Fatty ills and their masquerades

Front matter

FATTY ILLS

AND THEIR MASQUERADES

BY

Table Of Contents

DEDICATION, V-VI

PRELUDE, VII-VIII

DEFINITIONS IX-XIV

Dedication

HENRY A. ROBBINS, A.M.,M.D., Washington, D. C.

PROF. S.WEIR MITCHELL, M.D., LL.D.,

Clinician, author, etc., of Philadelphia.

I. Fatty Degenerations That Are Normal

This chapter may seem out of place, as it clashes with the definition; still, normal uterine subinvolution and the clinical morphology of puerperal discharges beautifully demonstrate fatty epithelia, oil globules, and muscular fibres of uterus, large, long, flat, pointed at both ends, and undergoing fatty degeneration, whereby the organ is reduced to normal in a few weeks if health is good.

There is normal ovarian subinvolution in the Graffian follicles or corpora lutea of the ovaries after ovulation.

Epithelial cells of the kidneys, according to one author; epithelia of the breasts producing fat of milk; epithelia of the sebaceous glands; corpora amylacea, or amyloid bodies found in the brain, called " brain sand," and considered as normal by some writers, come under this chapter.

If the diseases due to old age are normal, then, as most of them are fatty ills, they are diseases due to normal conditions. At least, it is maintained that death from old age is a natural death, or that the way in which death comes by molecular changes when the normal limit of life is reached is natural. " The thing that is seen is temporal " applies to the animal and vegetable kingdoms. Organic life has periods of termination to its existence, while spirit is "eternal."

Adipocere, though not a clinical change, may be mentioned here. Corpses have been known to turn, after burial generally for years, into a hard, fat, waxy substance, and portions of human muscle have undergone the same change when kept under water. Adipocere is regarded as a chemical change which certainly prolongs the existence of the parts thus changed, and, though a degeneration, it is a preservative one after death.

Obesity is an accumulation of fat where it naturally belongs in the human body, but does not necessarily include the substitution of other tissues by fat, though the two conditions are sometimes found together. Excessive obesity may become a fatty ill, and then is amenable to the same treatment as the latter. The obese, save from the inconvenience of excessive bulk, are to be regarded as in a normal condition until there is an invasion of tissues and organs and these are more or less replaced by fat. When obesity and fatty degeneration are found together, skill in diagnosis is well displayed in determining the existence of the latter. The two conditions are popularly connected together, and generally obesity is thought to precede and induce fatty degeneration; but the fallacy of this is shown by lean people presenting the most typical cases of tatty degeneration of tissues and organs.

The offices of fat in the healthy body are too well known to need repeating here. They are needful to perfect living; but when omental fat accumulates in masses as large as a man's hand, it is "obesity" and as much a condition of disease as it would be to have one's arm four feet long. Obesity is amenable to diet more than any other means, and does not have the proper attention from the profession; hence the demand for advertised nostrums.

II. Fatty Ills Which Are Abnormal And Recognized As Fatty Degeneration

Premature old age.

Fatty Heart.

Fatty Liver.

Fatty Kidneys.

Fatty Muscles, especially of limbs.

" Not only do muscular tissues, but also "capillary, venous, and arterial vessels, " connective fibrous tissues, epithelia, in- " tercellular and areolar fat tissues, glandu- "lar structures, and even tuberculous a lungs, fattily degenerate." *

A common example is the subcutaneous solid fat becoming oils, and in the writer's estimate this is an important primal link in the chain of evidence necessary to establish the diagnosis of fatty ills, of which more later. Fatty thyroid glands occur in acute diseases.

" Cancer cells and cells of inflammatory " exudation, when their functions have attained their full development and cease, "fattily decay. The flesh and other pro- "tein components of one animal, when "kept in the peritoneal cavity of another "animal, will undergo fatty degeneration."*

* Micrographic Dictionary.

The fatty degeneration, acute, which occurs in phosphorus poisoning, and lately noted in a case of death from eating a bad oyster, raw, where death ensued in a few hours.*

Probably also in water-gas poisoning.

* Editorial New York Medical Journal^ 1896.

