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OXFORD MEDICAL PUBLICATIONS
MANUAL OF SURGERY
BY
ALEXIS THOMSON, F.R.C.S.Ed.
_PROFESSOR OF SURGERY, UNIVERSITY OF EDINBURGH_
SURGEON EDINBURGH ROYAL INFIRMARY
AND
ALEXANDER MILES, F.R.C.S.Ed.
SURGEON EDINBURGH ROYAL INFIRMARY
VOLUME FIRST
GENERAL SURGERY
_SIXTH EDITION REVISED_
_WITH 169 ILLUSTRATIONS_
LONDON
HENRY FROWDE and HODDER & STOUGHTON
THE _LANCET_ BUILDING
1 & 2 BEDFORD STREET, STRAND, W.C.2
First Edition 1904
Second Edition 1907
Third Edition 1909
Fourth Edition 1911
" " Second Impression 1913
Fifth Edition 1915
" " Second Impression 1919
Sixth Edition 1921
PRINTED IN GREAT BRITAIN BY
MORRISON AND GIBB LTD., EDINBURGH
PREFACE TO SIXTH EDITION
Much has happened since this Manual was last revised, and many surgical
lessons have been learned in the hard school of war. Some may yet have
to be unlearned, and others have but little bearing on the problems
presented to the civilian surgeon. Save in its broadest principles, the
surgery of warfare is a thing apart from the general surgery of civil
life, and the exhaustive literature now available on every aspect of it
makes it unnecessary that it should receive detailed consideration in a
manual for students. In preparing this new edition, therefore, we have
endeavoured to incorporate only such additions to our knowledge and
resources as our experience leads us to believe will prove of permanent
value in civil practice.
For the rest, the text has been revised, condensed, and in places
rearranged; a number of old illustrations have been discarded, and a
greater number of new ones added. Descriptions of operative procedures
have been omitted from the _Manual_, as they are to be found in the
companion volume on _Operative Surgery_, the third edition of which
appeared some months ago.
We have retained the Basle anatomical nomenclature, as extended
experience has confirmed our preference for it. For the convenience of
readers who still employ the old terms, these are given in brackets
after the new.
This edition of the _Manual_ appears in three volumes; the first being
devoted to General Surgery, the other two to Regional Surgery. This
arrangement has enabled us to deal in a more consecutive manner than
hitherto with the surgery of the Extremities, including Fractures and
Dislocations.
We have once more to express our thanks to colleagues in the Edinburgh
School and to other friends for aiding us in providing new
illustrations, and for other valuable help, as well as to our publishers
for their generosity in the matter of illustrations.
EDINBURGH,
_March_ 1921.
CONTENTS
PAGE
CHAPTER I
REPAIR 1
CHAPTER II
CONDITIONS WHICH INTERFERE WITH REPAIR 17
CHAPTER III
INFLAMMATION 31
CHAPTER IV
SUPPURATION 45
CHAPTER V
ULCERATION AND ULCERS 68
CHAPTER VI
GANGRENE 86
CHAPTER VII
BACTERIAL AND OTHER WOUND INFECTIONS 107
CHAPTER VIII
TUBERCULOSIS 133
CHAPTER IX
SYPHILIS 146
CHAPTER X
TUMOURS 181
CHAPTER XI
INJURIES 218
CHAPTER XII
METHODS OF WOUND TREATMENT 241
CHAPTER XIII
CONSTITUTIONAL EFFECTS OF INJURIES 249
CHAPTER XIV
THE BLOOD VESSELS 258
CHAPTER XV
THE LYMPH VESSELS AND GLANDS 321
CHAPTER XVI
THE NERVES 342
CHAPTER XVII
SKIN AND SUBCUTANEOUS TISSUES 376
CHAPTER XVIII
THE MUSCLES, TENDONS, AND TENDON SHEATHS 405
CHAPTER XIX
THE BURSÆ 426
CHAPTER XX
DISEASES OF BONE 434
CHAPTER XXI
DISEASES OF JOINTS 501
INDEX 547
LIST OF ILLUSTRATIONS
FIG. PAGE
1. Ulcer of Back of Hand grafted from Abdominal Wall 15
2. Staphylococcus aureus in Pus from case of Osteomyelitis 25
3. Streptococci in Pus from case of Diffuse Cellulitis 26
4. Bacillus coli communis in Pus from Abdominal Abscess 27
5. Fraenkel's Pneumococci in Pus from Empyema following 28
Pneumonia
6. Passive Hyperæmia of Hand and Forearm induced by Bier's 37
Bandage
7. Passive Hyperæmia of Finger induced by Klapp's Suction 38
Bell
8. Passive Hyperæmia induced by Klapp's Suction Bell for 39
Inflammation of Inguinal Gland
9. Diagram of various forms of Whitlow 56
10. Charts of Acute Sapræmia 61
11. Chart of Hectic Fever 62
12. Chart of Septicæmia followed by Pyæmia 63
13. Chart of Pyæmia following on Acute Osteomyelitis 65
14. Leg Ulcers associated with Varicose Veins 71
15. Perforating Ulcers of Sole of Foot 74
16. Bazin's Disease in a girl æt. 16 75
17. Syphilitic Ulcers in region of Knee 76
18. Callous Ulcer showing thickened edges 78
19. Tibia and Fibula, showing changes due to Chronic Ulcer of 80
Leg
20. Senile Gangrene of the Foot 89
21. Embolic Gangrene of Hand and Arm 92
22. Gangrene of Terminal Phalanx of Index-Finger 100
23. Cancrum Oris 103
24. Acute Bed Sores over right Buttock 104
25. Chart of Erysipelas occurring in a wound 108
26. Bacillus of Tetanus 113
27. Bacillus of Anthrax 120
28. Malignant Pustule third day after infection 122
29. Malignant Pustule fourteen days after infection 122
30. Colony of Actinomyces 126
31. Actinomycosis of Maxilla 128
32. Mycetoma, or Madura Foot 130
33. Tubercle bacilli 134
34. Tuberculous Abscess in Lumbar Region 141
35. Tuberculous Sinus injected through its opening in the 144
Forearm with Bismuth Paste
