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Section II, Page 2

Contents

480

FIG.226.- Anterior of right thigh. There is considerable swelling and several small wounds, probably due to high explosive. The skin, which is extensively blackened, indicates that there has been a putrefactive infection of superficial hemorrhages. Accession number 2881, Army Medical Museum. Negative number 31831. (See fig. 227)


481

FIG. 227.- Posterior aspect of thigh of Fig. 226. There is a débrided high explosive wound with projecting muscle masses. Skin is blackened from putrefactive bacterial infection of subcutaneous hemorrhage. Accession number 2881, Army Medical Museum. Negative number 31931


482

FIG. 228.- Vertical section of right thigh, cutting through the center of the femur showing advanced putrefactive infection around the wound tract and moderate accumulation of gas below the tract. The muscle throughout the limb is textureless, a type of change seen in cases which clinically showed marked toxemia. Accession number 2881, Army Medical Museum. Negative number 3192


483

FIG. 229.– Internal aspect or the right upper arm. High-explosive wound of the middle of the biceps with marked swelling. The base of the wound is covered with a shaggy exudate and is surrounded by a raised zone of extruded muscle. The skin markings around the wound are obliterated by the tension upon the skin from below. The mid section through this arm shows a fracture of the humerus, a marked edema of the biceps, with little gas accumulation, and a putrefactive reaction about the wound tract and in the hemorrhage from the marrow. There is a loss of texture and color of the muscle secondary to the toxic type of gangrene. Accession number 2881, Army Medical Museum. Negative number 30856


484

FIG. 230.- Section of the wound tract in the thigh which shows massive hemorrhage, fragments of bone, dirt, and foreign bodies carried in by the missile. Accession number 2881, Medical Museum. Negative number 45855. Hematoxylin and eosin stain; X 470


485

FIG. 231.- Section from the margin of the wound tract, showing rupture of a muscle fiher, a loss of its markings and separation into myomeres. The fiber is surrounded by a purulent exudate which indicates a contamination of the wound tract at this point by pyogenic organisms. Accession number 2881, Army Medical Museum. Negative number 45853. Hematoxylin and eosin stain; X 505


486

FIG. 232.- Section from the putrefactive gangrenous area in the thigh. This shows organisms that resemble Welch bacilli, others with central spores, and members of the pyogenic group. There is splitting of muscle fibers and small accumulations of gas. Some of the splitting of fibers is probably due to direct trauma, as this section was taken from the wound tract. Accession number 2881. Army Medical Museum. Negative number 45849. MacCallum slain; X 545


487

FIG. 233.- Section of the gangrenous tissue in the arm, showing a cross section of a muscle fiber completely honeycombed with fine bubbles. There are occasional leucocytes and a few Gram-positive rods whose morphology is not clear enough to indicate the type. Accession number 2881, Army Medical Museum. Negative number 46255. MacCallum stain; X 2100


488

FIG. 234.– At the end of the muscle fiber there is a large rod-shaped organism with an end spore. There is solution of the fiber about this organism. Muscle markings are lost and there is a moderate accumulation of leucocytes. Accession number 2881, Army Medical Museum. Negative number 45850. MacCallum stain; X 2000


489

FIG. 235.- An area of hemorrhage around the wound tract in the thigh which showed a putrefactive gangrenous process. It is evidently a mixed infection with the gangrene group, the majority of which resemble Welch bacillus and vibrion septique. There are occasional diptheroids. Accession number 2881, Army Medical Museum. Negative number 46222. MacCallum stain X 950


490

FIG. 236.- External surface of the right foot with a débrided wound below the external malleolus measuring 5 by 9 cm. There is an ordinary gangrene of the anterior third of the foot, including all the toes, due to vascular occlusion. The skin surface of the remainder of the foot shows the reaction due to putrefactive gangrene. Accession number 2934, Army Medical Museum. Negative number 30961


491

FIG. 237.- Midsection of the foot shown in the preceding figure. There is Putrefactive gangrene of the os calcis and some of the neighboring bones and muscles around a hemorrhage in this area. There is a gaseous infiltration in the interosseus muscles about the level of the line of demarcation of the gangrene in the anterior portion of the foot. Accession number 2934, Army Medical Museum. Negative number 30961


492

FIG. 238.– Section from the gangrenous area of muscle in close relation to the wound tract. It showes formation of gas bubbles within muscle fibers, There are numerous foreign bodies throughout this section which are portions of the bearding of a wheat head. Accession number 2934, Army Medical Museum. Negative number 46031. MacCallum stain; X-780


493

FIG. 239.- Section from an area of emphysematosis gangrene in the interosseus muscles. The cross striations of the muscles are accentuated as a result of swelling and also from chemical change. Accession number 2934, Army Medical Museum. Negative number 46017. Hematoxylin and eosin stain; X 200


494

FIG. 240.- Section from near the same area as that of the preceding figure. There is gas in the swollen muscle fibers and a marked variation in their staining reaction. There is an occasional rod-shaped Gram-positive organism in close relation to muscle fibers. Accession number 2934 Army Medical Museum. Negative number 46,023. MacCallum stain; X 265


495

FIG. 241.- Section from the same area as the preceding figures, somewhat nearer the wound tract. It shows numerous Gram-positive and Gram-negative rods and coccoid organisms. Muscle fibers are swollen and markings lost. Accession number 2934, Army Medical Museum. Negative number 46036. MacCallum stain; X 575


496

FIG. 242.– Section from a frankly putrefactive gangrenous area. There is marked degeneration of muscle with coarse granular debritus within fibers and many organisms with terminal and central spores, most of which are Gram-positive. The picture is typical of the putrefactive gangrenous process. Accession number 2934, Army Medical Museum. Negative number 46035. MacCallum stain; X 660.


