- Email: [email protected]
Basic processes in healing
BASIC PROCESSES IN HEALING* STEPHEN S. HUDACK,
M.D.
AND
J.
WALLACE
BLUNT,
JR.,
M.D.
New York, New York
A
S discussed herein, healing connotes the restoration of supportive tissue of the mesenchyme, that is, connective tissue. Consideration of special connective tissues such as bone and cartilage will be indirect. Correlated healing of other special tissues such as dermal epithelium or mucosa will be implied. The orientation of this paper may be given by citing the preface of the book by R. Leriche and A. Policard’ who gave as their reason for writing approximately ten years of clinical and experimental observation. They wrote, “The problem of osteogenesis has passed through many phases. It has been histological and surgical and at the present time it is above all, chemical. It is useless now for histologists to repeat what has been done so many times, and for surgeons to experiment on periosteum, on grafts and on the osteogenesis of repair. It is now the turn of the chemists and physicists. They alone can open up new horizons by giving us some of the certainties we lack. When they have solved certain pending questions, it will be possible to resume with profit the studies of the past. We can then progress and, perhaps, have bone formed at will, accelerate the union of fractures and prevent the pathological or physiological rarefactions of bone, but for this to occur, it is necessary for us to ask them dehnite questions.” It is our intent to clarify some questions on the basis of work initiated fifteen years ago. The sustaining thesis has been the paramount importance of local factors in the healing of tissue.* Evidence has gradually accumulated which, although admitting the importance of local, chemica1 and physical forces, shows that under special circumstances, the general metabolism has considerable influence. CELLS
AND
CELL
PRODUCTS
It is well to restate briefly what takes place at the site of injury. There is laceration of tissue,
hemorrhage and tissue necrosis. This immediately starts the cycle of repair by increasing capillary permeability in the form of a simple polypeptide,3 an intermediary breakdown product preparing the way for polymorphonuclear infiltration. With increased lactic acid formation as a result of the anaerobic respiration in acutely injured tissues and unaugmented alkali reserve, the hydrogen ion concentration moves toward pH 6.5 or below. In this environment the leukocytes do not survive well and the secondary phase of lymphocytic infiltration is set up. Considering the disturbance of fluid balance in early inflammation, permeability studies using the polypeptide,5 leukotaxine,3 revealed that corticosterone and adrenal extract prohibited increase in capillary permeability, but desoxycorticosterone actually increased it. Adrenal-cortical extract almost completely stopped increased capillary permeability. This may not seem important except that cortisone can for a time virtually stop completely the reactivity of tissue to injury7 and temporarily inhibit granulation tissue and retard the healing of fractures and wounds.8 hloreover, the response of rats to acute stress9 is proportionate to the decrease of ascorbic acid in the adrenal and is interpreted to mean that elaboration of ACTH is at a rate inversely proportional to the concentration of the cortical hormones in the body fluids and according to the requirement of peripheral tissue cells for cortical steroids. Knowledge of the relationship of the steroids to cells is relatively new, but the literature is too deep to cite except briefly. Desoxycorticosterone can be changed into a glycogenic material in vitro.*0 Kendall showed the influence of the adrenal cortex on glycogenesis.” The corrective action of Compound E and corticosterone in the abnormal carbohydrate metabolism of Addison’s diseaseI is clear. Moreover, cortin-like compounds produce glycosuria and even severe ketonuria. l3 In passing,
* From the Department of Orthopedic Surgery, Fracture Division, ColIege of Physicians and Surgeons, Columbia University, New York, N. Y. This work was made possible by a grant through The O&e of Naval Research, United States Navy Department. 680
American
Journal of Surgery
Hudack,
BIunt-Basic
Processes
in Healing
