Principles of surgical pathology, for the use of the student

Preface

It would be ideal if the student could learn Patholog}^, which forms the foundation of his knowledge, on the living and on the cadaver, macroscopically and microscopically, by direct demonstration. Such is, of course, out of question in the present methods of teaching with the number of students and the amount of material at the disposal of the teacher.

Didactic and theoretical teaching is next to valueless. Experience has taught me that the best method to teach surgical pathology was to demonstrate as many as possible fresh pathologic specimens; if this is impossible, preserved specimens: and then to examine microscopically as many pathologic conditions as possible. But the students impress the pictures of the miscroscope far better upon their minds if they themselves draw from the specimen, and they understand the drawings better; this is the reason why I have not appended any drawings to this book.

My method is this: I distribute to 125-150 students in two hours lectures five or six pathologic specimens, draw and demonstrate on the blackboard these same. The nature of the pathologic changes to be studied has been given to the students before and they study them theoretically at home. During the lecture they correct their ideas about the changes which they have gained by theoretical studies and draw from the microscopic specimen correct figures, which remain longer and clearer with them than the best drawing of the artist. • C. B.

Introduction

Surgical pathology is that branch of pathology which deals with the changes of the human body peculiar to surgical diseases, viz. : those which are amenable to surgical treatment. Inasmuch as the field of surgery has changed from time to time, and is constantly enlarging, the field of surgical pathology is also variable. It is not the object of the science to divide pathology distinctly into two parts : one surgical and the other medical, but this division is made merely as a matter of convenience. Besides, surgical diseases have so many pathologic changes strictly characteristic of them that such a classification is logical.

Before entering into the discussion of these particular changes we must state some facts which hold good for the general pathology of the body. A human body of ideal health and absolutely normal conditions is a rarity; perhaps it never exists. It would be a body in which every organ, in its minutest detail, would correspond with the ideal state as found by comparison of many, and it would be hard, perhaps impossible, to prove such a state with our many methods of investigation. The normal condition of the body is, therefore, only a relative one. JSTeither are the pathologic conditions well-defined types ; for example, erysipelas is an infectious disease of the skin, which shows a characteristic appearance of redness, swelling, and eventually blister formation, fever, etc. In most cases the pathologic conditions will correspond with this picture, but there may be erysipelas without redness, without swelling, or any of the characteristic symptoms, only revealing itself by the same consequences, the same subjective symptoms, or only diagnosed by comparison with other cases occurring at the same time. If all these exceptions and varieties were embodied in primary teaching, it would perplex the student.

I shall endeavor to give, in my descriptions of pathologic conditions, the changes observed in typical cases, and leave out as much as possible theories, varieties and rarities. It is an easy matter to fill into the framework of positive knowledge all the possibilities and controversies, and it will by no means be a dogmatic teaching, because we may as well state here that there is no statement in medicine so positive that it may not be given up if a subsequent discovery is made. These facts must be clearly understood if we do not wish to be disappointed in our studies, for if we expect types of disease and types of pathologic conditions in nature we shall be very much disappointed. In our teachings, however, we must present such types which represent the majority of cases, leaving plenty of space for varieties within each type. For the student who has no knowledge of this science it is best to first impress such types upon his mind, and it becomes then an easy matter for him to group around this type different varieties of the typical condition and to explain the individual difi:erences, if he refers in his comparisons to the type learned at first.

Anatomy and its auxiliary branches will teach you the normal conditions of form and structure; physiology, the functions of the parts and organs of the body in health; pathology comprises the teachings of changes in structure, form and function caused by disease.

What is DISEASE? Disease is the condition of the body in which the functions are performed in an abnormal manner; this is, in most of the cases, combined with an abnormal state of the body. The functions of the body are many; some are of a nature which one may distinguish by his senses; we call these OBJECTIVE, others which are perceptible only to the individual ;

Besides tlicsc four li(';i(liii,^s of cliMnoos rroiii norinai to diseased eojiditions, we have eoiioenital differences from the normal, called AiixoK'MAi.iTiEs. An\- disease may be classified witliin this IVaiiie, with tlie understanding that nature does not allow distinct i v|)cs, as alluded to in our introduction. A pa t lioloii ic cniidilion may at the same; tijne belong to t^vo or three or all groups (jI this division,

GROUP I.

