ABNORMAL FORMS OF NUTRITIVE PROCESS INFLAMMATION. 453 



become organized ; the filling up of a wound with granulations being thus a 

 much more rapid process than that renewal of the completely formed tis- 

 sues which may take place in the absence of inflammation. The imperfect 

 character of the granulation structure is shown, by the almost complete 

 disappearance of it after the wound has closed over. The portion of it in 

 immediate contact with the subjacent tissue, however, appears to undergo a 

 higher organization ; for it becomes the medium by which the cicatrix is 

 made to adhere to the bottom of the wound. It is very liable to undergo 

 changes which end in its disintegration ; as is evident from the known tendency 

 to reopening, in wounds that have been been closed in this manner. 



369. When two opposite surfaces of granulations, well developed, but not 

 yet covered with cuticle, are brought into apposition, they have a tendency 

 to unite, like the two original surfaces of an incised wound. This method 

 of union, which was noticed by John Hunter, has been appropriately 

 termed "secondary adhesion" by Mr. Paget. The surgeon may frequently 

 have recourse to it with great advantage, when primary adhesion is impos- 

 sible, and when the filling up of the wound with granulations would be a 

 tedious process, and very exhausting to the patient. In applying it to prac- 

 tice, it is essential to success, first that the granulations should be healthy, 

 not inflamed or profusely secreting, nor degenerated, as those in sinuses 

 commonly are; and secondly, that the contact between them should be gentle 

 but maintained: it seems desirable, also, that the granulation surfaces should 

 be as much as possible of equal development, and alike in character. 1 



4. Abnormal Forms of the Nutritive Process. 



370. Under the preceding head we have considered the chief variations 

 in the degree of activity that are witnessed in the ordinary or normal con- 

 ditions of the Nutritive process, those conditions, namely, in which the 

 products are adapted, by their similarity of character, to replace those 

 which have been removed by disintegration. But we have now to consider 

 those forms of this process in which the products are abnormal, being dif- 

 ferent from the tissues they ought to replace. We shall confine ourselves to 

 a brief examination of a few of some of the most important of these states; 

 and that which first claims our consideration, on account of the frequency 

 of its occurrence and the importance of its results, is Inflammation. Al- 

 though Pathologists have been accustomed to look for the "proximate 

 cause" of the phenomena which essentially constitute the Inflammatory 

 state, or, in other words, for the first departure from the normal course of 

 vital action, in the enlarged or contracted dimensions of the bloodvessels of 

 the inflamed part, or in the altered rate of movement of the blood through 

 it, yet it may now be safely affirmed that these are only secondary altera- 

 tions, depending upon an original and essential perversion of that normal 

 reaction between the blood and the tissues, which constitutes the proper 

 Nutritive process. This perversion manifests itself in the early stages by a 

 disposition of the cellular elements to return to their embryonic condition, 

 and in the later periods by (1) a diminution in the formative activity of the 

 tissues, leading to their degeneration and death ; (2) by an augmentation of 

 the plastic components of the blood, proceeding in all probability, as Vir- 

 chow has suggested, from their increased local production, and subsequent 

 conveyance into the circulating fluid by the lymphatics; and (3) by these 



1 On the whole subject of the Separative Processes, see Mr. Paget's admirable Lec- 

 tures on Surgical Pathology (vol. i, Lect. vii-xii) ; from which many of the fore- 

 going statements and doctrines are adopted. 



