[Extracted from the American Journal of the Medical Sciences for April 1864.]
                          REPORT

                                 OP

CASES  OF HOSPITAL GANGRENE TREATED IN DOUGLAS HOSPITAL,
                        WASHINGTON, D.C.

                 By WILLIAM  THOMSON, M. D.,
                       ASSISTANT SUKGEON U. S. A.
   The following histories of cases of hospital  gangrene treated in Doug-
 las Hospital, Washington, serve  to illustrate several points of great inte-
 rest in the etiology, pathology, and treatment of a disease hitherto rare in
 our military hospitals, and most worthy of careful study.
   The victims  of this disease were wounded at Fredericksburg, Va., Dec.
 13th,  1862.  For several weeks previous to this battle, the army had been
 resting on the Rappahannock, and had been exposed to no great hardships.
 It had been amply supplied  with  good and varied food,  and  the men were
 free from any scorbutic or other cachectic taint.
   It is well known that the fullest preparations had been made by Surgeon
 Letterman for that engagement.  The operations were performed promptly,
 and the  wounded probably received better care than ever  before in the
 history of the war.
   On  the 26th of December, 1862, about  two hundred wounded from the
 battle  of Fredericksburg, were received into the Douglas Hospital.
   I cannot  speak of their treatment, medical, surgical, or hygienic, as at
 that time I  was not connected with the hospital.  I  am, however, aware
 that the building in which  the gangrene appeared contained fifty  badly
 wounded, and recent cases;  that  there was a deficiency  of medical officers
 and dressers to insure the necessary cleanliness,  and that the  sanitary con-
 dition  of the ward was far from perfect.
   This hospital consists of the  three brick houses known as " Minnesota
 Row;" and  two large wooden pavilions, each divided into two wards.
   The ward  in which  this disease originated  is one  hundred and forty-
three feet in length, twenty-three feet in  breadth, and sixteen feet in height
(eighteen feet at the cone, and fourteen at the eaves of the roof), and con-
tains beds for fifty patients, thus giving 1050 cubic feet  of space for each
bed.   There  are two raws of windows, the lower of which contains two, 
   SL$6                         2
 the upper one sash each ;  the upper windows so constructed as to be opened
 by means of a cord,  but when opened directing a current of cold air imme-
 diately downwards upon the beds beneath.
   On the 16th of Feb. 1863,  I took charge of the hospital, and found the
 ward mentioned  in the following condition : There was no  ridge ventila-
 tion, nor was there any egress for foul air, except through two large wooden
 shafts connected  with two of the stoves, which had been placed there only
 a few days previously.  The ward was  heated by ordinary sheet-iron radi-
 ating coal stoves ; and no provision had been made, until a few days before,
 to introduce any supply of fresh air.   It contained from  forty to fifty
 patients, all  wounded—many of them very severely.   The police  was not
 unexceptionable,  too  little attention having been paid to the removal of
 offensive discharges.   The medical officer in charge preferred to water, as
 a dressing, either simple cerate or mutton tallow, which had been issued to
 the hospital, and which had become  rancid.  The attendants were, from a
 want of strict discipline, careless and inattentive.   There was a perceptible
 and offensive odour in the ward, which felt close and badly  ventilated;
 and this condition of the atmosphere seemed to have a marked effect on the
 spirits of the men ; they were all gloomy, despondent, and homesick.
   On Feb. 17th,  when making  my first visit with the officer in charge of
 the ward, I discovered

   Case I. Sergt. Otto Kosack, Co. K,  2d  Md. Vols., who had been struck
 by a shell, Dec. 13th, 1862, which made  it necessary to amputate his left leg
 at the middle.  The operation  was done ten minutes after the injury.   He
 was received here on the  26th  Dec.  The  stump closed by granulation, a
 small portion of the tibia having been removed by exfoliation.   The cica-
 trization had been almost complete, when, a few days previous to the  17th,
 the still open wound commenced  to slough.  He  was  aneemic, very pallid,'
 haggard, and with an expression of great depression  in his features;  his
 pulse was very feeble and rapid.  He had  been  " feeling very badly" for
 several  days, and complained of a burning  pain in the stump.
   On the outer side of the tibia there was an ulcer, one inch  in  diameter
 covered with a yellowish-gray, pultaceous  slough, and a serous and very
 fetid discharge; the edges were thickened and everted, and  an  areola  of
 purple,  livid congestion, extended for half an inch from the margin which
 was undermined.
   This  sore was at once treated with pure nitric acid, applied both to the
 ulcer and to the areola ; the  ulcer was dressed with an antiseptic solution of
 creasote;  and citrate of iron and quinine, with stimulants and nutrients
 were freely given.
   On the 18th the sloughing  had extended to  the border of yesterday's
 livid areola,  but was now more superficial; and the areola, which  had
 likewise invaded the surrounding skin, was more florid.  The ulcer was now
 two inches in diameter.  As there was  some doubt as to its specific cha-
 racter, the patient was not removed from the ward until the 23d when he
 was  transferred, with  several others, to a small ward prepared in the brick
building, and completely isolated from the other wounded men
   The iron and quinine was  found to disturb his  stomach  and destroy  his 
3
>m<?7
appetite, and was replaced by a mixture of nitro-muriatic acid and tincture
of opium.
   March 3.  The sore was now perfectly healthy, and was granulating ra-
pidly.

   This was a  mild case—treated  in  its incipiency with nitric acid most
thoroughly.  The ulceration had not extended so deeply, nor so far beneath
the  margin of the skin, as  to  make it  almost impossible to reach every
portion of the diseased surface.
   There was no scorbutus.  The gums were firm and  hard.   The patient
 was very pallid, his heart feeble, and his pupils dilated.  The mucous mem-
branes were very pale, and the expression  of the face haggard and  anxious.
   He  recovered rapidly, with a  good stump, and was transferred  to St.
Elizabeth Hospital, May 4th, to enable him to procure an artificial limb.
   This mau was seen several months after walking with  great ease on his
artificial leg.

