ThelargenumberofmenconfinedwithintheStockadesoon,underadefectivesystemofpolice,andwithimperfectarrangements,coveredthesurfaceofthelowgroundswithexcrements。Thesinksoverthelowerportionsofthestreamwereimperfectintheirplanandstructure,andtheexcrementswereinlargemeasuredepositedsonearthebordersofthestreamasnottobewashedaway,orelseaccumulateduponthelowboggyground。Thevolumeofwaterwasnotsufficienttowashawaythefeces,andtheyaccumulatedinsuchquantitiesinthelowerportionofthestreamastoformamassofliquidexcrementheavyrainscausedthewaterofthestreamtorise,andasthearrangementsforthepassageoftheincreasedamountsofwateroutoftheStockadewereinsufficient,theliquidfecesoverflowedthelowgroundsandcoveredthemseveralinches,afterthesubsidenceofthewaters。Theactionofthesunuponthisputrefyingmassofexcrementsandfragmentsofbreadandmeatandbonesexcitedmostrapidfermentationanddevelopedahorriblestench。
　　Improvementswereprojectedfortheremovalofthefilthandforthepreventionofitsaccumulation,buttheywereonlypartiallyandimperfectlycarriedout。Astheforcesoftheprisonerswerereducedbyconfinement,wantofexercise,improperdiet,andbyscurvy,diarrhea,anddysentery,theywereunabletoevacuatetheirbowelswithinthestreamoralongitsbanks,andtheexcrementsweredepositedattheverydoorsoftheirtents。Thevastmajorityappearedtoloseallrepulsiontofilth,andbothsickandwelldisregardedallthelawsofhygieneandpersonalcleanliness。Theaccommodationsforthesickwereimperfectandinsufficient。Fromtheorganizationoftheprison,February24,1864,toMay22,thesickweretreatedwithintheStockade。InthecrowdedconditionoftheStockade,andwiththetentsandhutsclusteredthicklyaroundthehospital,itwasimpossibletosecureproperventilationortomaintainthenecessarypolice。TheFederalprisonersalsomadefrequentforaysuponthehospitalstoresandcarriedoffthefoodandclothingofthesick。Thehospitalwas,onthe22dofMay,removedtoitspresentsitewithouttheStockade,andfiveacresofgroundcoveredwithoaksandpinesappropriatedtotheuseofthesick。
　　Thesupplyofmedicalofficershasbeeninsufficientfromthefoundationoftheprison。
　　ThenursesandattendantsuponthesickhavebeenmostgenerallyFederalprisoners,whointoomanycasesappeartohavebeendevoidofmoralprinciple,andwhonotonlyneglectedtheirduties,butwerealsoengagedinextensiverobbingofthesick。
　　FromthewantofproperpoliceandhygienicregulationsaloneitisnotwonderfulthatfromFebruary24toSeptember21,1864,ninethousandfourhundredandseventy—ninedeaths,nearlyone—thirdtheentirenumberofprisoners,shouldhavebeenrecorded。IfoundtheStockadeandhospitalinthefollowingconditionduringmypathologicalinvestigations,institutedinthemonthofSeptember,1864:
　　STOCKADE,CONFEDERATESTATESMILITARYPRISON。
　　AtthetimeofmyvisittoAndersonvillealargenumberofFederalprisonershadbeenremovedtoMillen,Savannah;Charleston,andotherpartsof,theConfederacy,inanticipationofanadvanceofGeneralSherman'sforcesfromAtlanta,withthedesignofliberatingtheircaptivebrethren;however,aboutfifteenthousandprisonersremainedconfinedwithinthelimitsoftheStockadeandConfederateStatesMilitaryPrisonHospital。
　　IntheStockade,withtheexceptionofthedamplowlandsborderingthesmallstream,thesurfacewascoveredwithhuts,andsmallraggedtentsandpartsofblanketsandfragmentsofoil—cloth,coats,andblanketsstretcheduponstacks。Thetentsandhutswerenotarrangedaccordingtoanyorder,andtherewasinmostpartsoftheenclosurescarcelyroomfortwomentowalkabreastbetweenthetentsandhuts。
