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Connective Tissue Vol. 5 : 2， 35~50， 1973.
A Study on the Changes of Connective Tissue
from the Viewpoint of Ground
Substance Pathology
y uichi Otaka
Department of Pathology， Tokyo Medical College
SUlllInary
In the former pathology， ground substance of connective tissue was cal1ed
amorphous substance， and the alteration of it could not be clarified microscopical1y.
Recently， by the practical use of el巴ctronmicroscope， we have come to b巴
able to observe the alterations not only of col1agen fibrils but also of ground substance
to some extent.
The author has paid special attention to the fact that w巴 canfind qualitative
alteration of ground substance more accurately through synthetic study of the
substance of a single material， using histochemistry and immunohistochemistry
with fluorescent antibody method besides electron microscopy. Thus， in 1971， the
author named the pathological morphology based on these studying methods
“ground substance pathology".
The author has especial1y elaborated histochemical demonstration of acid
mucopolysaccharides (AMPS)， which are essential components of ground substance，
and， in 1972， original1y developed a histochemical method， applying the several
AMPS-digesting enzymes together with the enzymes recently isolated in J apan. By this method the AMPS can be differentiated into four groups， and also AMPS them-
selves can b巴 differentiatedfrom sialic acid.
The pathological changes of connective tissue， from the viewpoint of the author，
consist of both alterations of connective tissue itself and insudation of blood com-
ponents into the tissue， but differentiation of blood components cannot be thoroughly
carried out only by electronmicroscopy. Therefore， the author employed fluorescent
antibody method， and demonstrated fibrinogen， albumin and immunoglobulins.
By means of thos巴 threemethods， new observation results have been obtained
regarding fibrinoid degeneration， mucous degeneration， mucoid degeneration，
amy-loid degeneration and hyaline degeneration， whose chemical natures and formal
genesis have so far remained unknown as pathological changes of connective tissue.
Furthermore， as for both of the Aschoff body in rheumatic fever and tumors
originated from connective tissue as particular pathological changes in connective
Tokyo Medical College 412， 1-Chome， Higashiokubo， Shinjuku-ku， Tokyo， Japan. (昭和48年7月8日受付) Received， July， 8， 1973.
35
36 結合組織
tissue， new resu1ts from a standpoint of ground substance patho1ogy cou1d be obtained
for the first time.
Some of these tissue changes mentioned above have been argued for a 10ng
time. But the studies of the author proved that K1inge， Bahrmann and Aschoff were
right in some of the changes in their presumption.
On the other hand， although a concept of collagen disease was proposed in
the United States， the author considered it impossib1e to develop physica1 and chemic-
a1 studies on connective tissue more widely and profound1y， when we were re圃
stricted within the six collagen diseases.
Thus the author came to propose a new concept of“connective tissue disease"
in 1969， which includes all of the connective tissue changes and diseases besides
collagen diseases.
The author has a1ready succeeded in estab1ishing the basis of ground substance
patho10gy， and now wishes to comp1ete systematization of the connective tissue
changes from the viewpoint of ground substance patho10gy with the help of the
recent advances of physics and chemistry.
Preface
1. Introduction
11. The methods of study on ground substance patho1ogy
111. Pathomorpho1ogica1 findings in the connectiv巴 tissuefrom the viewpoint of ground substance
patho1ogy
a. Fibrinoid degeneration
b. Edematous change
c. Amy10id degeneration
d. Hya1ine degeneration
e. Patho1ogica1 changes pecu1iar to the connective tissue
1) Aschoff body
2) The tumors originated in the connective tissue
IV. Conclusion
1. Introduction
So many kinds of patho10gica1 changes of connective tissue have been already reported.
They are fibrinoid degeneration， edema， edematous changes， mucoid degeneration， myxomatous
degeneration， amy10id degeneration， hya1ine degeneration， scar-formation， keloid， and so on.
Such a classica1 concept has been fostered that every one of these changes is presumably
caused by alterations of intercellular stroma of connective tissue， especially of interfibulary ground
substance.
However， in the field of patho10gy， there was no suitable method so far to catch the changes
in the ground substance properly. Therefore， practically， we were used to define and identify
these connective tissue changes merely through conventiona1 staining methods.
The man who emphasized the importance of alterations of ground substance to the formation
of connective tissue changes was F. Klinge (1933)， and he considered fibrinoid to be one of the most
Otaka: A Study on the Changes of Connective Tissue 37
essential connective tissue changes.
Since the concept of collagen diseases was put forward by P. Klemperer in 1950， the interest
in the pathological changes of connective tissue has grown more and more intense.
After the introduction of this concept， a number of new findings have been reported on the
immunological abnormalities which are supposed to be th巴 causeof these diseases， but there has
been no essential development on pathomorphological findings of connective tissue changes which
gave birth to fundamental concept of collagen diseases.
This is due to the defect of morphological method to find changes of ground substance of con-
necIlve Ilssue.
According to the author， both alteration of the ground substance itself and exudation of the
blood components into connective tissue ground substance probably take part in the formation of
connective tissue changes from the viewpoint of ground substanc巴 pathology.
