54 



ADHESION. 



herniae which have been inflamed ; the intestines 

 engaged in the tumour are enveloped by a 

 more or less dense layer of cellular tissue ; and 

 hence many herniae thus circumstanced have 

 been described as having no hernial sac. This 

 sac has, however, originally existed, but has 

 disappeared by the adhesions which have been 

 formed between it and the displaced organs, 

 adhesions by which the cellular tissue which 

 replaces the serous membrane has been deve- 

 loped. 



If we consider these adhesions in relation to 

 their frequency in the serous cavities, we see 

 that they exist most frequently in the pleura, 

 existing in nearly half the adult bodies ex- 

 amined. After the pleura comes the perito- 

 neum, then the pericardium ; those of the tunica 

 vaginalis are less common, but the arachnoid 

 is, of all serous membranes, especially relative 

 to its extent, that where these adhesions are 

 most unfrequent. 



The absence of mobility appears singularly 

 to favour this phenomenon : thus in the pleura 

 they most frequently occupy the superior parts, 

 and in the peritoneum most frequently occur 

 between the viscera forming a hernia, and be- 

 tween the convex surface of the liver and the 

 diaphragm. 



The membranes between which such adhe- 

 sions occur, must usually, of course, be in 

 intimate relation, the one with the other 

 during the time when the process is in progress 

 of accomplishment, though now and then the 

 distance is considerable ; but they may after- 

 wards become separated to great distances : 

 those cellular bands which are so commonly 

 seen in the thorax are evidences of this fact. 



Some circumstances tend to demonstrate 

 that these bands in serous structure may at a 

 certain period of their existence be absorbed 

 and disappear, and the secreting surface be 

 reproduced. M. Ribes states that occasi- 

 onally we do not find any trace of such bands, 

 nor any adhesion in the peritoneum of persons 

 who have had penetrating wounds of the ab- 

 domen. Beclard examined an insane person 

 who had several times stabbed himself in the 

 abdomen. At the points where the more 

 recent of these wounds had been inflicted 

 considerable adhesions were found; beneath the 

 older cicatrices no vestige of adhesion was 

 found. A case of artificial anus occurred in 

 the practice of M. Dupuytren, by which faecal 

 matter passed during twelve days. The pa- 

 tient died at the end of seven months. At the 

 examination after death, it was found that the 

 portion of intestine in which the accidental 

 opening had existed, was distant from the ab- 

 dominal cicatrix between four and five inches. 

 A very attenuated cellular band extended from 

 the cicatrix to the portion of intestine. Doubt- 

 less a short time would have sufficed for the 

 absorption of this band, when the intestine 

 would have been set at liberty and the serous 

 surface restored. 



In the course of lectures which Bichat de- 

 livered only a few months before his death, 

 he maintained that adhesion was never pro- 

 duced between mucous surfaces, and that con- 



sequently the cavities lined by this tissue were 

 never obliterated. Few statements have given 

 rise to more extensive discussion than this ; 

 few discussions have up to the present moment 

 been attended by less satisfactory results. In 

 his first dictum I believe he was clearly right, 

 in the second as clearly wrong. 



Mr. Hunter's opinion was in accordance 

 with that of Bichat : he says, " that in all the 

 outlets of the body called mucous membranes, 

 the order of inflammation differs from that 

 which occurs in cellular membrane, or in cir- 

 cumscribed cavities. In these latter adhesive 

 inflammation is immediately admitted to ex- 

 clude, if possible, suppuration," In internal 

 canals, where adhesions would in most cases 

 prove hurtful, the parts run immediately into 

 the suppurative inflammation, the adhesive in- 

 flammation being in common excluded.* 



Mucous membranes, when unchanged by 

 disease, are not capable of becoming adherent 

 the one to the other, and the reason of this is 

 simple. 1 have already stated that no per- 

 manent adhesion can occur in the living body 

 without the intervention of a new tissue, which 

 at a certain indefinite or undetermined period 

 of its existence becomes organized. 



A pseudo-membrane of considerable extent 

 may be thrown out upon an inflamed mucous 

 surface; but this membrane, 1 apprehend, 

 never becomes organised, and union between 

 mucous surfaces cannot therefore be permanent 

 unless some other agency be called into action. 

 But, as soon as inflammation has destroyed the 

 characters from which these membranes derive 

 their name ; when the mucus, which like an 

 inorganic layer appears to oppose itself so 

 successfully against immediate contact, thereby 

 preventing the organization of the effused mat- 

 ter, no longer exists ; when the cellular element 

 which forms the basis of this membrane is 

 developed, then adhesion by means of the 

 union of granular surfaces is effected with the 

 greatest facility ; of this we have evidence in 

 most of the mucous canals. It is not rare, 

 for instance, to meet with complete obliteration 

 of the vagina, of the cystic duct, and so on. 



It is stated very generally that the opinion 

 of Bichat is entirely unfounded ; that inflam- 

 mation of the vagina is followed by complete 

 occlusion, without destruction or transforma- 

 tion of the mucous membrane, and that similar 

 effects may occur in the Fallopian tubes, the 

 uterus, and other mucous canals. That these 

 are produced is perfectly true, but never until 

 the disorganization to which I have alluded 

 has occurred. 



It is maintained triumphantly as a con- 

 firmation of the opinion that no transformation 

 occurs, that when these adhesions are sepa- 

 rated, we have the healthy mucous membrane 

 performing its functions as before. This, how- 

 ever, is not the case ; the membrane is essen- 

 tially different, and it is not without difficulty 

 that we can overcome its tendency to enter 

 into adhesion again. That a membrane is pro- 

 duced, which performs functions analogous to 



* Loc. cit. p. 305. 