III. Masquerades Of Fatty Ills

The effort is to show that clinicians should consider systemic conditions more than theoretical names if they wish success to crown their labors. While one must respect old names as vehicles of thought and information, he must be guided so as to remove abnormal conditions which were unknown when our nomenclature of disease was made up. At the same time, the medical men of the past must not be dishonored, since if they "did not know everything, they knew something, and knew enough to name causes of heart failure, " and who made the best use of what they had. Some time medicine will be rewritten on these lines, for the reason that it is foolish to fritter away opportunities of doing good by the use of defective " nouns *' that masquerade the results of fatty degeneration.

It is not well to treat disease by names. We should treat their essence, unmask all physiological sins of their disguises, call " a spade, a spade," go for the lesion causes, remove them as far as possible and give Nature a chance to cure.

These are so many masquerades of Fatty Ills that a brief alphabetical mention of them will be made, as follows :

Alcoholism is a masquerade of fatty ills. A friend suggests King Alcohol wears the mantle of fatty degeneration. It certainly is a carbohydrate; it certainly makes fatty noses, livers, kidneys, hearts, brains, etc.; it loads down all the systemic functions when used in excess. Alcoholism may be termed an acute locomotor ataxia, acute dementia, acute softening of the brain, acute idiocy, acute mania, acute epilepsy, so much so that it seems wise to introduce it here as a masquerader. Again, the alcohol and carbonic acid gas found inside the alimentary canal of vegetable eaters are factors in producing fatty ills.

Amaurosis, or partial or total loss of vision, from paralysis of the retina; and I presume most of my readers would not admit it is a masquerade of fatty degeneration. But such is a fact, and I do not feel at liberty to leave it out, notwithstanding the evidence is not so clear as in the other masks; and the conviction this is true is forced after long consideration, owing to the fact oculists assert amaurosis is mainly due to an excess of carbohydrate diet and that paralysis of the retina may be due to, and is part and parcel of, fatty degeneration. "According to some statistics," says Weir Mitchell, "out of one hundred and fifty cases of Bright's disease of the kidneys, fifty have retinal complications."*

The complex structure of the eye being of terminal tissues where the circulation has to

*" Diseases of Women," Doctor McNaughton Jones, page 82, London, 1890.

5 stop and turn back on itself, furnishes facilities for impeded or retarded circulations and renders it easier for paralysis to supervene than would be the case if the channels ran straighter; indeed the eye is often the first organ to suffer from fatty degeneration, as oculists have shown.

Amyloid is a starch-like body or bodies, appearing and disappearing in the urine in the first stages of Bright's disease. The mammae and the liver have at times been found to be almost wholly amyloid; the same bodies are found in the brain, and many imagine they are normal — definite evidence that the line of demarcation between health and disease is not always clean cut. People apparently in good health present signs of latent disease; and so amyloid degeneration may come under both conventional health and conventional disease; at any rate, from the close affiliation of amyloid with normal fatty degeneration I think it should be regarded as one of the early stages of the latter, from a clinical point of view, for I have found this estimate safe and useful. Treated as a fatty degeneration I have seen amyloid yield very readily and permanently disappear. Note, however, that care must be take to distinguish starch grains from amyloid bodies.

The consensus of all medical opinion, as far as known, is that angina pectoris is due to calcareous deposits in, or degeneration of, the coronary arteries; these deposits are of the nature of fatty degeneration of the circular muscular fibers of these arteries, and are made up of atheromatous matters, mostly cholesterine, which attain a hardness like stone; hence the term "calcareous." Lime deposits also occur along with the purely fatty, and their deposition also is probably due to the retarded and impeded circulation, and to the want of sufficient fluid in the system to keep the lime salts in solution. It is easy to see how fatty degeneration of the heart substance may follow the partial obliteration of the coronary arteries. There is mechanically retarded function, and likewise an element of neuralgia, which may be explained by the deposits diminishing the supply of nerve force because they partially cut off the normal blood-supply, and by a partial paralysis of the heart muscles because in their ill-fed condition the interval between the beats is not sufficient for rest and because they thus overwork. Overworked muscles are apt to have painful cramps, as in writer's and organist's paralysis; hence one cause of the choking pain, " angina," in the overworked and ill-fed heart muscles. Again, it has been reported, to anticipate a little, when facial neuralgia has been relieved by extirpation of the Gasserian ganglion or the infraorbital nerve, that the ganglion and nerve have been found to be affected with fatty degeneration so frequently that this latter may be suspected to be a cause of the neuralgia, and that its treatment should be by Nature's own processes of metabolism rather than by the surgical changes wrought by the knife. I know of one case of surgical interference and removal of ganglion for facial neuralgia in which the pain returned in ten days and persisted until death. Why?

