V. From the sameness of the food, and from the action of the poisonous
gases in the densely crowded and filthy Stockade and Hospital, the blood
was altered in its constitution, even, before the manifestation of actual

In both the well and the sick, the red corpuscles were diminished; and in
all diseases uncomplicated with inflammation, the fibrinous element was
deficient. In cases of ulceration of the mucous membrane of the
intestinal canal, the fibrinous element of the blood appeared to be
increased; while in simple diarrhea, uncomplicated with ulceration, and
dependent upon the character of the food and the existence of scurvy,
it was either diminished or remained stationary. Heart-clots were very
common, if not universally present, in the cases of ulceration of the
intestinal mucous membrane; while in the uncomplicated cases of diarrhea
and scurvy, the blood was fluid and did not coagulate readily, and the
heart-clots and fibrinous concretions were almost universally absent.
From the watery condition of the blood there resulted various serous
effusions into the pericardium, into the ventricles of the brain, and
into the abdominal cavity.

In almost all cases which I examined after death, even in the most
emaciated, there was more or less serous effusion into the abdominal
cavity. In cases of hospital gangrene of the extremities, and in cases
of gangrene of the intestines, heart-clots and firm coagula were
universally present. The presence of these clots in the cases of
hospital gangrene, whilst they were absent in the cases in which there
were no inflammatory symptoms, appears to sustain the conclusion that
hospital gangrene is a species of inflammation (imperfect and irregular
though it may be in its progress), in which the fibrinous element and
coagulability of the blood are increased, even in those who are suffering
from such a condition of the blood and from such diseases as are
naturally accompanied with a decrease in the fibrinous constituent.

VI. The impoverished condition of the blood, which led to serous
effusions within the ventricles of the brain, and around the brain and
spinal cord, and into the pericardial and abdominal cavities, was
gradually induced by the action of several causes, but chiefly by the
character of the food.

The Federal prisoners, as a general rule, had been reared upon wheat
bread and Irish potatos; and the Indian corn so extensively used at the
South, was almost unknown to them as an article of diet previous to their
capture. Owing to the impossibility of obtaining the necessary sieves in
the Confederacy for the separation of the husk from the corn-meal, the
rations of the Confederate soldiers, as well as of the Federal prisoners,
consisted of unbolted corn-flour, and meal and grist; this circumstance
rendered the corn-bread still more disagreeable and distasteful to the
Federal prisoners. While Indian meal, even when prepared with the husk,
is one of the most wholesome and nutritious forms of food, as has been
already shown by the health and rapid increase of the Southern
population, and especially of the negros, previous to the present war,
and by the strength, endurance and activity of the Confederate soldiers,
who were throughout the war confined to a great extent to unbolted corn-
meal; it is nevertheless true that those who have not been reared upon
corn-meal, or who have not accustomed themselves to its use gradually,
become excessively tired of this kind of diet when suddenly confined to
it without a due proportion of wheat bread. Large numbers of the Federal
prisoners appeared to be utterly disgusted with Indian corn, and immense
piles of corn-bread could be seen in the Stockade and Hospital
inclosures. Those who were so disgusted with this form of food that they
had no appetite to partake of it, except in quantities insufficient to
supply the waste of the tissues, were, of course, in the condition of men
slowly starving, notwithstanding that the only farinaceous form of food
which the Confederate States produced in sufficient abundance for the
maintenance of armies was not withheld from them. In such cases, an
urgent feeling of hunger was not a prominent symptom; and even when it
existed at first, it soon disappeared, and was succeeded by an actual
loathing of food. In this state the muscular strength was rapidly
diminished, the tissues wasted, and the thin, skeleton-like forms moved
about with the appearance of utter exhaustion and dejection. The mental
condition connected with long confinement, with the most miserable
surroundings, and with no hope for the future, also depressed all the
nervous and vital actions, and was especially active in destroying the
appetite. The effects of mental depression, and of defective nutrition,
were manifested not only in the slow, feeble motions of the wasted,
skeleton-like forms, but also in such lethargy, listlessness, and torpor
of the mental faculties as rendered these unfortunate men oblivious and
indifferent to their afflicted condition. In many cases, even of the
greatest apparent suffering and distress, instead of showing any anxiety
to communicate the causes of their distress, or to relate their
privations, and their longings for their homes and their friends and
relatives, they lay in a listless, lethargic, uncomplaining state, taking
no notice either of their own distressed condition, or of the gigantic
mass of human misery by which they were surrounded. Nothing appalled and
depressed me so much as this silent, uncomplaining misery. It is a fact
of great interest, that notwithstanding this defective nutrition in men
subjected to crowding and filth, contagious fevers were rare; and typhus
fever, which is supposed to be generated in just such a state of things
as existed at Andersonville, was unknown. These facts, established by my
investigations, stand in striking contrast with such a statement as the
following by a recent English writer:

“A deficiency of food, especially of the nitrogenous part, quickly leads
to the breaking up of the animal frame. Plague, pestilence and famine
are associated with each other in the public mind, and the records of
every country show how closely they are related. The medical history of
Ireland is remarkable for the illustrations of how much mischief may be
occasioned by a general deficiency of food. Always the habitat of fever,
it every now and then becomes the very hot-bed of its propagation and
development. Let there be but a small failure in the usual imperfect
supply of food, and the lurking seeds of pestilence are ready to burst
into frightful activity. The famine of the present century is but too
forcible and illustrative of this. It fostered epidemics which have not
been witnessed in this generation, and gave rise to scenes of devastation
and misery which are not surpassed by the most appalling epidemics of the
Middle Ages. The principal form of the scourge was known as the
contagious famine fever (typhus), and it spread, not merely from end to
end of the country in which it had originated, but, breaking through all
boundaries, it crossed the broad ocean, and made itself painfully
manifest in localities where it was previously unknown. Thousands fell
under the virulence of its action, for wherever it came it struck down a
seventh of the people, and of those whom it attacked, one out of nine
perished. Even those who escaped the fatal influence of it, were left
the miserable victims of scurvy and low fever.”

While we readily admit that famine induces that state of the system which
is the most susceptible to the action of fever poisons, and thus induces
the state of the entire population which is most favorable for the rapid
and destructive spread of all contagious fevers, at the same time we are
forced by the facts established by the present war, as well as by a host
of others, both old and new, to admit that we are still ignorant of the
causes necessary for the origin of typhus fever. Added to the imperfect
nature of the rations issued to the Federal prisoners, the difficulties
of their situation were at times greatly increased by the sudden and
desolating Federal raids in Virginia, Georgia, and other States, which
necessitated the sudden transportation from Richmond and other points
threatened of large bodies of prisoners, without the possibility of much
previous preparation; and not only did these men suffer in transition
upon the dilapidated and overburdened line of railroad communication,
but after arriving at Andersonville, the rations were frequently
insufficient to supply the sudden addition of several thousand men.
And as the Confederacy became more and more pressed, and when powerful
hostile armies were plunging through her bosom, the Federal prisoners of
Andersonville suffered incredibly during the hasty removal to Millen,
Savannah, Charleston, and other points, supposed at the time to be secure
from the enemy. Each one of these causes must be weighed when an attempt
is made to estimate the unusual mortality among these prisoners of war.

VII. Scurvy, arising from sameness of food and imperfect nutrition,
caused, either directly or indirectly, nine-tenths of the deaths among
the Federal prisoners at Andersonville.

Not only were the deaths referred to unknown causes, to apoplexy, to
anasarca, and to debility, traceable to scurvy and its effects; and not
only was the mortality in small-pox, pneumonia, and typhoid fever, and in
all acute diseases, more than doubled by the scorbutic taint, but even
those all but universal and deadly bowel affections arose from the same
causes, and derived their fatal character from the same conditions which
produced the scurvy. In truth, these men at Andersonville were in the
condition of a crew at sea, confined in a foul ship upon salt meat and
unvarying food, and without fresh vegetables. Not only so, but these
unfortunate prisoners were men forcibly confined and crowded upon a ship
tossed about on a stormy ocean, without a rudder, without a compass,
without a guiding-star, and without any apparent boundary or to their
voyage; and they reflected in their steadily increasing miseries the
distressed condition and waning fortunes of devastated and bleeding
country, which was compelled, in justice to her own unfortunate sons, to
hold these men in the most distressing captivity.

I saw nothing in the scurvy which prevailed so universally at
Andersonville, at all different from this disease as described by various
standard writers. The mortality was no greater than that which has
afflicted a hundred ships upon long voyages, and it did not exceed the
mortality which has, upon me than one occasion, and in a much shorter
period of time, annihilated large armies and desolated beleaguered
cities. The general results of my investigations upon the chronic
diarrhea and dysentery of the Federal prisoners of Andersonville were
similar to those of the English surgeons during the war against Russia.