the profound influence of the steroids on the excretion of electroIytes’4 shouId be cited with the equaIIy important influence that they have on the inhibition of increased permeabiIity due to hyaIuronidase on membranes and the neutralization of their effect by products reIeased in viva by rabbits exposed to the alarm stimulus.15 As the progress of events in the response of tissue to injury moves on, the infiltration of Iymphocytes and macrophages increases, and a shift toward the acid hydrogen ion range causes the neutrophiIes to disappear. Soon tibropIasia becomes manifest and a later phase of heahng AIthough fibropIasia is probabIy supervenes. most manifest under the microscope, correIated with it are histochemica1 events of the greatest importance at this stage of heahng. FIBRILLAR
MATRIX
The first IibrilIar matrix to form in injured tissue is the fibrin cIot. Without it, hemorrhage becomes uncontroIled and the earIy formation of a cIot is impossible. This in turn can prevent the systematic infiItration of ceIIs. The earIy observations on fibrin formation16 have been working with purified expanded. RecentIy,17 bovine fibrinogen and thrombin, using the eIectron microscope, the cIose correlation of hydrogen ion concentration and effective cIotting has been shown. A cIot formed at pH 6.3 produces strong, we11 formed fibriIs which show poorer and poorer poIymerization and structure moving toward a pH of 8.3. Later studiesI indicate that through the action of thrombin, fibrin moIecuIes are poIymerized to form needleshaped, crystaI-Iike protofibriIs which become aIigned to form strands by IateraI association. The integrity of the unit fibriIs is maintained in the unit strand. Studies of the genera1 response of bIood fibrinogenlg to coId, fasting and adrenalectomy indicate that fasting for twenty-four to seventytwo hours may depress, aIthough not aIways signihcantIy, the fibrinogen concentration in rats. The trauma of nephrectomy increases plasma fibrinogen. This increase is unaffected by fasting. Exposure to coId aIone does not affect the fibrinogen IeveI. TotaI adrenaIectomy greatIy decreases the fibrinogen response to the trauma of nephrectomy. The acute stress of exposure to coId increases the rate of eIaboration of ACTH by the pituitary. As previously mentioned, other steroid hormones9 suppress this response to acute stress. Estimated in terms of
November
I 5, 1930
FIG. I. Electron micrograph of colIagen mat from nineday tissue culture. Printed by permission of K. Porter and P. Vanamee, RockefeIler Institute for Medical Research.21
suppression of the stress response numerically, the effect on the pituitary by Compound E is 4, cortias 4, equa1 to I 7 hydroxycorticosterone I, desoxycorticosterone acetate ~6 costerone and progesterone fso. It is beIievedlg that fibrinogen metaboIism is inffuenced by the adrenals. AdrenaIectomized rats are unabIe to cataboIize protein, but adrena steroidszO convert protein to carbohydrate. In a tissue cuIture when the fibrin cIot begins to dissoIve and the ceI1 population gets scanty, coIIagen IibriIs begin to form. Studying these with the electron microscope reveaIszl that unit fibers 300 Angstrom units in diameter do not vary appreciabIy in diameter although the ends may taper to 50 A. or Iess. (Fig. I.) The smaI1 diameter fibriIs carry striations of 270 A. Larger fibers show striae in groups of three in a 650 to 800 A. spacing. The larger fibers have a characteristic periodicity of 640 A. units.22 The cross striations from human skin coIIagen are grouped in composites of si,x bands.*3 Some of the observed differences in the spacing of striations and their number may be accounted for by differences in preparation technics. In studying human skin coIIagenz3 reference is made to background interfibriIIar
682
Hudack,
Blunt-Basic
I r and Wratten B No. $3 filters. Reprinted by permission of the Society for Experimental Biology and hledicinc. material beyond the resolution of the electron akhough in the tissue cukure microscope, studies entities Iarger than cohagen fibers are mentioned as possible components of the interfibrillar matrix or the ground substance to which we now come.22,24 GROUNDSUBSTANCEORINTERFIBRILLARMATRIX
Moving into the intertibrillar spaces in which molecular aggregates may be beyond the resolution of the eIectron microscope, we go from the reaIm of confusion to regions of chaos. Here, our observations rest mostly on indirect evidence and histochemicaI technics. Our interest centered here because of the obscurity of the metabohsm of cakium, phosphorus and carbonate compounds which are the means of the transformation of soft tissue heahng to the healing of fractures. Histochemical observations in the heaIing of fractures?” showed what we beIieved to be acid mucopolysaccharide(s) present in the granuIation of repair. This mate-
Processes
in Healing
3. Eight-day caIIus from cortisone treated rabbit. Note absence of cartilage, suppression of granulation tissue and meager response to injury. Hematoxylin and eosin stain; Iow magnification.
