164. This most destructive disease owes its names of hospital gangrene,
phagedena, gangrenosa, _pourriture d’hôpital_, sloughing ulcer,
etc. etc. to the different appearances the affected parts assume
on different occasions, according to the intensity of the morbid
poison applied, and possibly also to the state of constitution of the
individual attacked. The peculiar nature of this poison has not yet
been ascertained. Professor Brugmans says that in 1797, in Holland,
charpie composed of linen threads cut of different lengths, which, on
inquiry, it was found had been already used in the great hospitals in
France, and had been subsequently washed and bleached, caused every
ulcer to which it was applied to be affected by hospital gangrene; and
the fact that this disease was readily communicated by the application
of instruments, lint, or bandages which had been in contact with
infected parts, was too firmly established by the experience of every
one in Portugal and Spain to be a matter of doubt. Its character as a
thoroughly contagious disease is indisputable. Its capability of being
conveyed through the medium of the atmosphere to an ulcerated surface
is also admitted, although some have thought that the infection was
not always applied to the sore, but affected it secondarily, through
the medium of the constitution. Brugmans says that hospital gangrene
prevailed in one of the low wards at Leyden in 1798, while the ward or
garret above it was free. The surgeon made an opening in the ceiling
between the two, in order to ventilate the lower or affected ward,
and in thirty hours three patients who lay next the opening were
attacked by the disease, which soon spread through the whole ward. Our
experience in Portugal and Spain confirmed this fact, and left no doubt
on the mind of any one who had frequent opportunities of seeing the
disease, that one case of hospital gangrene was capable of infecting
not only every ulcer in the ward, but in every ward near it, and
ultimately throughout the hospital, however large. The disease, as long
as it remains unaltered by destructive applications, may be considered
to be infectious as well as contagious.
This infection can penetrate the dressings so as to affect the ulcer
through them, although requiring a difference of time in different
parts of the body. Ulcers on the lower extremity experienced the
influence of the morbid poison in general at an earlier period than
those on the upper extremity; and a wound might be seen in a healthy
state on the arm, while one on the leg had been evidently suffering
from this disease for some days, if the complaint had become mild, or
somewhat chronic. If the morbid poison were in its active state, then
the deterioration of the ulcers on the arm was almost if not quite
contemporaneous with that on the leg.
165. Mr. Blackadder has given the following account of the disease from
inoculation in his own person, which is, therefore, more to be relied
upon than any other:--
“While engaged in examining the stump of a patient who had died from
this disease, I accidentally wounded one of my fingers with the
point of a double-edged scalpel, but so slightly that not a drop of
blood made its appearance, and on this account I did not consider
any particular precautionary means necessary. In the course of about
sixty hours, however, the wound had become inflamed, and I was
attracted to it by an occasional smart, stinging sensation, which
ultimately extended a considerable way up the arm. On the fourth day
the inflammation had increased, and the stinging sensation was almost
constant. Headache, nausea, and general indisposition followed, with
frequent chills, which increased very much toward evening; but which,
with the other symptoms, were considerably relieved by the use of
neutral salts, the pediluvium, and warm diluents. A vesicle, having
a depression in its center, and containing a watery fluid of a livid
color, was now forming upon a hard and elevated base; the surrounding
integuments became tumefied, of an anserine appearance, and extremely
sensitive to the touch; at about the distance of the fourth of an inch
from the base of the tumor, a very distinct areola, of a bluish-red
color, made its appearance, and remained visible for several days. At
this period, circumstances rendered it necessary for me to be exposed
to wet, to undergo considerable fatigue, and immediately afterward to
travel to a considerable distance. The inflammation, however, gradually
subsided, but the stinging, accompanied by a burning sensation, still
continued, and the sore had no disposition to heal; yet it did not
enlarge externally, but was disposed to burrow under the integuments.
This phagedenic disposition was ultimately got the better of by laying
open the sore, and by repeated applications of caustic; but it was
two months before a complete cicatrix had formed. The new cuticle
remained for a length of time extremely sensitive to the touch; and
it was upwards of six months before it had acquired the color of the
surrounding integuments.”
