until evening, when the wounded were removed. His consciousness never forsook him. Was removed that night to Griffin, Georgia, and was from thence transferred to the Blind Asylum Hospital in Macon. The gangrene appeared in the wound about ten days afterwards, and he was transferred to the Empire Hospital, Vineville. After the appearance of the gangrene, his mind wandered, and he had no recollection of what passed during the active progress of the disease. The wounds in both eyes were swollen, with everted edges. The eyelids were especially swollen, and the patient presented a most distressed and horrible spectacle. I visited his case frequently during his convalescence, and found him always cheerful and happy. He was in the habit of singing merry songs, and in fact was the most cheerful and happy man apparently in the entire hospital. I executed the, following drawing, October 25, 1864, with the design of illustrating the fact that a small strip of skin and tissue may remain uninjured, although surrounded on both sides and even undermined by hospital gangrene. See Plate 5.^ At the time of the execution of this drawing, the wounds presented a healthy granulating surface, and the patient was in good health and cheerful spirits. He took great interest in the execution of the draw- ing, and begged for a copy ; and after its completion, he sang several songs. On the next day, October 26, this soldier was sent home under the charge of a companion. (The patient was a man of family — a wife and six children.) 1 Omitted. 260 CASE X. — HOSPITAL GANGRENE. When gangrene terminates favorably, the surface from which it Appearance is removed presents a bright red and scarlet, exquisitely oftheBur- .. „. . -. 1-1 1*1,1 face after re- sensitive mass ot Juxuriant granulations, wliicn are iiignjy gangrene. vascular, and bleed upon the sliglitest touch. So sensi- tive is this surface, that the most gentle touch will frequently cause the patient, even though he may be a stout, brave soldier, to cry like a child. Although the appearance here described is highly favorable, at the same time many cases terminate fatally, even after the removal of the gangrene, from various causes, as exhaus- tion of the system by profuse suppuration, the depressing effects of the previous disease, the permanent derangement of the digestion, caused during the active stages of the disease, by bed sores, by pyaemia, and by diarrhoea. After the establishment of healthy granulation, the bones which liave been denuded by the gangrene will frequently be rapidly covered by an abundant growth of granulations. When the bones of the leg have been denuded in a stump after amputation, I have observed a most luxuriant crop of granulations sprouting out of the medulla of the bone, like a fungus growth. In most cases the granulations die, and the injured bone separates. When the bone has been exposed in its length, the outer table will frequently scale off, and the separation of bone proceeds no further, and the new tissue forms over the denuded bones. The following case presents a good illustration of the condition of extensive wounds, after the removal of hospital gangrene : — Case X. Captain John F. Cox, Company D, 29th Regiment Mis- Case X. sissippi Vols., Brantley's Brigade, Anderson's Division. Age, Jtaap'JeM? thirty-one. Height, five feet seven and one half inches. surface 'after Weight in health, one hundred and seventy pounds. Suf- ofhMp°tai' ^^'■^'^ ^'*^ typhoid fever in 1855, and had measles in child- gangrene, hood, but otherwise has been perfectly healthy. Has been in Confederate service since 27th of April, 1861. Black hair and eyes. Florid, dark complexion. Has been wounded four times, slightly, before the present wound. Wounded 31st of August, 1864, at Jonesboro', Georgia. Minie-ball passed through left ankle. Amputation performed after he was taken prisoner, at Federal field hospital, about midnight. Remained two days in the Federal field hospital, which was a large tent crowded with wounded. His wound was not examined or dressed during this time. On the third day was removed to a small church in Jonesboro', crowded with about eighty wounded men. His wound was not examined until the fifth day, and was not dressed until the seventh day. During these CASE X — HOSPITAL GANGRENE. 261 seven days no attention was paid to the wound, and the stump was not even wet once with cold water. When examined on the fifth day, in the church, the wound was found to be gangrenous, and the patient was then removed into a private house about one hundred yards from the church. On the seventh day, the gangrenous stump was burnt with strong nitric acid. Erysipelas also appeared. Two days after this. Captain Cox was recaptured by the Confederates, after the Federals withdrew from Jonesboro'. He was first sent to Lovejoy's Station, and from thence to the Ocmulgee Hospital in Macon ; and was finally transferred to the Empire Hospital, on the 16th of September. At this time the gangrene was progressing in the inflamed and swollen and erysipelatous stump. The free use of nitric acid as a cau- tery, with tincture muriate of iron and quinine internally, arrested the disease in one week. On the 5th of October, I executed the following outline sketch, Plate No. 6.' At this time the wound presented a bright red, granulating, highly sensitive surface, which secreted pus in large quantities. The end of the fibula, which had been exposed, is now covered with a rich crop of luxuriant granulations. They are also seen rising out of the medullary cavity of the tibia. The patient has been greatly exhausted and reduced in flesh by the preceding disease, and by the profuse suppuration. Pulse weak and thready ; ninety-eight per minute. Suffers with great oppression at the chest, and eructates continually. Has no appetite, and suffers with con- stant nausea. Bowels loose ; complains of great weakness. Manifests great nervous depression and irritability. Whilst I was executing the drawing, a large drove of cattle, which were passing along the road to Vineville, were stampeded by the whistle of the passing engine and cars, and rushed down the streets of this tent hospital. The Captain was greatly agitated, and cried out, fearing lest one of the cows might run against his injured leg. This case progressed unfavorably. Suppuration very profuse from the stump. The stomach gave way entirely, and he appeared to suffer from acute gastritis, attended with much burning pain in the stomach, and constant nausea and vomiting, retching and belching. A large abscess formed in the back, and discharged large quantities of pus. This gallant soldier died October 31. According to Mr. Blackadder, when the disease attacks an old sore, where a considerable depth of new flesh has been progress of formed, the first thing generally observed is a small dark- ^Ine'^^^' colored spot, usually situated at the edge of the sore, upfo^^oia But he states that in several cases of ulcers, the disease, "'"• 1 Omitted. 262 PROGRESS OF HOSPITAL GANGRENE IN SORES. when carefully watched, was found to begin in the form of a vesi- cle, filled with a livid, or brownish black fluid, which afterwards burst, and assumed the appearance of the dark colored spot which is commonly noticed. Mr. Blackadder always found, that when there had been a considerable bed of new flesh formed, the phage- daenic ulceration made comparatively a very slow progress, and put on rather the appearance of mercurial phagedsena, until the mor- bific matter had found access to the natural texture of the part, when the progress of the disease became suddenly accelerated, acute inflammation supervened, and a large slough was formed. According to the same careful observer, when the disease attacks a recent gunshot wound, the discharge, two or three days after infection, is found to be lessened, and to have become more of a sanious than purulent nature. The sore has a certain dry and rigid appearance ; its edges are more defined, somewhat elevated, and sharpened ; the patient is sensible of a change in the usual sensation in the sore, and complains of the occasional stinging sen- sation, resembling that produced by the stinging of a gnat. At this period, but sometimes a day or two later, the integuments at the edge of the sore become inflamed, and the surface itself assumes a livid or purple color, and appears as if covered with a fine pel- hcle, such as is formed on a coagulum of blood. When left to itself, this pellicle gradually increases in thickness, forming what has been termed a slough. At this period the progress of the dis- ease is hardly in any two instances precisely alike. Generally in the course of from five to ten or fifteen days, a thick, spongy, and putrid looking slough is formed over the whole surface of the sore, and which is more or less of an ash, or blackish brown color. When the pellicle is destroyed, — as frequently happens in the process of cleaning, — it is not in every case reproduced, but an offensive mat- ter begins to be discharged, which becomes daily more copious, is of a dirty yellow color, and ropy consistence, and is very adherent to the sore. The substance which formed the apparent bottom of the sore or wound is raised up, and pushing the edges, makes the sore appear considerably enlarged. The edges, which are usually jagged or pectinated, become extremely irritable, of a deep red color, and dotted in their inner surface with numerous small ele- vated and angry looking points, which may be considered as one of the characteristic marks of the disease. The surrounding integ- uments become indurated and inflamed, assuming not unfrequently an anserine appearance ; and the patient complains of a constant burning lancinating pain. In the vicinity of the sore the integu- PKOGEESS OF HOSPITAL GANGRENE. 263 ments become more and more of a dark red color, in consequence of the violence of the inflammation, which is of an erysipelatous nature, and apt to terminate in sloughing, and carry off the patient. However, the inflammatory symptoms are sometimes mild, and in other cases exceedingly violent, — a fact accounted for by differ- ences of constitution.^ As the disease progresses, the complexion assumes an unhealthy, dusky, leaden hue, the eyes express anxiety, depression. Appearance and nervous irritation and exhaustion, the pulse is small, pLxionTnd frequent, and feeble, and indicates an irritable, enfeebled theM?™"' state of the nervous and muscular systems. Sg*h?prog- It is possible by these symptoms alone to decide in pttai°gan°'" many cases whether gangrene is present, and whether it ^"'°' is progressing or disappearing. In some cases the progress of the disease is rapid and terrible. The edges of the wound become hardened and everted, Ravages of the smrface of the wound rises up into a pulpy, ragged, grene. gray and greenish mass. When the sloughs are detached, the dis- ease attacks other adjacent structures from day to day, extend- ing its ravages both in length and breadth, and involving apo- neuroses; muscles, blood-vessels, nerves, tendons, the periosteum, and bones and joints. In a case of hospital gangrene supervening upon a slight wound of the scalp, which came under the notice of Mr. Blackadder, half of the cranium was denuded, the bones having become as black as charcoal, and the integuments detached posteriorly to the second cervical vertebra, and anteriorly to the middle of the zygomatic process of the temporal bone. In another case, which was origi- nally a simple flesh wound, the muscles, large arteries, and nerves of both thighs were exposed and dissected, the integuments and cellular substance being entirely removed, with the exception of a narrow strip of the former, which remained on the outer side of the thigh. In still another case, the integuments and cellular substance on the anterior part of the neck were destroyed, exposing the trachea, which was attacked by the disease. Most commonly, after the muscles have been exposed, they continue to be gradually dis- sected ; their connecting membrane is completely destroyed, and they are left covered with an offensive, greasy looking matter. When a muscle has been invaded by the disease, it sometimes swells to a great size, loses its irritability, and assumes the appear- ance of a large coagulum. 1 On Phagedcena Gangrcsmsa, pp. 31-33. 264 PROGRESS OF HOSPITAL GANGRENE. As the disease advances, hemorrhage from small vessels is a common occurrence, and in the more advanced stage some of the large vessels are apt to give way, and the patient is frequently destroyed by the consequent hemorrhage. In the last stage of the disease, as it occurred in the military hospitals at Bilboa, as described by Dr. Hennen, the surface of the sore was constantly covered with a bloody oozing, and on lifting up the edge of the flabby slough, the probe was tinged with dark colored, grumous blood, with which also its track became immedi- ately filled. Repeated and copious venous bleedings now came on, which rapidly sunk the patient ; the sloughs, whether they fell off spontaneously, or were detached by art, were quickly suc- ceeded by others, and brought into view thickly studded specks of arterial blood. At length an artery gave way, which was generally torn through in the attempt to secui'e it with a ligature ; the tourniquet or other pressure was now applied, but in vain ; for while it checked the bleeding, it accelerated the death of the limb, which became frightfully swelled and horribly fetid. Incessant retchings came on, and with coma, involuntary stools, and hiccough, closed the scene. Often, however, the patient survived this acute state of the disease, and sunk under severe irritation, absorption of putrid matter, and. extensive loss of substance, with common hectic symptoms. CHAPTER SECOND. MICEOSCOPICAL AND CHEMICAL INVESTIGATIONS UPON HOSPITAL GANGRENE. Microscopical Examination of the Gangrenous Matter. — Consists of the Various Structures in a Disorganized State, together with the Products of the dead Disorganizing Tissues. — The Pus Glohule absent in the Gangrenous Mass. — The Appearance of the Pus Globule in Hospital Gangrene a Favorable Sign. — Animalcules present in Considerable Numbers in tlie Gangrenous Matter. — The Results of these Microscopical Observations clearly sustain the View that Hospital Gangrene is due to the Action of an Irritant Or- ganic Poison, which, after the Manner of aFerment, is capable of inducing such Decompo- sition in the Tissues and in the Blood, that all Development of the Cellular Elements of the Liquor Sanguinis into Cells or Fibres, or into Pus, is arrested. — Chemical Examina- tion of the Gangrenous Matter. — Observations of Surgeon Jackson Chambliss, of Camp Winder Hospital. — First Chemical Examination of Gangrenous Matter by Mr. Cruik- shank, Chemist of the Royal Artillery. — Microscopical Examination of the Pus secreted by Wounds, after the Removal of Hospital Gangrene. — Changes of the Blood in Hospital Gangrene. — Illustrative Cases. — Analysis of Blood. — These Investigations tend to Establish that the Action of the Poison of Hospital Gangrene is attended with both Local and Constitutional Symptoms of Inflammation, and that the Changes excited both lo- cally and constitutionally by the Gangrenous Poison, are such that the Products and Phenomena of the Disease vary to a certain Extent from those of Ordinary Inflamma- tion. MICROSCOPICAL EXAMINATION OF THE GANGRENOUS MATTER. I HAVE made numerous microscopical examinations of the gan- grenous matter, and discovered that it consists of the Microsoop- ,-,.,■, 1*1 icalexamina- various structures m a disorganized state, together with i;ionofgan- the various products resulting from the altered physical matter. and chemical changes. Innumerable granules are observable, with detached masses of fibrous and muscular tissue, broken blood- vessels, disorganizing blood corpuscles, and in some cases, espe- cially when strong mineral acids have not been applied to the gangrenous wound, crystals of the triple phosphates. Animalcules of simple organization, and endowed with active rotary motion, abound in ho.spital gangrene. The num- Animalcules ber of these vary very much, both in the gangrenous matter and in the urine, with the temperature of the sur- rounding atmosphere. In cold weather they are less numerous than in hot weather. When the decomposition of the living tissues has taken place under the sound skin, I have also found that the animalcules are not present, or if present, exist in small num- bers. abound in gangrenous matter. 266 PUS GLOBULE ABSENT FROM GANGRENOUS MATTER. After a careftil examination of various vegetable and animal Noproofthat matters exposed to the atmosphere under similar circum- m^uTraare stanccs of temperature and moisture, I have come to the Mr'connre'tl couclusion that in the present state of our knowledge we ori^n and' ^^e unablo to demonstrate that these animalcules are in horpltai^n- any way connected with the origin and spread of hospital ^"''°' gangrene. The gangrenous matter appears to afford a nidus in which these simple forms of animal and even of vegetable life are rapidly generated and multiplied. As far as my observa- tions extend, they show that these animalcules will be generated with similar rapidity in urine containing albumen, or in any nitrogenized body undergoing putrefaction in a warm, moist situa- tion, like that of the wards of a hospital. The warmth of the human body also, without doubt, affords a most favorable condition for the rapid development of the simpler forms of animal life. I have been unable to discover any forms of animalculae peculiar to hospital gangrene. With reference to the simpler forms of vegetation, they are also present, but in less abundance than those of animal life ; and in like manner these vegetable organizations are not peculiar to hos- pital gangrene, but are found in all organic matter undergoing decomposition under similar circumstances. I have been unable to establish any relation between the rapidity of the spread of the disease and the number and character of the living organisms, and have even found them absent in the most extensive gangrene which had been excluded by the sound skin from the atmosphere. These microscopical investigations have thus far afforded only negative testimony upon the animalcular origin of hospital gan- grene. I have determined, by careful microscopical examinations, that Pus globule *^^ P"s globule is not formed in true gangrenous matter, ^n'^oou? I do not wish to be understood as asserting that pus is matter. nevcr formed in a gangrenous wound. It frequently happens that gangrene may exist in certain portions of a wound, whilst in other portions the reparative process is active. So also portions of the structures may resist for a time complete death, whilst passing into a state of gangrene, and may present some of the changes of inflammation, and yield some of the products of inflammation, one of which may be an altered and imperfectly developed pus. In the healthier portions of a gangrenous wound, we may therefore have the formation of pus, whilst in the gan- CASE XI.— NECROSIS OP FEMUR. 267 grenous mass this evidence of the organizing force is absent or only accidentally present. After gangrene has set in, the reappearance of pus should be regarded as a favorable sign, indicating an attempt at Appearance organization, and an improvement in the plastic powers giobuiea' . of the parts immediately surrounding the altered gan- sigo'^ gan- grenous matter. ^™'' The following figures in Plate 7,^ will illustrate the appearance of tbe gangrenous matter. In the local manifestations of the actions of many organic poi- sons, as those of small-pox, syphilis, gonorrhoea, of sibbens or sivvens, of yaws, and of various skin diseases, the formation of pus is invariably observed. In the extensive sloughing of tissue, so often observed accom- panying necrosed bones, the formation of pus is universally pres- ent. We might illustrate this by numerous cases, but the following instance will be sufficient to represent a class of cases so common in our present struggle for independence : — Case XI. Charles E. Barker, Company D, 7th Eegiment Louis- iana Vols. Age, twenty-three. Height, five feet eight inches. "Weight in health, one hundred and fifty-four pounds. Brown hair ; brown eyes ; nervo-sauguine temperament. Wounded in right leg, at first battle of Manassas, 21st July, 1861. Minie-ball struck the lower portion of the right femur, about two inches above its inferior termination in the knee joint. The bone was not fractured ; the ball simply buried itself in the femur. The force of the ball must have been greatly spent, otherwise it would have passed entirely through the bone. The wound inflamed, and assumed an unhealthy appearance ; and twenty days after the reception of the wound the thigh was amputated near the middle, or about eight and a half inches from the trochanter major, in the general hospital at Culpepper Court House, Virginia. After the operation the stump did not heal, and the surfaces assumed an unhealthy, suppurating state. The patient was confined to his bed for more than four months, during which time there was but little progress in the healing of the wound ; the discharge continued, although there was partial union of the flaps. At the end of this period the patient attempted to walk about on crutches, and on the 20th of February, 1862, whilst the snow covered the ground, went out. This caused the stump to inflame, an accumulution of pus took place around the bone, and the flaps were opened. At this time, large quantities of offensive pus were discharged. The 1 Omitted. 268 CASE XI.— NECROSIS OF FEMUE. patient was so much reduced by this condition of the stump that he was •compelled to remain in bed until the 1st of June. After this date the wound slowly improved, and considerable portions of the flaps united. In December, this patient was able to travel to Georgia, and entered the general hospital at Augusta, January 20, 1863, and at this time came under my treatment. After careful examination, the bone was found to be extensively necrosed, and the dischai-ge from several fistulous openings was profuse and fetid. At the time that this patient entered the general hospital, he •was in a most weak and feeble condition, and suffered from hectic fever, consequent upon the condition of the stump. The pulse was rapid and feeble, and the complexion dusky and unhealthy. The sloughing went on rapidly, until the bone of the thigh was exposed and denuded. The patient was placed upon the tartrate of iron and potassa, sulphate of quinia, generous diet and stimulants, with opiates whenever necessary. Under this treatment the patient gathered sufficient strength to resume the use of his crutches, and on the 9th of March, at his urgent request, was allowed to visit some friends at Union Point, Georgia. Returned to the general hospital in Augusta in a miserable condition ; wound suppurating profusely ; bone sticking out more than one inch from the stump ; extensive sloughing of the structures around the bone. Strength completely exhausted. The plan of treatment above described was again instituted, and the wound dressed with a liniment of simple cerate, containing morphine and tincture of iodine. The pulse was so rapid and feeble, and the prostration of the nervous and muscular sys- tems was so great, that fears were entertained that this patient would not recover. Under the free administration of tonics and stimulants, combined with the most nutritious diet, however, the general health gradually improved. The bone, which was examined daily, now pre- sented unmistakable evidences that it was detached from the shaft above. On the 24th of May, 1863, 1 placed the patient under the influence of chloroform, and abstracted the bone. Length of dead bone, seven and one half inches. The entire length of the femur from the trochan- ter was abstracted, and the thigh remained without any bone through- out its extent. The following Plate, No. 8,^ represents an outline sketch of this dead bone. After the removal of the bone, the patient rapidly improved in health. Notwithstanding the continuance of this distressing source of irrita- tion, and the prolongation of the struggles of nature during the exhaus- tive processes necessary for the separation of the dead bone during a period of twenty-two months and three days, and notwithstanding the feeble state of the patient, pus was always secreted. 1 Omitted. CONDITIONS OF INFLAMMATION IN GANGRENE. 269 Had this case at any time been attacked by hospital gangrene, the secretion of pus would have ceased almost immediately, and the destruc- tion of tissue would have been greater in the course of twenty-two hours than in the whole period of twenty-two months. Even in the phagedsenic ulcers arising from the abuse of mercury, in constitutions worn down by vicious habits, deteriorated Pus formed by the abuse of alcoholic stimulants and bad diet, and da:nic°uioers poisoned by the syphilitic virus, the spread of the ulcera- the abuse tions and the detachment of the tissues is attended with in constitu- the constant formation of pus. Whether we view this down by yi- fluid as resulting from the degeneration of the affected andbaddiet. fluids and tissues in these diseases, or as analogous to a secretion thrown out by the parts surrounding the immediate focus of the inflammation, destined to dissolve the diseased tissues, or as one of the natural stages of the changes of coagulable lymph, and of gran- ulation cells in the progress of inflammation, it is nevertheless true that the absence of pus in any wound or ulcer which is rapidly enlarging its bounds, indicates marked derangement in the changes of the solids and fluids, and in the action of the forces concerned in ordinary inflammation. Whilst inflammation is justly called a diseased action, and is necessarily attended with derangements in the constitution and forces of the affected part, and in the pro- cesses of nutrition and secretion, at tiie same time it is governed by definite laws, and often progresses in such a manner as to pre- serve the life of an animal, and the functions of the part inflamed ; therefore uniform perturbations of the process as ordinarily ob- served, indicate clearly the action of some definite cause. And hence also we may correctly speak of a derangement of even the changes characteristic of inflammation. If we accept the definition that inflammation is " an alteration in the healthy structure and function of a part, accompanied by a perverted condition of the blood and capillary blood-vessels, ordi- narily attended with redness, heat, and swelling, and inducing more or less febrile disturbance in the general system," Essential . conditions of then in hospital gangrene we observe all the essential inflamma- conditions of inflammation. In this disease, there is an >i hospital gangrene. alteration in the healthy structure and function of the observations *' on innam- affected parts, as indicated by the change of color and nation. structure, the fetid odor, and the suspension of secretion and healthy nutrition ; there is an altered condition of the blood, as manifested by the dark livid areola, by passive hemorrhages, and by the dusky hue of the complexion ; there is derangement of the 270 KELATIONS OF INFLAMMATION TO GANGRENE. capillary circulation, as manifested in the effusion in and around the gangrenous tissues, and the intense congestion of the blood-vessels in immediate contact with the diseased part ; there is redness, pain, heat, and swelling ; and there is more or less febrile disturbance of the general system, as manifested in the rapid, feeble pulse, the marked diurnal elevations and depressions of temperature, the de- pressed spirits, and deranged muscular and nervous actions. When the injury of the living tissues is simple, as in a wound caused by a mechanical instrument, the natural result of inflammation appears to be the production of such a fibrous effusion as will surround and isolate the injured or diseased parts. In such uncomplicated cases of the inflammatory process, there will be observed in the injured structures the perversion of nutrition, the destruction of capillaries, the alteration of blood, the exudation of lymph, and the formation of pus ; and around the focus of actual destructive changes, the blood-vessels are distended with blood, and exude the plastic lymph from which the coagulable elements separate, containing the germ cells destined not merely to form a structure inclosing the diseased part, but also by their development to form a tissue which will replace that which has been destroyed. The living cells of the lymph may either form tissue or granulations, or they may be arrested and altered in their development and form the pus globule. With regard to the vital properties of coagulable lymph, its essential character is its power to develop itself, and to assume organic structure. The character and rapidity of the transforma- tions and development of the living cells of the lymph effused in inflammation, will depend chiefly upon the cause exciting the dis- ease, and upon the powers of the general system, and upon the constitution of the blood, and consequently of the lymph itself. Thus, in open wounds, when the constitutional forces are deflcient, the granulations may be arrested in their development, or they may become more granular, and lose the well-marked characters of their nucleus, and acquire the structure of the pus cell. This degeneration of the lymph cells and granulations into pus, should however by no means be taken as an evidence that the natural powers of the system are defective, or that the constitution of the blood and lymph are abnormal, for it is invariably present in all wounds which do not heal by immediate contact or by the first intention, and appears to be intimately associated with, if not abso- lutely necessary to the successful healing of the injured parts. It is rather the amount and character of the suppuration which indi- cate the extent to which the powers are involved. We should RELATIONS OF INFLAMMATION TO GANGRENE. 271 therefore regard pus on the one hand as a secretion, destined to dissolve certain organic tissues, and to shield by its bland proper- ties delicate granulating surfaces from the direct action of the atmosphere ; and on the other hand, as a rudimental, imperfectly developed, or degenerated substance, essentially similar to the materials of the lymph of inflammatory exudation, or of granula- tions, but which has either failed of being developed like them, or which has degenerated after a certain amount of develop- ment. In hospital gangrene the lymph effused around the focus of disease possesses the power of coagulation, as in other in hospital varieties of inflammation, as I have determined by actual fhefymph experiment, and there appear to be all tlie conditions eesses thT' necessary for the arrest of the disease, by the develop- coagulation, ment of coagulable lymph through nucleated cells into pLrtoSi*^ the fibrous and fibro-cellular or connective tissue ; but the uons necea- characters of the irritant poison are such, that the prod- arrest of the ucts of inflammation, together with the blood-vessels organization and the blood itself, are rapidly disintegrated. The life elements; of the blood is destroyed by the gangrenous poison, and actersofthe the fluids and living organizable matter and cells upon son arc such, which tne progress ot miiammation depends, are poisoned, dncts or in- T i/»i'i IT ' ' n^ 1 flammation It results from this that the uquor sanguinis, ettused togetiierwith .,.,,. , . , tlieblood- within the diseased structures, does not pass into the vessels ana . - 1 1 1 1 1-1 the blood it- state or pus, as in healthy wounds, and in the common self are 1 T 1 1 • -1 rapidly dis- furuncle and carbuncle, or even in erysipelas and the integrated. pustules of small-pox, and the exudation corpuscles are so poisoned and disorganized that they are not further changed in either a pro- gressive or descending series, and wherever the limiting fibrous wall is thrown out with its cellular elements, it is in like manner destroyed whenever it is reached by the poison. All the changes of the blood characteristic of ordinary inflammation may be present around the gangrenous part, as the increase of liquor sanguinis, with increase of its albumen and fibrin, both actually and relatively to the blood corpuscles, aggregation of the red corpuscles, and increase of the colorless or lymph corpuscles ; but no arrest of the disease will take place as long as the poison is capable of exciting rapid change and decomposition, after the manner of a nitrogenized ferment, in the products of inflammation. If, in a wound infected with hospital gangrene, the morbid pro- cess did not advance as in any other wound, from the The rapidity centre to the circumference, with the central focus of ressofhos- 272 CHEMICAL EXAMINATION OF GANGRENOUS MATTER. ^^eltoited infection and active disorganization surrounded and ratent b?^'" guarded, as it were, by a circle of active congestion, aotiOT^of'the ''^i*^ blood-vessels loaded with colored corpuscles, with poison. interrupted circulation and exudation of plastic liquor sanguinis, and with venous and lymphatic absorption greatly impeded, if not altogether arrested, the gangrenous poison would enter directly and rapidly into the circulation, and prove speed- ily fatal. And even after the excitation of inflammation, in vir- tue of the irritant properties of the poison, in every case of hos- pital gangrene of any standing, more or less of the poison is absorbed, and affects the general system. The extent of this absorption of the deleterious agent or agents will depend upon many circumstances, but chiefly upon the character and extent of the inflammatory processes around the immediate centre of in- fection. We may in these facts find some explanation of the relief sometimes afforded by hemorrhage in hospital gangrene. The poison is diluted and washed out by the blood at the same time that "the inflammatory congestion is re- lieved by the hemorrhage. Finally, the results of these microscopical observations Explanation of the relief Bomctimes aSbrded by hemorrhage in hospital gangrene. Hospital gangrene due to the action of an irritant clcarlv sustain the view that hospital gangrene is due to organic poi- '' i o o son, which after the manner of a ferment is capable of inducing decomposi- tion in the tissues and . in the blood. the action of an irritant organic poison, which, after the manner of a ferment, is capable of inducing such decom- position in the tissues and in the blood, that all develop- ment of the cellular elements of the liquor sanguinis into cells, fibres, or into pus, is arrested. CHEMICAL EXAMINATION OF THE GANGRENOUS MATTER. From the disintegration of the organic constituents of the struc- tures in hospital gangrene, a number of compounds re- sult, which are either unknown or are very rare in the living organism. Some of these products, when absorbed, act as animal poisons upon the muscular and nervous sys- tems, and tend to disorganize the blood and derange the actions of the alimentary canal. When absorbed in large quantities, these products sometimes act as irritants to the intestinal canal, and the patients are sometimes destroyed by the diarrhoea consequent upon their action. The extent of these changes is well illustrated by the fact, which I have demonstrated by microscopical and chemical investigation, that ammonia is some- Chemical ex- amination of gangrenous matter. Ani- mal poisons generated during the progress of hospital gan- grene. COMPLEX NATURE OF GANGRENOUS MATTER. 273 times generated in such large quantities in gangrenous muscles, as not only to give a strong alkaline reaction to the naturally acid muscular juices, but also to cause the precipitation of the phos- phates in the form of well-defined crystals of triple phosphate. These crystals were chiefly prismatic, and were found in great numbers in the muscular structures and in the alkaline gangrenous juices pressed out of the muscles. The products of the dead tissues which prove when absorbed so deleterious to the patient, are nevertheless harmless to certain forms of animal life. Thus, the common maggot is rapidly developed and multiplied in the gan- grenous matter, and if allowed to remain, will consume the dead tissues completely. Such a cleaning of a gangrenous wound is said in some cases to have been beneficial. The full analysis of the gangrenous matter will be reserved for the final report ; we will content ourselves for the present with a brief reference to the great complexity of the investigation. Thus, in a gangrenous mass of matter upon the thigli or upon any muscular portion of the human body, there are more complicated than thirty different organic and mineral bodies in various maSriab^en- states of combination which should be examined, besides ^""gaigran- the various products resulting from their decomposi- ""^ changes. tion. There is the skin and its excretions ; the blood, with its water colored and colorless corpuscles, liquor sanguinis, extractive . and fatty matters, and various mineral salts (hsematin, globulin, cell membrane, extractive matters, serolin, phosphorized fat, choles- terin, saponified fat, iron, phosphorus, sulphur, fibrin, albumen, colorless corpuscles, exudation corpuscles, phosphates of soda, potassa, lime, and magnesia, sulphates of soda and potassa, and chlorides of sodium and potassium) ; muscular tissue (muscular fibre, syntonine, gelatine, albumen, creatine, creatinine, inosic acid, lactic acid, fat, sulphur, and phosphorus, chlorides of sodium and potassium, sulphates and phosphates of, the alkalies and alkaline earths) ; nervous structures, with various fats and phosphorus : elastic and fibrous tissue, and the structures of the capillaries, veins and arteries. In hospital gangrene we have all these sub- stances, many of which are highly complex in their chemical con- stitution, mingled together in a disorganizing decomposing mass. The problem involves not merely the determination of the peculiar poison inducing gangrene, but also the various products resulting from the chemical changes which it induces in these highly com- plex organic compounds. 274 OBSERVATIONS OF SURGEON CHAMBLISS. During my investigations u^on hospital gangrene in the hospitals in and around Richmond, Virginia, in the month of August, 1863, I received the following interesting communication from Surgeon J. C. Chambliss, of Winder Hospital : — WiNDEK Hospital, Division No. 2, ( 2ith August, 1863. ) Dr. J. Jokes, Surgeon P. A. C. S. Sir, — You will please accept a specimen of matter taken from a Observationa Violent case of hospital gangrene. The wound is situated in S'a cSam- middle third of thigh, received at Gettysburg, July 3, 1863. th?°cEcai ^° remedies had been applied when the matter was taken, properties of J Send vou also a small vial, containing a pink-colored hospitiLl gan- *" ' c x grene. fluid or precipitate, caused by the action of nitric acid upon a Pink prccip- solutiou of this matter in distilled water. Now I have tried ducedby the this experiment with matter taken from this and other wounds trie Mid*^ "'" affected with gangrene, and have the pleasure to state that ^n''oQs''' the results have been in every case similar, namely, a beauti- matter. {^\ pink-colored precipitate. Again, I have tried the action of the acid upon healthy pus, taken from a wound which had been gangrenous, and find only a white coag- ula ; also upon pure blood and this pus mixed, but the result is similar to that from healthy pus alone. Again, I thought probably this peculiar precipitate of the gangrenous matter might be the result of putrescence or the presence of sulphu- retted hydrogen gas. This, however, I disproved by testing matter taken from the body of a decayed rat, which was acted upon, and a straw-colored precipitate the result, the usual action of the acid upon animal tissue. I have also discovered that the peculiar pink-colored precipitate is pro- duced in the wound when the acid is applied, the parts being thoroughly gangrenous, which I at first took for blood, but since, I am satisfied that it is the action of the acid upon this element, if I may so call it. Now the obtained precipitate, so peculiar in color, and so unlike that obtained from healthy pus, or animal tissue generally, and my knowing so well the specific action of nitric acid, and observing a fluid of this color in the wound when it was applied, induced me to try and discover the cause of hospital gangrene. I have tested with pyroligneous acid, nitrate of silver, and other remedies, but nothing has appeared similar to the action of nitric acid. Gangrenous matter I find is highly acid, reddening litmus paper ; the smell indicates the same when freshly taken from the wound. You will please be so kind as to repeat my experiments, and tell me what this precipitate results from. I have noticed that the color of the pink precipitate is permanent only when the vessel is kept well stoppered ; otherwise it will fade to a OBSERVATIONS OF ME. CRUIKSHANK. 275 dirty whitish color, in a few hours, by exposure to air, probably by the absorption of oxygen. I regret to say that my limited knowledge of chemistry, and my poor apparatus for testing, has brought me to this perplexing halt, the solu- tion of which will be long remembered and highly appreciated bv Yours, most respectfully, J. CHAMBLISS, Surgeon P. A. C. S. In charge Division No. 2. P. S. — I am making some interesting experiments upon dogs, relating to the same subject, which I will communicate if the results prove important. j. c. When the specimen of gangrenous matter tested with nitric acid, referred to by Dr. Chambliss, reached me in Rich- Nitric acid mend, the peculiar pink color had disappeared. A few uwe test for days afterwards, I visited Winder Hospital, and repeated grenc. Re- .•', „ Vm, , 1- 1 . '■ suits not with Surgeon Ghambhss the experiments upon gan- uniform. grenous matter and healthy pus. The results were not uniform, and I was led to believe that this was not an infallible test for the presence of the disease. The first chemical examination of the matter of hospital gan- grene, appears to have been made by Mr. Cruikshank, chemist of the Royal Artillery ; and it was published by Dr. Rollo, Surgeon- General to the Royal Artillery, in the first edition of his work on Diabetes,^ under the head of " A Short Account of a Morbid Poison acting on Sores, and of the Method of destroying it." The following are the remarks of Mr. Cruikshank upon his experiments instituted for the purpose of examining the matter of ulcers, which, from the careful description of Dr. Rollo, were evidently nothing more nor less than the disease now denoted hospital gangrene : — " The matter of this sore is sparingly soluble in water, but readily diffused through it, producing a milky appearance ; pure vol- Jg™^/^, atile alkali first reduces it to a transparent jelly, and after P'JJ'^^^""'^ some time dissolves the greatest part ; a similar effect is pro- chemi^ na- duced on pure pus. These solutions are but partially precip- matter of itated by acids, particularly the sulphuric. The tinctures of grene. litmus and Brazil-wood are not changed by this matter ; it does not,, therefore, possess either acid or alkaline properties. • If to the filtered solution of this matter in distilled water a little nitrated silver be added, a whitish colored precipitate will be produced. Similar precipitates, but much more copious, are occasioned by nitrated and muriated mer- 1 London, 1797. 276 CHEMICAL CHARACTER OF GANGRENOUS MATTER. cury. When pure pus is treated in this way, these precipitates, partic- ularly that by muriatic mercury, have somewhat of a different appear- ance, which it would be difficult to describe. The fetid smell is somewhat changed by lime-water, but not destroyed ; the sulphuric acid rather increases it ; a similar effect is produced by alcohol, and by the alkaline solution of arsenic. A decoction of the Peruvian bark does not destroy the fetor. This, however, is effected by the nitrates and muriates of mercury, by the nitrous acid, but most completely by the oxygenated muriatic acid and gas. Nitrated silver produces very little change, either in its color or smell, a circumstance the more remarkable as this salt possesses the property of destroying the most offensive smells, even that of the matter of cancer. " It must be allowed that the offensive smell of the matter of this sore is produced by that part of the discharge which is altered from the nature of pure pus ; for we know that every ill-conditioned discharge has more or less smell, while good pus has none. It is a known fact in chemistry, admitting of few exceptions, that a substance cannot have its smell totally destroyed or altered, without having its properties changed at the same time. If therefore this peculiar matter, by the addition of nitrated or muriated mercury, the oxygenated muriatic acid, etc., should have its smell completely destroyed, there is every reason to believe that its peculiar properties will be so also ; and should it be capable in its original state of producing an ill-conditioned action in sores, the addition of such substances might prevent this mischief If it should be sup- posed, therefore, that an acrid matter, somehow produced on the surface of sores, were capable of producing ulceration of a specific kind, and that this ulceration, like the venereal, should generate more of a nature similar to itself, capable of extending the mischief, and even of bringing on a general affection of the system, some important conclusions might be drawn from. these experiments. " 1. It is easy to see that a sore once clean, might be preserved from the effects of the matter alluded to, by washing it at every dressing with a weak solution of nitrated mercury, or the oxygenated muriatic acid ; and that even the generation of such matter might be entirely prevented by the same means. " 2. After the action has taken place, and before a general disposition ' is formed, it might be possible to put a stop to its progress by very active topical applications, such as should be capable not only of destroy- ing the specific nature of the matter generated, but also the action itself. From the experiments already related, it is evident we should prefer in this case the most active mercurial preparations, such as red precipitate, not entirely deprived of its acid, or the muriated mercury ; and if an active caustic were to be employed, we should have recourse to the strong nitrous acid applied in Mr. Hunipage's method, rather than the nitrated silver, especially as it may have also the effect of MICROSCOPICAL CHARACTER OF PUS. 277 changing the nature of the discharge. This consists in dipping a little lint in the acid and applying it to the part ; it communicates less pain than any other caustic, except the nitrate of silver." MICROSCOPICAL EXAMINATION OF THE PUS SECRETED BY WOUNDS AFTER THE REMOVAL OF HOSPITAL GANGRENE. After the removal of hospital gangrene from a wound or ulcer, the pus secreted from the granulatiiiff surface will vary Microsoop- , ,., i.i-i icalexamina.. in its character, accordmg to the extent to which the uonofthe blood and general system have been involved by the dis- by wounds ease. W hen the constitution oi the blood has not been mo™' of , , , „ - , . , , hospital gan- impaired, and the forces ot the system remain unabated, grene. the pus will present the usual characters of this fluid secreted from healthy granulating surfaces ; it will be thick and cream-like, with numerous well-formed pus globules, and comparatively few gran- ules. If, however, the constitution of the blood be deranged by the action of the gangrenous poison, and its fibrin be diminished below the standard usual in the phlegmasiae, and the nervous and muscular forces be greatly reduced, the granulations will be slow in forming, and the pus thrown out will be thin and ofttimes fetid, with comparatively few pus globules, and numerous undeveloped granules. The results of these microscopical observations confirm those previously recorded by Rokitansky and Mr. Paget : .»— " The conditions which are chiefly powerful in determining the character and tendency of inflammatory lymph, are three, observations , of Rokitaa- namely : — sky and « 1. The state of the blood. J'J^.IS " 2. The seat of the inflammation. "f ""? "'"' . oiintiamnia- " 3. The degree of the inflammation. ^ry lymph. " First, In regard to the influence of the state of the blood in deter- mining the characters of an inflammatory product, Rokitansky has happily expressed it by saying that ' the product of the inflammation exists, at least in part, in its germ pre-formed in the whole blood.' " Some indeed have supposed that lymph is only the liquor sanguinis, exuded in excess through the walls of the blood-vessels ; but of this opinion we cannot be sure ; and many facts, such as the occurrence of inflammatory lymph which does not spontaneously coagulate ; e. g., in herpes, will not agree with it. Still, it ,is not difficult to show that a certain character is commonly impressed by the state of the blood on the inflammatory product from it. " I will not refer here to the cases of inoculable diseases in which some of the morbid material that was in the blood may be incorporated 278 MICROSCOPICAL CHARACTER OF PUS. with the product of a local inflaratnation, though in these the corre- spondence of the blood and the inflammatory product is manifest enough, but I will refer to cases that may show a more general corre- spondence between the two, a correspondence such that, according to the state of the blood, so is the lymph more fibrous or corpuscular, more characteristic of the adhesive or of the suppurative inflamma- tion. " Some of the best evidence of this is supplied by Rokitansky, in the first volume of his ' Pathological Anatomy.' In this work, he has shown clearly that the characters of inflammatory deposits, in diflTerent diathe- ses, correspond very generally and closely with those of the coagula found in the heart and pulmonary vessels ; and that, in general, the characters of inflammatory lymph formed during life, are imitated by those of clots found in the body after death, when the fibrin of the blood may coagulate very slowly and in contact with organic sub- stances. " Other evidence may be obtained by examining the products of sim- ilar inflammations excited in several persons, in whom the state of the blood may be considered dissimilar. And here the evidence may be more pointed than in the former case ; for, if it should appear that the same tissue, inflamed by the same stimulus, will in different persons yield different forms of lymph, we shall have come near to certainty that the character of the blood is that which chiefly determines the character of an inflammation. " To test this matter, I examined carefully the materials exuded in blisters raised by cantharides plasters, applied to the skin in thirty patients in St. Bartholomew's Hospital. Doubtless, among the results thus obtained, there might be some diversities depending on the time and severity of the stimulus applied ; still, it seemed a fair test of the question in view, and the general result proved it to be so. For, although the differences in the general aspects of these materials were slight, yet there were great differences in the microscopic characters ; and these differences so far corresponded with the nature of the disease, or of the patient's general health, that at last I could generally guess accurately, from an examination of the fluid in the blister, what was the general character of the disease with which the patient suf- fered. Thus in cases of purely local disease, in patients otherwise sound, the lymph thus obtained formed an almost unmixed coagulum, in which, when the fluid was pressed out, the fibrin was firm, elastic, and appar- ently filamentous. In cases at the opposite end of the scale, such as those of advanced phthisis, a minimum of fibrin was concealed by the crowds of corpuscles imbedded in it. Between these were numerous intermediate conditions which it is not necessary now to particularize. It may suflSce to say that, after some practice, one might form a fair CHAlifGES OP THE BLOOD IN GANGRENE. 279 opinion of the degree in which a patient was cachectic, and of the degree in which an inflammation in him would tend to the adhesive or the suppurative character, by these exudations. " The highest health is marked by an exudation containing the most perfect and unmixed fibrin, the lowest by the formation of the most abundant corpuscles, and their nearest approach, even in their early state, to the characters of pus cells. The degrees of deviation from general health are marked, either by increasing abundance of the corpuscles, their gradual predominance over the fibrin, and their grad- ual approach to the characters of pus cells, or else by the gradual dete- rioration of fibrin, in which, from being tough, elastic, clear, uniform, and of filamentous appearance or filamentous structure, it becomes less and less filamentous, softer, more paste-like, turbid, nebulous, dotted, and mingled with minute oil-molecules. . . . " Simple as the observations are, they may illustrate what often seems so mysterious, namely, the different issues of severe injuries inflicted on difierent persons. To what, more than to the previous or some acquired condition of the blood, can we ascribe in general the various conse- quences that follow the same operations on different patients ? The local stimulus, and the conditions by which the inflammatory product finds itself surrounded, may be in all alike ; but, as in the simpler case of the blister, the final events of the inflammation are according to the blood."! CHANGES OF THE BLOOD IN HOSPITAL GANGRENE. In this disease, it would be manifestly improper to abstract blood by venesection simply for analysis, when the lancet changes of vv^ound would be liable to be attacked by gangrenous h'J,spi't^'^„. inflammation, and the life of the patient might be sacri- ^^^^t^} ficed. This danger was especially to be dreaded in the woodfu'^ crowded Confederate hospitals, scantily supplied with *■*"«• lint, rags, and utensils and instruments. My examinations, there- fore, have been necessarily limited to the examination of the blood collected during hemorrhages and amputations. As the period and mode of occurrence of hemorrhages were necessarily uncertain, I was dependent in a great measure upon the assistance of the medical officers and nurses for the careful collection and preservation of the blood. I furnished a number of the medical officers at various times with porcelain capsules, suitable for the reception of from two hundred to two thousand grains of blood. My thanks are especially due to 1 Lectures on Surgical Pathology, etc., by James Paget. Philadelphia, 1854, pp. 219- 221. 280 CASE XEL — CHANGES OF BLOOD IN GANGRENE. Assistant-Surgeon A. A. Powell, of the Empire Hospital, Macon, Georgia, for valuable aid in the collection of the blood of hemor- rhages occurring during various stages of hospital gangrene. The first and most important subject in the relations of the changes of the blood to this disease, which we endeavored to inves- tigate, was the character and quantity of the fibrin. We proceed at once to present such cases as we conceived were suitable for this investigation. Case XII. Arnold Nowell, Company E, 57th Regiment Alabama Casexii. Vols. Age, thii'ty-seven. Native of Washington County, thechanio- Georgia. Black hair and eves. Weight in health, one hun- ters of the ^ o ' bioodinhos- dred and fifty-six pounds; now much reduced. Very dark, lienef" sallow, unhealthy complexion. Wounded July 20, 1864, at battle on Peach-tree Creek, near Atlanta. Was carried from the field of battle to Loring's Division Hospital in Atlanta. Minie-ball struck the fleshy part of the fore-arm about its middle. No bones were injured ; and although there was some hemorrhage, the wound was con- sidered by the attendant surgeon as slight. Remained in Atlanta one day, and was then transferred to the City Hall Hospital, in Macon. Had been in the City Hall Hospital for one month, and the wound was healing rapidly ; the point of entrance was healed, but the point of exit was still open and suppurating. At this time the wound took on gan- grenous inflammation ; it became swollen, and was surrounded by a red, livid areola, and " burned most painfully." The gangrene, therefore, appeared about the 20th of August Was transferred to the Empire Hospital, in Vineville, about the middle of September. At this time the muscles of the arm and fore-arm, in the region of the elbow joint, were extensively denuded, and the gangrene was spreading. Under the local application of nitric acid, and the internal use of quinine and tincture muriate of iron, the rapidity of the spread of the gangrene appeared to be somewhat diminished, but the disease was never entirely arrested. October 1 . — Sallow, dark, unhealthy complexion. The gangrene has made fearful ravages, denuding the nmscles of the fore-arm and arm, exposing the condyles of the humerus, and the bones and tendons of the joint of the right arm. The muscles exposed present smooth red and purplish and greenish colors in different portions, and the raw sur- face is without any suppuration, and the gangrene is spreading chiefly along the inferior edges of the wound, and has penetrated the joint The odor is insupportable. Patient nervous and restless. Bowels greatly disturbed, — running off" continually. Had several most offen- sive and fetid evacuations, which diffused a most overpowering and disgusting gangrenous odor, whilst I was executing a sketch of the wound. Eye expressive of great dejection and nervousness ; the well CASE XII. —CHANGES OF BLOOD IN GANGRENE. 281 arm and hand trembles upon the slightest exertion ; has scarcely strength to lift a cup of water to his mouth, and the hand is so tremulous that it cannot retain the cup to the lips. Prostration of nervous power complete. Talks to himself, and although when aroused and directly interrogated gives a coherent answer, still his intellect is very sluggish, and his answers are slow and hesitating. In fact, his condition, when the attention is not directly held, might be justly de- scribed as that of low muttering delirium. One of the most striking proofs of the aberration of nervous and intellectual action is that the patient appears to be wholly insensible to his most distressing condition, — does not notice the horrible stench from his rotten arm, or from his fetid evacuations, and in reply to inquiries after his health, states that he is much better, and will be soon well. When, however, his arm is moved, his face is greatly contorted, he groans out, and weeps like a child. Tongue dry, and of a dark purple and blue color. No appetite. Refuses food ; or if he attempts to eat, takes a mouthful or two, and then says that he is satisfied. Skin dry, and rather harsh to the feeling. Two o'clock p. M. Temperature of hand, 39° C. (102.2° F.). Tem- perature of axilla, 39.2° C. (102.6° F.). Pulse 100, very feeble, a mere thread. Eespiration 21. Treatment, directed by the attendant medical officer, Assistant-Surgeon Powell, consists of tincture muriate of iron, m. XV., and sulphate of quinia, grains iii., three times a day ; astringent pills of tannin and opium, every three hours, designed to control the bowels ; turpentine emulsion, table-spoonful every four hours ; and nu- tritious diet. This day I made the sketch, Plate No. 9,^ of the right arm of this patient, designed to give a general idea of the extent and color of the gangrenous wound. This represents the right arm bent as it rested upon a pillow. In making this drawing, I was seated upon the left side of the patient facing his head. The denuded bones were exposed upon the opposite side, and are not therefore represented in this sketch. October 2. — Nine o'clock A. m. Speech low, and intellect sluggish. Left hand trembles continuously. Tongue trembles when protruded, and the muscles of the mouth tremble, as well as the balls of the eye when speaking. Voice tremulous, hesitating, and feeble. Still imcon- scious of his condition, and says that he is better. The muscles present the same glazed appearance, and red, purple, and green and bluish colors. The odor of the wound intolerable. Gangrene continues to spread, and is destroying the capsular ligament of the elbow joint. No pus is secreted by the denuded surface, nothing but a fetid, sanious, greenish, gangrenous, disorganized matter flows in small quantities from the wound. Tongue presents the same dry, dark purple, blue color. No appetite whatever. Bowels still running off, — discharges of a yellow 1 Omitted. 282 CASE XIL— BLOOD IN HOSPITAL GANGRENE. color, with abundant evidence of bile. Stools emit a most disagreeable smell, similar to that of gangrenous matter, with the addition of a strong human foecal smell. Some hemorrhage from the wound this morning. Temperature of axilla, 38.5° C. (101.4° F.). Temperature of hand, 37.2° C. (99 F.). Pulse 100, very feeble. Eespiration, 18. As the day advanced,, the pulse became more rapid, and reached 120 at two p. m. The respira- tion also increased in frequency, and the temperature of the body rose several degrees. (Treatment continued.) Examination of Urine. — Amount of urine collected during twenty- four hours (October 1, one o'clock p. m.), grains 5581.63 ; specific gravity, 1013. Deep orange-red color. The amount of urine collected does not represent the entire amount excreted, as it was impossible to collect a large portion of the urine on account of the incessant actions on the bowels. At the end of four days the urine still gave a strong acid reaction ; and at this time a white scum floated upon the surface, which was found under the microscope to consist of numerous veg- etable cells, resembling the Torula of diabetic urine ; and the body of the fluid was turbid from the presence of thousands of these vegetable cells. A few casts of the tubuli urimferi were also observed. When first collected the urine was perfectly clear. ANALYSIS OF URINE, NO. 8. Elements. Amount of urine collected during twenty-four hours (Oct. 1, one p. M., to Oct. 2, one p. m.,) only a small portion of the entire amount collected, on account of the affection of the bowels .... Urea TJric acid Free acid Phosphoric acid Equivalent of phosphorus in phosphoric acid . . . Sulphuric acid Equivalent of sulphur in sulphuric acid . ... Chloride of sodium Equivalent of chlorine in chloride of sodium . . . Urine collected during 24 hours, contained grains 5581.63 177.87 2.45 10.78 16.60 7.28 5.16 2.06 5.39 3.55 1,000 parts of urine COQ. tained 21.11 0.43 1.93 2.97 1.10 0.92 0369 0.96 0.63 October 3. — No improvement At nine o'clock a. m., the pulse was very feeble and rapid, could scarcely be felt, and could not be counted with accuracy. Surface of hands very cool ; patient very feeble and restless. As the day advanced, the temperature gradually rose, and the extremities became warm; and at 12 m., the temperature of the axilla was 39° C. (102.2° F.), and the temperature of the hand 38.2° C. (100.8° F.). Pulse 124, very feeble, and could scarcely be counted, but feebler than at nine a. m. Respiration, 24. Says that toward morning CASE XIL— BLOOD IN HOSPITAL GANGRENE. 283 he had felt completely chilled. Tongue inclined to be dry, slightly furred at the sides, but of a deep purplish and blue and leaden hue in the centre and around the edges. This color is very striking. Bowels very loose ; operations exceedingly fetid. Still no suppuration from wound. Gangrene progressing. Patient very feeble, nervous, restless, and stupid ; appears to be somewhat deaf. Six o'clock p. M. Pulse, 120 ; very feeble. Respiration, 29. Tem- perature of hand, 38.2° C. (100.8° F.). Temperature of axilla, 39.2° C. (102.6° F.). Tongue of a bluish color and very dry. Patient continues in the same miserable state ; he is, however, wholly unconscious of his true condition, and when aroused from his dull, stupid state, says that he feels somewhat better. October 4. — Hemorrhage from the brachial artery, near where it di- vides into the ulnar and radial arteries, took place this morning at sun- rise, and the patient died in twenty minutes. Although not more than one pint of blood was lost, the patient was so feeble that death was the result. Examination of Blood. — The blood was preserved for examination and analysis. The blood presented a dark grumous appearance, and the surface changed very slowly to the arterial hue when exposed to the action of the atmosphere ; and the scarlet, or rather the purplish-scarlet color, did not penetrate for any distance into the coagulum. In coagu- lating, the clot did not inclose all the colored blood corpuscles, and the serum presented a turbid red color. Many of the colored corpuscles settled to the bottom of the serum. No buffy coat was formed, and the clot resembled that of a case of malarial fever more nearly than the blood of the phlegmasiae. During the hemorrhage, seven hundred and seventy grains of blood were carefully received into a porcelain capsule, and from this I sepa- rated and determined the fibrin with great care, and found it to amount to three and one tenth (3.1) grains. Fibrin, in 1,000 parts of blood, 4.02. The structure of the clot was less firm than in health, or in inflam- matory diseases of a sthenic character. The arm was carefully examined after death, and the parts were found to be firmly contracted. In attempting to straighten the arm, the rotten muscles and tendons were ruptured. Gangrene had penetrated the joint, which contained fetid sanious, greenish, gangrenous fluid matter. Commentary. — The question of amputation was one of most serious importance in this case. The arm should have commen- been ampuUted immediately after the opening of the «onof?mf" joint. This was the only chance for the salvation of this ^"^"3^5 patient. This question will be more fully discussed here- p"'°^°'=«- after under the head of treatment. In the present case, it was 284 CHANGES OF BLOOD IN HOSPITAL GANGRENE. thought advisable by the attendant physician to delay the opera- tion until the constitutional symptoms were improved, and there were some evidences of the arrest of the progress of the gangrene. In such cases, when any large joint is extensively denuded, exposed, and opened, amputation under almost any circumstances appears to be demanded, even though from the extent to which the general system has been involved tlie disease will certainly return in the stump ; for we thus remove the large diseased painful source of infection, substituting a much smaller wound, and the danger of hemorrhage is, for a time at least, lessened. The proper course of treatment in this case would have been to The arm have amputated as soon as the joint was exposed and been ain''p™ Opened, and there was risk of hemorrhage ; and then the ^'^*^°?,j°™ patient should have been placed upon large doses of tur- wM exposed, pg^tiue (m. XX. to fsi. in form of emulsion every three or four hours), and alcoholic stimulants (whiskey or brandy, fsss. to fsi. every two or three hours), and upon the most concen- trated animal food and digestible vegetables ; and the stump should have been kept scrupulously clean, and surrounded with cloths saturated with Labarraque's solution of chlorinated soda, and with tincture of camphor. The action of the gangrenous poison upon the general system Signs of the was manifested by the feeble, rapid action of the heart, the gangre- the great changcs of temperature, the depressed, enfee- upon the blcd uervous and muscular forces, the trembling hands tern. and the low muttering delirium, and the trembling eye- balls and quivering features, and the insensibility of the organs of sense, the derangement of digestion, and the fetid diarrhoea. The dusky sallow" hue of the complexion, and the livid blue color of the tongue, were manifestly due to derangements induced by the gangrenous poison in the constitution of the blood and in the capillary circulation, and in the processes of nutrition, secre- tion, and excretion. The blood appeared to have lost in great measure its power of absorbing oxygen. And were the processes of analysis sufficiently exact and comprehensive, it might have been possible to have detected the gangrenous poison or the prod- ucts of its action in the blood. The intestinal canal appears to eliminate considerable quantities of the offending matters from the blood. The fibrin was slightly increased above the standard of health, 3h''e''wno"d° °' ^®"^g ^-^^ P^'^'^^ ™ -"-'^^^ P^''*^ °f '^I'^o'^ ; whilst in healthy toSSd"^ blood the fibrin may vary from 2 to 3.-5 in 1,000 parts, CHANGES OF BLOOD IN HOSPITAL GANGRENE. 285 it was below the standard observed in the phlegmasise gen- "^"J'f'^' . erally ; thus, according to Andral and Gavarret, the mean ^1^1^^^°'^' of fifty-eight analyses of the blood of pneumonia gave 7.3 ^jlhlh""' parts of fibrin, with a minimum of 4, and a maximum of Jf t^"""". 10.5 ; in pleuritis, mean of five analyses, 6.1 ; in angina Ta'iius'di"- tonsillaris, mean of six analyses, 5.55 ; and according to '''^' Becquerel and Rodier, the standard for the phlegmasiss generally, as determined by numerous observations, is 5.8. In this case the fibrin was increased above the standard usual in idiopathic fevers ; thus, in nine cases of malarial fever I found the fibrin to rano-e from 0.877 to 2.938, with a mean in 1,000 parts of blood of 2.018 ; in marsh cachexy, induced by the malarial poison, Becquerel and Rodier found in five cases the fibrin to range from 2.36 to 4.27, with a mean of 3.39 ; Andral and Gavarret, in forty-one analyses of the blood in typhoid fever, give the minimum of fibrin as 0.9, .the maximum, 4.2, and the mean, 2.6 ; in typhus fever, according to M. H. Guenaud de Mussy and M. Rodier, maximum, 3.9, mean, 2.466, minimum, 1.2. The fibrin was increased above the standard for small-pox, as determined by Andral and Gavarret (mean of blood of five cases of small-pox, 2.4, maximum, 4.4, minimum, 1.1) ; it was less than that of scarlatina, according to the same observers (mean of four cases, 4.35, maximum, 6.8, minimum, 3.1) ; it was somewhat greater than that of measles : mean of seven cases of measles (Andral and Gavarret), 2.742, minimum, 2.4, maximum, 3.4. It is also important to note that this constituent of the blood was in larger amount than in acute or chronic scurvy ; thus. The fibrin in according to Becquerel and Rodier, the fibrin in 1,000 a^untthan parts of the blood of a man aged 48 years, sick with I-hroSc " scurvy 42 days, was 2.5 ; in a man aged 21 years, sick =="'y- 30 days, 2.2; in a man aged 32, sick 456 days, 1.85; in a man aged 23, sick 552 days, 1.32. As far as my observations have extended, there is no necessary connection between hospital gangrene and scurvy. The j,,, necessary two diseases may exist together, and hospital gangrene Smdiim- appears to commit most frightful ravages in scorbutic pa- pt^^^i tients, but they are not related to each other as cause ^'^y- and effect. This observation is still further sustained by the fact that the remedies best adapted to the cure of scurvy exert little or no effect upon the progress of hospital gangrene, and I have seen hundreds of cases arising in men in whom no sign of scurvy was present. 286 CASE Xni. — BLOOD IN HOSPITAL GANGRENE. When the two diseases exist in the same individual it is un- doubtedly true that it is difficult to eradicate and cure the hospital gangrene until the scurvy has been removed by a proper course of treatment and diet ; but this fact does not at all establish any identity or even relationship between the two diseases. It is also worthy of consideration that the fibrin was increased The fibrin ^^ ^ much Icss extent than is usual in erysipelas ; thus, toamuX** Popp found this constituent to exist in the blood of a man ttSn^isu°aai Suffering from erysipelas in as large a proportion as 6.6 ; in erysipelas. ^^^ Andral and Gavarret, in eight analyses of the blood in this disease, determined the mean to be 5.676, minimum, 3.6, maximum, 7.3. Some have supposed that hospital gangrene was intimately related to erysipelas ; this fact, however, together with the absence of pus in the former, and the rapid and almost invariable and abun- ■ dant formation of this result of the inflammatory process in the latter, demonstrates that the two diseases are distinct. Finally, the results of the examination of the blood in this case sustain the observations recorded in the first pages of this chapter, and sustain the view that the essential conditions of inflammation are present in hospital gangrene. Case XIIL J. M. Broom, private, Company A, 9th Mississippi Reg- Case xra. iment. Age, twenty-eight Occupation before entering the ttie"liSng(S Confederate service, farming. Native of Mississippi. Wounded I'nhMpi'bd'' ^* Jonesboro', Georgia, September 2, 1864. Sent from the gangrene. figld of battle to the Floyd House Hospital in Macon, and was transferred from thence to the Empire Hospital, Vineville, on the 27th of September. Minie-ball passed through the muscles of the neck and shoulder above and almost parallel with the scapula. Gangrene is said to have appeared in this wound about the 20th of September. The application of nitric acid, accompanied with the inter- nal administration of quinine and tincture of chloride of iron, appeared to arrest the gangrene. When I examined this case on the 30th of September, the wound on the left shoulder and side of neck was six inches in length by about three inches in breadth, extending from the median line of the neck to the acromio-clavicular articulation. The muscles of the neck were extensively denuded, and the clavicle was exposed throughout a con- siderable portion of its anterior surface. In the act of swallowing, the play of the muscles could be most distinctly seen and studied. The gangrene appeared to be arrested and removed, and the surface of the wound presented a bright red appearance, and in some parts granula- tions were forming, and some pus was secreted. The patient was able CASE Xm. — BLOOD IN HOSPITAL GANGRENE. 287 to sit up, and was cheerful, with a good complexion, bright eye, excel- lent appetite, bowels regular, and little or no constitutional disturbance. The attendant physician affirmed that " the gangrene was all out, and the wound was healing rapidly." October 1. — In the evening was seized with a chill, followed by fever. October 2. — About six o'clock in the morning, hemorrhage took place from the wound in the neck. The hemorrhage was very slow, as if issuing from a vein, and the amount of blood lost was not more than one half-pint The hemorrhage appeared to be almost immediately arrested upon the application of a strong solution of persulphate of iron to the wound. The patient, however, who was sitting up at the time of the occurrence of the hemorrhage, was immediately seized with great diffi- culty of breathing, loss of muscular power, irregular thumping action of the heart, and total cessation of the pulse ; and he lay with eyes fixed, gasping for breath, unable to articulate, with cold, purple hands and lips, as if in articulo-mortis, and finally died in the afternoon, about eight hours after the hemorrhage. Examination of Blood. — The coagulum was firm, and changed to a bright red color, with very nearly the same rapidity as in healthy blood. Sixteen hundred and eight grains were carefully collected, which were employed for the determination of the fibrin. Upon careful analysis this quantity of blood yielded 9.7 grains of fibrin. Fibrin in 1,000 parts of blood, 6.03. Autopsy, Twelve Hours after Death. — The wound was first carefully explored. The external jugular vein had been completely destroyed by the gangrene. Notwithstanding the healthy appearance of those por- tions of the wound which were exposed to the naked eye during health, it was found that gangrene still existed in and around the cellular tissue surrounding the internal jugular vein, and that it had destroyed the anterior coats of this blood-vessel for the space of about the fourth of an inch in diameter. A firm coagulum of laminated fibrinous matter plugged up the vein almost completely beneath the point of erosion. The jugular vein, both above and below the fibrinous laminated con- cretion, was distended with air. The fibrous formation did not appear to fill the vein sufficiently to prevent either the access of air or the escape of blood. I carefully dissected out the carotid artery, and traced its trunk and branches ; the descending into the arteria innominata and aorta, and the ascending trunk into the carotid foramen and into the muscles of the face. The carotid artery was carefully examined, therefore, far into the sound parts, both above and below the wound, but throughout, its coats were found to be sound and healthy. The gangrene had not invaded this vessel. The clot in the internal jugular vein formed at the eroded and gan- grenous part, did not appear to have been, formed by the action of the 288 CASE XIV. — BLOOD IN HOSPITAL GANGRENE. persulphate of iron, but appeared to have been the result of the gan- grenous inflammation, for the concretion was almost entirely free of colored blood corpuscles, was firm and laminated and elastic in its texture, and was firmly attached to the walls of the vein. This was evidently the process by which veins are often obliterated by hospital gangrene, with little or no hemorrhage. The right side of the heart was greatly distended. When the scalpel was plunged into the auricle, it collapsed just as a gut filled with air collapses when punctured, only more rapidly and completely. With this collapse there was an audible puff of air. The right ventricle was as much distended as the auricle, and both contained much frothy blood, as if the blood and air had been violently churned together. The lungs were both healthy, and collapsed as usual in healthy lungs. I examined the apex of the left lung, which came quite up to the wound, but discovered no appearance whatever of gangrene or of inflammation. The costo-pleural cavity on the left side contained about fjv. of bloody serous fluid. Abdomen. — Liver, a little darker upon the anterior surface than usual; inferior surface of a slate color. When incisions were made through the slate-colored portions, the structures of the liver presented a bronze color for a few lines beneath the surface. Spleen enlarged to three times its normal size and somewhat softened. This man had a chill fourteen hours before death. Alimentary canal (stomach, duodenum, jejunum, ileum, colon, and rectum), healthy throughout its entire extent. Commentary. — Death was caused in this case evidently from Commen- the entrance of air into the internal jugular vein throuo-h tary. Death . i i , * caused by tile erosion caused by the gangrene. Nature had Cif we the entrance ./^ o c v th^f ternai ""^^ ^^® ^^ Bxpression) made great efforts to repair by jugular yein. a fibrinous clot the ravages of the gangrene, but had not been entirely successful. Fibrillin- The fibrin, although the gangrene was rapidly disap- creased. pearing, was above the normal standard. It is worthy of notice that the fibrin was more abundant in this case, in which there were little or no constitutional symptoms, than in the preceding case, where the blood had been evidently altered and poisoned by the virus and its products. Case XIV. William Martin, private, Company H, 3d Tennessee Case XIV. Regiment. Age, twenty-five. Height, five feet six inches. th"S"gel Weight in health, about one hundred and fifty-five. Light "nhM^tai* complexion, red hair, blue eyes. Entered Confederate ser- gangrene. vice,'May 1861. Has always enjoyed good health, both in and out of the army. Was wounded in the left hand at Raymond, Mis- CASE XrV.