rial which may well consist of a related series of compounds is in the interhbrillar spaces of early granulation and cartilage. Its presence parallek the hbroplasia of healing granulationqz5 has a ciose time relationship with maturing of fibrous tissue and almost disappears in fully mature fibrous tissue or bone. Its formation is aImost compIeteIy suppressed by cortisone,26 except in the dermis, which ako greatly deIays the heahng of experimental fractures. The profound suppression of the reactive response of tissue to injury by cortisone7 not only inhibits the formation of granulation tissue but virtuahy. stops the formation of the metastaining ground substance.26 chromatically (Figs. z and 3.) Phosphatase activity parallels the suppression of fibroplasia, and the meager reparative tissue appears defective in development, as in profound Vitamin C deficiency. (Figs. 4 and 3.) The chemistry of tissue destruction and repair which goes on in the primordia1 interstitial spaces of granukttion tissue is not confined to wounds alone but is present in the protean tides
American
Journal
qf Surgery
Hudack,
4. Eight-d:ly Comori technic; FIG. 5.
Blunt-Basic
4
rabbit callus; alkaline phosphatase magnification.
of living, aging and disease. Diseases of the collagen system, such as scleroderma, rheumatic fever and Iupus erythematosusz7 have as a common denominator changes in the fibrillar and interfibrillar components of connective tissue. Tonsillitis, scarIet fever, nervous strain and cold have been grouped as incitants to set OR the adaptiveZR response of the adrena cortex. Correlating these are pathoIogic changes in the intercellular matrix. It is no Ionger Sufficient to speak of fibrinoid degeneration in the supportive structures of the body2Y but of acid mucopoIysaccharide(s) in the ground substance(s). In the granuIations we have studied, there are increased phosphatase activity, Iysozyme, suIfate radicaIs and implied phosphate enrichment.30 The fixation of the suIfate radica1 by granuIation tissue in uitro3’ and histochemical study of poIysaccharide(s) in diseased skin3? leave very little of the body out. The distribution of the intercellular matrix throughout the body includes all of it.
November
I $, I g$o
Processes
activity
in Healing
indicated
5 by dark areas of
6%
healing
SUMMARY
Some of the physioIogy of injury and repair has been discussed. Observations on the “ground substance” of healing tissue are reported. Supportive tissues, because of their distribution throughout the body, participate in virtualIy all phases of the body economy, whether normal or diseased. REFERENCES L.
2. 3. 4.
5.
LERICHE, R. and POLICAKD A. The Normal and Pathological Physiology of Bone. St. Louis, 1928. C. V. Mosby. MURRAY, C. R. The timing of the fracture-healing process. J. Bone e* Joint Surp., 23: 598, 1941. MENKIN, V. Dynamics of Inflammation. P. 47. New York, 1940. Macmillan Co. MENKIN, V. and WARNER, C. R. Studies on inffammation. Carbohydrate metabolism, IocaI acidosis, and the cytoIogica1 picture in inflammation. Am. J. Path., 13: 25. ,937. FREED, S. C. and LIUDNEK, E. Effect of steroids of the adrena cortex and ovary on capillary permeability. Am. J. P1’~v.d.. ‘34: 258, r9_tr.
Hudack,
684
BIunt-Basic
6. MENKIX, V. Effect of adrena cortex extract on capilIary permeability. Am. J. Pbysiol., 129: 691,
I gL$o. 7. RA(;AN, C., HOWES, E. L., PLOTZ, C. M., MEYBK, K. and BLUNT, J. W. Effect of cortisone on production of granuIation tissue in the rabbit. Proc. SK. Exper. Biol. u Med., 72: 718, 1949. 8. HARTMAN, F. A. Functions of the adrenal cortex. Endocrinology, 30 : 86 I, I pp. 0. SAYERS, G. and SAYERS, M. A. ReguIation of pituitary adrenocorticotrophic activity during the response of the rat to acute stress. Endocrinology, 40: 265, 1947. IO. HAYAP~O, M. DORFMAN, R. I. and PRINS, D. A. MetaboIism of steroid hormones: conversion of desoxycorticosteronc to glycogenic material in vitro. Proc. Sot. Exper. Biol. w Med., 72: 700, 1949. I I. KENDALL, E. C. The function of the adrena cortex. Proc. Staff Meet., Mayo Clin., 15: 297, 1940. 12. THORN, G. W., KOEPF, G. F., LEWIS, R. A. and OLAN, E. F. Carbohydrate metabolism in Addison’s disease. J. Clin. Investigation, 19: 813, 13.