ANOMALIES OF CIRCULATION.

Under the inthienee of ti-igiit the face blanches, but this local lack of circulation is not a disease; it passes away witli the disappearance of tlie impulse. But if the face remains blanched for some time — days or weeks — we speak of a pathologic lack of circulation, or anemia of tlie face. Under the influence of excitement the face flushes, but this flush disappears very soon. If the face remains red beyond limit of time and space — if it be burning hot on account of increase of circulation, enlarged vessels, etc. — we speak of hyperemia or euythemia. With other words, circulation may change within the limits of normal, but if these differences pa.ss beyond such limits, that is, persist longer than the physiological iminilse, or occur without such pliysiological impulse, then the diseased condition, anemia or liyperemia, is produced.

These changes of circulation are:

1. Local Hyperemia. It means that the circulation of a part of the body is increased beyond the physiological limit. It may be (a) active, (b) passive.

(a) Active hyperemia (fluxion) , which is, as a rule, not a lasting condition, consists of an abnormal dilatation of blood vessels due to a nervous influence upon the muscles in the blood vessel walls. Its symptoms are increased redness and turgescence (hardness and stiffness) of the tissues. If it has been lasting for some time, the blood vessels may remain dilated. The result will then be increase of fluid between the tissue spaces and often increase of the size of the tissue cells. After death, hyperemia may leave no signs except this increase in cellular elements.

(b) Passive Hyperemia is due to partial or total obstruction to the flow of blood through the veins (stasis) ; its signs are bluish discoloration and turgescence of th^ parts, Its cgnsequerices, if lasting for some time^ are the same as in active hyperemia;, but there is more tendency to the formation of edema (which means an increase of serum between the cells and within the same). Active hyperemia permits of more nourishment to the tissues through its increased flow of blood; passive hyperemia reduces it by the slowing up of the flow. In extreme cases, however, both conditions may endanger the life of the cellular elements and lead to death of the same (necrosis).

2. Local Anemia (ischemia) is the decrease of the blood supply to a part. It may be due to general lack of blood in the body or to an obstruction of the supply. This latter may be caused by compression or obstruction of the arterial blood supply or the nervous influence upon the muscles in the blood vessel walls. If it be lasting for a time, anemia endangers the life of the tissue cells and may lead to necrosis. Its signs are loss of color and flabby condition of the tissues.

HEMOEEHAGE.

Hemorrhage is the extravasation of blood. Under normal conditions blood is always confined to the vessels. We speak of hemorrhage if through some cause the blood has left the vessel. It may be:

1. Arterial.

2. Venous.

3. Capillary.

4. Parenchymatous.

According to its size and extent we may divide hemorrhage: (1) Point-like, or ecchymosis; (2) suffusions, if they are larger and less defined; (3) hematoma, if they are tumor-like accumulations and clots; (4) hemorrhagic infarcts, if the hemorrhage extends between the cells of the tissue of the organ. If a hemorrhage takes place from one organ into a cavity, or outside of the body, it is called by a specific name, usually indicating the source; for instance, epistaxis, bleeding from the nose; hemoptoe, bleediniT from the lunajs : iie:\iatemesis, from the stomach; metrorrhagia, bleeding from the uterus; hematuria, from the urinary organs ; hematometra, bleeding into the uterus ; HEMARTHROS, bleeding into the joints; piematocele, info the tunica vaginalis testis : hemothokax^ bleeding- into the pleural cavity ; hemopericardium, bleeding into the pericardium.

The cause of hemorrhage may be threefold: (1) A rupture of the wall of the blood vessel by an injury; (2) by changes in the wall lessening the resistance offered to the force of the blood current, often produced by regressive changes^ which will be discussed later; (3) in rare instances to nervous influences^ as in vicarious bleeding; for example^ bleeding into the conjunctiva or skin instead of normal menstruation.

THKOMBOSIS AND EMBOLISM.