36. Spirochæte pallida 147
37. Spirochæta refrigerans from scraping of Vagina 148
38. Primary Lesion on Thumb, with Secondary Eruption on 154
Forearm
39. Syphilitic Rupia 159
40. Ulcerating Gumma of Lips 169
41. Ulceration in inherited Syphilis 170
42. Tertiary Syphilitic Ulceration in region of Knee and on 171
both Thumbs
43. Facies of Inherited Syphilis 174
44. Facies of Inherited Syphilis 175
45. Subcutaneous Lipoma 185
46. Pedunculated Lipoma of Buttock 186
47. Diffuse Lipomatosis of Neck 187
48. Zanthoma of Hands 188
49. Zanthoma of Buttock 189
50. Chondroma growing from Infra-Spinous Fossa of Scapula 190
51. Chondroma of Metacarpal Bone of Thumb 190
52. Cancellous Osteoma of Lower End of Femur 192
53. Myeloma of Shaft of Humerus 195
54. Fibro-myoma of Uterus 196
55. Recurrent Sarcoma of Sciatic Nerve 198
56. Sarcoma of Arm fungating 199
57. Carcinoma of Breast 206
58. Epithelioma of Lip 209
59. Dermoid Cyst of Ovary 213
60. Carpal Ganglion in a woman æt. 25 215
61. Ganglion on lateral aspect of Knee 216
62. Radiogram showing pellets embedded in Arm 228
63. Cicatricial Contraction following Severe Burn 236
64. Genealogical Tree of Hæmophilic Family 278
65. Radiogram showing calcareous degeneration of Arteries 284
66. Varicose Vein with Thrombosis 289
67. Extensive Varix of Internal Saphena System on Left Leg 291
68. Mixed Nævus of Nose 296
69. Cirsoid Aneurysm of Forehead 299
70. Cirsoid Aneurysm of Orbit and Face 300
71. Radiogram of Aneurysm of Aorta 303
72. Sacculated Aneurysm of Abdominal Aorta 304
73. Radiogram of Innominate Aneurysm after Treatment by 309
Moore-Corradi method
74. Thoracic Aneurysm threatening to rupture 313
75. Innominate Aneurysm in a woman 315
76. Congenital Cystic Tumour or Hygroma of Axilla 328
77. Tuberculous Cervical Gland with Abscess formation 331
78. Mass of Tuberculous Glands removed from Axilla 333
79. Tuberculous Axillary Glands 335
80. Chronic Hodgkin's Disease in boy æt. 11 337
81. Lymphadenoma in a woman æt. 44 338
82. Lympho Sarcoma removed from Groin 339
83. Cancerous Glands in Neck, secondary to Epithelioma of Lip 341
84. Stump Neuromas of Sciatic Nerve 345
85. Stump Neuromas, showing changes at ends of divided Nerves 354
86. Diffuse Enlargement of Nerves in generalised 356
Neuro-Fibromatosis
87. Plexiform Neuroma of small Sciatic Nerve 357
88. Multiple Neuro-Fibromas of Skin (Molluscum fibrosum) 358
89. Elephantiasis Neuromatosa in a woman æt. 28 359
90. Drop-Wrist following Fracture of Shaft of Humerus 365
91. To illustrate the Loss of Sensation produced by Division 367
of the Median Nerve
92. To illustrate Loss of Sensation produced by Complete 368
Division of Ulnar Nerve
93. Callosities and Corns on Sole of Foot 377
94. Ulcerated Chilblains on Fingers 378
95. Carbuncle on Back of Neck 381
96. Tuberculous Elephantiasis 383
97. Elephantiasis in a woman æt. 45 387
98. Elephantiasis of Penis and Scrotum 388
99. Multiple Sebaceous Cysts or Wens 390
100. Sebaceous Horn growing from Auricle 392
101. Paraffin Epithelioma 394
102. Rodent Cancer of Inner Canthus 395
103. Rodent Cancer with destruction of contents of Orbit 396
104. Diffuse Melanotic Cancer of Lymphatics of Skin 398
105. Melanotic Cancer of Forehead with Metastasis in Lymph 399
Glands
106. Recurrent Keloid 401
107. Subungual Exostosis 403
108. Avulsion of Tendon 410
109. Volkmann's Ischæmic Contracture 414
110. Ossification in Tendon of Ilio-psoas Muscle 417
111. Radiogram of Calcification and Ossification in Biceps and 418
Triceps
112. Ossification in Muscles of Trunk in generalised Ossifying 419
Myositis
113. Hydrops of Prepatellar Bursa 427
114. Section through Gouty Bursa 428
115. Tuberculous Disease of Sub-Deltoid Bursa 429
116. Great Enlargement of the Ischial Bursa 431
117. Gouty Disease of Bursæ 432
118. Shaft of the Femur after Acute Osteomyelitis 444
119. Femur and Tibia showing results of Acute Osteomyelitis 445
120. Segment of Tibia resected for Brodie's Abscess 449
121. Radiogram of Brodie's Abscess in Lower End of Tibia 451
122. Sequestrum of Femur after Amputation 453
123. New Periosteal Bone on Surface of Femur from Amputation 454
Stump
124. Tuberculous Osteomyelitis of Os Magnum 456
125. Tuberculous Disease of Tibia 457
126. Diffuse Tuberculous Osteomyelitis of Right Tibia 458
127. Advanced Tuberculous Disease in Region of Ankle 459
128. Tuberculous Dactylitis 460
129. Shortening of Middle Finger of Adult, the result of 461
Tuberculous Dactylitis in Childhood
130. Syphilitic Disease of Skull 463
131. Syphilitic Hyperostosis and Sclerosis of Tibia 464
132. Sabre-blade Deformity of Tibia 467
133. Skeleton of Rickety Dwarf 470
134. Changes in the Skull resulting from Ostitis Deformans 474
135. Cadaver, illustrating the alterations in the Lower Limbs 475
resulting from Ostitis Deformans
136. Osteomyelitis Fibrosa affecting Femora 476
137. Radiogram of Upper End of Femur in Osteomyelitis Fibrosa 478
138. Radiogram of Right Knee showing Multiple Exostoses 482
139. Multiple Exostoses of Limbs 483
140. Multiple Cartilaginous Exostoses 484
141. Multiple Cartilaginous Exostoses 486
