.llllllillllllllll HX00019194 RD3I Columtiia Wini\}tv^itv in tf)£ Citj) of i^eh3 |9orfe College of $i)p£(tciansi anb ^urgeonsf Hibtaxp £St:;?g«B^f CoE^R{^Bf.K#. Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/principlesofsurg1901senn PRINCIPLES OF SURGERY N. SENN, M.D., Ph.D., LL.D. Professor of Surgery in Rush Medical College in Affiliation with the University of Chicago ; Professoriai. Lecturer on Military Surgery in the University of Chicago ; Attending Surgeon to the Presbyterian Hospital ; Surgeon-in-Chief to St. Joseph's Hospital ; Surgeon-General of Illinois ; Late Lieutenant-Colonel of United States Volunteers and Chief of the Operating- staff WITH the Army in the Field during the Spanish-American "War. THIRD EDITION. THOROUGHLY REVISED (UltD 230 (Uooa-engravinds, l^alf-tones, and Clolored Illustrations PHILADELPHIA AND CHICAGO F. A. DAVIS COMPANY, PUBLISHERS 1901 COPYRIGHT, 1890, BY F. A. DAVIS. COPYRIGHT, 1895, BY THE F. A. DAVIS COMPANY. COPYRIGHT, 1901, BY F. A. DAVIS COMPANY. [Registered at Stationers' Hall, London, Eng.] Philadelphia, Pa., U. S. A.: The Medical Bulletin Printing-house, 1916 Cherry Street. PEEFACE TO FIEST EDITION. A MODERN work on the principles of surgery in the English lan- guage has become a generally and well-recognized necessity. The recent great discoveries relating to the etiology and pathology of surgical dis- eases have made the text-books of only a few years ago old and almost worthless. The many treatises on surgery, by American and English authors, which have made their appearance in rapid succession during the last ten years or more, are replete with valuable practical informa- tion, but most of them are defective in those parts relating to the matter treating of the fundamental principles of the art and science of surgery. It has been my aim to write a book for the student and general practitioner which should, at least in part, fill this gap in surgical litera- ture, and which should serve the purpose of a systematic treatise on the causation, pathology, diagnosis, prognosis, and treatment of the injuries and affections which the surgeon is most frequently called upon to treat. The successful study and practice of any branch of the healing art re- quire a thorough knowledge of the principles upon which it is based. The student who has mastered the principles of surgery will have no difficulty in applying his knowledge in practice, while the one who has burdened his memory with numerous details to meet special indications is always at a loss in making prompt and judicious use of his thera- peutic resources when confronted by rare lesions or unexpected emer- gencies. In writing this book it has been my intention to keep in constant view the difference between the cellular processes, as we observe them in regeneration and inflammation, and to connect the modern science of bacteriology more intimately with the etiology and pathology of sur- gical affections than has heretofore been done by most authors who have written on the same subjects. In showing the direct etiological rela- tionship which exists between certain pathogenic microorganisms and definite pathological processes, I have frequently made liberal use of the experimental and clinical material contained in my work on "Sur- gical Bacteriology." When the subject of tumors was reached it was found that the manuscript had become so voluminous that it was deemed advisable to publish the volume without this part of the intended scope of the work, — an arrangement to which the publisher kindly gave his consent. It is the author's intention to make good this defect by the (iii) . IV PKEFACE. preperation, in the near future^, of a special work on "The Pathology and Surgical Treatment of Tumors/^ With few exceptions the sources from which my information was taken are not given, as a copious bibliography would have required considerable valuable space. At the same time the author hopes that he has presented the views and opinions of the authorities quoted with sufficient clearness and thoroughness to render a resort to the original articles, in most instances, unnecessary. Among the text-books which I have consulted I desire to mention the following: Histology: Klein, Schafer, Heitzmann, and Satterthwaite. Pathology: Klebs, Hamilton, Birch-Hirschfeld, Paget, Virchow, Coates, Lebert, Rindfleisch, Delafield, and Prudden. The Principles of Surgery: Konig, Hueter-Lossen, Lan- derer, Billroth- Winiwarter, and Van Buren. Bacteriology: Flligge, Baumgarten, and Cruikshank. The illustrations were selected from modern text-books not readily accessible to the average student. A prolonged absence from home made it impossible for the author to attend the proof-reading, and he asks the indulgence of the reader for any imperfections which may appear in the book from any sources for which he cannot be held personally responsible. Should this volume become the means of lightening and facilitating the student's work in acquiring a thorough knowledge of the funda- mental principles of surgery, and of serving as a useful source of in- formation for the busy general practitioner, the author will feel abun- dantly rewarded for the many sleepless nights which were required in its preparation. IST. Senn. Milwaukee, October, 1890. PKEFACE TO THIKD EDITION. The text of this edition has heen thoroughly revised and many additions made, among them two new chapters, one on "Degeneration" and the other on "Blastomycetic Dermatitis": snhjects which should he included in a text-hook on the "Principles of Surgery." Many new illustrations have heen added, most of them original. The author be- speaks for this the same favorable consideration as has been so freely showered upon the first two editions. N. Senn. Chicago, 1901. (^) TABLE OF CONTENTS. PAGE Preface to First Edition iii Preface to Third Edition v Table op Contents : vii List of Illustrations -si CHAPTEE I. Eegeneration 1 CHAPTER 11. Eegeneration of Different Tissues 31 CHAPTER III. Degeneration 81 CHAPTEE IV. Inflammation 91 CHAPTEE V. Inflammation (continued) 120 CHAPTEE VI. Pathogenic Bacteria 157 CHAPTEE VII. Necrosis 187 CHAPTEE VIII. Necrosis (continued) 205 CHAPTEE IX. Suppuration 220 (vii) VIU TABLE OF CONTENTS. CHAPTEE X. SUPPUEATION" (continued) 244 CHAPTER XL Ulceeation and Fistula 369 CHAPTER XII. SuppuKATivE Osteomyelitis 274 CHAPTER XIII. SuppuEATioN IN Laege Cavities; Abscess of Inteenal Organs. . 309 CHAPTER XIV. Septicemia 354 CHAPTER XV. Pyemia 383 CHAPTER XVI. Eeysipelas 411 CHAPTER XVII. Tetanus 436 CHAPTER XVIII. Hydeophobia 459 CHAPTER XIX. Suegical Tubeeculosis 475 CHAPTER XX. Clinical Foems of Suegical Tubeeculosis 506 CHAPTER XXI. Tubeeculosis of Lymphatic Glands and Peeitoneum 529 CHAPTER XXII. Tubeeculosis of Bones and Joints 550 CHAPTER XXIII. Tubeeculosis of Tendon-sheaths, etc 591 TABLE OF CONTENTS. IX CHAPTEE XXIV. p^^^ Actinomycosis Hominis G19 CHAPTEE XXV. Blastomtcetic Dermatitis 645 CHAPTEE XXVI. Anthrax 659 CHAPTEE XXVII. Glanders 679 Index (!93 LIST OF ILLUSTKATIONS. FIG. PAGE 1. A wound twenty-six hours old. (Thiersch) 4 2. A wound twenty-six hours old. (Thiersch) 5 3. Quiescent nucleus. (Flemming) 8 4. Living cell of salamander. (Flemming) i 8 5. Endothelial cells. (Flemming) 9 6. Epithelial cell of salamander. (Flemming) 10 7. Epithelial cell of salamander. (Flemming) 10 8. Epithelial cell of salamander. (Flemming) 11 9. Cell-division. (McKendrick) 13 10. Granulating wound. (Billroth-Winiwarter) 14 11. Granulation-tissue from wound. (Hamilton) 15 12. Superficial capillaries of a wound beginning to granulate. (Hamilton) 17 13. Formation of new blood-vessels by budding. (Arnold) 18 14. Development of blood-corpuscles in connective-tissue cells, and transformation of the latter into capillary blood-vessels. (Fliigge) 19 15. Granulating wound undergoing cicatrization. (Landerer) 20 16. Embryonal connective-tissue cell undergoing transformation into mature state. (Ziegler) ' 21 17. Wandering epithelial cells from frog. (Klebs) 22 18. Corneal corpuscles in a state of proliferation. (Senftleben) 33 19. Wounds of cornea. (Von Wyss) 34 20. Healing of experimental fracture of the tibia of a rabbit. (Colored) 35 21. Rhinoplasty and transplantation of large skin-grafts. (Thiersch) 40 22. Microscopical appearances of the interior of artery of dog 43 23. Microscopical appearances of the interior of vein of dog 44 24. Femoral artery of dog fifty days after double ligation with silk. (Natural size) 45 25. Collateral circulation eight months after ligation of the aorta in a dog. (Luigi Porta) ... 46 26. Muscular fibres near a wound in a state of proliferation. (O. Weber) 49 27. Muscle-suture 50 28. Tenorrhaphy. (Esmarch) , 51 29. Tendoplasty. (Esmarch) 51 30. Secondary suturing of extensor tendons of fingers by the suture d distance 52 31. Tendon elongations 53 32. Section through callus. (Bajardi) 55 33. Transverse section through callus. (Maas) 56 34. Osteoclasts absorbing bone 58 35. Old method of bone-suture 60 36. Improved bone-suture 60 37. Wire drawn through the perforation 60 38. Wire cut in the centre and each half twisted separately 60 39. Senn's hollow intraosseous splint 61 40. Circular bone ferrule for humerus or femur made of an ox-femur 61 41. Triangular bone ferrule for tibia made of an ox-tibia 61 42. Wide perforated bone ferrule ■ 61 43. Oblique fracture of femur united by bone ferrule 62 44. Transverse fracture of humerus immobilized by a wide perforated bone ferrule 62 45. Senn's splint apparatus applied 63 46. Senn's splint apparatus for treating fracture of the neck of femur 64 47. Wound of kidney. (Tillmanns) 66 48. Healing of wound of liver. (Tillmanns) 67 49. Tubular suture of Van Lair with decalcified-bone tube 71 50. Nerve-fibre in a state of regeneration. (Gluck) 72 51. Longitudinal section through nerve. (Gluck) 73 52. Nerve-suture, showing application of direct and paraneural sutures 75 53. Neuroplasty. (Letievant) 78 54. Cross-sutures. (Tillmanns) 78 55. Ischasmic paralysis of muscles of leg 82 (Xi) Xll LIST OP ILLUSTRATIONS. FIG. PAGE 56. Patty degeneration of the heart-muscle 84 57. Amyloid degeneration of the kidney. (Colored) 89 58. Capillary vessels of the frog's mesentery. (Klein) 93 59. Leucocyte, showing reticulum of protoplasmic strings. (Klein) 94 60. Change of forms of a moving leucocyte by amoeboid movements. (Klein) 95 61. Amoeboid movements of red blood-corpuscles. (Leonard) 97 62. Third corpuscle. (Eberth and Schimmelbusch) 98 63. Normal circulation in frog's web. (Landerer) 104 64. Capillaries of frog's web in a state of hyperemia soon after application of irritant. (Landerer) 105 65. Plasma-cells in acute interstitial nephritis. (Low power. Colored) 106 66. Three plasma-cells in acute interstitial nephritis. (High power. Colored) 108 67. Leucocyte passing through capillary wall. (Landerer) 113 68. Inflammation of frog's web at stage where capillary stream is imbedded by commencing emigration. (Landerer) 115 69. Germinating endothelium. (Hamilton) 124 70. Omentum of young dog, experimentally inflamed. (Hamilton) 125 71. Acute pleurisy. (Hamilton) 126 72. Artificial keratitis. (Hamilton) 133 73. Phagocytosis. Struggle between anthrax bacillus and leucocyte 136 74. Hueter's inf usor 147 75. Cold coil. (Esmarch) 151 76. Cold coil for the head. (Letter) .' 152 77. Different forms of bacteria. (Baumgarten) 158 78. Zoogtea 159 79. Endogenous spore-production in bacillus anthracis cultivated upon meat-infusion pep- tone-gelatin. (Baumgarten) 160 80. Spore of bacillus of anthrax. (De Bary) 161 81. Gelatin cultures following surface inoculation. (Fliigge) 163 82. Cultures in gelatin growing in the track made by the needle. (Fliigge) 164 83. Experimentally-produced growth of streptococci in centre of cornea of rabbit. (Baum- garten) 191 84. Dry gangrene of foot. (Lebert. Colored) 209 85. Vertical section through a subcutaneous abscess. (Baumgarten. Colored) 225 86. Microscopical pictures of staphylococcus. (Rosenbach) 231 87. Common forms of pus-microbes. (Colored) 233 88. Micrococcus pyogenes tenuis. (Rosenbach) 234 89. Microscopical picture of streptococcus pyogenes. (Rosenbach) 234 90. Bacillus pyogenes foetidus. (Fliigge) 235 91. Bacillus pyocyaneus. (Fliigge) 235 92. Bacillus pyocyaneus 236 93. Gonococcus. (Bumm) 236 94. Gonorrhoea! pus 237 95. Gonorrhoeal conjunctivitis. (Bumm. Colored) 238 96. Bacillus coli communis 238 97. White corpuscles and pus-corpuscles. (Koch) 239 98. Fragmentation of nucleus in leucocytes undergoing transformation into pus-corpuscles. (Landerer) 241 99. Pus with staphylococcus. (Fliigge) 242 100. Pus with streptococcus. (Fliigge) 242 101. Pus-corpuscles. (Billroth-Winiwarter) 242 102. Infiltration of connective tissue of cutis, with beginning suppuration in the centre. (Billroth-Winiwarter) 249 103. Vessels (artificially injected) from walls of an abscess artificially produced in the tongue of a dog. (Billroth-Winiwarter) 250 104. Irrigating apparatus 258 105. Osteomyelitis of the tibia 282 106. Osteomyelitis of the tibia 284 107. Osteomyelitis of the radius. (Sciagraph) 286 108. Necrosis of humerus. (Lebert) 288 109. Sequestra following acute diffuse suppurative osteomyelitis 289 110. Hollow, padded, posterior splint. (Esmarch) 290 LIST OF ILLUSTRATIONS. Xlll FIG. PAGE 111. Board splint for upper extremity. (Bsmarch) 290 112. Wire splint. (Esmarch) 291 113. Interrupted plaster-of-Paris splint 292 114. Incision for necrotomy of the tibia 299 115. Bone-cavity after removal of sequestrum and granulations in necrosis of the tibia. (Esmarch) 301 116. Inversion of soft tissues on each side into the bone-cavity. (Neuber) 302 117. Healing of bone-cavity. (Neuber) 302 118. Osteoplastic necrotomy. (Bier) 304 119. Shulten's method of necrotomy 305 120. Central syphilitic osteomyelitis of the femur. (Sciagraph) 306 121. Cortical syphilitic osteomyelitis of the femur. (Billings. Sciagraph) 306 122. Gumma 307 123. Bacillus typhosus. (Colored) 310 124. Micrococcus gonorrhoeae. (Colored) 311 125. Gonococcus. (Bumm) 312 126. Motor areas 326 127. Wilson's cyrtometer 328 128. Wilson's cyrtometer applied 328 129. Head, skull, and cerebral fissures. (Adapted from Marshall) 329 130. Vein of the diaphragm of a septicaemic mouse. (Koch) 356 131. Bacillus of mouse-septicaemia. (Fliigge) 357 132. Glomerulus of a septicsemic rabbit. (Koch) 358 133. Capillary vessels surrounding the intestinal glands of a septicffimic rabbit. (Koch) 359 134. Bacillus of malignant cedema. (Koch) 360 135. Spore-formation in bacillus of malignant oedema. (Fliigge) 360 136. Cultures of bacillus of malignant oedema in gelatin. (Fliigge) 361 137. Bacillus saprogenes 1. (Rosenbach) 366 138. Bacillus saprogenes 2. (Rosenbach) 366 139. Bacillus saprogenes 3. (Rosenbach) 366 140. Proteus vulgaris. (Hauser) 367 141. Proteus mirabilis. (Hauser) 368 142. Involution forms of proteus mirabilis. (Hauser) 369 143. Vessel from the cortex of the kidney of a pyemic rabbit. (Koch) 386 144. Suppurating thrombus in vein. (Tillmanns) 389 145. White thrombus. (Landerer) 392 146. Red thrombus. (Landerer) 393 H7. Laminated thrombus in a vein. (Birch-Hirschf eld) 394 148. Thrombophlebitis. (Billroth) 395 149. Embolus of branch of pulmonary artery. (Birch-Hirschfeld) 397 150. Pyaemic abscess of lung. (Hamilton) 398 151. Coagulation-necrosis from a kidney infarct. (Birch-Hirschfeld) 399 152. Pyaemic pus. (Landerer) 403 153. Section of ear of rabbit parallel to surface of cartilage. The morbid process resembled erysipelas. (Koch) 412 154. Streptococcus erysipelatosus. (Baumgarten) 413 155. Stab culture of streptococcus of erysipelas in gelatin. (Baumgarten) 414 156. Section through skin near the margin of the erysipelatous zone. (Koch) 418 157. Section of skin in erysipelas. (Cornil and Babes) 418 158. Tetanus bacilli. (Frankel-Pfeiffer) 437 159. Culture of bacillus tetani in nutrient gelatin. (Kitasato) 438 160. A blood-vessel from medulla oblongata in a case of hydrophobia. (Coates) 467 161. From the salivary gland in a case of hydrophobia. (Coates) 468 162. Tubercle bacilli containing spores. (Koch. Colored) 478 163. Tubercle bacilli from a tubercle cavity. (Colored) 478 164. Giant cell with one tubercle bacillus (Fliigge) 480 165. Giant cell. Miliary tuberculosis. (Fliigge) 480 166. Glass-slide preparation from the tissue-juice of a fresh inoculation-tubercle. (Baum- garten. Colored) 480 167. From encysted bronchial glands in miliary tuberculosis. (Koch. Colored) 480 168. Tubercle bacilli. (Frankel and Pfeiffer. Colored) 480 169. Vegetations of tubercle bacilli upon sterilized blood-serum. (Baumgarten. Colored) 482 XIV LIST OF ILLUSTEATIONS. FIG. PAGE 170. Inoculation-tuberculosis 487 171. Lupous nodule situated deeply in the corium. (Colored) 495 172. Tubercle-nodule in lymphatic gland 496 173. Giant cell from centre of tubercle of lung. (Hamilton) 497 174. Tuberculosis of trochanteric bursa 498 175. Section from mucous membrane of pharynx, showing epithelioid cells with a few small giant cells. (Birch-Hirschf eld) 499 176. Fully-developed reticular tubercle of lung. (Hamilton) 500 177. Tuberculosis of trochanteric bursa 503 178. Caseated submaxillary gland. (Colored) 504 179. Membrane lining tubercular abscess. (Landerer) 512 180. Senn's injection-syringe 516 181. Tubercular lymphadenitis 530 182. S-shaped incision in the operation for removal of tubercular glands of the neck 540 183. Tubercular peritonitis. Parietal peritoneum. (Colored) 543 184. Tuberculosis of the lower epiphysis of the humerus. (Sciagraph) 550 185. Caries of fourth metacarpal bone. (Sanger Brown. Sciagraph) 554 186. Tubercular focus near the epiphyseal line of the lower end of the femur 555 187. Tuberculosis of astragalus. (Tillmanns) 557 188. Tubercular sequestra. (Landerer) 557 189. Tubercular infarct in the head of the femur. (Volkmann) 558 190. Tubercular debris from caseated nodule. (Colored) 559 191. Central tuberculosis of the neck of the femur. (Volkmann) 568 192. Tuberculosis of lower epiphysis of femur. (Weber) ; 571 193. Tubercular empyema of knee-joint 574 194. Tubercular coxitis of right hip-joint. (Sciagraph) 574 195. Knee-joints. (Albert) 576 196. Dry tuberculosis of the shoulder-joint. (Sciagraph) 576 197. Pathological subluxation of the hip-joint. (Sciagraph) 578 198. Hahn's incision for arthrectomy or resection of knee-joint 583 199. Interrupted plaster-of-Paris splint for resection of knee-joint 585 200. Tubercle bacilli in urine. (Colored) 613 201. Tubercle bacilli in urine. (Cornil and Babes) 614 202. Ray-fungus. (Ponfick) 620 203. Actinomycelial granules. (Hektoen) 621 204. Actinomycosis of liver. (Colored) 622 205. Actinomyces from a section of a maxillary tumor of a cow. (Crookshank. Colored) 623 206. Actinomycelial cluster in giant cell. (Schulze) 627 207. Giant cell with actinomycelioid cluster. (Lubarsch) 627 208. Actinomyces. Section from actinomycotic swelling. (Fliigge) 628 209. Actinomyces from lung of cow. (Marchand) 637 210. Miliary abscess in the epithelium of the hand. (Hektoen) 646 211. Three organisms more highly magnified. (Hektoen) 647 212. An epithelial pearl. (Coates) 648 213. Vacuolated and solid diffusely-stained organisms. (Hektoen) 649 214. Chains of the minute form. (Hektoen) 650 215. Development of pigment-granules. (Hektoen) 651 216. Giant cell showing budding vacuolated organism 654 217. Giant cells containing organisms in different stages of development 654 218. Giant cell showing organisms apparently in sporulation-stage 655 219. Section showing epithelial proliferation. (Herzog) 655 220. Miliary abscess of blastomycetic dermatitis 656 221. Anthrax bacilli. Spore-formation and spore-germination. (Koch) 660 222. Stab culture of anthrax bacilli in gelatin. (Baumgarten) 661 223. Anthrax colony upon gelatin. (Fliigge) 663 224. Intestinal villus of anthracic rabbit. (Koch) 664 225. Bacillus anthracis. (Crookshank. Colored) 665 226. Anthrax. Section from liver. (Fliigge) 672 227. Bacilli of glanders from a young potato culture. (Baumgarten) 680 228. Glanderous nodule from the liver of a field-mouse. (Baumgarten) 683 229. Acute glanders. (Birch-Hirschfeld) 689 230. Section of a glanders nodule. (Fliigge. Colored) 690 CHAPTEE I. Eegeneration. The student should first familiarize himself with the histological proc- esses as observed during the growth, development, and repair of tissues preparatory to a study of inflammation and the various destructive processes attending and following it, as in the complicated process called inflamma- tion attempts at repair are always manifested, and after its subsidence de- struction always gives way to regeneration. Eegeneration includes a multitude of processes which are intended to repair the normal physiological waste of the tissues in the living body or to restore tissues lost by injury or disease. In the human body normal regeneration or repair of tissues is a physiological process, which is essential for the maintenance of the anatomical perfection and functional activity of the different tissues and organs. In a condition of perfect health, in the full-grown body, the normal waste incident to the increasing activity of the tissues is balanced by this reparative process, while during the development of the body an excess of material is added upon which depends the increase of tissue which constitutes growth. If cell-destruction is in excess of cell- reproduction atrophy is the inevitable result, and if the function of regen- eration is completely suspended death must necessarily ensue, the blood being the first tissue the seat of extreme atrophic changes, soon to be fol- lowed by similar changes in all the tissues, resulting in diminution of func- tion proportionate to the degree of atrophy, and, finally, death from maras- mus. Studied from a surgical aspect, regeneration includes the process ob- served in the healing of wounds produced by a trauma and the complete or partial restoration of parts damaged or destroyed by the action of chemical substances, extremes of cold and heat, and the various destructive inflam- matory processes caused by the presence of specific pathogenic microorgan- isms. Eegeneration and inflammation are distinct conditions, which should no longer be confounded or considered from the same etiological and patho- logical stand-point. An ideal regeneration takes place without inflamma- tion provided the seat of injury or tissue-destruction remains aseptic; that is, free from pathogenic microbes. On the other hand, a regenerative proc- ess within or around an inflammatory focus can only be established in tissues in which the cause which has produced the inflammation has not been suf- ficiently intense to destroy the protoplasm of the cells. Under these cir- cumstances the reparative process is initiated at a time when the cause which (1) 2 PEINOIPLES OP SUEGERT. has given rise to the inflammation has ceased to be active, or in tissues not deprived of their vegetative power by its action. In a circumscribed sup- purative inflammation the cells exposed to the direct action of the pus- microbes and their ptomaines are destroyed, and the process of repair starts from the abscess-walls and their immediate vicinity, from tissues which have retained their power of cell-proliferation. Any organ the seat of a tubercular infection, in which the parasitic cause is not sufflciently intense to destroy the vitality of the c^lls, retains its normal structure and function by virtue of this intrinsic power of regeneration of its cells. All reparative processes consist of homologous cell-development, and the new tissue re- sembles, anatomically and physiologically, the fixed cells from which it is produced. The legitimate succession of cells is now a well-established law in pathology as well as embryology, and, according to this tissue, is never produced by substitution of function. According to this histogenetic law, each cell-element possesses an intrinsic vegetative power from the earliest embryonal development throughout life, which, in case of loss of tissue by injury or disease, enables it to produce its own kind and never any other materially different histological structure. In conformity with this general law of tissue-production, an injury or defect of a nerve-flbre is repaired by proliferation from preexisting cells which compose this structure, epithelial cells are produced only by epithelial cells, new vessels are formed from cells which exist in a normal vessel-wall, etc. From this stand-point will be con- sidered: — I. HEALING OF WOUNDS. A wound may be deflned as a sudden solution of continuity of any of the tissues of the body caused by the application of mechanical force. A wound is open or subcutaneous according as the surface covering the skin or mucous membrane has been cut or torn or has remained intact. Since the introduction of the antiseptic treatment of wounds, the classification into open and subcutaneous wounds is no longer of the same practical im- portance, as an open wound, under careful antiseptic treatment, Is at once placed under the same favorable conditions for a satisfactory and rapid heal- ing as a subcutaneous wound. All wounds, irrespective of the anatomical structure of the tissues involved, heal by the production of new material from preexisting fixed tissue-cells. The fixed tissue-cells at the site of in- jury, being endowed from earliest embryonal life with a peculiar power of adaptation to existing conditions surrounding them, assume active tissue- proliferation, and the embryonal cells thus produced constitute the granula- tion-tissue, which, toward the completion of the healing process, is trans- formed into mature cells, representing the tissue or tissues which have un- dergone the reparative process. IMMEDIATE, OE DIEECT, UNION. IMMEDIATE, OE DIEECT, UNION. Since the time of John Hunter a great deal has been said and written on immediate, or direct, union of wounds. Hunter believed that this method of healing would be accomplished within a few hours, and without the in- terposition of new material between the accurately coaptated surfaces. Ma- cartney was a supporter of this view, as will be seen from the following: "The circumstances under which immediate union is effected are the cases of incised wounds that admit of being, with safety and propriety, closely and immediately bound up. The blood, if any be shed on the surface of the wound, is thus pressed out, and the divided blood-vessels and nerves are brought into perfect contact, and union may take place in a few hours; and, as no intermediate substance exists in a wound so healed, no mark or cicatrix is left behind." Paget applies this method of healing to large wounds where rapid union is accomplished, and where, on examination, no interposed tis- sue is found between their edges. Such a case came under his own observa- tion. A patient on whom he had performed an operation for the removal of a carcinomatous breast died from an attack of erysipelas a few days later. Examination showed that firm union had taken place apparently without any intermediate material. He also made three experiments on rabbits for the purpose of studying this rapid method of repair. The hair was removed, the skin incised, and the wound accurately sutured. Three days later he examined the parts, and found the wound quite firmly united, without any macrosccJpical evidences of inflammation. On microscopical examination he found some exudation material in the immediate vicinity of the wound. Among the more modern investigators, we find Thiersch still uphold- ing the possibility of immediate union by direct cohesion of similar parts. He studied the repair of wounds in the tongue of guinea-pigs. The tongue was incised in a longitudinal direction, and the parts were examined a few hours to several days after the injury had been inflicted. Before sections were made for microscopical examination the lingual vessels were injected with liquid glue stained with carmine. In specimens where the wound was only a few hours old he found, at least, parts of the wound firmly adherent^ and on microscopical examination he satisfied himself that the connective tissue, saturated with blood and plasma, had formed an immediate and per- manent union. He described also a plasmatic circulation in the wound which he considered of great importance for the nutrition of the tissues. He believed that these new channels, by becoming paved with the adjacent connective cells, could be transformed into permanent blood-vessels. The same section examined under a higher power furnishes a good illustration of the part taken by the fixed tissue-cell in the repair of the wound. PEINCIPLES OF SURGEEY. Some surgeons still believe in immediate union in the repair of wounds of nerves, as many cases have been reported where complete restoration of function was claimed to have been established within a few hours after nerve- suture. Such observations are not free from criticism, because func- tional results after nerve-suture may lead to wrong conclusions, as restoration of function in distal parts may be owed to the presence of other nerves which reach such parts, and it may be due partly to physical conduction of irritation. The occurrence of immediate union was doubted by O'Halleran, a dis- tinguished contemporary of Bell, as may be learned from the following Fig. 1.— A Wound Twenty-six Hours Old. A, coaptated parts apparently united. Tissues only slightly stained with coloring material of blood; few leucocytes. B, B, spaces between wound-surfaces filled with red and white blood-corpuscles, some of' the former well preserved, others showing various degrees of disintegration; between them oedematous connective-tissue fibres. O, C show that these fibres are continuous with the connective tissue of the wound-surfaces. Surface of wound coaptation imperfect- the epithelial cells dip down into the wound. D, a separated cone of new tissue. B, infil- tration of fatty tissue with blood and leucocytes. Gf, divided muscular fibres' with escaped pieces which have partly undergone colloid degeneration. (Hartnack obi 4 00. 