Thrombosis is the formation of a clot within the blood vessel. Under normal conditions blood is always liquid within the vessel wall. If, however, the circulation is weakened to such a degree that the flow of blood is retarded to an extreme, or cut off altogether, or if the blood vessel Avail undergoes regressive changes, so that they do not permit the sliding along of the blood column, or if the blood is changed in its constituent part, it coagulates and obstructs partially or totally the lumen of the vessel. Such a clot is called a thrombus. It is composed of blood corpuscles and fibrin, but may undergo a gTeat many changes. It may form a connective tissue (organized thrombus), or melt through degeneration. If a part of this clot is carried on with the circulation it may find its way into a small blood vessel, where it obstructs the circulation. The clot itself is called an embolus, the process EMBOLISM. The signs of thrombosis are those of loss of circulation in the parts depending upon those vessels, and the results are those described in passive hyperemia and local anemia. The embolus may be aseptic or infected with microorganisms (septic embolism) .

Upon this differentiation hinge a great many possibilities. The formation of clots charged with streptococci, then embolism, will spread the process, and thus cause many local processes of infection. This is often the way infective diseases are caused through the body.

ANOMALIES OF LYMPHATIC CIECULATION.

The lymphatic circulation is dependent upon the blood circulation; every increase of blood to the vessels is followed by a like increase of lymph within the lymphatic vessels and between the cells of the part which is affected. This increase of serum between the cells is called edema or hydrops. If it is present in the exposed parts of the body, the skin, the name anasarca is used. Within the abdominal cavity it is called ascites. It contains the same elements as the lymph. Besides these clianges in circulation there may be other causes for the development of edema. We distinguish three kinds of edema: (1) Edema through stasis (hyperemia, active and passive) ; (2) inflammatory edema (changes in blood vessel walls; increased permeability of the cells composing the blood vessel walls often tends to induce the formation of edema) ; (3) hydremic edema, due to excess of the amount of water in the blood, with simultaneous lack of albuminous matter. Such conditions exist in individuals run down by wasting diseases, as cancer, long-standing suppurations (cachexia), etc.

LYMPHOEEHAGIA.

Ltmphorrhagia is a process analogous to hemorrhage. It consists in the extravasation of lymph from an injured lymph vessel. Its causes are similar to those of hemorrhage. The persistence of such a flow of lymph from the body produces a LYMPH-FISTULA. A flow from a lymphorrhagia may lead to the filling of a body cavity with lymph, viz. : Peritoneum, called LYMPH-AsciTES, or into the thorax, called lympho-thorax.

GROUP II.

REGRESSIVE AND PROGRESSIVE CHANGES A. REGRESSIVE CHANGES.

We understand by regressive change all those possibilities of transformation of a well-developed and organized protoplasm, as we find it in the cells of the normal body, into tissue of less vitality, or into material of lower physiological value. They range from a slight deterioration to the partial or total death of the cell material and its results.

1. Atrophy. As the simplest change in a retrograde direction should be placed "aplasia, hypoplasia, or simple ATROPHY. The cell is anatomically of the same construction as in the ideal condition, but smaller in size and consequently of lower functional value. The causes for this backward step are poor nutrition or mechanical difficulties (peessure atrophy)^ or an inactivity or neurotic condition (trophoneurosis). This latter is very interesting, showing that the growth of tissue is regulated hy a nervous influence. As examples may he cited the atrophy of the old age from poorer nourishment, all tissue cells being affected, or the atrophy from the mechanical pressure of a tumor, or, finally, the atrophy of a paralyzed limb.

2. The slightest change in the cell is cloudy swelling or granular degeneration, and may be only temporary. It often happens during fever diseases in which the protoplasm of the cells become disintegrated. The change is microscopically shown by their change of color and consistency (the organs appear like cooked), and macroscopically by the appearance of granules within the cells, which are easily stained by the anilin dyes and give the appearance of cocci within the cells.

3. Hydropic Degeneration. If the cells undergo a change slightly greater than granular degeneration, they show accumulation of liquid within the cell bodies (hydrops of the cell). These accumulations of liquids appear as empty, round spaces within the cell body when seen under the microscope, and the organs thus affected are softer than normally.

4. Fatty Degeneration. The formation of smaller or larger fat globules within the cells, in wiiich normally no fat is found, is a degeneration. Fat is easily recognized under the microscope by its lustre (dark hue), and the characteristic test with osmic acid, which stains it black. Fatty degenerations are mainly caused by a lessened oxidation of the protoplasm, that is, less or poorer blood supply, and its result is a lower functional value.

Fat may crystallize within the cells in various forms, as rhomboid crystals or plates or groups of needles (cholesterin) .

