Chapter IV: Part II: , Showing Predominance of Malarial Element . . . . 617 (3)

At the same time, an increase in the quantity of blood in the vessels is not necessarily productive of any considerable increase in the fluid transuded. Cohnheim calls attention to the experiments of Worm Müller, which show that a plethoric condition may readily be produced by the injection of quantities of blood into the circulation of animals, the amount of which cannot exceed twice the volume of the animal's blood without producing death. Although a temporary increase of the blood-pressure results, a return to the normal quickly follows. This is permitted by the propulsion of the excess of blood into the capillaries and veins, which become consequently distended, especially those of the abdominal organs. There is no increased transudation corresponding with the quantity of fluid introduced, nor is there any considerable distension of the blood-vessels of the skin, subcutaneous or intermuscular connective tissue. Such experiments show no permanent increase in the blood-pressure within the large veins if there is no obstruction to the admission of venous blood into the heart, presumably owing to their capacity for considerable distension.

Although experiments show that a simple plethora with great distension of the capillaries of the abdominal organs occasions no considerable increase of transudation, a different result follows a hydræmic plethora[25] induced by the injection of immense quantities of salt water into the blood-current--often six times as much liquid as the animal had blood. Here, too, the arterial blood-pressure shows no permanent increase, nor does that within the large veins become perceptibly increased till enormous quantities of fluid are injected. The blood flows through the vessels with increased rapidity in consequence of the diminished friction of the diluted blood, and an increased transudation begins at once. The various glands, salivary and gastro-intestinal, kidneys and liver, secrete more copiously, and the flow of a dilute lymph from the thoracic duct becomes greatly increased, while that from the cervical lymphatics becomes moderately accelerated. The lymph from the extremities, however, is no greater in quantity than that flowing from an animal in a perfectly normal condition. The localization of the increased transudation from the blood-vessels is further characterized by the abundant accumulation of watery fluid in all the abdominal organs and abdominal cavity, in the salivary glands and surrounding connective tissue, while elsewhere in the body the organs and tissues are almost invariably in the same condition with {69} regard to moisture as are those of a healthy animal under normal circumstances.

[Footnote 25: Cohnheim and Lichtheim, _Virchow's Archiv_, 1877, lxix. 106.]

The importance of these experiments with reference to the causes of the transudation of fluid from the blood is obvious. The pressure upon the walls of the blood-vessels cannot become sufficiently increased to be accompanied with augmented transudation until limits are reached which are beyond the possibilities of occurrence in the human body. When such limits are attained in animals, the increased pressure, however great it may be, does not suffice to produce a general transudation, but one limited to the vessels of those parts of the body whose normal function is connected with too abundant transudation of fluid. A simple hydræmic condition of brief duration has been proven, by experiment, insufficient to give rise to increased transudation, neither increased secretion nor increased flow of lymph taking place. The inference from these experiments is that an increased transudation is more dependent upon conditions of the filter than upon those of blood-pressure. The absence of any observable changes in the filter leads to the assumption of an increased permeability, of physiological occurrence in certain parts of the body, as the chief feature in the occurrence of increased transudations.

Dropsy arises when the transudation is accumulated. As dropsical accumulations are transudations from the blood, essentially blood-serum with a diminished percentage of albumen, and as such blood-serum is practically lymph from its presence in the lymph-vessels, dropsical effusions are to be regarded as stagnant lymph. Such stagnations may be present in the small lymph-spaces within the connective tissue, or in the larger lymph-sacs, as the peritoneal, pleural, pericardial, and scrotal cavities. In like manner, the stagnation may take place in the cavities of joints and in those of the brain and cord, although the latter represent functional rather than structural lymph-canals.

The term oedema is applied to the accumulation in the connective-tissue lymph-spaces in general, while the term anasarca is confined to those cases where the subcutaneous lymph-spaces are concerned. The accumulation in the great lymph-cavities is known as ascites when peritoneal, hydrothorax when pleural, hydropericardium when pericardial, hydrocele when in the cavity of the tunica vaginalis, hydrocephalus if within the ventricles of the brain, and hydromyelocele when within the central canal of the spinal cord.

The accumulation of dropsical effusions may be considered as possibly resulting from an obstruction to the channels through which the transudation should flow, or from insufficient force to overcome normal obstructions, or from an abnormally increased transudation.

Lymph-channels are frequently obstructed, but no appreciable diffused retention of lymph results unless the thoracic duct is obstructed. This rare affection is followed by enormous distension of the thoracic and abdominal portions of the parts beyond the stenosis. Ascites and hydrothorax may follow, but not necessarily any considerable oedema of the peripheral parts of the body. As a result of the distension of the thoracic duct, rupture is not unlikely to take place, and the effused fluid contains chyle.[26]

[Footnote 26: Quincke, _Deutsches Archiv für Klin. Med._, 1875, xvi. 121.]

{70} That the obstruction is not followed by oedema is attributable to the innumerable anastomoses between the lymph-spaces, and also to the probability that a part of the transuded fluid returns to the blood-vessels when the obstruction is impassable.

The forces necessary to promote the flow of lymph have already been mentioned, and their entire removal is inconsistent with life. A diminution of their activity is more likely to result in a diminished flow of lymph than its accumulation, although a slowing of the lymph-current may represent a favoring element in the accumulation of an increased transudation.

