OUTLINE OF OBSERVATIONS 
ON 
HOSPITAL GANGRENE 
As it manifested itself in the Confederate Armies, 
DURING THE AMERICAN CIVIL WAR, 1861-1865. 
BY 
JOSEPH JONES, M. LX, 
Professor of Chemistry in the Medical Department of the University of 
Louisiana. 
NEW ORLEANS. 
Printed at the “ Bronze Pen” Book aud Job Office, No. 112 Gravier Street 
1869. OUTLINE OF OBSERVATIONS 
ON 
HOSPITAL GANGRENE 
As it manifested itself in the Confederate Armies, 
DURING THE AMERICAN CIVIL WAR, 1861-1865. 
BY 
JOSEPH JONES, M. D., 
Professor of Chemistry in the Medical Department of the University of 
Louisiana, 
NEW ORLEANS. 
1869. OBSERVATIONS ON HOSPITAL GANGRENE. 
The present u outline v was prepared in accordance with the 
order of the Surgeon General, assigning the author to special 
duty in the investigation of camp diseases, and in its official 
deliverance was accompanied with the following explanatory 
note. 
C. S. of America, Augusta, Ga., August, 1864. 
Surgeon General S. P. Moore. C. S. A. 
Surgeon Generals’s Office, War Department Richmond, Va. 
Sir : In accordance with the request of the Surgeon General “ that the 
general results of my investigations upon hospital gangrene, should be forwarded 
to the Medical Department, as soon as practicable after my return from Vir- 
ginia,” I have the honor to submit the follo wing brief outline of my labors. 
In the final and full report, the general results here announced, will be sup- 
ported and illustrated by cases, experiments, and chemical and microscopical 
investigations. 
The general hospitals Attached to the Army of Tennessee, at the present time 
afford a wide and important field for the full investigation of hospital gangrene 
and pyaunia, and I design entering immediately upon the extended pathological 
labors projected at Andersonville, and in the field and general hospitals of the 
Western Department. 
The Surgeon General will please excuse the imperfect manner in which 
these results are now presented, as it was impossible to do justice to the subject 
in the brief space of time, which has been occupied with the numerous prepara- 
tions necessary to rthe pathological investigations ordered by the Surgeon 
General ; and especially in the present state of my health, after my energies 
have been greatly taxed for twelve months in numerous inspections, and in the 
preparation of an extended report on camp fevers. 
Very respectfullv your obedient servant, 
JOSEPH JONES, Surgeon, P. A. C. S. 
I.—Outline of the Symptoms and Changes of the Solids and Fluids 
Characteristic of Hospital Gangrene as it has Manifested itself 
in the Confederate Armies. Constitutional Disturbances amongst 
the earlier symptoms of Hospital Gangrene; Local and Con 
stitutional Origin of the Disease. 
In many cases the appearance of gangrene in the wounds was 
preceded by fever, which was sometimes ushered in by a chill 
This fever was most commonly attended with loss of appetite, 
depression of spirits, constipation of the bowels, and such an en- 
feebled irritative action of the circulatory apparatus, as denoted, 
a depression of the vital, nervous and muscular forces. 
It has been difficult to determine whether the fever was the resultant, or the necessary accompaniment of the early changes 
in the wound. It is, however, a i>oint of interest in its bearing 
upon the determination of the nature of the disease, as well as 
upon the treatment, that the constitutional symptoms in many 
cases do precede such local changes as are sullicient to attract 
the attention of the patient and physician. 
The Confederate troops have been so often exposed to malarious 
influences, that it is impossible to determine in most cases the 
cause and nature of the chill which sometimes precedes the fever. 
Without doubt, it was in some cases at least, of malarious origin. 
When the system has been brought under the influence of 
malaria, any depressing cause, as a gun shot wound, especially if 
unfavorable changes are set up in the injured parts, may induce 
true chill and fever. 
In the geaeral hospitals attached to the Army of Northern 
Virginia, to the Department of South Carolina, Georgia and 
.Florida, and to the Army of Tennessee, I have seen a number of 
cases of extensive hospital gangrene, in gun-shot wounds, ami of 
those resulting from amputation and various operations, in which 
the disease was said to have appeared as a local affection, with- 
out any constitutional symptoms. Loss of appetite and febrile 
excitement was said to have been entirely absent, or else to have 
appeared only after the local disease had progressed to a con- 
siderable extent. These cases certainly manifested constitutional 
disturbances of the gravest character, when they passed under 
my examination, and in no case was 1 able to discern any accu- 
rate or critical record of the condition of the patients, and esj>e- 
cially of the circulation, respiration, and temperature, and of the 
alimentary canal and nervous system, in the earliest stages of the 
disease. Such testimony to the local origin of hospital gangrene, 
should therefore be regarded only so far as to excite careful ob- 
servations and investigations, upon the first recognizable symp- 
toms. The question of the local or constitutional origin of hospi- 
tal gangrene, can be settled definitely only by extended and 
minutely recorded observations upon the whole progress of the 
disease, from the first deviation from the condition of health. It 
is im]K>rtant to consider this question well, because the best 
writers on this subject differ in their views; and because it is 
intimately connected with every theory of the origin and nature 
of the disease, and with the great practical question, whether 5 
hospital gangrene, is to be treated locally or constitutionally, or 
by both means combined. 
In attempting to settle this question by an appeal to authority, 
the great difficulty is the want of accurate and minute observa- 
tion of the earliest symptoms preceding the actual appearance of 
the gangrene. Thus, as far as our knowledge extends, no writer 
up to the present time has given any critical observations upon 
the changes of the temperature, urine and blood, at any period 
of the disease; and by the majority of writers, even the changes 
of the pulse aud tongue are noticed only after the establishment 
of the gangrene. The simple announcement that the disease 
commenced as a local affection and manifested no constitutional 
symptoms, until a certain period, should not be taken as a final 
decision. Such general statements should be sustained by criti- 
cal observations upon the most obvious phenomena of the animal 
system. 
In its mode of origin, hospital gangrene may be viewed in four 
ways: 
1st.—As a local disease, communicable only by contact with animal 
matter in a certain state of change or decomposition. 
Whatever constitutional disturbances arise, they are always 
consequent to, and upon, the changes in the wound itself, and 
arise chiefly from a propagation of the derangement by nervous 
sympathy. If this proposition be true, amputation would be one 
of the most certain methods of removing the disease. 
2d.—As a constitutional disease. 
The constitutional disturbance manifesting itself in gangren- 
ous inflammation, in any wounded surface, may be produced 
either by previous exposure and bad diet; or by the constant in- 
halation of an atmosphere deprived of its active oxygen, and 
electrical fluid, and loaded with carbonic acid gas and sulphu- 
retted hydrogen aud other deleterious gases and animal matters. 
According to this view, when the constitution is deranged, the 
blood altered, aud the forces depressed, by such agencies, the 
disease may appear in any wounded surface, apart from any 
direct application of poisonous animal matter. 
3d.—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 6 
inflammation; or the system may be so depressed by the action 
of gases and toul air inhaled, and by the previous exposure and 
bad diet, that this lorm of inflammation may result from the de- 
pression of the forces, the derangement of nutrition, and the 
consequent degeneration of the wounded part. 
If the disease arises locally, the absorption of the gangrenous 
matter commences as soon as it is applied to any wounded sur- 
face, and goes on continuously as long as any gangrene is present; 
and the decomposing matters entering the blood, derange its 
composition and the nutrition of the body and depress the forces. 
In this way the constitutional derangements maybe 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 tho sume 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 cer- 
tain extent the forces, therefore amputation will not arrest the 
disease. Whether or not the severing of the gangrouous mass 
from the body will arrest the disease, will depend not upon tho 
mere fact of the absorption of the gangrenous matter, but upon 
the extent to which it lias deranged the 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 tho blood, acts upon 
the heart, deranges the nutrition, disturbs the circulation and 
respiration, and depresses the venous and muscular 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 ab- 
sorbed, that therefore the stump must also become gangrenous. 
Neither does it follow that because the gangrene was not repro- 
duced in the stump, therefore the poison of the rattlesnake did 
not act constitutionally. 
In the case of amputation for a gangrenous wound, the re ap 
l>earance of gangrene in the wound, will depend on the amount 
of the matter absorbed from the local source, and the extent to 
which it has deranged the system. 
4th.~TAe disease may arise from the action of a specific poison, 7 
wh ich acts in a manner similar to that oj small pox, measles or scar- 
let fever. 
After the introduction of the poison either through the wound- 
ed 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 rela- 
tions of cause and effect with the local manifestations. In other 
words, the specific cause of hospital gangrene, may induce such 
changes in the constitution of the blood, and so modify the nutri- 
tion 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 inflammation may manifest 
its specific gangrenous action. 
The third proposition expresses most nearly our views ; for it is 
capable of demonstration by cases and instances which I have 
recorded and observed: 
First—That hospital gangrene may arise in those exposed to the 
exhalations from gangrenous wounds, without any abrasion of the 
surface. 
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 ot' 
defective nutrition, degeneration or inflammation or depressed in 
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 intact, until they were involved by 
the gangrene from within. 
Second—That hospital gangrene can be communicated through the 
atmosphere to wounded surfaces, without any direct application of 
the matter. 
Third—That in some cases, after the wounds had been subjected to 
the action of the cause of hospital gangrene, a certain period of time 
elapses before the disease appears. 
Fourth—That in some cases poisonous matters are so rapidly ab- 
sorbed from the infected atmosphere of the crowded wards, and the 
diseased action is propagated with such rapidity from the local injury 
to the central organs in constitutions broken down by bad diet, expo- 
sure, and by the influence of the foul emanations from the icounded 8 
and side crowded into badly ventilated hospitalh, that death result* 
from the effectual and almost immediate poisoning of the system, be- 
fore the local disease has progressed to any extent. 
progress and character of tiie local changes. 
In many cases of gun-shot wounds, which subsequently became 
gangrenous, the attention of the wounded man was first called 
to the injured parts, by severe and darting pains in the wounds. 
These pains were sometimes compared by the Confederate sol- 
diers to the pricking of ten thousand needles. 
In other cases, the early stages of the disease were announced 
by a stinging or itching sensation; whilst in some cases there 
was little or no change in the sensation of the parts. 
In some cases, in the earliest stages, the wounds presented a 
dark-red glazed surface; the granulations became altered in ap- 
pearance, and rapidly disappeared; the discharge of healthy pus 
disappeared and was followed by a reddish and greeni h sanious 
foetid discharge. The parts around the wound became painful 
and swollen, and frequently a well defined red and purplish in- 
durated border in the sound skin surrounded the wound. The 
wound itself rapidly assumes a swollen, ragged appearance (the 
gangrenous matter often rising several lines above the surround 
ing tissues), with swollen ragged, everted edges. With the infil- 
tration of the diseased structures, and the consequent elevation 
of the surface and eversion of the edges of the wound, the glazed, 
dark-red apj>earance of the wound disappears, and the gangrenous 
mass presents a greenish and grayish color. 
V» hen the wounds were extensive, the gangrene would frequent- 
ly appear in one or more circumscribed spots of a dark-gray and 
greenish color, and gradually spread over the entire surface and 
destroy the surrounding tissues. I have seen extensive ulcerated 
surfaces, in which the gangrenous parts remained almost sta- 
tionary, whilst the surrounding portions of the wound presented 
a bright, florid appearance. 
In cases of amputation, in patients whose systems were de- 
pressed and deranged by bad food and foul air, as in the case of 
prisoners in filthy, crowded military and civil prisons, hospital 
gangrene frequently made its appearance, in the wounds, in from 
twenty-four to seventy two hours; and m such instances, the 9 
first symptoms of the disease were manifested in the 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. During the active stages of hospital gangrene, the 
surrounding parts are swollen and infiltrated with serum, and the 
temperature of the parts immediately around the diseased struc- 
tures is elevated somewhat above that of the parts beyond. 
As far as my observations extend, the serous fluid infiltrating 
the tissues, is liquor-sanguinis, and is capable of coagulation. 
The blood-vessels surrounding a gangrenous wound are always 
engorged with blood, as if the capillaries had lost their power to 
contract; and if an incision be made around the wound, in the 
unbroken skin, those distended vessels bleed freely. I have no- 
ticed in several cases of severe gangrene, that after serious 
haemorrhage, the recovery of the patient was very rapid, as if 
the emptying of the surrounding engorged vessels had contribu- 
ted to the rapid improvement of the wound. 
