Report on gangrene by A. Thornburgh, Assistant Surgeon, Provisional Army, C. S.,
C. S. military prison hospital, Andersonville, Ga.

UNION AND CONFEDERATE CORRESPONDENCE, ORDERS, ETC., RELATING TO PRISONERS OF WAR AND STATE FROM JANUARY 1, 1865, TO THE END.--#26
O.R.--SERIES II--VOLUME VIII [S# 121]

C. S. MILITARY PRISON HOSPITAL.

Surg. JOSEPH JONES, Provisional Army, C. S., Augusta, Ga.:

        SIR: It was our original intention to give you in this report a description of the stockade, its location and general condition, but we learn you have it already drawn up by abler hands than ours. We will therefore, after stating some of the most prevalent diseases among the prisoners, confine our remarks principally to the subject of ulcers and gangrene. As we will have to rely altogether on our notes and observations, taken for the most part within the last few months, drawn up under the most unfavorable circumstances imaginable, we fear, therefore, our remarks will prove both dry and uninteresting. The constant interference of an overdemand for our services as medical officers has prevented us from writing, except at irregular and uncertain intervals, therefore this report will present many deficiencies, both in arrangement and accuracy of detail.
        When first we promised to contribute our mite to the subject before us we must confess we thought the task much easier than it has since proved to be. On looking over our notes we find them incomplete in many important particulars, and as we have but little time to investigate the subject in so scientific a manner as its importance demands, we are almost tempted to at once desist and confess our inability to do justice to the subject. But as our promise is out, and this paper is for your use, and not for public criticism, we will make the effort, hoping you will judge its merits with "Christian charity," and correct us in any errors we may make through ignorance or inexperience, and give us such information as you may deem necessary for our benefit in the future.
        In order to show you the kind of material we have to work on it will be necessary to first give you a list of the most prevalent diseases among the prisoners, consequent on great mental and nervous depression, from long confinement in overcrowded and badly arranged prisons, seclusion from society, long-deferred hope, a lack of cleanliness, insufficient supply of nourishing food, a want of proper exercise of both body and mind, and from breathing an atmosphere so much vitiated by idio miasma as to be insufficient to produce the proper degree of oxygenation of the blood, a condition so necessary to both mental and bodily soundness. This depraved blood then affords an imperfect stimulus to the brain and nervous system, and as a result we have languor and inactivity of the mental and nervous functions, with a tendency to headache, syncope, hypochondriasis, and hemeralopia. The diseases most commonly met with are diarrhea, dysentery, intermittent and remittent fever, with continued, or camp, fever, as many term it. We also have catarrhal affections, with occasional pneumonia, and pleuritis, and, above all, scorbutus.
        As it so rarely happens in the course of a long experience of the medical practitioner or surgeon that he has an opportunity of witnessing this most formidable and loathsome disease in all its aggravated forms, it might not be amiss to introduce in this place a detailed account of that fearful disease, as it has prevailed and is still prevailing in this prison. But as that would be a work of supererogation and lead us too far from our subject, we will not attempt the task. Out of 30,000 prisoners who have been confined at this place during the past spring and summer, perhaps not less than one-half have suffered from this disease in some of its various forms.
        As a sequel to the above-named diseases we have dema, anasarca, ascites, hydrothorax, anaemia, and ulcers of nearly every variety and form. These ulcers are produced from the slightest causes imaginable. A pin scratch, a prick of a splinter, a pustula, an abrasion, or even a mosquito bite are sufficient causes for their production. The phagedenic ulcer is the most common variety met with among the prisoners, and usually commences from some of the causes enumerated above, or from wounds or injuries of a more serious nature. When from any of these causes an ulcer forms, it speedily assumes a phagedenic appearance and extends over a large extent of surface, and presents irritable, jagged, and everted edges, and slowly destroys the deep tissues down to the bone. The surface presents a large ash-colored or greenish-yellow slough and emits a very offensive odor. After the slough is removed by appropriate treatment the parts beneath show but little tendency to granulate. Occasionally, however, apparently healthy granulations spring up and progress finely for a time, and again fall into sloughing, and thus, by an alternate process of sloughing and phagedenic ulceration, large portions of the affected member or large masses of the body are destroyed. In this condition gangrene usually sets in, and if not speedily arrested soon puts an end to the poor sufferer's existence.