No surgeon could treat angina pectoris by extirpating the cardiac arteries or ganglia, but they can treat it through the interstitial and profound influences of proper nutrition, which obtain and reign in the most hidden, profound and vital parts of the body systemic. In order to give point and force to these words, the writer may be allowed to state that he has seen cures of this masquerade performed on these principles.

Aphasia is a term signifying loss of speech — literally dumbness; but medical language is flexible and does not mean that altogether, and it is employed rather to signify inability to use language fluently; it is the loss of a perfectly familiar word where the speaker knows what should be said but is unable to speak it. This in my opinion is nothing but a result of fatty degeneration of the nerveganglia centers in which is located the function of speech; and this degeneration is undoubtedly acute as well as chronic, while both are amenable to treatment by food, music, rest, and management.

Apoplexy is another very common masquerade. The essence of sanguineous apoplexy is when blood escapes from the cerebral basilar arteries, and is forced by vascular pressure into the substance of the brain or into the cerebral ventricles. It forms a clot, as blood usually does outside of live arteries, veins and capillaries, which clot by its abnormal pressure paralyzes usually the other side of the head or body more or less completely — sometimes pressing on the ganglia of the pneumogastric nerve and instantly producing death; at other times usually entailing a loss of consciousness and motion, so that the erect subject falls as if struck on the head by a club or stone. But the real clinical, essential and exciting cause of apoplexy is the rupture of an artery by normal blood-pressure. The popular idea that apoplexy arises from an increased force of circulation has some foundation, but not the special significance that it arisef from a weakening of the arteries by changing their substance partly into the flabby, soft, weak body of oil, lard, tallow, or grease. While it is true that an increased force of circulation is a causal element of apoplexy, it is truer that the degenerated artery gives way under normal heart pressure often during sleep, which is usually the quietest part of man's existence. To repeat, the essence of sanguineous and possibly of the serous apoplexy is a fatty degeneration. In addition, some writers state that the brain tissue around the diseased arteries is softened probably by the same degeneration, which if true only makes the claim stronger that this malady is a masquerade to be exposed by a better nomenclature if possible. The succession of apoplectic shocks or fits is explained by successive portions of the arteries becoming successively softened by the fatty degeneration progress, and giving way. It is merely a question of time, some parts degenerating sooner than others. The rational treatment of apoplexy should be directed to the diagnosis and removal of the fatty degeneration and the substitution of normal tissues.

• In retinal apoplexy appear the same causative lesions as in cerebral apoplexy: The muscular coats of the retinal arteries are softened by fatty degeneration in some form, and the normal heart pressure ruptures the vessels; the ophthalmoscope diagnoses the extravasation and the clots in the retinal substance. Were the real lesion of retinal apoplexy not concealed by its name it would be better, for then relief would probably be sought in an endeavor to eliminate the predisposing fatty degeneration.

Arcus senilis, the senile ring of the cornea, is a milky circle about the periphery of the cornea of the aged, and should be regarded as one of the simpler fatty ills, though it has been cited in court as an evidence of insanity. While it may be found in cases of unsound mind, it frequently occurs in the eyes of the perfectly sane. The transparent glassy cornea is nourished by inhibition mostly; hence there is a difficult circulation and the easier occurrence of fatty degeneration when the powers of life begin to fail. "Arcus senilis" is consistent with health, good or otherwise, and is another example of the frequent inadequacy of language to express an exact condition.