2.) (Thiersch.) ' ' ' quotation: "I would ask the most ignorant tyro in our profession whether he ever saw, or heard even, of a wound, thou.gh no more than one inch long, united in so short a time," adding: "These tales are told with more con- fidence than veracity; healing by inosculation, by the first intention, by IMMEDIATE, OR DIRECT, UNION. O immediate coalescence without suppuration is merely chimerical and opposite to the rules of nature." Gussenbauer repeated the experiments of Thiersch and Wywodzoff on the healing of wounds in the tongue of guinea-pigs, and came to entirely different conclusions. In wounds eight to twelve hours old he found that the margins formed an elliptical space, the separation being widest in the middle. The divided- muscular fibres had retracted, imparting to the wound an uneven surface, which was covered with a layer of reddish, gelatinous material. In recent wounds the space is filled with blood-corpuscles which Fig. 2. — A, embryonal cells showing karyokinetic figures: B, lymph-spaces; C, striped masses infiltrated with red blood-corpuscles in various stages of disintegration; D, blood-vessel; F, fat-tissue. (Hartnack, obj. 8, oc. 4.) (Thiersch.) are often much changed in color, size, and shape. In wounds twenty-four to fortjr-eight hours old the material between the surfaces of the wound presented a reticulated appearance, each one of the spaces corresponding to a blood-vessel. Contrary to Thiersch, he asserts that in this substance no connective tissue can be found; the reticulated structure he attributed to the presence of fibrin, the coagulum infiltrating at the same time the ad- jacent tissues. He believes that the parenchyma-fluid takes part in the formation of the coagulum. He was unable to verify, by his own observa- tions, the existence of the plasma-channels described by Thiersch. When the wound-surfaces were kept accurately approximated he found few blood- b PRINCIPLES OF SUEGERY. corpuscles, but the net-work of fibrin was never absent. In harelip opera- tions and incised wounds of the face and scalp, if uninterrupted apposition is maintained for a day or two, the parts are found so firmly glued together that the belief that immediate union had taken place might still be main- tained from a superficial examination, but a microscopical examination will always reveal the conditions described by Gussenbauer, and the union is therefore only apparent, and not real. The surfaces of the wound have be- come adherent by the interposition of an adhesive material. A certain amount of coagulation-necrosis takes place in every wound, and the mate- rial thus formed serves as a cement-substance which temporarily glues the parts together. This mechanical union, the result of destructive chemical changes in the extravasated blood, is the form of union which has been wrongly interpreted and described as immediate union. This primary ad- hesion occurs most readily in wounds of dense vascular tissue and where approximation and fixation of the edges of the wound are most thoroughly secured, — conditions which favor the subsequent definitive healing of the wound by the interposition of new tissue. UNION BY PRIMARY INTENTION. Organic union, the union aimed at in the treatment of all wounds, is only obtained by tissue-proliferation from the fixed cells of the injured parts, and is completed only after restoration of the continuity of the divided structures, and the return, partial or complete, of the functions suspended by the injury or disease. Eeturn of structure and function to an at least approximately normal standard implies a return of the interrupted circula- tion by the formation of new blood-vessels; in other words, organic union cannot be said to have taken place without an adequate supply of new blood- vessels in the new tissue which form a capillary collateral net-Avork be- tween the divided blood-vessels. Such a union, even under the most favor- able circumstances, cannot be established in less than six to eight days, and its attainment may require weeks and months. The next method of repair described by John Hunter was union by adhesive inflammation. Ab- sence of suppuration and rapid union have always been considered as essential features of this mode of healing, and corresponds to the healing of wounds per primam intentionem, — an expression which, for obvious reasons, has been retained in modern literature to distinguish it from the method of healing per secundem intentionem, where the reparative process is often indefinitely delayed by suppuration. All wounds which heal without suppuration heal by primary union, either without or with visible granulation-tissue. An ideal result is obtained if the separated surfaces unite throughout and the repair in the depth of the wound is accomplished during the same time un- KAKYOKINESIS. V derneath the united skin or mucous membrane. If there has been a con- siderable loss of surface tissue and the superficial portion of the wound can- not be approximated, or, if rapid healing at the surface of the wound fails to take place, the wound heals slowly by the formation of a larger amount of granulation-tissue, and yet, if suppuration does not complicate the process, it must be said that the wound has healed by primary union. This method of healing was exceedingly rare before antiseptic surgery was practiced, but since that time it is of frequent occurrence. All wounds which heal without suppuration heal without inflammation. All inflamed wounds suppurate; the reparative process is delayed until the inflammation has subsided. The proper modern classification of wounds in reference to the method of repair consists in a distinction between (1) aseptic wounds and (2) infected wounds. Aseptic wounds — that is, wounds not contaminated with paihog&nic microor- ganisms — heal without inflammation. An aseptic wound, as a rule, is pain- less, and does not present any of the other witnesses of inflammation. The slight swelling and, perhaps, redness are the result of mechanical disturb- ances of the circulation, and subside with the formation of an adequate col- lateral circulation; hence, from an etiological and pathological point of view, we have no legitimate right to apply the term inflammation to such a method of repair. Koenig makes the statement that the product of tis- sue-proliferation in the healing of an aseptic wound is not in excess of the local demand; hence, the process is purely one of regeneration, and not inflammation. Hueter was one of the first who insisted on limiting the meaning of the term inflammation, which he wished to have applied only to destructive processes caused by the action of specific microbes. In an aseptic wound the fixed tissue-cells assume tissue-proliferation, by virtue of their intrinsic vegetative power, within a few hours after the injury has been inflicted, and all the permanent material utilized in the process of re- pair is derived from this source. The leucocytes serve a useful purpose in the temporary closure of divided capillary vessels and in the formation of the temporary cement-substance by which the surfaces of the wound are mechanically glued together, and, lastly, as food for the embryonal cells, l)ut they taJce no active part in the production of new tissue. In studying the process of healing in wounds as well as in the consid- eration of regeneration in general, it is of the greatest importance to become familiar with the histological changes which precede and attend the forma- tion of new tissue; hence, in this connection should be given a description of KAEYOKIlSrESIS. Karyokinesis, or karyomitosis, as described by Fkmming, is the in- direct reproduction of cells as compared with direct cell-division by seg- a PEINCIPLES OF SUEGEEY. mentation. It is a process by which the net-work of chromatin threads within the nucleus undergoes great development, and is subject to certain transformations of form, which are instrumental in effecting division of nucleus and cell. The term karyokinesis was first used by Schleicher, and the first accurate description of the process, as seen in the cells of a number of animals, simple in form and structure, was given by Biitschli in 1876. The modern definition of a cell is much more complicated than that given by Schleiden and Schwann, as recent researches have shown that it is not such a simple structure as it was formerly believed to be. When we speak of a cell now we mean a mass of circumscribed living substance, with or with- out an envelope, which contains as an essential element in its interior a nucleus, with the property of forming new compounds out of substances taken into it, and is capable of reproduction by division. Both the nucleus and cell are composed of threads and intermediate substance. The cell- Fig. 3. Fig. 4. Fig. 3. — Quiescent Nucleus. Epithelial Cell of Salamander Entering upon the "Glomerular" Phase. (Flemming.) Fig. 4.— Living Cell of Salamander. A, granules aggregated round a pole of the ceU; B, coils of "glomerular" net- work; C, cell-body. (Flemming.) body consists of threads somewhat irregularly distributed, seldom forming a net-work, imbedded in a homogeneous substance. The nuclear threads stain with hsematoxylin and safranin, and hence are called chromatin threads, which are arranged in a net-like figure, the meshes of which are filled with a substance which cannot be stained, and hence is named by Flemming achromatin. The nucleus is surrounded by a membrane com- posed of two layers; the inner can be stained, but not the outer. The nucleoli, usually multiple, are made up of a substance more refractile than the structures described in the nucleus. They are round and smooth, and either suspended in the net-work or between the threads. The nucleus in a cell that is not in a condition of functional activity is said to be in a quies- cent or resting state. At this time the chromatin threads become transformed into a sort of skein, formed apparently of one long, convoluted thread; the inner layer KAKYOKINESIS. 9 of the nuclear membrarie and nucleoli disappear, or are incorporated into the achromatin substance of the nucleus. The development of the net-work of the chromatin substance in the nucleus undergoes five phases until com- plete division of the nucleus and cell has been effected. Phase I. The first change indicative of beginning karyokinesis, accord- ing to Flemming, is the formation within the cell-protoplasm of two poles opposite to each other and near the nucleus. The next change noticed is that in the nucleus: the chromatin threads become plainer, thicker, and more convoluted. This increase of chromatin substance is the result of longitudinal splitting of its threads. The achro- matin layer of the nuclear envelope increases in thickness, while the inner layer has become a part of the chromatin net-work. Phase II. Durina: this stage the chromatin threads are drawn out into Fig. 5.— Endothelial Cells; Abdomen of Salamander. 1. Surface view of nuclear net-work; A, cell-body; B, threads of net- work; 0, one of the poles with the achro- matin threads radiating from it. 2. Equatorial view of a corresponding cell; A, one of the poles; B, the nuclear net-work seen on edge; C, the achromatin threads forming a spindle between the poles. {Flemming.) loops with long limbs. This arrangement imparts to the looped net-work the figure of an aster, or star. In the middle of the star is a clear space, which does not stain and is occupied by achromatin substance. In animal cells the greater portion of the space within the nuclear membrane is filled with chromatin threads, while in vegetable cells the achromatin substance predominates. The nuclear spindle in the centre of the achromatin substance (Fig. 4, C), ac- cording to Strassburger and Biitschli, consists of fine, colorless fibres, which do not stain at all, or only slightly, by using special nucleus-staining re- agents, and on this account the achromatin threads probably contain no nuclein. Phase III. The star-shaped mass of nuclear threads divides into two equal portions, with the angles of the loops to the poles, and theiT limbs partly obliquely, partly perpendicularly to the equator of the nucleus. 10 PEINCIPLES OF SURGERY. The equatorial disk is formed in this manner, and indicates the com- pletion of this phase. Phase IV. This phase begins with a separation of the threads at the equator, and ends with concentration of the threads in each polar segment of the cell. As the number of loops in each segment is the same as in the old nucleus, it may be conjectured that the halves of each thread separate into the two daughter-stars. Phase V. The threads in the daughter-nucleus form a wreath, after which they contract more and more until the undivided convolutions can hardly be recognized. A nuclear membrane again appears, after which the net-work returns to its quiescent state. Fig. 7. Fig. 6. — Epithelial Cell of Salamander. A, pole and achromatin threads; B, cell-body.; C, disk-like arrangement of chromatin threads at equator of nucleus. (Flemming.) Fig. 7.— Epithelial Cell of Salamander. A, A', chromatin threads of daughter-stars; B, achromatin threads and pole. (Flemming.) There is a strong tendency at the present time to refer all karyokinetic changes to the agency of the nucleus, and to ascribe to the protoplasm of the cell the passive role of a nutritive substance. In the impregnated ovum the influence of nuclear changes has been described, but at the same time it was shown that the protoplasm of the cell is capable of automatic as well as responsive action. Pfiliger asserted that gravitation is the sole guiding agency in the process of cleavage of protoplasm. According to Born, Herturg, Weismann, and Kolliker, the protoplasm alone is isotropic, but Whitman thinks that this is far from the truth. Others, like Pflueger, believe that the protoplasm contains physiological molecules from which organs are de- veloped. Polarity of cell-protoplasm and in nucleus exists independently, and is not reciprocal. Contractions in unfertilized ova have been observed. M. Nussbaum was first to prove that enucleated fragments of an infusorium are incapable of reproduction, while parts of an infusorium containing a KAEYOKINBSIS. 11 nucleus possessed this power. This would tend to establish the fact that the nucleus is indispensable to the preservation of the vegetative energy of the cell. On the other hand, Gru.ber, in one of his experiments, divided a stentor before fission had taken place in such a manner that the sections contained no nuclear substance, and yet the next day each one of these parts represented a complete stentor. Against the conclusions drawn from this experiment it might be urged that some of the nuclear chromatin threads might have found their way into the cell-protoplasm, and that from them the process of reproduction started. Nussbaum regards a combination of nuclear structure and cell-protoplasm as essential for cell-production. Ac- Fig. 8.— Epithelial Cell of Salamander. A, A', daughter-glomeruli; B, achromatin threads still uniting the two daughter-cells. {Flemming.) cording to Flemming, the cell-body begins to divide toward the end of the fourth phase of karyokinesis. Cell-division commences with a constriction at the equator, which becomes deeper and deeper as the daughter-cells as- sume cell form, until complete segmentation takes place. Toward the com- pletion of the separation only a few achromatin threads (Fig. 8, B) connect the two. To Flemming belongs the credit of having first discovered karyo- kinetic changes in cells undergoing division, but our knowledge of this sub- ject has been greatly advanced by the combined labors of Strassburger, Arnold, Klebs, and Whitman. Arnold studied this method of cell-division in giant cells of the medulla and in the blood-corpuscles of leuksemic blood. 12 PEINCIPLES OF SURGEEY. He preserved the blood-corpuscles in a 6-per-cent. methyl-green salt-solu- tion^ which preserves cells in a good condition if the solution is kept at a proper temperature in the moist chamber on the object-glass. If to this solution a 25-per-cent. solution of chloride of gold is added, the karyokinetic figures are made clearer. In studying the process of karyokinesis in fixed tissue-cells in a state of proliferation, it is necessary to resort to the fixation and staining methods described by Flemming. The modern observers who have studied regeneration of epithelial cells have come to the conclusion that cell-division takes place almost exclusively by karyokinesis. Podwyssozki has studied this method of cell-reproduction with special reference to regen- eration of liver-cells, and has come to some very important conclusions. In cats and young guinea-pigs he observed, after injury of the liver, extra- nuclear chromatin substance before he could detect any karoykinetic figures in the nucleus. The chromatin in the cell-body appeared in two forms: either as fine granules scattered diffusely through the protoplasm of the cell or as lumps of chromatin, and he designated these larger masses as pro- chromatin; but he also noticed that the granular form, at a later stage, aggregated and formed masses which united with the nuclear chromatin. Klebs explains the presence of chromatin in the cell-protoplasm to an extra- cellular origin: the leucocytes. He believes that the chromatin contained in leucocytes is liberated after fragmentation has taken place and enters the young cells, where they serve as food and become a part of the nuclear net- work. This view is strengthened by the statement of Podwyssozki that he found numerous leucocytes in the immediate vicinity of the new cells. Ziegler and Obolensky produced arsenical intoxication in animals by ad- ministering the drug in daily doses subcutaneously, and when they examined the liver they found well-marked karyokinetic figures in the endothelial cells of the intraacinous capillaries, the epithelia of the bile-ducts, and, less fre- quently, in the secreting cells. Karyokinetic figures were first visible in the nuclei of the capillary endothelia, and were undoubtedly caused by the direct action of the arsenic upon the cells. These experiments show that karyo- kinesis will follow the application of chemical, as well as traumatic, irritants. FEAGMENTATION OF NUCLEUS. Arnold and Pfitzner have described, in giant and other cells under- going pathological changes, direct fragmentary division of the nucleus, by which it may break up into many parts, often of unequal size, without con- temporaneous division of the cell. Arnold and others have also described incomplete fragmentation of the nucleus where the nuclear masses remain connected with each other, and can be seen as lobulated and reticulated structures. Arnold saw fragmentation of the nucleus in the cells of the GRANULATION-TISSUE. 13 marrow of bone and in leucocytes undergoing transformation into pus-cor- puscles. A nucleus which undergoes fragmentation contains but little chromatin substance, and is therefore incapable of multiplication by karyo- kinesis; and such cells, according to the investigations of Klebs, never take an active part in the regeneration of tissue. -DIEECT CELL-DIVISION. In 1841 Martin Barry first made the observation that the division of cells was accompanied with division of the nucleus, and for a long time it was believed that this process is simply a segmentation of the nucleus, fol- lowed by division of the whole cell. Eemak taught that direct division com- menced in the nucleolus, extended to the nucleus, and finally resulted in fission of the cell-body, each of the new cells containing a daughter-nucleus. According to Pfitzner, direct cell-division is a more frequent method of cell-multiplication than the indirect in young animals where cell-prolifera- tion is rapid. In the embryo the nucleus contains but little chromatin, and therefore the karyokinetic figures are less abundant. c D Fig. 9. — A, mature cell; B, commencing division of nucleus and contraction of cell- protoplasm in the centre; C, complete division of nucleus and cell; Z), formation of two new cells. (McKendrick.) In most of the regenerative processes in mature tissue-cells reproduc- tion takes place by karyokinesis, and only in exceptional instances by direct division. The new cellular elements present karyokinetic figures in all stages, and wherever these are seen it is a positive evidence that the fixed tissue- cells are the seat of tissue-proliferation, and that wounds are healed and defects repaired exclusively by this method of cell-formation. GEANULATION-TISSUE. The new cells formed by indirect or direct cell-division in a wounded or injured part, the seat of regenerative processes, constitute the granula- tion-tissue as long as they remain in their embryonal state. As immediate union never takes place in any part or tissue of the body, we are forced to admit that every wound heals only by the interposition between the divided parts of a greater or less amount of granulation-tissue. If the wound remain aseptic, and the surfaces of the wound are kept in accurate coaptation, the healing is accomplished in a short time, and by the production of a mini- mum amount of new tissue. A similar wound, with great loss of tissue pre- 14 PEINCIPLES OF SUKGERY. eluding the possibility of bringing the parts in apposition by mechanical resources, must necessarily heal by the production of a large quantity of granulation-tissue, the process of repair in both instances being the same, the difference being mainly the length of time required to complete the heal- ing process and the amount of new material necessary for this purpose. In the first case the wound heals without visible granulation-tissue; in the latter the defect becomes covered with granulations before the wound can heal. The macroscopical and microscopical appearances of granulating sur- faces are nearly identical in all the tissues. A bone covered with granula- tions looks the same as a granulating surface of any of the soft tissues. Even Pig. 10. — Granulating Wound. Capillary Loops Surrounded by Embryonal Cells. X 300-400. {Billroth-Winiwarter.) the embryonal cells of which the granulations are covered, so long as they remain in this state, furnish, from their microscopical appearances, only re- mote or no indications as to their histogenetic source and ultimate destina- tion. Differentiation takes place during their further development toward the completion of the healing process. The bulk of all granulation-tissue is derived from the connective tissue, as this mesoblastic structure is diffused throughout the entire body, and, with the exception of the nervous system, is found in almost every organ. In the nervous system it is represented by an almost similar tissue, — the neuroglia, — which performs the same role in the repair of injuries and defects of the brain and spinal cord. A wound GRANULATION-TISSUE. 15 or defect covered with granulations presents a velvety appearance, each tuft or papilla representing a separate loop or net-work of new capillary vessels. The new capillary vessels are paved with endothelial cells containing a very large nucleus. Sometimes a single capillary vessel enters a papilla and gives off a number of branches, which form a net-work of convoluted vessels, rendering the granulations exceedingly vascular and liable to bleed on the slightest provocation. Fig. 11. — Granulation-tissue from Wound. Blood-vessels Injected. X 400. A, A, capillary loops with several branches; B, ordinary granulation-cells; G, fibroblasts; D, stroma. (Hamilton.) The blood in the tuft is collected and returned usually through one vein. Emigration of leucocytes through the walls of the new capillary ves- sels is a common occurrence, and, when they reach the surface, form one of the elements of secretion of the wound. When the capillary vessels are imperfectly developed, or when they are in a state of inflammation, the ex- udation becomes profuse and the granulation-surface becomes covered with a membrane consisting of the products of coagulation-necrosis. Wounds 16 PRINCIPLES OF SURGEEY. presenting such an appearance have frequently been mistaken as an evidence of diphtheritic infection. The so-called healthy granulations are small, firm, and of a pinkish-red color, and the surface from which they spring is only moistened with colorless, viscid fluid. Wounds covered with such gran- ulations heal rapidly and leave a small, pliable cicatrix. Profuse flabby and pale granulations indicate a want of general vitality, or more frequently the presence of pathogenic microbes, which act injuriously upon the process of transition of embryonal cells into tissue of a higher type. Such granulations are frequently met with in wounds after imperfect operations for tubercular lesions, in suppurating wounds, and in ulcers of the lower extremities, where the vascular conditions are unfavorable for the growth and development of new tissue. Histologically granulation-tissue is composed of a delicate, oedematous reticulum, and upon its fibres can be seen numerous connective- tissue corpuscles. The reticulum is intimately connected with the blood- vessels, and in its meshes are contained the embryonal cells and leucocytes, the latter serving as food for the former. The embryonal connective-tissue cells are about two or three times larger than the leucocytes. The giant cells which are occasionally found are fibroblasts which have grown to such enor- mous proportions by inclusion of nutritive material derived from disin- tegrating leucocytes. VASCULARIZATION OF GRANULATION-TISSUE. The vessels which furnish the blood-supply to the granulation-tissue are new structures, and are usually formed from preexisting vessels in in- jured vascular tissue, and from the nearest blood-vessels in non-vascular tis- sue. Vessel-formation and tissue-proliferation are initiated simultaneously, and keep pace with each other until the necessary amount of granulation- tissue has been produced, when, during the transformation of the embryonal cells into permanent tissue, the vascular supply is gradually diminished by the obliteration and disappearance of all of the superfluous vessels. As the layer of granulation-tissue seldom exceeds more than ^/g inch in thickness, the new vessels always remain short, and retain their communication with the preexisting vessels from which they started. Travers, in his experiments on injuries of the frog's web, has observed that the blood in the divided ves- sels becomes stagnant some little distance from the wound. During this time material oozes from the cut vessels, which constitutes the primary wound-secretion. Before granulations can be established the circulation must become restored by enlargement and multiplication of preformed vessels. The capillary vessels which have been cut or otherwise injured are closed with Nature's hsemostatic: a minute thrombus. The intravascular pressure on the proximal side of the obstruction results in dilatation of the VASCULARIZATION OF GEANULATION-TISSUE. 17 vessel, which produces an increased blood-supply to the part commensurate with the increased demand for nutritive material. The new blood-vessels are formed by angioblasts, which are proliferated from preexisting vascular structures. Arnold has studied the formation of new blood-vessels in the stump of the tail of tadpoles after amputation, and in keratitis vasculosa artificially produced in the cornea of rabbits. To the researches of this au- thor we owe most of the knowledge we possess on this subject. The new vessels are produced by the budding process from capillaries near the surface of the wound. The bud appears first as a circumscribed thickening of the capillary wall, which soon projects outward in the form of a triangular cel- Fig. 12. — Superficial Capillaries of a Wound Beginning to Granulate, about Forty- eight Hours after its Infliction. X 350. A, free surface; B, the capillary loops all dis- tended with blood, and being driven outward in tortuous festoons; C, embryonal cells. (Hamilton.) hilar mass composed of angioblasts. The bud is then transformed into a long string, terminating in a delicate granular thread. The base of such a projection becomes excavated, and blood enters from the vessel to which it is attached. When the terminal ends of two of such projections meet they unite and form an arch, which, after they have be- come permeable to the blood-current, constitute a capillary loop from which branches again may develop in the same manner. The new channels con- tain, upon their inner surfaces, nuclei at variable distances, which subse- quently undergo transformation into endothelial cells. The adventitia is formed by round cells, which arrange themselves along the outer surface of the new channels. Hunter maintained that blood-vessels are formed in 18 PEINOIPLES OF SUEGERT. granulations independently of preexisting vessels, in the same manner as in the embryo, and that they enter into communication with the yaseular system subsequently. Such a method of vascularization during post-em- bryonic life is not proved. A number of pathologists, and among them Bill- roth, still believe that blood-corpuscles and blood-vessels can be produced from connective tissue. They claim that connective-tissue cells in the inter- capillary spaces enlarge, become branched, and that by union between similar projections between two or more cells hollow spaces are created which serve as blood-vessels, while the nucleus assumes the role of an hsemapoietic organ: a process which is well illustrated by Fig. 14. Still another method of vessel-formation in granulations has been ob- served and described by Travers. He noticed that, when one of the new capillary vessels ruptures and blood is poured out into the granulation- tissue, among the embryonal cells a vascular space without walls is formed. The extravasated blood, under these circumstances, did not disintegrate, and Fig. 13.- -Formation of New Blood-vessels by Budding. B, after six hours. {Arnold.) A, after three hours; as soon as the space came in contact with another capillary loop the wall gave way and a communication was established between the two capillary vessels, and later the channel became lined with endothelial cells. This method of vessel-formation is termed canalization. While the possibility of the development of new vessels independently of preformed blood-vessels cannot be denied, such an origin is, to say the least, exceedingly rare, and for all practical purposes, when we speak of vascularization of granulation- tissue or the formation of new blood-vessels in general, we mean the forma- tion of new channels by tissue-proliferation from the walls of preexisting blood-vessels. D. J. Hamilton, author of the excellent "Text-book of Pathology," asserts that the blood-vessels in granulation-tissue are not new, but dilated, tortuous, preformed vessels. In wounds that heal rapidly the existence of most of the new blood- vessels is a short one. With the beginning of cicatrization they disappear rapidly, and comparatively only a few of them remain as permanent struct- CICATRIZATION. 19 ures as a system of collateral vessels which restore indirectly the loss of con- tinuity between the divided vessels. A failure of the vessels to disappear after cicatrization has been completed usually is an indication that some pathogenic microorganisms have become imbedded in the scar-tissue, which interfere with the proper and prompt transformation of embryonal into per- manent tissue. Such scars are often met with after operations for tubercular lesions and after the healing of extensive burns, being caused, in the first instance, by the bacillus of tuberculosis and in the latter by pus-microbes. The vascular conditions in granulating surfaces should be carefully studied, and in the treatment due attention should be given to this important point, as compression and position are potent measures in improving a faulty cir- culation, which may have indefinitely retarded the healing process. b Fig. 14. — Development of Blood-corpuscles in Connective-Tissue Cells, and Trans- formation of the Latter into Capillary Blood-vessels. A, an elongated cell with a cavity in its protoplasm occupied by fluid and by blood-corpuscles; B, a hollow cell, the nucleus of which has been multiplied; the new nuclei are arranged around the wall of the cav- ity, the corpuscles in which have now become discoid; C, shows the mode of union of a "hgemapoietic" cell, which, in this instance, contains only one corpuscle, with the pro- longation (BL) of a previously existing vessel. A and C, from the newborn rat; B, from fcetal sheep. (Fluegge.) CICATRIZATION. The process of transformation of the embryonal cells in granulation- tissue into permanent, fixed tissue-cells is called cicatrization. Sir James Paget well said that during the stage of the healing process a life of eminence is changed into one of longevity. In tissues endowed with great vegetative powers and a high degree of adaptation, even large defects are replaced by tissue which resembles to perfection — anatomicall}^ histologically, and phys- iologically — the injured preexisting tissue. This is the case in injuries in- volving considerable loss of substance in bone, tendons, and peripheral 20 PKINCIPLES OF SUEGERY. nerves. Complete restoration of a peripheral nerve frequently takes place after resection of more than an inch of its continuity. In subcutaneous Fig. 15. — Granulating Wound Undergoing Cicatrization. A, vessel with numerous lateral branches; granulation-cells not much changed, only few spindle cells near the main trunk; B, cicatrization farther advanced; spindle cells predominate; C, D, D', cicatrization well advanced; E, E', epithelial cells; F, hair-follicle with proliferation of epithelial cells in its interior, new cells reaching the surface, G. (Landerer.) CICATEIZATION. 21 tenotomy the tendon-ends may be kept separated for two or more inches, and yet after a few months it would be difficult to ascertain, even after the most careful examination, the site of operation. The fractured ends of a broken bone may be completely separated by lateral displacement during the entire time required in the healing process, and yet they are firmly united by the interposition of a connecting bridge of new bone. In other tissues endowed with less reparative energy, as — for instance — -the musciilar fibre, a slight separation results in the formation of cicatricial tissue between the anatomical structure which it is the intention to unite. By cicatrization is therefore understood the completion of the reparative process, and the term does not necessarily imply the formation of a permanent cicatrix. An ideal healing culminates in the formation of tissue which effects a physiological restitution of a defect caused by injury or disease. As a rule, it can be stated Fig. 16. — Embryonal Connective-Tissue Cell Undergoing Transformation into Mature State. A, the cell-body; still contains a considerable amount of protoplasm, whicli, how- ever, gradually diminishes toward D, where it represents a mature connective-tissue cell with a very small amount of protoplasm surrounded by connective-tissue fibres. (Ziegler.) that the result will be satisfactory in proportion to the amount of granula- tion^tissue produced or required in the process of repair. In an aseptic wound the reparative material will not be in excess of the local demand, and the demand will depend on the degree of accuracy of approximation of the surfaces of the wound. Cicatrization begins in the granulation-tissue nearest the preformed vessel; that is, the margins and surface of the wound. The embryonal connective-tissue cells, or fibroblasts, as they are called, at first round, become elongated with thread-like prolongations from the extremities. (Fig. 16.) The new connective tissue contracts, thus bringing the margins of the wound or granulating surface in closer apposition, and by its constricting effect assisting in the obliteration of superfluous vessels. The cicatrix or scar will be large if the process of granulation has been in excess of the de- mand, or if a large defect had to be healed by the deposition or interposition 22 PEINCIPLES OF SURGERY. of a large quantity of cicatricial material. Large scars should be prevented, if possible, by appropriate treatment, as from the contraction they give rise to distressing deformities, and from their low vitality they furnish a per- manent predisposition to ulcerative processes and not infrequently become the seat of malignant disease. After the healing of any ulcer of considerable size upon the mucous surface of any of the hollow viscera the cicatricial con- traction often gives rise to the formation of strictures. Nerves appear to form in granulations, as these are often exceedingly tender to the touch. Their existence, however, has not been demonstrated. The pain and tender- ness may be caused by force being transmitted to subjacent nerves. Accord- ing to Van der Kolk, no lymphatic vessels are present in granulation-tissue. Fig. 17. — Wandering Epithelial Cells from Prog. A, old epithelial cells upon edge of wound of skin, with proliferation of nucleus. (Elebs.) During the process of cicatrization all the embryonal cell-elements undergo transformation into mature tissue, the fibroblasts are converted into con- nective tissue, the angioblasts into vessels, the myoblasts into muscle-fibres, the osteoblasts into bone, etc., each histological element represented in the wound or defect furnishing the material for its own repair. EPIDERMIZATION. A wound of the external surface of the body can be said to have healed after the completion of epidermization. In accordance with the general law of succession of cells, epidermization takes place exclusively by proliferation of preformed epithelial cells. The new epithelial cells have a more or less rounded shape, and cover the granulations from the margins of the wound, where the new skin appears as a bluish-pink pellicle. At first they do not POSITIVE INDICATIONS IN THE TKEATMENT OF WOUNDS. 