— BLOOD IN HOSPITAL GANGRENE. 289 sissippi, 12th of May, 1862. This wound healed readily. Eeceived his present wound on the 16th of August, 1864, at Atlanta. The minie- ball passed through the middle of the right fore-arm. The ulna was shattered, and the fractured fragments were resected in the field hospi- tal. The day after the reception of this wound, the patient was sent from Atlanta to the Blind Asylum Hospital, Macon, where he remained ten days, and during this time gangrene appeared in the wound. Trans- ferred to Empire Hospital, Vineville, on the 29th of August. September 30. — Patient pale, an»mic, with hectic flush ; little or no appetite ; nervous and excitable. Pulse feeble and accelerated. Wound six inches in length, and two inches in width. The local application of nitric acid, together with the internal administration of muriate of iron and quinine, have been attended with marked improvement in the wound, portions of which look healthy, with florid granulations which are now secreting pus. The gangrene, however, is still present in the deeper portions of the wound, and especially along the track of the large blood-vessels. Extensive sloughing is going on around the elbow joint, and upon that portion of the fore-arm resting upon the pillow and subjected to pressure, and sinuses are forming in various places and dis- charging fetid pus ; and it is evident that there are dead portions of bone still inrthe woimd. Consideraole hemorrhage took place from the wound this day. Examination of Blood. — The blood presented a dark color, which was slowly changed to the color of arterial blood by the action of the atmosphere. The clot was soft and large ; serum clear ; no bufFy coat was formed. One thousand grains of blood were carefully received during the hemorrhage into a porcelain capsule ; this yielded two and one tenth grains of fibrin. Fibrin, in 1,000 parts of blood, 2.1. October 6. — The hemorrhage was arrested by applying the muriated tincture of iron (tinctura ferri sesquichloridi) directly to the bleeding surface, and applying compresses saturated with this strong styptic. Up to the present time the hemorrhage has not returned, and the wound presents rather a better appearance ; the granulations are some- what more numerous. The discharge of thin, offensive pus is, how- ever, very great, and the sloughing is extending amongst the tissues subjected to pressure. The general system is seriously involved ; hec- tic fever, with great nervous depression and restlessness. October 9. — The arm was amputated near the middle. The struc- tures were found to be extensively disorganized, and the bones necrosed. October 25. — The flaps have not united, and the wound of the stump looks pale and flabby and swollen, and discharges a thin, aqueous, and fetid sanies. Flaps swollen and everted. Bone prominent, with mar- row protruding. The end of the humerus as well as its protruding marrow is of a jet-black color. 19 290 CASE XIV. — BLOOD IN HOSPITAL GANGRENE. Several gangrenous limbs were amputated about the same time in the Empire Hospital, and they all present very much the same appear- ance, — sallow anaemic complexions, with pale, flabby, swollen, ununited stumps, protruding bones, and fetid ichorous discharges. October 29. — No improvement of the stump ; wound pale, flabby, swollen, with thin, offensive discharge ; bone protruded beyond the pale, unhealthy, grayish tissues ; marrow of bone prominent and black. Flaps swollen, with everted edges ; purplish areola around the edges of the wound, and extending up, encircling the arm, which is much swollen up to its junction with the trunk. Bright hectic flush upon the cheeks. Patient has a hot fever. Pulse 124, very feeble and flicker- ing. Skin hot and dry and harsh to the feeling. No appetite. Bowels loose. The patient appears drowsy and stupid, and is evidently not in his right mind. Mutters to himself and answers incoherently, and re- sembles a man under the influence of a strong narcotic ; he has, how- ever, taken nothing of the kind. When aroused, the face expresses great anxiety and even horror, and the patient cries like a child when the stump is touched. Large bed-sores are forming on the back, and hospital gangrene has commenced its ravages, and is rapidly denuding the muscles. There is a very bad gangrenous bed-sore over the right scapula on the same side with the amputated arm. Although the orifice in the skin of this bed- sore is not more than two inches in diameter, still the tissues are exten- sively destroyed beneath the apparently sound skin. Considerable por- tions of the dead tissues have been removed by the forceps. When a good light is thrown upon the orifice, we can look for a considerable distance within and under the edges of the orifice and see the gray, greenish, and bluish gangrenous tissues. October 31. — Pulse 126, very feeble. Tongue red, cracked, and coated with sticky, clammy saliva, and flakes of whitish fu'-. Bright hectic flush upon cheeks. Skin hot and dry. Patient dull and stupd, and continues in the same low muttering delirium. Wound presents no improvement. Gangrene continuing its ravages both in the stump and in the bed-sores. November 1. — Continues to grow worse. Had a chill, followed by fever. Eyes and complexion jaundiced. During this day and night had several chills, and the complexion became still more deeply jaundiced as in pyaemia. Early in the morning, November 2, hemorrhage took place from the arm, and the patient died. Commentary. — In this case the profuse discharge of unhealthy Oommcn- sanious pus and ichorous sranm'enous matter, and the tary. Pibria ^ . . , -. , i i . , decreased. gravc Constitutional disturbances, were attended with a decrease of fibrin below the standard of health. CASE XV. — BLOOD IN HOSPITAL GANGKENE. 291 Case XV. James House, private, Company K, 2d Mississippi Eeg- iment, Jackson's Division. Native of Scott County, Missis- Case xv. A . TT.irt/. ' 1 -w- • -i lUustratiDg sippi. Age, sixteen. Height, five feet seven inches. Light the oharae- brown hair; bluish gray eyes. Fair, freckled complexion, tiood in hoa- Mild, boyish expression of countenance. Has been in Con- grenef*" federate service since the 16th of April, 1864. Wounded on Flint Riven near Lovejoy's Station, 1st of August, 1864. This young soldier was re- tiring for ammunition, when a ball severed the tendo-achillis of the right leg and shattered the lower portion of the fibula, and passed out upon the anterior part of the ankle. Was transferred from the field of battle to Macon, and entered the Stout Hospital. After remaining there four or five days, gangrene made its appearance, and the patient was trans- ferred to the Empire Hospital at Vineville. At this time was suffering from both gangrene and erysipelas. A portion of the fibula exfoliated ; and the outer side of the right foot became gangrenous, and the destruc- tion of tissue around the ankle, instep, and side of the foot was exten- sive. The usual local and constitutional treatment appeared to arrest the spread of the gangrene to a considerable degree, and healthy gran- ulations sprang up in many portions of the wound, and pus was secreted in large quantities. It was evident, however, that much dead bone remained, and that the great swelling of the leg, together with the profuse discharge of an un- healthy fetid pus and the formation of numerous sinuses, were due to necrosed bone, and that there was no chance for recovery but in amputation. October 29. — Leg greatly swollen, and discharging large quantities of most offensive pus. The constitutional symptoms are pretty good. The appetite is fair, and the spirits excellent. All parts of the wound which can be examined by the naked e3'e present a bright florid appear- ance, with luxuriant granulations. The pus discharged from the deeper portions of the wound resem- bled, in its horribly fetid odor, that which is so often discharged in and around necrosed bones, and mingled with the products of gangrenous tissues. Amputation of the lower third of the thigh was performed upon the evening of this day. Examination of Blood. — Blood changed slowly to arterial hue. Clot firm and well formed. No buffy coat. Serum clear. During the op- eration 1,137 grains of blood were carefully received into a porcelain capsule. Upon analysis, the fibrin in this quantity of blood amounted to three and thirty-six hundredths grains. Fibrin in 1,000 parts of blood = grains 3.04. November 5. — After the operation the stump swelled greatly, and fever set in. The leg was dissected after amputation, and the bones in the region of the ankle joint, and especially the fractured fibula, were 292 CASE XVI. — BLOOD IN HOSPITAL GANGRENE. extensively necrosed, and portions of gangrenous tissue were found in the lower part of the leg, and the pus had burrowed amongst the muscles extensively. At the present time, November 5th, pulse, 120 ; skin hot and dry ; hectic flush on cheek ; pale anaemic countenance- Patient very nervous ; cries like a child when even the proposition to look at his thigh is made. Stump much swollen ; it is at least three times the size of the other sound thigh, which is greatly emaciated. Edges of flaps swollen and everted and widely separated, and bone pro- truding more than one inch beyond the swollen tissues. The marrow of the bone protrudes, and is of a black color. But little pus dis- charged from the wound, but in its stead a thin, unhealthy sanies. November 9. — Some improvement in the stump ; swelling subsiding, and a little pus secreted. My observations upon this case did not ex- tend beyond this date. At this time the chances of this patient were slim indeed. Commentary. — The fibrin in this case vs'as neither increased commen- ^1°'^ diminished ; that is, it vras within the limits of health, Mmafln"" ^^ ^^^ ^^ '''^ quantity was concerned. In so extensive an amount. inflammation of the structures of the leg as this patient was laboring under, we would naturally look for an increase of the fibrous element of the blood. We are justified by the whole his- tory of this case in believing that there was some cause or combi- nation of causes which hindered the increase of fibrine usual in such cases of inflammation. The profuse discharge from the affected limb, as well as the absorption of the products of the disorganized tissues, may have had much to do with restraining the increase of the fibrinous ele- ment of the blood. Case XVI. John F. Kelly, private. Company A, 26th Alabama Case XVI Regiment, Conley's Brigade, Walthall's Division. Native of niustrating Alabama. Age, twenty-five. Height, five feet ten inches. the composi- ° "^ o ' tionofthe Weight in health, one hundred and sixty pounds. Brown pitaigan- hair, brown eyes. Wounded on the 28th of July, 1864, at grene. Atlanta ; the musket-ball passed through the right foot, from the middle toe to the heel. A number of fragments of bone were taken out by the field surgeon. Was sent from Atlanta direct to the Stout Hospital, in Macon, and remained three weeks before gangrene attacked the wound. The patient says that he had a severe attack of fever before the gangrene appeared, and the fever continued for three weeks, during which time there was much delirium. Gangrene made extensive ravages amongst the tendons and bones of the foot, and penetrated the ankle joint. Transferred to the Empire Hospital, 21st of August. The external CASE XVI.— BLOOD IN HOSPITAL GANGRENE. 293 portions of the wound improved under treatment, but the carious bones excited a continuous fetid discharge, and so continuous was the loss of tissue and exhaustion of strength, that amputation was resorted to as the only means of preserving life. The leg was amputated just below the knee joint, on the 18th of Oc- tober, by Assistant-Surgeon Powell. The bones were necrosed in various places, and the gangrene was still present in the deep-seated tissues. Examination of Blood. — Blood coagulated firmly. No buffy coat. Serum clear. The clot changed slowly to the arterial hue, upon expos- ure to the atmosphere, and the color of the surface was darker and more purplish than in health. Six hundred and twenty grains of blood were carefully preserved for analysis. The fibrin in this quantity of blood amounted to two grains and fifty-five hundredths. Fibrin in 1,000 parts of blood, 4.11. October 21. — The wound looks pale, and the edges are swollen. The stump discharges pus of a disagreeable odor. Patient pale, anaemic. Pulse 120, feeble. Tongue clean and natural. Bowels running off. Had four actions during the past twenty-four hours. Nervous system depressed, and in an irritable state. October 25. — Appears to be better. Has but little fever. The wound discharges pus. Little or no union has taken place between the surfaces of the flaps. The edges of the flaps look pale and swollen. Complexion of patient pale and anemic. Spirits better, and appetite improved. October 29. — ■ Twelve o'clock m. At this time the patient is vomit- ing ; the vomiting appeared to be due to some casual derangement of digestion, and was very different from that vomiting of green bilious matter which is so fatal a sign in these cases of ill-conditioned and gan- grenous wounds. Appetite has been quite good. Wound looks pale, and discharges a thin pus. There appears to be some union at the lower and upper portions of the flap. Pulse, 94. Skin cool. Tongue clean. Complains of a small pimple on the neck of his penis, which gives much pain, especially during micturition. Several small bed- sores have formed upon his back. November 6. — Doing well. Wound healing. Discharges quite healthy in appearance. Appetite good. Spirits excellent. Complexion clear ; and eye clear and bright, with cheerful expression of counte- nance. November 10. — Continues to improve. Commentary. — The fibrin in this case was increased somewhat above the standard of health, but was below that of the Sry.^Ktaia 11 • „ slightly in- phlegmaSlSe. creased. 294 FIBRIN IN HEALTHY AND DISEASED BLOOD. We will proceed in the next place to examine the collective results of these observations upon the changes of the blood in hos- pital gangrene. In the final report, we hope to be able to present complete analyses of all the constituents of the blood in this disease. The determination of the variations of the fibrin appears to be Importance of the first importance, because of the relations which the of the deter- .. ^ t- ^.i- • r minatioQof quantitative and qualitative changes or this constituent ot the amounts iii*, it n i i of fibrin. the blood bear to the phenomena of the two great classes of disease, the phlegmasise and the pyrexias. The true theory of hospital gangrene, as well as of all other dis- Groundsfor eascs, must be based not merelv upon the outward mani- the estab- «■ i lishmentof festations or symptoms, but also upon the more intricate theory of and Complicated changes in the constitution, and qualita- grene. tivo and quantitative relations of the individual constitu- ents of the blood and tissues, and of the secretions and excretions. However imperfect the present labors may be, we feel, however, that they are at least in the right direction, and that this method of investigating diseases, when perfected and applied to those sub- jects which are capable of successful investigation, will ultimately lead to the discovery of those facts upon which the true theory and classification of diseases should rest. We have drawn up the following table of the proportions of fibrin in various diseases, that we may be able, as far as this con- stituent of the blood is concerned, to determine whether hospital gangrene should be classed with the phlegmasiaa or with the pyrexiae. TABLE OF THE FHiRIN IN 1,000 PARTS OF HEALTHY AND DISEASED BLOOD. Andral et Gavarret Becquerel et Rodier Joseph Jones • . Joseph JoDes Joseph Jones Joseph Jones . . Joseph JoDcs . . Joseph Jones Joseph Jones Joseph Jones . . Becquerel et Rodier Becquerel et Rodier Becquerel et Rodier Andral et Gavarret Andral et Gavarret Andral et Gavarret Andral et Gavarret Andral et Gavarret Andral et Gavarret Becquerel et Rodier standard of health . Hospital gangrenn . Hospital gangrene . Hospital gangrene . Hospital gangrene . Hospital gangrene . Hospital gangrene . Hospital gangrene . Hospital gangrene . Fhlegmasiffi generally Pneumonia Pneumonia . . Pneumonia . Pneumonia Pneumonia Pleuritis . . Pleuritia . . . Pleuritis . . . Pleuritis .... Remarks. f In healthy blood the ) from I fibrin may vary J to Mean of five cases . . . Maximum Minimum Case XI Case XII CaseXIH Case XIV Case XV Mean of numerous observat'ns Mean of 1st bleedings . . Mean of 2d bleedings . . . Mean of fifty-eight analyses Maximum of ditto .... Minimum of ditto . . Mean Maximum ... . . Minimum Mean of five cases .... 2.00 3.60 3.86 6.03 2.10 4.02 6.03 2.10 3.04 4.11 5.80 7.40 6.80 7.30 10.50 4.00 4.66 6.90 3.80 6.10 FIBKIN IK HEALTHY AND DISEASED BLOOD. 295 TABLE OF THE FIBRIN IN 1,000 PARTS OF HEALTHT AND DISEASED BLOOD. — ( Continued.) Becquerel et Rodier Andral et Gavarret Andral et Gavarret Andral-^t Gavarret Aadral et Gavarret Andral et Gavarret Andral et Gavarret Andral et Gavarret Andral et Gavarret Andral et Gavarret Becquerel et Rodier Becquerel et Rodier Heller Popp Popp . Popp Popp . Popp Popp . Popp . Popp . Popp . Popp . Popp . Andral et Gavarret Andral et Gavarret Andral et Gavarret Andral et Gavarret Andral et Gavarret Andral et Gavarret Becquerel et Rodier Glover Heller . Heller Heller . "Wittstock . Simou Becquerel et Rodier Becquerel et Rodier Becquerel et Rodier Becquerel et Rodier Becquerel et Rodier Becquerel et Rodier Joseph Jones . . Becquerel et Rodier Becquerel et Rodier Becquerel et Rodier Becquerel et Rodier Andral et Gavarret Andral et Gavarret Andral et Gavarret Andral et Gavarret Andral et Gavarret Joseph Jones Joseph Jones Joseph Jones , . Joseph Jones Joseph Jones Joseph Jones Joseph Jones Joseph Jones Joseph Jones Joseph JoDcs Joseph Jones Joseph Jones Andral et Gavarrei Andral et Gavarrei Andral et Gavarrei M- H. Guenand de Mussy et M, M. H. Guenand de Mussy etM M.H. Guenand deMussyetM. Rodier Rodier Rodier Acute bronchitis Acute bronchitis Acute bronchitis Angina tonsillaris Angina tonsillaris Angina tonsillaris Acute rheumatism Acute rheumatism Acute rheumatism Chronic rheumatism Articular rheumatism Puerperal fever Puerperal fever . . Febrile arthritic rheumatism Febrile arthritic rheumatism Febrile arthritic rheumatism Febrile arthritic rheumatism Febrile arthritic rheumatism Febrile arthritic rheumatism Glanders Glanders Inflammation of brain Inflammation of brain Erysipelas Erysipelas Erysipelas Erysipelas Phthisis Phthisis Phthisis Phthisis Scrofula Carcinoma Carcinoma Carcinoma Cholera Cholera Cholera Cholera Bright^s disease, acute Bright's disease, chronic . Chlorosis .... Anaemia . . . Diabetes mellitus . . . Acute scurvy Acute scurvy . . . . Chronic scurvy . Chronic scurvy . . . Small-pox .... Small-pox . . Small-pox Scarlatina . Measles ... Malarial fever Malarial fever Malarial fever Malarial fever Malarial fever Malarial fever Malarial fever Malarial fever Malarial fever Malarial fever Malarial fever Malarial fever Typhoid fever Typhoid fever Typhoid fever Typhus fever Typhus fever Typhus fever Remarks. Mean of four coses . . Maximum of six cases . Mean of ditto . Mean of six cases . Maximum of ditto . . . Minimum Mean of forty-three cases Maximum of ditto . . . Minimum .... Mean of ten cases . Mean .... Mean of four cases . . Female aged 20, 1st bleeding Female aged 20, 2d bleeding Male aged 22, Ist bleeding . Male aged 22, 2d bleeding Male aged 22 3d bleeding Female aged 20 . Female aged 20 . Female aged 20 . Female aged 20 . Female aged 20 . Man aged 33 years Mean of eight analyses Maximum of ditto , Minimum of ditto . . . Mean of twenty -one cases Maximum of ditto . Minimum of ditto . Mean of sixteen cases Mean of eight cases, males Mean of seven cases Maximum of ditto . . . Minimum of ditto . . One case . . . One case Man, day of death . Man, day of death . Mean of fifteen cases . . Mean of thirteen cases Mean of six case^ Mean of ten cases . . Man aged 48 years, sick 42 days Man aged 21 years, sick 30 days Man aged 32 yrs., 6ick455 days Man aged 23 y rs. , sick 552 days Mean of five cases . Maximum of ditto . Minimum of ditto . Mean of four cases . Mean of seven cases Mean of nine cu£es Maximum of ditto . Minimum of ditto . Intermittent fever of 12 days Intermittent fever of 5 weeks Intermittent fever of 6 weeks Remittent fever of 16 days . Remittent fever of 10 days . Remit, and typhoid fever 11 d's Remittent fever 2 weeks . Congestive fever .... Congestive fever .... Mean of forty-one analyses. Maximum of seven ditto Minimum of seven ditto Mean of six cases . . . Maximum of ditto .... Minimum of ditto .... 4.80 9.30 6.70 5.65 7.20 3.80 6.70 10.20 2.80 3.80 5-80 6.76 5.16 11.89 12.97 11.40 7.91 9.25 13.34 6.37 10.48 6.40 6.30 6.60 5.67 7.30 3.60 4.40 6.90 2.10 4.80 3.13 6.58 16.44 3.30 11.00 11.00 1.88 6.50 2.99 4.34 4.20 3.72 2.80 2.50 2.20 1.85 1.32 2.40 4.40 1.10 4.35 2.74 2.01 2.93 0.87 1.90 2.54 1.92 2.93 1.43 2.33 2.71 0.87 1.45 2.60 4.20 0.90 2.40 3.90 1.20 296 HOSPITAL GANGRENE, LOCAL AND CONSTITUTIONAL. As far as the observations recorded in the preceding table extend, the fibrin of the blood is increased somewhat above the standard of health in hospital gangrene, whilst in this disease it is less than in the phlegmasise generally, but more abundant than in the pyrexia. From the observations recorded in this and in the preceding chapter, and especially from the results of the microscopical and chemical examination of the gangrenous matter, and of the pus secreted by wounds after the removal of hospital gangrene, and the changes of the blood in this disease, the following conclusions may be drawn : — 1. Hospital gangrene is caused by the action of an irritant, 1. Hospital corrosive, organic poison, generated during the decom- SS°byan position of animal matter under certain conditions, and ^We\r°'' capable of exciting change and decomposition in living ganio poison, structures with which it is brought into contact, after the manner of a ferment. 2. This poison may arise de novo whenever certain conditions 2. The poi- favorable to its development exist. son may arise , . „ , ,, , de novo. 1 he most important oi these conditions are, crowding together of sick and wounded soldiers in imperfectly ventilated and filthy hospitals, in which there is an insufficient supply of utensils, bandages and lint, and instruments ; and transportation of large numbers of wounded soldiers in close box-cars, without any cleans- ing of their filthy, offensive wounds. Bad diet, previous exposure, and crowding of soldiers into confined spaces during sieges, and in filthy camps, with defective police, and with the air contaminated with unburied fseces, induce such states of the system as are favorable to the development of hospital gangrene upon the recep- tion of wounds. 3. Hospital gangrene may be both local and constitutional in its 3. Thedis- origin. i^th'S/"' Animal matter, in a certain state of decomposition, is tStlo^Mi'S' capable of acting upon a wounded surface, and of devel- its origin. oping gangrenous inflammation ; or the system may be so depressed by the action of gases and foul air inhaled, and lay pre- vious exposure and diet, that this form of inflammation may result from the depression of the forces, the derangement of nutrition, and the consequent degeneration of wounded parts. If the disease arise locally, the absorption of the gangrenous matter commences as soon as it is applied to any wounded surface, and goes on con- tinuously as long as any gangrene is present, and the decomposing matters entering the blood derange its composition and the nutri- HOSPITAL GANGRENE, LOCAL AND CONSTITUTIONAL. 297 tion of the body, and depress the forces. In this way the consti tutional derangements may be manifested before the local changes are evident to the senses, without at all standing in the relation of cause and effect. The admission of its local and constitutional characters at the same time, is not at all contradicted by the fact that we may have in the same patient one gangrenous wound and another entirely free from the disease. Neither does it follow that because the absorbed matters disturb the nutrition and composition of the blood and derange to a certain extent the forces, therefore amputation will not arrest the disease. Whether or not the severins; of the gangrenous mass from the body will arrest the disease, will depend, not upon the mere fact of the absorption of the gangrenous mat- ter, but upon the extent to which it has deranged nutrition and depressed the forces. Thus, the poison of the rattlesnake pro- duces death of the immediate parts into which it is injected, and at the same time that portion which is absorbed alters the blood, acts upon the heart, deranges the nutrition, disturbs the circulation and respiration, and depresses the nervous and muscular systems. If the limb poisoned and rendered gangrenous by the action of the poison of the rattlesnake be amputated in the sound parts, it does not follow that because the constitution has been affected by the poison absorbed, that therefore the stump must also become gan- grenous. Neither does it follow that because the gangrene was not reproduced in the stump, therefore the poison of the rattle- snake did not act constitutionall3% In case of amputation for a gangrenous wound, the reappearance of the gangrene in the stump will depend on the amount of the matter absorbed from the local source and the extent to which it has deranged the system, and also upon the previous condition of the solids and fluids, and of the forces, before the reception of the infection. 4. The action of the poison of hospital gangrene is attended with both local and constitutional symptoms of inflamma- 4. The m- tion of the tlOn. poisoD of Thus, within the focus of active change and disintegra- greneattend- tion, there are alterations in the healthy structure and locaiand function of the affected parts, as indicated by the change tsonai symp- of color and structure, the fetid odor, and the suspension flammauon. of secretion and healthy nutrition by the altered condition of the blood, as manifested in the surrounding dark livid areola, by passive hemorrhages, and by the rapid decomposition of this fluid ; and around the focus of active disintegration there is active deter- 298 HOSPITAL GANGRENE A FORM OF INFLAMMATION. mination of blood, congestion of the capillary blood-vessels, accu- mulation and stagnation of the colored blood corpuscles, relative and absolute increase of fibrin, albumen, and colorless corpuscles, effusion of coagulable lymph, and redness, heat, swelling, and pain. In the general system there is increase of fibrin in the blood, and more or less febrile disturbance, as manifested in the accelerated circulation, increased temperature, and deranged muscular and nervous actions. 5. The changes excited both locally and constitutionally by the 5. Tho phe- gangrenous poison, are such that the products and phe- the disease nomena of the disease vary to a certain extent from those Tary to a p t . n certain ex- of Ordinary inflammations. tent from ^"^ iv i ^ tiioseofordi- Thus, in hospital ijanffrene the lymph effused ai'ound nary mSam- ' r » » J I mations. the focus of discasc possesses the power of coagulation and development into tissue, and there appears to be all the condi- tions necessary for the arrest of the disease by the development of coagulable lymph through nucleated cells into the fibrous and fibro- cellular or connective tissue ; but the characters of the irritant poison are such that the products of inflammation, together with the blood-vessels and the blood itself, are rapidly disintegrated, the life of the blood is destroyed by the gangrenous poison, and the fluids and living organizable matter and cells, upon which the prog- ress of inflammation depends, are poisoned. It results from this that the liquor sanguinis effused within the diseased structures does not pass into the stage of pus, as in healthy wounds, and in the common furuncle and carbuncle, or even in erysipelas and the pustules of small-pox, and the exudation corpuscles are so poisoned and disorganized that they are not further changed in either a pro- gressive or descending series, and wherever the limiting fibrous wall is thrown out, with its organizable cell elements, it is in like manner destroyed when it is reached by the poison. All the changes of the blood characteristic of ordinary inflamma- tion may be present around the gangrenous part, as the increase of liquor sanguinis, with increase of its albumen and fibrin, both actually and relatively to the blood corpuscles, aggregation of the red corpuscles, and increase of the colorless and lymph corpuscles, but no arrest of the disease M'ill take place as long as the poison is capable of exciting rapid change and decomposition, after the manner of a nitrogenized ferment in the products of inflamma- tion. 6. Tiiegan- 6. The gangrenous poison, as well as the compounds fOT°»ndits resulting from the disintegration which it induces in the DERANGEMENTS OF BLOOD IN HOSPITAL GANGRENE. 299 organic constituents of the structures, when absorbed, act products, af- ^ ^ 1 **'^ absorp- as poisons upon the muscular and nervous systems, and «»", "ct aa ^ ., , ^ . poisons upoa tend to disorganize the blood and derange the actions of the muscular cj o and nervous the alimentary canal. systems, and *' ^ ^ disorganize When absorbed in large quantities, these products fre- tie biood. quently act as irritants to the intestinal canal, by which they are eliminated, and patients are sometimes destroyed by the diarrhoea consequent upon this action upon the intestinal mucous mem- brane. The absorption and consequent action of the gangrenous poison upon the general system is manifested by the feeble, rapid action of the heart, the marked elevations and depressions of temperature, the depressed, enfeebled nervous and muscular forces, the trem- bling hands, the low muttering delirium, the trembling eyeballs and quivering features, the insensibility of the organs of sense, and by the derangement of digestion, and the fetid diarrhoea. The derangements induced by the gangrenous poison in the constituents of the blood and in the capillary circulation, are mani- fested by the dusky, sallow, livid, and leaden hue of the com- plexion, the livid blue color of the tongue, the derangements of nutrition, secretion, and excretion, the diminution of the power in the colored corpuscles to absorb oxygen from the atmosphere, and by the partial increase of the fibrin, notwithstanding the presence of an inflammatory state. It appears, therefore, that the fibrin is not increased in hospital gangrene to the extent usual in ordinary inflammations, on account of the absorption and action in the blood of the poison producing the disease, and of the products of the decompositions which it excites in the structures and fluids of the living animal. A similar condition is observed in the action of the poison producing small- pox. In this disease, also, as will be seen from the preceding table, notwithstanding the presence of both local and constitutional symptoms of inflammation, the fibrin is less than in uncomplicated inflammations, as in pneumonia. CHAPTER THIRD. Variations of the Temperature and Circulation in Hospital Gangrene. — Marked Daily Variations of tiie Temperature, also Marked Variations between the Temperature of the Trunk and Extremities. — Daily Variations of the Pulse. — The Observations upon the Variations of the Pulse and Temperature, of Importance in their Bearing upon the Nature and Treatment of this Disease. — Hospital Gangrene is especially characterized by the Great DiflFerence which frequently exists between the Temperature of the Central Organs and that of the Extremities. — Whilst the Trunk presents the Heat of a Warm Fever, the Extremities will in many Cases feel cold, and in Fact the Temperature be not higher in Degree than that of a Regular Chill. — The Symptoms of Open Sthenic Inflammation are in general wanting in this Disease. — As a General Rule, the Respiration in Cases of Ordinary Severity is not disturbed to any Great Extent either in Character or Frequency; in this Respect the Febrile Excitement of Hospital Gangrene presents a Marked Difference fro m that of Malarial Fever. — Changes of the Urine in Hospital Gangrene. — Increase of Coloring Matteis, of Urea and Uric Acid, Free Acid, Phosphoric and Sulphuric Acids. — Decrease of Chloride of Sodium. — When Pycemia supervenes upon Hospital Gangrene, the Urine assumes a most beautiful Pink Color, from the Great Destruction of the Col- ored Blood Corpuscles, induced by the Presence of Pus in the Blood. — Cases illustrating the Changes of the Temperature, Circulation, and Urine, in Hospital Gangrene. The temperature is subject to marked periodical variations, as Changes of wcll as to great differences between that of the central the tempera- i p i . • t i • i ture Id hos- organ.s aiid or the extremities. In hospital gangrene a gtene. marked diminution of the frequency of the pulse, as well as a decrease in the degree of animal temperature, almost inva- riably occur in the morning. As the day advances, the pulse increases in frequency, and the temperature progressively rises, and often attains a degree equal to that of a hot fever. The febrile excitement continues to increase, or remains stationary until near midnight, or until some refreshing sleep has been obtained, and then progressively declines, and reaches its lowest point about the period of waking in the morning. Thus the pulse in severe cases will frequently vary during the twenty-four hours twenty beats and over, and the temperature of the trunk will frequently rise from 99° F. in the morning to 104° F. in the afternoon and evening. Hospital gangrene is especially characterized by the great differ- ence which frequently exists between the temperature of the cen- tral organs and that of the extremities. I have frequently observed the temperature of the hands from ten to fifteen degrees below that of the head and trunk. Whilst the trunk presents the heat of a warm fever, the extremities will in many cases feel cold, and in URINE IN HOSPITAL GANGRENE. 301 fact the temperature be not higher in degree than that of a regular chill. This observation is of moment in the light which it throws upon the nature of this disease, and in the indications which it affords for treatment. It is evident that whilst the nervous and circu- latory systems are excited in this disease, the excitement is limited by the enfeebled condition of the system, and manifests itself in feeble, irritative, irregular forms of action. The symptoms of open sthenic inflammation are in general wanting in this disease. As a general rule, the respiration in cases of ordinary severity is not disturbed to any great extent either in character or in fre- quency. In this respect the febrile excitement of hospital gan- grene presents a marked difference from that of malarial fever. CHANGES OF THE URINE IN HOSPITAL GANGRENE. The coloring matters are increased, and the height of the color of the urine corresponds with the severity of the gan- changes of grene and the extent of the constitutional disturbances, hospiwgan- In light cases, the urine approaches both in color and ^"°*' ''°'°''' in chemical constitution to the urine of health. The color of the urine in this disease resembles most nearly that of typhoid fever. When pyaemia supervenes upon hospital gangrene, the urine assumes a ^^ost beautiful pink color, from the great character- destruction of the colored blood corpuscles, induced by Sie°iriM iS' the presence of pus in the blood, the coloring matter of s^^^™*- the blood resulting from the disintegration of the colored blood corpuscles being eliminated by the kidneys. In the urine of hospital gangrene we find such changes as char- acterize the increased physical and chemical changes of the febrile state. Thus the urea and phosphoric and sulphuric acids are increased, but to a much less comparative extent than in the true ^^^ p^„j. fevers, as for example in typhoid fever. This difference ^04™!°*'*' is without doubt due to the depressed state of the system '''"""° °*'*- in hospital gangrene, as induced by the action of a special poison upon the blood, and upon the nervous and muscular systems. As in other forms of disease the extent of the destruction of the living tissues, as measured by the amounts of urea and phosphoric and sulphuric acids excreted by the kidneys, is proportional to the severity of the constitutional symptoms. 302 CASE XVn. — TEMPERATURE AND URINE. The chloride of sodium is diminished, and in the severest cases Chloride of disappears almost entirely. Diminutions in the amount, sodium. ^^^ variations of the characters of the nutriment, without doubt, have much to do with the diminution of this constituent of the urine ; this fact, however, is of interest, as similar changes in the amounts of the chloride of sodium in the urine have been observed in various diseases, as pneumonia, small-pox, and typhoid fever. In most cases, the uric acid is greatly increased. The same fact is noticed in typhus and typhoid fevers, and in the TJnc Mid. •' ^ , . depressed state of the system following malarial fever. CASES ILLUSTRATING THE CHANGES OF THE TEMPERATURE, CIRCULA- TION, AND URINE IN HOSPITAL GANGRENE. Case XVII. Edward I. Wainwright, private, Company B, 1st Case XVII. Florida Cavalry. Age, twenty-eight. Height, five feet nine thechang'S inches. Weight in health, one hundred and seventy-five perature"and pounds. Occupation before entering the Confederate army, urine in hoB- farminsf. Native of Nassau, Florida. Entered service 15th pitalgan- " ' grene. of October, 1861. Says that previous to entering the army, he has always been strong and healthy. His mother, who was with this patient during my inquiries, affirmed that he had never been seriously sick since his birth. Was wounded on the 19th of September, at Chick- amauga, by a piece of shell, which imbedded itself in the left buttock, about the middle of the gluteus maximus. The fragment of iron was taken out by the surgeon on the field. Was sent to the division hos- pital near the field of battle, and remained there until the next day, when he was transferred to Ringgold, Georgia. At this place he remained two days at the depot, receiving little or no attendance during this time, his wound not being dressed or receiving any attention. Was transferred from Ringgold to Atlanta, where he remained in hospital a few days, and was then sent to Augusta. After arriving in Augusta, remained at the railroad depot from 1 o'clock a. m. to 6 o'clock p. m., and was then, with a number of other wounded soldiers from the same battle-field, transferred to the Presbyterian Church. Two hundred and seventy-five wounded men were crowded into this building, which was only capable, according to the official regulations in cubic feet, of accom- modating one hundred and twenty-five ; and they were simply placed in the pews, a plank being placed so as to connect the seat with the side of the pew. In these badly-ventilated boxes the wounded lay. The windows of the church are elevated above the pews, and from their structure did not admit of free ventilation. In addition to this, the church was surrounded by a thick growth of trees. Tiiis patient remained in the Presbyterian Church three days, and was then trans- TEMPERATURE AND URINE IN HOSPITAL GANGRENE. 303 ferred to the Second Georgia Hospital, on Broad Street, and walked there on crutches, the distance being not more than two hundred yards. "At the time of his admission into the Second Georgia Hospital, his gen- eral health was good, and he presented the appearance of a strong, healthy man. The hygienic condition of this hospital does not appear to have been much better than that of the Presbyterian Church on Telfair Street. On the 6th of October his wound became very painful and red, and he had high fever, accompanied with loss of appetite, low spirits, and depression of the muscular and nervous forces, and thirst. Had no chill, and his fever, although changing in severity at different periods of the day and night, did not go off with a sweat. Quinine was freely administered, but it produced no perceptible abatement of the febrile symptoms, although it caused ringing in the ears and deafness. The wound was so painful that the patient was unable to sleep at night. On the following day after the fever, the wound showed marks of gangrene, and the disease spread with considerable rapidity. November 2. — Complexion of an unhealthy, leaden hue. Pulse fre- quent, and rather feeble. Respiration natural. The wound on the buttock is oval, and about five inches in diameter, and over one inch in depth, with swollen, everted edges. The gangrene is still progressing in portions of the wound, whilst healthy granulations are to be seen in a few spots, which now secrete a little pus. The granulations, however, are not abundant, and they are paler than in a healthy wound. Appe- tite poor. Expression of eye dull and anxious. Spirits depressed. November 3. — Symptoms much the same. Examination of Urine. — Amount of urine passed during twenty-four hours, November 2, 1 p. m., to November 3, 1 p. m., 1,220 CC. = grains 19,507.30. Specific gravity, 1,016. Orange-red color. (See figure.') Clear when first passed. At the end of thirty hours slight deposit of large, well-formed, highly colored, lozenge-shaped crystals of uric acid. ANALYSIS OF URINE, NO. 9. Amount of urine collected during twenty-four hours . Urea Uric acid . • Free acid (30 lirs. after collection, and in warm weather) Phosphoric acid Equivalent of phosphorus in jjhosphoric acid . . . Sulphuric acid _ Equivalent of sulphur in sulphuric acid ... Chloride of sodium Equivalent of chlorine in chloride of sodium . . . 1 Omitted. Urine collected during 24 houra, contained grains 19,507.30 526.06 13.82 16.90 43.58 19.13 32.22 12.88 140.91 85.39 1,000 parts of urine con- tained 26.45 0.70 0.86 7.36 0.98 1.65 0.66 7.22 4.37 304 TEMPERATURE AND URINE IN HOSPITAL GANGRENE. November 6. — Nine o'clock a. m. Pulse 80, and feeble. Respira- tion, IG. Bowels constipated. Skin moist and warm. Wound some- what diminished in size, and granulating, except along the upper border, which is filled with a humid slough. Temperature of hand, 31.1° C. (88° F.). Temperature of axilla, 36.4° C. (97.5° F.). Treatment con- sists of tincture muriate of iron, gtts. x., and chlorate of potassa, grs. v., three times a day. Local treatment of wound, saturated solution of sulphate of copper. Lint saturated with this was stuffed into the wound. Nine o'clock p. m. Pulse 98, moderately full. Respiration, 18. Temperature of hand, 38.4° C. (101.1° F.). Temperature of axilla, 39.2° C. (102.5 F.). Tongue red at tip and centre ; clear at tip and edges ; slight coating of light white fur in two lines on either side of centre. Complexion of an unhealthy, leaden hue. Spirits depressed. Gangrene still progressing. November 6. — Nine o'clock a. m. Pulse 86, and full. Respiration, 18. Skin warm and dry. Tongue cleaner and moister. Wound presents very much the same condition. Treatment and diet con- tinued. Five o'clock p. m. Pulse 96, and full. Respiration, 18. Tempera- ture of hand, 36.2° C. (97.1° F.). Temperature of axilla, 37.4° C. (99.3° F.). November 8. — Nine o'clock a. m. Pulse 80, and full. Respiration, 18. Tongue clean and moist. Skin warm and dry. Bowels con- stipated. Wound looks better ; granulations increasing in number and extent. Temperature of hand, 31.2° C. (88.1° F.). Temperature of axilla, 37.2° C. (98.9° F.). Treatment and diet continued. November 9. — Nine and one half o'clock a. m. Pulse 80, and full. Respiration, 18. Tongue cleaner and moist. Skin warm and dry. Temperature of band, 32.2° C. (89.9° F.). Temperature of axilla, 36° C. (96.8° F.). Cool, frosty morning. Wound still improving. Treat- ment, and nutritious diet of beef and chicken soup and soft boiled eggs, etc., continued. Eight o'clock p. M. Pulse 88, and full. Temperature of hand, 29.2° C. (84° F.). Temperature of axilla, 37.3° C. (99.1 F.). November 10. — Continues to improve. Temperature, pulse, and respiration about the same as at this time yesterday morning. Examination of Urine. — Deep orange color, inclining to red, but lighter than in the preceding examination. Amount of urine collected during twenty-four hours, 1,140 CC. = grains 18,270.00. Specific gravity, 1,015. Urine clear, and without deposit, when first passed. The color of the urine is represented in Figure 1, Plate X.^ The appetite of this patient is moderately good, and as he is allowed a nutritious diet, the chloride of sodium exists in considerable amount in his urine, as will be seen by the following analysis : — 1 Omitted. TEMPERATURE AND URINE IN HOSPITAL GANGRENE. 305 ANALYSIS OP URINE, NO. 10. Elements. Urine collected during 24 hours, contained grains 1,000 parts of urine con- tained Amount of urine collected during twenty-four hours . Tlrea Uric acid 18,270.00 395.01 15.30 30.72 39.32 17.25 16.82 6.72 108.84 65.95 21.07 Free acid (three hours after collection) Phosphoric acid Equivalent of phosphorus in phosphoric acid . . . Sulphuric acid 1.68 2.15 0.94 92 Equivalent of .sulpliur in sulphuric acid Chloride of sodium 0.36 5 95 Equivalent of chlorine in chloride of sodium . . . 3.62 November 15. — Continues to improve. Wound, as well as the gen- eral health, greatly improved. The gangrene has entirely disappeared. No febrile excitement during the day. Skin cool and pleasant. Com- plexion clear. Countenance bright and cheerful. Examination of Urine. — Amount of urine passed during twenty-four hours, November 14, 9 a. m., to November 15, 9 a. m., 1,210 CC. = grains 19,373.85. Specific gravity, 1,017. Light orange color, nearly normal. (See Plate X., Figure 2.^) No deposit after standing ten hours. ANALYSIS OF URINE, NO. 11. Amount of urine passed during twenty-four hours Urea Uric acid Free acid (five hours after collection) Phosphoric acid Equivalent of phosphorus in phosphoric acid . . Sulphuric acid Equivalent of sulphur in sulphuric acid .... Chloride of sodium Equivalent of chlorine in chloride of sodium . . Urine collected during 24 hours, contained grains 1,000 parte of urine con- tained 19,373.85 372.68 19.23 12.38 0.63 11.18 0.57 25.33 1.30 11.11 0.57 17.01 0.88 6.80 0.35 214.29 11.06 129.85 6.70 Plate X, Figure S,^ represents the colors of the urine of this patient. The case continued to improve, and was discharged cured. Case XVIII. Isaac Parker, private. Company D, 45th Mississippi Kegiment. Light brown hair; fair complexion; blue eyes, casexvm Age, twenty-six. Height, six feet. Native of Mississippi. Has been in service three years. During this time, as well as during his entire life, has enjoyed good health. Weight in health, one hundred and sixty-five pounds. Admitted into 1 Omitted. ^ Omitted. 20 Illustrating the changes of the tem- perature and urine in hos pital gan- grene. 306 TEMPERATURE AND URINE IN HOSPITAL GANGRENE. the Second Georgia Hospital, Augusta, Ga., October 6, 1863, with a gunshot wound of left fore-arm, the ball entering near the wrist, and escaping near the elbow joint. The bones were fractured. At the time of admission, the parts were very highly inflamed, threatening mortification. Irrigation was employed, but without any effect in arresting the progress of the inflammation. Hospital gangrene appeared in the wound on the 10th, the constitu- tional effects of which were so great as to require amputation, as afford- ing the only chance for recovery. October 14. — Amputation at middle third of arm, by Surgeon Doughty, in charge of Second Georgia Hospital (circular method). Chloroform administered, and its effects well borne. Patient being on quinine and iron, it was continued. October 17. — Stump dressed ; looks well, and general condition favorable. Treatment continued. October 19. — Gangrene reappears in stump. Patient has fever. Quinine and iron continued, with generous diet. Saturated solution of sulphate of copper applied to the stump. October 20. — Gangrene extending. Pulse frequent and feeble. Great restlessness and nervous irritability. Tongue dry. Constitu- tional symptoms well marked. (Tincture muriate of iron, gtts. x. ; chlorate of potassa, grains v., three times a day. Saturated solution of sulphate of copper to wound.) October 23. — General condition improved. Sloughs are being detached in large pieces. Treatment continued. October 26. — General condition decidedly better. Granulations appearing in the stump. Treatment continued. For the preceding facts in the history of this case, I was indebted to Assistant-Surgeon Christian, of the Second Georgia Hospital, who assisted me in the determination of the temperatures in this and in several other cases of liospital gangrene which I investigated at this hospital. November!. — Nine o'clock a. m. Pulse, 80. Respiration, 18. Tem- perature of hand, 32° C. (89.9° F.). Temperature of axilla, 37.3° C. (99.1° F.). Tongue clean and moist. Skin of trunk feels warm and dry. Stump improving. Continue treatment. Five o'clock p. m. Pulse, 86. Temperature of hand, 31.2° C. (88.1° F.). Temperature of axilla, 37.4° C. (99.3° F.). November^. — Nine o'clock A. M. Pulse, 80. Respiration, 16. Tem- perature of hand, 31.3° C. (88.3° F.). Temperature of axilla, 38° C. (1.00.4° F.). Stump improving. Treatment continued. ^ Five o'clock p. m. Pulse, 80. Respiration, 16. Temperature of hand, 32.1° C. (89.8° F.). Temperature of axilla, 39.1° C. (102.3° F.). November 10. — Nine o'clock a. m. Pulse, 80. Respiration, 16. Temperature of hand, 30° C. (86° F.). Temperature of axilla, 37.2° C. TEMPERATURE AND URINE IN HOSPITAL GANGRENE. 307 (99° F.). Stump does not look so well ; some swelling and redness, as if the gangrene was about to return. Examination of Urine. — Amount of urine passed during twenty-four hours, November 8, 9 A. m., to November 9, 9 a. m., 720 CO. = grains '11,589.26. Specific gravity, 1,022. Light orange color. (See Plate XL, Figure 1."^) Heavy light-yellow deposit of urates, upon cooling (cold, frosty morning), and the sides of the glass vessel in which the urine was contained were encrusted with this light yellow deposit, and with large, well-formed, lozenge-shaped, highly colored (red) crystals of uric acid. ANALYSIS OF TJRINB, NO. 12. Amount of urine collected during twenty-four hours . Urea . . . . . . Uric acid Free acid (three hours after collection) Phosphoric acid Equivalent of phosphorus in phosphoric acid . . . Sulphuric acid Equivalent of sulphur in sulphuric acid Chloride of sodium Equivalent of chlorine in chloride of sodium . . . Urine collected 1,000 parts of during 24 hours, urine con- contained grains tained 11,589.26 388.08 33.48 13.59 1.17 28.82 2.48 31.79 2.74 13.04 1.12 19.75 1.74 7.90 0.68 77.61 6.69 47.03 4.05 Eight o'clock p. M. Pulse, 86. Respiration, 16. Temperature of hand, 29.2° C. (84° F.). Temperature of axilla, 38.1° C, (100.6° F.). Stump painful and swollen, and redder than normal, and appears as if the gangrene is about to return. November 11. — Gangrene has returned, and all the constitutional symptoms are aggravated. November 14. — Arm much swollen. Pulse, 102. November 15. — Arm much swollen. Gangrene progressing ; has a troublesome cough. The left lung appears to be chiefly afi'ected. Patient nervous, restless. Spirits dejected. Countenance anxious and distressed. Dusky, leaden complexion. Examination of Urine. — Amount of urine passed during twenty-four hours, November 14, 9 a. m., to November 15, 9 a. m., 800 CO. = grains 12,915. Specific gravity, 1,025. Slight light-yellow deposit at the end of the twenty-four hours in which the urine was collected (weather warm and moist, a great change since the last observation upon the urine) ; slight deposit of uric acid upon the sides of the vessel. When the urine was treated with hydrochloric acid, there was an imme- diate and heavy precipitate of uric acid. So sudden and great was this precipitation, that at first I suspected that this was caused by albumen. Heat, however, did not throw down any precipitate, but dissolved even that produced by the hydrochloric acid. 1 Omitted. 308 TEMPERATURE AND URINE IN HOSPITAL GANGRENE. ANALYSIS OF URINE, NO. 13. Amount of urine excreted during twenty-four hours . Urea TJric acid Free acid (six hours after collection) Phosphoric acid Equivalent of phosphorus in phosphoric acid . . . Sulphuric acid Equivalent of sulphur in sulphuric acid Chloride of sodium Equivalent of chlorine in chloride of sodium . . . Urine collected during 24 hours, contained grains 1,000 parts of urine con- tained 12,915.00 492.80 38.10 18.27 1.41 32.0.3 2.40 39.42 3.05 17.10 1.32 26.89 2.08 10.75 0.83 86.24 7.06 52.26 4.04 Six and one half o'clock p. m. Stump swollen and inflamed. No improvement of symptoms. Pulse 100, moderately full. Respiration, 20. Temperature of hand, 38.2° C. (100.7° F.). Temperature of axilla, 39.4° C. (102.9° F.). Skin moist. Tongue moist, with a very slight coating of light white fur. JNbvember 15. — Continues in the same state. Arm much swollen. Troublesome cough. Lower lobes left lung dull upon percussion. November 17. — Continues in much the same state. Lower lobes of left lung (same side with stump) dull upon percussion. A very slight improvement of general symptoms and stump. Gangrene still present. Appetite pretty good. Examination of Urine. — Amount of urine passed during twenty- four hours from November 16, 9 A. m., to November 17, 9 a. m., 1,020 CC. == grains 16,360.80. Specific gravity, 1,020. Orange-red color. Reaction at end of fifty hours acid (clear, cool weather). Slight deposit in urine after standing. This under the microscope was found to consist of amorphous urates, and thousands of beautifully formed octohedral crystals of the oxalate of lime. ANALYSIS OF URINE, NO. 14. Urine collected during 24 hours, contained grains 1,000 parts of urine con- tained Amount of urine passed during twenty-four hours Urea Uric acid Free acid Phosphoric acid Equivalent of phosphorus in phosphoric acid . . Sulphuric acid Equivalent of sulphur in sulphuric acid .... Chloride of sodium Equivalent of chlorine in chloride of sodium . . 16,360.80 454.53 15.23 25.91 27.64 12.12 25.88 10.35 138.23 83.76 27.78 0.93 1.52 1.07 0.74 1.52 0.63 8.44 5.11 TEMPERATUKE AND URINE IN HOSPITAL GANGRENE. 309 Plate XI.^ represents the colors of the urine subjected to analysis, November 9, 15, and 17. This case continued to improve very slowly, and lingered for many days before convalescence was fully established. Commentary. — This, as well as the preceding case, No. XVII., illustrates in a striking manner the diurnal variations of the tern- perature in hospital gangrene, as well as the marked differences which sometimes exist between the temperatures of the central organs and of the extremities. In the former one, No. XVII., the urine is observed to approach to the standard of health, and to lose its high color just as the local and general symptoms improve, whilst in the latter. No. XVIII., the urine becomes more highly colored, and recedes from the standard of health just in proportion to the increase of local and constitutional disturbance. The analysis of the urine of the 9th of November is interesting, as showing the condition of this fluid just as the gangrene was reappearing. The chemical examination of the urinary excretion is important not merely as affording materials for the determination of the nature of hospital gangrene, but also as affording valuable data for the institution of comparisons with other diseases, and especially with those, as small-pox and measles, which are due to the action of animal poisons. It is important also that the phenomena of hospital gangrene should be carefully compared with the phe- nomena of such a disease as typhoid fever, in which we have in like manner a large, irritated, inflamed surface, and most grave constitutional disturbances. If upon comparison the causes of local disturbance be equal in both diseases, then the excess of con- stitutional disturbances in the one or the other, as manifested by the variations and increase of certain constituents in the urine, might afford ground for reasoning as to the action of the causes producing the disease, as well as their nature and physical and chemical properties. If we find an invariable increase of sulphuric acid in the urine of one disease, and an invariable decrease of this substance in the urine of another disease, we would naturally be led to examine the source of sulphuric acid in the urine, and to inquire if these differences do not point to differences in the chemical affinities and actions of the poisons producing the diseases. Thus if we knew the whole amount of sulphur existing in the animal body, and the 1 Omitted. 310 TEMPERATURE AND URINE IN HOSPITAL GANGRENE. proportions existing in the different tissues and in different articles of food, and, still further, the amount normally excreted in combi- nation with oxygen in health and in different diseases, we may from such knowledge form a reasonable conclusion as to the tis- sues which have been especially affected by any poison inducing disease. These remarks apply to phosphoric acid, and to all the constituents of the urine. Such comparisons are especially inter- esting in two diseases — hospital gangrene and typhoid fever - — which evidently appear to arise very much from the same causes, neglect of hygiene and crowding in filthy tents and hospitals. Case XIX. S. M. Perrin, private, Company C, 19th Regiment Case XIX. Arkansas Vols. Age, twenty. Dark hair dark gray eyes- the"chM'ges Height, five feet nine inches. Weight in health, one hundred peratare" ^^^ sixty pounds. Wounded at battle of Chickamauga, Sep- and urine in tember 19, 1863. Ball entered anteriorly two inches above hospital gan- ' •' 8"°"- ankle joint, and passed out on same side, making a flesh-wound of two and one half inches in extent. Patient's general health good at the time of the reception of this wound. Gangrene attacked the wound October 6th, ten days after his transference to Augusta, and seven days after his entrance into the Second Georgia Hospital. This patient had remained three days in the Presbyterian Church on Telfair Street im- mediately aiter his arrival in Augusta. Patient states that he had fever for two days before the appearance of gangrene in the wound. Under the action of quinine and iron and the local application of sulphate of copper, the wound improved and the gangrene appeared to have disap- peared. On the 1st of November, however, the patient was seized with fever, and the gangrene returned. November 6. — Nine o'clock A. m. Pulse 86, and full. Respiration natural. Bowels regular. Tongue clean and moist. Skin warm and dry. Temperature of hand, 31.1° C. (88° F.). Temperature of axilla, 37. 2° C. (98.9° F.). Wound about three and one half inches in diame ter, and gangrenous in its upper portion. The treatment consists of tinct. mur. of iron, gtts. x., sulphate of quinia, grs. iii., three times a day Saturated solution of sulphate of copper to wound and nutritious diet. Five o'clock p. m. Pulse, 98. Temperature of hand, 32.3° C (90.1° F.). Temperature of axilla, 38.4° C. (101.1° F.). Eight o'clock p. M. Pulse 96, small and feeble. Temperature of hand, 38.2° C. (100.7° F.). Temperature of axilla, 39° C. (102.2° F.). Skin hot and dry. Tongue moist, pale, and coated with yellow fur at root. November 7. — Nine o'clock a. m. Pulse, 84. Tongue clean and moist. Respiration, 18. Skin warm and dry. Temperature of hand, 33.2° C (91.7° F.). Temperature of axilla, 36.1° C. (97° F.). Much of the gan grenous matters have been ren)oved with forceps and scissors. Granu- TEMPERATURE AND URINE IlSf HOSPITAL GANGRENE. 311 lations are springing up beneath the slough. Treatment and diet continued. November 9,. — Nine o'clock a. m. Pulse, 86. Tongue clean and moist. Respiration, 18. Skin slightly moist and warm. Wound very much im- proved in appearance. Treatment and diet continued. Five o'clock p. m. Pulse, 100. Respiration, 18. Temperature of hand, 34° C. (93.2° F.). Temperature of axilla, 39.2° C. (102.5° F.). iV^oueniJer 9. — Nine o'clock A. M. Pulse, 86. Respiration, 18. Tem- perature of hand, 30.2° C. (86.3° F.). Temperature of axilla, 38° C. (100.4° F.). Tongue clean and moist. Skin dry and warm. Sloughing has ceased, and the wound looks more healthy. Eight o'clock p. M. Pulse, 90. Respiration, 18. Temperature of hand, 28° C. (82.4° F.). Temperature of axilla, 39.1° C. (10^.4° F.). JVovember 10. — Nine o'clock a. m. Pulse, 80. Respiration, 18. Tongue clean and moist. Skin cool and slightly moist. Wound looking well and healing around the edges. Treatment and diet continued. Examination of Urine. — Amount of urine collected during twenty- four hours, November 9, nine a. m., to November 10, nine a. m., 1,100 CC.= grains 17,715.20. Deep orange-colored, with heavy deposit of urates upon cooling (weather cool with frosty mornings). Hydro- chloric acid produced an immediate and heavy deposit of light yellow crystals of uric acid. Specific gravity of urine, 1,024. Plate XII.' represents the color of this urine. ANALYSIS or URINE, NO. 15. Elements. Urine collected during 24 hours, contained grains 1,000 parts of urine con- tained Amount of urine excreted during twenty-four hours . Urea TJric acid Free acid (four hours after collection) . ' Phosphoric acid Equivalent of phosphorus in phosj)horic acid . . . Sulphuric acid Sulphur in sulphuric acid Chloride of sodium Chlorine in chloride of sodium 17,715.20 677.60 16.43 49.12 48.78 21.41 44.67 17.86 149.07 98.38 38.19 0.92 2.77 2.75 1.208 2.52 1.008 8.307 5.49 Case XX. Sergeant J. J. Lamb, Company B, 5th Regiment Ar- kansas Vols. Age, twenty-one. Height, five feet ten inches. Weight in health, one hundred and sixty-five pounds. Red- dish hair and gray eyes. Wounded at battle of Chickamauga, September 19th, in left leg, three inches below the knee, on the outer side. Only one opening appeared, and the ball could not be found. ' Was transferred a few days after the battle to Augusta, and was placed, together with two hundred and seventy-four 1 Omitted. Case XX. Illustrating the changes of tempera- ture and urine during hospital gan- grene- 312 TEMPERATURE AND URINE IN HOSPITAL GANGRENE other wounded men, in the Presbyterian Church. His wound appeared to be doing well and healing until the 8th of October, when the patient was taken with a chill followed by fever. On the 9th, the wound was painful and much inflamed, presenting a dark-blue ring around it. On the 10th, the dark-blue ring had assumed a black color. The patient suflfered with another chill, followed by fever. The gangrene con- tinued to extend, and on the 16th the skin and superficial fascia had become gangrenous for four inches in width and five in length. This dead tissue was removed, as far as possible, on this day. October 17. — The back and upper portions of the wound are stud- ded with healthy granulations, whilst in the lower parts gangrene is still progressing. October 18. — A red spot, about the size of a silver half-dollar made its appearance on the right or inner side of the calf of the diseased leg, about four inches below the knee joint; at this part there was no wound or abrasion previous to the appearance of this discoloration. This spot rapidly changed its hue and extended its base, and on the 19th presented a black color, with an inflamed base, extending to the in- flamed base of the original wound. October 11. — The gangrenous wounds have formed a junction in front of the tibia. October 15. — The gangrenous mass was removed, and consisted of skin and superficial fascia. The wound now encircled the leg with the exception of a strip of sound skin and tissue at the back of the calf of the leg, about one and a half inches in width. On this day a small red spot was visible about four inches above the external malleolus, which soon became gangrenous. I was indebted to Assistant-Surgeon J. W. Warren, of the Third Geor- gia Hospital, for the preceding outline of this case. This officer also assisted me in the determination of the temperatures in this and in several other cases upon which I instituted inquiries at the second divis- ion of the Third Georgia Hospital. October 30. — Eleven and one half o'clock a. m. Pulse, 94 Respira- tion, 20. Temperature of hand, 35.7° C. (96.3° F.). Temperature of ax- illa, 37.9° C. (100.3° F.). Tongue clean and moist; bowels regular; his bowels have been regular throughout. Treatment has consisted of tinct. mur. of iron, gtts. xx. ; quinine, grs. iv. ; whiskey, feii., three times a day, and at bed-time, four grains of opium. Nutritious diet, eggs, chickens, and beef The local treatment has been quite simple ; the gangrenous wound was first burned with nitric acid, and followed by charcoal and yeast poultices. Complexion dusky; hectic flush about the cheeks. Wound below the knee exposes a raw surface of near forty square inches. Muscles in most parts denuded of all fibrous tissue, and of a slick red color, with some granulations. Gangrene is still extending, but to a limited extent, along a small portion of the border. Gan- grene also exists in the diseased part near the ankle. TEMPEKATURE AND URINE IN HOSPITAL GANGRENE. 313 JEkcamination of Urine. — Amount of urine collected during the past twenty-four hours, 810 CC. ^= grains 12,966.75. Specific gravity, 1,017. Deep orange-red color." When first passed, clear, and of a strong acid reaction. At the end of fifty hours the reaction became alkaline, and a heavy deposit fell, consisting of the urates and phos- phates (chiefly of the phosphates). In the sunlight, this light yellow deposit presented a brilliant, sparkling appearance, like spangles of silver. I have frequently noticed a similar appearance in the urine during convalescence from malarial fever. These shining silver bodies are large well-formed prismatic crystals of triple phosphate. ANALYSIS OF TJRINB, NO. 16. Amount of urine excreted during twenty-four hours . Urea Uric acid Free acid (alkaline at end of fifty hours) Phosphoric acid Equivalent of phosphorus in phosphoric acid . . . Sulphuric acid Equivalent of sulphur in sulphuric acid Chloride of sodium Equivalent of chlorine in chloride of sodium • . . Urine collected during 24 hours, contained grains 12,966.75 374.22 10.58 alkaline 12.47 5.45 20.00 8.00 31.18 18.89 1,000 parts of urine con- tained 28.87 0.81 0.96 0.42 1.54 0.61 2.404 1.45 November 1. ■ — Eleven o'clock A. m. Pulse, 88. Temperature of hand, 94T. Temperature under tongue, 101° F. Temperature in axilla, 99° F. Six o'clock p. M. Pulse, 112. Temperature of hand, 95° F. Tempera- ture under tongue, 102° F. Temperature in axilla, 100° F. Gangrene still extending. Constitutional disturbances marked. In the morning this patient appears to be comparatively free from fever, and in the evening there is a marked rise in the temperature, and the pulse in- creases in frequency. Muscular and nervous forces greatly prostrated. November 2. — l.'he slough, from the gangrenous spot above the ankle, has this morning been removed, leaving a healthy granulating wound two inches in length, and about the same in diameter. No escha- rotic was applied to this gangrenous spot ; nothing but the charcoal and yeast poultices. It is a matter of grave interest to determine whether or not the severe local applications, as nitric acid and sulphate of copper, may not be dispensed with. In many cases, the constitu tional treatment appears to be the great means of arresting the disease. The practice of applying either nitric acid or the actual cautery, or any one of the more powerful caustics, to only circumscribed portions of the wound at any one time, .as well as the frequent application of weak nitric acid, or of any severe styptic, as sulphate of copper, to the gran- 1 See Plate No. XHI. 314 TEMPERATURE AND URINE IN HOSPITAL GANGRENE. ulating surface, after the removal of the gangrene, is to be condemned. I have seen patients tortured day after day almost to death by the use- less application of these severe remedies to healthy surfaces. November 5. — Continues in much the same condition. Wounds ap- pear to be improving somewhat. Examination of Urine. — Amount of urine passed during twenty-four hours, November 4th, 12 m., to November oth, 12 m., 1,120 CC. = grains 17,657.52. Specific gravity, 1,018. Urine red-colored. Deposit of large, well-formed, lozenge-shaped, highly colored (red) crystals of uric acid on side of vessel. ANALYSIS or UKINE, NO. 17. Amount of urine collected during twenty-four liours . Urea Uric acid Free acid Pliosphoric acid Equivalent of phosphorus in phosphoric acid . . . Sulphuric acid Equivalent of sulphur in sulphuric acid Chloride of sodium Equivalent of chlorine in chloride of sodium . . . Chlorine by direct determination with nitrate of silver Urine collected during 24 hours, contained grains 17,957.52 551.93 21.16 35.73 34.65 15.23 23.96 9.58 98.31 59.57 52.83 1,000 parts of urine con- tained 30.73 1.17 1.908 1.92 0.84 1..33 0.53 5.41 3.31 2.94 The color of these two specimens of urine are represented in Plate No. 13.1 November 7. — Two red or inflamed spots were observed, one upon the external malleolus, and the other about two inches above the inter- nal malleolus of the diseased leg. The latter disappeared (no local application being made to either of the spots) ; the former became gangrenous, and extended slowly. No puncture or abrasion could be observed upon either of these spots. November 10. — Four o'clock p. m. Temperature of palm of hand, 73° F. Temperature under tongue, 99° F. Pulse, 100. November 11. — Four o'clock p. m. Temperature of hand, 79° F. ; November 12. — Ten o'clock a. m. Temperature of hand, 73° F. ; under tongue, 98° F. Pulse, 96. Eleven o'clock a. m. Temperature of hand, 22.4° C. (72.4° F.). Temperature under tongue, 98° F. Pulse, 94. Respiration, 14. Five o'clock p. m. Temperature of hand, 82° F. Temperature under tongue, 101° F. Pulse, 100. November 13. — Eight o'clock a. m. Temperature of hand, 74° F. ; under tongue, 99° F. Pulse, 98. Continues to improve slowly. 1 Omitted. TEMPERATURE AND URINE IN HOSPITAL GANGRENE. 315 The depression of the temperature in the extremities, as well as the feeble capillary circulation in this case, was interesting, not only as illus- trating the true nature of the disease, and as indicating the principles of treatment, but also as throwing much light upon the formation of the gangrenous spots on the leg without any apparent abrasion. Case XXI. B. J. Talley, Lieutenant, 20th Texas Regiment. Age, twenty-one. Gray eyes ; light hair ; fair complexion, case xxi. Wounded at the battle of Chickamauga, 19th September, 1863, It^Jhtngi in the posterior fleshy portion of the right thigh, midway be- perature'and tween the hip and knee joints. A few days after the battle Ti"" " ^°^- was transferred to Augusta, and entered the Presbyterian grene. Church, second division. Third Georgia Hospital. After remaining in the hospital several days, was sent to a private house, where he re- mained until the appearance of gangrene, and the patient returned to the Presbyterian Church. Wound did well until the 18th of October, when gangrene set in. On this day the patient had a chill, followed by fever. The chill com- menced at three o'clock p. m., and lasted about two hours. On the evening of October 18th, the wound at point of entrance presented an angry look, with an inflamed areola in the surrounding skin. October 19. — Nitric acid applied to gangrenous wound, and five grains of quinine administered three times. Diet generous ; soft-boiled eggs, beef, and chicken, etc. October 20. — Bowels costive. Chill and fever again in the evening. Tongue red, coated, and moist. Very little appetite. Two compound cathartic pills prescribed in addition to treatment of yesterday. October 21. — Patient again had fever, without the chill, however, in the evening. The pills did not act upon the bowels, and were repeated. Nitric acid applied daily to wound, and followed with charcoal poultices ; quinine continued ; half-grain of morphine administered at bed-time to procure rest. October 22. — Bowels have been acted on. Appetite has not im proved. Fever returned in the evening. Nitric acid applied, and wound dressed with charcoal and yeast poultice ; five grains of quinine three times a day ; and four grains of opium at bed-time. October 24. — No change in symptoms ; bowels costive ; no improve- ment of appetite ; chill preceded fever this evening. Two compound cathartic pills administered ; local treatment continued ; fifteen drops of tincture muriate of iron added to each dose of quinine ; also, whis- key, fsii., three times a day. October 25. — Bowels still costive ; two compound cathartic pills given to be repeated in four hours. Patient has fever which was not preceded by chill. Treatment continued. October 26. — Bowels have been acted on twice; the destruction of tissue goes on slowly. 316 TEMPERATURE AND URINE IN HOSPITAL GANGRENE. No change of note in the treatment or progress of the disease until October 30, when there was some improvement in appetite ; the tongue appeared less furred, and the febrile excitement appeared to be less. The foregoing facts in the history of this case were furnished by As- sistant-Surgeon Warren and Acting Assistant-Surgeon Henry F. Heriot, in charge of the second division Third Georgia Hospital. October 31. — Wound dry, inflamed, and painful, having been dressed with dry, powdered charcoal ; the patient suffers much pain. Constitu- tional symptoms well marked ; high fever, flushed face, head much affected, at times severe pain, and an inclination to low muttering de- lirium. Gangrene still slowly progressing. Pulse about 94 in the morning, and over 100 in the evening. No nitric acid applied. Qui- nine is still continued. Tincture muriate of iron and whiskey are dis- continued ; also the anodyne. Examination of Urine. — Amount of urine collected during twenty- four hours, 750 CC. = grains 12,012.4. Deep orange-red color.