As for observation methods， first of all， the recent electron microscope enables us to observe
changes offibrils which compose the collagen fibers. This observation method is really indispensable
to research the connective tissue ground substance because alteration of ground substance also can
be conjectured to some extent by the use of it. But we cannot di汀erentiateand identify altered
components of ground substance or exudated blood components respectively if only by this method.
As the second method， we have histochemistry of ground substance. The main substances
histochemically demonstrable in it are acid mucopolysaccharides (AMPS). The histochemical
method for AMPS has been much developed with the recent success of isolation of AMPS-digesting
enzymes.
The third of observation methods is the demonstration method of exudated substances from
the blood vessels. The components of blood plasma proteins can be demonstrated by the so・
called immunohistochemistry which employs fluorescent antibody method. Of course， there are
certain limitations both in histochemistry of AMPS and in immunohistochemistry by fluorescent
antibody method， so w巴 cannotalways identify all sorts of these substances.
The author paid attention to the necessity and the significance of synthetic use of the above-
mentioned three methods in the research of pathological change. This is achievedonly by putting
together the pathological findings obtained by each of the three methods which are respectively
excellent and yet have certain limitations as researching method of alterations of connective tissue
ground substance. In the literatures up to the present， the author cannot find such an attempt
as investigates the changes of connective tissue ground substance by using these three methods
together. On the other hand， the author developed a unique histochemical method to differen-
tiate AMPS by the first histochemical application of newly isolated enzymes.
Thus the author has come to make a proposal to name that pathology as ground substance
pathology， in which the changes in connective tissue ground substance are investigated through
the synthetized methods mentioned above.
Yet， for ground substance pathology， it is necessary to secure fresh tissue materials in diseased
state enough to employ these three methods. The author has studied this ground substance pathology
hard for these three years. He has not yet accomplished a complete systematization of all of the
pathological changes of connective tissue from the viewpoint of ground substance pathology， but it
is safely able to say that pathological methodology for studying ground substance has almost b巴en
38 結合組織
established. In the next chapter the outline of the studying methods will be set forth， and then some parts of the results obtained by these methods will be shown.
n. The Dlethods of study on ground substance pathology
The substances， which are considered as the essential componen臼 ofconnective tissue ground
substance having various important physiological functions， are acid mucopolysaccharides. For
a long time the author studied the histochemistry to demonstrate and differentiate AMPS， and
then devised a unique differentiation method of the substances in 1972.
This method is to dye-out AMPS with toluidine blue metachromasia at pH 4.1. By parallel
use of various enzymes to the serial sections of tissues， it became possible broadly to differentiate
AMPS and also to identify AMPS from sialic acid which demonstrates simi1ar metachromasia
(Table 1).
Used enzymes are streptomyces hya1uronidase， testicular hyaluronidase， chondroitinase ABC
and sialidase. As the first test-procedur巴 wemade serial sections of tissue and applied staining
and digesting procedure as shown in Table 1. The most critical point in this procedure is the di-
gesting condition of enzymes. Through the study on diseased connective tissues as well as on
normal connectiv巴 tissues，the author settled the condition which seems to be most adequate in
1972 (Table 2).
Through the histochemical methods established by the author， AMPS can be broadly di丘erent-
iated into four groups;
(i) hyaluronic acid (HA)
(ii) chondroitin su1fate AjC (ChS-AjC)
(iii) chondroitin sulfate B (ChS-B)
(iv) kerato聞sulfate(KS)， heparin (Hep) ， heparitin sulfate (Hep-S)， etc.
Some detailed studies were made on toluidine blue metachromasia method， as defects':;:were
conspicuous in conventional TBM method， in which high concentration alcohol was used for distinc-
tion， but it caused overall marked color fading even in metachromatic site and the staining results
Table 1 Histochemical differentiation of AMPS with several AMPS-digesting enzymes
E王A ChS・.AjC ChS-B KS Hep Sialic acid E王ep-Setc.
HE general histological observation pH 4.1 TBM O O O O O pH 2.5 alcian blue O O O O O pH 2.5 TBM O? O? Hep 0 others?
pHaft4位 1百 M ト向I|TC副hHHi2曲sa町εs c Ac B
O O O O
O O O O treatment O O O? with I Chase ABC O O O
Pap observation of the relation between argenta伍nfibers and A~ν，fPS
Note 1. The materials were fixed in 0.5% CPC-lO% neutral formalin for 24 hrs. 2. RNase and DNase treatment were done when nece日ary.
3. A better distinction method for TBM: After distinction with 10% alcohol for 30
seconds， the stained tissue sections were dried at room temperature and then immersed in xyrol for making transparency.
Otaka: A Study on the Changes of Connective Tissue
Table 2 Standa1'd conditions fo1' enzymatic t1'eatment
Buffer pH Concentra。tilountiooIIf TempErature enzyme s Time
0.1 M accetate Sialidas巴 COI0lt.a014I1M 1ng C 5.25 0.35mgjm1 370C 6-18h1's.
a++
SthreYpatloumroyncieds a acetate h(oar t se phosphate) 5.00 100Ujm1 580C 2-3 h1's.