23 readily adhere to the granulations, but appear to cover them (Fig. 15, E'): later, however, they throw down long processes which penetrate the granu- lations, and in this way obtain a permanent foot-hold. New epithelial cells possess amoebid movements, may become detached from the epithelial matrix, and wander some distance and form permanent attachments, and in such an event an independent centre of epidermization is established. Migration of epithelial cells was first observed and described by Klebs in superficial wounds in the skin of the frog. (Fig. 17.) The irregular projections of the new skin over the granulations, so frequently observed during the healing of wounds by granulation, is undoubtedly often due to such a displacement of embryonal epithelial cells. In granulating surfaces following destruction of the skin by burns, caustics, or ulceration, independent centres of epi- dermization are often seen in the midst of the field of granulations. In such cases the entire thickness of the skin at some points has not been destroyed, and epithelial proliferation takes place from remaining remnants of glands, as is well shown at F and G in Fig. 15. The granulations in the immediate vicinity of the zone of epidermization become reduced in size, the blood- vessels are diminished in number, and the subjacent fibroblasts are rapidly converted into connective tissue. In wounds of the skin which heal without visible granulations the papillae are absent from the cicatrix, even though it be broad from subsequent yielding to traction. In wounds healing by open granulations new papillge are formed in the new skin, because the capillary loops atrophy downward and become the papillary vessels. Epidermization and cicatrization are favorably influenced by measures which secure for the wound an aseptic condition throughout, and by keeping the delicate granula- tions covered with protective silk until the wound is completely healed. POSITIVE INDICATIONS IN THE TKEATMENT OF WOUNDS, WITH SPECIAL EEFEKENCE TO SECURE UNION BY FIRST INTENTION. Absolute Asepsis. — -Absolute asepsis can only he secured hy strictest anti- septic measures. Surgical cleanliness is more than ordinary cleanliness. Antiseptic precautions are employed for the purpose of securing for the wound and everything that is brought in contact with it an aseptic con- dition. The term antiseptic, used as a noun, shou.ld be restricted to agents which retard the growth of pathogenic germs, in contrast with the term germicide, which is applied to agents which destroy pathogenic microbes. A solution of corrosive sublimate, when introduced into a culture solution in the proportion of 1 to 300,000 will restrain the development of anthrax spores; but to insure the destruction of these spores a solution of 1 to 1000 must be used. The mechanical removal of microbes from the field of opera- tion by shaving and washing with warm water and potash-soap should be as 24 PEINCIPLES OF SUEGERY. thorough as possible, but cannot be relied upon in securing asepsis. The sur- face must be disinfected with a reliable germicidal solution, either a 1-to- 1000 solution of corrosive sublimate or a 4-per-cent. solution of carbolic acid. Accidental wounds must always be considered as infected wounds, and a faithful effort must be made to render them aseptic by exposing, if possible, the entire wounded surface to the direct action of one of these solutions, while the surface for a considerable distance around it is also disinfected. Re- cently, a weak solution of the double cyanide of mercury and zinc has been recommended by Sir Joseph Lister as an antiseptic, and, from his experi- mental investigations and clinical experience, it appears that this substance possesses an advantage over carbolic acid, corrosive sublimate, and other anti- septics, as it exerts an inhibitory effect upon microbes which still may re- main in the wound or its immediate vicinity, which prevents them from multiplying in the tissues or in the dressing. At the present time many sur- geons depend almost exclusively on pure alcohol or a 50-per-cent. solution as an antiseptic for surface disinfection after thorough scrubbing with hot water and potash-soap. The finger-nails require special attention in hand- disinfection. Fuerbringer recommends the following procedure for the dis- infection of the hands: 1. Remove all visible dirt from beneath and around the nails. 2. Brush the spaces beneath the nails with soap and hot water for a minute. 3. Wash for a minute in alcohol, and, before this evaporates, in the following solution: 4. Wash thoroughly for a minute in a solution containing 1 to 500 of corrosive sublimate or 3 per cent, of carbolic acid. On each side of the wound or field of operation a towel wrung out of an anti- septic solution is spread smoothly, in order that, during the operation, in- struments and sponges will not be contaminated by being brought in con- tact with non-aseptic clothing or surface. None but sterilized sponges are to be used, and, in the absence of such, pieces of aseptic gauze folded into convenient shape should be used as substitutes. The cheapest and most reliable method of disinfection of instruments is to boil them for five min- utes in a 1-per-cent. solution' of carbonate of soda, and then place them upon an aseptic towel, ready for use. If these antiseptic precautions have been faithfully carried out, sterilized water can be used for irrigation during the operation, or the dry method of operating recently introduced into practice by Landerer can be followed in operating upon aseptic tissues or in the treat- ment of aseptic wounds. In the operative treatment of suppurative affec- tions, irrigation with a l-to-5000 solution of sublimate must be frequently resortedto during the operation, and, in the removal of tubercular products, irrigation with an aqueous solution of the tincture of iodine, made by add- ing enough of the tincture to sterilized water to impart to the solution a sherry color, should be used. CAEEFUL HJEMOSTASIS. 25 CAEEFUL H^MOSTASIS. The presence of a blood-clot between the surfaces of the wound is ob- jectionable for the following reasons: 1. It separates mechanically the sur- faces which it is intended to unite. 2. It serves as a culture-medium for microdrganisms which, if in contact with living tissue, might remain harm- less. 3. It gives rise to tension, and consequently becomes productive of pain and an undue degree of reflex irritation. For years von Bergmann has insisted that careful arrest of hsemorrhage is one of the most urgent and im- portant indications in the treatment of wounds, and his teachings merit the attention of every prudent surgeon. Bleeding-points should be tied with sterilized catgut or silk. A number of surgeons have discarded catgut, as it is more difficult to render it aseptic than silk. The latter can be readily sterilized by boiling. The haemorrhage that so often interferes with an ideal healing of the wound is the capillary or parenchymatous oozing, and this should always be carefully arrested before the wound is sutured. The fol- lowing measures should be resorted to in controlling this form of bleeding, and in the order named: 1. Position. 2. Surface compression. 3. Hot- water irrigation. 4. Antiseptic tampon. 1. In wounds of the extremities capillary oozing is usually promptly arrested by holding the limb in a perpendicular position. In this position the intraarterial pressure is diminished and the return of venous blood favored, both of which are important elements in reducing the amount of blood in the capillary vessels. In order to produce the desired efEect, this position should be maintained for fifteen to twenty minutes, and the limb should be kept elevated for at least six hours after the operation. 2. Surface pressure with a flat sponge or a compress mechanically arrests the bleeding, and the capillary vessels, partly or completely emptied of blood, are placed in a more favorable condition for the formation of a thrombus. After an amputation, for instance, the sponge or compress is applied to the surface of the cut muscles and the flaps are laid over it and compression with two hands applied, with the limb in a perpendicular posi- tion before the elastic constrictor is removed. Compression, continued in this manner for ten or flfteen minutes, will usually be successful in com- pletely/arresting parenchymatous bleeding. 3. Irrigation with salt water (sodic chloride, 0.7 of 1 per cent.) at a temperature sufficiently high to coagulate the albumen on the surface of the wound seals mechanically the cut vessels, and, at the same time, produces a localized anaemia by contracting the terminal arterial branches. A tempera- ture of 120° F. will answer for this purpose. 4. Styptics should never be employed in arresting bleeding from a re- cent wound. If the procedures mentioned fail in accomplishing the desired 26 PEINCIPLES OF SUEGEEY. object, the wound should not be sutured until hsemorrhage has been com- pletely checked by the use of the antiseptic tampon. The wound is packed with iodoform gauze, and the customary dressing is applied in such a man- ner as to exercise uniform gentle pressure. After twenty-four hours the dressing and tampon are removed, and the wound closed with sutures. In such cases secondary suturing is of great value in securing a speedy and satis- factory healing of the wound. ACCUEATE SUTUEING. Brilliant operators are not always the best surgeons. The dest results in surgery follow the one who is most painstahing in following out the minutest details. This assertion applies most forcibly in the treatment of wounds. The surgeon here occupies the position of handmaid to the vis medicatrix naturce, and in the exercise of his duties must do all in his power to tax only to a minimum extent the regenerative resources of the wounded tissues. In the treatment of wounds it becomes his imperative duty not only to unite the surfaces of the wound accurately and neatly, but to unite, whenever it . becomes necessary, tissues of the same anatomical structure and physiological function. Divided nerves, tendons, muscles, fascia, must be separately united with absorbable buried sutures before the wound is closed by the ordinary interrupted or continuous suture. When several nerves or tendons have been divided in the same wound, great care must be exercised to unite the ends of the same nerve or tendon. Accurate approximation of a deep wound is impossible without the buried suture. Several rows of these sutures may be required. Eeliable catgut should be preferred for the deep sutures, but if this material is not at hand fine silk can be used. The best materials for the ordinary interrupted sutures are silk or silk-worm gut. Separate sutures for the skin are usually required in order to approximate the superficial mar- gins of the wound accurately, and for this purpose horse-hair is the most desirable material. If the surgeon has reason to believe that the wound is aseptic, drainage should be dispensed with, because the manner of suturing, as just described, guards against the occurrence of "dead spaces." An ab- sorbent antiseptic compress, composed of a few layers of iodoform gauze and a thick layer of salicylated cotton, or sublimated moss or wood-wool, is the most appropriate dressing for such cases. The gauze bandage to retain this dressing is applied in such manner as to exercise uniform equable compres- sion: an important element in affording support to the injured vessels and in securing rest for the parts involved in the injury. Fixation of the wounded part by splints to secure rest and elevation to influence favorably the cir- culation are likewise important measures in aiding the process of repair by insuring UNIOK BY SECONDAEY INTENTION. 37 PHTSIOLOGICAL REST. In the after-treatment of a wound nothing is more important than to secure for the parts which have been mechanically united, as far as possible, physiological rest. The importance of rest in the prevention and treatment of inflammation has been prominently brought forward by Hilton, and his teachings have resulted in a great deal of good in the treatment of inflam- matory surgical affections. If one of the extremities is the seat of the wound, immobilization upon a splint or with a plaster-of-Paris dressing, in such a position as to relax the muscles involved in the wound, is of paramount im- portance. The injured part must be kept in a position which will favor a normal blood-supply and prevent passive hypersemia. A wound properly dressed should not be disturbed until union has taken place. If any one of the three most important indications for a change of dressing — pain, rise in temperature, and saturation of the dressing with wound-secretions — do not arise, the first dressing is allowed to remain for eight days to six weeks, according to the location, character, or size of the wound. In wounds of the gastro-intestinal canal physiological rest is secured by abstinence from food, and, if necessary, peristalsis is diminished by a few doses of opium. In wounds of the bladder distension of the organ is prevented by the intro- duction and retention of a catheter. In wounds of the brain or its envelopes rest is secured by exclusion of light and by enforcing quietude in the patient's room. UNION BY SECONDARY INTENTION. In an aseptic wound all the new material resulting from proliferation of the fixed tissue-cells is used in the process of repair, and the time for healing of the wound will depend on the anatomical structure of the part injured and the amount of material required to form a bridge of living tis- sue between the divided parts. As long as the wound heals without destruc- tion of any of the new tissue-elements by specific microbic causes, it is proper to speak of a union by primary intention, whether the healing is completed in three or four days or whether it is protracted for months until the ulti- mate object of wound treatment has been reached. From a pathological, and even from a practical, stand-point, it is not correct to include, under the head of healing by the second intention, aseptic wounds that, on account of want of proper approximation, or on account of loss of tissue, have of neces- sity to heal by granulation, with infected wounds in which the regenerative processes are disturbed by suppuration. In a suppurating wound the em- bryonal cells which are destined to become transformed into new tissue are exposed to the destructive action of pus-microbes and their toxins, their protoplasm is destroyed, and they become one of the histological sources of pus-corpuscles. The cells on the surface of the wound, being most distant 28 PEINCIPLES OF SUEGERY. from the vascular supply, possess the least power of resistance to the action of pus-microbes, and on this account, as well as from the greater number of pus-microbes on the surface of the wound than in the deeper tissues, they are converted into pus-corpuscles. As long as suppuration remains active the superficial layer of granulation-cells is destroyed, and as soon as other embryonal cells take their place the process is repeated, and thus the healing of the wound is indefinitely delayed. When a favorable change takes place in the wound, either spontaneously or from the employment of antiseptic measures, suppuration is diminished, the granulations become firmer and more vascular, and cicatrization and epi- dermization now progress in a satisfactory manner. Such a favorable change in the condition of the wound can be readily explained after the use of such agents as are known to destroy the microbic cause of the suppuration when brought in contact with the .wound. In such a case we would naturally expect that, with the removal, destruction, or rendering inert of the pus- microbes, the embryonal cells would remain attached to the point where they were produced, and would soon be converted into tissue resembling the matrix- which produced them. Spontaneous cessation of suppuration, and with it the conversion of .a surface covered with dead material into a healthy, granulating surface, would indicate either that the virulence of the pus- microbes had become attenuated, that the soil was no longer congenial for their multiplication, or finally that the resistance on the part of the tissues to their pathogenic action had become increased. That tissue-resistance has a potent influence in neutralizing and modifying the action of pathogenic microorganisms has been observed clinically and demonstrated experiment- ally. Suppurating wounds are graver affections, and are more difficult to manage in the aged and in badly-nourished persons, as well as in patients debilitated from all kinds of excesses and protracted diseases. A good cir- culation of the part is an important element in counteracting the cause of suppuration. A chronic varicose ulcer of the leg that suppurates freely, as long as the patient continues to use the limb, is often transformed into a healthy granulation-surface after a few days of rest in bed with the affected limb in an elevated position. TEEATMENT OF SUPPUEATING V70UNDS, V^ITH SPECIAL EEFEEENCE TO HASTENING THE PROCESS OF EEPAIE. In the treatment of an accidental wound, which always must be re- garded as a septic wound, or in the management of a wound where the anti- septic precautions have failed, no time should be lost in securing for the wound and its vicinity an aseptic condition by thorough disinfection. The surroundings of the wound are disinfected in the same manner as for an operation. The wound is exposed as thoroughly as possible to direct treat- SUTUKING OF GEANULATING WOUNDS. . 39 ment by enlarging it over recesses otherwise inaccessible, after which it is thoroughly irrigated with jseroxide of hydrogen, followed by a solution of sublimate (1 to 2000) or carbolic acid (3 V2 to 5 per cent.). If the granula- tions are copious and flabby, they must be removed with Volkmann's sharp spoon, and after the bleeding has ceased a 12-per-cent. solution of chloride of zinc is applied; after a few minutes the surplus fluid is washed away by irrigation with the sublimate or carbolic solution. The wound is, now dried, sutured, and drained. Drainage in these cases is a necessary evil, as the surgeon can never feel certain that he has succeeded in obtaining perfect asepsis. If the wound is extensive, or if pus has been burrowing in different directions along the deep tissues, as in cases of compound fracture where a thorough disinfection of every part of the wound, as already described, is impossible or impracticable, constant irrigation with a saturated solution of acetate of aluminum or Thiersch's solution should be instituted and con- tinued until the wound has been rendered aseptic. Acetate of aluminum is a reliable antiseptic, is non-toxic, and penetrates the tissues deeply. The treatment most appropriate for a recent aseptic wound is to be adopted as soon as suppuration has ceased and the general symptoms at the same time point to an aseptic condition. SUTURING OF GRANULATING WOUNDS. If union by primary intention has failed to take place, for any reason, in wounds which can be closed by suturing, a second attempt can be made to approximate the surfaces with sutures, with fair prospects of success as soon as the granulations are in an aseptic condition. Aseptic granulating surfaces when brought in contact unite rapidly, as vascular connections be- tween the new capillary loops are established in a remarkably short time, and the wound then heals in the same manner as after primary suturing. The cases best adapted for secondary suturing are those where suppuration has ceased, the granulations have become small and firm, — in short, wounds in which cicatrization has commenced. The technique in the treatment of such wounds is the same as in cases of aseptic recent wounds. The advan- tages of this method of dealing with wounds that have failed to unite are pronounced when the wound is deep and the margins can be coaptated with- out much tension. Buried sutures can be used for the same purpose and with the same benefit as in the treatment of recent wounds. Before the sur- faces are brought in contact with the sutures it is important to disinfect and dry the granulations thoroughly. As secondary suturing is applicable only in the treatment of such wounds where we have every reason to assume that an aseptic condition exists or can be secured by disinfection, the whole wound should be carefully closed and drainage must be dispensed with, in order to 30 PEINCIPLES OF SUEGEEY. obtain rapid healing of the entire wound. It has been recently suggested by Hahn that in extensive defects of the skin a covering for the wound can be obtained by sliding of the skin, after undermining it for some distance, in a direction most suitable. That this procedure is applicable only under circumstances when the surgeon is sure of asepsis is to be taken for granted, as otherwise it might be followed by gangrene and still greater loss of tissue. CHAPTER II. Regeneeation of Different Tissues. In connection with the subject of healing of wounds it is very im- portant for the student to familiarize himself with the vegetative capacity of the different tissues of the body in order to estimate with some degree of accuracy the part taken by each tissue in the reparative processes which take place after an injury or disease. No 'positive -proof has yet he&n furnished that the leucocytes or any other of the cellular elem&nis of the Hood take any active part in the restoration of lost parts. It does not appear to me reason- able or logical that such an indifferent cell as the leucocyte should ever be- come transformed directly into a fixed tissue-cell, and it is still more im- probable that it should be possessed with such a diverse vegetative capacity as to undergo a transition in one place into a connective-tissue cell, in an- other into bone, and still another into a muscle-fibre. It is much more rational to assume, in the repair of an injury and in the regeneration of a part destroyed by disease, that the universal law of legitimate succession of cells asserts itself, according to which the reparative process is initiated and completed by homologous cell-proliferation. In the following pages experimental and clinical proofs will be ad- vanced which will at least tend to establish the truth of this assertion. NON-VASCULAR TISSUE. The part taken by blood-vessels in regenerative processes is well shown in the healing of wounds of non-vascular tissue. Large wounds of the cornea and cartilage can only heal after a blood-supply has b^en established through new vessels from the nearest vascular district. Rapid vascularization of the non- vascular tissues is always observed when the wound has become infected. Cornea. — - The normal cornea contains no blood-vessels, but vascular spaces, which form a system of channels for the circulation of the plasma- fluid. In 1863 Recklinghausen discovered in these spaces migrating cor- puscles, resembling in size and shape the white blood-corpuscles, which he regarded as offspring of the corneal corpuscles. Later, Cohnheim showed that these wandering cells were leucocytes which had escaped from the peri- corneal capillary vessels and had found their way into these channels. In traumatic keratitis these spaces become blocked with leucocytes, and they constitute largely the primary product of inflammatory exudation long be- fore the fixed cells of the cornea could have yielded such an amount of cel- lular elements. Strube and His studied experimentally the healing of (31) . 33 PKINCIPLES OF SUEGERY. "wounds of the cornea and traumatic keratitis. They injured the cornea of rabbits by cutting and cauterization. As the cornea is freely supplied with nerves, they observed as one of the earliest tissue-changes a reflex paretic dilatation of the marginal blood-vessels. The marginal hyperaemia was fol- lowed by the formation of new blood-vessels in the direction of the seat of injury. The early opacity around the wound and the space between the wound and the advancing channels are caused by the presence of leucocytes in the vascular spaces; later, to proliferation of the corneal corpuscles. That leucocytes enter the plasma-canals when the cornea is irritated has been definitely settled by Cohnheim by one of his most ingenious experiments. He injected finely-divided carmine suspended in an acid, or precipitated aniline into the dorsal lymph-sacs of frogs, with the result that when he irritated the cornea, a few days later, leucocytes stained with the pigment- material appeared at the margin of the cornea where cell-migration was known to appear first. He found a rapid increase of corneal corpuscles in the animal subjected to experimentation; thus, in one instance, eighteen hours after the injury, he found, in spaces normally occupied by one cor- puscle, as many as twenty to thirty young cells closely packed together. D. J. Hamilton regards as the first change in an irritated cornea an increase of the plasma-current, which may destroy the endothelial lining of the canals, and according to this observer cell-migration into the corneal spaces occurs later. Unimpaired innervation of the cornea is an important factor in the prompt healing of wounds of this structure, as it is well known that in patients suffering from glaucoma, and in the aged, wounds of the cornea heal often in a very unsatisfactory manner. An aseptic wound of a normal cornea heals without opacity; the new corneal corpuscles, after they attain maturity, transmit light as perfectly as the cells from which they are produced. Imperfect restoration of tissue is to be expected when the regen- erative process is complicated by a suppurative inflammation with consid- erable destruction of tissue. Gussenbauer incised the cornea in rabbits half- way between the centre and its margin to the extent of half a line to a line, and found, in examining the specimens after twenty-four hours, that no union had taken place. The wound-surfaces at this time were glued together by an interposed substance. The surfaces of the wound were in close con- tact at a point corresponding to the middle portion of the cornea, and the gap widened toward each of its surfaces, so that the temporary cement-sub- stance represented two cones with their apices directed towa,jd each other and the bases toward the surfaces. On staining the specimens with chloride of gold it was found that this substance contained cells which were most numerous toward the surfaces of the cornea. The corneal corpuscles on the cu.t surfaces were seen to be enlarged and presenting different stages of cell- division. Instead of round, the corpuscles were spindle-shaped, some con- NON-VASCULAK TISSUE. 33 taining one nucleus, others two nuclei; intercellular substance granular. In specimens eight days old the space between the cut surfaces was occupied almost exclusively by new corneal corpuscles^ and the edges of the wound could no longer be clearly defined. During cicatrization of the wound the number of cells is diminished, while in form and size they resemble more and more the mature corneal corpuscles from which they Avere derived. In a non-penetrating incised wound of the cornea the gap is filled up after a few days with young cells derived from the cylindrical cells of the deepest layer of the corneal epithelia. If the wound has penetrated, the posterior third of the wound gapes toward the anterior chamber of the eye, and is first plugged with the prod- ucts of coagulation-necrosis, which is later replaced by epithelial cells from the membrana Descemeti (Fig. 19, C), while the anterior portion is occupied by epithelial cells the same as in the non-penetrating wounds. At the end Fig. 18.— Corneal Corpuscles in a State of Proliferation. A, old corneal corpuscles with one or two nuclei and young offshoots, B and C. (Senftleben.) of the first week the corneal corpuscles begin to proliferate, and the cells from this source gradually displace the epithelial cells and bring about the definitive healing of the wound. As wounds of the cornea are not sutured, the surgeon should aim to secure approximation by removing coagulated blood, if present, and by correcting any existing displacements by di- rect measures, and finally by applying a dressing which will exert uniform and equable elastic compression. Although the antiseptic treatment cannot be carried out with the same precision in the treatment of wounds of the cornea as in other localities, it is at least the duty of the surgeon to use only sterilized instruments and aseptic sponges, and to employ such mild anti- septic solutions as will at least exercise an inhibitory influence upon pathog- enic microorganisms that may be present in the wound or upon the surface of the eye. Cartilage. — Cartilage is in every sense of the word a non-vascular structure, as even the plasma-channels found in the cornea are absent here. 34 PEINCIPLES OF SUEGEEY. Plasma-diffusion must take place between or through the cells. It is un- doubtedly on account of the limited provisions for nutritive supply that the vegetative capacity of this tissue is so exceedingly low. Normal cartilage when injured is unable to repair the defect. The process of healing of wounds of cartilage was first studied experimentally by Redfern. In one experiment he found the wound almost unchanged after twenty-nine days. In one specimen, where the healing process had been completed, he found the defect repaired by connective tissue. The microscopical description of the healing process corresponded with that given by Goodsir of inflammatory Fig 19. — Wound of Cornea. A- A', new corneal corpuscles; B-A', temporary plug of fibrin; G, epithelia from membrana Descemeti. (Von Wyss.) processes in this structure. iVlong the margins of the wound the cartilage- cells multiply and the cement-substance is dissolved. No new cartilage-cells are produced, and the space is occupied by connective tissue. Vasculariza- tion toward the seat of injury from the marginal vessels of the perichon- drium takes place in the same manner as in the cornea. Eeitz traced the formation of connective tissue from the cartilage-cells in tracheotomy wounds in rabbits. He observed, after the cement-substance had become dissolved, that the cartilage-cells were transformed into spindle cells, and later into connective tissue. He found the gap between the divided carti- lage-ring filled with such cells a few days after the wound had been inflicted, VASCULAE TISSUE. 