142. Multiple Chondromas of Phalanges and Metacarpals 488
143. Skiagram of Multiple Chondromas 489
144. Multiple Chondromas in Hand 490
145. Radiogram of Myeloma of Humerus 492
146. Periosteal Sarcoma of Femur 493
147. Periosteal Sarcoma of Humerus 493
148. Chondro-Sarcoma of Scapula 494
149. Central Sarcoma of Femur invading Knee Joint 495
150. Osseous Shell of Osteo-Sarcoma of Femur 495
151. Radiogram of Osteo-Sarcoma of Femur 496
152. Radiogram of Chondro-Sarcoma of Humerus 497
153. Epitheliomatus Ulcer of Leg invading Tibia 499
154. Osseous Ankylosis of Femur and Tibia 503
155. Osseous Ankylosis of Knee 504
156. Caseating focus in Upper End of Fibula 513
157. Arthritis Deformans of Elbow 525
158. Arthritis Deformans of Knee 526
159. Hypertrophied Fringes of Synovial Membrane of Knee 527
160. Arthritis Deformans of Hands 529
161. Arthritis Deformans of several Joints 530
162. Bones of Knee in Charcot's Disease 533
163. Charcot's Disease of Left Knee 534
164. Charcot's Disease of both Ankles: front view 535
165. Charcot's Disease of both Ankles: back view 536
166. Radiogram of Multiple Loose Bodies in Knee-joint 540
167. Loose Body from Knee-joint 541
168. Multiple partially ossified Chondromas of Synovial 542
Membrane from Shoulder-joint
169. Multiple Cartilaginous Loose Bodies from Knee-joint 543
MANUAL OF SURGERY
CHAPTER I
REPAIR
Introduction--Process of repair--Healing by primary union--Granulation
tissue--Cicatricial tissue--Modifications of process of
repair--Repair in individual tissues--Transplantation or grafting
of tissues--Conditions--Sources of grafts--Grafting of individual
tissues--Methods.
INTRODUCTION
To prolong human life and to alleviate suffering are the ultimate
objects of scientific medicine. The two great branches of the healing
art--Medicine and Surgery--are so intimately related that it is
impossible to draw a hard-and-fast line between them, but for
convenience Surgery may be defined as "the art of treating lesions and
malformations of the human body by manual operations, mediate and
immediate." To apply his art intelligently and successfully, it is
essential that the surgeon should be conversant not only with the normal
anatomy and physiology of the body and with the various pathological
conditions to which it is liable, but also with the nature of the
process by which repair of injured or diseased tissues is effected.
Without this knowledge he is unable to recognise such deviations from
the normal as result from mal-development, injury, or disease, or
rationally to direct his efforts towards the correction or removal of
these.
PROCESS OF REPAIR
The process of repair in living tissue depends upon an inherent power
possessed by vital cells of reacting to the irritation caused by injury
or disease. The cells of the damaged tissues, under the influence of
this irritation, undergo certain proliferative changes, which are
designed to restore the normal structure and configuration of the part.
The process by which this restoration is effected is essentially the
same in all tissues, but the extent to which different tissues can carry
the recuperative process varies. Simple structures, such as skin,
cartilage, bone, periosteum, and tendon, for example, have a high power
of regeneration, and in them the reparative process may result in almost
perfect restitution to the normal. More complex structures, on the other
hand, such as secreting glands, muscle, and the tissues of the central
nervous system, are but imperfectly restored, simple cicatricial
connective tissue taking the place of what has been lost or destroyed.
Any given tissue can be replaced only by tissue of a similar kind, and
in a damaged part each element takes its share in the reparative process
by producing new material which approximates more or less closely to the
normal according to the recuperative capacity of the particular tissue.
The normal process of repair may be interfered with by various
extraneous agencies, the most important of which are infection by
disease-producing micro-organisms, the presence of foreign substances,
undue movement of the affected part, and improper applications and
dressings. The effect of these agencies is to delay repair or to prevent
the individual tissues carrying the process to the furthest degree of
which they are capable.
In the management of wounds and other diseased conditions the main
object of the surgeon is to promote the natural reparative process by
preventing or eliminating any factor by which it may be disturbed.
#Healing by Primary Union.#--The most favourable conditions for the
progress of the reparative process are to be found in a clean-cut wound
of the integument, which is uncomplicated by loss of tissue, by the
presence of foreign substances, or by infection with disease-producing
micro-organisms, and its edges are in contact. Such a wound in virtue of
the absence of infection is said to be _aseptic_, and under these
conditions healing takes place by what is called "primary union"--the
"healing by first intention" of the older writers.