497

FIG. 243.- Vertical section of the left leg cut Posterior to the tibia, the upper third of which has been shot away by high-explosive shell fragments. There is a thrombosis of the Popliteal vessel and its branches. There is a putrefactive gangrene in the calf muscle around the tibial arteries. There is a small amount of gas in the inner aspect of the calf muscles. The remainder of the calf muscles show loss of muscle texture and color characteristic of the toxic type of gangrene. Accession number 2892, Army Medical Museum. Negative number 32110


498

FIG. 244.- The surface shown is cut several centimeters posterior to the preceding section. It shows a portion of the wound tract with a surrounding putrefactive gangrene. The remaining muscles show the toxic type of gangrene, excepting the gastrocnemius, occupying the middle of the lower portion of the picture, which alone shows a well advanced emphysematous type of gangrene, with wide separation of muscle bundles by large bubbles of gas. Accession number 2892, Army Medical Museum. Negative number 32106


499

FIG. 245.- X ray of the left leg, showing numerous foreign bodies and evidence of emphysematous gangrene apparently confined to the single muscle shown in the preceding photograph. Accession number 2892, Army Medical Museum. Negative number 46817


500

FIG.246.- Section from the gangrenous emphysematous gastrocnemius which shows at the margin of two gas bubbles muscle fibers which are split by gas yet retain their cross striations. There are a few round-ended rods, which appear from their morphology to be Welch bacilli. Accession number 2892, Army Medical Museum. Negative number 46296. MacCallum stain; X 750


501

FIG. 247.- Section from the same area as the preceding figure. It shows accumulation of gas between muscle bundles, and around four separate fibers which are swollen approximately four times the size of neighboring fibers. These four fibers have undergone chemical alteration which makes them take the basic dye intensely. Accession number 2892, Army Medical Museum. Negative number 46299. MacCallum stain; X 230


502

FIG. 248.- Section from around the tibial arteries, showing the putrefactive gangrenous process. There is fragmentation of muscle fibers, a variety of rod-shape organisms, and an occasional coccoid form. There is a moderate accumulation of leucocytes. Accession number 2892, Army Medical Museum. Negative number 46297. MacCallum stain; X 730


503

FIG. 249.– Section from the same area as the preceding figure, showing a lymphatic distended with gas and lined by masses of bacteria. Accession number 2892, Army medical museum. Negative number 46293. MacCallum stain; X 750


504

FIG. 250.- Section is from the gastrocnemius which shows the emphysematous reaction. The muscle is split by gas and there is a chemical change of the muscle fibers as indicated by retention of the basic dye. Numerous coccoid organisms are visible. Accession number 2892, Army Medical Museum. Negative number 46291. MacCallum stain; X 640


505

FIG. 251.- Mid section of the thigh amputated in the upper third, with thrombosis of the femoral artery and vein and marked gaseous gangrene of muscle bundles on both sides of these vessels. Accession number 2789. Army Medical Museum. Negative number 30881


506

FIG. 252.- Mid vertical section in the upper portion of the thigh with fracture through the condyles. There is marked secondary infection of the bone marrow of all fragments, and an extensive gas gangrene with massive gas accumulation along fascial planes. Accession number 2789, Army Medical Museum. Negative number 30880


507

FIG. 253.- Cross section through a medium-sized artery. There is an extreme shredding of the adventitia of this vessel, with gaseous gangrene of the muscular coat. The bulk of this damage is probably due to the effect of the missile and indicates a rupture of the vessel above or below this point. With the rupture below, this is the typical form produced by the missile at a distance from the injury through hydraulic transmission of the force, which resulted in the massive secondary hemorrhages in these wounds. There are numerous bacteria in the walls of the vessel and its lymphatics. One rounded rod occupies a gas bubble in the muscular coat. Accession number 2789, Army Medical Museum. Negative number 46074. MacCallum stain; X 235


508

FIG. 254.- Cross section of muscle fibers from the putrefactive area. There is a granular hemoglobin detritus in all fibers, extensive chemical in the two central fibers, indicated by retention of the basic dye, and numerous accumulations of gas around muscle bundles. Bacteria are numerous and are all Welch bacilli, as is indicated by form and staining reaction. Accession number 2789, Army Medical Museum. Negative number 46053. MacCallum stain; X465


509

FIG. 255.- Muscle fibers from a gangrenous area showing large gas bubbles in muscle bundles. Accession number 2789, Army Medical Museum. Negative number 46056. MacCallum stain; X 125


510

CASE 13.- Gunshot wound of left arm with comminuted fracture of the lower third of humerus, complicated by gas gangrene. Wound of entrance on posterior surface; large wound of exit on anterior surface with hernia of biceps muscle. Amputated limb shows gas gangrene in the muscles of the forearm with considerable putrefactive change in the tissues of the upper arm. The skin, over tissue filled with gas, is greenish in color and there is separation of the tissues along fascial planes as a result of the accumulation of gas. (See figs. 266 to 272, inclusive.)