　　Ifonemightjudgefromthelargepiecesofcorn—breadscatteredaboutineverydirectiononthegroundtheprisonerswereeitherverylavishlysuppliedwiththisarticleofdiet,orelsethiskindoffoodwasnotrelishedbythem。
　　EachdaythedeadfromtheStockadewerecarriedoutbytheirfellow—
　　prisonersanddepositeduponthegroundunderabusharbor,justoutsideoftheSouthwesternGate。Fromthencetheywerecarriedincartstotheburyingground,one—quarterofamilenorthwest,ofthePrison。Thedeadwereburiedwithoutcoffins,sidebyside,intrenchesfourfeetdeep。
　　Thelowgroundsborderingthestreamwerecoveredwithhumanexcrementsandfilthofallkinds,whichinmanyplacesappearedtobealivewithworkingmaggots。Anindescribablesickeningstencharosefromthesefermentingmassesofhumanfilth。
　　TherewerenearfivethousandseriouslyillFederalsintheStockadeandConfederateStatesMilitaryPrisonHospital,andthedeathsexceededonehundredperday,andlargenumbersoftheprisonerswhowerewalkingabout,andwhohadnotbeenentereduponthesickreports,weresufferingfromsevereandincurablediarrhea,dysentery,andscurvy。Thesickwereattendedalmostentirelybytheirfellow—prisoners,appointedasnurses,andastheyreceivedbutlittleattention,theywerecompelledtoexertthemselvesatalltimestoattendtothecallsofnature,andhencetheyretainedthepowerofmovingabouttowithinacomparativelyshortperiodofthecloseoflife。Owingtotheslowprogressofthediseasesmostprevalent,diarrhea,andchronicdysentery,thecorpseswereasageneralruleemaciated。
　　IvisitedtwothousandsickwithintheStockade,lyingundersomelongshedswhichhadbeenbuiltatthenorthernportionforthemselves。Atthistimeonlyonemedicalofficerwasinattendance,whereasatleasttwentymedicalofficersshouldhavebeenemployed。
　　DiedintheStockadefromitsorganization,February24,186ltoSeptember2l。3,254
　　DiedinHospitalduringsametime。6,225
　　TotaldeathsinHospitalandStockade9,479
　　Scurvy,diarrhea,dysentery,andhospitalgangreneweretheprevailingdiseases。Iwassurprisedtofindbutfewcasesofmalarialfever,andnowell—markedcaseseitheroftyphusortyphoidfever。TheabsenceofthedifferentformsofmalarialfevermaybeaccountedforinthesuppositionthattheartificialatmosphereoftheStockade,crowdeddenselywithhumanbeingsandloadedwithanimalexhalations,wasunfavorabletotheexistenceandactionofthemalarialpoison。
　　Theabsenceoftyphoidandtyphusfeversamongstallthecauseswhicharesupposedtogeneratethesediseases,appearedtobeduetothefactthatthegreatmajorityoftheseprisonershadbeenincaptivityinVirginia,atBelleIsland,andinotherpartsoftheConfederacyformonths,andevenaslongastwoyears,andduringthistimetheyhadbeensubjectedtothesamebadinfluences,andthosewhohadnothadthesefeversbeforeeitherhadthemduringtheirconfinementinConfederateprisonsorelsetheirsystems,fromlongexposure,wereproofagainsttheiraction。
　　Theeffectsofscurvyweremanifestedoneveryhand,andinallitsvariousstages,fromthemuddy,palecomplexion,palegums,feeble,languidmuscularmotions,lownessofspirits,andfetidbreath,tothedusky,dirty,leadencomplexion,swollenfeatures,spongy,purple,livid,fungoid,bleedinggums,looseteeth,oedematouslimbs,coveredwithlividvibices,andpetechiaespasmodicallyflexed,painfulandhardenedextremities,spontaneoushemorrhagesfrommucouscanals,andlarge,ill—
　　conditioned,spreadingulcerscoveredwithadarkpurplishfungusgrowth。