The deep 'purple and blue color of the skin surrounding gan- 
grenous wounds which are spreading rapidly, appear 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 
purplish color in the surrounding skin, is one of the most infalli- 
ble signs of the active progress of the disease. After the disap- 
pearance of the gangrene, the blue and purple border either dis- 
appears entirely, or else fades away. 
When the system has been thoroughly poisoned by the absorp- 
tion of the gangrenous matter from a large wound, and by the 
constant inhalation of the foul atmosphere of the crowded ward, 
I have, in a number of instances observed parts removed from the 
immediate wound, but generally upon the same limb, take on the 
gangrenous inflammation, and that, too, without any apparent 
cause as pressure. 
In such cases, a purple or blue spot is first perceived, or the 
color might more properly be termed, in some cases, an ash-gray 
or leaden hue. The cuticle is sometimes raised and contains 
serum below. The rapidity of the progress of the gangrene iu 10 
such spots, will depend chiefly upon the extent to which tho ays 
tem has been poisoned by the absorption of the deleterious mat- 
ters. I have seen the skin iu tho 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 widening circles, 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 ray 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 
bones resist its action for a greater length of time. It is not un- 
common to see large surfaces of muscles and even bones exposed, 
the skin and cellular tissue having been completely dissected 
away by the disease. The blood-vessels yield more readily in 
hospital than in dry gangrene, and hence in the former, hremor- 
rhage, 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 
presents a mottled appearance from the lnernorrhages of limited 
extent taking place from tho smaller vessels destroyed in the 
ravages of the disease. Whilst there is a tendency to the coag 
ulatiou 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 gaugrene. This difference may be 
due to the more rapid progress of the disease, as well as to differ- 
ences in the quantity and quality of the fibrous element in the 
different forms of gangrene. 
As far as my observations extend, the bones do not yield readily 
to hospital gangrene, and even when exposed, and iu part sur- 
rounded by the disease, with the exception of slight exfoliation 
of the cuter table, little or no erosion or death takes place ; and 
when the disease is arrested, granulations spring up rapidly and 
•over the diseased surface of the bones. 11 
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 sanioas foetid matter issued, and wTho 
died, apparently, from the exhaustive effects of colliquative 
diarrhoea, resulting, apparently, from the absorption of the pro- 
ducts of the disorganizing tissues, the skin over the injured 
thigh and buttock appeared sound, whilst the cellular and mus- 
cular tissues of the thigh and buttock were in a state of gangrene, 
presenting blue and green and greenish grey disorganized mat- 
ter. 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 completely disorganized, and nothing but the fibrous 
tissue remained. Innumerable granules and granular masses, 
crystals of the coloring matter of the blood, prismatic crystals of 
the phosphates of ammonia, magnesia and lime, altered blood cor- 
puscles, detached masses of cellular tissue and of muscular fibres, 
in which the stria? were fast disappearing, together with oil glo- 
bules, all pervaded by afcetid, greenish, sanious fluid, constituted 
the mass of the gangrenous muscles. The disorganized struct- 
ures were strongly impregnated with ammonia, one of the pro- 
ducts of the disintegration of the nitrogenizcd constituents, and 
the normal acid reaction of healthy muscular structures, was 
charged to a strongly alkaline reaction. 
In another case where this operation of ligating the bronchial 
artery was performed to arrest limmorrhage 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. 
In a case of typhoid fever, treated in a gangrene ward, in the 12 
midst of patients suffering from hospital gaugreue, during con 
valesence from the fever, a painful swelling appeared upon the 
margin of tho pcrinamm aud left buttock. The skin over the 
affected part assumed a bluish ash-color and 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. Tho odor was so offensive 
that it was almost impossible for the attendants to remain in the 
tent. After the evacuation of the dark-foetid matters, the struc- 
tures within presented the general appearance of hospital gan- 
grene and not of an ordinary abscess. The spread of the gau- 
greue was rapid aud distressing in this case. 
I have frequently seen a narrow strip of apparently souud skin 
passing between two gangrenous wounds aud even passing across 
a large gangrenous mass. 
When gangrene terminates favorably, the surface from which 
it is removed, presents a bright red and scarlet exquisitely sensi- 
tive mass of luxuriant granulations, which are highly vascular, 
and bleed upon the slightest touch. Bo sensitive is this surface, 
that the slightest 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 re- 
moval of the gangrene, from various causes; as exhaustion 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 granulations, the bones 
which have been denuded by tho gangrene, will frequently be 
rapidly covered by a luxuriant growth of granulations. When 
the bones of the leg have been denuded in a stump, after arapu 
tation, I have observed a most luxuriant crop of granulations 
sprouting out of the medulla of the bone like a fungous growth. 
In most cases these grann’ations die, aud the injured bone exfo- 
liates. When the bone has been exposed in its length, the outer 
table will frequently scale off, and the destruction of bone pro- 
ceeds no further, aud the new tissue form over the denuded bones. 13 
As the disease progresses, the complexion assumes an un- 
healthy, dusky, leaden hue, the eyes express anxiety, depression 
and nervous irritation and exhaustion, the pulse becomes small, 
frequent and feeble, and indicates an irritable, enfeebled state of 
the nervous and muscular systems. It is possible, by these 
symptoms alone, to decide, in 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, the sur- 
face of the wound rises up into a pulpy, ragged, grey and green- 
ish mass. When the sloughs are detached the disease attacks 
other adjacent structures from day to day, extending its ravages 
both in length and breadth, involving apeneuroses, muscles, 
bloodvessels, nerves, tendons, the periosteum, and bones and 
joints. 
Most commonly after the muscles have been exposed, they con- 
tinue to be gradually dissected; 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 appearance of a large, purple and greenish 
coagulum. As the disease advances, haemorrhage from small 
vessels is a common occurrence, and in the more advanced 
stages, some of the large vessels give way and the patient is fre- 
quently destroyed by the consequent haunorrhage. Colliquative 
diarrhcea caused by the absorption of the gangrenous matters, is 
a frequent cause of death. 
Microscopical Examination of the Gangrenous Matter: Consists 
of the various structures in a disorganized state, together with the 
products of the dead disorganized 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 num- 
bers in the gangrenous matter. 
I have made numerous microscopical examinations of the gan- 
grenous matter, and discovered that it consists of various struc- 
tures in a disorganized state, together with the vaiious products 
resulting from the altered physical and chemical compounds. 
Innumerable granules are observable, with detached masses of 14 
flbrons and and muscular tissue, broken bloodvessels, disorgan- 
izing blood corpuscles, and in some cases, especially when strong 
mineral acids have not been applied to the gangrenous wound, 
crystals of the triple phosphate. Animalcules of simple organi- 
zation and endowed with active rotary motions, abound in hos- 
pital gangrene. After a careful examination of various vegetable 
and animal matters exposed to the atmosphere, under similar 
circumstances of temperature and moisture, I have come to the 
conclusion, that in the present state of our knowledge we are un- 
able to demonstrate that these animalcules are in any way con- 
nected 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 observations 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 situation, 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 simple foims of animal life. I have been 
unable to discover any forms of animalcul® peculiar to hospital 
gangreno. 
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 organisms are not peculiar to hospi- 
tal gangrene, but are found in all organic matter undergoing de- 
composition under similar circumstances. 
I have been unable to establish any relation between the rapidi- 
ty 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, 
therefore, have thus far afforded only negative testimony upon 
the aniinalcular origin of hospital gangrene. 
I have determined, by careful microscopical examination, that 
the pus globule is not formed in true gangrenous matter. We 
do not wish to be understood as asserting that pus is never pres- 
ent in a gangrenous wound. It frequently happens that gan- 15 
grene may exist in certain portions of a wound, whilst in other 
parts the reparative process is active. So also portions of the 
structures may resist for a time complete death, and whilst pas- 
sing into a state of gangrene, present some of the changes of 
inflammation, one of which may be an altered or imperfectly 
developed pus. In the healthier portions of a gangrenous wound, 
we may therefore have the formation of pus, whilst in the gan- 
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 organiza- 
tion, and an improvement in the plastic powers of the parts im- 
mediately surrounding the altered gangrenous matter. 
In the local manifestation of the actions of many organic poi- 
sons, of sibbens or sivens, of jaws and of various skin diseases the 
formation of pus is invariably observed. Even in the phagedenic 
ulcers arising from the abuse of mercury iu constitutions worn 
down by viscious habits, deteriorated by the abuse of alcoholic 
stimulants and bad diet, and poisoned by the syphilitic virus, the 
spread of ulcerations and the detachment of the tissues is attend- 
ed with the constant formation of pus. Whether we view this 
fluid, as resulting from the degeneration of the affected 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 j or as one 
of the natural stages of the changes of coagulable lymph, and of 
granulation cells, in the progress of inflammation : it is neverthe- 
less true, that the absence of pus in any wound or ulcer which is 
rapidly enlarging its bounds, indicates marked derangements 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 incessantly attended with 
derangements in the constitution and forces of the affected parts, 
and iu the processes of nutrition and secretion; at the same time, 
inflammation is governed by definite laws, and often progresses 
in such a manner, as to preserve the life of an animal, and the 
functions of the part inflamed j therefore uniform perturbations 
of the process as ordinarily observed, indicate clearly the action 16 
of some definite cause. And lienee also we may speak of a de- 
rangement of even the changes.characteristic of inflammation. 
If we accept the definition that iuflammatiou is “an alteration 
in the healthy structure and function of a a part, accompanied by 
a perverted condition of the blood and capillary blood vessels; 
ordinarily attended with redness, heat and swelling; and induc- 
ing more or less febrile disturbance in the general system then 
in hospital gangrene wo observe all the essential conditions of 
inflammation. In this disease, there is an alteration in the 
healthy structure and function of the affected parts, as indicated 
by the change of color and structure, the feetid 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 haemorrhages, and by the dusky hue of the complexion ; 
there is derangement of thecapillary 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 parts; there is redness, pain, heat and swelling; ana 
there is more or less febrile disturbance of the general system, as 
manifested in the rapid feeble pulse, the marked diurnal eleva- 
tions and depressions of temperature, the depressed spirits and 
derauged muscular and nervous actions. 
When the injury of the living tissues is simple, as iu the wound 
caused by a mechanical instrument, the natural result of inflam- 
mation appears to be the production of such a fibrinous effusion 
as will surround and isolate the injured or diseased parts. In 
such uncomplicated cases of the inflammatory process, there w ill 
be observed in the injured structures, the perversion of nutrition, 
the destruction of capillaries, the alteration of the blood, the exu- 
dation 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 parts, but also by their 
development to form a tissue 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 tj 17 
the vital properties of coagulable lymph, its essential character, 
is its power to develop itself and assume organic structure. We 
should regard pus, on the one hand, as a secretion destined to 
dissolve certain organic tissues, and to shield by its bland pro- 
perties 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 development. 
In hospital gangrene, the lymph effused arcund the focus of 
disease, possesses the power of coagulation, as in other varieties 
of inflammation, as I have determined by actual experiment; 
and there appears to be all the conditions necessary for the arrest 
of the disease by the development of coagulable lymph through 
nucleated cells into the fibrous and flbro cellular or connective 
tissue; but the characters of the irritant poison are such, that 
the products of inflammation, together with the blood-ves- 
sels and the blood itself are rapidly disintegrated. The life of 
the blood is destroyed by the gangrenous poison, and the fluids 
and liviug organizable matter and cells, upon which the progress 
of inflammation depends are poisoned. It results from this, that 
the liquor-sanguinis effused within the diseased structures does 
not pass into the state of pus, as in healthy wounds, and in the 
•tmmon furuncle and carbuncle* or even in erysipelas and the 
pustules of small pox, and the exudation corpuscles are so poi- 
soned and disorganized that they are not further changed in 
either a progressive or descending series, and wherever the limit- 
ing fibrinous 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 parts ; 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 cor- 
puscles, but no arrest of the disease will take place, as long as 
the poison is capable of exciting rapid chemical change and de- 
composition, after the manner of a nitrogenized ferment in the 
products of inflammation. 18 
If in a wound infected with hospital gangrene, the morbid pro- 
cess did not advance, as in any other wound, from the centre to 
the circumfereuce, with the central focus of infection and active 
disorganization surrounded and guarded as it were by a circle of 
active congestion, with blood-vessels loaded with colored cor 
puscles, with interrupted circulation and exudation of plastic 
liquor-suuguinis, and 'with venous and lymphatic absorption 
greatly impeded, if not altogether arrested ; the gangrenous poi- 
son would enter directly and rapidly into the circulation and 
prove rapidly fatal. And even after the excitation of inflamma- 
tion, in virtue of the irritant properties ot the poison, in every 
case gangrene of any standing, more or less of the 
poison is absorbed and effects the general system. The extent of 
this absorption of the deleterious agent oi agents, will depend 
upon many circumstances, but chiefly upon the character and 
extent of the inflammatory process around the immediate centre 
of infection. 