TestICular acpet1a10tse ph(oar t hyaluronidase phosphate) 6.80 150 Djml 370C 24 h1's.
ChAoBndC roitinase Tris HCLbufrer 8.00 0.2-0.5 Ujm1 370C 2-18 h1's.
Comment: Some kinds of mate1'ia1s need highe1' concent1'ation 01' 10nge1' t1'eatment than
this table.
39
were not constant. After various experiments， consistent results have been secured by follwing
proc巴dureafter the staining; 30 seconds distinction by 10% alcohol， drying at room temperature
and making transparency by use of xyrol.
When necessary， digestion by RNase and DNas巴 wasused to identify nucleic acids from
AMPS. Furthermore， digestion with trypsin was applied when AMPS had a possibility of being
masked by serum proteins， and digestion with collagenase was tried against a possible masking by
collagen. According to the author's experience， 24 hours fixation by use of 0.5% cetyl pY1'idinium
chlo1'ide (CPC)・10%neutral formalin has proved to be best fo1' histochemical analysis of AMPS
of connective tissue. Howeve1'， with materials that had to be fixed in 1'outine formalin fluid，
I・e-fixationwas applied by use of eithe1' CPC-01' 2% sodium acetate-neutral fo1'malin.
As for blood components as ground substance components of connective tissue derived from
blood vessels， serum proteins can be immunohistochemically demonst1'ated by fluorescent
antibody method. The author examined them by use of fluorescent antibodies against fibrinogen，
albumin， Ig， IgG， IgM and IgA. These antibodies were of cou1'se serologically ascertained， before
use， to be pure and not to contain any antibodies against other materials. Also， the specific char司
acteristics in fluorescent 1'eaction was confi1'med by so-called block-test， where if norトlabelled
antibody is p1'eviously added to a specimen， the 1'esult would be negative even iffluo1'escent antibody
is added late1'. Zeiss' photomicroscope was us巴das fluo1'escent microscope.
Fo1' the electron microscopic obse1'vation of connective tissue， ]EMT 6S and ]EM 100B of
J apan Elect1'onics K.K. were used and ]SM scanning electron mic1'oscope of the same manufactu1'e1'
was also employed when necessa1'y.
Electron microscopically， the fo1'm of collagen fibril can certainly be an object of obse1'vation，
but fo1' ground substance pathology， expansion of spaces between fibrils， interfibrilla1' st1'oma and
abno1'mal mate1'ials within inte1' fibrillar spaces are more impo1'tant objects of obse1'vation. lt is
possible by this method to obse1've formation and sedimentation of materials that have various
elect1'onic densities and granular，五lamentous01' non-st1'uctural fo1'ms. The fibrinogen that in-
filtrates from blood vessel into stroma can be identified electron microscopically， becau
40 結合組織
observation is fresh. But， it is difficult to obtain a large biopsied tissue piece. Therefore， it is
often impossible to obtain necessary and sufficient materials to apply all three methods mentioned.
Thus， all three methods were adopted when the material was enough amount， but， when it was
evidently unnecessary to apply immunohistochemistry， only the other two methods were applied
for observation.
The following is the summary of results obtained so far.
111. PathoDlorphological findings of connective tissue
froDl the viewpoint of ground substance pathology
a. Fibrinoid degeneration
Historically， the fibrinoid degeneration of connective tissu巴 wasfirst recorded by N eumann
in 1880. The naming of 五brinoidderives from its characteristic to be strongly stained like fibrin
by picrocarmin. Later， this change gathered signi五cantattention of many researchers as connective
tissue change， and various theories have been built up regarding what it is and how it is formed.
(Table 3)
The theories on the formation of fibrinoid degeneration can be broadly classified into:
i) those which presume it as change of connective tissue itself，
a) those which presume it as change of fibres，
b) those which presume it as change of ground substance， ii) those which presume it to be infiltration of serum proteins such as fibrin，
iii) those which consider it to be combination of connective tissue change and infiltration of
serum proteins， and
iv) those which consider it to be derived from nucleoproteins.
Table 3 Various theories on the formation of fibrinoid degeneration
1. The change of tissues themse1ves
a. The change of connective tissue fibers
b. The change of ground substances of
connective tissue
2. Exudation of fibrin and the other serum
protems
3. Combination of the change of connective
tissue and the exudation of serum proteins
4. Originated from nuc1eoproteins
Neumann (1880) Ricker (1901)
Wu (1937)
Schade (1923) Talalajew (1929) K1emperer (1941) A1tshu1er (1949)
Marchand (1896) もVo1per (1950) Meyer (1950) Amano (1955)
Movat (1957)
Git1in (1957) Dixon (1958)
K1inge (1933)
Bahrmann (1937)
Otaka (1962)
K1empere (1953) Gueft (1954)
Otaka: A Study on the Changes of Connective Tissue 41
Of course all these theories are based on findings by common tissue staining and were formed
prior to the ground substance pathology of the author. Out1ines of these theories are explained
below.
