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LEUKEMIA NOT ALWAYS PHTHINOPLASTIC.
scope discovers in the overcrowding of hardened cells, which have lost their plastic and self-sustaining power as sarcophytes, and so become causes of obstruction and irritation to adjoining tissues, and are themselves prone to an early decay.
That an excessive abundance of lymph corpuscles alone does not suffice to produce the decaying tumours, which characterise scrofula and tuberculosis, is evident in the disease called leukæmia, or leucocythæmia, in which they not only are found in unusual proportion in the blood, but by their accumulation they cause lymphomata, great enlargements of the lymphatic glands, spleen, and liver ; but these are all soft swellings, tending less to the decay of their substance, than to the exhaustion of the frame by monopolising the nutritive material of the body in its protoplastic state, so that the victims of the disease die of anæmia and asthenia before there is time for the lymphatic swellings to go into decay. But the vital properties of the sarcophytes in leukæmia require further investigation before we can be sure of the true nature of this disease.
In conclusion, we may say that as there seems to be good reason for regarding the lymphatic and chyliferous system as the source of the plasma from which both blood and flesh are formed, nourished, and renovated, it becomes quite intelligible that any disease in the plasma, or germinal matter, or in its representatives, the sarcophytes, will manifest its effects commonly, and at an early period, in some part of this system.
ON CASEATION AND FATTY DEGENERATION OF TISSUES.
Fatty Degeneration discovered by Gulliver--Proved to be a chemical change
-Causes maturation and softening of Tubercle, Fibrin, &c.; and an extensive agent in Pathology-The most gentle step to the death of tissues.
That the texture of certain organs are sometimes transmuted into fatty matter was noticed by Laennec and other older authors; but the common tendency of many tissues and morbid products to fatty degeneration was first distinctly pointed out by Mr. Gulliver, who found an abundance of fatty matter in the atheromatous patches in arteries, in diseased testicles and kidneys, and in chronic inflammation and tuberculous disease of the lungs.
Even at that early period he hints that these changes were evidences of decay of animal matter, induced by age or disease; and in the same year (1843) I first suggested the formation of adipocire from flesh kept moist without access of air as an analogous instance of the chemical conversion of flesh into fat.2 Subsequently Mr. Gulliver
1 Med.-Chir. Trans. vol. xxvi.; and Edinb. Med. and Surg. Journ. vol. xl., 1843.
2 Some years after, Dr. Alison, in his essay on · Vital Affinities' (Trans. of Royal Soc. of Edinb., 1847), proposed a formula to explain the chemical conversion of albumen and water into fat and carbonate of ammonia. Mr. Gulliver had previously stated that Dr. John Davy had found an increase of oil, with the formation of carbonic acid and ammonia, in the liver of the cod, after it had been kept twenty-five days in a damp place. We may bear in mind that the common representative of living animal catamorphosis (downward change of form), urea, has the same elementary composition as carbonate of ammonia, and that the excessive excretion of urea is often observed in the same wasting diseases in which fatty degeneration invades the textures.
FATTY DEGENERATION A CHEMICAL CHANGE.
adduced several instances of the production of fat in albuminous and fibrinous matters after death ; ? and both Dr. Hodgkin and myself noticed in several instances a decided increase of fat globules in morbid specimens after death.
This chemical view of the nature of fatty degeneration was afterwards completely established by the observations of Dr. R. Quain. He produced the fatty conversion in healthy muscle by simply keeping it for a sufficient length of time in water, to which a little spirit or nitric acid had been added to prevent putrefaction. After some days, oil globules appear in the fibres of the muscle, and gradually increase until much of the sarcous element is converted into them, and under the microscope, or by the action of chemical tests, the change is proved to be identical with fatty degeneration as it occurs in the living body.
That which Dr. Quain conclusively established with regard to fatty degeneration of the heart—that it is a chemical conversion of muscle into fat from imperfect supply of blood, or malnutrition—has since been generally adopted and acknowledged to be a process common to most textures and morbid products in the body; and one playing a very important part in pathology. In the first and second editions of my • Principles of Medicine' (published respectively in 1843 and 1848), I had already advanced a similar view as to the nature of fatty degeneration, and as to the large share which it has in producing the maturation and decay of tubercle and other products of inflammation and malnutrition. This is now the generally received opinion, and may be expressed in this proposition :-That all proteinaceous matters and tissues in the animal body, whether albuminous or fibrinous, under various circumstances which impair their vital nutrition, are prone to a chemical transformation into fatty matter.
| Notes to Hewson's Works, Sydenham Soc. edit., 1846.