The occurrence of dropsy with unobstructed lymph-channels, and in the presence of efficient agencies in promoting the flow of lymph, indicates the importance of an increased transudation as the chief element in the occurrence of a dropsical accumulation. An increased transudation, with resulting oedema, is readily produced by preventing the flow of blood from a part, and may be directly observed with the microscope. Cohnheim states that after a sudden venous obstruction, in case an efficient collateral circulation does not interfere, the capillaries and small veins become distended with stagnant blood and appear as masses of red blood-corpuscles. This distension results from the continuance of the arterial flow into the capillaries of the obstructed region under a pressure which is only neutralized by the resistance of the tissues and the transudation from the capillaries. Sotnitschewsky[27] shows that a concurrent paralysis of the vaso-motor nerves, as claimed by Ranvier, is unnecessary. The transudation through the capillary wall is increased, the flow of lymph from the part is accelerated, and oedema arises when the transudation is so much augmented that the calibre of the lymph-vessels is insufficient for its removal; and the greater this insufficiency the greater is the oedema. With the continuance of the arterial flow and intravenous resistance, red blood-corpuscles are forced through the filter, and form an important constituent of the effusion from venous stagnation.

[Footnote 27: _Virchow's Archiv_, 1879, lxxvii. 85.]

Although the existence of an increased pressure upon the capillary wall is obvious from the experiment referred to, there is no increased arterial pressure--rather a diminution--and the important element in occasioning the increased permeability of the capillary wall is the obstruction to the outflow of venous blood from the oedematous region. In consequence of the latter the arterial flow is followed by increased transudation.

Dropsies resulting from venous obstruction, as well as those following an obstruction of the thoracic duct or its branches, or of the several lymphatics of a part, are classified as mechanical dropsies. That from venous obstruction is the most frequent, and its seat may lie in the course of venous trunks or in the heart, lungs, or liver. The venous obstruction must be so situated that the stagnant blood is unable to find a ready escape through collateral branches. The more sudden and complete it is, the more likely is the effusion to contain considerable numbers of red blood-corpuscles.

In addition to the element of venous stagnation in producing increased transudation, the condition of the filter is of importance. The occurrence of oedema in chronic diseases, especially of the kidneys, and in those attended with protracted suppuration, continued hemorrhage, and the {71} rapid growth of tumors, has usually been attributed to the watery condition of the blood, with a diminution of the albumen. Cohnheim, however, suggests that the condition of the vessel wall is of more importance than the contents as the immediate cause of the increased transudation. The more or less protracted action of various agents--temperature, insufficient oxygen, and diminished albumen--is likely to so modify the condition of the endothelium as to favor an increased permeability of the wall. Experiments show that a simple acute hydræmia produces no increased transudation, and that a chronic hydræmia, if connected with dropsy, is likely to be influential by increasing the permeability of the wall. Even in those cases where a hydræmia and an oedema co-exist, the localization of the latter is favored by obvious disturbances of the function of the capillary walls, as in case of the cutaneous oedema after scarlatina. In like manner, a feeble heart, favoring venous stagnation, and gravitation are of importance, as general causes, in promoting dropsy in hydræmic conditions.

The possibility of the occurrence of oedema through nervous influence is not to be denied. The localized and fleeting oedema of urticaria and erythema, the swollen lip and tongue in connection with digestive disturbances, are not to be explained by the two main factors of oedema--viz. venous stagnation and increased permeability of the vascular walls. Cohnheim refers to the rapid occurrence of oedema of the tongue as a result of irritation of the lingual nerve, and oedema is known to occur rapidly in cases of acute myelitis. A similar result follows the experimental destruction of the spinal cord, although the mechanism of its production is not apparent.

Dropsies are subdivided, as regards their distribution, into general and local forms. The causes producing the two varieties are essentially those already described. The causes of all local dropsies are not always to be regarded as the same. Regions which are the seat of mechanical dropsies are often affected by inflammation, with abundant serous exudation--the so-called inflammatory dropsy. The properties of the effusion and exudation are quite different, the former having a small percentage of albumen, but few leucocytes, with a corresponding absence of fibrin, and few or many red blood-corpuscles. The exudation, on the contrary, is highly albuminous, though less so than the blood-plasma; it contains numerous leucocytes and much fibrin; under ordinary circumstances there are but few red blood-corpuscles.

The local dropsies are often characterized by special terms. Hydrops ex vacuo is applied to the collections of fluid found in closed cavities with unyielding walls, as the cranium and thorax, or to the recurrence of fluid in cavities from which the same has been rapidly removed, in the absence of inflammatory disturbances. Collateral oedema is usually applied to the association of oedema with inflammatory disturbances, and represents an extension of the inflammatory process to the region concerned. Oedema of the glottis and circumscribed oedema of the lung are instances. The term hypostatic oedema is often used to designate the association of oedema and inflammation, the former caused by the latter, and to indicate the effect of gravitation in the localization of oedema from the general causes already mentioned.

Another localized oedema of interest, from its frequent occurrence and {72} importance, is oedema of the lungs, often taking place toward the end of life, at times quite suddenly. This form has usually been attributed to increased transudation from arterial congestion or venous stagnation. The former view is directly refuted by the experiments of Welch,[28] who offers the explanation now accepted. With the obliteration of three-fourths of the arterial supply to the lungs of the animals experimented upon, no oedema resulted from the assumed collateral fluxion into the branches of the pulmonary artery which were left open. The obliteration of the same area of venous distribution was necessary before the occurrence of oedema. Oedema of the lungs was further found to result from a ligature of the aorta near the heart. The comparative frequency of oedema of the lungs in man, and the rarity of such extreme mechanical disturbances as those produced experimentally, led Welch to paralyze the left ventricle. The conditions as regards the pulmonary circulation then corresponded with those mentioned as causes for oedema from venous obstruction. The continued action of the right ventricle forced blood into the pulmonary capillaries, where it was compelled to accumulate in consequence of the inability of the left ventricle to receive and expel it. Welch consequently regards the immediate cause of this form of pulmonary oedema as a predominant weakness of the left ventricle. A weak heart does not suffice for the production of the oedema, since this condition is not found when both ventricles are alike enfeebled.