We may in these facts find some explanation of the relief some- 
times afforded by limmorrhage in hospital gangrene. The poison 
is diluted and washed out by the blood, at the same time that the 
inflammatory congestion is relieved by the hemorrhage. 
From the disintegration of the organic constituents of the struc- 
tures in hospital gangrene, a number of compounds result, 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 systems, 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 inves- 
tigation, that ammonia is sometimes 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 phosphates in the form of well- 
defined crystals of triple phosphate. 
The results of these microscopical observations, clearly sustain 19 
the view; that hospital gangrene is due to the action of an irri- 
tant organic poison, which, after the manner of a ferment, is ca- 
pable of inducing such decomposition in the tissues and in the 
blood, that all developments of the cellular elements of the liquor- 
sanguinis into cells, fibres or into pus, is arrested. 
CHANGES OF THE BLOOD IN HOSPITAL GANGKENE. 
In this disease, it would be manifestly improper to abstract 
blood by veneseclion simply for analysis, when the lancet wound 
would be liable to be attacked by gangrenous inflammation and 
the life of the patient might be sacrificed. This danger was 
specially to be dreaded in the crowded Confederate hospitals, 
scantily supplied with lint, rags, utensils and instruments. My 
investigations, therefore, have been necessarily limited to the ex- 
amination of the blood collected during haemorrhages and ampu- 
tations. 
The first and most important subject of investigation, in the 
relations of the changes of the blood in this disease, which we 
endeavored to elucidate, was the character and quantity of the 
fibrin. The determinations of the variations of the fibrin, appeared 
to be of the first importance, because of the relations which the 
quantitative and qualitative changes of this constituent of the 
blood bear to the phenomena of the two great classes of disease 
—the plilegmasiae and the pyrexiae. We have drawn up the fol- 
lowing table of the proportions of fibrin in various diseases, that 
we may be able, as far as this constituent of theblood is concerned, 
to determine whether hospital gangrene should be classed with 
the plilegmasiae. 
Observers. 
Diseases. 
Remarks. 
Fibrin in 1000 
Parts Blood 
Andral & Gavarret ) 
Standard of Health 
t In Healthy Blood the 
2.00 to 
Becquerel * Rodier i 
l Fibrin may vary from 
3.50 
3.86 
6.03 
f! u“'*“uSlouo 
Maximum. 
II II 
Minimum 
2.10 
II II 
First Case 
4.02 
II II 
Second “ 
6.03 
M “ 
Third “ 
2.10 
“ “ 
Fourth " 
3.04 
II u 
II It 
Fifth “ 
4.11 
Becquerel <fc Rodier 
Phlegmasire Generally... 
Mean of Numerous Obs.. 
5.80 
Pneumonia 
“ First Bleeding.. 
“ Second “ 
7.30 
»» u 
“ 
6.80 
Andral & Gavarret 
" 
Mean of 58 Analyses 
Maximum of 58 Analyses 
7.30 
10.50 
“ 
• * ? ' 
Minimum “ 
4.0J 
Table of the Fibrin in 1000 Parts •/ Healthy and Diseased Blood: 20 
Observers. 
Diseaaaa. 
Remarks. 
Flbr1o la IQ00 
pqrta Hlrwd. 
Plenritt* 
4.m 
ti 
5.90 
II II 
II 
3.80 
• 1 
0.10 
4.00 
Autlral & Gavarret 
•1 •• 
Maximum of Six Cases... 
Moan of 
9.30 
5.70 
5.55 
• • #• 
*4 * II 
• 1 II 
Maximum of " 
Minimum of " 
7.90 
3.HJ 
6.70 
II M 
Chrooie Rheumatism 
Articular Rheumatism... 
Maximum of 43 Cases.... 
Minimum of “ 
10.90 
3.80 
3.HO 
5.80 
6.76 
Heller . 
5.16 
Febril Arthritic Rheu 
\\ n 
•I II II 
Female aged 90, 1st bl'dng 
“ “ 2d 
Male aged 33, 1st bleeding 
“ *' 3d " 
11.80 
12.97 
11.40 
7.91 
9.95 
13.34 
6.37 
10.4ft 
0 41 
6.30 
Man, aged 33 years 
6.60 
Mean of eight Analyses.. 
5.67 
*« •* 
Berquerel Sl Rosier 
IPbthlais 
*? 
Maxioium oft) “ 
Minimum of 8 “ 
Mean "1 tweiiij one <"**«•« 
Maximum of 91 
Miolmum of 91 
Meau of sixteen “ 
Meau of a fosses. Males 
7.31 
3.60 
4.40 
5,90 
3.10 
4.80 
3.13 
Mean of seven Cases 
6.58 
Witt* toe k 
Smith 
Cholera 
Maximum of seven fanes 
Minimum of •* >r 
One Case 
16 44 
3.30 
11.00 
11.1:0 
Rec<juerel & K<xlier 
Man, day of Death 
1 88 
6.50 
Bright'sDiseaas, Ara s. 
“ “ Cbronii 
3.99 
1* *• 
Meau of 13 “ 
Moan of 6 “ 
4 34 
4 90 
it if 
Mean of 10 M 
3.79 
v 
9,81 
Man aged 4h, sick 43 days 
3.50 
.. a, .. ;iu .. 
•• 39, “ 455 " 
3.90 
1 85 
« », •' wa •• 
Mean of five Cases 
1 33 
9.40 
Maximum of five Cases.. 
4.40 
1.10 
.. •• 
Sear Latina. 
Meauof seven “ 
435 
•• ll 
Mean of nine •* 
3.74 
Joeeph Jones 
it •• 
Malarial Fever 
<• II 
10 •• 
Maximnm of nine Case*. 
Minimum of “ 
IlialsuUR of " 
lut rm'nt fever of IS dav* 
“ “ 9 weeks 
“ 8 weeks 
Remittent lever of II days 
•• of 10 ’• 
Remit, s Typhoid 11 “ 
Remittent fever 9 weeks 
2.01 
2.93 
0.87 
1.90 
254 
1.99 
2.93 
1.49 
2 38 
3.71 
0.87 
H •« 
1 45 
Mean of 41 Analyses 
Maximum of 41 Analyte* 
Minimum of “ 
2.60 
421 
U •• 
M •• 
0.90 
M.H.Guenard. DeMusaej 
Typhus Fever 
Mean of sixCase* 
2 46 
« 
% 
M 7l 
[Maximum of six Cases... 
[Minimum 
1 3.96 
I 1,» 21 
The first case of hospital gangrene, in which we examined the 
"blood, was of the gravest character: the diseased action involved 
a large portion of the arm and fore-arm, and the elbow-joint was 
opened by the extensive ravages of the gangrene. The case ter- 
minated fatally after slight haemorrhage from the brachial ar- 
tery. 
The action of the gangrenous poison upon the general system ; 
the feeble rapid action of the heart; the great changes of temper- 
ature ; the depressed, enfeebled, nervous and muscular forces; 
the trembling hands ; the low, muttering delirium; the trembling 
eye-balls and quivering features; the insensibility of the organs 
of sense; the derangement of digestion, and the foetid diarrhoea; 
the dusky, sallow hue of the complexion, and the livid, blue 
color of the tongue, were manifestly due to derangementsinduced 
by the gangrenous poison in the constitution of the blood, in the 
capillary circulation, and in the processes of nutrition, secretion 
and excretion. The blood appeared to have lost, in a great meas- 
ure, its power of absorbing oxygen; and were the process of 
analysis sufficiently exact, and comprehensive, it might have been 
possible to have detected the gangrenous poison, or the products, 
of its action in the blood. The intestinal canal appeared also to 
eliminate considerable quantities of the offending matter from the 
blood. 
In this case the fibrin was slightly increased above the stand- 
ard of health, being 4.02 parts in one thousand parts of blood, 
whilst in healthy blood, the fibrin may vary from 2. to 3.5 in the 
thousand parts. It was below the standard observed in the phleg- 
masise generally. Thus, according to Audral and Gavarret, the 
mean of 58 analyses of the blood of pneumonia, gave 7.3 parts of 
fibrin, with a minimum of 4. and a maximum of 10.5; in pleuritis, 
mean of 5 analyses G.l; and according to Beequerel and Rodier, 
the standard for the phlegmasire generally, as determined by nu- 
merous 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 range from 0.877 to 2.938, with a mean in the thou- 
sand parts of blood of 2.018; in marsh cachexy, induced by the 
malarial poison, Becquerei and Rodier found, in five cases, the 
fibrin to range from 2.26 to 4.27, with a mean of 3.49; Andral and 22 
Gavarret, in 41 analyses of the blood in typhoid fever, give the 
minimum of the fibrin as 0.9, the maximum 4.2, and the mean 2.0; 
in typhus fever, according to M. H. Guenard de Mussey and M. 
liodier, maximum 3.9, mean 2.446, and 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 0.8, minimum, 3.1. It was somewhat great- 
er than that of measles: mean of seven cases of measles (Andral 
and Gavarret) 2.742, minimum 2.4, maximum 8.4. 
It is also important to note that this constituent of the blood 
was in larger amount than in acute or chronic scurvy: thus, ac- 
cording to Becquerel and liodier, the fibrin in one thousand parts 
of the blood of a man, aged 48 years, sick with scurvy forty-two 
days, was 2.5; in a man aged 21 years, sick thirty days, was 2.2; 
in a man aged 22 years, sick 445 days, 1.85; in a man aged 23 
years, sick 553 days, 1.32. 
As far as my observations have extended, there is no necessary 
connection between hospital gangrene and scurvy. The two dis- 
eases may exist together, and hospital gangrene appears to com- 
mit most frightful ravages in scorbutic patients, but they are not 
related to each other as cause and effect. This observation is still 
farther sustained by the fact that the remedies best adapted for 
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. When the two dis- 
eases exist in the same individual it is undoubtedly true, that it is 
difficult to eradicate and cure the hospital gangrene, until the scur- 
vy has been removed by a proper course of treatment and diet; 
but this fact does not at all establish any indentity, or even rela- 
tionship, between the two diseases. 
It is also worthy of consideration, that the fibrin was increased 
to a much less extent than is usual in erysipelas: thus, Popp found 
this constituent to exist in the blood of a man suffering from ery- 
sipelas, in as large a proportion as 0.6; and Andral and Gavarret 
in eight analyses of the blood in this disease, determined the mean 
to be 5.07, minimum, 3.0, maximum 7.3. Some have supposed 23 
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 abundant 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 view that the essential conditions of inflamma- 
tion are present in hospital gangrene. 
In the second case the fibrin amounted to 6.03 parts in the 
thousand of blood. 
This soldier after suffering with gangrene in a gun-shot 
wound of the neck, which extensively denuded the muscles on 
the left side above the scapula, was suddenly seized with a 
slight haemorrhage from the internal jugular vein, which was 
followed by such complete prostration of the muscular and nerv- 
ous forces, and such loss of power and variation in the action of 
the heart, that the gravity of the symptoms could only be ac- 
counted for on the supposition that air had entered the venous 
system. 
The patient, who was sitting up at the time of the occurrence 
of the haemorrhage, was immediately seized with great difficulty 
of breathing, loss of muscular power, irregular, thumping action 
of the heart, and total cessation of the pulse ; although the haem- 
orrhage was very slow, as if issuing from a vein, and insignificant 
in amount, and promptly arrested upon the application of a solu- 
tion of per-sulphate of iron, 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 about eight hours 
after the haemorrhage. 
A careful post-mortem examination revealed the fact, that 
death had been caused in this case, by the entrance of air into 
the internal jugular vein, through the erosion caused by the 
gangrene. Nature had (if we may use the expression) made great 
efforts to repair, by a fibrinous clot, the ravages of the gangrene, 
but had not been entirely successful. 
The fibrin, although the gangrene was rapidly disappearing, 
was above the normal standard. It is worthy of notice that the 
fibrin was more abundant ip this case, in which there were little 24 
or no constitutional symptoms, than in the preceding case, when 
the blood had been evidently altered and poisoned by the virus 
and its products. 
In the third case in which the arm had been amputated from 
the effect of hospital gangrene, and which was attended with a 
profuse sauious fuetid discharge from the stump (the case termin- 
ating fatally from haemorrhage), the grave constitutional disturb- 
ances were attended with a decrease of fibrin below the standard 
of health, this constituent being only 2.1 parts in the thousand of 
blood. 
