Subcutaneous tissue

“ The wound track is occluded by an effusion of lymph, commencing organisation of which is shown under a higher magnifying power by the presence of leucocytes near the margin of the bounding tissue, and some giant cells. The effusion of lymph occupies a slightly wider area immediately beneath the papillary layer of the skin, then narrows, and broadens again as the subcutaneous fascia is reached, indicating the effect of resistance in widening the area of damage. ”

“ If the inflammatory process, instead of being localized as a furuncle, extends to the subcutaneous tissues, and especially if it is accompanied by much pain, pyrexia, and occlusion of the external meatus, linear scarification may become necessary. ”

“ As the action proceeds, the pain and heat often subside—the parts become flaccid—dark-coloured serum is effused beneath the cuticle, forming what are termed Phlyctenæ—the skin becomes dull and livid—dark streaks extend along the limb, perhaps from the colouring matter of the blood transuding, as in commencing putrefaction in the dead body—air is effused into the subcutaneous cellular tissue, causing a sense of crepitation when pressed by the finger—sloughs form, either black or of an ash colour—and the gangrene involves a greater or less extent of the limb. ”

“ The mass after having been molded in the shape desired may be further hardened and set by the application of ice cloths or spraying with ether before the needle is withdrawn from the skin, yet this is hardly necessary, and the author advises against the practice for the reason that pressure of the needle prevents proper and free molding of the mass and renders the tissue liable to further injury by scraping its point to and fro subcutaneously, adding to the extent of the wound and the dangers of infection and repair. ”

“ The soft cellular tumours are composed mainly of spindle or round cells; they grow from the marrow of the spongy ends or from the periosteum of the long bones, the diploë of the skull, the pelvis, vertebræ, and jaws. As they grow they may cause little alteration in the contour of the bone, but they eat away its framework and replace it, so that the continuity of the bone is maintained only by tumour tissue, and pathological fracture is a frequent result. ”

“ 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. ”

“ The surface of the skin only may be affected—that and the subjacent cellular tissue may be involved, gorged with serous, lymphatic, or purulent infiltration—there may exist great tension of the parts, with a sloughy state of the cellular tissue, established in addition to suppuration—and again, there may be infiltration of the subfascial and intermuscular tissues, leading ultimately to exposure and exfoliation of bones or disease of articulations. ”

“ A fresh cut is made into the organ or tissue, and the excess of blood absorbed by a pad of absorbent paper devoid of lint. A clean scalpel held at an angle of 45° is then drawn with some force back and forth over the cut-surface until its blade collects a sufficient amount of “tissue-juice” made up of the cells of the tissue. This is then put upon a slide, and covered with salt-solution or any desired reagent, and is then examined. This method is used especially for cellular infiltrations, soft tumors, and parenchymatous organs (spleen, lymphnodes, bone-marrow, liver, etc.) ”

“ 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 ”

“ One or two sutures may also be taken across the angles of union of the alæ and the flap A. The inferior raw surface of each wing may be found to be too wide, owing to the presence of the thickened cartilage at this point of the wing. The skin and the mucous membrane are then carefully peeled away from the cartilage, and the latter cut away as high as possible, or a gutterlike incision is made along its edges as shown in C (Fig. 485) , excising the elongated elliptical piece of tissue which includes the cartilage. ”

“ The integuments over the inflamed bone are swollen, and the tumour is œdematous; whilst a hard and solid tumefaction exists in the more deeply-seated parts, caused partly by enlargement of the osseous tissue and partly by effusion of lymph into the cellular substance. The bone is imbedded in a gelatinous or lymphatic effusion, situated mostly beneath the periosteum. This membrane is more vascular than in its natural condition, thickened, and at the same time opened out in texture. The bloodvessels of the affected bone are much increased, both in activity and in size ”

“ The cuticle, epidermis, or scarf-skin, as it is indifferently termed, is formed of cells or scales, much flattened and horny in the upper layers, rounder and plumper below. The true skin, or “cutis,” is fibrous in structure, and lies immediately beneath, the two together constituting the skin, properly so called. Beneath lies a layer of tissue filled with fatty globules, and containing the glands by which the perspiration is secreted. ”

“ The skin covering the tumour seldom undergoes any change, unless it is very large, when it is apt to become attenuated at some points and thickened at others. The subcutaneous veins may also then present a tortuous and distended 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 ”

“ For the initial puncture in sensitive or inflamed tissue, it is proper to use a needle of the finest lumen so as to cause the least possible amount of pain. The ordinary needle, which comes with the usual hypodermic outfit, is about the proper length for the ordinary work already mentioned, but could be improved upon for anesthesia by being made a little finer in calibre. This length (three-quarters of an inch) will be frequently found insufficient to reach the deeper tissues and in the [Pg 239] removal of a more or less rounded growth, a longer needle must be selected at the start. ”

“ They advance steadily on all sides, filling the gaping wound until the level of the original surface is reached, the new tissue organizing behind them, and contracting as it organizes, so that the space to be filled is daily made smaller by this contraction as well as by the production of new tissue. As the surface is reached, the epithelial cells on the edges of the granulating area slowly spread over it, the granulations generally projecting above the adjoining surface and the epithelium growing over them as they contract again to their proper level. ”