[Footnote 28: _Virchow's Archiv_, 1878, lxxii. 375.]

Degenerations.

The degenerations represent disturbances in the nutrition of the tissues of the body, in consequence of which their functions become impaired, if not destroyed. The latter result obviously attends the death of cells, which may occur in the course of the degeneration. The processes concerned are called necrobiotic by Virchow, as they represent vital processes leading to death. Although in many of them the cell is decaying during their continuance, its recovery is possible with the disappearance of the conditions which have transformed physiological into pathological processes. The degenerations affect intercellular substance as well as cells, and are called metamorphoses, infiltrations, or degenerations, as a transformation of normal into abnormal material, or the addition of extraneous substances, or the functional impairment of the part assumes the greatest prominence.

_Cloudy Swelling, Albuminoid Infiltration, Granular Degeneration, Parenchymatous Degeneration._

Of the various modifications in the appearance of cells under pathological conditions, there is none, perhaps, more commonly met with than that known by the above terms. A granular appearance may be regarded as an essential characteristic of protoplasm, and is an attribute of cells of epithelial origin as well as of those which belong to other groups of tissues. The abundance of granules present in a normal cell depends largely upon its shape, size, and situation. These granules present various {73} relations to chemical agents, some being soluble in alcohol and ether, others in acids and alkalies, and many of them, especially those met with in the form of degeneration now being considered, show from the various reactions that they are of the nature of albumen. Since their exact composition, in all instances, is undetermined, they are called albuminoid, and when in excess the cell is considered to be infiltrated with these granules, and the organ presents the appearances regarded as characteristic of an albuminoid infiltration. A granular cell becomes much more granular when it is thus infiltrated, and it is therefore a matter of difficulty to recognize from the appearance of certain single cells, as those of the liver or kidney, whether or not the number of granules present is abnormally increased. When, however, a large number of cells of any given organ contain more than the normal quantity of these albuminoid granules, the appearance of the organ becomes modified. In extreme cases the latter is swollen, doughy in consistency, with ill-defined structural details, and in all instances presents an opaque appearance. The term cloudy swelling is thus purely descriptive, and was applied by Virchow to designate the optical appearances of the condition in question. The granules, which disappear on the addition of acids and alkalies, are apparently either added to the cell or result from a precipitation within the same.

Frequently associated with these albuminoid granules are others, distinctly recognizable as globules of fat. An apparent increase of nuclei is often observed, and in certain organs, as the kidneys, the cells seem less coherent than is normally the case. The study of this condition in the kidneys is further of interest as indicating that the border-line between a parenchymatous degeneration and a parenchymatous inflammation is purely arbitrary. From similar exciting causes there may be associated, with the described alterations of the epithelial lining of the tubes, the exudation of albumen, the formation of casts, the desquamation of epithelium, and the presence of leucocytes within the tubules.

When the macroscopic changes are of moderate degree, and the disturbance of function relatively slight, while the concurrent alterations elsewhere, from the simultaneous action of the same cause, are predominant and characteristic of the disease, the condition is conveniently regarded as a degeneration occurring in the course of the latter, rather than an inflammation. The latter term, on the contrary, is to be applied when the granular infiltration of the cells is associated with other evidences of an inflammatory exudation, and when the pathological disturbances are to be directly attributed to the parenchymatous changes.

It is customary to speak of cloudy swelling as a nutritive change, and the condition may be induced by those causes which interfere with the nutrition of parts or of the whole of an organ. Many authorities regard this granular or parenchymatous degeneration as closely allied to fatty degeneration, since many of the causes which produce the one occasion the other. The former is often spoken of as an earlier stage of the latter, from the frequent association of the albuminoid granules with numerous globules of fat as a result of the more prolonged or more intense action of a given cause.

Organs which give evidence of a granular degeneration contain, as a rule, a diminished quantity of blood. This feature is usually attributed to the pressure of the swollen cells upon capillary blood-vessels. The {74} anæmic organ obviously becomes still more cloudy, gray, and opaque in appearance from the diminished quantity or impoverished quality of the blood.

The granular degenerations of the heart, liver, and kidneys, as a whole, usually occur simultaneously, and afford a most important means for the post-mortem recognition of the infective diseases. The condition is therefore to be looked for in the exanthemata, especially in small-pox and scarlet fever, also in erysipelas, septicæmia in its manifold forms, diphtheria, typhoid and typhus fevers, cerebro-spinal meningitis, etc. A common feature in all these cases is the occurrence of fever, and it has been claimed that this element is the cause of the degeneration. In opposition to this view is the well-known fact of its presence in afebrile cases of poisoning from carbonic oxide, and its absence in certain cases of pneumonia and exposure to high temperatures.

The universal occurrence of cloudy swelling in fatal cases of the affections above mentioned leads to the inference of its presence in those instances terminating in recovery without obvious permanent impairment of the organs and tissues concerned. It is therefore agreed that the process may terminate in resolution--_i.e._ in a disappearance of the excess of granular material. On the other hand, its association, under circumstances, with fatty degeneration suggests as extremely probable that the latter condition may represent a result of the albuminoid infiltration. Even if this more serious issue exists, the possibilities are still at hand for an absorption of the degenerated material and a restitution of the destroyed protoplasm. The effect upon the individual is evidently determined by the persistence and dissemination of the condition, which, in turn, are controlled by the immediate cause and the peculiarities of the individual acted upon.

