An American text-book of surgery : for practitioners and students / By Phineas S. Conner, M.D., Frederic S. Dennis, M.D., William W. Keen, M.D., Charles B. Nancrede, M.D., Roswell Park, M.D., Lewis S. Pilcher, M.D., Nicholas Senn, M.D., Francis J. Shepherd, M.D., Lewis A. Stimson, M.D., J. Collins Warren, M.D., and J. William White, M.D. Ed. by William W. Keen and J. William White.
- William Williams Keen
- Date:
- 1899
Licence: Public Domain Mark
Credit: An American text-book of surgery : for practitioners and students / By Phineas S. Conner, M.D., Frederic S. Dennis, M.D., William W. Keen, M.D., Charles B. Nancrede, M.D., Roswell Park, M.D., Lewis S. Pilcher, M.D., Nicholas Senn, M.D., Francis J. Shepherd, M.D., Lewis A. Stimson, M.D., J. Collins Warren, M.D., and J. William White, M.D. Ed. by William W. Keen and J. William White. Source: Wellcome Collection.
Provider: This material has been provided by the Augustus C. Long Health Sciences Library at Columbia University and Columbia University Libraries/Information Services, through the Medical Heritage Library. The original may be consulted at the the Augustus C. Long Health Sciences Library at Columbia University and Columbia University.
![is i(>niic(l between tliein. witli wliicli tlicv hlcml. \\\ the or^raiii/ation aiul development of the new tissue a |)erniaiient ttoiid of uiiioTi is foimccl. In no case is union of divided tissue effected without tlie inteijtosition of new material. AVheii divided tissues are at once hrouf^ht into jx'rfect apposition, and there retained and shielded from disturbance, the amount of new tissue required for the accomplishment of union will be extremely small, and may be with difficulty recognizal)le; but its existence in some degree is nevertheless undeniable. When the process of i-ejiair wliereby the union of divided surfaces is secured proceeds without comj)lication or interruption, union by first intention or by primary adhesion is said to have taken place. (See Cha])ter TIL) This pri- mary union is the ideal to be sought for whenever possible. To secure it it is necessary that the divided surfaces be brought together and kept in close apposition ; that the wound be protected and kept from all further injury ; and that adefjuate local nutritive conditions be maintained. Wliatever interferes ■with any of these conditions will introduce a complication in the healing of a ■wound. It is not infrequently the case that wounds occur in which from the outset it is apparent to a surgeon that in some one or all of these respects it will be impossible to secure the necessary conditions, so that no attempt to secure union by first intention can be made. Thus the loss of tissue may be so great that apposition of the <livirled surfjices is impracticable, or some motion is unavoidable, or there is pre-existing infection, or such relation of the wound to the bodily excretions or secretions exists that some contamination is inevitable. The presence of any of these conditions will make it obvious that a wound should not be closed. Again, the tissues bordering the wound may be so bruised or reduced in their vitality by general or local causes that their power of sustaining the necessary processes of repair is uncertain, perhaps obviously hopeless. In all such cases the method adopted by the surgeon for the treat- ment of the wound will be quite different from those in which primary union is expected. Healing by second intention is the process which is now the resource of the surgeon, as it is also in those cases in which attempts at primary union have been made and have failed. By its means the ultimate healing of the Avound is secured. The conditions which may thwart the ideal primary rej)air of the wound •will have to do with either the apposition, the ])rotection. or the nutrition of the ■wounded parts. Under the first of these headings the surgeon must consider the natural gaping of divided tissues and the necessity of supply- ing adequate means of retaining them in coaptation. The inevitable aggrava- tion of this natural gaping by certain positions of the body or of the limbs and by motion at joints suggests at once the necessity of considering a favor- able posture for wounded parts, so that relaxation of the injured tissues as complete as possible may be secured. The accumulation of blood and of wound-secretions between the divided surfaces is a frequent cause of lack of success in attempts at securing primary union. Under conditions of typically perfect protection from external infection, as in most subcutaneous wounds, and in some operation-wounds made under rigid conditions of ase])sis. such accumu- lations of blood and wound-secretions may not introduce any serious complica- tion into the healing of the wound. Later, these effusions become absorbed, or they are diffused among the adjacent connective tissue-spaces, and the nat- ural processes of repair proceed. In yet other cases the blood-clot, remaining as an intervening mass between the wound-surfaces, serves as a su])j)ort and scaffolding for new tissue ■which is thrown out from the surrounding ])arts, and which penetrates the mass of the clot and coalesces with it, and finally replaces](https://iiif.wellcomecollection.org/image/b21217014_0134.jp2/full/800%2C/0/default.jpg)