',  Case II. L. D.  Thurston, private, Co. A, 16th Regiment New Hamp-
shire Vols., aged 42,  was struck by a fragment of shell on December 13th,
 1862, at Fredericksburg, Va., which caused a severe but superficial wound
of the integuments on the outer side of the left thigh.
   When seen, Feb. 17th, 1863, there was  a wound  at the  middle of the
thigh, on its outer  aspect,  three and a half inches long by two and a half
wide, exposing the  muscular  tissue slightly, the surface of which was glazed
and  dry.
   On the 10th of February it had been found desirable to open an abscess,
three inches below the  left  greater trochanter.  On  the  13th, this had
assumed an  unhealthy look, and when I saw it on  the 17th, the incision
made by the lancet, half an inch in  length, was  surrounded by a border of
sphacelus one  inch in width, and  by an areola of purple  congestion, in
which  there seemed to have  occurred a complete stasis of the circulation.
There  was  no  pus, but  a discharge of  very fetid, dark-coloured serum.
There  was  no swelling, ulceration,  or eversion  of  edges of  the  incision,
which, although mortified, remained as sharp as when first made.
   There was  profound nervous prostration,  which was indicated by his
rapid,  feeble, and irritable pulse;  by his sallow hue; his haggard and
anxious expression of countenance; his weary and helpless  decubitus, and
great mental despondency.
   He  was  treated internally with  stimulants, the most  condensed and-
nourishing food, and  citrate  of iron and  quinine; nitric acid was applied
locally, followed by a weak solution of creasote, three drops to the ounce
of water, as an antiseptic dressing.
   The sphacelus extended in all directions rapidly, unchecked by this treat-
ment, from which  I hoped little, since it was  impossible to  bring the acid
into contact with the diseased tissues, although it was  injected into  the
incision. • The  constitutional symptoms, also, became more grave.
  On the night of the 20th,  there was quite a severe hemorrhage from the
incision, oozing slowly and very difficult  to restrain, since it was caused
by the erosion of vessels at a distance from the small incision.  There was
now a circular patch  of sphacelus  surrounding this small  incision, three
inches in diameter. 
22i
4
   On February 23d  he was removed to the ward  in  the brick building.
 The  original  wound, hitherto  unaffected,  now began  to be  black  and
 offensive.  The sphacelus extended from these two  centres, at  the rate of
 one inch daily, preceded by the above-mentioned areola of  purple stasis.
   No treatment, local or constitutional,  produced the least effect.   Stimu-
 lants were given in every possible form, until the stomach refused to retain
 them.  Pure nitric acid was freely applied to the diseased surfaces with no
 benefit.  He fell into a  typhoid condition, with  muttering delirium,  sub-
 sultns tendinum, etc., and finally  expired February 28th.
   The sphacelus then extended from the trochanter major to three inches
 above the outer condyle ;  and from the median line in front to a correspond-
 ing point behind.   There  had never been any ulceration,  but  the tissues
 seemed to  perish en  manse.  The incision made by the  lancet was  yet
 plainly seen in the  centre of an extensive surface of mortification.  This
 man was 42 years old, had had chronic diarrhoea, and was in a feeble state
 of health when wounded.
   No benefit was observed from any treatment.   He took, in  addition to
 the nutrients and tonics, the acid  mixture with tincture of opium.
   The preparation  was forwarded to the Army Medical Museum.

   Case III.  Private  Samuel Fossett, Co. I, 12th Regiment Rhode Island
 Vols., suffered a compound fracture of the right clavicle, by a fragment of
 shell, at Fredericksburg, Va., December  12th, 1862.  There was very ex-
 tensive injury to the soft parts.  He was admitted to this hospital Decem-
 ber 26th.
   On February 18th,  1863, a large granulating surface, two inches deep,
 was  covered with an  ashy,  gray slough,  and  the discharge was  converted
 from  pus into an offensive ichor ;  the edges were thickened and everted, and
 surrounded by the characteristic areola of congestion, fading  away into  a
 bronzed hue.
   The ulceration here attacked cicatricial tissue, which disappeared very
 rapidly.  The entire surface was treated with  nitric acid diluted, and tonics
 and stimulants  were given internally.
   The acid changed at once the character of the sore.   It soon commenced
 to granulate, and the  repair was then as rapid as had been the destruction.
 He was discharged the service, April 7th, for partial paralysis of the right
 arm, from traumatic injury of the brachial plexus.
   This case was easily treated, being recognized as gangrene at once, and
 terminated  quickly  in convalescence, with a perfect recovery.  The consti-
 tutional symptoms  were never severe, although the man was amende, and
 had great mental despondency.
  He was also removed from the crowded ward, and placed in a more salu-
 brious one in the brick building.

  Case IV. Charles  Underwood, Co. D, 31st  Georgia, aged   24, for a
 wound caused by a shell, on December 13th, 1862, at Fredericksburg, Va.,
 suffered an amputation of the left leg at its middle.
  He entered this hospital December 25th.  Nothing interesting occurred
until February 20th, 1863, when  a granulating  surface on  the face of  the
stump became covered with a gray slough, and the discharge was changed
from  pus to an offensive ichor.   He was anaemic and  much depressed*3 in
spirits.  This case  occurred in the same ward, but on  the opposite side 
                                  5                             st a?

from the previous ones.  The ulcer was dressed with sol.  of creasote, and
tonics and stimulants given internally.
  On the 23d he was removed to the brick building, his ulcer freely treated
with nitric acid, and then dressed with  a mixture of equal parts of bals.
copaiba? and ol.  ricini.   The ulceration had never been rapid in this case,
and  it was only considered specific because other undoubted cases had oc-
curred  in the same ward.
  The character  of the ulcer soon  became changed, the  granulation was
rapid, and he was  finally transferred to military headquarters, May 4th,
1863, perfectly recovered.