_Fatty Metamorphosis, Fatty Degeneration, and Fatty Infiltration._

The fat which is present within the body under physiological conditions owes its origin primarily to the food taken. A diet which is abundantly fatty furnishes a direct source for much of the fat which appears accumulated in the various organs and tissues. Although it may now appear that such a statement needs but little confirmation, it is not long since the opinion prevailed that nearly all the fat in the body came from the hydrocarbons of the food. This seemed all the more plausible as the herbivora readily accumulated fat, although their diet might contain this element in very small quantities. Hofmann[29] made a decisive experiment with reference to the origin of fat from fatty food by feeding a dog, made lean by starvation, with bacon in abundance, but with little meat. In the course of a few days the greater part of the fat introduced was deposited within the tissues of the animal. Other experimenters have arrived at a similar result, and it can no longer be questioned that fat, accumulated within the body, owes its origin chiefly to the absorption of fat from the food taken.

[Footnote 29: _Zeitschrift für Biologie_, 1872, viii. 153.]

Another source for the fat of the body has long been suggested--namely, the albuminates of the food. In the admirable article on the formation of fat by Voit,[30] from which most of the information herein {75} presented is derived, it is claimed that he and Pettenkofer were the first to prove the origin of fat in the body, under normal conditions, from albumen. This proof was an inference, however, although presenting a high degree of probability. Valuable evidence in the same direction was furnished by Kemmerich, who found that the milk of a cow during a certain period held more fat than was contained in the food; Subbotin and Voit have shown that more milk is secreted the richer the diet in albumen. Still other observers have furnished more decisive proof that fat is formed from albuminates.

[Footnote 30: _Hermann's Handbuch der Physiologie_, 1881, vi. 1, 235.]

Two sources for fat in the body under physiological conditions are thus recognized: 1, the free fat in the food; 2, the fat derived from the decomposition of the albuminates of the food.

Voit admits the possibility of the hydrocarbons serving as a third source, although this possibility is unnecessary in most cases. Should instances arise, however, where other sources for fat are found insufficient, the hydrocarbons must be regarded as filling the gap.

Fat which is taken into the body is considered to be either consumed or stored. That which is stored is chiefly accumulated in the great reservoirs--viz. the subcutaneous and perinephritic fat tissue, the mesentery, omentum, and bone-marrow--although it may be found elsewhere, in the fluids and tissues of the body. This accumulation serves as a source to be drawn from in case of need, and is called upon where the easily-decomposed soluble albumen is disposed of by the functional activity of the cells. An acting muscle demands food for its work, and consumes first the soluble albumen, then the fat. An excessive waste of fat is delayed by the decomposition of hydrocarbons, but the demands may become so great that albumen, fat, and hydrocarbons are consumed more rapidly and constantly than they can be supplied. It being, therefore, admitted that fat is formed from the albuminates, as well as from the fat of the food, the question readily presents itself whether fat may not be formed from the fixed albuminates of the body, especially from those contained within its cells.

It is well known that in the secretion of sebum the superficial cells of the sebaceous follicles contain fat in great quantity, while the deeper layers are comparatively free from any appearances indicative of the presence of fat. It is further admitted that when pus is retained for a time the individual corpuscles contain fat-drops in quantity and become transformed into fatty granular corpuscles. Eventually, the pus is transformed into a detritus in which fat-drops are found in great number.

Similar appearances may be present in the protoplasm of muscular tissue, the cells of the liver, kidneys, and gastric glands, when poisonous doses of phosphorus or arsenic are given. The occurrence of an acute fatty metamorphosis of the cells of various organs in new-born children has repeatedly been observed. The presence of fat in various organs of the body in pernicious anæmia, and in the heart in connection with stenosis of the coronary artery, is universally recognized. The abuse of alcohol, long-continued obstruction to the flow of venous blood, exposure to high temperatures, are all known to be conditions in connection with which fat-drops are found in the various cells of the body. The effects of poisoning with phosphorus and arsenic are of special importance, as showing that the abundance of fat present in the cells represents a result of the degeneration of these cells, {76} since it takes place when the animal is deprived of food. Although there is an evident destruction of albumen, there is also a diminished elimination of carbonic acid and admission of oxygen. These facts are explicable on the ground that the fat present is not consumed, and the accumulation in the cells is evidence of this lack of consumption. The fat is not simply stored, as none is taken in, nor is any food received from which fat might be formed. Its presence, therefore, must be regarded as due to degeneration.

Since fat may be formed in the body as a result of the metamorphosis of cell-protoplasm, it is desirable to ascertain whether there are any means by which stored fat may be distinguished from that present as the result of a degeneration of the cell. The term fatty infiltration has been used to indicate the presence of stored fat, the latter being regarded as simply taken into the cell and retained for a longer or shorter time, without any necessary interference with other functions possessed by the cell.

In fatty degeneration, on the contrary, it is considered that the quantity of fat present indicates a corresponding diminution in the albuminates of the cell, and is connected with a diminution in the function of the latter, all the greater the more abundant the fat.

It is found that in fatty infiltration, as a rule, the fat is present in large drops, the size of the cell being increased in proportion to the quantity of fat present. Although there may be several drops present, they tend to run together, as is suggested by their different size, varying proximity, and the constant presence of a considerable quantity of protoplasm. In organs, on the contrary, whose function is seriously, even fatally, impaired, the fat, as a rule, assumes rather a granular form. Many minute fat-drops are present, and the cell is not particularly, if at all, increased in size. The more abundant the fat the less the protoplasm. Appearances are met with indicating a transition between cells with few fat-granules and those with many.

If the morphological appearances of fatty infiltration and of fatty degeneration were constant, there would obviously be little or no difficulty in determining the nature of the process manifested by the presence of fat. The exceptions occur both in fatty infiltration and fatty degeneration. In the cells of the liver of an animal poisoned with phosphorus fat makes its appearance in large drops, while in the heart and kidneys of the same animal the fat is present in a granular form.

