562 OF NUTRITION. 



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

 mation, 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 procuring 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 intention." He sup- 

 posed that the union takes place through the medium of the blood intervening 

 between the lips of the wound, which undergoes organization into a connecting 

 tissue ; but it is now certain that although blood may become organized, espe- 

 cially when effused into a wound secluded from the air, yet that its intervention 

 rather opposes than favors healing by immediate union. 



602. That which is commonly known amongst British Surgeons as "healing 

 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 circum- 

 stances, is presented after operations for harelip; 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. 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 Inflamma- 

 tion can be regarded as salutary, is that in which there is a deficiency of Fibrin 

 in the blood, causing a deficient organizability of the lymph. It has been seen 

 that the amount of fibrin is rapidly increased by inflammation : 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. 



603. The reparation of wounds, in which there has been so great a loss of 

 substance that neither immediate union nor adhesion by a thin layer of coagula- 

 ble lymph can take place, is accomplished by the gradual development of new 

 tissue from the "nucleated blastema" with which the cavity is first filled. But 

 this may take place in different modes, according to the degree in which it is 

 disturbed by the Inflammatory process; and it should be the great object of the 

 Surgeon to procure the most favorable method of its performance. It has been 

 shown by Mr. Paget,.that the mode in which the process of filling up is accom- 

 plished differs essentially according as the wound is subcutaneous, or is exposed 

 to air. In the former *ase, the nucleated blastema is gradually developed into 

 fibrous tissues ( 224) without any loss, and usually with freedom from local 



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 detachment ; and no effusion 

 of coagulable lymph, or production of a connecting tissue, being detectible by microscopic 

 examination. 