An accumulation of larger amounts of fat may lead to the formation of oil (yellow), or, if mixed with blood of reddish or even a greenish color (oil cysts). With the naked eye the organs thus affected appear yellowish, are more friable, and show fatty substances, even oil drops upon the freshly broken surface.

5. Mucoid and Colloid Degeneration. Mucus and the aggregate condition of glue (colla) are changes which are peculiar to some cells of the body in mucous membranes under physiological conditions (gol)let cells) ; however, under pathologic condiditions not only goblet cells, Init any kind of cell transforms into mucoid masses; especially tumor cells • are predisposed to such mucoid and colloid degenerations. The difference between mucoid and colloid masses is their chemical reaction. If mucus is treated with acetic acid it coagulates, and the cpagulum can not be dissolved by adding acid; alcohol also coagTilates it, l)ut water added to it will swell it. These reactions are not applicable to colloid cells. The cells in l)oth instances appear tilled witli a jelly-like mass, which may be colored green or yellow.

6. Hyaline Degeneration. Hyaline degeneration is the transformation of the cells into a substance which does not show any texture, but is transparent, and accumulates in irregular masses within the cells. It appears within the vessel walls, the connective tissue, brain and kidneys, and its origin is obscure. It seems that the cells are first swelled up by a liquid which coagulates and forms the hyaline masses. Blood vessels may he easily occluded.

7. Amyloid Degeneration. Amyloid degeneration is the transformation of the protoplasm into an allmminous body of a glairy, albuminous appearance, transparent, which gives a characteristic reaction toward iodine and various anilin dyes. Hyaline degeneration is very similar, but lacks this reaction. Macroscopically, the tissues appear like sago or wood, and if treated with methyl or anilin violet they appear ruby red, while the healtliv tissue appears blue or dark violet. If treated with a watery or potassium iodide solution of iodine, amyloid is brown, normal tissue yellow.

This characteristic reaction enables us to make the correct diagnosis of this change; it is caused by poor nutrition, characteristic of cachectic conditions as they follow suppurations of long standing; tuberculosis, syphilis, etc., while carcinoma rarely causes such a change.

8. Pigmentation introduces a degenerative process inasmuch as all foreign substances which are physiologically inactive must reduce the vitality of a cell. Such pigmentation may be formed in the body or may enter it from without. Blood is the most common source of pigment (hemin, hematin, hemoglobin). It may form darker or brighter masses of crystals or cry^ allized formations within the cells, or they may transform into melanotic masses, as we find them in some tumors (melanosarcoma) .

Bile is another source of pigmentation. Icterus is the pigmentation of the tissues caused by the absorption of bile; pigmentation may be caused by foreign bodies like silver (argyeia), copper, iron, nickel, and other metals.

9. Chalky Degeneration is a higher degree of regressive change by deposits of foreign material within the cells and subsequent lowering of function is their impregnation with salts, viz. : The chalk from the calcium salts as it is found in amorphous masses and crystals, especially in the cells of old individuals, in the blood vessels (arterio-sclerosis), or in the tumors (fibroids). Uric acid salts are often deposited in cells in disease (arthritis urica).

10. Osseous Degeneration. The osseous deposit of calcium salts with the formation of bone is a degeneration of common occurrence in some organs (lungs) where cartilage or connective tissue is present, but even in organs where cartilage or bone is not present normally.

11. ^^ecrosis. We may define as the last degree of degeneration the change which transforms the cells to such an extent that they die; this regressive condition is called the cell-death or NECROSIS. If the cell has been disturbed in its vitality by mechanical, chemical or thermal influences, or by its lack of nutrition (local asphyxia), the result is a death or necrosis of the same. A slight impairment of the cell will lead perhaps through a number of stages of regressive changes before the cell dies; a rapid injury may lead to a sudden death, and between both the slow course (necrobiosis) is a hovering between life and death. Sometimes the cells recuperate. In other instances they are doomed to destruction. This local death is, of course, of different value, according to the cells affected. While in the muscle a local necrosis is of no great significance, in the brain a minute necrosis may lead to the gravest possibility. The final result of all regressive changes offers a great many possible outcomes.

