THE progress of the British Army from the Middle East to Tunisia, to Sicily, and to Italy has been attended by a gradual increase in the incidence of gas gangrene among the wounded. This increase has been barely perceptible to the clinical surgeon, but is borne out by the figures of incidence-3.4 per 1000 in the Middle East, and 6.7 per 1000 in Tunisia (MacLennan, 1944). In Italy the true figure cannot yet be stated, but it will not be less than 10 per 1000. Although gas gangrene is now more common, as was to be expected when the cultivated fields of Europe became the battlefield, it is by no means rampant, owing to early and good surgery.
In Tunisia the mortality from gas gangrene was tending to diminish (30 per cent in 44 cases -MacLennan, 1944), and this improvement was rightly attributed to education of the surgeons in accurate diagnosis, full surgery, intensive serotherapy, resuscitation, and sulphonamide chemotherapy. I n Sicily and Italy the mortality figures have been higher; 126 cases of gas gangrene were reported to the Army authorities from August, 1943, to February, 1944, with 62 per cent mortality (MacLennan and Macfarlane, 1944). By February, 1944, when the present investigation with penicillin was started, the surgeons were becoming increasingly experienced and the mortality was about 50 per cent. Similar statistics were noted by a group of American surgeons studying anaerobic myositis among American troops in Italy (Colonel E. D. Churchill, Consultant Surgeon-personal communication) : in over IOO cases of undoubted gas gangrene the mortality was 54 per cent.
SELECTION OF CASES
This is a report of 33 cases of gas gangrene occurring in Italy in the spring of 1944, in which penicillin was given in an attempt to reduce the mortality. We accepted MacLennan's definition of gas gangrene as a clostridial infection of muscle, and included in this investigation only cases of undoubted true clostridial myositis. Indeed, so anxious were we not to claim merit for penicillin in doubtful cases, that we accepted wellestablished instances only for consideration in this report. Thus there were several cases of ' early gas gangrene ', and cases of anaerobic cellulitis, successfully treated with surgery, antiserum, and penicillin, which we have not included. Apart from this method of selection, the cases formed a consecutive series of thirty-three. At the end of the main body of this report we have described an additional case under the term 'gas edema '.