1940.
D. J. Diabetogenic effect of some cortinlike compounds. Proc. Sot. Exper. Biol. ti Med.,
JNGLE,
44: 176, 1940. 14. THORN, G. W. and ENGEL, L.. L. The effect of sex
hormones on the renal excretion of eIectroIytes. J. Exper. Med., 68: 299, 1938. IS. SEII;TER, J., BAEDER, D. H. and DERVENIS, A. Alteration in permeability of some membranes by hyaturonidase and inhibition of this effect by steroids. Proc. Sot. Exper. Biol. CYMed., 72: 136, ‘949.
16. HOWELL, W. H. The clotting of bIood as seen with the uItramicroscope. Am. J. Pbysiol., 35: 143, 1914.
17. HAWN, C. V. Z. and PORTER, K. R. The fine structure of clots formed from purified bovine librinoeen and thrombin: A studv with the eIectron &roscope. J. Exper. Med., 86: 285, 1947. 18. PORTER, K. R. and HAWN, C. V. Z. Sequences in the formation of cIots from purified bovine fibrinogen and thrombin: A study with the electron microscope. J. Exper. Med., 90: 225, 1949.
Processes
in Hearing
19. HENRIQUES,0. B., HENRIQUES,S. B. and SELYE, H. Inffuence of cold, fasting and adrenalectomy on the blood fibrinogen response to trauma. Proc. Sot. Exper. Riol. TVMed., 74: 61 I, 1950. 20. LONG, C. N. H., KATZIN, B. and FRY, E. G. AdrenaI cortex and carbohydrate metabolism. Endocrinology, 26: 309, 1940. 21. PORTER, K. R. and VANAMEE, P. Observations on the formation of connective tissue fibers. Proc. Sot. Exper. Biol. ti Med., 7 I : 5 I 3, 1949. 22. SCHMITT, F. O., HALL, C. E. and JAKUS, hl. J. EIectron microscope investigation of the structure of collagen. Cellular Ed Compurative Pbysiol., 20: II, 1942. 23. GROSS, J. and SCHMITT, F. 0. The structure of human skin coIIaeen as studied with the electron microscope. J. EGper. Med., 88: 555, 1948. 24. HUDACK, S. S., BLUNT, J. W., HIGBEE, P. and KEARIN, G. M. A probabte acid mucopoIysaccharide present in granuIation tissue. Proc. Sot. Exper. Biol. Ed Med., 72: 526, 1949. 25. HIGBEE, P. Unpublished data in Master’s Thesis. 26. BLUNT, J. W., JR., PLOTZ, C. M., LATTES, R., HowE~., E. L., MEYER, K. and RAGAN, C. Effect of cortisone on experimental fractures in the rabbit. Proc. Sot. Exper. Biol. &+ Med., 73: 678, 1950. 27. KLEMPERER, P. Diseases
of the collagen system. Bull. New York Acad. Med., 23: 581, 1947. 28. SELYE, H. and PENTZ, E. I. PathoIogicaI correlations between periarteritis nodosa, renaI hypertension and traumatic lesions. Canad. M. A. J., 49: 264, 1943. 29. ALTSHULER, C. H. and ANGEVINE, D. M.
Histochemical studies on the pathogenesis of fibrinoid. Am. J. Patb., 25: 1061, 1949. 30. UnpubIished work in progress with G. M. Kearin on problems in heaIing tissue; made possible by a grant through the OffIce of Naval Research, United States Navy Dept. 31. LAYTON, L. L. In vitro sulfate fixation by granulation tissue and injured muscIe tissue from healing wounds. Proc. Sot. Exper. Biol. ti Med., 73: 570, ‘950. 32. STOUGHTON, R.
and WELLS, G. A histochemical study of polysaccharide(s) in diseased skin. J. Invest. Dermat., 14: 37, 1950.