#Granulation Tissue.#--The essential and invariable medium of repair in
all structures is an elementary form of new tissue known as _granulation
tissue_, which is produced in the damaged area in response to the
irritation caused by injury or disease. The vital reaction induced by
such irritation results in dilatation of the vessels of the part,
emigration of leucocytes, transudation of lymph, and certain
proliferative changes in the fixed tissue cells. These changes are
common to the processes of inflammation and repair; no hard-and-fast
line can be drawn between these processes, and the two may go on
together. It is, however, only when the proliferative changes have come
to predominate that the reparative process is effectively established by
the production of healthy granulation tissue.
_Formation of Granulation Tissue._--When a wound is made in the
integument under aseptic conditions, the passage of the knife through
the tissues is immediately followed by an oozing of blood, which soon
coagulates on the cut surfaces. In each of the divided vessels a clot
forms, and extends as far as the nearest collateral branch; and on the
surface of the wound there is a microscopic layer of bruised and
devitalised tissue. If the wound is closed, the narrow space between its
edges is occupied by blood-clot, which consists of red and white
corpuscles mixed with a quantity of fibrin, and this forms a temporary
uniting medium between the divided surfaces. During the first twelve
hours, the minute vessels in the vicinity of the wound dilate, and from
them lymph exudes and leucocytes migrate into the tissues. In from
twenty-four to thirty-six hours, the capillaries of the part adjacent to
the wound begin to throw out minute buds and fine processes, which
bridge the gap and form a firmer, but still temporary, connection
between the two sides. Each bud begins in the wall of the capillary as a
small accumulation of granular protoplasm, which gradually elongates
into a filament containing a nucleus. This filament either joins with a
neighbouring capillary or with a similar filament, and in time these
become hollow and are filled with blood from the vessels that gave them
origin. In this way a series of young _capillary loops_ is formed.
The spaces between these loops are filled by cells of various kinds, the
most important being the _fibroblasts_, which are destined to form
cicatricial fibrous tissue. These fibroblasts are large irregular
nucleated cells derived mainly from the proliferation of the fixed
connective-tissue cells of the part, and to a less extent from the
lymphocytes and other mononuclear cells which have migrated from the
vessels. Among the fibroblasts, larger multi-nucleated cells--_giant
cells_--are sometimes found, particularly when resistant substances,
such as silk ligatures or fragments of bone, are embedded in the
tissues, and their function seems to be to soften such substances
preliminary to their being removed by the phagocytes. Numerous
_polymorpho-nuclear leucocytes_, which have wandered from the vessels,
are also present in the spaces. These act as phagocytes, their function
being to remove the red corpuscles and fibrin of the original clot, and
this performed, they either pass back into the circulation in virtue of
their amœboid movement, or are themselves eaten up by the growing
fibroblasts. Beyond this phagocytic action, they do not appear to play
any direct part in the reparative process. These young capillary loops,
with their supporting cells and fluids, constitute granulation tissue,
which is usually fully formed in from three to five days, after which it
begins to be replaced by cicatricial or scar tissue.
_Formation of Cicatricial Tissue._--The transformation of this temporary
granulation tissue into scar tissue is effected by the fibroblasts,
which become elongated and spindle-shaped, and produce in and around
them a fine fibrillated material which gradually increases in quantity
till it replaces the cell protoplasm. In this way white fibrous tissue
is formed, the cells of which are arranged in parallel lines and
eventually become grouped in bundles, constituting fully formed white
fibrous tissue. In its growth it gradually obliterates the capillaries,
until at the end of two, three, or four weeks both vessels and cells
have almost entirely disappeared, and the original wound is occupied by
cicatricial tissue. In course of time this tissue becomes consolidated,
and the cicatrix undergoes a certain amount of contraction--_cicatricial
contraction_.
_Healing of Epidermis._--While these changes are taking place in the
deeper parts of the wound, the surface is being covered over by
_epidermis_ growing in from the margins. Within twelve hours the cells
of the rete Malpighii close to the cut edge begin to sprout on to the
surface of the wound, and by their proliferation gradually cover the
granulations with a thin pink pellicle. As the epithelium increases in
thickness it assumes a bluish hue and eventually the cells become
cornified and the epithelium assumes a greyish-white colour.
_Clinical Aspects._--So long as the process of repair is not complicated
by infection with micro-organisms, there is no interference with the
general health of the patient. The temperature remains normal; the
circulatory, gastro-intestinal, nervous, and other functions are
undisturbed; locally, the part is cool, of natural colour and free from
pain.
#Modifications of the Process of Repair.#--The process of repair by
primary union, above described, is to be looked upon as the type of all
reparative processes, such modifications as are met with depending
merely upon incidental differences in the conditions present, such as
loss of tissue, infection by micro-organisms, etc.
_Repair after Loss or Destruction of Tissue._--When the edges of a wound
cannot be approximated either because tissue has been lost, for example
in excising a tumour or because a drainage tube or gauze packing has
been necessary, a greater amount of granulation tissue is required to
fill the gap, but the process is essentially the same as in the ideal
method of repair.
The raw surface is first covered by a layer of coagulated blood and
fibrin. An extensive new formation of capillary loops and fibroblasts
takes place towards the free surface, and goes on until the gap is
filled by a fine velvet-like mass of granulation tissue. This
granulation tissue is gradually replaced by young cicatricial tissue,
and the surface is covered by the ingrowth of epithelium from the edges.