In the fourth case in which the structures of the leg were so 
extensively involved and the strength of the patient so complete- 
ly drained by the exhausting and unhealthy discharges, as to 
necessitate amputation at the lower third of the thigh ; the fibrin 
was 3.04 parts, and was within the limits of health, as far as its 
quantity was concerned. In so extensive an inflammation of the 
structures of the leg as this patient was laboring under,we should 
naturally look for an increase of the fibrous element of the blood. 
We are justified by the whole history of this case, in believing 
that there was some cause or combination of causes which hin- 
dered the increase of fibrin usual in such cases of inflammation. 
The profuse discharge from the affected limb, as well as the ab- 
sorption of the products of the disorganized tissues may have had 
much to do with restraining the increase of the fibrinous element 
of the blood. 
In the fifth case, gangrene committed such extensive ravages 
in a gun-shot wound of the foot, as to penetrate the ankle-joint 
and expose the bones and tendons of the leg, and to necessitate 
amputation below the knee-joint, on account of the great loss of 
tissue, the carious constitution of the bonep, and the progressive 
exhaustion of the strength of the patient. 
As in the preceding cases, the blood collected during the ainpu- 
tation, coagulated firmly, but the clot changed more slowly and 
less perfectly to the arterial hue ui>ou the surface, than in the 
blood of health. The fibrin was 4.11 in the thousand parts, and 
was increased somewhat above the standard of health, but was 
below that of the phlegmasiae. 
From the preceding observ ations we conclude— 25 
1. The action of the poison of hospital gangrene is attended with 
both local and constitutional symptoms of inflammation. 
Thus within the focus of active change and disintegration, 
there are alterations in the healthy structure and function of the 
affected parts, as indicated by the change of color and structure, 
the fcetidodor, and the suspension of secretion and healthy nu- 
trition, by the altered condition of the blood, as manifested in 
the surrounding dark livid areola, by passive haemorrhages and 
by the rapid decomposition of this fluid j and around the focus of 
active disintegration there is active determination of blood, con- 
gestion of the capillary blood-vessels, accumulation and stagna- 
tion 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. 
2. The changes excited both locally 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 inflammations. 
Thus in hospital gangrene, the lymph effused around the focus 
of disease possesses the power of coagulation and development 
into tissue, and there appears to be all the conditions 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 progress 
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 j and the exudation corpuscles are so 
poisoned and disorganized, that they are not farther changed 
either in a progressive or descending series, and wherever the 26 
limiting fibrous wall is thrown out, with its organizablo cell ele- 
ments, it is in like manner destroyed when it is reached by the 
poison. All the changes of the blood characteristic of ordinary 
inflammation may bo present around the gangrenous part; as the 
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 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. 
3d. The gangrenous poison, as Kell as the compounds resulting 
from the disintegration tchich it induces in the organic constituents 
of the structures, tchen absorbed, acts as a poison upon the muscu- 
lar and nervous systems, and tends to disorganize the blood and de- 
range the actions of the alimentary canal. 
When absorbed in large quantities these products frequently 
act as irritants to the intestinal canal, by which they are elimi- 
nated, and patients are sometimes destroyed by the diarrhoea 
consequent upon this action upon the intestinal mucous membrane. 
The absorptiou and consequent action of the gangrenous poison 
upon the general system, is manifested by the feeble rapid action 
of the heart; the m.arked elevations and depressions of tempera- 
ture; the depressed enfeebled nervous and muscular forces, the 
trembling hands, the low muttering the trembling eye- 
balls and quivering features, and the insensibility of the organs 
of sense, and by the derangement of digestion and the foetid 
diarrhoea. 
The derangements induced by the grangrenous poison in the 
constituents of the blood, and in the eapillaryfcirculation are mani- 
fested by the dusky, sallow, livid and leaden hue of the complexion, 
the livid blue color of the tongue, the derangements of nutrition, 
secretion aud excretion, diminution in the power of 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 of 
the poison producing the disease, and of the products of the 27 
decompositions whicli it excites in the structures and fluids. A 
similar condition is observed in the action of the poison producing 
small pox. In this disease also, as will be seen from the preced- 
ing table, notwithstanding the presence of both local and consti- 
tutional symptoms of inflammation, the fibrin is less than in com- 
plicated inflammation, or in pneumonia. 
Variations of the temperature and circulation in hospital gangrene. 
Marked daily 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 the disease. Characters 
of the urine in hospital gangrene. 
From a large number of observations upon individuals selected 
from over fifteen hundred cases of hospital gangrene, we were 
enabled to establish the following conclusions : 
1st. The local manifestations of hospital gangrene, are attended 
by febrile action in the general system. 
The fever of hospital gangrene, like that accompanying other 
diseases, is characterized by increase of heat, increased chemical 
change, and increased elimination of those substances, as urea, 
uric acid, phosphoric acid, sulphuric acid, and coloring matters 
which result from the destructive metamorphosis of the solids 
and fluids. 
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; 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 disturbances, 
characterized by loss of appetite, depression of spirits, constipa- 
tion of the bowels, and such an enfeebled irritative action of the 
circulatory apparatus, as denoted a depression of the vital and 
nervous and muscular forces, certain local changes were noted in 
the wounds, as the transformation of the mosit florid granula- 28 
tions into a dark-red, glazed surface, a change or total suppres- 
sion of the natural discharges of pus, increased heat and pain, 
and an increased congestion of the blood-vessels in and around 
the wound. 
2d. The fever of hospital gangrene appears to ht manifestly the 
result of the action of an organic poison. 
This proposition is sustained by the facts clearly established 
by the preceding investigations; viz: that gunshot wounds are 
not necessarily attended by fever; that the fever accompanies or 
follows the supervention of hospital 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 appeal ance cf healthy 
granulations, and pus in the wound, and the arrest of the farther 
progress of the gangrene, are certainly attended, if not preceded 
by corresponding improvements in the constitutional symptoms. 
After the removal of the gangrene and the establishment of 
granulation and suppuration, the pulse becomes fuller and slower, 
the diurnal variations of temperature less, the normal relations 
between the temperature of the extremities ami central organs 
are re-established, 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 lieeomes cheerful. Cor- 
responding changes are olmerved 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 
standard of health. So crisis, or sudden change is observed in 
the urine during the period of convalescence, but the changes in 
this excretion correspond with the gradual changes of the wound. 
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 for example, in ma- 
larial fever. 
The favorable changes just indicated, will frequently take 29 
place, even when 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 constitu- 
tional 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 ex- 
clusively or even in great measure to the local irritation of the 
nerves exposed by the gangrene. 
When, on the other hand, hospital gangrene progresses un- 
favorably, the constitutional symptoms, become progressively 
more grave, and the fatal termination is generally announced by 
a feeble, rapid pulse, extreme prostration—twitching of the ten- 
dons, vomiting, hiccough, involuntary dejections, and oftimes 
coma. 
In this disease, death unquestionably results in many cases, 
from the absorption of the gangrenous matter. In this case the 
cause of death is often profuse and uncontrolable diarrhoea. 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 symp- 
toms, 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 
disturbances, are due in a great measure to the absorption of 
deleterious poisonous matters from the wound. 
3d. The febrile state of hospital gangrene is characterized by in- 
creased chemical change in the blood, and textures, increased develop- 
ment of heat above the standard of healthy marked diurnal variations 
of temperature, great irritability and feebleness of the general circula- 
tion, and imperfect and feeble capillary circulation, as manifested by 
the marked difference of temperature between the trunk and extremities, 
and the inability of the extremities to maintain a definite temperature, 
and withstand the effects of external cold. 
The periodical elevations and depressions of temperature, were 
intimately associated with the action of the heart. As a general 30 
rule, acceleration of the heart’s action, was attended with an in- 
crease 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 slowest. 
The decomposing poisonous matters, and the products of in- 
flammation absorbed from the gangrenous wounds after their 
introduction into the circulatory system, cause derangement in 
the blood and excite increased chemical change and consequently 
cause an elevation of temperature. It is well known that in- 
creased heat, tends to excite aud accelerate the heart’s action. 
If the conditions remained the same, the introduction of a morbific 
material (capable of exciting change) into the blood should be 
attended by uniform results and uniform elevations of tempera- 
ture. But in man the conditions are vastly varied during the 
different periods of the day. 
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 as the day advances, the heart re- 
sponds to the increased excitement of the nervous and muscular 
systems. 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 light and the 
removal of the incentives to nervous and muscular exertion, is 
attended with decreased action of the heart and reduction of 
temperature. During sleep also the respiration is not so full, 
and aeration of the blood is not so perfect. The skin also is re- 
laxed, and the perspiration increased, and the reduction of the 
temperature by evaporation promoted. 
The patient suffering from hospital gangrene, is under the 
action of a depressing organic poison, which alters the constitu- 
tion of the blood, deranges the nutrition of all the organs, and 
renders the nervous system irritable and irregular iu its action. 
The strongest men are reduced under the action of this poison, 
to the condition of weak, irritable children, being not only in- 
capable of any great muscular exertion, but also of prolonged 
and vigorous mental efforts. The exciting agencies of the day, 31 
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. 
We have in these characteristics of hospital gangrene, most 
valuable indications for treatment—the general system must be 
supported by tonics and stimulants and those measures instituted 
which will most effectually promote the elimination of all poison- 
ous matters from the general system, and destroy them in the 
local disease, and at the same time improve the quality of the 
blood, strengthen and equalize the circulation and invigorate the 
nervous and muscular systems. The following table presents 
the relations of the pulse, respiration, temperature, and changes 
of urine in this disease: 32 
Table of Observations on the Pulse, Respiration, Temperature, and Urine, in Hos- 
pital Gangrene: Consolidated from Observations of Joseph Jones, M. D., 
Surgeon, P. A. C. S. 
Explanation: 1st column—number of case ; 2d—Htnte of wound; P sig- 
nifies Gangrene progressing ; A signifies Gangrene arrested ; 3d—hour of day ; 
A. M.—morning observation ; P. M.—evening observation, (these observation* 
most generally at 8 a. m. and 8 p. M.); 4th and 5th—Pulso and respiration ; 
6lh and 7th—temperature of hand and axilla ; 8th, 9th, 10th 11th 12th—Urea, 
Uric Acid, Phosphoric Acid and Sulphuric Acid, and Chloride of Sod uni, ex- 
creted in 24 hours, expressed in Troy grains. 
1 
2 
3 
4 
6 
6 
7 
8 
9 
.N urn ber 
of Case. 
State of 
Wound. 
KKKKKKKXKSKKKKKKXKSKIiSSXKSXKKKEKSSKKKSKSSS 
Hour of 
Day. 
! 118 
96 
84 
108 
101 
91 
108 
100 
100 
104 
100 
9H 
1(H) 
120 
100 
100 
11 
105 
134 
100 
100 
120 
! 80 
98 
I 96 
80 
80 
88 
80 
86 
80 
80 
80 
86 
86 
98 
96 
84 
100 
86 
96 
Pulse. 
— — — ■_> — to — to to to to to to tO — — — — 
QDQDOBQD A A A A 00 00 00 00 30 05 00 00— — 050 004^005000500000030 
Respiration. 
ODgpooooooODgpoDaooooooBOooD50oo505000oooooBOOoooposo®50 ooo 
tCAW — 0©3044AcD00 30cD44;DW-'l — OOOtOtCSDW — AAAWWOA*C — tCtCAOaoOOOO — 
:: s ::::: i I:::::::::::::::::; : 
4* CO to -1 -I —■* 00 CO — O CO — — — 00 to CO OT 50 A to — t<9A 44 »o CO 44 
Temperature 
of Hand. 
OppOOOOO«COOcOOOOOOO!COOOOOOO®e®®2©®®OQOOOOO«20 
tOOtl-OtC — 0D©5DtC©5D©CDAa0cDte-lte-*te©AtOA©5OCO© _ to 44 — 1C 44 00 A CO © 30 i 
: t ::: t : 
44 44 A M-OC5 WODW — — OOCOWAAAWAOD — A—A A A MMOifcMOOOOMOOO 
Temperature 
of Axilla. 
a 44 44 co a co e< 44 05 a a 44 ©, Gh*. 1 rea i n 
3 SfSS 8 S§ S S3 S 24 hours. 
— — — — —— — —A — — 
A A 30 CO to A CO ©: A Op — 
44 1C W A COO» 00 — — M A 
w — 00 44 tc 44 
Grams Uric- 
Acid in 24 
hours. 