CASE 14.- Soldier was wounded by fragment of high explosive shell, resulting in a compound comminuted fracture of the femur followed by the toxic type of gas gangrene. The specimen consists of the amputated thigh showing a debrided wound on the anterior surface whose base is covered with a shaggy exudate. (Fig. 273.) This thigh shows an extreme swelling due more to edema than to gas. The wound shows the extent of this swelling by the bulging of its edges. There is a moderate amount of blackening of the skin around this wound. This is a typical example of the toxic type of gas gangrene. (See figs. 273 to 275, inclusive.)

The mixed form of gas gangrene was a combination of the three types and presented all of their features. It stood third in the scale of virulence, and occasionally was found among the avirulent forms. There was usually a fairly pure infection of the deep muscles by either B. welchii, V. septique or B. edematiens, with invasion of the edematous fascial planes and lymphatic structures by the putrefactive anaerobes. The deeper muscles were brick red or pale, and were dry or moist, according to the bacteria producing the lesion. The putrefactive infection blackened connective tissues around lymphatics, and only tended to involve the exposed muscles in the base of the d brided wounds of entrance and exit. The following cases illustrate this type of gas gangrene.

CASE 15.- Soldier was wounded October 25, 1918, by high explosive shell; died October 28, from sepsis and gas gangrene. Specimen consists of a left leg showing a severe, compound comminuted fracture of both bones, and penetrating gun-shot wounds.

There is a wound, 3 by 5 cm., at the middle of the tibia in the anterior midline and another 2 by 3 cm., 2 cm. inferior and 3 cm. posterior to the internal malleolus.

The X ray shows many foreign bodies and shell fragments, posterior to an extremely comminuted fracture of the tibia, at the middle third, and oblique fracture of the fibula at the same level. There are multiple foreign bodies in the region of the os calcis, one measuring 1½ by 2½ cm. in the midline just below the posterior margin of this bone. (See figs. 276 to 283, inclusive, and Pls. XX and XXI.)

CASE 16.- Soldier received a high explosive shell wound of the popliteal space July 21, 1918. Wound of entrance was two inches above the popliteal space and there was a fragment of shell in the joint. The limb was amputated in the upper third of the right thigh on July 22, for gas gangrene, approximately 60 hours after receipt of the wound.

The amputated limb shows discoloration of the skin in the popliteal space and a small entrance wound. On dissection the popliteal nerve is found to be partially severed; the popliteal vein is ruptured laterally; the artery is completely severed and the surrounding tissues are impregnated with blood. The knee joint contains reddish fluid and the synovial membrane is red in color. There is some gas in the surrounding muscles and areolar tissue, which extends also into the muscles of the thigh and upper calf. (See figs. 284 to 287, inclusive.)

CASE 17.- Wound by high explosive shell fragment through the lower third of the leg. Specimen consists of the lower half of the leg from which the foot has been removed, by disarticulation at the ankle. On the internal side there is a large débrided wound. There is an oblique fracture of the tibia, 9 cm. from the lower end and a transverse fracture of the fibula at about the same level, the ends of this bone being separated by intervening muscle. The tissues show gas gangrene. There are several foreign bodies about the fractured bones including a shoe islet in the tissues a short distance from and opposite the lower end of the tibia. (See figs. 288 to 294, inclusive.)


PLATE XVIII

NECROTIC MUSCLE FIBERS

Variation in staining due to chemical changes. (See Fig. 262)
Accession 2891, Army Medical Museum. H. & E. Stain. Autochrome.


PLATE XIX

GAS GANGRENE.

Cross section of muscle from an area of toxic edema near the wound tract. Contamination with pyogenic bacteria. Necrotic muscle fibers show variations in their affinity for the dyes.
Accession 2891, Army Medical Museum. MacCallum stain. Autochrome.


511

FIG. 256.- Right arm amputated through the surgical neck of the humerus, showing a large debrided wound of the inner aspect which runs from the site of amputation to the inner condyle. The lower arm has been cut away, as it showed no lesion. Débridement was apparently done to remove all the damaged muscle and to assure the operator of the condition of the main nerves and arteries. There is little exudate on this wound except over the belly of the biceps, which appears to be swollen and contains a few gas bubbles. Accession number 2891, Army Medical Museum. Negative number 32076


512

FIG. 257.- Anatomical dissection of the arm shown in the preceding figure done to illustrate the injury to the musculospiral nerve. It shows beginning gangrene of a putrefactive character around a hemorrhage opposite the upper end of the lower fragment of the humerus, which has extended into the musculospiral sheath at this level. Except for this hemorrhage the nerve at this point is uninjured. There is some blackening of the skin in the bend of the elbow, secondary to a putrefactive gangrene at this point. The X ray of this specimen does not reveal any gross evidence of gangrene. Accesion number 2891, Army Medical Museum. Negative number 32077


513

FIG. 258.- Mid section of the arm of the preceding figures showing a beginning putrefactive gangrene around the lower third of the humerus, with some accumulation of gas bubbles in the muscles above this area There is a fibrinous exudate around the fracture which extends into the marrow of both fragments The muscles around this point show lack of texture and color typical of the toxic or edematous type of gas gangrene. Accession number 2891, Army Medical Museum. Negative number 32072