　　Iobservedthatinsomeofthecasesofscurvytheparotidglandsweregreatlyswollen,andinsomeinstancestosuchanextentastoprecludeentirelythepowertoarticulate。Inseveralcasesofdropsyoftheabdomenandlowerextremitiessuperveninguponscurvy,thepatientsaffirmedthatpreviouslytotheappearanceofthedropsytheyhadsufferedwithprofuseandobstinatediarrhea,andthatwhenthiswascheckedbyachangeofdiet,fromIndiancorn—breadbakedwiththehusk,toboiledrice,thedropsyappeared。Theseverepainsandlividpatcheswerefrequentlyassociatedwithswellingsinvariousparts,andespeciallyinthelowerextremities,accompaniedwithstiffnessandcontractionsofthekneejointsandankles,andoftenwithabrawnyfeeloftheparts,asiflymphhadbeeneffusedbetweentheintegumentsandapeneuroses,preventingthemotionoftheskinovertheswollenparts。
　　Manyoftheprisonersbelievedthatthescurvywascontagious,andIsawmenguardingtheirwellsandsprings,fearinglestsomemansufferingwiththescurvymightusethewaterandthuspoisonthem。
　　Iobservedalsonumerouscasesofhospitalgangrene,andofspreadingscorbuticulcers,whichhadsuperveneduponslightinjuries。Thescorbuticulcerspresentedadark,purplefungoid,elevatedsurface,withlividswollenedges,andexudedathin;fetid,saniousfluid,insteadofpus。Manyulcerswhichoriginatedfromthescorbuticconditionofthesystemappearedtobecometrulygangrenous,assumingallthecharacteristicsofhospitalgangrene。Fromthecrowdedcondition,filthyhabits,baddiet,anddejected,depressedconditionoftheprisoners,theirsystemshadbecomesodisorderedthatthesmallestabrasionoftheskin,fromtherubbingofashoe,orfromtheeffectsofthesun,orfromtheprickofasplinter,orfromscratching,oramusketobite,insomecases,tookonrapidandfrightfululcerationandgangrene。Thelonguseofsaltmeat,ofttimesimperfectlycured,aswellasthemosttotaldeprivationofvegetablesandfruit,appearedtobethechiefcausesofthescurvy。Icarefullyexaminedthebakeryandthebreadfurnishedtheprisoners,andfoundthattheyweresuppliedalmostentirelywithcorn—
　　breadfromwhichthehuskhadnotbeenseparated。Thishuskactedasanirritanttothealimentarycanal,withoutaddinganynutrimenttothebread。Asfarasmyexaminationextendednofaultcouldbefoundwiththemodeinwhichthebreadwasbaked;thedifficultylayinthefailuretoseparatethehuskfromthecorn—meal。Istronglyurgedthepreparationoflargequantitiesofsoupmadefromthecowandcalves'
　　headswiththebrainsandtongues,towhichaliberalsupplyofsweetpotatosandvegetablesmighthavebeenadvantageouslyadded。Thematerialexistedinabundanceforthepreparationofsuchsoupinlargequantitieswithbutlittleadditionalexpense。Suchalimentwouldhavebeennotonlyhighlynutritious,butitwouldalsohaveactedasanefficientremedialagentfortheremovalofthescorbuticcondition。
　　ThesickwithintheStockadelayunderseverallongshedswhichwereoriginallybuiltforbarracks。Theseshedscoveredtwofloorswhichwereopenonallsides。Thesicklayuponthebareboards,oruponsuchraggedblanketsastheypossessed,without,asfarasIobserved,anybeddingorevenstraw……
　　Thehaggard,distressedcountenancesofthesemiserable,complaining,dejected,livingskeletons,cryingformedicalaidandfood,andcursingtheirGovernmentforitsrefusaltoexchangeprisoners,andtheghastlycorpses,withtheirglazedeyeballsstaringupintovacantspace,withthefliesswarmingdowntheiropenandgrinningmouths,andovertheirraggedclothes,infestedwithnumerouslice,astheylayamongstthesickanddying,formedapictureofhelpless,hopelessmiserywhichitwouldbeimpossibletoportraybywordsorbythebrush。