^ Specific gravity, 1,018. No deposit after standing sixty hours. Reac- tion still strongly acid at the end of eighty hours. ANALYSIS OF URINE, NO. 18. Amount of urine collected during twenty-four hours . Urea Uric acid . . Free acid (at end of eighty hours after collection) Phosphoric acid Equivalent of phosphorus in phosphoric acid . . . Sulphuric acid Equivalent of sulphur in sulphuric acid Chloride of sodium Equivalent of chlorine in chloride of sodium . . . Urine collected during 24 hours, contained grains 12,012.40 404.25 9.32 28.87 43.89 19.30 25.00 10.00 19.32 11.70 1,000 parts of urine con- tained 33.65 0.77 2.403 3.65 1.606 2.08 0.88 1.68 0.97 November 4. — Ten o'clock a. m. Pulse, 96. The death and removal of the tissues progress very slowly. Portions of the wound are improv- ing. Dark pus of an unhealthy odor is now discharged. Bowels regular. Tongue nearly natural in appearance. Patient now takes no medicine. The local treatment of the wound consists of the application of concen- trated solution of sulphate of copper, twice a day, followed by charcoal and yeast poultices. November 5. — Pulse, 98 at ten o'clock a.m., and 108 at half-past four o'clock p. M. Examination of Urine. — Amount of urine passed during the last twenty-four hours, November 4, twelve m., to November 5, twelve m. 1,275 CC. = grains 20,360. Specific gravity, 1,018. Deep orange-red color. No deposit ; only slight turbidness thirty hours after collection.'' 1 Plate No. XrV. (Omitted.) 2 See Plato No. XIV. Fig. 2. (Omitted.) TEMPERATURE AND URINE IN HOSPITAL GANGRENE. 317 ANALYSIS OF URINE, NO. 19. Elements. Amount of urine collected during twenty-four hours . Urea Uric acid Free acid (thirty hours) Phosphoric acid Equivalent of phosphorus in phosphoric acid . . . Sulphuric acid Equivalent of sulphur in sulphuric acid Chloride of sodium Equivalent of chlorine in chloride of sodium . . . Urine collected during 24 hours, contained grains 1,000 parts of urine con- tained 20,360.00 785.40 38.52 22.00 1.08 40.25 1.97 51.05 2.507 20.61 1.01 53.35 2.52 21.34 1.04 64.79 3.37 41.28 2.02 November 7. — Pus of an unhealthy character is still discharged, and the tissues are still sloughing. Pulse, at ten o'clock a. m., 96; at four p. M., 108. Temperature, at four o'clock p. m., in hand, 103° F. ; under the tongue, 103.5° F. Tincture muriate of iron, gtts. xv., quinine, grs. iii., whiskey, fsii., three times a day ; solution of sulphate of copper applied to wound, and followed with charcoal and yeast poultices. November 9. — Ten o'clock a. m. Pulse, 96. Temperature of hand, 94° F. ; under tongue, 101.75° F. November 11. — Wound does not increase in size, but there is still some destruction of tissue. Ten o'clock a. m. Pulse, 94. Temperature of hand, 90° F. ; under tongue, 99° F. Chill and fever in the evening. Respiration, 18. November 12. — Four o'clock p. m. Pulse, 108. Temperature of hand, 103° F. Temperature under tongue, 103.5° F. Hectic flush on cheek. Had a chill at three p. m. Tongue red at edges, and furred. Patient weak and nervous. Bowels costive. November 13. — The discharge of pus from the wound is greater than usual, and more healthy. Appetite is very good ; bowels continue reg- ular ; tongue slightly furred, red, and moist. Ten o'clock A. m. Pulse, 90. Temperature of hand, 80° F. ; under tongue, 100° F. Treatment continued. November 14. — Considerable dead tissue came off with the poultice, showing healthy granulations in several small spots. Ten o'clock A. m. Pulse, 100. Temperature of hand, 95° F. ; under tongue, 100° F. November 15. — Sloughing appears to have ceased. Some dead tissue has been removed, and healthy granulations were found to exist under the mass. The solution of sulphate of copper is very painful to the wound, and will therefore be discontinued. Charcoal and yeast poul- tices continued. Ten o'clock a. m. Temperature of hand, 85° F. ; under tongue, 101° F. Pulse, 100. 318 TEMPERATURE AND URINE IN HOSPITAL GANGRENE. Four o'clock p. m. Temperature of hand, 100° F. ; under tongue, 102° F. November 16. — All dead tissue has been removed. The wound is now about four inches long and three inches wide, and presents a red granulating appearance. Treatment continued. Nine o'clock a. m. Temperature of hand, 83° F. ; under tongue, 99° F. Five and a half o'clock p. m. Temperature of hand, 97° F. ; under tongue, 100° F. November 17. — Nine o'clock a. m. Pulse, 100. Temperature of hand, 90° F. ; imder tongue, 99.5° F. Wound looks well. Appetite good. Tongue still slightly furred. Bowels regular. Urine nearly normal in color. Treatment continued. November \9i. — Pulse, 96. Wound looks well. Simple cerate the only local application. November 20. — Wound continues to improve ; febrile symptoms almost entirely subsided, even in the latter part of the day. Pulse, 86. November 21. — Pulse 80, at eight o'clock a. m. November 22. — Wound heals very slowly, though it has a healthy granulating surface. Pulse, 88. November 25. — All constitutional disturbances have disappeared. Ap- petite good ; skin warm, moist, and soft. Tongue nearly natural ; slightly red and coated. Wound healthy ; fills up very slowly. The patient has been much reduced by the long suffering and the effects of the gangrene. Case XXII. R. D. Beck, private, Company I. 1st Regiment Case xxn. Florida Cavalry. Age, twenty-nine. Dark hair, gray eyes, tti'e"chang s w n ■flaiBJQ 'pioy aa-t.! 1^ 1 1 1 1 1 1 1 1 1 O 1 en 1^1,1,., •flujBJO 'pioy aun. 1^1 1 1 , 1 1 , iS ,^ s as ^ 1 rH r-i 1 ^ 1 1 1 1 1 1 U3 •saiBJf) *TraJ£|, ■i i 'i CO 1 ■i ■^fjiAUio OBPSdS U3 i-T 1,010 •aopil io ioioo Deep orange Deep orange red Deep pink Deep pink red Deep scarlet •annuo 's-moH K Sujinp papoiioo auufljo^unouiy i§ li i§ CO »- CO- £5 1-1 22,271 H Oh a IS h B CK jo wnnuaduiai Oi COt-aiOOCDCD OOCO (NC^JM 1 WW 1 1 -aspij S 'gSS|ggg|8 g§ § § g^ggss^g 1 ■£va JO -moH ^ a>aiTtcocc>i-(>cncno ow 5^ S ^ gCO-^-^tllOCOCOfr-OO o g ■d C {i 1 Wounded Sept. 19, 1863, in right leg. Gangrene attacked the wound Oct. 1st. Nov. 2, patient pale and anaemic. Hos- pital gangrene in wound. Nov. 6, wound covered with dark, unhealthv slough. Nov. 9, had a chill at ten o'clock, p. M. Nov. 10, pa- tient nervous and rest- less. Nov. 11, symp- toms of pyromia well marked ; pulse small and feeble. Nov. 17, died at five o'clock, "Wounded at Jones- boro', Sept. 1, 1864, left leg. Gangrene attacked wound on the 13th of Sept. Oct. 3, gangrene pro- gressing slowly. Oct. 6, patient had a chill, followed by diar- rhoea. Oct. 6, aymp- 111 Ira Parker, Con- federate soldier, Company G, 1st Texas Regiment. Age, 23; light hair, gray eyes: height, 6 feet 8 inches. Case XLTI. J. B. Carrico, Confederate sol- dier. Age, 29; height, 6 feet ^ inch ; weight in health, 186 lbs. Corporal in Sel- den's battery. CASE XLVII. TABULAR STATEMENT OF OBSERVATIONS. 337 I 1 I I "2 I I I I I II"! II 111"= <^ III 1 1 1 1 ^ 1 1 1 1 1 c«l 1,1 s s S fe s 1 1 <» II 1 1 1 "O Illicit] II" III s e S s s 1 1 ■* II 1 1 1 >a •^ III 1 1 t 1 ^ 1 1 1 11^ III fS S S ^ s 11*? II III''! S , 1 , 1 1 1 1 '~j 1 1 1 s 3 o> to ' ,i CO ' ' 'i i ' " 1 1 g III 11^ iiitiSq^ 111 o o o I I 1 1^ I I I I I ^ I I ^ £ I I 1 I I -^ g-o gill &:§ s B s o M « i-< .™ I I I I g I I , p. S3 m; CO eo llS 11111$ E; III I I I I ^ I I I I I i'g o s C4 00 00 lOUS o 1 a ,i| •a .3 ss a sa i-l«0 SSJ 1 =1^ r-li-l iO WD lO O CO 53 CO en JO N -j"-fc.^ o -*«o -tw I 00 O CC CO ■**<■* lO lO «D tot-t- Oi-(C<101CCTt*iOeOtDt- TOi-ii—ii— lr-tr-trHr^T-(rHi— 1 r. O o J^COrHrH TOO ill a 1 o o - wounded. Right leg amputated at upper third on iield of bat- tle. Gangrene at- tacked the wound Sept 21. Oct.2, gan- grene progressing u is it and fever ; restless and nervous. Oct. 6, had a chill. 6th, chills continued ; py- cemia well marked. Died Oct. 12, 11 a. m. "Wounded 19th of Sept., at Chickamau- ga. Eall wounded foot. Gangrene at- tacked wound, Nov. 4, 1863. 10th, gan- grene spreading. 15th, wound improving. 17th, swelling subsid- ed ; wound granu- latitig. Sept. 22, poisoned his thumb in nursing cases of hospital gan- grene. Oct. 5, gan- 1 £ ft a ■S r£ §« . -nj3 22 Is rl K. O t-H ICDM ; o (o ) M — i^ll^l ■SSa 2S§3 rfl H a Js b& (i^ S 2 2 o'3"S '^o.2-Sgg-S aas •2 -I 338 TABULAE STATEMENT OP OBSERVATIONS. $ s s g g 2 O g i 1 -Buroif) *iunip -OS JO 3puon(b 1-1 (H CO 5.8 S 1 1 1 f 1 1 1 *pi3y Buniiding eg ' 1 1 00 ' CO 27.2 28.2 5.16 32.2 •ptoy ouondfloni CO CO o 1 r I «D 1 00 19.12 22.4 16.6 43.5 •annuo 'P!3V3W.i 24.2 24.2 13.2 17.2 40.7 (O 1 1 1 1 1 1 1 •8nnu{) 'ppv ^rjfl CO e5 CO 1 ' Ir-i i^ 8.28 10.14 2.45 00 o5 1 1 1 1 1 r 1 •BnnuQ *w3jfl^ i'"§ •§ ' 'IS' , g ,, ^ 1 1 1 1 1 I 1 •jCjiabjo agiaadg 1,011.5 1,012 1,015 1,014 1,024 1,013 1,016 •anua JO joioo Bright red Deep orange Reddish or- Light orange Light orange Deep orange- red Orange red •9U1BI0 •BjnoH fz Suunp P3133I103 auuxijoianouiv 23,891 Portion lost, 10,322 13,601 27,479 14,853 Considerable portion lost, 5,681 g 1 1 1 1 1 1 1 a a IS s e •wnxv JO ajniaiodmax 10^.80 104.1 100.8 100.8 100.8 104.1 102.2 101.5 104.76 100.8 100.8 102.6 101.3 102.2 102.6 97.5 102.6 99.3 98.9 96.8 99.1 -pnnH JO ainiwaauiox 8^.1 103.5 93.2 100.4 100.4 102.2 99.2 94.1 104.4 93.3 102.2 99 100.4 100.8 88 101.1 97.1 88.1 B9.9 84 ■noi^oiidfla^ sjsass SS ^S' ' ' a S S§5 'SSSS2S ' ■aninj ggag, Very feeble, lOO 100 124 120 'SSSgSggg 1 ■Xoa joinoH aaa a a as -^ fc -< pi 0^ .< fc •iiu < •< h OOOOrHOOO s a a -^ (C ^ fc .< .< fa OS 03 d> lO A -« 03 ■qinOM JO £va pan inaJS. ^(MCqCOCO-* U310 "1 o cgcottuDt-t-oooacra !5 I 1 shell struck flesh of thigh. Hospital gan- grene attacked the wound on the 27th of August, and de- stroyed considerable portions of tissues of thigh. Wounded July 20, 1864, near Atlanta, in arm. Gangrene at- tacked wound 20th Aug., and rapidly destroyed the tissues. Patient died Oct. 4th. Wounded Sept. 19, 1863. Piece of shell imbedded itself in left buttock. Fragment of shell removed on the field. Oct. 6, gan- grene attack'd wound and destroyed large 111 Age, 22 ; height, 6 feet 10 inches ; weight, 150 lbs. ; brown hair, gray- ish-black eyes. CASE vin. Arnold Nowell, prlTate, 67th Al- abama Regiment. Age, 37 ; weight, 168 lbs.; black hair and black eyes. CASE XII. E. J. Wain- Wright, Confed- erate soldier, Florida cavalry. Age, 28 ; height, 5 feet 9 inches; weight, 176 lbs. CASE XVII. TABULAE STATEMENT OF OBSERVATIONS. 339 O M CO I I I 1 bl I CO I CO t- 00 i-l t I I I I I I I s oog l- 00 oo «D ss 's 'H 1 t ) 1 1 1 1 ) ^ TOM t- -* «3 t- SS ' ' ' ' !S CO 's 'S t-S 00 Oi 8S ' ' ' 's 'g '^ COCO s s S CO sa ' ' ' 's 1 o6 's 1 1 1 1 1 1 1 1 u3 r-t to UDN 1 1 1 ll 'i 1 , , , , , , ,g ... I I I Ig3 1^ Ig o o o_ t r r I I I I 1 ^ p a fig o o p'>3 0) w ir-t-e>ioci ' Oi00010>OT-IO -OSrHCOOO '^'^ ^OSc6Q6oi«DTt<-*00 oooooooooooooooo iH I- 1- t- d CO ■* ■* . r I I oocooooooooo Ol lO 05 >0 OJ 00 oo H«-*:< sssasssss Qt^t-OOOOOlOiOiOt- JsSSs2g."=«aoSssa coeo^cDt-ooooososo fe5 igags-gja-tiS SgEg-Saol-irlorSla' s^rai-i:":>gi^ ^slPl £ i i Is i U &^' ^s si^ltjl ^i r is i--g--l i g|« Sag I ^Ja- 0) o -a a "^ S bo g^« s a siS'-' Mgsg:M.a3-go £ o 'So S o .^ fj, "? E 340 TABULAE STATEMENT OF OBSERVATIONS. is o n o •sniuio 'oinip CO CO t- -og JO apuomo g s •BnTBJJf) o> eo 'ppV 3iJnnd[ns s I ) M 1 1 1 1 I s- CO 1 1 1 1 1 1 1 t i 'ptay ouoqdsoqj a s xo •sniwo'ppvaajj (M ■* 00 CD IM •BaTTUr)'pi3V3"n. '° CO ;=i 1 igH r . I 1 I S3 cq tH ■9nn«o Siaifi ^ 1 !o 1 1 1 1 1 ^ oo 1 r 1 1 1 1 1 1 1 03 iO ■* ■.£)jATjjQ ogiDadg S 1 1 » 1 I r 1 1 CO ^ 1 1 1 1 1 1 1 1 1 T-l r-* iH iH s. 13 tJ §. •3u«ajo loioo ■g 1 1 1 1 t 1 O g 1 1 r 1 1 1 1 1 1 p.^ (X p< Si s n P o ■BUTBJO 'MnOH ^ 5S fX . 2 § 1 1 1 1 r 1 1 1 1 Sa^inp papaiioo ^ 1 g 1 1 1 1 1 g anu^jo^utioiuy C4 j^ S F-l t-i ■IHIIXV JO ain^matiuiax ooooaoosooi ■pmiH JO ajn)iuaauiax -nopcxidaag r I Cq I I rH 1 1 Ol oS rH »-l O O Oi O Ol , iOl-— iO I I I r r I I •-( I I I I ocoooooeoooto^oo S8S •^d JO jnoH Bsaasaas -qruOM JO ACQ pan Jua^ o g H^o ■# o o -* o o o m rt © ain)BJ3dui9x ■nonmidaay; t I -jjcfl-**; lO ■* lo -^j^ Tj< CO N OOOOOOJOSOiOOSO ooos 1- oo3a>O0ja)O}ooaiooo> eDOCD00O'»MTtCiJCI JO jnoH ■innOK JO iza pun i»3A «i«)t~i?-ajoooioo«Hi-(«>o> '"Oaia'cowcow •S S S-i'« ^^ 5S } ft** "ja'rs a "=13 3^3 A.^ aj 3 to g g+3 «'S a3003c:'a)coooQoo ■*0OeD GO CO rH "* rtOr-« CO NO to M OOiO 000003 f^0 0i-li-(0^ I I »BB s s a s s s » a s ;^ a s s a OOOOCO OO CO OO CX9 QO 03 C3 00 03 OO 00 CD CO to s-:- ■^tOtO CO <0 t- 1:^ 03 C3 O O T-H 1-4 eq C^ 00 A CO . Sill l-^^J^30 n.gpff-»3 aoP-^d « om Fh o ,ot>. ^-^w^ t^— H S ^Sg" »o« w Sis- "h su TABULAR STATEMENT OF OBSERVATIONS. ia ■< o H EH -og JO apuomo ■9UnU£> *ppY ouaqcling 00 cp ■satmo •pjoy oiioqdaoiij ■Bureio piov aw J •BureiQ *ppV3U£|_ OOCO oo COU3 -^lAuo ogpads •auiia. JO loioQ tod I-Hr-I OO p o bbbo n p OO aiiunp p3p9i|oo aou]^ JO lanouiy o «; luax JO ain}iu3dai3x -noi^tujdflag I 'Avd JO jnoH •maoK JO Xbq: pUB iV3X i-H O So o tl " m ^ ■■Sg.-S'; -s-:5g''Si a 5) ■3 2 ^. 1 a o 5 "o 9" Oj « o ■2°' O 3 lis sggjss 5Se£o ■g > ss ^ .tS .< la's TABULAE STATEMENT OF OBSERVATIONS. 345 I I I I I oi ■ ^ 1 S s C s, t- s S < . 1 1 .^. §3 (O i "3 1 1 1 1 ig 1 I I I I I o I 3, g 1 a £ fi o o t [ r I 1 1^ I ea -tf »S "S "^ o o o> oj cs o 3^1 _ 2 -S rt * Ooi OJ CO CO lo CO oi g*© ?« Oi OS Ol CT) CT) Oi 00 s ss ssss :0 to L- CO CO O^ 03 .-^ *'!*'**' O Ld n f^ ^^ n^ H ..U ^^ .H -> sB "i: "-.lio Si d B . K ! ^ « S bo . fi,:3 Ph g a) rt O 346 TABULAR STATEMENT OF OBSEKVATIONS. o •Bopuo 'nmn> Q I I I I I I I I -OS JO spuoiqo g -Bnn«o ^ 1 9.66 1 t-: 1 t 1 1 1 1 o 14.76 5; ■annuo *ppv 3"J[ 1 1 1 1 1 1 00 21.69 oo ■° 5! •Bnnuo 'PPV »Ha ^ ,,,,,, 2 -BUIBJO *""I1 ■^ 303.6 3 '.£l!AVJO Offloads I I I I I I I I ■aaujijo JOiOQ t I t ( 1 p Suunp p»i33no3 auij'fl. JO ^anoiuy ^ I I I I I ■mxv JO ainiowduiax o 102.3 101.1 101.1 102.3 99.3 96.9 100.7 93.9 •pnuH JO oiniwadoiaj^ 95.3 98.6 97.1 98.6 96.9 92.1 93.7 93.2 •noHwidflaa t fatOtDtDrOtO 1 ID | 1 •anna 1 03000o8coOO«00 1 1 •jfua JO JnOH CO COCDt-l- CQ •llnOH 1 oc JO i.a p [« anDj^ s o 55 ^ s 1 !S5 . SS'Ss'Sg. g 3 I o o Q S O m *3 2 o » p « P' S .J 'S .2 .SI'S S.°S.gcfS.g - gg« jj o g O f ofS 5 S "^ S ■r, "il -• js .5 S mS-S, 9 o a) d j3 i,. -00^ V'EH c Mm „ TABULAE STATEMENT OP OBSERVATIONS. 34T in OS s =1^ S3 ss ^ o §85 S s sn s oo a. *s § g ss « g ;t-s''3''^^ £ t< _-0-cJ ' » ."S « ^ ^ ^^ o d " — ^ |--!s1';iililsil^g P o db ^S a- ^ S: ,ri t^ d P ■o J3 ^ go ■.g-s^:i2s§ ' S el o> ® »ii 4> it»s a^ ot: bo-H dggs^oSs e^gs,. ""e 3 Mta "p P •CI n M ^5 . ■ ** ■$! ■ 1* a p CO ■s M oQ caw ,a^i-< 348 GENERAL CONCLUSIONS. The preceding observations establish the following conclu- sions : — 1. The local manifestations of hospital gangrene are attended by The local febrile actions in the general system. tions of hos- The fcvcr of hospital gangrene, like that accompany- grene.at- ing Other diseases, is characterized by increase of heat, febrile ac- increased chemical change, and increased elimination of general those substanccs, as uric acid, phosphoric acid, sulphuric Character- acid, and extractive and coloring matters, which result istics of the ^ _ ^ . i • p i t i t fever of hos- trom thc destructivo metamorphosis ot the solids and pital gan- grene. tluldS. The fever appeared, in many cases of hospital gangrene, before the wounds had actually assumed the gangrenous state, with swollen, everted edges, and gray, sloughing surface ; and after careful investigation, it appeared to be more reasonable, at this stage of the disease, to consider the fever as the resultant and necessary accompaniment of the earliest changes in the wound, than as the cause of the gangrenous inflammation. Simultaneously with the development of the fever, and the constitutional disturb- ances characterized by loss of appetite, depression of spirits, con- stipation of the bowels, and such an enfeebled, irritative action of the circulatory apparatus as denoted a depression of the vital, nervous, and muscular forces, certain local changes were noted in the wounds, as the transformation of the moist fluid granulations into a dark-red glazed surface, the marked change, or total sup- pression of the natural discharges of pus, increased heat and pain, and an increased congestion of the blood-vessels in and around the wound. 2. The fever of hospital gangrene appears to be manifestly the The fever of Tcsult of the action of an organic poison. grenl'^l-^"" This proposition is sustained by the facts clearly estab- thllitfonof lished by the preceding investigation, namely, that gun- poison!""° shot wounds are not necessarily attended by fever ; that tokj°ng"thiB tl''^ fever accompanies or follows the supervention of hos- proposiuon. pj^.^] gangrene in those cases of gunshot wounds which, up to this period, had been unaccompanied by febrile excitement ; and finally, that the complete separation of the ragged, spongy, gray sloughs, and the appearance of healthy granulations and pus in the wound, and the arrest of the further progress of the gan- grene, are certainly attended, if not preceded, by corresponding improvements in the constitutional symptoms. After the removal of the gangrene, and the establishment of GENERAL CONCLUSIONS. 349 granulation and suppuration, the pulse becomes fuller and slower, the diurnal variations of temperature less, the normal relations between the temperature of the extremities and central organs are reestablished, the capillary circulation in the extremities becomes more active, and the appetite improves, the complexion loses its leaden, dusky, unhealthy hue, the eye expresses hope and life, and the distressed countenance becomes cheerful : corresponding changes are observed in the urinary excretion ; as the wound improves, the urine progressively loses its high color and the febrile characters, and approaches by gradual degrees to the stand- ard of health. No crisis or sudden change is observed in the urine during the period of convalescence, but the changes in the excre- tion correspond with the gradual changes of the wound. In this respect, all the symptoms correspond, in that they all gradu- ally and progressively improve, without any marked or sudden changes as in certain diseases, as for example, in malarial fever. The favorable changes just indicated, will frequently take place, even where a most extensive surface is exposed and raw, as a large portion of the back, or of the buttock, or of the thigh, six or eight inches in diameter. The fact that all the constitutional symptoms may improve, even before the diminution of the size of the wound, and whilst a large raw surface of muscles, nerves, and blood- vessels and bones remain exposed, demonstrates conclusively that the constitutional disturbances are not due exclusively or even in great measure to the local irritation of the nerves exposed by the gangrene. Where, on the other hand, hospital gangrene progresses unfa- vorably, the constitutional symptoms become progressively more grave, and the fatal termination is generally announced by a feeble, rapid pulse, extreme prostration, twitching of the tendons, vomiting, hiccough, involuntary dejections, and ofttimes coma. In this disease, death unquestionably results in many cases from the absorption of the gangrenous matter. In this case, the imme- diate cause of death is often profuse and uncontrollable diarrhcea. The absorbed gangrenous matter may also in certain cases excite mortification of important internal organs. Such a change may take place rapidly, and without the manifestation of any symptoms during the life of the patient which indicate the presence of the disease. We conclude, therefore, from these well established facts, that in every case of hospital gangrene which terminates favorably or unfavorably, the character and extent of the constitutional dis- 350 GENEEAL CONCLUSIONS. turbances are due in a great measure to the absorption of delete- rious poisonous matters from the wound. 3. The febrile state of hospital gangrene is characterized by Character- increased chemical change in tlie blood and textures, febrile state increased development of heat above the standard of gangrene. health, marked diurnal variations of temperature, great irritability and feebleness of the general circulation, and im- perfect and feeble capillary circulation, as manifested by the marked difference of temperature between the trunk and extremi- ties, and the inability of the extremities to maintain a definite tem- perature, and withstand the effects of external cold. It will be seen from the table, that the periodical elevations and depressions of temperature were intimately associated with the action of the heart. As a general rule, acceleration of the heart's action was attended with an increase of temperature ; and decrease in the frequency and force of the heart's action was attended with decrease of temperature. The temperature fell to the lowest point in the mornings, when the action of the heart was slow- est. The cause of the periodic increase and decrease of temperature, must be sought in the causes which produced the disturbances in the action of the heart, and in the constitution and amounts of blood circulating through the system in given periods of time. We might conceive that the cause which excited the heart to action also excited an increased chemical change in the blood, or so depressed the force which is supposed in health to regulate the waste of tissue, that the elements were allowed to enter into more rapid chemical changes than usual, or that the relations of the vital, nervous, and physical forces were so disturbed that instead of the generation of nervous force or electricity, there was only the increased development of the physical force heat. As, however, the increase of heat was invariably attended with an increased cir- culation of the blood, which furnished the elements of chemical change, and consequently the conditions for the development of the physical forces ; and further, as the increased generation of heat was attended by an increase in the products of the changes of the tissues, as manifested by the increased amounts of urea, phosphoric acid, sulphuric acid, and coloring matters excreted, it is reasonable to conclude that the elevation of temperature was not due so much to some direct action of the nervous system, or to disturbances of the correlation of the vital, nervous, and physical forces, as to the more rapid circulation of the elements of chemical change. GENERAL CONCLUSIONS. 351 The question may still be asked, whether or not the disturbances in the heart's action be due to the direct action of the nervous system upon this organ ? Irregularities in the heart's action may be due to various causes, as the direct action of poisonous bodies upon this organ, or upon the ganglia of the sympathetic system, or upon the constitution of the blood from which the lieart derives its nutrition, or upon the cerebro-spinal system, or to all these causes at once. It would appear that disturbances in the action of the heart, in hospital gangrene, are due to a number of causes, as the Disturbances direct action of the gangrenous matter upon the struc- oaheheaH^ tures of the heart itself, or upon the blood, or upon those ^ng^rene, portions of the sympathetic and cerebro-spinal nervous number of , 1 . 1 ,* ,1 1 , causes,aflthe systems related to the heart. direct action The decomposing poisonous matters, and the products grenousmat- of inflammation absorbed from the gangrenous wounds, structures of after their introduction into the circulatory system, cause itseif, or derangement in the blood, and excite increased chemical biood.and change, and consequently cause an elevation of tempera- and cerebro- ture. It is well known that increased heat tends to excite yous system. and accelerate the heart's action. If the conditions remained the same, the introduction of a mor- bific material, capable of exciting change, into the blood, should be attended by uniform results and uniform elevations of tempera- ture at all periods of the day. But in man the conditions are vastly varied during the different divisions of each twenty-four hours. During the day-time he is subjected to the stimulus of light, and to an increase of external temperature, all the faculties and functions are aroused and quickened, and as the day advances the heart responds to the increased excitement of the nervous and muscular systems. This periodical excitement will take place, whether the patient be in bed in the close ward, or moving about out-doors. By long habit, the nervous system and the muscular apparatus has become accustomed to excitement and action during the work- ing hours of the day. During the period of rest at night, the conditions are changed ; the wastes of the working hours are repaired during those of repose ; the withdrawal of the stimulus of liffht, and the removal of the incentives to nervous and muscu- lar exertion, are attended with decreased action of the heart, and reduction of temperature. During sleep, also, the respiration is not so full, and the motion of the blood is not so perfect. The 852 HOSriTAL GANGRENE COMPARED WITH PYEMIA. skin also is relaxed, and the perspiration increased, and the reduc- tion of the temperature by evaporation promoted. The variations of the temperature at different periods of the day, in hospital gangrene, are without doubt associated with the relative states of activity of the nervous and muscular system, dependent upon the action of external stimuli. The increased action of the heart is to be regarded in this dis- The in- ^^^® ^s ^^ evidence, not of increased power, but rather of JS^of the debility and irritability. The patient suffering from hos- K^drf'^i pital gangrene is under the action of a depressing organic no "nQ-''^' poison, which alters the constitution of the blood, deranges po^r^but ths nutrition of all the organs, and renders the nervous and ta'iSbu- system irritable and irregular in its actions. The strongest ''^' men are reduced under the action of this poison to the condition of weak, irritable children, being not only incapable of any great muscular exertion, but also of prolonged and vigorous mental effort. The exciting agencies of the day produce in this state an irritable and accelerated action of the circulation ; and on the other hand, during the depressed state of sleep there is a rapid diminution of temperature, from the causes to which we have just referred. In the next place, we will proceed to draw some general com- parisons between the changes of the pulse, respiration, temperature, and urine in hospital gangrene, with the phenomena of certain other diseases caused by special poisons. COMPARISON OF THE PHENOMENA OF HOSPITAL GANGRENE WITH THOSE OF CERTAIN DISEASES CAUSED BY SPECIAL POISONS. Pyomiia. — It will be seen, upon reference to the first three Comparison cases rccorded in the preceding tables, that notwithstand- nomena of ing the low, dcpresscd state, accompanied by febrile ex- grene with citemeut, induced by the action of the poison of hospital those of , . „ ^ ,. ,^ , pyajmia. gangrene, the supervention of a new disease, and the action of a new poison, induced an entirely new train of symptoms. This new disease, pyaemia, engrafted upon the low, depressed Symptoms of ^tate induccd by hospital gangrene, was characterized by fcS'ftmn' increased nervous depression and irritation, increased p^w ^n^"'" derangement in the general and capillary circulation, and ^"'"- increased derangement of the blood. The increased ner- vous derangement of pyaemia was attended by ^ marked increase of phosphoric acid in the urine ; and the increased changes in the INFLAMMATORY OR SURGICAL FEVER. 353 blood, especially the destruction of the colored blood corpuscles, ■was attended with a great increase of the coloring matters of the urine. It is worthy of observation, that in this disease and in malarial fever, in both of vv'hich there is a more rapid destruction of the colored blood corpuscles than in any other class of diseases, chills should characterize the diseases, and form the most marked diagnostic symptoms. If such facts do not point out the nature of the cause of malarial fever, they at least sustain the belief that the disease is due to the action of a special poison, and not to mere variations of climate and changes of moisture and tempera- ture. Inflammatory or Surgical Fever. — A considerable proportion of gunshot wounds and injuries heal without any marked inflamma- febrile excitement. As far as my observations reach, the gicarreve" extent and character of surgical and hectic fever corresponds with the extent and character of the inflammatory changes in and around the wound. Unhealthy and profuse suppurations, espe- cially when the bone is involved, present the most marked and persistent elevations of temperature. In surgical fever, as well as in that accompanying hospital gangrene, we have increased chem- ical change in the blood, and elimination of increased amounts of urea, uric acid, phosphoric and sulphuric acids. The most plausible explanation of this increase of chemical change in surgical fever is the absorption of decomposing nje^ost matters, as well as the products of inflammation from the planSoTf Tvnnnrl the increase WOUna. of chemical Billroth, O. Weber, and others, have established the sSSS/L fact that the introduction in the blood of a healthy ani- absmption mal, not only of putrescent serum of blood or pus, but f^^matterer also of the fresh serum of blood or pus, of the fluid ^,„7u'it?„f° expressed from exudations and inflamed tissues, of dried uol™^' pus, and of infusions of decomposing vegetable matter, "'^ wound, causes fever. Moreover, a considerable febrile increase of^Siurothf of temperature follows the injection of perfectly fresh and ana^thS, still warm pus into the subcutaneous connective tissue, or t^a' p^opod- into the pleural cavity. And finally, the injection of fresh ''""• defibrinated blood, taken from an animal affected with a traumatic or other fever, into the blood of a healthy individual of the same species, hkewise invariably produced fever, with an elevation of temperature sometimes exceeding that of an animal from which the blood was taken. It has even been shown, by actual experiment, that the blood of 23 354 INFLAMMATORY OR SURGICAL FEVER. a dog in whom fever had been excited by a fractiired leg, acquires the property of exciting fever in another dog. In these experi- ments, the elevation of temperature took place within a few hours, and sometimes even reached its maximum within that time. Re- peated injections of pus, or of serum puris, caused a continual remittent fever, marking an exacerbation after each injection. It has also been shown, by carefully conducted experiments with healthy blood and otherwise, instituted with the design of controlling and elucidating these results, that the fever thus artifi- cially produced is entirely independent of the local injury inflicted by the injection, which does not lead to inflammation until several days later, and that it is not caused by a simple transfusion of blood, nor by the increase of volume of the blood, nor by its dilu- tion, nor by the coagulation of the fibrinous element. John Simon, almost without hesitation, assumes that the process Doctrine of of inflammation, in inflammatory fever, spreads by com- John Simon, ' . i i , . n ■ -, that the pro- mon material contagion, and that the returnmg fluids of cees of in- i./ii iiii flammatioD, the inflamed part, its venous blood, and its lymph, are ininflamma- „ '^ . . , . „ . tr .1 , • tory fever, the agents or constitutional infection. " Yet, says this spreads by ,...,, 1 1 ■ • r> 1 i 1 • common ma- distinguished pathologist, " it a part be developing preter- tagion. natural heat, and undergoing preternatural change, its venous and lymphatic outflow must of necessity represent those excesses of heat and change ; and this outflow with all its belong- ings, material and dynamical, shedding itself without interruption into the blood, must straightway be diffused throughout the body. Not inactively we may presume ; for the blood, receiving such increments of heat as the inflamed part thus contributes to its temperature, and receiving also that unwonted afflux of chemically changing material which comes from the disorganizing textures, is doubtless itself stimulated to greater activity of change. And as it circulates throughout the body, so to every texture which it supplies there is brought more than common incentive to change, till in proportion as the fever is great, every texture, according to its chemical mobility, gets to participate in the excitement, reflects as it were in a lesser scale the disorder of the inflamed part, and contributes a share to that over production of waste products and of heat which is characteristic of inflammatory fever." Whilst, therefore, inflammatory and hectic fever is characterized in common with hospital gangrene by an increased temperature of the blood, which causes the apparent drought of the body,i and acts as a universal stimulant, exciting the nervous centres and the organs dependent upon them, and exciting the heart's action by a HOSPITAL GANGRENE COMPAEED WITH SMALLr-POX. 355 stimulant impression on the endocardium, and the muscles, and the cardiac ganglia ; and whilst both diseases are attended by an increased transformation of organic material, resulting from the catalytic action of the deleterious materials, introduced into the circulatory system from the inflamed and gangrenous textures, at the same time inflammatory fever is of a more sthenic character, and subject to less diurnal variation, and the complexion of the patient is clearer, and as a general rule the spirits and strength of the patients are better than in hospital gangrene. Small-pox. — The fever of this disease, as well as that of mea- sles, scarlatina, typhus and typhoid fevers, in like manner smaii-pox. with that of hospital gangrene and surgical fever, is due smaii-pox to the contamination of the blood by a specific organic contamina- poison. As the abnormal phenomena of hospital gan- wood by a -, . , ,1 . . , specific or- grene are due ni large measure to the absorption mto the ganic poison. blood of poisonous animal matter, and as small-pox is clearly a disease arising from an animal poison, it is therefore important that a comparison be instituted between the chemical and path- ological phenomena of the two diseases. Small-pox differs from hospital gangrene in that it is caused by a poison which has a definite course to run, produces a uniform cycle of changes, and a permanent and protective alteration in the constitution ; whilst the latter disease is caused by an animal poison, it does not run a definite course, but, if unchecked, may proceed to the destruction of the part affected, and may recur again and again in the same individual or wound. As we have shown, the constitutional symp- toms of hospital gangrene are caused chiefly, if not wholly, by the absorption into the blood of the gangrenous matter ; as soon as the wound improves, and is entirely free of hospital grangrene, the urine becomes normal in color, and the temperature and pulse return to the normal standard. The poison of hospital gangrene resembles a ferment, and is produced in the manner most favorable to the development of an albuminous poisonous matter, in a state capable of exciting similar changes in the tissues and blood ; and this poison, unlike that of small-pox, proceeds to contaminate and destroy, beyond redemp- tion, the entire solids and fluids, and possesses no self-limited prop- erties, and no power of exciting such changes as are permanent and protective against subsequent attacks. The poison of hospital gangrene, therefore, resembles more i^arly the action of the poison of certain venomous rep- tiles, as of the rattlesnake (^Crotalus durissus and ada- of hospital 356 HOSPITAL GANGRENE COMPARED WITH SMALL-POX. fmWMmore '>^<^nteus), of the water moccasin (^Trigonocephalus pisdv- Snof'the orus}, and copperhead QTrigonocephalus contortrix). This teta°y''noS-" disease produces a depressed, depraved state of the sys- ous reptiles. \Qxa, upon which other diseases may be engrafted. I have observed the supervention of varioloid in cases of hospital gangrene and pyaemia. One of the wards of the gangrene hospi- tal at Macon, Georgia, was devoted to the treatment of small-pox ; and, through the neglect of a perfect quarantine, the latter disease became pretty generally diffused amongst the unprotected nurses and patients. In this manner, we were able to determine this fact in the natural historj' of hospital gangrene. The material producing small-pox being definitely related chem- The material 'cally and physiologically to the organic constituents of smaii-pM, t^'s living body, the development of the disease is trace- nudyreiated ^We tlirough wcll-marked stages. During the period of andphysio- iHcubation (the duration of which varies within narrow th?o'rgani° Hniits, according as the poison has been introduced by of"thc'iwrng the mucous or cutaneous tissues, in the former case, or east''^pre°ente' natui'al small-pox, the period of latency varying from ten Sarked" ^0 sixtccn days, and in the small-pox produced by inocu- itafof thcT*^ lation, from seven to nine da\'s), the specific poison ab- the'sta'^3 °' sorbed gradually infects the blood, rendering it contagious ofemaii-pox. j^.^ jj^ properties, and excitant and irritant to the nervous system and circulatory apparatus. The period of incubation of the small-pox poison varies within narrow limits, whilst that of hos- pital gangrene depends largely upon the condition of the sys- tem and wounded surface exposed to its influence. In those whose strength has been exhausted and blood deteriorated by ex- posure, bad diet, and severe labor, the disease may be developed within three days after the exposure to infection, or to the causes capable of exciting this morbid action. Tiie infection and alteration of the blood during the period of incubation in small-pox gives rise to the secondary stage of pri- mary fever, lasting from two to six days, till the eruption appears, when, in most cases, it remits. Tliis stage is characterized by high fever, the temperature of the axilla rising in some cases to 106° F., severe muscular pains, especially in the small of the back, nausea, and in some cases obstinate vomiting, oppression of the brain, drowsiness, stupor, and even coma, and occasionally con- vulsions. Next succeeds the exudative stage, during Avhich the eruption appears and becomes fully developed. On the appearance of the HOSPITAL GANGRENE COMPARED WITH SMALL-POX. 357 eruption, the fever remits, the heat abates, the pain in the muscles of the back and the affection of the head subsides, the vomiting ceases, the pulse returns to the natural standard, and the temper- ature falls rapidly during the first and second days of the eruption, from 106° to 100° F. About the fourth day of the eruption, and about the eighth day of the disease, inclusive, from the first attack of the primary fever, when the eruption is fully out, and the most advanced pustules commence to maturate, the commencement of suppuration is an- nounced by the swelling of the integument, and especially of the whole face, head, and neck. During this period of intumescence (generally lasting three days), simultaneously with the renewed hyperaemia of the skin, and introductory to the change taking place in the cavities of the pustules, the fever, which had remitted, returns, and the last stage, or "that of secondary or suppurative fever, commences. In cases of ordinary intensity, this stage is marked by a rise of temperature to a considerable height (104°, 105°), by acceleration of the circulation, and by slight delirium and rigors. In cases of greater intensity, severe delirium, a harsh, dry cough, and hemorrhages from the lungs and kidneys may be added to the other symptoms. The secondary fever, and the swelling- and redness of the face, having lasted from three to five days, subside, and the now fully ripe pustules burst and discharge a thin yellow matter, which, concreting into a crust, falls off on the fourteenth or fifteenth day, and the disease terminates. During these changes, the temperature sinks gradually to the normal stand- ard. The secondary fever of small-pox is clearly related to the suppurative process, and, without doubt, has much the same origin as true, uncomplicated inflammatory fever. It is mainly due to the absorption of the serum of the pus, and of the products of the inflammatory exudations. The urine of small-pox presents changes corresponding, to a certain extent, with the four well-marked stages of the The urine of _ , . ,. 1 . ,. small-pox disease. In this disease, the urmary excretion presents presents , . . changes cor- uniform characteristics, namely, great concentration, in- responding, .-,, , , ,, . to a certain crease of urea and uric acid, phosphoric and sulphuric extent, with IT /■ 1 thefour acids, and diminution and even total disappearance ot the weii-marked ^ stages of the chloride of sodium. disease. The following table contains a consolidated statement of the re- sults of the author's labors upon the changes of the urine in small- pox, during the recent war : — 858 OBSERVATIONS ON SMALL-POX. H Pi H m o Pi S is o £ P ■Batwo 'flapiioiqo 1 g s fHCO Trace 4.63 48.97 84.94 68.84 s 00 ■* 19.93 23.95 66.24 24.11 31.38 id 5 22 64 32.60 30.70 32.61 46.32 •gnnjjo'ppvsajj to 3 coo 26.24 32.42 24.68 39.14 46.32 •Buiujo'PPVaHA S3 S CO 6.80 12.00 11.66 16 90 18.60 S & M S3S 434.66 407.61 376.62 443.68 655.84 •Jopo 1 1 >> s, a £ o It |i 3 Deep orange red Deep orange red Deep orange red Orange Orange -^;iiW£) jgioads 1 as l-TtH 1,031 1,024.5 1,016 1,016 1,016 •gniwj) 'sinon K 9uunp pajoanoD auunjoiunoiuy lO CO t-Oi woo 6,496 9,322 16,967 26,999 23,88ii SCO CO I '. i 6.|;.Sj V, « a o g.o'o a£a -osa.erti*' '':at .-a-o 3-3-2 3 o ii-o~ S.-S » s g ■^soflpi^ig -&•- S -o "S » o ft ".2 §'=: B:-S 'SS^ . "^ .'=.£■ S S 2-3 S^S . S i ft a D • ^°|.sggs|gS R'SoaaS .'^■- -??9 o ".IS " o g ft c Co5(B^ S3^?? ft I " « g °L S- . . -a 5g6..-S-='B2.dS '.till III -;r ^oS-g-oa ^ to a ft-d ^ o » ''a if g o * ^.|Soo-g§S£a Sg'-ig'"-|§'3ft| ^§S&-oggloM OBSERVATIONS ON SMALL-POX. 359 O O « MO rH 6cOC4C>«OlC4 sraS^uSco b-OOSiOiMOS omoooNO 3i-(0 ■*o "S "O "^ "O "tf "C ES£££S bo ^ tfl bll bo m a B g □ d □ 0} u S a a oo 'h COOO (NrH OO g3S OO CO CO 1- 1- o o Oi Tt* Cfl lO OO I— 03 OJ L-* t^O fl rS o i o fl °; S ° «d .cfl «d fl"f&-J3 fl t; ft CJ l|H|B^ilii CO O.'" -' i a :B , C3 5*02 3 T) ^Td *-"■ iW r3 .^ >^ TS •Jo.*' S 3 13 .■S-g'^ jfl«r -■"'"'1-^ "i; gap a "13 'p 2 •^ ft 3 .^ .2 ^ .- - . o «i ¥ u o . fl 60=^ rH fl » as S Sf o jS-H H at a;,2 O 'SS I §§•3; S« ^-Sja a a a i tea •cfl'SBJflSoijoio > 3 S > cs w-S s-dflS (JO " — ' fl fl — m 3 fl"^ M T" 0^ fl I =" °^l Q) ^ fl 'o-^ o .fl t_,ii --S, « =" £~ m bO b „ g 3 d O"^ ^ « (fl fl « I « B L- g n S ° ^ Su. 23 » Sd°°£ga- «,1S 3 5 o to-g g J-S (, u a P.2 'a 00 „ i S * o M^fl .- S « " ? m'S a)S fl » -?■= £ I «3 H S -2 o o ■« S I'sSaj 860 HOSPITAL GAl^GRENE COMPARED WITH SMALL-POX. When it is considered that these patients partook of but little Urea uric food, and Were in a state of almost absolute rest, it is evi- phoTOMid <^^"t t^'^*^ th® "''®* '^ considerably increased in the urine phuricacid ^^ small-pox, amounting in one case to over six Imndred the'mine " grains during the twenty-four hburs. As a general rule, ofsmaii-pox. ^jjg increments of this constituent corresponded with the severity of the disease, being but little above the normal standard in mild cases of varioloid, and increasing to double and even treble the usual amount in cases of confluent small-pox. In like manner, the uric acid and the phosphoric and sulphuric acids were increased. The excretion of these constituents furnishes a measure of the destructive metamorphoses of the blood and mus- cular and nervous systems during the progress of the disease. The uric acid and urates exist in such large amounts in the concentrated and scant urine of small-pox as to form heavy deposits upon cool- ing. Uric acid is in like manner largely increased in hospital gangrene ; and this increase, as in tlie case of small-pox, must be referred to the derangement of the nutrition, and oxidization of the nitrogenized elements and constituents and tissues. The great concentration of the urine in small-pox may be due to several causes, as the congestion of the kidneys, the peculiar constitution of the blood, in virtue of which the water is held more tenaciously in combination witii the nitrogenized elements and con- stituents, and the large abstraction of this constituent of the blood during the morbid changes in the integument. The rapid diminution and complete disappearance of the chlo- Bapid dim- I'idcs during the exudative and suppurative stages of small- iworinc'in pox ^^ important, as illustrating the offices of these metal- smaii-pox."^ lie Salts in the animal economy. The chlorides disappear ofThfsTm- so completely from the urine of severe cases of small- inution. pQ^^ ^i^g^j nitrate of silver gives scarcely a perceptible tur- bidness, when added to the urine acidulated with nitric acid. Tiie wide diff"usion of the chloride of sodium through the solid and fluid portions of the earth's surface, and its similar diffusion throughout all animal substances in definite proportions, as well as the cravincr of men and animals for this substance, and its established benefi- cial effects when used as an article of food, point to the importance of this substance in the metamorphosis of animal tissues. It is now well established that this salt is constantly associated with cer- tain animal matters, and essentially influences their chemical and physical properties, rendering albumen, casein, and fibrin more soluble, and modifying their coagulating properties. The influence HOSPITAL GANGRENE AND TYPHOID FEVER. 361 which this salt exercises on these protein compounds, and upon the physical properties of the blood corpuscles, as well as its relations to urea and glucose, renders the view probable that it is capable of forming definite chemical compounds with certain organic bodies which are most active in the changes characteristic of inflamma- tion. Recent investigations upon the composition of inflammatory ex- udations, pus and mucus, indicate that this salt discharges an important office in the metamorphosis of the inflammatory mate- rials of various diseases, as pneumonia and small-pox. And it is not unreasonable to refer the absence of this salt from the urine in small-pox, not merely to the diminution of the amount ingested with the food, but to its abstraction by the exudation, and the part which it plays in the metamorphosis of the organic con- stituents into organized cells and fibres. During the active stages of hospital gangrene, pus is not formed, and the exudation does not progress to the formation of cells and new tissue, as in pneumonia and small-pox ; and it is worthy of note that there is comparatively small diminution of the chloride of sodium in the first named disease. Typhoid Fever. — The fever accompanying hospital gangrene, without doubt, partook of the nature of continued fever, Typhoid and has even been confounded with typhus fever ; and the parison of its , , -,, !•• 'IT • •! phenomena expression has been used by a distmguisiiea writer with with those of reference to the hospital gangrene of the Crimea, that it grene. was in many cases a veritable " child of the typhus^ During the recent war, genuine typhus fever was almost unknown in the Con- federate army, and the continued fever of the camps was in all respects typhoid or enteric fever. The continued fever of hospital gangrene, whilst possessing some points in common with this dis- ease, differed in that it was of uncertain duration, depending upon the condition of the wound, and was not so marked in its elevation of temperature, and the destructive metamorphosis of tissue was less. The following table, drawn up from my investigations upon the continued fever of the Confederate camps and hospitals, will furnish data for comparison with the preceding observations : — 362 TYPHOID FEVER. o to fc !« W t^. 0. o PI B CJ W M H D n - iz n «s . -R P^ CQ P H H !^ -«! O « >-= Sa WPl S w tH^ != e: c K1 0( ^ o M Ed Pk s K Cm l<5 W » W R e> O ^ o g ?1 2 -<: H M P o « IS O m m 55 o SS •< *; > BJ ■oinTp -og jo Bpuoiqb -pioy outiqding 39.6 39.6 83.8 62.8 62.8 66.9 66.9 33.3 33.3 63.3 63.3 45.7 40.49 40.49 27.04 27.04 31.34 31.34 22.63 16.46 16.46 •PPV ouoqdsoiij 53.3 63.3 27.6 63.2 53.2 67.2 67.2 42.6 42.6 69.6 69.6 42.6 50.66 60.66 23.84 23.84 33.86 33.86 38.20 49.89 49.89 ■pioy aaij •pioy oua SS BESS S SS 1 1 1 1 1 t I 1 1 1 1 1 1 1 i^i~; r uaiONci 1 r^ 1 Tii.* 1 I ' ' ' 'hjhoh K HuHnp 647.3 647.3 674 798 798 829 829 816.2 816.2 1,146.6 1,145.6 680.9 723.6 723.5 446.6 446.6 680.9 680.9 492.62 668.19 668.19 •A'AB^O »5P37rH"*f-;r-'Tj;COu3COlOd'*COU3CO t— --dtOO-^ o 1 eoto«JcDcDioifO"flcDuio"*co^e4dmT--iedoooioOr-io " ' OOOOOOOOOOOOOOOOOOOOC5 00 03 00 0IO •puiiH > aitiiTUsduiax -aoiiiuidsag rHddOiOil-;!-- CDCOC^t^t-;t^WaeDl.-^Oit-l>;U3t>-lOOCOCOOdrHC- o I co'icocidairHcqQdo6aJaJodorHoi ' OOOOOOOOOOOOOCOOOiOOOOOOOJOlOiOlOoSs tlOOCDTf-^COdddOdOO "^Bfi JO inoH I I I ICDOOOOSOCDdMOdddOCO-^TPdOOCOtOCOOOC^Od-^O osooo6cocno>cnaso>oosoooobobooaooocooooocoooooL-^L— t— ^ ^rHrHr--( d CO CO ■* ■asnasiQ jo £vq I O Tt-t'— ( (-1— iddddc^ddddddd ^ S'tn «3 ^ - " " " $ -5 3 2-- J --c ° ^15 .n.d|; 4 a d -i3 s ° S ■ g„ giM J. 2 -■§ -a -g (3 ■" ■" *■ & 'S. o B = a|"a£ S m D ^ S ."- w3 fc S ° >< o S = « ^7^ d ri u o u5 (M ca I I I I I I 0000CQ'*-*O3 ' CO l^ lO TO CO O M C4 I I I I I I I I I I I I I ) 111(111 rt<«3 j- eoi— ^'"t+'-dii- oocciOOiOT Tl »0 ?0 iH r^ f-l O Cfl ^ ^ Ol (N M r- 1-H OOOOOO O C-li- b£ U faO tfi Ul faO □ a a a Q p a ooooooo ppccaaaa OOOOOOOO p.fitCLiQiAQ'O.fit 00 CO 1.^ t- 1- 1— CO t-OOOOOOiQ ■O O^ to U3 lO lO t^ OS ^oooooeD CO QOOOOiOkOC0 »0 r- Oi Ci T— I OJ OJ CO t-; O OS Oi W3 lO OO CJ o C3 en OS o> OS o OS rH CQrH CO CO CO ^ s s a s s s a a B E a a ^- a a ■* lO CO I— t- OO OS I— e^ r-i ca* «3 CO o EC ^^ 5 5 "^^gasr a> ™-a o -S 2 g s a ^ ?. -5 .2 §2"; • -"S :2 "O o «fl ». n . 1*1 rt a^ ^^ f) * ^ ( »J3 C „J3 »^ S-S «« g°£M ■§2 = s^§s ^ ^ '^ oi ^ t^ ° — lO *" ° r; o a •- 0,1-- - < as ja , ,« jj j3 ^ ■ § a ^.^„-^ g ^ '-3 s^ 364 CHEMISTRY OP TYPHOID FEVER. During the active stages of typhoid fever, whilst the tempera- Greatandre- ture is elcvatcd, the circulation accelerated, and the res- creasoof the piration labored, tlie intellect wandering, and the muscu- uentsof the lar and nervous powers prostrated, rapid and destructive phoid fever, chemical changes take place in the blood and in the ner- vous and muscular structures, as evidenced by the great and re- markable increase of the soHd constituents of the urine. In the first case which we have brought forward to illustrate the Urea greatly Composition of the urine in typhoid fever, during the increased. height of the diseasc, upon the tenth, eleventh, twelfth, thirteenth, and fourteenth days, the average amount of urea ex- creted -was 886 grains, and upon the fourteenth day the urea reached the high figure of 1,145 grains. During the period that this large amount of urea was excreted, little or no food was con- sumed ; in fact, the patient might be considered as in a state of starvation. If we place the average amount of tirea excreted by men moderately well fed, engaged in the ordinary exercise of the duties of life, at 500 grains, it is evident that the amount of urea was doubled in this case during the active stages of the disease. The experiments of Dr. Hammond and others have shown, that, during starvation, not more than 200 grains of urea are excreted daily, and the quantity may even sink as low as 100 grains. In this case, therefore, the urea was five times as abundant as it would have been in an individual in health similarly starved. This in- creased production of urea is clearly due to the increased chemical Explanation chaugcs cxcitcd in the nitrogenized constituents by the wasteo?^''' action of the typhoid poison. We thus have an expla- Se'i'n'^ nation of the rapid and extensive waste of the muscular lll^°'naK- structures in typhoid fever. In nine days, during the tio^jjfurea j^gight of tlic fcvcr, this patient lost no less than 7,251 muSr°^ grains of urea. If ^^'e accept the formula CjH N2O2 for flbro. urea, we may readily calculate the amount of nitrogen which escaped from this patient during this period, and this will furnish important data for the calculation of the approximate amount of nitrogenized materials in the blood and tissues, from the decom- position of which this element of the urine was derived : 3,383 grains of nitrogen were excreted by this patient from the fourth to the fourteenth day of the fever. It would certainly greatly facilitate our investigations upon the phenomena of fever, if we were able to point out with accuracy the tissues and substances which yielded the chief constituent re- sulting from the decomposition of the nitrogenized substances of TYPHOID FEVER AND HOSPITAL GANGRENE. 365 the body. Whilst these questions have not been definitely settled, still such intimate chemical relations exist between certain ele- ments of muscular structure from which urea may be formed by artificial process, and the muscular structures present such vital activity, such marked and rapid metamorphosis of their nitrogen- ized constituents, that we are justified in referring to the muscular structures as one of the chief sources of urea. This view is sus- tained by many facts established by various physiologists, as the waste of muscular structures under starvation and exercise, and tlie increase of urea under increased muscular exertion, even dur- ing starvation, and the marked diminution of urea when the mus- cular structures are kept at rest. We naturally connect together the rapid waste of muscular structure and the large increase of urea, even during starvation, in typhoid fever, and are justified in inferring that the former is the source of the latter, in large meas- ure, at least. We have elsewhere shown that the albumen of the blood diminishes in typhoid fever, whilst the colored blood corpus- cles are but slightly affected. In this fever, therefore, whatever the case may be in health, the urea is not derived from the decomposition or chemical changes of the colored blood corpuscles. The bearing of this question is im- portant, in its connection with certain physiological problems. Whether or not the whole mass of blood be diminished in typhoid fever, it is very evident that the albumen and fibrin are in maiiy cases decidedly diminished. And whilst we cannot determine whether these elements were directly decomposed in the blood, or whether they first entered into the composition of the organs and structures, and especially of the muscles, and passed through a definite series of changes before being reduced to urea, we are nevertheless justified in selecting albumen and fibrin as the repre- sentatives of the nitrogenized tissues and constituents from which the urea has been derived. The fact that albumen forms the great soluble constituent of the blood, as well as its direct chemical and physical relations to the nitrogenized structures, furnish reasons for its selection as their great representative, in the attempt to de- termine approximately the waste of the body resulting during these nine days of fever, from the formation and excretion of 7,251 grains of urea. It would cause a needless consumption of time to dwell upon the well-established and universally admitted facts, by physiologists, that albumen occurs in all those animal substances which supply the whole body, or individual parts of it, with the materials necessary for nutrition and the renovation of effete mat- 366 CHEMCSTRT OF TYPHOID FEVER. ter ; that albumen forms the principal constituent of the blood, the lymph, and chyle, and of all those serous fluids which contrib- ute directly towards the nutrition of the organs ; and that albumen requires but very slight modifications to become consolidated under different forms into various structures, and especially into the mus- cular structures. In like manner, it would involve a needless waste of time to attempt an explanation of the exact mode in which albumen is converted into fibrin, or attempt to decide the question whether the protein substance which can be extracted from the muscular fibrils by dilute hydrochloric acid, called, by Lehmann, syntonin, and which appears to be the true matrix of the essential element of animal motion, both in the striped and unstriped muscles, be directly derived from the albumen of the blood, or from the fibrin which had in turn been derived from albumen. The only essential fact to the accuracy of the present calculation is the very near relation of albumen, fibrin, and syn- tonin, and the essential element of animal motion. It would, without doubt, render the calculation far more useful and accurate, if we were able to determine the exact relations of the syntonin to the complex contents of the muscular fibrils, to the gelatinous substance, the creatine, creatinine, inosic acid, lactic acid, and other undefined constituents of the muscular juice. Such an attempt, however, would end only in profitless speculation, for it must be confessed that the exact i-elations of these various con- stituents of muscles to syntonin and fibrin and albumen have not yet been satisfactorily determined ; and whilst it is easy to repre- sent on paper, by figures, the amount of oxygen which it would require to reduce the syntonin or the fibrin or the albumen to such states as creatine or creatinine, still these arithmetical amusements would afford no true explanation of the actual changes, which, for all that we know to the contrary, may involve a number of com- plex processes of arrangement and of reduction, as well as of pro- gression, oxidation, and resolution into simple compounds. If we take the nitrogen of the urea (3,383 grains) as the Method of basis of the calculation, then 7,251 grains of urea repre- the amount scut 21,825 grains of albumen, or 21,967 grains of Buueddur- fibrin, or 22,111 grains of unstriped muscular fibre, or the amount 21,392 of syutouin, the chief constituent of both striped creted. and uustripcd muscular fibre. In this calculation it is assumed that the nitrogen is the stable element of nitrogenized substances, and that whatever changes and losses the carbon and hydrogen may undergo, the nitrogen remains to a great extent un- CHEMISTRY OF TYPHOID FEVER. 367 altered. If, however, it enters into the various chemical changes, and is finally evolved to a certain extent as pure nitrogen, then the figures here representing the equivalent of urea in albumen, fibrin, unstriped muscular fibre, and syntonin, are lower than they should be. These nitrogenized bodies are here considered in their anhydrous state, and tiie calculation does not give us a correct representation of the absolute amount of flesh in its natural, living, moist condition, corresponding to the urea excreted by this patient during nine days of typhoid fever. Von Bibra found from 72.66 to 74.45 pounds of water in the 100 parts of human muscle. Leh- mann, from a course of observations instituted by one of his pupils, affirms that water existed in upwards of 80 parts in the 100, of the muscles of the bodies of healthy persons who had committed suicide. Berzelius estimated the quantity of water in the muscles when in a fresh state at 77.5, and Schatz at 77.6 in the ox. Leh- mann gives the mean results of the determinations of various ob- servers of the water and solids of the muscles, at water, 74.0 to 80 per cent ; solid constituents at 26.0 to 20 per cent. If we em- ploy the last figures, we obtain the following results : 7,251 grains of urea represent in the living, moist condition, from 85,042 grains to 110,555 grains of unstriped muscular tissue, or from 82,661 grains to 106,960 grains of syntonin. In nine days the urea excreted by this patient would represent from twelve to sixteen pounds avoirdupois weight of j„ ^^.^^ ^^^^ muscular structure, and a still larger proportion of albn- °4gM^'ty- men, as this element in the animal body is associated with the^urS^S- a larger proportion of water. If we connect with this senMfrom" the loss of various constituents, nitrogenized and non- ^^uJcu'iar , nitrogenized, and mineral, which appear in the urine ^''■"''''"^°- as free acid, uric acid, extractive and coloring matters, free phos- phoric and sulphuric acids, chloride of sodium, and the phosphates and sulphates of alkalies and alkaline earths, as well as the free evacuations of the bowels and the excretions of the lungs and skin, we have an explanation of the rapid and characteristic waste in typhoid fever. We have here a solution of the important question as to the cause of the great increase of heat in typhoid fever. By a comparison of these results with those relating to hospital gangrene previously rendered, it will be seen that the The solid ,., . c.i • c IJi.- constituents solid constituents or the urine are tar more abundant in are more typhoid fever, and the temperature is higher and more and the t^m- uniform, the diurnal variations being far less. It results more eievat- from this that the waste of tissue is less and more grad- fever than ual in hospital gangrene. We conclude, therefore, that gangrene. <^68 CHEMISTRY OF TYPHOID FEVER. the fever accompanying the active stages of hospital gangrene par- takes more of the nature of inflammatory and hectic fever than of true typlioid or enteric fever. The uric acid was increased in typhoid fever, and as in hospital nric acid in- gangrene, it presented none of those sudden variations boTh'dis" i'^ amount which characterize malarial fever. This uni- easc-8. form presence of uric acid in increased amount, as well as the absence of marked fluctuations in it, are valuable facts in enabling the physician to still farther distinguish typhoid from malarial fever. The phosphoric and sulphuric acids are increased in typhoid Phosphoric fevcr, whilst the chlorine and consequently the chloride and sul- ..... ^ J phuric acids of sodium is diminished to a marked degree. As the increased, . , . , . and the amouut ot nitrogeu excreted m the urine was made the chlorine de- ..«,,?„,, .. creased in basis ot Calculation tor the determination ot the amount Ter. Method of nitrogcnized matter chemically altered durinsr fever, ofestimating ^ ^ 111 i i i the waste of in like manner phosphorus and sulphur may be employed the nervous . i i • >. i ^ i i . , , and muscu- m the calculatiou ot the extent ot the chemical clianges tares from of the sti'uctures and substances with which they are the amount<3 . -, , _ ^ i i m /i i of phosphoric essentially associated, ii the daily amounts of phos- and sul- . •: i i i i i • , . . ^ phuric acids phOHC acid excretcd by healthy active men, living upon the urine. their Ordinary diet, and taking their usual exercise, as determined by Breede, Neubauer, Mosler, Winter, Hammond, and others, be compared with the amount of phosphoric acid excreted during the active stages of typhoid fever, it will be evident that the latter not only equals the former, but in most cases exceeds the amount of phosphoric acid excreted in health upon full diet. To appreciate correctly the importance of this fact, we must consider, first, the condition of absolute rest, in which the typhoid fever patients were placed; and, second, the condition of partial and in some cases almost absolute starvation in which patients suffering with this disease are necessarily placed during the active stages of the disease, wlien they are incapable of taking anything more than small quantities of simple fluid nourishment. It has been clearly demonstrated by the investigations of Leh- mann and others, that intellectual and bodily activity increases the amount of urea and phosphoric acid and sulphuric acid in the urine, whilst rest, on the other hand, causes a marked diminution of these constituents. Diminution of food exerts still more marked influence upon the excretion of phosphoric acid, urea, and sulphuric acid. Mosler found that during abstinence from food, even for a short period, phos- CHEMISTRY OF TYPHOID FEVER. 369 phoric acid, sank to half the ordinary quantity. During the ten days in which Dr. Hammond confined himself to a diet of albumen, the phosphoric acid in the urine sank from 36.17 grains the first day of the experiment to 9.16 grains on the tenth day ; during a similar period in which this observer confined himself to starch, the phosphoric acid decreased in like measure progressively, but to a greater extent, and upon the tenth day of tfie experiment reached the low figure of 6.31 grains during twenty-four hours, and the daily average for the entire period of ten days, excreted by this stout, athletic observer, engaged in his ordinary duties, -was only 13.66 grains ; and, finally, during the diet of gum-arabic, this con- stituent of the urine decreased in four days from 24.12 grains the first day to 4.55 grains the fourth day, when the experiment was ended. In the first case of typhoid fever, the phosphoric acid during the height of the fever, whilst the temperature of the body was 106.3° F., reached 57.5 grains during twenty-four hours. In the second case of typhoid fever, during the height of the disease, whilst the temperature of the body was 107.2° F., the phos- phoric acid reached the high figure of 75.9 grains during twenty- four hours. As these patients were consuming but very small quantities of milk as nourishment, and as they were in a state of rest, it would be within the bounds of truth to place the amount of phosphoric acid which would have been excreted during health under similar circumstances, at 20 grains ; and if we accept the experiments of Hammond as accurate, it would be correct to estimate the amount of phosphoric acid at a much lower figure, corresponding with the amount excreted by this observer upon the last day of his experi- ments. The amount of milk consumed by each of the patients during the twenty-four hours was not more than one pint. If the phosphoric acid in this milk be calculated by tlie analyses of R. Weber and Hardin of cow's milk, it will be found to be less than ten grains. In the normal state, a portion of this would be retained in the various organs and tissues. Allowing, however, that the entire phosphorus and phosphoric acid of the food ap-- peared in the urine during the active stages of the disease, there are still remaining more than ten grains, according to this calculation, which would be twice as great as the quantity ordi- narily excreted in health during starvation. It would be just, therefore, to consider 55.9 grains of phosphoric in the second case, and 37.5 grains in the first case, as clearly the results of the chem- 24 370 CHEMISTRY OF TYPHOID FEVER. ical changes of various substances containing phosphorus and phos- The increase phates during twenty-four hours. This increase of the phori°c and phosphoric and sulphuric acids from three to six fold in SdeTiTthe *^® urine of typhoid fever is clearly due to the increased phoidfever chemical changes excited by the febrile poison of typhoid bTthe^n-^ fever. In attempting to determine the tissues of the body chemical which fumisli the increased amounts of phosphoric and ciSXy ^^' sulphuric acids, we are met with the facts, which I have potso* ofV established by numerous and laborious experiments, that phoidfever. ^jjggg geids exist chiefly in an uncombined state in the urine of typhoid fever. The alkaline bases are inadequate to the saturation of the mineral acids. Now if a large proportion of the phosphoric acid and even of the sulphuric acid in the urine of typhoid fever be not combined with alkalies and alkaline earths, it is reasonable to suppose that these free acids have resulted from the oxidation of sulphur and phosphorus in the muscular and nervous structures. The wandering intellect, the low muttering delirium, the twitch- ing tendons, and the utter prostration of the muscular and nervous forces, characteristic of this disease, are attended by, if not directly referable to, rapid and destructive chemical changes of the ele- ments of the muscular and nervous structures. The nervous disturbances and debility characteristic of ty- phoid fever are in a measure, if not entirely, due to these rapid changes in the phosphorescent materials of the nervous structures, and especially of the central ganglionic cells. And in conclusion, the careful comparison of the changes of the Poisons in- blood in hospital gangrene with those of typhoid fever, phoid^fCTer taken in connection with the preceding analysis and com- Sngrene'^f- parison of the physical and chemical phenomena of the th?i?n'a° t^o diseases, leads to the conclusion that the poisons in- tures. ducing the two diseases are different in their mode of origin and action, and that the fever of hospital gangrene is most nearly allied to inflammatory and hectic fever. CHAPTER FOURTH. Progress of Hospital Gangrene to Recovery. — Cases illustrating the Slow Con%-aIescence which follows in Cases in which the Constitution has been extensively involved. — Dis- ability resulting from Hospital Gangrene. — Number of Men disabled by Hospital Gan- grene in the Army of Tennessee during the Months of July and August, 1864:. — Causes of Death in Hospital Gangrene, and Results of Post-mortem Examinations. — 1. Pro- gressive Failure of the Powers under the Action of the Depressing and Irritating Effects of a Large and constantly Increasing Wound, and of the Derangement in the Constitu- tion of the Blood and of the Nutrition, induced b}- the Absorption of the Gangrenous Matter and its Products. — 2. Hemorrhage from the Blood-vessels exposed and eroded by the Gangrene. — 3. Entrance of Air into Veins eroded and opened by the Ravages of Hospital Gangrene. — 4. Opening of Large Joints by the Gangrene. — 5. Formation of Large Bed-sores during the Progress of the Disease, and the Appearance of Gaa-grene in them. — 6. Diarrhoea resulting from the Irritant Action of the Poison of Iwspital Gangrene upon the Intestinal Mucous Membrane. — 7. Extensive and Rapid Disorganiza- tion of the Tissues around the Original Wound, beneath the Sound Skin, accompanied by Absorption of the Gangrenous Matters, great Nervous and Muscular Prostration, and Obstinate Diarrhoea. — 8. Mortification of Internal Organs, induced by Gangrenous Matter absorbed by the Local Disease. — 9. The Invasion of Organs essential to Life, by the Direct Destruction of Intervening Structures. — 10. Pyscmia; Investigations upon the Changes of the Temperature, Pulse, Respiration, and Urine in Pyicmia, illustrated by Cases. — 11. Phlebitis. — 12. Various Sequelae. The complete separation of the ragged, spongy, gray sloughs, and the appearance of healthy granulations and pus in Progress of the wound, and the arrest of the further progress of the grene to re- .1 1 1 'p 111 covery; local gangrene, are certainly attended it not preceded by cor- and consti- responding improvement in the constitutional symptoms, changes. The pulse becomes fuller and slower, the diurnal variations of tem- perature less, the normal relations between the temperature of the extremities and of the central organs are reestablished, the capillary circulation in the extremities becomes more active, the appetite improves, the complexion loses its leaden, dusky, unhealthy hue, the eye expresses hope and life, and the distressed countenance be- comes cheerful. Corresponding changes are observed in the urinary excretion ; as the wound improves, the urine progressively loses its high color and the febrile characters, and approaches by grad- ual degrees the standard of health. I have as yet observed in this disease no crisis or sudden change in the urine during the period of convalescence. In this respect all the symptoms correspond, in that they all gradually and progressively improve without any marked or sudden changes as in certain diseases, as in malarial fever. 372 PROGRESS OF HOSPITAL GANGRENE. The favorable clianges which I have just indicated, will fre- quently take place even when a most extensive surface is exposed and raw, as a large portion of the muscles of the back, or of the buttock, or of the thigh, six or eight inches in diameter. The fact that all the constitutional symptoms may improve, even constitu- before the diminution of the size of the wound, and whilst turti'n'^es ^ ^^"^g® ^^'^ surface of muscles, nerves, blood-vessels, and cui'sfv^'i/to bones remains exposed, demonstrates conclusively that totira o/*' the constitutional disturbances are not due exclusively or IZliby'the even in great measure to the local irritation of the nerves gangrene. exposed to the gangrene. I have observed no uniform periods in the progress of the dis- No uniform case, to either a favorable or fatal termination. lu^ca in'the As far as my observation extends, the duration of hos- hMpMgan- pital gangrene depends upon the condition of the system progress ■ i convaica- of age. Has been m Confederate service smce the 24th of cases of hog- March, 1861. Was sick with typhoid pneumonia at Loudon, grene*'"' Tennessee, in the spring of 1862. This is the only attack of sickness with which he has suffered up to the time of the re- ception of the present wound. Age, twenty-nine. Height, five feet eleven and one half inches. Weight in health, one hundred and sixty pounds. Black hair, beard, and eyes. Dark, sallow complexion. Habits virtuous and temperate. Was wounded at Jacksonboro', 31st of Au- gust, 1864. Minie-ball shattered the elbow. Arm amputated near the middle, on the field of battle. Was sent immediately to Griffin, Georgia, and remained there nearly one month. I have been unable to ascer- tain certainly whether this patient suffered with gangrene during this 1 Chapter Third, Case X. CASE XXXV. — HOSPITAL GANGRENE. 375 month ; it appears, however, that he did not, as he affirms that his wound appeared to be progressing pretty well until he was transferred to the Stout Hospital, in Macon, Georgia. After entering this hospital, his wound was pronounced to be gangrenous, and he was sent to the Empire Hospital, at Vineville, Georgia, on the 23d of September. October 25. — Dark, sallow, anaemic, unhealthy complexion. The stump for near one month has been in a miserable condition ; inflamed, swollen, and exceedingly painful, with ragged, everted edges, and a black projecting bone. During the past week the wound has improved considerably, and the swelling and marks of inflammation in the stump have been greatly reduced under the careful attention of Assistant-Sur- geon Perry. The stump presents the appearance represented in Plate No. XXI.1 Much of the dark-looking portions are due to the action of nitrate of silver. With this pale, unhealthy, flabby, ragged condition of the wound, with the dead black bone projecting, exists the sallow, dusky hue, and great exhaustion and derangement of digestion. Patient does not weigh more than ninety pounds ; a mere skeleton, very nervous and irritable ; cries like a child whenever the wound is touched, although in health a brave and gallant soldier, who has fought many battles. Bowels running off. Appetite poor. Tongue clean, and only moder- ately red. Pulse quick and jerking, and feeble. Twenty days after this observation, this patient lay in much the same state, with little or no change in the wound or in his general symptoms, and upon this, my last observation upon the case, I considered his recovery doubtful in the extreme. The follovi^ing case will illustrate the slow convalescence vrhich follows in cases in which the constitution has been extensively involved : — Case XXXV. A. M. McGowan, Lieutenant, Company K, 3d Mississippi Battalion, Lowrey's Brigade, Cleburn's Division, Oasexxxv. Army of Tennessee. Light hair ; fair complexion ; blue eyes. thrsiTw °on- Age, twenty-nine. Wounded at Atlanta, Georgia, October ™jJXfoi! sC 1864. Minie-ball struck the outer portion of the lower l^^.^Stu- third of the left thigh, about five inches above the knee joint, f^^^^^^^" and passed through the muscles without injuring the femur, iavoived. Remained in the brigade hospital until next day ; then sent to Griffin, where he remained one night, and was then forwarded to Newsom Hos- pital, at Thomaston, Georgia, and after remaining here until October 2d was transferred to Ocmulgee Hospital, Macon, and finally was sent to the Empire Hospital, October 5. Gangrene made its appearance in this wound, September 10. October 5. The patient has just entered the Empire Hospital, and 1 Omitted. 