35 and explains the discrepancy between the results he obtained and those described by Eedfern on the gronnd of the close proximity of vascular sup- ply in his case and the remoteness of vessels from the wound studied by Redfern, as the latter experimented' on articular cartilage. Gussenbauer studied the repair of cartilage wounds after incising subcutaneously costal cartilage. In wounds twenty-four hours old a triangular gap was found filled with fibrin and blood-corpuscles. No change was found at this time in the cartilage-cells and cement-substance. The cells of the perichondrium in- creased in volume and changed in form. Gussenbauer was unable to verify the observation made by Eeitz in wounds of trachea, that cartilage-cells are transformed into connective-tissue cells, and believes that the ammonia used by Eeitz to provoke croupous pnevimonia, by its introduction into the bron- chial tubes through the tracheal wound, may have modified the result. He traces tissue-proliferation almost exclusively to the perichondrium, the Fig. 20. — Healing of Experimental Fracture of the Tibia of a Rabbit. A, young fibrous tissue. Ji, osteoid tissue forming by metaplasia from C, cartilage. X 250. cells of which were found in all stages of division and development, while only a few of the cartilage-cells presented evidences of segmentation. Uorner studied not only the manner of repair of simple incised wounds of cartilage, but also produced more complicated injuries, and invariably found that the perichondrium took a more active part in the process of healing than the cartilage-cells. Wounds of fibro- and reticulated cartilage heal in the same manner as wounds of hyaline cartilage. The histological changes observed by Eedfern, Dorner, and Gussenbauer during the repair of wounds of carti- lage are descriptive of the changes which attend chondritis. VASCULAE TISSUE. The healing of wounds of vascular tissue is accomplished more rapidly than of non-vascular tissue, as the primary wound-secretion, which is derived mostly from the wounded vessels, forms a temporary cement-substance which glues the parts together, — a condition which renders material assistance in 36 PRINCIPLES OF SUEGERY. maintaining coaptation, — while the direct blood-suppl}^ to the injured part cannot fail in increasing the vegetative capacity of the cells, and, lastly, the leucocytes present in the recent wound serve as food for the cells which are undergoing karyokinetic changes. As a rule, to which there are few ex- ceptions, it may be stated that the rapidity with which the healing process is completed is proportionate to the vascularity of the wounded part. For instance, wounds of the fingers heal much more rapidly than wounds of the arm or forearm, and wounds of the face more rapidly than wounds of the neck. Karyomitotic changes are first noticed in the nuclei of cells in close -proximity to blood-vessels. In studying the healing of wounds of vascular tissue, Graser noticed that the connective-tissue cells a little distance from the surface of the wound were first to show evidences of karyokinetic changes; hence, it is apparent that the reparative process is initiated in cells most favorably located in reference to an abundant blood-supply, which corre- sponds to the location of capillary vessels which are undergoing dilatation prior to the formation of new blood-vessels. Eegeneration of tissue takes place most rapidly in parts where new blood-vessels are developed early, rapidly, and abundantly. The healing process is retarded or completely sus- pended when the capillary vessels, new and old, are seriously altered by in- flammation. Surface Epithelia. — Epithelial cells in a normal condition receive no direct blood-supply, but their relations to the subjacent vascular tissue are so intimate, and their proliferation in the healing of surface wounds and in the repair of defects caused by pathological conditions is so largely de- pendent on the development of new blood-vessels, that the study of their regeneration among the vascular tissues appears appropriate. In the con- sideration of this subject of epidermization, it has been shown that epithelial cells are derived exclusively from an epithelial matrix, either from the mar- gin of the wound or an islet of the epiblast buried among the granulations. Loeb has very recently advanced the theory that under certain conditions connective tissue can be produced from epithelial cells, but more experi- mental proof is required to disprove the law of the specific histological func- tion of cell growth and reproduction established by Eemak. Eegeneration of epithelial cells of the hypoblast takes place in a similar manner as has been described in epidermization of a wound of the cutaneous surface. Of special interest is the rapid regeneration of the gastro-intestinal mucous membrane. A recent gastric or intestinal ulcer presents elevated and swollen margins, and, as long as this condition remains, the healing process fails to become established until the swelling subsides, and paving of the granula- tions with epithelial cells is postponed until the surface of the ulcer is nearly on the same level with the surrounding border of the mucous membrane. Griffini and Vassale made gastric fistulse in dogs for the purpose of studying VASCULAR TISSUE. 37 directly, and during the life of the animals, the process of repair of wounds of the mucous membrane of the stomach. Through the fistulse they made superficial wounds of the inner surface of the organ, and from their observa- tions they satisfied themselves that healing takes place rapidly, and that re- generation of epithelial cells occurs in the peptic glands, where even as early as the third day the epithelial cells showed evidences of active proliferation. The new epithelial cells spread over the interglandular spaces, while a part of the glandular structure is lost during the process of healing. In traumatic defects where the glands have been excised with the mucous membrane the epithelial covering of the granulating surface is derived from the preformed epithelial cells of the mucous membrane bordering the wound. At a later stage new glands are formed by karyomitotic cellular changes after the nor- mal type of development of glands in the embryo. Even the youngest glands have an outlet, and the structure increases in depth by extension of mitotic changes in that direction. Pepsin-secreting cells are found only after the glands have attained nearly their normal depth. In one instance they were found only partly developed on the fortieth day. Connective-tissue prolifera- tion takes no essential part in the growth and development of the new glands. Visceral wounds of the stomach heal kindly and rapidly. Even gunshot wounds of this organ, when made with a small bullet, may heal without sur- gical interference, more especially if at the time the injury has been in- flicted the stomach is empty and all food is withheld for a few days. A strict diet is important in the treatment of wounds or ulcers of the stomach, as Leube has obtained excellent results from treatment of chronic ulcers of this organ by an exclusive milk diet. Griffini also made the observation that the traumatic defects which he produced in the interior of the stomach of dogs healed most rapidly when food was withheld entirely for a few days, and later on nothing but milk was allowed. From these observations and ex- periments it is evident that the young cells are unfavorably affected by the action of the gastric juice. Quincke has demonstrated experimentally, which has been a long- known and familiar clinical fact, that anaemia retards regeneration of the gastro-intestinal mucous membrane. In two dogs a gastric fistula was made, and through it a defect of the mucous lining was made of the same size in both animals. One of the animals was in perfect health, and healing was completed in eighteen days. The other dog was anaemic, and the healing process was prolonged thirty-one days. In the healing of an ulcer of the stomach or any portion of the intestinal canal the epithelial cells are first to take an active part in establishing a process of repair, the connective-tissue cells entering later upon their part of tissue-production. The healing process terminates most satisfactorily when only a small amount of connective tissue is formed and the epithelial covering is completed in a short time, as such a 38 PKINCIPLES OF SURGERY. scar represents almost to perfection the normal tissue it has replaced. If a large quantity of granulation-tissue is produced by the connective tissue, and the formation of the epithelial covering is delayed for a long time, or is imperfectly accomplished, there is great danger of subsequent cicatricial contraction of the new tissue, producing a stricture. The best possible prophjdactic means against the occurrence of strictures under such circum- stances are such dietetic and therapeutic measures as will secure for the ulcerated or wounded surface such favorable conditions as will expedite the paving of the surface with •epithelial cells and limit the production of cic- atricial tissue. TRANSPLANTATION OF SKIN. Epidermization of a large granulation surface is a slow process, even under the most favorable circumstances, and the resulting cicatrix is often large, gives rise to contraction, and not infrequently becomes the seat of keloid or ulcerative processes subsequently. Modern surgery offers means by which this tedious process can be materially shortened, and healing is accomplished by the formation of a more satisfactory scar. Reverdin's Method. — In 1854 F. H. Hamilton practiced successfully transplantation of skin in the treatment of chronic ulcers, and called the procedure anaplasty. In 1870 Eeverdin discovered that small, thin pieces of superficial skin, transplanted upon a healthy, granulating surface, formed, in a short time, organic connections with the granulations, and that epi- dermization proceeded independently from such transplanted islets of skin. Later, Schwenninger demonstrated, by his experiments, that hairs could similarly be transferred to a granulating surface. An open, granulating M^ound or ulcer can be covered over with epidermis in a short time by resort- ing to Eeverdin's method of transplantation of skin. The most essential condition for success is an aseptic condition of the granulations. In sup- purating wounds this method of treatment is not applicable until suppura- tion has ceased and the granulations are small and firm. The part from which the skin is to be taken, in preference the thigh or arm, should be shaved and disinfected. The only instruments required for cutting and transferring the skin is an ordinary sewing-needle fixed in a needle-holder, or, what is still better, a pair of hasmostatic forceps and a sharp razor. With the needle the skin is transfixed, and with a razor a thin section the size of the circumference of a split pea is removed and at once transferred to the granulating surface with the needle in such a manner that the cut sur- face is brought accurately in contact with the granulations. As the de- tached portion of the skin always curls toward the raw surface at its mar- gins, it must be carefully flattened out with the point of one or tAvo needles, care being taken to imbed it well among the granulations without causing TEANSPLANTATION OF SKIN. 39 any bleeding. The grafts are planted in rows, commencing near the border and leaving small spaces between the separate grafts. Each row of grafts is then separately protected with a narrow strip of protective silk, and a thick, antiseptic compress is applied and retained by a bandage, which should exercise uniform gentle compression. The dressing should not be removed in less than a week. At this time the grafts will not only have become firmly attached to the subjacent surface, but each of them has become surrounded with a zone of new epithelial cells. As each graft now constitutes an inde- pendent centre of epithelial proliferation, the remaining portion of the gran- ulation surface soon becomes paved by new epithelial cells, and epidermiza- tion and cicatrization are rapidly completed. The results obtained by this method of treatment have not always been such as to satisfy the earlier ex- pectations. The new skin is but a poor substitute for the normal structure. Epidermization is hastened, and the results are better than after-healing without skin-grafting, but the ideal result, the formation of tissue resem- bling true skin, is not obtainable by this method of skin transplantation. Thiersch's Method.^ — If after an operation or injury it is found that a too extensive defect of the skin renders approximation by suturing impos- sible, the surgeon has it now in his power to supply the defect at once by taking large skin-grafts from another part of the body, or from another per- son, and planting them in the form of a mosaic upon the raw surface. This method of skin-grafting in the treatment of extensive superficial Avounds, as after the extirpation of a lupus, or a surface epithelioma, was devised by Thiersch. Experience has shown that grafts of the whole thickness of the skin, and an inch square, if planted smoothly upon the raw surface and kept uninterruptedly in contact with the wound by an appropriate dressing, not only retain their vitality, but enter rapidly into organic connections with the part with which they have been brought into contact, and, at the same time, their anatomical and physiological properties are maintained to perfection. Thiersch found that after eighteen hours they were supplied with new blood- vessels, which could be successfully injected from the vessels of the part to which they had become adherent. This method of transplantation of skin is now extensively practiced in connection with plastic operations about the face. For such purposes the skin is taken from the region of the trochanters, as the skin here is almost or entirely devoid of hair. All bleeding from the Abound to be covered with the grafts is carefully arrested by surface pressure before the grafts are planted, as it is necessary to secure accurate coaptation of the wound-surfaces in order to secure a favorable result. The modern method of performing rhinoplasty furnishes a good illustration of this method of skin transplantation. As a matter of course, success by this method of skin-transplantation can only be expected when the wound and grafts are aseptic, and the parts 40 PEINCIPLES OF SURGEEY. are kept in this condition at least until vascularization of the grafts has taken place. After the grafts have been planted the treatment of the wound is the same as in Eeverdin's method. During the after-treatment it is important to secure rest for the part, and to prevent, by appropriate means of fixation, even the slightest displacement of the grafts in any direction. A good plan is to apply a thin plaster-of-Paris bandage over the dressing. Schede has substituted Thiersch's for Eeverdin's method in the treatment of granulating surfaces by skin-grafting, and the results have been very gratifying. The Pig. 21.— Rhinoplasty and Transplantation of Large Skin-grafts. A, A, skin-flaps from face turned inward and covered with large flap from forehead, C after C", and B after B'. Defects covered with mosaic of large skin-grafts from trochanteric region. (Thiersch.) granulating surface is transformed into a recent aseptic wound by removing the granulations with a sharp spoon. After all bleeding has ceased the wound is covered with large skin-grafts in the manner described. The skin obtained after this method of transplantation presents a normal appearance. I have repeatedly seen that, after excision of an epithelioma of the frontal or parietal region, a defect the size of the palm of the hand was healed completely in less than three weeks by using Thiersch's grafts. This method of skin- grafting must be a welcome resource to the oculists in the operative re- TKANSPLANTATION OF SKIN. ' 41 moval of tuberculous lesions and malignant affections of the eyelids, as well as in the treatment of some forms of ectropion. Wolfe's Method. — Wolfe has obtained excellent results by covering defects of skin an inch or more in diameter with a single graft of skin de- prived of every vestige of subcutaneous fat. The removal of the graft must be done with the utmost care, to insure the entire thickness of the skin, and equal care is necessary not to transfer adipose tissue. If necessary, the graft may be fastened in place with a few fine catgut or horse-hair sutures. Hirsohberg's Method. — Hirschberg has been successful in planting large skin-grafts without depriving them of the subcutaneous fat. In my own hands Wolfe's method has yielded better results. Transplantation of Mucous Membrane. — In the treatment of traumatic or ulcerative defects of accessible mucous membranes, it would seem that restoration of the defect by transplantation of grafts of mucous membrane, if found feasible, would be the ideal treatment. The first attempt at trans- plantation of mucous membrane was conducted by Czerny, in 1871. From 1873 to 1888 it found practical application, but exclusively in ophthalmic surgery. Wolfler has recently shown that such a method of treatment is not only practicable, but has resorted to it successfully in the treatment of ob- stinate strictures of the urethra. After excision of the cicatrix at the seat of resection he sutured a circular graft of mucous membrane to each end of the resected urethra, and had the satisfaction to observe that the graft not only retained its vitality, but became adherent and constituted an essential part of the new portion of the urethra. Wolfe has also succeeded in transplanting the whole of the tissues of the conjunctiva of the rabbit on to that of man, in order to fill a defect caused by cicatricial contraction. Djatschenko, in 1890, studied this subject experimentally, and elucidated the histological process. He experimented on dogs, taking mucous membrane from the mouth and inserting it in defects made by excising portions of the con- junctiva. He found complete union toward the ninth day, no real cicatricial tissue forming. He places great stress on rendering the graft bloodless and washing it in a warm 6-per-cent. solution of salt before it is implanted. While the graft should be freed of all fat-tissue, care should be taken not to deprive it of its submucous cellular tissue, as otherwise the conditions for the rees- tablishment of the circulation in the transplanted piece are less favorable. Another* important rule laid down is to cut the graft sufficiently large to cover the entire defect, as the uncovered portion forms a scar. This method of dealing with large defects of mucous surfaces accessible to direct treat- ment holds out many inducements for future imitation. The difficulties in the way of equal uniform success in the transplantation of grafts of mucous membrane, as in skin-transplantation, are owed to the location of the seat of operation. In the former instance it must always be such as to preclude 3a 42 PEINCIPLES OF SUEGERY. the possibility of securing perfect asepsis, on the one hand, and the impos- sibility of applying an efficient protective dressing; at the same time, it is also more difficnlt to obtain the proper material for the grafting. CONNECTIVE TISSUE. The granulations seen upon a wound or ulcerating surface are formed almost exclusively by the transformation of mature connective tissue into embryonal tissue, the cellular elements of which they are composed being embryonal connective-tissue cells. This transition of mature into embryonal cells is accomplished by karyokinesis. As connective tissue is found almost in every part and organ of the body, it takes an active part in the repair of all wounds, and, when the more important tissues in the wound cannot be approximated for organic union to take place, its greater vegetative capacity enables it to produce a large amount of new material, which later forms a connecting bridge of cicatricial tissue. For instance, in a transverse wound of a muscle, where it is often difficult, if not impossible, to keep the divided ends sufficiently approximated for the wound to heal by the interposition of new muscle-cells, the gap is spanned by a band of connective tissue, which, if not completely, at least partially, restores the function of the muscle by furnishing it with two additional fixed points of attachment. G-raser has shown that the first karyokinetic changes are seen in connective-tissue cells some distance from the surface of the wound, and that the new cells reach the surface with the new blood-vessels, where they constitute the granula- tion-tissue. In aseptic wounds, where cicatrization progresses rapidly, the embryonal connective-tissue cells, or granulation-cells, are short lived, as they are rapidly transformed into mature connective tissue, which here con- stitutes the cicatrix. In suppurating wounds the superficial layer of em- bryonal cells is brought in contact with the pus-microbes and their toxins, which destroy the protoplasm of the cells, when they are transformed into pus-corpuscles, while those nearer the blood-vessels retain their vitality and capacity of undergoing cicatrization. BLOOD-VESSELS. "Wounds of large blood-vessels, with few exceptions, require such meas- ures in their treatment which completely arrest the circulation and which aim at permanent obliteration of the lumen by the usual method of cell- proliferation and cicatrization. A wound of an artery, if accessible to direct treatment, should be treated by cutting the vessel completely across and applying a ligature to each end. A small wound of a large vein can be treated successfully, under favorable conditions, by closing it with a lateral ligature. With a tenaculum the margins of the wound are transfixed, and, by making BLOOD-VESSELS. 43 slight traction, the vein-wall is raised, and around the base of the little cone thus formed a tine catgut ligature is applied. If the wound remains aseptic, the mural thrombosis at the seat of ligation is slight, and the closure of the wound is effected without obliteration of the lumen of the vessel. Larger vein wounds have been successfully treated by suturing with fine catgut. The sutures are inserted in the same manner as Lembert's suture in closing a wound of the intestine. A wound of a blood-vessel usually terminates, spontaneously or through the intervention of art, in permanent interruption of the circulation by the formation of an intravascular cicatrix. For many Vasa vasonim. Intima. Partly-formed connective tissue from erdothelia. Proliferated connective tissue in lumen. Fig. 22. — Microscopical Appearances of the Interior of Artery of Dog Forty-nine Days after Ligation. Transverse Section through Border of Artery. X 240. years it has been maintained that obliteration of a vessel after injury, dis- ease, or ligature resulted from what was termed "organization of the throm- bus." It was believed that the thrombus became vascular either from the lumen of the vessel or the vasa vasorum, and that the histological elements in the thrombus took an active part in the production of the intravascular cicatrix. Numerous experimental investigations by different authors, un- dertaken for the purpose of demonstrating that in wounds of blood-vessels healing takes place in the same manner as in the wounds of other tissues, have shown that the blood-clot always occupies only a passive role, and, if present, is only in the way of a speedy, definitive closure, which invariably is 44 PRINCIPLES OF SUEGERY. effected by proliferation from the fixed cells of the vessel-wall. Eliminating the thrombus as an active agent in the obliterating process, we can say that union between the tissues which are brought in contact by the ligature takes place by tissue-proliferation from the walls of the vessel itself. In the true sense of the word, direct or immediate imion is as impossible here as in any other wound, and, like everywhere else, the intravascular cicatrix is formed from tissue derived from the tissue of the injured vessel-wall. In case the inner tunics are severed by the ligature, the lacerated surfaces are brought in contact with the adventitia, and repair takes place as in other tissues which are largely composed of connective tissue, the process extending from both Young connective- tissue cells. Endothelial proliferation. Proliferation of connective tissue. Fig. 23. — Microscopical Appearances of the Interior of Vein of Dog Forty-nine Days after Ligation. Transverse Section of Part of Vein in Ligated Portion. X 240. sides of the ligature, where endothelia assist in the process of cicatrization. If, on the other hand, the continuity of the vessel is not destroyed by the ligature, and the intima is simply brought in contact without being ruptured, the new cells from the connective tissue perforate the endothelial lining, and the new elements of the latter join in the reparative process by being con- verted from their embryonal state into connective tissue. The histological changes in the interior of veins undergoing obliteration are the same as in arteries, the new material of which the cicatrix is composed being derived exclusively from the endothelial and connective-tissue cells. J. Collins Warren, who has done excellent work in studying experiment- BLOOD-VESSELS. 45 ally the healing of arteries after ligature, maintains that he has seen suffi- cient evidence in his specimens that the muscle-cells in the tunica media take an active part in the process of repair. The same author compares the process of healing in arteries to the formation of callus after fracture, and hence calls the intravascular material the internal and the extravascular the external callus. Ballance and Edmunds, in their classical work, "Ligation in Continuity," have given the profession the most reliable and exhaustive treatise on this subject. The numerous experiments of the author on ligation of arteries and veins have demonstrated, to his own satisfaction, that the most speedy obliteration of a vessel is obtained if the vessel is rendered blood- less by the application of two ligatures. The ligatures are applied with suffi- cient firmness to obliterate the lumen of the vessel ivithout rupturing any of its coats. After ligation the walls of the vessel became thickened; so that, a few weeks after the ligatures had been applied, the vessel presented a spindle shape, tapering toward each side, a condition entirely due to the formation of new material: the external callus of Warren. The bloodless Fig. 24.— Femoral Artery of Dog Fifty Days after Double Ligation with Silk. Be- low, Transverse Section showing Bloodless Space Filled with Cicatricial Material. (Nat- ural size.) space between the ligatures is obliterated in a short time by cells which enter it from the vessel-wall. In the obliteration of veins and ligation of arteries in their continuity, the double ligature, including a bloodless space about ^/a inch in length, places the tissues in the most favorable conditions for speedy, definitive closure by an intravascular cicatrix. When the vessel is exposed catgut should be used, but in the subcutaneous ligation of veins silk is preferable. Since the introduction of antiseptic surgery and the aseptic ligature, sec- ondary haemorrhage has become an exceedingly rare accident, and, when it does occur, it is in wounds where the antiseptic measures have failed. A vessel in an aseptic wound, tied with an aseptic ligature, becomes, in a few hours, the seat of a regenerative process which effectually guards against the possibility of hsemorrhage, even if the mechanical obstruction caused by the ligature should be removed after a few days. The aseptic ligature, applied under strict antiseptic precautions, has been advantageous in other directions. The older surgeons always expected, after ligating an artery in its continuity, that the thrombus would extend on the proximal side to the 46 PEINCIPLES OF SUEGERY. nearest collateral branch, and, on this account, they were ahvays anxious to secure a space of an inch or more between the ligature and the nearest large collateral branch, in order to prevent secondary hsemorrhage. The aseptic ligature is never followed by such extensive thrombosis, and the intravas- cular cicatrix is often exceedingly narrow, — in fact, almost linear. The lim- ited thrombosis and the prompt formation of an intravascular cicatrix place the surgeon now in a position that he can ligate a large artery, close to a collateral branch or near a point of bifurcation, without a particle of fear of incurring secondary haemorrhage. In the ligation of veins the aseptic liga- Fig. 25. — Collateral Circulation Bight Months after Ligation of the Aorta in a Dog. (Luigi Porta.) ture has dispersed all fear of suppurative thrombophlebitis and pygemia: com- plications which were formerly so much feared, even after insignificant op- erations on veins. In the repair of wounds union between the divided ends of blood-vessels is probably never effected. The vessel-ends are temporarily closed either by tying with a ligature or by the formation of a thrombus, the former being the case when vessels of some size have been divided, the latter being accomplished usually spontaneously in vessels which give rise to parenchymatous haemorrhage. In either instance the ends of the vessel are, later, permanently sealed by the formation of a cicatrix by proliferation of fixed tissue-cells, the endothelia, and connective-tissue cells. The inter- rupted circulation between the two sides of the wound is restored indirectly MUSCLES. 47 through collateral branches, which are always new blood-vessels. The angio- blasts in the injured capillary vessels assume active tissue-proliferation within twenty-four hours after the injury has occurred, and through them, almost exclusively, the new blood-vessels are formed, in the shape of loops, which, coming, as they do, from both sides, establish the vascular connection be- tween the two surfaces of the wound. (See Fig. 25.) Many of these new blood-vessels disappear ' after the consummation of the reparative process, while others remain as permanent collateral vessels between the closed ends of the old blood-vessels permanently separated by the injury. MUSCLES. It is only quite recently that it has been ascertained that a divided mus- cle can unite, under favorable circumstances, by interposition of new mus- cular tissue between the divided ends. It was formerly believed that healing was always accomplished by the formation of connective tissue, and that the ends of the cut muscle remained permanently separated by a bridge of cic- atricial tissue. The theory that connective tissue can be transformed into muscular tissue is untenable, since Pflueger has demonstrated the minute striicture of muscular fibre. Kolliker has shown that the fibrillse in the mus- cle-fibre constitute the real ground-substance. Eabl ascertained, by his em- bryological researches, that the muscular tissue is derived from a distinct portion of the mesoblast, and, consequently, proved that, at a very early period of embryonal life, an absolute difference takes place between mus- cular and connective tissue. Heterotopic muscular structures must, there- fore, be looked upon not as products of connective-tissue proliferation, but as a growth from a displaced embryonal matrix of muscular tissue. The vegetative capacity of muscle-cells, striped and unstriped, is quite limited, as compared with some of the other tissues; so that, if the ends of a muscle that has been cut transversely are separated for more than an inch, complete restoration of the continuity of the muscle is not attained, and the two ends are connected by a band of connective tissue. If, during the heal- ing of the wound, the cut surfaces of the muscle are kept in accurate contact, and even if a gap of half an inch exist between them, restoration ad integrum takes place by proliferation of the muscle-elements near the seat of injury. Non-striated Muscular Fibre, — Stilling and Pfitzner, as well as Busachi, have shown that unstriped muscular fibres multiply by indirect division of their nuclei, and, in the repair of wounds of this tissue, new fibres are pro- duced exclusively by this method. These authors studied the karyokinetic changes in the muscular fibres of the Triton tceniatus. They observed, after the division of the nucleus in the usual manner by karyokinesis, that as the new nuclei separated and approached the poles of the cell the protoplasm 48 PEINCIPLES OP SUKGEEY. of the cell-body at the transverse axis became narrower, showing a well- marked constriction, which would indicate that subseqnentl}^ cell-division occurred. Herczel witnessed similar changes in the hypertrophic muscular coat of the intestines on the proximal side of strictures. In defects caused by the injury, removal, or destruction of unstriped muscular fibres, regen- eration takes place only from the margins, while the centre at first is oc- cupied by connective tissue. The new muscular fibres are at first irregularly arranged, and it is only toward the completion of the healing process that the new tissue represents to perfection the mature muscular fibres. Klebs is of the opinion that the leucocytes serve as food for the cells which undergo karyokinetic changes. Striated Muscular Fibre. — 0. Weber, as early as 1854, claimed that in the healing of wounds new muscular fibres are produced, but, in accordance with the views which then prevailed, believed they were derived from con- nective tissue. Wittich saw, in hibernating frogs, new fibres which he be- lieved had developed from the cells of the internal perimysium. In 1865, after an examination of a genuine myoma striocellulare. Buhl expressed the opinion that new muscular fibres are produced from old fibres. In the same year Waldeyer discovered the muscle-cell sheath, and he regarded the cell inclosed by it as a derivative of the nucleus of the fibre, but, with Zenker and others, he still regarded the perimysium as the source of new muscular fibres. In 1868 E. Neumann made the observation that after section or laceration of a muscle the ends of the fibres became the seat of active tissue- changes, which resulted in the formation of what he termed muscle-buds. These muscle-buds were not only found at the ends of the fibres, but also on their sides; at first they were seen to be composed of numerous nuclei and protoplasm, while later they were transformed into striated fibres. The sar- colemma is such a delicate structure that new cells which form within it readily find their way through it, and appear upon its outer surface in the shape of buds, as described by Neumann. Tizzoni has recently investigated the karyokinetic changes in the nuclei or sarcoblasts in the perimysium during the repair of muscle wounds. The first evidences of cell-proliferation were seen in the nuclei or myoblasts nearest the seat of injury, and proliferation took place in fibres which had undergone degeneration as well as in those which presented a striated ap- pearance. Leven found, during the first twenty-four hours after injury, an increase of nuclei of the sarcolemma-sheath. These new neuclei are arranged in the form of rows and heaps, and by mutual pressure are flattened. Many of these new elements present karyokinetic figures, and aroimd them proto- plasm is deposited, and the new cells become spindle-shaped. The new cells increase in number from the third to the fourth day, so that at this time from five to six can be seen under one field. Klebs studied regeneration of mus- MUSCLES. 