This modification of the reparative process can be best studied
clinically in a recent wound which has been packed with gauze. When the
plug is introduced, the walls of the cavity consist of raw tissue with
numerous oozing blood vessels. On removing the packing on the fifth or
sixth day, the surface is found to be covered with minute, red,
papillary granulations, which are beginning to fill up the cavity. At
the edges the epithelium has proliferated and is covering over the newly
formed granulation tissue. As lymph and leucocytes escape from the
exposed surface there is a certain amount of serous or sero-purulent
discharge. On examining the wound at intervals of a few days, it is
found that the granulation tissue gradually increases in amount till the
gap is completely filled up, and that coincidently the epithelium
spreads in and covers over its surface. In course of time the epithelium
thickens, and as the granulation tissue is slowly replaced by young
cicatricial tissue, which has a peculiar tendency to contract and so to
obliterate the blood vessels in it, the scar that is left becomes
smooth, pale, and depressed. This method of healing is sometimes spoken
of as "healing by granulation"--although, as we have seen, it is by
granulation that all repair takes place.
_Healing by Union of two Granulating Surfaces._--In gaping wounds union
is sometimes obtained by bringing the two surfaces into apposition after
each has become covered with healthy granulations. The exudate on the
surfaces causes them to adhere, capillary loops pass from one to the
other, and their final fusion takes place by the further development of
granulation and cicatricial tissue.
_Reunion of Parts entirely Separated from the Body._--Small portions of
tissue, such as the end of a finger, the tip of the nose or a portion of
the external ear, accidentally separated from the body, if accurately
replaced and fixed in position, occasionally adhere by primary union.
In the course of operations also, portions of skin, fascia, or bone, or
even a complete joint may be transplanted, and unite by primary union.
_Healing under a Scab._--When a small superficial wound is exposed to
the air, the blood and serum exuded on its surface may dry and form a
hard crust or _scab_, which serves to protect the surface from external
irritation in the same way as would a dry pad of sterilised gauze. Under
this scab the formation of granulation tissue, its transformation into
cicatricial tissue, and the growth of epithelium on the surface, go on
until in the course of time the crust separates, leaving a scar.
_Healing by Blood-clot._--In subcutaneous wounds, for example tenotomy,
in amputation wounds, and in wounds made in excising tumours or in
operating upon bones, the space left between the divided tissues becomes
filled with blood-clot, which acts as a temporary scaffolding in which
granulation tissue is built up. Capillary loops grow into the coagulum,
and migrated leucocytes from the adjacent blood vessels destroy the red
corpuscles, and are in turn disposed of by the developing fibroblasts,
which by their growth and proliferation fill up the gap with young
connective tissue. It will be evident that this process only differs
from healing by primary union in the _amount_ of blood-clot that is
present.
_Presence of a Foreign Body._--When an aseptic foreign body is present
in the tissues, _e.g._ a piece of unabsorbable chromicised catgut, the
healing process may be modified. After primary union has taken place the
scar may broaden, become raised above the surface, and assume a
bluish-brown colour; the epidermis gradually thins and gives way,
revealing the softened portion of catgut, which can be pulled out in
pieces, after which the wound rapidly heals and resumes a normal
appearance.
REPAIR IN INDIVIDUAL TISSUES
_Skin and Connective Tissue._--The mode of regeneration of these tissues
under aseptic conditions has already been described as the type of ideal
repair. In highly vascular parts, such as the face, the reparative
process goes on with great rapidity, and even extensive wounds may be
firmly united in from three to five days. Where the anastomosis is less
free the process is more prolonged. The more highly organised elements
of the skin, such as the hair follicles, the sweat and sebaceous glands,
are imperfectly reproduced; hence the scar remains smooth, dry, and
hairless.
_Epithelium._--Epithelium is only reproduced from pre-existing
epithelium, and, as a rule, from one of a similar type, although
metaplastic transformation of cells of one kind of epithelium into
another kind can take place. Thus a granulating surface may be covered
entirely by the ingrowing of the cutaneous epithelium from the margins;
or islets, originating in surviving cells of sebaceous glands or sweat
glands, or of hair follicles, may spring up in the centre of the raw
area. Such islets may also be due to the accidental transference of
loose epithelial cells from the edges. Even the fluid from a blister, in
virtue of the isolated cells of the rete Malpighii which it contains, is
capable of starting epithelial growth on a granulating surface. Hairs
and nails may be completely regenerated if a sufficient amount of the
hair follicles or of the nail matrix has escaped destruction. The
epithelium of a mucous membrane is regenerated in the same way as that
on a cutaneous surface.
Epithelial cells have the power of living for some time after being
separated from their normal surroundings, and of growing again when once
more placed in favourable circumstances. On this fact the practice of
skin grafting is based (p. 11).
_Cartilage._--When an articular cartilage is divided by incision or by
being implicated in a fracture involving the articular end of a bone, it
is repaired by ordinary cicatricial fibrous tissue derived from the
proliferating cells of the perichondrium. Cartilage being a non-vascular
tissue, the reparative process goes on slowly, and it may be many weeks
before it is complete.
It is possible for a metaplastic transformation of connective-tissue
cells into cartilage cells to take place, the characteristic hyaline
matrix being secreted by the new cells. This is sometimes observed as an
intermediary stage in the healing of fractures, especially in young
bones. It may also take place in the regeneration of lost portions of
cartilage, provided the new tissue is so situated as to constitute part
of a joint and to be subjected to pressure by an opposing cartilaginous
surface. This is illustrated by what takes place after excision of
joints where it is desired to restore the function of the articulation.
By carrying out movements between the constituent parts, the fibrous
tissue covering the ends of the bones becomes moulded into shape, its
cells take on the characters of cartilage cells, and, forming a matrix,
so develop a new cartilage.
Conversely, it is observed that when articular cartilage is no longer
subjected to pressure by an opposing cartilage, it tends to be
transformed into fibrous tissue, as may be seen in deformities attended
with displacement of articular surfaces, such as hallux valgus and
club-foot.
After fractures of costal cartilage or of the cartilages of the larynx
the cicatricial tissue may be ultimately replaced by bone.
