Middleton Goldsmith and Hospital Gangrene

Middleton Goldsmith was a surgeon in the Union Army during the American Civil War working primarily in the Louisville, Kentucky area. He was born in Port Tobacco, Maryland in 1818, the son of surgeon Alban Goldsmith. His father was the professor of Surgery at Kentucky School of Medicine in Louisville in the mid-1830s, and Middleton served as his anatomy and surgical assistant. Middle enrolled in the New York College of Physicians and Surgeons in 1837 and graduated in 1840. He was a multi-talented and very popular young man who played guitar and banjo, knew Greek and Latin, and was an excellent storyteller. He cofounded the New York Pathologic Society and in 1844 became Chair of Surgery at Castleton Medical College in Vermont. After 12 years, he succeeded his father as Chair of Surgery at Kentucky School of Medicine, soon becoming the Dean of Faculty. He joined the Union Army at the outbreak of the Civil War as a Brigade Surgeon and was quickly appointed Surgeon-in-Chief of all military hospitals in Kentucky and the Army of the Ohio, supervising the daily operations of multiple hospitals.

 

Sketch of Civil War solider patient with gangrene in arm stump

American Civil War soldier lies in bed with a gangrenous amputated arm

The picture above is a sketch of Private Milton E. Wallen of Company C, 1st Kentucky Calvary, wounded by a Minié ball while in prison at Richmond, July 4, 1863.  He was being treated for gangrene in August 1863 when Edward Stauch traveled from Washington to make this sketch.   By USG [Public domain] via Wikimedia Commons.

 

Over 700,000 combined Union and Confederate soldiers perished in the 4 years of that war – more than in all other United States conflicts up to the Vietnam War, combined. More than two thirds of those succumbed to disease and surgical infection, not to direct battlefield trauma. Surgeons faced the formidable problem of treating the infections of wounds sustained during battle, and hospital gangrene was the worst.

British surgeons with experience during the Crimean War a decade earlier recommended patients should have at least 1600 cubic feet to themselves to prevent the spread of gangrene between patients. In some Union hospitals, the space per patient was only about 175 cubic feet, less than a six-foot cube, nearly 10 times less than the British recommendation. Attempts to improve ventilation for gangrene soldiers in such crowded conditions prompted surgeons to cut holes in ceilings or walls to draw the air through. This often backfired, allowing the microbes causing the gangrene to spread to patients in other areas of the hospital.

Many gangrene treatments were tried, including hand washing between patients, whiskey, cathartics, balanced diets, and topical agents applied directly to the gangrenous wound along with debridement, which was often too late or spread the infection. Experiments with poultices of mud, flaxseed, slippery elm, or charcoal were tried. Chlorinated soda water, extremely strong sodium hypochlorite solutions, nitric acid, tinctures of iodine and iron, and turpentine were applied, often in combination and often overpowering and painful and difficult to tolerate and usually without the desired effect of curing the infection or curing it but causing even more damage to healthy tissue.

When Goldsmith found himself surrounded by many hospital gangrene patients in Kentucky, he focused on the problem. He reviewed many of the documented outbreaks from early in the war and theorized that the three diseases of gangrene, erysipelas, and pyaemia were in some way connected, although his lack of knowledge of the “putrefactive agent” made his task very difficult. He reviewed the curative agents then in use and concluded that corrosive acids such as nitric acid stopped the gangrene but were also very destructive of living tissues and were impossible to administer safely. He also noted other topical remedies like poultices did not arrest the infection and the consumption of coffee and whiskey did nothing.

 

Picture of pages from Goldsmith's book discussing various treatments for gangrene

Discussion by Goldsmith of various treatments for gangrene (Click to enlarge)

 

Goldsmith noticed that in hospital wards where bromine was used as an aerosolized deodorant, gangrene patients seemed to recover more than in other wards. He recommended the placement of volatile bromine in all patient wards. He developed a method of applying bromine deep into muscular layers after wound debridement then injecting bromine subcutaneously and applying it topically to exposed surfaces. A second application was only applied in cases where the gangrene odor returned.

 

In an independent report of Goldsmith’s method by another surgeon, G. R. Weeks, it was noted that of 104 patients receiving a bromine-based treatment, there were only 3 deaths, which were due not to gangrene but to pyaemia and cellulitis after the gangrene was improved. Weeks concluded the treatment was 100% successful in preventing death in hospital gangrene patients while other treatment regiments averaged around 25% mortality. Patients recovering with other treatments averaged 15 days convalesce, those with weak bromine 9 days, and pure bromine only 2 days. Similar results were reported by other observers such as John H. Brinton, another high-ranking Union surgeon.

 

Picture of title page of Goldsmith's report

Title page of Goldsmith’s report on Hospital Gangrene

Goldsmith thoroughly documented his investigations in his report to the Surgeon General entitled A Report on Hospital Gangrene, Erysipelas and Pyaemia, as observed in the departments of the Ohio and the Cumberland, with cases appended. This 1863 report included colorfully detailed case reports and a foldout table containing all his research data, as well as his correspondence with other surgeons. The data collected included patient’s name, rank, company, regiment, when wounded, where and when gangrene began, tissues involved in the wound, region of wound, general treatment, local treatment, when infection arrested, duration of gangrene, and hospital. His precise data collection and reporting allowed him to claim near complete eradication of hospital gangrene from his wards.  Only 8 of his 304 patients receiving bromine-based therapy died, a mortality rate of 2.6 per cent. The overall mortality of hospital gangrene cases from the Civil War has been reported as 45.6 %. By the end of the war, surgeons applied variations of his bromine treatment throughout the country.

Case report of Wilbur F. Nichols, first patient treated with Bromine for gangrene

 

Picture of table from Goldsmith's book showing results of various treatments for gangrene

Condensed Table of Results of Various Gangrene Treatments (Click to enlarge)

 

Goldsmith died in 1888.  He greatest achievement was his contribution to surgical antisepsis and his revolutionary bromine therapy. His work predated Joseph Lister’s 1867 paper linking microbes and surgical infection and preventive measures.

Note: Most of the material in this article, other than illustrations, was summarized from John Trombold’s excellent article on Middleton Goldsmith’s research on gangrene therapy. (See sources below.)  Book illustrations were scanned from the Nixon Library’s copy of Goldsmith’s book.

Come view Goldsmith’s Report on Hospital Gangrene, Erysipelas and Pyaemia in the P. I. Nixon Medical Historical Library.

Anne Comeaux, Assistant Director for Special Collections

(For more information on the Nixon Library or to set up an appointment, contact Anne Comeaux, comeaux@uthscsa.edu or 210-567-2428 or Mellisa DeThorne, dethrone@uthscsa.edu or 210-567-2470.)

 

Sources:

John M. Trombold, M.D. “Gangrene Therapy and Antisepsis before Lister; Civil War Contributions of Middleton Goldsmith of Louisville. “ The American Surgeon, vol. 77:1138-43, September 2011.

 

Wikipedia contributors, “Gangrene,” Wikipedia, The Free Encyclopedia, http://en.wikipedia.org/w/index.php?title=Gangrene&oldid=611179702 (accessed June 23, 2014).