Atheromatous deposits are masquerades, as they "consist of globules of oil of the most varied sizes, frequently exceedingly minute, mixed with albuminous matter in the form of amorphous masses or flakes and molecules, plates of cholesterine, and granules of carbonate of lime. ,, * They are usually found in arteries, especially so in the aorta, and take the place of the lining membrane and the fibrous and muscular coats. Surely

* Mlcrographic Dictionary.

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it is a fatty degeneration, and shows the kinship of the latter to calcareous degenerations. All are due to the same cause, retarded circulation by chemical and mechanical means. No one who has seen an atheromatous aorta can deny that the circulation must be retarded and impeded by the marked roughness of the interior of the blood-vessel that thus becomes a secondary cause. The term is derived from a Greek word meaning "groats," or meal; and may be applied to tumors which from the closure of sebaceous glands and the retention of the contents accumulate into masses sometimes as large as a hen's egg; this latter condition is not so much of a masquerade as the term is, when applied to arteries; but if the science of language exists to apply to things nouns which indicate their nature, then "atheroma" is a signal failure in these days of higher criticism.

Over forty years ago I was lectured to on Bright's disease of the kidneys, and I have studied it ever since and cannot but believe it is a masquerade of fatty degeneration. Its characters are determined by three signs which must be present as a general rule in the urine, at the same time or in successive periods of time, viz., albumen, casts of kidney tubes, fatty epithelia; besides these, free oil, amyloid and catarrhal discharges in the urine, apoplexy of the retina, arcus senilis, glaucoma and puffy eyelids may be present. Rarely is albumen absent; it should be recognized as present when the urine becomes only slightly hazy from the nitric acid and heat test. The idea of this disease being an

II

inflammation, chronic or acute, of one of more kidney tissues is at least not a good clinical one. There is a necrosis and breaking down of parenchymatous substance sometimes wonderful to contemplate. Some fifty years ago I attended Warren Academy, Massachusetts, kept by Mr. A. K. Hathaway, who had Bright's disease. I remember well how he had uraemic coma in school hours — how he would lean back in his armchair against the wall, leaving dents in the floor which are visible to-day, I believe; how he would go to sleep during a recitation; how the boys would "catch on" to the situation and begin to break rules of order; how he would wake up suddenly and reduce things to quiet, even if he did shy a Virgil or Herodotus at a roguish boy's head! His case was treated for twenty years by my father, the late Doctor Benjamin Cutter, and among other things he used lamp- wick setons in the loins with much benefit. After death an autopsy revealed both kidneys as empty white lardaceous or tallow shells, less than one-quarter inch thick — the rest of the kidney substance was broken down and absent. How any one could live with so little kidney substance was a wonder to all, but the lesson taught was that the lesions were those of fatty degeneration, which softened the nephritic structures so that they broke down and disappeared in the urine, leaving the suetlike shell as evidence of the wonderful endurance of the human frame.

When I was a medical student at Harvard, Professor G. C. Shattuck spoke at length on Bright's disease, and employed exquisitely beautiful colored and life-sized French plates for illustrations. The gist of his instruction was fatty degeneration, but the good doctor never gave any clue to really curative treatment. It seemed to me then, as it does now, that the magnificent foreign monographs on disease were sadly incomplete. If any one doubts that Bright's disease is a fatty degeneration resort should be had to the morphology of the diseased kidney, and let the histological evidence settle the question.

According to our definition of fatty degeneration as due to a retarded and impeded circulation, it is easy to see how it can apply to the kidneys: The circulation in the papillae, the Malpighian tufts, the urinary tubules, must be naturally somewhat impeded because of their tortuosity; there is constant excretory action and liability to overwork; the tubules are deprived of their epithelia — filled with casts, albuminous, fibrous, or waxy; the cells and tubules are loaded with fat globules or with waxy matter or amyloid, — all of which make things worse by mechanically obstructing the circulation of blood and urine. The loss of albumen from the blood and the retention of urea tend to weaken the system and retard the circulation more.