AfeelingofdisappointmentandevenresentmentonaccountoftheUnitedStatesGovernmentuponthesubjectoftheexchangeofprisoners,appearedtobewidespread,andtheapparenthopelessnatureofthenegotiationsforsomegeneralexchangeofprisonersappearedtobeacauseofuniversalregretanddeepandinjuriousdespondency。IheardsomeoftheprisonersgosofarastoexoneratetheConfederateGovernmentfromanychargeofintentionallysubjectingthemtoaprotractedconfinement,withitsnecessaryandunavoidablesufferings,inacountrycutofffromallintercoursewithforeignnations,andsorelypressedonallsides,whilstontheotherhandtheychargedtheirprolongedcaptivityupontheirownGovernment,whichwasattemptingtomakethenegroequaltothewhiteman。SomehundredormoreoftheprisonershadbeenreleasedfromconfinementintheStockadeonparole,andfilledvariousofficesasclerks,druggists,andcarpenters,etc。,inthevariousdepartments。
　　Thesemenwerewellclothed,andpresentedastoutandhealthyappearance,andasageneralruletheypresentedamuchmorerobustandhealthyappearancethantheConfederatetroopsguardingtheprisoners。
　　Theentiregroundsaresurroundedbyafrailboardfence,andarestrictlyguardedbyConfederatesoldiers,andnoprisonerexcepttheparoledattendantsisallowedtoleavethegroundsexceptbyaspecialpermitfromtheCommandantoftheInteriorofthePrison。
　　Thepatientsandattendants,neartwothousandinnumber,arecrowdedintothisconfinedspaceandarebutpoorlysuppliedwitholdandraggedtents。Largenumbersofthemwerewithoutanybunksinthetents,andlayupontheground,oft—timeswithoutevenablanket。Nobedsorstrawappearedtohavebeenfurnished。Thetentsextendtowithinafewyardsofthesmallstream,theeasternportionofwhich,aswehavebeforesaid,isusedasaprivyandisloadedwithexcrements;andIobservedalargepileofcorn—bread,bones,andfilthofallkinds,thirtyfeetindiameterandseveralfeetinhight,swarmingwithmyriadsofflies,inavacantspacenearthepotsusedforcooking。Millionsoffliesswarmedovereverything,andcoveredthefacesofthesleepingpatients,andcrawleddowntheiropenmouths,anddepositedtheirmaggotsinthegangrenouswoundsoftheliving,andinthemouthsofthedead。Musketosingreatnumbersalsoinfestedthetents,andmanyofthepatientsweresostungbythesepestiferousinsects,thattheyresembledthosesufferingfromaslightattackofthemeasles。
　　Thepoliceandhygieneofthehospitalweredefectiveintheextreme;
　　theattendants,whoappearedinalmosteveryinstancetohavebeenselectedfromtheprisoners,seemedtohaveinmanycasesbutlittleinterestinthewelfareoftheirfellow—captives。Theaccusationwasmadethatthenursesinmanycasesrobbedthesickoftheirclothing,money,andrations,andcarriedonaclandestinetradewiththeparoledprisonersandConfederateguardswithoutthehospitalenclosure,intheclothing,effectsofthesick,dying,anddeadFederals。Theycertainlyappearedtoneglectthecomfortandcleanlinessofthesickintrustedtotheircareinamostshamefulmanner,evenaftermakingdueallowancesforthedifficultiesofthesituation。Manyofthesickwereliterallyencrustedwithdirtandfilthandcoveredwithvermin。Whenagangrenouswoundneededwashing,thelimbwasthrustoutalittlefromtheblanket,orboard,orragsuponwhichthepatientwaslying,andwaterpouredoverit,andalltheputrescentmatterallowedtosoakintothegroundfloorofthetent。Thesupplyofragsfordressingwoundswassaidtobeveryscant,andIsawthemostfilthyragswhichhadbeenappliedseveraltimes,andimperfectlywashed,usedindressingwounds。Wherehospitalgangrenewasprevailing,itwasimpossibleforanywoundtoescapecontagionunderthesecircumstances。Theresultsofthetreatmentofwoundsinthehospitalwereofthemostunsatisfactorycharacter,fromthisneglectofcleanliness,inthedressingsandwoundsthemselves,aswellasfromvariousothercauseswhichwillbemorefullyconsidered。
