Civil War Washington

In February, 1863, a number of cases of hospital gangrene occurred at the Douglas Hospital, Washington, D. C., and were observed by Assistant Surgeon William Thomson, U. S. A., who, in a special report to the Surgeon General, gives the following interesting account of the pathology and treatment of the cases. In several instances later information has been added to the cases cited by Dr. Thomson:

"On the 26th of December, 1862, about two hundred wounded from the battle of Fredericksburg were received into the Douglas Hospital.

"CASE V.—Isadore Wick, Co. D, 1st New York Artillery, aged 32 years, had his right thigh amputated on the field, for comminuted fracture of the tibia, received December 13, 1862, at Fredericksburg, caused by a minié ball. He was admitted December 26th. I regret that I can give no account of his progress, but I learn that the flaps had been insufficient, and that the stump had been closing by tedious granulation. There had been a free discharge, and his general condition was, therefore, unfitted to withstand the depressing influence of hospital gangrene. His bed was on the same side of the ward, and in close proximity to the first case reported. The operation had been a circular one; the granulation had entirely covered the end of the bone, and there was, when seen on the 18th of February, only a narrow strip, not yet cicatrized between the margins of skin. This was now covered with a gray slough and had the characteristic fetid odor. It was dressed simply with the creasote solution, my faith in the acid treatment having been shaken by the reports of medical officers who had visited the cases at Annapolis. February 23d : The case was now considered an unequivocal one of hospital gangrene, and was removed to the ward selected for such cases. The cicatricial tissue had all yielded to the sloughing, and the subcutaneous connective tissue had been destroyed for two inches beneath the skin at the outer angle of the original incisions. No change was made in the local treatment, as the creasote was a perfect deodorant, and as good results were hoped for from its local use, as had been reported from Annapolis. The destruction was limited to the connective tissue until March 9th, when there was a margin of sphacelus half an inch wide in the true skin. The constitutional symptoms had been growing more grave. His mental despondency was most marked, his face pale and anxious, his pupils dilated, his pulse 100 per minute and feeble, and his skin very moist; a free diarrhœa had also commenced. The tonics and stimulants, having produced anorexia and nausea, were replaced by a mixture of tincture of opium and hydrochloric acid in such proportions that he took gtt. xvi of tr. opii and git. iv of acid, hydrochlor. every fourth hour. Beef essence and milk punch were given as freely as his stomach would tolerate them, llth : As his general condition became less favorable the local action was changed from molecular death to sphacelus. The whole face of the stump has now a margin of black mortification of the skin, outside of which was the usual areola of purple congestion the complete stasis of to-day becoming the sphacelus of to-morrow. The end of the femur, protected by rosy granulations, now protrudes from the black mass of sphacelus. the integument having become loosened by the destruction of the subcutaneous connective tissue and retracted. The presence of this mass of putrefaction seems to add to the nervous prostration, if indeed the absorption of such peccant material is not its sole cause. Pure nitric acid had been applied several times, but it had been found impossible to convey it into the depths of the ulcer. 21st : No change except for the worse had occurred. Stimulating poultices of cinchona, ginger, and flaxseed had been used locally, but with no benefit. Antiseptics, such as the solutions of chloride of soda, creasote, and per manganate of potash, were necessary to purity the ward and render it endurable for his attendants. Nutrients and stimulants had been pushed to the last extent, and opium had been largely given for its supposed specific effect in the disease as well as to allay suffering. The symptoms had been typhoid for several days; emaciation had gone on rapidly ; there had been subsultus tendinum and muttering delirium with extreme prostration until this date, when death occurred. The limb was removed after death and the specimen sent to the Army Medical Museum. [Specimen 1000, Surg. Sect ] The sphacelus had involved all the tissues for five inches above the divided bone, and there seems to have been a faint effort to form a line of demarcation.

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