  Case V.  Isadore Wick, Co.  D, 1st  N.  Y. Artillery, aged 32, had  his
right thigh amputated  on  the field, for a comminuted fracture of the tibia,
received December  13th, 1862, at Fredericksburg, Va., caused  by a minie
ball.
  He was admitted December 26th.   I regret  that I can  give  no account
of his  progress, but I learned that the flaps had been insufficient, and that
the stump had been closing by tedious  granulation.   There had been a free
discharge, and his general condition was, therefore,  unfitted to  withstand
the depressing influence of hospital gangrene.   His bed was on the same
side of the ward, and in close proximity to the first case reported.
  The operation had  been  a circular  one; the granulation had entirely
covered the  end of the bone, and there was,  when seen on the 18th Feb.,
only a narrow strip, not yet cicatrized, between the margins of skin.  This
was now  covered with a gray slough, and had the  characteristic fetid
odour.  It was  dressed simply with the creasote solution, my faith in  the
acid treatment having  been  shaken by the reports of medical officers who
had visited the cases at Annapolis, Md.
  Feb. 23rf.  The case  was now considered  an unequivocal one of hospital
gangrene, and was removed  to the ward selected for such cases.   The cica-
tricial  tissue had all yielded to the sloughing,  and the subcutaneous con-
nective tissue had been destroyed for  two inches beneath  the skin  at  the
outer angle of the  original  incisions.   No change was made in  the local
treatment, as the creasote was a perfect deodorant, and as good results were
hoped  for, from its local use, as had been reported from Annapolis.
  The destruction was limited  to the  connective tissue until  March  9th,
when there  was a margin of sphacelus  half an inch wide  in the true skin.
The constitutional symptoms had been growing more  grave.   His  mental
despondency was most  marked, his face pale and anxious, his pupils dilated,
his pulse 100 per minute,  and feeble, aud his  skin very moist; a free diar-
rhoea had also commenced.
  The tonics and stimulants  having produced  anorexia and nausea, were
replaced by a  mixture of tincture of opium and hydrochloric acid, in such
proportions that he took gtt. xvj of tr. opii, and gtt.  iv of  acid, hydrochlor.
every fourth hour.   Beef essence and  milk punch were given  as freely as
his stomach would tolerate them.
   Wth. As  his general condition became less favourable,  the local  action
was changed from molecular death  to  sphacelus.  The whole face  of  the
stump has now  a  margin of black mortification of the  skin, outside of
which  was the usual areola  of purple congestion—the complete stasis of
to-day becoming the sphacelus of to-morrow.   The end of the  femur, pro-
tected  by  rosy granulations,  now protrudes from the black mass of spha-
celus, the  integument  having become loosened  by the  destruction  of  the 
  WO
subcutaneous connective tissue and retracted.   The presence of this mass
of putrefaction seems  to  add to the nervous  prostration—if  indeed  the
absorption of such peccant material is not its sole cause.   Pure nitric acid
had been applied several times, but it had been  found impossible to convey
it into the depths of the ulcer.
  2lst. No change except for the worse had occurred.   Stimulating poul-
tices of cinchona, ginger, and flaxseed had been used  locally, but with no
benefit.
  Antiseptics, such  as the  solutions  of the chloride of soda, creasote, and
permanganate of potash were necessary to purify the ward  and render it
endurable for his attendants.   Nutrients  and stimulants had been pushed
to the last extent, and opium  had been largely  given for its supposed spe-
cific effect in the disease, as well as to allay suffering.  The symptoms had
been typhoid for several days ; emaciation had gone on rapidly ;  there had
been subsultus tendinum and  muttering delirium with extreme prostration
until this date, when death occurred.
  The limb was removed after death and the specimen sent to the Army
Medical Museum.  The sphacelus had involved all the tissues for five inches
above the divided bone, and there seemed to have been a faint effort to form
a line of demarcation.

  This was, at first, a very mild case, with no  very decided  constitutional
depression, until the system seemed to be  poisoned by the absorption of the
products of the gangrene, when  the ulceration became  more  rapid, and
was finally, as the strength succumbed, converted into  uncontrollable and
rapidly extending sphacelus,  accounting  satisfactorily for the unfortunate
result.
  The treatment locally had been, first, weak  sol.  of creasote, gtt. iv to
water  |j, made  soluble by alcohol  3j 5  a°d second, strong nitric  acid;
never fully applied,  however,  to the  depths  of  the diseased tissues.   The
constitutional treatment was stimulating, sustaining, and tonic.

  Case VI.  Patrick Morrisey, private, Co. K, 20th  Mass. Vols., aged
46,  had been wounded on the 13th  Dec, at  Fredericksburg, and  suffered
an amputation of the left leg at its middle.
  He was admitted Dec. 26th, 1862.  There had been  no union ; the flaps
had sloughed and the bone protruded, as  in almost every case  transported
hither on that occasion.   He had been  broken  down by a free  discharge
and diarrhoea.  His bed was  in the same ward, and on the  same side with
the previous cases, and his wound was dressed  by the same  medical officer
and nurses.
  March 6. His leg for six inches above the face of stump was swollen,
erysipelatous looking, and riddled with small orifices leading to  abscesses.
The face of the stump was composed of purplish, lowly organized, cicatri-
cial tissue, upon which a patch of sphacelus as large  as a  nickel penny,
surrounded by the livid purple areola, now appeared.   This was freely in-
cised, touched thoroughly with pure nitric acid, and dressed with a ferment-
ing poultice  sprinkled with  sol.  soda? chlorinat.   Internally, gtt. xv of
McMunn's elixir of opium were given every fourth hour.
  This attack was ushered in by nausea, rigors,  and fever;  and the patient
had a desponding, yet anxious expression of countenance.  His diet was
"extra" with stimulants. He was at once removed from the large ward and 
1
£*//
placed in a pleasant one selected for these cases  on the second story of  the
brick  house.
  9th. The edges have yielded until the ulcer is now two and a half inches
in diameter, covered with a tough  yellow slough, which adheres  strongly
and extends  deeply into  the tissues of the centre.   The  pure acid was
again thoroughly applied both to  the diseased surface and to the areola.
Internally  a  mixture of tr.  opii,  gtt. xvj,  acid, hydrochlor. gtt.  iv, every
three  hours, with extra diet and stimulants, was ordered.
  12th. Ulceration was unchecked, was now three by two inches in extent,
and the margins, undermined by destruction of connective tissue, were "piled
up," thickened, and everted.  There was diarrhoea with decided nervous
prostration.   The sloughs were all removed with the forceps and scissors,
until  the  vascular tissue beneath  was reached, the sore, well  dried, was
thoroughly cauterized with  nitric acid, and dressed  with  a poultice and
disinfectants.  Elixir vitriol was ordered for the diarrhoea.
  13/A. The appearance  of the sore was improved, and the general con-
dition was better.
  14//?. Granulations were now seen on the sore,  and  the  areola  had lost
its livid hue.
  April 20th. An immediate improvement in  the general condition fol-
lowed the thorough  acid treatment of the ulcer.   The  tongue became
clean, the diarrhoea  was  checked,  the appetite  returned,  the food was
assimilated, the whole expression of countenance was changed from anxiety
to cheerfulness, the  gnawing pain  was relieved, and  the patient slept
soundly.   The appearance of the  sore was also changed as  suddenly from
a foul, offensive, sloughing ulcer,  to a rosy, granulating  surface,  in which
repair was as rapid as the previous destruction.
  This man  recovered with  a  good stump, and  was transferred  to  St.
Elizabeth Hospital to receive an artificial leg.

