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OBSERVATIONS on the PATHOLOGY of PERIPHERAL Postgrad Med J: First Published As 10.1136/Pgmj.22.245.75 on 1 March 1946

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OBSERVATIONS on the PATHOLOGY of PERIPHERAL Postgrad Med J: First Published As 10.1136/Pgmj.22.245.75 on 1 March 1946 OBSERVATIONS ON THE PATHOLOGY OF PERIPHERAL Postgrad Med J: first published as 10.1136/pgmj.22.245.75 on 1 March 1946. Downloaded from VASCULAR DISEASE (Exclusive of congenital malformations and neoplasms) By WILLIAM BLACKWOOD, F.R.C.S.E. (From the Scottish Mental Hospitals' Laboratory, The Royal Infirmary, Edinburgh, and the Department of Pathology, Universitv of Edinburgh.) Introduction mediate between those of large calibre and (3) The Although the circulatory system cannot properly arteries of medium calibre (e.g. radial) (Fig. I), be considered except as a whole, there is such an which comprise the majority of the macroscopically abundance of pathological conditions to which it visible arteries in the body. They regulate the is subject, in whole or in part, that limitations of flow to the major and minor regions of the body. space alone demand that it be divided into parts In their media the elastica is less, being generally and that only a part be considered here. This limited to an internal and external elastic lamina. paper will therefore be confined to the peripheral (In the cerebral vessels the external elastic lamina vascular system, which is arbitrarily defined as all is absent.) Unstriped muscle is however present the circulatory system exclusive of the heart, in large amount and, by response to autonomic aorta and pulmonary system. For a similar nervous impulses, can produce wide variations in reason it is proposed to omit the consideration of calibre. As in the large arteries the {fibrous vascular malformations and neoplasms. adventitia contains the small vasa vasorum through which blood is conveyed to most of the media. The intima and inner layers of the media are Anatomical, Physiological and General nourished by the blood in the lumen of the vessel Considerations itself, either directly or possibly through internal The purpose of the blood vessels is to conduct vasa vasorum. Serious local disease of theseProtected by copyright. blood in the right quantity to the right place at vessels and the resultant ischaemia can often be the right time and it is at the capillary level that overcome by means of collateral circulation, the metabolic i.nterchanges occur. The demands through unaffected protions of the vascular tree. of the tissues vary greatly from time to time, e.g. (4) The arterioles (e.g. afferent renal glomerular muscles in action require a greater blood flow arterioles) (Fig. 2), which are chiefly muscular in than those at rest. Such intermittent demands construction and have but little elastica. The for large quantities of blood are met by means of a calibre of the arterioles is an extremely important capillary bed of variable size. Economy of work factor in the general arterial blood pressure. In and conservation of heat are effected by diminishing the voluntary muscles the calibre of the vessels the blood flow by vascular constriction, pre- (possibly of all sizes) is controlled largely by local dominantly at the arteriolar level. metabolites. (Barcroft et al, I943.) Elsewhere These functions of the vascular system are it is controlled by the autonomic nervous system. associated with appropriate anatomical structure. A "pressor" substance, hypertensin (angiotonin), (i) The arteries of large calibre (e.g. aorta, inno- is now known to influence the calibre of thehttp://pmj.bmj.com/ minmate, subclavian) which convey blood easily to arterioles and its action is thought to be directly all parts of the body, have a smooth endothelial upon the muscle of the vessel wall. lined intima which confines but does not appre- (5) The capillaries have walls consisting only of ciably impede the flow of blood: a thick media endothelial cells and an outer fibrous perithelium. composed of fibrous and elastic tissue, fibrous It is at this level that metabolic exchange occurs. tissue for strength and elastica for storing the They are liable to damage from circulating toxins dynamic energy of each cardiac systole and for and when pre-stasis or stasis of blood occurs they releasing it during diastole, and so prolonging the are the point at which plasma and erythrocytes on September 26, 2021 by guest. forward impulse to the blood: and a connective may leak out of the circulatory system (Fig. 3). tissue adventitia. Their structure does not allow In the acral subcutaneous parts of the body them to vary much in calibre and serious inter- provision is made for by-passing the capillaries by ference with their integrity has very dangerous. means of (6) Arteriovenous anastomoses. These consequences for the individual. Syphilis (pro- are richly innervated vessels with thick walls ducing aneurysms), atheromatous degeneration composed chiefly of modified muscle cells. Amongst (not usually to a degree to cause serious obstruc- the functions ascribed to these shunts is that of tion) and mechanical trauma (producing dissecting thermo-regulation. They do not suffer from any, aneurysm, traumatic aneurysm, haemorrhage, etc.) as