During absorption from the intestine in the process of digestion fat is present in the epithelium in a finely granular form. When digestion is completed fat is no longer met with in these cells. The presence of large or small drops, therefore, cannot be regarded as a sufficient test of the origin of the fat. It is of equal, if not greater, importance to bear in mind the organ concerned.

In the heart, liver, kidneys, and gastric glands, as well as elsewhere, with the exception, perhaps, of the mammary gland, the presence of many small fat-drops in the cells indicates a degeneration of its protoplasm. The presence of large fat-drops, on the contrary, in the organs and tissues, with the exception of the liver, indicates an infiltration. Large fat-drops, then, may be present in the cells of the liver as the result of an infiltration or of a degeneration. In order to form a satisfactory opinion of the {77} nature of the appearances in the liver in doubtful cases, it is important to note the condition of those organs which may be simultaneously in a state of fatty degeneration.

The accumulation of fat under physiological conditions is obviously brought about, on the one hand, by those causes which permit a free introduction, absorption, and deposition, and, on the other, by those which check its oxidation or elimination with the secretions of the body, as the bile, in which it may be present to a considerable extent. A diet rich in fat, or in albuminates readily converted into fat, offers a favorable element for the absorption of fat by the healthy individual. If the organism demands but little of this fat for oxidation, as in the case of the sedentary person, an accumulation is likely to occur. This may become so considerable that obesity results. Tissues in which normally but little fat is accumulated may become infiltrated to a large extent. The intermuscular fibrous tissue thus becomes loaded, and the activity, as well as the nutrition, of the muscles is impaired. This accumulation may be manifested not only in the voluntary muscles, but in the heart as well, which may present abundant sub-pericardial and sub-endocardial fat, the myocardium also being interlarded with streaks of fat, the so-called fatty infiltration of the heart. The abdominal walls may become thickened to the extent of a couple of inches, and the mesentery, omentum, perinephritic tissue, and liver may become enormously increased in weight from the mass of accumulated fat.

This infiltration of fat may take place under pathological as well as physiological conditions. It is apparent that those causes which check oxidation are likely also to prevent the consumption of fat, and it is well known that the destructive processes in the lung, grouped under the term pulmonary consumption, accomplish this result. Something more, however, is necessary than the obliteration of pulmonary blood-vessels and the destruction of an aërating surface. There may be, as in emphysema of the lung, a diminished respiratory and vascular surface, yet evidences of fatty infiltration, particularly of the liver, are wanting. It seems probable that the constant anæmia, with the loss of the blood-corpuscles, of pulmonary phthisis is an important additional factor in checking oxidation in this disease. This factor, it is needless to say, is not a necessary occurrence in pulmonary emphysema.

Litten[31] has shown that when certain animals are exposed to high temperatures the appearances of fatty infiltration and degeneration are present in various organs of the body. He attributes the fatty degeneration to a direct poisoning of the red blood-corpuscles and a resulting diminution of the oxidizing processes.

[Footnote 31: _Virchow's Archiv_, 1877, lxx. 10.]

It is universally admitted that in chronic alcoholism a fatty liver is frequently met with, even in the absence of those chronic interstitial tissue-changes usually characterized under the name cirrhosis. Alcohol is known to check the reception of oxygen and the elimination of carbonic acid, and, whatever other disturbance of cell-activity it may produce, its effect in favoring the accumulation of fat is directly attributable, in part at least, to this disturbance of oxidation.

In those conditions known as cachexiæ, the constant accompaniment of progressive and wasting diseases, as cancer, leucæmia, chronic dysentery, {78} etc., a fatty infiltration, particularly of the liver, is a frequent accompaniment. A cachexia is dependent upon a complex series of processes, many of which tend to check oxidation, and in this respect is to be grouped with the conditions previously mentioned. That the associated fatty infiltration is intimately connected with the deficient oxidation is not to be doubted, although the agents producing this deficiency may vary in detail.

The causes which favor fatty degeneration are numerous, and the result represents one of the most serious conditions which can affect an organ. As oxidation represents the chief means of normally disposing of fat, so, pathologically, deficient oxidation favors the retention of fat due to degeneration. Were a constant renewal of protoplasm to take place, the degenerated fat might be displaced into the circulation or retained within the cell. If the latter event should occur, the result would be apparent as an infiltration, owing to the increased size of the cell, although the condition giving rise to the presence of the fat is a degenerative process. The importance of impairment of nutrition as the chief cause for fatty degeneration is thus obvious. It may readily be produced, experimentally, by measures which check the flow of blood to a part. The same measures necessarily prevent the presence of abundant oxygen, as fewer red blood-corpuscles are presented.

Fatty degeneration resulting from impaired nutrition is apparent in the heart in consequence of stenosis of its coronary arteries, in the kidneys as a result of interstitial processes obstructing the capillary circulation, in the brain from obliterative processes in the arteries at the base or within the organ, and in blood-vessels from the effect of age.

The cause of fatty degeneration may be general as well as local. In poisoning from phosphorus and arsenic the appearances in most of the organs indicate an actual destruction of protoplasm. Analysis of the secretions confirms this inference, as the production of urea is largely increased. Furthermore, there is less oxygen taken in and less carbonic acid eliminated. As has been previously stated, these conditions may be present in the starving animal. The fatty degeneration is thus easily explained as a metamorphosis of cell-protoplasm, and the deficient oxidation of the fat calls direct attention to its accumulation rather than elimination.