That paralyzing foods have something or much to do with the retarding of the circulation and keeping up of the fatty degeneration has been often proved to me, and to others, by the results accruing upon the withholding of and substituting a diet that would not induce these paralyzing effects — a diet that would be assimilated with the minimum expenditure of vital force, and yet furnish the maximum of potential energy to the system. This history is almost uniformly the disappearance in a shorter or longer time of the albumen, casts, and fatty epithelia, one or all, and by their reappearance when the paralyzing foods are eaten again. To be sure these results are affected by the way in which the patient expends life force. If wasted in work, worry, or pleasure of body, soul, or mind, the abnormal morphologies will be longer in disappearing, or may not entirely disappear; or if they have disappeared, under the above losses of vital force they will reappear, even if the food is all right, and more rapidly if the food is all wrong. A cheerful disposition aids the circulation.

Acute Bright's disease I have known to disappear in less than a week by following this line of treatment, but it may require two or three years in chronic cases.

Bright's disease of the lungs is another fatty masquerade. Some years ago an eminent physician asked me to see a patient with consumption, who had had the best local and metropolitan consultant talent — at the rate of six hundred dollars a month for the latter; she was in bed, feeble, pale, coughing hard, emaciated, with rather violent heart action, and night sweats; physical signs of lesion of left upper third lung front; haemoptysis severe. Sputum with granular and crystalline triple phosphates, giant mucous corpuscles filled with gravel; no lung fiber; blood did not show the morphology of consumption. Urine, hyaline with fatty casts of the kidney tubules and fatty epithelia; albumen to one-half the bulk of specimen — thus evidencing fatty degeneration of kidneys as well as of the lungs, for the blood gave no evidence of consumption. On mentioning this to the late Doctor Louis Elsberg, he remarked the Germans recognized a Bright's disease of the lungs; and he agreed with me in diagnosis on this description. Certainly there is no good reason why lungs should not fattily degenerate as well as any other organ, nor why Americans should not adopt this form of disease in their nosology; had the other medical gentlemen who saw the case not been satisfied with the lung lesions as a sufficient cause they would have explored the urine and got the same striking and positive result ! This is a lesson, and teaches one should never take a chronic case without exploring the morphology and chemistry of the urine; indeed this is a far better means of daily testing a case than the study of the pulse or temperature.

Ruptured or broken heart and fatty heart are not uncommon. Once I was summoned in greatest haste to a lady very ill. She was dead before I arrived at her home, and an autopsy revealed rupture of the left ventricular posterior wall, a pericardium filled with blood, and the muscles undergoing fatty degeneration. With as good reason as exists for cerebral apoplexy this might have been called cardiac apoplexy, for there was the same giving way of the muscles from fatty degeneration, the same extravasation of blood, etc., but with death from loss of blood, not from its pressure, as in some cases of is

cerebral haemorrhage. When the heart muscle is fatty it is liable to break at any time without unusual effort, as in the case cited. The possibility of producing fatty degeneration in phosphorous poisoning in so brief a period as twenty minutes should be remembered. Possibly phosphorus interferes with capillary and interstitial nutritive circulations, so as to cause degeneration.

The changes of nutrition in our bodies are far more rapid than usually surmised. If the chalky, friable textures of dentine can be changed to firm normal fibrous texture in three months' time (as has been reported), why not more rapidly in the softer tissues ? It is a remarkable fact, one I have often noted, that when cases of fatty heart are treated on the principles here laid down, I have seen the normal loudness of cardiac pronunciation reappear in the course of a few weeks, not to say days. Give Nature a chance and she will replace fatty cardiac muscles with healthy ones !

Catalepsy is also, I think, a masquerade, as in my experience it frequently presented all the signs of fatty degeneration — i.e., oil in the blood, fat in leucocytes and albumen, amyloid casts, and fatty epithelia in urine; also cystine in the blood, this traced to the eating of forbidden yolks of eggs; there was also vaginismus, uterine anteflexion and hyperesthesia in one case. The fact that local treatment — i.e., reposition by uterine sound — with vaginal and intra-uterine iodoformization and general treatment of fatty ills as here laid down, were followed by a cure of catalepsy in three months* time and of the abnormal signs i5

in six months, save fatty epithelia which disappeared months later, certainly justifies the mention here of catalepsy as a masquerade of fatty degeneration.