yet known, specific disease processes, apart from are the commonest agents in diseases of these vessels. neoplasia. The large arteries merge into (2) The atteries of (7) Venules and veins (Fig. i). These vessels mixed type (e.g. common iliacs) which are inter- convey the blood back to the heart. Lined by 76 POST-GRADUATE MEDICAL JOURNAL March, 1946 Postgrad Med J: first published as 10.1136/pgmj.22.245.75 on 1 March 1946. Downloaded from endothelium, the wall is composed of elastica and B. Due to Chemical Trauma or Circulating Toxins. plain muscle and of relatively more connective Ergotism. tissue than in an artery. The distinction between Glomerulo-nephritis. the media and the adventitia and between veins C. Due to Mechanical Trauma. of various sizes is not sharp. They are controlled Arterial concussion, contusion Venous contusion and by the autonomic nervous system. Disease of the and laceration. laceration. Periarterial haematoma and Spontaneous venous veins does not usually have such severe conse- false aneurysm. thrombosis (of the quences as that of the arteries, with the possible Traumatic arteriovenous com- axillary vein). exception of pulmonary embolism. Two distinct munication. Femoral venous throm- systems of veins, the systemic and portal systems Bland embolism. bosis. are known. These systems communicate at certain D. Due to Thermal Trauma (cold). well-known regions, at which the veins may Raynaud's disease and the become engorged in portal obstruction. Recently Raynaud Phenomenon. the importance of the paravertebral and spinal Immersion foot or Trench foot. veins has becomerecognised in the explanation of the Frostbite. spread of emboli to the spine from the viscera E. Due to, or Associated with, Increased Intra- without involvement of the lungs, e.g. bony meta- vascular Pressure. stases from prostatic carcinoma. (Batson, I940). Diffuse hyperplastic sclerosis: Varicose veins. (a) of arteries, Haemorrhoids. The Effects of Vascular Disease (b) of arterioles (fibrous, hyaline and necrotic). The effect of vascular disease is frequently to Massive cerebral haemorrhage. produce some degree of ischaemia in the field of distribution of the diseased vessels. The degree F. Of Uncertain or Unknown Aetiology. of ischaemia will depend upon the degree of Chronic arterial disease: Thrombo-phlebitis (a) Monckeberg's medial migrans. Protected by copyright. narrowing of the arterial lumen, upon the site or sclerosis, sites of narrowing, upon the degree of collateral (b) Atherosclerosis. circulation, the degree of associated vasospasm, Thrombo-angiitis obliterans -upon the way in which the available blood is (Buerger's disease). shared out amongst the different tissues, upon the Rheumatic arteritis. metabolic demands of the tissues, upon the rate Periarteritis nodosa. at which the ischaemia develops and upon its duration. In the limbs the effect of vascular obstruction are generally:-(i) diminution of the pulse, (2) lowering of the skin temperature, (3) a A. Diseases Due to Bacterial pale or cyanotic skin colour, (4) pain, (5) glove or Infection stocking anaesthesia. Structurally there may be: Pyogenic organisms.-Vessels passing through (i) generalised atrophy or necrosis, (2) nerve or adjacent to a focus of pyogenic infection may degeneration. In muscle ischaemia necrotic muscle show acute inflammation of the wall-an acute http://pmj.bmj.com/ may be replaced by fibrous tissue, Volkmann's bacterial arteritis or thrombophlebitis. Thrombosis Ischaemic Contracture (Griffiths, I940). is the usual sequel, especially in veins. Septic emboli may arise from the heart (e.g. ulcerative Classification endocarditis) and become impacted in a small Medical nomenclature and classification being artery, cause secondary infection and weakening still debatable subjects the opportunity is taken of the wall with the formation of a mycotic aneurysm of classifying upon an aetiological basis. The 4 and (Figs. 5). on September 26, 2021 by guest. word arteriosclerosis, unqualified, is deliberately Syphilis.-In the aorta syphilitic disease of excluded, for it is too general, and too compre- the vasa vasorum and damage to the elastica are hensive in meaning. the main features. In the arteries of medium Diseases of the Systemic Peripheral calibre, especially in the brain, the condition is a pan-arteritis. The organism is present in the Vascular System vessel wall and the severity or tempo of the reaction varies. Sometimes the condition is associated Arterial, Artcriolar and Venous with much necrosis, a gummatous arteritis, some- Capillary times necrosis is slight or absent and there is well marked concentric intimal fibrosis, minimal damage A. Due to Bacterial Infection. to the elastic medial Acute bacterial arteritis. Thrombophlebitis. internal lamina, slight replace- Tuberculous arteritis. Pylephlebitis. ment fibrosis, adventitial fibrosis and infiltration of Syphilitic arteritis. all coats by lymphocytes and plasma cells (Fig. 6). PERIPHERAL VASCULAR DISEASE WM. BLACKWOOD, F.R.C.S.E. 77 Postgrad Med J: first published as 10.1136/pgmj.22.245.75 on 1 March 1946. Downloaded from Illustrations FIG. I.-Control posterior tibial vessels from a case without FIG. i8.-Traumatic arteriovenous communication, of four vascular disease.
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