　　Isawseveralgangrenouswoundsfilledwithmaggots。IhavefrequentlyseenneglectedwoundsamongsttheConfederatesoldierssimilarlyaffected;andasfarasmyexperienceextends,thesewormsdestroyonlythedeadtissuesanddonotinjurespeciallythewellparts。Ihaveevenheardsurgeonsaffirmthatagangrenouswoundwhichhadbeenthoroughlycleansedbymaggots,healedmorerapidlythanifithadbeenlefttoitself。Thiswantofcleanlinessonthepartofthenursesappearedtobetheresultofcarelessnessandinattention,ratherthanofmalignantdesign,andthewholetroublecanbetracedtothewantoftheproperpoliceandsanitaryregulations,andtotheabsenceofintelligentorganizationanddivisionoflabor。Theabuseswereinalargemeasureduetothealmosttotalabsenceofsystem,government,andrigid,butwholesomesanitaryregulations。InextenuationoftheseabusesitwasallegedbythemedicalofficersthattheConfederatetroopswerebarelysufficienttoguardtheprisoners,andthatitwasimpossibletoobtainanynumberofexperiencednursesfromtheConfederateforces。Infacttheguardappearedtobetoosmall,evenfortheregulationoftheinternalhygieneandpoliceofthehospital。
　　Themannerofdisposingofthedeadwasalsocalculatedtodepressthealreadydespondingspiritsofthesemen,manyofwhomhavebeenconfinedformonths,andevenfornearlytwoyearsinRichmondandotherplaces,andwhosestrengthhadbeenwastedbybadair,badfood,andneglectofpersonalcleanliness。Thedead—houseismerelyaframecoveredwitholdtentclothandafewbushes,situatedinthesouthwesterncornerofthehospitalgrounds。Whenapatientdies,heissimplylaidinthenarrowstreetinfrontofhistent,untilheisremovedbyFederalnegrosdetailedtocarryoffthedead;ifapatientdiesduringthenight,heliesthereuntilthemorning,andduringthedayeventhedeadwerefrequentlyallowedtoremainforhoursinthesewalks。Inthedead—housethecorpseslieuponthebareground,andwereinmostcasescoveredwithfilthandvermin……
　　Thecookingarrangementsareofthemostdefectivecharacter。Fivelargeironpotssimilartothoseusedforboilingsugarcane,appearedtobetheonlycookingutensilsfurnishedbythehospitalforthecookingofnearlytwothousandmen;andthepatientsweredependentingreatmeasureupontheirownmiserableutensils。Theywereallowedtocookinthetentdoorsandinthelanes,andthiswasanothersourceoffilth,andanotherfavorableconditionforthegenerationandmultiplicationoffliesandothervermin。
　　Theairofthetentswasfoulanddisagreeableintheextreme,andinfacttheentiregroundsemittedamostnauseousanddisgustingsmell。
　　Ienterednearlyallthetentsandcarefullyexaminedthecasesofinterest,andespeciallythecasesofgangrene,uponnumerousoccasions,duringtheprosecutionofmypathologicalinquiriesatAndersonville,andthereforeenjoyedeveryopportunitytojudgecorrectlyofthehygieneandpoliceofthehospital。
　　Thereappearedtobealmostabsoluteindifferenceandneglectonthepartofthepatientsofpersonalcleanliness;theirpersonsandclothinginmostinstances,andespeciallyofthosesufferingwithgangreneandscorbuticulcers,werefilthyintheextremeandcoveredwithvermin。
　　ItwastoooftenthecasethatpatientswerereceivedfromtheStockadeinamostdeplorablecondition。IhaveseenmenbroughtinfromtheStockadeinadyingcondition,begrimedfromheadtofootwiththeirownexcrements,andsoblackfromsmokeandfilththatthey,resemblednegrosratherthanwhitemen。ThatthisdescriptionoftheStockadeandhospitalhasnotbeenoverdrawn,willappearfromthereportsofthesurgeonsincharge,appendedtothisreport……