376 CASE XXXV. — HOSPITAL GANGRENE. is in a most deplorable condition. Pale, ansemic, dusky complexion, with swollen, ghastly features, and eyes with a dead, leaden stare. Pulse rapid and feeble. Every muscle and tendon of the entire body appears to be in a state of nervous agitation, trembling, and twitching. The gangrene has denuded the muscles upon the outer portion of the thigh to a great extent, and the wound is seven inches in the longest di- ameter, and about twenty-three inches in circumference. A portion of the wound presents some granulations, and secretes pus in other parts ; especially along the inferior border there is some of the characteristic gray and greenish slough of hospital gangrene. Stimulants were freely administered, and they appeared to exert a most marked effect in quieting the excessive twitching of the muscles and trembling of all the extremities. October &. — Six o'clock a.m. Pulse, 96. Respiration, 22. Tem- perature of hand, 35.2° C. (95.4° F.). Temperature of axilla, 38° C. (100.4° F.). Tongue red and dry. Bowels loose. Skin cool. The free use of alcoholic stimulants has been attended with most beneficial results. There has been a most marked diminution of the nervous excitement and depression. Eight o'clock p. M. Pulse, 110. Respiration, 28. Tongue red and dry. Bowels not so loose. Temperature of hand, 35° C. (95° F.). Temperature of axilla, 39.6° (102.2° F.). October 7. — Eight o'clock A. m. No improvement of wound. Pulse, 116. Respiration, 22. Temperature of hand, 34° C. (93.2° F.). Tem- perature of axilla, 38° C. (100.4° F.). Bowels more regular. (Tincture muriate of iron, gtts. xx., sulphate of quinia, grains v., three times a day. Whiskey, fsii., three times a day. Chicken soup ; bread and toast. Eight o'clock p. M. Pulse, 118. Respiration, 24. Temperature of hand, 38° C. (100.4° F.). Temperature of axilla, 40° C. (104° F.). Tongue red and dry. Skin warm. Bowels regular. October 8. — Nine o'clock a. m. Pulse, 110. Respiration, 1 6. Tongue moist. Bowels regular. State of wound and general symptoms con- tinue much the same. Temperature of hand, 37.4° C. (99.3° F.). Tem- perature of axilla, 38.6° C. (100.4° F.). Eight o'clock p. M. Pulse, 126. Respiration, 22. Tongue dry. Bowels regular. Temperature of hand, 36.4° C. (97.5° F.). Tempera- ture of axilla, 37.4° C. (99.3° F.). October 9. — ^. Eight o'clock a. M. Pulse, 122. Respiration, 18. Tongue moist. Bowels regular. General symptoms and condition of wound much the same. Temperature of hand, 34° C. (93.2° F.). Tempera- ture of axilla, 36.4° C. (97.6° F.). Treatment same. October 10. — Nine o'clock a. m. Pulse, 124. Respiration, 16. Tongue dry. Bowels regular. Slight improvement of wound. Patient still nervous, restless, and feeble, with sallow, distressed countenance. Temperature of hand, 32° C. (89.6° F.). Temperature of axilla, 37.4° C. (99.4° F.). CASE XXXV. — HOSPITAL GANGRENE. 377 Eight o'clock p. M. Pulse, 104. Eespiration, 21. Tongue moist. Bowels regular. Temperature of hand, 36.4° C. (97.6 F.). Tempera- ture of axilla, 38° C. (100.4° F.). October 11. — Eight o'clock a. m. Pulse, 126. Respiration, 18. Tongue moist. Bowels regular. No material change in condition. Much of the rise in the pulse in the mornings is due to the application of nitric acid, and the dressing of the wound. Temperature of hand, 32.1° C. (89.8° F.). Temperature of axilla, 36.25° C. (97.2° F.). Eight o'clock p. M. Pulse, 112. Respiration, 18. Temperature of hand, 37° C. (98.6° F.). Temperature of axilla, 38.4° C. (101.2° F.). I was assisted in the determination of the temperature, pulse, and respiration in this case by Assistant-Surgeon Calhoun, in charge of Ward No. 3. October 18. — Up to this time there has been but little change for the better in this patient. The treatment, together with the local applica tion of nitric acid, has been persevered in. There is still some gangrene in the wound. Patient depressed, nervous, and emaciated ; but the excessive nervous disturbance and trembling of the hands and limbs has in a great measure disappeared. Pulse 128, and feeble. Tongue bright red, and furred slightly in strips on either side of a central clean strip. Has no appetite ; eats very little, and oftentimes refuses food altogether. Examination of Urine. — Amount of urine collected during twenty- four hours, 400 CO. = grains 6,419.70. The bottle was accidentally overturned, and a portion was lost. Specific gravity, 1,019. Deep red color. Strong acid reaction. Clear when first passed. After seventy- two hours, heavy deposit of urates, of a pinkish-yellow color. The pur- purine formed a beautiful layer upon the top of the yellow deposit. The deposit consisted almost entirely of granular amorphous urates, with very few defined crystals of uric acid. The chief constituent of the deposit appeared to be urate of ammonia. ANALYSIS OF URINE, NO. 33. Amount of urine collected during twenty-four hours (only a portion of entire amount) Urea TJric acid Free acid ■ • Phosphoric acid Equivalent of phosphorus in phosphoric acid . . . Sulphuric acid • ■ Equivalent of sulphur in sulphuric acid Chloride of sodium Equivalent of chlorine in chloride of sodium . . . Urine collected 1,000 parts of during 24 hours, urine con- contained grains tained 6,419.70 203.28 31.60 4.96 0.77 13.86 2.15 11.08 1.72 4.85 0.75 11.52 1.76 4.60 0.73 18.48 2.87 11.19 1.74 378 CASE XXXV. — HOSPITAL GANGRENE. October 19. — Appears to be a little more comfortable. Appetite still very poor. Had three or four loose stools during the night. Con- dition of the wound and general symptoms much the same. Examination of Urine. — Amount of urine collected during the past twenty-four hours, 700 CC. = grains 11,240.40. Not the entire amount, as a small portion was lost during the action on the bowels. Specific gravity, 1,020. Strong acid reaction. The acid reaction was retained for several days, apparently with little diminution. This patient takes so little food that it would be correct to consider this the urine of star- vation. Urine clear when first passed, but after standing over night (cold night), there was a slight light deposit of granular amorphous urates. ANALYSIS OF URINE, NO. 34. Amount of urine collected during hventy-four hours . Urea Uric acid Free acid Phosphoric acid Equivalent of phosphorus in phosphoric acid . . . Sulphuric acid Equivalent of sulphur in sulphuric acid Chloride of sodium ... Equivalent of chlorine in chloride of sodium . . . Urine collected during 24 hours, contained grains 1,000 parts of urine con- tained 11,240.40 324.55 28.96 9.80 0.87 29.64 2.65 41.05 3.65 18.06 1.69 20.64 1.83 8.25 0.73 32.34 2.87 19.59 1.74 November 5. — Up to the present time there has been scarcely any perceptible improvement, with the exception of a decrease of the ner- vous excitement and irritation, and a slight improvement in the wound, which now presents an extensive surface of clear, raw muscles, with little or no gangrene. The wound is now twelve inches in the longest diameter, and about eight inches in the transverse or shortest diameter. There is still a little gangrene in the centre of the wound, burrowing amongst the muscles. Bowels running off. Tongue red. Pale, anaemic, sallow complexion. The complexion is clearer, however, and the pulse is fuller and stronger, and the expression of the countenance a little more cheerful. November 10. — Continues in the same condition. My observations upon this case did not extend beyond this date ; but it will be seen that during a period of sixty days there had been but little change in the condition of either the wound or the constitutional symptoms. The nature of the local and constitutional treatment has much Tiio nature to do With the ppogress and extent and duration of lios- tionai and pital gangrene ; for if the disease be due to the action of DUKATION OF HOSPITAL GANGRENE. 379 a certain kind of animal matter, and if it be possible to jocai treat- destroy that matter by chemical agents, and at the same m™h'trdo time to arouse by the same means the surrounding tissues progres/and into healthy inflammation, it is evident that the physician h"spiJ^°g°n. possesses the means of cutting short the disease. After ^°™' the removal and arrest of the local disease, the period of con- valescence will depend upon various circumstances, as the extent to which the general system has been involved, the extent of the local injury, the condition of the wound, and the surrounding hygienic condition. But above all, the duration of hospital gangrene will S,""-^^"' depend upon the hygienic condition of the hospital, and ^^^^^'' the sanitary regulations. hyp^ot^on- If the hospital be crowded with wounded and gan- gin,™^"™- grene cases, and if it be poorly ventilated, and if but "'»"<'■"- little attention be paid to the cleanliness of the bedding and uten- sils, patients will be liable to constant returns of the disease, intro- duced through one or all of the avenues of infection existing in filthy, badly regulated hospitals. In such cases, patients may be cured of the gangrene several times, and finally die from a recur- rence of the disease. I have seen nurses dress healthy, granu- lating wounds with the same filthy hands and instruments which but a moment before had been busy in cleansing and picking the most offensive gangrenous wounds. The tendency of this disease is to a low, depressed state of the nervous system and of the gen- eral and capillary circulations, and hence bed-sores are exceed- ingly common in this disease, when the patients are not properly attended to. There is no doubt but that, in the hands of inatten- tive and slovenly surgeons, this is often a cause of most tardy con- valescence, and even of death itself, in hospital gangrene. The patients should be moved out of the wards into the open air when- ever possible, and the most sci'upulous attention should be paid to the condition of the bedding and to the change of position. The patient should be propped up in bed, if possible, for a portion of the day, at least. I have, in many cases which suffered in- tensely and finally died, witnessed a most lamentable indifference and inattention on the part of nurses and medical attendants to the personal comfort of the patients, and especially in the matter of shifting the position frequently, and in stimulating the parts pressed upon with various applications, as tincture of iodine, brandy and salt, and tincture of camphor, in order that the most troublesome of all complications in hospital gangrene might be avoided. 380 DISABILITY RESULTING FROJI HOSPITAL GANGRENE. As far as my observation extends, bowel affections, and espe- cially obstinate diarrhoea, are much more liable to occur in dirty, foul hospitals than in those properly regulated. This serious com- plication of hospital gangrene appears in many cases to be the im- mediate cause of death, by the consequent exhaustion. We wiU consider in the next place the effects of hospital gangrene in pro- ducing permanent disability. DISABILITY RESULTING FROM HOSPITAL GANGRENE. The extensive destruction of tissue caused by this disease will in Disability re- many cases involve the permanent injury of the affected holpuli'^^™ limbs. The character and extent of the disability will ^°°°" depend upon the situation of the gangrene, as well as upon the extent of its ravages. When the disease invades tissues in the region of large blood-vessels and nerves, impaired circula- tion, nutrition, and even complete paralysis of the parts below the seat of injury may result. Withered, discolored, cold, contracted, and paralyzed arms and legs are sometimes seen even at this early period of the war, as the results of the local injuries inflicted by hospital gangrene. Even when the important nerves and blood- vessels are not injured, the denuded muscles which have lost their natural fibrous coverings, and even in many cases their natural tendinous attachments, during the process of healing by granula- tion, form numerous new attachments, and the symmetry and pre- cision of the muscular movements are deranged. When entire muscles, or only portions of one or more muscles, are destroyed, more or less contraction, according to the position and action of the muscles, will take place. In most cases, the extent of the disa- bility is in no manner related to the size or depth of the primary wound. A small scratch of the surface may be attended with as great destruction of muscular tissue as the deepest wound. The extent and nature of the contraction, whether forwards or backwards or lateral, will manifestly depend upon the relations and actions of the muscles injured or destroyed. The following case is selected from a large number, to illustrate the effects of hospital gangrene in impairing the value and effi- ciency of the injured limb : — Case XXXVI. M. D. Davis, Co. F, 23d Regiment, Alabama Vol- CasexxxTi. unteers, Pettus's Brigade, Army of Tennessee. Age, twenty. th^Uabufty Height, five feet seven inches. Weight in health, one hun- hospitai'^ dred and forty-five pounds. Native of Lowndes County, Ala- gangrenc. bama. Residence about fourteen miles below Montgomery, CASE XXXVL — HOSPITAL GANGRENE. 381 Alabama, in a fertile, malarious region. Previous to entering the ser- vice, has had repeated chills. Has been in Confederate service three years. During this period, has enjoyed good health, and has suffered only with slight diarrhoea, which yielded readily to treatment. Patient says that, as far as his knowledge extends, he has never had typhoid fever. The wound from which he is now sufffering is the first that he has received in Confederate service. Wounded on the 22d of June, 1864, on the Powder Springs road, near Marietta, Georgia. A shell grazed the external surface of the middle of the right thigh, and car- ried off a portion of the skin about two inches in diameter. The mus- cles did not appear to be specially injured, and the surgeon in the field considered the wound as comparatively slight. Was carried to Steven- son's Division Hospital, where he remained two days and nights. The patient affirms that, during this term, his wound received but little atten- tion, and maggots were bred in considerable numbers in the wounded parts. Was sent from Marietta to the Fair Ground Hospital, No. 2 (Surgeon Crawford), in Atlanta. Eemained in Atlanta two days and nights, and was then transferred to the Ocmulgee Hospital, in Macon. A few days after entering this hospital, gangrene appeared in the wound. On the 13th of August, was transferred to the Empire Hospi- tal, Vineville, devoted to the treatment of hospital gangrene. At the time of his entrance, the gangrene was spreading, and the constitutional symptoms were strongly marked : sallow, unhealthy complexion, feeble, rapid pulse, great nervous excitability, with loose bowels. The free application of nitric acid (patient under the influence of chloroform), accompanied with constitutional treatment of tincture mu- riate of iron and quinine, together with stimulants and nutritious diet, arrested the further progress of the gangrene. After his entrance into the Empire Hospital, before the arrest of the gangrene, the patient suf- fered with several chills, followed by fever. Erysipelas also appeared, and complicated the gangrene. October 2. — Patient pale, anaemic, and greatly reduced in flesh and strength. His appetite, however, is excellent, and bowels regular, spirits good, and the constitutional symptoms relieved. The wound presents a bright red, healthy color, and is covered with florid granulations, which bleed upon slight pressure. No gangrene is to be seen in any part of the wound. The denuded surface covers the greater portion of the right thigh. The granulations have filled up in a great measure the deep interstices of the thigh, which had been dissected out by the gan- grene. The raw surface is very sensitive, and the patient cries like a child whenever it is dressed or washed, or even gently touched. The slightest touch appears to occasion great pain, or else the system of the patient has been so much reduced that he is unable to bear the slightest touch without crying. The following sketch,* which I have drawn of the natural size, 1 Plate No. XXII. (Omitted.) 382 CASE XXXVI. ^HOSPITAL GANGRENE. represents the appearance of the surface, and also the contraction of the leg and the wasted condition of the patient. The discoloration of the skin of the lower portion of the thigh and upper portion of the leg, is due to the effects of the tincture of iodine, which had been ap- plied to arrest the progress of the erysipelas. The right leg is firmly contracted, and the patient is unable to extend the limb more than a few inches. October 18. — Continues to improve ; appetite excellent ; eats large quantities of nutritious and strong food. The spirits of this young sol- dier have always been cheerful and good. From the constant pressure of the head on the pillow, the scalp is now ulcerated. Examination of Urine. — Amount of urine passed during the last twenty-two hours, up to October 18, ten o'clock a. m., 1,800 CC. = grains 28,752.80. Specific gravity, 1,016. Light orange yellow color, and turbid, from a light yellow deposit. The deposit which appeared in the urine at the end of its collection had increased considerably at the end of forty-five hours, and was almost perfectly white. Under the microscope, this deposit was found to consist of numerous octahedral and dumb-bell crystals of oxalate of lime, amorphous granular urates, and large prismatic crystals of triple phosphate, and other large tabu- lated, thin, transparent crystals, resembling the purer forms of urea and nitrate of urea. Urine alkaline at the time of this observation. ANALYSIS OP URINE, NO. 35. Amount of urine collected during twenty-four hours Urea Uric acid Free acid Phosphoric acid Equivalent of phosphorus in phosphoric acid . . . Sulphuric acid Equivalent of sulphur in sulphuric acid Chloride of sodium Equivalent of chlorine in chloride of sodium . . . Urine collected duriog 24 hours, contaitied grains 28,752.80 693.00 9.36 I9.J0 11.08 4.87 34.23 13.69 110.88 67.19 1,000 parts of uriDG con- tained 24.102 0.32 0.709 0.38 1.69 1.19 0.51 3.89 2.33 It is of some interest that the chloride of sodium exists in consid- erable amount, notwithstanding the existence of a large suppurating wound. The salt disappears from the urine in all severe diseases, not only on account of the loss of appetite, and consequent absence of salt from the food, but also because, in the febrile state of various diseases, this salt is retained in the blood and tissues. The retention of this and other salts in the blood during fever may account in a measure for the accompanying thirst. In variola (small-pox), chloride of sodium disap- CASE XXXVI. — HOSPITAL GANGRENE. 383 pears almost entirely during the active stages of the disease, even in patients who are walking about and eating their accustomed food. October 19. — Continues to improve. Appetite good. The patient ate heartily of beefsteak, hash, corn-bread, loaf-bread, and drank two cups of coffee with great relish, whilst I was observing him in the ward. The ulcer on the back of his head, caused by pressure, ^presents a healthy appearance. Examination of Urine. — Amount of urine passed during eighteen hours (October 18, 12 m., to October 19, 6 a. m.), 1,850 CC. == grains 39,090.50. Specific gravity, 1,016. Yellow color, with a tinge of or- ange. Carefully tested for grape sugar. No trace of this substance. No deposit observed in the urine twenty-four hours after its collection. In forty-eight hours, a light, cloudy deposit floated through the mass of the urine, and became gradually more dense and defined towards the bottom of the glass vessel. This deposit consisted of large, well-defined octahedral crystals of oxalate of lime. Reaction of urine, alkaline. The presence of oxalate of lime in this and in other cases of conva- lescence from hospital gangrene appeared to be connected with the de- pressed state of the nervous system, and with slightly impaired digestion, and the consumption of much food, without exercise. ANALYSIS OE URINE, NO. 36 Amount of urine passed during eighteen hours Urea Uric acid Free acid Phosphoric acid Phosphorus in phosphoric acid Sulphuric acid Sulphur in sulphuric acid Chloride of sodium Equivalent of chlorine in chloride of sodium . Urine collected 1,000 parts of duriof; 24 hours, urine con- contained grains tained 39,090.50 512.82 13.119 4.81 "0.14 28.49 0.72 11.39 0.29 5.00 0.15 33.47 0.85 13.38 0.34 102.56 2.62 62.15 0.158 October 30. — The patient sat up outside of the hospital tent this day for the first time since his entrance into this hospital. Appetite and spirits excellent. Wound continues to fill up by granulations, and to contract in size. Sore on the back of his head healing rapidly. Some ten days ago, an eruption of pustules or small boils appeared on various parts of his body. This is now drying and rapidly disappearing. November 5. — Walks about the streets of the hospital on crutches. Has gained considerable flesh. Spirits excellent. Wound rapidly clos- ing. The sore on the back of the head has healed. The muscles of the thigh have not regained any of their lost motion, and the injury appears 384 LOSSES OCCASIONED BY DISABILITY. to be permanent. At least, so great is the contraction of the muscles that the services of the soldier for active duty in the field appear to be lost to his country. In the treatment of such cases, it requires great resolution and TopreTent attention on the part of the patient as well as the physi- permanent . , • p i 1 A contraction of Clan to ovcrcome the contraction or the muscles. As anddisibii- far as mv observation extends, many valuable soldiers ity following ^ . ^ . . i , p hospital gan- are lost to the service from inattention on the part ot quires' great nurscs and mcdical attendants to the posture of the body, andatten- and of the affcctcd limb, during the progress of hospital tionontlie ttti -i i ■ i i t J part of both gangrene. Whilst endeavoring to place the diseased patient and J^ ° . . . ^. „ Burgeon. limb m the most favorable position tor a perfect cure, without unnecessary deformity and contraction, it should also be remembered that there is a marked tendency to the formation of the most distressing and dangerous bed-sores, in all parts subjected to long continued pressure on account of the depression of the general and capillary circulation, and of the nervous and muscular forces, and the derangement of nutrition induced by the absorption and action of the poison and its organic products. The physician has also to regard at the same time, with the most scrupulous care, the proper drainage of the wound. I have instituted inquiries at various times to determine, if pos- Numbers of sible, the numbcr of soldiers lost to the Confederate ser- to'^he'con-' '^'^6 on account of disability following hospital gangrene, Ticc'on'^'' ^ut have thus far been unable to form even an approxi- abmty°foi^' mate estimate, on account of the following difScul- lowing hos- +;„(,. pital gan- ^^'^^ • ^^'"'- It is evident that the field reports furnish no materials for such an inquiry, as the patients do not remain long enough in the regimental, brigade, and division hospitals, to determine the results of any injury ; and after the patient is transferred to the general hospital, his subsequent history is in most cases lost to the field surgeon. In the general hospitals the cases are constantly transferred from one hospital to another, and in the present system of registration, his disease and injury, with even the date and character of his wound, appears anew upon the reports of every hospital which he enters ; so that the cases recorded in the general hospitals con- nected with the Confederate armies greatly outnumber those trans- ferred from the field. Again, hospital gangrene, under the title " Phagedasna Gan- DISABILITY CAUSED BY HOSPITAL GANGRENE. 385 graenosa," has only recently been introduced into the list of diseases recorded in the Confederate reports of the sick and wounded. Thus the first reports from the general hospitals attached to the Army of Tennessee in vvhicli phagedsena gangrenosa appeared, was for the month of July, 1864. I have condensed the table on the following page from the monthly reports of the sick and wounded of the general hospitals of the Army of Tennessee during the months of July and August, 1864. During the month of July, 1864, 21 cases of hospital gangrene were admitted into the general hospitals attached to the Army of Tennessee, and ainongst this number only 1 death is recorded, whilst 147 cases originated within the hospitals ; 41 cases are entered as " gangrsena huraida ; " these cases were without doubt in almost every case hospital gangrene. The total number of cases of phagedsena arising in the hospitals during the month of July would amount to 188, with 7 deaths. During the month of August, 45 cases of gangrsena humida and 4 deaths, and 230 cases of phagedaena gangrenosa and 9 deaths (total, 275 cases hospital gangrene, 13 deaths), were admitted ; whilst 79 cases gangrajna humida and 2 deaths, 256 cases phage- dsena gangrenosa and 3 deaths, originated within the hospitals (total, 335 cases and 5 deaths hospital gangrene) ; thus giving a grand total of cases of hospital gangrene treated during the month of August of 610, with 18 deaths. During the months of July and August, 819 cases, or if the 5 cases of gangrsena humida admitted during the month of July be added, 824 cases of hospital gangrene were treated in the general hospitals attached to the Army of Tennessee, 26 of which proved fatal. If we assume that one half of these cases were permanently dis- abled by this disease, then four hundred men were lost to the Army of Tennessee by this supervening disease, the origin of which was dependent in great measure upon tlie hygienic condition of the hospitals. As far as ray experience extends, from a personal inspection of the sick and wounded of many of the general hospitals of the Army of Tennessee, I feel assured tliat this estimate is below the truth ; for many more cases of hospital gangrene occurred than were entered upon the sick reports. These cases were entered simply as gunshot wounds ; and even when the disease supervened, the fact of its supervention was in many cases, and 25 386 GANGRENE IN ARMY OP TENNESSEE. -< ft is ■< p a EH S5 w EH O n p a p 11 1— oo to 00 s c^ r- tn o o t- 00 Tf -^ *o c^ co r- c^ <-< ■ CO co_ lOCNCOllllllllllllll '2 bo o 5 cs u 2 bo S S 8J =!'2 5 o ^ 3 5 , •a ^ 1— 1 o B 1 1 £N CO O 1 1 1 1 1 I C* I 1 r^ 1 1 1 1 ba fi -o m •^ Oi CD (M »n Oi CO iO l-H C o ¥ a t- io r- f-t 1 1 1 (M 1 ^ " g OS I-- a 1 III I '^ ' 1 1 1 1 1 1 -* « 4 •n o ,— mooor^oO"*oo o ■^ ^ Oi (M t-- to eD O to s W rH CT> IN i t^ t^ m -^ (T^ ITS 00 ■^ -* CN "C =! ^ ^ _C ^ 5 5 ■ " .2 b b '-^ ^ '«3 fs^ jD as S J5 C CAUSES OF DEATH m HOSPITAL GANGRENE. 387 we might almost say in the majority of cases in certain hospitals, not recorded at all. The truth of this proposition I have demonstrated by an actual comparison of the number of gangrene cases in certain hospitals, and the number appearing upon the sick report. It was to have been expected that when the form of classification of diseases, as well as a new method of registering the cases, was introduced during an active campaign, the first returns would be imper- fect. I think that it would be fair to assume that during the months of July, August, September, and October, 1864, about three thousand cases of hospital gangrene occurred amongst the wounded of the Army of Tennessee, and of this number about one half, or fifteen hundred, were disabled, for the war at least, by the disease. Surely, everything connected with the history and treatment of a disease so destructive to the efficiency of an army is worthy of investigation. Being a contagious disease, capable of arising whenever the hospitals are crowded with men, wounded when their constitutions are debilitated and broken down by bad diet, fatigue, anxiety, and exposure, we must expect to see hospital gangrene progressively increase as the war goes on, and especially if the disasters of the campaign in Northwestern Georgia should be often repeated. The evacuation of large tracts of country, and the consequent crowding of the hospitals in the rear, is a fruitful cause of the disease. CAUSES OF DEATH IN HOSPITAL GANGRENE, AND RESULTS OF POST- MORTEM EXAMINATIONS. When hospital gangrene progresses unfavorably, the constitu- tional symptoms become progressively more grave, and Nausea of the fatal termination is generally announced by a feeble, l^^g^^°^ rapid pulse, extreme prostration, twitching of the ten- fesuftfo? dons, vomiting, hiccough, involuntary dejections, and examS^" and ofttimes coma. Many cases, however, die without *""'^- any derangement of the brain, and the patients are sensible and calm up to the moment of death. Death from hospital gangrene may result from one or more causes. 1. Progressive failure of the powers under the action of the depressing and irritating effects of a large and constantly i. Effects of increasing wound, and of the derangement in the constitu- tion of the 388 CASE XXXVIL — HOSPITAL GANGRENE. gangrenons tion of the hlood, and of the nutrition, induced by the matters in t ■ j- , I . t producing oosorption of the gangrenous matters and its products. The following case furnishes a good illustration of this cause of death, and of the progressive failure of the circulatory and nervous systems in many fatal cases of hospital gangrene : — Case XXXVIL John W. Coleman, Company H, 2d Regiment Case XXXVII. Georgia State Reserves. Native of Oglethorpe County, ttofataf'ef? Georgia. Occupation, farming. Age, forty. Height, five Srpti'on^ f^^' eleven inches. Muscular, well-built man. Black hair ; ofthegan- black evcs. Dark, sallow complexion. Wounded at Jones- grenous mat- *' ' *^ *«"• boro', on the 31st of August, 1864. The ball passed through the posterior muscular parts of the left thigh, entering about two inches above the knee joint, on the outer side of the lower third of the thigh, and, ranging upwards and backwards through the large muscles on the posterior of the limb, escaped in the lower portion of the middle third. The wound was considered comparatively slight, as no important blood-vessel nor nerve was injured, and the bone remained untouched. Was taken prisoner, and placed in a Federal hospital, and remained there two or three days ; and from thence was sent to Jonesboro', and was recaptured by the Confederates, or rather abandoned by the enemy, on the 6th of September. From Jonesboro' was sent direct by railroad to Macon, and remained only one night at the Ocmulgee Hospital, and was transferred the next day (9th of September) to the Empire Hospital. At this time, the external wounds of entrance and exit were quite small, and they were said not to be gangrenous. Shortly after entering this hospital, how- ever, gangrene appeared in the wound of entrance, and spread with steady advance, unchecked by local remedies. October 18. — Pulse, 100. Patient very nervous, every muscle twitch- ing. Low muttering delirium. Talks to himself, and picks at the bedclothes. When addressed in a firm, distinct manner, or aroused by a gentle shake, gives a coherent answer for a few seconds, but soon wanders and gives inaccurate statements, and in a few moments relapses into the same state of low muttering delirium, talking to imag- inary persons, and about his home, and picks, with his emaciated, trembling hands, at the bedclothes, and motes in the air. Complexion of an unhealthy, leaden hue. Tongue red and dry. Skin hot and dry, and has a harsh, unpleasant feeling to the touch. Bowels rather loose. Up to the present time, however, his bowels have not been specially deranged. No appetite. Great nervous and muscular prostration. The wound presents a most distressing and disagreeable appearance. On the outer surface of the left thigh, it extends from near the knee CASE XXXVIL— HOSPITAL GANGRENE. 389 joint upwards for eight inches, and is seven inches in diameter. The muscles are denuded, and the gangrene is extending along the everted and ragged and purplish edges. The surface of the wound presents a grayish and bluish appearance, except over the largest muscles, which appear to be cleaning off to a certain extent, and present a more purplish-red color. The color of the denuded muscles is far different from the florid, bright color of healthy muscles ; it is paler, and of a dirty, unhealthy hue. The internal wound (point of exit of the ball) is separated from the larger external wound (or rather, the wound upon the outer parts of the thigh) by a portion of sound skin, and is about two inches in diameter. The smaller wound upon the internal surface of the thigh presents a more healthy appearance than the external wound. As we have before shown, it is by no means uncommon for the two wounds upon the same limb to present different conditions, one being gangrenous and the other covered with healthy granulations. There are cases at the present time in this hospital, in which the original wound is healing, whilst the bed- sores resulting from pressure are gangrenous, and are rapidly destroy- ing the patients. This will be illustrated more fully in this chapter. Such facts are important in their bearing upon the theory of the disease, and also upon the mechanical and constitutional treatment. The wound in this case emits a most powerful and overpowering stench. It makes a decided impression upon the organ of taste ; and the clothing, after remaining a length of time in the atmosphere of the small tent in which this patient lies, partakes strongly of this disgusting odor. Tongue slightly furred, and of a deep purplish and bluish color. As far as my experience extends, this is a most unfavorable sign in this disease, and indicates serious derangement of the blood and circula- tion. Examination of Urine. — This should be considered as approaching very nearly to the urine discharged during starvation in hospital gan- grene, for this patient has no appetite whatever, and scarcely eats any- thing. Amount of urine collected during twenty-four hours, from October 17, 11 A. M., to October 18, 11 a. m., 560 CO. = grains 9,014.04. Deep-red color. Specific gravity, 1,022. In the morning after the completion of the collection, the night having been cold and frosty, a heavy yellow deposit of granular amorphous urates, chiefly urate of ammonia. The reaction of the urine was strongly acid at the time of the formation of this deposit. The vegetable cells and animalcules which had been so abundant in this disease during the hot weather, were not present in this during the colder weather, even forty-eight hours after its passage. Upon standing longer, however, they gradually formed. Carefully tested for grape sugar ; none discovered. 390 CASE XXXVn.— HOSPITAL GANGRENE. ANAITSIS OF URINE, NO. 37. Elements. Amount of urine collected during twenty-four hours . Urea Uric acid Free acid Phosphoric acid Equivalent of phosphorus in phosphoric acid . . . Sulphuric acid Equivalent of sulphur in sulphuric acid Chloride of sodium Equivalent of chlorine in chloride of sodium . . . Urine collected during 24 hours, contained grains 9,014.04 349.27 8.51 25.00 20.69 9.09 20.74 8.29 8.62 5.21 1,000 parts of urine con- tained 38.74 0.94 2.88 2.29 1.06 2.307 0.92 0.95 0.51 The treatment of this patient now consists of tincture of muriate of iron, gtts. xv. ; quinine, grains iiss. ; chlorate of potassa, grains iv., four times a day. Wound touched with nitric acid, and washed with Labar- raque's solution of chlorinated soda. October 19. — Patient very nervous. Hands tremble incessantly. Continues in the same low muttering delirium. Pulse rapid, small, and feeble. No improvement of the wound. Keeps the affected limb bent, and appears to be unable to straighten it, on account of the con- traction of the muscles. The denuded muscles of the thigh in the wound quiver continually. This quivering is greatly increased whenever they are touched, or when any caustic application is made to the raw surface. Tongue slightly coated with fur at the root ; body and tip clean, and of a purplish and bluish unhealthy aspect. This patient complains of little or no pain, and never expresses a single want When I addressed him, and drew his attention, he spoke in a most cheerful manner, imagining himself at home and with his old companions, grasped my hand, and continued talking for several min- utes about his family and friends. A change then passed over his cheerful countenance, and he appeared like one bewildered and lost, and attempting to discover his true situation, and to recognize some familiar face or object. This poor fellow appears to be wholly uncon- scious of his most distressing condition. The offensive odor from his wound does not at all disturb him. Treatment continued. Examination of Urine. — Amount of urine collected during the past twenty-four hours, up to 11 o'clock a. m., 680 CC. = grains 10,962.15. Specific gravity, 1,024.5. Heavy deposit of brownish-yellow granular amorphous urates in the morning after the cooling of the urine (cool, frosty weather). Under the microscope, the granules presented a bright orange-red color. The purpurine formed a beautiful pink layer upon the deposit, and also upon the bottom and sides of the vessel. CASE XXXVn. — HOSPITAL GANGRENE. 391 ANALYSIS or URINE, NO. 88. Elements. Amount of urine collected during twenty-four hours . Urea Uric acid Free acid (twenty-four hours after collection) . . . Phosphoric acid Equivalent of phosphorus in phosphoric acid . . . Sulphuric acid Equivalent of sulphur in sulphuric acid Chloride of sodium Equivalent of chlorine in chloride of sodium . . . Urine collected 1,000 parts of during 24 hours, urine con- contained grains tained 10,962.15 439.82 40.12 12.92 1.17 31.41 2.95 33.51 3.05 14.73 1.59 25.65 2.33 10.26 0.93 10.47 0.95 6.34 0.57 October 25. — Continues in the same miserable, nervous state, with rapid, feeble pulse, depressed nervous and muscular forces, and low muttering delirium. Skin warm and dry. Hands and muscles tremu- lous. The ash-colored and gray gangrenous slough has disappeared from a considerable portion of the surface of the denuded muscles, but the destruction of tissue still continues at the lower and upper borders of the wound, which continues to emit a most noisome and disgusting stench. The raw muscles quiver continuously. The destruction of tissue has been very great, and the popliteal artery is nearly exposed. Pulse 98, small and thready. Tongue bluish and purplish. Bowels regular. The patient now has sore throat, and complains of difficulty and pain in swallowing. The mucous membrane of the fauces and ton- sils are covered with small white ulcers. This day I made the following outline sketch of the wound upon the external surface of the thigh. This will give a general idea of the size and position of the wound. (Plate No. XXII.^) October 30. — Continues to grow worse. General symptoms the same. The local and constitutional treatment alike fail to arrest the disease or restore the wound to a healthy condition. November 1. — Intellect still dull and wandering ; general symptoms and condition unchanged, except for the worse. Tongue dry, and coated with cracked flakes of white fur. Throat sore, with small white ulcers. Pulse 112, and very feeble. Dusky, leaden complexion. Dull, de- jected eyes. Destruction, dissection, and denudation of the muscles of the thigh very extensive, and still continue ; there are still gangrenous sloughs in the upper and lower portions of the wound. Up to the pres- ent time, no granulations have appeared upon any part of the denuded miiscles ; and the wound has discharged no pus, but a filthy, fetid sanies. The odor of the wound continues to be foul and disgusting in the extreme. Has no appetite, and continues to lose flesh, and is now 1 Omitted. 392 HEMORRHAGE IN HOSPITAL GANGRENE. wasted to a skeleton. No bed-sores upon the back as yet, although the parts upon which the body rests look as if they would soon ulcerate. The ground of the tent which this patient occupies is situated in a sink or natural drain, somewhat lower than the surrounding portions of the hospital grounds ; and when much water falls, it rushes through this tent, and it has been necessary to open a drain directly through the tent. In fact, the entire hospital grounds are low and damp, and sub- ject to overflow during a hard rain. As the ground slopes towards a small stream about two hundred yards distant, the water during heavy rains rushes under many of the tents. I have observed that, after heavy rains, when the soil was saturated with water, and the atmosphere with the vapor steaming up from the uncovered ground, the gangrene cases almost all progressed unfavorably. The damp ground floor is one great objection to the use of tents in hospital gangrene. November 5. — Pulse 140, very feeble and weak. Patient reduced to a mere skeleton. The muscles are almost entirely denuded from the bone ; and on the inner side of the thigh, especially at the lower por- tion of the popliteal space, little else than the skin remains. The circumference of the wound still increases slowly, and the gangrene is still present. The denuded muscles present a smooth, pale, red color, with little discharge. Bowels running off". Low muttering delirium, with trembling of the muscles and picking at the bedclothes, continues. Patient gradually sinking ; cannot hold out much longer. November 6. — This patient died in the evening. The exhausted powers sank very gradually, and almost by imperceptible stages, into death. 2. Repeated hemorrhage from the blood-vessels exposed and eroded by the gangrene. The separation of the dead parts is almost always accompanied 2. Death in with more or less hemorrhage, and in the last stages of grene caused tlie dlseasG there is frequently a bloody oozing from the rhage. surface of the denuded parts. When hemorrhage takes place from the large arteries which re- quire ligation, it happens that, in the severest cases, the coats of the artery are sometimes ruptured by the ligature ; and when the hemorrhage is controlled by pressure, the limb becomes greatly swollen, and the progress of the gangrene accelerated. In such cases, whether the ligature and the mechanical means of compres- sion be applied or withheld, an unfavorable issue appears to be almost equally certain. When the forces have been reduced by the long continued ac- tion of the gangrenous poison, a very slight hemorrhage will some- times cause death. OPENING OF LARGE JOINTS BY GANGRENE. 893 The cases of Arnold Nowell,^ and William Martin,^ which we have already presented in the fourth chapter, illustrate in a clear manner the effects of slight hemorrhages in terminating life, in the depressed state of the system caused by the action of the poison of hospital gangrene. 3. Entrance of air into veins eroded and opened hy the ravages of hospital gangrene. As far as my observations extend, death from this cause is of rare occurrence. We have already presented an inter- 3. Death in Q -n • 1 • 1 p I 1 T-i hospital gan- estmg case ^ lUustratmg this mode of death. By post- grene caused . . , 1 1 7 1 1 •; ^ , by the cn- mortem examination 1 have been able to determme the trance of air important fact that the blood is frequently coagulated, or eroded and • rather a firm, fibrous, laminated clot forms in veins sur- the ravages ... of the dis- rounded by gangrenous matter. This formation of fibrin- ease. ous clots in the veins appears to precede the erosion of their walls. And hence, by this process and provision of nature, we do not often have the entrance of air into the veins when they are de- stroyed by hospital gangrene. We have before shown that the fibrin of the blood is increased above the normal standard, and that, even in the worst cases, the blood is capable of forming a firm clot. 4. Opening of large joints hy the gangrene. When gangrene attacks parts in the neighborhood of the hip and shoulder joints, or of the knee and elbow, the dis- ^ jj^^ti, ease, all things being equal as to its intensity and the J^sptfalgan condition of the system, is far more dangerous than when ^p™ing^of''* situated upon the middle parts of the thigh, leg, arm, and ''"■e« Jo'^t^- fore-arm. The opening of a large joint to the air subjects the patient to the additional irritation of the large diseased synovial membrane ; and the surface for the action and absorption of the gangrene is at once greatly increased. The gangrenous matters frequently ac- cumulate within the opened joint, and still further, by their putre- faction and absorption, increase the danger. The membranes lining the articulating surfaces of the bones are finally eroded by the gangrene, and the extremities of the bones themselves are attacked in their most vascular and spongy portions. When the extremity of a bone is thus opened, the gangrenous sanies may descend by gravity, or ascend by capillary action through large tracts of sound bone, and in this way, by the opening of a joint, 1 Case XI. 2 Case XIII. ^ j. M. Broom, Case XII., Chapter Fourth. 394 CASE XXXVni. — HOSPITAL GANGRENE. the difficulties of any case may be greatly increased, and in fact rendered hopeless, unless the limb be promptly amputated. The following case will serve to illustrate the effects of gangrene when it invades a large joint : — Case XXXVIII. — F. M. McWaters, sergeant, Co. E, 41st Georgia Case Eegiment, Stovall's Brigade, Cleburn's Division, Army of ^xxTOi. Tennessee. Black hair, dark eyes, dark complexion ; mus- the fatal ef- cular, wclI-built man. Wounded August 31, by minie-ball ; fectsofthe - , " o i i i • J opening of flesh-wound, ball entenng the inner portion of the lower third by the ray- of the left thigh, two inches above the joint. Sent to division piSi gan-^" hospital the day he received his wound, and remained until ^'"'- next night ; then sent to Fair Ground Hospital, No. 2, Vine- ville, Georgia, and transferred to Empire Hospital, September 16. Gan- grene was present at the time of his entrance into this hospital, and the wound was about nine inches in circumference, with a black, hard crust. The wound continued to present a dry, dark crust, notwithstanding the application of nitric acid and poultices, and the gangrene spread rap- idly, without any secretion of pus or appearance of healthy granulation until the 2d of October, when there was some appearance of granula- tion and pus. Ball extracted October 5, from the popliteal space. The usual treatment of tincture muriate of iron and stimulants internally, and nitric acid, chlorinated soda, oil of turpentine, oak-bark poultices, and even the actual cautery, were used with little or no apparent effect. October 4. — Eight o'clock p. m. Pulse, 104. Eespiration, 22. Tongue red and dry. Bowels regular. Temperature of hand, 37.2° C. (99° F.). Temperature of axilla, 39.2° C. (102.6° F.). October 5. — Eight o'clock a. m. The surface of the wound looks more healthy. Granulations are springing up, and some pus is ex- creted. The gangrene is still, however, progressing slowly at the upper and lower borders of the wound, and over the knee joint, and the de- nuded surface progressively enlarges. Wound twenty-four inches in circumference. Pulse, 98. Respiration, 18. Tongue red and moist. Skin moist. Bowels regular. Temperature of hand, 33° C. (91.4° F.). Temperature of axilla, 38° C. (100.4° F.). Eight o'clock p. M. Pulse, 106. Respiration, 16. Tongue red and dry. Skin dry and warm. Temperature of hand, 38.2° C. (100.8° F.). Temperature of axilla, 40° C. (104° F.). Examirtation of Urine. — Amount of urine passed during twenty-four hours, from October 4, 8 p. m., to October 5, 8 p. m., 1,000 CC. = grains 16,025.62. Deep reddish orange color. Specific gravity, 1,017.5. Heavy light-yellow deposit of amorphous urates and prismatic phos- phates, with alkaline reaction and strong ammoniacal odor, twenty-four hours after collection. CASE XXXVIII. — HOSPITAL GANGRENE. 395 ANALYSIS OF TJRINB, NO Urine collected 1,000 parts of daring 24 hours, urine con- contained grains tained 16,025.62 41 ■2.72 2.5.75 7.60 0.47 alkaline - .W.82 3.42 24.12 1.50 16.80 1.42 6.72 0.41 46.20 2.08 27.99 1.12 Amount of urine collected during twenty-four hours . Urea . . Uric acic Tree acid Phosphoric acid Equivalent of phosphorus in phosphoric acid . . . Sulphuric acid Equivalent of sulphur in sulphuric acid Chloride of sodium Equivalent of chlorine in chloride of sodium . . . October 6. — Eight o'clock a. m. Pulse, 108. Eespiration, 18. Tongue red and moist. Bowels regular. Temperature of hand, 35° C. (95° F.). Temperature of axilla, 40.2° C. (104.4° F.). Eight o'clock p. SI. Pulse, 108. Respiration, 18. Temperature of hand, 37.4° C. (99.4° F.). Temperature of axilla, 40.4° C. (104.8° F.). Tongue red and moist. Bowels regular. October 7. — Eight o'clock a. m. Pulse, 101. Eespiration, 16. Tongue red and dry. Skin warm. Bowels regular. Temperature of hand, 33.4° C. (92.1° F.). Temperature of axilla, 38.5° C. (101.3° F.). Eight o'clock p. M. Temperature of hand, 33° C. (91.4° F.). Tem- perature of axilla, 38.5° C. (101.3° F.). Pulse, 104. Eespiration, 18. Tongue red and dry. Bowels regular. October 9. — Nine o'clock a. m. Pulse, 91. Eespiration, 18. Tongue dry and red. Bowels regular. Temperature of hand, 38° C. (100.4° F.). Temperature of axilla, 38° C. (100.4° F.). Nine o'clock p. M. Pulse, 110. Eespiration, 18. Tongue dry. Bow- els regular. Temperature of hand, 37.4° C. (99.3° F.). Temperature of axilla, 38.2° C. (100.8° F.). October 10. — Nine o'clock A. m. Pulse, 101. Eespiration, 21. Tongue red and moist. Bowels regular. Temperature of hand, 38° C. (100.4° F.). Temperature of axilla, 38° C. (100.4° F.). Eight o'clock p. M. Pulse, 108. Eespiration, 22. Tongue red and dry. Temperature of hand, 37.4° C. (99.3° F.). Temperature of ax- illa, 40° C. (104° F.). October 11. — Nine o'clock a. m. Pulse, 112. Eespiration, 18. Tongue red and dry. Bowels regular. Temperature of hand, 30.5° C. (86.9° F.). Temperature of axilla, 37.2° C. (99° F.). Eight o'clock p. M. Pulse, 110. Eespiration, 18. Temperature of hand', 32° C. (89.6° F.). Temperature of axilla, 38° C. (100.4° F.). Tongue red and dry. Bowels regular. October 12. — Eight o'clock a. m. Temperature of hand, 30° C. (86° 396 CASE XXXVin. — HOSPITAL GANGRENE. F.). Temperature of axilla, 37.5° C. (99.5° F.). Pulse, 106. Respi- ration, 19. Tongue red and moist. Six o'clock p. M. Temperature of hand, 37° C. (98.6° F.). Tempera- ture of axilla, 40° C. (104° F.). Pulse, 112. Respiration, 16. Tongue red and moist. Skin moist During this period the gangrene has progressed slowly, denuding the muscles ; and on the 9th, the joint was opened by its erosive action, and the synovial fluid escaped. October 18. — Tongue tremulous and red. Complexion dusky, with a deep hectic flush upon the cheek. Hands tremulous. Pulse, 92. The wound continues to enlarge slowly. The joint is opened. The raw muscles present an unhealthy, smooth appearance, without granula- tions, wherever the gray and greenish slough has been removed. Bowels loose ; had six evacuations during the past twenty-four hours. Wound emits an intolerable stench. The patient drinks nothing but strong red- oak bark tea, in the place of water, to control the bowels. No appetite. Eats little or nothing. Examination of Urine. — Amount of urine collected during twenty- four hours, October 17, 11 a. m., to October 18, 11 a. m., 480 CC. = grains 7,726.32. Deep-red color. Specific gravity, 1,022. Heavy light-yellow deposit, consisting of amorphous granulated urates and vegetable cells, many of which presented a dumb-bell shape. These vegetable cells have materially diminished in the urine of hospital gan- grene since the commencement of cold frosty weather. ANALYSIS OP URINE, NO. 40. Amount of urine collected during twenty-four hours . Urea Uric acid Free acid Phosphoric acid Equivalent of phosphorus in phosphoric acid . . . Sulphuric acid Equivalent of sulphur in sulphuric acid . . . . Cliloride of sodium Equivalent of chlorine in cliloride of sodium . . Urine collected during 24 hours, contained grains 1,000 parts of urine con- tained 7,726.32 303.07 39.22 9.12 1.05 15.52 2.008 17.74 2.20 7.79 1.08 14.81 1.91 5.92 0.76 8.87 1.15 5.37 O.GI October 19. — Up to the present time, the patient appears to have been unconscious of his condition, as well as of the foul stench emitted by his wound. No appetite. Tongue clean, and of an unhealthy red and purplish blue color. Bowels loose. Continues to take red-oak bark tea as an astringent. The purplish leaden hue of the tongue betokens much derangement in the composition of the blood. Wound CASE XXXVIII — HOSPITAL GANGRENE. 397 still enlarging, and the bones of the joint are exposed in several minute spots. Examination of Urine. — Amount of urine collected during twenty- four hours, 350 CC. = grains 5,631.22. Specific gravity, 1,022. Deep- red color ; clear ; no deposit when first passed, as in the preceding specimen ; but after standing seventy-two hours, a heavy yellow depasit of granular urates gradually fell, with a few octahedral crystals of oxa- late of lime. Immediately after its collection, the urine was tested for grape sugar ; no trace. ANALYSIS OF URINE, NO. 41. Amount of urine collected during twenty-four hours . Urea Uric acid Free acid Phosphoric acid Equivalent of phosphorus in phosphoric acid . . . Sulphuric acid Equivalent of sulphur in sulphuric acid Chloride of sodium Equivalent of chlorine in chloride of sodium . . . Urine collected during 24 hours, contained grains 1,000 parts of urine con- tained 5,631.22 218.29 38.65 7.70 1.03 20.21 3.59 8.50 1.509 3.74 0.67 10.80 1.91 4.32 0.76 5.39 0.95 3.26 0.57 The free acid of the urine appeared to be, to a certain extent, a mod- ified form of tannic acid, derived from the red-oak bark tea, which was the only fluid which this patient was allowed to take to quench his thirst. In testing for phosphoric acid, the urine gave with the per- chloride of iron, acetate of soda, and ferro-cyanide of potassium, before the blue spot was formed, a deep bluish leaden color. When the per- chloride of iron was added to the urine, it gave a dark, blackish color, as if tannic or gallic acid were present. The phosphate of iron thrown down in the test for phosphoric acid, did not present the reddish-brown color usual in the urine, but a dark brown inclining to black precipitate. The reaction of the urine continued strongly acid for a week or ten days, and even longer. October 24. — Eleven o'clock a. m. Pulse, 128. Skin hot and dry. No appetite whatever. Has had none since the appearance of the gan- grene. Tongue dry and red at the edges, and of a deep purplish blue in the centre. All cases in which I have observed this purplish, leaden hue of the tongue, have terminated fatally. The wound has reached frightful dimensions, and the patient is rap- idly sinking under the effects of the gangrene. Large tracts of the denuded muscles, and of the capsular ligament of the joint, present a slick red appearance, and secrete little or no pus. No granulations are to be observed. From the openings in the capsular ligament of the 898 FORMATION OF BED-SORES IN GANGRENE. knee joint, pus and a thin, fetid, sanious fluid continually issue. The synovial fluid of the joint escaped fifteen days ago. A consultation of surgeons was called at this time by the attendant medical officer, Assistant-Surgeon Calhoun, and the question of amputation debated. It was decided to attempt to save the limb. I was not present at this consultation, but immediately after gave my decided opinion that the leg should be amputated, as the only chance to save the life of the patient. The limb should have been amputated, without any question or hesi- tation, as soon as the joint was opened by the gangrene. As far as my experience extends, the opening of the knee or elbow joints by gan- grene, has always insured a fatal termination, either from hemorrhage or from the gradual exhaustion of the patient. In such cases, the parts beyond the joint are liable to gangrene of a rapid and destructive char- acter. In such low cases as the present one, after amputation, the spirits of turpentine should be most liberally administered internally, together with alcoholic stimulants and nutritious diet. I remained the entire day in the tent with this patient, examining his condition, and executing a drawing of the leg and foot. (See Plates XXIV. and XXV.i) These sketches will give a better idea of the ravages of the disease, and the appearance of the wound, than a long description. The left foot, on the outer side, where it had rested four days ago, manifested a blue spot, as if gangrene was about to spread in the parts subjected to pressure. The blue spot gradually enlarged. The advancing lines aroimd the circumference presented a dark purplish blue color, whilst the central portions (those parts first and longest affected) assumed a greenish gray color. The entire foot became much swollen, and the parts around the advancing blue line were much inflamed, and the sound skin presented a bright scarlet blush, which gradually shaded into the deeper purple and blue. From the central gray and greenish and bluish mass of dead gan- grenous tissues, a thin fluid issued. The drawing, Plate No. XXV.,'' represents the appearance of the out- side of the left foot. The bottom and heel of the foot had been poul- ticed, and hence the wrinkled appearance. The patient continued to grow gradually worse ; gangrene spread over the entire foot, and the case terminated fatally on the 26th in the evening. This patient retained his senses and intelligence to the last moment. I conversed with him only a few moments before death, and he spoke calmly and intelligently, and cried out with pain when his left leg was touched or moved in the least. 6. Formation of large bed-sores during the progress of the disease, and the appearance of gangrene in them. 1 Omitted. 2 Omitted. fecta of bed- sores in somo cases of hos- pital gan- CASE XXXIX. — HOSPITAL GANGRENE. 399 As we have before shown by numerous cases, the tendency of the poison of hospital gangrene, after its absorption, is to 5 ^hm ^_ the rapid derangement of the constitution of the blood and of the nutrition of the body generally, and by its action the general and capillary circulations are greatly ^"^^ depressed and deranged. It follows from this, that all parts sub- jected to continuous pressure in this disease, are liable to death. Hence the most scrupulous attention should be paid to the change of posture, and to the friction and stimulation of all parts neces- sarily subjected to pressure in patients suffering with this dis- ease. I have seen a number of cases which appeared to terminate fatally, entirely on account of the gangrenous bed-sores, after all gangrene had been removed from the original wound, in which botli granulation and suppuration had been established. The following case will illustrate this proposition : — Case XXXIX. Thomas Nesbit, private, Company A, Austin's Battalion, Louisiana Sharpshooters. Age, nineteen. Brown case hair ; brown eyes. Height, five feet eight inches. Native of Biu^tSting New Orleans. Has been engaged in active service three ^^iJ^^g years : and during this time has served with the Army of Jjcd-sorfs in •^ ^ '' hospital gan- Tennessee, from Columbus, Kentucky, to Atlanta, Georgia. B«nc. Has enjoyed good health both before and after entering the Confed- erate army. Has never suffered with the venereal disease. Was wounded for the first time at Atlanta on the 28th of July, 1864. The ball (minie) glanced from the ground and inflicted a slight wound upon the foot, near the instep, and appeared only to take off the skin and slightly to bruise the surrounding parts. No bones were broken, and the field surgeon pronounced it a slight wound. Patient says that he was in very good health at the time of the reception of the wound. Was removed from the battle-field to the division hospital, and remained there only an hour and a half, and was transferred to the railroad station (receiving hospital), where he remained during the night, and started the next day for Macon. The cars were delayed one day and night on account of a raid of Federal cavalry. They were crowded with wounded soldiers, so crowded in fact that many of the men did not have room to lie down ; and there was but a poor supply of water, and but little attention to the dressing of the wounds. Entered the Fair Ground Hospital, in Vineville, and the gangrene appeared in his wound about three weeks after. Has been in the Empire Hospital about one month. The gangrene progressed for a time apparently without any check, and destroyed the tendons of the foot upon the upper or dorsal surface 400 DIARRHCEA CAUSED BY THE POISON OF GANGRENE. (extensor tendons) and the flexors have curled the foot under, as repre- sented in the drawing, Plate No. XXVI.^ Under the local action of nitric acid, and of other remedies, the gan- grene disappeared, and the wound assumed a healthy granulating sur- face, and discharged laudable pus. The recovery of the patient appeared to be highly probable, when large bed-sores formed upon the back, and took on the gangrenous inflammation. After the appearance of the gangrene in these large diseased surfaces upon the back, obsti- nate diarrhoea set in. October 4. — Pale, sallow, dusky hue, with sunken eyes and pinched features. Dejected, wasted, wan countenance. Bowels running off continually. Evacuations watery, and very fetid. Great muscular and nervous exhaustion. Cries like a child, not only whenever his wounds are touched, but whenever anything crosses him. A mere skeleton. Pulse, 112 ; a mere thread, so feeble as to be counted with difficulty. Respiration, 20. The wound presents a florid, granulating surface, with thick, green- ish, tenacious pus. I executed the sketch of the appearance of the right (diseased) foot The heel is becoming gangrenous from pressure, as represented in Plate No. XXVI.2 The condition of the wound is not such as to account for the feeble state of the patient. Large gangrenous bed-sores, emitting a most foul odor, and present- ing inflamed, everted edges, and an internal gray and greenish pulpy slough, have formed, and are rapidly spreading and denuding the muscles upon the back and hip. This patient died a few days after this observation. It appeared evident that this case fell a victim to the extensive bed-sores. 6. Diarrhoea resulting from the irritant action of the poison of hospital gangrene upon the internal mucous membrane. After the absorption of the gangrenous matter, the immediate 6. Death ca'usc of death is in many cases of long standing, profuse, diar^c^V ^"'i uncontrollable diarrhoea. In the early stages of the thilmtoDt" disease, the bovfels are most generally constipated, and ^^■loD of""* the use of occasional purgatives beneficial ; hut when the grenl'Spm''" disease has continued for a length of time, and a large mucom "'"'' surface has been exposed to the action and absorption of membrane, jj^g deleterious materials, diarrhoea of an obstinate and fetid character frequently sets in. In some cases the diarrhoea precedes the favorable changes in the diseased structures and in the constitutional symptoms, and appears thus to be of the nature of a critical discharge, the mucous membrane of the intestinal canal I Omitted. 2 Omitted. DIAERHCEA CAUSED BY THE POISON OP GANGRENE. 401 acting the part of an emunctory, and eliminating from the blood and lymphatic system the poisons and the deleterious compounds resulting from its action upon the organic constituents of the blood and lymph. The discharges from the bowels generally present a healthy bilious yellow color, unlike the pea-soup evacuations of typhoid fever. The odor partakes of the nature both of that of fsecal matter and of the gangrenous matter, and is ofttimes overpowering and intolerable. I considered it to be of some importance to determine whether there were any characteristic lesions of the mucous mem- no uniform brane, with its glandular elements, of the intestinal canal, intestinal ca! in this diarrhoea, and accordingly subjected the question of hospital' to the only practical test. As far as my observations terminating extend upon the condition of the intestinal canal in cases diarrhoea?" of hospital gangrene terminating fatally on account of diarrhoea, there is no uniform lesion of the alimentary canal, beyond the marks of irritation and congestion. In the most obstinate cases, I have observed large tracts of the intestinal mucous membrane, especially in the jejunum, which presented the appearance of healthy mucous membrane, with no marks of congestion or irrita- tion. The marks of irritation and congestion are most striking in the ileum, especially towards the ileo-csecal valve. The mucous membrane presented a red and irritated appearance, with an arbo- rescent and punctated congestion and injection of the blood-vessels. I have observed no enlargement nor. softening of the glands of Peyer, nor of the solitary glands, nor of the lymphatic glands of the mesentery. Neither is the mucous membrane of the intes- tinal canal, as a general rule, ulcerated. Ulcerations of the mucous membrane of the ileum and colon have been observed when dysen- tery has preceded or been engrafted upon hospital gangrene as a distinct disease ; but these solutions in the continuity of the mucous membrane appeared to be in no manner connected with the action of the gangrenous matter during its elimination. In the post-mortem examinations which I instituted upon the Federal prisoners at Andersonville, in the Confederate Results of ™ ... . , . n 1 post-mortem btates military prison, ulcerations ot the mucous mem- examina- brane of the intestinal canal, and especially of the colon tutedupon , . , P _ the Federal and rectum, were present m a number ot cases. JBut prisoners they were just as abundant in the cases of diarrhcea and sumter, dysentery without hospital gangrene. A careful exam- Tiiie.oeo. ination of the causes inducing diarrhoea and dysentery in these 26 402 DIARKHOEA CAUSED BY THE POISON OF GANGRENE. prisoners demonstrated conclusively that the ulcerations in both classes of cases were due to special causes, and that in the gan- grene cases they were not at all connected with the special action of the poison. A fact of interest in these cases of the Federal prisoners was, Gangrene ^^^^^ ^^c inflamed mucous membrane of the intestines in Slated 'q! the cases of diarrhoea and dysentery, arising from bad c?us"meS-"" diet, scurvy, and foul air, frequently took on gangrene, bwds°of the l^oth with and without the existence of any liospital gan- ^iie^is-" grene upon the exterior. The mucous membrane, instead oners. ^jp pj-egenting the bright red color, with the inflamed ul- cerations of ordinary cases of diarrhoea and dysentery, presented a gray, greenish, slate-colored, and bluish surface. After the establishment of hospital gangrene in the intestinal canal, the failure of the powers was rapid, and death terminated the cases, even before the structures could be disintegrated to any extent. This fact is of great importance in sustaining the proposition which I advanced in the third chapter, namely: — The poison inducing hospital gangrene is capable of entering the system through the pulmonary and cutaneous systems, and of exciting gangrene in parts which were probably in a state of defective nutrition, degeneration, or inflammation, or of depressed vitality, but which, as far as known, were not exposed in any manner to the direct action of the poisonous matter, and over which the integuments were in an unbroken and uninjured state. The results of the investigations instituted amongst the Federal prisoners at Andersonville, will be considered more fully in the chapter devoted to the consideration of the causes of hospital gan- grene. In passing, we will allude to a practical point illustrated by the In some preceding investigations. If the diarrhoea occurring in cases diar- a o o rs rhoea'super- many cascs of hospital gangrene be of the nature of a Tening upon ..,,., I'-iii hospital gan- critical discharge, physicians should exercise caution and grene to be,, ii* i-ii regarded as a ludgmeiit as to the niode in which thev attempt to con- criticaldis- ,,,,.,«. » ,. . , , charge. trol or chcck this enort ot nature to eliminate deleterious agents from the blood. When the blood is greatly disorganized, and loaded with inju- rious compounds, more harm than good will result from locking up with opiates, tannin, sugar of lead, and other astringents, the channel by which the offending matters are naturally removed. CASE XL.— HOSPITAL GANGRENE. 403 The following cases will illustrate the preceding observations upon the changes of the intestinal canal in hospital gangrene, accompanied with diarrhoea. They will also afford other points of interest, bearing upon the nature and pathology of the dis- ease : — Case XL. J. A. J. Shelton, Lieutenant, Company G, 50th Reg- iment, Tennessee Vols. Occupation before entering ser- case XL. vice, merchandizing. Wounded at the battle of Jonesboro', and'S^ Georgia. Right thigh amputated on the field of battle at fu^^^^iog the lower third. "pop tos- Received into the Empire Hospital, Vineville, Georgia, grene. August 31, 1864, with gangrene in the stump of right thigh. The stump was much swollen, and at one time discharged a large quantity of fetid, gangrenous, bloody, dark, almost black matter. On the 8th of October, when I first examined this patient with a view to study his condition, he appeared to be in extremis. Twitching of all the tendons and muscles of the extremities ; rapid, feeble pulse, scarcely perceptible, and so small and flickering that it could not be counted. Cold extremities. Sallow complexion. Pinched and ghastly features. The attendant medical officer had directed my attention to this case as one presenting strong symptoms of pyaemia. I was so impressed with his low condition, that all hopes of his rallying from this state were abandoned. It was, however, deemed advisable to administer alcoholic stimulants freely, as they had been discontinued for some time before these distressing symptoms manifested themselves. Under the hourly administration of small quantities of whiskey, the patient rallied, and for several days appeared to improve ; the stump also diminished in size, and appeared to be undergoing some favorable changes. The discharge, however, from parts of the stump was quite great, and extensive sloughing continued along the back of the thigh. Obstinate and exhausting diarrhcea set in, and the patient died Octo- ber 23. PosT-MOKTEM. — Eoderior. — The anterior and upper portions of the wound appeared to be free of gangrene, and presented a granulating surface. The posterior portions of the thigh were in several places gangrenous, and the denudation of skin and muscles had extended for near ten inches up towards the buttocks. The femoral vein and artery were carefully dissected out. The ligated end of the artery was closed by a firm fibrous coagula, one inch in length, and composed of alternate layers of fibrin. The femoral vein was occluded at its lower extremity, and its diameter for several inches above the wound was greatly diminished. The occlusion of the vein was not accomplished by the formation of a fibrous clot, as in the 404 CASE XL. — HOSPITAL GANGEENE. case of the artery, but by the firm adhesion together of the walls, thus forming a fibrous ribbon of the formerly hollow blood-vessel. A firm fibrous clot was discovered in the main branch of the femoral vein, which conveyed blood from the parts in the back of the thigh which had been so extensively involved in the slough. This clot was likewise firm, and composed of layers of fibrin. The clot did not completely occlude the vein, and a small stream of blood evidently passed from the parts to which it had been distributed. This observation is important, as illustrating the mode in which important blood-vessels are sometimes occluded during the progress of gangrene, even for some distance from the seat of the disease. This occlusion may account for the sudden and great swelling which some- times occurs in hospital gangrene. If the vein be a large one, this occlu- sion may also accomplish beneficial results by preventing the admission of air and of the decomposing structures and matters, and of pus directly into the blood through the eroded end of the vein in the gangrenous or sloughing wound. It is probable that many cases of gunshot wounds would terminate in pyaemia, if nature did not thus close by fibrinous clots the channels through which the products of the disintegrating tis- sues might enter. This subject offers a wide field for investigation, and much light might be thrown upon the nature of pyaemia and of sudden blood poisoning, by a careful examination of the blood-vessels in all fatal cases of gunshot wounds. If in large suppurating wounds nature ordi- narily prevents the entrance of deleterious matters into the blood by occluding the veins in this manner with fibrinous clots, before their coats are eroded, the question naturally arises, whether in pyaemia the veins have at any time been occluded, and if they have been, what has destroyed the barriers to the entrance of the pus ? If the veins have not been occluded, what is the condition of the blood which has prevented the formation of these fibrinous masses ? Do not these questions indicate the direction in which we may seek for the explanation of the fact that pyaemia is most likely to occur in the crowded atmosphere of the hos- pital, and in those the constitution of whose blood has been depraved by bad diet, vicious habits, and foul air, and by imhealthy suppurating or gangrenous wounds ? This question will manifestly involve the determination of the effects of foul air, and of various organic matters absorbed from unhealthy wounds, upon the constitution of the blood, and especially upon the quantity and quality of the fibrinous con- stituent. Abdominal Gavity. — Spleen enlarged about twice its natural size, but firm in its structure, and changed to the arterial hue when exposed to the action of the atmosphere. Under the microscope, the blood cor- puscles and mud of the spleen presented the normal appearance, and no black masses, as in the malarial spleen, were observed. The microscopical examination revealed nothing abnormal in this organ. DIARRHCEA CAUSED BY POISON OF GANGRENE. 405 The enlargement of the spleen appeared to have been of long standing, and not connected with the gangrene. Liver normal in size and in the consistence of its structures, and only a little paler than usual. Under the microscope, the liver cells looked pale and devoid of fat in a great measure. This patient was greatly emaciated, a mere skeleton, and the absence of oil globules, or rather the diminution of the quantity usual in cases terminating fatally in acute diseases, before there had been extensive wasting of the tissues, appeared to be nothing abnormal, but simply the effects of the long- continued and progressive consumption of the hydro-carbons of all the tissues. The abdominal muscles were without any layer of fat, and the mesentery and omentum were in like manner without any, or rather with very little fat. Gall-bladder distended with yellow bile. Alimentary Canal. — Stomach pale and healthy ; mucous membrane pale, and with no abnormal appearance. Mucous membrane of duode- num and jejunum healthy in color and consistence. The ileum presented many congested portions, especially towards the ileo-caecal valve. The congestion of the mucous membrane of the ileum was not uniform ; many portions presented a healthy appearance. Plate No. XXVII."^ represents the appearance of a portion of the ileum, near the ileo-caecal valve. The portion from which this drawing was made, was one of the most congested parts of the intestinal tract. Peyer's and the solitary glands, as well as the mesenteric glands, were unaffected, — neither engorged, enlarged, nor inflamed nor soft- ened. The ileum contained much tenacious yellow nnicus and fetid yellow faeces. Under the microscope, the contents of the bowels presented nothing unusual, or of special interest. No living animalcules were observed. When the mucous membranes of the intestines were floated in water, and examined with a magnifying power, the capillaries of many of the villi and of the highly-colored spots of the mucous membrane were found to be engorged with red blood. I observed during these examinations no abrasion, ulceration, or solution of continuity in any part of the mucous membrane. The large intestine was filled with thin, yellow, fetid faeces, and the mucous membrane presented a healthy appearance, without any ulcera- tion. The diarrhoea in this case appeared to have been due to the ijritant action of the matters absorbed from the gangrenous tis- sues. As we have before remarked, in many cases of hospital 1 Omitted. 406 CASE XLL — HOSPITAL GANGRENE. gangrene recovery is preceded and accompanied with diarrhoea, which appears to be salutary in its effects, and leaves no per- manent lesion of the intestinal mucous membrane ; whenever, however, the bowels are uncontrollable for a length of time in this disease, a fatal issue almost invariably follows. Case XLI. This Confederate soldier had suffered with a gangrenous wound of the left thigh and hip for near six weeks. During ratal diar- the last two wecks of his disease the bowels were affected ing from tho with a Constant and exhausting diarrhosa, and there was low ofg'angren- muttering delirium, and great muscular and nervous pros- ous ma rs. ^j.