Neumann (1880) who first discovered the change considered it simply as degeneration of
connective tissue fibres. But Schade (1923) claimed it to be formed by contraction of colloid and
swelling of collagen fibres through increase of ions in ground substance. Klemperer (1941)， who
introduced the collagen desease concept， considered it as physiological and chemical changes of
ground substance. Later in 1953， he regarded some of the changes to b巴 derivedfrom nucleo-
proteins. A1tshuler (1949) established a concept that it is the result of the precipitation of ground
substance Al'vIPS by basic proteines generated through the contact between tissue and 吋Ul・mg
factors.
On the other hand， Marchand (1896) considered it to be nothing but one of the fibrinous in-
fiammations of connective tissue caused by infiltration of五brin. Meyer (1950) claimed it to be
caused by the exudation of fiuid blood components into the connective tissue similar to the case
of serous infiammation; it is fibrinous infiammation of particular stage; it is nothing but interstitial
fibrinous infiammation in more advanced stage than in serous inflammation， as pointed out by
Rossle (1914) and Eppinger (1949); the connective tissue itself， through such process， demonstrates
contraction of protein components and following homogenization. 1n J apan， the study by Amano
(1955) is significant. He explained that fibrinoid degeneration was one of the phenomena of
existent fibres dispersing through the effect of acute exudation and that its main cause was the
intervention of exudates including fibrin.
Along the similar exudation theories， Dixon et al (1958) applied fiuorescent antibody observa-
tion and pointed out that there were two kinds of fibrinoid degeneration; one in which fibrin was
demonstrated and the other in which r-globulin was demonstrated.
On the other hand， Klinge (1933) who emphasized fibrinoid degeneration of connective
tissue as basic morphological change in rheumatism had difficulties in proving its formation. He
pointed out that the main cause of its formation could be considered to be swelling of ground sub-
stance due to physicochemical changes of ground substance surrounding fibrils， which is called
“Gelose" by Schad
42 結合組織
in the site of fibrinoid degeneration. With fluorescent antibody method， fibrinogen， Ig， IgG and IgM are positive and albumin is occasionally positive. Electron microsc∞opicall片y，micαro、刀ofibril辺lla釘r
五肋b耐r巾 .
dis叩pe釘rs舵ed白brils a抗tthe s討副i江t匂eoぱffib耐rinoid. Fibrin-shaped material is clearly observed by a scanning
electron microscope on the surface of synovia affected by fibrinoid degeneration.
The affected synovia in its early stage， observed by electron microscope， exhibits synovial cells
of type A or B with degeneration and dispersed collagen fibrils in itercellular spaces， and a part of
which shows fibrin. From these finding百，it is difficult to consider that fibrinogen abruptly exudes
into normal synovia but that serum components consisting mainly of fibrinog、enexudes into con-
nective tissue denatured by injuring factors， and thus forms fibrinoid degeneration.
Secondly， the subcutaneous nodule forming around a joint in the case of rheumatoid arthritis
consists of a degenerated center， a fibrinoid degeneration portion， a pallisade granulation portion
and a fibular granulation portion.
Histochemically， this subcutaneous nodule was evidently AMPS-positive only in the pallisade
portion; the differentiation of this AMPS showed the highest positiveness of ChS・.AjCwith the next
highest one of HA and ChS-B. The fibrinoid portion was AMPS・negativeand did not turn
positive even after trypsin treatment. The degenerated center was slightly AMPS-positive.
Th巴 subcutaneous nodule， observed by fluorescent antibody method， was fibrinogen-，
Ig・， IgG蝿 and IgM-positive in its fibrinoid portion. Electron microscopically， the number
of collagen fibrils was reduced in th巴 degeneratedcenter and amorphous material of high electron
density was observed between the fibrils. This material is supposed to be the altered ground sub-
stance itself according to the findings by histochemistry and fluorescent antibody method. The
fibrinoid degeneration in such subcutaneous nodule is considered to be formed by the exudation
of serum components consisting mainly of fibrinogen into the connective tissue already altered.
The fibrinoid degeneration of connective tissue takes place on the surface of granulation of
gastric ulcer and in the placental connective tissue. The fibrinoid of gastric ulcer had a stratified
structure with newer fibrinoid in deeper zone; his
Otaka: A Study on the Changes of Connective Tissue 43
it is sometimes expressed as myxomatous degeneration.
In any case， all these alterations， when observed by common homatoxylin・eosinstaining， look
edema-like， as connective tissue fibers are dispersed. So the author takes a stand that all of them
should be generally regarded as edema-like alteration until biochemical status of each is identified，
and that then findings in ground substanc巴 pathologyshould be carefully collected. Some altera-
tions on which some findings on this standing have been obtained 80 far are discribed below.
As edema-like alterations are comparable to regular edema， an outline of findings in ground
substance pathology regarding regular edema is first mentioned.
With regular infiammatory edema in the case of appendicitis， col1agen fibrils were electron
microscopically dispersed on the wall of appendix and， in the spaces between the dispersed fibrils，
albumin was positive and fibrinogen was partial1y positive. AMPS was not demonstrated histo-
chemically.
