“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.