^jJqjj^ ^^^ twitching of the tendons, and picking at the bed- clothes, as in typhoid fever. In fact, before I examined this case, the attendant medical officer called my attention to it as one of typhoid fever. The discharges of the bowels, however, were different from those of this disease, and the complexion was more sallow and less florid than in typhoid fever. These facts, taken in connection with the exten- sive gangrene, led me to dissent from the diagnosis, and to pronounce it a case of diarrhoea resulting from the action of the absorbed gangrenous matters. This patient died in the Empire Hospital, October 1, 1864. PosT-MORTEjf. — Exterior. — Greatly emaciated. Wound on left thigh and hip, about three inches in diameter, with a deep blue and greenish gangrenous surface. Dissection revealed extensive gangrenous disorganization of all the parts surrounding the hip joint. Trochanters and back, and head of femur, and acetabulum, and bones of pelvis immediately surrounding the hip joint, denuded of periosteum. Capu- lar ligament in a measure destroyed. The muscles of the thigh and buttock, around the dead bones and opened joint, disorganized, gan- grenous, and infiltrated with the fetid gangrenous matters. The skin over large portions of these disintegrated tissues appeared upon the exterior to be quite sound, and there was during life no change of color and but little swelling to denote the extensive destruction of nmscles, ligaments, and cellular tissue. In fact, this state of things was not at all suspected by the attendant physician, who informed me a few days before the death of this patient that the wound was progressino- favor- ably. Abdominal Cavity. — Skin of the abdomen of a greenish and bluish color, as if the bowels were in a state of mortification. As this patient had suffered with most obstinate diarrhoea, and had died delirious, and as his case had been pronounced to be typhoid fever supervening upon a gangrenous wound, I examined his bowels with great care, from the oesophagus to the anus, in the presence of several of the medical stafif of this hospital. When the abdominal walls were divided, the muscles were found to present a blue and purplish color, far different from the color of the muscles in patients who die from other acute diseases, as pneumonia, or even from typhoid fever. EXTENSIVE DISOBGANIZATION OF STRUCTURES. • 407 Stomach. — Mucous membrane appeared to be healthy, and not con- gested. Nothing unusual was observed in this viscus. Duodenum and Jejunum. — Congested in patches, which presented a bright red punctated appearance. No softening or ulceration was observed in the mucous membrane of the duodenum and jejunum. The ileum, colon, and rectum presented an arborescent and punc- tated congestion ; and in like manner no ulceration or solution of continuity was observed in the raucous membrane of this portion of the intestinal tract. The lymphatic glands of the mesentery presented a dark bluish color, and were enlarged and softened. The glands of Peyer and the solitary glands, on the other hand, were normal in appearance, and presented no evidence whatever of the deposit and softening of typhoid fever. The bowels, especially the ileum and colon and rectum, contained much fetid yellow faecal matter. In the color and general appearance of the faeces, however, nothing peculiar was discovered. Liver. — Pale, but healthy in appearance and structure. Gall-bladder distended with yellow bile. Spleen. — Enlarged to three times its normal size, and somewhat soft- ened, but not .softened to the extent common in malarial fever. Commentary. — This case illustrated the following points which I have verified in other autopses : — 1. The most extensive disorganization of tissues from hospital gangrene may exist, vrithout manifesting any marked signs during life upon the external surface. This is especially apt to be the case when the forces have been reduced by the absorp- tion of the gangrenous matter, and by an active and debilitating diarrhoea. It v^'-ould appear as if the thorough poisonini; of the blood by the gangrenous matters prevented the occurrence of the usual symptoms of inflammation. 2. The obstinate diarrhoea accompanying this case appeared evidently to be due to the irritant effect of the absorbed poison- ous matters upon the intestinal mucous membrane, rather than to any primary or serious lesions of the intestines. 3. From this and other cases, we conclude that the lymphatic glands are sometimes, but not uniformly, involved in hospital gan- grene to such an extent as to be enlarged and softened. 7. JExtensive and rapid disorganization of the tissues around the original wound, beneath the sound shin, accompanied hy ,j_ (,^^^ ^^ absorption of the gangrenous matters, great nervous and pftafgM^'"' muscular prostration, and obstinate diarrhoea. srene. 408- CASE XLIl — HOSPITAL GANGRENE. The following case furnishes a good illustration of these causes of death in hospital gangrene : — Case XLII. John Kelly, Federal prisoner. Wounded and captured CaMXLn. at the battle of Chickaniauga, September 19, 1863. Age, Kusl"^ thirty. Medium size. Height, five feet eight inches. The hy^hetl-*"^ wound appeared at first to be slight. A minie-hall passed ra^w diso* through the external portion of the lower third of the left ffuiSusuea ^high, just above the knee joint. The femur appeared to and by the havc been rudely jarred and splintered upon its external absorption -^ "^ *^ ^ ofthegan- surface, but not fractured by the ball. Whether the joint matters. had been seriously injured, I was unable to ascertain. Tlie synovial fluid does not appear to have been evacuated, as the patient states that he was able to walk about for several days after the recep- tion of the wound. Twelve days after his capture, was transferred from Atlanta to Augusta, Georgia. The patient states that the travel in the cars caused him great pain in the limb, and the agony was intense towards the close of the ride, from the effects of the jolting of the cars. After his entrance into the Second Georgia Hospital, his sufferings were exceedingly great, and the limb continued to swell. A low, irri- tative hectic fever made its appearance immediately after the arrival of the patient. Pulse rapid and feeble. Complexion sallow, and slightly jaundiced. Loss of appetite, and nervous irritability and prostration. Tonics, stimulants, and opiates, with nutritious diet, were faithfully administered, but with no beneficial results. The swelling in the wounded limb increased, and the wound, near the left knee joint, dis- charged much unhealthy pus ; and two weeks before his death, a large abscess which had formed in the left groin was opened, and discharged much pus. After the formation of this abscess, the bowels became loose, and the patient suffered from a most offensive and exhausting diarrhoesl. Towards the close of this case, chills and other symptoms of pyaemia made their appearance. Throughout the disease the intellect remained clear. I saw him in the last hours of life, and although pulseless, he spoke in a calm, collected manner. The complexion presented a sal- low, jaundiced hue. This patient died in the morning, November 4, 1863. Autopsy, Four Hours after Death. — Exterior. — Body greatly ema- ciated. Sallow hue of skin. No external marks of disease, except in the left thigh and leg, which are greatly swollen, considering the emaciated condition of the general system. The lips of the abscess in the left groin present a bluish, greenish, and ashy gangrenous color. The original wound on the outer side of the lower portion of the left thigh, above the knee joint, appears to be nearly healed. CASE XLIL — HOSPITAL GANGRENE. 409 Thorax. — Lungs healthy. Heart and great blood-vessels normal. Abdominal Cavity.. — Liver enlarged and slightly indurated, and of a light brownish-yellow color, the upper surface showing evident marks of congestion of the inter-lobular veins ; edge of right lobe appeared to be much congested. Internally there were no evidences of congestion ; in fact the cut surface presented rather an ensanguined appearance. Microscopical examination confirmed the view which I expressed during the post-mortem, that the liver was partially cirrhosed, and in a state of fatty degeneration. Under the microscope, numerous large oil globules were visible in the secreting cells, as well as in the fibrous tissue and around the capillaries. The proper reagents extracted large quantities of fat from the liver. In fact it was thus demonstrated that the great bulk of this organ was fat. Croll Bladder. — Apparently healthy, and distended with light-yellow bile. Plate No. XXVIII.^ was painted with the natural bile. There appeared to have been no absence of bile in the alvine evacua- tions during life, and it was abundant in the contents of the bowels after death. The condition of the liver was by no means the result of the gan- grene, or of the causes producing death, and was without doubt of long standing; neither was it related in any perceptible manner to the obstinate diarrhosa. A very fair degree of health may exist together with such a state of this organ, which is comparatively common in those of intemperate habits. Great and small omentum healthy. Spleen. — Enlarged and indurated. Under the microscope, I was unable to detect any of the altered blood corpuscles and hsematin which characterize the splenic mud of malarial fever. The enlargement of the spleen did not appear to have been recent. After careful examina- tion of the organ, I came to the conclusion that the enlargement was in no way due to the cause of the disease and death of this patient, and was most probably of several years' standing. The texture of the spleen was even more firm than in health ; and in this respect as well as others, this organ was wholly unlike the enlarged softened spleen of malarial fever or of typhoid fever. The spleen changed to a bright arterial color when exposed to the atmosphere. Pancreas. — Normal in size, and healthy in structure. Stomach. — Distended with bile and ingesta, and appeared to be healthy. The mucous membrane was pale, and there were only a few spots, of a bright reddish tinge, in the more dependent portions, the slight congestion in these parts being referable to gravitation of the blood. SmaU Intestines. — From the stomach to the ileo-csecal valve, pre- sented both externally and internally a healthy appearance. The glands of Peyer, as well as the solitary glands, presented a healthy appearance, and were not in the slightest degree enlarged or softened. 1 Omitted. 410 CASE XLIL — HOSPITAL GANGRENE. When the mucous membrane was floated in water, and viewed under a magnifying glass, the villi of the intestines appeared to be normal. Mesenteric Glands. — Somewhat enlarged, but firm, and with no marks of disease. The softened condition of the mesenteric glands, as well as the peculiar deposit characteristic of typhoid fever, were nowhere found. The enlargement and induration of these glands, as well as of the spleen, may have been due to a previous attack of typhoid fever, many months or even years before. Large Intestine. — Somewhat congested, but without any ulceration or abrasion of the mucous membrane. The faecal matters, throughout the intestinal canal, were of the normal yellow color, and, with the exception of consistency, presented nothing unusual except in the fetid odor. When the mucous membrane of the intestines were floated in distilled water, and viewed under a strong magnifying glass, I was unable to detect any alteration in the tubuli or solitary and agminated glands, and no abrasions of the mucous membrane. Examination of Left Thigh. — The thigh was laid open from the crest of the ilium to the knee joint. All the muscles of the thigh and but- tock were affected with hospital gangrene. The femur was denuded of periosteum, and the muscles were detached from the bone. The muscles possessed but little strength, and could be ruptured by slight traction. The muscles presented a purplish and bluish green color, inclining to black in some parts, and in others a greenish-gray color. Plate No. XXIX.* represents the appearance of a portion of the vastus extensus muscle, which was simply pulled away, being detached with little or no force. The connective cellular, or areolar connective tissue of the muscles, together with the tendons, appeared to have resisted the disintegrating action of the gangrene to a greater extent than the sarcolemma which appeared to be completely broken down in many parts. In the region of the abscess, some pus was found, also in the neighborhood of the knee joint, as well as within the joint itself; and it would appear as if the pus had, before the spread of the gangrene, burrowed amongst the muscles, and thus prepared the way for the rapid and extensive spread of the gangrene. Under the microscope, the muscular tissue appeared to be almost completely disintegrated, with nothing but the areolar con- nective tissue remaining. Granules, crystals of triple phosphate, crys- tals of hijematin of the decomposed blood, together with broken capilla- ries and blood-vessels, meshes of fibrous tissue, oil globules, and irregular fragments of muscular tissue partially decomposed, with irreg- ular striai, composed the mass of gangrenous muscular tissue. No pus globules were found in the gangrenous muscles. The presence of crys- tals of triple phosphate in great abundance, presented at once a great departure from the composition of the healthy muscular substance, and 1 Omitted. MORTIFICATION OF INTERNAL ORGANS IN GANGRENE. 411 led me to infer that this gangrenous muscular mass had lost its normal acid reaction, and was now alkaline. As soon as the litmus red was applied to the gangrenous mass, it changed to a decided blue, thus con- firming the microscopical examination. It was very evident that this large number of prismatic crystals of triple phosphate could be formed and exist only in an alkaline fluid. The juices flowing from the gan- grenous muscles presented a dirty greenish and yellowish appearance, as represented in Plate No. XXIX.' Plate No. XXX.^ represents the appearance of the decomposing, gan- grenous, muscular matter from the muscles of the diseased thigh. The odor from this gangrenous matter was very fetid and disgusting. When a rod dipped in hydrochloric acid was held over these disinte- grating muscles, heavy white fumes were formed of the chloride of ammonium. The knee joint was distended with pus, and the articulating surface of the femur presented several black carious spots, and the entire shaft was dark colored and apparently dead. The leg and foot were much swollen, but gangrene had not involved the textures below the knee. The muscles throughout the body generally presented a leaden, un- healthy hue, far different from the florid hue of health. The exhausting diarrhoea which appeared to be the immediate cause of death, was due to the absorption of the gangrenous matter, and its action upon the intestinal mucous membrane. Case XLIII. In the case of a Confederate soldier, wounded in the upper third of the left thigh, at the battle of Chancellorsville, case xliii. who died with an obstinate and profuse diarrhoea, I found the thrTtiTm^e intestines, as in the preceding case, healthy in appearance, hospul'igan- and the solitary and agrainated glands in like manner nor- srene. mal. In this case the femur had been fractured, and had been united by a large amount of callus. The ball was found flattened, and lying against the callus. The cause of constant irritation, and which pre- vented the wound from healing, was a small section of the femur, about one inch in diameter, entirely detached and dead. Hospital gangrene had attacked this wound, as in the preceding case, and the parts around the dead bone presented livid, purplish, blue, green, and grayish colors. Liver. — Healthy. Spleen. — Enlarged but indurated, and fully as firm as the spleen of health. The pulp did not differ in microscopical characters from that of health, and contained no hiematin, and changed to the arterial hue when exposed to the atmosphere. 8. Mortification of internal organs., induced hy gangrenous mat- ter absorbed from the local disease. 8. MorUHoa- , . Hon of inter- The absorbed gangrenous matter may in certain cases nai organs 1 Omitted. 2 Omitted. 412 MORTIFICATION OF INTERNAL ORGANS IN GANGRENE. ^ngrenou^'a ^xcite mortification of important internal organs. The Borbrffrom development of gangrene witliin important internal or- thc^iocai dis- gans may take place rapidly, and sometimes without the manifestation of such symptoms during the life of the patient as would indicate the true nature of the disease. It is probable that in many of these cases, tlie organ which becomes gangrenous was previously in a diseased state, either of active inflammation or of progressive degeneration. In the case of Hollingsworth, which occurred in the Ocmulgee Hospital (reported at my request by Assistant-Surgeon F. A. Anderson, and given at length in the third chapter of this volume), the lungs were in a state of pneumonic inflammation, before the introduction of the gangrenous poison into the system by direct application of the matter to a blistered surface. I examined this case during life, and inspected the lungs carefully after death, and it appeared more than probable that death resulted from the action of the absorbed gangrenous matters upon the previously inflamed lung. Previous to the application of the gangrenous matter to the blistered surface upon the chest, the patient was improving. As soon as hospital gangrene manifested itself in the blistered surface, the pneumonic symptoms increased in intensity. The breathing became labored, and the bronchial tubes became so filled with fluid that a laborious churning sound was emitted. From the infiltration of the lungs and consequent increase in size, the thorax appeared to be preternaturally distended. The cheeks lost the bright florid flush so characteristic of pneumonia, and the whole countenance assumed a most unpleasant, sallow, dusky, cadaverous hue. After death, the lungs were found to be infiltrated with serous fluid, softened, and, in many circumscribed portions, in a state of incipient gangrene. Such cases present points of great practical importance. If the poison of hospital gangrene is capable of transmission through the atmosphere to inflamed surfaces, cases of pneumonia should never be treated in the same ward, or in close pro.\imity with the disease. The following cases, reported at my request by Assistant-Sur- geon F. A. Anderson, of the Ocmulgee Hospital, demonstrate the liability of the lungs in pneumonia to take on hospital gangrene, when the patients are treated in the same ward with gano^rene cases : — CASE XL V. — HOSPITAL GANGRENE. 413 Case XLIV. Thomas Rains, 5th Georgia Reserves. Age, forty- nine. Occupation before entering service, farming. Ad- casoXLiv. mitted into Ward No. 7, October 30, 1864, having suffered th"proS witli pneumonia about fifteen days. After remaining in this bylhemo'-' ward amongst the cases of gangrene, his symptoms became fn^t^^jTor- more grave. Great prostration. Pulse, 130. Complexion e^s. very sallow. Brilliancy of eyes. He did not cough very much. Ex- pectoration inconsiderable. Upon examination, dullness and bron- chophony right side of chest. Complained of no pain, but at every expiration there was a short moan, or grunt, which he said was en- tirely unavoidable. Patient not delirious, but very restless, depressed, and anxious. For two hours previous to death, respiration appeared to be entirely voluntary. Very marked distention of thorax and abdomen. Died November 4. Post-mortem. — Upon opening the thorax, a very considerable quan- tity of gas escaped, also some serum. The anterior portion of the lower and middle lobes, in the suppuration stage ; posterior portion of the same dark and indurated, presenting dark and very much softened spots. The left lung normal, with the exception of numerous minute extravasations. The lungs emitted an offensive, gangrenous smell, resembling that accompanying rapid decomposition. Liver normal. Enlargement and softening of spleen. Numerous extravasations throughout the intestinal canal. Very marked in the large bowel. Case XLV. Arthur (negro man), about forty years of age ; from fortifications around Macon. Was admitted into Ward No. cascXLv. 11, about the 1st of November, with pneumonia, and died on thes'tomodo the 4th of November. hospt^i^n- Post-mortem. — Upon opening the thorax, escape of gas. b"*"^- Left lung normal, with the exception of numerous hemorrhagic spots. Right lung a mere slip, occupying about one fourth of the cavity of the right side of the thorax, the lower lobe being excavated at its under side by a large, dark, and very offensive ulcer, large enough to receive a hen's egg. The whole lung was a mass of broken down, offensive, black structure. This dark purple color was fixed ; exposure to the air for a length of time did not produce any change. The liver very much enlarged, and pushing the diaphragm well up into the cavity upon this the right side of the thorax. Spleen very much enlarged and softened, the finger readily passing through it upon slightest pressure. The intestinal canal presented numerous extravasations of blood throughout the small and large bowel. This was more prominent in the transverse and descending colon, some of the spots being ten or twelve lines in diameter. No ulceration of mucous membrane of intes- tines. It appeared as though this condition must have taken place but a short time previous to death. 414 PYEMIA SUPERVENESTG UPON GANGRENE. Ill tne militaiy hospitals at Bilboa, upon dissection after death, Similar re- the disease was not found to be confined to the imme- eults ob- ^"sd^'Bi'- diate parts, but frequentlj'^ spread much further than Hennen. external appearances indicated, as a diseased track was often found running up into the groin or axilla, and completely dissecting the muscles and great vessels. When the disease had occupied the outside of the chest, Dr. Hennen found the lungs in two cases, and the pericardium in a third, covered with gan- grenous spots, and when the parietes of the abdomen had been attacked, he often observed the same appearances in the liver. 9. The invasion of organs essential to life, hy the direct destruc- 9. Cause of ^*''"* "/ intervening structures. pS.'''gan-''°^' When gangrene attacks the stump after amputation mvaSon^f" ^t or near the shoulder joint, the disease may progress HaTtoMfl^'' along the cellular tissue into the cavity of the thorax, dit?uctiOT°' ^"d invade the pulmonary structures, and thus produce i'ig'steuc™ ^ rapid fatal termination. I have seen the lungs thus *""^' attacked also in a case of resection of the humerus, near the shoulder joint. I have observed that in those cases in which hospital gangrene attacks the lungs, the complexion immediately assumes a most cadaverous, sallow hue. When gangrene attacks the tissues in the groin, it may penetrate the abdomen, and speedily cause death. In like manner, when the scrotum and testicles are attacked by the disease, it may penetrate the abdomen. During the present war, I have seen three cases of gangrene of the scrotum and testicles, in which these organs were entirely exposed, and even destroyed. Each case terminated fatally. 10. Pycemia. 10. Pyemia I* sometimes happens that when the gangrene appears upm hTsp"? to lie disappearing from the wound, and after the appear- tai gangrene. ^^^^ ^f grauulations and the formation of pus, this fatal disease supervenes. It is a subject for interesting investigation, to be settled only by carefully recorded cases and statistics, whether pyjemia is more common in cases of hospital gangrene than in those cases in which the wounds present the appearance of ordinary suppurative inflam- mation. It is reasonable to suppose that all depressing causes which tend to produce such a state of the system as favors the rapid disorganization of tlie structures, would favor the production of pyasmia. This question will be considered more fully hereafter ; and we will proceed at once to the more important practical illus- CASE XL VI.— PYEMIA. 415 trations of the relations of gangrene to pyjemia, as well as of the true characters of the latter disease. Case XL VI. Ira Parker, private, Company G, 1st Texas Eegiment. Age, twenty-three. Light hair ; gray eyes. Height, five feet case xlti. eight inches. Occupation before entering the army, farming. Jheeuper-^ Patient states that he has never had typhoid fever, nor any IV'^mfs."^ venereal disease ; had chill and fever five or six years ago. "P™ 'L°n. Has been in the Confederate army two years, and during that erene- time has not been sick. Was wounded before in Kentucky ; the wound healed rapidly, and gave no trouble. Wounded at battle of Chickamauga, September 19, 1863. Ball entered three and one half inches above external malleolus of right leg, and passed through the muscles and out on the opposite side, two and one half inches above its entrance. The wound was considered by the examining surgeon as a simple one of the tissues, not involving either the bones or the important nerves and blood-vessels. The patient was transferred on the railroad to Augusta, and entered the Second Georgia Hospital. His general health appeared to be good at the time of his admission, and the wound was thought to be progress- ing favorably until the 1st of October, when the patient complained of severe and darting pains in the wound, which became red and swollen. These changes in the injured parts were accompanied with fever, which was ushered in by no perceptible chill. On the 5th of October the wound presented the pulpy, gray, and green slough of hospital gangrene, with swollen, livid, and everted edges. The case was treated constitutionally with tincture of the sesquichloride of iron and sulphate of quinine, and nutritious diet ; and locally with a saturated solution of sulphate of copper, without any marked improvement in either the constitutional or local symptoms. November 2. — Pale, anaemic, with the sallow, leaden hue character- istic of some cases of hospital gangrene. The largest wound in the gastrocnemius muscle is oval in shape, about two and one half inches in its longest diameter, which corresponds with the length of the muscle, and about two and one half inches in its transverse diameter. The calf of the leg is much swollen. The wounds of entrance and exit are separated by a small strip of intervening tissues. In portions of the wound, especially where the gangrene still exists, the edges are swollen and everted. In the healthier portions, the edges present a more natural appearance. The parts around the wound are purplish red, indurated, and much swollen. Pus issues from those por- tions of the wound which are granulating, whilst in other parts the gray and green slough of hospital gangrene is still present ; and here no true pus appears to be forming. The odor of the wound is fetid and disagreeable. 416 CASE XLVL — PT.3EMIA. One o'clock p. m. Pulse 118, small and feeble. There appears to be great depression in both the general and capillary circulations. Respiration, 18. Tongue clean, smooth, and moist, but redder than in health. Patient nervous and depressed. Bowels costive. Appetite poor. Temperature of hand 33° C. (91.4° F.). Temperature of axilla, 40.5° C. (104.9° F.). The hand which had been lying by his side felt quite warm when I first placed my hand upon it ; but after its removal from the trunk, it rapidly lost its heat. This indicated the feeble nature of the circulation in the extremities. November 3. — Symptoms continue unchanged. Examination of Urine. — Amoimt of urine collected during twenty- four hours, up to November 3, 1 o'clock p. m., 850 CC. = grains 13,407.85. Specific gravity, 1,023.5. Deep orange, inclining to red color ; in fact, it may more correctly be termed light-red. No deposit at the end of thirty hours ; only slight turbidness. ANALYSIS OF UKINB, NO. 42. Elements. Amount of urine collected during twenty-four hours . Urea Uric acid Free acid (thirty hours after collection of urine) . . Phosphoric acid Equivalent of phosphorus in phosphoric acid . . . Sulphuric acid Equivalent of sulphur in sulphuric acid Chloride of sodium Equivalent of chlorine in chloride of sodium . . . Urine collected during 24 houra, contained grains 13,407.85 552.39 10.48 29.45 31.41 13.82 34.98 13.99 70.68 42.78 1,000 parts of • urine con- tained 33.71 0.77 2.19 2.38 1.03 0.26 1.04 5.26 3.19 November 5. — Nine o'clock a. m. Pulse 96, small. Respiration, 18. Bowels regular. Skin dry and cool. Tongue red about the tip and edges; slightly coated, and moist. Temperature of hand, 31.3° C. (88.3° F.). Temperature of axilla, 37.2° C. (98.8° F.). (Tincture muriate of iron, gtts. x., chlorate of potassa, grains v., three times a day. Saturated solution of sulphate of copper to wound. Nutritious diet.) November 6. — Nine o'clock A. m. Pulse, 84. Respiration, 18. Tongue slightly coated and moist. Skin moist and warm. Tempera- ture of hand, 32° C. (89.6° F.). Temperature of axilla, 38.2° C. (100.7° F.). Wound covered in parts with a dark, unhealthy sloutrh. Treat- ment continued. Diet, milk punch, egg soup, and beef tea. Four o'clock p. m. Pulse, 100. Respiration, 18. Temperature of hand, 31.2° C. (88.1° F.). Temperature of axilla, 39.4° C. (102.9° F.). Nine o'clock p. m. Pulse 108, small. Respiration, 18. Tongue CASE XL VI. — PYEMIA. 417 clean and moist ; smoother than usual, as if there were no papillae ; redder than usual. Temperature of hand, 36.8" C. (98.2° F.). Tem- perature of axilla, 39.9° C. (103.8° F.). Nmiember 7. — Nine o'clock a. m. Pulse, 96. Respiration, 18. Tongue slightly coated and moist. Skin of trunk dry and warm. Tem- perature of hand, 34.3° C. (93.7° F.). Temperature of axilla, 39° C. (102.2° F.). Swelling of leg continues to increase, and now extends from lower border of gastrocnemius to popliteal space. Gangrenous parts of wound very tenacious, and not disposed to separate by slough- ing. A considerable quantity was cut out with scissors. Treatment and diet continued. Five o'clock p. m. Pulse, 104. Respiration, 18. Tongue slightly coated, and moist. Temperature of hand, 30.6° C. (87.1° F.). Tem- perature of axilla, 39.2° C. (102.5° F.). November 8. — Nine o'clock a. m. Pulse, 100. Respiration, 18. Tongue pale, slightly coated, and moist. Skin dry and warm. Tem- perature of hand, 31.3° C. (88.3° F.). Temperature of axilla, 38.4° C. (100.1° F.). Sloughs are being detached in large pieces. Wound of exit looking red, and with granulations springing up over its entire extent. Wound of entrance also looking red, with granulations over a considerable portion, with the exception of the region about the upper border. Swelling of leg still continues the same. Treatment and diet continued. Five o'clock p. m. Pulse, 108. Respiration, 18. Temperature of hand, 30.2° C. (86.3° F.). Temperature of axilla, 39.4° C. (102.9° F.). November 9. — Nine and one half o'clock a. m. Pulse, 96. Respira- tion, 18. Tongue red at the tip and edges, coated with yellowish fur, and moist. Skin dry and warm. Temperature of hand, 32.3° C. (90.1° F.). Temperature of axilla, 38.2° C. (100.7° F.). Wound in the same condition as on yesterday. Swelling of calf continues. Considerable pus is now secreted by the wound. Treatment and diet continued. Eight o'clock p. M. Pulse, 106. Respiration, 18. Temperature of band, 28.2° C. (84° F.). Temperature of axilla, 39.1° C. (102.3° F.). Ten o'clock p. m. Patient had a chill. November 10. — Ten o'clock a. m. Pulse, 100. Respiration, 16. Tongue slightly coated, and moist. Bowels loose. Thin, pale yellow stools. Skin cool and dry. (Tincture of opium, gtts. xxv., adminis- tered at once.) Wound continues in much the same condition. Dis- charges pus. Leg still greatly swollen. Examination of Urine. — Amount of urine passed during twenty- four hours, 1,000 CC. = grains 16,080.75. Specific gravity, 1,021. Heavy, cream-like deposit of urates, upon cooling. (Cold, frosty morn- ing-) 27 418 CASE XL VI. — PYEMIA. ANALYSIS OF URINE, NO. 43. Elementa. Amount of urine passed during twenty-four hours Urea . . Uric acid Free acid (immediately after collection) .... Phosphoric acid . . Equivalent of phosphorus in phosphoric acid . . Sulphuric acid . . Equivalent of sulphur in sulphuric acid .... Chloride of sodium Equivalent of chlorine in chloride of sodium . . Chlorine determined directly by nitrate of silver . Urine collected 1,000 parts of during 24 hours, unne con- contained graina tained 16,080.75 492.80 30.64 11.02 0.68 50.05 3.11 57.28 3.56 25.19 1.56 26.06 1.62 10.42 0.64 63.14 3.93 38.26 3.37 37.05 2.30 Eight o'clock p. M. Pulse, 112. Skin hot and dry. Very severe pain in the leg. Restless and nervous. (One half grain of mor- phine.) November 11. — Continues much the same ; has had several chills. Symptoms of pysemia well marked. November 12. — Continues to grow worse. Had several chills, or rather fits of chilly feeling. November 13 and 14. — No improvement. Continues to grow worse. November 15. — Pale, ansemic, sallow, icteric hue of complexion. Conjunctiva jaundiced. Knee joint of right leg distended with pus. The entire leg and thigh is much swollen. Blood-vessels (veins) upon the surface distended with dark-colored blood. The track of each vein is marked by a purple red inflamed line, shooting up the leg and thigh from the wound in the gastrocnemius muscle. Patient feeble and ner- vous, with restless, trembling eyes and lips. Depressed, anxious coun- tenance, expressive of great distress and weakness. Features sunken ; nose pinched. Tongue tremulous, moist, pale, and smooth, as if the papillas were indistinct. Appears to be wholly unconscious of his true condition, and complains chiefly of loss of appetite, and of pain in the affected limb. The joint is very tender to the touch, as well as the lecf, and the patient cries like a child whenever the limb is moved. There is a peculiar weak, nervous trembling of the muscles of the face when- ever the patient speaks. Breath offensive. Wound offensive in the ex- treme. The entire body appears to exhale a most offensive odor. The patient appears to be entirely unconscious of the stench, and keeps his head covered with the bedclothes, as if he was very chilly. The hands tremble whenever they are stretched forth. The skin has a moist, disa- greeable, sticky, clammy feeling, and the integuments of the hands have a wrinkled, shriveled appearance, resembling the appearance of hands •which have been long immersed in water. Has had a succession of SYMPTOMS OF PYJEMIA. 419 chills, followed by profuse sweating. All the symptoms of pyaemia are well marked. In looking at such a case as this, we are strongly reminded of the description of pyaemia by M. Sedillot : ^ — " A patient is attacked by suppuration, when suddenly, without any other premonitory symptom, or some days after a hemorrhage, or diarrhoea, a diffuse inflammation, a phlebitis, an erysipelas, or a painful engorgement of a wound, a, more or less violent shivering fit comes on. Frequently there is observed a general trembling, chattering of the teeth, a drawing in of the limbs towards the trunk, and a morbid diminution of temperature of the skin ; speech is diffi- cult, the words uttered being short and interrupted ; the eyes are hollow, and the features contracted ; the countenance is of a leaden and yellowish color ; the respiration frequent ; the pulse small, soft, and rapid, and an instinctive sense of great peril is presented. The shivering ceases after a period varying from ten to forty-five minutes ; the warmth of surface returns, and a slight transpiration is established. Erratic shiverings, however, return, and not unfre- quently at the same hours as in the first instance ; the wound dries up, or the suppuration becomes grayish and fetid ; the surfaces of wounds assume a with- ered, flabby aspect ; the bones become denuded, and ill-conditioned ulcers arise or extend. The patient seems as if exhausted by fatigue, and plunged into a kind of coma vigile, with occasional delirium, or into a deep stupor ; the inspirations are made laboriously, and become more and more accelerated, so that thirty, forty, and fifty per minute are counted ; the breath exhales a puru- lent odor ; subcrepitant r3,les are heard in the chest, the air also not seeming to attain the minuter bronchial ramifications : the skin becomes daily more earthy, yellowish, generally as if jaundiced ; articular pains, with swelling, and intra-synovial effusion, manifest themselves successively in the various joints ; one or both of the calves may become the seat of inconsiderable swelling, attended with great suffering ; and sometimes severe stitches in the side of the chest force cries from the patient. The tongue becomes dry ; the lips and teeth are covered with a fuliginous paste ; the belly is tender ; the pulse trem- ulant and rapid ; subsultus agitates the limbs ; the eye looks dull ; the cornea has lost its polish; the bladder is no longer emptied; partial paralyses may manifest themselves ; the voice is lost ; and the patient dies from the fourth to the eighth day, in a state of extreme emaciation, and after a prolonged agony. These are the most common traits of purulent infection, but it is seldom that we find them all present " Any wounded person having a suppurating wound, in whom irregular shiverings, difficulty and frequency of respiration, a leaden or icteric coloring of the integuments, great prostration of strength, and sudden wasting, manifest themselves, is, in our eyes, the subject of pyemia. We would deliver the same opinion, if in the absence of shiverings, the above named symptoms were pres- ent, too-ether with a drying of the wound, or a changed character in its dis- charge. The existence of an ascertained phlebitis allows of our pronouncing upon the invasion of pyaemia the moment the local symptoms become compli- cated with shivering, prostration, yellow coloring of the integuments, and altered respiration. Arthritic pains and effusions, disorders of the nervous system, the typhoid appearance, induration or abscess of the calves, etc., add 1 Brit, and For. Med. Chir. Review, October, 1849. 420 CASE XL VI. — PYEMIA. but additional degrees of certainty to our diagnosis. Not unfrequently we only suspect the existence of pyaemia upon the discovery of already advanced changes, which we cannot explain upon the supposition of the presence of any other disease.'' Examination of Urine. — Amount of urine collected during twenty- four hours, from Na ••vmber 14, 9 a. m., to November 15, 9 a. m., 550 CC. = grains 8,847.i5D. Purplish-red color. The shade of pink is very decided and beautiful. Specific gravity, 1,024. Heavy light- orange yellow, cream-like deposit of urates, with highly colored, large, well-formed, lozenge-shaped crystals of uric acid. ANALYSIS OF URINE, NO. 44. Amount of urine collected during twenty-four hours . Urea Uric acid Free acid (six hours after collection) Phosphoric acid Equivalent of phosphorus in phosphoric acid . . . Sulphuric acid Equivalent of sulphur in sulphuric acid Chloride of sodium Equivalent of chlorine in chloride of sodium . . . Urine collected 1,000 parts of duriog 24 hours, anne con- contabied grains tained 8,847.36 398.16 45.00 10.36 1.17 21.17 2.39 35.57 4.01 16.64 1.88 17.92 2.02 7.16 0.808 8.47 0.95 5.13 0.58 This sudden diminution of the chloride of sodium appears to be an interesting fact in connection with the sudden accumulation of pus in the knee joint. It may, however, be due in a great measure to the loss of appetite. The nurse states that the patient has taken but little nourishment during the past two or three days, and has subsisted chiefly upon chicken soup, and eggs, and milk punch. Six o'clock p. M. Pulse 120, vermicular, compressible. The pulse feels as if the artery was quite full, and yet the beat is very quick and feeble, and when pressed, even gently, disappears entirely. Respira- tion, 26 ; more labored than his usual calm, quiet respiration. Tongue moist and clean ; looks smooth. In a profuse perspiration, which has saturated his shirt. Pale, haggard expression of countenance. Icteric hue of complexion. Conjunctiva jaundiced. Temperature of hand, 38.6° C. (101.5» F.). Temperature of axilla, 39° C. (102.2° F.). In speaking, the voice is feeble, as if crying. Muscles of face in frequent motion, as if suffering occasional pangs of pain. Eyes frequently filled with tears, which trickle down his cheeks. In speaking, the contraction of the muscles of the face give the expression of crying. Swelling of the diseased limb continues to increase. November 16. — Ten o'clock a. m. Pulse 136, small and feeble; scarcely perceptible. Surface bathed in sweat Voice feeble and CASE XL VI.— PYEMIA. 421 whining. Intellect apparently enfeebled, but still without delirium. Body emits a most disagreeable odor. Breath very offensive. The odor from the diseased limb fills the entire ward, and resembles the heavy odor of hospital gangrene. Countenance sunken. Features pinched. Breathing labored. Respiration, 20. When asked how he is, complains that he feels weak, and has no appetite. Tongue moist, clean, and pale, with enlarged papillae, and transparent blisters scat- tered over the anterior portion and edges of the tongue. Examination of Urine. — Amount of urine passed during twenty-four hours, November 15, 9 a.m., to November 16, 9 a. m, 700 CC. = grains 11,273.46. Specific gravity, 1,023. Reddish pink color, and strong acid reaction. Heavy deposit of urates immediately after its passage. The deposit was granular, with a few well-formed, lozenge- shaped crystals of uric acid. When this amorphous, granular deposit was treated under the microscope, with acetic and hydrochloric acids, thousands of lozenge-shaped crystals of uric acid made their appear- ance. For colors of the urine of the patient, see Plate XXX.' ANALYSIS OF URINE, NO. 45. Elements. Amount of urine collected during twenty-four hours . Urea Uric acid Free acid (fifty hours after collection) Phosphoric acid Equivalent of phosphorus in phosphoric acid . . . Sulphuric acid Equivalent of sulphur in sulphuric acid Chloride of sodium (mere trace) Equivalent of chlorine in chloride of sodium . . . Urine collected 1,000 parts of during 24 hours, urine con- contained gmns tained 11,273.46 431.20 38.07 11.02 0.97 29.64 2.63 36.65 3.25 16.12 1.43 20.40 1.89 8.16 0.72 2.15 0.19 1.30 0.11 During the past two days the patient has complained much of a severe pain in his left lung, resembling the pain of pleurisy. The left lung is duller upon percussion than normal, and subcrepitous rale is heard over the chest Wound of leg discharges large quantities of yellow pus. November 17. — Eleven o'clock a. m. Pulse a mere thread, 120 a minute. Intellect clear. Complains of loss of appetite and feeling weak. Lies with eyes closed, but answers in a feeble voice when inter- rogated. Features pinched. Complexion jaundiced and cadaverous. Odor from breath, body, and limb most disagreeable and penetrating. Respiration labored. The limb does not appear to be so much swollen. When the knee is pressed, the patient still complains of pain. There appears to be a slight diminution of the size of the joint During the 1 Omitted. 422 CASE XLVl — PYiEMIA. preceding night this patient was out of his head somewhat, and his mind appeared to wander. This was the first wandering of intellect noticed by his nurse. The patient is evidently in articulo mortis. He gradually sunk, and died at 5 o'clock p. m. Autopsy, Next Morning, November 18y Thomas Trotter M. D., late physician to His Majesty's Fleet, etc., vol. ii. pp. 169-196. i88 MALIGNANT ULCER OF BRITISH NAVY. " In the summer of 1799 the malignant ulcer made its appearance on board the Temeraire, with all the characteristic symptoms and virulence which marked it in other ships. Every wound, abrasion of the cuticle, blistered part, scald or burn, passed rapidly through the various stages of inflammation, gangrene, and sphacelus, in a few days leaving the bones almost bare from the separation of immense sloughs. The ten- dency of the bone to caries, after inflammation in this disease, has been more frequent than in any other species of ulcer. It has been chiefly observed in the tibia, but also in some of the bones of the face. These bones being superficial, the periosteum is from contiguity afifected by inflammation, and with it also the blood-vessels which enter the bone partake of the aflfection, slough, and leave a portion of the osseous sub- stance without the supply of blood ; and thus the external lamina be- come carious, decay, and exfoliate. This has, in many cases, rendered the cure tedious and painful, and many have sunk under the long con- finement. The Temeraire had been lately commissioned when the ulcers first appeared : the crew was composed of men that had just returned from foreign stations, and from having some years' wages to receive, they plunged as usual into all the excesses of drinking " In the San Josef, fitted at Plymouth in January, 1801, to bear the flag of Lord Nelson, this ulcer soon began to make its appearance. In February, Mr. Walker mentions four cases being sent to the hospital. Four were sent to the hospital with very ill-conditioned ulcers, and those remaining on board (seven) have not the most favorable appear- ance. In the succeeding month he remarks : ' The number of ulcers has increased (13) ; two were sent to the hospital ; again, others nearly cicatrized have broken out afresh. This ulcer has all the appearance and symptoms of the malignant ulcer that has of late infested the Chan- nel fleet. It does not seem quite so rapid in its progress, nor are the symptoms so violent' In April the list of ulcers still increased (23). ' Our ulcers increase and begin to assume a formidable appearance. Every bruise, wound, or scald, in the course of a few days put on the appearance of the malignant ulcer, and go through its different stages, attended with little or no fever. It seems to be highly contagious. The worst cases I have put by themselves. I cannot trace its introduction into the ship !'.... " A change took place in the month of May, between the surgeons of the Neptune and San Josef, and Dr. Felix describes the situation of his sick-berth in the following manner : ' You will perceive that I have no great reason to congratulate myself on the exchange, at least for the present. I found not less than forty ulcers on board the San Josef, of the most unfavorable, if not of the most malignant nature that ever came under my observation. Upon inquiry of the mates, I found that a disposition to this sore had prevailed for several months ; that the most trivial hurt on the extremities, or even the smallest wound, be- MALIGNANT ULCER OF BRITISH NAVY. 489 came, in forty-eight hours, an ulcer of the worst description, and that no means could stop its spreading and sloughing for several days. Latterly a contusion or blow on the leg, etc., produced the same appear- ance, and I observed in one man, of the name of Henderson, an ulcer that had followed a blow on the ear, that was attended with a very slight wound. In two men the entire muscles of the leg sphacelated, and the disposition to spread still manifest ; in another man the foot was in the same condition ; in two or three the tibia bare and exfoliating, and in many the same process was to be expected.' " Mr. Jarvis, surgeon of the Indefatigable, in a letter dated the 5th of July, 1801, observes, that after the celebrated battle of the Nile, several malignant ulcers made their appearance in the GiiUoden, of which ship he was then surgeon, that generally arose from very slight scratches, scalds, or wounds, and some from boils or small pimples, all of which resisted every method of treatment that he put in practice. If the pim- ple or boil were seated on the lower extremity, it was very inert and slow in suppurating, although cataplasms, etc., were applied, and after the dead cellular substance or core appeared through the cuticle, sev- eral days elapsed before the slough was separated. When the slough was thrown off, the edges in some became ragged, in others quite callous and horny, and when this last separated, the ulcer was much extended in size. Absorption took place from several of the ulcers, and produced considerable turgescence of the lymphatic vessels. In some cases, when the ulcer began to heal, another boil appeared in its vicinity, which sometimes suppurated and formed a second ulcer more malignant than the first, but the boil more frequently disappeared, the original ulcer began to discharge again, and pass through all its stages with symptoms of augmented violence. He says it appeared to him that the system was struggling to be freed from something highly noxious and hostile to its healthy action, and that he at last left the treatment to nature. "When the ulcers attacked the knee or other parts thinly covered with cellular substance, the slough was generally so deep as to destroy part of a tendon or muscle, and to injure their motion. One patient had an ulcer seated between the tendons of the ham, which was at length healed, but the tendons were contracted, and the motion of the joint entirely lost. Another had a similar ulcer, which was so irritable and painful that he could not suffer it to be dressed ; he became dyspeptic ; his stomach rejected everything he took, and, after lingering a month in the utmost agony, he died. Another patient was attacked with inflam mation on his shin, which proceeded to suppuration in spite of leeches, cathartics, etc. When the abscess was opened, the tibia and fibula were found to be carious, and in a few days the man became weak and much emaciated. Soon afterwards a large abscess formed above the knee, and it is extraordinary that no previous pain was felt, nor inflammation observed in the part. It had been hinted to him a few days before, that 490 MR. McARTHDR ON ULCERS OF SEAMEN. it would probably be necessary to resort to amputation, which he was unwilling to comply with, but when he saw the abscess he solicited to have the operation performed, — a circumstance that created some em- barrassment in Mr. Jarvis, for the abscess ran so far up the thigh that the stump must necessarily be very short. As his strength was how- ever declining rapidly, the operation was resolved on and performed above the seat of the abscess. The muscles were found to be so flaccid as scarcely to resist the knife. The stump was healing, and the patient recovering his strength and spirits, when he was sent to the Naval Hos- pital at Port Mahon, where he was soon cured." The following observations vs^ere furnished Dr. Trotter by Mr. McArthur, whose communication is dated His Majesty's ship JBellisle, in Torbay, IStli December, 1 801. These facts concern- ing " the Malignant Ulcer " were collected by Mr. McArthur whilst he was surgeon of His Majesty's ship Granges, in the year 1797: — " She had been employed in the West Indies several years at the be- ofMr^M'""' ginning of the war, and had arrived from thence at Spithead, Arthur on jn Octobcr, 1796. Between this time and my appointment to Dant Dicer her, the 1st of June, 1797, about two hundred men had been on board the , i • i , • i /^ , i /-^ Bhip Ganges, sent to the hospital ; near two thirds oi these were ulcers. On the 4th of June we sailed to the North Sea to join Admiral Duncan's squadron, and continued off the Texel, until a few days before the 11th of October. I soon found a strong disposition to ulcers on board, the most trifling hurts in a few days degenerating into extensive sores. A small scratch that at the last dressing discharged healthy pus, and ap- parently had every disposition to heal, at the next was found painful, the discharge dark and streaked with blood, its edges livid, and the sur- rounding integuments inflamed. From this beginning, a gangrene ex- tended with great rapidity, occupying, if situated on the legs or thighs, etc., in three or four days from five to ten or twelve inches in circum- ference. Wlien the diseased parts were thrown off", the ulcer would soon fill with healthy granulations, and would contract considerably ; or was nearly cicatrized over, when a small black speck, not larger than the head of a pin, would appear upon its edge ; from this point a second gangrene commenced, and extended as rapidly as the former. This was their most common beginning and progress ; but frequently, instead of a sphacelus being formed, the new granulations, the lips of the wounds, the surface of burns, blisters, etc., seemed to be converted into a kind of thick adhesive pus, which adhered firmly to the parts under- neath ; these did not extend so rapidly as the former, but the diseased action continued much longer. In whichever way the ulcers extended, they were very painful, the discharge considerably bloody and offensive ; the patients were restless, complained of headache and thirst ; the skin MALIGNANT ULCER OF SEAMEN. 491 was hot and dry, and the pulse, for the most part, full. These febrile symptoms disappeared as the diseased parts were thrown off. The first gangrene, except when situated on the fingers or toes, or the cicatrice of old ulcers, seldom destroyed more than the integuments ; the next affected the muscles, and, if situated on the tibia or bones thinly cov- ered, destroyed the periosteum, leaving a considerable portion of the bone denuded and carious. Every subsequent mortification affected the muscles more and more ; in one instance the gastrocnemius was com- pletely destroyed. This ulcer first appeared on board in the West In- dies about the beginning of 1795, and from every information I received, it did not deviate from its original character until it disappeared in Jan- uary, 1798. It is somewhat singular that the marines and landsmen who were sent on board to complete her complement of men, a consid- erable time after her arrival in England, were as susceptible to the same kind of sore as the old part of the ship's company, and men in good health, and to all appearance of a good habit of body, as those who had been previously reduced by diseases. It was also particularly remarked, that the men who were employed as nurses, and almost every person who was put into the sick-bays was soon afflicted with ulcers, and that some men who had suffered amputations, and had been permitted to remain in the sick-bays where the ulcers were, did not recover so well as others who had been separated, and put in a separate berth under the half-deck. I did not observe any symptoms of scurvy among the men afflicted with ulcers, excepting sometimes a wasting of the gums, which I attributed more to a want of cleanliness and the use of tobacco than to a scorbutic diathesis. In the treatment of these ulcers, I thought that bark and wine given during the progress of the gangrene, augmented the local inflammation and constitutional affection, but the moment the sphacelus began to separate, and the febrile symptoms subside, they were very serviceable in supporting the strength under sometimes an excessive discharge ; nor was opium in the earlier stages of so much use in alleviating pain as might have been expected. Warm poultices seemed to accelerate the gangrene, but they also hastened the separation of the slough ; on the contrary cold solution of the acetate of lead constantly applied to the sore and surrounding parts retarded the gangrene, but the separation of the sphacelus was more tedious. The nitrous fume was applied to ulcers in every stage, but particularly to those that continued indolent after the separation of the mortified parts, or such as were covered with the thick adhesive pus, but I did not observe any good effect from it ; it was, however, of con- siderable use in destroying the bad smell in the sick-berth while the ulcers were dressing. I thought the hydrarg.-nitrat. rub. prevented in some instances the ulcers from extending after they had put on the unhealthy appearance ; and latterly, in consequence of reading Dr. Rollo's account of the ulcer that prevailed at the Artillery Hospital, 492 MALIGNANT ULCERS IN BRITISH NAVY. the black speck was destroyed with the argentum nitratum. In some cases it was successful, in others it had no effect. As the cold weather set in, the disposition to ulcers seemed stronger. Towards the latter end of December, being completely disappointed in every hope I had of curing them on board, and perplexed at their daily increase, I deter- mined upon sending all the ulcers on shore to the hospital at Yarmouth, and at the same time applied to the Commissioners for Sick and Hurt for a vegetable diet for the ship's company. The Board, in the most liberal manner, directed Captain McDowall to cause to be purchased vegetables, not exceeding four pence a man per diem, but I believe they did not amount to more than three half-pence. Twelve dozen cabbages, five bags turnips, three ditto carrots, and four bushels of onions, were daily put in their broth, or distributed in the messes. The vegetable diet commenced, and the remaining ulcers were sent on shore between the 25th and 31st of December, and by the middle of January not a vestige of the ulcer remained on board. There were indeed several ulcers upon the sick list, but they had not the smallest resemblance to the ulcers that had made such ravages on board during the last three years. Between the 10th January, 1798, and November following, only one ulcer was sent to the hospital, but during the pre- ceding seven months there was no less than seventy. I shall make no remark upon this fact further than observing, that although the vegeta- ble diet would seem to have destroyed the disposition to ulcers, yet these ulcers did not at all resemble the scorbutic ulcer, but would alternately heal and extend after a scorbutic diathesis must have been removed by the use of lemon-juice and vegetables, even if such a diathesis had orig- inally existed. I also thought the removal of the ulcers from the ship was of considerable utility, as the air of a sick-berth when there are ten or twelve ulcers, some of them in a state of gangrene, must be vitiated. Would men breathing this contaminated atmosphere acquire a similar habit with those already afflicted with ulcers ? And would they not in consequence be susceptible to the same kind of sore ? " ^ The following is the account given by Mr. McDovs'all of this disease as it prevailed in the Royal Creorge, in the month of Jan- uary, 1802 : — " Since our leaving Cawsand Bay we have been severely afflicted Mr. Mc- with several sores of considerable magnitude ; whether they the™ing- originated from contusions, wounds, scalds, chilblains, or blis- on'the"B^yaZ ^^rcd parts, ctc, they very soon assumed symptoms of very Gmge. great malignity, and with very few exceptions they all observe the same degenerate tendency, notwithstanding we have paid the great- est attention in dressing to obviate the pending evil ; the disease pursues such a magisterial course, ending only in a vast destruction of organized 1 Medicina Nauiica, vol. iii. pp. 4G7-499. DR. JACKSON ON THE CAUSES OF MALIGNANT ULCER. 493 parts. It appears to be a disease of very high excitement ; but I am doubtful whether it be contagious, although it appears to be endemic at present in this ship. I have distinctly marked several sores in our sick- berth at the same time with some of the worst cases under our consid- eration, without ever being affected by them. Also a patient has com- plained to me of a small pimple, arising from a hurt, and when it was impossible to trace his exposure to the infection of any sore ; yet so re- bellious would the case prove that in the course of a day or two it would rapidly pass through the several stages of inflammation, gan- grene, and sphacelus ; and all our art has as yet devised, is quite inadequate to arrest its progress in the destruction, to a considerable extent, of the adjacent integuments, muscles, membranes, and even the bones, also, in some instances have not escaped the general devastation. We cannot impute anything of a scorbutic taint to our people ; they are now living (and have been for months back) on more than two thirds of fresh beef, beer, and plentifully supplied with vegetables. Neither is there anything in it of a scorbutic nature." ^ Doctor Robert Jackson, in his " Sketch of the History and Cure of Febrile Diseases," expresses the opinion that the malig- nant ulcer, which is so common in the West Indies, whether mild and disposed to assume the healing process, or gangrenous and rapidly destructive of muscles and bones and of life itself, is con- nected in its origin with the general cause which produces fever, either endemic or contagious. " The circumstances which were observed in the 3d regiment of foot in 1794, and the occurrences which took place in the force Dr. Robert which was collected on Spike Island in autumn 1795, im- fe^a°thr pressed the author with the idea that the ulcerative form of iiJfLn°ni^ disease, as here described, is radically connected with the J^^jj^ ^™^g cause of contagious fever. The history of health among ^^^j°*"*'' the troops in St. Domingo brought evidence, satisfactory to ^"'^ '"^t"- himself at least, that the connection extended to the endemic ; the experience which he has since had in different scenes of service con- firms me in the opinion then formed. The febrile, the dysenteric, and ulcerative forms of disease, are ordinarily the three prominent columns on the sick returns of military hospitals. Sometimes the one predominates, sometimes the other ; but fluctuate as they may, a balance is generally observed between them so poised and so adjusted as to furnish a valid argument that they ultimately have their dependence on the same general cause, modified by circumstances often so minute or so complicated as to escape detection " The medical history of armies shows that the gangrenous action sometimes arises suddenly and unexpectedly, and spreads so rapidly 1 Medicina Nautica, vol. iii. pp. 501, 502. 494 HOSPITAL GANGEENE IN NAPOLEON'S ARMY. that it can scarcely be supposed to have its origin from actual contact of person, much less from contagious matter applied to a suppurating surface ; it appears, in fact, to be infectious by imitation of what may be supposed to fall within the sphere of vision." ' We have in the second chapter of this work examined the views of Baron Larrey on "Traumatic Gangrene ; " we will now give some extracts from his " Surgical Memoirs," which contain facts bearing upon the present discussion. " On the 28th, Bonaparte arrived before El Arich with his head- observationa quarters and the park of artillery. We besieged the fort, Lamy on drew trenches round it, and battered it in breach. The be- grenetJi1;hT siegcd agreed to capitulate, and after two days' negotiation undm'Na™^ they demanded permission to retire with the honors of war, poieon. which was acceded to on our part. " Some of our men were severely wounded in this siege, and were seized with tetanus ; they died, notwithstanding every possible attention was paid to them. As the rain continued all the time we remained before the fort, it was impossible to preserve them from the moisture to which they were a long time exposed. " As soon as the fort surrendered, the general ordered me to visit its interior, and to take such measures as I thought proper to purify its apartments and clean them of infection. An officer of the etdt major, who had thirty Turkish prisoners at his disposal, was to act in concert with me in the execution of this measure. I immediately examined whether any wounded and sick had been left by the besieged, and dis- covered fifteen in subterranean caverns, deprived of light and air, laid on mats that were almost rotten, without bedclothes, and covered with vermin. These unfortunate men had received no medical aid ; in almost every instance their wounds were without dressings,'gangrenous, and filled with animalculae. Some of them presented all the symptoms of malignant fever ; one of them had a pestilential bubo in the right side of the groin, and a carbuncle on the right leg " At break of day the signal to engage was given on both sides, the enemy having also resolved to attack us the same day. The first shock was very severe, but success was never doubtful. A most complete vic- tory on our part was the result of this brilliant and memorable battle, called the Battle of the Three Emperors, or the Battle of Austerlitz. The enemy lost more than forty stand of colors or standards, more than five hundred pieces of cannon, twenty generals, and thirty thousand men prisoners. Between ten and twelve thousand were killed on the field of battle, or drowned in the lakes, besides a great number of wounded that we successively collected and had transported to Brunn. . . . We had scarcely collected the wounded of the French and 1 Medicinn Nautica, vol. iii. pp. 190-196. HOSPITAL GANGRENE IN NAPOLEON'S ARMY. 495 Russian armies, the number of whom was considerable, when an epi- demic disease appeared among them which we recognized as a malig nant, nervous, and putrid hospital fever (adynamia-ataxick), or conta- gious typhus of the old nosologists. It attacked with heavy pains of the head and irregular chills, especially of the extremities. These chills were succeeded by a transient burning hes.L. " The wounds in which suppuration first diminished were affected with the hospital putrefaction,^ which advanced in the most rapid man- ner. The pains of the head, the external heat, and anxiety, increased ; the pulse, which at first was small and slow, became more quick and irregular, and the urine was turbid and yellow. In some cases costive- ness attended, but generally a diarrhcea was one of the first symptoms of the disease. The ear and the eyes became exquisitely sensitive ; the functions of the muscular system were disordered ; a tremor of the limbs, subsultus tendinum, and delirium commonly attacked the pa- tient at the end of the first stage. " To the above symptoms succeeded pains of the epigastric region, wandering colic pains, vomiting preceded and attended by singultus, retention or suppression of urine, clammy and colliquative sweats, an increase of a dysenteric discharge of fetid black blood, and finally hemorrhage of the nose. The tongue was black in the centre, and dry and red on its edges ; the gums and teeth became covered with black glutinous sordes. The patient sunk into a state of drowsiness and general insensibility, made involuntary motions which, on account of the prostration of strength, were but of short duration. The pulse decreased in volume as it increased in quickness. The features of the face became surprisingly altered, and indicated the change of the or- ganic functions. Whenever I saw this symptom in the last stage I predicted a fatal issue. " These symptoms generally increased while the disease was passing from the second to the third stage. The pulse intermitted, exacerba- tions or paroxysms occurred once, or even twice, in the twenty-four hours. During the paroxysms, the delirium in some cases became more furious, and was often attended with convulsions. Turbid or dimin- ished secretion of urine were fatal symptoms, and if it suddenly became clear and limpid, the danger was most imminent; the abdomen then was inflated, the internal spasm increased, and the singultus returned. The patient lost all his intellectual faculties, fell into extreme debility, and soon sunk. When the disease terminated in this manner the patient rarely survived the ninth day, but generally died on the fifth or seventh. In this last stage the wounds assumed a real gangrenous appearance, and emitted a very fetid odor. The effluvia produced by the purulent 1 When this affection takes place, the suppuration is of a grayish lead color, thick and glutinous, and emits a fetid odor; the edges of tlie wound puff up and become black. The heat and sensibility of the parts affected are destroyed. 496 LARREY'S DESCRIPTION OF HOSPITAL GANGRENE. secretion or exhalation of these ulcers was very infectious, and all that were near those sick of this epidemic were in great danger, as were also the physicians who visited them. All who lay in these wards were soon attacked by the same symptoms. The disease spread further and further, infected the hospitals, and finally the houses in their vicinity, either by the communication of persons with the sick, or the transmis- sion of air by the south wind, especially when it had but a short space to traverse. These winds, as I remarked in speaking of the plague, favor the production of almost all ataxick diseases. " The transportation of the sick also extended the contagion, which increased to such a degree that the hospital of the line lost one fourth of their wounded. They who had fractures of the limbs, and especially of the inferior extremities, were its first victims. Because, in the first place, these wounds affected the membranes of the bones, the liga- ments, and the aponeuroses, which receive their sensibility or life from the trisplanchnic nerve, and thus the power or life of the nutritive sys- tem is impaired. And secondly, because adynamia more readily follows the debility of these functions produced by this sympathetic affection. And finally, because the permanent inaction to which the wounded are obliged to submit subjects them continually to the action of the infected atmosphere of the wards, and renders them more obnoxious to this disease. These facts support the argument adduced in my memoir on amputation to prove the necessity of taking off the limb on the field of battle, when we cannot expect to cure the fracture by the usual mode of treatment. The hospitals in which those who had fevers were de- posited were soon crowded, and the mortality was increased in propor- tion. The epidemic also broke out among the Russian prisoners who had been from necessity crowded in great numbers into the churches and other large buildings ; finally it soon spread among the inhabitants, and extended itself along the whole line, and even into France, in con- sequence of the transportation of prisoners and of the sick of both nations. The disease was irregular in its progress when it attacked those who had fractures of the thigh. It ran its course with great rapidity, and nothing relieved the symptoms. I saw several superior officers who died with such wounds very suddenly after I had enter- tained strong hopes of their recovery. When the wounds were less severe, the disease was milder, and in its progress less rapid. Many of the sick recovered by the use of suitable remedies " This epidemic rarely appeared among the wounded guards who were placed in the hospital La Charite, which was distant from the other hospitals and from the populous parts of the city. It was well lighted, well-aired, and kept perfectly clean. " The causes of this epidemic may be referred to the fatigue and privations which the troops of both nations had undergone ; to the severity and vicissitudes of the season ; to the crowding together the CONTAGIOUS NATURE OF HOSPITAL GANGRENE. 497 prisoners, tie wounded, and the sick of both armies ; to the bad diet, and their confinement after the most fatiguing and rapid marches." Doctor Macleod, in his " Notes on the Surgery of the War in the Crimea," states that — " The French suffered most dreadfully from hospital gangrene in its worst form. The sj'stem they pursued of removing their Dr. Macieod •J J r o on the cause wounded and operated cases from the camp to Constantino- of hospital gangrune pie at a very early date, the pernicious character of the amongst the transit, the crowding of their ships and hospitals, all tended the Crimea. to produce the disease, and to render it fatal when produced. Many of their cases commenced in camp, but the majority arose in the hos- pitals on the Bosphorus, where the disease raged rampant. In the hospitals of the south of France it also prevailed, and from what M. Lallour, surgeon to the Euphrate transport, tells us in his paper on the subject, it must have committed great ravages in their ships, from one of which, he says, sixty bodies were thrown over during the short pas- sage of thirty-eight hours to the Bosphorus. With them the disease was the true ' contagious gangrene,' and attacked not only open wounds but cicatrices and almost every stump in their hospitals. They em- ployed the actual cautery, after the manner of Delpech and Pouteau, with apparent success, to arrest it. The perchlorate of iron, charcoal, the tincture of iodine, lemon-juice, etc., they employed as adjuvants. In both the French and Russian hospitals, gangrene was often com- bined with typhus, and in such cases the mortality was fearful." All these facts show that the origin of hospital gangrene is pre- eminently due to over-crowding. 3. The contact of the gangrenous matter with diseased and wounded surfaces, as in using unclean sponges, bandages, wash- howls, and surgical instruments. * " No doubt appears to exist in the minds of many surgeons that hospital sangrene may be readily communicated by actual 3. Cause of A V n 1 X it J hospital gan- contact 01 the matter irom one wound to another, and grene the that the matter may be inoculated into the healthy sub- gangrenous iect, iust as in the case of the matter of small-pox, and diseased and 1 . 1 1 ■ -1 -L r wounded produce a poisoned wound exactly similar to the one from surfaces. which the matter was taken. This question can be settled onlj' by direct observation and experiment. In the first chapter of this w^ork the author has pro- pounded several inquiries upon the mode of origin and nature of hospital gangrene under the divisions " D. Is hospital gangrene contagious ? " " E. If hospital gangrene be contagious, how is it transmitted, — through the atmosphere, or by direct contact and 32 498 MODE OP PROPAGATION OF HOSPITAL GANGRENE. inoculation ? " " F. Wliat are the essential conditions and causes of hospital gangrene ? " A number of the questions contained under these general divis- ions have been already discussed, and we will now confine our- selves chiefly to the discussion of the following questions : — («.) Can hospital gangrene be propagated by direct contact and inoculation ? As far as my observation extends, this question is no longer an The question Unsettled ouc. A number of cases have come under my as to thepos- , - - ^ -in Bibiiity of notice Where nurses and surgeons have accidentally hospiui gan- wouuded their hands in dressing; p;angrenous wounds, or grene defi- . ... o o D ^ '^ niiciy settled in Operating with spiculae of necrosed bones, in which intheaf- i i- . ,. , , i p i • finnative. the discase was immediately reproduced atter the inocu- niustratlve - . -, , . . „ , observations, lation 01 the matter, ihe severity ot such cases, as a general rule, appeared to depend chiefly upon the state of the constitution, and the extent to which the patient had been exposed to the foul emanations of the hospital, and especially of the gan- grenous wounds. Case VII.,-' which we have already presented in the third chapter of this work, illustrated not only the direct inoculation and reproduction of hospital gangrene on two distinct occasions in the same individual, but also afforded a clear demon- stration that the continued residence in the infected atmosphere, and the constant attention upon the gangrenous wounds, gradually poisoned the system to such an extent that in the second attack the local treatment did not arrest the disease. Near one half the nurses attending upon the cases of hospital gangrene in the first ward of the Empire Hospital took the disease in their hands or in their feet. Five out of twelve nurses contracted the disease. In four of these cases the disetise appeared to be the result of direct inoculation. In the other,^ a small boil appeared on the tendo Achillis twenty days after his employment as nurse. This soldier did not dress the wound, but simply waited on the sick, handing water around, and assisted in erecting the tents. He did not sleep with the sick, but on the outer line of tents with the kitchen, etc. He wore shoes and stockings, and it was not possible to ascertain whether or not there had been any direct application of the gan- grenous matter. In five days the small boil enlarged to three inches in diameter. Nitric acid was then applied and arrested the disease, and this nurse was sent home eleven daj^s after. At this time the surface of the ulcer presented a florid, granulating surface, with a discharge of pus. 1 W. J. Black, Company G, Lee's Invalid Battalion. 2 Case of E. Slorgan, Company C, 10th Regiment, Mississippi Vols. CONTAGIOUS NATURE OF HOSPITAL GANGRENE. 