In the site of th巴endocardialconnective tissue with rheumatic fever， which has been for sometime
cal1ed myxomatous degeneration， dispersed collagen fibers were observed and toluidine blue
metachromasia was positive in some portions and negative in others. In the positive
portion， as AMPS， HA showed the highest concentration and ChS-AjC， ChS-B and the fourth
group of AMPS showed the next highest; the composition of AMPS was roughly similar to the
五ndingsof normal endocardium but HA seemed to be somewhat increased. The author， Reynals
(1950)and Sprunt(19S0)， considered this phenomenon as a kind of reaction of ground substance to
injuring factors.
An edema-like lalteration found in aortic intima it is discussed as one of the possibl巴 initial
phenomena of arteriosclerosis. With this alteration， fat staining was negative， and as AMPS，
HA showed high concentration and ChS-AjC as well as two other groups were also observed.
With the interstitium in mastopathy， intralobular intersitium is edema-like. Here TBM was
strongly positive and much HA and less ChS-AjC were observed. Electron microscopically， also，
the spaces between col1agen fibrils or between their bundles in this part were evidently wider than
in normal， which demonstrates abundant existence of ground substance.
The endometrial connective tissue is edema-like in its secretory phase and in the case of ovarial
dysfunction. In the latter case， AMPS was no
44 結合組織
and the observation results of ground substance pathology， especially of histochemistry of AMPS，
show a wide variety according to position or kind of lesions.
c. A:rnyloid degeneration
Amyloid degeneration occurs both in reticuloendothelial system and connective tissue. The
author observed an example of the latter tissue amyloid in the singer's node of the voice cord.
The degeneration was typically stained by Congo red， which permitted the identification of amyloid，
but the amyloid itself could not be stained by AMPS-stainings， even after trypsin treatment. On
the other hand， TBM was positive at connective tissue with edema-like change around the amyloid， and， by histochemical differentiation method， it was shown that HA was moderately positive and
ChS-A/C weakly positive.
The precipitation of amyloid was found in focal form in the voice cord connective tissue mainly
around the blood vessels. Electron microscopically， irregularly arranged amyloid fibrils were 0か
served from the subendothelial portion of capillaries to th巴 pericapillaryregion. Fibrin and the
other serum proteins could not be demonstrated in the same spots.
d. Hyaline degeneration
The alteration of connective tissue which is stained homogeneously by eosin is commonly
called “hyaline degeneration". l'vIacroscopically， the site of this alteration becomes hard and
whitish. It is called“hyalinization" when the tissue falls in hyline degeneration. Th巴 author
has hitherto observed some of hyalinized tissues from the viewpoint of ground substance pathology.
At first， as for the hyalinized portion in the pleural callositas form巴dafter pyothorax， existence
of every group of AMPS was demonstrated histochemically， and quite thick collagen fibrils with
diameters from 450 to 500A were observed through electron microscopy.
SecondJy， the author examined the material of bursitis since the transition from fibrinoid to
hyaline was found in this tissue. Hyaline was contrast to fibrinoid because the latter showed
negative histochemical findings of AMPS， while th巴 formershowed positive findings of HA and
ChS-AjC as AMPS. Electron microscopically， the fibrin-like materials were found in the fibrinoid
part， but in the hyalinized part， fibrin was not demonstrated but collagen fibrils and string-shaped
materials smaller than fibrils were observed.
In the hyalinized portions of the white corpora of ovary‘AMPS were demonstrated only in
afi
Otaka: A Study on the Changes of Connective Tissue 45
electron microscopic examination， di釘erentfindings are obtained from different tissue portions
which look like equally hyalinized by common staining. These discrepancies are presumably
due to the different kind of tissues or of original lesions which cause hyalinization. Anyhow， it
was shown what had been called “hyaline" or“hyaline degeneration" was not a single change
through the observation methods in the ground substance pathology.
e. Pathological changes pecuIiar to the connective tissue
1) Aschoff body.
In the myocardial interstitium of rheumatic fever， Ascho釘 (1904)found nodular lesions first，
and named it“noduli rheumaticiぺ Today，the nodule is called “Aschoff's node" or“Aschoff
body". Aschoff regarded it as one of granulation tissues. There have been many arguments ever
since on tissue origin of multiple giant cells with large polymorphous nuclei which characterize the
node. However， their origin has not still been elucidated completely. Klinge (1933) supposed
that fibrinoid degeneration first occurred in the intermyocardial connective tissue， and that the
Ascho丘、'snode followingly appeared to absorb the abnormal materials produced in the process of
fibrinoid formation. That is， both Aschoff and Klinge considered the lesion as one of connective
tissue changes.
On the other hand， the myocardiogenic theory of the cells of Aschoff body has been also
maintained for a long time. Murphy (1952) advanced this so司 calledmyogenic theory， and con-
tended that the Aschoff body was built up by the myocardial lesion and the multi-nuclear cell
formation which occurred in the regenerative course of the lesion， and that the body should be
called “myofiber Aschoff body" to express the origin of it most exactly.
The author made an observation from the standpoint of ground substance pathology of con-
nective tissue to make the origin of Aschoff body clear.
Histochemically， ChS-AjC and ChS-B were positive in the protoplasma of Aschoff cells， in
contrast to the negative AMPS-白ndingon myofibrils. Also in the intercelluJar spaces between
Aschoff cells， these AMPS were positive， among which HA was the main component and ChS-
AjC and ChS-B were slightly positive too.