American
Journal of Surgery
M.D.
AND
J.
WALLACE
BLUNT,
JR.,
M.D.
New York, New York
A
S discussed herein, healing connotes the restoration of supportive tissue of the mesenchyme, that is, connective tissue. Consideration of special connective tissues such as bone and cartilage will be indirect. Correlated healing of other special tissues such as dermal epithelium or mucosa will be implied. The orientation of this paper may be given by citing the preface of the book by R. Leriche and A. Policard’ who gave as their reason for writing approximately ten years of clinical and experimental observation. They wrote, “The problem of osteogenesis has passed through many phases. It has been histological and surgical and at the present time it is above all, chemical. It is useless now for histologists to repeat what has been done so many times, and for surgeons to experiment on periosteum, on grafts and on the osteogenesis of repair. It is now the turn of the chemists and physicists. They alone can open up new horizons by giving us some of the certainties we lack. When they have solved certain pending questions, it will be possible to resume with profit the studies of the past. We can then progress and, perhaps, have bone formed at will, accelerate the union of fractures and prevent the pathological or physiological rarefactions of bone, but for this to occur, it is necessary for us to ask them dehnite questions.” It is our intent to clarify some questions on the basis of work initiated fifteen years ago. The sustaining thesis has been the paramount importance of local factors in the healing of tissue.* Evidence has gradually accumulated which, although admitting the importance of local, chemica1 and physical forces, shows that under special circumstances, the general metabolism has considerable influence. CELLS
AND
CELL
PRODUCTS
It is well to restate briefly what takes place at the site of injury. There is laceration of tissue,
hemorrhage and tissue necrosis. This immediately starts the cycle of repair by increasing capillary permeability in the form of a simple polypeptide,3 an intermediary breakdown product preparing the way for polymorphonuclear infiltration. With increased lactic acid formation as a result of the anaerobic respiration in acutely injured tissues and unaugmented alkali reserve, the hydrogen ion concentration moves toward pH 6.5 or below. In this environment the leukocytes do not survive well and the secondary phase of lymphocytic infiltration is set up. Considering the disturbance of fluid balance in early inflammation, permeability studies using the polypeptide,5 leukotaxine,3 revealed that corticosterone and adrenal extract prohibited increase in capillary permeability, but desoxycorticosterone actually increased it. Adrenal-cortical extract almost completely stopped increased capillary permeability. This may not seem important except that cortisone can for a time virtually stop completely the reactivity of tissue to injury7 and temporarily inhibit granulation tissue and retard the healing of fractures and wounds.8 hloreover, the response of rats to acute stress9 is proportionate to the decrease of ascorbic acid in the adrenal and is interpreted to mean that elaboration of ACTH is at a rate inversely proportional to the concentration of the cortical hormones in the body fluids and according to the requirement of peripheral tissue cells for cortical steroids. Knowledge of the relationship of the steroids to cells is relatively new, but the literature is too deep to cite except briefly. Desoxycorticosterone can be changed into a glycogenic material in vitro.*0 Kendall showed the influence of the adrenal cortex on glycogenesis.” The corrective action of Compound E and corticosterone in the abnormal carbohydrate metabolism of Addison’s diseaseI is clear. Moreover, cortin-like compounds produce glycosuria and even severe ketonuria. l3 In passing,
* From the Department of Orthopedic Surgery, Fracture Division, ColIege of Physicians and Surgeons, Columbia University, New York, N. Y. This work was made possible by a grant through The O&e of Naval Research, United States Navy Department. 680
American
Journal of Surgery
Hudack,
BIunt-Basic
Processes
in Healing
the profound influence of the steroids on the excretion of electroIytes’4 shouId be cited with the equaIIy important influence that they have on the inhibition of increased permeabiIity due to hyaIuronidase on membranes and the neutralization of their effect by products reIeased in viva by rabbits exposed to the alarm stimulus.15 As the progress of events in the response of tissue to injury moves on, the infiltration of Iymphocytes and macrophages increases, and a shift toward the acid hydrogen ion range causes the neutrophiIes to disappear. Soon tibropIasia becomes manifest and a later phase of heahng AIthough fibropIasia is probabIy supervenes. most manifest under the microscope, correIated with it are histochemica1 events of the greatest importance at this stage of heahng. FIBRILLAR