514

FIG. 259.- Section from the edematous muscle around the fractured humerus. There is evidence of gross damage to the muscle due to trauma, massive hemorrhage with edema, and beginning gangrene of the muscles, which are infiltrated with blood. There are numerous small accumulations of edematous fluid throughout. Accession number 2891, Army Medical Museum. Negative number 45628. Hematoxylin and eosin stain; X 13


515

FIG. 260.– Section from the margin of the gangrenous reactions around the fracture. There is marked edema along the fascial plane in the upper portion of the picture and a large accumulation of edema fluid in the lower left hand area. There is beginning accumulation of gas between muscle bundles. Accession number 2891, Army Medical Museum. Negative number 45631. Hematoxylin and eosin stain; X 23


516

FIG. 261.- Section taken from the area between the emphysematous and edematous areas of gangrene. It shows extreme edema between muscle fibers and their envelopes, and between muscle bundles, and a beginning formation of gas within muscle fibers. It is a typical example of the tissue changes in the toxic form of gas gangrene which, if it does not cause amputation or kill, goes on to the pure emphysematous type. Accession number 2891, Army Medical Museum. Negative number 45626. Hematoxylin and eosin stain; X 290


517

FIG. 262.- Cross section of muscle fibers from the typical edematous area of gangrene. It shows massive edema everywhere within muscle envelopes and between muscle bundles. There is a beginning accumulation of fine gas bubbles within all of the fibers. There is pyknosis of muscle nuclei and a ground-glass appearance of the fibers, one of which shows a crescent of liquefied material within the fiber itself. This crescent has undergone a chemical alteration which results in an affinity for the basic dye. Accession number 2891, Army Medical Museum. Negative number 45624 Hematoxylin and eosin stain; X 710


518

FIG. 263.- Section from an area near the wound tract showing a moderate amount of edema, a marked swelling and loss of markings in muscle fibers, with a moderate chemical alteration of these structures, as indicated by retention of the basic dye. The chemical change is secondary to a beginning emphysematous gangrene which forms acid in the tissues. The edema has separated muscle fibers about twice their normal distance, and the degeneration in them is marked by the intense pyknosis of the nuclei of the sarcolemma. In the lower portion of the picture is a cross section of a leaf carried in by the missile. Two other small foreign bodies lie near it. Accession number 2891, Army Medical Museum. Negative number 46000. MacCallum stain; X 285


519

FIG. 264.– Section from the emphysematous area of gangene in the biceps muscle, which shows a marked alteration in reaction of the muscle fibers to the basic dye. Portions of the myomeres in some of them appear jet black from the intensity of staining with crystal violet and basic fuchsin. Accession number 2891, Army Medical Museum. Negative number 46039. MacCallum stain; X 300


520

FIG. 265.- Section in close relation to the wound tract, showing an early regeneration of muscle fibers. Considerable edema is between muscle bundles. Accession number 2891, Army Medical .Museum. Negative number 46037. Hematoxylin and eosin stain; X 250


521

FIG.266.- Mid section.of the left arm showing an emphysematous gangrene around a fracture of the humerus. Numerous gas bubbles are in the biceps, and an advanced putrefactive and edematous process is in the triceps muscle. The muscles of the forearm show advanced autolysis, probably due to vessel injury at the site at fracture. Accession number 2797, Army Medical Museum. Negative number 32079


522

FIG. 267.- Palmar surface of the left hand with the typical gangrene due to complete failure of the blood supply, the end result of the process of autolysis of the muscles noted in the forearm in the preceding figure. Accession number 2797, Army Medical Museum. Negative number 46254.


523

FIG. 268.- Cross section of the forearm showing the emphysematous process well established in the muscles and connective tissues of the wrist, as evidence by the numerous gas bubbles. Accession number 2797, Army Medical Museum. Negative number 46252


524

FIG. 269.- X ray showing accumulations of gas around the point of fracture in the muscles of the upper arm and between the radius and ulna in the lower arm. Accession number 2797, Army Medical Museum. Negative number 46258


525

FIG. 270.- Muscle fibers cut in cross section near vessels. There is a loss of normal markings of muscle fibers. One fiber in cross section shows an accumulation of gas and hemoglobin detritus. Occasional gas bubbles are between the fibers. There is an infected thrombus in the vessel with surrounding edema and gaseous infiltration. Accession number 2797, Army Medical Museum. Negative number 45993. Hematoxylin and eosin stain; X 210


526

FIG. 271.- Section from the same area as the preceding figure, showing a leucocytic exudate in the débrided wound and considerable rupture of muscles due to gas bubbles. One muscle fiber shows coarse scattered hemoglobin detritus. Accession number 2797, Army Medical Museum. Negative number 45994. Hematoxylin and eosin stain; X 235


527

FIG. 272.- Section of gangrenous muscle, showing marked chemical alteration, probably due to the acid-forming power of these bacteria and evidenced by the intense basic staining of parts of the fibers. One fiber shows a solution of the muscle tissue, the cavity containing Gram-positive and Gram-negative rods. Both fibers show blood detritus. There is a moderate leucocytic reaction. Coccoid forms and various sizes of Gram-positive and Gram-negative rods are present. Accession number 2797, Army Medical Museum. Negative number 46069. MacCallum stain; X 570


528

FIG. 273.- Debrided high-explosive shell wound of thigh. Secondary toxic edematous type of gangrene. Marked bulging of the muscles forcing the edges of the wound apart. Considerable blackening of the skin. Accession number 2923, Army Medical Museum. Negative number 31717


529

FIG. 274.- Mid section of the thigh through the fractured femur, showing a moderate amount of gas gangrene of the internal group of muscles and an extreme edema in the outer group. Accession number 2923, Army Medical Museum. Negative number 31716


530

FIG. 275.- X ray of the specimen of the two preceding figures; shows a moderate amount of gas gangrene, comminution of the fracture, and a piece of high-explosive shell casing, probably of a small-caliber shell. Accession number 2923. Army Medical Museum. Negative number 46818


PLATE XX

TYPICAL GAS GANGRENE OF CALF MUSCLES.