499 In many of the patients treated for hospital gangrene in this hospital, the disease recurred after its removal, and in several of the fatal cases death was the result of a second or third attack. Upon careful examination I was convinced that the reappearance of the disease in these cases was not entirely due to the condition of the constitution of the patient, nor to the infected atmosphere of the hospital and the exhalations from the neighboring cases of gangrene (fresh cases being brobght in continually from other hos- pitals in Macon and Vineville), but chiefly to the fact that there was no division of labor amongst the nurses, and the utensils were not sufficient to supply each patient with his own basin. The rags also were frequently washed after having been used upon bad gan- grene cases, and then employed indiscriminately upon the conva- lescent and gangrene cases. When nurses infected with the foul odor of the worst gangrene cases went directly to a healthy gran- ulating wound, and with the same fingers and instruments which but a moment before were employed in cleaning and pulling away gangrenous sloughs, the recurrence of the disease was almost inev- itable. In many extensive and granulating wounds a small gan- grenous spot would appear, and in a night spread over considerable portions of the raw surface. This subject may be still further illustrated by the following cases : — Case LI. — Thomas Benton Childers, Company C, 1st Regiment Ala- bama Vols., Quarel's Brigade, Polk's Corps. Age twenty- 9^J'\ one : height, five feet eight inches. Native of "West Alabama, thecon- ^ , ° , , tagious n»- Had been in Confederate service since 15th of July, 1862. tureofhoa- Entered the City Hall General Hospital, in Macon, Ga., 14th |renef*° of July, 1864, with dysentery. After recovering was appointed to nurse the gangrene cases. The patient had been suffering with an erup- tion upon the instep of both feet. The weather was warm, and at night he would frequently nurse the patients in his bare feet ; and as the eruption occasioned considerable itching, after nursing the gangrene, the patient would scratch his feet. In the course of two weeks after he had commenced nursing, the gangrene appeared on the instep of both feet (September 2), and spread with considerable rapidity. On the 16th of September this patient was transferred to the Empire Hospital at Vineville. After the inoculation of the gangrenous matter the abrased surface was very painful, with a dark-colored, purplish areola around, and the disease progressed rapidly. The local application of nitric acid to- gether with the internal administration of tinct. muriate of iron and quinine, arrested the spread of the gangrene in various parts of the wounds. 500 CASE ILLUSTRATING CONTAGION OF GANGRENE. October 6. — Denuded surface of instep of left foot about two inches in diameter ; gangrene apparently removed ; granulations springing up ; the surface is, however, paler than in healthy wounds, and the pus secreted is of a yellowish, greenish color, and tenacious character, and adheres quite firmly to the granulating surface. The instep of the right foot is extensively denuded, the tendons and the periosteum of the bones being exposed. Between the big toe and the second toe, the gangrene has invaded the structures to a great ex- tent, exposing the tendons and periosteum. The gangrene appears to be still progressing around and under these bones. Also upon the superior portion of the wound the gangrene is burrowing upwards towards the ankle joint. This ulcer is about four and a half inches in diameter, and the surface in those portions from which the gangrene has been removed, presents pale, unhealthy granulations, coated with thick, tenacious, greenish yellow pus, which adheres to the surface. In those parts where the gangrene is still progressing, the color is of a greenish gray. The constitutional symptoms in this case are well marked : rapid, feeble pulse, febrile excitement in the afternoons and evenings, loss of appetite, progressive loss of flesh, with depressed spirits. The granu- lating surface appeared to possess an exquisite sensibility. The appli- cation of nitric acid caused the most intense pain, and the patient, dur- ing its action and the dressing of the ulcers, cries like a child. October 18. — Pale, emaciated, and in an exceedingly nervous and excitable state. Cries like a child whenever his feet are touched, or whenever he sees the nurse passing with the bottle of nitric acid. The play of his features at such times is very marked, and expresses great dejection, fear, and pain. No appetite. The ulcer upon the left foot is stationary ; whilst that on the right slowly enlarges, especially along the upper and lower borders. Granulations, pale and unhealthy. Surface of both ulcers still covered with the tenacious, light green, and green- ish yellow fetid pus. Examination of Urine. — Amount of urine collected during the past twenty-four hours (October 17, 12 m., to October 18, 12 m.), 380 CC. = grains 6,099. This is not the entire amount, as the pa- tient lost a portion during the action on his bowels. The urinary excretion has, however, decreased to a marked extent. The patient is much reduced, and eats nothing. Urine of a deep red color, and strong acid reaction. The acid reaction remained apparently un- changed for more than seventy-two hours, and during this period no deposit fell. Under the microscope, a few crystals of the oxalate of lime (octahedral) were discovered. After several days the urine be- came alkaline, and prismatic crystals of triple phosphate were thrown down, in conjunction with the octahedral crystals of oxalate of lime. Specific gravity of urine, 1,016.5. CASE ILLUSTRATING CONTAGION OF GANGRENE. 501 ANAtTSIS OF URINE, NO. 60. Amount of urine collected during twenty-four hours . Urea Uric acid Free acid Phosphoric acid Equivalent of phosphorus in phosphoric acid . . . Sulphuric acid Equivalent of sulphur in sulphuric acid Chloride of sodium Equivalent of chlorine in chloride of sodium . . . Urine collected during 24 hours, contained grains 1,000 parts of urine con- tained 6,099.00 169.70 27.98 6.08 0.99 5.26 0.86 2.80 0.45 1.22 0.20 8.85 1.28 3.54 0.57 2.92 0.47 1.76 0.28 The treatment at the present time consists of turpentine emulsion, with the addition of three grains of quinine to each dose. Whiskey fsij. three times a day. Half diet. October 19. — Twelve o'clock m. Appetite poor; eats little or noth- ing. Has had two or three rather thin operations during the past twenty-four hours. Nervous and excitable. The deep excavation between the bones of the left big toe and of the second toe discharges a thin, fetid pus. The granulating surface in other portions is still covered with a thick, tenacious, light-green and yellow pus. The following drawing was executed on this day. (See Plate No. XXXIX. 1) Examinatio7i of Urine. — Amount of urine collected during the past twenty-four .hours, 670 CC. = grains 10,681.87. The patient affirms that the urine was collected with the greatest care, and that this is the entire amount. Orange-red color. Specific gravity, 1,012.5. ANALYSIS OF URINE, NO. 61. Amount of urine collected during twenty-four hours . Urea • • Uric acid Free acid (twenty-four hours) Phosphoric acid Equivalent of phosphorus in phosphoric acid . . . Sulphuric acid Equivalent of sulphur in sulphuric acid Chloride of sodium . . . . Equivalent of chlorine in chloride of sodium • . . Urine collected during 24 hours, contained grains 1,000 parts of urine con- tained 10,681.87 2U.51 19.80 5.03 0.47 5.15 0.48 2.03 0.19 n.98 0.09 16.01 1.49 6.40 0.05 2.06 0.19 1.24 0.11 The solution of chloride of iron gave scarcely any indication of phosphoric acid in the urine, and when a solution of the sulphate of 1 Omitted. 502 PROPAGATION OF GANGRENE BY CONTACT. magnesia in chloride of ammonium was added, only a slight deposit of the phosphate of magnesia was thrown down. Forty-eight hours after the collection of the urine, it became slightly turbid from the formation of a deposit of granular urates, etc., beautiful, large, well-formed prismatic crystals of triple phosphate. It is impor- tant to note that although the phosphates were in so small amount, still well-formed crystals of the phosphates were formed, which sparkled like grains of shining silver when the urine was held in the sunlight. This observation illustrates the care which should be exercised in deciding upon the amount of phosphoric acid present in any sample of urine from the size and number of the crystals of triple phosphate. Reaction of the urine at this time (forty-eight hours after its passage), alkaline. This case improved not at all, and appeared to remain stationary, or rather slowly losing flesh and strength. October 27. — No improvement in local or constitutional symptoms, and patient transferred to private quarters. Case LU. Mrs. Jackson, wife of private E. L. Jackson, Company Cm« MI. Q^ 25th Regiment Georgia Vols., whose case has been already the con- deUiled in the fifth chapter (Case XXVI.). This lady tagious na- ^ i^^^i tnreofhoa- came down to Augusta in the month of October, 1863, to grene. nursc her husband, whose arm had been amputated in conse- quence of a gunshot wound received at the battle of Chickamauga. In coming down to Augusta, this woman wore a new pair of shoes, which blistered her left foot, upon the outer side, just above the hollow. After entering the hospital she walked about in her bare feet, nursing her husband. Gangrene of a severe form appeared, and spread rapidly, involving the bones of the tarsus. As the floor, especially just under the gangrenous stump of her husband, contained more or less gangre- nous matter, it is highly probable that the matter was introduced directly into the foot through the blistered surface. The spread of the gangrene was rapid, and the constitutional symp- toms well marked : great nervousness, periodic febrile excitement, feeble, rapid pulse, and dejected countenance, great suffering and no power to bear pain, and a dusky, sallow hue. Case LIII. The report of this case was furnished me by Assistant- iuS™n Surgeon Anderson of the Ocmulgee Hospital, at Macon. the con- Mrs. V. Oneal, age seventeen, wife of a conscript : detailed tagious na- , tmeofhos- nursc in Ward No. 8; came to see her husband on the grene. 20th of Octobcr. The same evening Dr. Anderson removed an encysted tumor, about one inch in diameter, from the dorsum of the right wrist joint, and adjusted the wound carefully with a view to as speedy union as possible. She visited the ward daily, and remained with her husband a greater part of the time, who was one of the wound dressers of the ward. He dressed his wife's arm. On the 24th of Oc- CONTAGIOUS NATURE OF HOSPITAL GANGRENE. 503 tober Dr. Anderson was called to see the woman, and found the wound phagedaenic, presenting a circular, sloughing surface of about one and a half inches in diameter ; dark gray, or grayish color. Hand and wrist very painful, and very much swollen. Three or four whitish-looking spots were to be observed in the vicinity of the ulcer, the largest about eight lines in diameter ; these were for the most part above, on the upper side of the wound. These proved to be superficial effusions of appar- ently healthy pus, being rather limpid, and external to the cutis vera. The patient was not allowed to visit the ward any more, and was treated with nitric acid as a local remedy. October 27. — Considerable constitutional disturbance. Pulse 130, and thread-like. Arm very much swollen. (Quinia sulph., grains viii., at six and nine a. m. every morning. Whiskey toddy every three hours during the day. Absolute quiet. Arm and hand supported in splint.) October 29. — Decided improvement, both local and constitutional. November 9. — Disease has entirely disappeared, and wound healing kindly. This vyoman belonged to the humbler class ; had been subjected to impoverished diet and hardship. She was in tolerable health at the time of the operation, but appeared to be in an exsanguineous condition, and was inclined to scrofula. This case illustrates the production of the disease by inoculation, or by direct contact of the gangrenous matter. Her husband being a nurse, and being ex- posed to the poisonous wounds of numerous patients, and dressing her wound at the same time, yfas most probably the medium of the communicaticfn of the gangrenous matter. Several of the nurses and medical officers of the Ocmulgee Hos- pital contracted the disease during their attendance upon the gan- grene cases. Two cases of gangrene in the fingers of nurses at this hospital, came under my direct observation. Surgeon Battey, in charge of the Polk Hospital, Vineville, Georgia, showed me an ulcer upon his finger, which had been gangrenous, and which had arisen from the prick of a spicula of bone, during an operation upon a gangrenous limb. In the Institute Hospital, in charge of Surgeon O'Keefe, I examined a gangrenous ulcer upon the leg of a soldier, who had contracted the disease whilst nursing and attending upon cases of gangrene. This soldier (J. H. McNight, Company C, 19th Louisiana Regiment) had a small scratch upon his leg, to which the gangrene was conveyed by his fingers, after washing and dressing gangrenous wounds. The following communication from Surgeon Doughty furnishes several interesting facts bearing upon the discussion of the conta- gious nature of hospital gangrene : — 504 SURGEON DOUGHTY ON CONTAGION OF GANGRENE. Office Second Georgia Hospital, Augusta, Ga., December 14, 1863 Surgeon Joseph Jones: — Sir, — I have hesitated to reply to your communication of October Oiservations 31, 1863, knowing that the proposed method of investigation Doug?^" contemplated only the admission of data obtained from sys- conup^JTus tematic records of cases ; opinions, however well matured, hosptar ^^^" when based upon the most extensive experience and gangrene. observation, are of no value unless accompanied with the recorded facts from which they were derived. The manner in which most of the cases treated in military hospitals come before the observer, precludes the possibility of possessing, or rather preparing such records as may be said to possess strictly scientific value. If, however, an expression of opinion, supported by isolated facts, be not entirely inadmissible in the invited discussion of the numerous points suggested, I will venture to present such an one. You ask, " Is hospital gangrene local or constitutional ? " That it is not always constitutional in the primary signification of that word, is, I believe, true. In support of this, I may refer to the occasional inocula- tion of nurses and physicians whilst in attendance on this disease. Whilst on duty in Mississippi during the past summer, Assistant-Sur- geon Ames exhibited to me the scar of an ulcer of this kind, the disease having been contracted by contact with the fluids and dressings used with cases of this character in an actively corroding condition ; it was destroyed by the early and repeated application of a powerful escha- rotic. Again, private Logan Luke, Company C, 1st Battalion Georgia Sharpshooters, was admitted August 10, 1863, into Walker's Division Hospital, at Lauderdale Springs, Mississippi, with hospital gangrene affecting the second and third phalanges of the little finger. Said soldier had been temporarily detailed for the care of the wounded, at the time of the second occupation of Jackson by the enemy, and con- tracted the disease by reason of an abrasion upon the finger. He was very careless, and whilst dressing those affected with hospital gan- grene, kept the part in frequent contact with the fluids and dressings. The constitutional symptoms in this case ran high. On August 12, 1863, the finger, including the head of the metacarpal bone, was re- moved, the disease having extended by this time so far as to encroach upon the web of the fingers. Indeed, a part even of the inflamed areola was necessarily included in the flaps ; the patient made a good recovery, without the recurrence of the disease in the stump. The constitutional symptoms promptly subsided after the operation, and the patient was placed under conditions favorable to his well doing. Although tlie non-recurrence of the disease in this case does not prove that it may not have been constitutional (for constitutional dis- eases do not always promptly recur), yet, whether considered conjointly EXPERIMENTS UPON ANIMALS. 505 with the probable and apparent mode of origin of the disease, it to say the least authorizes the presumption that hospital gangrene is not always constitutional. I am not aware of the existence of any statistics showing the results of operations upon the disease classified as here indicated, i. e., consid- ering those as local which can be traced to inoculation, and those as constitutional which are apparently of spontaneous origin. In regard to the relations of the local and constitutional disturbances, I am not prepared to offer anything definite. Recently, however, in several cases of relapses, the constitutional symptoms were not appar- ent, if indeed they existed at all ; although the local ones were not of that markedly corroding nature which distinguished the original attacks. Regretting that I have nothing of more value than the above to offer, I remain Yours very respectfully, WILLIAM H. DOUGHTY, Surgeon in Charge. I have performed experiments, to determine whether hospital gangrene can be inoculated into dogs. The following experiment will be sufficient to illustrate the results : — Augusta, Georgia, November 7, 1863. — Subject of experiment, fine large pointer dog, in excellent condition ; fat and healthy. J^^n^^^ail Temperature of rectum, 39.7° C. (103.4° F.). At 12 m., I £f§°fp^ shaved the hair off the neck and shoulders of this dog, and terofhos- ,,,. pital gan- making an incision two inches in length through the skm, grene. inserted several pieces of the disorganized and bluish gray, green, and black masses, with the greenish gray fluid, from the thigh of the dead Federal prisoner whose case was detailed in the sixth chapter of this volume.^ About half an ounce of gangrenous matter was thus intro- duced, and pushed down amongst the meshes of the cellular tissue, on the left side of the neck, and on the outer side of the left shoulder. The incision was then closed with the interrupted suture. The blood which flowed from the wound after the introduction of the gangrenous matter presented a dark, tar-like appearance. The dog appeared to suffer but little from the operation, and afterwards appeared quite lively. November 8. — The dog remained during this day quiet. The wound appeared to itch, and he made repeated efforts to scratch it. Dark blood, together with softened particles of the gangrenous muscles, issued from between the sutures. The wound had the odor of gan- grenous matter, evidently from the gangrenous matters still remaining in the tissues, and not from any decomposition of the structures. The 1 See Case XL. 506 EXPERIMENTS UPON ANIMALS. dog refused to eat food, and even meat, but drank water freely. The parts around the wound, and especially in the region of the left side of the neck, where the gangrenous matter was introduced, was much swollen. In walking, the dog moves the left shoulder with evident pain, and shrinks when the foot touches the ground. November 9. — Healthy, yellow, thick pus issues from the wound in considerable quantities. The pus and the wound still emit a most dis- agreeable, gangrenous odor. The appetite of the dog continues poor, although he runs about quite lively when loosed. Temperature of rec- tum, 41.2° C. (106.1° F.). "We observe a decided increase of tempera- ture. Eleven o'clock a. m. Pulse, 104 per minute. The rise of the ther- mometer is marked, and the degree of heat is equal to a warm fever in the human being. The muscles of the dog frequently tremble spas- modically, and the animal evidently feels badly. The wound still emits a most disagreeable, gangrenous odor. The swelling of the parts appeared evidently to be due in a measure to an accumulation of pus ; when squeezed, about f 5 iv. of thick, yellow, healthy-looking pus issued, which gave a slight acid reaction, and emitted the same gangrenous odor as the matter originally introduced, November 10. — The appetite of the dog appears to be a little better, but is still quite poor. The pus from the wound appears to be chang- ing in character, and presents a more watery and sanious appearance. The lips of the wound are much swollen. November 11. — The sutures have torn out; the lips of the wound are much swollen and everted. The wound presents an unhealthy appearance, and a thin, fetid fluid mixed with some pus, issues from it. The dog shakes himself violently at intervals, and the thin, sanious fluid is thrown out with considerable force from the gaping mouth of the wound. This thin fluid is mixed with bubbles of air, and emits a disagreeable odor, and is very unlike the thick pus of the second and third days of the experiment. Temperature of rectum, 40° C. (104° F.). November 12. — Wound presents much the same appearance, with dirty, brown, everted edges, and discharges the same fluid, mixed with bubbles of air. Dog still eats little or nothing, and is losing flesh rapidly. November 13. — Slight improvement in the appearance of the wound, and in the appetite of the dog. Lips of the wound not so much swol- len. The discharge of thin fluid still continues. November 14. — Some pus discharged from the wound, the surface of which is much redder and more healthy. Dog livelier, and with a pretty good appetite. The animal is now reduced to a mere skeleton. After this observation, the dog improved slowly, and the wound gradually healed. INOCULATION OF HOSPITAL GANGRENE. 607 It is evident that in the preceding experiment the gangrenous matter excited disturbances in the general system, as manifested in the elevation of temperature and the loss of appetite ; and also that the local effects resembled to a certain extent those of hospital gangrene in the human subject. The differences observed may- be due to the differences of inflammatory and gangrenous actions in the dog and man. (6.) Can hospital gangrene be communicated to strong, healthy individuals by inoculation, the subjects of the experi- The question ments being removed entirely from the atmosphere of the dwiity ©r^' 1 «. 1 o * commuQicat' hospital I ing hospital We arg able to answer this question, also, in the ftrol^™° m i ■ healthy in- atnrmative. dividualsby T . J 1, Til, inoculation, WO stout negro women, in good health, were em- the subjects ployed in washing the rags from the gangrenous wounds meute'iS^' of the patients in the Empire Hospital. These women tireiy&om ■washed the rags and bedclothes in a small stream, over phereofthe half a mile from the hospital, and at night slept about imteiy set- the same distance from the gangrene cases ; and, as far affirmative. , 1 1 • T . 1 Illustrative as known, never came upon the hospital inclosure at observations, all. In the first case, the skin upon the inner parts of the wrists were abraded in washing the rags from the gangrenous wounds. Both these abrasions assumed, in the course of two or three days, a gan- grenous appearance ; and the woman was unable to continue her labors, on account of the pain and the spreading of the ulcers. The ward-master, in response to her complaints about sore wrists, being ignorant of the cause, ordered the woman to tramp the gangrenous rags with her feet, in a tub of water. The gan- grene attacked abrasions on the feet in like manner. The other negro woman took the gangrene in the wrists in the same manner, after washing the gangrenous rags for a few days. In both these cases, the constitutional symptoms were well marked. Although the progress of the disease was arrested by the appli- cation of strong nitric acid, still the healing of the ulcers was very slow. At the end of two months, the ulcers still presented an unhealed, granulating surface. Assistant-Surgeon Powell, in charge of Ward No. 1, Empire Hospital, Vineville, communicated the preceding facts with reference to these two women. A young negress, fourteen years of age, and in good health, 508 DESCRIPTION OF HOSPITAL GANGRENE, BY GUTHRIE. who was employed in picking up rags, emptying vessels, and in washing the faces of the patients about the Empire Hospital, acci- dentally stuck a pin from a gangrenous rag into the skin over the ball of the great toe. The pin merely inflicted a slight prick in the skin. The wound commenced to inflame almost immediately after, and in two or three days presented a gangrenous appear- ance. The ulcer spread rapidly, and destroyed the tissues, and exposed the bone in the course of six days. These local changes were attended with fever, loss of appetite, and diarrhoea. The healing of the wound, after its arrest with nitric acid, was very slow ; and two months after the accident the ulcer was stiU upon the foot, and incapacitated the servant for labor. It is important to note that the gangrene was inoculated, and com- menced its ravages, only four or five days after the patient com- menced her attendance upon the sick, and that this patient had been scarcely at all exposed to the atmosphere of the hospital. It is true that such cases did not equal in severity the following picture drawn by G. J. Guthrie, in his " Commentaries on the Surgery of the War in Portugal, Spain, France, and the Nether- lands ; " nevertheless, they presented all the characteristics of true hospital gangrene : — " A wound attacked by hospital gangrene, in its most concentrated „ „ . , , and active form, presents a horrible aspect after the first Gathne's de- ' '^ /. i , Bcription of forty-eight hours.' The whole surface has become of a dark- grene as It red color, of a ragged appearance, with blood partly coagu- thTBngiish lated, and apparently half putrid, adhering at every point t^Vsp^K '^^^ edges are everted, the cuticle separating from half to fhe iSth«- three quarters of an inch around, with a concentric circle of lands. inflammation extending an inch or two beyond it ; the limb is usually swollen for some distance, of a shining white color, and not peculiarly sensible, except in spots, the whole of it being perhaps oedem- atous or pasty. The pain is burning, and unbearable in the part it- self, whilst the extension of the disease, generally in a circular direc- tion, may be marked from hour to hour ; so that in from another twenty-four to forty-eight hours, nearly the whole of the calf of a leg, or the muscles of a buttock, or even of the wall of the abdomen, may dis- appear, leaving a deep, great hollow, or hiatus, of the most destructive character, exhaling a peculiar stench, which can never be mistaken, and spreading with a rapidity quite awful to contemplate. The great nerves and arteries appear to resist its influence longer than the mus- cular structures, but these at last yield; the largest nerves are de- stroyed, and the arteries give way, frequently closing the scene, after DESCRIPTION OF HOSPITAL GANGRENE, BY GUTHRIE. 609 repeated hemorrhages, by one which proves the last solace of the un- fortunate sufferer. I have seen all the largest arteries of the extrem- ities give way in succession, and until the progress of the disease was arrested by proper means, the application of a ligature was useless. The joints offer little resistance, the capsular and synovial membranes are soon invaded, and the ends of the bones laid bare. " The extension of this disease is in the first instance through the medium of the cellular structure of the body. The skin is undermined, and falls in ; or a painful red and soon black patch or spot is per- ceived at some distance from the original mischief, preparatory to the whole becoming one mass of putridity, whilst the sufferings of the patient are extreme. A complaint of this kind cannot long be local, even if a local origin be admitted; the accompanying fever is usually dependent on the previous state and general constitution of the patient, modified by the season of the year, or the prevailing type of febrile disease." ^ The differences were merely those of degree, and were due to the comparatively good condition of the general systems of these patients into whose structures the gangrene had been inoculated. In fact, Guthrie himself admits that — " This gangrenous disease does not always prevail in this, its most concentrated form ; the destroying process assumes more of a sloughing than of a gangrenous character, whence Delpech has denominated it pulpous rather than gangrenous. It is in its nature almost equally destructive, although not quite so formidable in appearance. It may attack the whole surface of an ulcer at once or in distinct points, all however, rapidly extending towards each other until they constituted one whole. The red of the granulations becomes of a more violet color, and the change is accompanied by burning, a pain not usually felt in the part, while a layer of ash-colored matter is soon seen covering them, which adheres so firmly as not to be readily moved, or, if sepa- rated, shows that it is a substance formed upon the surface and consti- tuting a part of the granulations themselves, which are ultimately confounded vrith it. " About the end of the first week, and sometimes much later, this kind of ulcer becomes more painful ; the edges or the circumference of the wound assume a browner hue, and the parts become somewhat pasty, the whitish color of the part particularly affected being opaque, gray, and soft. It may be said that the false membrane, having become very thick, has lost the little vitality it possessed, and become putrid ; the discharge, which had been partially suppressed, now reappears, not as pus, but as a fetid ichor, exhaling the peculiar offensive stench of 1 Commentaries on the Surgery of the War in Portugal, Spain, France, and the Nether- lands. London, 1855, pp. 162, 163. 510 , DESCRIPTION OP HOSPITAL GANGRENE, BY DR ROLLO. this disease. This pulpy, yellowish, putrid substance becomes thicker and extends deeply ; it invades the whole substance of a muscle, under which a probe may be passed and the instrument brought out through it, with the loss, perhaps, of some striae of blood from parts which are not yet actually destroyed. The mass is, however, adherent, although its extent diminishes by the putrefaction and wasting away of its sur- face." 1 We will examine in the next place the views of different writers upon the direct contagion of hospital gangrene. We have already presented the views of Sir Gilbert Blane and others upon its contagious nature, supported by various facts simi- lar to those observed in the Confederate hospitals. M. Pouteau, chief surgeon to the Hotel de Dieu of Lyons, who gave the first distinct account of hospital gangrene, had his atten- tion directed to the disease at a very early period of life from his having been affected by it while employed as a dresser in the hos- pital to which he afterwards became surgeon. Doctor KoUo, who wrote in 1797, fourteen years after the pub- lication of the posthumous works of M. Pouteau, expresses the opinion that this disease is due to the action of a poison which possessed, like other poisons, the property of assimilation, or of producing matter similar to itself. The following account of hos- pital gangrene by Dr. RoUo, as it occurred in the Royal Artillery Hospital of Woolwich, is interesting, not only historically, but also for its accuracy and completeness : — " After the formation of the brigade of Eoyal Horse Artillery, many ofhospitar accidents occurred, especially in kicks in the legs of the men ©■"aSiT ^^ ^y ^^^ horses' feet, and, being generally on the shin, very un- it preTsjied pleasant sores were produced. The wound was sometimes amongst the ,, , -i i . . ^ , Koyai Horse small and punctured, having arisen from the turned-out part 1797."'^' of the horse's shoe as formerly practiced. The bone was often laid bare. We seldom had less than forty cases at that time in the hospital. When this sore engaged our particular attention — and from the ra- pidity of its progress and eflfects very watchful examination was bestowed — it was found that a sore of any extent (some were very con- siderable, as three or four by five or six inches, and others small) in the promising state of healthy cicatrization was liable to have a solitary ulceration on its edge of unequal dimensions, the size varying, being smaller or larger than a pea. This distinct little ulcer was of a darkish color, its edges jagged, its bottom unequal and ragged, and discharged a thin matter having a peculiar smell. Such was the earliest state in 1 Commeniaries, etc., pp. 163, 164. OBSERVATIONS OF DR. ROLLO ON GANGRENE. 511 which it was perceived, but probably it might have been distinguishable sooner. The disappearance of the sore in the hospital deprived us of a more minute and early inquiry. " The day after the little ulcer had been discovered, it had acquired the size of a sixpence or a shilling, extending itself every way, even on the skin as well as on the surface of the former sore. The discharge was now changed, having become thickish, of a whitish color inter- mixed with dark shades, and adhering strongly to the surface of the part The 'peculiarity of the smell continued, and was become more offensive. " In another day the ulcer had spread farther, and on other parts of the former sore might probably be perceived small ulcerations of the same appearance and kind as those of the first discovery, and which went on extending until they united. " Five or six days from the appearance of the small ulcer or ulcera- tion, when it had extended (or by its union with other ulceration) over one third of the former sore, with pain and redness in the course of the lymphatics and the glands through which they led, with enlargement of them, general indisposition became evident. This consisted in nausea, loss of appetite, heat of skin, a very small and quick pulse, extreme irritability, a whitish tongue, and thirst When these symptoms took place the ulceration rapidly went on, extending beyond the limits of the former sore, and destroying the adjacent parts. In this state of the sore the parts were puffed and bloody, accompanied with much uneasi- ness, having a burning and lancinating sensation, and the action fre- quently terminated in apparent gangrene. Sometimes, however, the ulcerating part remained covered with the thick, adhesive matter, and ' gradually, without any other apparent change, assumed the healing state. " The operation of the poison in slowness or rapidity probably de- pends on some constitutional circumstance, as it was not in all of equal degrees of facility. These sores, which spread rapidly and extensively to sloughing and even to gangrene, from one, two, or more small ulcer- ations, very likely happened in those who might be said to have a con- stitutional susceptibility; while on the contrary, in those where the ulcerations continued distinct and remained covered with a thick, whitish, and adhesive matter, without acquiring the sloughing and gan- grenous states, their constitutions had no favorable tendency to the operation of the poison. " The first favorable change was in the edges of the sore, with a sepa- ration of dead parts, which went on until the whole were thrown off, and then healthy granulation and cicatrization took place. " The most singular phenomena in the progress of this sore consisted in the various actions which were not unfrequently perceived in it at the same time, and which seemed to depend on constitutional differ- ences. We have seen the ulcerating, suppurating, and cicatrizing states 512 DR. ROLLO'S OBSERVATIONS ON GANGRENE. going on at the same time in one sore. It was not unusual for the ulcerating process to be checked before it had extended over the whole sore, when the former cicatrizing parts went on without interruption, and the ulcerating part, having assumed a disposition to healthy action, arrived at the cicatrizing point, and then proceeded with the others to skinning. " The smallness of the ulcer, the appearance of its edge and base, its ulcerative tendency, the absorption of its matter, affecting the lymphatic glands and vessels and then the whole system, pointed out the operation of a morbid poison. " The action of this poison seemed to be limited and confined to specific effects ; the first were local, producing only general affection by a more extended operation on the sore, and which in a certain time terminated in the healthful separation of parts, granulation, and cica- trization, and a state of constitutional convalescence. " Sores having specific actions, as the venereal, scrofulous, and vario- lus, resisted this poison, and in the hospital were not affected, though such patients were in the same wards. " Some men in quarters, one with a blistered part, another with a cut on the outer ear, and another with a sore on the leg, besides several others, were affected with the poison. The men in the same wards were not generally affected with it ; those with specific sores, or with sores of small extent and having little discharge, though lying within two feet of the men under the action of the poison, escaped. " From the very serious ravages of this poison we were induced to make the most particular inquiries. Being fully persuaded it was nei- ther the sore acted on by erysipelas nor the sore described as peculiar to hospitals, we found ourselves involved in considerable difficulties. We consulted everything that had been written by the ancients or moderns within our reach, and we found nothing resembling our sore. "We saw, however, similitudes, in some of its stages, to phagedasna, especially as it was described by Mr. Adams in his account of morbid poisons. But the local attack of this sore, its progress, and the conse- quent general indisposition and changes in the sore, remained new, and to us unnoticed and unexplained. " Impressed strongly with the notion that a morbid poison was ap- plied locally to a part of the sore, which, like the venereal poison, had the power of assimilation, and thus augmenting its power, as also of being absorbed, producing general effects on the system and a reaction on the sore, we were determined ia adopt local means of treatment, consisting in the chemical destruction of the poison in parts under its direct action, and in exciting a new action. " We were led to propose an early and vigorous treatment of the local operation from observing that when the constitutional effect took place any plan of cure was inadequate, the disease then going on and appar- DR. EOLLO ON HOSPITAL GANGRENE. 613 ently ceasing of itself, but not until very extensive destruction of parts had been accomplished. " The oxygenated muriatic acid and the nitrates of silver and mer- cury were the applications employed, and latterly the oxygenated muri- atic acid gas. " When either of these were applied four or five times the little ulcer soon put on the suppurating state and granulated. They did not give pain in any degree, and it was of short continuance. While the ulcer was directly touched with the nitrated silver, the whole sore was moist- ened with a diluted solution of nitrated mercury, or a mixture of the oxygenated muriatic acid in distilled water, after which the whole was covered with lint that had been previously moistened by ether, or the oxygenated muriatic gas applied to the ulcer, and over the sore the diluted solution of nitrated mercury in distilled water. " By these means gently persevered in, the poison and ulcer were destroyed, and the sore went on cicatrizing. The only failures were in those cases where the ulceration had so extended that the nitrated sil- ver, or oxygenated muriatic acid gas, could not be completely employed. It is necessary to mention that washing the sore with warm water was always previously performed. " The success of this treatment afforded additional strength to the opinion we have formed of the existence of a poison, its locality, and that it possessed, like other poisons, the property of assimilation, or producing matter similar to itself. " Having gained this much, we were prepared to make some inquiry into its origin. " From the local commencement of the poison, and the power we had of destroying its peculiar nature and consequent action by a direct application, and at the same time considering the circumstances of the sore previous to its appearance, we entertain the notion that the poison was formed on the surface or edges of the sore. " Iq all those sores on which the poison showed itself, both in and out of the hospital, the discharge from them was considerable ; they were most generally dressed with an ointment of wax and oil, spread over coarse linen, and when dressed, the matter was seldom cleaned off, by which it formed incrustations about the edge, or at a little distance from the sore. This arose from the opinion of some, that the washing of sores, if it did no harm, was at least superfluous, and from the great number of sores at that time to be daily dressed, by which less atten- tion was probably given than might have been otherwise required and bestowed. " We suspected, however, in a few cases, that the poison was propa- gated from one sore to another by means of the sponge employed in the occasional wiping or washing, the same sponge having been un- guardedly used for different sores. 33 514 MR. BLACKADDER ON HOSPITAL GANGRENE. " The discharge of a sore, remaining confined, or some of it suffered to adhere long on the edge of the sore, may undergo such changes as to produce a matter possessing new properties of an apparently poisonous nature and effect. On several sores, but one in particular, where a con- siderable quantity of finely powdered nitrated mercury had been sprin- kled, in twelve hours, the time of the next dressing, the mercury formed a shining crust, was firm, and appeared as if a portion of the mercury had been revived. This might be owing to hepatic gas on the surface of the sore." The preceding observations possess peculiar interest also in the light which they throw upon the discovery and early application of the effects of the mineral acids in the treatment of hospital gan- grene. Mr. Blackadder, whose observations were made at Passages, in Spain, considers the gangrenous ulcer as specific, produced and prop- agated by the direct contact of specifically contagions matter to an open surface. This author considers the communication of the disease through the medium of the atmosphere as very rare, and only possible when the effluvia are allowed to accumulate in a most negligent manner, so as to resemble a vapor bath, which mode he regards as equivalent to inoculation : — " Whatever may be the source of the disease (says Mr. Blackadder), ^j«'?»f Mr- it js at least sufficiently ascertained, that, when it occurs, its on the coQ- propagation is only to be prevented by the most rigid atten- tate of hos- tion to cleanliness, and by insulating the person or persons lienef""' affected, so as to prevent all direct intercourse between them and the other patients ; for, so far as I have had an opportunity of observing, ninety-nine cases in the hundred were evidently produced by a direct application of the morbific matter to the wounds, dressings, etc. ; while others who were, in every other respect, equally exposed -to its operation, never caught the disease. " In attempting to prove this by experiment, I have placed three pa- tients with clean wounds alternately between three other patients, sev- erally afflicted with the disease. They lay in a part of the ward which was appropriated for patients who were laboring under the disease, and of whom there were at the time a considerable number. Their beds were on the floor, and not more than two feet distant from each other ; but all direct intercourse was forbidden, and they were made fully aware of the consequences that would follow from inattention to their instructions. The result of this trial was, that not one of the clean wounds assumed the morbid action peculiar to the disease, nor was the curative process in any degree impeded." MR. BLACKADDER ON HOSPITAL GANGRENE. 615 According to Mr. Blackadder, — " When the morbific matter has been applied to some part of the surface of the body from which the cuticle has been removed, as by a blister, one or more small vesicles first appear, which are filled with a watery fluid or bloody serum of a livid or reddish-brown color. The situ- ation of the vesicle is generally at the edge of the sore. Its size is not unfrequently that of a split garden pea, and is easily ruptured, the pelli- cle which covers it being very thin. When the vesicle is filled with a watery fluid, and has not been ruptured, it assumes the appearance of a grayish-white or ash-colored slough ; but, when it contains a dark col- ored fluid, or has been ruptured, it puts on the appearance of a thin coagulum of blood, of a dirty, brownish-black color. During the forma- tion of the vesicle, there is generally a change in the sensation of the sore, accompanied with a painful feel, like that of the sting of a gnat. " After a slough is formed, it spreads with more or less rapidity, until it occupies the whole surface of the original sore ; and, when left to itself (which seldom happens), there is little or no discharge, but the slough acquires daily greater thickness. " When the formation of the slough has been interrupted, the sting- ing sensation becomes more frequent, and active phagedasnic ulceration quickly commences ; and such is frequently the rapidity of its progress, that even in the course of a few hours a very considerable excavation will be formed, while the parts in the vicinity retain their usual healthy appearance. The cavity, the edges of which are well defined, is filled with a thick glutinous matter, which adheres strongly to the subjacent parts. When this matter is removed, the surface underneath presents itself of a fine granular texture, which, in almost all instances, is pos- sessed of extreme sensibility, and is very apt to bleed when the opera- tion of cleaning is not performed with great delicacy. At each dress- ing the circumference of the cavity is found enlarged, and if there are more than one, they generally run into each other. The progress of the disease is much quicker in some individuals than others, but it never ceases until the whole surface of the original sore is occupied. The stinging pain gradually becomes of a darting or lancinating pain ; and either about the fourth or sixth day from the time when the mor- bific matter has access to the sore, or afterward, at the period of what may be termed secondary inflammation, the lymphatic vessels and glands are apt to become affected. The discharge becomes more copious, its color varying from a dirty yellowish white to a mixture of yellow, black, and brown, depending upon the quantity of blood mixed with it. " The soft parts in the immediate vicinity of the sore daily become more painful, tumefied, and indurated ; and in a great number of cases, particularly in those of plethoric and irritable habits, an attack of acute inflammation speedily ensues, and is accompanied by a great increase of pain, the sensation being described to be such as if the sore were 516 MR. BLACKADDER ON HOSPITAL GANGRENE. burning. The period at which this inflammation begins to subside is by no means regular. Sometimes it subsides in the course of two days, and sometimes it continues upwards of five ; depending very much on the constitution of the patient, as well as the treatment that has been adopted. During its progress the thick, putrid-looking, and frequently spongy slough which is formed on the sore becomes more and more moist, and of a pulpy consistence. (Hence this form of disease is actually named by the Germans, pulpy gangrene.) In the course of a very few days, a very offensive matter begins to be discharged at its edges. The slough then begins to separate ; by and by it is thrown off, but only to prepare the way for an extension of the disease by a con- tinued process of ulceration, and by a recurrence of the last-mentioned symptoms." Mr. Blackadder has still further strengthened his testimony and enriched his description of hospital gangrene by the folloviring ac- count of the disease from inoculation in his ovm person : — " While engaged in examining the stump of a patient who had died from this disease, I accidentally wounded one of my fingers with the point of a double-edged scalpel, but so slightly that not a drop of blood made its appearance, and on this account I did not consider any partic- ular precautionary means necessary. In the course of about sixty hours, however, the wound had become inflamed, and I was attracted to it by an occasional smart, stinging sensation, which ultimately extended a considerable way up the arm. On the fourth day the inflammation had increased, and the stinging sensation was almost constant. Head- ache, nausea, and general indisposition followed, with frequent chills, which increased very much towards evening ; but which, with the other symptoms, were considerably relieved by the use of neutral salts, the pediluvium, and warm diluents. A vesicle, having a depression in its centre, and containing a watery fluid of a livid color, was now forming upon a hard and elevated base ; the surrounding integuments became tumefied, of an anserine appearance, and extremely sensitive to the touch ; at about the distance of the fourth of an inch from the base of the tumor, a very distinct areola, of a bluish-red color, made its appear- ance, and remained visible for several days. At this period, circum- stances rendered it necessary for me to be exposed to wet, to undergo considerable fatigue, and immediately afterwards to travel to a consid- erable distance. The inflammation, however, gradually subsided, but the stinging, accompanied by a burning sensation, still continued, and the sore had no disposition to heal ; yet it did not enlarge externally, but was disposed to burrow under the integuments. This phagedsenic disposition was ultimately got the better of by laying open the sore, and by repeated applications of caustic ; but it was two months before a complete cicatrix had formed. The new cuticle remained for a length DR. THOMSON ON THE CONTAGION OF GANGRENE. 517 of time extremely sensitive to the touch ; and it was upwards of six months before it had acquired the color of the surrounding integu- ments." Mr. Hennen, who has given a striking picture of hospital gan- grene as it occurred amongst the wounded at Bilboa in viewsofHen- Spain, and whose careful observations were made in the H^^om!^' same general field, and on the same class of subjects with conta^oS^ those of Mr. Blackadder, whilst admitting the contagious So'pm' nature of hospital gangrene, at the same time gives due sangrene. prominence to the condition of the system and the effects of foul air. In fact, in the treatment of the disease. Dr. Hennen placed reliance chiefly upon internal remedies, and regarded external ap- plications as merely secondary in their effects. Delpech, whilst admitting that the disease may be communicated through the medium of the atmosphere, at the same time affirms that, in almost every instance, he traced the propagation of the disorder to the direct application of morbific matter to the sores. Dr. John Thomson, in his " Lectures on Inflammation," thus disposes of this question : — " The contagious nature of hospital gangrene appears to me to be suf- ficiently proved, — " 1. By the fact that it may be communicated by sponges, charpie, bandages, and clothing, to persons at a distance from those infected with it. " 2. By its having been observed to attack tlie slight wounds of sur- geons or their mates, who were employed in dressing infected persons, and that even in circumstances where the medical men so employed did not live in the same apartment with the infected. " 3. By our being able often to trace its progress distinctly from a sin- gle individual through a succession of patients. " 4. By its attacking recent wounds, as well as old sores, and that in a short time after they are brought near to a patient affected with the disease. " 5. By our being able to prevent the progress of the disease, in par- ticular situations, by removing the infected person before the contagion which his sores emit has had time to operate'. " 6. By its continuing long in one particular ward of an hospital, or in one particular ship, without appearing in other wards or ships, if pains be taken to prevent intercourse between the infected and unin- fected. I have seen hospital gangrene introduced into a hospital by a single individual ; and when proper precautions were not taken, spread extensively among the other patients, but chiefly among those who lay nearest in the ward to the persons originally affected, or among those 518 MR. .GUTHRIE ON CONTAGION OF GANGRENE. who had had most frequent intercourse with him. I have also known patients attacked in succession with hospital gangrene, who had used the same bedding, or had occupied in quick succession the same small apartment." In like manner Guthrie, in his Commentaries, strenuously ad- vocates the contagious nature of hospital gangrene : — " Professor Brugmans says, that in 1797, in Holland, charpie com- ^trenuOTsiy P^^ed of linen threads cut of different lengths, which on advocates the inquiry it was found had been already used in the great hos- conta^ous , . , nature of pitals in France, and had been subsequently washed and grene. bleached, caused every ulcer to which it was applied to be affected by hospital gangrene ; and the fact that this disease was readily commimicated by the application of instruments, lint, or bandages which had been in contact with infected parts, was too firmly estab- lished by the experience of every one in Portugal and Spain, to be a matter of doubt. Its character as a thoroughly contagious disease, is indisputable. Its capability of being conveyed through the medium of the atmosphere to an ulcerated surface, is also admitted, although some have thought that the infection was not always applied to the sore, but affected it secondarily, through the medium of the constitution. Brug- mans says that hospital gangrene prevailed in one of the low wards at Leyden in 1798, whilst the ward or garret above it was free. The sur- geon made an opening in the ceiling between the two, in order to ven- tilate the lower or affected ward, and in thirty hours three patients who lay next the opening were attacked by the disease, which soon spread through the whole ward. Our experience in Portugal and Spain con- firmed this fact, and left no doubt on the mind of any one who had frequent opportunities of seeing the disease, that one case of hospital gangrene was capable of infecting not only every ulcer in the ward, but in every ward near it, and ultimately throughout the hospital, however large. The disease, as long as it remains unaltered by destructive applications, may be considered to be infectious as well as conta- gious. " This infection can penetrate the dressings so as to affect the ulcer through them, although requiring a difference of time in different parts of the body. Ulcers on the lower extremity experienced the influence of the morbid poison in general at an earlier period than those on the upper extremity ; and a wound might be seen in a healthy state on the arm, whilst one on the leg had been evidently suffering from this dis- ease for some days, if the complaint had become mild or somewhat chronic. " If the morbid poison were in its active state, then the deterioration of the ulcers on the arm was almost if not quite contemporaneous with that on the leg." CONTAGION OF HOSPITAL GANGRENE. 619 The following are the conclusions of Mr. Guthrie with refer- ence to the contagious nature of hospital gangrene : — " First. Hospital gangrene never occurs in isolated cases of wounds. " Second. It originates only in badly-ventilated hospitals, crowded with wounded men, among and around whom cleanliness has not been too well observed. " Third. It is a morbid poison, remarkably contagious, and is infec- tious through the medium of the atmosphere applied to the wound or ulcer. " Fourth. It is possibly infectious, acting constitutionally, and pro- ducing great derangement of the system at large, although it has not been satisfactorily proved that the constitutional affection is capable of giving rise to local disease, such as an ulcer ; but if an ulcer should occur from accidental or constitutional causes, it is always influenced by it when in its concentrated form. " Fifth. The application of the contagious matter gives rise to a sim- ilar local disease, resembling and capable of propagating itself, and is generally followed by constitutional symptoms. " Sixth. In crowded hospitals the constitutional symptoms have been sometimes observed to precede and frequently to accompany the appear- ance of the local disease." ^ The preceding quotations might be greatly extended, but these observations prove conclusively that hospital gangrene may be communicated to the most simple wound or ulcer, in a healthy in- dividual, placed in the best hygienic condition, by merely putting in contact with such wound or ulcer the poisonous matter of this disorder ; and that, after the inoculation of the poison, the rapidity and extent of its ravages will be in proportion to the condition of the general system, and to the extent to which the patients have been exposed to the influence of such causes as are themselves capable of producing the disease. In order to illustrate more fully the causes of hospital gangrene, and the principles established by the preceding discussion, we will conclude this section of the work with the results of my inquiry into the origin and causes of the hospital gangrene which prevailed so extensively amongst the Federal prisoners confined in Camp Sumter, Andersonville, Georgia. 1 Commentaries on the Surgery of the War, etc., by G. J. Guthrie, F. K. S., sixth edition. London, 1855, pp. 160, 161, 171. 520 HOSPITAL GANGRENE OF ANDERSONVILLE. OEIGIN AND CAUSES OF THE HOSPITAL GANGRENE WHICH AFFLICTED THE FEDERAL PRISONERS CONFINED IN CAMP SUMTER, ANDERSON- VILLE, GEORGIA. The condition and diseases of these unfortunate men have been briginof described in the " Sanitary Memoirs of the United States greneatAn- Sanitary Commission, 1867," pp. 469-655 ; and the pre- dersonvUle, ,. •',. . . i ■ i • i , Georgia. codmg discussion contamed m this chapter was necessary to the correct comprehension of the causes which gave rise to the hospital gangrene of Andersonville. In the depraved and depressed condition of the systems of these prisoners, in the foul atmosphere of the stockade and hospital, reeking with noxious exhalations, small injuries — as the injury inflicted by a splinter running into a hand or foot, the blistering of the arms or hands in the sun, or even the abrasions of the skin in scratching the bites of insects — were sometimes followed by ex- tensive and alarming gangrenous ulceration. In the spreading ulcers of the foot, the Federal prisoners almost invariabl}' referred the origin of the gangrene to walking in the filthy mud, mixed with human excrements, upon the borders of the stream flowing through the stockade. The following drawing, Plate No. XL.,^ was made by myself, CaseiUus- from the arm of a Federal prisoner, who had scratched trating the , tendency of and abraded the skin around the bite of some insect, small injuries i i i i /. • . n i td degenerate most probably that of a musquito, inflicted m the stock- into hospital , gangrene. ade. The abrasion did not heal, but gradually assumed a dark, un- healthy hue, and the irritation commenced to spread. In two ■weeks it had reached the size of a silver half dollar. This patient Was then transferred to the Confederate States Military Prison Hospital, and in the course of six days it reached the size and pre- sented the appearance represented in the drawing. When I ex- amined this patient the constitutional symptoms were well marked — hot, dry skin ; small, rapid, feeble pulse ; leaden, sallow, un- healthy hue of complexion ; dejected, distressed countenance ; coated and tremulous tongue. The stench emitted from this gan- grenous mass was intolerable. The elbow joint was exposed, and the gangrenous mass presented a ragged, pulpy, putrescent mass, without pus, and with ragged, everted edges, and elevated above the surrounding tissues. It was also surrounded by a livid blue and deep purple border in the skin. This deep blue and purple areola is a sure index of the spread of hospital gangrene. The 1 Omitted. HOSPITAL GANGRENE OF ANDERSONVILLE. 521 patient was most urgent in his entreaties for the removal of this arm ; and it was decided upon consultation with the attendant medical officers, that his condition could not be rendered worse by an amputation, which would substitute a smaller flesh wound for this most extensive and foul ulcer, invading the joint and exciting intense pain. Notwithstanding the probability that in the condi- tion of the system of this patient, in this foul atmosphere, the gan- grene would return again in the stump, it was nevertheless con- sidered proper to amputate, on account of the reasons just given. Numerous amputations had been performed in the Confederate States Militarv Prison Hospital, for gangrene superven- Numerous ,.,... 1 1 • 1 . 1 amputations mg upon slight miuries, and attackmg scorbutic ulcers, performed in T 1 ? 11 11 1 o . » the C.S.M.P. I endeavored to collect all the cases of amputation for Hospital for 1 . , 1 1 • 1 • p 1 hospital gan hospital gangrene, and to determme the ratio or mortal- grene. ity ; but it was impossible to arrive at accurate results, from the almost total absence of records, and from the imperfect organiza- tion of the hospital. Hospital gangrene was not recognized among the list of diseases recorded upon the Confederate sick reports, until near the middle of 1864 ; and hence the disease, under the name of phagedsena gangrsenosa, does not appear in the sick reports of the Federal prisoners at Andersonville prior to July, 1864. During the month of August, fifty-four cases and thirteen deaths of phagedena gangrsenosa were reported, whilst during the entire six months, two hundred and thirty cases of ulcers were recorded. I requested the medical officers on duty in the Confederate States Military Prison Hospital of Camp Sumter to prepare a classified report upon the number and character of the cases of gangrene arising from ulcerations, and following gunshot wounds and amputations, together with statements of the causes of the disease, the condition of the patient, and the nature of the treat- ment and the results of operations. The records of the individual wards and divisions were so incomplete that the report was imperfect. Upon this incomplete report, two hundred and sixty-six cases of hospital gangrene are recorded, with sixty-seven amputations in consequence of the disease, and twenty-five deaths ; one hundred and two cases are given as supervening upon gunshot wounds, and the remainder were reported as gangrenous ulcers, arising from the scorbutic and deranged condition of the system. Twelve cases of gangrenous ulcers are recorded as following vaccination. These figures are far below the truth. Many cases of gangrenous ulcer- ation which arose in the hospital were originally entered upon the hospital register under the head of scurvy, diarrhoea, dysen- 622 HOSPITAL GANGRENE OF ANDERSONVILLE. tery, or some other disease. The plan of entering the diseases as they arose in the hospital under a distinct head, as " re-admitted," was not inaugurated until the month of July, 1864 ; and in fact it was not properly carried into execution until the month of August. The number of deaths given above is below the true statement ; for on the reports of a number of the wards, the final result was not given, and no reports were received from some of the wards. After careful inquiry, and personal examinations of the wards and patients, I was convinced that the number of amputations for hos- pital gangrene reached, and perhaps exceeded, one hundred. Hospital gangrene returned almost invariably after amputation, AtAnderson- in thcse scorbutic and enfeebled patients, and in this in- gangrene re- fected atmosplierc ; and in some cases the disease reap- most inTari- peared in the stump within thirty-six hours after the amputation, operation. The day before I arrived at Andersonville, the cars had run off the track, and been crushed against the sides of the cut through which they were passing. These railroad cars were loaded with Federal prisoners en route for Millen, Ga. The accident happened only three miles from Andersonville, and less than two hours after the prisoners had left the stockade. A num- ber of the prisoners were killed and wounded. I observed the Observations wouuded who Were brought to the Confederate States rapidity witii Military Prison Hospital daily, and noted the first appear- which fresti ;; ' '' . .'■ , wounds be- aucc 01 the gangrene. In a case or amputation in the come gan- .iiipiii/. i • in grenousat middle of the thigh, for a compound comminuted fracture Anderson- . , Tiue. of the foot and leg received at this time, the lips of the wound did not unite ; and although the patient was a stout Irish- man, and apparently in good health, in the course of twenty-four hours a deep blue line appeared along the edges of the wound, and the skin around the lips of the wound presented an excoriated, blistered appearance. The sutures came away, the edges of the wound gaped open, the flaps of the stump assumed a grayish, greenish, and bluish appearance, and in a few days the thigh bone was denuded, and projected nearly one inch from the gan- grenous mass. In a second case of railroad accident, in which the cap of the knee was simply cut longitudinally, to no great depth, the wound appeared to penetrate simply through the skin ; gan- grene appeared in the wound in the course of fifty hours, and pro- gressed rapidly. In another case of amputation in the upper third of the leg, for a gangrenous wound following a slight injury of the foot by a splinter, gangrene appeared in twenty-four hours after the operation, and at the end of forty hours the stump pre- sented a blue, mottled appearance up to the knee joint. HOSPITAL GANGEENE OF ANDERSONVILLE. 623 In these cases, which became rapidly gangrenous after jfop„g amputation, no pus was formed, and coagulable lymph th™'ound« was thrown out to a very limited extent, and the dis- ramfrapidiy charges assumed a thin, sanious character. gangrenom In the gangrenous stumps examined after death, the disorganiza- tion of the osseous and muscular structures was wide- wide-sprcad aisorgamza' spread. Stumps from which the gangrene had apparently tionof the J- * o o lit/ osseous and disappeared, and which were thought to be doing well muscular 1 1 T 1 11 Till Structures m and heahng, were discovered after death to be thoroughly *^e stumps *• 1 • -1 Til 11-1 examiDed rotten withm, notwithstandmg that there was but httle after death, discoloration of the skin, and comparatively little swelling. In the deranged state of the blood, and in the depressed state of the forces, gangrene appeared to affect the tissues with great rapidity, and with but slight external marks of inflammatory action. The powers appeared to be too feeble, and the blood and structures too much deteriorated, to oppose any effectual barriers to the onward march of the decay. Without doubt, these foul ulcers and this devastating and poi- sonous gangrene were to a great extent but tlie manifes- ^^^ jj,„, tations of scurvy, if we may apply the term to a state of aiya^tfung the system induced by sameness of diet and salt meat, langreo" to It was clearly demonstrated in my report contained in teuTbutThe the " Sanitary Memoirs," published by the United States Zn^T^ Sanitary Commission, that diarrhoea, dysentery, scurvy, ^"""y- and hospital gangrene were the diseases which caused the extraordi- nary mortality of Andersonville. And it was still farther shown that this mortality was referable in no appreciable degree to either the character of the soil or waters, or the conditions of climate. The effects of salt meat and farinaceous food, without fresh vege- tables, were manifest in the great prevalence of scurvy. The scorbutic condition thus induced, modified the course of ihescor- every disease, poisoned every wound, however slight, ttou'ind^Md and lay at the foundation of those obstinate and exhaust- Anderson-"'' ing diarrhoeas and dysenteries which swept off thousands je'a t™^" of these unfortunate men. By a long and painful inves- every dis- tigation of the diseases of these prisoners, supported by ^°- numerous post-mortem examinations, I demonstrated conclusively that scurvy induced nine tenths of the deaths. Not only were the deaths registered as due to unknown causes — to apoplexy, to ana- sarca, and to debility — directly traceable to scurvy and its effects, and not only was the mortality in small-pox and pneumonia and typhoid fever, and in all acute diseases, more than doubled by the 624 HOSPITAL GANGRENE OF ANDERSONVILLE. scorbutic taint, but even those all but universal and deadly bowel affections arose from the same causes, and derived their fatal char- acters from the same causes which produced scurvy. Scurvy and hospital gangrene frequently existed in the same individual. In such cases vegetable diet, with vegetable acids, would remove the scorbutic condition without curing the hospital gangrene. It has been well established by the observations of Blane, Trot- Theobserva- tcr, and others, that the scorbutic condition of the sys- Biane, Trot- tcm, especially in crowded camps, ships, hospitals, and ere', have beleaguered cities, is most favorable to the origin and esta^blished the fact that sprcad of foul ulccrs and hospital gangrene. In many the scorbutic ' . , --f , ? ? at condiuonof cascs occurrmg amongst the Jbederal prisoners at Ander- is most fa- sonville, it was difficult to decide at first whether the the origin ulcef was a simple result of the scorbutic state, or of the of foul ulcers actiou of the poison of hospital gangrene; for there was gangrene. great similarity in the appearance of scorbutic ulcers and genuine hospital gangrene. So commonly have these two diseases been combined, that the description of scorbutic ulcers by many authorities, evidently includes also many of the prominent charac- teristics of hospital gangrene, as will be seen by a reference to the descriptions of Lind, Trotter, Blane, and others. The British seamen in Lord Anson's voyage, and in fact in all long voyages before the mode of preventing scurvy was practiced, suffered terribly from scorbutic ulcers. John Huxham, in his " Essay on Fevers," in the chapter in which he discourses on the " dissolved and putrid state of the blood," observes that — " The salt and half rotten provisions of sailors, in long voyages, of'!^hifHu°- <^^'^s^ s"*^^ * sharpness and corruption of the humors, that they ham on the are rendered almost unfit for the common uses of life, pro- effects of salt ^ , . , and half rot- duciug great wealcuess, languors, wandermg pains and aches, ions. stinking breath, corroded, spongy gums, black, blue, and sal- low spots, sordid, dark, livid, fungous ulcers, gangrenes, etc., and such scorbutics frequently fall into petechial fevers, bloody dysenteries, hemor- rhages, etc. What is mentioned by the Rev. Mr. Walter, in Lord Anson's voyage, is very surprising, namely, that the blood bursts forth from the wounds of some of the scorbutics, after they had been dca^ trified for twenty or thirty years. I have known many a ship's com- pany set out on a cruise in high health, and yet in two or three months return vastly sickly, and eaten out with the scurvy, a third part of them being half rotten, and utterly unfit for service. About four or five weeks after they have been out, tliey begin to drop down one afler an- other, and at length by dozens, till at last scarce half the complement SCORBUTIC ULCERS. 625 can stand to their duty. Particularly I remember some years since, from a squadron under Admiral Martin, we had near twelve hundred men put on shore sick at one time, though they went out very healthy, and returned in about twelve or thirteen weeks." * Sir Gilbert Blane, in his " Observations on the Diseases of Sea- men," affirms that there is no complaint more hurtful to observations the public service by sea and land, none more afflicting I'fne on*""' to the individual, than ulcers, and that it had been found ^"u^ of* from direful experience, in numerous expeditions, that ^"""y- not only those who are affected with actual symptoms of scurvy, but those who are exposed to the causes of it, and whose constitu- tion is in such a train as to fall into it, are peculiarly susceptible of ulcers of the most malignant kind, from the smallest injury which breaks the skin. Dr. Thomas Trotter, in his " Medicina Nautica," has in like manner recorded a large number of instances where ma- spontaneous lignant gangrenous ulcers have arisen spontaneously in figfin^jX" various ships, and attacked with violence not only exter- SceraTn the nal injuries, but, in a number of cases, where neither ^"'TrotS wound, puncture, scab, or contusion could be said to have °i'«'"*'«""- first taken place, a small circumscribed red spot would be first per- ceived, scarcely to be felt, but in a few hours rising to a pimple, becoming black in the centre, and inflamed round the edges, till it increased in size, swelled, and assumed every characteristic symp- tom of the malignant ulcer, with concomitant fever and subsequent ulceration, sloughs, and fetid discharges. This malignant or gan- grenous ulcer attacked also the flesh wounds made by the lancets in bleeding for different inflammatory diseases, as catarrhs and sore throats. Contused spots, even where the cuticle was not broken, were not exempted from this general tendency to gan- grenous ulceration. On board the TSmiraire, in 1799, every wound, abrasion of the cuticle, blistered part, scald, or burn, passed rapidly through the various stages of inflammation, gangrene, and sphacelus, in a few days, leaving the bones almost bare from the separation of immense sloughs. The tendency of the bones to caries was most marked, and many cases sank under the long confinement necessary to the separation of the dead bone. Dr. Lind, in his valuable work on the scurvy, has recorded the fact that the slightest bruises and wounds of scorbu- J'^Jj'^fon tic persons may degenerate into offensive, bloody, and ^^ot'^''""" 1 Page 47. 526 HOSPITAL GANGRENE OF ANDERSONVILLE. fungous ulcers, which are prone to spread with great rapidity, and which are cured with the greatest difficulty. The distinguishing characteristics of scorbutic ulcers, as given by Dr. Lind, are as follows : — " They do not afford a good digestion, but a thin, fetid matter mixed with blood, which at length has the true appearance of coagulated blood lying cracked on the surface of the ulcer, and is with great diffi- culty wiped off or separated from the parts below. The flesh under- neath these sloughs feels to the probe soft and spongy. No irritating applications are here of any service, for though such sloughs be with great pains taken away, they are found again at next dressing, when the same bloody appearance presents itself. Their edges are generally of a livid color and puffed up, with excrescences of luxuriant flesh arising under the skin. When too tight a compression is made, in order to keep these excrescences from arising, they are apt to have a gangrenous disposition, and the member never fails to become swollen, painful, and for the most part spotted. As the disease increases, they come at length to shoot out a soft, bloody fungus, which the sailors express by the name of bullock's liver ; and indeed it has a near resemblance, in consistence and color, to that substance when boiled. It often rises, in a night's time, to a monstrous size; and although destroyed by caustics, or the knife (in which last case a plentiful bleeding generally ensues), is found at next dressing as large as ever. They continue, however, in this condition a considerable time without tainting the bone." We might add many other facts, from various authors, estab- Thespon- lishing the spontaneous origin of malignant, spreading, ^nlTm^ig- gangrenous ulcers, in many navies and armies, as the U^''^^' result of scurvy and crowding ; but the facts just recorded at"Andlre?n- *''® Sufficient to show that the foul scorbutic ulcers and S"th°hL°°" hospital gangrene of Andersonville were by no means Sneb^utthe ^^^ ^^ *^^ Ijistory of mediciue, and that the causes S?ed'''°'' which induced these distressing affections have been t^if^af- active in all wars and sieges, and amongst all armies and been active navies. Md '11™, The tendency to gangrenous ulceration, as well as to aii''am£s^' the scurvy, in all its manifestations, could have been and navies, eradicated from these prisoners only by such a supply of fresh vegetables and lemons (citric acid) as it appears could not have been obtained even for the struggling armies of the be- leaguered and desolated Confederacy. Various inquiries were addressed to the medical officers, relating Inquiries ad- to tlie most important diseases, and especially to hospital dressed to ... ,.it-iii. Confederate gangrene, prevailing amongst the JBederal prisoners. HOSPITAL GANGRENE OF ANDERSONVILLE. 