166. M. Delpech was disposed to consider that the misfortunes and
sufferings of the French army had a great depressing influence on the
soldiers, from which at other times they would have been exempted, and
that this aided the propagation of the malady; but many soldiers of the
British army, free from these particular depressing causes, suffered in
a similar manner. Dr. Tice, at Coimbra, says:--
“An uncommon depressing affection of the mind often exists among
persons suffering from this disease, painful to witness--a morbid
dejection, or apathy, which could scarcely be removed, and on which,
in very bad cases, no impression could be made. In others, the humane
solicitations of the medical officers have failed against the influence
of oppressive gloom, amounting to despair. Expectation and hope seemed
to be exiled from their minds by the dominion of painful despondency,
which, prevailing in melancholy disorder, seemed uncontrolled or
checked by the intrusive importunities of the present, or the
consciousness of a future existence.”
A wound attacked by hospital gangrene in its most concentrated and
active form presents a horrible aspect after the first forty-eight
hours. The whole surface has become of a dark-red color, of a ragged
appearance, with blood, partly coagulated, and apparently half putrid,
adhering at every point. The edges are everted, the cuticle separating
from half to three-quarters of an inch around, with a concentric
circle of inflammation extending an inch or two beyond it; the limb is
usually swollen for some distance, of a shining white color, and not
peculiarly sensible, except in spots, the whole of it being perhaps
edematous or pasty. The pain is burning, and unbearable in the part
itself, while the extension of the disease, generally in a circular
direction, may be marked from hour to hour; so that in from another
twenty-four to forty-eight hours, nearly the whole of the calf of a
leg, or the muscles of a buttock, or even of the wall of the abdomen,
may disappear, leaving a deep, great hollow, or hiatus, of the most
destructive character, exhaling a peculiar stench, which can never be
mistaken, and spreading with a rapidity quite awful to contemplate.
The great nerves and arteries appear to resist its influence longer
than the muscular structures, but these at last yield; the largest
nerves are destroyed, and the arteries give way, frequently closing the
scene, after repeated hemorrhages, by one which proves the last solace
of the unfortunate sufferer. I have seen all the largest arteries of
the extremities give way in succession, and until the progress of the
disease was arrested by proper means, the application of a ligature was
useless. The joints offer little resistance; the capsular and synovial
membranes are soon invaded, and the ends of the bones laid bare. The
extension of this disease is, in the first instance, through the medium
of the cellular structure of the body. The skin is undermined, and
falls in; or a painful red, and soon black patch, or spot, is perceived
at some distance from the original mischief, preparatory to the whole
becoming one mass of putridity, while the sufferings of the patient
are extreme. A complaint of this kind cannot be local, even if a local
origin be admitted; the accompanying fever is usually dependent on the
previous state and general constitution of the patient, modified by the
season of the year, or the prevailing type of febrile disease.
This gangrenous disease does not always prevail in this, its most
concentrated form; the destroying process assumes more of a sloughing
than of a gangrenous character, whence Delpech has denominated it
pulpous, rather than gangrenous. It is in its nature almost equally
destructive, although not quite so formidable in appearance. It
may attack the whole surface of an ulcer at once, or in distinct
points, all, however, rapidly extending toward each other, until
they constitute one whole. The red of the granulations becomes of a
more violet color, and the change is accompanied by burning, a pain
not usually felt in the part, while a layer of ash-colored matter is
soon seen covering them, which adheres so firmly as not to be readily
removed; or, if separated, shows that it is a substance formed upon the
surface, and constituting a part of the granulations themselves, which
are ultimately confounded with it.
About the end of the first week, and sometimes much later, this kind
of ulcer becomes more painful, the edges or the circumference of the
wound assume a browner hue, and the parts become somewhat pasty, the
whitish color of the part particularly affected being opaque, gray, and
soft. It may be said that the false membrane, having become very thick,
has lost the little vitality it possessed, and become putrid; the
discharge, which had been partly suppressed, now reappears, not as pus,
but as a fetid ichor, exhaling the peculiarly offensive stench of this
disease. This pulpy, yellowish, putrid substance becomes thicker, and
extends deeply; it invades the whole substance of a muscle, under which
a probe may be passed, and the instrument brought out through it, with
the loss, perhaps, of some striæ of blood, from parts which are not yet
actually destroyed; the mass is, however, adherent, although its extent
diminishes by the putrefaction and wasting away of its surface.