Darker color near bone produced by putrefactive organisms. Brick-red color of gas gangrene with separation of muscles by gas. Shell fragment 1 x 1 ½cm. behind proximal fragment of tibia which shows purulent myelitis.
Accession 4711, Army Medical Museurn. Colored photograph.


PLATE XXI

PUTREFACTIVE GANGRENE

Muscle fibers showing Gram-positive and negative rods and Gram-positive cocci. Accession 4711, Army Medical Museum. MacCallum stain. Autochrome.


531

FIG. 276.- Anterior aspect of a vertical section of the left leg, showing a fracture of the fibula and tibia. A foreign body, apparently apiece of a medium-sized high-explosive shell, is internal to the lower end of the upper fragment of the fibula. The muscles of the calf above the fragment show atypical gas gangrene without much gas. The muscles and connective tissue below and internal to the foreign body show a putrefactive form of gas gangrene. Accession number 4711, Army Medical Museum. Negative number 30211


532

FIG. 277.- Posterior aspect of a vertical section through the middle of the tibia showing a comminuted fracture of this bone, with mixed putrefactive and edematous infection of the muscles about the upper end of the lower fragment and gas gangrene of the calf muscles above. The muscles show the typical brick-red change due to this process, though there are no massive accumulations of gas. Accession number 4711, Army Medical museum. Negative number 30212


533

FIG. 278.- Fragment of bone surrounded by putrefactive gangrene. This section was taken from the deeper layers of the gangrene and at a distance from the shell fragment. Accession number 4711, Army Medical Museum. Negative number 46156. Hematoxylin and eosin stain; X 115


534

FIG. 279.- Section of the gaseous area showing a distinct shredding of the coats of a medium sized vein of the type caused by the missile at a distance from the tract. The artery shows stripping of its intima, which could be caused by the infection. Lack of hemorrhage indicates that the force which shredded this vessel must have severed it considerably above this level. Accession number 4711, Army Medical Museum. Negative number 46159. Hematoxylin and eosin stain; X 115


535

FIG. 280.- Muscle fibers from the gaseous area of gangrene. There is little gas formation; considerable damage of the fibers, probably from swelling, and some irregularity of staining due to the chemical changes produced by the gas gangrene. Accession number 4711, Army Medical Museum. Negative number 46145. Hematoxylin and eosin stain; X 810


536

FIG. 281.- Muscle fibers in the putrefactive area of gangrene. The fibers are segmented and partially liquefied. There are two types of Gram-positive rods shown which appear to be Welch bacilli and one of the putrefactive group. The latter show terminal spores. Small amounts of gas were present. Accession number 4711, Army Medical Museum. Negative number 46151. MacCallum stain; X 810


537

FIG. 282.- Muscle fibers from an area of putrefactive change in gas gangrene. There is a rupture across one fiber and a "ground-glass" degeneration of the lower right-band fiber. The remaining fiber retains faintly some of its cross striations. This is a putrefactive area with marked mixed infection near the wound tract. There are present numerous Gram-positive and Gram-negative rods, diphtheroids, and cocci. Accession number 4711, Army Medical Museum.Negative number 46147. MacCallum stain; X 810


538

FIG. 283.- Muscle fibers from a contaminated area near the wound tract. There is a far greater variety of contaminating organisms and much more muscle change than is shown in. Fig. 282. There are numerous Gram-positive and Gram-negative rods and a much greater number of cocci. Accession number 4711, Army Medical Museum. Negative number 46152. MacCallum stain; X 810


539

FIG. 284.- Mid section of the lower third of the thigh and upper two-thirds of the leg. There is massive damage to the muscles in the popliteal area and to the Posterior thigh and calf muscles. The popliteal and thigh muscles appear to be affected by a putrefactive gangrene. There are small accumulations of gas in the calf muscles. Accession number 2918, Army Medical Museum. Negative number 32232


540

FIG. 285.- X ray of the leg shows a moderate accumulation of fine gas bubbles in the muscles extending to the middle third of the fibula. Accession number 2918, Army Medical Museum. Negative number 46260


541

FIG. 286.- Muscle fibers from the putrefactive area in th popliteal region. There is considerable edema, probably secondary to the trauma. Fragment of muscle fiber in the edematous area in the center of the picture due rather to the missile than to gas formation. Occasional round-ended rods are seen, which are apparently Welch bacilli. A few leucocytes are present. Accession number 2918, Army Medical Museum. Negative number 46166. MacCallum stain; X 710


542

FIG. 287.- Section from the gaseous area of the calf muscle showing two masses of foreign bodies, evidently dirt, in accumulations of gas. There are occasional bacteria, rare leucocytes, and moderate "ground-glass" and blood detritis changes in the muscle fibers. The bacteria are all in vegetative form, and there is evidence that there is a mixed infection, forms like Welch bacilli being common. Barred forms of a diphtheroid character are seen near the foreign bodies. Accession number 2918, Army Medical Museum. Negative number 46167. MacCallum stain; X 710