627 The following report on hospital gangrene was drawn ^'^^^t^' up by Dr. Thornburgh, in response to these inquiries, 4™j^n^'ifi^' and forwarded to me after the completion of my investi- gations at Andersonville : — Confederate States Military Prison Hospital, J Camp Sumter, Andeesohville, Ga., > October, 1864. ) Surgeon Joseph Jones: — Sir, — It was our original intention to give you in this report a description of the stockade, its location, and general con di- . Report of tion ; but learning that this would be unnecessary, we will, surgeon after stating the most prevalent diseases amongst the pris- on the to? oners, confine our remarks principally to the subject of ulcers dCTMnviUe,' and gangrene ^X^^^ The diseases most commonly met with are diarrhoea, dys- *« hospital ■^ 7 J gangrene entery, intermittent and remittent fevers, with continued or which af- " . ' , /y. flictcd the camp fever, as many term it. We also have catarrhal aiiec- prisoners. tions, with occasional pneumonia and pleuritis, and above all scorbutus. As it so rarely happens, in the course of a long experience of the medical practitioner or surgeon, that an opportunity is afforded of wit- nessing this most formidable and loathsome disease in all its aggravated forms, it might not be amiss to introduce in this place a detailed account of the scurvy, as it has and is still prevailing in this prison. But as that would be a work of supererogation, and lead us too far from our subject, we will not attempt the task. Out of over thirty thousand prisoners who have been confined at this place during the past spring and summer, perhaps not less than one half have suffered from this disease, in some of its various forms. As a sequel to this and the other diseases named above, we have cedema, anasarca, ascites, hydrothorax, anaemia, and ulcers of nearly every variety and form. These ulcers are produced from the slightest causes. The scratch of a pin, the prick of a splinter, a pustule, an abrasion of the skin, or even a mosquito bite, are sufiicient causes for their production. The phagedaenic ulcer is the most common variety met with amongst the prisoners, and usually commences from some of the causes just enumerated, or from wounds or injuries of a more serious nature. When from any of these causes an ulcer forms, it speedily assumes a phagedaenic appearance, and extends over a large surface, and presents irritable, ragged, and everted edges, and slowly destroys the deep tis- sues down to the bone. The surface presents a large ash-colored or greenish-yellow slough, and emits a very offensive odor. After the slough is removed by appropriate treatment, the parts beneath show but little tendency to granulate ; occasionally, however, apparently healthy granulations spring up around and within, and progress finely for a time, and again fall into sloughing, and thus by an alternate pro- cess of sloughing and phagedaenic ulceration, large portions of the 528 HOSPITAL GANGRENE OF ANDERSOKVILLE. affected member, or large masses of the body, are destroyed. In this condition the gangrene frequently progresses with great rapidity, and if not speedily arrested, soon puts an end to the poor sufferer's existence. Gangrene first made its appearance in the stockade in the latter part' of April, or first of May last. The first that came under our observa- tion was the result of frost-bite. These cases (three or four in number) occurred among the prisoners who had been imprisoned on Bellisle, Eichmond, Virginia, last winter, where they received the injury. The parts attacked from this cause were usually the toes. The treatment was cold-water dressing, and the whole affected member enveloped in cloths spread with simple cerate ; tonics were also administered to sup- port the system. This treatment usually succeeded, with the loss per- haps of one or more of the affected toes. Early in the spring small-pox made its appearance in the prison, and as a prophylactic measure, we were ordered to vaccinate all who could not show the proper vaccine scar ; consequently we went to work, and in a week or ten days two or three thousand were vaccinated. Out of this number, nearly every prisoner who happened to be affected with scurvy was attacked with ulceration of the pustule. These small ulcers soon began to slough, and extend over a large extent of surface ; when the superficial sloughs were separated, the parts beneath were found to be in an unhealthy sloughing condition ; finally these ulcers would become phagedaenic, and destroy every structure in their tract for a considerable extent. In this condition gangrene would set in, and if the disease was not speedily arrested by powerful escharotics, emollient poultices, and the proper vegetable diet, amputation became necessary, or the poor sufferer sank under the irritation. Diarrhoea and dysentery frequently supervened, and speedily destroyed the patient. The next and most common form of ulcer with us is what we call the scorbutic ulcer. In cases of scurvy, we have the upper and lower extremities covered with blue or livid spots, varying from the size of a millet seed to three or four inches in diameter, or the whole limb may become of a dark livid or copper color ; the blotches become painful, open, and ulcerate ; this condition continues for a time, when the slough- ing is so extensive as to destroy whole toes, feet, and even arms and legs, the affected parts apparently not having sufficient energy or vitality to set up inflammatory action. The most prominent symptoms of this kind of gangrene are a weak and small pulse ; great prostration of the already enfeebled vital powers ; a dry, glazed tongue ; great anxiety of countenance ; with a foul, grayish slough all over the surface of the wound or ulcer, which discharges a large quantity of filthy and very offensive sanies, destroying everything before it, to the bone. If an operation be not in such cases resorted to, we have hemorrhage, caused by the destruction of the blood-vessels of the part. "We have operated on perhaps twenty or thirty cases in this condition, and we do not HOSPITAL GANGRENE OF ANDERSONVILLE. 529 recollect a single case where the gangrene did not reappear in the stump and speedily destroy the patient. In the other forms of gangrene, however, we have had much better success. Out of perhaps one hundred operations, twenty or thirty are well, and as many others doing well, apparently. We think this a fair estimate of all the capital operations performed in this hospital during the spring and summer. The treatment adopted in all forms of gangrene consists of such tonics as quinine, tincture of iron, tfnctures of salix, eupatorium perfoliatum, and such other indigenous remedies as we can obtain from the woods. We are now making some experiments with a decoction of the baptisma tinctoria, which grows abundantly around the hospital. As local appli- cations, we use nitric acid, nitrate of silver, tincture of iodine, oil of tur- pentine, and Darby's prophylactic fluid, followed by emollient poultices made of powdered flaxseed, or a common mush poultice, made by thickening a strong decoction of red-oak bark with corn meal. The following is a tabular statement of the patients received and treated in one ward, namely, No. 5, second division, Confederate States Military Prison Hospital, Andersonville, during the past three months. We regret not being able to give you a similar report for the entire hospital. NUMBER OP PATIENTS TREATED IN WARD NO. 6, SECOND DIVISION, C. S. M. P. HOS- PITAL, ANDERSONVILLE, DURING THE MONTHS OF JULY, AUGUST, AND SEPTEMBER, TOGETHER WITH FIVE DAYS OF OCTOBER, AND RESULTS OF TREATMENT AS FAR AS KNOWN. Present in Ward. Admitted. Sent to Quarters. Detailed. Trans- ferred. Died. Bemaining in Ward. r-i 68 I-H s a < 77 1 a. 72 ,6 1 62 9 80 S 57 1 12 s P -< i J3 1 Pi GQ CD 1 s 7 •-3 1 D bO 3 < s t 6 1 s o 2 10 1 15 a 1 14 to B -g 1 8 66 bo p < 86 a. OQ 47 «5 o t 7 CO a 66 00 S 79 1 62 O 60 It will be seen by the above statement that we treated, in a little more than three months, 325 patients ; and out of that number 208 have died ; 47 were transferred to other wards ; 13 were detailed for duty in hospital as nurses (after they were cured) ; and 11 were sent to quarters cured, which leaves 50 still in the ward, October 6 ; and out of the 50, there are two or three about well, four or five convalescent, and the remainder pretty badly off". In the month of August, we had in the 5th ward twenty-one opera- tions of all kinds ; out of these cases we had ten deaths', attributable chiefly to diarrhosa and dysentery, while only two or three were caused by recurrence of gangrene in the stump. 34 630 HOSPITAL GANGRENE OF ANDERSONVILLE. In September, we had eleven operations for the same condition, of which seven died from diarrhcea and dysentery. The wliole number of operations for the two months (August and September) were thirty-eight, of which seventeen died, nine were trans- ferred to other wards, six are convalescent in the ward, and we know of four or five others who were transferred to other wards, and who are also convalescent. The deaths, as far as known, are reported in the above. We will now give you a case of what we took for true hospital gan- grene : — J. Mailer, aged twenty-four years. Admitted August 5, with a large sphacelus covering the whole arm, up to within two and a half inches of the shoulder joint. The arm was very much tumefied, and presented around the border of the large sphacelus a kind of erysipelatous inflam- mation ; this inflamed surface was covered with green and yellow spots ; these in turn opened, and discharged filthy and very offensive sanies. The pulse beat 120 to the minute, was weak, and had a peculiar vibratory thrill. Tongue dry and glazed ; very red at the tip and the edges. Bowels a little loose, but not amounting to diarrhcea. Appe- tite poor. Urine scant, and high colored. Complains of considerable pain in affected arm and shoulder ; has copious night sweats ; complains of chilliness of mornings, and fever in the afternoon. (Sulphate of quinia, grs. xx. ; Dover's powder, grs. x. ; mix and divide into eight parts ; one of these powders to be given every six hours, in one fluid ounce of good whiskey. Apply pure nitric acid to the gangrenous parts, and envelop the whole arm in a flaxseed poultice.) August 6. — Patient no better ; is very anxious to have the arm amputated. Gangrene extending. Pulse 125 in the morning, and 137 in the evening. Tongue about the same. Bowels still loose. Appe- tite somewhat improved. Fore-arm oedematous. (Continue treat- ment.) Aiigust 7. — Gangrene still extending above the elbow. Presents a pea-green appearance, and emits an intolerable odor. Pulse 130, at 8 o'clock A. M. ; 141, at 5 o'clock p. m. Bowels painful. Has mucous discharges. Appetite weak. Cannot obtain diet of proper kind. A'ugiist 8. — This morning the gangrene has extended into the shoul- der joint, and half-way to the hand. Pulse 140 in the morning, and 157 in the evening. Patient has dysentery. (Continue treatment, and administer internally turpentine emulsion.) In this condition the patient remained up to the 10th instant, at which time he began to sink, and died on the 14th instant, with the whole arm in a state of sphacelus. Now if this be hospital gangrene, we have had quite a number of cases We will now endeavor to answer the questions upon hospital gan- HOSPITAL GANGRENE OF ANDERSONVILLE. 531 grene with which you honored us, whilst prosecuting your investiga- tions amongst the sick and wounded of the Confederate States Military Prison Hospital. We take the ground that we have hospital gangrene in its most ag- gravated form in this hospital ; and also that it has prevailed, and is still prevailing to an alarming extent amongst these unfortunate prison- ers. We regard the sloughing phagedaena, so common and so fatal in its consequences, as a true type of this disease. We have had under our immediate care a goodly number of cases of this disease within the last few months, and have witnessed a great many more in other wards, and have consulted with various medical gentlemen on the subject, and find but few who differ in opinion with reference to the disease usually diagnosed phagedasna gangraenosa being hospital gangrene. From the experience we have had with hospital gangrene, we regard it as a constitutional disease, from the fact that it is invariably attended with constitutional symptoms, generally of a low grade. These symp- toms may or may not precede the local invasion of the disease. If the constitution of the patient is greatly deteriorated by previous disease, as from scorbutus or chronic diarrhoea, we usually have primary symp- toms, such as great depression of the vital powers, anxious counte- nance, quick and feeble pulse, and a dry, red, or glazed tongue. Fever and other constitutional disturbances are invariably met with in this disease, but do not always precede it. When the disease is brought on in healthy patients, with fresh wounds, by contagion, we have the above symptoms following the local disturbance or invasion of the dis- ease. We have had no chance of settling the question of contagion in this hospital. Our patients have been crowded together on the same ground with other patients, suffering from the various diseases incident to the prisoners, and in very many instances in the same tent, or even in the same bed. Again we have only one wash-pan to the tent, and it is utterly impossible for the nurses, if they were ever so particular, to keep those who have no gangrene from using the same basin as the gangrene patients. The same sponge is doubtless often used for every •patient in the tent ; and owing to the great scarcity of bandages, we are compelled to use the same several times, and in washing they are not unfrequently changed, and applied to healthy wounds, and thus the dis- ease may be transmitted from one patient to another by actual contact. So we are not in possession of the proper data to justify us in giving an affirmative answer as to the disease being contagious ; but from our limited experience with the disease, and from what we know of its na- ture and general character, we are inclined to the opinion that it is highly contagious. We have not the least doubt of the constitutional nature of the dis- ease, but cannot speak from experience of the success of a strictly con- 632 HOSPITAL GANGRENE OF ANDERSONVILLE. stitutional treatment. "We are always so anxious to relieve our patients of whatever disease they may chance to have, that we make every effort for their relief in pur power ; hence we have never treated this disease without using local applications, nor do we believe that we would be justified in making the experiment of treating hospital gan- grene by constitutional means only. "With the life of a human being in our hands we would not think of risking constitutional treatment alone, therefore we cannot answer the question from experimental knowledge. Hospital gangrene may appear in slight wounds, even in perfectly healthy patients, if they should be exposed to the atmosphere in which patients are confined who are suffering from this disease. Having never tried the experiment of inoculation with gangrenous matter, we cannot speak positively, but we have no doubt that we should have a modified form of the disease as a result. "We do not believe that this disease ever originates spontaneously in well regulated and properly ventilated hospitals, unless the patients are overcrowded and neglected. Still, such cases are on record ; but -it will be remembered that at the time of their occurrence other diseases were prevailing epidemically, such as influenza, erysipelas, and phlebitis, which may, under certain circumstances, act as one of the causes of this affection. Influenza prevailed very extensively in the prison about the time this disease originated, and may have had something to do with its production. Let the causes be what they may, when the disease is once established in an extensive hospital, it generally spreads rapidly by con- tagion, or otherwise, and its rapid spread is only checked by isolating all who are affected with the disease from the other sick and wounded. The essential conditions and causes of the disease under considera- tion are of various kinds, such as derangement of the blood, over- crowding in hospitals, a lack of proper cleanliness, and insufficient ven- tilation. In fact, everything which causes diseases of a low form might be enumerated as causes of this truly formidable disease. . . . "Very respectfully. Your obedient servant, A. THOENBURGH, AssUtant-Surgeon P, A, C. ers at An- four hours off, dunng the twenty-four hours. Before leaving dersonviiie. home received a slight scratch on the side of the left foot, a little below the ankle. This boy did not usually wear shoes at home, and on the way to Andersonville the shoes bruised and enlarged the small injury. This small abrasion did not heal after the commencement of his duties as a soldier at Andersonville. It did not, however, give him any special trouble, or appear inflamed, until about the first of September, three weeks ago, and forty-two days after his arrival at this post. Up to this time this young recruit had never been inside the stockade, and had never stood guard around or within the hospital. On the 4th of September, the patient was com- pelled to quit duty, and on the 12th instant (ten days ago), he was transferred to the Confederate General Hospital. At the time of his entrance into the hospital the gangrenous spot was not larger than a silver half dollar, and presented an inflamed areola in the sound skin, elevated, everted edges, and elevated, pulpy, ragged, greenish and grayish central mass. Up to the present time, the gangrene has spread rapidly, and the wound now presents the appearance represented in the following figure, which I rapidly sketched from life. (Plate No. XLI.') Hemorrhage was constantly taking place from numerous small eroded vessels, and hence the red and mottled appearance of certain portions of the gangrenous mass. Several smaller gangrenous spots were visi- ble upon the leg, and are represented in the figure. These are said to have arisen spontaneously ; that is, without any preceding abrasion or injuryi The black mass in the centre of the large ulcer upon the ankle joint appeared to be the surface of the necrosed bone. The constitutional symptoms were well marked in this case. At night when I examined the patient, he had hot fever, with rapid pulse, pale, anaemic, sallow, unhealthy complexion. This morning, has less heat of surface, and the pulse is less frequent, but still tliere is febrile excitement, and he is very nervous and weak ; cries like a child when his wound is touched, even in the gentlest manner. Bowels loose ; had a large, loose, yellow, very offensive evacuation whilst I was engaged in executing the sketch. In this Confederate hospital at Andersonville, I observed a patient with the thigh amputated at the lower third; the history of Another caw this case was similar to that just given. theo'rTgiSof 1 Omitted. 534 HOSPITAL GANGRENE OP ANDERS ON VILLE. hospital gan- rphls Confederate soldier had suffered for several years *™°°sst the ^ith a small indolent ulcer of the foot. After coming to An- aoidiers dersonville, and performing guard duty for several weeks, this guarding tlie , , ' ^ , , • j, i Federal pris- ulcer became gangrenous, and the parts were so rapidly and deraonvuie. extensively disorganized, and the bones denuded of muscles, that amputation was deemed necessary. At the time that I examined this patient, he was isolated in a tent. After the amputation, gangrene reappeared in the stump, but the use of nitric acid, and the constitutional treatment with quinine and tinct- ure of the sesquichloride of iron, arrested the progress of the disease, and the stump is now suppurating. The pus, however, is unhealthy, thin, and offensive, and the constitutional symptoms are unfavorable — weak, feeble, rapid pulse, hectic flush on cheek, sallow, unhealthy, leaden hue of complexion, bowels loose, no appetite, depressed spirits. I instituted a series of post-mortem examinations designed to Post-mortem illustrate and determine the true causes of the great mor- tions con- talitv amongst the Federal prisoners confined at Ander- ducted by ./ o i author at sonviUc. The following observations are selected as Tiiie. illustrations of the subject now under consideration : — Case LV. — Julius Bozwood, sergeant, Company I, 15th New York Case LV. Cavalry. Jew by birth and religion ; hatter by occupation the"orS^n'^ before entering the United States service. Was captured on ofho"pite7 the 14th of May, near Newmarket, Virginia, 1864. Arrived Kraou-"' ^' Andersonville on the loth of June, 1864. During his Tiiie. confinement in the stockade, accidentally stuck a small splinter into the plantar surface of the left foot This occurred shortly after his entrance into the Confederate States Military Prison. The patient states that this slight injury pained him, and commenced to ulcerate shortly after wading in the filthy mud along the banks of the stream flowing through the stockade. The patient expressed his firm belief that this mud had poisoned the wound. Assistant-Surgeon A. Thornburgh, furnished me with the following facts and outline of this case. The ulcer became gangrenous about the 3d of July, and continued to increase in size up to his admission into the Confederate Military Prison Hospital, on the 10th of this month. At the time of his entrance into the hospital the patient was found to have a large mass of black putrid matter imhiediately under the instep of the right foot. The edges of the gangrenous mass were swollen, everted, and surrounded by a circle half an inch wide, and of a livid hue. Pulse, 78 ; tongue slightly furred; respiration natural; urine high colored ; appetite good; bow- els regular, with natural discharges; no appearance of scurvy. The gangrenous parts were freely touched with nitric acid, morning and evening, and dressed with flaxseed poultices. HOSPITAL GANGRENE OF ANDERSONVILLE. 535 This treatment was continued to the 14th, when a large slough sepa- rated, leaving the parts exposed nearly to the bone. The diseased parts were then bathed freely in a strong solution of chlorate of potassa. Ten drops of the tincture of sesquichloride of iron were administered three times a day, and the wound dressed with simple cerate. Under this treatment the patient continued to improve up to the 1st of Au- gust, at which time the ulcer was covered with healthy granulations. August 2. — The ulcer looks pale, with dark or livid spots about the centre. Margin of ulcer livid and everted. (Nitric acid to the parts, followed with flaxseed poultice. Continue tincture of the sesquichlo- ride of iron.) August 3. — "Whole foot tumefied ; edges of ulcer completely everted. The entire surface of the ulcer of an ashy hue, with a dark or muddy a,nd vilfy offensive discharge. Pulse 100 in the morning, and 115 in the evening. Tongue coated with thick, brown fur. Appetite fail- ing. Yellow patches are appearing in the livid circles surrounding the ulcer. August 4 — No improvement ; condition much the same. August 20. — No improvement, and the condition of the patient has continued with little alteration since the last observation. At the pres- ent time the pulse is 114, and very compressible and feeble. Tongue coated, with dark color and dry fur. No appetite ; urine scant and high colored. Slight cough, with pain in right side near the fifth intercostal space. (Quinine, grs. xii. ; Dover's powder, grs. xv. ; mix, divide into five powders, and give one every six hours in whiskey.) August 23. — Patient much the same. Continue treatment. August 27. — Patient says that he feels much better, but has consid- erable oedema of the lower extremities, and slight tumefaction of abdo- men. Pulse, 107. No improvement in appetite. Urine still scanty and high colored. The whole ulcer in a state of sphacelus, much larger than at any previous period. (Discontinue quinine; resume tincture sesquichloride of iron, gtts. xx., three times a day ; Dover's powder, grs. x., at bed-time. Apply nitric acid to ulcer, and follow with flaxseed poultices.) September 4. — Patient growing worse. Pulse 125, very feeble. Skin of extremities cool. For some time has been suffering with diar- rhoea, which on the 2d instant increased to a most troublesome and dangerous extent. Last night the patient passed bloody mucus from the bowels. No appetite. Intellect clear. Vital forces appear to be failing fast. Pain in the bowels considerable, and the abdomen is much swollen, and is tympanitic. (Turpentine emulsion, tea-spoonful every six hours; whiskey, fsii., during the day.) Diet such as the prison hospital affords, and not what could be desired in such a case, consist- ing of boiled beef and rice, and unbolted corn meal, without milk, tea, coffee, or butter. The patient is unable to eat his rations. 536 HOSPITAL GANGRENE OF ANDERSONVILLE. SepUmher 10. — Pulse 131, a. m. ; 137, p. m. ; weak and thready. The bloody discharges mixed with mucus have nearly disappeared, and the discharges from the bowels present more nearly the appearance of those of diarrhoea. Continue treatment. September 12. — Continues to grow worse. Bowels still swollen and tympanitic. Ulcer looks dry and black from passive hemorrhage last night. September 15. — Patient says that he is dying. Pulse 141, very feeble. His complexion has presented an ashy, deathlike hue for several days. Tongue dry and hard. Has no appetite or power to eat September 18. — Died at six o'clock p. m. Autopsy, Eighteen Hours after Death. — Exterior. — Body greatly reduced in flesh, but the emaciation was not so great as in many other cases which I examined. Gangrenous ulcer in plantar surface (bottom) of left foot, oval in shape, between three and four inches in diameter, and extending entirely across the hollow of the foot, rose up for an inch or more along the inner side of the foot, and involved extensively the ligaments, tendons, and bones of the instep. This ulcer was of a dark greenish and pur- plish hue, and emitted a most horrible stench. I dissected the femoral and popliteal veins of the diseased leg, and drew out a firm clot of coagulated blood. The arteries were empty. The blood-vessels leading to and from the ulcer and diseased struc- tures, were carefully examined, but no pus was discovered. It is a matter of interest that there should have been so marked coagulation of the blood in this case of hospital gangrene; while in those bodies in which gangrene had not appeared, the blood in all parts and in all the blood-vessels was fluid. Reaction of gangrenous ulcer alkaline. Head. — Dura-mater healthy. The longitudinal and lateral sinuses contained well defined and firm clots of coagulated blood, which could be drawn out, and possessed considerable tenacity. Arachnoid and pia-mater more congested than in the cases uncom- plicated with gangrene ; but in the present case those membranes pre- sented no marks of inflammation, and nothing abnormal beyond a moderate degree of congestion. The intellect had been clear up to the time of death. The arachnoid was separated from the pia-mater by light yellow serous fluid, which also infiltrated the fibrous tissue of the pia-mater. The lateral ventricles of the brain contained each about three fourths of a fluid ounce of serous fluid. The structures of the brain appeared to be normal, being neither softened nor hardened, nor altered in color. HOSPITAL GANGRENE OF ANDERSONVILLE. 53T Chest. — Heart somewhat larger than usual, and of a brownish yel- low, pale color. The pericardium and heart showed marks of a former attack of peri- carditis and endocarditis ; fibrous matter (coagulable lymph) had been thrown out extensively upon the external surface of the heart, and upon the internal surface of the pericardium, and the valves of the heart were also thickened from this deposit, the result of inflammatory action. This fibrous deposit was of long standing, and the inflammatory action in which it was thrown out must have long preceded the last fatal illness, and from all appearances occurred before the entrance of this soldier into the United States service. The right auricle and ventricle contained a large golden-colored polypus (fibrous concretion), which sent branches several inches in length into the pulmonary arteries. The fibrous clots were in great measure free of colored blood corpuscles, and were firmly attached to the columnae carnae and cordae tendinse. The left auricle and ventricle also contained golden-colored fibrous clots, attached in a similar manner. Lungs. — Numerous adhesions of an old date. These adhesions were firm, elastic, and by no means of recent date. These organs were somewhat congested, and when cut, mucus, mixed with some pus, issued from the bronchial tubes. Abdominal Cavity. — Liver slightly darker and more mottled than in health, upon the anterior surface ; upon the inferior surface, of a slate color, like that of malarial fever. Structure of liver firm. Spleen. — Enlarged, about twice its natural size, but not softened, and the enlargement appeared to be the result of a previous attack of mala- rial fever. Pancreas healthy. Alimentary Canal. — Stomach distended with gas, and of a greenish yellow and gray color upon the exterior. Mucous membrane of stomach of a greenish-yellow color, with numerous dark purple and almost black arborescent patches of gangrene. SmaU Intestines. — The mucous membrane of the intestinal canal was generally of a slate and brownish-gray color, and softened, as if in a gangrenous state. The small intestines were distended with gas, and upon the exterior presented a bluish and greenish color. Large Intestine. — Ulcers were scattered over the mucous membrane of the colon, which presented blue, gray, ash, and greenish-yellow colors. No appearance of ordinary red blood was seen in the blood- vessels of the mucous membrane, although they were filled with this fluid in an apparently disorganized state. The appearance of the mucous membrane of the colon in this case is represented in Plate No. L.^ The mucous membrane of the rectum was extensively ulcerated, and covered with a yellow fibrous deposit. The mucous membrane of the 1 Omitted. 538 HOSPITAL GANGRENE OP ANDERSONVILLE. rectum was also in a state of gangrene, and presented a bluish and grayish color. Plate L.^ represents the general appearance of the mucous membrane of the rectum in this case. The walls of the abdomen presented a dark greenish hue, and the muscles presented a dark purplish and greenish color, as represented in Plate L. The dark-colored blue muscles of the abdominal walls gave an alka- line reaction ; and when the muscular fibres were examined under the microscope, numerous prismatic crystals of triple phosphate were dis- covered amongst the fibres. Commentary. — This case presented all the local and constitu- cornmeu- tional symptoms of hospital gangrene. I examined the ^^- patient carefully upon several occasions, and found the pulse very frequent and feeble, and the complexion of a sickly, sallow, leaden hue ; the countenance anxious and depressed ; the temperature elevated above the normal standard, and subject to marked variations during the twenty-four hours. The fact that the prisoners in most cases attributed the origin of gangrene in the foot to the poisonous action of the morass of human excrement on the banks of the stream in the stockade, does not at all demonstrate that this mud vi'as capable of poisoning a wound and rendering it gangrenous, for gangrene attacked the upper extremities after injuries, just as frequently as the lovirer. And gangrene followed railroad accidents, gunshot wounds, and even vaccination and amputation, within a short period, and in some instances within fifty hours after the reception of the injury. In my numerous examinations of the wounded in the filthy tents and in the foul atmosphere of the hospital, I observed every variety of appearance in the stump after amputation, from fully developed gangrene to the denuded stump, with the dead bone protruding several inches ; and after an inquiry into the various causes, was led to refer the extensive prevalence of the disease to the condi- tion of the patients, induced by long confinement, sameness of diet, salt meat, scurvy and exposure, and filth and crowding, and to the extensive use of rags which had been applied to gangrenous wounds, and to the neglect of all those precautions so essential to prevent the spread of a contagious disease like hospital gangrene. The presence of clots in the heart and veins, in this case of hos- pital gangrene, whilst they were entirely absent from the cases which had never suffered from gangrene, was of interest as sus- taining the view that gangrene is accompanied with inflammatory 1 Omitted. HOSPITAL GAJSGRENE OF ANDERSONVILLE. 639 action in the general system, as well as in the textures surround- ing the local disease, in which action the fibrous element and coagulability of the blood is increased, even in those patients who had been reduced in flesh and exhausted by bad food and diar- rhoea. The change in the color of the mucous membrane of the intes- tinal canal appears to have been ante mortem to a great extent, and was probably due in great measure to the absorption and action of the poison of iiospital gangrene. Case LVL Federal prisoner. Confederate States Military Prison Hospital, Andersonville, Georgia. A small injury in the caseLVi. hand, from a sharp bone, whilst this prisoner was performing th"ori^S'^ police duty in the hospital grounds, was followed by hospital „? hosp'itef gangrene, and the fore-arm was amputated near the elbow f^^j^^™.*' joint. Gangrene appeared again, and the arm was amputated "U"- about three inches from the shoulder joint Gangrene appeared again ; but under local and constitutional treatment the stump appeared to im- prove. At the time of my examination, two days before the death of this patient, the stump appeared to be doing pretty well, as far as the absence of great swelling and discoloration of the skin extended ; but it emitted a thin, stinking sanies. Notwithstanding that there was but little swelling and discoloration of the external cutaneous surface, the discharge from the stump was thin, greenish, unhealthy, and fetid. The flaps appeared to be partially united, and the bone was not exposed. The patient, however, was very weak, and greatly emaciated from an exhausting and obstinate diarrhoea, and from the effects of the amputa- tions and gangrene. The absence of swelling in the stump may have been due in great measure to the reduced condition of the patient and the exhausting diarrhoea. AtiTOPST, Six Sours after Death. — Exterior. — Emaciation extreme ; a mere skeleton. "Wound with dark brown and green edges, and emit- ting a fetid, bloody, and sanious fluid, with a most disagreeable gan- grenous odor. When an incision was made from the wound upwards to the shoulder joint, the structures were found to be thoroughly disor- ganized and broken down, gangrenous, and infiltrated with dark gru- mous blood. The bones of the head of the humerus, and neck of scapula, were rough, completely denuded of periosteum, and apparently dead. The surrounding muscles were disorganized, and readily crushed upon slight pressure. Notwithstanding this extensive disorganization of the internal structures, the skin showed no discolorations, except a slight greenish tinge, and several small blisters. There were no signs upon the exte- rior indicating the extent of the internal disorganization. In fact, I had 640 HOSPITAL GANGRENE OF ANDERSONVILLE. been informed by the attendant physician, only a day or two before the death of this patient, that the wound was doing well, and was free of gangrene. T examined the subclavian, vena innominata, and jugular veins, but did not discover any pus in these vessels, or any marks of inflammation or disorganization in their coats. The adjacent lung also was examined with care, without discovering any evidence of the transference of the gangrene to this organ. A small isolated abscess, filled with pus, was discovered in the walls of the abdomen, just over the region of the bladder, and above the symphysis pubis. Reaction of gangrenous matter in stump of arm alka- line. Head. — Brain presented the same appearance as in the preceding cases. Dura mater healthy. Serous effusion, between arachnoid and pia mater. Ventricles filled with light yellow, clear, serous fluid. Struc- tures of cerebrum, cerebellum, medulla oblongata, and spinal cord with- out any appearance of disease, and apparently healthy. Thorax. — The heart contained well-formed fibrous clots, as in the preceding case. Pericardium, as in the preceding case, distended with yellow serum. Muscular structure of heart of a pale, brownish yellow color, anaemic and flabby. Lungs. — Healthy. Abdominal Cavity. — Alimentary Canal. — Upon the exterior greatly congested, and dark-colored in different portions. Stomach. — Mucous membrane highly rugose, with rose-colored, punc- tated, congested rugae. Small Intestines. — Mucous membrane apparently healthy in many parts, but in other portions highly congested, especially in the region of the ileo-caecal valve. Large Intestine. — The mucous membrane of the colon, near the ileo- caecal valve, was of an intense red color, as represented in Plate No. LI.^ Under the magnifying glass the villi of the intestine appeared swollen, and in some portions of the intestines they were absent, as if these structures and the epithelium had been denuded. In all the highly congested portions of the intestinal mucous membrane, the villi were intensely congested, and the mouths of the tubuli (tubular or Lieberkiihnian glands — cryptae mucosae) appeared to be filled with blood. Through large tracts of the colon the congestion was as intense as that represented in Plate No. LI., and resembled the surface of raw flesh ; and under the magnifying glass the tubular glands pre- sented the same appearance as if their mouths were filled with blood. The rectum was greatly but not uniformly congested. Plate No. LI. represents the appearance of the rectum in the most highly congested portions. 1 Omitted. HOSPITAL GANGRENE OP ANDEKSONVILLE. 541 Liver. — This organ presented a darker color than in the preceding case, and the lower surface was of a slate color. Spleen. — Enlarged about three times its normal size, but firm in structure, and not softened. If this change was not the result of mala- rial fever, it was of long standing. Gall bladder distended with bright yellow bile. The stomach contained much bilious matter mixed with mucus ; and as in other cases which had been similarly affected with chronic diarrhoea, the entire alimentary tract contained bile in large quantities. Pancreas healthy. Kidneys healthy. Reaction of contents of colon and rectum alkaline. Case LVII. Federal prisoner. Confederate States Military Prison Hospital. Death caused by diarrhoea, dysentery, and super- ^^^^^^ vening gangrene, September 20, 1864. 'tth*h"^° Autopsy, Twelve Hours after Death. — Exterior. — A mere p'«ai b»°- 11 !,■ Ti.i -r»T grene at An- skeleton. Sunken eyes, and thm, wasted limbs. Bed-sore dersonviue. over region of sacrum. The anus appeared to be gangrenous. When the body is laid upon the face, the anus is very much relaxed, and it is possible to look into the rectum for the distance of an inch or two. It presents the appearance of the parts in hospital gangrene ; the edges are swollen and everted. The color is of a bluish green, and numerous small maggots are crawling in and out. Head; Brain. — Blood-vessels filled with blood. This brain is somewhat more congested with blood than in the other cases of diar- rhoea, but presents nothing abnormal, however, as far as the amount of blood and the consistency of the structures are concerned. Serous effusions between the membranes of the brain ; cedema of the fibrous tissue of the pia mater, as in the preceding cases. Substance of brain somewhat more watery and serous than usual in those dying in compar- atively vigorous states, and in comparatively healthy conditions of the blood. Ventricles of the brain filled with light yellow serum. Struc- ture of brain normal, neither softened nor indurated. Thorax, — Heart pale, anaemic. Right auricle and ventricle con- tained heart clots, partially devoid of red corpuscles. Lungs with old adhesions, but apparently healthy. Abdominal Cavity. — Liver dark mottled color ; slate and purple upon the anterior surfaces, and slate-colored upon the posterior. When cut, the liver was found to inclose numerous bubbles of gas, and it was evident that decomposition had progressed to a considerable extent. The peculiar color of the liver appeared to be due to its decomposition ; and from the comparatively short period which had elapsed after death, as well as the condition of the intestinal canal, it is probable that the liver was in a state of incipient gangrene at the time of death. Spleen. — Enlarged to three times its natural size, but not specially softened. This enlargement was evidently not recent. It is probable 542 HOSPITAL GANGRENE OF ANDERSONVILLE. that at some former time this patient had suffered with malarial fever. Alimentary Oanal. — The mucous membrane of the stomach and intestines presented a green and grayish, bluish mottled appearance, with black patches. The structures were softened, as if in a gan- grenous state. The colon and rectum throughout their entire extent were ulcerated, and the ulcerations presented evidences of gangrene, being green and bluish and black, and emitting the disagreeable odor of hospital gan- grene. Plate No. LL* represents the color and appearance of a large ulcer, and of the surrounding mucous membrane in the transverse colon. Commentary. — As far as we were able to form an opinion in this commen- case, the alterations in the color of the mucous mem- ^^^' brane of the alimentary canal in a measure preceded death. If it be true that gangrene supervened in the diseased intestinal structures before the close of life, and probably in the seventy hours preceding death, the important fact is established, that hospital gangrene, or a disease resembling it in all essential respects, may attack the intestinal canal of patients laboring under diarrhoea and dysentery, accompanied with ulcerations of the mucous membrane, although there be no local manifestations of gangrene upon the surface of the body. Case LVIII. Hospital gangrene accompanied with chronic diarrhoja. iHustaStta''' F^'^Sf'^l prisoner. Confederate States Military Prison Hos- 'henature pital, Andersonville, Georgia. pitaigan- This patient had injured his foot slightly in the stockade, dersonTiiie. by Striking against a small stump. The injured limb (left leg) was amputated at the lower third, in consequence of the extensive ravages of hospital gangrene in the foot. Gangrene reappeared in the stump, and ten days after the amputation the patient died. Autopsy, September 21, 1864, Six Hours after Death. — Exterior. — Body emaciated, but not to so great an extent as in the preceding case. Stump of left leg swollen. The bones project from the ragged, gan- grenous mass two inches. Large, deep, and dark-colored bed-sore upon the sacrum. Head. — Brain presented much the same appearance as in the pre- ceding cases. Blood-vessels moderately filled with blood. Nothing unusual in the appearance of the brain, except the effusion of serum between the membranes and into the lateral ventricles of the brain. Structures of the brain and medulla oblongata appeared to be normal. Coagulated blood in the longitudinal and lateral sinuses. The appfear- ance of the brain is represented in Plate No. LIL' after the removal of the dura mater. 1 Omitted. 2 Omitted. HOSPITAL GANGRENE OF ANDERSONVILLE. 643 Thorax ; Lungs. — Numerous old adhesions ; otherwise healthy. Heart. — Pale, and of a brownish yellow color. Fibrous concretions of golden color on both sides of heart, and one clot extended into the aorta for several inches, and was free from colored blood corpuscles. Pericardium contained several fluid ounces (about fsv.) of golden-col- ored serous fluid. Abdominal Cavity. — Liver of a brownish-yellow color, with distinct lobules, the lobuli being of a brownish-yellow color, and surrounded by a border of purplish blood-vessels. The liver was cirrhosed, and cut like fibrous substance under the knife, and the lobules started out from the cut surface. This cirrhosis appeared to have been of months' if not of years' standing, and had, perhaps, little or nothing to do with the dis- ease and death of the patient. Spleen. — This organ was enlarged about three times the natural size, and somewhat softened. Alimentary Canal ; Stomach. — This viscus presented no special de- rangement, and contained, as usual, much thin bilious matter mixed with the food. Small Intestines. — The mucous membrane of the intestines presented a grayish and bluish mottled appearance, and was softened, and evi- dently in a state of gangrene. The colon and rectum were extensively ulcerated, and were in a state of gangrene, and presented a lead gray and bluish color. This case was examined six hours after death, so that these gangrenous marks in the intestinal tract were evidently not post-mortem changes. Examination of Stump. — The gangrenous stump was carefully exam- ined and dissected. The tissues above the seat of the gangrene, up to the junction of the thigh with the trunk, were extensively swollen and infiltrated with serum. I dissected out the femoral vein, and found it filled with a firm clot of coagulated blood, which was readily drawn out for several inches in length towards the seat of the disease. The gan- grene did not extend into the structures more than an inch or two from the wound. Commentary. — The following facts are worthy of note in this case ! Oommen- 1. The gangrenous state of the intestines. This state, '*^- as shown by previous autopsies, was not peculiar to those who had died with gangrenous wounds, but was found in those who never had gangrene in any external wound, and who had no abrasion upon the surface. 2. The coagulation of the blood in the heart and in the veins leading to the gangrenous wound. It is worthy of note, that in those cases in which gangrene existed in the wounds or in the bowels, clots were found in the 544 HOSPITAL GANGRENE OF ANDERSONVILLE. heart and in the sinuses of the brain, and in the blood-vessels of the diseased limb, whilst in those cases in which no gangrene existed, as a general rule, no coagula were found, the blood being uncoagulated, fluid, and watery. Case LIX. Calwell, Federal prisoner. Confederate States Military uu^trath) Prison Hospital, Andersonville, Georgia. Death resulting *«»"'»"= from obstinate diarrhoea and dysentery, and supervening gan- pitaigan- grene, September, 1864. grene of An- o * ' deraoQTiiie. AuTOPST, Four Hours after Death. — Exterior. — Great emaciation. Head. — The brain presented the usual appearance. Serous effu- sions between the membranes and into the lateral ventricles in consid- erable quantities. Structure of brain otherwise healthy. No unusual congestion of blood-vessels. The appearance of the brain is repre- sented in Plate No. LII.^ Thorax. — Heart pale, anaemic. When cut, the muscular structure of the heart presented a pale reddish brown color. The general appear- ance presented by the heart in this case, and in fact in all the Federal prisoners examined after death, is represented in the sketch, Plate No. LH. Fibrous clots in right side of heart Pericardium filled with golden-colored serum. Lungs. — Healthy. Several old adhesions. Abdominal Cavity. — Liver of a purplish and yellowish mottled color. Lobules distinct. Cut surface more yellow than usual. Structure firm. Cirrhosis commencing. Spleen slightly enlarged, but healthy. Kid- neys pale, but healthy. Alimentary Canal. — Stomach appeared healthy, and was not unusu- ally congested. Small Intestines. — Greatly congested in patches, and the mucous membrane appeared thickened and softened. Glands of Peyer and solitary glands neither enlarged nor softened, and not more congested than the surrounding mucous membrane. Large Intestine. — Mucous membrane of colon and rectum of a greenish grayish black color, ulcerated and gangrenous. The ulcera- tions were almost entirely black in color. The gangrene was confined almost entirely to the ulcerated colon and rectum. The gangrene of the large intestine in this case evidently preceded death, and was not a post-mortem change. From the preceding observations upon the hospital gangrene of Andersonville, we draw the following general conclusions : — 1. Scurvy, arising from sameness of food and imperfect nutri- ci™?OT8""' *^°"'' caused directly or indirectly nine tenths of the deaths drawn from amongst the Federal prisoners at Andersonville. From 1 Omitted. HOSPITAL GANGRENE OF ANDEESONVILLE, 545 the sameness of the food, and from the action of the poi- f^^JJ^^ sonous gases in the densely crowded and filthy stockade ti,°°^"sKi and hospital, the blood was altered in its constitution, even J^^l^o* °' before the manifestation of actual disease. In both the ■""'• well and sick the red corpuscles were diminished ; and in all dis- eases uncomplicated with inflammation, the fibrinous element was deficient. In cases of ulceration of the mucous membrane of the intestinal canal, the fibrinous element of the blood appeared to be increased ; whilst in simple diarrhoea, uncomplicated with ulcera- tion, and dependent upon the character of the food and scurvy, it was either diminished or remained stationary. The fibrin was increased in the cases of hospital gangrene. In cases of this dis- ease in the extremities, and in cases of gangrene of the intestines, heart clots and firm coagula were universally present. The pres- ence of these clots in the cases of hospital gangrene, whilst they were absent in the cases in which there were no inflammatory symptoms, appears to sustain the conclusion that hospital gangrene is a species of inflammation (imperfect and irregular though it may be in its progress), in wliich the fibrinous element and coagula- bility of the blood are increased, even in those who are suffering from such a condition of the blood, and from such diseases as are naturally accompanied with a decrease in the fibrinous element. 2. A scorbutic condition of the system appeared to favor the origin of foul ulcers, which frequently took on true hospital gan- grene. Scurvy consists not only in an alteration in the constitu- tion of the blood, which leads to passive hemorrhages from the bowels, and the effusion into the various tissues of a deeply colored fibrinous exudation, but, as we have conclusively shown by post- mortem examinations, this state is also attended with profound alterations in the appearance and consistence of the muscles of the heart and of the mucous membrane of the alimentary canal, and of the solid parts generally. We have, according to the extent of the deficiency of certain articles of food, every degree of scorbutic derangement, from the most fearful depravation of the blood and the perversion of every function subserved by the blood, to those slight derangements which are scarcely distinguishable from a state of health. 3. The fact that hospital gangrene appeared in the stockade first, and originated spontaneously without any previous contagion, and occurred sporadically all over the stockade and prison hospital, was proof positive that this disease will arise wherever the condi- tions of crowding, filth, foul air, and bad diet are present. The 546 HOSPITAL GANGRENE OF ANDERSONVILLE. exhalations from the hospital and stockade appeared to exert their effects to a considerable distance outside of these localities. The origin of gangrene amongst these prisoners appeared clearly to depend in great measure upon the state of the general system, induced by diet, exposure, neglect of personal cleanliness, and by various external noxious influences. The rapidity of the appear- ance and action of the gangrene depended upon the powers and state of the constitution, as well as upon the intensity of the poison in the atmosphere, or upon the direct application of poisonous mat- ter to the wounded surface. This was further illustrated by the important fact that hospital gangrene, or a disease resembling this form of gangrene, attacked the intestinal canal of patients laboring under ulceration of the bowels, although there were no local man- ifestations of gangrene upon the surface of the body. 4. Gangrenous spots, followed by rapid destruction of tissue, appeared in some cases in which there had been no previous or existing wound or abrasion ; and, without such well-established facts, it might be assumed that the disease was propagated from one patient to another in every case, either by exhalations from the gangrenous surface, or by direct contact. In such a filthy and crowded hospital as that of the Confederate States Military Prison, of Camp Sumter, Andersonville, it was impossible to isolate the wounded from the sources of actual contact of the gan- grenous matter ; the flies swarming over the wounds, and over filth of every description ; the filthy, imperfectly washed, and scanty rags ; the limited number of sponges and wash-bowls (the same wash-bowl and sponge serving for a score or more of patients), were one and all sources of such constant circulation of the gangrenous matter, that the disease might rapidly be propa- gated from a single gangrenous wound. Whilst the fact already considered, that a form of moist gangrene resembling hospital gan- grene was quite common in this foul atmosphere, in cases of dysen- tery, both with and without the existence of hospital gangrene upon the surface, demonstrated the dependence of the disease upon the state of the constitution, and proves in a clear manner that neither the contact of the poisonous matter of gangrene nor the direct action of the poisoned atmosphere upon the ulcerated sur- face, is necessary to the development of the disease ; on the other hand, it is equally well established that the disease may be com- municated by the various ways just mentioned. 5. The unfortunate accidents which followed vaccination in certain cases, were referable chiefly to the scorbutic state of the HOSPITAL GANGRENE OF ANDERSONVILLE. 547 patients, and the tendency of all abrasions and wounds, however slight, to assume gangrenous ulceration. 6. In the depressed condition of these prisoners, and in the foul atmosphere of the military prison hospital of Andersonville, ampu- tation did not arrest hospital gangrene ; the disease almost inva- riably returned. Almost every amputation was followed finally by death, either from the effects of gangrene or from the prevail- ing diarrhoea and dysentery. Nitric acid and local applications generally, in this crowded atmosphere, loaded with noxious effluvia, exerted only a tempo- rary effect ; the gangrene would frequently return with redoubled energy after its application ; and even after the gangrene had been entirely removed by local and constitutional treatment, it would return and destroy the patient. 7. Great as the rate of mortality from hospital gangrene appears to be amongst these Federal prisoners, it was equaled by the mortality from this disease before its treatment was well known, and when, as in the present instance, the medical officers did not have the necessary medicines and diet. CHAPTER SIXTH. Treatment of Hospital Gangrene. — Measures for the Prevention of the Disease. — Impor- tance of Ventilation in Hospitals. — Danger of crowding Wounded into Box Cars. — Value of Disinfectants. — Importance to Wounded Men of Good, Nutritious Diet, and Cleanliness of Person and Clothing. — Constitutional Treatment of Hospital Gangrene; Principles upon which this should be based. — The Indications in the Treatment of Hos- pital Gangrene; first, to remove the Patient from all Causes which depress the System and deteriorate the Blood; second, to eliminate the Deleterious Agent; third, to re- store the System to such a Condition that Healthy Nutrition, Keparation, and Inflamma- tion may take Place; fourth, to induce such Changes in the Injured Parts as will lead to a Complete Separation between the Diseased and Dead Structures; tifth, to destroy all Poisonous Matters in the Diseased Parts ; sixth, the Stimulation of the Capillaries and Structures around the Seat of Local Disease to Healthy, Active, Inflammatory Action. — Value of Quinine, Tincture of Sesquichloride of Iron, and Alcoholic Stimulants in the Constitutional Treatment of Hospital Gangrene. — Importance of Concentrated and Nu- tritious Diet: Milk, Beefsteak, Mutton, Soft-boiled Eggs. — Local Treatment of Hos- pital Gangrene. — Importance of clearing out all Dead Gangrenous Masses and Tissues. — Value of Nitric Acid; Method of its Application. — Mode of using Poultices. — Stimulating Applications, Oil of Turpentine, Tincture of Iodine, etc. — Value of Arsen- ical Applications in the Treatment of Hospital Gangrene. — Testimony of Ancient and Modem Writers. — Various other Remedies: Sulphates of Copper, Zinc, and Iron ; Acid Nitrate of Mercury, Nitrate of Silver, Chloride of Zinc, etc — Testimony of Ancient and Modem Surgeons. MEASURES FOR THE PREVENTION OF HOSPITAL GANGRENE. The observations upon the relations of insufficient food, fatigue, The previous ^"d the exhalations of crowded tents and hospitals, to the SS^s"he origin and spread of hospital gangrene, indicate at once, SfprCTmtog without further discussion, the best means for the pre- Md7pSd vention of the disease. ranmn^ Abundant supplies of nutritious animal and vegetable Importance food, free Ventilation, with the largest possible supply of BuppiiM*of ' fresh air to each patient, with scrupulous cleanliness of Teg"toWe°* the wounds, as well as of the person's clothing and bed- T^uiaHon, ^ingi ^ud apartments of the wounded, are the great pro- ness^'totie phylactic measures against hospital gangrene. When wounded. ^j^jg discasc appears in a filthy or crowded hospital, a heavy responsibility rests upon the medical officers. It would be far better after great battles, to scatter the wounded under sheds, and even under trees, than to crowd them into close tents and hospitals, or to transport them to a distance in close box cars. Unfortunately it has been deemed necessary, after several IMPORTANCE OF VENTILATION. 649 great battles, to transport large numbers of wounded soldiers in close, badly ventilated box cars, hundreds of miles from the scene of action. In many instances the supply of water, and of rags suitable for dressing, was limited ; the wounded men shut up in these hot, confined boxes suffered from thirst, and the unwashed, undressed, and filthy wounds emitted a foul stench which contam- inated the entire atmosphere. The severest epidemics of hospital gangrene have appeared amongst the wounded subjected to these most favorable conditions for the origin and spread of the dis- ease. Hospitals for the treatment of the sick and wounded should be located in elevated, well-drained, and well-watered and General ob- 11,.. 1 , n serrations healthy situations, where the most perfect arrangements upon the lo- may be made for free ventilation and the removal of all arrangement 1 .« -1 1 • 1 1 of hospitals excrementitious matters, and it possible without the forsicicand ... 11, wounded. bounds of large towns and cities, and the largest space evh effects •1 1 -1 •!• T ■ T 1 T 1 1 oflocating compatible with military discipline and medical attend- hospitals in 1111 11 1 11 • 1 1 -1 T 1 theheartof ance should be allowed to the hospital buildings and popnioua wards and tents. In many of the large hospitals of the cities. Confederacy the density of population exceeded that of London or New York ; that is, it exceeded upon an average 200,000 per square mile, whilst in well-constructed hospitals it should not exceed 15,000 per square mile. Thousands of valuable lives were sacrificed by the suicidal pol- icy instituted upon an immense scale in the earlier periods of the war, of using hotels, warehouses, stores, churches, and colleges, in the heart of cities and towns, for military hospitals. In Richmond, Virginia, hotels and tobacco factories within the heart of the city, were, after fair trial, abandoned for hospital purposes, and commo- dious wards were erected at Chimborazo, Camp Winder, and Camp Jackson, and Howard's Grove, and it is no exaggeration to say that thousands of lives were saved by this change. The value of well-constructed hospitals in the country was clearly shown, even in Georgia, which State up to the last twelve months of the war was not the seat of any very extensive or active military operations. Thus, the ratio of deaths from pneumonia was, in the Floyd House Hospital, Macon, Georgia, during thirty months, 22.9 per cent., or one death in 4.3 cases ; in General Hospital No. 1, Savannah, Georgia, during twenty-five months, 31.35 per cent., or one death in 3.18 cases ; in General Hospital No. 2, Savannah, Georgia, June, 1862, to July, 1864, 23.14 per cent., or one death in 4.32 cases ; whilst in Guyton Hospital, situated some twenty 550 CONSTRUCTION OF HOSPITALS. miles from Savannah, in a healthy, sandy, pine-barren region, the deaths from pneumonia* were only 8.98 per cent., or one death in 11.14 cases. A similar difference existed in the mortuary statistics of the other diseases and gunshot wounds. The excess of mortality in the general hospitals of Savannah and Macon, Georgia, over that of Guyton, was clearly referable in great measure to the hygienic conditions and relative locations of the various hospitals. In the earlier periods of the war, the chief surgeon of the Department of Georgia, Dr. H. V. M. Miller, at one time seriously contemplated breaking up all the general hospitals, with the exception of the well-constructed and salubriously located hospital at Guyton, and perfecting and enlarging the field, regimental, and division hos- pitals. When General Robert E. Lee commanded the Depart- ment of South Carolina, Georgia, and Florida, the propriety of establishing large hospitals in the elevated primitive regions of South Carolina and Georgia, immediately above the extensive eocene plain reaching to the Atlantic and Gulf of Mexico, as at Aiken, South Carolina, and the sand-hills near Augusta, Georgia, was debated. In the crowded hospitals, the simplest diseases assumed malig- nant characters ; the typhoid poison altered the course of mumps, and measles, and pneumonia, and was the cause of thousands of deaths ; and the foul exhalations of the sick poisoned the wounds of healthy men, and induced erysipelas, pyasmia, and gangrene. Who can estimate the suffering inflicted, as in the celebrated case of the Augusta hospitals, by the development and spread of hos- pital gangrene in overcrowded hospitals situated in the heart of towns and cities ? As a rule in military practice, the wounded should never be Thewounded placed in wards with patients suffering from anv one Bhould never '^ „ , . . „ . ,. ,, be placed in 01 the contagious or mrectious diseases, as small-pox, patients euf- mcaslos, scarlet fever, typhus fever, typhoid fever, erv- ferlogfrom ' . , ., , j .1 • any one of sipBlas, pyEBmia, or hospital gangrene ; and these various tagiousor discascs should not be indiscriminately mingled together. infectious . ... . 1, diseases. The voice of the profession is unanimous as to the exclu- sion and isolation of small-pox, but we know from extended expe- rience that sufficient care was not exercised in the isolation of the other diseases. A diversity of opinion existed amongst the Confederate surgeons Relative ^^ to the relative value of tents and wooden hospitals. value of tcnta ^f^gj, careful examination, we were led to prefer the HYGIENE OF mLITARY HOSPITALS. 551 permanent wooden structures for the treatment of both ^^^ wooden sick and wounded ; at the same time it mu'st be admitted ^^^yj^^. that the sudden emergencies of the recent war neces- ^'"■ sitated the employment of tents to a great extent. Theoretically a tent admits air on all sides, but practically the occupants in cold or rainy weather exclude the external air, and that within rapidly becomes vitiated by respiration and the emanations from the sick. When the tent is not carefully floored with boards, exhalations take place from the damp soil, especially in wet weather, and the earth becomes a convenient receptacle of filth of all kinds. In pi'ofuse suppurations, the nurses and patients frequently allow the discharges to saturate the ground, and wjien this dries, the dust blown about by the wind or stirred up in sweeping becomes a serious vehicle for the propagation of pyasmia and hospital gan- grene. Properly constructed wooden hospitals, on the other hand, allow of regular cleansing, disinfection, and whitewashing, and afford more regular supplies of fresh air and of light, as well as greater facilities for the regulation of the temperature and the moisture. In general hospitals, each seriously wounded man should be allowed, if possible, two thousand cubic feet of air; the jjy^^^^of severest cases should be distributed uniformly amongst "i'dlJ^Bi^!" the lightest cases, and each ward should be thoroughly ciSmS?'^" I sing evacuated, cleansed, whitewashed, and fumigated with '°'""'^- chlorine or sulphurous acid at least every two weeks, or oftener if possible. A continuous rotation should thus be kept up throughout the wards of large hospitals, and during the period of cleansing the windows and doors should be left open for two or three days. The floors should be cleansed with a solution of chlorinated soda, or of carbolic acid. The most efficient and economical agent in disinfec- tion is sulphurous acid, which may be readily generated by the combustion of sulpluir. As the gas is irrespii'able, the occupants should be removed from the ward ; and to insure the destruction of the vermin, decomposing organic matter, and materies morhi, the windows and doors should be closed, the gas should be evolved in large quantities, and the bedding and clothes subjected to the ac- tion of its fumes. It is well established, that fumigations with chlo- rine are also highly efficacious in purifying the wards of hospitals. In the present state of the Confederacy, however, it is almost im- possible to command the necessary supplies of the mineral acids. The best indigenous substitute which has fallen under my obser- vation is the tar fumigation ; in the tar smoke, carbon in a highly 652 ATTENTION TO PERSONAL CLEANLINESS OF WOUNDEIX divided state, together with various disinfecting empyreumatic matters, are the active agents which purify the infected atmosphere of the crowded hospital. After an extended use of tar fumigations in military practice, I found that this smoke, so far from irritating the lungs, appears to act beneficially upon pulmonary complaints. For the absorption of noxious gases, and for the arrest of de- composition in the fsecal and urinary matters in the bed -pans and privies of hospitals, a long list of substances might be given, but the most efficient and readily attainable are charcoal, sulphate of lime, sulphite of lime, chloride of lime, protosulphate of iron, and coal-tar. The two latter, namely, coal-tar and sulphate of iron, form most valuable disinfectants in the bed-pans, water-closets, and privies. The coal-tar should be used freely about the privies, water-closets, and drains, when it can be obtained. The lime of the gas-works also acts as a valuable disinfectant. The straw of the bedding should be frequently renewed, the old straw burned, and the bed sacks boiled in water, to which a por- tion of permanganate of potassa has been added. The most scrupulous attention should be paid to the personal Importance clcanliness of the wounded. When from the nature of to th^^°° tlis wound the patient cannot be thoroughly washed at HnMsof the Stated intervals, great benefit may be derived by spong- woundci jj^g Qff ^Yie entire body with the following disinfecting, stimulant, and cleansing lotion : — I^. Labarraque's solution of hypochloride of soda, f 5 ii. ; tincture of camphor, f5ss. ; whiskey, fsii. ; common salt, si. ; water, fsxvi. In military practice I have derived great benefit from the use of this lotion, not only in severe cases of gunshot wounds, but also in typhoid and low forms of fever. This lotion effectually removes the greasy sweat from the skin, and all filth, and imparts a clean, wholesome smell, which refreshes the patient. The free use of Labarraque's solution of hypochloride of soda, or of a solution of permanganate of potassa, to all serious wounds, will not only add to the comfort of the patients, and promote the healing of the wounds, but it will also tend to prevent the origin and spread of hospital gangrene. When Labarraque's solution cannot be ob- tained, a weak solution of nitro-muriatic acid, in the proportion of one ounce of the acid to a gallon of water, will make a useful dis- infecting and slightly stimulating wash for wounded surfaces, es- pecially when the granulations are tardy. This solution should be prepared fresh each morning, and the wounds should be carefully washed with it when necessary, at least morning and evening. CONSTITUTIONAL TREATMENT. 553 The healing of ill-conditioned and unhealthy wounds may also be promoted by combining tincture of iodine' and carbolic acid with the simple cerate used in dressing, I have found the following formula of great value in the treatment of gunshot wounds : — IJi. Tincture of iodine, fsi. ; carbolic acid (pure crystallized), slii. ; tincture of opium, fsiv. ; simple cerate, Bxii. ; mix ; use as an ointment to the diseased surface. The tincture of iodine and carbolic acid may be increased two or three fold, if necessary, in the more unhealthy wounds. This ointment fulfills a useful purpose, in that in addition to its stimulant and cleansing action, it drives oif effectually flies and other insects from the neighborhood of the wound. The greatest attention should also be paid to the cleanliness of the clothing of the wounded, and to the dressings of the wounds. The clothing should always be boiled in water containing a por- tion, if possible, of permanganate of potassa ; the boiling temper ature can always be commanded, and should never be neglected, as by this means we coagulate, alter, and destroy the decomposing poisonous organic matters. The dressings from the wounds, and the soiled clothing, should never be allowed to accumulate about the hospital. The only safe rule for the prevention of hospital gangrene is to bum and destroy all materials which have been used in ah materials . , IT 7 1 used in dress- dressms: wounds. Even when the lint and rags have ingwounda ° . . ° , sliouldbe been carefully washed and boiled, they may still act dele- burned or teriously upon the diseased surfaces. untand ,,^r>,...i. r^oS may be Professor Brusmans, as quoted by Guthrie, in Ins the medium o ^ ^ •! _ ' ofcommu- " Commentaries on the Surgery of the War in Portugal, "icatinggan- G J . , o ' grene and France, and the Netherlands," saj's that in 1797, in Hoi- py»mia. land, charpie, composed of linen thread cut of different lengths, which, on inquiry, it was found had been already used in the great hospitals of France, and had been subsequently washed and bleached, caused every ulcer to which it was applied to be affected by hospital gangrene. Finally, each patient should be supplied with his own wash- basin and sponge and towel, which should be regularly cleansed, and kept scrupulously clean. CONSTITOTIONAL TREATMENT OF HOSPITAL GANGRENE. Inflammation in the healthy system is a reparative process of nature, and should be studied and treated as a modifica- General prin- n 1 1 1 . ii ciples whicli tion of the natural processes concerned in the preserva- ehouid guide 654 CONSTITUTIONAL TREATMENT. the constitu- tioH of the bodj ; or, in the language of John Hunter, meatof ho3- " Inflammation in itself is not to be considered as a dis- pital gan- grene, ease, but as a salutary operation consequent either to some violence or some disease ; " it is " only a disturbed state of the parts, which require a new but salutary mode of action to re- store them to that state wherein a natural mode of action alone is necessary." When a foreign body is thrust into the living tissues, the deli- cate capillaries are broken up, the mutual relations of the forces are disturbed, the nerves are injured in such a manner as no longer to be capable of exerting their normal influence. If the foreign body be immediately withdrawn, and if the animal wounded be in a state of perfect health, that is, with a proper constitution of blood and structures, and a proper correlation of the forces, the blood, and especially the coagulable lymph, may close up the wound ; and with the exception of pain, and of a temporary congestion of the sur- rounding parts, from the obstruction of the circulation in the in- jured capillaries, thus forcing more blood around the injured part, as well as from the disturbance of the nervous force, and of the processes of nutrition in the surrounding capillaries, no other phenomena are manifested. The effused fibrinous matter endowed itself with life, and surrounded by living tissue, and subjected to the influences of living tissue, passes through various changes, which resemble the changes in normal nutrition, secretion, and develop- ment, and which result in development and repair. If, on the other hand, the structures are too much injured to be repaired in this manner, the same disturbances and the same phenomena are manifested, but being increased in intensity, the changes in the nutrition of the injured part progress to cor- respondingly greater effects. The same effusion, and the same reparative processes, are active in the one case as in the other, but in the latter the dead tissue acts as a foreign body, and must be removed, and a process instituted by which its place may be supplied by other matter. As the matter effused and the injured tissue possess a definite chemical constitution, and are related by definite affinities to the surrounding forms of matter, and as they are subjected to the action of fixed forces exciting and controlling the nutrition and circulation of the surrounding parts, the products will, to a great extent, be uniform in the healthy organism. When, on the other hand, a mechanical injury is inflicted upon an animal whose forces are depressed, and the nutritive elements of which are deficient in quantity and quality, the process of re- CONSTITUTIONAL TKBATMENT. 555 pair will be correspondingly retarded, and the products will be correspondingly altered from those formed in the healthy organism. If the system be under the influence of some disturbing agent, as a poison, at the time of the reception of the injury, the charac- ters of the inflammatory process will manifestly depend upon the affinities of the extraneous substance or poison, for the elements of nutrition, and upon its power to disturb the nutrition, secretion, excretion, and the nervous and muscular forces. In the case of a poison acting in the blood, its local and inflam- matory effects will be chiefly manifested in that organ for which it has the greatest affinity, or in the nutritive processes of which it produces the greatest disturbance ; and as the most essential changes of the blood take place in the capillaries, it is in these parts that we must look for the chief disturbances. In this case, the effects of inflammation may be widely extended, not only by the reflection of the local disturbances to other parts through the nervous system, but also by the entrance into the circulation of certain products of inflammation which will be capable of inducing changes in the mass of the blood, and in the nutrition and secre- tion of various organs. In this last form of inflammation, when, in addition to the local injury, we have a poisoned condition of the blood, and of the structures involved in the local inflammation, the manifest indica- tions from the principles just laid down are, — First. To remove the patient from all causes which tend to depress the system, and especially from those causes indications which are known to have been directly and specially ^ik|[ni,,e »^4-:.m treatment active. of hospital Second. To eliminate the deleterious agent. gangrene. Third. To i-estore the system to such a condition that healthy nutrition, reparation, and inflammation may take place. Fourth. To induce such changes in the injured parts them- selves as will lead to a complete separation between the diseased and dead structures. Fifth. To destroy all poisonous matter in the diseased parts. Sixth. After the removal of the dead parts, and after the destruction of all contagious elements capable of disseminating the disease to the surrounding tissues, to stimulate the capillaries and absorbents around the local injury to such healthy, active, inflam- matory action, as will result in the development of healthy granu- lations. The three last indications will be considered under the head of the local treatment. 656 CONSTITUTIONAL TREATMENT. In the treatment of hospital gangrene, the first essential meas- boiation and ure, without vvhicli the most enlightened system of treat- tion the first ment is comparatively valueless, and at best tardy in its and most es-.. , .