  Case VII. John Jordan, private, Co. H,  2d Maine, aged 20, was struck
at Fredericksburg, Va., Dec. 13th, 1862, by  a fragment  of shell, which
passed across the right  thigh  below  Poupart's  ligament, through the
scrotum, destroying the right testicle, and behind  the left thigh, producing
in its course very extensive but superficial wounds of the anterior  portion
of right, and posterior portion of  left thighs.   He was admitted Dec. 26th,
1862, and placed in Ward No. 5.
  Feb. 27, 1863.  He had  febrile disturbance and  anorexia, a yellow furred
tongue, an anxious, restless expression of countenance, and a burning pain
in his left thigh.   There  was, on the right thigh, a granulating surface
three by two inches in dimensions, level with the integument and cicatrizing
rapidly : a smaller, equally healthy surface remained unhealed on  the scro-
tum ; whilst on the posterior portion of the  upper part of the left thigh, an
ulcer, three by two inches in extent, was found, oval in shape, covered with
an ashy, gray slough, with its margin thickened and everted, surrounded by
a livid areola, and, instead of normal  pus, discharging a thin fetid serum
mixed with debris.   He was at once removed to the house,  the whole dis-
eased surface was touched with pure nitric acid, and dressed  with the crea-
sote lotion : stimulants and the best extra diet, with beef essence and milk
punch at  short  intervals, and ferri. et quin. citrat. three times daily, were
ordered.
  March  5.   The attempt to push the nutrients and  stimulants produced,
as it generally does, anorexia, nausea, vomiting, and diarrhoea.  The tongue 
became thickly coated with a  yellow fur, and dry and red  at  the tip ; and
so great was the  gastric disturbance, that  all medicines were discontinued
and the stomach allowed to recover its tone by rest, no longer being teased
either by drugs or excessive and undesired nutriment.
  No benefit Mowed the local application, and the ulceration had extended
in every direction.  There was the characteristic margin,  preceded  by the
areola of livid stasis, preparing the tissues for their rapid destruction.  The
connective tissue beneath the skin had been destroyed, so that the skin for one
inch from its margin was perfectly movable.  The muscles separated from each
other by the death of their connective tissue lay in the wound, bathed in its
discharge, but rosy and florid,  and resisting the advance of the disease.
  This sore was so unmistakably hospital gangrene that several pictures of
it were taken by direction of Surgeou Brinton,  which  represent well the
surface of the ulcer, dripping with its thin serous discharge mingled with
shreds  of dead connective tissue,  its  " piled-up," thickened,  and everted
margin, surmounted by a  thin line of vivid redness, and its broad zone of.
purple congestion, shading away into a bronze hue:  the  depth of  colour
in the areola indicating the engorgement of the small vessels, and its  hue,
the feebleness and slowness of the movement of the blood.
  It was determined to try the opium treatment, with  hydrochloric  acid as
a touic, and this  mixture was given  in the proportion  of tinctura  opii
gtt. xvj, with acid, hydrochloric, gtt. iv, every three hours.  The sore was
dressed with  a stimulating poultice composed of flaxseed, cinchona, and
ginger, mixed with porter.
  Wlh.  Under the use of  the acid internally, the  tongue had become clean
and moist, the tone of the digestive apparatus improved, and a fair quan-
tity of food had been taken. Porter and ale had been given as the stomach
would retain  them.  But  little change had  taken  place in  the  character of
the ulcer, which was eight inches in length by seven in breadth, extending
to the perineum, and irregularly oval in shape.   The  muscles exposed  (the
semi-membranosus and  biceps) had yielded, and were now almost  divided.
The sores on the right thigh and scrotum had not been in the least affected,
but were cicatrizing rapidly.
  The entire surface of the gangrenous sore was now thoroughly cleaned,
all  sloughs and  shreds removed with forceps and scissors, was well dried
with lint and carefully  painted with pure nitric acid.   The brush,  charged
with acid, was passed beneath the excavated margin,  in some places more
than an inch.  The patient was etherized,  and this  acid  application was
made most carefully and completely.  This was considered a dernier ressort,
for, although  the capacity for  taking and assimilating food seemed to have
been increased by the  acid treatment internally, yet his strength was daily
diminishing from the exhausting discharge and from the absorption  of the
products  of the gangrene.
  On the succeeding day an entire change in the sore  was observed ;  there
had  been no  extension of  the gangrene, the fetid  odour was gone, and the
discharge was more consistent and less serous.  In a few days more all the
shreds of dead fascia were removed, and  the surface was  found to be  per-
fectly healthy.  The contrast between the ragged, offensive, yellow-coloured
ulcer, before the last  application of acid, and the florid, perfectly normal,
granulating surface, which replaced it, was as gratifying as it was surprising.
With the local there was also a constitutional improvement.   The appetite
became voracious ; the patient slept well; there was no pain,  and the pro-
cess of repair was  very rapid.   The acid  was continued internally. 
9
2W
  April 1.  The sore was now two by three inches in extent, and cicatrizing
rapidly.
  20//). But a small surface yet remained unhealed.   The patient was in
perfect health, had gained flesh very rapidly,  and was ijow on crutches.
  There was some contraction of the flexors, as the biceps and  semi-mem-
branosus were both involved in the  destruction.

  The  most remarkable circumstance  in  this typical case is the fact that
when the  gangrene attacked the  granulating surface of the left thigh, the
equally large granulating surface of the right thigh  was unaffected; and
that whilst the gangrene was ravaging the left thigh the rapid cicatrization
of the right proceeded uninterruptedly.   The discharge from the left  thigh
was  so profuse that no precaution would have prevented the virus from
coming in contact with the excoriated  surfaces of the scrotum and right
thigh.  If, therefore, the disease be propagated by inoculation, all  the  cir-
cumstances were favourable ; since the proximity of the thighs at their upper
part, and a  denuded surface on the scrotum, that might act as a link, render
it certain  that a portion of the great discharge from the left must frequently
have been placed in contact with both of the other sores.   If, on the  other
hand, the gangrene be not a local but a constitutional disease, why should
it spend itself on one granulating surface when there were two others equally
obnoxious ?  The contrast between these sores was marked;  for whilst the
tissues of the left thigh were melting away under one's very gaze, the pro-
cess  of repair in the scrotum and right thigh was progressing as rapidly as
under the most favourable  circumstances.  In  its earlier stages this case
was  twice treated with nitric acid, and  perhaps imperfectly, from its  not
having been carried  into the recesses of the ulcer.
  The system  of urging nutrients, stimulants, and tonics, irrespective of
the natural  desires of the patient, is, I am satisfied, pernicious.   The vital
energy being depressed, the digestive organs are enfeebled ; and the intro-
duction of milk-punch, beef-essence, eggnog, &c, with stimulants, porter,
ale,  &c,  into an  unwilling stomach, simply xproduces anorexia,  nausea,
vomiting, and  diarrhoea.   The  tongue became  furred  and dry, and  there
was  a perfect disgust for all food.   The hydrochloric  acid was given  to
correct this condition ; and  whether its action was confined  to the stomach
in rendering soluble the aliment, given in very small quantities,  or whether
its action  was catalytic or eliminative, I shall not pretend to state, but  under
its influence the tongue became moist and clean, and the patient made known
his desire for food.   Nutrients were then given  more freely as his appetite
returned.   The recovery of this man is due,  first, to the thorough  applica-
tion  of nitric acid to every portion of the ulcer, which changed its specific
nature immediately; and, second, to the combined effect of acid  and opium
internally.  After the last complete  application of acid the sore was changed
in character, the areola disappeared, the surface became clean, the margins
lost  their elevated  appearance, the  serous discharge became purulent, and 
&^    £^U                      10
     the offensive odour was entirely destroyed.  An equally marked improve-
     ment occurred in his general condition.