44 1C W W tew 44 tc A 44 A Co w 
OB —CD— A CD W tC © © OOA — 
t tss :: : :• : : : : 
-J A 44 -| tC W A 00 00 A QO tC 44 
Grains Phos- 
phoric Acid 
in 24 hrs. 
44 tO tO — — — 00 tO 00 CO 44 to W 
44 A A © — 04 to 00 tO — © to 44 
A bo bo © bo tc to -J C5 00 A !d 
Grs. Sulph- 
uiic Acid in 
24 ! r- 
- — x -o tc- - A- - - tc -2 Gr«.Chloride 
Srr4 £3 © To o f* F* r Of Sodium 
«o • tc a ti tew A in 24 hr*. 33 
Table of Observations—Continued. 
»-* tO tO t-4 >-» H* »-* H-f 
O MO O X -4 05 *-* 
Number of 
Case. 
Miflu ot' 
Wound. 
2 2 2 2 2 2 222222222222222222 2 2222222222222222222 
Hour of 
Day. 
fc—*►—*»—»»—* t—i M M M M K» h-4 »—*‘ h-4 >—4 ►—4 >—* t—* »—i »-J>MH»»—* h-» 
OtOOOt-'O 00 0000 00 © ® 30 OOOO ©'-■0©©©©®©>-‘k-.kk<£>0©©©©t©©®©©®0 
| © © 4- © t© 4k © 4k © 00 © 4- © ©4- t©t000i-k0oco©004k00©©©©4k4k©00©©©004»©00 
Pulse. 
M to m hm mwh i-‘tOtO»-‘i-,i-*t-‘ts3tOfcOtOtvD ‘ *—• *—* •—* 
© ©©©©©© C0ts5i-‘00 00 ©00l0rfi.t000t0 ooooooco 
Respiration. 
d zO *— *— M r—‘ , ►■—* 
) oo *<i cd co cocdcococdcdco©o?dcdco?dogocdococoo50?ooococo^cdcooocd<dcocdococdo 
to co co co pi 05 [O jopo w 
CO tO *~ Jfca 4* CO 00 4fc 4*. tO 4>k bi b cn 
Temper’ture 
of Hand. 
! P ° P P P cooSooooocdcooooooooo ooooooqooooooooocdoo 
r r* r N 9 
co b c: w w m m b bi * lu - * It* bo ’ it* bi' to !*> b* * * * * b** * bt ’ bt 
- " C" 
Temper’ture 
of Axilla. 
© 03 © © >a. 4k 4k 4k 03 toco 4k coto >a- COCO Mik 
Oi kl - 0 K) <1 © «Ol l—© M to© 00 © 03 00© 
H4‘M»COOCC to CO 00 03 to CO © i-» 4k ©4k 
Grs. Urea 
in 24 hrs. 
t5M M t-k k-*l-*<-*tO 
i—1 © 4k © to © 4k -4 © -4 ® -4 ©4k © 03 m to® 
05 bo so be i» b * b© 
05 to 
Grs. Uric 
Acid in 24 
hours. 
M(-*l-kMC04k M to k-* © 4k *—* © t© 1—‘ ©4k 
4k to k-k © 4k © © 03 CO 4k k— k-» kk 00© 4-03 
03 4k 03 ■ ' 4k -4 © ©’ bo © © © bo 
Grs. Phos- 
phoric Acid 
in 24 hrs. 
tO tO CO 03 tO CO tO w-* ►—* •—» >-* to—1 to >—» K-* CJ» tO 
CO O CO C5 W tO 0 4* 05 o ‘ H-* OOCn CO Cn 
©4k .CD 00 © 83 4k 
Grains Sul- 
phuricAcid 
in24 lirs. 
19.. 
64.. 
81.. • 
62.. 
203.. 
18.. 
32.. 
46.. 
8..8 
5.. 
129.. 
180.. 
181.. 
207.. 
192.. 
110.. 
102.. 
31.. 
98.. 
Grs. Ghlo-k 
ri e Sodi- 
um 24 hrs. 34 
DURATION of HOSPITAL GANGRENE. 
I have observed no uniform periods in the progress of this 
disease, to either a favorable or fatal termination. 
As far as my observations extends, the duration of hospital 
gangrene depends upon the condition of the system and constitu- 
tional powers, at the time of the infection ; the extent to which 
the constitution is involved by the absorption of the gangrenous 
matters; the position, relations, and functions of the dise sed 
parts; the rapidity and extent to which the disease progresses 
before it is arrested, by the powers and processes of nature, or by 
treatment; the nature of the local and constitutional treatment; 
and above all, upon the hygienic condition of the hospital in 
which the patients are treated. 
Bad diet, previous exposure and hardship, together with the 
atmosphere of crowded, filthy camps, beleaguered cities, and 
filthy crowded prisons, induce a state of the system which favors 
the origin and rapid spread of hospital gangrene. Such de- 
rangements of the blood and tissues and in the physical and vital 
forces as we find in scurvy, appear to be eminently adapted to 
the rapid spread of hospital gangrene. 
The effects of bad diet, exposure to cold and wet, with imper- 
fect clothing, and of the constant inhalation of deleterious gases 
arising from animal and vegetable decomposing matter, may 
gradually induce such a change in the composition of the living 
tissues, that they are prone to disintegration, and when any 
poisonous agent capable of exciting rapid change, as that which 
produces hospital gangrene, is introduced, the physical and 
chemical an3 vital powers are so reduced, that the disintegration 
excited is not only rapid but wide spread. We might call this an 
unstable condition of the chemical elements and physical and 
vital forces of the living system, and with some show' of analogy 
compare it to that of certain unstable compounds as the iodide of 
nitrogen and chloride of nitrogen, which are rapidly altered even 
by mechanical motion. 
It is manifest that when such a state of the system has been 
induced, the spread of gangrene will be far more rapid and exten- 
sive, and the convalescence will be more tedious than in healthy 
constitutions. And even under the best local treatment, the 35 
recovery is necessarily tedious in constitutions broken down by 
the agencies just specified, and by habits of intemperance and 
vice. 
Even when the constitution is vigorous and healthy, before the 
infection, the absorption of the gaugrenous matter and its pro- 
ducts, may induce a state of general derangement and depression, 
similar to that just alluded to, as resulting from the causes which 
may be considered as extraneous and accidental. When the 
system has been once thoroughly poisoned by the matter of hos- 
pital gangrene, the recovery will be tedious if not exceedingly 
doubtful under the best local and constitutional treatment. 
The natural temperament appears to exert an important effect 
upon the progress of hospital gangrene. All things being equal, 
the disease will be most readily managed and convalescence will 
be most rapid in the nervo-sanguine temperament. Men with 
black hair, and ej’es, and dark sallow complexions of the bilious, 
nervo-bilious, and bilio-lymphatic temperaments, appear to suffer 
most in the acute stages, and to have the most tedious convales- 
cence. One or all of these causes may tend to aggravate the 
disease, and prolong its course. Any system of treatment which 
neglects the previous condition of the system, or that induced by 
the absorption of the poison, and its products, should be con- 
demned as radically defective. Thus in hospital gangrene, en- 
grafted upon a scorbutic system, what folly would it be to treat 
the disease entirely by local remedies, without any attention to 
the derangements of the blood and of several of the important 
organs, and of the general nutrition of the body. 
That the position, relations and functions of the diseased parts, 
have much to do with the character and duration of hospital 
gangrene, would seem to be almost self-evident. The disease is 
especially dangerous, when located upon, or in the vicinity of a 
large joint, or along the track of important blood-vessels, as upon 
the neck over the track of the jugular veins and carotid artery; 
or in the thigh over the femoral vein and artery 5 or in the 
neighborhood of important organs, as the testicles and lungs. 
I have never seen a case of recovery from this disease, after 
the opening of the hip or knee-joints; and in fact in all cases 
where the elbow-joint was opened, in which amputation was not 
performed the result was fatal. 36 
The exposure aud consequent death, of bones denuded of flesh 
and periosteum by hospital gangrene, greatly prolong convales- 
cence. A portion of dead bone, is one of the most common causes 
of prolonged and tedious and exhausting suppuration from 
wounds even after the removal of all gangrene, and the establish- 
ment of health}' florid granulations. The system may, after a 
prolonged struggle, finally sink under the irritation and extensive 
suppuration caused by a i>ortion of dead bone, after the system 
has successfully resisted the most extensive and dangerous des- 
truction of tissues by the gangrene. Iu such cases, nature perish- 
es in the attempt to throw off the dean) bone; or during the 
depressed and irritated state induced by the action of the poison, 
and by the inflammatory process, and the constitutional dis- 
turbances which it has excited, the stomach and bowels may 
give way, and the patient fall a victim to gastritis or diarrhoea. 
The nature of the local and constitutional treatment, has much 
to do with the progress and extent and duration of hospital gan- 
grene, for if the disease be due to the action of a certain kind of 
animal matter, if it be possible to destroy that matter by chemical 
agents, and at the same time arouse by the same means, the 
surrounding tissues, with heaUliy inflammation, it is evident that 
the physician possesses the means of cutting short the disease. 
After the arrest aud removal of the local disease, the j>eriod of 
convalescence, will dei»end upon various circumstances, as the 
extent to which the general system has been involved, the extent 
of the local injury, and the condition of the wound, and the 
surrounding hygienic state. 
Rut, above all, the duration of hospital gangrene, will depend 
upon the hj'gienic condition of the hospital, and the sanitary 
regulations. If the hospital be crowded with wounded and gan* 
grene cases, if it be poorly ventilated, and if but little attention 
be paid to the cleanliness of the bedding and utensils, the patient* 
will be liable to constant returns of the disease, introduced 
through oiio or all the avenues of infection existing in filthy 
badly regulated hospitals. In such cases, patients may l»e cured 
of the gangrene several times, ami finally die of a recurrence of 
the disease. I have seen nnrses dress healthy granulating wounds 
with the same filthy hands, sjionges and Intruments, which bat a 37 
tnoment before had been busy in cleaning and picking the most 
offensive gangrenous wounds. The tendeucy of the disease is to 
a low depressed state of the nervous system, and of the general 
and capillary circulations, and hence bedsores are exceedingly 
common in this disease when the patients are not properly at- 
tended to 5 and there is no doubt but that in the hands of inat- 
tentive aud slovenly surgeons, bed sores are the cause of most 
tardy convalescence and even death itself in hospital gangrene. 
As far as my observations extend, bowel affections, and especially 
obstinate diarrhcea, are much more liable to attack patients with 
hospital gangrene in dirty foul crowded hospitals, than in those 
properly regulated. 
DISABILITY RESULTING FROM HOSPITAL GANGRENE. 
The extensive destruction of tissue, caused by this disease, will 
in many cases involve the permanent injury of the affected 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 circulation, nutrition, and even com- 
plete paralysis of the parts below the seat of iniury may result. 
Withered, discolored, cold, contracted and paralyzed arms and 
legs, are sometimes seen, even at this 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 had lost their natural fibrous coverings, 
and even in many eases their natural tendinous attachments, 
during the process ot healing by granulation form numerous new 
attachments, and the symmetry and precision 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 actions of the muscles will take place. 
In most cases, the extent of the disability, 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 38 
of the contraction, whether forwards or backwards, or lateral, 
will manifestly depend upon the relations and actions of the 
muscles injured or destroyed. 
During convalescence from hospital gangrene, it requires great 
resolution and attention on the part of the patient, as well as the 
physician, to overcome the contraction of the muscles. As far as 
my observation extends, many valuable soldiers are lost to the 
service, from inattention on the part of the nurses and medical 
attendants to the posture of the body, and of the affected limbs 
during the progress of hospital gangrene. Whilst endeavoring 
to place the diseased limbs in the most favorable position for 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 subject 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 atmosphere and action of the poison and its or- 
ganic 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 
possible, the number of soldiers lost to the Confederate service, 
on account of disability following hospital gangrene, but have 
thus far been unable to form any approximate estimate, on ac- 
count of the following difficulties: 
It is evident that the field repoits, 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 frequently transferred 
from one hospital to another, and in the present system of registra- 
tion, his disease and injury, with even the date and character of 
his wound appears anew upon the records of every hospital which 
he enters, so that the cases recorded in the general hospitals con- 
nected with the Confederate armies, greatly outnumber those 
transferred from the field. 39 
Again, hospital gangrene, under the title of phagedena gan- 
grenosa, has only recently been introduced into the list of diseases 
recorded in the Confederate reports of the sick and wounded; 
thus, the first report from the general hospitals attached to the 
army of Tennessee, in wdiich this disease appears, was for the 
month of July, 1864. 
