Lectures on the processes of repair and reproduction after injuries: delivered at the Royal College of Surgeons of England / [Sir James Paget].

  • James Paget
Date:
[1849]
Catalogue details

Licence: Public Domain Mark

Credit: Lectures on the processes of repair and reproduction after injuries: delivered at the Royal College of Surgeons of England / [Sir James Paget]. Source: Wellcome Collection.

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    The attainment of the other necessary condition,—the absence of inflammation,— is quite consistent with these means for in¬ suring perfect and continued contact of the wounded surfaces. How the condition is to be fulfilled I need not say : the means are some of those that are commonly laid down for preventing inflammation from being, as it is said, more than is necessary for the union by the first intention ; and the best of them are temperance and rest. The necessity of observing them will appear the greater, if it is remembered that what is wanted for im¬ mediate union is, not a certain undefined slight degree of inflammation, but the com¬ plete absence of inflammation ;—for, the pro¬ bability of the occurrence of immediate union may be reckoned as being in an in¬ verse ratio to the probability of inflamma¬ tion occurring in the time necessary for its accomplishment. I pa s now to the second mode of repair that I enumerated—that, namely, by primary adhesion. This is the process which Mr. Hunter named union by adhesion, or union by the adhesive inflammation. My reasons for pre¬ ferring the term “ primary adhesion,” will presently appear. He says (vol. iii. p. 253,) “Where the former bond of union,” [«'. e. the union by blood or by the first intention], “ is lost in a part, to produce a new one, a second operation takes place—namely, inflamma¬ tion.’’ Observe how carefully Mr. Hunter distinguishes the case in which inflammation ensues* from that in which none is necessary : and presently alter, “ if the divided parts are allowed to remain till the mouths of the divided vessels are entirely shut, inflamma¬ tion will inevitably follow, and will furnish the same materials for union which are con¬ tained in extravasated blood, by throwing out the coagulated lymph ; so that union may still take place, though some time later after the division of the parts. This inflam¬ mation I have called the adhesive.” On this sentence, Mr. Palmer, expressing the opinion entertained by all the pathologists of ten or twelve years ago, says—“ It is now generally considered that union by the first intention and adhesive inflammation are es¬ sentially the same processes, modified by the degree of inflammation. Union by the first intention is uniformly attended with some degree of pain and swelling, together with increased heat and vascularity, which, taken conjointly, constitute the definition of in¬ flammation.” And again : “ According to the modern views, the modes of union above detailed” [i. e. the modes of union included by Mr. Hunter under the union by the first intention], “ are always accompanied by ad¬ hesive inflammation .... The parts are united, not by the extravasated blood be¬ coming vascular, but by the effusion and or¬ ganization of coagulable lymph.” After what I have said respecting the pro¬ cess of immediate union, it may appear that Mr. Hunter was more nearly right than his successors. It would be an instructive piece of the history of surgery to show, exactly, how this truth being mixed with error came, therefore, to be thrown away, and to make room for an error which had less truth mixed with it. The stages of transition in opinions seem to have been that—first, sufficient rea¬ son was found for disbelieving his statement, that blood forms the bond of union by the first intention; then, as it was assumed that there must always be some intermediate bond, this, it seemed, could be none but co¬ agulable lymph. Now, coagulable lymph being known only as the product of inflam¬ mation, it followed that inflammation must be necessary for the healing of every wound ; and then there ceased to be any distinction between the union by the first intention and the union by adhesion ; both alike seemed to be the result of lymph, the product of in¬ flammation, being effused between the wounded surfaces, and united to them both. The typical examples of union by primary adhesion may be watched in the cut edges of skin that are brought close together. Here, when the cut surfaces are not in exact con¬ tact, the wound is exposed, and lymph is formed, and fills up the space ; or, when they are in contact, the sutures, or other means employed to keep them so, excite inflammation enough for the production of some lymph between them. The lymph organizing itself, and becoming vascular, connects the two edges or surfaces, and forms between them a thin layer of cellular tissue, on the surface of which, if it be exposed, a very delicate layer of cuticle is developed. The smooth shining surface of this cuticle gives the pecu¬ liar character of the scar, and one that scarcely changes, except in the alteration of apparent colour when the new material be¬ comes less vascular. The lymph effused in the healing by pri¬ mary adhesion always, so far as I know, developes itself through nucleated cells, as the lymph of acute inflammation does; doubtless, the whole process is very similar to that of the adhesion of inflamed serous membranes. It may be very quickly accomplished. Lately, a boy died eighty hours after re¬ ceiving a lacerated wound of the abdomen ; and, for forty-eight hours of these eighty, he was so manifestly dying, that I think no re¬ parative process could have been going on. A portion of the edges of the wound was united with lymph, which presented well- marked cells, like those of granulations, and contained new-formed blood-vessels. But it may be accomplished more quickly