        Case VIII. R.  W. Plummer, private, Co. D, 1st Delaware Vols., aged
      34, was struck on the  outer  aspect of the left thigh, at its middle, by a
     bullet, at Fredericksburg, Va., Dec. 13th, 1862.  The bullet struck against
     his bayonet, and penetrating his leg caused a severe flesh wound.
        He was admitted Dec. 26th, 1862.  The ball dropped out Jan. 1st, 1863.
      This was the only  case of gangrene that occurred in the brick building, and
      appeared  on the upper floor, at a distance and  entirely disconnected from
      the wooden pavilion  where the other cases were treated.
        Feb. 15. The wound was almost closed.
        March  9.  For three days past there have been anorexia and fever.  There
      is now an ulcer on the  left thigh as large as a silver quarter dollar, with
      everted edges, livid areola, and a  fetid  discharge.   The connective tissue
      has been removed from beneath the margins by ulceration, leaving the skin
      undermined.   Pure nitric acid was applied to the ulcer, which  was then
      dressed with solution of sodas  chlorinat., and tinctura opii and acid, hydro-
      chloric, given  every three hours internally.
         12th. The ulceration having continued unchecked, nitric acid was again
      applied, followed by a  poultice; the man was  moved into  the gangrene
      ward.
         Ibth. The second use of the acid locally has changed the whole character
      of the ulcer.   It is now about  two inches in diameter, free from odour, rosy
      in colour, and granulating rapidly.
         22d.  This  improvement continued until this date, when the repair had
      brought the bottom  of the ulcer to a level with  the surrounding skin, and
      cicatrization had fairly commenced.  There was at this time a profuse diar-
      rhoea from some error in diet, with depression of  the vital energies, which
      was  accompanied by a relapse into the gangrene.  The sore is now covered
      with a gray slough, is very painful, and has the characteristic areola.  The
      expression of the  patient's face is very anxious  and haggard.   Nitric acid
      was  most thoroughly carried into the recesses of the ulcer, and the acid and
      opium mixture ordered internally.
         28th. The ulceration has extended very rapidly, and is now a perfectly
      characteristic specimen of hospital gangrene.   The  local use of the acid
      seemed to do  harm,  since  the  destruction of tissue was more rapid after its
      application.   The general condition is alarming.   There are  uncontrollable
      diarrhoea  and nausea.   The pulse is very rapid and feeble,  the skin relaxed,
      the  mind dejected;  and the expression of face, and  the decubitus betoken
      profound  debility.  Nitric acid was again most carefully applied.
         April 2. The ulcer now measures seven by six inches.  The whole surface
      is dripping, with  a fetid, sanious discharge, laden  with debris of the fascia
      and  connective tissue ; the skin, undermined, is separated from  its attach-
      ments for the distance of one  and a half inches from the free margin, which
      is " piled up," everted, and surrounded by an  areola of  livid, bluish  red-
      ness, three inches  in width.   The general condition  is most unfavourable.
      There are great prostration, profuse perspiration and diarrhoea; with a pulse
      of 130 and very feeble, and tongue red and dry ; and a complete disgust for
      food, with nausea.  His condition is  so desperate, that I feel no hope of his
      recovery.   The nitric acid, when last used, had only hastened  the destruction
      of tissue,  and after its failure, I  was without a substitute.   It had been twice
      used with no good effect, and had been applied most carefully to the entire 
                                  11                          £/,r  2
surface.  The nervous prostration, which is so prominent a symptom of this
disease, was so profound that I think this man would have died within forty-
eight hours, exhausted, but for the treatment employed.   The constant burn-
ing pain had destroyed his rest; his diarrhoea was profuse, his skin bathed
with  perspiration, his stomach so  irritable as  to reject all nutrients and
stimulants, and the expression of his face was dejected,  depressed, anxious,
and haggard to a remarkable extent.
   The  surface was again carefully cleaned of  all sloughs and  discharge,
and thoroughly cauterized with the solution of  bromine, employed by Sur-
geon  Goldsmith,  U.  S. Vols., viz.:—
   Bromine,  3j;  potassii  bromid.,  3"j >  aquas, 3iij.    The  patient was
anaesthetized, and the caustic solution applied  most liberally to the entire
diseased surface, which was immediately deodorized, and covered with a tough
yellow  deposit.   The sore was  then  covered with a  piece  of  dry lint, a
second piece  of lint, wet with the bromine solution, was placed over it, upon
this a piece of muslin spread with cerate, and over all a piece of oiled silk,
confined closely with a roller, was bound; and the local effect of bromine was
thus continued in the form of vapour.   The burning pain disappeared; the
antiseptic effect of bromine seemed to restore the appetite by destroying the
virus that had been poisoning the  whole system, and, for the first time for
many days, he took  some food.
   May 4.  The  exposure  of the surface of the body  to the air  at this
application of the bromine was followed by a severe attack of  bronchitis,
with  viscid and  bloody expectoration, and severe dyspnoea,  which was
treated by warm  cataplasms to the  chest, and by expectorants.
   1th.  The  ulceration has ceased,  the odour disappeared, and the surface
is now clean  and rosy.   The vapour has been used twice daily.   An imme-
diate improvement followed the use of bromine, both locally and constitu-
tionally.  The pain, diarrhoea, and  profuse perspiration ceased, the appetite
returned, and the nervous prostration soon yielded to the extra diet and
stimulants.   The bromine was used twice in  solution, and continued in the
form  of vapour until the granulations  became normal.
   23d.  He is convalescent, and the ulcer entirely cicatrized.  The bromine
produced this gratifying change, after  the  entire failure of nitric acid ; nor
do I  hesitate to  affirm  that, but for its employment, the case would have
terminated fatally.

