previous state and general constitution of the patient, modified by the season of the year or the prevailing type of febrile diseases.' 14

Such is Mr. Guthrie's description of this formidable complication, as he observed it during the war in the Peninsula. În its less virulent forms, an amendment might be observed to commence five or six days after the beginning of the attack. The pain in such an instance would become less; the discharges lose their offensive odour, and become more healthy in consistence and appearance; the turgid and dark red integument surrounding the diseased part become more bright, and assume a condition of healthy inflammation; while the wound or sore would regain its normal tendency to granulation and cicatrisation. Such a favourable change was rarely observed, however, unless the position and circumstances of the patient were altered from what they had been at the time he was first attacked.

Varieties of hospital gangrene.-Two forms of hospital gangrene have been generally recognised, viz., the ulcerative and the pulpous; the first-named being the least active and least destructive, the latter the graver form of the disease, but both forms liable to succeed each other in the same wound or sore. Some other varieties have been brought to notice by military surgeons. M. Legouest, from his observations of the disease in the French hospitals during the Crimean war, was led to describe two varieties, which he designated the gelatinous and the gelatinous hæmorrhagic: the former being named from the exudations occasionally assuming a colloid and partly translucent character; the latter, from the sanguineous infiltrations with which these colloid exudations are sometimes mingled, especially in patients of a scorbutic taint. It is chiefly in the pulpous form of hospital gangrene that the false membranes are produced which originated the name of 'wound diphtherite' for the disease. The granulations of the surface of the wound in this variety first become dull and turgid in appearance, and are then covered by a layer of whitish-grey or ash-coloured exudation with dark points, and a characteristic odour of tainted meat. The exudation quickly increases in thickness and consistence; the disease thus differing from what has been described as the ulcerous form, in which there is no other covering than a sanious discharge. This membranous coating is strongly adherent to the granulations beneath; it can in some instances be peeled off them like a diphtheritic membrane, though not without giving rise to oozing of blood from their surface. When this coating has acquired a certain thickness, it softens down, becomes putrid, dark in colour, and emits a horribly fetid odour. At the same time the gangrene burrows and extends itself in the areolar tissue, while other structures in the neighbourhood become more or less implicated in the morbific process. Each variety of the disease is accompanied with intense local pain.

Different symptoms of hospital gangrene and simple gangrene. Hospital gangrene differs in several respects from the complication of simple gangrene elsewhere described. The manner in which it attacks a wound, and the remarkable rapidity with which it destroys the integrity of the surrounding structures, more particularly the connective tissue; its capability of propagation from person to person; the circular outline which the diseased action generally assumes as it spreads superficially; its nauseous odour, almost characteristic of the disease; the severity of the attendant pain; its special effects on certain structures, such as its invasion of arteries without causing thrombosis-these are all circumstances which cause it to fall within a distinctly separate category from ordinary gangrene.

Various modes of origin attributed to hospital gangrene.The majority of the surgeons who have recorded their experience of hospital gangrene have regarded it as the result of a local poison. That it was due to a special virus they considered to be established by the fact that the gangrene might be communicated to a wound in a healing condition in a patient of good constitution and good general health, by the direct contact of sponges, charpie, bandages, lint, and other articles, which had been impregnated with the discharges from another wound affected with the disease. In like manner a slight wound or abrasion in the hand of a surgeon might become infected with the disease through touching a wound which had been attacked by hospital gangrene; or a puncture by an instrument soiled with the matter discharged from such a wound would propagate its kind, even though efforts might be made to escape from its noxious effects, not only by local treatment, but also by going away to a situation where the air was of the purest character.

In the year 1810, M. A. F. Olivier of Paris allowed himself to be inoculated in the right arm with matter from a case of hospital gangrene. He was in good health, and went into a pure atmosphere away from the neighbourhood where hospital gangrene was existing. By the fifth day the part had assumed all the characteristic features of hospital gangrene, when M. Olivier interrupted the progress of the sore by removing the sloughs and applying strong nitrate of silver. Assistant-Surgeon Blackadder became the subject of it by accidentally puncturing himself in one of his fingers while examining the stump of a patient who had died from the effects of the disease. M. Legouest also mentions that several of his subordinates contracted the disease in the East in consequence of pricking their fingers with pins while fastening the dressings of the wounded.15 Mr. Holmes Coote has mentioned that during an outbreak of hospital gangrene which took place in the year 1846 in St. Bartholomew's Hospital, 'the extension of the disease was clearly traced in two instances to the

use of a sponge which had been first applied to a gangrenous sore, then boiled, and afterwards applied to a healthy wound.16 Thus subjection of the sponge to the temperature of boiling water did not suffice to destroy the materies morbi contained in it. This fact agrees with the results of repeated experiments on the subject.

A striking illustration of the communication of the disease by contact, as well as of the necessity of rigid surgical cleanliness on the part of those who have to deal with it, as it occurred at Bonn during the war (1870-71) between France and Germany, was mentioned by Mr. A. E. Barker in a paper read before the Surgical Society of Ireland in 1873.17 The gangrene only manifested itself among the patients of one particular surgeon, whose dressers, as Mr. Barker considerately remarked, could not be said to be of cleanly habits. In the case of one patient who had arrived at Bonn with a perfectly clean-looking amputation wound of the thigh, a ligature, which was still adherent to a large artery on the inner aspect of the stump, was removed, and the hospital gangrene commenced distinctly at that spot. In this case the thread was removed by the surgeon in attendance on the other cases of gangrene, whose hands may have conveyed the poison, whatever it be." The cases attacked were lying in a room with about ninety other wounded men, and yet only those subjected to the manipulations of one set of dressers were attacked.'