3 After noticing Mr. Gulliver's recent discovery of increasing fat globules in softened tubercle, the general inference follows:- The formation of fat, also, in old pus, in atheroma of arteries, and in gangrene of the lungs, seems to show that fat is sometimes a débris of animal matter, as in the conversion of flesh into adipociro. The detection by Dr. Davy of olein and margarin
This change of material is, in fact, a partial chemical decomposition, and incapacitates the parts for the functions of life ; but it is not rapidly or suddenly destructive, like putrefaction, which not only rots and disintegrates, but spreads a septic poison into surrounding parts. Fatty transformation, on the other hand, is a gradual decay; it is a step downwards from highly organised to imperfectly organised matter, more like vegetable than animal in composition; and with this change are lost the higher vital properties of the part-contractility, healthy nutrition, and the power to resist further decay. An organ or tissue thus degenerating may be said to vegetate awhile before it loses all vitality; and there may be for a time even increasing cell-proliferation and growth, but of an imperfect, perishable material, soon turning to fatty decay and disintegration.
It would lead too far from our present subject to enter into the history of fatty degeneration as affecting individual tissues and organs. Our concern is chiefly with that occurring in inflammatory or other deposits or growths, and especially in those in the lungs connected with the progress of pulmonary consumption.
The fibrinous products of acute inflammation will supply a good example of the manner in which a plastic material, in opaque exudation corpuscles shows a tendency to the production of fat in all degenerated plasma.' (Principles of Medicine, 1st ed., 1843, p. 321.) This was, I believe, the first announcement of the general fact of fatty degenerations. It was further developed and illustrated in succeeding editions, and in the meantime the same views were entertained and extended by Rokitansky, Virchow, Quain, Paget, and others.
CASEATION OF INFLAMMATORY EXUDATIONS.
which under favourable circumstances is capable of organisation, degenerates and decays by this chemical change, when it is either wanting in vitality or when it is cut off from the nutrient influence of the circulating blood and of living tissues. The coagulable lymph, exuded in moderate quantities by an inflamed pleura in a healthy subject, is either reabsorbed or is organised into loose adhesions of connective tissue, which may not interfere with the motions of the part. But if the lymph effused be excessive in quantity, or bad in quality, as manifested by its opacity and a large predominance of the corpuscular elements, it may either form only a dense tough solid, of low organisation, binding down and impairing the movements, or it may not become organised at all, but degenerate and disintegrate into a cheesy or curdy mass, tending to further decomposition and mischievous results,
I CASE I.-- The following case exemplifies this kind of inflammatory product :- Master ---, æt. 45 years. Feb. 9, 1847. Father (middle-aged) lived long in India. Mother subject to liver disorders. The child has always been precocious and delicate. Last summer had a feverish attack, and has ever since been failing in appetite and flesh. For the last eight months has had slight cough, and feverishness at night, sometimes ending in perspiration. Bowels formerly costive; now irritable, and fæces pale and slimy. Right side tender, both at and below ribs. Pulse 120, weak. Urine turbid and very acid.
Dulness; no motion or breath in lower half of right chest, which is larger than the left; bronchophony in middle region, ægophonic in parts; breath weak above ; obscure crepitus on deep breath. Liver dulness two or three inches below ribs ; abdomen distended, with superficial fluctuation and dulness on percussion.
A small dose of hydrarg. c. creta, digitalis, and Dorer's powder twice a day; citrate of potass three times ; iodine ointment to abdomen, with a constant covering of piline.
After a week of this treatment, the urine became more abundant, bile appeared at times in the fæces, and the abdominal tenderness, distension, and fluctuation subsided, with improvement of appetite and cessation of cough ; but the pulse continued frequent, with fererish accessions at night, and the physical signs remained the same. In March and April there was a little improvement in flesh and strength, especially after leaving off milk, which was found always to stop the flow of bile. In June appetite again