Through the electron microscopic observation of Aschoff cells， abundant rough ER were
revealed， but no myofibril was recognized. On the other hand， as for the surrounding myofibers，
the process of degeneration or elimination of m
46 結合組織
be described on the several findings of the tumors originated from collagenous tissues and cartilages
from the viewpoint of ground substance pathology.
As for the AMPS in chest wall fibroma， ChS-A/C were demonstrated besides HA. In dermato-
fibroma， in which both fibromatous and myxomatous portions were recognized， every group of
AMPS besides HA was identified in the former portion， and abundant HA was in the latter
portlOn.
Next， in the connective tissue of mammary fibroadenoma， HA-increase and slight positive-
ness of ChS-AjC were observed in th巴 edema-likeportion of intralobular interstitium. In the
edema-like portion around the gland structure， the spaces between collagen fibrils or their bundles
were observed to be much widen巴d electron-microscopically， where the ground substance
AMPS and/or the compounds of them with some proteins were thought to exist from the histo同
chemical findings.
As to fibromyxosarcoma， not only HA but also ChS-AjC and ChS-B were foul1d in the portion
with abundant fibrous elements. But， in the myxomatous portion， ChS was minor and HA was a
major compon巴ntof AMPS.
Concerning the histochemical findings of synovial sarcoma， a little amount of ChS and the
fourth group AMPS was demonstrated in the portion of epithelial element， and HA， ChS-AjC
and ChS-B were identified in the portion with fibroblast-like celIs， wh巴realmost the same AMPS-
findings were observed as with fibrosarcoma.
Through the histochemical examination of AMPS of chol1droma al1d chondrosarcoma， the
former revealed abundant ChS-AjC which are common with 110rmal cartilage， but il1 the latter，
HA was predomil1ant al1d the other AMPS were minor compol1el1ts; these findil1gs almost corre-
spond to the gel1巴raldata of th巴 latterby biochemical al1alysis.
Furthermore， the author examil1ed a chondromyxoendothelioma origil1ated from subcutan巴ous
tissue of arm as an example of mixed tumors. In this case， di汀erentfindings of AMPS were ob-
tained in every tissue component. HA was the main component of AMPS in the myxomatous
portion， but in the cartilagenous portion highest HA and next highest ChS-AjC were observed.
It is considered to b巴 thecharacteristic finding of the groul1d substance AMPS of those tumors
that the myxomatous portiol1s are rich in HA and the sarcomatized tumors are also rich in HA.
Lastly the author observed an experimental fibrosarcoma， which was generated in the back
subcutaneous tissue of hamster by SV 40 viru
Otaka: A Study on the Changes of Connective Tissue
shouJd be a certain amount of undersulfated or desulfated Hep-S was also shown.
IV. Conclusion
47
From the pathological observation， there are various kinds of lesions in the connective tissue.
It is true that the diseased states of connective tissu巴 havebeen the center of many researchers'
interest and the studies on them have come popular sinc巴 theconcept of collagen diseases had
been introduced.
However， what were defined at五rstas collagen diseases were restricted to the six diseases of
rheumatoid arthritis， erythematodes， etcリ andas th巴 fundamentalalteration of connective tissue
common to collagen diseases， fibrinoid degeneration was noted.
Generally surveying the diseased states of human body， we can find not only six collagen
diseases but also so many kinds of diseases as dis巴asedstates of connective tissue or as various
diseases characterized by these diseased states. Furthermore， as already described in the introduc-
tion， we can find not only fibrinoid degeneration but also various kinds of alterations as the pathomor-
phological changes of connective tissue.
On the other hand， not only the collagenous tissue but also the cartilage and bone belong
to the connective tissue as analogous tissue.
Accordingly， it should be impossible to elucidate the essential quaJities of the connective tissue
changes thoroughly， so far as studies are restricted within six collagen diseases. 1t goes without
saying the fibrinoid degeneration is only one of various diseased forms of connective tissue.
From the viewpoint mentioned above， the author felt that it was necessary to establish a new
concept of diseases in which all of the diseased states of connective tissue in human body and all
of the diseases characterized by these diseased states were comprised， and came up to offer the
concept of connective tissue diseases in wide sense containing collagen diseases in 1969.
1t is necessary for pathological researchers to collaborate with chemists， biochemists， physiolog-
ical chemists， clinical chemists of various fields， in order to clarify the fundamental qualities of
connective tissue changes. It was impossibl巴 underthe restricted concept of collagen diseases
to realize such a collaboration， but finally it became possible after the establishment of the
concept of connective tissue diseases by the author.
1n ]apan， this concept has promoted a cooperative study on the connective tissue since 1969.
The author's researching results on the ground substance pathology described in the present p
References
1) Klinge， F.: Der fieberhafte Rheumatismus. Ergebn. allg. Path. path. Anat.， 27: 274， 1933.
2) Klemperer， P.: The concept of collagen disease. A. J. Path.， 26:久 1950.
3) Neumann， E.: Die Picrocarminfarbung u. ihre Anwendung auf die Entzundungslehre. Arch. mikro.