49 cle in young guinea-pigs after puncturing subciitaneously the gastrocnemius muscle. He came to the following conclusions: A portion of the muscular fibres die and shrink, and in this condition they can be stained more deeply with hsematoxylin than the others. Such fibres are completely removed by absorption within the first four days. In the fibres which remain striated the fibrillse become plainer, and in them the regenerative process can be dis- tinctly seen. The nuclei increase in number, and are packed densely to- gether, but at this stage he was unable to detect any evidence of karyokinesis. During this stage Steudel was also unable to detect any appearances which indicated indirect cell-division. These young cells are called sarcoblasts by Klebs, and their transformation into muscle-fibres is effected by aggregation Fig. 26.— Muscular Fibres Near a Wound in a State of Proliferation. A, contused end of muscular fibre; B, muscular fibre retracted within sarcolemma, the latter ter- minating in a sharp point; C, old fibre degenerated into a colloid mass; D, young nuclei between and upon fibres; E, nuclei surrounded by cell-protoplasm; F, new cell, show- ing striations; G, new muscular fibre. (0. Weher.) around them of a very thin layer of protoplasm. The youngest cells are round, and the change into spindle form is gradual. The new cells are arranged in rows between the old muscular fibre (Fig. 26, between G and B). Some au- thors believe that the sarcoblasts unite end to end, and that the muscular fibre is formed in this manner. Kraske and Klebs maintained that muscular fibres result from a single cell by gradual elongation of the cell-body. In the regeneration of the muscular fibres of the heart after injury, Martinti and Bonome witnessed karyomitotic changes in the interior of the sheath of numerous fibres, while in others where degenerative changes had taken place no such changes could be seen. In wounds of the heart of old rats karyo- mitosis commences five to six days after the injury, and does not last longer than six to seven days, and results only in incomplete regeneration. In myo- 50 PRINCIPLES OF SURGERY. carditis the formation of new muscular fibres has been observed by Yirchow, Boettcher, and Waldeyer. Muscle-suture. — In the treatment of recent wonnds special pains should be taken to secure accurate approximation between the ends of divided mus- cles. For this purpose special means must be employed when large muscles have been divided transversely. In such cases the retraction which follows gives rise to great separation, which can only be overcome by suturing re- spective ends separately with buried animal sutures. Great care is necessary not to invert the margins, but to unite the cut surfaces throughout, using for this purpose, if necessary, as many as six sutures, which must include considerable tissue in order to prevent their tearing through. The muscle- ends should be secured with a mattress-suture of chromicized catgut as shown in Fig. 27, and the edges carefully coaptated with three or more points of Fig. 27. — Muscle-suture. suture of the same material. In muscles supplied with a well-marked sheath this should be sutured separately. In the after-treatment it is necessary to place the limb in such a position that will relax the sutured muscles, and to secure immobility of the limb in this position by a proper mechanical sup- port, which should not be removed until the healing process is completed, in order to prevent subsequent diastasis between the sutured ends. When it is desirable to elongate a contracted muscle in the correction of deformities, as in the treatment of torticollis, the contracted muscle should be exposed by incision, and after section a suture a distance is applied. A number of heavy catgut sutures will answer an excellent purpose, as they will maintain fixation of the separated ends in a desirable position, and will furnish an admirable scaffolding for the new connective-tissue cells, which, later on, are transformed into a tendon which permanently connects the retracted ends of the divided muscle. MUSCLES. 51 Tenorrhaphy. — The operation of suturing a tendon is called tenor- rhapliy. The histological processes in the regeneration of a tendon are the same as in the repair of connective tissue. Tendons are composed of com- pact connective tissue surrounded by a delicate membrane: the tendon- Pig. 28. — Tenorrhaphy, a, mattress-suture; 6, c, after Wolfler; d, e, paratendinous suture, after Hueter. (Esmarch.) sheath. In injuries of tendons the fibroblasts furnish the new material^ which is interposed between the cut or torn ends and which restores the con- tinuity of the tendon. The process of repair is instituted near the tendon- ends and shows itself in the splitting up of the fibrils. The new material acts Fig. 29.— Tendoplasty. a, after Madelung; &, after TiUaux; c, after Hueter; d, after Gluck. (Esmarch.) first the part of a cement-substance, but in the course of two or three weeks is transformed into new connective tissue. In open wounds, complicated by injury to tendons, the careful surgeon never neglects to place the tendon- ends in the most favorable conditions for speedy and satisfactory repair by 52 PKINCIPLES OF SUEGEEY. resorting to primar}' tendon-suture. If a number of tendons have been in- jured at the same time, it is often difficult to identify the ends which belong together and much time is often consumed, and a great deal of care must be exercised in finding and suturing the respective ends. If the proximal end has retracted into the sheath beyond easy reach it is better to lay the sheath open than to make repeated fruitless attempts to grasp the tendon. The best suturing material is chromicized catgut. The technique of tenorrhaphy is well shown in Fig. 28. ' The surgeon is often called upon to restore the continuity of a tendon Fig. 30.— Secondary Suturing of Extensor Tendons of Fingers by the suture a distance. (E. J. Senn.) in cases in which primary tendon-suture was neglected or in which it failed, and then resorts to secondary tenorrhaphy, which is performed in the same manner as primary tendon-suture, after the tendon-ends have been exposed and vivified. Tendoplasty. — In cases in which the loss of substance in tendon injuries renders approximation of the tendon-ends impossible, and in many cases of open tenotomies for contractured tendons, restoration of the continuity of the tendon can only be secured by a plastic operation, which in this instance MUSCLES. 53 is called tendoplasty. A number of valuable procedures are shown in Fig. 39. Gluck interposes between the ends of the tendon a braided bundle of catgut, which acts as a temporary bridge-work for the fibroblasts and which is replaced, in the course of time, by permanent tissue. E. J. Senn employed this method of suturing; a distance, with 2:reat success in a case of extensive 1. — Tendon-elongations. loss of tendon-tissue involving all of the extensor tendons of the fingers of one hand. The degree of separation of the tendon-ends and technique of operation are shown in Fig. 30. The patient recovered full use of the ex- tensor tendons in the course of two months. An exceedingly valuable method of effecting elongation of a contract- ured tendon was devised by Anderson. It consists in splitting the tendon longitudinally and cutting each half on opposite sides sufficiently far apart 54 PEiNCirLES or surgery. so that tlie necessary degree of elongation can be secured by suturing to- gether, end to end or laterally, the long ends. (Fig. 31.) In uniting a large tendon, either by simple suturing or by a plastic operation, it is important to suture the sheath separately; or, if this is absent, to make a new sheath of connective tissue with which the tendon should be covered. Immobiliza- tion of the limb must be continued until the process of repair is completed, which will require from three to six M'eeks. BONE. The granulation material by which the fractured bone unites is called callus. According to the location of this material around, within, or between the fragments, we speak of an external, internal, or intermediate callus. The external, or provisional, callus is abundant, as a rule, where the broken bone is surrounded by a thick cushion of soft parts, and when the fragments are not well immobilized. It forms early and disappears gradually after the fracture has united. The internal, or medullary, callus, which takes the place of the medullary tissue in fractures of the shaft of the. long bones, serves a useful purpose as a means of fixation of the fragments, and is also removed in the course of time after union has taken place, and with its dis- appearance the medullary cavity is restored. The intermediate, or definitive, callus is the material interposed between the broken surfaces, and which is transformed into permanent tissue. Callus is the product of cell-prolifera- tion of those tissue-elements which are directly concerned in the growth and development of bone. Duhamel de Monceau attributed to the periosteum and endosteum the function of producing callus. Haller and his prosector, Detlef, believed that the periosteum takes no part in the regeneration of bone, but that callus is derived from the fractured ends of the bone, more especially the myeloid tis- sue. Dupuytren maintained that the periosteum and the paraperiosteal con- nective tissue were bone-producing tissues. Cruveilhier claimed that the , lacerated soft tissues around the fractured bone-ends, the jDcriosteum, con- nective tissue, muscles, tendons, etc., furnished the material for the callus. Flourens claimed that the periosteum alone could produce new bone. Rokitansky asserted that callus is developed directly from bone and its con- nective tissue, including the periosteum. From his own experimental work, R. Heine came to the conclusion that regeneration of bone takes place from connective tissue in and around bone and the periosteum. According to Virchow, callus is produced from connective tissue outside of the bone, as well as from the medullary tissue. Hofmokl considered as sources of callous formation the periosteum, bone, and marrow. Gegenbauer takes the ground that bone is produced directly from connective tissue. He asserts that BONE. 55 Sharpey's fibres, if traced carefully, can be seen springing from a bony point between the Haversian canals, from which point they radiate toward both sides into the lamellar systems. The fibres form net-works, and -at points of intersection bone-cells are produced, and a deposit of lamellse takes place aronnd the connective-tissue fibres. It is now generally conceded that the provisional callus is the product of tissue-proliferation from the periosteum, while the definitive, or perma- nent, callus is produced directly from the medullary tissue. The provisional '11 '" 1 A^M' Fig. 32.— Section through Callus Fifty-two Hours after Fracture of Ulna from Rabbit. Beginning Formation of Osteoid Tissue. A, cortical portion of bone; B, osteoid tissue; O, beginning of formation of a lamella, surrounded by osteoblasts; D, perios- teum. (Hartnack, obj. 8.) (.Bajardi.) callus is Nature's splint, its only object being to immobilize the parts until the definitive callus firmly and permanently unites the fragments. The temporary callus is an accidental product, and appears earliest and most copiously where the paraperiosteal tissues are most abundant and motion be- tween the fragments greatest; the intermediate or permanent callus is pro- duced later, and is transformed into permanent tissue. Oilier and Bucholtz, in their experiments on transplantation of periosteum, found that the trans- planted tissue first produced cartilage, which later was transformed into 56 PEINCIPLES OF SUEGERY. bone; but they also ascertained that such bone disappeared again unless it formed in a place where bone normally exists. Cohnheim and Maas came to the sama conclusion from their experiments on intravenous transplantation of periosteal graft. It is possible that special cells (Mastzellen) are the active agents in the removal of tissue in places where it has no physiological exist- ence. Macewen has maintained for years that bone grows only from bone,' and the results obtained by applying this principle in practice speaks strongly in favor of this supposition. That medullary tissue alone can produce bone has been experimentally demonstrated by Bruns. The osteoblasts from R jH - '- ■ — p Fig. 33.— Transverse Section through Callus of Tibia of Rabbit Forty Days after Fracture, with External Resorption. P, periosteum, much thickened; R, giant cells or osteoclasts; Q, blood-vessels; M, medullary resorption-spaces; K, compact portion of bone. {MO'O'S.^ which bone-production alone can take place are found in the periosteum, more especially its inner layer, the cambium, and in the interior of bone. Eegeneration of bone from these cells takes place in two ways: either the cells are transformed into an osteoid tissue or they are first changed into cartilage-cells, and the latter at a later stage undergo ossification. The osteo- blasts in the periosteum, and, to a lesser extent, those in the central medul- lary cavity, produce bone by this indirect method, while in other places ossification is effected in a more direct way by the osteoblasts being trans- formed into an osteoid substance. In the normal regeneration of bone cartilage plays an important part. BONE. 57 As the bone-cells disappear, or at least lose their nuclei where cartilage- cells form, it is probable that the cartilage-cells represent structures inter- mediate between osteoblasts and bone-cells. Cartilage is abundant where union is retarded, and especially in cases of pseudarthrosis. During ossifica- tion the hyaline cement-substance between the cartilage-cells is dissolved, and the space gives way to lamellae, while the cells are transformed into bone-cells. According to Krafft, multiplication of the bone-producing cells of the periosteum can be seen twenty to thirty hours after fracture, in the shape of karyokinetic figures in the nuclei of the cells, while somewhat later the same figures are to be seen in the endothelia lining the blood-vessels. The new cartilage-cells also multiply by karyokinesis. Like in the healing of wounds in soft parts, the cells on the surface of the fracture take no part in the process of regeneration, as their proliferative capacity has been de- stroyed by the trauma as well as the sudden diminution of the vascular sup- ply. Osteoporosis at the seat of regeneration is always present, and results from the action of another kind of cells discovered by Kolliker, — the osteo- clasts. Eobin described them as my elo plaques. They are found in How- ship's lacunae, where resorption takes place. The osteoclasts appear to be nothing else but myeloid cells which have lost their bone-producing function; they are, in reality, hyperplastic osteo- blasts. Absorption of bone takes place because these cells do not produce bone. There is no reason to believe that these cells are altered bone-cells, as no intermediate forms have been found. Ziegler does not assign much influence to these cells in the resorption of bone. Wegner has shown that in pathological processes in bone where resorption takes place they are arranged along the sides of blood-vessels, and on this account he believed they were derived from the vessel-wall. Klebs is of the opinion that the osteoclasts may secrete a chemical substance which decalcifies the bone. Eesorption of superfluous callus is accomplished undoubtedly by the action of osteoclasts, an exceedingly useful function, as by it form and strength of the broken bone are restored. According to Meyer, the architectural structure of the spongiosa, after the healing of a fracture, adapts itself to the new conditions, so that the new traction and pressure-curves are arranged in such a manner as will resist the greatest degree of force. This capacity of adaptation is present to a very high degree in bone. Abnormal and Defective Callus. — Callus may be formed in excess of local requirements after a fracture, and yet no union take place. The osteo- blasts respond promptly to the stimulus created by the trauma, karyokinetic changes occur early, new cells are formed with great rapidity, and a large mass of new material is deposited at the seat of fracture, but bony consolida- tion does not occur, because the new tissue does not undergo ossification. 58 PRINCIPLES OF SUEGERY. The normal development of cells is arrested at an early stage, and the chem- ical processes upon which ossification depends are delayed or fail to appear altogether. Prompt bony union does not only imply that the osteoblasts at the seat of fracture should undergo karyokinetic changes and multiply, but that the new tissue must be placed under the influence of favorable chemical conditions which will enable it to be transformed into bone. A few years ago B. von Langenbeck reported two cases of fracture of the femur where he resorted to amputation of the thigh under the belief that the luxuriant callus, which formed in each case at the seat of fracture, was a sarcoma. Microscopical examination in both instances showed that the swelling was composed of cells which are found in callus at an early stage of its formation, without any evidences of ossification of the new material. The causes of delayed ossification are not known, but, as in a number of instances of profuse callous formation and delayed union a vigorous anti- m ^ w Fig. 34.— Osteoclasts Absorbing Bone. A, osteoclasts. B, osteoblasts. syphilitic course of treatment produced favorable results, it appears that the virus of syphilis may at least be one of them. We know that in gummata the same conditions prevail in the persistence of tissue in its embryonal state for an indefinite period of time, or until the syphilitic virus has been re- moved or neutralized by proper antisyphilitic treatment. In cases where no such cause for the delay of the transition of callus into bone can be surmised, the internal administration of minute doses of phos- phorus should be tried. KassoAvitz produced osteoporosis in animals ex- perimentally by large doses of phosphorus, while minute doses produced an opposite effect. He recommended the remedy in small doses in the treat- ment of rickets, and since then it has been extensively used in the treatment of this disease, and with the best results. The action of this drug undoubt- edly would produce a favorable effect upon the osteoid material, in hastening its transition from the embrvonal into a mature state. BONE. ' 59 The amount of callus thrown out in every instance depends on: 1. The general condition of the patient. 2. The location and structure of the fract- ured bone. 3. The amount of local injury. 4. The degree of displacement. 5. The perfection of immobilization. As a rule, a minimum amount of callus is produced when the patient is suffering from any wasting or acute febrile affection or is the victim of any so-called constitutional diseases; when the broken bone is very com- pact and located near the surface of the body; when the injury was slight, with little or no displacement, and when during treatment the broken ends have been kept at rest and in constant and in uninterrupted coaptation. Opposite conditions are followed by an exuberant production of callus. The influence exercised by paraperiosteal tissues in determining the amount of callus is well illustrated in fractures of the tibia and ulna; where the bone is subcutaneous little or no callus is found, while in places where it is deeply covered by muscular and aponeurotic tissue the amount of callus is great, — in some instances so great that it fills the entire interosseous space, forming a bridge of bone across it, permanently cementing the fibrda or radius, as the case may be, to the broken bone. To obtain bony consolidation after a fracture certain well-recognized conditions are necessary: 1. A sufficient blood-sujaply to the part. 2. Un- impaired innervation of the part. 3. Placing and maintaining the frag- ments in contact, or at least in such close proximity that the callus thrown out from both extremities can meet and establish a bony bridge between. Injury of any principal vessel or nerve of a limb, as a .complication of any fracture, does not only endanger the integrity of the limb, but may consti- tute an important element in the production of non-union. Injury of the nutrient vessels of long bones has no influence in prevent- ing the formation of callus, claimed by several writers, inasmuch as the com- bined statistics from the practice of different surgeons do not sustain this assertion. An excessive supply of blood in the part — either from an undue afflux of blood, the consequence of an excessive irritation about the seat of fracture, or from obstruction to the venous return — frequently affects callous formation in a detrimental manner. These conditions often interfere with the normal reparative process, the histological elements which are intended to furnish the callus not undergoing the ty]oical embryonal tissue-transforma- tion. The following are the principal causes which have been enumerated as giving rise to false joints: — , Rachitis. Syphilis. General i ^i:°^^.^™^;. Acute febrile affections. I Wasting diseases. Preo-nancy L Prolonged lactation. *= -^ 60 PEINCIPLES OF SUEGEEY. f Interposition of soft tissue between fracture. I Separation of fragments. I Imperfect immobilization. Local -{ Imperfect circulation from concomitant swelling, too tight I dressing, or position of limb. I Obliquity of fracture. I, Complication of fracture. I have not enumerated old age as a cause for delayed or non-union. Statistics show that these accidents are found almost exclusively in young people at the age of 20 to 35 years. With the exception of joint fractures. Fig. 35. Fig, Fig. 35.— Old Method of Bone-suture. Fig. 36. — ^Improved Bone-suture. Transverse Fracture, Wire Suture including Entire Thickness of Both Fragments. fractures unite promptly and in a short time in the aged. Senile osteoporosis may be considered a favorable condition for a callous formation. A great diversity of opinion prevails among surgeons in regard to the influence of general conditions on the production of callus. Some claim that non-union is almost invariably due to general causes. I recollect very well the remark of the late Professor von E^ussbaum on this subject. In a lecture he claimed that nearly all, if not all, fractures that fail to unite by Fig. 37. Fig. 38. Fig. 37. — Wire Drawn through the Perforation. Fig. 38.— Wire Cut in the Centre and Each Half Twisted Separately. bone occur in patients suffering from some constitutional taint, more espe- cially syphilis. He referred to several cases where no attempt at union took place imder the most favorable local conditions, and where a course of mer- curial inunction was promptly followed by bony consolidation. Defective callous formation will necessarily follow a fracture if the osteoblasts fail to enter upon an active process of cell-proliferation. These are the cases where the surgeon resorts to local measures which are intended BONE. 61 to stimulate the cells to increased activity. Fractures of the lower extremi- ties which have failed to unite as long as the patient is kept in bed often unite promptly after he is allowed to walk around on crutches, the favorable change being brought about by an increased blood-supply to the seat of fracture. Dumreicher suggested that the local blood-supply could be increased by applying a compress and bandage above and below the seat of fracture, while Helferich more recently, and with the same object in view, advised Fig. 39. — Senn's Hollow Perforated Intraosseous Splint. moderate constriction with an elastic bandage applied in such a manner as not to interfere with the arterial circulation. Eubbing of the fragments forcibly against each other is an old method of treating delayed union, and has often been sufficient to rouse the dormant osteoblasts into active cell- proliferation. The distinguished Brainard made the treatment of delayed union a special study during many years of his useful life, and devised a new method of treatment, — the subcutaneous drilling of the ends of the frag- ments, — which has been extensively practiced and has yielded most excel- Fig. 40. Fig. 41. , Fig. 42. Fig. 40. — Circular Bone Ferrule for Humerus or Femur Made of an Ox-femur. Fig. 41. — Triangular Bone Ferrule for Tibia Made of an Ox-tibia. Fig. 42.— Wide Perforated Bone Ferrule. lent results. The drilling of the ends of the broken bone has a most de- cided effect in stimulating the sluggish reparative process, as it produces osteoporosis and increases the vascularity of the parts, both of these condi- tions being well calculated to increase the local nutrition. Dieffenbaeh went one step farther, and advised the use of ivory nails, which were allowed to remain until they became loose and dropped out. The term non-union is a relative one, as in some fractures this condition may have been reached in three to four months, while others may unite after a year. 62 PKINCIPLES OF SURGEKY In a fracture of the femur, in a healthy man who came under the au- thor's observation, that had not united a year after the accident, bony con- solidation took place after this time without any operative interference. In another case bony union did not occur until nearly two years after.the fract- ure had taken place. When a pseudarthrosis has once become established, Fig. 43. ' Fig. 44. Fig. 43.— Oblique Fracture of Femur United by Bone Ferrule. Fig. 44.— Transverse Fracture of Humerus Immobilized by a Wide Perforated Bone Ferrule. all measures which have been found useful in the treatment of delayed union are useless, and the only rational treatment in such cases consists in transforming the old fracture into a recent one. The ends of the fragments are exposed, the interposed ligamentous structures— muscles or tendons — or false joint excised, and the ends vivified in such a manner as to furnish large surfaces for apposition. The bone should never be cut transversely, but BONE. 63 always obliquely, or, what is still bef;ter, Volkmann's step-operation should he done wherever the existing conditions make this possible. Direct fixa- tion of the fragments with aseptic bone or ivory nails should always be prac- ticed, as by this expedient we are able to secure greater immobility between the fragments, and at the same time the perforations and the presence of the foreign bodies cannot fail in imparting an additional stimulus to the tissues which will expedite the process of repair. The silver-wire suture has been used for a long time to secure fixation of the fragments in recent fractures and in cases of non-union. Fig. 45.— Senn's Splint Apparatus Applied; Pad Making Pressure over Trochanter in the Direction of Neck of Femur. In uniting oblique fragments Wille's method of suturing, shown in Figs. 37 and 38, is to be preferred. Bircher has employed cylinders of ivory, which he introduced into the medullary cavity as a means of fixation. The writer has substituted, for the solid ivory, hollow perforated intraosseous splints to meet the same indications. As another means of direct fixation, the author has devised and successfully employed bone ferrules in a number of cases. The shape, size, and application of these ferrules are well shown in the accompanying illustrations. (Figs. 39 to 42.) The frequency with which non-union is met with after intracapsular fracture of the neck of the femur has almost by universal consent been at- 64 PEINCIPLES OF SUKGERY. tributed to defective callous formation. It has been claimed that in such a fracture, occurring as it usually does in persons advanced in life, callous production is always defective, and, as the upper fragment is but scantily supplied with blood-vessels, it was asserted that it was not in a condition to take an active part in the reparative process. The author made numerous experiments on animals, fracturing the neck of the femur within the limits of the capsular ligament, and as long as the fracture was treated in the cus- tomary way bony union was never attained. He then resorted to direct means of fixation by transfixing both fragments with an absorbable nail, and with this treatment succeeded in obtaining^bony union in the majority of cases. Since that time he has treated fractures of the neck of the femur by im- mediate reduction and permanent fixation with a plaster-of-Paris splint, with pressure over the trochanter major in the direction of the axis of the neck of the femur with a compress and set-screw, the latter passing through a Fig. 46. — Senn's Splint Apparatus for Treating Fracture of Neck of Femur. splint which is incorporated in the plaster-of-Paris dressing. With this treat- ment he has obtained bony union in a number of instances where all the signs and symptoms pointed to a fracture within the capsular ligament. It is a well-established clinical fact that in the aged other fractures unite readily, and pseudarthrosis is exceedingly uncommon, excepting after this fracture; and the writer is satisfied that this undesirable result occurs more in consequence of improper treatment than defective callous pro- duction. If the fragments can be brought in accurate apposition soon after the accident has occurred, and coaptation can be maintained uninter- ruptedly for three months by an appropriate dressing, bony union can be secured, not only in exceptional, but in the majority of, cases. In the treat- ment of fractures, as in the treatment of wounds of the soft parts, accurate coaptation and effective fixation should be aimed at, so as to place the parts in the most favorable condition to unite by the smallest possible amount of new material. GLANDS. 65 GLANDS. Testicle. — Griffini studied regeneration of testicle-substance in frogs, dogs, chickens, and guinea-pigs. He excised a wedge-shaped piece under strict antiseptic precautions, and killed the animals in from three to seventy- five days. Examination of the specimens showed that an increase of tubuli seminiferi had invariably taken place. They appeared to have originated as blind pouches from preexisting tubules. Liver. — Tizzoni has also observed, in his experiments on dogs, produc- tion of new gland-tissue during the healing of wounds of the liver and after partial excision of this organ. Ponfick studied regeneration of liver-tissue in dogs and rabbits, remov- ing two-thirds to three-fourths of the organ. The animals were killed in from two to fifty days. Karyokinetic changes were seen as early as the second day. Following regeneration of the parenchyma, vascularization of the new tissue set in promptly. Eegeneration of the biliary ducts was studied by injecting indigo-carmin into the circulation. The animals were killed in from one and one-half to two hours, and even at this early period after operation distinct evidences of a beginning process of repair were de- tected. There are now a number of cures recorded in which extensive losses of liver-tissue caused by injury or operation in the human were repaired without any functional disturbances following. Spleen. — The same author studied experimentally regeneration of the spleen-tissue, and found that this occurred after partial and complete ex- tirpation, the new tissue being made up of elements in connection with blood-vessels of the adjacent peritoneum. After complete extirpation of the organ the new spleens appear as nodules of a brownish color, which are attached to the vessels of the peritoneum, and develop around new buds of these vessels. The beginning of such a minute spleen appears as an accumu- lation of new, loose, connective tissue, in the meshes of which lymph-cor- puscles are found; later, follicles and pulp-substance appear, with a corre- sponding arrangement of blood-vessels. As these little organs always appear about the hilum of the spleen, they cannot be supernumerary spleens. After excision of wedge-shaped pieces of the spleen, formation of new spleen-tissue has also been observed upon the omentum at a point opposite the wound and independently from tissue-proliferation in the wound. Eeproduction of tissue therefore takes place in the same manner as in the regeneration of lymphatic tissue. After the removal of the entire spleen, tissue-proliferation takes place in the adjacent blood-vessels, the product of which corresponds with normal splenic tissue, and doubtless possesses the same physiological functions. As the immediate result of such proliferation, an altered condi- tion of the vessels must be accepted, as the blood-vessels of the omentum e6 PEINCIPLES OF SURGERY. and peritoneum correspond with the fundus of the stomach. Mayer claimed regenerative capacity for the pulp of the spleen, but he may have been de- ceived by the presence of lymphatic glands of the color of the spleen at the seat of extirpation. Picard and Malassez, Bizzozero and Salvioli, and finally Tizzoni and Fileti showed that after splenectomy a diminution of the blood- corpuscles is observed first, but as the new spleen-tissue is produced their number again increases. Lymphatic Glands. — Bayer and Bacialli have shown, by their experi- mental investigations, that new Ij'-mphatic tissue is rapidly produced after partial as well as after complete removal of a lymphatic gland. In the regen- eration of this tissue the adjacent adipose tissue appeared to take an active Fig. 47.