　　WewillexaminefirsttheconsolidatedreportofthesickandwoundedFederalprisoners。Duringsixmonths,fromthe1stofMarchtothe31stofAugust,forty—twothousandsixhundredandeighty—sixcasesofdiseasesandwoundswerereported。NoclassifiedrecordofthesickintheStockadewaskeptaftertheestablishmentofthehospitalwithoutthePrison。Thisfact,inconjunctionwiththosealreadypresentedrelatingtotheinsufficiencyofmedicalofficersandtheextremeillnessandevendeathofmanyprisonersinthetentsintheStockade,withoutanymedicalattentionorrecordbeyondthebarenumberofthedead,demonstratethatthesefigures,largeasthey,appeartobe,arefarbelowthetruth。
　　Asthenumberofprisonersvariedgreatlyatdifferentperiods,therelationsbetweenthosereportedsickandwell,asfarasthosestatisticsextend,canbestbedeterminedbyacomparisonofthestatisticsofeachmonth。
　　Duringthisperiodofsixmonthsnolessthanfivehundredandsixty—fivedeathsarerecordedundertheheadof'morbivanie。'Inotherwords,thosemendiedwithouthavingreceivedsufficientmedicalattentionforthedeterminationofeventhenameofthediseasecausingdeath。
　　DuringthemonthofAugustfifty—threecasesandfifty—threedeathsarerecordedasduetomarasmus。Surelythislargenumberofdeathsmusthavebeenduetosomeothermorbidstatethanslowwasting。Iftheywereduetoimproperandinsufficientfood,theyshouldhavebeenclassedaccordingly,andiftodiarrheaordysenteryorscurvy,theclassificationshouldinlikemannerhavebeenexplicit。
　　Weobserveaprogressiveincreaseoftherateofmortality,from3。11percent。inMarchto9。09percent。ofmeanstrength,sickandwell,inAugust。TheratioofmortalitycontinuedtoincreaseduringSeptember,fornotwithstandingtheremovalofone—halfoftheentirenumberofprisonersduringtheearlyportionofthemonth,onethousandsevenhundredandsixty—seven（1,767）deathsareregisteredfromSeptember1to21,andthelargestnumberofdeathsuponanyonedayoccurredduringthismonth,onthe16th,viz。onehundredandnineteen。
　　TheentirenumberofFederalprisonersconfinedatAndersonvillewasaboutfortythousandsixhundredandeleven;andduringtheperiodofnearsevenmonths,fromFebruary24toSeptember21,ninethousandfourhundredandseventy—nine（9,479）deathswererecorded;thatis,duringthisperiodnearone—fourth,ormore,exactlyonein4。2,or13。3percent。,terminatedfatally。Thisincreaseofmortalitywasdueingreatmeasuretotheaccumulationofthesourcesofdisease,astheincreaseofexcrementsandfilthofallkinds,andtheconcentrationofnoxiouseffluvia,andalsototheprogressiveeffectsofsaltdiet,crowding,andthehotclimate。
　　CONCLUSIONS。
　　1st。ThegreatmortalityamongtheFederalprisonersconfinedinthemilitaryprisonatAndersonvillewasnotreferabletoclimaticcauses,ortothenatureofthesoilandwaters。
　　2d。Thechiefcausesofdeathwerescurvyanditsresultsandbowelaffections—chronicandacutediarrheaanddysentery。Thebowelaffectionsappeartohavebeenduetothediet,thehabitsofthepatients,thedepressed,dejectedstateofthenervoussystemandmoralandintellectualpowers,andtotheeffluviaarisingfromthedecomposinganimalandvegetablefilth。Theeffectsofsaltmeat,andanunvaryingdietofcornmeal,withbutfewvegetables,andimperfectsuppliesofvinegarandsyrup,weremanifestedinthegreatprevalenceofscurvy。
　　Thisdisease,withoutdoubt,wasalsoinfluencedtoanimportantextentinitsoriginandcoursebythefoulanimalemanations。
