Gangrene

Gangrene is the death of body tissue. It happens when tissue loses its blood supply, when infection kills it, or both. Doctors describe three main forms: dry gangrene, where tissue starved of blood shrivels and darkens; wet gangrene, where dead tissue becomes infected; and gas gangrene, a fast infection of muscle by Clostridium bacteria that produce gas and toxins. Dead tissue does not heal. It has to be removed.

Ancient medical writers knew it. Celsus, writing in the first century AD, describes gangrene and advises cutting the limb between healthy and dead tissue when nothing else stops it. For most of history, gangrene was one of the main reasons a wound that should have healed ended in amputation or death.

In the First World War, gas gangrene became a central surgical problem on the Western Front. Shell fragments drove soil, cloth and debris deep into muscle, and the fields of France and Flanders had been farmed and manured for generations. Delay made everything worse. The longer a wound waited for surgery, the more time the infection had.

1. Lost blood supply. A crushed limb, a damaged artery, a band left on too long, or frostbite cuts off oxygen. The tissue beyond it dies.
2. Infection. Bacteria grow in dead and damaged tissue, where the body's defences cannot reach. In wet and gas gangrene the infection spreads into living tissue nearby.
3. Gas gangrene. Clostridium bacteria grow where there is little oxygen, such as deep, dirty muscle wounds. Their toxins destroy muscle and enter the blood. It can spread through a limb in hours and cause shock and death.

Treatment in the First World War moved toward early surgery: opening the wound, cutting away dead and contaminated tissue (debridement), and leaving it open. Antiseptic irrigation, notably the Carrel-Dakin method, was added. When that failed, the answer was amputation. Antibiotics were not widely available until the Second World War.

• The Western Front, 1914–1918. Gas gangrene was a major cause of death and amputation among the wounded. Reducing it drove changes in when and how wounds were treated, including faster movement to surgery and routine debridement.