MATRIX
The first IibrilIar matrix to form in injured tissue is the fibrin cIot. Without it, hemorrhage becomes uncontroIled and the earIy formation of a cIot is impossible. This in turn can prevent the systematic infiItration of ceIIs. The earIy observations on fibrin formation16 have been working with purified expanded. RecentIy,17 bovine fibrinogen and thrombin, using the eIectron microscope, the cIose correlation of hydrogen ion concentration and effective cIotting has been shown. A cIot formed at pH 6.3 produces strong, we11 formed fibriIs which show poorer and poorer poIymerization and structure moving toward a pH of 8.3. Later studiesI indicate that through the action of thrombin, fibrin moIecuIes are poIymerized to form needleshaped, crystaI-Iike protofibriIs which become aIigned to form strands by IateraI association. The integrity of the unit fibriIs is maintained in the unit strand. Studies of the genera1 response of bIood fibrinogenlg to coId, fasting and adrenalectomy indicate that fasting for twenty-four to seventytwo hours may depress, aIthough not aIways signihcantIy, the fibrinogen concentration in rats. The trauma of nephrectomy increases plasma fibrinogen. This increase is unaffected by fasting. Exposure to coId aIone does not affect the fibrinogen IeveI. TotaI adrenaIectomy greatIy decreases the fibrinogen response to the trauma of nephrectomy. The acute stress of exposure to coId increases the rate of eIaboration of ACTH by the pituitary. As previously mentioned, other steroid hormones9 suppress this response to acute stress. Estimated in terms of
November
I 5, 1930
FIG. I. Electron micrograph of colIagen mat from nineday tissue culture. Printed by permission of K. Porter and P. Vanamee, RockefeIler Institute for Medical Research.21
suppression of the stress response numerically, the effect on the pituitary by Compound E is 4, cortias 4, equa1 to I 7 hydroxycorticosterone I, desoxycorticosterone acetate ~6 costerone and progesterone fso. It is beIievedlg that fibrinogen metaboIism is inffuenced by the adrenals. AdrenaIectomized rats are unabIe to cataboIize protein, but adrena steroidszO convert protein to carbohydrate. In a tissue cuIture when the fibrin cIot begins to dissoIve and the ceI1 population gets scanty, coIIagen IibriIs begin to form. Studying these with the electron microscope reveaIszl that unit fibers 300 Angstrom units in diameter do not vary appreciabIy in diameter although the ends may taper to 50 A. or Iess. (Fig. I.) The smaI1 diameter fibriIs carry striations of 270 A. Larger fibers show striae in groups of three in a 650 to 800 A. spacing. The larger fibers have a characteristic periodicity of 640 A. units.22 The cross striations from human skin coIIagen are grouped in composites of si,x bands.*3 Some of the observed differences in the spacing of striations and their number may be accounted for by differences in preparation technics. In studying human skin coIIagenz3 reference is made to background interfibriIIar
682
Hudack,
Blunt-Basic
I r and Wratten B No. $3 filters. Reprinted by permission of the Society for Experimental Biology and hledicinc. material beyond the resolution of the electron akhough in the tissue cukure microscope, studies entities Iarger than cohagen fibers are mentioned as possible components of the interfibrillar matrix or the ground substance to which we now come.22,24 GROUNDSUBSTANCEORINTERFIBRILLARMATRIX
Moving into the intertibrillar spaces in which molecular aggregates may be beyond the resolution of the eIectron microscope, we go from the reaIm of confusion to regions of chaos. Here, our observations rest mostly on indirect evidence and histochemicaI technics. Our interest centered here because of the obscurity of the metabohsm of cakium, phosphorus and carbonate compounds which are the means of the transformation of soft tissue heahng to the healing of fractures. Histochemical observations in the heaIing of fractures?” showed what we beIieved to be acid mucopolysaccharide(s) present in the granuIation of repair. This mate-
Processes
in Healing
3. Eight-day caIIus from cortisone treated rabbit. Note absence of cartilage, suppression of granulation tissue and meager response to injury. Hematoxylin and eosin stain; Iow magnification.