— Wound of Kidney, Fourth Day. Large regeneration-cells of different forms (6) ; a, blood-extravasation containing new cells (c) produced by coalescence of leuco- cytes. (Tillmanns.) part. According to Bayer, the adipose tissue is first infiltrated with leuco- cytes, while Bacialli saw new endothelial cells and lymph-spaces develop from the connective-tissue cells, after having seen mitotic figures in the nuclei. After complete extirpation of a lymphatic gland, reproduction of lymphoid structure in all probability does not take place from any other but lymphatic tissue, and the new gland-tissue is the product of tissue-prolifera- tion from the cut ends of lymphatic vessels. Kidney. — The experiments of TuJffier have demonstrated that the kid- ney is endowed with a recuperative capacity which is common to nearly all of the glandular organs. They show that it is possible to successively re- move a large part of the normal renal tissue, and that, after a certain num- ber of days, — the sooner, the less renal parenchyma removed, — the specific CEXTEAL KEEVOUS SYSTEM. 67 gravity of the urine and the excretion of urea are perfectly reestablished, and that compensation was due partially to hypertrophy of the remaining paren- chyma and partially to the new formation of glomeruli, and this happened even in cases of animals in which one kidney had already been extirpated, and was folloAved by a partial removal of the kidney on the other side. Tuffier, as a result of his experiments, states that, in animals, from 15 to 33 grains of renal gland-tissue are sufficient for two pounds of weight. Esti- mating the weight of the human body at one hundred and forty pounds, from 1200 to 1500 grains of renal parenchyma, apart from the capsule, which is not counted, are sufficient to maintain life. This would amount to about one-third or one-fourth of the normal organ. Surgically, therefore, it is possible to remove a large part of the kidne}^ the remaining portion still retaining its function; and in partial destruction of the renal tissue it is not necessary to remove the whole organ, and we can be satisfied with a par- Fig. 48.— Healing of Wound of Liver, Tenth Day. a, young connective tissue; b, liver-tissue at the margin of the wound, showing fatty degeneration, and infiltrated with red and white blood-corpuscles. (Hartnack 3, oc. iii.) (Tillmanns.) tial excision, es]Decially if the condition of the other kidney is not known. Partial excision may become necessary in injuries of this organ, in circum- scribed abscesses, and non-malignant tumors. Successful partial nephrec- tomy has been done by Herczl, Kiimmell, James Israel, and others. Success- ful partial nephrectomies have usually been performed for circumscribed inflammatory affections, and there is every reason to believe that the defect was repaired in part, at least, by regeneration to the same extent as in the experiments on animals. CENTRAL NERVOUS SYSTEM. The central nervous system is built up partly from the mesoblast and partly from the epiblast. The stellate and spider-shaped cells are derived from the mesoblast, while the neuroglia and the nerve-cells proper spring from the neuroblast, a part of the epiblast, which, in the embryo, is located nearest the middle axis. The neuroglia represent channels of nutrition. 68 PEINCIPLES OF SUEGERY. which are formed only at a time when the neuroblastic tissues have reached the height of their development. The mesoblastic portion of the brain and spinal cord does not increase during the healing of a wound of these parts. In pathological conditions, however, as in cases of multiple sclerosis, the stellate and spider-shaped elements proliferate so actively that the nerve- cells are completely displaced by the new product. Many authors have ex- pressed their doubts as to the possibility of regeneration of brain-tissue after injury or disease, while others have gone to the opposite extreme and claim that complete repair can take place in cases of extensive defects. Voit claims that in pigeons he has observed complete restoration of both structure and function after extirpation of the entire cerebrum. Vitzow destroyed the occipital lobes in monkeys and found that vision which was completely de- stroyed was gradually restored. Histological examination proved that the restoration of sight was due to production of new nerve-cells and fibres. Tedeschi is somewhat skeptical on the subject of repair of large defects of the central nervous system. He produced wounds in the cortex of animals. As the immediate consequence of the injury degeneration and limited necrosis followed. However, in a short time a limited process of repair was initiated in the adjacent tissue. The endothelial cell formed capillaries and the neuroglia glia tissue, which constituted the main portion of the scar. Karyokinetic figures were seen in some of the ganglia-cells, and later nerve- fibres were also found in the scar, showing that a limited process of repair followed the primary degeneration. While large defects are not repaired, the regenerative capacity of the nervous elements cannot be doubted, and such a doubt would come in conflict with a general law. Eegeneration of the cerebral nervou.s system comprises the production of new ganglia-cells and neuroglia., the latter consisting of a fine net-work, sometimes of nervous, at others of basic, substance. During the healing of every wound of the brain the observer can satisfy himself that the neuroglia possesses a high capacity of reproduction, as well-marked karyokinetic changes can be seen during the first twenty-four hours after injury. The new cells are very abundant, and arrange themselves in groups. More diflicult is the demonstration of the same changes in the ganglia-cells, but Mondino (1886) and Coen (1887) have given descriptions of these cells which leave no further doubt that they also multiply by karyokinesis. Klebs has also observed karyokinetic figures in the nuclei of ganglia-cells during the repair of injuries of the brain. In the embryo, increase of ganglia-cells by karyokinesis has been witnessed by Pfitzner, Uskoff, Eauber, Merk, and Cattani. It is true that brain wounds heal with some defects, but this applies to extensive injuries in which the regenerative capacity of the brain-substance is not equal to the emergency; hence, only a part of the defect is repaired. Klebs gives an accurate account of his examination on the reparative process in two cases of brain injury: CENTEAL NEEVOUS SYSTEM. 69 one recent, the other of long standing. Microscopical examination of the tissues from the seat of injury in both cases showed that new tissue had been produced. He found many new cells from the neuroglia which he is inclined to believe may functionally take the place of ganglia-cells. The same author made numerous experiments on young animals for the purpose of studying the process of healing in wounds of the brain. With an aseptic needle the brain was punctured. No symptoms followed the injury. The brain was examined from two to four days after puncture; only slight meningeal hgemorrhage. The needle-track in the brain not closed. Mitotic changes were found, not in the cells in the immediate neighborhood of the puncture, but in the cells corresponding to from the second to the fifth row from it. In the same place were found an accumulation of resting nuclei. Mitotic cell-proliferation of injured cells was found completed on the fourth day. Ganglia-cells undoubtedly increase in number in the same manner. He found no leucocytes in the brain, and believes that those that must have been present had been appropriated as food by the cells which had under- gone karyokinetic changes. The gray matter of the surface of the brain is composed of numerous, but exceedingly small, cells, and their numerous con- nections would indicate great reproductive capacity. Peripheral Nerves. — When Cruikshank suggested the possibility of re- storing physiological function in a divided nerve by suturing, his contem- poraries regarded the suggestion as an absurdity. Since that time the sub- ject of nerve-regeneration has engaged the attention of some of the best men in the profession, and from the knowledge which has thus accumulated it is safe to repeat the statement made by Van Lair recently, that "the sur- geon who neglects to suture a divided nerve commits the same mistake as he who neglects to reduce a fracture or fails to unite a divided tendon." Re- generation of a nerve takes place exclusively from preexisting nerve-fibres. Schwann's sheath isolates the nerve-fibre so thoroughly from the mesoblast that it would be almost impossible for the latter to take any direct or active part in the regeneration of the former. The neuroblasts from which tissue- proliferation takes place are found within the nerve-sheath. Confluence of the new nerve-elements within the neurolemma does not take place, as, ac- cording to Cattani, they receive envelopes from the medulla. The part played by the cells of the sheath of Schwann in the regeneration of nerves has become to be a moot question. Von Bungner, Galrotti and Levi, Ziegler and von Wieting have claimed that these cells are a kind of neuroblast the protoplasm of which gives origin to parts of the new axis-cylinders. Kolster and Huber traced the formations of the myelin in the regenerating nerve to differentiation in the protoplasm of Schwann's cells, while others main- tained that the myelin-sheath grows down simultaneously with the axis- cylinders. Section of a motor fibre is at once followed by degeneration of 70 PKINCIPLES OF SUEGERY. the motor terminal part; hence, degeneration and regeneration in the divided nerve and the muscles supplied by it are parallel processes. Degen- eration and regeneration have been studied in nerves that were stretched, lacerated, or completely cut across, and the histological processes were found almost identical in all of these conditions. The study of degenerative and regenerative processes side by side in injured nerves has thrown much light upon their minute anatomy. The medullated peripheral nerve-fibres is com- posed essentially of Schwann's sheath, the axis-cylinder, and a fluid which appears as a periaxial layer. Klebs looks upon this fluid as a sort of nervous endolymph, which, by virtue of its great mobilit}'', takes part in the nutri- tion of the nerve. The space which contains the fluid, being between the axis-cylinder and the sheath, serves not only the purpose of a channel for the fluid, but also for the dissemination of movable elements, — as, for in- stance, migration-corpuscles. Leucocytes are only present in any consid- erable numbers in pathological conditions. Schwann's sheath is composed of connective tissue. The large oval nuclei, containing each one or two. shining nucleoli, which are attached to its inner side, are the neuroblasts. It is as yet not definitely settled whether the portion of nerve between two of Eanvier's constrictions is composed of one or more cells. Eeclus accepts . Eanvier's theory, that the new nerve-elements originate from the axis- cylinder of the central end, and generally from Eanvier's ring nearest the section. A single myelin-fibre is produced here, or an axis-cylinder which later is enveloped by myelin. From this tube new tubes are formed, finally, from twenty-five to forty in number, which approach the peripheral end, insinuate themselves into empty Schwann's sheaths or the spaces between them. Klebs is inclined to accept the view that such a space is represented by one cell, and if several nuclei are present they are the product of nuclear segmentation. The nuclei must be regarded in the light of peripheral nerve- cells. The specific functional contents of a nerve-fibre are the axis-cylinder, the endolymph, and medulla. The first two are continuous with the neigh- boring elements, but not so the medullary sheath. The medullary sheath is a very complicated structure. The masses of fat are held together and are inclosed by a frame-work of keratin. Finer keratin-threads unite both sheaths in the form of Golgi's spirals, which are present in the funnels of Schmidt-Lautermann's medullary spaces; besides, numerous transverse threads are strung out in zigzag shape between the sheaths. The constituent parts of the medullary portion of the nerve-fibre can disappear separately; if the medullary fat is removed by absorption, the keratin frame-work be- comes visible: a condition which is present during the early stages of neu- ritis parenchymatosa. If the keratin frame-work is dissolved, the fat ap- pears in drops, as can be seen during the degeneration of a nerve after sec- tion. The axis-c5dinder is a preexisting structure, which, however, can be CENTKAL NERVOUS SYSTEM. 71 only distinctly outlined against tlie medullary sheath and endolymph by post-mortem influences. Its structure, in the larger medullated fibres at least, is not simple, but is composed of fine fibrillge, held together by an amorphous, gelatinous substance. Physiologically, this part of the nerve must be regarded as a complex of difl:erent conductors, which only differ by the qualities of motility and sensibility. Regeneration of a peripheral nerve- fibre is a regular typical process, as far as it serves as a substitute for lost elements of a nerve. The process resembles the physiological growth of a nerve, which always occurs only in connection with the central nervous sys- tem. If the separation between the nerve-ends exceeds an inch, restoration of its continuity without assistance cannot take place. In such an event the ends become bulbous, the medullary substance in the distal portion under- goes degeneration, and the axis-cylinder becomes more and more indistinct. The same changes take place in the nerve-ends after amputation. When a Fig. 49. — Tubular Suture of Van Lair with Decalcifled-Bone Tube. Transverse Sec- tion, a, concentric fissures; 6, radiating fissures; c, central canal, showing new nerve- flbres. nerve is simply divided and there is no loss of substance, the ends remaining in close contact, function is established in a remarkably short time. In two instances Gluck observed perfect function within twenty-four hours. He concludes that the granulation-tissues must have been the means of conduc- tion in these cases. In his experiments on the sciatic nerve in fowls, where he divided the nerve and immediately sutured with catgut, function was re- stored in from fifty to eighty-six hours. Waller and Van Lair are of the opinion that regeneration proceeds entirely from the proximal end. Ac- cording to Van Lair, the zone of proliferation extends one and one-half to two and one-half centimetres above the divided end, and the new material is principally furnished by the cortical tubes. The young fibres may attain a length of from one to even six centimetres; beyond this distance they require the support of empty nerve-sheaths. If such a support is not present the new fibres cease to grow and undergo atrophy. Whqn there is a space be- 72 PEINCIPLES OF SUEGEKY. tween the severed nerve-ends, tlie fibres easily penetrate through the cica- tricial tissue as long as it is embryonal. Upon this observation are based the experiments of Van Lair, who secured union between nerve-ends widely separated by interposing between them a decalified-bone tube, the new nerve- fibres following the Haversian canal or the fissures caused by absorption. By Van Lair's method a distance of six to seven centimetres has been successfully bridged. The time required in the repair of such large defects depends on the age of the patient, — from three to eight months. Colasanti claims that degeneration of the peripheral end only extends as far as the Fig. 50.— Nerve-fibre in a State of Regeneration Fifty to Seventy Hours after In- jury. A, proliferation of neuroblasts; B, spindle cell, which, becoming confluent with similar cells from both sides, unites the nerve-flbres; O, rows of spindle cells, forming amyelinic nerve-fibres; B, young amyeloid cells, formed from nuclei of neurolemma. (GZMCfc.) next Eanvier ring, while Tizzoni found that degeneration extends from the seat of injury in both directions, only that it is more marked on the distal side. Most of the recent writers on the subject assert that when a piece of the nerve is resected the entire nerve on the distal side undergoes degenera- tion, while, if the nerve is only divided and the ends are immediately sutured, at least a number of the nerve-fibres retain their integrity. Eichhorst and others, who have made regeneration of the nerves a special stud}^, are of the opinion that the nerve-fibres of both ends participate in the process of repair, and that regeneration commences with degeneration. Eichhorst believes that regeneration takes place exclusively by splitting of the axis-cylinder CENTRAL NEEVOUS SYSTEM. 73 within Schwann's sheath, so that the latter in the course of time becomes distended with the product of proliferation. Continuity is restored by the central fibrils being pushed outward through the cicatrix to meet the periph- eral, and coalescence follows. Beneke, on the other hand, traced the origin of the new fibres to protoplasm of the neuroblasts, which are transformed into delicate fibrils, which become surrounded by a coating of myelin: the future medulla. It is more probable that regeneration of a nerve takes place by the latter method. After a trauma reproduction of the axis-cylinder al- ways follows. According to a number of investigators who have studied this subject, several axis-cylinders are formed within each Schwann sheath, each 1 ,' Fig. 51. — Longitudinal Section through Nerve Twenty-one Days after Injury, show- ing Medullated and Non-medullated Nerve-fibres with Round Cells between them. of which is surrounded by a separate medullary sheath. It is difficult to ascertain whether these new fibres, growing out of one of the old fibres, again become united some distance toward the periphery, or whether they remain isolated to their point of peripheral distribution. After nerve-section the axis-cylinder swells at the cut end and becomes striated; this swelling, how- ever, is not an active process, but the result of imbibition of stagnant endo- lymph. The longitudinal striations and formation of vacuoles which have been described by Tizzoni are due to the same cause. The granular appear- ance is brought about by disintegration of the fibrillse. The old axis-cylinder breaks down into isolated fragments, which, in part at least, are removed by 74 PRINCIPLES OF SURGERY. leucocytes, wMcli at this time have made their appearance. With such ex- tensive destructive changes in the axis-cylinder it is difficult to conceive how regeneration of this structure could take place in the manner described by Eichhorst. The only histological elements within the fibre-sheath exempt from degeneration are the nuclei of the inner surface of the sheath, the neu- roblasts, and from these regeneration takes place. At the seat of regeneration the nerve is enlarged from the accumulation of the products of tissue-proliferation within the neurolemma-sheaths. The first stage of regeneration of a nerve is initiated by multiplication of the neuroblasts and increase of protoplasm. The nuclei increase to double their normal size and then divide into two or more. Division of nuclei prob- ably takes place by karyokinesis. The protoplasm is granular, and is stained a reddish color with neutral picrocarmin. The nerve-fibre originates from the protoplasm, and, according to Tizzoni, in the forpa of separate pieces, around which already can be distinguished a medullary sheath and trans- parent contents. In other cases there may be a direct connection between the old and new axis-cylinder. Longitudinal striation of the axis-cylinder probably takes place at a time when the fibre has formed a direct connection with distant parts, the seat of active physiological processes. Leucocytes have been found within the neurolemma by Tizzoni and Korybut-Daskiewicz, while Neumann denies their presence in this locality. Cattani believes that they are present within the fibre-sheath after nerve-stretching, and can be found as far as the motor ganglia of the cord. Nerves of different function, when united, will undergo repair and establish useful conductors for the transmission of nerve-force. The late Professor Gunn established the cor- rectness of this assertion by a series of interesting experiments on dogs. Early functional results after nerve-suture are often fallacious, as the func- tion attributed to sutured nerves may be performed by other nerves which reach over such areas; and, again, the peripheral manifestation may be the result of physical conduction of the irritation, and apparent motor recoveries may be stimulated by the action of muscles other than those supplied by the sutured nerve. NERVE-SUTURE. ISTerve-suture was first performed by Baudens in 1836, with negative result. The procedure was revived by Nelaton in 1863, and the following year by Langier. The first operations were made with fine-silk sutures, which were not out short, and subsequently came away by suppuration. Failures will occasionally follow both primary and secondary nerve-suture in spite of good coaptation, as such results may be due to secondary degen- eration of motor nerve-cells in the cord, as was suggested by Willard. 0. Weber advised the uniting of the nerve-ends by passing the sutures, not NERVE-SUTUEE. 75 through the nerve-substance, but only through the connective tissue sur- rounding the nerve: the paraneural suture. Experience, however, has shown that transfixion of the nerve-ends by the sutures does not give rise to pain, and does not interfere with the normal reparative processes, and at the same time, by resorting to this direct method of suturing, more perfect coaptation is secured. In the case of large nerves, it is advisable to reenforce the direct sutures with a number of paraneural sutures. The best material for the su- tures is aseptic catgut. An ordinary sewing-needle with a dull point is pref- erable to a surgical needle, as it is more sure to pass through the nerve without injuring the fibres. From one to three direct sutures, according to the size of the nerve, are applied, and from three to six paraneural sutures. The needle is passed straight through the nerve on each side, one-eighth to one-fourth of an inch from the ends, and care must be exercised, in tying the sutures, to bring the cut surfaces in accurate apposition, and not to tie the sutures too tightly. DircctSutare Fara-neural i'lUure Fig. 52.— Nerve-suture, showing Application of Direct and Paraneural Sutures. as by doing so the nerve-ends are liable to become displaced by overlapping. In tying the paraneural sutures the necessary precautions must be taken to prevent the margins of the sheath from insinuating themselves between the nerve-ends. Primary Nerve-suture. — A primary nerve-suture is one used to unite a nerve immediately or soon after the injury has occurred, and before any degenerative changes have taken place. It should always be resorted to in the treatment of accidental wounds where one or more nerves have been divided, also where in operations a nerve has been divided accidentally, and, finally, in cases where a neurectomy for pathological conditions cannot be avoided. The results after primary suture have been very satisfactory. Bruns has collected 71 cases from different sources, and in more than 33 per cent, of the number function was restored. As suppuration in a wound where a nerve has been sutured would, in all probability, cause tearing out of the sutures and displacement of the nerve-ends, it is of the greatest practical 76 PRINCIPLES OF SUEGERY. importance to secure for such wounds an aseptic condition and to obtain primary union throughout, and consequently no provision for drainage should be made. If the wound-surfaces cannot be approximated, and a greater or less space has to fill up by granulation, a bundle of catgut-threads can be used for a capillary drain, in order to avoid tension from the accu- mulation of blood or the primary wound-secretion. Secondary Nerve-suture. — When a divided nerve fails to unite, the ends become bulbous, are usually found imbedded in a mass of cicatricial tissue, and separated from each other from one to two or more inches. The bulb- ous enlargement of the proximal end remains permanently and is often a useful guide to the nerve in cases requiring secondary nerve-suture. Func- tion below the point of division is completely lost; the distal portion of the nerve itself, being no longer in connection with the central nervous system, undergoes degeneration, and the muscles supplied by the injured nerve be- come atrophic and useless. The reuniting of such a nerve is done by the secondary suture. Experience has shown that function can be restored by this procedure years after the injury. Jessop vivified the nerve-ends and applied sutures nine years after injury of the median nerve, and restored function. Langenbeck sutured the sciatic nerve two years after division; sensation returned in three days, and, later, motion. As a rule, sensibility returns first after nerve-suture, followed considerably later by restoration of motor function. The most speedy restoration of function, both sensory and motor, after secondary suture is reported by Tillaux. He operated on the median nerve three years after division. The ends were found imbedded in a cicatrix and separated from each other four centimetres. The ends were vivified and sutured. He claimed that physiological function was re- stored completely three hours after the operation. There can be no doubt of the ultimate recovery of nerve-function in this case, but that this should have been attained in three hours appears next to impossible. Enough has been said to show that secondary nerve-suture can be resorted to with good prospects of success years after an injur}'-, but for well-known reasons it should not be postponed after it has become evident that union has failed to take place. Unnecessary delay is dangerous, because when a nerve has become permanently disconnected from the central nervous system muscular degeneration goes hand in hand with degeneration of the distal portion of the nerve, and, the longer the operation is delayed, the greater the length of time required to complete the regeneration of the nerve and the muscles. The first secondary nerve-suture was made by ISTelaton in 1865. In Ger- many the first operation was made by Gustav Simon in 1876, and he was followed by Langenbeck the following year. In 1884 Bruns found 33 re- corded cases, and in 24 of this number the result was satisfactory. As a rule, sensation returned srraduallv in from two to four weeks, while motion NEEVE-SUTUKE. 77 did not return nntil three weeks to three months after the operation. Com- plete restoration of function was seldom completed until half a year to one year after the operation. As in cases which require secondary suture the nerve-ends are sealed with a mass of cicatricial tissue, it is always necessary to resect the ends, after which the sutures are applied in the same manner as in primary nerve-suture. Both nerve-ends must be freed from all cica- tricial adhesions before approximation is attempted, and, if this cannot be readily done on account of previous retraction, both ends are carefully stretched and sufficient elongation secured so as to prevent any tension upon the sutures. A great deal can be done to prevent tension by placing the limb in such a position as will relax the nerve; for instance, flexion of the hand and forearm in suturing the ulnar, median, or musculo-spiral, and flexion of the leg and extension of thigh after reuniting the sciatic. Th-e position of the limb most favorable for the union of a sutured nerve is best secured by a plaster-of-Paris dressing, which is allowed to remain not only till the external wound is healed, but until the nerve has firmly united. When a nerve has suffered a considerable loss of substance at the seat of in- jury it is often found impossible to bring their ends in contact by nerve- stretching and position of limb, and in such cases restoration of continuity becomes an exceedingly difficult task. Letievant suggested that the defect in such cases should be corrected by a neuroplastic operation. He proposed that a flap should be taken from each end sufficiently long that, when turned toward each other, they could be sutured at the middle of the defect, thus making a connecting bridge of nerve-tissue between the separated nerves. (Fig. 53.) As could be expected, in a case where he performed this operation the result was negative. In a case operated on by Tillmanns after this method, partial restoration of func- tion was established three and a half months after the operation. The suc- cess in this case was probably not the result of conduction of nerve-force along the fibres of the flaps, but the production of new fibres across the gap, perhaps through the tissues composing the temporary bridge. The same author devised for a similar class of cases what he calls cross-sutures (Fig. 54), where the_ nerves are cut at a different level and the ends separated too far for any direct method, suitable in the median and musculo-cutaneous in the arm or the median and cubital nerve in the forearm. The two longer ends are united by direct suture and the shorter ones grafted into the ad- joining trunk. The success of this operation is based on the physiological law of the conductibility of nerve-fibres. This operation has resulted suc- cessfully in a number of instances in the human subject. From his experi- ments on animals, Gluck came to the conclusion that nerve-defects could be corrected by transplantation of nerves; that is, inserting a piece of nerve from an animal, corresponding in size to the nerve to be reunited, between 78 PEINCIPLES or SURGEEY. the nerve-ends, and uniting it with them with sutures. He reports a num- ber of successful experiments on chickens, filling the gap with a nerve taken from rabbits. Phiiipeaux and Vulpian, from their own researches, came to the conclusion that a transplanted nerve alwa3^s degenerates and disappears, and that restoration of structure and function onh' takes place by regenera- f. I Pig. 53. Fig. 54. Fig. 53. — Neuroplasty. A, upper end; A', lower end; H, H', flaps turned toward each other; D', B', suture of the two flaps; B, D, level of section of flaps. {After Letievant.) Fig. 54. — Cross-suture. 1. The ends A B and C D are too far apart to be sutured; the upper end (0) of the nerve will be united with the lower end (B) of the other nerve. 2. Completed suture; the ends A D are implanted into the adjoining nerve-trunk. {Till- manns.) tion from the nerve-ends. It is probable that the methods of nerve-restora- tion devised b}^ Letievant and Gluck are useful in reuniting separated nerve- ends in the same manner as the suture a disla-iice of catgut suggested by Assaky. The interposition of an aseptic, absorbable substance like catgut NEEVE-SUTURE. 