Anat. 18: 130， 1880.
4) Neumann， D.: Zur Kenntniss der五brinoidenDegeneration des Bindegewebes bei Entzundungen.
Virchows Arch. Path. Anat.， 144: 201， 1896.
48 結合組織
5) Schade， H.: Die physiologische Chemie in der inneren Medizin. T. Steinkopf， Dresden， Leipzig，
605， 1923.
6) A1tshuler， C. H. and Angevine， D. M.: Histochemical studies on the pathogenesis of fibrinoid. Am.
J. Path.， 25: 1061， 1949.
7ηMarchar
Path. Anat.， 145: 279， 1896.
8) Meyer， W. W.: Interstitielle fibrin凸seEntzundung in Formenkreis dysorischer Vorgage. Klin.
Wchschr.， 28: 697， 1950.
9) Rossle， R.: Uber Merkmale der En以tzu註u吋 u碍 i泊nal1er噌gisch】henOr砲ganismu山1S. Ve町rhand心1.d. dt臼scぬh.path.
Ges.， 17: 281， 1914.
10) Eppinger， H.: Die Permiabilitat“Pathologie. 755， Julius Springer， Wien， 1949.
11) Amano， S.: Generation， structure and pathology of the connective tissue五bers. Jap. J. Allerogology.
4: 110， 1955.
12) Vasquez， J. J. and Dixon， F. J.: Immunohistochemical analysis of lesions associated with fibrinoid
change. Arch. path.， 66: 504， 1958.
13) Bahrmann， E.: Uber die五brinoidDegeneration des Bindegewebes. Virchows Arch. Path. Anat.，
300: 342， 1937.
14) Otaka， Y.: Pathogenesis of fibrinoid change in the connective tissue. 1959 Year in the Medical
Science of Japan， 2: 175， 1959.
15) Otaka， Y.: Fib巾 oidchang←←the pathological叩 ificanceof the concept of collagen diseases一一.Jap. J. Allerogology. 11: 1， 1962.
16) Otaka， Y.: Pathology of the connective tissue diseases-一明ithspecial references to rheumatism一一九
J. Jap. Path. Asc.， 60: 3， 1971.
17) Ascho司L.: Zur Myokardfrage. Verh. dtsch. path. Ges.， 8: 2， 1904.
18) Murphy， C. E.: Evidence that Aschoff bodies of rheumatic myocarditis develop from injured myo・
fibe四. J. Exp. Med.， 95: 1952.
19) Otaka， Y.: On the concept of the connective tissue diseases‘ The connective tIssue diseases， 1st
Issue， edited by Oshima， Y. & Otaka， Y.， Igaku・.shoin，Tokyo， p. 1， 1969.
20) Otaka， Y.: A classification of the connective tissue diseases from th巴viewpointofpathology. Rinsho・
kagaku， 7: 485， 1971.
Discription of figures
Fig. 1. An immunohistochemical finding of articular synovia in rheumatoid arthritis through the fluores-
cent antibody method. Fibrinogen is positive in the fibrinoid focus.
Fig. 2. Ibid. IgG is positive in the fibrinoid focus.
Fig. 3. Ibid. IgM is positive in the fibrinoid focus.
Fig. 4. E)ectron microscopic findings of articular synovia in rheumatoid arthritis. Degeneration of
synovial cells， dispersion of collagen fibrils in the stroma and exudation of fibrin are shown.
(x 20000)
Fig. 5. Ibid. The五gureof fibrin in the fibrinoid focus. ( x 20000)
Fig. 6. A scanning electron microscopic figure on the surface of articular synovia in rheumatoid arthritis.
Fibrin fibers are observed at the五brinoidfocus. ( x 11000)
Fig. 7. A subcutaneous nodule in rheumatoid arthritis. Toluidin blue metachromasia is positive in the
palisade zone.
Fig. 8. An immunohistochemical finding of a subcutaneous nodule in rheumatoid arthritis through the
Otaka: A Study on the Changes of Connective Tissue
日uorescentantibody method. Fibrinogen is positive in the fibrinoid focus.
Fig. 9. Ibid. IgG is positive in the fibrinoid focus.
Fig. 10. Ibid. IgM is positive in the fibrinoid focus.
49
Fig. 11. An electron microscopic figure of a subcutaneous nodule in rheumatoid arthritis. A qualitatively
changed portion at the center of the nodule is shown. Collagen fibrils have decreased in number
and amorphous substances of high electron density are observed in the interfibrillar spaces.
(x 10600)
Fig. 12. Ibid. In the fibrinoid focus， collagen fibrils are comparatively well preserved and fibrin is observed
in the interfibrillar spaces. Amorphous substances of high electron density are also demonstrated
in the stroma. ( X 20000)
Fig. 13. An immunohistochemical finding in the superficial layer of granulation tissue at the bottom of
gastric ulcer through the fluorescent antibody method. Fibrinogen is positive in the fibrinoid
focus.
Fig. 14. Ibid. Albumin is positive in the fibrinoid focus.