543

FIG. 288.- Outer aspect of the left leg with high-explosive wound about 2 cm. in diameter cm., above the external malleolus. The instep shows desquamation of the skin characteristic of the ordinary gangrene due to vascular occlusion. Above this the skin shows some of the blackening characteristic of putrefactive gangrene. Accession number 2802. Army Medical Museum. Negative number 32257


544

FIG. 289.- Anterior aspect of the left leg with the foot disarticulated at the ankle joint. A debrided wound approximately 8 cm. in length has been dissected away, exposing the fractured ends of the tibia and fibula. The muscles, especially those between the two bones, show gas bubbles. Beneath the skin in front of the tibia is a putrefactive reaction which parallels this bone. Accession number 2802, Army Medical Museum. Negative number 32256


545

FIG. 290.- Mid section of the specimen through both bones, showing a massive clot in the marrow of the tibia undergoing a putrefactive process and putrefactive change, beneath the skin in front of the tibia. Some putrefactive gangrene is around the upper end of the lower fragment of the fibula. A moderate accumulation of gas is in the muscles about the fibula. Accession number 2802, Army Medical Museum. Negative number 32256


546

FIG. 291.- X ray showing fracture of both bones with foreign bodies, probably fragments of small-caliber high-explosive Medical Museum. Accession number 2802, Army Museum. Negative number 46268


547

FIG. 292.- Section from the putrefactive area around the larger blood vessels. It includes a missile tract which scores the margin of the posterior tibial artery. The wall of the vessel is split at this point, and a small thrombus has formed on that part of the intima nearest the injury. Two small veins in the left-hand lower portion of the picture near the wound tract show rupture of their walls. This whole area showed considerable hemorrhage undergoing putrefactive changes. Edema and gas are along the wound tract, especially about a bundle of nerve fibers. Accession number 2802, Army Medical Museum. Negative number 46176. Hematoxylin and eosin stain; X 26


548

FIG. 293.- The missile tract showing a tear through the adventitia and media of the artery and a separation of the media from the internal coats and the small thromhus. There is a moderate hemorrhage, a low-grade infection, and some accumulation of gas. There is a rupture of a medium-size nerve sheath, with accumulation of edema and gas between the nerve fibers. Accession number 2802. Army Medical Museum. Negative number 46178. Hematoxylin and eosin stain; X 105


549

FIG. 294.- Beginning chemical change in the muscle fibers, resulting in retaining the basic dye in an irregular marblelike distribution. Accession number 2802, Army Medical Museum. Negative number 46163. MacCallum stain; X 710


550

The putrefactive form of gas gangrene rarely occurred in purity, but often involved the superficial lymphatics, and areolar connective tissue near the wound tract of avirulent as well as virulent forms. The avirulent form very often was accompanied by bronzed erysipelas, especially when the putrefactive bacteria invaded extremely superficial extravasations of blood, near enough to the surface to be seen through the skin. It only became virulent when accompanied by pyogenic bacteria or when it occurred late in shock cases, or those secondary anemias following severe hemorrhage. The following cases illustrate the putrefactive form of gas gangrene.

CASE 18.- Perforating machine gun bullet wound of the left thigh, with compound, comminuted fracture of the femur and gas infection. Débrided 48 hours after the injury. Amputation was done for gas gangrene, three days after the débridement. The specimen consists of left thigh amputated at its middle third, with the leg cut away 8 cm. below the patella. There is a debrided wound of entrance on the inner aspect of the posterior surface of the thigh 4 cm. in diameter, 10 cm. above the internal condyle and 4 cm. internal to the midline. There is a débrided wound of exit 6 cm. in diameter on the outer aspect of the anterior surface of the thigh 6 cm. higher than the wound of entrance. Both wounds are lined by a greyish-green exudate, and bony fragments can be seen in the anterior wound. (See figs. 295 to 303, inclusive.)

CASE 19.- Soldier received a bullet wound of the right leg at 8 a.m., October 28, 1918. There was a perforating wound with compound comminuted fracture of both bones. The wound was débrided at 8 p.m., October 29. Amputation November 3 for gas gangrene.

Amputated limb shows a débrided wound on the external surface measuring 12 by 4 cm., beginning 5 cm. below the head of the fibula. There is a similar wound on the inner aspect. Both wounds are lined with a shaggy exudate and the tissues of the calf are swollen and boggy. A median vertical section shows a fracture of the tibia at the middle third with marked comminution and a fracture of the fibula at the same level. There is extensive gas gangrene of all the calf muscles with a secondary mixed infection of the muscles on the inner or tibial sides. There is also a myelitis of both fragments of the tibia. (See figs. 169 and 304 to 307, inclusive, and Pl. XXII.)

The avirulent gas gangrene is usually a mild form of the putrefactive type and is very often accompanied by bronzing of the skin over the lesion. This is produced by an oxidation of superficial subcutaneous hemorrhages, in which the blood is oxidizing and producing those variations of blue, black, and bronze, that occur in an ordinary "black eye." The mechanics is not unlike that of this condition, plus a mild form of infection. This bronzing is a valuable symptom since, unless there is a massive amount of swelling in an injured limb, it indicates that the infection is an avirulent one and ordinarily does not require any surgical interference. The following case illustrates the avirulent form of gas gangrene.