79 or nerve-tissue serves as a temporary scaffolding for the products of tissue- proliferation from the nerve-ends, which at the same time determines the direction for the new material, providing the shortest route to meet the same material from the other side. When catgut is employed two or three sutures are used, so that the combined size of the strings will at least approximately correspond to the size of the nerve. Van Lair, who believes that regenera- tion of a" nerve takes place exclusively from the proximal end, resected a piece of the sciatic nerve in dogs, and then sutured both ends of the nerve to the ends of a decalcified-bone tube, which in length corresponded to the section of nerve removed. From the results of his experiments, ten in number, he became satisfied that continuity of the nerve was restored by the new nerve- fibres from the proximal end growing into the tunnel, bridging the defect in a comparatively short time, as they had no resistance to overcome, and uniting with the end of the nerve on the opposite side of the tube. It ap- pears to the author that this method of overcoming the difficulties of re- uniting nerve-ends widely apart is not only an ingenious procedure, but, if applied in practice, promises better results than any other method hereto- fore proposed. In certain cases where the distal end cannot be found, or where the separation is so great that none of the methods of approximation so far devised hold out any inducements of a successful issue, Letievant sug- gested the idea of grafting the central end upon the intact trunk of a neigh- boring nerve. This operation failed in his hands, but Tillaux and Tillmanns, slightly modifying the method, were successful. In Tillmanns' case the ulnar nerve had been divided, the ends were found separated four and one- half centimetres, and the proximal end was grafted upon the median nerve. Sensation returned in a month, and by using electricity and massage recov- ery was complete a year later. JSTerve-grafting, as advocated by Letievant, should only be resorted to after implantation of a decalcified-bone tube be- tween the nerve-ends has been tried and proved a failure, or in cases where the defect is very extensive, or, finally, if, after the most diligent search, the distal end cannot be found. Eestoration of function does not always follow after the continuity of a nerve has been restored by operative measures. Ehrmann has reported such a case. The radial nerve was divided below the elbow and failed to unite. Complete paralysis of all the muscles supplied by this nerve. After the lapse of seven months the nerve was exposed, and the ends, which were five centimetres apart, were vivified and sutured. Seven months after the operation, no improvement. The nerve was again exposed at the former site of operation, and it was found that union had taken place, but the nerve was compressed by a firm cicatrix two or three centimetres in length. The nerve was relieved from its imprisonment, and when the faradic current was applied all the muscles supplied by the nerve responded. Pour months later, complete recovery. This case reminds us 80 PEINCIPLES OF SURGERY. of the importance of securing healing of tlie nerve and wound with as little cicatricial tissue as possible, wliich can only be done by absolute asepsis and careful attention to suturing of the wound. CHAPTER III. Degeneeation.^ Degeneeatiox is the counterpart of regeneration. Regeneration is an active cellular process which results in the formation of new tissue within normal physiological limits, while degeneration consists of cell-changes which lead to atrophy or complete destruction by processes in which the protoplasm of the cells takes no actiTC part. Regeneration is an active build- ing-up process in which the products of tissue-proliferation are utilized in the formation of new tissue or in replacing tissue destroyed by injury or dis- ease. On the other hand, degeneration consists in the waste or destruction of existing tissue by inadequate nutrition or noxious extrinsic influences which destroy cell-life and activity. It is proper that the subject of degen- eration should be discussed after the student has familiarized himself with the nature and histology of regeneration and before he begins to study the complicated processes which characterize inflammation, and because, in every inflammation, cell-destruction is a constant feature, and also because there is no inflammation so severe but what, somewhere in the infected field or in its periphery, attempts at repair can be seen. Regeneration is characterized by karyokinesis, — great cell-activity; degeneration by nuclear fragmentation, karyolysis, and cell-destruction. ATEOPHY. The simplest form of degeneration is atrophy. It is caused by defective nutrition. It may be limited to isolated cells, a part, or organ, or may impli- cate the entire body, according to the extent of the etiological influences. As a normal condition, it is seen in some of the organs of the body after periods of high physiological activity, and is then known as involution- atrophy. Gen- eral atrophy attends old age, and follows acute and wasting diseases and any affections which interfere with digestion, absorption, and assimilation of food or defective food-supph^ and is then called marasmus. Atrophy from pro- longed non-use is termed inactivity-atrophy. It is seen most frequently as one of the constant results in advanced cases of joint tuberculosis. In atrophy the macroscopical and microscopical changes are more of a quanti- tive than qualitative nature, the essential etiological feature consisting of a defective substitution of nutritive material, and the conditions would be de- 1 The author desires to acknowledge his indebtedness to Perls' "Pathologie'' for valu- able information in preparing this chapter. (81) 82 PKINCIPLES or SURGERY. scribed more correctly if the term aplasia were substituted for what is usually understood and described as atrophy. The atrophy of fat-tissue pro- duced by the withdrawal of food in animals has been studied most carefully by Flamming, who ascertained that in the cells deprived of their fatty con- tents in this manner an active multiplication of nuclei and production of young cells takes place whereby a microscopical picture is created which very much resembles inflammatory tissue. Similar observations were made by Grawitz and his pupils in atrophy of muscles and nerves. Kolliker regards the giant cells in the myeloid tissue as the essential agents in the production of atrophy of bone, and excavation of Howship's lacunae as their almost spe- cific product. Eustitzki believes that these cells secrete an acid substance Fig. 55.— Ischasmic Paralysis of Muscles of Leg Following Degeneration Produced by Scar-contraction after an Extensive Burn. Large Circular Ulcer Remained Unhealed. which dissolves the earthy constituents. Atrophy of muscles after section of the motor nerves, with or without fat-formation, can reach a consider- able degree after a few months. On the other hand, muscle-degeneration and atrophy the result of ischasmia sets in within a very few days, and leads to permanent results, as has .been shown by Volkmann, Leser, and others. This form of muscle-atrophy is observed most frequently in conse- quence of harmful constriction by fixation dressings in the treatment of fractures, but has also been seen as a remote consequence of cicatricial con- traction, more especially after extensive burns of the extremities. Muscle- degeneration from defective blood-supply is better known under the term ischasmic paralysis. (Fig. 55.) Progressive hemiatrophy of the face is gen- erally regarded in the light of a trophoneurotic disturbance. CLOUDY SWELLING. 83 CLOUDY SWELLING. Degenerative changes in the protoplasm of living cells depend largely on modifications of their albuminous contents. It is difficult to determine in individual instances whether such modifications are caused by chemical or physical influences. Bacteriological investigations have opened up a wide field for investigation in this direction, as it is now Avell known that many cell-degenerations, both of the acute and chronic type, are caused by toxic substances eliminated from pathogenic bacteria. In most of the acute in- fective diseases cell-degeneration in different parts of the body is a constant feature and produced solely by toxins elaborated in the tissues or brought in contact with them through the medium of the general or lymphatic circula- tion. The most frequent form of retrograde tissue-metamorphosis is the cloudy swelling, known also as albuminous infiltration or metamorphosis, granular degeneration, and parenchymatous degeneration. The parenchyma-cells are usually affected by this form of degeneration, and hence the designation "parenchymatous degeneration." The con- nective tissue, if affected, does not show the pathological conditions as plainly. The organs and tissues the seat of cloudy swelling are somewhat enlarged, softened, pale, and of a dirty-gray color; the normal outlines of glandular structures obscured, and the transparency of the tissues is dimin- ished. Under the microscope the cells exhibit a granular appearance; the granules are very fine, refract light feebly, and impart to the cell-protoplasm a dusty, cloudy appearance, which, in the muscle-fibre, for instance, obscures the nuclei and striations. The cells are enlarged, their form irregular, and outlines ill defined. Acetic acid clears up the protoplasm, and the nuclei become more distinct. The granules are degenerated albuminous products, which are dissolved by the acetic acid. Cloudy swelling is constantly seen in acute infectious diseases, phosphorus poisoning, and catarrhal infiamma- tion. Cloudy swelling often precedes fatty degeneration, cell-death, or also proliferation. Virchow, who first described cloudy swelling, found it during the early stage of parenchymatous infiammation. It was discovered, however, later, that in most instances it is present in patients the subjects of acute infectious diseases, in organs which were not the seat of inflammation. The textural changes in the protoplasm of the cells point either to an increased supply of albuminoid substances or a modification (coagulation) of the existing cell-contents into a less soluble substance. It is very probable that in inflam- mation the former and in acute infectious diseases the latter process takes place. The destructive effect of toxins on cells is well known, and we can safely assume that the degree of parenchymatous degeneration is determined largely by the amount and virulence of the toxins which are brought in con- 84 PEINCIPLES OF SUKGEKY. tact with the cells, in this respect resembling the toxic effects of phos- phorus. FATTY DEGENERATION. An advance in the regressive metamorphosis of cloudy swelling leads to fatty degeneration. In fatty degeneration the contours of the granules are more sharply defined, the dusty appearance is changed into a dotted field, the groups of molecules appear clear and, when dense, present an al- most black appearance. (Fig. 56.) These granules are not altered albumen, but fat, which takes the place of albumen. In acetic acid the normal cell- contents are cleared up, but the granules remain unchanged; hence, can be seen more distinctly. These fat-molecules are soluble in ether. The gran- ules vary much in size, those of medium size corresponding with the red blood-corpuscles. If the degeneration is far advanced, these granules co- alesce into larger masses, and crystals make their appearance. As the cells Fig. 56. — Fatty Degeneration of the Heart-muscle in Pernicious Anaemia. Fat Stained Blaclc with Osmic Acid. A, fat-droplets. and tissues involved in the fatty degeneration are not increased in size we have no reason to assume that preformed fat was supplied, but are forced to the conclusion that it is an intracellular product. In degenerative lipogene- sis the fat is probably formed from the constituents of the cell, which suffers grave protoplasmic and nuclear lesions. Lindemann takes it for granted that fat can form from albumen, although Pfliiger, Eosenfeld, and others take an opposite view. Lindemann lays stress on the formation of fats from pro- teids by bacteria, as is supposed to be the case in the production of adi- pocere, and which might therefore occur in infections. As pointed out by Taylor, even though we admit that fat is formed in degenerated cells, it can still be claimed that it is a chemical product from carbon compounds — sugar, glycogen, glucosides, and mucin — which abound in cells rather than from the proteids: a contingency which Lindemann does not consider suifi- ciently. Occasionally fatty degeneration is associated with the formation of a substance which resembles the coagulated medulla of nerves (myelin de- generation). This combination of degenerative processes is seen most fre- FATTY DEGENERATION". 85 quently in the alveoli of the lungs. This substance is probably liberated lecithin, which, when dissolved in water, assumes the myelin form. If the fatty degeneration is far advanced and extensive, a mass is formed composed of free fat-globules, remnants of protoplasm, and nuclei, which is known as fatty detritus. In old deposits of this kind fat-crystals — so-called margaric- acid needles — make their appearance. Besides these delicate soft crystals plates of cholesterin isolated and in masses mark the advanced stage of the degenerative process. Fatty degeneration is a very frequent tissue-change. All those causes which have been enumerated in connection with simple atrophy and cloudy swelling produce fatty degeneration; very often we find the latter side by side with the two first conditions and occasionally all coexist at the same time. A mild form of fatty degeneration con- stantly takes place in most of the tissues as an expression of the con- stant changes incident to the substitution of new for old cells, and in the aged it is almost constantly found in the intima of the large blood-vessels, as well as in the walls of the small arteries of the brain, and occasionally also in the parenchyma-cells of the organs which undergo atrophy., As a patho- logical process we find fatty degeneration, in the first instance, as a local affection limited to certain parts of the body, and, in the second place, as an acute and diffuse lesion involving different organs and tissues. The localized form is caused either by a defective blood-supply like simple atro- phy, or increased tissue-destruction with impaired resorption and imperfect restitution, caused either by a disproportion between action and rest, by impairment of the blood- and lymph- circulation, by ferment — or similar infiuences which are destructive to the cell-contents. Inflammatory proc- esses are frequently the direct cause of quite extensive fatty degeneration of the fixed tissue-cells, but more particularly of the cells in the exudate derived either by cell-migration or proliferation. After nerve-section fatty degeneration takes place in the peripheral end. Eight to ten days after section of a nerve the homogeneous medullary substance around the axis- cylinder breaks up into irregular clumps varying in size, which in a few days become smaller and present the appearance of droplets of fat, which dis- appear slowly; so that after about two months only the axis-cylinder and the collapsed neurilemma remain. Of the greatest interest are those obscure cases in which acute fatty degeneration takes place simultaneously in sev- eral organs. In acute infectious diseases the cloudy swelling is not infre- quently followed by fatty degeneration. In other cases of acute diffuse fatty degeneration attended by icterus and punctiform ecchymoses poisoning with phosphorus or arsenic was shown to be the cause of death. It is in such cases that the parenchyma-cells of the liver exhibited in a most marked man- ner the condition known as fat-infiltration. The same condition is found in acute atrophy of the liver. Acute fatty degeneration of different organs 86 PRINCIPLES OF SUEGERY. with punctiform extravasation of blood has also been found in connection with progressive pernicious ansemia; the organs principally involved were the heart and blood-vessels. Although fatty degeneration and fat-infiltra- tion resemble each other in many respects, they constitute two different pathological processes. By fat-infiltration is understood the deposition of preformed fat in the tissues, while in fatty degeneration the fat is produced from the cell-contents by the conversion of the protoplasm into fat. The latter takes place when the organ is supplied with an excess of fat or when the existing fat fails to disappear by normal processes which regulate the supply and waste of this constituent of the body. The artificial fattening of animals furnishes a good illustration of what we mean by fat-infiltration. In some animals — especially the domestic goose — thus treated the liver be- comes the principal depot for the deposition of the surplus fat. In contra- distinction to the liver the seat of fatty degeneration, in fat-infiltration the organ becomes very much enlarged, the capsule tense, anterior border thick and rounded, and the parenchyma fragile. The cells are filled, not with granules, but large droplets of fluid fat densely crowded together. The amount of fat in fat-infiltration is much greater than in fatty degenera- tion. For instance, in fatty degeneration of the heart the fat seldom ex- ceeds one-fourth of the heart in weight, while, on the other hand, in fat- infiltration it often reaches one-half to four-fifths. MUCOID, COLLOID, AND WAXY DEGENERATION. Mucin is a degenerative product of the protoplasmic contents of cells. This substance is characterized by its intrinsic properties to absorb water to an unusual extent. Filtration, even when much diluted, is exceedingly dif- ficult, and the apparent solution is exceedingly viscid and can be drawn out into fine threads. It differs from other albuminous substances in that on the addition of acetic acid it is precipitated in the form of white flakes which, on adding an excess of acetic acid, are not dissolved; if it is precipi- tated by alcohol, it appears under the microscope usually, not in the form of granules, but as a fine fibrillated deposit, and is free from sulphur. It is this substance which imparts to the different mucous secretions their viscid property. It is found also in a normal condition in the vitreous humor of the eye and in the umbilical cord. As a pathological product we find mucin in cells as well as in the intercellular substance. In the former as a quan- titative increase of the physiological metamorphosis in catarrhal and inflam- matory affections of the mucous membranes, the mucous glands are en- larged and filled with mucin-globules; their cells are also greatly swollen by the accumulation of mucin; others rupture and are destroyed. In the in- tercellular substance — especially that of cartilage and bone — also in tumors MUCOID, COLLOID, AND WAXY DEGENEKATION. 87 mucin-production takes place occasionally in inflammatory processes as well as during passive conditions, at times with diminished coherence of the tis- sue; so that a mucoid softening takes place; this softening can increase until liquefaction ensues, with the formation of cysts filled with a mucoid substance and detritus of cells. An exclusively pathological product, the result of degeneration, is what is known and described as colloid substance. It differs from mucin" in being more consistent and presents itself macroscopically in the form of boiled sago with at times a yellowish tint of color. The jelly-like substance is not affected by alcohol and acetic acid. The colloid degeneration of cells is very similar to the mucoid, the same droplet formation in the protoplasm, only that the globules are firmer; but it appears that the colloid masses can form in albuminoid fiuids independently of cell-activity. The thyroid gland is the organ which exhibits most frequently colloid masses in greatest amount, and miasmatic struma consists largely of a distension of its follicles with honey-like homogeneous masses. x\ccording to VirchoAv, the colloid substance is not the product of cell-transformation, but it represents the inspissated fluid rich in sodic albuminate transuded into the follicles. Col- loid formation also takes place in the parotid, prostate, and ovaries. The surface of the masses is covered by epithelial cells, and in the middle of the substance besides remnants of epithelial cells will be found granules of albu- men and fat and often drops of a thinner fluid. In the course of time the colloid substance becomes firmer and more brittle. Mucoid and colloid de- generation are often seen side by side, especially in tumors and cysts, often combined with other regressive metamorphoses. Eecklinghausen has described a degenerative process under the name hyaline degeneratio.n which, in some respects at least, differs from colloid degeneration. The hyaline substance differs from the colloid material in that it can be stained in acid fuchsin and eosin and resists water, alcohol, acids, and ammonia; and from amyloid as it does not react to iodine. Hyaline degeneration affects different organs and epithelial cells as well as connective tissue. Hyaline masses and thrombi were found by Manasse in the vessels of the brain in acute infectious diseases. Transformation of striated muscle-fibres into a fragile homogeneous shining substance anal- ogous to colloid masses occurs quite frequently. Zenker described this change first in 1864, and called attention to its constant occurrence in ab- dominal typhus. The lower ends of the abdominal recti and the adductors are most frequently affected, and it is here where the degeneration is most extensive. In many of the fibres the degeneration is most extensive, in others it is localized. The striations disappear entirely and the fibre is transformed into a structureless mass interspersed with a granular detritus, and is permanently destroyed. Zenker describes this change as a peculiar 88 PEINCIPLES OF SUKGERY. form of waxy degeneration. The same change has been also found in other acute febrile affections and it has been suggested that the degeneration might be the result of rupture of the muscle-fibres. Maier and Perls have seen colloid degeneration of the muscular fibres of the stomach and intes- tinal canal. AMYLOID DEGENERATION". Under the term of corpora amylacea and amyloid substance we include substances which, like the colloid material, have an homogeneous, faintly- shining appearance and which likewise resist chemical reagents, but which differ from the products of degeneration already described by its peculiar behavior toward iodine and some of the stains. Like starch, the amyloid substance is stained a beautiful blue or brown color on the addition of iodine. If the substance is stained brown the color is converted into greenish-blue color if sulphuric acid or chloride of zinc is added. In aged men amyloid granules are found in the prostate which react to iodine specifically. These minute round bodies present a concentric structure, in the centre of which occasionally a detritus of cells is found. Their consistence is variable, but they are always brittle. If exposed to iodine, some of them stain a deep blue in a few minutes, others bluish-green or brown, while others do not stain at all, showing that the reaction to iodine is influenced by inorganic constituents and modified albumen. In other organs smaller granules of a similar structure and composition are found; a constant location for these bodies is the ependyma of the ventricles of the brain and the acoustic nerve and in those pathological conditions of the central nervous system in which increase of connective tissue is followed by a corresponding increase of the parenchyma. These granules are paler than the myelin drops from which they are probably formed. Concentrated sulphuric acid increases the staining properties of iodine. Amyloid bodies are frequently found in the lungs, also, especially in hsemorrhagic infarcts. Similar bodies are sometimes found in cartilage, especially in the intervertebral cartilages in a state of inflammation, and occasionally they are seen in diverse other tissues, such as cicatrices of the skin, phlebolites, and tumors. While the instances mentioned above represent a localized form of degeneration and without much pathological importance, there is a diffuse process which is known as amyloid degeneration of the tissues that appears simultaneously in different organs, accompanied by anaemia and hydropic conditions: a frequent cause of fatal marasmus. This degeneration mani- fests itself under the microscope in the form of swelling of different tissues, especially of the vessel-walls, and presents itself in the form of shining, vitreous, homogeneous masses, which, on the addition of iodine, are stained brown, which is changed into a greenish blue or a pure blue or violet if AMYLOID DEGENERATION. 89 acids are added. Spleen, kidneys, liver, and lymphatic glands are the organs most frequently affected, and the change in them takes place in a definite part. In the spleen amyloid degeneration takes place in two distinct forms. In the so-called waxy spleen the organ is much enlarged, firm, inelastic, and somewhat doughy. The cut surface appears uniformly brownish red, shiny, unusually transparent, resembling smoked ham. Iodine stains the surface only somewhat deeper, but uniform, so that the change is not very apparent. Microscopical examination shows that the capillary spaces are surrounded by a narrow zone of a clear, homogeneous substance to which the normal or endothelial cells which have undergone fatty degeneration are attached. In the other form of amyloid degeneration of the spleen — the so-called sago spleen — the organ is softer and on section only the fol- U 36-- B Ct Fig. 57. — Amyloid Degeneration of the Kidney Involving the Glomeruli and the Capil- laries of the Cortex. The Amyloid Material has been Stained Brown with Iodine. Double knife section. From a case of chronic pulmonary tuberculosis. X 75. A, capillaries showing amyloid degeneration. B, glomerulus showing amyloid degeneration. C, large vessel showing amyloid degeneration. licles present the characteristic changes in the form of sago-like structures, and only these react to iodine, and in them the blood-vessels appear as yel- low dots or stripes. In the amyloid kidney the glomeruli are enlarged and pale and on the addition of iodine become conspicuous by their brown color; very often the vasa recta of the pyramids are also found much degenerated and react intensely to the iodine stain. In the liver the amyloid degenera- tion begins and is most marked in the centre of the acini. The villi of the intestinal canal are frequently affected by amyloid de- generation, while the mucous membrane over Peyer's patches remains intact. In the suprarenal capsule and lymphatic glands the cortical layers of the parenchyma are principally affected and exhibit in the most marked manner the reaction to iodine. Examination of different organs which have under- 90 PEINCIPLES OF SURGERY. gone amyloid degeneration have shown that different tissue-elements fur- nish the amyloid su.bstance. Most frequently the walls of the small blood- vessels are primarily affected, and in these the change is first observed in the media, which is transformed into a structureless glassy mass, and the thickening of the walls thus caused diminishes the lumen of the affected vessels, which accounts for the anemia so constantly found in amyloid or- gans. That the parenchyma-cells can undergo amyloid degeneration can. be best seen in the amyloid follicles, of the spleen and the acini of the amy- loid liver. Diffuse amyloid degeneration of different organs is most fre- quently observed as a remote result of prolonged suppuration following often tuberculosis of bones and joints and long-standing empyema and old cases of syphilis. It is more than probable that the toxins of the different kinds of pyogenic microbes play an important role in the etiology of diffuse amy- loid degeneration, which appears simultaneously or in more or less rapid succession in different organs in the course of chronic suppurative processes. The different forms of degeneration which have been described are of special interest to the surgeon, as he is often in a position to prevent such changes, and in the presence of some of them he recognizes the necessity of abstaining from performing major operations unless called for by emergen- cies which leave no other alternative. Among these special mention must be made of di^ffuse amyloid degeneration and fatty degeneration of the large blood-vessels, with and without calcification. Timely resumption of func- tion of diseased parts or organs, massage, and electricity are best calculated to prevent further degeneration and restore normal nutrition in the localized forms of degeneration, more especially fatty degeneration, the consequence of prolonged inactivity. CHAPTER IV. Inflammation. The subject of inflammation is one of deep interest both to the student and practitioner, as it initiates the former into the field of general and special pathology, and the latter meets with it daily in some form in his practice. We have already set apart from inflammation those numerous processes by which injuries or defects are repaired without destruction of any of the new tissue-elements which have been described in the flrst chapter under the head of "Eegeneration." From a scientific and practical stand-point, it is exceedingly important to draw a distinct line between the series of tissue-changes which attend regenerative processes, uncomplicated by the action of pathogenic bacteria, and true inflammation, which is always caused hy the presence of one oi' more hinds of pathogenic microbes. As compared with true inflammation, it has been customary for quite a number of years to speak of regeneration as a plastic or regenerative, inflammatory process; but the term inflammation ifi the future should be limited to the series of histological changes which ensue in the living body from the presence and action of specific microorganisms, while the word regeneration should be used to designate the histological changes which take place in tissues which have been primarily in an aseptic condition or have been rendered so after the inflammation has subsided. From this it will be seen that the study of inflammation is intimately and inseparably associated with a consideration of the new science of bacteriology. For most forms of inflammation the presence of a specific microorganism has been demonstrated, and its etio- logical relationship established by cultivation and inoculation experiments; and in the few inflammatory diseases where no such positive proofs can be furnished we have, from analogy and circumstantial evidence, reason to suspect the presence of undiscovered microbes. Inflammation, in the widest and most comprehensive meaning of the word, should be made to embrace pathological conditions which are caused by the action of pathogenic mi- crobes or their toxins upon the histological elements of the blood and the fixed tissue-cells. A correct definition of inflammation, which should em- body the etiological, anatomical, and pathological characteristics of the dis- ease from our present knowledge of the subject, cannot be given, as many important points connected with the complicated processes await explana- tion by future investigation. Sanderson defines inflammation as "the suc- cession of changes which occur in a living tissue ivhen it is injured, provided that the injury is not -of su^h a degree as at once to destroy its structure and (91) 92 . PRINCIPLES OF SURGERY. vitality." As we have restricted the term inJElamniation to the succession of changes which occur in a living tissue from the action of pathogenic microbes or their toxins, this definition would cover processes which, for reasons already given, we have considered as instances of tissue-proliferation un- attended by any of the characteristic features of inflammation. J. Bland Sutton uses the term inflammation in a more restricted sense in coining the following definition: "It is the method hy which an organism attempts to I'ender inert noxious elements introduced from without or arising within it." As nothing is said of the method, the most important part of the definition, it certainly cannot be said to cover the whole ground. The conception of the true nature of inflammation for the present, at least, must remain symptomatic. As a rule, inflammation subsides as soon as the primary cause has disappeared or has been rendered inactive, as is well shown by the spontaneous disappearance of febrile disturbances in the general in- fective diseases, and the subsequent rapid repair of the local lesions which characterize them. If an acute inflammation become chronic, either from a diminution of the quantitative or qualitative intensity of the primary cause, or from the tissues becoming accustomed to its action, it is sometimes difficult to tell whether the primary cause has disappeared or has ceased to act, or whether it is still present and active. In chronic inflammation the most reliable indications of the presence and potency of the primary bac- terial cause are acute exacerbations, as chronic inflammation only consists of a series of acute inflammatory processes which repeat themselves at longer or shorter intervals. The differences between an acute and chronic inflam- mation are not in kind, but in degree. The complicated processes which characterize inflammation can be studied most profitably by considering separately and conjointly the symptoms to which they give rise, which Galen enumerated as calor, rubor, dolor, et tumor, to which may now be added the functio Icesa of modern authors. The study of the objective and subjective manifestations of inflammation should be preceded by a short description of THE HISTOLOGICAL ELEMENTS WHICH ARE DIRECTLY CONCERNED IN THE INFLAMMATORY PROCESS. In a very recent article, the veteran pathologist, Virchow, makes the statement that inflammation is not a uniform process with constant char- acteristics. He recognizes and describes four distinct varieties, viz.: 1. Exudative. 