While some changes are passing, and the tissues recuperate, in other instances it leads from bad to worse, and the fate is necrosis. The results of necrosis may be :

1. The removal of dead tissue b}^ exfoliation or absorption and its replacement b}- normal tissue (kegeneration) .

2. An exfoliation of the necrosed tissue and replacement by a new tissne of scar formation.

3. Partial absorption of necrotic tissne and chalky infiltration of the remainder, with the formation of a capsule around it (encystment).

4. The transformation into a liquid with its surrounding capsule. This latter condition is very common, and especially peculiar to some organs of the body. The formation of cysts with distinct walls is usually the result of such local necrosis. The fluid is of a different character, according to the tissue from which it has been formed. The color and consistency of the fluid of the cyst depends upon the blood supply to the part previous to the necrosis.

The walls of the cyst are usually the result of a reactive inflammation in the neighborhood of the necrosed portion. When the inflammatory cells have formed out to connective tissue, a solid wall is formed.

. FORMS OF NECEOSIS.

ISTecrosed cells dissolve in difi^erent manner. Thus we distinguish the difterent forms of necrosis:

1. Coagulatiois' iSTecrosis. The dead cells form a fibrinous, granular or homogenous mass, with a loss of contour and structure of the organ.

2. CaseatiojsT' or Cheesy Dege^^eration is the transformation of tissue into soft consistency, partly fatty, parti)- albuminous, white or yellowish, often hardened.

3. Liquefaction, or transformation of the cells into fluid.

4. MuMMiFACTiON, or death of tissues, with death of the cells, transfusion of the coloring matter of the blood, and consequent dark discoloration (dry gangrene).

5. Moist Oangrene,, or the transformation of tissue into easily friable, livid, structureless masses, decomposing with the formation of foul gases.

B. PEOGEESSIVE CHANGES'.

Progressive changes of tissues or whole organs are such which show an increase in size or number of cells when compared with the normal. The increase in number is called hyperplasia. The increase in size is called hypertrophy. Both conditions are pathologic changes, though they do not always signify a deterioration or lower functional value of tissues or organs. The cause is usually a nutritive irritation, or loss of the resistance to growth of organs or cells. The organs or cells are, as a rule, under certain mechanical relations which allow only a certain size or growth, but if the resistance or obstacles are removed, then such cells or organs may proliferate in size or number. For example, if the valves of the heart fail to act promptly, the muscle of the heart has to perform more work in order to keep the same amount of blood in circulation. This increase of work will cause the muscle to become larger, more cells will be developed, and the volume of the muscle as well as the number of cells composing it will increase. In the same way the muscular apj^aratus increases within the bladder if a stricture of the urethra prevents the normal flow of urine, and the bladder has to perform more work.

Another kind of increase in volume is represented in the hypertrophy of the prostatic gland in old men, where the elements of the prostate increase in number and size, but also the interstitial elements of connective tissue as the result of chemical chano-es, irritation and other causes. The diaoriosis of these progressive changes is easily made l)y comparisons of the organs. The physiological value may be decreased if, as is the rule, in the ultimate stage the hypertrophic tissue undergoes degenerative changes.

In connection with these (pathologic) changes there must be considered certain physiologic processes of growth and development of cell and tissues called by the collective name of regeneration or CELL repair.

EEGENEEATIO^s^

If tissues have been destroyed by an injury of any kind, there are three possible consequences which may follow, viz. : Necrosis, or scar formation, or regeneration.

1. Eegeneration of Epithelium!. Epithelium is a highly organized cell, whether in epidermis or mucous membrane. When destroyed, ne^v epithelium may be formed by the process known as karyokinesis. Only when all the epithelium is destroyed is its place taken b}^ connective tissue. As long as small remnants of epithelium (cells witli nuclei) remain, new cells can grow from these^ but the character of the epithelium must not always remain the same, so that, for instance, cuboid or cylindroid epithelium may be replaced by the pavement variety. Epithelial cells may retain their life for some time, even when separated from thfc body, so that they may be transplanted. This possibility is proven by grafting of skin or mucous membrane. The process of karyokinesis is characterized by the gradual development of two cell bodies from one through stages as shown by the illustration.