In acute yellow atrophy of the liver and in cases of severe jaundice fatty degenerations are constantly met with. That the origin and accumulation of fat in these affections is also due to rapid tissue-metamorphosis and checked oxidation is highly probable. Although the elimination of urea diminishes rather than increases, as shown by Schultzen and Riess, there are other links in the chain of retrograde changes, as the appearance of leucin and tyrosin, indicative of the extensive destruction of albuminates.

It is unnecessary in a work of the present character to call attention to all the possible circumstances under which fat is present in the body as the result of degeneration. Mention may be made of the acute parenchymatous (fatty) degeneration of new-born children, of the results of excessive bleeding, and of pernicious anæmia otherwise occasioned. The fatty degeneration of the uterus after parturition, of paralyzed muscles, and of tumors, the atrophic fatty degeneration of the liver in chronic {79} passive congestion (nutmeg liver), are all well-known examples. To these may be added the fatty degenerations associated with amyloid and interstitial processes. It is apparent that in most of these instances the common features of rapid tissue-metamorphosis and deficient oxidation are present, and, being present, offer a ready explanation for the appearance of the fat.

The clinical importance of fatty metamorphosis requires consideration in connection with the description of the diseases in which its occurrence is a constant feature. As the presence of fat in cells is not necessarily pathological, so an interference with the function of the cell is not invariably implied by its presence. When its existence is suggestive of a local destruction of albuminates, a diminution of cell-activity is a necessary consequence. Such diminished activity must produce different results as the cells are those of muscles, of vessels, or of glandular organs.

Even if fat is found in cells under conditions favoring such a suggestion, it does not follow that the destruction of the cell must result. Not only is it possible that the fat may be reserved for eventual oxidation, and its place in the protoplasm be filled by normal constituents, but it is also possible that the fat may be eliminated, as such, from the body. The latter event is made apparent by the experiments of numerous observers referred to by Cohnheim, who have found free fat in the urine after its introduction into the venous current.

_Cheesy Metamorphosis, Cheesy Degeneration, Caseation._

Virchow introduced the term cheesy metamorphosis, tyrosis, to designate the process resulting in the incomplete absorption of pus and the production of apparently similar changes in certain other occasional constituents of the body. The characteristic cheesy appearances were regarded as due to the inspissation of the material concerned, in consequence of the absorption of its fluid. With this inspissation there was frequently associated a partial fatty degeneration, and the cheesy matter represented dead material, which might undergo further changes, of which softening and calcification were the more important.

Inflammatory products, as pus and fibrin, were especially prone to become thus transformed, as well as other relatively transitory materials of new formation--viz. tubercle and parts of various tumors. The type of the cheesy metamorphosis was found in the enlarged lymphatic glands, commonly called scrofulous.

The importance of a clear understanding of the cheesy metamorphosis is now a matter of history. It is merely necessary to allude to the fact that these cheesy products were formerly regarded as indicative of the presence of tubercle, and were the tubercles. Tuberculization and the cheesy condition were synonymous terms, and their indiscriminate use led to much confusion with reference to the nature of tubercle.

Quite recently Weigert[32] has called attention to the conditions present in necrosis resulting from the intermediate stoppage of the blood-current in a part. The effect is manifested, under favoring circumstances, by a cheesy appearance of the affected region, to which the terms decolorized hemorrhagic infarction, anæmic or ischæmic necrosis, have been applied. {80} Weigert lays stress upon the existence of a coagulation of the protoplasm of the cells, with an early disappearance of the nuclei, as the essential feature of this form of necrosis, the conditions present being regarded as analogous to those met with in the coagulation of the blood. The term coagulative necrosis has consequently been introduced by Cohnheim to represent the process first fully described in detail by Weigert. The optical and physical properties of the ischæmic or coagulative necroses of tissue are often manifested as cheesy appearances, although the term coagulative necrosis includes conditions which do not present a suggestion of cheese. It is thus apparent that cheesy appearances may result in two ways: 1, by the inspissation of material in a state of partial fatty degeneration; 2, by a coagulation of the constituents of cells whose blood-supply is suddenly and completely cut off. In the more restricted sense these caseous appearances are regarded as indicative of a cheesy metamorphosis which arises by the former of these methods. Cheesy appearances, on the contrary, dependent upon the sudden death of a part, indicate an ischæmic or coagulative necrosis.

[Footnote 32: _Virchow's Archiv_, 1880, lxxix. 87.]

Whatever may be the origin of the cheesy condition, the material presenting this appearance is liable to further changes, known as softening and calcification. The former event results from the soaking of the dead part with liquid, in consequence of which a detritus results. The softening usually begins at the oldest part of the cheesy mass, and advances toward the periphery. The sanatory evacuation of the emulsive detritus is permitted when a surface continuous with that of the external surface of the body is reached, as instanced by the escape of softened cheesy material from the lungs through a bronchus. The possibility of the complete removal of the dead mass is thus at hand, and an eventual obliteration of the resulting cavity may take place by an adhesive inflammation of its walls.

The complete absorption of the cheesy material of an ischæmic necrosis may occur by the extension into the latter of a granulation-tissue from the periphery. Whenever cheesy appearances are found on surfaces, as the degenerated tubercles of mucous membranes or the circumscribed necroses in diphtheritic inflammation or in typhoid fever, healing may be accomplished by their detachment as sloughs, a clean ulcer being left. Cheesy material is frequently encapsulated--_i.e._ imbedded in a layer of dense connective tissue, a condition which indicates a local cessation of the process through which the cheesy appearances arose. The same may be said of the infiltration of the cheesy mass with earthy salts--calcification--an event which will again be referred to in connection with the consideration of the general subject.