The losses from disability occasioned by hospital gangrene have 
been considerable in the Confederate armies, up to the present 
time, and will most probably progressively increase as the war 
with its numerous privations, and rapidly accumulating horrors 
advances. 
The service has lost far more men from the effects of the gan- 
grene, destroying the power and use of limbs, than from the 
actual number of deaths caused by this disease. 
CAUSES OF DEATH IN HOSPITAL GANGRENE. 
When hospital gangrene progresses unfavorably, the constitu- 
tional symptoms, become progressively more grave, and the fatal 
termination is generally announced by a feeble, rapid pulse, ex- 
treme prostration, twitching of the tendons, vomiting, hiccough, 
involuntary dejections, and oftimescoma. Many cases, however, 
die without any derangement of the brain, and the patients are 
sensible and calm, up to the moment of death. 
Deaths from hospital gangrene may result from one or more 
causes, as: 
1st. 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 matters 
and its products. 
2 d. Repeated haemorrhage from the blood-vessels exposed and eroded 
by the gangrene. 
The separation of the dead parts, is almost always accompanied 
with more or less hemorrhage, and in the last stage of the dis- 
ease, there is frequently a bloody oozing from the surface of the 
denuded parts. 
When hemorrhage takes place from the large arteries, which 40 
require ligation, it happens that in the severest cases, the coats 
of the arteries are sometimes ruptured by the ligature, and when 
the haemorrhage is controlled by pressure, the limbs becomes 
greatly swollen, and the progress of the gangrene accelerated. 
In such cases, whether the ligature, and the mechanical means of 
compression be applied or withheld, an unfavorable issue appears 
to be almost equally certain. The sesqui-chloride and persul- 
phate of iron should always be used freely locally in such cases, 
in addition to the other measures. 
"When the forces have been reduced by the long continued 
action of the gangrenous poison, a very slight haemorrhage will 
sometimes cause death. 
3d. Entrance of air into reinx eroded and opened by the ravage* of 
hospital gangrene. 
As far as my observations extend, death from this cause is of 
rare occurrence. We have already in the section relating to the 
changes of the blood, presented an interesting case illustrating 
this mode of death. Jiy post mortem examinations, I have been 
able to determine the important fact, that the blood is frequently 
coagulated, or rather a firm fibrous laminated clot forms in veins 
surrounded by gangrenous matter. This formation of fibrous 
clots in the veins appear 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 arc des- 
troyed by hospital gangrene. We have before shown, that the 
fibrin of the blood is increased above the normal standard, and 
that eveu in the worst cases, the blood is capable of forming a 
firm clot 
4th. Opening of the large joints by the gangrene. 
When gangrene attacks parts in the neighborhood of the hip 
and shoulder-joints, or of the knee and elbow joiuts, the disease, 
all things being equal, as to its intensity and the condition of the 
system, is far more dangerous than when situated upon the 
middle parts of the thigh, leg, arm, and fore arm. 
The opening of a large joint lo 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 41 
at once greatly increased. The gangrenous matters frequently 
accumulate within the opened joint, and still farther, by their 
putrefaction 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 sauies 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, 
the difficulties of any case may be greatly increased, and, in fact, 
rendered hopeless, unless the limb be promptly amputated. 
5tli. Formation of large bed-sores during the progress of the disease, 
and the appearance of gangrene in them. 
The tendency of the poison of hospital gangrene, after its absorp- 
tion, is to 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 circulation are greatly depressed and de- 
ranged. It follows from this that all parts subjected to continu- 
ous 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 necessarily subjected 
to pressure in patients suffering with this disease. 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, iu which both granulation and 
suppuration had been established. 
6th. Diarrhoea resulting from the irritant action of the poison of 
hospital gangrene, upon the intestinal mucous membrane. 
After the absorption of the gangrenous matter, the immediate 
cause of death, is. in many cases, of long standing, profuse and 
uncontrollable diarrhoea. In the early stages of the disease, the 
bowels are most generally constipated, and the use of occasional 
purgatives beneficial; but when the disease has continued for a 
length of time, and a large surface has been exposed to the action 
and absorption of the deleterious materials, diarrhoea of an obsti- 
nate foetid character frequently sets in, and finally carries off the 
patient. 
7th. Extensive and rapid disorganization of the tissues, around the 42 
original wound, beneath the Hound skin, accompanied by absorption of 
the gangrenous matters, great nervous and muscular prostration and 
obstinate diarrhea. 
Hth. Mortification of internal organs, induced by gangrenous matter 
absorbed Jrom the local disease. 
The absorbed gangrenous matter, may, in certain cases, excite 
mortification of important internal organs. The development of 
gangrene within important internal organs 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, the organ which be- 
comes gangrenous, was previously in a diseased state, either of 
active inflammation or of progressive derangement. 
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 proximity 
with this disease. 
9th. The invasion of organs essential to life, by the direct des- 
truction of intervening structures. 
When gangrene attacks the stump after amputation, at or near 
the shoulder-joint, the disease may progress along the cellular 
tissue into the cavity of the thorax, and invade the pulmonary 
structures, and thus produce a rapid fatal termination. I have 
seen the lungs thus attacked in a case of resection of the humerus 
near the shoulder-joint. I have observed that in those cases in 
which hospital gangrene attacked the lungs, the complexion im- 
mediately assumed a moist, cadaverous, sallow hue. When gan- 
grene attacks the tissues in the groin, it may penetrate the 
abdomen, and speedily cause death. In like manner when the 
serotum and testicles are attacked by the disease, it may pene- 
trate 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. 
lOf A. Pyemia. 
It sometimes happens that after the gangrene has disappeared 43 
from the wound, and after the appearance of granulation, and 
the formation of pus, this fatal disease supervenes. It is a subject 
for interesting investigation, to be settled only by carefully re- 
corded cases, whether pyaemia is more common in cases Of hos- 
pital gangrene, than in those cases in wlrich the wounds present 
the appearance of sthenic inflammation. It is reasonable to sup- 
pose, that all depressing causes, which tend to produce such a 
stale of the system as favors the rapid disorganization of the 
structures would favor the production of pyaemia. 
In several cases of this disease supervening upon hospital 
gangrene which have come under iny observation, the symptoms 
have been marked and distinct from the first disease, the urine 
lias assumed a brilliant carmine tint, and after death, the veins 
of the diseased parts were discovered, upon dissection, to be dis. 
tended with pus. 
11 tli. Phlebitis. 
12th. Various results or sequelce of the local and constitutional 
effects of hospital gangrene, as profuse and unhealthy suppuration 
from large granulating surfaces—necrosed bones, causing irritation 
and keeping up suppuration, and hectic fever—permanent impairment 
and debility of the digestive Organs. 
II.—CAUSES OF HOSPITAL GANGRENE. 
1st. A debilitated and cachectic state of the constitution. Such de. 
rangement of the solids and fluids as favors the 'production of hos- 
pital gangrene, may be the result of exposure, fatigue, bad diet dnd 
impure water ; and also of the rapid or slow action of a spe&htl 
poison in a low, humid and miasmatous atmosphere. 
If the doctrine advanced by John Hunter, that a certain degree 
of vital tone or energy is requisite for the formation of coagtilable 
lymph, by which the spreading of inflammation and sphacelation 
will be prevented, and that when owing to deficiency of vital 
energy, vascular action is incompetent to the formation of coagnla- 
ble lymph, these lesions will extend, and the morbid fluids will 
contaminate the surrounding tissues, be accepted as an axiom 
in pathology, and be enlarged so as to embrace the doctrine that 
the character and progress of inflammations will depend also 
upon the physical and chemical constitution of the solids and 44 
fluids, we will have an explanation of the fact, that hospital gan- 
grene, which was almost unknown as an American disease, 
previous to the present war, has, at least, in the Confederate 
armies, progressively increased in amount and severity. 
An insufficient supply of food, as well as the prolonged and 
too exclusive use of salt food, not only impair the efficiency of 
soldiers by rendering them less capable of enduring exposure and 
fatigue, and by inducing that cachectic state of the system 
which is favorable to the development of diarrhcea and scurvy ; 
but also render the accidents of battle more fatal by the unfavor- 
able progress of inflammation iu gunshot wounds. 
In the earlier periods of the present war, the Conlederate 
armies were composed in large measure of men who had been 
accustomed to an abundant and varied diet, a large portion of 
which consisted of animal food. Notwithstanding the unavoid- 
able crowding of the hospitals, and the existence of all the 
circumstances most favorable to the development and spread of 
hospital gangrene, in the first months of the war this disease 
appears to have been almost unknown, until a change had been 
wrought in the constitution of the soldiers, by fatigue, exposure, 
aud reduced rations, from which both coffee and vegetables were 
almost universally absent. 
A low, moist stagnant, malarious atmosphere, is not only in 
itself favorable to the origin and spread of hospital gangrene, 
but it also produces iu troops serving in low malarial regions, 
changes iu the solids and fluids unfavorable to sthenic inflamma- 
tion. 
Thus, as I have shown by previous investigations, the malarial 
poison produces profound alterations in the constitution of the 
blood. Under its action, the colored blood-corpuscles are more 
rapidly, and to a greater extent, destroyed than in any other 
disease, with the exception perhaps of pyaemia. The fibrin is 
diminished, and also altered in quality. 
The albumen is, in like manner, diminished. The extractive 
and coloring matters of 'he blood are frequently increased. 
During the active stages of malarial fever, phosphorus and the 
compounds of phosphorus in the nervous structures and in the 
colored blood corpuscles, as well as sulphur and the compounds 45 
of sulphur, iu the muscular structures, undergo more rapid 
changes than in the normal state,—and phosphoric .acid and the 
phosphates, and sulphuric acid, and the sulphates appear in in- 
creased quantities in the urine. The waste of phosphorus and its 
compounds in the blood-corpuscles and nervous structures during 
the active stages of the fever, are far greater than the supply of 
these elements through the blood. During the slow action of the 
malarial poison, as well as during the active stages of the parox- 
ysm, important changes take place in the liver and spleen. In 
both organs, the colored blood-corpuscles are destroyed in large 
numbers, and the coloring matter resulting from the disintegra- 
tion of the red corpuscles accumulates in them, and in conjunction 
with other changes in the nutritive process of these organs pro- 
duce the alterations characteristic of malarial fever. That the 
chemistry of the body is still farther deranged in malarial fever, 
is evidenced by the changes of the excretions. Thus, during the 
chill, and at the very commencement of the hot stage, phosphoric 
acid disappears almost entirely from the urine; as the hot stage 
progresses, and the febrile action and heat commence to decline, 
there is an augmentation of phosphoric acid. But what is still 
more important in its bearings upon inflammatory affections 
engrafted upon the malarial constitution, the uric acid is either 
increased, or remains at the normal standard, during the chill; 
disappears almost entirely during the fever, and then increases 
rapidly and rises to a high figure at the subsidence of the febrile 
excitement, and often continues for days, two and three and even 
six times more abundant than in the normal state. If it be true 
that the presence of a morbific agent in the blood, as uric acid, in 
gout and rheumatism, will often prove an excitant to inflamma 
tory action, then this tendency in malarial fever, to the generation 
of large quantities of uric acid, during the intermission, and even 
during the period of convalescence, is important in its bearing 
upon inflammations accompanying or following malarial fever. 
It results from these effects of the malarial poison. 
First. When inflammation is excited from any cause, in a 
system subjected to the influence of the malarial poison, the 
natural tendency is for the inflammation to assume a low form, 
from the altered condition of the constituents of the blood and 46 
structures, and from the derangement in the process of nutritiou, 
and pf those physical and chemical acts by which the nervous 
and muscular forces are developed. It is well known that the 
causes which are most influential in the production of inthunmu 
tiou, are such as enfeeble the heart, impair the tone of the 
arteries, reduce the activity of the secreting organs, and debili- 
tate the muscular and nervous forces. Imperfect nourishment 
also, either in consequence of the defect in the quantity or quality 
of the food, or of iucapaeity of the digestive powers, impairs the 
power of the system to resist the effects of deleterious and depress- 
ing agents, as cold, and produces a liability to lo v forms of inflam- 
mation and fever, and to various epidemic and contagious 
diseases. 