IX. Drugs exercised but little influence over the progress and fatal
termination of chronic diarrhea and dysentery in the Military Prison and
Hospital at Andersonville, chiefly because the proper form of nourishment
(milk, rice, vegetables, anti-scorbutics, and nourishing animal and
vegetable soups) was not issued, and could not be procured in sufficient
quantities for the sick prisoners.

Opium allayed pain and checked the bowels temporarily, but the frail dam
was soon swept away, and the patient appears to be but little better,
if not the worse, for this merely palliative treatment. The root of the
difficulty could not be reached by drugs; nothing short of the wanting
elements of nutrition would have tended in any manner to restore the tone
of the digestive system, and of all the wasted and degenerated organs and
tissues. My opinion to this effect was expressed most decidedly to the
medical officers in charge of these unfortunate men. The correctness of
this view was sustained by the healthy and robust condition of the
paroled prisoners, who received an extra ration, and who were able to
make considerable sums by trading, and who supplied themselves with a
liberal and varied diet.

X. The fact that hospital gangrene appeared in the Stockade first, and
originated spontaneously, without any previous contagion, and occurred
sporadically all over the Stockade and Prison Hospital, was proof
positive that this disease will arise whenever the conditions of
crowding, filth, foul air, and bad diet are present.

The exhalations from the Hospital and Stockade appeared to exert their
effects to a considerable distance outside of these localities.
The origin of gangrene among these prisoners appeared clearly to depend
in great measure upon the state of the general system, induced by diet,
exposure, neglect of personal cleanliness; and by various external
noxious influences. The rapidity of the appearance and action of the
gangrene depended upon the powers and state of the constitution, as well
as upon the intensity of the poison in the atmosphere, or upon the direct
application of poisonous matter to the wounded surface. This was further
illustrated by the important fact, that hospital gangrene, or a disease
resembling this form of gangrene, attacked the intestinal canal of
patients laboring under ulceration of the bowels, although there were no
local manifestations of gangrene upon the surface of the body. This mode
of termination in cases of dysentery was quite common in the foul
atmosphere of the Confederate States Military Prison Hospital; and in the
depressed, depraved condition of the system of these Federal prisoners,
death ensued very rapidly after the gangrenous state of the intestines
was established.

XI. A scorbutic condition of the system appeared to favor the origin of
foul ulcers, which frequently took on true hospital gangrene.

Scurvy and gangrene frequently existed in the same individual. In such
cases, vegetable diet with vegetable acids would remove the scorbutic
condition without curing the hospital gangrene. . . Scurvy consists
not only in an alteration in the constitution of the blood, which leads
to passive hemorrhages from the bowels, and the effusion into the various
tissues of a deeply-colored fibrinous exudation; but, as we have
conclusively shown by postmortem examination, this state is attended with
consistence of the muscles of the heart, and the mucous membrane of the
alimentary canal, and of solid parts generally. We have, according to
the extent of the deficiency of certain articles of food, every degree of
scorbutic derangement, from the most fearful depravation of the blood
and the perversion of every function subserved by the blood to those
slight derangements which are scarcely distinguishable from a state of
health. We are as yet ignorant of the true nature of the changes of the
blood and tissues in scurvy, and wide field for investigation is open for
the determination the characteristic changes–physical, chemical, and
physiological–of the blood and tissues, and of the secretions and
excretions of scurvy. Such inquiries would be of great value in their
bearing upon the origin of hospital gangrene. Up to the present war,
the results of chemical investigations upon the pathology of the blood in
scurvy were not only contradictory, but meager, and wanting in that
careful detail of the cases from which the blood was abstracted which
would enable us to explain the cause of the apparent discrepancies in
different analyses. Thus it is not yet settled whether the fibrin is
increased or diminished in this disease; and the differences which exist
in the statements of different writers appear to be referable to the
neglect of a critical examination and record of all the symptoms of the
cases from which the blood was abstracted. The true nature of the
changes of the blood in scurvy can be established only by numerous
analyses during different stages of the disease, and followed up by
carefully performed and recorded postmortem examinations. With such data
we could settle such important questions as whether the increase of
fibrin in scurvy was invariably dependent upon some local inflammation.

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