_Tendons._--When a tendon is divided, for example by subcutaneous
tenotomy, the end nearer the muscle fibres is drawn away from the other,
leaving a gap which is speedily filled by blood-clot. In the course of a
few days this clot becomes permeated by granulation tissue, the
fibroblasts of which are derived from the sheath of the tendon, the
surrounding connective tissue, and probably also from the divided ends
of the tendon itself. These fibroblasts ultimately develop into typical
tendon cells, and the fibres which they form constitute the new tendon
fibres. Under aseptic conditions repair is complete in from two to three
weeks. In the course of the reparative process the tendon and its sheath
may become adherent, which leads to impaired movement and stiffness. If
the ends of an accidentally divided tendon are at once brought into
accurate apposition and secured by sutures, they unite directly with a
minimum amount of scar tissue, and function is perfectly restored.
_Muscle._--Unstriped muscle does not seem to be capable of being
regenerated to any but a moderate degree. If the ends of a divided
striped muscle are at once brought into apposition by stitches, primary
union takes place with a minimum of intervening fibrous tissue. The
nuclei of the muscle fibres in close proximity to this young cicatricial
tissue proliferate, and a few new muscle fibres may be developed, but
any gross loss of muscular tissue is replaced by a fibrous cicatrix. It
would appear that portions of muscle transplanted from animals to fill
up gaps in human muscle are similarly replaced by fibrous tissue. When a
muscle is paralysed from loss of its nerve supply and undergoes complete
degeneration, it is not capable of being regenerated, even should the
integrity of the nerve be restored, and so its function is permanently
lost.
_Secretory Glands._--The regeneration of secretory glands is usually
incomplete, cicatricial tissue taking the place of the glandular
substance which has been destroyed. In wounds of the liver, for example,
the gap is filled by fibrous tissue, but towards the periphery of the
wound the liver cells proliferate and a certain amount of regeneration
takes place. In the kidney also, repair mainly takes place by
cicatricial tissue, and although a few collecting tubules may be
reformed, no regeneration of secreting tissue takes place. After the
operation of decapsulation of the kidney a new capsule is formed, and
during the process young blood vessels permeate the superficial parts
of the kidney and temporarily increase its blood supply, but in the
consolidation of the new fibrous tissue these vessels are ultimately
obliterated. This does not prove that the operation is useless, as the
temporary improvement of the circulation in the kidney may serve to tide
the patient over a critical period of renal insufficiency.
_Stomach and Intestine._--Provided the peritoneal surfaces are
accurately apposed, wounds of the stomach and intestine heal with great
rapidity. Within a few hours the peritoneal surfaces are glued together
by a thin layer of fibrin and leucocytes, which is speedily organised
and replaced by fibrous tissue. Fibrous tissue takes the place of the
muscular elements, which are not regenerated. The mucous lining is
restored by ingrowth from the margins, and there is evidence that some
of the secreting glands may be reproduced.
Hollow viscera, like the œsophagus and urinary bladder, in so far
as they are not covered by peritoneum, heal less rapidly.
_Nerve Tissues._--There is no trustworthy evidence that regeneration of
the tissues of the brain or spinal cord in man ever takes place. Any
loss of substance is replaced by cicatricial tissue.
The repair of _Bone_, _Blood Vessels_, and _Peripheral Nerves_ is more
conveniently considered in the chapters dealing with these structures.
#Rate of Healing.#--While the rate at which wounds heal is remarkably
constant there are certain factors that influence it in one direction or
the other. Healing is more rapid when the edges are in contact, when
there is a minimum amount of blood-clot between them, when the patient
is in normal health and the vitality of the tissues has not been
impaired. Wounds heal slightly more quickly in the young than in the
old, although the difference is so small that it can only be
demonstrated by the most careful observations.
Certain tissues take longer to heal than others: for example, a fracture
of one of the larger long bones takes about six weeks to unite, and
divided nerve trunks take much longer--about a year.
Wounds of certain parts of the body heal more quickly than others: those
of the scalp, face, and neck, for example, heal more quickly than those
over the buttock or sacrum, probably because of their greater
vascularity.
The extent of the wound influences the rate of healing; it is only
natural that a long and deep wound should take longer to heal than a
short and superficial one, because there is so much more work to be
done in the conversion of blood-clot into granulation tissue, and this
again into scar tissue that will be strong enough to stand the strain on
the edges of the wound.
THE TRANSPLANTATION OR GRAFTING OF TISSUES
Conditions are not infrequently met with in which healing is promoted
and restoration of function made possible by the transference of a
portion of tissue from one part of the body to another; the tissue
transferred is known as the _graft_ or the _transplant_. The simplest
example of grafting is the transplantation of skin.
In order that the graft may survive and have a favourable chance of
"taking," as it is called, the transplanted tissue must retain its
vitality until it has formed an organic connection with the tissue in
which it is placed, so that it may derive the necessary nourishment from
its new bed. When these conditions are fulfilled the tissues of the
graft continue to proliferate, producing new tissue elements to replace
those that are lost and making it possible for the graft to become
incorporated with the tissue with which it is in contact.
Dead tissue, on the other hand, can do neither of these things; it is
only capable of acting as a model, or, at the most, as a scaffolding for
such mobile tissue elements as may be derived from, the parent tissue
with which the graft is in contact: a portion of sterilised marine
sponge, for example, may be observed to become permeated with
granulation tissue when it is embedded in the tissues.
A successful graft of living tissue is not only capable of regeneration,
but it acquires a system of lymph and blood vessels, so that in time it
bleeds when cut into, and is permeated by new nerve fibres spreading in
from the periphery towards the centre.
