Commentaries on the Surgery of the War in Portugal, Spain, France, and the Netherlands / from the battle of Roliça, in 1808, to that of Waterloo, in 1815; with additions relating to those in the Crimea in 1854-55, showing the improvements made during and since that period in the great art and science of surgery on all the subjects to which they relate.

by G. J. Guthrie

LECTURE VIII.

CHARACTERS OF HOSPITAL GANGRENE.

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.

STATIONS.	No. of cases occurred.	Discharged cured.	Died.	Under treatment.	No. operated upon.	REMARKS.
Santander	160	72	85	53	25	{Most of these {cases were sent {from Vittoria.
Bilbao	972	557	387	28	183
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