CASE 20.- This soldier entered an evacuation hospital 48 hours after receiving two machine gun wounds of the chest and one of the calf of the left leg. The wounds of the chest were cleaned and closed, and the leg wound was debrided. A bronzing of the whole of the calf of the leg began 48 hours after debriding, but the swelling was only moderate and since the symptom of bronzing indicates only mild forms of gas gangrene, the wound was Dakinized and amputation advised against.

A streptococcus empyema began on the fifth day and the patient sank rapidly. A delayed gangrene of the muscles of the leg began on the tenth day and amputation was performed. The soldier died on the fifteenth day.

Autopsy revealed that death was due to a streptococcus septicemia and the gas gangrene in the leg was secondary, being reestablished during the terminal process of the septicemia when hemolytic jaundice and failure of the circulation made it possible. (See figs. 308 to 312 and Pls. XXIII and XXIV.)


551

FIG. 295.- External surface of the left thigh amputated at the middle third, A machinegun bullet wound 4 cmt, in diameter, 9 cm,. above the knee joint, has been debrided, is covered with a shaggy exudate, and the muscles surrounding the wound are under extreme pressure and extrude above the Surface of the skin, There has been some bronzing of the skin in the fold of the knee joint. Accession number 4709, Army Medical Museum. Negative number 32107


552

FIG 296.- Mid section of the thigh of Fig. 295. There is a wound tract running obliquely down from the wound of entrance and internally, making its exit in the posterior fold of the knee, rupturing the profunda femoris artery just above the popliteal vessels. All of these vessels are thrombosed. There is putrefactive change all along the wound tract, with exudate in the tract itself and blackening of the surrounding muscles. There is gas gangrene of the biceps muscle, which involves the lower fourth of that part of the muscle shown in the picture. There are gas bubbles in this area and a loss of normal color and markings in the neighboring muscles. Accession number 4709, Army Medical Museum. Negative number 32105


553

FIG. 297.– Section of muscle from the putretative area. There are numerous Gram-negative and Gram-positive rods, no leucocytic reaction, and a fine granular hemoglobin detritus in muscle fibers. Accession number 4709, Army Medical Museum. Negative number 30928. MacCallum stain; X1200 FIG. 298.- Liquefaction of approximately, two-thirds of a muscle fiber. All fibers are separated by gas which has penetrated the muscle envelopes. Many of the fibers contain a fine hemoglobin detritus. Accession number 4709, Army Medical Museum. Negative number 31045. MacCallum stain, X 1500


554

FIG. 299.- Gram-positive bacilli between muscle fibers from an area of putrefactive gangrene. Some of them show barred staining. Accession number 4709, Army Medical Museum. Negative number 31040. MacCallum stain; X 1000 FIG. 300.- Cross section of a small nerve fiber with marked shrinkage and an accumulation of gas about them and within the nerve sheath. Accession number 4709, Army Medical Museum. Negative number 46110. Hematoxylin and eosin stain: X 700


555

FIG. 301.– Muscle fibers in close relation to the wound tract. Rupture of fibers probably by the trauma of the missile. Numerous leucocytes indicate a pyogenic invasion. One muscle fiber in the lower right-hand corner shows chemical change, as indicated by retention of the basic dye. Accession number 4709, Army Medical Museum. Negative number 46117. Hematoxylin and eosin stain; X900


556

FIG. 302.- Muscle fibers separated by gas and exudate. This area was near the wound tract and shows a marked leucocytic infiltration, as well as a large amount of gas. There are marked chemical changes in muscle fibers, as evidenced by the marked variation in the way in which they take the stain. One fiber in the upper central area contains a relatively large gas bubble. Accession number 4709, Army Medical Museum. Negative number 46172. MacCallum stain; X 200


PLATE XXII

COMMINUTED GUNSHOT FRACTURE OF TIBIA.

Putrefactive infection of the marrow cavity of the lower fragment. Putrefactive gangrene of muscles and connective tissues to the right of this fragment. The calf muscles show a mixed form of gangrene with little accumulation of gas. Accession 4717, Army Medial Museum. Colored photograph.


557

FIG. 303.- Necrotic muscle fibers in the gaseous area cut in cross section. They contain gas bubbles, and show marked chemical alteration. There are a few bacteria and a moderate leucocytic infiltration. Accession number 4709. Army Medical Museum. Negative number 46111. MacCallum stain; X 545


558

FIG. 304.- Cross section of a medium-sized artery showing marked shredding and swelling of the adventitia, with a zone of edema between it and the media. The perivascular lymphatics are filled with leucocytes. This is the type of injury to the bloods vessels which, when accompanied by secondary pyogenic infections, undergoes thrombosis and gives rise to secondary hemorrhage. The vessel usually shows a linear tear when hemorrhage occurs. Accession number 4717, Army Medical Museum. Negative number 46072. Hematoxylin and eosin stain; X 180


559

FIG. 305.- Clot in tissue near vessel shown in Fig. 304. it contains numerous leucocytes and diplococci, probably a mixture of pyogenic cocci. Accession number 4717, Army Medical Museum. Negative number 46149. MacCallum stain; X 830


560

FIG. 306.- Field of the hemorrhage in the gangrenous area which contains numerous cocci and rod-shaped bacteria. There are no forms which appear like the uniform round-ended Welch bacillus, which probably accounts for the small amount of gas in this case. Accession number 4717, Army Medical Museum. Negative number 46068. MacCallum stain; X 870