It is instructive to associate the period of survival of the different
tissues of the body after death, with their capacity of being used for
grafting purposes; the higher tissues such as those of the central
nervous system and highly specialised glandular tissues like those of
the kidney lose their vitality quickly after death and are therefore
useless for grafting; connective tissues, on the other hand, such as
fat, cartilage, and bone retain their vitality for several hours after
death, so that when they are transplanted, they readily "take" and do
all that is required of them: the same is true of the skin and its
appendages.
_Sources of Grafts._--It is convenient to differentiate between
_autoplastic_ grafts, that is those derived from the same individual;
_homoplastic_ grafts, derived from another animal of the same species;
and _heteroplastic_ grafts, derived from an animal of another species.
Other conditions being equal, the prospects of success are greatest with
autoplastic grafts, and these are therefore preferred whenever possible.
There are certain details making for success that merit attention: the
graft must not be roughly handled or allowed to dry, or be subjected to
chemical irritation; it must be brought into accurate contact with the
new soil, no blood-clot intervening between the two, no movement of the
one upon the other should be possible and all infection must be
excluded; it will be observed that these are exactly the same conditions
that permit of the primary healing of wounds, with which of course the
healing of grafts is exactly comparable.
_Preservation of Tissues for Grafting._--It was at one time believed
that tissues might be taken from the operating theatre and kept in cold
storage until they were required. It is now agreed that tissues which
have been separated from the body for some time inevitably lose their
vitality, become incapable of regeneration, and are therefore unsuited
for grafting purposes. If it is intended to preserve a portion of tissue
for future grafting, it should be embedded in the subcutaneous tissue of
the abdominal wall until it is wanted; this has been carried out with
portions of costal cartilage and of bone.
INDIVIDUAL TISSUES AS GRAFTS
#The Blood# lends itself in an ideal manner to transplantation, or, as
it has long been called, _transfusion_. Being always a homoplastic
transfer, the new blood is not always tolerated by the old, in which
case biochemical changes occur, resulting in hæmolysis, which
corresponds to the disintegration of other unsuccessful homoplastic
grafts. (See article on Transfusion, _Op. Surg._, p. 37.)
#The Skin.#--The skin was the first tissue to be used for grafting
purposes, and it is still employed with greater frequency than any
other, as lesions causing defects of skin are extremely common and
without the aid of grafts are tedious in healing.
Skin grafts may be applied to a raw surface or to one that is covered
with granulations.
_Skin grafting of raw surfaces_ is commonly indicated after operations
for malignant disease in which considerable areas of skin must be
sacrificed, and after accidents, such as avulsion of the scalp by
machinery.
_Skin grafting of granulating surfaces_ is chiefly employed to promote
healing in the large defects of skin caused by severe burns; the
grafting is carried out when the surface is covered by a uniform layer
of healthy granulations and before the inevitable contraction of scar
tissue makes itself manifest. Before applying the grafts it is usual to
scrape away the granulations until the young fibrous tissue underneath
is exposed, but, if the granulations are healthy and can be rendered
aseptic, the grafts may be placed on them directly.
If it is decided to scrape away the granulations, the oozing must be
arrested by pressure with a pad of gauze, a sheet of dental rubber or
green protective is placed next the raw surface to prevent the gauze
adhering and starting the bleeding afresh when it is removed.
#Methods of Skin-Grafting.#--Two methods are employed: one in which the
epidermis is mainly or exclusively employed--epidermis or epithelial
grafting; the other, in which the graft consists of the whole thickness
of the true skin--cutis-grafting.
_Epidermis or Epithelial Grafting._--The method introduced by the late
Professor Thiersch of Leipsic is that almost universally practised. It
consists in transplanting strips of epidermis shaved from the surface of
the skin, the razor passing through the tips of the papillæ, which
appear as tiny red points yielding a moderate ooze of blood.
The strips are obtained from the front and lateral aspects of the thigh
or upper arm, the skin in those regions being pliable and comparatively
free from hairs.
They are cut with a sharp hollow-ground razor or with Thiersch's
grafting knife, the blade of which is rinsed in alcohol and kept
moistened with warm saline solution. The cutting is made easier if the
skin is well stretched and kept flat and perfectly steady, the
operator's left hand exerting traction on the skin behind, the hands of
the assistant on the skin in front, one above and the other below the
seat of operation. To ensure uniform strips being cut, the razor is kept
parallel with the surface and used with a short, rapid, sawing movement,
so that, with a little practice, grafts six or eight inches long by one
or two inches broad can readily be cut. The patient is given a general
anæsthetic, or regional anæsthesia is obtained by injections of a
solution of one per cent. novocain into the line of the lateral and
middle cutaneous nerves; the disinfection of the skin is carried out on
the usual lines, any chemical agent being finally got rid of, however,
by means of alcohol followed by saline solution.
The strips of epidermis wrinkle up on the knife and are directly
transferred to the surface, for which they should be made to form a
complete carpet, slightly overlapping the edges of the area and of one
another; some blunt instrument is used to straighten out the strips,
which are then subjected to firm pressure with a pad of gauze to express
blood and air-bells and to ensure accurate contact, for this must be as
close as that between a postage stamp and the paper to which it is
affixed.
As a dressing for the grafted area and of that also from which the
grafts have been taken, gauze soaked in _liquid paraffin_--the patent
variety known as _ambrine_ is excellent--appears to be the best; the
gauze should be moistened every other day or so with fresh paraffin, so
that, at the end of a week, when the grafts should have united, the
gauze can be removed without risk of detaching them. _Dental wax_ is
another useful type of dressing; as is also _picric acid_ solution. Over
the gauze, there is applied a thick layer of cotton wool, and the whole
dressing is kept in place by a firmly applied bandage, and in the case
of the limbs some form of splint should be added to prevent movement.
A dressing may be dispensed with altogether, the grafts being protected
by a wire cage such as is used after vaccination, but they tend to dry
up and come to resemble a scab.