rial which may well consist of a related series of compounds is in the interhbrillar spaces of early granulation and cartilage. Its presence parallek the hbroplasia of healing granulationqz5 has a ciose time relationship with maturing of fibrous tissue and almost disappears in fully mature fibrous tissue or bone. Its formation is aImost compIeteIy suppressed by cortisone,26 except in the dermis, which ako greatly deIays the heahng of experimental fractures. The profound suppression of the reactive response of tissue to injury by cortisone7 not only inhibits the formation of granulation tissue but virtuahy. stops the formation of the metastaining ground substance.26 chromatically (Figs. z and 3.) Phosphatase activity parallels the suppression of fibroplasia, and the meager reparative tissue appears defective in development, as in profound Vitamin C deficiency. (Figs. 4 and 3.) The chemistry of tissue destruction and repair which goes on in the primordia1 interstitial spaces of granukttion tissue is not confined to wounds alone but is present in the protean tides
American
Journal
qf Surgery
Hudack,
4. Eight-d:ly Comori technic; FIG. 5.
Blunt-Basic
4
rabbit callus; alkaline phosphatase magnification.
of living, aging and disease. Diseases of the collagen system, such as scleroderma, rheumatic fever and Iupus erythematosusz7 have as a common denominator changes in the fibrillar and interfibrillar components of connective tissue. Tonsillitis, scarIet fever, nervous strain and cold have been grouped as incitants to set OR the adaptiveZR response of the adrena cortex. Correlating these are pathoIogic changes in the intercellular matrix. It is no Ionger Sufficient to speak of fibrinoid degeneration in the supportive structures of the body2Y but of acid mucopoIysaccharide(s) in the ground substance(s). In the granuIations we have studied, there are increased phosphatase activity, Iysozyme, suIfate radicaIs and implied phosphate enrichment.30 The fixation of the suIfate radica1 by granuIation tissue in uitro3’ and histochemical study of poIysaccharide(s) in diseased skin3? leave very little of the body out. The distribution of the intercellular matrix throughout the body includes all of it.
November
I $, I g$o
Processes
activity
in Healing
indicated
5 by dark areas of
6%
healing
SUMMARY
Some of the physioIogy of injury and repair has been discussed. Observations on the “ground substance” of healing tissue are reported. Supportive tissues, because of their distribution throughout the body, participate in virtualIy all phases of the body economy, whether normal or diseased. REFERENCES L.
2. 3. 4.
5.
LERICHE, R. and POLICAKD A. The Normal and Pathological Physiology of Bone. St. Louis, 1928. C. V. Mosby. MURRAY, C. R. The timing of the fracture-healing process. J. Bone e* Joint Surp., 23: 598, 1941. MENKIN, V. Dynamics of Inflammation. P. 47. New York, 1940. Macmillan Co. MENKIN, V. and WARNER, C. R. Studies on inffammation. Carbohydrate metabolism, IocaI acidosis, and the cytoIogica1 picture in inflammation. Am. J. Path., 13: 25. ,937. FREED, S. C. and LIUDNEK, E. Effect of steroids of the adrena cortex and ovary on capillary permeability. Am. J. P1’~v.d.. ‘34: 258, r9_tr.
Hudack,
684
BIunt-Basic
6. MENKIX, V. Effect of adrena cortex extract on capilIary permeability. Am. J. Pbysiol., 129: 691,
I gL$o. 7. RA(;AN, C., HOWES, E. L., PLOTZ, C. M., MEYBK, K. and BLUNT, J. W. Effect of cortisone on production of granuIation tissue in the rabbit. Proc. SK. Exper. Biol. u Med., 72: 718, 1949. 8. HARTMAN, F. A. Functions of the adrenal cortex. Endocrinology, 30 : 86 I, I pp. 0. SAYERS, G. and SAYERS, M. A. ReguIation of pituitary adrenocorticotrophic activity during the response of the rat to acute stress. Endocrinology, 40: 265, 1947. IO. HAYAP~O, M. DORFMAN, R. I. and PRINS, D. A. MetaboIism of steroid hormones: conversion of desoxycorticosteronc to glycogenic material in vitro. Proc. Sot. Exper. Biol. w Med., 72: 700, 1949. I I. KENDALL, E. C. The function of the adrena cortex. Proc. Staff Meet., Mayo Clin., 15: 297, 1940. 12. THORN, G. W., KOEPF, G. F., LEWIS, R. A. and OLAN, E. F. Carbohydrate metabolism in Addison’s disease. J. Clin. Investigation, 19: 813, 13.