About twenty years ago I consulted some eminent Boston oculists as to the cause of cataract, and all agreed it is a " degeneration," though of what kind they knew not. I got quite a number of cataractous lenses from ophthalmic surgeons, studied their morphology and photographed them, and with the result that I decided it must be due to a fatty degeneration. The microphotographs I took show it. Later mentioning this fact to Baltimore oculists they at once declared our German confreres had arrived at the same conclusion. Accordingly I think it is safe to include cataract among fatty masquerades. If it is natural to expect fatty degeneration in the cornea — i.e., arcus senilis — much more is it to be expected in the crystalline lens which obtains its nourishment through its capsule by inhibition, and is a hyaline, glassy, chitinoid substance to begin with. The dislocation of the crystalline lens by a blow retards and impedes the circulation needed for its nutrition and thus produces traumatic fatty degeneration or cataract. The obliteration of the ocular arteries by the deposit of fatty or calcareous matters must impede the circulation in the eye and promote the fatty degeneration. In London, in 1889, I asked Sir Benjamin Ward Richardson whether did not both he and Doctor Weir Mitchell, the former in 1852, the latter in 1861, produce cataract in ten minutes by injecting a teaspoonful of a saturated watery solutioo of n

sugar under the skin of a frog or a guineapig. He replied in the affirmative, adding the result was produced "even quicker than that ! "

It seems incredible that so generally used a substance as common white sugar should produce cataract in so short a time, but the facts are well authenticated and need no repetition unless in penal physiology on man. Sugar works right in the line of producing fatty degeneration in man, and should not I think be so recklessly and profusely used as now. A teaspoonful of sugar in tea or coffee, taken by a case of Bright's disease where the morphology of the urine has become normal under treatment, must be expected to bring back the abnormal morphology; in any event this is the way to detect such lapses in diet of patients unless they have become firmly established in the way of cure. In my opinion the defective organs of vision common among schoolchildren are due to feeding upon carbohydrates in excess. Probably the behests of social ethics in putting sweets to the fore as food have had more to do with the production of lenticular troubles than any other cause. Avoid the use of sugars in excess (better altogether) if you want good crystalline lenses. No " sugar trust" to help bring on fatty ills for me !

Circulation impeded from embolism is another fatty ill. Thrombi and emboli are made up of fibrin filaments which are large and massive, in threads curled upon each other by rotation and twisting in the circulation of the blood. Often these emboli embrace within their substance colloid jellies, crystals of oxalate of lime, triple phosphates, etc., which are formed in the blood. Embo i are also made up of white blood-corpuscles in addition, their huddling together in the blood under the microscope is regarded as a sign of embolism (there are emboli of fat).

.The conventional idea that thrombi are formed in and on the valves of the heart by some action of these same valves is probably incorrect; more likely that the edges and angles of the valve surfaces present mechanical arrangements whereby the clots or thrombi already formed are caught, incorporated together, and grow; this is rendered more feasible because the blood - stream makes a full stop at the ventricle funda, and is reversed in its direction. During the instant of stasis or stopping an opportunity is given for the adhesive fibrinous masses to be caught on the edges of the valves, especially if the valves are sticky. The valves do not originate the thrombi from the normal subtile, all but invisible, fibrin filaments of the blood, but accrete them from the larger, coarser and more massive abnormal fibrin filaments caused by the action of sour fermenting food in the alimentary canal.

It is easy to see from the foregoing how the circulation is impeded by emboli, and how the parts supplied by this impeded circulation may fattily degenerate; at the same time I do not claim that all the results of embolism are necessarily the result of fatty degeneration, but only that some of them are and must be. By taking in this idea can be understood the importance of regulating the diet in all cases of embolism; and diet and embolism together constitute an American idea destined to honor the practise of medicine everywhere and for all time to come, it being one of the most important dicta of this or any age that embolism can be induced at will by feeding fermenting foods, and likewise that embolism can be cured by feeding on food that does not have acetic acid fermentation — food that requires the minimum of vital force for Nature to work with in the functions of the living human body. In this way there will be no growth of excessive alcoholic and vinegary ferments, which are found associated with thrombosis. It is easy to understand how emboli and thrombi arc causal of fatty degeneration, because they mechanically obstruct, retard and impede the functions of all organs whose blood-vessels they block up.