When the grafts have healed, it is well to protect them from injury and
to prevent them drying up and cracking by the liberal application of
lanoline or vaseline.
The new skin is at first insensitive and is fixed to the underlying
connective tissue or bone, but in course of time (from six weeks
onwards) sensation returns and the formation of elastic tissue beneath
renders the skin pliant and movable so that it can be pinched up between
the finger and thumb.
_Reverdin's_ method consists in planting out pieces of skin not bigger
than a pin-head over a granulating surface. It is seldom employed.
_Grafts of the Cutis Vera._--Grafts consisting of the entire thickness
of the true skin were specially advocated by Wolff and are often
associated with his name. They should be cut oval or spindle-shaped, to
facilitate the approximation of the edges of the resulting wound. The
graft should be cut to the exact size of the surface it is to cover;
Gillies believes that tension of the graft favours its taking. These
grafts may be placed either on a fresh raw surface or on healthy
granulations. It is sometimes an advantage to stitch them in position,
especially on the face. The dressing and the after-treatment are the
same as in epidermis grafting.
There is a degree of uncertainty about the graft retaining its vitality
long enough to permit of its deriving the necessary nourishment from its
new surroundings; in a certain number of cases the flap dies and is
thrown off as a slough--moist or dry according to the presence or
absence of septic infection.
The technique for cutis-grafting must be without a flaw, and the asepsis
absolute; there must not only be a complete absence of movement, but
there must be no traction on the flap that will endanger its blood
supply.
Owing to the uncertainty in the results of cutis-grafting the
_two-stage_ or _indirect method_ has been introduced, and its almost
uniform success has led to its sphere of application being widely
extended. The flap is raised as in the direct method but is left
attached at one of its margins for a period ranging from 14 to 21 days
until its blood supply from its new bed is assured; the detachment is
then made complete. The blood supply of the proposed flap may influence
its selection and the way in which it is fashioned; for example, a flap
cut from the side of the head to fill a defect in the cheek, having in
its margin of attachment or pedicle the superficial temporal artery, is
more likely to take than a flap cut with its base above.
Another modification is to raise the flap but leave it connected at both
ends like the piers of a bridge; this method is well suited to defects
of skin on the dorsum of the fingers, hand and forearm, the bridge of
skin is raised from the abdominal wall and the hand is passed beneath it
and securely fixed in position; after an interval of 14 to 21 days, when
the flap is assured of its blood supply, the piers of the bridge are
divided (Fig. 1). With undermining it is usually easy to bring the
edges of the gap in the abdominal wall together, even in children; the
skin flap on the dorsum of the hand appears rather thick and
prominent--almost like the pad of a boxing-glove--for some time, but
the restoration of function in the capacity to flex the fingers is
gratifying in the extreme.
[Illustration: FIG. 1.--Ulcer of back of Hand covered by flap of skin
raised from anterior abdominal wall. The lateral edges of the flap are
divided after the graft has adhered.]
The indirect element of this method of skin-grafting may be carried
still further by transferring the flap of skin first to one part of the
body and then, after it has taken, transferring it to a third part.
Gillies has especially developed this method in the remedying of
deformities of the face caused by gunshot wounds and by petrol burns in
air-men. A rectangular flap of skin is marked out in the neck and chest,
the lateral margins of the flap are raised sufficiently to enable them
to be brought together so as to form a tube of skin: after the
circulation has been restored, the lower end of the tube is detached and
is brought up to the lip or cheek, or eyelid, where it is wanted; when
this end has derived its new blood supply, the other end is detached
from the neck and brought up to where it is wanted. In this way, skin
from the chest may be brought up to form a new forehead and eyelids.
Grafts of _mucous membrane_ are used to cover defects in the lip, cheek,
and conjunctiva. The technique is similar to that employed in
skin-grafting; the sources of mucous membrane are limited and the
element of septic infection cannot always be excluded.
_Fat._--Adipose tissue has a low vitality, but it is easily retained and
it readily lends itself to transplantation. Portions of fat are often
obtainable at operations--from the omentum, for example, otherwise the
subcutaneous fat of the buttock is the most accessible; it may be
employed to fill up cavities of all kinds in order to obtain more rapid
and sounder healing and also to remedy deformity, as in filling up a
depression in the cheek or forehead. It is ultimately converted into
ordinary connective tissue _pari passu_ with the absorption of the fat.
The _fascia lata of the thigh_ is widely and successfully used as a
graft to fill defects in the dura mater, and interposed between the
bones of a joint--if the articular cartilage has been destroyed--to
prevent the occurrence of ankylosis.
The _peritoneum_ of hydrocele and hernial sacs and of the omentum
readily lends itself to transplantation.
_Cartilage and bone_, next to skin, are the tissues most frequently
employed for grafting purposes; their sphere of action is so extensive
and includes so much of technical detail in their employment, that they
will be considered later with the surgery of the bones and joints and
with the methods of re-forming the nose.
_Tendons and blood vessels_ readily lend themselves to transplantation
and will also be referred to later.
_Muscle and nerve_, on the other hand, do not retain their vitality when
severed from their surroundings and do not functionate as grafts except
for their connective-tissue elements, which it goes without saying are
more readily obtainable from other sources.
Portions of the _ovary_ and of the _thyreoid_ have been successfully
transplanted into the subcutaneous cellular tissue of the abdominal wall
by Tuffier and others. In these new surroundings, the ovary or thyreoid
is vascularised and has been shown to functionate, but there is not
sufficient regeneration of the essential tissue elements to "carry on";
the secreting tissue is gradually replaced by connective tissue and the
special function comes to an end. Even such temporary function may,
however, tide a patient over a difficult period.