2. Infiltrative. 3. Parenchymatous. 4. Proliferative. Each of these furnishes different products. Infiammatory hypergemia is a prime factor in exudative and infiltrative inflammations, while it takes a secondary part in metamorphosing and the proliferating forms. In the study of the complicated processes which characterize inflammation, it is important to HISTOLOGICAL ELEMENTS IN THE INELAMMATORY PEOCESS. 93 study the part which the different tissues take in the morbid process. The most important structures, and which are always concerned in inflammation of all types and varieties, are the Capillary Vessels. — The most important histological changes in inflam- mation, acute or chronic, transpire within, and in the immediate vicinity of, capillary vessels. The smallest arteries and veins, the vessels on either side of the capillaries, undergo changes, and the disturbance of circulation within them constitutes a part of the picture of inflammation, but it is in the capillaries that the most serious disturbances occur; it is here where Fig. 58.— Capillary Vessels of the Frog's Mesentery, Stained with Nitrate of Silver only; the "Wall of the Vessel is Viewed from the Surface, and is Seen to Consist of Elongated Endothelial Cells, Marked by their Outlines only; the Nucleus of the Indi- vidual Cells is not Shown. (Klein.) the noxce are brought in closest contact with the paravascular tissues, and it is here where the inflammatory exudation and transudation take place. The capillaries are minute vessels, or rather channels, which connect the arteries and veins, the walls of which are composed of a thin, elastic, endo- thelial membrane; that is, a single layer of nucleated cells held together by an amorphous cement-substance. In silver-stained specimens the cement- substance appears as dark lines which outline the boundaries of the cells. The shape of the cells is more or less elongated, with pointed extremi- ties, and their outline smooth or sinuous. The nuclei of these cells are oval, situated either about the middle of the cell or near one extremity. The 94 PEINCIPLES OF SUEGEEY. nucleus contains within a well-defined membrane a net-work of chromatin threads^ but no nucleolus. When the capillaries undergo alteration and dis- tension, as in inflammation, the cement-substance yields in many places; in consequence of this minute openings appear, called by Arnold stigmata, which become gradually enlarged into stomata. Winiwarter found that by injecting inflamed capillaries the contents of the vessel escaped through these openings. Through these openings emigration of leucocytes takes place, and when the inflammation is very intense the red corpuscles escape: a process which Strieker has named diapedesis. If the capillary vessels, through which emigration has been going on, be stained with nitrate of silver, it is seen that the emigration is limited to the interstitial cement- substance of the endothelial wall. (Purves.) Klein has shown that the walls of all capillary vessels in the adult state form a direct connection with the process of the connective-tissue corpuscles of the surrounding tissue: a matter of great interest in studying the rela- Fig. 59. — Leucocyte, showing Reticulum of Protoplasmic Strings. (Klein.) tionship between the capillary vessels and the surrounding connective-tissue spaces. Blood-corpuscles. — The blood-corpuscles frequently serve as carriers of the microbic cause of the inflammation; they block the lumen of inflamed capillary vessels, partially or completely, and constitute the histological ele- ments of the primary exudation. The element of the blood which is more intimately associated with the histology of inflammation is the 1. Leucocyte, or "White Blood-corpuscle. — This is a nucleated, spherical, transparent mass of protoplasm, without a limiting membrane or envelope. Heitzmann made the discovery that it'is composed of a reticulum of proto- plasmic strings, with a hyaline substance in the meshes. The nucleus shows a similar structure, and its net-work is continuous with that of the cell-body. Strieker and Klein, as well as a number of other histologists, have adopted Heitzmann's views in reference to the minute anatomy of the leucocyte. The reticulated structure is well shown by stain- ing with chloride of gold, which stains the protoplasmic strings, but not the HISTOLOGICAL ELEMENTS IN THE INFLAMMATOEY PKOCESS. 95 interstitial substance. The leucocyte is endowed with intrinsic power of locomotion, — amoeboid movements,- — a function which is performed by the reticulum. Wharton Jones discovered motion of protoplasm in leucocytes of human blood as early as 1846. In 1862 Haeckel showed that the white blood-corpuscles absorb pigment-granules: a process which can only take place by amoeboid movements, which by change of form of cell bring the foreign material into its interior by inclusion. These observations enabled Cohnheim to demonstrate later that the white blood-corpuscles found in the vascular spaces of the cornea were derived from the blood; in other words, to establish the fact of emigration of leucocytes through the inflamed wall of capillaries. The amoeboid movements of the colorless corpuscles can be well observed for hours in the moist chamber on the warm stage. The movements of a leucocyte are peculiar. The first effort consists Fig. 60. — Change of Forms of a Moving Leucocyte by Amceboid Movements. (_Elein.) of a protrusion of a hyaline film. This is withdrawn and another is pro- truded; in the next moment this is diminished to a very minute process, whereas, on the opposite side, a new, broad process appears. After this the corpuscle is seen to throw out processes of various length and thickness, and thus to alter its shape in a considerable manner. By virtue of the amoeboid movement of leucocytes they move from place to place independently of the blood- or plasma- current. This independent locomotion enables them to pass through the small opening in the wall of inflamed capillaries, and, after they have reached the paravascular tissues, to travel along connective- tissue spaces until arrested by some mechanical obstruction. If pigment- material, in a finely-divided state, is mixed with blood, either before or after withdrawing it from the vessels, the projections thrown out by the leuco- cytes inclose the particles brought in contact with it, and the granules reach 96 PEINCIPLES OF SUEGERY. in this manner the interior of the leucocytes, and are variously distributed according to the shape and movements of the protoplasm. Microbes reach the interior of the leucocytes in the same manner. In cases of intravascular infection the emigration corpuscles convey with them the microbes through the wall of inflamed capillaries into the tissues surrounding them. Grawitz certainly underestimates the part the leucocytes perform in inflammatory processes, as he denies, in toto, the leucocytic nature, — that is, their derivation from the blood in exudates, — claiming there is no proof in support of Cohnheim's teachings. He does not consider the proliferation theory of Virchow alone in cell-production. His own view, that cells arise from the intercellular substance and from cell-particles, is emphasized, and is called " ScMummerzelUn theory." He combats the teachings of Senftleben and Leber, who claim that cells formed in a supposed dead cornea introduced into tissues as immigrated cells. He claimed the corneal tissue was not dead, because: (1) cornea was removed from animal several days; (3) heating to 80° C. for one-quarter hour; (3) desiccation of tissue; all of which are in- sufflcient, in his opinion, to destroy the tissue. If such tissue is introduced into the lymph-sac of frogs, it is invaded by wandering cells, which are not immigrated cells, but are derived from the corneal tissue itself. In dead corneal tissue (heating to 53° C. or immersion in sublimate solution), no wandering cells when inserted in a frog's lymph-sac. Ingenious as these experiments may appear, they do not militate against the theory that leu- cocytes are constantly found in inflammatory tissue, and perhaps the most important proof of the important part they take is the marked leucocytosis which is always found during all acute inflammatory affections. 2. Red Blood-corpuscle. — The colored blood-corpuscle serves less fre- quently as a carrier of microbes than the leucocyte, as it does not possess as active amoeboid movements. For the same reason it is not found so con- stantly as a component part of the inflammatory exudation, as its transit through the capillary wall is a more passive process, and is accomplished principally by the vis a tergo in case the stomata are suiSciently large to permit its passage. Leonard has recently demonstrated the amoeboid move- ments of the red corpuscles by instantaneous microphotography. The move- ments extended over half an hour upon the warm stage, and the pictures obtained are well shown in Fig. 61. The presence of numerous colored cor- puscles in the exudation is an indication of great acuity and intensity of the inflammation: conditions causing serious and extensive alterations of the capillary wall. The escape of whole blood through a capillary vessel greatly damaged by the cause of the inflammation is called rliexis. 3. Third Corpuscle. — A third cellular element in the blood, the third corpuscle, was discovered by Max Schultze, in 1865. He described it as a small, colorless sphere, or granule. Elaborate descriptions of this corpus- HISTOLOGICAL ELEMENTS IN THE INFLAMMATORY PROCESS. 97 cle were given by Hayem^ in 1878, and Bizzozero, in 1882. Hayem, from his observations;, believed that these minute structures represented young colored blood-corpuscles, and hence named them hsematoblasts. Bizzozero entered his protest against this theory and called them blood-plates (Blut- pldttcJien). Under the microscope they appear as minute, faintly-colored blood-corpuscles. They seem to possess a little stroma like the red blood- corpuscles, but contain no nucleus and are devoid of any cell-membrane. What appears as a nucleus is, according to Hayem, an optical defect. Hayem estimates that they are forty times more numerous in man than the leucocytes, and twenty times more abundant than the colored corpuscles. As there has been no positive proof furnished that the third corpuscle is an embryonal red blood-corpuscle, and as it has been shown that blood-corpus- cles are produced from the fixed cells of blood-producing organs, as, for in- stance, the spleen and medullary tissue, it is advisable not to apply to it the Fig. 61. — AmcEboid Movements of Red Blood-corpuscles. (After Leonard.) term hgematoblasts, but to distinguish it from the remaining two morpho- logical elements of the blood numerically by calling it the third corpuscle. Under a higher power the third corpuscle can be readily recognized in the blood-stream of capillary vessels in the mesentery or web of a frog. In blood withdrawn from a vessel it is destroyed as soon as coagulation sets in; hence it disappears almost immediately after it leaves the blood-vessel. In order to study it outside of the body, means must be employed to prevent coagula- tion, which can be done by mixing the blood with the following solution, recommended by Hayem: — Distilled water 200.00 cubic centimetres. Sodic chloride 1.00 gramme. Sodic sulphate 5.00 grammes. Mercury bichloride 0.50 gramme. From a needle-puncture the blood is allowed to mix with the solution in the proportion of about 1 to 20 up to 1 to 10-0. In this mixture the third 98 PEINCIPLES OF SURGERY. corpuscle will retain its shape and size for twelve to twenty-four hours. The third corpuscle is a fibrin-producing structure, and, as such, it takes an active part in the formation and growth of intravascular blood-clots. The white mural thrombus, produced intra vitam, is composed almost exclusively of this element of the blood. If, from a trauma or disease, the endothelial lining of a blood-vessel is injured and the smooth surface becomes uneven, the third corpuscles, floating in the peripheral portion of the axial current. Fig. 62. — 1. Third corpuscle. A, natural appearance when seen on surface and on edge; B, C, C", D, and E, appearance presented by them during coagulation. 2. Shows the little heaps of granules formed by them after coagulation (Hayem). 3. A small blood- vessel as stasis is approaching. A, third corpuscles in periphery of stream; B, colored blood-corpuscles; C, leucocyte. (Eljerth and Schimvielhusch.) come in contact with projecting points, and are arrested and become attached to the vessel-wall, layer after layer is added, and in this manner the mural thrombus is formed. On the surface of recent wounds they appear in large numbers, lose their fibrin-ferment, and give rise to the formation of fibrin, which acts both as an hsemostatic and temporary cement-substance. In in- flammation the third corpuscle escapes through the capillary wall in the same manner as the red corpuscles, but, on account of its smaller size, its peripheral location in the blood-stream, and its greater abundance, it is numerically more abundant in the inflammatory exudation. The fibrin in inflamed tissues is undoubtedly derived largely from this source. 4. Fixed Tissue-cells. — The flxed tissue-cells behave differently in the inflamed part, according to the intensity and nature of the primary mi- HISTOLOGICAL ELEMENTS IN THE INFLAMMATOEY PROCESS. " 99 crobic cause. The microbes, or their ptomaines, may possess such intense local toxic properties as to destroy their vitality directly, when the inflam- mation results in necrosis, as in the case in the centre of an ordinary furuncle and on a larger scale in cases of progressive phlegmonous inflammation. The fixed tissue-cells may be destroyed by starvation, by the primary inflam- matory exudation being so abundant as to obstruct the circulation in the inflamed part. If the cause of the inflammation is less intense, as is the case in chronic inflammation, the fixed tissue-cells are brought in direct contact with the microbes which produced the inflammation, and active tissue-proliferation is the result, and this furnishes the bulk of the inflam- matory product. The histological structure of tubercle furnishes a good illustration of the part taken by the fixed tissue-cells in chronic inflamma- tion. In chronic suppurative inflammation the fixed tissue-cells are first transformed into embryonal tissue, and, as the protoplasm of the new cells is destroyed by the ptomaines of pus-microbes, they are converted into pus- corpuscles. A passive role in the inflammatory process was assigned to the fixed tissue-cells by Boerhaave, who regarded stasis as the essential feature of inflammation; by Andral, who believed that hypersemia was the charac- teristic pathological condition in an inflamed part; and by Eokitansky, who taught that exudation constituted the most important element in all in- flammatory lesions. Virchow located the primary seat of inflammation in the flxed tissue-cells, and asserted that nutritive or formative irritation oc- curred in them independently of vessels or nerves. He maintained that, the more the cells were disposed to take up nutritive material, the greater the danger that they themselves would be destroyed. Remaining faithful to the doctrine that inflammation is only caused by the presence and action of a specific microbic cause, we shall find that, the more acute the process, the less the probability that the fixed tissue-cells take an active part, and that, the more chronic the inflammation, the greater the amount of the new material that has been derived from the fixed tissue-cells, and the smaller the quantity of vascular exudation. 5. Plasma-cells and Mast-cells. — An occasional cellular product of in- flammation are the plasma- and mast- cells. Ivannoics distinguishes two distinct morphological forms of plasma-cells: (1) a round or oval cell, which may send out short processes, the nucleus being deeply stained and present- ing coarse parietal granules; and (2) an oval, spindle-shaped cell, with numerous processes and not unlike connective-tissue cells; the nucleus is long and the chromatin granules more lightly stained than in the flrst. He believes the first are derived from polymorphonuclear leucocytes and lymphocytes, and the second from connective-tissue cells, and claims that this cell can only form connective tissue. Gherardini believes that the mast- cells are identical with plasma-cells and that they originate from leucocytes 100 PEINCIPLES OF SUEGEKY. and which, during their 23hagocytic activity, retain some of the products of cell-disintegration. The differences between the mast-cell and plasma-cell are simply different stages in the development of the same cell. SYMPTOMS or INFLAMMATION. The structural changes caused by inflammation give rise to a charac- teristic complexus of symptoms, — pain, redness, swelling, heat, and suspen- sion — diminution, increase, or perversion of function. These symptoms vary in intensity, according to the nature of the primary cause and the anatomical structure and location of the tissues affected. One or more of the symptoms enumerated may be absent, when the existence of inflammation must be ascertained by a more careful study of those presented. In acute inflamma- tion the symptoms appear in rapid succession or almost simultaneously, while in the chronic form they come on slowly, often almost insidiously, and fre- quently one or more are wanting, even when the disease is far advanced. The number and intensity of the individual symptoms vary not only accord- ing to the virulence of the primary microbic cause, but are also modified by the resisting capacity of the individual and the tissues affected. We speak of a complete or partial immunity to certain microbic diseases, and of a gen- eral or local, hereditary or acquired, disposition. For diagnostic purposes the symptoms must be studied individually and collectively, and with spe- cial reference to their etiology and the location and structure of the inflamed tissues or organ. (a) Pain. — Pain is one of the most variable symptoms of inflammation. It is caused by traction or pressure to which sensitive nerve-filaments are subjected in the inflamed tissues, and probably, also, in some instances, at least, by extension of the inflammatory process to the structure of the nerves themselves. Some patients are more sensitive to pain than others. The same extent and degree of inflammation of the same part giving rise to sen- sation of discomfort in a torpid person may cause excruciating pain in pa- tients with a nervous temperament. As the degree of pain will depend largely upon the number of sensitive nerves present in the inflamed area and the amount of exudation, we would naturally expect to find pain a prominent symptom in inflammations of unyielding tissue freely supplied by sensitive nerves. This, as a rule, is the case. Pain is a distressing symptom in cases of phlegmonous inflammation of the fascia and tendon-sheaths of the fingers and palm of the hand. Pain is the most conspicuous symptom in periostitis and inflammation of the serous membranes. Wherever the inflammatory exudation appears rapidly in parts freely supplied with sensitive nerves, pain from tension appears as one of the foremost symptoms, and continues with- out intermission until tension is relieved. In acute suppurative osteomye- litis intense pain is present from the very commencement of the disease, and SYMPTOMS OF INFLAMMATION. 101 continues unabated until tension is removed by operative procedures, or by escape of inflammatory product, through, some defect in the bone, into the more yielding paraperiosteal tissues. The pain is throbbing, sometimes syn- chronously with the pulse, in acute circumscribed phlegmonous inflamma- tion. It is sharp and lancinating in inflammation of serous membranes. It is described as a burning sensation in inflammation of the skin. The pain is of a dull, aching, boring character in deep-seated inflammation, especially in the interior of bone. Nocturnal exacerbation of pain is a common occur- rence, and seldom absent in painful syphilitic affections. ' The pain is not always referred by the patient to the seat of inflammation, as in the early stages of coxitis it is not in the hip, but over the inner aspect of the knee, and in inflammatory affections of the nerves the pain radiates along the peripheral branches, and is usually felt most severely some distance from the seat of the disease, at points supplied by the peripheral branches. In ascertaining the existence and exact location of a deep-seated inflammation, tenderness is a more valuable symptom than spontaneous pain. Tenderness is th-e pain elicited by pressure. If the inflamed part is tender on pressure and accessible to palpation, the area of tenderness will correspond to the extent of the inflammation. During the beginning of an attack of phleg- monous inflammation the surgeon is able to locate the affection accurately by searching for the point where the tenderness is most acute, and the same symptom will indicate to him, earlier than any other, the direction in which the process is extending. In periostitis the area of tenderness will show whether the inflammation is circumscribed or diffuse. The existence of cir- cumscribed points of tenderness about the epiphyses of the long bones is almost a certain indication of central osseous tuberculosis, and, at the same time, furnishes a reliable guide in their early operative treatment. Firm pressure relieves pain in nervous hysterical patients, while it aggravates it when it is caused by inflammation. On the other hand, superficial pressure made with the tips of the fingers increases the suffering in parts the seat of functional disturbance, while it does not materially affect the pain resulting from inflammatory lesions. (b) Redness. — The composition of normal blood is admirably adapted for the passage of this fluid through capillary vessels. As long as the relation of corpuscular elements to the blood-plasma remains normal, and the intima of the blood-vessels remains intact, and the vis a tergo is adequate, there is no tendency to capillary obstruction. If the capillary circulation in the mesentery of a frog is examined under a microscope, there is no difficulty in distinguishing two currents: the axial and peripheral. The axial, or central, current is rapid, and conveys the red corpuscles, which have the same spe- cific gravity as the blood-plasma, while the peripheral current between the axial and vessel-wall is considerably slower, and in this current the colorless 103 PRINCIPLES OF SURGERY. corpuscles are conveyed, their rotating motion being due to their coming in contact with the wall of the vessel. D. J. Hamilton has shown, by numerous experiments, that, in fluids holding in suspension solid particles passing through capillary tubes, the heaviest particles are carried along the central current, while those specifically lighter than the fluid seek the peripheral current. The leucocytes are specifically lighter than the fluid in which they are contained; hence they are forced into the space between the axial cur- rent and the vessel-wall (Fig. 63, C). The third corpuscle, probably for the same reasons, moves also in the peripheral stream. The colorless corpuscles accumulate more in the peripheral stream when the current is feeble than when it is rapid. This fact is of great importance in the study of the altered circulation when the capillary vessels are in a state of inflammation. The accumulation of colorless corpuscles in the peripheral stream in inflamed capillary vessels, according to Thoma, Eberth, and Schimmelbusch, is owed to the slowness of the current, which, although insufficient to propel the specifically light, colorless corpuscles, is still competent to force onward the less-resisting and specifically heavier-colored corpuscles. Eberth and Schimmelbusch state that in the vessels of a warm-blooded animal four kinds of stream are noticed, in accordance with its velocity: (1) the normal stream, in which the axial current and peripheral zone are readily recognizable; (3) a slow stream, in which the leucocytes accumulate in the periphery; (3) a still slower stream, in which the third corpuscles also leave the axis and accumulate in the periphery, and in which, these observers assert, the leucocytes become less numerous; and (4) a stream so slow as to ap- proach stagnation, in which all the elements of the blood are indiscriminately mixed. From the above it can be seen that all general and local conditions which tend to diminish the velocity of the blood-current in the capillary vessels are productive of accumulation of the colorless corpuscles and of the third corpuscles in the peripheral stream: a condition which greatly ag- gravates the existing local impediments to capillary circulation, and when well advanced, by encroaching more and more upon the central stream, will result in complete stasis. Temporary hypersemia of a part or organ is a fre- quent occurrence, and is often the result of abnormal innervation. The in- fluences of the nervous system — particularly of the sympathetic nerves — over the circulation are familiar to every student of physiology. Temporary hypersemias and ansemias of certain parts or organs of the body — the result of abnormal innervation of the vasodilators or vasoconstrictors — frequently bring about vascular changes which predispose to the localization of the essential microbic cause of inflammation. Injury to nerves, mental excite- ment or depression, and exposure to cold are potent factors in the produc- tion of temporary vascular disturbances. Two forms of active hyperamia, due to faulty innervation, must be recognized. When caused by a paralysis SYMPTOMS OF INFLAMMATION. 103 of the vasoconstrictors it is described as hypergemia of paralysis. A classical demonstration of this form of hypersemia was furnished by Claude Bernard by his experiment, which consisted of division of the cervical sympathetic in the rabbit, which was invariably followed by marked hyperasmia and dila- tation of the blood-vessels in the ear on the corresponding side. When the vasodilators are irritated by mechanical or electrical stimulation the arte- rioles dilate and the part presided over by the affected nerve becomes hyper- semic, and the condition of the circulation is known as hypersemia of irrita- tion, A good illustration of this form of hyperasmia can be produced by stimulation of the chorda-tympani nerve, which, as was shown first by Claude Bernard, always produces dilatation of the vessels in the submaxillary gland. Passive hyperemia is caused by mechanical conditions which inter- fere with the return of venous blood. Ligation of a vein furnishes the sim- plest variety of this form of venous congestion. Thrombophlebitis; varicose veins; pressure upon veins caused by tumors, the pregnant uterus, and in- flammatory products; and pressure caused by a dislocation or fractured bone, as well as organic disease of the heart and lungs and cirrhosis of the liver, afford familiar instances of the more common mechanical interfer- ences with the venous circulation. The chronic or frequently-recurring hy- peremia in a part usually results in increased nutritive activity of the tissues and hyperplasia in the absence of infection. This effect of chronic hyper- semia has been made use of in practice by producing the condition artificially in the treatment of tubercular affections accessible to this kind of treatment (Bier). Eedness as a symptom of inflammation signifies an excess of blood in the part, and the terms used to indicate its existence are hypersemia and congestion, while complete arrest of the capillary circulation is expressed by the word stasis. Accurately speaking, hyperemia should be used to designate that condition of the circulation where the part not only contains an in- creased amount of blood, but where an increased amount of blood flows to and returns from the part: an exalted physiological process; while the word congestion literally means only an accumulation of blood in a part: a con- dition owed to some form of local or distant mechanical obstruction. The conditions giving rise to redness, hypersemia, congestion, and stasis should not be studied only from descriptions, but in order to be understood they should be seen. This can be readily done by producing artificially an in- flammation in a transparent part of some lower animal, preferably the frog, and studying the circulation in the inflamed part step by step under the mi- croscope. For this purpose experimenters have usually selected the frog's web, mesentery, tongue, lung, and bladder, and the tadpole's tail. For general use the frog's web should be selected, as the preparations for this experiment are very simple. Inflammation is provoked by cauterizing the web with a needle heat-ed to a red heat, or by applying with a small plug of cotton some power- 104 PRINCIPLES OF SUEGEEY. ful irritant, as ammonia, tincture of cantharides, or croton-oil, or by touch- ing the surface with a sharp stick of nitrate of silver. Hamilton gives the following directions for making the experiment: "Nothing more is neces- sary than a piece of tin or other soft metal, about 1 ^/g to 2 inches broad and about 6 to 8 inches long, or, what is better, a thin piece of hard wood of the same dimensions. At the end where the web is to be stretched it should not be so broad. From the narrow end of this a V-shaped piece is cut out, over which the web is to be spread. The frog should first be curarized, as this does not interfere with the circulation, provided that the solution employed Fig. 63. — Normal Circulation in Frog's Web. A, artery; B, vein; O, capillaries. Vessels covered by a net-work of polygonal epithelial cells of web, in which pigmented cells are not represented. (Landerer.) be not too strong. The ^/aooo of a grain, in watery solution, injected under the skin, is sufficient. Chloral may be substituted. Caton recommends a solution of 4 grains to the drachm. As many minims should be injected subcutaneously as the frog is drachms in weight. The injection is made un- der the skin of the back with an ordinary hypodermic syringe. The animal is laid on the piece of metal or wood, and, the web being stretched over the cleft at the end, the toes are held by tying a piece of thin thread to them and fixing the ends into a fine slit cut in the metal or wood." The micro- scope is so arranged and adjusted that the field of observation will correspond to the point of irritation. A sufficiently high power is used so that the dif- SYMPTOMS OF INFLAMMATION. 105 ferent corpuscular elements in the capillary stream can be readily seen and recognized. In order to witness the different stages of the inflammatory process it is necessary to continue the observation for hours. Any one of the irritants mentioned applied to the frog's web will pro- duce in the capillaries over a limited area a series of changes which are always present in inflammation, and a description of them will represent what takes place in capillaries the seat of inflammatory processes of bacterial origin; almost simultaneously with the application of the irritant a momentary con- traction of the vessel occurs, caused by the stimulation of the vasocon- strictor nerves, which is followed b}^ dilatation, with increased velocity of Fig. 64.— Capillaries of Frog s Web m a State of Hyperasmia soon after Application of Irritant. A, artery; B, vein; C, capillaries. (Landerer.) the capillary current: a true hypergemia. The bright-red color of the hyper- ffimic part at this stage, according to Eecklinghausen, is due to increase in the rapidity of the blood-current, but, as the color of the blood indicates a diminished expenditure of oxygen and a smaller quantity of carbon in the blood, increased velocity alone would not explain this change. Diminished alkalescence in the inflamed tissues may reduce the amount of oxygen used, as is the case in glands during active secretion, where Claude Bernard showed that defective oxygenation is always present. At this stage the corpuscular elements circulate in their respective streams, and the whole picture is one of increased physiological activity. Dilatation of the vessels follows con- 106 PRINCIPLES OF SURGEET. traction so quickly that it would be difficult to explain it as a paralytic phe- nomenon. Its early outset and the rapidity with which it appears would point to a neurotic cause, traceable to the action of ganglia in the vessel- wall. It has not yet been satisfactorily explained whether this early dilata- tion of the vessel is due to vasomotor paralysis or irritation of the vaso- dilators, but it is more probable that it is caused by the vasodilators, while, later, paralysis from overdistension occurs. Division of the sym- pathetic in the neck brings about increased vascularity, but no inflam- mation. The difference between dilatation of an inflamed vessel and the dilatation following division of the sympathetic consists in alteration of the capillary wall, in the former instance produced by the action of the causes >. 4 © ^. "" ! : o 1 1 r .^. ^- e v_^ ■& ' ^ \ ' - ^ / i \ * -'».. i o'^ -^- J*' rt -■| * ® \