EEPARATIVE PROCESS. 449 



which is termed by Dr. Macartney " immediate union." It is often seen in 

 the case of small incised wounds, such as cuts of the fingers, or the incision 

 made in venesection, in which the two edges can be brought into close ap- 

 proximation, so that they grow together without any connecting medium of 

 blood or lymph ; but it sometimes occurs in larger ones, 1 and as it is the best 

 imaginable process, the surgeon ought to favor it as much as possible, by pro- 

 curing the most exact coaptation of the wounded parts, and by repressing any 

 tendency to inflammation which will interfere with it. This is the mode of 

 union which was spoken of by John Hunter as ''healing by the first inten- 

 tion." He supposed that the' union takes place through the medium of the 

 blood intervening between the lips of the wound, which undergoes organiza- 

 tion into a connecting tissue ; but it is now certain that although blood may 

 become organized, especially when effused into a wound secluded from the 

 air, yet that its intervention opposes, rather than favors, healing by immediate 

 union. 



3G4. That which is commonly known amongst British Surgeons as " heal- 

 ing by the first intention," is that which was designated by Hunter as " union 

 by adhesion" or by "adhesive inflammation." This process takes place in 

 the case of incised wounds, of which the edges are not brought into perfect 

 coaptation, or in which some inflammatory action is present, which gives rise 

 to the effusion of plastic lymph. In either case, the connection is finally re- 

 established by the organization of the lymph, into which vessels pass from 

 both surfaces ; but the intervention of this bond is manifested in the persistence 

 of the cicatrix, which is quite distinguishable by its peculiar appearance from 

 the surrounding tissue. A very good example of this process, as it takes 

 place under favorable circumstances, is presented after operations for hare- 

 lip; the wound left by which, however, may partly heal by "immediate 

 union." Even the moderate effusion of lymph, to a degree that is altogether 

 salutary, cannot be regarded as alone sufficing, under such circumstances, 

 to constitute Inflammation. But it is well known that if a slight wound 

 which is thus healing, be provoked to an increased degree of inflammation, 

 its progress is interrupted ; and all the means which the Surgeon employs to 

 promote union are such as tend to prevent the accession of this state. The 

 only case in which the concurrence of Inflammation can be regarded as 

 salutary, is that in which there is a deficiency of Fibrin in the blood, causing 

 a deficient organizabUity of the lymph. It has been seen that the amount of 

 fibrin is rapidly increased by inflammation ( 200); and the Surgeon well 

 knows that a wound with pale flabby edges, in a depressed state of the system, 

 will not heal, until some degree of Inflammation has commenced. But when 

 the inflammatory state has developed itself, in however trifling a degree, there 

 is always a risk of its proceeding further, and occasioning a degeneration of 

 the plastic material, so that the formation of pus-cells and the effusion of 

 purulent fluid take place, instead of the development of uniting tissue. 



365. The regeneration of epithelium when the injury has been so slight as 

 only to effect its abrasion has chiefly been studied in the case of the corneal 

 epithelium, 2 and appears to be effected chiefly by the adjoining cells thrusting 

 out processes towards the wound and gradually bridging it over and covering 

 it ; but some new cells may also arise from the multiplication and develop- 



1 Mr. Paget mentions a case of extirpation of a mammary tumor, in which the 

 greater part of the wound was found to have healed after this fashion ; the skin and 

 fascia having so firmly adhered, that no indication existed of their previous detach- 

 ment ; and no effusion of coagulable lymph, or production of a connecting tissue, was 

 detectable by microscopic examination. (Lectures on Surgical Pathology, vol. i, p. l'J3.) 



2 See Arnold, Virchow's Archiv, Band xlvi, Heft 2; Hoffmann, idem, 1870, p. 373 ; 

 Heiberg, Strieker's Jahrbiicher, 1871, p. 7, and Kiiss, Cours de Physiologic, 1872. 