        Gangrene first made its appearance in the stockade in the latter part of April or first of May last. The first that came under our observation was the result of frostbite. These cases (three or four in number) occurred among the prisoners who had been imprisoned on Belle Island last winter, where they received the injury. The parts attacked from this cause were usually the toes. The treatment was cold-water dressing, and the whole affected member enveloped in cloths spread with simple cerate, with tonics to support the system. This treatment usually succeeded, with the loss, perhaps, of one or more of the affected toes.
        Early in the spring smallpox made its appearance in the prison, and as a prophylactic measure we were ordered to vaccinate "all who could not show a healthy scar." Consequently we went to work, and in a week or ten days 2,000 or 3,000 were vaccinated. Out of these nearly every man who happened to be affected with scurvy was attacked with ulceration of the pustule. These small ulcers soon began to slough and extend over a large extent of surface. These sloughs would become detached, the parts beneath suppurate, as in the case of other ulcers in a sloughy condition, until at last the ulcer would become phagedenic and destroy every structure in its track for a considerable extent. In this condition gangrene would set in, and if the disease be not speedily arrested by powerful escharotics, emollient poultices, and the proper vegetable diet, amputation became necessary, or the poor wretch would sink under the irritation; diarrhea or dysentery would supervene and speedily destroy the patient. The next and most common form of ulcers with us are what we call the scorbutic ulcer.
        In severe cases of scurvy we have the upper and lower extremities covered with blue or livid spots, varying from the size of a millet seed to three or four inches in diameter, or the whole leg may be of a dark livid or copper color. These blotches become painful, open and ulcerate. This condition continues for a time, and finally slough, destroying whole toes, feet, and even arms and legs, apparently without there being sufficient energy or vitality in the system to set up inflammatory action. In this lamentable condition gangrene sets in and exhibits a more striking example of hospital gangrene than any other form of gangrene with which we have had to contend. The most prominent symptoms of this kind of gangrene are a weak and small pulse, great prostration of the already enfeebled vital powers, a dry, glazed tongue, great anxiety of countenance, with a foul grayish slough all over the surface of the wound or ulcer, which discharges a large quantity of filthy and very offensive sanies, destroying muscles and everything before it down to the bone. If an operation be not resorted to, we have hemorrhage, caused by the destruction of the blood vessels of the part. We have operated on perhaps twenty or thirty cases in this condition, and we do not recollect of a single case where the gangrene did not reappear in the stump and speedily destroy the patient. In the other forms of gangrene, however, we have had much better success. Out of perhaps a hundred operations twenty or thirty are well and as many others apparently doing well. We think the above a fair estimate of all the capital operations performed in this hospital during the spring and summer.
        The treatment adopted in all forms of the disease (when we have it) is tonics, such as quinine, tincture of iron, salix alba, eupatorium perfoliatum, and such other indigenous remedies as we can obtain from the woods. We are now making some experiments with a decoction of the baptisia tinctoria, which grows abundantly around the hospital. As local applications we use pure nitric acid, nitrate of silver, tincture of iodine, oleum terebinthinæ, and Darby's prophylactic fluid, followed by emollient poultices made of pulverized lini, or a common mush poultice made by thickening a strong decoction of quercus rubra with corn-meal.
        We will give you a tabular statement of the patients received into and treated in our ward alone for the past three months, with the result. We regret not being able to do the same for the whole hospital.