　　3d。Fromthesamenessofthefoodandform,theactionofthepoisonousgasesinthedenselycrowdedandfilthyStockadeandhospital,thebloodwasalteredinitsconstitution,evenbeforethemanifestationofactualdisease。Inboththewellandthesicktheredcorpuscleswerediminished;andinalldiseasesuncomplicatedwithinflammation,thefibrouselementwasdeficient。Incasesofulcerationofthemucousmembraneoftheintestinalcanal,thefibrouselementofthebloodwasincreased;whileinsimplediarrhea,uncomplicatedwithulceration,itwaseitherdiminishedorelseremainedstationary。Heartclotswereverycommon,ifnotuniversallypresent,incasesofulcerationoftheintestinalmucousmembrane,whileintheuncomplicatedcasesofdiarrheaandscurvy,thebloodwasfluidanddidnotcoagulatereadily,andtheheartclotsandfibrousconcretionswerealmostuniversallyabsent。
　　Fromthewateryconditionoftheblood,thereresultedvariousserouseffusionsintothepericardium,ventriclesofthebrain,andintotheabdomen。InalmostallthecaseswhichIexaminedafterdeath,eventhemostemaciated,therewasmoreorlessserouseffusionintotheabdominalcavity。Incasesofhospitalgangreneoftheextremities,andincasesofgangreneoftheintestines,heartclotsandfibrouscoagulawereuniversallypresent。Thepresenceofthoseclotsinthecasesofhospitalgangrene,whiletheywereabsentinthecasesinwhichtherewasnoinflammatorysymptoms,sustainstheconclusionthathospitalgangreneisaspeciesofinflammation,imperfectandirregularthoughitmaybeinitsprogress,inwhichthefibrouselementandcoagulationofthebloodareincreased,eveninthosewhoaresufferingfromsuchaconditionoftheblood,andfromsuchdiseasesasarenaturallyaccompaniedwithadecreaseinthefibrousconstituent。
　　4th。ThefactthathospitalGangreneappearedintheStockadefirst,andoriginatedspontaneouslywithoutanypreviouscontagion,andoccurredsporadicallyallovertheStockadeandprisonhospital,wasproofpositivethatthisdiseasewillarisewhenevertheconditionsofcrowding,filth,foulair,andbaddietarepresent。TheexhalationsfromthehospitalandStockadeappearedtoexerttheireffectstoaconsiderabledistanceoutsideoftheselocalities。Theoriginofhospitalgangreneamongtheseprisonersappearedclearlytodependingreatmeasureuponthestateofthegeneralsysteminducedbydiet,andvariousexternalnoxiousinfluences。Therapidityoftheappearanceandactionofthegangrenedependeduponthepowersandstateoftheconstitution,aswellasupontheintensityofthepoisonintheatmosphere,oruponthedirectapplicationofpoisonousmattertothewoundedsurface。Thiswasfurtherillustratedbytheimportantfactthathospitalgangrene,oradiseaseresemblingitinallessentialrespects,attackedtheintestinalcanalofpatientslaboringunderulcerationofthebowels,althoughtherewerenolocalmanifestationsofgangreneuponthesurfaceofthebody。ThismodeofterminationincasesofdysenterywasquitecommoninthefoulatmosphereoftheConfederateStatesMilitaryHospital,inthedepressed,depravedconditionofthesystemoftheseFederalprisoners。
　　5th。Ascorbuticconditionofthesystemappearedtofavortheoriginoffoululcers,whichfrequentlytookontruehospitalgangrene。Scurvyandhospitalgangrenefrequentlyexistedinthesameindividual。Insuchcases,vegetablediet,withvegetableacids,wouldremovethescorbuticconditionwithoutcuringthehospitalgangrene。FromtheresultsoftheexistingwarfortheestablishmentoftheindependenceoftheConfederateStates,aswellasfromthepublishedobservationsofDr。Trotter,SirGilbertBlane,andothersoftheEnglishnavyandarmy,itisevidentthatthescorbuticconditionofthesystem,especiallyincrowdedshipsandcamps,ismostfavorabletotheoriginandspreadoffoululcersandhospitalgangrene。