   Case IX.  George Zilch,  Sergeant Co. K,  7th N. Y. Vols., aged  25, had
his left leg amputated at its upper third, for  a bullet wound received at
Fredericksburg, Va,, Dec. 13th, 1862.
   He was admitted to Douglas Hospital December 26th, and placed in Ward
No. 5.   The stump had closed slowly by granulation, until there remained
an ulcer as large as a half dime on  its face.
   April 14, 1863.  This ulcer was inflamed around its edges, and  covered
with  a white pultaceous slough; there was  no constitutional disturbance,
and the patient  was allowed to  remain on  his crutches.   The ulcer was
cauterized with nitric acid, and dressed with solution sodae chlorinatae.
   lath. The ulceration  and areola are both enlarged, and the slough, yet
very tough, is thicker.   Acid was again used locally.
   21s/.   He is feverish, and inclined  to nausea;  his pulse 120, skin hot,
and tongue thickly coated.   The ulcer is extending in  depth, and he was
removed to the gangrene ward.
   22d. The  solution of bromine was applied  to the  sore after cleansing 
the surface as much as possible of the tenacious slough,   nis general con-
dition was unfavourable, and there was a tendency to diarrhoea and perspi-
ration.   Internally he took muriatic acid, with extra diet and stimulants.
   24/ft.  Bromine was again applied to the surface, and used in the form  of
vapour.    The ulcer was now three inches in diameter, irregularly circular
in form, with  ragged, everted,  and thickened  edges, and surrounded by a
purple areola.   The  slough  was one inch  in thickness,  and resisted the
action of  the bromine.
   26//).  The sore is looking  better;  it has  been disinfected  since the first
application of bromine, and the constitutional  symptoms are better.
   27//).  A painting in oil was made to-day by  Surgeon Brinton's direction,
which would be pronounced a good representation of  hospital gangrene.
   28//).  The slough  is much  thinner to-day, and the  granulations  are
showing through the  thin gray covering.
   29//).  The sore  is much better, is becoming covered with  granulations,
and has lost almost entirely its specific appearance.    There is no constitu-
tional disturbance, no fever, no headache ; the tongue is cleaning off, and
there is  a return of the appetite.  The bromine vapour  was discontinued,
and a sol. sod. chlorinat. substituted.
   BOth.  The livid areola has  been changing daily in hue under the bromine
treatment, has now entirely disappeared, aud the sore  is perfectly healthy.
   May  6.  He is still  improving,  and is taking tonics  and nutrients.
   20//).  The sore is reduced to  half its original size, and is now cicatrizing
rapidly.
   24th.  There is now  a surface as large as a penny unhealed.   The patient's
health is very good;  he is about the ward on  crutches, and is no longer
considered an interesting case.

