Manual of Surgery - Alexis Thomson (read me a book txt) 📗

href="@public@vhost@g@gutenberg@html@files@17921@17921-h@17921-h-19.htm.html#Pg_429" class="pginternal" tag="{http://www.w3.org/1999/xhtml}a">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 Stump 454 124. 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 Tuberculous Dactylitis in Childhood 461 130. 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 resulting from Ostitis Deformans 475 136. 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 Membrane from Shoulder-joint 542 169. 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