_Hyaline Degeneration, Fibrinous Degeneration, Croupous Metamorphosis._

Certain of the conditions now regarded as indicative of a coagulative necrosis or a hyaline degeneration were previously described by Wagner as the result of a croupous or fibrinous metamorphosis. According to this observer, the cell-contents were transformed, under certain circumstances, into a substance resembling externally clotted fibrin. The formation of croupous and diphtheritic membranes, especially of the larynx, pharynx, and trachea, was thus explained, also the hyaline casts of the kidney.

{81} The results of this metamorphosis presented a hyaline appearance under the microscope, and the term hyaline degeneration is now applied more especially to indicate the production of microscopic changes, while the hyaline appearances visible to the eye are rather included under mucous, colloid, or amyloid metamorphoses.

The limitations in the use of the term hyaline degeneration are but ill defined. On the one hand, there is included the transformation of muscular tissue, first discovered by Zenker; on the other, the various changes described by Recklinghausen and others, among which are embraced the results of Wagner's croupous metamorphosis. As the hyaline appearances are a frequent result of coagulative necrosis, these terms are frequently used to indicate the same condition, according as the optical or etiological features are uppermost in the mind of the observer.

The hyaline or waxy degeneration of muscular fibre described by Zenker represents a metamorphosis of the protoplasm of striated muscle in particular, although the fusiform cells of the muscular coat of the stomach and intestine may present a similar transformation.

The microscopic appearances are more characteristic than those visible to the naked eye. To the latter the muscle appears paler, more translucent, and homogeneous, and proves to be more brittle than normal. The muscular fibres are found with the microscope to be swollen, irregular in outline, the myosin transformed into flaky, glistening masses, without evidence of the normal transverse striation. These appearances have given rise to the term waxy degeneration, which suggests a possibility of confusion with the earlier recognized waxy degeneration of organs, due to the presence of amyloid material. The waxy transformation of muscular fibre, however, does not present the reaction with iodine characteristic of amyloid substance. The degeneration of the muscle is usually regarded as the result of a coagulation of the myosin, and it is claimed by Cohnheim that the latter takes place only in dead muscle, either during the life of the individual or as a post-mortem appearance.

The hyaline degeneration of muscular fibre is found in certain febrile diseases, as typhoid and typhus fevers, scarlatina, variola, and cerebro-spinal meningitis. It may also be met with when a muscle has been exposed to violence, as in the insane who have been placed under mechanical restraint. It has further been found in the vicinity of tumors, especially where muscles have been invaded by their growth. Cohnheim and Weil describe a similar condition in the tongue of frogs after ligature of the lingual artery.

The pathological importance of the above-mentioned degeneration of muscle is most prominent in cases of typhoid fever. The occurrence in this disease of the hæmatoma or blood-tumor of the rectus abdominis is thus explained, the degenerated muscle and its contained blood-vessels being ruptured. The muscles of the thigh and the diaphragm frequently undergo this degeneration; the change is more rarely met with in other muscles of the body.

Recklinghausen regards a hyaline substance, hyalin, as a normal constituent of cell-protoplasm which escapes in drops when the cell dies. Its presence indicates a diminution in the vitality of the cell from various causes. Under the microscope it appears as a sharply defined, highly refractive meshwork, enclosing spaces of irregular shape and size, in {82} which are frequently found nuclei, more rarely cells or granules. Langhans has described this appearance as channelled fibrin. It has been met with in the placenta, diphtheritic membranes, blood-vessels, tubercles, and gummata.

The latest contribution to the history and nature of this form of degeneration has been furnished by Vallat,[33] from whose article many of the above data have been obtained.

[Footnote 33: _Virchow's Archiv_, 1882, lxxxix. 193.]

_Mucous Degeneration, Mucous Metamorphosis, Mucous Softening._

Of the various degenerations presenting a colloid--_i.e._ gelatinous--condition, the mucous variety is one of the most striking. Its gross appearances may not differ materially from those to be described under the head of colloid degeneration, but the diagnostic characteristic of the change is to be found in the presence of mucin. The presence of this substance is readily detected by the addition of acetic acid to mucus, the effect being a fibrillated appearance of the latter, the fibres presenting a more or less parallel distribution. This fibrillation of mucus is regarded as the result of a coagulation of its mucin, previously held in solution by an alkali. Mucin is thus present in the body as a normal constituent, and, in the secretions from mucous membranes, owes its origin to the existence of epithelial cells, whether these represent gland-cells, as in the case of the muciparous glands of the bronchial mucous membranes, or whether they are superficial cells, as those of the gastric and intestinal mucous membranes.

In the origin of mucus as a secretion from glands Heidenhain[34] claims that a destruction of gland-cells accompanies the continuance of the secretion. At the outset, however, the mucin escapes from the cells, the latter remaining relatively intact. With the persistence of the secretion there results a destruction and a new formation of the muciparous cells. In the pathological production of mucus from mucous membranes, as in catarrh, there is no reason to doubt that the persistence of an irritation is the cause of abundant mucus, and that the latter is dependent upon the rapid formation and destruction of epithelial cells.

[Footnote 34: _Hermann's Handbuch der Physiologie_, 1880, v. 64.]

The origin of mucus from epithelial cells under physiological and pathological conditions being apparent, it readily follows that the epithelioid cells of tumors might be supposed to be liable to a similar metamorphosis. It is well known that cancerous tumors, especially those of the stomach and large intestine, are frequently met with, which present an abundant gelatinous material, more or less completely filling the spongy, fibrous meshwork. These are the alveolar, gelatinous, or colloid cancers.