In malarial fever, even when the digestion is unimpaired, the 
action of the poisou, by impairing the constitution of the blodd, 
and by deranging the nutritive processes of the different organs 
aud tissues, and by deranging and depressing the chemical 
actions concerned in the development of the physical and nervous 
forces, produces similar results to those w itnessed in ill fed and 
ill-conditioned beings. 
process of inflammation, whilst including both congestion 
and determination of blood, is essentially more complex than 
either or. both of these conditions, and includes changes of the 
blood within the vessels, aud changes of the relations of the 
capillaries to the blood, and of the blood to the surrouuding 
tissues. The character of these changes as well as the extent 
and progress of the ipflgmmatiou, will depend upon the constitu- 
tion of the blood, the forces moving the blood, and the condition 
of the forces active in the nutritiou of all the organs as well as 
of the forces especially active in the inflamed tissue. Thus 
when the character of the blood has been altered, and the forces 
depressed, the solid products of inflammation are less capable of 
organization, the lymph effused possesses inferior plasticity, and 
the effects of the local inflammation upon the general system in 
causing inflammatory fever, are more depressing and dangerous. 
As therefore the tendency of the malarial poisou is to derange 
the conditions upon which the maintenance of healthy nutrition 
depends, viz., the regular supply of healthy blood i»ossessing a 47 
definite composition and fixed relations of its elements, and of a 
certain supply of physical and nervous force, and the bealtliy con. 
stitution of the organs and tissues, it is evident, not only that 
inflammation engrafted upon the system laboring under the 
effects, or under the direct action of the poison, must be cor- 
respondingly altered from its progress in the healthy constitu- 
tion ; but also that the state of the system induced by the action 
of the malarial poison is conducive to the origin of inflammation. 
Second. From the destruction of the fibrin, and red corpuscles, 
consequent upon the action of the malarial poison, the tendency 
of inflammation excited in systems under the influence of the 
malarial poison, is to diffusion. The increase of fibrin in the 
blood and in the inflamed structures appears to be destined in 
the economy of Nature to limit and circumscribe the inflammatory 
action by the fibrous matter thrown out within and around the 
inflamed part. The colored blood-corpuscles which crowd the 
inflamed parts appear to contribute hy the chemical changes 
which they excite, and especially by the increased oxidization of 
the albuminoid elements, to the formation of fibrin, which in this 
view may be considered as oue of the controlling and limiting- 
elements of inflammation. Whatever, therefore, tends to di- 
minish the red corpuscles and fibrin, tends to interfere with the 
natural processes employed by Nature in the limitation of inflam 
inatiou, and directly promotes the diffusion of the inflammation 
over a greater extent of tissue, and in a corresponding degree 
renders it more severe and dangerous. 
From these facts and considerations, we conclude that, whilst 
the malarial poison cannot be said directly to produce hospital 
gangrene, still it is capable of inducing sqcU changes in the blood 
and in the nutritive and excretory processes as alter the usual 
course of inflammations. 
In scorbutic patients, all injuries tend to form ulcers of an 
unhealthy character, and even so simple an operation as vaccina- 
tion may be followed by the most extensive sloughing and even 
gangrene of a fatal nature. 
In dejected scorbutic prisoners confined in filthy military 
prisons, I have seen the smallest accidental injuries and abrasions 
of the surface, as from splinters, or bites of insects, followed by 48 
MiH'li extensive gangrene as to necessitate amputation. The 
scorbutic condition induced by salt meat and farinaceous food 
without fresh vegetables, frequently modifies the course of dis- 
eases, poisons wounds however slight, and lies at the foundation 
of those obstinate and exhausting diarrhoeas and dysentery, 
which prove so fatal to beleagnred armies, to soldiers in military 
prisons, and to seamen upon long voyages. 
Scurvy and hospital gangrene frequently exist in the same 
individual. In such cases, vegetable diet, with vegetable acids, 
would remove the scorbutic condition without curing the hos- 
pital gangrene. 
It has been well established by my own observations, as well 
as those of Blane, Trotter and others, that the scorbutic condition 
of the system, especially in crowded camps, ships, hospitals and 
beleagured cities, is most favorable to the origin and spread of 
foul ulcers and hospital gangrene. In many cases, it is difficult 
to decide at first whether the ulcer be a simple result of the 
scorbutic state, or of the action of the poison of hospital gangrene ; 
for there is 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 promi- 
nent characteristics of hospital gangrene, as will be seen by a 
reference to the description of Lind, Trotter, Blane and others. 
2d. The air of crowded hospitals, tents, and ships, loaded with 
animal exhalations. 
The causes examined in the preceding section, should more 
correctly be termed, conditions favorable to the delopment of 
hospital gangrene. The most essential condition and efficient 
cause of hospital gangrene, is found in the exhalations which 
contaminate the atmosphere of the crowded, badly ventilated 
and filthy tent, prison, hospital or ship. 
In the present condition of the Confederate troops, exposed as 
they have been to unparalleled labors and fatigue, with short 
and unvaried rations, the crowding of the wounded into close 
box cars, and thence oftiraes into hastily extemporised, badly 
ventilated ahd filthy houses and hotels for hospitals, is almost 
uniformly attended by the appearanee of hospital gangrene. The 49 
severity of the disease will be greatly increased in a damp, warm, 
low, malarious atmosphere. In a stagnant moist atmosphere, it 
is almost impossible to secure in the wards of large hospitals, 
even when the windows are kept always open, such a constant 
change of air, as will prevent the deleterious action of the ex- 
halations from the wounded surfaces, and from the lungs and 
skin and excretions of the patients. As far as my observations 
extend, I am led to the belief that the exhalations act not only 
upon the wounded surface, but also through the lungs and skin ; 
and that by the continuous absorption of these deleterious matters 
through these channels, the nervous system may be so depressed 
and the constitution of the blood so altered, that hospital gan- 
grene may arise independently of local action. This question 
however admits of much investigation and discussion. 
It is now at least believed by a large portion of the profession, 
if not established, beyond all doubt, that the animal exhalations 
of crowded tents and hospitals, are capable of developing in the 
healthy nurses, two distinct species of fever, characterized by 
many of the symptoms of hospital gangrene. It is without doubt 
true, that the heavy mortality from pneumonia and typhoid fever, 
in the Confederate hospitals, has been due in great measure to 
the depressing effects of animal exhalations; and it is probable 
that many cases of pneumonia have been converted by these 
agents, into cases of hospital gangrene of the lungs. 
3d. 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 gangrene may be readily communicated by actual con- 
tact of the matter, from one wound to another, and that the 
matter may be inoculated into the healthy subject, just as in the 
case of the matter of small-pox, and produce a poisoned wound 
exactly similar to the one from wThich the matter was taken. 
I have demonstrated conclusively by experiments upon animals, 
and by careful observation of gangrene in healthy wounds and in 
nurses attending gangrenous patients and upon the origin of the 
disease in washerwomen, who did not enter the wards or come in 
contact with the patients, but who simply washed the clothing 50 
and rags soiled with fire discharges of gangrerratis w-onnds, that 
the matter of this disease possesses contagions properties, and 
that it will reproduce itself When fnoetrlated trpon a healthy 
individnal. 
After carefnl observatiOTrand consideration, the follow-jog con- 
elusions have been drawn : 
First. Hospital gangrene is caused by (he action of an irritant 
corrosive organic poison, generated during the decomposition of ani- 
mal matter under certain conditions, and capoldeof exciting chantje 
and decomposition in living stratiform with which it is Itrouyht into 
contact, after the manner of a ferment. 
Second. Hospital gangrene may at any time arise de novo, when 
sick and tcounded soldiers are crowded together in badly ventilated 
houses, filthy hospitals, close boa cars, or on ship board. 
Third. Hospital gangrene will arise most readily under these 
circumstances, when the soldiers hare been on scanty and poor food, 
and have been exposed to fatigue, bets of rest, the constant excitement 
of Irattle, and the unhealthy atmosphere of retarded filthy camps and 
Iwlcaguered cities. 
Fourth. When crowded together a large proportion of the wounds 
may become gangrenous, without any direct application of the matter, 
and Itcfore even the dressings hare been removed. 
Fifth. If tases of hospital gangrene be introduced amongst the sick 
and wounded of any hospital in tchich the disease is not prevailing, 
the rapidity with Ichirh it will spread wilt depend upon the hygienic, 
condition of the hospital, and also upon the deration of its situation, 
and the temperature and moisture of the cHmate. 
Sixth. If (he preceding propositions be -true, it is evident that the 
crowding of human beings together, whether sick or well, in confined 
spaces, so deteriorates and poisons the atmosphere, that all wounded 
surfaces are liable to become infected. As 'the disease, sometimes 
arises amongst freshly wounded soldiers, -without any introduction of 
the disease, from without, and also asutngsi isolated casts of wounds 
introduced into hospitals crmrdrd simply with the sick ; the conclusion 
is inevitable that the disease arises as much from the action of air 
rendered foul by animal exhalations, and by changes in its chemical, 
physical and electrical constitution, upon wamded surfaces, as from 
any contagious afllttri* arising from the gangrenous wo tends. 51 
III.—TREATMENT OF HOSPITAL GANGRENE. 
Measures for llie prevention of the disease. 
The observations upon the relations of insufficient food, fatigue 
and the exhalations of crowded tents and hospitals to the origin 
and spread of hospital gangrene, indicate at once, without farther 
discussion, the best means for the prevention of this disease. 
Abundant supplies of nutritions animal and vegetable food, 
free ventilation with the largest possible supply of fresh air to 
each patient, with scrupulous cleanliness of the wounds, as well 
as of the person’s clothing, bedding and apartments of the wound- 
ed are the great prophylactic measures against hospital gangrene. 
When this disease appears in a filthy or crowded hospital, a 
heavy responsibility rests upon the medical officers. It would be 
far better alter 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 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 was limited, the 
wounded men shut up in these hot confined boxes suffered from 
thirst, and the unwashed and filthy wounds emitted a foul stench 
which contaminated the entire atmosphere. The severest epi- 
demics of hospital gangrene have appeared in wounded subjected 
to these most favorable conditions for the origiu and spread of 
the disease. 
In general hospitals, each seriously wounded man, should be 
allowed if possible, two thousand cubic feet of air; the severest 
cases should be distributed uniformly amongst the slightest 
cases; and each ward should be thoroughly cleansed, white- 
washed and fumigated, at least every two mouths. The free use 
of Labarraques’ solution of hypo-cldoride of soda, as a wash 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 origiu and spread of hospital gangrene. When La- 
barraques’ solution cannot be obtained, a weak solution of nitro- 52 
muriatic acid, in the proportion of one fluid ounce of the acid to 
a gallon of water, will make a useful disinfecting and slightly 
stimulating wash for wounded surfaces. This solution should be 
prepared fresh each moruing, and the wounds should be carefully 
washed with it, at least morning and evening. 
It is well established that fumigations with chlorine, are more 
efficacious in purifying the wards of hospitals than any other 
means. In the present state of the Confederacy, however, it is 
almost impossible to command the necessary supplies of the 
mineral acids, and the best indigenous substitute which has 
fallen under my observation is the tar fumigation. In the tar 
smoke, caibon in a highly divided state, together with various 
disinfecting emperumatic matters, are the active agents which 
purify the infected atmosphere of the crowded hospital. This 
smoke so far from irritating the lungs, appears to act beneficially 
upon pulmonary complaints.* 
CONSTITUTIONAL TREATMENT OF HOSPITAL GANGRENE. 
inflammation in the healthy system is a reparative process of 
Nature, and should be studied and treated as a modification of 
the natural processes concerned in the preservation of the hotly ; 
or, in the language of John Iiuntcr: “ Inflammation in itself is 
not to be considered as a disease, but as a salutary operation, con 
sequent either to some violence or some diseaseit is “ only a 
disturbed state of parts which require a new but salutary mode 
of action to restore 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 so as no longer to be capa- 
ble of exerting their normal influence. If the foreign body lie im 
Note—* Ju*t after the dote of the recent war, I commenced the nxe of carbolic acid ax a 
stimulative and disinfecting application to wound* and unhealthy ulcer*, and the result* 
have been most satisfactory. 
A solution of one ounce ot the crystallized acid to the gallon of water, would make a most 
useful and cleansing wash fu» all unhealthy wounds and ulcers, combined with simple cerate, 
in the proportion of from mi xv to one drachm to the ounce of simple aerate, It acts most 
beneficially upon wounded surfaces, audin hot weather entirely keeps away the flies and in 
sects. 53 
mediately withdrawn, and if the animal wounded be in a state of 
perfect health, that is, with a proper constitution of the blood and 
structures, and a proper circulation 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 
surrounding parts, from the obstruction of the circulation in the 
injured capillaries, thus forcing more blood around the injured 
part, as well as from the disturbance of the nervous force and of 
the process of nutrition in the surrounding capillaries, no other 
phenomena are manifested. The effused fibrous matter, endowed 
itself with life and surrounded by living tissue, and subjected to 
the influences ot living tissue, passes through various changes 
which resemble the changes in normal nutrition, secretion and 
development, and which result in development of cells and fibres, 
and in the repair of the injured part. 