In the month of August we had in the fifth ward twenty-one operations of all kinds. Out of these cases we had ten deaths, mostly attributed to either diarrhea or dysentery, while only two or three were caused by recurrence of the gangrene in the stump.

Number of patients treated in Ward 5, Second Division, C. S. military prison hospital, during the months of July, August, and September, together with five days of October, and result of treatment as far as known.

Number of tents  11
 
Present in ward  
July 1  68
August 1  77
September 1  72
October 5 62
 
Admitted  
July 80
August 106
September 57
October 5 12
   
Sent to quarters
July  
August 4
September  
October 5 7
   
Detailed or transferred
July-  
Detailed 1
Transferred 10
August-  
Detailed 4
Transferred 15
September-  
Detailed 6
Transferred 14
October 5-  
Detailed 2
Transferred 8
 
Died  
July 66
August 86
September 49
October 5 7
 
Remaining in ward  
July 31 66
August 31 79
September 30 62
October 5 50

        It will be seen by the above statement that we treated in a little over three months 325 patients, and out of that number 208 have died, 47 were transferred to other wards, 13 were detailed for duty in hospital as nurses (after they were cured), and 11 were sent to quarters (cured), which leaves us 50 still in the ward (October 5), and out of the 50 there are 2 or 3 about well, 4 or 5 convalescent, and the remainder pretty bad off.
        In September we had 11 operations for the same condition, of which 7 died from diarrhea and dysentery. The whole number of operations for the two months (August and September) were 38, of which 17 died, 9 were transferred to other wards, 6 are convalescent in the ward, and we know of 4 or 5 others who were transferred to other wards, and who are also convalescent. The deaths as far as known are reported in the above.
        We will now give you a case of what we took for true hospital gangrene. J. Mailer, aged twenty-four years, admitted August 5, with a large sphacelus covering the whole arm up to within two and a half inches of the shoulder joint. The arm was very much tumefied, and presented around the border of the large sphacelus a kind of erysipelatous inflammation. This inflamed surface was covered with green and yellow spots; these in turn opened and discharged filthy and very offensive sanies. The pulse beat 120 to the minute, was weak, and had a peculiar vibratory thrill. Tongue dry and glazed, very red at the tip and edges. Bowels a little loose, but not amounting to diarrhea. Appetite weak. Urine scant and highly colored; complained of considerable pain in the affected arm and shoulder; had copious night-sweats; complained of chilliness of mornings and fever in the afternoon. (R Quiniæ sulph., gr. xx. Pulv. Doveri, gr. x. M. ft. chart. iii and to be given every six hours in one ounce good whisky. Apply pure nitric acid to the sphacelus, envelope the whole arm in pulverized lini poultices.)
        6th.
Patient no better; is very anxious to have the arm amputated; gangrene extending. Pulse 125 in the morning, 137 in the evening. Tongue about the same. Bowels still loose. Appetite somewhat improved; forearm edematous; continued prescription.
        7th.
Gangrene still extending above the elbow; presents a pea-green appearance, and emits an intolerable odor. Pulse 130 at 8 a.m., 141 at 5 p.m. Bowels painful; has mucous discharges. Appetite weak; cannot obtain diet of proper kinds.
        8th.
This morning the gangrene has extended into the shoulder joint and half way to the hand. Pulse 140, a.m.; 157, p.m. Has dysentery. Prescription continued with turpentine emulsion. In this condition the patient remained up to the 10th, at which time he began to sink, and as we could do nothing more we continued about the same treatment up to the 14th, at which time the patient died, with the whole arm in a state of sphacelus.
        Now, if this was "hospital gangrene," we have had quite a number of cases of this disease, and if not, the disease has not prevailed at this post. Although the case above described is but a faint outline of the disease, yet we hope it is sufficiently plain to be understood.
        We will close this paper, lest we weary you with dry and uninteresting matter, by giving a short description of our so-called hospital. We have from 1,600 to 2,000 patients, besides nurses and attendants, crowded together in small and almost useless tents erected on less than three acres of ground. The hospital is located on a narrow tongue of land between two small creeks on each side of which are swamps forty or fifty yards in width; on the west and up these creeks from the hospital are the camps and stockade. Now, all the debris from over 30,000 human beings have to pass along the small brook on the north of the hospital grounds and within a stone's throw of patients' tents. A large portion of this filth is deposited on the marsh and produces a most sickening stench. Our patients are carried from the stockade and placed in the tents by the attendants, We put in the common small A tent four patients, in the large wall tent eight, and in the common fly from six to eight. About one-third have bunks or scaffolds and the remainder have to lie on the ground without straw or anything else to protect them from its dampness.
        Those who are not fortunate enough to have a blanket are compelled to lie on the damp ground with no covering but their clothing, which in many instances they have worn for six months without washing.
        The diet is of the coarsest kind, consisting of boiled beef, rice, molasses, and coarse corn bread baked without sifting, and from one to two ordinary-sized biscuits. To this we sometimes have added a small allowance of vegetables, such as peas, potatoes, and collards. These vegetables are generally issued raw and the patients are compelled to hire their comrades to cook them in some sort of style and pay them out of their scanty allowance.
        We also have great difficulty in procuring medicines. The supplies for a month are usually exhausted in ten days, and the remainder of the time we are compelled to rely on such indigenous remedies as we can procure from the adjacent woods. Our cooking department has been very deficient all summer, consisting of two large salt kettles placed on a furnace in the open air. The water is good and the supply plenteous.
        With these facts before you you will not wonder at the fearful mortality presented in our report and in the tabular statement from our ward, presented above.
        Feeling we have done our whole duty, both in the eyes of God and man, we leave the matter to rest with those whose duty it was to furnish supplies and build up a hospital that might have reflected credit on the Government and saved the lives of thousands of our race.

HOSPITAL GANGRENE.