There are two characters always peculiar to this disease, in which it
differs from all other gangrenous ulcers from ordinary causes; these
are, the circular form it assumes after a very few days, even in its
slighter varieties, and its peculiar odor or stench.
167. If this disease were entirely a local complaint, caused by the
application of a morbid poison, giving rise to the destructive changes
described on the surface of an ulcer, it should be followed by febrile
or constitutional symptoms at the end of several days only; and
Delpech is disposed to think that in such cases these constitutional
symptoms take place from and after the sixth day. If it were entirely
a constitutional disease, giving rise to the destructive changes
described as taking place on the surface of an ulcer, the febrile
symptoms should precede the changes in the ulcerated surface. That
the febrile symptoms do seem to follow the appearance of the local
alteration, is in many cases indisputable; that they precede or
accompany the local symptoms in many other cases, is indubitable;
and that the disease in a mild state, although yet capable of
committing much mischief, is neither preceded nor followed by febrile
or constitutional symptoms, cannot be doubted. The febrile symptoms
themselves differ essentially from each other when they do occur,
generally partaking the character of the endemic fever prevailing in
the country at the season at which they appear. The fever is sometimes
inflammatory, sometimes typhoid, and occasionally resembles the
bilious remittent of the summer and autumn in hot climates, and ends in
typhus. It is probable that a want of attention to these circumstances
decided the opinions entertained by different individuals as to the
general character of the febrile symptoms, and of the treatment to be
pursued for their removal. That this disease was generally considered
a constitutional complaint, until nearly the end of 1813, must be
admitted; and it was the very indifferent success which attended its
treatment by constitutional means and simple detergent applications,
which caused the surgeons of the British army to view it more as
a local disease, capable of giving rise to severe constitutional
symptoms--a change of opinion which was materially influenced by the
knowledge that the French surgeons more generally considered, with
Pouteau, that it was local in the first instance, and treated it by
the actual cautery. In my hands, constitutional treatment, and every
kind of simple mild detergent applications, always failed, unless
accompanied by absolute separation, the utmost possible extent of
ventilation, and the greatest possible attention to cleanliness; and
not even then without great loss of parts in many instances. This
induced me, at Santander, in November and December, 1813, to try the
mineral acids, not as then generally used as stimulants or detersives,
but as caustics. This proceeding was always, however, accompanied by
a constitutional treatment, regulated by the nature of the symptoms,
which at that station were never benefited by bleeding, although it had
proved so effectual, without the local remedies, at the neighboring
sea-port of Bilbao.
168. Dr. Boggie, the great advocate for constitutional treatment, says
that under him, at Bilbao, in 1813, where caustic applications were not
used, or only as detersives, the disease was arrested by blood-letting
to the amount of one or two pounds, and, in some cases, to the extent
of three or four. He admits, however, that bleeding must be resorted
to with the greatest caution in persons of less robust constitutions,
who may have lingered long in hospital, or suffered much from ill
health; and that in some cases it is altogether inadmissible--an
acknowledgment which is decisive, in my mind, that constitutional
treatment is only auxiliary. He says he never saw the puncture made by
the lancet affected by this disease; a convincing proof to me, who have
seen it, that the virulence of the complaint, as an infectious disease,
was subsiding at Bilbao when the treatment he introduced proved so
effectual.
In one case at Santander, in which hospital gangrene in the hand and
arm and tetanus existed together, they were both cured by venesection,
which failed as signally in doing the least good in a case in the next
bed, under nearly similar circumstances.
Dr. Boggie admits that “in that form of gangrene named phagedena, a
very great destruction of parts may sometimes take place without the
constitution being much affected by it. Now, if blood-letting be used
in such a case, or even in the advanced stage of the true inflammatory
gangrene, when disorganization has taken place, and the system is
sinking under the consequent debility, the vital powers being nearly
exhausted, the result must be obvious; but when it is used with
caution, and in cases where it is really applicable, it will be found
to be a most valuable remedy.” In all cases, Dr. Boggie, like every
one else, had recourse to emetics, purgatives, and such other general
treatment as the febrile symptoms appeared to indicate. As local
applications, he recommends cold water, alone or mixed with a small
portion of acetic acid, constantly applied and frequently renewed.