1940.
D. J. Diabetogenic effect of some cortinlike compounds. Proc. Sot. Exper. Biol. ti Med.,
JNGLE,
44: 176, 1940. 14. THORN, G. W. and ENGEL, L.. L. The effect of sex
hormones on the renal excretion of eIectroIytes. J. Exper. Med., 68: 299, 1938. IS. SEII;TER, J., BAEDER, D. H. and DERVENIS, A. Alteration in permeability of some membranes by hyaturonidase and inhibition of this effect by steroids. Proc. Sot. Exper. Biol. CYMed., 72: 136, ‘949.
16. HOWELL, W. H. The clotting of bIood as seen with the uItramicroscope. Am. J. Pbysiol., 35: 143, 1914.
17. HAWN, C. V. Z. and PORTER, K. R. The fine structure of clots formed from purified bovine librinoeen and thrombin: A studv with the eIectron &roscope. J. Exper. Med., 86: 285, 1947. 18. PORTER, K. R. and HAWN, C. V. Z. Sequences in the formation of cIots from purified bovine fibrinogen and thrombin: A study with the electron microscope. J. Exper. Med., 90: 225, 1949.
Processes
in Hearing
19. HENRIQUES,0. B., HENRIQUES,S. B. and SELYE, H. Inffuence of cold, fasting and adrenalectomy on the blood fibrinogen response to trauma. Proc. Sot. Exper. Riol. TVMed., 74: 61 I, 1950. 20. LONG, C. N. H., KATZIN, B. and FRY, E. G. AdrenaI cortex and carbohydrate metabolism. Endocrinology, 26: 309, 1940. 21. PORTER, K. R. and VANAMEE, P. Observations on the formation of connective tissue fibers. Proc. Sot. Exper. Biol. ti Med., 7 I : 5 I 3, 1949. 22. SCHMITT, F. O., HALL, C. E. and JAKUS, hl. J. EIectron microscope investigation of the structure of collagen. Cellular Ed Compurative Pbysiol., 20: II, 1942. 23. GROSS, J. and SCHMITT, F. 0. The structure of human skin coIIaeen as studied with the electron microscope. J. EGper. Med., 88: 555, 1948. 24. HUDACK, S. S., BLUNT, J. W., HIGBEE, P. and KEARIN, G. M. A probabte acid mucopoIysaccharide present in granuIation tissue. Proc. Sot. Exper. Biol. Ed Med., 72: 526, 1949. 25. HIGBEE, P. Unpublished data in Master’s Thesis. 26. BLUNT, J. W., JR., PLOTZ, C. M., LATTES, R., HowE~., E. L., MEYER, K. and RAGAN, C. Effect of cortisone on experimental fractures in the rabbit. Proc. Sot. Exper. Biol. &+ Med., 73: 678, 1950. 27. KLEMPERER, P. Diseases
of the collagen system. Bull. New York Acad. Med., 23: 581, 1947. 28. SELYE, H. and PENTZ, E. I. PathoIogicaI correlations between periarteritis nodosa, renaI hypertension and traumatic lesions. Canad. M. A. J., 49: 264, 1943. 29. ALTSHULER, C. H. and ANGEVINE, D. M.
Histochemical studies on the pathogenesis of fibrinoid. Am. J. Patb., 25: 1061, 1949. 30. UnpubIished work in progress with G. M. Kearin on problems in heaIing tissue; made possible by a grant through the OffIce of Naval Research, United States Navy Dept. 31. LAYTON, L. L. In vitro sulfate fixation by granulation tissue and injured muscIe tissue from healing wounds. Proc. Sot. Exper. Biol. ti Med., 73: 570, ‘950. 32. STOUGHTON, R.
and WELLS, G. A histochemical study of polysaccharide(s) in diseased skin. J. Invest. Dermat., 14: 37, 1950.
American
Journal of Surgery