        The above description of ulcers attended with gangrene are so nearly allied to hospital gangrene that we are of the opinion that many cases of the above diseases are identical with this disease.
        As hospital gangrene proper is of rare occurrence in our country, and as our public institutions have never been visited by this disease in its epidemic form like the large hospitals of Europe, it has rarely happened that our teachers of medicines and surgery have had an opportunity of witnessing and investigating the disease in its most aggravated forms. Hence we have comparatively little written on the subject by American authors; and what little has been written is difficult to understand, on account of the very different descriptions given by different authors, both of this and other countries, so that we are at a loss to know how to proceed with our investigation, lest in forming an opinion on a subject so interesting and important we should make some fatal blunders. We will therefore content ourselves by giving such answers to the questions you honored us with while with us as may seem in our humble judgment proper.
        We take the ground that we have hospital gangrene in its most aggravated form in this hospital; and also that it has and is still prevailing to an alarming extent among these unfortunate prisoners. We regard the sloughing phagedæna so common and so fatal in its consequences as a true type of this disease. At least, this disease corresponds so accurately with descriptions of hospital gangrene given by European writers that we conclude the disease is one and the same.
        We have had under our immediate care a goodly number of cases of this disease within the last few months, and have witnessed a great many more in other wards, and have consulted with various medical gentlemen on the subject, and find but few who differ in opinion with reference to the disease usually diagnosed "phagedæna gangrænosa" and "hospital gangrene" being the same disease.
        From the experience we have had with hospital gangrene we regard it as a constitutional disease, from the fact that we invariably have it marked by constitutional symptoms, generally of a low grade. These symptoms may or may not precede the local invasion of the disease, according to circumstances. If the constitution of the patient is greatly debilitated by previous disease, as from scorbutus or chronic diarrhea, we usually have primary symptoms, such as great depression of the vital powers, anxious and expressionless countenance, quick and feeble pulse, and a dry, red, or glazed tongue. Fever and other constitutional disturbances are invariably met with in this disease, but do not always precede it. When the disease is brought on in healthy patients with fresh wounds by contagion we have the above symptoms following the local disturbance or invasion of the disease. We have had no chance of settling the question of contagion in this hospital. Our patients have been crowded together on the same ground with other patients suffering from the various diseases incident to the prisoners, and in very many instances in the same tent, or even on the same bed. Again, we only have one wash pan to the tent, and it is utterly impossible for the nurses, if they were ever so particular, to keep those who have no gangrene from using the same basin used by the gangrene patients. The same sponge is doubtless often used for every patient in the tent, and owing to the great scarcity of bandages we are compelled to use the same bandages several times, and in washing they not unfrequently get changed, and thus the disease may be transmitted from one patient to the other by actual contact. So we are not in possession of the proper data to justify us in giving an affirmative answer as to the disease being contagious; but from our limited experience with the disease, and from what we know of its nature and general character, we are inclined to the opinion that it is highly contagious.
        We have not the least doubt of the constitutionality of the disease, but cannot speak from experience as to the success of a strictly constitutional treatment. We are always so anxious to relieve our patients of whatever disease they may chance to have that we always make every effort for their relief in our power. Hence we have never treated this disease without using local applications, nor do we believe that we would be justifiable in making the experiment of treating hospital gangrene by constitutional means only. With the life of a human being in our hands, we would not think of risking constitutional treatment alone. Therefore we cannot answer the question from experimental knowledge.
        Hospital gangrene may appear in slight wounds, even in perfectly healthy patients, if they should be exposed to the atmosphere in which the patient or patients are confined who are suffering from this disease, but the dangers of contagion are not so great as in other diseases of this nature. Having never tried the experiment of inoculation with gangrenous matter, we cannot speak positively, but we have no doubt but that we would have a modified form of the disease as a result. We do not believe this disease ever originates spontaneously in well-regulated and properly ventilated hospitals, unless the patients are overcrowded and neglected. Still, such cases are on record, but it will be remembered that at the time of their occurrence other diseases were prevailing epidemically, such as influenza, erysipelas, and phlebitis, which may, under certain circumstances, act as one of the causes of this affection. Influenza prevailed very extensively in the prison about the time this disease originated, and may have had something to do with its production. Let the causes be what they may, when the disease is once established in an extensive hospital it generally spreads rapidly, by contagion or otherwise, and its rapid spread is only checked by isolating all who are affected with the disease from the other sick and wounded. The essential conditions and causes of the disease under consideration are of various kinds, such as deprivation of the blood, overcrowded hospitals, a lack of proper cleanliness, and insufficient ventilation. In fact, anything which would cause other diseases of a low form might be enumerated as causes of this truly formidable disease.
        The last question we will not attempt to answer at this time. We have not performed a sufficient number of post-mortem examinations of patients who have died from this and other diseases to entitle us to speak positively as to any peculiar "local lesions which are characteristic of this disease."
        We will therefore close this already too lengthy paper, hoping that it may in some way assist you in making your report to the Surgeon-General, and thereby prove of some benefit to the profession and the country.

Source: "Official Records of the War of the Rebellion"

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