« i ti*i Bentiai meas- actjon, IS to remove the patient irom the crowded wards, ure in the n i ' ' • i i 11 treatment of and secure for iiim m an isolated room or tent the largest hospital gan- ■, 1 i p c 1 • grene. possible supply 01 iresh air. We have seen that the constitutional symptoms in most cases of Importance hospital gangrene hold a prominent place. The dejected ofattending . ' ? ° , * , to the con- spirits, the depressed state of the nervous system, the disturbances small, accelerated pulse, the feeble, sluggish, capillary gangrene. circulation, and the depressed state of the temperature in the extremities, all point to the supporting tonic and stimulating plan of treatment as the rational system. The therapeutic indications are to furnish the elements of Therapeutic healthy blood, and of active nutrition, secretion, and indications. . •' . 1 . i Supply of repair, to excite and support the vital powers, and to elements of ,, • • 1 -t mi • • healthy allay nervous irritability. These intentions are best ful- blood and ^ '^ , ^ , , nutrition. filled by resortiug to combinations of tonics and anodynes after the morbid secretions of the bowels have been evacuated by gentle purgatives or enemata. In many cases emetics may be used with advantage ; and it will Emetics and always be found best to evacuate the constipated bowels purgatives, ^j ^ purgative. From eight to ten grains of blue mass or calomel, followed with castor-oil in four or six hours, will gen- erally accomplish the desired result. The compound cathartic pill of the United States pharmacopoeia also answers this indica- tion equally well in most cases. The subsequent tonic and supporting plan of treatment will prove far more certain and beneficial in its actioij after the portal system has been unloaded, and the bowels cleared of morbid secretions. Throughout the treatment the bowels should be kept open by the compound cathartic pill at bed-time, or by salines, as the Seidlitz powder, in the morning. Blood-letting should, as a general rule, be avoided, as tending Blood-letting Still further to depress the enfeebled powers, and as tend- to be avoided, jjjg ^^ inflict a wound which in turn may become gan- grenous. Quinine and the tincture of the sesquichloride of iron deserv- Siireof edly hold a high place in the estimation of Confederate chioride"o'f surgeons, in the treatment of hospital gangrene. In w!i"d°effi- ^^ses of ordinary severity, three grains of quinine and S.""°" fifteen drops of the tincture of the sesquichloride of iron, CONSTITUTIONAL TREATMENT. 557 administered three or four times a day, will be found to be suffi- cient, in conjunction with the other measures, to induce a marked and rapid improvement in those patients properly isolated and ventilated. When the ravages of the disease are extensive, and the danger of extensive and exhausting hemorrhage great, the amount of the tincture of the sesquichloride of iron may with benefit be increased to twenty drops, every two or three hours. The mercurials should not be given at the same time with the tincture of iron, from the well-known danger of generating corro- sive sublimate by the combination. The tincture of the sesqui- chloride of iron should be temporarily suspended during the administration and action of mercurials. When troops have been exposed to malaria, the accompanying fever of hospital gangrene will frequently partake of an intermit- tent and remittent character ; and in such cases the quinine may be freely administered, in an average dose of five grains, three or four times during the twenty-four hours ; but as far as my experi- ence extends, in cases uncomplicated with malarial fever, quinine in large doses exerts no beneficial effects upon the progress of the constitutional and local symptoms. The best effects will be ob- tained with the small doses indicated above. Huxham's tincture of bark (tinctura cinchona composita), ad- ministered in full doses, varying from one fluid drachm Huxham's to half a fluid ounce, every three or four hours, fulflils in bark. this disease important indications as a stimulant, diuretic, and elegant stomachic cordial. The sesquichloride of iron may, with advantage to the patient, be administered in combination with chlorate of potassa, Combination I . p « 1 n \ r of chlorate of m the proportion ot from ten to twenty drops ot the tor- potassa with T n nn ■ c ^ 1 Til- the tincture mer and five to fifteen grams of the latter, dissolved m ofthesesqui- r^i ■ T chloride of four ounces of water. This dose toaj be repeated every >ron. two, three, or four hours. Whilst we are unable to explain the exact manner in which chlorate of potassa acts upon the system, still it is well established that it proves highly beneficial in those complaints in which a depraved state of the solids and fluids shows itself by malignant typhoid symptoms, and a disposition to phage- dsenic ulceration and gangrene. The combination of this salt with sesquichloride of iron is especially valuable from the liberation of some chlorine and hypochlorous acid. The following formula lias proved useful in the treatment of hospital gangrene and other diseases of an asthenic typhoid char- acter in my hands : — 658 CONSTITUTIONAL TREATMENT. ^ Tincture sesquichloride of iron, fsi. ; chlorate of potassa, ziv. ; sulphate of quinia, sii. ; hydrochloric acid, fsi. ; distilled water, fsii. Dissolve the chlorate of potassa in the distilled water, add the hydrochloric acid, and then dissolve the quinine in this acid mixture, and finally mingle this solution with the tincture of iron. Dose, thirty to sixty drops, in wine-glassful of sweetened water (sucked through a quill), three or four times a day. Hydrochloric and nitric acids, singly or combined, exert benefi- Hydrochioric cial cfFccts in some cases. Wherever they are indicated, and nitnc ... . . i . i ao'ds. the sesquichloride of iron, or the combination of this salt with chlorate of potassa, will answer an equal if not better pur- pose, except when tliere is jaundice and marked torpidity of the liver, in which case the nitro-muriatic acid may be employed both internally and externally in the form of the nitro-muriatic acid bath. These acid mixtures should not be continuously employed for more than two or three weeks at any one time, as in some cases the coats of the stomach appear to suffer from their prolonged action. When it is necessary to intermit the tincture of the sesqui- chloride of iron and the mineral acids, we have found the follow- ing formula of great value as tonics in hospital gangrene, ill-condi- tioned wounds, and profuse suppurations : — I^ Tartrate of iron and potassa, 3i. ; tartaric acid, sii. ; sulphate other com- of quinia, sii. ; distilled water, fsxii. Dissolve the tar- kon and' °^ i^rlc acid in the water, and add the quinine and then the quinine. tartrate of irou and potassa. (Shake well before using.) Dose, table-spoonful in wine-glassful of water three times a day. In some cases, when it is desirable to overcome the astringent effects of the iron and keep up a gentle action on the bowels, the following combination is valuable : — ^ Strychnine, grains ii. ; sulphate of quinia, sii. ; precipitated iron (iron by hydrogen), siii. ; extract of rhubarb, 5ii. Mix; divide into one hundred pills ; sig. one pill three times a day. A mixture of equal parts of the phosphates of lime and iron, admin- istered in doses of from- ten to twenty grains in a glass of fresh milk, three times a day, is an admirable and efficient tonic, and strengthens the digestive powers, whilst it enriches the blood. When gangrene attacks a patient suffering with constitutional hos°?ter an- syphiUs or scrofula, iodine, iodide of potassium, and iodide irrafted"" °^ ^""^^ should be freely used. The following mixture tutiona™""" ^'^^ ^^^ *''® important indications of acting both as a tonic Sil" and alterative : — CONSTITUTIONAL TREATMENT. 559 ^- Syrup iodide of iron, hi. ; tincture of iodine, fsii. ; iodide of potassium, sii. ; syrup of ginger, fjvi. ; distilled water, fji. Dis- solve the iodide of potassium in the distilled water, and add the tincture of iodine, and then mingle with the syrups of iodide of iron and ginger. Dose, tea-spoonful in wine-glassful of water, three times a day. The arsenical solution (Fowler's solution arsenite of potassa) has been employed with benefit in some cases. Amnicai Oil of turpentine, camphor, musk, and warm aromatics «<>'•"'''"'• and spices, frequently prove beneficial, and may be ad- """""S*"" ministered in various forms of combination. The stimu- ?''?'■ ™"*> ana aro- lant and depurant eflfects of the oil of turpentine appear °"'''°=- to be of some value in the treatment of hospital gangrene. To obtain decided effects upon the capillary circulation, in the debili- tated state of the system in this disease, the oil of turpentine should be administered in full doses at short intervals of time. So slow is the system to respond to stimuli in hospital gangrene, that I have known this remedy to be given in tea-spoonful doses, at regular intervals, without any marked effects upon the kidneys or bladder, as far as the production of strangury or bloody urine. It is, however, a question whether these large doses, especially if they be continued for a great length of time, may not lay the foundation of disease of the kidneys and bladder. Opiates are indispensable in the treatment of almost every case of hospital gangrene during the active stages, and should opiates in- be administered freely, to allay irritability, and to pro- j^aj'^fjl^j. duce sleep, and to check excessive discharges from the ^^i^^""" bowels. e"""- The diarrhoea which frequently complicates the worst cases of hospital gangrene, is the result of derangement of the Treatment alimentary canal, consequent upon the febrile action and rhrefi^m- the absorption of the poisonous matters from the diseased pftofran^"^ gangrenous tissues. The tincture of the sesquichloride ^™°°' of iron appears to exert a beneficial effect in such cases, especially when opium is freely used. As this diarrhoea in many cases par- takes of the nature of a critical discharge, it should not be suddenly checked. In camp life, the soldier is liable to chronic diai-rhoea and dysentery, and in military practice we should never lose sight pf the fact that the diarrhoea attending gunshot wounds may have had its origin in a deranged state of the intestinal mucous mem- brane preceding the reception of the wound or the supervention of gangrene. 660 LOCAL TREATMENT. Subniti'ate of bismuth, in doses of from twenty to forty grains, combined with from three to five grains of Dover's powder, every three or four hours, is perhaps one of tlie ' most valuable remedies in this class of diseases. The exclusive use of milk as a diet should be insisted upon in these cases. When the diarrhoea arises manifestly from the absorption of the gangrenous matters, the subnitrate or the carbonate of bismuth should be combined with finely divided charcoal. When it is necessary to control the diarrhoea by astringents, the ABtringent following formula has proved useful : — mixture for m* i • /» •• • in'" diarrhoea. i^i. Tincture Kmo, fsu. ; tincturc catechu, fjni. ; cam- phorated tincture of opium, fsi. j precipitated carbonate of lime, fsss. ; Huxham's tincture of bark, fsvi. Mix. (Shake well before using.) Dose, table -spoonful diluted with four parts of water, every three or four hours. When there is ulceration of the large intestines, nitrate of silver administered internally, in combination with opium, and also by the rectum in solution, is a well-known and standard remedy. The DIET throughout the course of hospital gangrene should be Diet highly ^* highly nutritious and nitrogenized as possible, and nutritious, should consist chiefly of concentrated animal soups, soft- boiled eggs, egg-nog, milk-punch, etc., with a liberal supply of vegetables and ripe fruit, if they can possibly be obtained. Alcoholic Stimulants. — Good brandy, whiskey, and wine. Alcoholic ^^ porter, administered in moderate quantities, at short Btimuiants. intervals, will prove highly beneficial in almost all cases. I have witnessed the most decided benefit from the careful but liberal use of alcoholic stimulants in hospital gangrene, and never in a single instance had occasion to regret their use. LOCAL TREATMENT OF HOSPITAL GANGRENE. Whether we regard the local affection as a poisoned wound, in pathoiogiciU which contagious poisonous matters are continuallv eren- andthera- ° i • i i ,. ,. . . •' " peuticai prin- erated, and from which the surrounding living tissues are should gov- contaminated ; or look upon the destruction of the tissues ern the local i /■ i n • i t • n treatment of as the rcsult ot dcfacient and perverted mflammatoi-y hospital gau- , ' ' i n t i i grone. actiou, the principles of the local treatment would in either view be much the same. If the first view be held, our efforts should be directed to the alteration, destruction, and complete removal of the dead and poisonous matters and tissues. If the second view be accepted, the manifest duty of the physi- LOCAL TREATMENT. 561 clan would be to use such measures as will increase the vital power of the tissues and vessels, and enable them to form coagulable lymph, by which the disorganization will be circumscribed and arrested. These indications are best fulfilled by the liberal and thorough application of concentrated nitric acid to the gangrenous Concentratea T ,. V . ..,.,, , ^ , . . nitric acid in parts. In this apphcation, it is desirable that the nitric the locai acid should not merely coagulate and alter completely hospitaigan- the gangrenous matters, but also come in contact with odofappu-. 11 11" - irt.i 1 cation, ef- the sound parts, and by its action upon the fluids and fect» of, etc. surface of the exposed parts, stimulate the living structures into a new form of inflammatory action, which will cause the complete separation of all the dead parts, the arrest of the further progress of the disease by the more exalted condition of the sound parts, and by the efiusion of healthy coagulable lymph, and the estab- lishment of the process of repair. In most cases, especially when the patient has been proper! j' isolated, one thorough applica- tion of nitric acid will be sufficient, if followed by the necessary constitutional and local treatment. If, however, the patients be retained in the crowded wards or tents, the most energetic treat- ment will fail entirely of arresting the disease. As this is a painful procedure, the patient as a general rule should be placed under the influence of chloroform and sulphuric ether. During the insensibility of the patient, the surgeon should carefully examine the wound, and first remove all the gangrenous tissues, using the scalpel and scissors, and causing the parts beneath to bleed quite freely. All sinuses formed under the skin, or between the muscles, or in the cellular or areolar tissue, must be freely laid open, and the dead tissues removed. The entire wound is then to be carefully wiped out with a sponge or dry lint, and the concentrated acid applied with a brush or mop to the entire sur- face ; and care should be taken that the acid penetrate into all the sinuses and cavities. If any diseased part be untouched or undestroyed by the acid, the disease will recommence and spread from that point. After extended observation, I am convinced that the failures with the nitric acid amongst the Confederate wounded were at- tributable mainly to the neglect of the careful cleansing of the wounds, and the failure in applying the acid freely and thoroughly to the diseased surfaces. The acid destroys the contagious properties of the gangrenous matter, and converts the diseased surface into that of a simple wound or ulcer ; and in many cases the pain and constitutional 36 662 LOCAL TREATMENT. symptoms are entirely removed by the destruction of the diseased surface. After the entire surface of the wound has been thoroughly mopped with the nitric acid, the subsequent treatment will consist in — The careful removal of all dead masses ; the application of stim- Subsequent ulating poultices ; the systematic and thorough cleansing after the ap- of the wound at stated intervals with water, and with so- nitric acid lutions of chlorinated soda, permanganate of potash, nitro- to the gan- muriatic acid, acetic acid, carbolic acid, and pyroligneous wound. acid. After the application of the nitric acid, the parts Disinfectant '^^ ^ and stimu- should bc covered with flaxseed, meal, hop, or charcoal lating appli- ,^ ,.,, cbi"""' ted poultices, rendered antiseptic and stimulating, with tur- soda, per- pentiuc. Camphorated tincture of opium, tincture of bark, manganate of ^ , ^ , ^ , ' ^tassa, ni- tiucturc of camphor, pyroligneous acid, creosote, or car- acid, acetic bolic acid. acid, carbolic "'"I- The prompt removal of all detached masses of tissues, and the thorough washing away of all morbid secretions, are most important measures to prevent the recurrence of the disease, and to secure the establishment of healthy inflammatory action. When- ever a circumscribed portion of the wound looks unhealthy and gangrenous, the nitric acid should be applied directly to the dis- eased parts, care being taken that the sound parts be not unneces- sarily subjected to its action. In many cases, before the wound assumes a healthy condition, instead of applying poultices daily (a poultice being always applied immediately after the application of the nitric acid to shield the sound parts and promote the casting off" of the dead tissues), it is preferable to fill the cavity of the wound with lint or cotton satu- rated with various stimulating fluids, as a weak tincture of iodine, oil of turpentine, tincture of camphor, tincture of Peruvian bark, pyroligneous acid, or a solution of carbolic acid. When there is danger of hemorrhage, either from large vessels Tincture ses- "r from the general surface of the wounds, lint saturated ofiron M** "^'th the undiluted tincture of the sesquichloride of iron, kwaiappuca- ^j, ^-^^^ ^ solution of the persulphate of iron, should be the'alTratof applied. It may be laid down as a general rule, that hemorrhage, jjgation or amputatiou should not be resorted to in cases of hemorrhage in hospital gangrene, until these eflScient styptics have been freely applied to the bleeding surfaces. Of course hem- orrhage from large arteries should be arrested, if possible, by liga- tion, but in hospital gangrene the sloughing of large arteries accom- LOCAL TREATMENT. 663 panied with hemorrhage is usually fatal. The operation of ligating arteries does not succeed in hospital gangrene, unless the local dis- ease has been first arrested, and the patient has been separated from all others suffering with it, and subjected to the best hygienic and dietetic measures. As a rule, no amputations, no matter what be the condition of the wounds, whether gangrenous or healthy, should be Amputation performed in the wards of a hospital in which gangrene '^^^Zfto is prevailing. Such practice is as reprehensible as the i"**™'*"!- careless distribution of healthy and fresh wounds amongst the gangrenous wards. When amputation is unavoidable, the patients, whether the wound be gangrenous or not, if the disease be present in the hospital, should be isolated as far as possible, and every at- tention paid to proper ventilation, cleanliness, and diet. Amputa- tion is rendered necessary in hospital gangrene under certain cir- cumstances, as when a large joint is exposed ; when the gangrenous wound is of great size, and the muscles, nerves, and blood-vessels and bones are extensively exposed, and the constitutional powers are undermined by the absorption of the gangrenous matter and the incessant suffering ; and when large blood-vessels are destroyed by the destructive action, and there is danger of death from hemor- rhage. In some cases, the surgeon gains an advantage by substi- tuting by amputation a small, defined wound for a large gangrenous surface from which the entire mass of blood may be infected. After the appearance of healthy granulation and of laudable pus, the stimulating, astringent, and caustic applications After the ap- should be abandoned, or only occasionally applied with Wealthy •^ ./ 1 X granulatioa caution, and the wound should be treated as any other and laudabie 1 • mi IT • 1 pus, caustic simple granulating ulcer. The carbolic acid cerate men- applications tioned under the head of the measures for the prevention abandoned, , . . . and the of the disease, may be advantageously applied as a stim- wound or ui- • «-i • !•! "11 cer treflitecl fls ulating and antiseptic dressing, which will promote any other o A o ^ L Bimple gran- healthy suppuration and granulation, and at the same mating uicer. time prevent a recurrence of the disease. The person of the gangrene patient should be kept scrupulously clean, and for this purpose the stimulating and cleansing fe^„„ ^^^ lotion previously recommended should be freely and g|,°*'°^o°g systematically used. Sponges should be discarded, all gekcpt*?iean, rags and dressings should be destroyed as soon as re- spong^,""^ moved from the diseased parts, each patient should be andli^^t to provided with his own wash-bowl and towel, and a nurse •>« destroyed. should be provided for every five patients. 564 HISTORICAL NOTES ON TREATMENT. Bed-sores. The surgeon should never lose sight of the tendency to the for- mation of bed-sores in this disease. In the depressed state of the forces and the feeble state of the capillary circulation, pressure is ofttimes attended with death of the injured tissues. Gangrene frequently attacks these bed-sores, and I have seen instances in which death was directly traceable to the bed- sores. The proper measures, as equalized pressure, soft beds, and, above all, frequent changes of the position and stimulating applica- tions to the surface, should be resorted to, in order to prevent this most distressing and unfortunate complication. At all times the proper drainage of the wounds should receive most careful attention. During the healing of gangrenous wounds great care is neces- Permancnt ^^U *** prcveut permanent contractions of limbs. Under of miMc'fci" the best and most careful treatment, many limbs are per- toim''^n- manently contracted under the action of this destructive ^°°- disease. Various other applications have been recommended and em- ployed by Confederate surgeons, in the local treatment of hospital gangrene, as the actual cautery, sulphate of copper, persulphate of iron, nitrate of silver, and tincture of iodine. These remedies, without doubt, exert beneficial effects, as I have myself frequently witnessed. The method, however, which has just been given, as far as my observation extends, is the most efficient. HISTORICAL NOTES UPON THE TEEATMENT OF HOSPITAL GAN- GRENE. As we have before shown, Hippocrates was acquainted with foul, Notes npon malignant, phagedsenic, gangrenous ulcers. The Father of treating of Mediciue gave many valuable precepts upon the treat- by the an- ment of ulcers ; thus he affirms that gentle purging of servations cf the bowcls agrees with most ulcers, and in wounds of the Hippocrates i ii . • upon the head, belly, or joints, where there is danger of gangrene, uiceta. in such as require sutures, in phagedsenic, spreading, and in otherwise inveterate ulcers. Hippocrates directs that the ulcer is to be frequently cleaned with a sponge, and then a dry and clean piece of cloth is to be frequently applied to it, and in this way the medicine, which it is supposed will agree with it, is to be applied, either with or without a bandage. Amongst the astringent and caustic substances applied by Hip- The virtues pocrates to ulcers, may be recognized many used at the of arsenic ^ i • i /. i • i and copper, prcscut day m the treatment or hospital gangrene, as HISTORICAL NOTES ON TREATMENT. 665 arsenic, sulphates of iron and copper, acetate of copper, in the treat- oxide and acetate of lead, carbonate of soda, and alum, cers, known The carioum of Hippocrates, used as a caustic application rates. to foul gangrenous ulcers, was composed of black hellebore, san- darach, flakes of copper and lead, sulphur, arsenic, and cantharides. In the long list of remedies recommended by Pliny, in his " Natural History," for the treatment of foul phage- Observations dsenic and gangrenous ulcers and wounds, many, as the tto trea,t- jiini ci 1 mentoful- blood and mashed flesh of dragons, toads, serpents, •^'■s. worms, and fish, appear evidently to have been recommended from superstitious notions rather than from any real therapeutic virtues ; but we recognize many really powerful agents, as the salts of cop- per, iron, lead, and arsenic. The sandarach of Hippoc- ihesanda- rates, Pliny, and of the ancient physicians is the realgar J^'ratoe"''' of the moderns, red opiment or red sulphuret of arsenic. \^elk^At^ Pliny describes the sandarach as being found both in re/sliphSret gold and silver mines. " The redder it is, the more pure "' "=™"=- and friable ; and the more powerful its odor, the better is its qual- ity. It is detergent, astringent, healing, and corrosive, but it is most remarkable for its septic properties. Applied topically with vinegar, it is curative of alopecy. It is also employed as an in- gredient in ophthalmic preparations. Used with honey, it cleanses the fauces, and makes the voice more clear and harmonious. Taken with the food, in combination with turpentine, it is a pleasant cure for cough and asthma. In the form of a fumigation also, with cedar, it has a remedial effect upon those complaints." ^ In com- bination with the wild astapMs, Pliny recommends it as a local application for itch-scabs and prurigo, and also for the destruction of vermin ; in combination with black hellebore and copper filings, it removes warts.^ The ashes of blood and of various plants, calcined shells and bones, as well as the excrements of various animals, rec- vaiueofcer- ommended by Pliny as applications to ulcers, without ^ente'l"ter- doubt possess valuable properties from their alkaline and fonnuuS" stimulant properties ; and to this day the dung of domestic "'^ anaento- animals, especially of the cow and of the camel in Africa, is used by the Africans, both in their native country and in America, as an efficient poultice to boils, carbuncles, and phagedasnic ulcers. The various admixtures of myrrh, frankincense, and balsams, and the 1 Book xxxiv. chap. 55. 2 Book xvii. chap. 47 ; book xxiii. chap. 13 ; book xxv. chap. 22 ; book xxviii. chap. 62. 666 HISTORICAL NOTES ON TREATMENT. astringent principles of certain plants, entering into the composi- tion of the ointments recommended by Hippocrates, Pliny, and the older writers on medicine, without doubt exerted a most bene- ficial action upon unhealthy and foul ulcers, in virtue of their stimulant, astringent, and antiseptic properties. Bile of the beef, which entered into some of these local applications to ulcers, is used by the common people to the present day ; and its virtues are probably due in part at least to its alkaline properties, and its ten- dency to arrest or modify certain forms of digestion and fermenta- tion. The various remedies recommended by Hippocrates for the Therarious treatment of wounds and ulcers were most probably, n^mmend- ^vBu in his day, of ancient origin, being derived in part rateJo? an^ at Icast from the Egyptians and from the votive tablets in cient origin. ^^iQ temples of the Asclepiadse ; and the subsequent med- ical writers improved but little upon the formulae of the Father of Medicine, and their most valuable remedies for the treatment of foul ulcers owed their virtues to the preparations of arsenic, alum, iron, copper, zinc, lead, mercury, and silver. *[t is evident that the discovery of many of these compounds was due to the labors of the miners and the workers in brass and iron and the precious metals ; and even the actual cautery dates back even beyond the days of Hippocrates ; and in such high repute was this method of arresting certain forms of disease with the Father of Medicine, that he placed it above all other remedies in power in his cele- brated aphorism : " Those diseases which medicines do not cure, iron cures ; those which iron cannot cure, fire cures ; and those which fire cannot cure, are to be reckoned incurable." The surgeon of the present day might learn a valuable lesson from Hippocrates and the older writers as to the great value of wine as a local application in the treatment of ulcers. In those portions of the writings of Galen, Oribasius, Aetius, Thevaiuoof Celsus, Actuarfus, Nonnus, Octavius Horatianus, Scri- tioni'Sir bonius Largus, Avicenna, Serapion, Averrhoes, Haly Sradua Abbas, Alsaharavius, Rhases, and Guido, which relate potent «m.^ *» ^^^ nature and treatment of putrid phagedaenic and meoSST; gangrenous wounds and ulcers, may be found frequent Hippocrates, references to the potent remedies recommended by Hip- pocrates, namely, the actual cautery, copper, and arsenic. Without doubt the preparations of arsenic were the most potent Stion"Sf w- "^ ^^' ^^^ ^°^^^ applications employed by the ancients, and lenictiio in modern times the attention of the profession has been HISTORICAL NOTES ON TREATMENT. 567 directed to the great value of this agent in hospital gan- most potent • grene, by Surgeon H. Home Blackadder, in his valuable toctuwuca- " Observations on the Phagedsena Gangrsenosa." The pio'^dbythe experience of this author is worthy of careful consider- the treat-" ation, and we extract his observations upon the use of Seers" arsenic : — " Fowler's solution of arsenic is a medicine which is furnished to hospitals on foreign stations, on account of its well-known ^^^ ^^f^^. good effects when used internally in cases of inveterate in- ""Vjj^^jn termittent fever. Its employment as an external application modem . , , .„ ,. , times called was certamly never intended ; yet, if too strong for that pur- to the value pose, it could readily be diluted, and if found too weak, it the treat- might be rendered stronger by evaporation, and thereby made pitTi ^n- to supply the want of what may be considered a more appro- mt^bu^- priate preparation. '^'*"- " Having accordingly resolved upon making trial of this solution, I selected two severe cases in the inflammatory stage of the disease. One of them had originally received a superficial gunshot wound on the inner side of the knee joint ; but at this period the sore was upwards of three inches in diameter, highly inflamed, the whole knee being swelled, and the pain excruciating, so as to make the patient cry out incessantly. The other had been wounded through the leg and thigh, but in every other respect the state of his sores was similar to that of the former. " Diluting the arsenical solution with an equal part of water, I com- menced its use by applying it to the whole surface of the sores, by means of pieces of fine lint, having previously carefully removed the glutinous discharge. Each of the patients were then provided with a small gallipot, containing a quantity of the diluted solution, and pieces of fine lint cut into the shape, but a little larger than the sores ; and they were ordered to keep their sores constantly moist with the solu- tion, and to renew the lint at least once every two hours. As this appli- cation occasioned a considerable degree of smarting when first applied, they were each provided with an opiate pill, but accompanied with a strong recommendation not to use it, if it could possibly be avoided, and by way of encouragement they were promised a certain and speedy cure. On visiting my patients next morning, it was impossible not to be struck with the change in the expression of their countenances — from that of acute pain, mingled with despair, to that of ease and gratu- lation. Upon inquiring whether their instructions had been strictly adhered to, I was answered, ' Yes, thank Grod, we feel now as if in a better world ; ' and, upon examining their sores, I found them completely dried up, and covered with a dark, semi-transparent, and insensible slough, of a somewhat horny consistence. The smarting, which was occasioned by the solution when first applied, had ceased, without their 568 HISTORICAL NOTES ON TREATMENT. having had recourse to the opiate pills ; and the pain, with which they have been more or less tormented from the commencement of the dis- ease, had also been removed 'soon after the application of the solu- tion. . . . -. " The farther progress of the disease was evidently and completely arrested ; and by suitable topical applications (to be afterwards particu- larized) for assisting nature in throwing off the slough, and cicatrizing the sore, they were in no great length of time completely cured, without having used any internal medicine, farther than what might be occa- sionally required to prevent constipation, and without any attention hav- ing been paid to the constitutional affection, which indeed disappeared of itself almost immediately after the destruction of the morbid action of the sores " From this period the solution of arsenic continued to be employed with uniform success. Patients whose sores had resisted, as was said, almost every other treatment, were admitted from other hospitals and cured by it ; and it was also, I was informed, ultimately introduced into other hospitals, and proved equally successful." Mr. Blackadder further states that the external application of the solution of arsenic was again resorted to with equal success, after the battle of Waterloo, in the British hospitals at Antwerp.^ This observer held the view that the arsenical solution was more efficient than the actual cautery, and that it not only acted locally, but also constitutionally by absorption from the diseased surface. Nitrate of The nitrate of the red oxide of mercury and nitric macuiy'i''^ acid were much recommended, and seem to have been enaacwT"" frequently employed locally as escharotics in cases of haTTbeen gangrene and foul ulcers by surgeons in the sixteenth phye?dMs''^ and seventeenth centuries. piiSons'to The value of these remedies appears to have been most lethlnd'nth clearly demonstrated to the British surgeons, by Dr. centuries. ^^^^^ ;„ j^gy^ This physician, strongly impressed with the belief that a morbid Dr. Roiio on poison was acting upon the foul ulcers in the Royal Ar- theSid'ni"' tillery Hospital of Woolwich, which, like the venereal cmy an^of poison, had the power of assimilation, and of being ab- at^°mari-" sorbcd, thus producing general effects on the system, and theiMai'" a reaction on the sore, determined to adopt local means hrapi'tS'gan- of treatment, consisting in the chemical destruction of *"°°' the poison, and in exciting a new action. " The oxygenated muriatic acid and the nitrates of silver and mer- 1 Observations on Phagedana Gangrmwsa, pp. 21-25, pp. 49-58. HISTORICAL NOTES ON TREATMENT. 569 cury were the applications employed ; and latterly, the oxygenated muri- atic acid gas. " When either of these was applied four or five times, the little ulcer soon put on the suppurating stage, and granulated. They did not give pain in any degree, and it was of short continuance. While the ulcer was directly touched with the nitrated silver, the whole sore was moist- ened with a dilute solution of nitrated mercury,. or a mixture of oxy- genated muriatic acid in distilled water ; after which the whole was covered with lint that had been previously moistened with ether, or the oxygenated muriatic gas applied to the ulcer, and over the sore the dilute solution of nitrated mercury in distilled water. " By these means, diligently persevered in, the poison and ulcer were destroyed, and the sore went on cicatrizing. The only failures were in those cases where the ulceration had so extended that the nitrated sil- ver or oxygenated muriatic acid gas could not be completely employed. It is necessary to mention that washing the sore with warm water was always previously performed." A careful examination of the works of Blane, Trotter, and others, will show that up to the war in Portugal and cp *« 1813, ' ^ ^ ^ ^ , the British Spain in 1813, theJBritish surgeons, as a general rule, did ■"^p """i not use the actual cautery, as was done pretty generally e*""^. ^ » ,,,. , ^ general rule, by the French, but treated the disease chiefly as a con- treated the •J ^ ^ , •' disease upon stitutional affection, by blood-letting, emetics, and purga- tte anapwo- tiveS. *°** ^ acon- stitutional The indifferent success which attended its treatment by affection. constitutional means and simple detergent applications, caused the surgeons of the British army to view it more as a local disease, capable of giving rise to severe constitutional symptoms — a change of opinion which was materially influenced by the knowledge that the French surgeons more generally considered, with Pouteau, that it was local in the first instance, and treated it by the actual cautery. The introduction of the mineral acids, not as then generally used as stimulants or detersives, but as caustics, into the ^^^ ^^^^^ English army, during the campaign in Spain in 1813, un- ?he m°ne°iii der Lord Wellington, was due to Guthrie, This distin- ^f^^^, guished surgeon affirms that in his hands constitutional du^to'"^^^^ treatment and every kind of simple, mild, detergent ap- '*""»™- plication always failed, unless accompanied by absolute separation, the utmost possible extent of ventilation, and the greatest possible attention to cleanliness, and did not succeed even then without great loss of parts in many instances. This induced Guthrie, at Santan- der, in November and December, 1813, to try the mineral acids 670 HISTORICAL NOTES ON TREATMENT. as caustics. In his hands this proceeding was always, however, accompanied by constitutional treatment, regulated by the nature of the symptoms, which at that station were never benefited by bleeding. At Bilbao, in 1818, when caustic applications were not used, or only as detersives, and blood-letting to the amount of two, three, or four pounds employed, out of nine hundred and seventy- two cases of hospital gangrene thus treated, three hundred and eighty-seven, or nearly one half, died. Notwithstanding this fear- ful mortality. Dr. Boggie, who was stationed at Bilbao, strongly advocated the exclusive constitutional treatment, and affirmed that the disease was arrested by blood-letting ! At Santander, where Mr. Guthrie introduced the mineral acids as caustics, out of one hundred and sixty case, thirty-five, or less than one fourth, died ; and at Passages, where Blackadder employed the arsenical solution, only two deaths are recorded in forty-one cases of hos- pital gangrene, or about one death in twenty cases. INDEX. Abernethy, division of mortification into two kinds, 178. Abscess, 258. Acupressure, needles used to control hemor- rhage, 73. Adams, on morbid poisons, 197. Adaptation of compensative appliances, 97, 98. of stump for artificial limb, 105, 128. Adhesive strips, 97, 111, 112, 122. Adynamia, 465, 496. Adynamic fever attending gangrene, 227. .^sculapius, honors to, 202. prodigies not believed, 205. Aetius, observations in fifth century, 212. Albumen, 273, 365-367, 369, 453. Alcoholic stimulants, 560. Alexander, physicians of, 201,202. Allotropism, 465. Alopecy, 565. Ammonia, 258. Amputation at ankle joint, causes of fail- ure in, 107-109. at ankle joint not adapted to trans- portation, 123. at ankle joint, comparative service of resulting stump, 104-106. at junction of upper and middle third of thigh, 60. at middle third of thigh, 59. average periods of healing and non- healing in irounds in leg and thigh, 96. comparative frequency of in right and left leg, 48. ■ comparative frequency of in various regions of thigh and leg, 49. comparative success of ankle-joint, 102; 103. definition of terms employed in the periods of, by Legouest, 78. during shock, 83. effect of transportation after, 91, 92. for fractures more frequent than for wounds, 53. for gangrene in the C. S. M. P. Hos- pital, 521, 522, 547. frequency of reamputation at the an- kle joint, 103. flap method preferred, 58. general conclusions in regard to suc- cess of, in different periods, 85. importance of a new division of the periods of, 77. Amputation, — Continued. influence of different methods of, on healing, 94. in gangrene to be avoided, 563. of thigh recovered from, table of 158 cases, 12-23. of leg recovered from, table of 287 cases, 24-47. of thigh, table of 141 cases, 55. of leg, table of 257 cases, 55. of lower third of thigh, 61. of thigh in Crimean war, 63. of thigh in Paris hospitals, 63. of thigh in Polish and Mexican wars, 63. of thigh and leg, method and fre- quency of, 65. of thigh in Confederate service, 74. of leg bv circular and antero-posterior flaps, 76. of ankle joint, cases, 109-111. of importance in cases of gangrene, 283, 284. opinion of surgeons in regard to time of, 79-86. period of, 61, 80-82. primary, the most successful, 76. results of immediate, 83. secondary, not as successful as pri- marj-, 85. success of, within six hours of injury, 84. testimony of surgeons in regard to dif- ferent methods, 66-71. value of ankle-joint, 102. Anaesthesia, amputation performed daring. Analysis of amputations in different periods, 81. Anchylosis of tarsal and ankle joints. 111, 112. Anderson, F. A., Asst-Surg., case of gan- grene reported by, 238, 239, 412. cases of pyajmia reported by, 443, 444. Andersonville, hospital gangrene of, 239, 520, 547. Andral and Gavarret, analysis of blood, 285. Animalcules in gangrene, 265, 266. Archiater, 202, 203. Aretaeus does not mention hospital gangrene, 202. • Arsenic, 212, 666. Arsenical solution, 559, B67, 570. Asclepiadse, 204. Asphyxia, 173, 180. Astringent mixture for diarrhoea, 560. Atrophy below the knee, 105. 672 INDEX. Atrophy, — Continued. influence of place of amputation upon amount of. 87-89. influence of the method of amputation upon, 89-94. Autopsy, 238, 2.39, 287, 288, 403-405, 408- 411,422, 444, 536-638, 539-544. Avent, B. W., Surg., opinion regarding the period of amputation, 86, 87. Avicenna, observations on gangrene, 213. . B. Bacon, Lord, on minute observations, 160. on too hasty generalizations, 156. Baer's consolidated tables, 74. Bailhache, P. H., Surgeon 14th Illinois Cav- alrj', opinion on amputation, 67. period of amputation, 86. testimony regarding transportation after amputation, 92. Baglive, on ulcers, 463. Batwell, E , Surgeon 14th Michigan Volun- teers, distinctions between flaps and circular amputations, 67. testimony regarding transportation after amputation, 93. Becquerel and Rodier, analysis of blood, 285. Bed-sores, cause of death in gangrene, 398, 399, 504. Bell, Charles, on gangrene, 178. Belloste, on gangrenous phagedsena, 213. Bennett, on pus globule, 436. Bennett and Barlow, experiments on pus, 432, 433. Berzelius, on water, in human muscle, 368. Bethesda, pool of, 206, 207. Bilguer, on non-operative interference, 5. Billroth, experiments of, 353. Blackadder, Mr., cases of gangrene of the scalp, 203. on application of Aeti us, 212. on constitutional disturbances, 221, 222. observations on gangrene, 514, 516. on arsenic, 567, 568. on poison of gangrene, 240. on progress of gangrene when en- grafted on an old sore, 261-264. on terms employed by diflerent au- thors, 212. on the history of phagedsenons gan- grene, 211. quotations from the works of, 213. Blane, Sir Gilbert, on the cautery, 569. on ulcers, 471, 472, 525. scorbutic condition of the system, 524. Blood, 160, 283, 289, 293, 925. Blood-letting, 656. Boucher on division of periods of amputa- tion, 78. Bowels, condition of, 159. Boyer, Baron, aflirmation on gangrene, 237. on divisions of gangrene, 181, 182. on gangrene, 180. communicated by contact of linen, 240. places constitutional symptoms last in gangrene, 222. Bronchophony, 413. Browne, Dr., of Royal Sovereign, on begin- ning of hospital gangrene, 224. on malignant ulcers, 485. Bryant, Thomas, Surg. Guy's Hospital, on amputation of thigh, 63. Busk, Mr., London, remarks, 114. c. Cachectic state of system, 452, 453. Calcaneum undergoes necrosis, 114. removed, 116. Cancer, dispositions to, 223. Carswell, R., Dr., on mortiflcation, 185. Case of wound of ankle by fragment of shell, 109, 110. of wound of ankle joint by a spiral case-shot, 110. of extensive laceration of the tissues of the foot and heel by fragment of shell, 110. of amputation of ankle joint for an old railroad injury, 110, 111. of bony anchylosis of tarsal and an- kle joints, 111, 112. of Pirogoff's amputation at the ankle joint, 116, 117. of wound of the ankle joint, 116, 117. of foot crushed by recoil of gun-car- riage, 118. of wound of ankle joint, 118, 119. related by Surg. Covey, C. S. A., 233. showing that hospital gangrene may arise in those exposed to exhala- tions from gangrenous wounds with- out any abrasion of the surface, 230, 231. showing that a certain period of time elapses after the wounds have been subjected to the causes of gangrene, 233-239. reported by Assistant-Surgeon F. A. Andrews, 238, 239. of gangrene among Federal prisoners, reported by Assistant-Surgeon Curby of twenty-ninth regiment, 241, 242. of inoculation of gangrene, 248, 249. of hospital gangrene, 250-256. illustrating the existence of sound skin between two gangrenous sores, 239. illustrating the appearance of surface after the removal of gangrene, 260, 261,374. of necrosis of femur, 267, 268. illustrating the character of blood in hospital gangrene, 280-283, 291, 292. illustrating the changes of blood in hospital gangrene, 286-290. illustrating composition of blood in hospital gangrene, 292, 293. illustrating changes of temperature and urine in hospital gangrene, 302-335. illustrating slow convalescence in hos- pital gangrene, 374-378. illustrating disability caused by hos- pital gangrene, 380-384. illustrating fatal eflfecta of absorption of gangrenous matter, 388-392. illustrating fatal effects of the open- ing of large joints, 394-398. INDEX. 573 Case, — Contintied. illustrating fatal effects of bed-sores in hospital gangrene 399, 400. of obstinate and fatal diarrhoea super- vening upon hospital gangrene, 405, 407. illustrating causation of death by dis- organization of tissue, 408-410. illustrating seventh and eighth mode of death by hospital gangrene, 411, 413. illustrating superyeution of pyaemia upon hospital gangrene, 415-427, 437-445. illustraling contagious nature of hos- pital gangrene, 499-503. of pvsemia treated in Foard Hospital, 448. of pyaemia treated in Quintard Hos- pital, 448, 449. of pyaimia treated in Gilmer Hos- pital, 449. of pysemia treated in Eeid Hospital, 449. illustrating the tendency of small in- juries to degenerate into hospital gangrene, 520, 521. of hospital gangrene at Andersonville, 530-534. illustrating the origin of hospital gan- grene among Confederate soldiers at Andersonville, 533-544. Cases, table of five, of amputation at the junction of upper and middle third of the thigh, 60. table of four, of amputation of upper third, 60. table of thirty-three, of recovered am- putations of thigh, 58. table twenty-nine, of recovered am- putations at junction of middle and lower third of thigh, 58. table of nineteen, of recovered ampu- tations at middle third of thigh, 59. Causes of hospital gangrene, 452. Cautery, 666, 568, 569. Celsus, on ulcers, 463. .Chaddock, Surgeon 7th Michigan Volunteers, flap amputation, 69. Chambliss, Surgeon J. C., observations on the chemical properties of hospital gangrene, 274. Chelius, operation by, 129. definition of mortification, 185. Chelsea Hospital founded, 209. Chemical examination of gangrenous mat- ter, 272, 273. Chemistrv, organic, applied to pathology, 464. Chigre, a cause of sores, 468. Chisholm, Professor Medical College South Carolina, statistics of conservative treatment of gunshot wounds of the knee joint, 57. Chloride of sodium, 302, 360, 361, 367, 368, 382, 420. Chloride, rapid diminution of in the urine of small-pox, 360. Chopart's method, 110. Circular method of amputation, 65. amputation in upper third of thigh, 73. operation in middle of thigh, 74. Clark, Thomas, Dr., on gangrene which seized £nglish troops in the West Indies, 226, 227. on ulcers, 461. Classification of phenomena of mortification, 186. Cleanliness, 552, 563, 555, 563. Cleghorn, George, Dr., on ulcers, 463. Coagula, 545. Coagulation, 530-543. CoUamore, George A., Surgeon, on causes of thigh amputation, 62. opinion on amputations, 67. Comparison of Syme's and Pirogoff's method of amputation, 124-131. Complexion, changes in, as a sign of disease, 158. Complicated nature of the material entering into gangrenous changes, 273. Compound fracture of thigh in Milan, five cases of, 63. Concentrated nitric acid in the local treat- ment of hospital gangrene, 561. Confederate service, circular amputation pre- ferred to flap, 74. Constitutional disturbances not due to the local irritation of the nerves ex- posed to gangrene, 372. Contagion defined, 164. Sir Henry Holland's inquiry concern- ing, 165, 166. Contusion of soft parts, 108. Cooper, Samuel, on mortification, 178. Sir Astley, on gangrene, 178, 179 Copland, James, Dr., on gangrene, 185. holds that gangrene is always at- tended -with adynamic fever, 227, 228. Covey, E. N., Surgeon, case of hospital gan- grene related by, 233. Croft, Mr., of Ih'eadnought hospital ship, experience of surgeons in cases of ankle-joint amputation, 114, 115. comparison of PirogofFs and Syme's operation, 126. on length of stump, 127. Crowding, effects of, 151, 466-469. Cruikshank, first chemical examination of hospital gangrene, 275. Crystals of triple phosphates, 265, 273, 313, 382, 410, 411, 500, 502, 538. of oxalate of lime, 308, 382, 383, 397, 500. of hsematin, 410. D. Death, caused by absorption of decomposed gangrenous blood, 148. caused by entrance of air into veins, 393. caused by opening of large joints, 393. caused by bed-sores, 398, 399. caused bj' diarrhoea, 400, 401, caused by rapid disorganization of tissues, 407. caused by pneumonia, 549, 550. De La Motte, case of asphyxia, 180. Delpech, on constitutional disturbances in gangrene, 222. 574 INDEX. Delpech, — Continued. denominates gangrene pulpous, 509. admits the disease may be communi- cated through the atmosphere, 517. Diet, 560. Deming, C. E., Surgeon 28th Wisconsin Vol- unteers, preference of flap amputa- tion, 66. testimony regarding transportation, 93. Democedes, cure of Darius, 202. Description of ancient battles by Homer, 198. Diarrhcea in hospital gangrene, 170, 400, 491. colliquative, death from, 258. consequent upon the action of animal poison in gangrene, 272. in gangrene a critical discharge, 402, 405, 406, 559, 560. Diathesis, 436, 491. Diorus, against operations in the Hotel Dieu, 214, 215. Direction in which to look for improvements during the war, 10. Disease may be both local and constitutional in its origin, 296. Diseases, bow communicated, 241. which caused the mortality at Ander- sonville, 523. reported by Assistant.Snrgeon Thom- burgh, 527. Disinfectants, 551-553. applications, 562. Displacement of heel flap backward, 121- 123. Distribution of the various methods of am- putation in different regions of thigh and leg, 73. Dorsey, John Syng, on mortification, 178. Doughtj'', Surgeon, on the contagious nature of hospital gangrene, 504, 505. Dzemickeritch, Dr., first to introduce Piro- gofif s method at Odessa, 129. E. Effects of crowding upon the wonnded in the hospitals at Augusta, 115, 152. of foul air in the bomb-proofs of Mor- ris Island, 149, 150. of exposure, diet, and water on prog- ress of gunshot wounds, 150. of the absorption of gangrenous mat- ter in producing death, 387, 388. of malarial poison, 454, 455. of crowded tents, 466. of fatigue, exposure, and bad diet, 468, 409. Emetics, 556. Empire Hospital, cases of gangrene, 498. Epidaurus, serpents of, 205. Erichsen, of Loudon, on Syme's amputation, 120. Erysipelas, after ankle-joint amputation, 116. occasionally contagious, 167. appeai-ance in gangrene, 261, 271, 286. Eve, Paul F., Professor, on success of ampu- tation of thigh, 62. Ewell, LieutenantrGeneral, survives ampn- Ewell, — Continued. tation through upper third of thigh, 64. Excretions of kidneys, importance of exam- ining cannot be overestimated, 159, 160. Experiments upon animals with inoculation of matter of hospital gangrene, 505, 506. Exsection, 8, 9. per cent of mortality in, 56. of tarsus, 124. Ffxix, Dr., on sick berths, 488. Femur, injury of, 62. Ferguson, Mr., of London, practice of Syme's operation, 113. on Syme's operation, 120. Fever, inflammatory, 353-355. of small-pox, 355. Fibrin in hospital gangrene, 160, 170, 280, 283, 287-289, 291, 293. unmixed, marks the highest health, 279, 365, 367. of blood increased, 234, 285, 293, 298, 393, 515. decreased, 290, 453. normal in amount, 292. determination of amount of, of great importance, 294. table of proportions of, 294, 295. not increased in hospital gangrene to the extent usual in ordinary inflam- mations, 299. changes in, 430, 444, 455. Field, N., Surgeon, Maryland Volunteers, preference of flap operation, 69. Flap amputation, 65. testimony of surgeons in regard to, 66-74. operations in middle third of thigh, 74. Formula for treatment of gunshot wounds, 553. for treatment of gangrene, 553, 559. for treatment of diarrhoea, 560. Fowler's solution of arsenic, 567. Fracture, comminuted, 61. of femur, 62. Frascatorius, 196. Frequency of amputation of right and left leg, 48. of amputation in various regions of thigh and leg, 439. of recovered cases, 49. of reamputation at ankle joint, 103, 125. of slonghing and necrosis after am- putaUon, 103, 107. Fumigations, 551, 552. G. Galen an authority on mortification, 211. Gangrene after ankle-joint amputation, 103. and scurvy no connection between, 285, 286. causes and conditions of, 169. INDEX. 575 Gangrene, — Coniimied. causes of, according to Dr. Copland, 228. caused by an irritant, organic poison, 296. causes of death in, and results of post- mortem examination, 387, 388. certain modes of life favorable to, 186. changes of blood in, 279. charaoteristio of fever of, 348. communicated by contact, 488. communicated by inoculation, 607. congestion around the wound, 248. constitutional disturbances, symptoms of, 218, 219. disability resulting from, 380. due to changes in the atmosphere, 164. first symptoms of, 247. Galen's definition of, 174. grounds for the true theory of, 294. Guthrie on, 184. history of, 194-217. hospital case of, 147, 148. hospital report of, 153. if contagious, how transmitted, 168. in the intestinal canal, 462. increased in proportion to the distance the wounded were transported, 152. inquiries upon, addressed to Confed- erate surgeons, 155. local and constitutional symptoms with inflammation, 297, 298. matter of, acid, 274. name misapplied, 181. number of cases of treated in Army of Tennessee, 385, 386. origin due to overcrowding, 497. phagedajna, first reports of, from Army of Tennessee, 385. progress of, to recovery, 371. progress of, when engrafted on an old sore, 261-264. position of diseased parts, 373. questions as to the best mode of treat- ing, 170, 171. ravages of, 262. senile, 192. sloughing of flaps from, 94. subdivisions of, 179. three hundred and eighty-five cases of, treated, 154. treatment in case of, 284. views of author in regard to its origin, 229, 230. whether a local or constitutional dis- ease, 163. whether contagious, 163, 164. Gavarret and Andral, analysis of blood, 285. Gillespie, Leonard, on the putrid ulcer, 475. first to give account of ulcer, 487. Granulations, 260, 261, 270, 289, 322, 323, 325, 330, 331-333, 348, 381, 383, 394, 459, 460, 500, 563. Greeks receive surgery from the Egyptians, 195. Gunshot wounds of knee ioint generally fatal unless the limb be amputated, 62. fractures of femur, 62. wounds of knee joint, 62. fractures of the tibia, 62. Gustavus Adolphus, medical organization, 204. Guthrie, G. J., on immediate amputation, 82. criticism of, on the division of gan- grene by Baron Larrey, 184. observations of, illustrating the rapid poisoning of the system iu some cases of hospital gangrene, 241- 243. on rapid absorption of the poison, 243-245. description of hospital gangrene, 608, 509. on contagion of gangrene, 518, 519. the introduction of mineral acids into the British army due to, 669, 570. H. H^MATIK of the blood, 273, 410, 411, 425. Hamilton, Professor, of New York, classifica- tion of the periods of amputation, 78. analysis according to divisions of, 81. on time of amputation, 82, 83. Hammond, Dr., experiments of, 364, 369. Hancock's statistics of British surgery, 126, 127. Hardin, analysis of cow's milk, 369. Heart, disturbances in the action of, 351, 427, 428. increased action of, an evidence of debility, 352. Hebrew camp, 197. Heel most exposed to injury, 108, 109. Hemorrhage in amputation controlled by acupressure needles, 73. very common in hospital gangrene, 267. from gangrenous wounds, 258, 479. from small vessels, 264. explanation of the relief afforded by, 272, 323. period and mode of occurrence un- certain, 279. from wound, 282, 287, 289. from brachial arterv, 283. from arm, 290, 3211 passive, 297. from the lungs, 357. * from blood-vessels exposed and eroded by the gangrene, 392. tincture sesquichloride of lime as a lo- cal application for, 562. Hennen, Dr., regards gangrene in origin as constitutional as well as local, 225, 226. description of last stage of gangrenous disease, 264. observations by, at Bilboa, 414. Heriot, Henry F., Assistant-Surgeon, facts in case of gangrene, 316. Herodotus afi^irms that the Assyrians had no physicians, 194. Hewson, of Philadelphia, on necrosis of the os-calcis, 115. cases reported by, 117-119. on Pirogoff's stumps, 120. Hippocrates, study of, 163. honors to, 202. describes phagedsenic ulcers, 210. works of, 215. on treatment of ulcers, 504. 57G INDEX. Historical notes upon the treatment of hos- pital gangrene, 564-570. History of hospital gangrene, 194-217. Hodgen, on treatment ot retracted flaps, 96. Holland, Sir Henry, on difficulties of medical observation, 156. on method of inquiiy as to contagion, 165-168. Home, Sir Everard, on ulcers of the leg, 457. Homer, account of fatal pestilence, 196. description of ancient battles by, 136. Hood, Lieuienant-General, amputation of thigh, 64. Hospitalia of the Romans, 207. Hospitals, amputation in the wards of, 563. at Vineville, 469. crowded, 151, 497. first established in the eleventh cen- tury, 209. hygiene of, 551. introduced by Christianity, 207. location of, 549, 550. of Virginia as field for investigation of hospital gangrene, 150, 151. of Dalton, Rome, Cassville, Kingston, and Marietta, 152. wooden compared with tents, 550, 051. HStel des Invalides, when founded, 209. Hudson, Dr. E. D., government commission for artificial limbs, 11. artificial limbs applied by, 110, 112. on Syme's amputation, 120, 121. Hunter, Dr. John, doctrine advanced by, 452. on mortification, 174, 175. on the efiFects of warm climates on ulcers, 458-460. on infiammation, 554. Hutchinson, on time of amputation, 79, 82. Huxham, John, advice of, 161, 163. on the effects of salt and half rotten provisions, 524. tincture of bark, 557. Hydrochloric and nitric acid, 558. Hygienic condition of hospitals, 372, 379, 385, 447, 467, 550, 551. I. Importakci: of abundant supplies of animal and vegetable food, 548. Indications to be fulfilled in hospital gan- grene, 555, 656. Infection defined, 164, 165. Inflammation excited in system under the influence of malarial poison, 455. not a disease, 554. observations on, 269, 270. sthenic, 453. terminating in gangrene, 191. Influence of various methods of amputation on nourishment of stump, 90. Injuries requiring amputation of thigh, 56. requiring amputation of leg, 64. Inquiries upon hospital gangrene, 155-174. Invasion of organs essential to life, 414. Investigations at Fort Sumter, 153. into the chemical constitution of the air, 169. of Mr. Cruikshank, 275. Irregularities in the action of the heart, 428. Isolation of diseases, 550, 556, 561. J. Jackson^ Dr. Robert, on ulcers, 460, 461, 493. Jarvis, Mr., on malignant ulcers, 493. Jones, Joseph, Surgeon, investigations on hospital gangrene, 165, 336, 337, 358, 359, 363. table of observations by, 362. K. Kestsob, Dr., of penal hospital at Strasburg, on PirogofTs method, 130. Kettinger, Surgeon, U. S. A., operation at ankle joint performed by, 110. Knee joint, gunshot wounds penetrating gen- erally fatal, unless knee amputated. 62. Kneeland, Surgeon B. T., New York Cav- alry, preference of flap amputation, 68. testimony regarding transportation after recent amputation, 94. Kolliker, view of structure of liver, 426. Labarraque's solution, use of, 552. Lairey, Baron H., distinguished three periods of amputation, 78. advocated immediate amputation, 82. on amputation during shock, 83. divisions of gangrene into spontaneous and traumatic, 182, 183. on gangrene in the French army, 494- 497. Lamotte, on gangrene, 214. Laurent's view, 465. Laycock, Dr. Thomas, on importance of reg- ular observations, 181. Leale, Assistant-Surgeon, rectangular flap amputation, 65. opinion that patients sufi«r more from amputation of leg than of thigh, 73. rectangular flap amputation performed five times, 75. Leavitt, D. F., Surgeon 3d Massachusetts Cavalry, on period of amputation, 80, 86. Lebert, M., observations on pus, 435. Lee, Dr. Henry, experiments on pus, 433. Legouest, three divisions of period of am- ■ putation, 78. definition of terms in period of ampu- tation, 78. Lehmann, on water in human muscle, 367. investigations of, 368. Leidy, view of structure of liver, 426. Lesions, characteristic of hospital gangrene, 170. of mucous membrane, 401. Lidell, Surgeon, opinion concerning time of amputation, 80. Lieberkuhnian glands, 540. Ligation of bracliial artery, 258. Lind, Dr., description of scorbutic ulcers, 525, 526. Lint and rags may be the means of commu- nicating gangrene, 553. INDEX. 577 Liquor sanguinis does not pass into a state of pus, 271. Lisfranc, disarticulation, 11 S. List of writers on hospital gangrene, 2'5. Lisbon's cutting forceps, 124. Local treatment of gangrene, 560-562. London medical journal, 215. Lotion, cleansing, 552. Lymph in gangrene possesses power of coagulation, 271. M. MACLEOD, on gangrene, 228, 245, 246, 297. Malaria, 453. Malarial fever, 174. Malgaigne, Professor, of Paris, report of wounded in Polish campaigns, 63. on Pirogofl''s method, 130. Manfred, W., Surgeon 22d Kentucky Volun- teers, on preference of flap to circu- lar amputation, 68. McArthur, Mr., on ulcers of seamen, 490- 492. McDowall, on hospital gangrene, 478-480. on malignant ulcer in the British navy, 492, 493. McLeod, on amputation of thigh, 63. st:atistics in Crimean war, 64. evidence in regard to time of ampu- tation, 80, 82, 83. McSherry, Dr., U. S. N., on gunshot wound of thigh, 63. Meacher, N. A., Assistant-Surgeon, prefers Listen's flap amputation, 66. Measles, infection from, 167. Mechanical difficulties to be avoided in am- putation, 72. Medical organization, 203, 204. Medicine, schools of, 206. Mercurial preparations, 276. M^rillat, Surgeon S. L. M., on the hospital gangrene of the Staunton General Hospital, 470, 471. Metastasis induced, 183. Method and frequency of amputation of thigh and leg, 65. of operating by circular or flap ampu- tation does not affect mortality, 75. of calculating amount of flesh con- sumed during fever, 366. Mexican war, report of Dr. McSherry on gunshot wounds of thigh, 63. Microscopical character of deposits, 159, 160. examination of gangrenous matter, 265, 266. Milk diet, 560. Miller, Dr. H. V. M., on breaking up of hos- pitals, 550. Mineral acids as caustics, 509, 570. Missiles with which wounds were inflicted, 51-53, 58-61. Moffat, Thomas, sustains views of Dr. Trotter on hospital gangreue, 224. on malignant ulcers of seamen, 486. Moisture, 466, 457. Moon, W. P., Assistant-Surgeon, operation at ankle joint, 109. preference of the oval of skin and circular of muscles in amputation, 71. Moore, Surgeon-General C. S. Army, order concerning hospital gangrene, 155. Mortalitv after amputation, 7, 50, 54, 5G, 61, "63, 64, 74, 75, 102, 103, 124, 125. 130. from hospital gangrene, 153, 154, 521, 529, 530, 547. in hospitals, 385. 386, 446,, 447, 549, 550, 570. Mortification arising from mechanical in- juries, 189, 190. arising from and following inflamma- tion of important organs and struc- tures without external inj urv, 190- 192. arising from constitutional derange- ments, 192. arising from the action of special poisons, 192, 193. as a generic term, 179, 185. classitication of phenomena of, 186. detinition of, by Chelius, 185. division into two kinds adopted by various writers, 178, 179. in habitual drunkards, 189. meaning of, 174. synonymous with sphacelation, 176, with and without inflammation, 175, 176. Moses, value of the hygienic laws of, 200. N. Nashville "Journal of Medicine and Sur- gery " ou fracture of thigh, 63. Necrosis follows amputation of ankle joint, 101, 103, 104, 106. in Syme's amputation, 113. in PirogofTs amputation, 113, 114. of OS calcis, 115. of OS calcis and tibia, 116. of fibula, 119. of tibia, 125. of femur, 267, 268. Nitric acid, inquiiy concerning, 170. singly, 437,"55B, 501, 562, 568. not an infallible test for hospital gan- grene, 275. Nitrogen, 364, 366. Nomenclature of diseases, 81, 165. Non-inflammatory diseases, 173. Numbers of soldiers lost to Confederate ser- vice on account of disability follow- ing gangrene, 384-387. o. Observations of Eokitansky and Paget, upon the varieties of pus and of in- flammatory lymph, 277-279. of the rapidity with which fresh wounds became gangrenous at An- dersonville, 522. of Sir G. Blane, on ulcers as a result of scurvy, 525. of J. Huxham, on effects of sait and half rotten provisions, 524, 525. of J. C. Cliambliss, on hospital gan- grene, 274. Occlusion of veins, 403, 404, 450. Oil of turpentine, 559. 578 INDEX. Opiates, 559. Origin of hospital gangrene at Anderson- ville, Ga., 520. Os calcis, disintegration of, 116. displacement of, US- grown together with epiphysis of the tibia, 129. left on the flap, 127. removed with tarsal bones, 124. union with tibia, 119. Osteoplastic operation, 129, 130. Ozone, as counteractor of deleterious influ- ences, 150, 164. little Isnowledge as to the effects, 467. P. Pae^, opinion in regard to time of amputa- tion, 79, 82. description of wounds at siege of Rouen, 213. Paris hospitals, cases of amputation of thigh, 63. Pathological changes, hours in which they take place, 160, 161. lesions m pysemia, 423, 427. Paulus £gineta, on mortification, 213. Pearson, John, on causes of gangrene, 177, 178. Period at which amputation should be per- formed, 86, 87. intermediary, 85. new names of, 81. of amputation after injury, 76, 81. of reaction, 84. of incubation of hospital gangrene not fixed, 239, 240. Peyer's glands, 401, 405, 407, 409, 425, 544. Phthisis, 278. Phlegmasiae 283, 285, 293, 294, 296. PhUbitis, 419, 430, 450. PirogoiTs amputation at ankle joint, cases of, 116, 119, 132-134, 135. letter to Mr. Hancock, 128, 129, 130. method of amputation, 101, 103, 104, 105. method compared with Syme's, 124, 128. remarks, 114. stump, displacement of heel flap in, 122. Pliny on scurvy, 196. on ulcers, 210, 211, 665. Pneumonia, 412. Poison acting on the blood, 555. gangrenous, 298, 299. mducing typhoid fever and hospital gangrene different, 370. morbid, 512. of hospital gangrene, 221, 241, 402. venomous reptiles, 355, 356. organic, 355. typhoid, 550. Post, A. C, Professor, ohservations on gun- shot wounds, 62. Pott, Percival, on mortification, 174. on mortification of feet and toes, 192. Potts, G. J., Surgeon 23d North Carolina Infantry, prefers circular operation, 71. Pouteau, M., on gangrene, 214, 21 5, 610. on treatment of gangrene, 669. Powell, A. A., Assistant-Surgeon, collection of blood of hemorrhage, 280. amputation by, 293. facts communicated by, 507. examination of diseased leg after death, 439. Powers, Assistant-Surgeon U. S. A., method of amputixtion, 66. Precipitates, 275, 276. pink produced by action of nitric acid on gangrenous matter, 274. Prince, David, Surgeon U. S. Volunteers, on mortification of Syme's operation, 123. Puerperal fever, controversy as to infection of, 167. Pus, 117, 298, 353, 354, 357, 361, 410, 411, 423, 424, 426-433, 436-437,439, 434, 446. appearance of in gangrene a favor- able sign, 267. a secretion to disolve tissues, 271. formation of, 270. formed in phagedenic ulcers arising from the abuse of mercur}', 269. globule absent &om gangrenous mat- ter, 266, 267. has no smell, 276. microscopical examination of, 277, 279. not formed in truly gangrenous mat- ter, 151. veins of diseased leg distended with, 422, 423. Putrefaction an accidental, not necessary result of mortification, 180. Pysemia, 403, 404, 408, 414, 418, 428, 430, 444, 445, 453, 661. a blood disease, 174. cause and nature of, 436. color of urine in, 301. comparison of phenomena of gan- grene, 352, 353. death of Zouave from, 63. death from, 7 1. description of by M. Sedillot, 419, 420. following amputation at ankle joint, 107. numerical relations to gangrene, 445- 447. poison acts according to fixed laws, 543. supervention upon hospital gangrene, 438-441. symptoms of supervened, 117. Pyrexia, 293, 296. Q- QuAiN on Syme's operation, 105, 120. Cuarrier, opinion in regard to time ot am- putation, 79. Quinme, 566, 557. E. Rapidity of the progress of hospital gan- grene limited, 272. INDEX. 579 Rapidity, — Cmtinmd. with which hospital gangrene destroys the different tissues, 257. Ravages ot hospital gangrene, 263. Reid, Dr., of Edinburgh, on the effects of carbonic acid in the air on hospital ganfp-ene, 169. Remedies for hospital gangrene when en- grafted on constitutional syphilis or scrofula, 558, 559. Report of Surgeon-General, on gunshot wounds of knee joint, 56, 102. Respiration, 159. Results of immediate amputation, 83. Kibes's examination of soldiers with regard to inj ury of femur, 62. Richardson, Professor, of New Orleans, am- putation performed by, 64. Robbins, H. C, Surgeon 101st Illinois In- fantry, preference of flap amputa- tion in the arm and thigh, circular in the fore-arm and leg, 68. Roberts, D. J., Surgeon, on hospital gan- grene, 232, 233. Rodier and Becquerel, analysis of blood, 285. Kokitansky, observations on pus, 277, 278. on pyemia, 430. Rolandus on wounds, 213. Rolls, Dr., chemical examination of hospital gangrene published by, 275. description of hospital gangrene amongst the Royal Horse Artillery, 510. description of gangrene in work on diabetes, 215. on the mode of origin of hospital gangrene, 220, 224. on value of mineral acids, 568, 569. Boux, Jules, Naval Surgeon at Toulon, on amputation of hip joint, 53. on secondary amputation of thigh, 64. on division of periods, 78. Rusk, on Syme's and PirogofPs amputa- tions, 120. Saiidarach, the, of Hippocrates, 565. Schatz, on water in human muscle, 367. Scorbutic diathesis, ulceration peculiar to, 223. patients, 470. ulcers, 475, 476, 487, 492, 528. Scurvy, 459, 471, 523, 524, 526, 544, 545. not connected with gangrene, 285, 286. Sedillot, M., on pyaemia, 419, 420. on pus, 434, 435. Sensitiveness of stump, 119-121. Serum, endosmosis of, 430. Serviceableness of stump, 127, 128. Sesquichloride of iron, 556, 557, 559, 562. Sherman's army, method of amputation in, 66. transportation in, after amputation, 92. Simon, Dr. John, doctrine of, 354. Slough, gangrenous appearance of, 257. Sloughing of flaps, 69, 102, 103, 106, 107- 109, 113, 125, 127, 129. case of. 111, 112. Sloughing wounds, 470. Small-pox, 167, 475, 528. chlorides disappear in, 154. compared with gangrene, 355-357. urea, uric acid, phosphoric acid, and sulphuric acid increased in the urine of, 360. Smith, David P., Surgeon U. S. Volunteers, on causes of failure in ankle-joint amputations, 107. on method of amputation of leg, 71, 72. Smith, Dr. Stephen, amputation at the ankle joint, chapter on, 99. amputation performed bj', HI, 112. Sphacelation, definition of, 177. sometimes appears suddenly, 178. Sphacelus, 174, 179, 180, 182, 183, 491, 530, 535. of Galen, 185. Statistics of the insurgent service, 75, 103. of ankle-joint amputation, 106. of British surgery, 127. regarding immediate amputation, 73. St. Clair, Surgeon of 6th Michigan Cavalry, amputation at ankle joint performed by, 116. Sugar-cane anti-scorbutic, 477. Suppuration, period of, 79. Surgeons, European, acquainted early with gangrene, 214. Sydenham, Ur. Thomas, advice on observa- tion of diseases, 161. Syme's amputation and Pirogoff's compared, H)6, 107, 124, 131. comparative service of stamp, 104, 106. four cases of, 107. modification of, 123. necrosis in, 113-115. one case of, 122. practice 6t by Ferguson, 113. sloughing after, 103, 104. table of cases of, 136-141. Syntonni, 366, 367. Syphilis, poison of, 165. how communicated, 241. Table of 158 cases of recovered amputation of thigh, 12-23. of 287 cases of recovered amputation of \e^, 24-26. of missiles with which wounds were inflicted, 51. of nature and location of injuries by various missiles in 423 recovered cases of amputation of lower ex- tremity, 53. of amputations bv Pirogoff's method, 132-135. of amputation by Syme's method, 135-141. for rapid record of cases, 162. of fibrin in 1000 parts of healthy and diseased blood, 294, 295. of observations on vital signs, by Joseph Jones, M. D., 330-347. of observations on the urine of small- pox, by Joseph Jones, M. D., 358, 359. 580 INDEX. Table, — Continued. of observations on the urine of typhoid fever, by Joseph Jones, M. D., 362, 363. of sick and wounded in the Army of Tennessee, 386, 446. of patients at Audersonville, 529. Taylor, Dr., remarks on gangrene, 237. Temperature, 156. changes of, in gangrene, 300. changes of, in urine, 302. exerts an important effect on gan- grene, 373. great difference between central or- gans and extremities in, 300, 301. normal relations reestablished, 371. of wound in gangrene, 259. Testimony of surgeons on modes of ampu- tation, 66-71. of surgeons as to period of amputa- tion, 86. of surgeons regarding transportation, 92-94. from various observers necessary to perfect generalization, 157. Tetanus, 494. Thomson, Dr. John, favors the view that constitutional symptoms precede local, 224, 225. on mortificatioD, 179. on commencement of gangrene, 241. on the contagious nature of gangrene, 517. Thomburgh, Assistant-Surgeon, outline of case by, 534. report on hospital gangrene, ^527-532. Tissues, rapidity ^vith which destroyed by gangrene, 257. Tongue, purplish and bluish color of, 389, 390, 396, 397. Toulouse, batUe of, followed by no case of gangrene, 242, 243. Travers, Mr., term gangrenous inflammations used by, 184, 185. Tripler, C- S., instructed surgeons to per- form Pirogoff's amputation, 101 Trotter, Dr. Thomas, observations on gan- grene, recorded by, 231, 232. on niiture of hospital gangrene, 223, 224. on hospital gangrene, 480. on malignant ulcer, 487. on scorbutic condition of system, 524. on spontaneous character of ulcers in the British navj-, 525. operation performed by, 114. on treatment of gangrene, 569. Tudor, Mr., operation performed by, 114. Typhoid fever, albumen an^ fibrin dimin- ished in, 365. chemistry of, 364. compared with hospital gangrene, 361. increase of heat in, 236. increase of acid in the urine of, 370. mortality from, due to exhalations, 466. u. Ulcers, 223, 224, 456-463, 478-480. gangrenous, 471-475. putrid, 475-478. gangrenous, of seamen, 480-482. malignant, 225, 231. malignant, of seamen, 482-486, 490, 492. malignant, of British navy, 487-493. malignant, causes of, 493, 494. malignant, mentioned by Pliny, 210, 211. malignant, mentioned by Hippocrates, 209, 210. Urine, analysis of, in cases of hospital gan- grene, 236, 250, 262, 253, 255, 282, 303, 305, 307, 308, 311, 313, 314, 317, 319, 320, 322, 324-327, 329, 330, 332-334, 377, 378, 382, 383, 390, 391, 395-397, 416, 418, 420, 421, 438, 441, 442, 501. changes of, in hospital gangrene, 301, 302. chemical examination of, important, 309. of small pox, 357-359. standard of, in starvation, 331. V. Vah Bubes, Professor, of New York, on case of Syme's amputation, 104, 105. on Syme's and Pirogoff's method, 126. Vaccination, 546, 547. Vegetable diet, 492, 548. Venesection, improper in gangrene, 279. Virus, 166-168. Von Bibra, on water ill human muscle, 367. w. Walter, Rev. Mr., on blood bursting from scorbutic wounds, 524. Walton, C. J., Surgeon, on time of amputa- tion, 80, 86. preference for flap amputation, 69. on transportation, 92. Warren, Assistant-Surgeon, facts from case of gangrene, 316. Weber, O., experiments of, 353. Weber, E. analysis of cow's milk, 309. Williams, J. W., Surgeon, on flap amputa- tion, 70, 71. Wiseman, on time of amputation, 79, 82. on putrid ulcerj 214. T. YouKG, Dr., on ulcers of the leg, 45T, 458. t. S.Saiulaiy Coiiunisswii. .Sii/ytm/-Ji'/r;i/un//v ■I'la/t; I. HOSPITAL OANGKJ3NE CASE OK WJ.BI-ACK, N? VTI D/mm- fmniuViiilre 6r/./any)/i Jones. Sil/yrrjn PA/.X BoWGrL&Cdironio-jTti. Pbilad* C. S.Sajiitari/ (ij/iLrnUaio/r . • '>il/y/ati. l/r/. ■pfuU .'' HOSPITAL GANGRENE CASE OF THO? PAINE. N? VUt. J)/uum^ /n7rnJ\^u-e l/y'/osip/t ^Jo/iay. Suraeon.Ji'A.CS. t. SWa/ii/a/-// Coiiii/i^fSi' SmrftfYiii: ')/f'i/vai>^' •PlaU^- KOSPITAI, GA'NTBJDrrE.-r'I.C'E'B APTER THE STiOUGH HAD SEPABATJEU. -BoMTpn & C° dhromo-lrdt FhUad^ yWrz/ioi/Af . S'Sa/iiiaiyy Coiiij/ustrn'ii . ■Pt.jjr -J jVPPEARANCE of PEWOHALVEIN rM A CASE OP PYAEMm. CASE XTJV Bow8ti&C?iihrcimolrt}i Pblod"- .Me/nr'us-l.'SScuityuiyyCiiftirniss^wn. 'J'i/j/^5. MICROSCOPICAL jVPPEARANCE Or QANORENOnS MATTER OP FEMOHAL VEIN. MAG.430 BIAMETEnS. BcTv/snS C° ohromolrfh. Fhilad?-