Poultices and warm applications he objects to; and after the sloughs
separate, he approves of dry lint and weak solutions of sulphate of
zinc. Should the sloughs adhere after the inflammation has abated,
warm, stimulating ointments, and sometimes weak solutions of the
nitrate of silver or of the mineral and vegetable acids, may be had
recourse to.
169. To Mr. Blackadder must be attributed the introduction of the use
of Fowler’s solution of arsenic as an escharotic, in November, 1813,
while he was at Passages; it answered remarkably well in arresting
the progress of the disease, and was afterward found to be equally
efficient in the hospitals at Antwerp. The only objection to its
use that I am aware of is, that it caused in some few cases slight
symptoms of its poisonous effect having taken place on the bowels,
apparently from absorption,--an inconvenience which might become a
serious evil, and which caused a preference to be given to the mineral
acids, which act equally well without incurring a similar risk of
evil. Mr. Blackadder, stationed on the same coast, within about forty
miles of Dr. Boggie at Bilbao, took a diametrically opposite view
of this complaint to the doctor; and believing the disease to be
purely local in the first instance, considered venesection as almost
always unnecessary, although he admitted that cases may occur in
which the abstraction “of a small quantity of blood would be likely
to be attended with more good than harm; but certainly,” he adds,
“blood-letting is an operation which ought to be avoided as much as
possible in gangrenous phagedena, particularly when the previous injury
has been extensive, such as that of a penetrating gunshot wound.”
Dr. Walker, who served at Bilbao at the same time, concludes an able
report in the following terms:--
“Lately, however, the disease put on a milder form, and the sloughing
did not proceed with that rapidity that it did at first, nor was the
fever so violent. And more lately still, since the setting in of the
cold weather, the type of the fever seems to have changed entirely,
and to have put on the inflammatory type, so as to require strong
evacuants, and even bleeding, which has been used with the greatest
success by Staff-Surgeon Boggie, who has for a considerable time had
the more immediate care of the patients of this description at the
Cordeleria Hospital.”
170. “When this disease does not proceed rapidly, and is confined to
the ulcerative form,” Delpech says, “it may be removed by stimulant
applications, such as vinegar, the vegetable and mineral acids, the
Egyptian ointment, etc.” Of these he prefers vinegar applied on lint,
after having rubbed or scraped off any false or pulpy membrane which
appears to conceal the surface of the ulcer. “Some good effect,” he
adds, “has been observed from the careful application of powdered
charcoal to the whole surface of the sore, which,” he says, “ought
not to be in the gangrenous, or pulpy, or putrid state, but merely
ulcerative or phagedenic; and not even then, when this peculiar
ulceration assumes a deeply hollowed-out form, rapidly filled with
an abundant and tenacious discharge.” Of constitutional treatment
he evidently thinks little; and, while he admits the propriety and
necessity of treating every accompanying state of fever, whether it be
inflammatory, catarrhal, bilious, remittent, etc., by its appropriate
means, he does not seem to think they have much influence on the local
disease, although he firmly believes that the suppression of the local
disease materially assists in arresting, in a great measure, such
constitutional symptoms as may be dependent on it, unless influenced
by some peculiarity of constitution. His principal local remedy was the
hot iron or actual cautery applied to every part.
He says (page 86) some surgeons of the Anglo-Portuguese army of Lord
Wellington had assured him that the mineral acids, the hydrochloric,
nitric, and sulphuric, had been frequently employed in the British
hospitals in Spain with success; and he particularly mentions M.
Guthrie, _Inspecteur au Service de Santé_, as the person from whom he
especially received his information; thus establishing the fact that
the use of the mineral acids in a dilute and concentrated state was
known to, and had been essentially introduced into practice by, the
surgeons of the British army during the war in Spain--a fact which
admits of no dispute as to the origin of its use.
171. In India, Mr. Taylor, late surgeon 29th Regiment, now a deputy
inspector-general in the medical department in the Crimea, reports:--
“Hospital gangrene appeared among the wounded of the 29th Regiment a
little later than in the hospitals of other corps. The disease declared
itself, on the 18th of January, in a stump case; and between that date
and the 26th of the same month fifteen cases had come under treatment.