The gelatinous or colloid material often gives the reaction of mucin, and the microscopic appearances of the tumor show that the jelly-like substance lies in that part of the tumor which corresponds with the position of the epithelioid cells. The latter are found in various stages of degeneration, the appearances being similar to those observed in the mucous degeneration of true epithelium.

The prevailing theory of the origin of cancer from epithelial structures {83} readily suggests an explanation for the frequency of the mucous variety of cancer in connection with those parts from which mucus normally arises from the degeneration of the epithelium.

The mucous metamorphosis affects connective tissues as well as epithelium. The Whartonian jelly of the umbilical cord and the vitreous humor of the eye are known, through the investigations of Virchow, to owe their gelatinous condition to the presence of mucin. The latter lies in the intercellular substance; that is, between the cells. The appearance of these indicates no degenerative process, but the presence of mucin is obviously an essential constituent of the tissue. Whether this mucin represents a transformation of the gelatin of the intercellular substance, or a secretion from the fixed cells, or a metamorphosis of the migratory cells of the tissue, is not known. In mucous tissue, however, there is present mucin, wholly independent of any epithelial degeneration. Mucous tissue is present in the eye as a normal constituent of the adult, and in the umbilical cord as a normal constituent of the infant at full term. It is also abundantly met with in the subcutaneous and intermuscular tissues of the foetus. Its pathological occurrence in the adult as a circumscribed tumor, the myxoma, may also be mentioned.

A gelatinous substance containing mucin is found in the adult independent of the mucous tissue, but obviously arising from a transformation of intercellular substance. The most striking example of this occurrence is the cystoid softening of cartilage, especially of the costal cartilages of old people, the basis substance being transformed into a fluid containing mucin. A similar metamorphosis is of frequent occurrence in the intervertebral disks and in the destruction of cartilage in acute and chronic inflammations of the joints. The intercellular substance of cartilaginous tumors also becomes softened and converted into a liquid containing mucin.

In osteomalacia and in the absorption of bone the mucous degeneration of the bone-cartilage plays an important part. The lime salts are first set free, and the cartilage then undergoes a mucous degeneration; the product is either absorbed or remains as a liquid within cavities of large or small size. The mucous metamorphoses of fibrous and fat-tissues, likewise of bone-marrow, are well recognized instances of the occurrence of a mucous transformation of the intercellular substance of connective tissues. Finally, clotted fibrin, so often met with as the product of the inflammation of serous surfaces, may undergo a mucous metamorphosis, and, thus transformed, offer a suitable material for absorption.

_Colloid Degeneration, Colloid Metamorphosis._

Laennec used the term colloid in a descriptive sense to indicate a gelatinous appearance, and for a long time its use was thus restricted. As the colloid appearances were found to differ in their chemical reaction, their distribution, and their pathological importance, and as the term was further extended to include appearances seen with the microscope, it obviously became necessary to subdivide the colloid series of changes according to the observed differences. Its use is now limited to those gelatinous conditions or appearances due to the presence of a fixed albuminate, homogeneous or finely granular, translucent, colorless or pale {84} yellow, of varying consistency, which does not become fibrillated on the addition of acetic acid, and which does not change in color when acted upon by iodine. This albuminate is considered in most instances to represent the result of a transformation, a metamorphosis of cells, and is associated with an impairment of their function--a degeneration which is progressive, and leads, sometimes, to the destruction of the organ, as occurs in certain instances of colloid degeneration of the thyroid body. Usually, the process is limited, affecting particular parts rather than the whole of an organ. The reaction presented by a solution of sodium albuminate in the presence of neutral salts leads to the view that colloid material may represent a coagulation of an albuminous substance or substances under favoring conditions. The presence of colloid masses in the kidney thus meets with a plausible explanation.

The place of its typical occurrence is the thyroid body in certain cases of goitre, and it is early met with as a homogeneous substance replacing the granular cell-protoplasm. With its increase the latter disappears, and the entire cell is transformed into a homogeneous sphere. At times the colloid substance may be seen to project from the surface of the cell as a pale rounded clump. The aggregation of these clumps results in the presence of masses of various size, in which may be found granules of fat or pigment and crystals of cholesterin, which are accidental, not essential. Colloid masses are sometimes met with--in lymphatic glands, for instance--as concretions, mulberry-like aggregations of stratified colloid bodies, which may be infiltrated with earthy salts. Colloid material may eventually become liquefied, transformed into a sodium albuminate; and the presence of cysts in certain varieties of goitre is thus explained. The coexistence in the kidney of colloid accumulations and watery cysts has led to the view that the latter may, under certain circumstances, result from the former through the liquefaction of the colloid material. The same view is held with regard to the origin of cysts frequently met with in the choroid plexuses.

The colloid metamorphosis of cells is also to be found in the epithelium of mucous membranes and their glands, in the prostate, suprarenal capsule, sebaceous glands of the skin, and in the cells of certain tumors.

_Amyloid Degeneration, Amyloid Infiltration, Waxy Degeneration, Lardaceous Degeneration._

The colloid appearances due to the amyloid degeneration of cells are of the greatest clinical importance from their frequent occurrence and the gravity of the symptoms connected with their presence. In amyloid degeneration there is the transformation of the cell-protoplasm into an albuminous material different from other albuminates found in the body. This transformation is at the expense of the functional activity of the cell, and the latter becomes inert. Amyloid degeneration represents no mere substitution, but an addition, since the affected tissue is increased in volume. The albuminate was called amyloid by Virchow in consequence of its color-reaction with iodine. Its method of origin is wholly unknown, never being found in the circulating fluids nor in articles of food. It is met with chiefly in the cell, although its presence in the intercellular substance of old people is recognized, and its occurrence in {85} the midst of the thrombotic deposition on inflamed valves and in the results of inflammatory processes is also recorded.