Arteriosclerosis and Vascular Failure

Degenerative arterial disease leads to vessel narrowing, irregularity, ulceration, thrombus formation, aneurysmal weakness or combinations of these, its morbidity increasing with age. Any of these complications, especially in the lower limb, may precipitate acute failure of the arterial circulation leading to gangrene (Fig. 2.1b) and a high rate of amputation or, alternatively, a chronic state of ischaemia, characterised by painful claudication on activity, with only some 10% ending in amputation.6 Whatever the precipitating cause of limb mortification, death of the tissues is caused by failure of cellular oxygenation transported by red blood cells in arteries which are narrowed, blocked, divided or ligated. Today, the resultant tissue blackening or mortification is described as gangrene, but in the past the term sphacelos or sphacelus (from the Greek and Latin meaning mortification) was also employed. Indeed, from the Hippo cratic writings until the 17th century (see Fig. 1.1), gangrene and sphacelus were viewed as distinct conditions, as Paul of Aegineta indicated in the 8th century:

"... we give the name of gangrene to mortifications arising from the violence of the inflammation, when they are not yet formed but forming;... But when the parts thus affected become totally insensible, the affection is no longer called gangrene, but sphacelus."1

Fabry (Hildanus) wrote De Gangraena et Sphacelo in 1593, noting the importance of frostbite, plague, toxins, ergot and the effect of tight splints He was one of the first to emphasise the importance of amputating above the level of gangrenous demarcation8 and also to undertake above-knee amputation.

In 1676 Wiseman wrote:

"Gangrene is a tendency to Mortification: it invades the softer Parts, as the Skin, Flesh, etc. and is the beginning of a Sphacelus. Sphacelus is a perfect Mortification, with the extinction of the native Heat and privation of Sense, not only in the Skin, Flesh, Nerve, Artery, but the very Bones. They differ from one another, as the Mortification is more or less ... Sphacelus is distinguished from Gangrene by the total Corruption and Stink, it being also insensible both of Knife and Fire."9

Heister, who visited many European surgical centres before writing his much-translated treatise in 1718, differentiated sphacelus from gangrene and wrote the former was distinguished when the part lost all sensation to pinprick and incision, when the local muscles became paralysed and the part turned black. Heister listed causes as internal, principally erysipelas, scurvy and poor circulation by reason of old age, and as external, that is, injuries from the air, cold water, noxious topical remedies, and hurts and accidents producing wounds, fractures and dislocations.10 By 1749, Quesnay maintained the term sphacelus was confusing and served no purpose, adding it was more important from the point of view of clinical presentation and of treatment to distinguish between wet and dry gangrene.11 In 1750, Sharp had discarded sphacelus for mortification, and even this term he found unhelpful:

"... a Gangrene is defined to be the Beginning of the Disorder; a Mortification (Sphacelus) the last stage of it; it is a Division however of little use, and not strictly adhered to by those who mention it,... ."u

These descriptive differences have been laboured here, as early writers considered gangrene and sphacelus distinct conditions requiring different management, that of sphacelus having no remedy save speedy separation of dead tissues, assisted either by the surgeon or by nature. For the past two centuries this distinction has not been preserved, and sphacelus has lapsed from the medical literature. It may be clearer to differentiate a pregangrenous state when ischaemia caused by arterial circulatory failure is evident but reversible, followed by a gangrenous state when tissue death, however small, is clinically visible and irreversible (Fig. 2.2a).

Acute failure or ischaemia may follow an arterial embolus associated with atrial fibrillation,

Fig. 2.2. a. Dry gangrene of foot and lower shin caused by vascular disease, showing early separation of necrotic tissues. (From Spence J, Lectures on Surgery Edinburgh: Black, 1875, vol 1, fig. 12.49) b. Arm amputation for gas gangrene of forearm from missile wound during World War I. (From Hull AJ. Surgery in War. London: Churchill, 1918,35 fig. 24.)

thrombotic occlusion caused by disruption of the internal lining of a weakened vessel, and obstruction following aneurysmal bleeding with dissection of a vessel wall, often associated with high blood pressure and excessive cigarette smoking. Before modern reconstructive surgery, amputation was the only treatment for resultant vascular failure and gangrene. Although arteriosclerosis or vessel calcification has been observed in mummies as illustrious as the pharaohs Rameses II and Merenptah,13 any earlier history is uncertain and, as it is believed, most humans died young in the prehistoric period, fully developed arterial disease was probably rare. By contrast, in the aging population of the 21st century senile gangrene is a common complication of arteriosclerosis and a frequent source of amputation.

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