“ When a bone, such as the scapula or mandible, is involved, it is better to excise the bone, or at least the part of it which bears the tumour. In the case of central tumours the shell of bone is removed over an area sufficient to allow of the enucleation of the tumour, or the affected portion of bone is resected. Should there be evidence of malignancy, such as increased rate of growth, a tube of radium should be inserted, and in advanced cases with destruction of tissue, amputation may be called for. ”

“ To assure the operator of a thorough dissection he may inject the site with sterile water through the opening made with the knife, squeezing it out before injecting the nose.
If the skin has had to be freed by surgical means the mass injected should be sufficient to overcome the defect almost entirely, to prevent the reformation of the bands of connective tissue which have been severed. ”

“ His method is now almost entirely used for covering large defects. The grafts can be applied over connective tissue, periosteum, bone, and even adipose tissue. The grafts consist of very thin strips of skin taken from the extensor surface of the arm or the anterior region of the thigh, after thorough antiseptic preparation. They should be taken from the patient in preference to those of other individuals or the new-dead or freshly amputated parts. ”

“ When, during life, one tissue is separated from another, as the periosteum from the bone, or the cuticle from the skin, or the mutual cohesion between different tissues is sensibly weakened, we find it to be owing to the intervention of serous fluid which does not belong to their healthy state; and this, together with increased vascularity, or redness and heat, and pain, is enough to bespeak the presence of inflammation. ”

“ Such a simple mode of division does not occur in the more highly specialized cells of various tissues. If the karyokinetic action be not very vigorous, the nucleus may divide, but the cell body remains intact, producing the cell with two or more nuclei so commonly observed. Every cell reproduces its kind, spindle cells producing connective tissue; epithelial cells epithelium; and bone cells producing bone.
Repair of Wounds and Healing by Apposition. When a wound occurs, the cut edges immediately retract on account of the elasticity of the tissues, and the gap fills with blood and serum. ”

“ Some grow rapidly, and prove troublesome in a few weeks or months; others remain without much increase for years, and produce little or no inconvenience. Occasionally tumours partly resemble the texture in which they grow; those of a fatty nature are frequently found to have their nidus in the adipose tissue; cartilaginous tumours project from the surfaces of bones or of a joint, are subsequently detached, and lie loose in its cavity; growths of a cellular structure internally, and invested by an apparently mucous lining, protrude from the surface of mucous membranes. ”

“ The body being placed on its back, and the operator standing on the right side, an incision is made through the skin, fascia, and muscles from the top of the sternum to the pubic bone, passing to the left of the umbilicus and dividing everything down to the sternum and the subperitoneal tissue. A small incision is now made through the peritoneum below the ensiform cartilage. Into this opening two fingers of the left hand are inserted, and by spreading the fingers and holding the knife horizontally the peritoneum can be divided to the pubes without injuring the intestines. ”

“ Substances like paraffin, strands of silk used to bridge a gap in a tendon, or portions of calcined bone, instead of being encapsulated, are gradually permeated and eventually replaced by new connective tissue.
Embedded bodies may remain in the tissues for an indefinite period without giving rise to inconvenience. At any time, however, they may cause trouble, either as a result of infective complications, or by inducing the formation of a mass of inflammatory tissue around them, which may simulate a gumma, a tuberculous focus, or a sarcoma. ”

“ Should a hyperplasia of connective tissue result from such an operation, a small linear incision, under four per cent eucain anesthesia, should be made directly over the greatest prominence, through which the offending mass can be removed by the aid of a small hooked knife or a fine pair of curved scissors.
The mass should be removed beyond the plane of the skin ”

“ After the hemorrhage has been controlled a piece of skin about one third larger than the defect is taken from the arm or temporal region of the patient. Next its reverse side is freed of all adipose tissue. It is then laid upon the freshly made open wound, covering it completely, and held in place by numerous fine silk sutures fixing it along the wound margin, as shown in Fig. ”

“ For very small losses of tissue about the lobule nonpedunculated skin grafts are to be employed. The author advises including some of the areolar tissue with them to avoid contraction.
These are to be dressed with the blood method referred to under skin grafting. Perforated rubber tissue is to be used next to the epidermal surface to prevent the dressings from tearing away the graft when changed.
Fine twisted silk is most suitable for suturing purposes. The loops must not be drawn too tightly and the knot be made so that it rests upon the healthy skin of the nose. ”

“ With the use of semisolid and cold paraffin mixtures, as heretofore advocated, redness rarely if ever follows the injection unless undue pressure has been made, in which case necrosis is more liable to follow unless the adjacent tissue will gradually allow the mass to become relieved by a change in form and position. ”

“ In such cases great care should be exercised in the amount injected, and if, after introducing the needle, the tissue be found to be unduly adherent and inelastic, to withdraw the needle and with a fine tenotome divide or dissect up the skin before the mass is injected. At no time would an operator be justified to inject more than ten drops of the mass, at a single operation, into the parts referred to. ”