Fig. 15. An electron microscopic figure of the superficiallayer of granulation tissue at the bottom of gastric
ulcer. Fibrin made up in bundles and striations with periodicity of about 200A are observed
on them. ( x 54000)
Fig. 16. An immunohistochemical finding of the fibrinoid focus in the placental vi1lus through the fluores-
cent antibody method. Fibrinogen is positive.
Fig. 17. So-called “myxomatous degeneration" of the endocardial connective tissue in rheumatic fever.
Slightly stronger toJuidin blue metachromasia than in normal cases is observed.
Fig. 18. Edema-like chang巴 ofthe aortic intima in malignant nephrosclerosis. Toluidin blue mtachrom・
asia is observed to have been intensified.
Fig. 19. Edema-like change of the intralobular stroma in mastopathy. Positive toluidin blue metachrom司
asia is obvious.
Fig.20. An electron microscopic figure of the edema-like intralobular stroma in mastopathy. Intra‘
fibri1lar spaces are widely expanded. ( x 8000)
Fig. 21. Mucinous degeneration of fibrous cartilage in herniation of intervertebral disc. Both portions
with positive toluidin blue metachromasia and with negative toluidin blue metachromasia exist.
Fig. 22. An immunohistochemical finding of a nucleus pulposus in herniation of intervertebral disc through
the fluorescent antibody method. Albumin is positive in the portion of mucinous degeneration.
Fig. 23. An amyloid node of vocal cords. Toluidin blue metachromasia is negative in the amyloid focus
and positive only in the surrounding edema-like portion.
Fig. 24. An electron microscopic figure of an amyloid node of vocal cords. Irregularly arranged amyloid
fibrils are observed in the subendothelial portion of capillary. (x 10000)
Fig. 25. The hyalinized portion of pl巴uralcallosity after pyothorax. Toluidin blue metachromasia is
positive.
Fig. 26. An electron microscopic figure of the hyalinized portion of pleural callosity after pyothorax.
Collagen fibrils with diameters合om450 to 500A are densely observed. ( x 8000)
Fig.27. The transitional portion from fibrinoid degeneration to hyaline degeneration in bursitis. Toluidin
blue metachromasia is positive in the hyalinized portion.
Fig.28. An electron microscopic figure of a hyalinized corpus albicans of ovary. The collagen五brilsare
not so dense， diameters of which are distributed from 250 to 400A， and amorphous ground sub-
stances are observed in the interfibri1lar spaces. ( X 20000)
Fig. 29. An electron microscopic figure of a hyalinized blood vessel wall of ovary. Medial smooth muscles
50 結合 組織
re degenerated， col1agen fibrils are scanty in the intercel1ular spaces and amorphous ground
substances are comparatively conspicuous. ( x 10600)
Fig. 30. An Aschoff's node in rheumatic fever. Toluidin blue metachromasia is positive in Aschoff cells.
Fig. 31. An electron microscopic figure of an Aschoff's node in rheumatic fever. In the Aschoff cel1，
rough-surfaced endoplasmic reticula are wel1 developed. No myofilament is recognized. ( x 6600)
Fig.32. Fibroadenoma of mammary gland. Toluidin blue metachromasia is obviously positive in the
edema-like portion of intralobular stroma.
Fig. 33. An electron microscopic figure of the edema-like portion of intralobular stroma of mammary fibro-
adenoma. In the spaces among col1agen fibrils， fine filamentous or granular substances are
observed in reticular forms. ( x 8000)
Fig. 34. Synovioma. In the fibrosarcoma-like portion， toluidin blue metachromasia is obviously positive.
Fig.35. Chondrosarcoma. Toluidin blue metachromasia in th巴 stromais intensely positive.
Fig. 36. Chondromyxoendothelioma. Toluidin blue metachromasia is strongly positive especial1y in the
myxomatous portlOn.
Fig.37. An electron microscopic figure of五brosarcomaexperimentally induced by SV40 virus in the sub-
cutaneous tissue of hamster. Tumor cel1s with abnormal1y numerous rough-surfaced endoplasmic
reticula are observed and collagen fibers are proliferous around the tumor cells. (x 10000)
Fig.38. Fibrosarcoma experimentally induced by SV40 virus in the subcutaneous tissue of hamster.
Toluidin blue metachromasia is positive inside the tumor cells as well as outside.
Otaka: A Study 01¥ the Ch<lngcR of Connectivc Tissuc f)!
Fig. 1 Fig. 4
li'ig. 2 Fig. 5
Fin-. 3 Fig. G
52 Wi
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Fig. 8
Fig. 9
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Fig. 10
Fig. 11
Fig. 12
Otaka : A Study on thc Changes of Connectivc Tissue 5::1
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Fig. 15 Fig. 18
Fi宮. 19
Fig. 20
Fig. 21
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Fi宮. 2:1
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Fig. 24
Otaka : 1¥ Stucly 011 thc Cha ngcs 0 r COI1 I1ccti vC '1、ISSUC
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Fig. 26 Fi百. 29
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56
Fig. 31
Fig. 33
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Fig-. 35
Fig-. 36
Otaka ^ Slucly 011 the Changes of Conncclivc Tissue 57
Fig. 37 Fig. :l8