   We have in this case  another instance in which the  acid, locally used,
proved useless, and in which the solution of bromine caused an immediate
improvement.   It was found necessary to apply the caustic solution to the
ulcer three times, owing to  the thickness  of the slough, which  was too
closely  attached to be  removed  by  spatula or forceps.  Its  action here
seemed to be to correct the fetor at once, to check the molecular death, and
to change the hue of the areola, by causing a more  healthy action in the
capillaries.  The gnawing, burning pain was  relieved, and the patient was
able to  sleep  in  comfort.  The  absorption of the virus produced  in the
ulcer was  prevented  by its  destruction, and  the nervous system  quickly
regained its tone.
   This man steadily improved, recovered with a good stump, and was finally
sent to  New York to  be mustered out of the service.
   I will conclude this brief clinical history by  a short summary.
   Etiology.—This disease made its appearance in a wooden pavilion, con-
taining  fifty beds, most  of them occupied by very seriously wounded men
unable to leave the building,  with a cubic capacity of 1050 feet to each bed,
heated by ordinary radiating coal stoves, devoid of any system  of  ventila-
tion, and having no ingress for pure  air, nor egress for foul, except through
the windows and doors.   This want of pnre air was combined with a want
of strict  police, and  a  careless  and unscientific method of dressing  the 
                                  13                         • &t*7
wounds, rancid ointments being largely used instead of the ordinary water
dressing.
  No case of  gangrene was received as such into  the hospital, nor is it
probable that it was otherwise introduced.
  Although a majority of the cases in this ward escaped gangrene, yet
there was evidently some depressing agent at  work, since but few wounds
healed rapidly.   The  patients  seemed  also  dispirited,  homesick,  and
moody.  Those who were attacked were removed to a ward in the brick
house,  where they were isolated, and at  the same time placed under better
hygienic influences.
  Two shafts  for foul air, connected with  the stoves, which withdrew  the
foul air from near the floor, had recently been placed in the ward by order
of the Surgeon-General.   This was not considered sufficient, and the long
doors of these foul air shafts were kept constantly open.  Strict attention
to cleanliness and careful dressing was enforced, and, what might have been
a very severe epidemic, was confined to  few cases.   The upper row of win-
dows were rehung in such a manner as to direct the currents of cold air
admitted in a  line with the roof, and,  to crown all, the  ridge ventilation
was applied to  the pavilion.
  These  precautions, and an improvement in the diet of the house,  giving
more vegetables and antiscorbutics, enabled me to prevent any  further seri-
ous manifestations.
No.	Names.	Ward.	Side. West	Date of attack.	Grade of disease.	Result.	Treatment.
1	Otto Kossacke	5		Feb. 15, 1S63	Ulceration	Cured	Nitric acid.
2	L D. Thurston	5	"	15, "	Spliacelus	Death	•«
3	Sam'l Fos«ett	5	"	18, "	Ulceration	Cured	"
4	C. Underwood	3	East	20, "	" mild	"	"
5	J. Wick	5	West	28, "	Sphacelus	1 Death	"
6	Pat Murrissey	5	"	March 6, "	Ulceration	Cured	"
7	J. Jordan	5	East	Feb. 27, "	"	"	"
8	R. W. Plummer	1	Building	March 9, "	"	"	Bromine.
9	Geo. Zilch	5	East	April 14, "		" 1	
  There were three other wards of like construction, with Ward No. 5, but
two of them  were unoccupied, and the third one contained  fewer, and  less
serious cases.
  The foregoing table  indicates  that of the nine unmistakable cases re-
ported, eight appeared in Ward No.  5 ;  and that of these eight five occur
red on the west, and three on the east side of the ward.   Although these
facts would suggest the probability of inoculation, yet I cannot but remem-
ber that there were at least thirty-five other wounded men in this ward who
escaped, although the disease had been in existence several days before  Feb.
17th,  when I took charge, and  no precautious against contagion had  been
employed.
  I shall not attempt to argue here the long-disputed point of contagion or
non-contagion,  but simply state it as  the result of my observation,  that  I
saw no well-marked instance of inoculation, whilst I did see many wounds 
t    &+48
14
escape this influence where inoculatiou was not only possible, but probable.
Nor was  it necessary to invoke the aid of  any specific virus, since  the
unfavourable hygienic influences which had surrounded these men from  the
date of injury, Dec. 13th, and the date of admission into hospital, Dec. 26th,
1862, to Feb. 15th, 1863, were sufficient to produce, in all the cases treated
in Ward 5, a well-marked cachexia—neither scorbutus nor anaemia, but more
unmanageable than either, and due, most probably, to the absence, simply,
of fresh, pure air in sufficient  quantities.  With  no further  improvements
than those mentioned, a marked change for the better took place  in  the
other inmates  of  this ward.  Their wounds  became healthy, and  healed
rapidly, and their spirits became cheerful.
  It will be observed from the table that I have described two grades of
hospital  gangrene, the  one mild, generally manageable, and  characterized
by ulceration or molecular death of the tissues, spending itself generally in
the subcutaneous and intermuscular connective tissue ; the  other, more rapid
in its course, more fatal, less amenable to  treatment, and  distinguished  by
sphacelus or mortification, en masse, of the invaded tissues.  It will be seen
that of the nine cases, seven are described as ulceration, and two sphacelus,
and the latter both fatal.
  These two cases last mentioned were entirely uninfluenced by the treatment
employed.   The rapid invasion and advance of the mortification, and  the
impossibility of reaching it  with  nitric acid, to influence it locally,  left
but little to do, but to observe its  profoundly depressing effect on the vital
forces.  Bromine may prove the antidote in  such  cases, but its virtues were
then unknown to me.
   Treatment.—Recognizing the depressed condition of the first few cases,
I endeavoured to remedy it by giving at short intervals nutrients and  sti-
mulants, with  such tonics as seemed  proper; and milk punch, alternating
with beef essence,  porter or ale, and egg-nog, was at first given, regardless
of  the desires of the  patient.   The ferri et quin. cit. with sherry wine  was
given  in  doses of  gr. vj to x  three times  daily.  This system was found
injudicious, since  it overpowered  the feeble digestive organs, and  caused
nausea, vomiting,  and diarrhoea; it was suspended, and acid, hydrochloric.
gtt. iv, in combination with tr. opii gtt. xvj, were given every three hours.
Under this treatment the tongue became moist and clean, and the appetite
returned sufficiently to cause the patient to ask for and enjoy a reasonable
quantity of food.   The opium  was given to allay the gnawing pain and to
give rest and sleep, as well as to obtain any specific influence over the dis-
ease which it might possess, as claimed for it by  the older writers.
   The local treatment consisted at first in the use of undiluted nitric acid,
freely applied to the  entire surface of  the  ulcer.  The table indicates the
success of that treatment.  Of the nine cases,  all  were treated with the  acid
in  the earlj stages.  Of these, two were fatal, and two  resisted the acid ;
or, in  other words, in  four cases  it was  useless.  Of these  four, the  two 
                                  15                          "&*p
fatal cases were not treated otherwise, whilst the other two were  treated
with success, with bromine.  The five cases  treated successfully with  acid
are marked  ulceration, and were milder than those that proved fatal, or
than those that were treated with bromine successfully.
  The dressing, after the  use  of the  acid, was an antiseptic wash, either
creasote or liq. sod. chlor.  in a dilute solution.   In some instances  a yeast
poultice, or a stimulating one of cinchona,  ginger, and porter, seemed to
assist in cleaning the surface.
  Where  the sore lost its  sloughing character, after the use of nitric acid,
the mild antiseptic washes were  sufficient  to encourage  rapid granulation.
   Of more  value  than  the acid  is the  solution of bromine%in water and
bromide of potassium, proposed by Surgeon Goldsmith, U.  S. Vols.  Two
cases were treated with  this agent, in  both of which nitric  acid had failed.
One of these would, doubtless,  have  proved fatal, whilst  the other was
progressing rapidly, although the acid had been used several times  without
benefit.
   The action of the  bromine is that  of  a caustic;  all the necrosed tissues
are converted into tough yellow shreds, and are perfectly deodorized.   The
ulceration seems to be checked at once, whilst the nervous system, no longer
depressed by the absorption of the fetid products of the mortification, soon
recovers from its depression.  The areola  loses its livid hue, becomes more
crimson, and finally disappears; the sloughs are rapidly thrown  off, and
a rosy, florid surface  appears beneath.
   The bromine was also used  in the form of vapour, confined to the surface
by oiled silk.   Its antiseptic influence is very powerful, since not the least
odour could be perceived on dressing these gangrenous sores, even when
they had  been  covered  closely with oiled silk for twelve hours.  From its
antidotal efficacy in these two cases,  I have  formed a high opinion of its
value in the local treatment of this disease.
   Microscopy.—The discharges from several of these cases were examined,
to ascertain whether some  of the speculative views in regard to the  presence
of fungi  and their influence in  producing the  disease could be sustained,
but no fungi were found.
   The discharge  consisted of fluid,  granular matter,  and debris.   The
connective  tissue seemed  to have been  broken down into unrecognizable
granular  material.  The fibrous  tissue was softened and easily teazed out,
and in  the muscular tissue the  striated  appearance was  lost before the
fibrous.
   No evidence  of textural growth was found in the discharges, although
the "piled-up"  and  thickened margins of the ulcers would probably reveal,
on examination, a multiplication of the connective tissue-corpuscles, as re-
ported in a similar group  of cases at Annapolis, Md.,by Assistant  Surgeon
Woodward, U.  S. A.
   Since the preceding report was drawn up, four other cases of  hospital 
  $.60                         u
gangrene  have been  observed,  occurring  sporadically,  and  treated with
success with bromine.   Their clinical  histories  are very briefly offered  for
consideration, in addition to those already submitted.   No other cases have
occurred in this  hospital.   It will  be observed that three of these four
cases were fully treated with pure nitric acid without benefit, and that  the
four did  yield  eventually to the local application of bromine.   Where that
remedy has required heretofore several repetitions, it would  now be used
more  energetically.  The diseased surface would be  thoroughly cleansed
of all sloughs,  by removing those portions dead, yet  tenaciously adherent,
with  the forceps  and  scissors, and pure bromine would be freely used by
means of a glass pipette or a  syringe.   A  number  of the cases reported
I am now satisfied would have  proved fatal but for this local treatment;
and it will be a proud satisfaction to Surgeon Goldsmith to know that he
has not  only  already been  instrumental in  preserving so  many valuable
lives,  but that he has provided the military surgeon with a defence against
one. of the most deadly and obdurate of his antagonists.
  In conclusion, the writer regrets that circumstances do not  permit him
to  render  these clinical histories more  acceptable to the  critical reader.
The report was made  to  the Surgeon General for the future use of the
surgical historian of the war, and now meets the public eye in this crude
form because it has been represented that further evidence as to the virtues
of bromine might be of service in the exigencies of the coming campaign.