Some facts have tended to show that the poison of hospital gangrene may be communicated by the specific emanations from wounds affected with the disease floating in the atmosphere. This would be as truly a local application as if the poison were applied by the direct application of some of the discharge on a sponge or piece of charpie. A notable instance of this nature has been mentioned by Dr. Hennen.18 It is mentioned by him in the following words: At the end of the summer of 1798, in a French military hospital at Leyden, hospital gangrene prevailed in one of the low wards, whilst the patients who had slight wounds, and were placed above this ward in a well-aired garret, were found to escape the disease. The surgeon judged it necessary to make an opening in the floor of the upper room, in order by that means to afford an outlet through the roof to the air of the infected ward below. Thirty hours afterwards three patients who lay next to the opening were attacked by the disease, which soon spread through the whole ward.' In this instance the position of the patients who were first attacked, the rapidity with which the gangrene followed the opening of communication with the infected ward, and the concurrent appearance of the disease in several patients, appear to leave little room for doubt that the diseased action was induced by the topical effects of the air, or rather of specific emanations from the wounds affected by hospital gangrene carried upwards by it as it rose from the ward below.

Mr. Blackadder was a strong believer in the contagious character of hospital gangrene. He asserted that, so far as he had had an opportunity of observing, ninety-nine cases in the hundred were evidently produced by a direct application of the morbific matter to wounds through the medium of sponges, tow, water, instruments, and dressers; and he adduced some remarkable illustrations of the escape from the disease of wounded patients in beds adjoining those in which other patients with hospital gangrene were lying, when rigid measures were taken to prevent all direct contact between them.19

It will be noticed that the conviction of many of the older surgeons that hospital gangrene depended mainly on the presence of a local poison, and all the facts adduced by them in support of this belief, are quite consistent with the modern views of specific micrococci found in the diseased tissues being the generators of a poisonous fermentation, the product of which fermentation constitutes an essential element of this disorder, and gives it its malignant character.

Hospital gangrene during the United States Civil War.Observations on hospital gangrene are recorded at considerable length in the Surgical History of the United States War, as it was then witnessed in the military hospitals. The remarks on the disease sufficiently show that while in the majority of cases it was due to direct infection, in some instances it was undoubtedly independent of it, and of indigenous origin. A very full and careful report by Surgeon Goldsmith, U.S.V., illustrative of the latter mode of origin, is quoted in the history. He had been sent to investigate an outbreak of the disease at Nashville. In one hospital there, thirty-eight cases of hospital gangrene had occurred, and they all took place in one ward, in a particular row of beds near to certain windows which opened upon a confined alley. Surgeon Goldsmith succeeded in tracing out the fact that the patients affected had been exposed to air entering through these windows, which had been opened for ventilation. This air was foul, and loaded with miasmata which had been generated by putrefying animal and vegetable matters in an area and cellar outside, and situated beneath the windows. All the cases occurred when the external atmosphere, being colder than the air of the ward, which was artificially heated, would naturally enter the ward forcibly; while no cases occurred after the weather grew so warm that the temperature of the outer air was higher than that of the air within the building. 20

Conditions which favour the development of hospital gangrene. Military experience has sufficiently established the fact that there are certain conditions which generate a predisposition to hospital gangrene, and materially assist in its dissemination when once it is established.

In all the instances in which hospital gangrene has appeared in a virulent epidemic form, there has been, at the beginning, too great a number of wounded men with sloughing and suppurating wounds in respect to the space in which they have been accommodated. This serious evil cannot always be avoided under the accidents of military operations; but formerly it seems to have been the rule, instead of the exception, in military hospitals. It is this circumstance which caused hospital gangrene to attract so much notice in connection with military practice. There have been civil hospitals within comparatively recent times which were never wholly free from hospital gangrene owing to original faulty construction, defective drainage, and to a bad position among a dense population; but, from the relatively limited numbers of wounds in these buildings, the disease did not assume such a virulent epidemic character as it has from time to time exhibited in military hospitals in time of war.

The situation of a hospital on low flat ground near a river, or in a marshy district, has sometimes appeared to act as a predisposing cause of hospital gangrene, and to excite a proneness on the part of the patients to be attacked by it. After the battle of Waterloo the disease prevailed much more at Antwerp, the situation of which is very low, than at Brussels, which is comparatively high. All the worst cases at Brussels were in the old or lower part of the town. The disease assumed an intense form in a hospital about two miles from Brussels, where the Brunswickers were treated: nearly every patient on whom amputation was performed died from it. This hospital was situated on a thickly-wooded swampy flat, through which the great Antwerp canal was cut.21 The only outbreak that occurred in the Crimea took place in a hospital, the surgeon in charge of which, as before mentioned, attributed the disease in a great measure to the confined position and undrained soil on which the hospital was placed.

The position of the wards in which the patients are under treatment has also seemed to exert an influence on the tendency to the disease. It has been noticed that outbreaks of hospital gangrene have usually commenced in the lowest rooms of the building in which the wounded have been collected. This might be attributable to the fact of these being the rooms in which there is least movement of air, owing to the obstruction of walls, streets, and adjoining buildings; while they are the most exposed to the reception of effluvia from the surface of the ground, from privies, and other such sources of contamination.

A high degree of temperature has seemed to favour the appearance and spread of hospital gangrene, though it may occur at all seasons of the year. The worst epidemics recorded by British surgeons have taken place in fixed hospitals