AsinthepresentcaseofAndersonville,soalsoinpasttimeswhenmedicalhygienewasalmostentirelyneglected,thosetwodiseaseswerealmostuniversallyassociatedincrowdedships。Inmanycasesitwasverydifficulttodecideatfirstwhethertheulcerwasasimpleresultofscurvyoroftheactionoftheprisonorhospitalgangrene,fortherewasgreatsimilarityintheappearanceoftheulcersinthetwodiseases。Socommonlyhavethosetwodiseasesbeencombinedintheiroriginandaction,thatthedescriptionofscorbuticulcers,bymanyauthors,evidentlyincludesalsomanyoftheprominentcharacteristicsofhospitalgangrene。ThiswillberenderedevidentbyanexaminationoftheobservationsofDr。LindandSirGilbertBlaneuponscorbuticulcers。
　　6th。Gangrenousspotsfollowedbyrapiddestructionoftissueappearedinsomecaseswheretherehadbeennoknownwound。Withoutsuchwell—
　　establishedfacts,itmightbeassumedthatthediseasewaspropagatedfromonepatienttoanother。InsuchafilthyandcrowdedhospitalasthatoftheConfederateStatesMilitaryPrisonatAndersonville,itwasimpossibletoisolatethewoundedfromthesourcesofactualcontactofthegangrenousmatter。Thefliesswarmingoverthewoundsandoverfilthofeverykind,thefilthy,imperfectlywashedandscantysuppliesofrags,andthelimitedsupplyofwashingutensils,thesamewash—bowlservingforscoresofpatients,weresourcesofsuchconstantcirculationofthegangrenousmatterthatthediseasemightrapidlyspreadfromasinglegangrenouswound。Thefactalreadystated,thataformofmoistgangrene,resemblinghospitalgangrene,wasquitecommoninthisfoulatmosphere,incasesofdysentery,bothwithandwithouttheexistenceofthediseaseupontheentiresurface,notonlydemonstratesthedependenceofthediseaseuponthestateoftheconstitution,butprovesintheclearestmannerthatneitherthecontactofthepoisonousmatterofgangrene,northedirectactionofthepoisonousatmosphereupontheulceratedsurfacesisnecessarytothedevelopmentofthedisease。
　　7th。Inthisfoulatmosphereamputationdidnotarresthospitalgangrene;thediseasealmostinvariablyreturned。Almosteveryamputationwasfollowedfinallybydeath,eitherfromtheeffectsofgangreneorfromtheprevailingdiarrheaanddysentery。Nitricacidandescharoticsgenerallyinthiscrowdedatmosphere,loadedwithnoxiouseffluvia,exertedonlytemporaryeffects;aftertheirapplicationtothediseasedsurfaces,thegangrenewouldfrequentlyreturnwithredoubledenergy;andevenafterthegangrenehadbeencompletelyremovedbylocalandconstitutionaltreatment,itwouldfrequentlyreturnanddestroythepatient。Asfarasmyobservationextended,veryfewofthecasesofamputationforgangrenerecovered。Theprogressofthesecaseswasfrequentlyverydeceptive。Ihaveobservedafterdeaththemostextensivedisorganizationofthestructuresofthestump,whenduringlifetherewasbutlittleswellingofthepart,andthepatientwasapparentlydoingwell。Iendeavoredtoimpressuponthemedicalofficerstheviewthatinthisdiseasetreatmentwasalmostuseless,withoutanabundantsupplyofpure,freshair,nutritiousfood,andtonicsandstimulants。Suchchanges,however,aswouldallowoftheisolationofthecasesofhospitalgangreneappearedtobeoutofthepowerofthemedicalofficers。
　　8th。Thegangrenousmasswaswithouttruepus,andconsistedchieflyofbroken—down,disorganizedstructures。Thereactionofthegangrenousmatterincertainstageswasalkaline。
　　9th。Thebest,andintruththeonlymeansofprotectinglargearmiesandnavies,aswellasprisoners,fromtheravagesofhospitalgangrene,istofurnishliberalsuppliesofwell—curedmeat,togetherwithfreshbeefandvegetables,andtoenforcearigidsystemofhygiene。