At first I could tell, by the peculiar dark, florid countenance of the
patient, that his wound had taken on the gangrenous affection; yet I
cannot say that there was, in these cases, any marked inflammatory
fever. Subsequently, in the prevalence of the disease, this dark-red
color of the face was neither well marked nor by any means so constant.
In many cases the disease seemed purely local; but in the great
majority there was certainly much feverish constitutional disturbance
accompanying the local affection, and often preceding it. My experience
of the disease, as it occurred among the wounded at Ferozepore, does
not enable me to determine, satisfactorily to myself, whether it be
essentially a local or a constitutional affection. I am inclined to
place it in the former category; and there is no doubt whatever in my
mind that the essential means of treatment are local.
“In the treatment of this disease, I proceeded regularly on one plan,
and found that so efficacious that I was not inclined to try any other.
The plan adopted was, the application of the strong nitric acid, so as
completely to cut off the diseased from the sound part, or part so far
sound as only to be affected with inflammation. The acid, however,
required to be rubbed in with the blunt end of the probe, so that it
not only destroyed the cuticle, but killed the cutis vera, and probably
the cellular membrane underneath. The narrow yellow ring of dead skin
thus formed separated like a piece of leather, generally carrying with
it the whole slough, and leaving a clean, healthy surface, as well as
edges to the wound. I never attempted to apply the acid to the surface
underneath the slough, neither is such an application necessary; the
vital seat of the disease is in its circumference, however large
the area. I must admit that the disease sometimes crossed the acid
boundary, and a second, and even a third application of the remedy
was required; but this was rare. Neither was constitutional treatment
neglected, but this varied according to the state of the patient;
emetics, purgatives, saline medicines, and low diet being sometimes
required; while in other instances ether, ammonia, laudanum, and
generous diet were administered.
“When speaking of the symptoms of this disease, I should have mentioned
that a burning, gnawing sensation was sometimes loudly complained of.
The application of the acid soon removed that pain, and the acid itself
did not often seem to produce much suffering. In one instance, deemed
a favorable one, I tried venesection, and I fear did mischief. Calomel
and antimonials were useful. I did not try the arsenical solution.
The change of air, which the march of the wounded, on their return to
Kussowlee, occasioned, certainly had a very beneficial effect on all
the gangrenous and sloughing sores.
“At the same time that hospital gangrene was prevalent at Ferozepore,
some wounds took on a malignant fungous affection, which spread
over the healthy surface like the hospital gangrene. The dirty,
fibrous-looking, fungous growth rose considerably above the edges of
the wound, partially overlapping them; these edges were inflamed, but
not livid and vesicated as in the cases of gangrene; but here also the
disease took the circular or oval form. The affection here noticed I
observed only in wounds of the forearm and hand; Colonel Barr’s wound,
which was of the forearm near the wrist, took on this disease. The
application of nitric acid in the same way as for hospital gangrene
eventually checked its progress.
“In no case that came under my observation did the gangrene directly
prove fatal, though in many cases it contributed largely in bringing
about an unfavorable termination.”
172. _Conclusions._ First.--Hospital gangrene never occurs in isolated
cases of wounds.
Second.--It originates only in badly-ventilated hospitals, crowded with
wounded men, among and around whom cleanliness has not been too well
observed.
Third.--It is a morbid poison, remarkably contagious, and is infectious
through the medium of the atmosphere applied to the wound or ulcer.
Fourth.--It is possibly infectious, acting constitutionally, and
producing great derangement of the system at large, although it has not
been satisfactorily proved that the constitutional affection is capable
of giving rise to local disease, such as an ulcer; but if an ulcer
should occur from accidental or constitutional causes, it is always
influenced by it when in its concentrated form.
Fifth.--The application of the contagious matter gives rise to a
similar local disease, resembling and capable of propagating itself,
and is generally followed by constitutional symptoms.
Sixth.--In crowded hospitals the constitutional symptoms have been
sometimes observed to precede, and frequently to accompany, the
appearance of the local disease.
Seventh.--The local disease attacks the cellular membrane principally,
and is readily propagated along it, laying bare the muscular, arterial,
nervous, and other structures, which soon yield to its destructive
properties.
Eighth.--The sloughing of the arteries is rarely attended by healthy
inflammation, filling up their canals by fibrin, or by that gangrenous
inflammation which attends on mortification from ordinary causes, and
alike obliterates their cavities. The separation of the dead parts is,
therefore, accompanied by hemorrhage, which, when from large arteries,
is usually fatal.
