History and Geography

Ergotism has long been an important cause of certain epidemics of gangrene in humankind. Gangrene of the limbs has been recognized since ancient times, and a description of gangrene following trauma appears in Hippocrates. It is probable that gangrene in ancient Greece and Rome was due mainly to infections initiated by trauma of either accidental or military origin.

In temperate and Arctic zones of the world, cold injuries causing frostbite that led to gangrene have always occurred. Explorers of cold regions were often affected, and gangrene produced by cold injury has also been a tremendous problem in troops engaged in wartime activities. Gangrene, for example, was quite prevalent among soldiers during Napoleon Bonaparte's invasion of Russia. Yet frostbite was only one of the causes of gangrene associated with military activity. Trauma from penetrating wounds, contusion of soft tissues, and compound bony fractures were often the initial insult. The introduction of gunpowder in Europe in the sixteenth century produced a tremendous loss of life and limbs from gangrene that developed in these traumatic wounds. Poor hygienic conditions and overcrowding in hospitals led to epidemic wound infections. Because hospital gangrene was rapidly progressive and lethal, many lives were lost, particularly during the Napoleonic Wars, the Crimean War, and the American Civil War. In many cases, there were almost as many soldiers killed from wounds and gangrene as were killed in action.

By the time of World War I, hospital gangrene was much less prevalent. The art of amputation and setting of fractures was advanced by the important contributions of such surgeons as Ambroise Paré in the sixteenth century, Pierre-Joseph Desault in the eighteenth, and John Bell at the turn of the nineteenth, among others. Their work significantly contributed to decreased mortality from gangrene. The concept of antisepsis and asepsis was introduced in the late nineteenth century with the work of Louis Pasteur. This concept, when applied to management of wounds, is known as Listerism, in honor of Lord Joseph Lister, who was the first to recognize the value and clinical application of Pasteur's discovery. Finally, the introduction of penicillin in the early 1940s totally eradicated hospital gangrene.

Arteriosclerosis is probably as old as humankind. Leonardo da Vinci, in the fifteenth century, illustrated the arteries of a subject with senile arteriosclerosis in one of his anatomic sketches. Along with prolonged life expectancy has come a greater susceptibility to degenerative diseases such as arteriosclerosis and other vascular disorders. In the early nineteenth century, it gradually became clear that organic occlusion of the arteries could cause dry gangrene. Maurice Raynaud, in his now famous 1862 thesis, On Local Asphyxia and Symmetrical Gangrene of the Extremities, attempted to prove that there was a disease of the arterial system that might produce gangrene, but in which arterial obliteration was not present. Only recently have the roles of life-style, diabetes, and hypertension been recognized as contributing factors in the production of arteriosclerosis. Fortunately, widespread public education is now contributing to the decline of severe peripheral vascular disease and its associated gangrene.

In advanced countries of the world today, gangrene is much less common. Infectious gangrenes are easily treated or avoided by the appropriate antiinfective agents. However, there are now a growing number of individuals who are immunosuppressed from chemo-therapeutic agents and corticosteroids, which are used to prevent rejection in transplant patients, and to treat various cancers and autoimmune diseases such as rheumatoid arthritis. In such an immunocompromised state, these patients are at increased risk of developing unusual infectious gangrenes whose etiologic agents may not be easily recognized or be readily treatable.

Diane Quintal and Robert Jackson

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