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 VIII.—John Jordan, Private, Co. H, 2d Maine, aged 20 years, was struck at Fredericksburg, December 13, 1862, by a fragment of shell, which passed across the right thigh below Poupart s ligament, through the scrotum, destroying the right testicle, and behind the left thigh, producing in its course very extensive but superficial wounds of the anterior portion of right and posterior portion of left thigh. He was admitted December 26, 1862, and placed in ward No. 5. February 27, 1863, he had febrile disturbance and anorexia, a yellow, furred tongue, an anxious, restless expression of countenance, and a burning pain in his left thigh. There was on the right thigh a granulating surface three by two inches in dimensions, level with the integument, and cicatrizing rapidly. A smaller, equally healthy surface remained unheuled on the scrotum, while on the posterior portion of the upper part of the left thigh an ulcer three by two inches in extent was found, oval in shape, covered with an ashy gray slough, with its margin thickened and everted, surrounded by a livid areola, and, instead of normal pus, discharging a thin fetid serum mixed with debris. He was at once removed to the house; the whole diseased surface was touched with pure nitric acid and dressed with the creasote lotion; stimulants and the best extra diet, with beef essence and milk punch at short intervals, and citrate of iron and quinine three times daily, were ordered. March 5th: The attempt to push the nutrients and stimulants produced, as it generally does, anorexia, nausea, vomiting, and diarrhœa. The tongue became thickly coated with a yellow fur and dry and red at the tip; and so great was the gastric disturbance that all medicines were discontinued and the stomach allowed to recover its tone by rest, no longer being teased either by drugs or excessive and undesired nutriment. No benefit followed the local application, and the ulceration had extended in every direction. There was the characteristic margin, preceded by the areoln of livid stasis, preparing the tissues for their rapid destruction. The connective tissue beneath the skin had been destroyed, so that the skin for one inch from its margin was perfectly movable. The muscles separated from each other by the death of their connective tissue lay in the wound bathed in its discharge, but rosy and florid, and resisting the advance of the disease. This sore was so unmistakably hospital gangrene that several pictures of it were taken by direction of Surgeon Brinton, which represent well the surface of the ulcer dripping with its thin serous discharge, mingled with threads of dead connective tissue, its piled-up, thickened, and everted margin surmounted by a thin line of vivid redness, and its broad zone of purple congestion shading away into a bronze hue, the depth of color in the areola indicating the engorgement of the small vessels and its line the feebleness and slowness of the movement of the blood. It was determined to try the opium treatment, with hydrochloric acid as a tonic, and this mixture was given in the proportion of 16 drops of tincture of opium with four drops hydrochloric acid every three hours. The sore was dressed with a stimulating poultice composed of flaxseed, cinchona, and ginger mixed with porter. Under the use of the acid internally the tongue has become clean and moist, the tone of the digestive apparatus improved, and a fair quantity of food had been taken. Porter and ale had been given as the stomach would retain them. But little change had taken place in the character of the ulcer, which was eight inches in length by seven in breadth, extending to the perineum, and irregularly oval in shape. The muscles exposed (the semi-membranosus and biceps) had yielded and were now almost divided. The sores on the right thigh and scrotum had not been in the least affected, but were cicatrizing rapidly. The entire surface of the gangrenous sore was now thoroughly cleaned, all sloughs and shreds removed with forceps and scissors, was well dried with lint and carefully painted with pure nitric acid. The brush, charged with acid, was passed beneath the excavated margin in some places more than an inch. The patient was etherized, and this acid application was made most carefully and completely. This was considered a dernier resort, for although the capacity for taking and assimilating food seemed to have been increased by the acid treatment internally, yet his strength was daily diminishing from the exhausting discharge and from the absorption of the products of the gangrene. On the succeeding day an entire change in the sore was observed; there had been no extension of the gangrene, the fetid odor was gone, and the discharge was more consistent and less serous. In a few days more all the shreds of dead fascia were removed, and the surface was found to be perfectly healthy. The contrast between the ragged, offensive, yellow-colored ulcer before the last application of acid, and the florid, perfectly normal granulating surface which replaced it, was as gratifying as it was surprising. With the local there was also a constitutional improvement. The appetite became voracious, the patient slept well; there was no pain, and the process of repair was very rapid. The acid was continued internally. April 1st: The sore was now two by three inches in extent and cicatrizing rapidly; but a small surface yet remained annealed. The patient was in perfect health, had gained flesh very rapidly, and was now on crutches. There was some contraction of the flexors, as the biceps and semi-membranoeus were both involved in the destruction. [Jordan was discharged June 9, 1863, and pensioned. Examiner J. C. Weston reported, September 11, 1869: "At the biennial examination in 1865 atrophy and increased weakness of right thigh and leg had occurred. His gait is always affected; he has severe pain in region of cicatrix of left thigh; this cicatrix is six by three inches, is depressed, indurated, adherent to muscles, and sensitive on account of rigidity and emaciation; he cannot fully extend the leg." His condition had not improved when examined in 1873.]

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