  Case X. Michael Flood, age 24, priv. Co. D, 33d NY. Vols., was struck
by a minie ball at the battle of  Chancellorsville, May 3d, 1863,  which  en-
tered  the right thigh anteriorly, comminuted the  femur for  four inches
at the junction of the middle and upper third, and escaped posteriorly.  He
was admitted on  the 8th of May.  This man had been suffering from diar-
rhoea, and was in a feeble condition.   The  usual  profuse suppuration fol-
lowed the injury, thus  reducing his strength still further.  The Teg was
lightly dressed, was supported by sand-bags,  and extended  by  means of a
brick  attached to  the limb by a band of adhesive plaster.  On July 23d, the
inner surface of the thigh, at its middle, was  found red and  inflamed oppo-
site the seat of fracture, and in the centre of this diffused redness there was
a spot  very tender  on pressure, slightly softened, and indicating an ap-
proaching abscess.   This was treated with  a poultice.  On  the 24th, a
small black spot of sphacelus was observed in the centre of this inflamed
region, which  was easily detached, and then revealed a sloughing condition
of the connective tissue.
  No previous abrasion of the skin existed, nor any wound which would have
permitted  of inoculation ;  nor was there any other case  of gangrene then
under treatment.   The diarrhoea simultaneously increased, and the patient's
condition became rapidly worse.  The  ulcer was  treated with the solution
of bromine and bromide of potassium.  This was followed on the following
day by pure nitric acid, with the apparent effect of adding to the rapid  de-
struction  of tissue.   On the 27th, the  ulcer was in dimensions five by four
inches, with irregular ragged edges, everted,  thickened, and  extensively un-
dermined at the margins ; and, in a word, presented  the characteristics of
severe hospital gangrene.   It was now thoroughly treated with pure bro- 
mine.   The improvement was marked ; the ulcer became deodorized ;  lost
rapidly its sloughing, ragged look ; became clean, then florid, from rapid
granulation, and in a few days was converted into a perfectly healthy, rosy
surface.  The  man's broken condition gave no hope of his recovery.  There
was still a free discharge from his fractured femur, his diarrhoea continued
unchecked, and  from these he sank exhausted, and died on the 6th of  Au-
gust.  The gangrene  here did  not  attack  the  gunshot wound through
which the discharge from the seat  of fracture escaped, but invaded a new
unwounded surface,  and one upon which no  abrasion was known to exist.
The gangrene was perfectly removed previous to his death.

   Case XI.   P. C. Barton, Co.  D, 26th  New York, age  25, was struck
at Chancellorsville, May 23d, 1863, by a piece of shell, which comminuted
with extensive  laceration  the  right tibia and fibula,  at  the  middle, and
fractured  the  right  femur at the junction of the lower and middle third.
This was  a most severe wound, since the soft parts were so greatly injured.
He was admitted on the 8th, his leg placed in a bran-box, and slight ex-
tension attempted by fastening the foot to the foot-board and elevating the
lower  end of  the bedstead.  Profuse discharge and occasional attacks of
diarrhoea  reduced his  strength, whilst his wounds were undergoing rapid
repair.   On July 1st, he was removed to a ward filled with other wounded
men, and in a few days the granulating wound on his leg became grayish,
and the discharge thin and offensive.  The wound of the thigh had almost
closed.  This  was recognized as mild hospital gangrene,  and was treated
with strong nitric acid, followed by yeast poultices.  No improvement fol-
lowed.  The  cicatrized tissue, the offspring of  the previous repair,  was
rapidly removed, the ulceration spread under the sound integument, and
the sore assumed the characteristic appearance of gangrene.   Stimulants
and mineral acids were given  internally, but rapid emaciation and general
prostration ensued from the continuance of the diarrhoea.  The sore  was
then treated with the solution of bromine, but required several applications
to check the ulceration.  Pure bromine would now be employed in such  a
case.  This man was moved to a better ward on July 30th, and  the ulcer
was then seven inches in length by four in width, occupying the outer  side
of the right leg.
   Soon after  his  removal an abscess formed in the outer  portion of the .
right thigh, the pus was evacuated,  and gangrene immediately attacked the
walls of the cavity; this extended with great rapidity, became four by three in
extent in two days, and was immediately arrested by the bromine.   No
hope whatever was entertained of this man's recovery.  A severe commi-
nuted fracture  of both bones of the leg, a  compound fracture of the same
femur, and two severe attacks of gangrene, combined with an obstinate
diarrhoea,  had brought him to the last stages of exhaustion.   By the 12th
of August his ulcers were normal in appearance, and were granulating
rapidly; the bones had united, and his diarrhoea had been checked by ni-
trate of silver  and opium.  The  improvement was gradual, but constant;
his stomach recovered its tone, the quantity of food was increased ; his whole
condition became more favourable, and he was finally sent home on the 20th
of September,  his term of service having expired.   He was able to travel
safely, and his  wounds were almost closed.

  Case XII.  Wm. Hutchinson,  age  32,  Co. F,  107th New York,  was
struck  by  a bullet at Chancellorsville, May 3d, 1863, in  the middle of the
2 
161
18
 right tibia, which  comminuted the bone, without, however, fracturing  it
 through.   He was  admitted June 17th;  the wound was discharging freely,
 and, shortly after his admission, several fragments of bone were  removed.
 He was kept quiet in bed and his leg dressed with  water.   On the 10th of
 August the open wound lost its healthy look, and the discharge became thin
 and offensive.   On  the 18th the case was beyond doubt a mild one of hos-
 pital  gangrene.   There were the burning pain, the livid areola, the thick-
 ened  everted  edges, and the deep, tenacious,  gray slough occupying  the
 former seat of the  opening.  No effort was made  to remove this  necrosed
 tissue, and hence the application  of the pure  bromine  produced less than
 the usual  effect.   For  six  days after the  18th the bromine was applied
 daily, and followed  by yeast poultices.   No ulceration occurred after  the
 first application ; but at the expiration of the  time stated, a florid, healthy
 surface  replaced the gangrenous  one; the excavation was deep and exten-
 sive enough to contain a large  egg.   After this complication the wound
 filled up rapidly, the man received a furlough, but was enfeebled by the long-
 continued discharge resulting from local necrosis.

   Case XIII. James  Hogan,  age 47, private, Co.  A, 127th Pa. Vols.,
 was struck at Fredericksburg, Va., December 13th, 1862,  by a minie  ball
 which comminuted his right tibia.  A resection of six inches of  the shaft
 was performed at a  field hospital.  The fibula was uninjured.  A tedious
 and almost hopeless convalescence, and the removal of sequestra from both
 upper and lower extremities of the tibia, found  him, after the closure of the
 extensive incision, in good health, and with  only a very small granulating
 surface near the tubercle of the tibia unhealed.   This was attacked by hos-
 pital gangrene, was treated ineffectually with nitric acid, and penetrated so
 deeply as to make the involvement of the knee-joint probable.
 _  Two or three applications of pure bromine at once checked the destruc-
 tive action, but not until an opening large enough to receive a hen's egg
had been produced.   The granulation was rapid; the constitutional symp-
toms of gangrene soon disappeared, and the  man recovered with a per-
fectly  useless leg, since a hiatus of eight inches remained between the two
extremities of  the tibia.   He was sent home on Oct. 12th, 1863, in good
health, his term of service having expired.
  Douglas Hospital, Washington, D. C. 
£63  CfZ. 
7X.IV  2 6*+