2. Blood Vessel Eegeneration. Blood vessels are apt to form anew when destroyed, and their formation is one of the most important factors in the process of tissue restoration. They develop as solid sprouts from the cells of the capillary vessels; the sprouts join in the shape of arched boughs; there arches gradually become hollow tubes, and open into the capillaries, thus allowing the entrance of blood corpuscles, and the circulation is established. The sprouts consist of cellular elements, but when they gradually develop into walled tubes a layer of connective tissue and the lining of endothelium forms in them, thus representing all the constituents of a blood vessel.

3. Eegeneration of Cot^nective Tissue. All the higher forms of connective tissue, as bone, cartilage, periosteum, lymph glands, fat tissue, etc., may regenerate also by the process of karyokinesis, but very often tissue of an indistinct, non-differentiated character, as observed in the embryonal period throughout, takes the place of the higher developed connective tissue. This is called the germinal tissue, and forms the scar as a result of an injury.

4. Muscle Tissue Regeneration. Muscle Tissue regeneration develops in the same manner after an injury as epithelium, viz. : By karyokinesis and cell division, but often germinal tissue takes the place of muscle cells, resulting in a scar, especially when a great deal of the muscle has been destroyed.

5. Nerve Regeneration, ^^'erve cells and fibers may be restored after injury. Fine filaments form sprouts (intact nerve fibers), and by gradual development of the nerve sheath about these filaments matured nerves are formed. Such a restoration of nerve filaments may take place even across a breach of the injured nerve if there is only some means of connecting the broken nerve, so that a thread of catgut or silk, or a decalcified bone tube, will afford a support for new-forming filaments. If the. nerve, however, is not directly connected, then these new-formed filaments often develop irregular, bulbous growths (see neuroma).

If a nerve has been cut, for instance, then that part of the nerve which is still in connection with the central nervous system throws out new fibers, which grow alongside the peripheral and dead, old fibers, and gradually replace the same, while the distal part of the cut nerve gradually disappears by absorption.

GROUP III.

INFLAMMATIONS.

Inflammations form a large group of pathologic changes. We call inflammation the combination of a number of symptoms, objective and subjective. We observe in inflammation some signs which are lost in the pathologic specimen. We speak of five cardinal symptoms of inflammation, viz.: (1) Redness (rubor); (2) swelling (tumor) ; (3) pain (dolor) ; (4) heat (calor), and (5) the impaired function; but these five S3^mptoms are not always necessarily present to form the pathologic change of inflammation, tion.

The cause for inflammation is a certain irritation of the tissues which is followed by changes in the circulation. These explain the cardinal symptoms. As a result of the irritation, the blood vessels of the inflamed part become dilated, and more blood enters the vessels. The current, however, is decreased, the white blood corpuscles and some red cells leave through preexisting openings (stomata) between the cells and the blood vessel wall, and fill the spaces between the cells. This process is called LEUCOCYTE-INFILTRATION. Scrum also Spreads through the tissue cells and forms an exudate (edema).

The results of these changes are manifold. Thev depend upon what kind of exudate is formed. These exudates may be solid, _ semi-solid, or even liquid, according to the different elements composing them.

We distinguish (1) the serous or sero-fibrinous exudate. It consists of serum with flakes of fibrin, leucocytes, and 'sparingly of red cells. If coming from the surface of a mucous membrane, this discharge is called CATAKiiHAL discharge. It often contains mucus from the goblet cells. (3) The croupous exudate consists of coagulated serum with a large amount of fibrin, it presents a white or grayish membrane. (3) The purulent exudate is an accumulation of large quantities of white blood cells, a small amount of fibrin, and debris of tissue. If this secretion be upon the surface of a mucous membrane, we speak of it as a purulent catarrh. Any of these exudates may be tinged with Ijlood, and are then classified as hemorrhagic.

THE EESULTS OF INFLAMMATION.

There are several possibilities as consequences of inflammation : ' .

1. All signs and symptoms may disappear, exudates may be absorbed, healing or restitution to the former state of health may be the result (restitutio ad integrum).

2. At the site of the inflamed part there may develop a new tissue of a character known as germinal or embryonal (granulation) tissue, with a large amount of newly-formed blood vessels. This may be gradually replaced by a scar, or may continually keep on forming and decaying, thus resulting in chronic (lasting) granulation with suppuration. Large amounts of such granulation tissue are called granuloma. If the pus finds its way outward, it passes through a canal lined with granulation tissue (fistula).

If the granulation is formed on the surface of a mucous membrane or epidermis, an ulcer is established.