Ninth.--The operation of placing a ligature on the artery at a
distance, or near the seat of mischief, does not succeed, because the
incision is soon attacked with the disease, unless it has been arrested
in the individual part first affected, and the patient has been
separated from all others suffering from it.
Tenth.--The local disease is to be arrested by the application of the
actual or potential cautery: an iron heated red hot, or the mineral
acids pure, or a solution of arsenic, or of the chloride of zinc, or
of some other caustic which shall penetrate the sloughing parts, and
destroy a thin layer of the unaffected part beneath them. If a sinus
or sinuses have formed under the skin or between the muscles, from the
extension of disease in the cellular or areolar structure, they must be
laid open, and the cautery applied; for if any part affected be left
untouched or undestroyed by the acid, the disease will recommence and
spread from that point. The parts touched by the acids or cautery may
be defended by cloths or other material, wetted with hot or cold water
according to the feelings of the sufferers, and poultices of various
kinds may be had recourse to, if unavoidable.
Eleventh.--After the diseased parts have been destroyed by the actual
or potential cautery, they cease in a great measure to be contagious,
and there is less chance of the disease being propagated to persons
having open wounds or ulcerated surfaces. A number of wounded thus
treated are less likely to disseminate the disease than one person on
whom constitutional treatment alone has been tried.
Twelfth.--The pain and constitutional symptoms occasioned by the
disease, considered as distinct from the symptoms which may be
dependent on disease endemic in the country, are all relieved, and
sometimes entirely removed, by the destruction of the diseased surface,
which must, however, be carefully and accurately followed, to whatever
distance and into whatever parts it may extend, if the salutary effect
of the remedies is to be obtained.
Thirteenth.--On the separation of the sloughs, the ulcerated surfaces
are to be treated according to the ordinary principles of surgery.
They cease to eliminate the contagious principle, and do not require a
specific treatment.
Fourteenth.--The constitutional or febrile symptoms, whenever or at
whatever time they occur, are to be treated according to the nature of
the fever they are supposed to represent, and especially by emetics,
purgatives, and the early abstraction of blood if the fever be purely
inflammatory, and by less vigorous means if the fever prevailing in
the country be of a different character. Pain should be alleviated by
opium, which should be freely administered.
Fifteenth.--The essential preventive measures are separation,
cleanliness, and exposure to the open air,--the first steps toward
that cure which cauterization will afterward in general accomplish.
Sixteenth.--If the sufferer be very young, or of a weakly habit, his
strength will frequently require to be supported in the most efficient
manner by a due administration of cinchona bark, wine, and a generous
diet,--means often found essentially necessary after all severe attacks
of debilitating diseases.
The formidable nature of this terrible disease, before the local
application of caustic remedies was fully adopted, will be best
understood by the following document.
RETURN _of the_ NUMBER OF CASES _of_ HOSPITAL GANGRENE _which have
appeared at the Hospital Stations in the Peninsula between 21st June
and 24th December, 1813_.
+---------+---------+-------+-----+----------+--------+------------+
| |No. |Dis- |Died.|Under |No. | |
|STATIONS.|of cases |charged| |treatment.|operated|REMARKS. |
| |occurred.|cured. | | |upon. | |
+---------+---------+-------+-----+----------+--------+------------+
|Santander| 160 | 72 | 85 | 53 | 25 |Most of |
|Bilbao | 972 | 557 | 387 | 28 | 183 |these cases |
| | | | | | |were sent |
| | | | | | |from |
| | | | | | |Vittoria. |
| | | | | | | |
| | | | | | | |
|Vittoria | 441 | 349 | 88 | 4 | 74 | |
|Passages | 41 | 2 | 2 | | |Thirty-seven|
| | | | | | |transferred |
| | | | | | |to |
| | | | | | |Santander. |
| | | | | | | |
| | | | | | | |
|Vera | | | | | |Vera, being |
| | | | | | |almost on |
| | | | | | |the field of|
| | | | | | |battle, had |
| | | | | | |no case. |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| +---------+-------+-----+----------+--------+ |
| | 1614 | 980 | 512 | 85 | 282 | |
+---------+---------+-------+-----+----------+--------+------------+