Tissue repair

“ Treatment for Broken Bones. When a bone is broken a surgeon is needed to set it, that is, to bring the broken parts into their natural position, and retain them by proper appliances. Nature throws out between and around the broken ends of bones a supply of repair material known as plastic lymph, which is changed to fibrous tissue, then to cartilage, and finally to bone. ”

“ 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desired may be further hardened and set by the application of ice cloths or spraying with ether before the needle is withdrawn from the skin, yet this is hardly necessary, and the author advises against the practice for the reason that pressure of the needle prevents proper and free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. ”

“ In the process of healing and repair of a wounded part of the body, a fluid, perfectly structureless substance, is secreted, or poured forth, from the parts about the wound. In this substance, cells arise and become abundant; so that the substance, at first structureless, becomes what is called cellular tissue. Then, by degrees, this structure transforms itself into vessels, tendons, nerves, bone, and membrane—into some or all of such parts—according to the circumstances of the case. ”

“ If the factors that bring about the multiplication of cells and the growth of tissues were discovered, Dr. Carrel said to himself, it would perhaps become possible to hasten artificially the process of repair of the body. Aseptic wounds could probably be made to cicatrise more rapidly. If the rate of reparation of tissue were hastened only ten times, a skin wound would heal in less than twenty-four hours and a fracture of the leg in four or five days. ”

“ If the natural protective effort is successful, the resulting tissue changes subserve the process of repair, but if the bacteria gain the upper hand in the struggle, the inflammatory reaction becomes more intense, certain of the tissue elements succumb, and the process for the time being is a destructive one. During the stage of bacterial inflammation, reparative processes are in abeyance, and it is only after the inflammation has been allayed, either by natural means or by the aid of the surgeon, that repair takes place. ”

“ Plastic surgery is resorted to in covering defects of the skin due to congenital or traumatic malformation, injuries, burns, the removal of neoplasms, or the ulcerative processes of disease. Furthermore, it can be employed cosmetically for the rebuilding of organs, whole or in part, or for their reduction when abnormally developed. This applies particularly to the nose, ears, and lips, wherein it may involve either the skin alone or the mucous membranes, or all the tissue making up the parts operated on. ”

“ 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. ”

“ Accordingly, many abscess cavities resulting from deep-seated suppuration are of irregular shape, with pouches and loculi in various directions--an arrangement which interferes with their successful treatment by incision and drainage.
The relief of tension which follows the bursting of an abscess, the removal of irritation by the escape of pus, and the casting off of bacteria and toxins, allow the tissues once more to assert themselves, and a process of repair sets in. The walls of the abscess fall in; granulation tissue grows into the space and gradually fills it ”

“ If the incised wound is deep or extensive, a physician is necessary to bring the cut edges together by stitches in order to get primary union. Oftentimes, in severe cuts, and generally in lacerations, there is a loss of tissue, so that the wound heals by “second intention”; that is, the wound heals from the bottom by a deposit of new cells called granulations, which gradually fill it up. The skin begins to grow from the edges to the center, covering the new tissue and leaving a cicatrix or scar with which every one is familiar. ”

“ 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. ”

“ He has invented processes for the preservation of bodies, both in the leathery or tanned state, and in the natural condition of the tissues. In the latter case, the tissues preserve their natural softness and even their transparency. Among the specimens exhibited, was a foot which had been prepared in 1864. On making an incision into this, the underlying tissues appeared to be as fresh as in a cadaver one day old. The tendons, ligaments, and fatty tissue, preserved all their usual characters, the muscles alone being in a slightly inferior state of preservation. ”

“ 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. ”

“ A method that has proved of great value in America is that of skin-grafting in blood. In this method the grafted site is covered with perforated protective silk or rubber tissue, covered with a thin layer of absorbent cotton, or, better, several folds of sterilized gauze, which is kept wet constantly with bovinine. The latter undoubtedly is the means of keeping life in the grafts by supplying the necessary nutrition until the grafts have formed [91] vascular connection, have become firmly adherent, and begin to spread or grow out at their edges. ”

“ A mechanical, a thermal, or a chemical irritant, acting alone, induces a degree of reaction directly proportionate to its physical properties, and so long as it does not completely destroy the vitality of the part involved, the changes in the tissues are chiefly directed towards repairing the damage done to the part, and the inflammatory reaction is not only compatible with the occurrence of ideal repair, but may be looked upon as an integral step in the reparative process. ”

“ 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. ”

“ Apart from internal and proper external electrical and other treatment the simplest surgical method to be employed is to remove an elliptical piece of skin from the eyelid and to suture the margins of the wound together. Care should be taken not to take out too much tissue, as this would involve inability to close the lid. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ When a localised portion of tissue, for example, a piece of skin, is so severely crushed or bruised that its blood vessels are occluded and its structure destroyed, it dies, and, if not infected with bacteria, dries up, and the shrivelled brown skin is slowly separated by the growth of granulation tissue beneath and around it. ”

“ This gap will necessarily be very small when the reflection of the mucous membrane has been complete. Where approximation of the two edges occurs union is rapid and healing by “first intention” results. Where some loss of substance occurs the gap becomes gradually filled by what is called granulation tissue, and the term “second intention” is given to the healing process.
Healing by first intention.
In amputating the foreskin a number of minute hair-like blood vessels which permeate the skin are [40] cut through. ”

“ Healing by second intention, or granulation, is usually seen where there has been loss of tissue, or extensive damage. The reactions of the tissues vary in degrees according to the nature and severity of the injury. In resenting such insults, a remarkable uniformity and regularity in the processes is brought about by the different cells and fluids of the healthy tissues of the body. ”

“ It may become necessary to repress the granulations, or else to soothe the wound and abate inflammatory action in the surrounding parts. Perhaps incisions may be required, to prevent the formation of matter, and destruction of the cellular tissue, and of the tendinous expansion, or to evacuate fluid already secreted. The patient’s strength may require support. He may stand in need of stimulants ”

“ 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 ”

“ 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. ”

“ All wounds are repaired by them, all fractures are united, and all diseased tissues brought back to their normal and healthy condition, unless there is not vitality enough to overcome disease, or they have been injured or killed by poisonous material. The body is kept in repair by this living matter, and all the functions of the body are but the result of its action. We may examine, watch and study bioplasm under the microscope; we see it take up pabulum and convert that which is adapted to itself into its own substance, while all other substances are rejected. ”

“ The general character of tertiary manifestations may be stated as follows: They attack by preference the tissues derived from the mesoblastic layer of the embryo—the cellular tissue, bones, muscles, and viscera. They are often localised to one particular tissue or organ, such, for example, as the subcutaneous cellular tissue, the bones, or the liver, and they are rarely symmetrical. They are usually aggressive and persistent, with little tendency to natural cure, and they may be dangerous to life, because of the destructive changes produced in such organs as the brain or the larynx. ”

“ 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. ”

“ From a knowledge of the astonishing powers of nature in repairing injuries, many and important improvements have of late years been made in the practice of surgery. In the majority of instances it is also requisite that the parts be brought in contact soon after division, otherwise granulation will have commenced in the different parts of the wound, and the surfaces then approximated will not so readily adhere: pus is formed, and, having lodged between the surfaces, acts as an extraneous substance, keeping them apart, and separating them still farther by its accumulation. ”