561

FIG. 307.- Cross section of a small vessel in the putrefactive area. There are many large evenly staining, Gram-positive rods in the perivascular lymphatics. The circulation of this vessel remained intact to the time of amputation, and these organisms had not invaded its lumen. Accession number 4717, Army Medical Museum. Negative number 46067. MacCallum stain; X 870


562

FIG. 308.- Four cross sections of leg shown in Plate XXIII (black lines indicate areas): (1) Section from above the wound, showing almost complete involvement of the muscles; (2) section at the upper limit of the debrided wound in the skin, which shows complete involvement of all muscles at this level by the putrefactive process; (3) section taken at the level of the middle of the débrided skin wound. It shows extension of the putrefactive gangrene process to the heavy muscles of the calf and to the perivascular areas around the posterior tibial artery and the surrounding muscle. Anterior muscles appear free from the infection; (4) section from area indicated by the lowest black lines, showing a blackening around the perivascular lymphatics from reverse lymphatic flow and putrefaction. Accession number 4705, Army Medical Museum. Negative number 46253


PLATE XXIII

BRONZING OF SKIN IN AVIRULENT GAS GANGRENE. Bronze erysipelas. This is a valuable clinical sign, as it usually indicates that no further surgical interference is necessary when it appears. Accession 4705, Army Medical Museum. Autochrome.


PLATE XXIV

PUTREFACTIVE GANGRENE. Cross section of leg shown in Plate XXIII. Putrefactive lesions are near the surface in relation to superficial hemorrhages near the debrided wounds. Accession 4705, Army Medical Museum. Autochrome.


563

FIG. 309.- Area of putrefactive gangrene of the muscles with beginning gas gangrene in one or two fibers, while the group of muscle fibers in the upper left and lower right corners show a much more gaseous process, with gas bubbles in the center of fibers between them and around the muscle bundles. Accession number 4705, Army Medical Museum. Negative number 46237. MacCallum stain; X 250


564

FIG. 310.- Field from the putrefactive gangrenous area with a beginning gaseous process. It shows a slight leucocytic reaction, some laking of muscle fibers , and in the tower left-hand corner a fiber containing a small gas bubble in its center. There is little chemical change. Accession number 4705, Army Medical Museum. Negative number 46235. Hematoxylin and eosin stain; X 195


565

FIG. 311.- Section of muscle fibers. Fiber in the center, with comparatively few bacteria around it, has gas bubbles in its center and a collection of gas beneath its sarcolemma. The other fibers show numerous forms or bacteria-Gram-positive and Gram-negative rods with terminal and subterminal spores and occasional cocci. This is a typical picture in putrefactive gangrene and indicates why it is difficult to determine the bacteria which produce it. Accession number 4705, Army Medical Museum. Negative number 46232. MacCallum stain; X 846


566

FIG. 312.– Field from a section of putrefactive gangrene of muscle with considerable gaseous change. The bacteria are few in number and variety, consisting chiefly of those bearing terminal spores. Accession number 4705, Army Medical Museum. Negative number 46224. MacCallum stain; X 835


567

REFERENCES

(1) Weinberg, M., et Séguin, P.: La Gangrène gazeuse. Bactériologie, Reproduction expérimentale, Sérothérapie. Monographes de l'Institut Pasteur, Paris, l918, Masson et Cie.
(2) McCampell, E. F.: The Toxic and Antigenic Properties of Bacterium Welchii. The Journal of Infectious Diseases, Chicago, 1909, vi, No. 4.
(3) Korentchevsky, W.: Contribution à 1étude biologique du "B. Perfringens" et du "B. Putrificus." Annales de l'Institut Pasteur, Paris, 1909, xxiii, No. 1, 91.
(4) Jablons, Benjamin: Pathology of War Surgery. Journal of the American Medical Association, Chicago, 1915, lxiv, No. 25, 2045.
(5) Klose, F.: Ueber toxin und antitoxin versuche mit dem Fränkelschen Gasbrandbacillus. Münchener medizinische Wochenschrift, 1916, 1xiii, 723.
(6) Bull, Carroll G., and Pritchett, Ida W.: Toxin and Antitoxin of and Protective Inoculation against Bacillus Welchii. Journal of Experimental Medicine, New York, 1917, xxvi, No. 1.
(7) Joffe, J. S., and Conn, H. J.: Factors Influencing the Activity of Spore-forming Bacteria in Soil. New York State Agriculture Experimental Station Technical Bulletin, 1923, No. 97.
(8) Based on sick and wounded reports sent to the Surgeon General.
(9) Sweetser, T. H.: Report to the director of laboratories, A. E. F. on wound bacteriology, at Base Hospital No. 15, A. E. F. On file, Historical Division, S. G. O.
(10) Petit, R. T.: Report to the director of laboratories, A. E. F., on wound bacteriology at Evacuation Hospital No. 8, A. E. F. On file, Historical Division, S. G. O.
(11) Bashford, E. F.: General Pathology of Acute Bacillary Gangrene Arising in Gunshot Injuries of Muscle. The British Journal of Surgery, London, 1916-1917, iv, 562-596.
(12) Emery, W. d'Este: The Biology of Clostridium Welchii. Journal of Bacteriology, Baltimore, 1920, v, 375-429.