If, on the other hand, the structures are too much injured to be 
repaired in this manner, the same disturbances and the samephe 
nomena are manifest; but, being increased in intensity, the 
changes in the nutrition of the injured part progresses to corres- 
pondingly greater effects. The same effusion, and the same repa- 
rative 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 sup- 
plied by other living 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 subject 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 or- 
ganism. 
When, on the other hand, a mechanical injury is inflicted upon 
a living animal whose forces are depressed, and the nutritive ele- 
ments of which are deficient in quantity, the process of repair will 
be correspondingly retarded, and the products will be correspond- 
ingly altered from those formed in the healthy organism. If the 
system be under the influence of some disturbing agent, as a poi- 
son, at the time of the reception of the injury, the characters of 
the inflammatory process will manifestly depend upon the affini- 54 
ties 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 inflammatory effects will 
be chiefly manifested in that organ for which it has the greatest 
affinity, or in the nutritive processes in which it produced 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 w idely extended, not only by the reflexion 
of the local disturbances to other parts, through the nervous sys- 
tem, but also by the entrance into the circulation of certain pro- 
ducts of inflammation w hich will be capable of inducing changes 
in the mass of the blood, and in the nutrition and secretion of 
various organs. 
In this last form of inflammation, w hen, 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 indi- 
cations from the principles just laid down are : 
First.—To remove the patient from all causes which tend to de- 
press the system, and especially from those causes which are 
known to have been directly and specially active. 
{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 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. 
8uth.—After the removal of the dead parts, and after the des- 
truction of all contagious elements capable of disseminating the 
disease to the surrounding tissues, to stimulate the capillaries and 
absorbents around the local injury to healthy active inflammatory 
actions, as will result in the development of healthy granulations. 
The three last indications will be considered under the head of 
the local treatment. 
In the treatment of hospital gangrene the first essential mea- 
sure, without which the most enlightened system of treatment is 55 
comparatively valueless and at best tardy, is to remove the patient 
from the crowded wards, and to secure for him in an isolated room 
or tent, the largest possible supply of fresh air. 
We have seen that the constitutional symptoms in most cases 
of hospital gangrene, hold a prominent place. The dejected 
spirits, the depressed state of the nervous system, the small accel- 
erated pulse, the feeble, sluggish capillary circulation, and the 
depressed state of the temperature in the extremities, all point to 
the supporting, tonic and stimulant plan of treatment as the only 
rational system. The therapeutical indications are to furnish the 
elements of healthy blood, and of active nutrition, secretion and 
repair—to excite and support vital power, and to allay nervous 
irritability. These intentions are best fulfilled by resorting to 
combinations of tonics and anodynes, after the morbid secretions 
of the bowels have been evacuated by gentle purgatives or ene- 
ma. In many cases emetics may be used with benefit; and it 
will almost always be found best to evacuate the constipated 
bowels by a purgative, and to keep them gently open by salines. 
The subsequent tonic and supporting plan of treatment will prove 
far more certain and beneficial in its action after the bowels have 
been cleared of morbid secretions. 
Blood-letting should be avoided as tending to a still farther de- 
pression of the enfeebled forces, and also as inflicting a wound 
which may become gangrenous. For similar reasons blisters 
should as a general rule be avoided. 
Quinine and the tincture of the sesqui-cliloride of iron, deserv- 
edly hold a high place in the estimation of Confederate surgeons 
in the treatment of hospital gangrene. In cases of ordinary 
severity three grains of quinine and fifteen drops of the muriated 
tincture of iron, administered three or four times during the 
twenty-four hours, will be found to be sufficient, in conjunction 
with the other measures, to induce a marked and rapid improve- 
ment in those patients who are properly isolated and ventilated. 
When the ravages of the disease are extensive, and the danger of 
hemorrhage great, the amount of the tincture of the sesquichlo* 
ride of iron may, with benefit, be increased to twenty drops every 
two or three hours. I have derived benefit from the following 
formula: sulphate of quinia 3ij, chlorate of potassa 3iij, tine* 56 
ture sesquichloride of iron f3ij, hydrochloric, acid f3ij, distilled 
water f §ij ; mix the hydrochloric acid and distilled water, and dis- 
solve in this acid solution the quinine and chlorate of potassa, 
and then mingle with the tincture of the sesquichloride of iron. 
Dose from thirty to sixty drops in a wineglassful of water (sucked 
through a quill to avoid injury to the teeth) every three, four, or 
six hours. 
As far as my experience extends quinine, in large 11 often, exerts 
no benetieial effects upon the progress of the const itutional and 
local symptoms ; the best results are accomplished with moderate 
doses. 
Huxhanvs tincture of bark (tinctura einchome composita) ad- 
ministered in full doses, varying from one fluid drachm to half a 
fluid ounce, every three or four hours, fulfils in this disease im- 
portant indications as a stimulant, tonic, diuretic, and elegant 
stomachic cordial. This should be administered at the intervals 
between the doses of the chloride of iron. 
The sesquichloride of iron may, with advantage to the patient, 
be administered in combination with chlorate of potassa, in the 
proportion of from ten to twenty drops of the former, and ten to 
twenty grains of the latter, dissolved in two or three ounces of 
water. This dose may be related every two, three, or four hours. 
'Whilst we are unable to explain the exact manner in which chlo- 
rate of potassa acts upon the system, still it is well established 
that it proves highly beneficial in those complaints in which a de- 
pressed state of the solids and fluids shows itself by malignant 
typhoid symptoms, and a disposition to phagedenic ulceration 
and gangrene. The combination of this salt with sesquichloride 
of iron is especially valuable from the liberation of chlorine and 
hypochlorous acid. 
Hydrochloric and nitric acids, singly or combined, exert bene- 
ficial effects in some cases. Whenever they are indicated the 
sesquichloride of iron, or the combination of this salt with the 
chlorate of potassa, will answer an equal, if not better purpose, 
except w hen there is marked torpidity of the liver. In such cases 
the uitro-muriatic acid should be employod internally, and in the 
form of the bath. 57 
The arsenical solution (Fowler's solution arsenite of potassa) 
has been employed with benefit in some cases. 
Oil of turpentine, camphor, musk, and warm aromatics and 
spices frequently prove beneficial, and may be administered in 
various forms of combination. 
The stimulant and depurant effects of the oil of turpentine ap- 
pear to be of some value in the treatment of hospital gangrene. 
To obtain decided effects upon the capillary circulation, in the de 
bilitated 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 teaspoonful doses, 
at regular and frequent intervals, without any marked effects upon 
the kidneys or bladder. It is, however, a question, whether these 
large doses, especially if they be continued for any great length 
of time, may not lay the foundation of disease of the kidneys and 
bladder. Opiates are indispensable in the treatment of almost 
any case of hospital gangrene, and should be administered, when 
necessary, freely, to allay irritability and to produce sleep, and to 
check excessive discharges from the bowels. 
The diet, throughout the whole course of this disease, should be 
as highly nutritious as possible, and should consist chiefly of con- 
centrated animal soups, soft boiled eggs, egg-nog, milk punch, 
etc., with a liberal supply of vegetables and ripe fruits, if they 
can possibly be obtained. Good brandy, whisky, wine, or porter, 
administered in moderate quantities, at short intervals, will prove 
highly beneficial in almost all cases. 
LOCAL TREATMENT OF HOSPITAL GANGRENE. 
Whether we regard the local affection as a poisoned wound, in 
which contagious, poisoned matters are continually generated, and 
from which the surrounding living tissues are contaminated, or 
look upon the destruction of the tissues as the result of deficient 
and perverted inflammatory action, 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, des- 
truction, and complete removal of the dead and poisonous mat- 
ters and tissues. 58 
If the second view be accepted, the manifest duty of the phy- 
sician would be to use such measures as will increase the vital 
power of the tissues and vessels, and enable them to form coagu- 
lable lymph, by which the disorganization may be circumscribed 
and arrested. 
These indications are best fulfilled, by the liberal and thorough 
application of concentrated fuming nitric acid, to the gangrenous 
parts. In this application it is desirable that the nitric acid 
should not merely coagulate and alter completely the gangrenous 
matters, but should also come in contact with the souud parts, 
and by its action upon the fluids and surface of the exposed 
parts, stimulate the living structures into a new form of inflam- 
matory action, which will cause the complete separation of all the 
dead parts, the arrest of the farther progress of the disease, by 
the more exalted condition of the sound parts, and by the effu- 
sion of healthy coagulable lymph, and the establishment of the 
process of repair. As the operation of dissecting away all the 
gangieuous masses and the subsequent application of nitric acid, 
is attended in many cases, with great suffering, it is advisable 
whenever practicable, to first put the patieut well under the in- 
fluence of chloroform and sulphuric ether. By performing this 
operation leisurely and thoroughly at first, much subsequent 
suffering is avoided. And from careful observation, I am j»er- 
suaded that the disease was in many cases greatly protracted by 
the suj>erficial manner in which the wounds were cleansed and 
the nitric acid applied. 
• In most cases, especially when the patients have been properly 
isolated, one thorough application 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 treatment will fail entirely of arresting 
the disease. 
After the entire surface of the wound has been thoroughly 
mopped with nitric acid, the subsequent treatment will consist in : 
The careful removal of all dead masses and particles of tissue; 
the thorough cleansing of the wound with water, and with solu- 
tions of chlorinated soda, nitro-muriatic acid, acetic and pyrolig- 59 
neous acid, tar water, solutions of creosote, and Huxham’s 
tincture of bark, at stated intervals during the day $ covering the 
parts with flaxseed, meal, yeast, hop, or charcoal poultices, ren- 
dered stimulating with turpentine, spirits of camphor, tincture of 
iodine, camphorated tincture of opium, Huxham’s tincture of 
bark, pyroligneous acid or creosote. 
The prompt removal of all detached masses of tissue, and the 
thorough washing away of all morbid secretions, are most impor- 
tant means to prevent the recurrence ot 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 
diseased parts, care being taken that the sound parts, be not un- 
necessarily subjected to its action. 
In many cases, before the wound assumes a healthy condition, 
instead of applying poultices, it is preferable to till the cavity 
of the wound with lint or cotton, saturated with various stimulat- 
ing fluids, as a weak tincture of iodine, oil of turpentine, tincture 
of camphor, tincture of Peruvian bark, or pyroligneous acid. 
When there is danger of haemorrhage, either from large vessels, 
or from the general surface of the wounds, lint saturated with 
the undiluted tincture sesqui-chloride of iron, or with a strong 
solution of the per-sulphate of iron should be applied. It may be 
laid down as rule, that ligation, or amputation, should not be 
resorted to in cases of haemorrhage in hospital gangrene, until 
these efficient styptics have been freely and fully applied to the 
bleeding surfaces. 
Whilst the patient is retained in the effeted atmosphere, or 
whilst the disease is progressing, amputation will in most cases, 
prove worse than useless. Under such conditions hospital gan- 
grene will invariably reappear in the stump, and the only effect 
of amputation will be to expose a larger diseased surface, and to 
bring the gangrene nearer the central organs. As a rule, no am- 
putations, no matter what be the condition of the wounds, whether 
gangrenous or healthy, should be performed in the wards of a hos- 
pital in which gangrene is prevailing. Such practise is as repre- 
lienisbleas the careless distribution of healthy and fresh wounds 
amongst the gangrenous wards. 60 
When amputation is unavoidable, as in the case of the opening 
of large joints, or the destruction of important arteries and nerves, 
the patients, whether the wounds be gangrenous or not, if the dis- 
ease be present in the hospital, should be isolated as far as possi- 
ble, and every attention paid to proper ventilation, cleanliness 
and diet. 
After the appearance of healthy granulation and of laudable 
pus, the stimulating, astringent, and caustic applications should 
be abandoned, or only occasionally used with caution, and the 
wound should be treated as any other simple granulating ulcer. 
Various other applications have l>een recommended and em- 
ployed by Confederate surgeons in the local treatment of hospital 
gangrene, as the actual cautery, sulphate of copper, acid nitrate 
of mercury, chloride of zinc, nitrate of silver, and persulphate of 
iron. 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 tin? 
most efficient.