50 



ADHESION. 



a certain epoch of embryo life, imperforate. 

 These organic states, which nosologists have so 

 often considered as diseases, are, therefore, 

 simply primitive conditions preserved by ano- 

 maly, and become permanent instead of tran- 

 sient.* It may, therefore, be inferred that the 

 greater number of cases adduced as evidence 

 of adhesion in intra-uterine life are not in 

 point, and if they were it may still be asserted, 

 and the assertion be borne out by analogy, 

 that they had not occurred in the absence of 

 inflammation. 



John Hunter seems to have had the idea that 

 adhesion may occur in the absence of inflam- 

 mation in certain cases, namely, in those where 

 blood has been effused, that this blood may 

 become organized and form a bond of union. 

 He says, " It does not seem necessary that 

 both surfaces, which are to be united, should 

 be in a state of inflammation for the purpose 

 of effecting an union ; it appears only necessary 

 that one should be in such a state, which is to 

 furnish the materials, viz. to throw out the 

 coagulating lymph, and the opposite unin- 

 flamed surface accepts simply of the union ; 

 nor is it even necessary that either surface 

 should be in a state of inflammation to admit 

 of union: we often find adhesions of parts 

 which can hardly be called inflamed ."f 



I believe that no solution of continuity can 

 be obliterated in the absence of inflammation, 

 the injury which has occasioned the solution 

 of continuity, and the effusion of blood, being 

 sufficient to excite inflammation. The only 

 circumstance under which it seems to me to 

 be possible that union could be produced in the 

 absence of inflammation, is one which can only 

 rarely occur; and even then, although the 

 possibility of the occurrence can hardly be 

 denied, its reality may be reasonably ques- 

 tioned. If a portion of blood, for instance, be 

 effused into a serous cavity, its colouring 

 matter is, after a time, removed, and a fibri no- 

 albuminous coagulum remains. This coagulum 

 coming in contact with a previously uninflamed 

 serous membrane, may become united to this 

 membrane : and it is believed by some pa- 

 thologists that this union occurs without the 

 supervention of inflammation. Another si- 

 tuation where it is believed by certain patho- 

 logists that union is produced by similar 

 means, is in a portion of artery included be- 

 tween two ligatures, the blood which has been 

 included between the two points undergoing a 

 similar change to that which I have already 

 described, and adhesion of the clot to the in- 

 ternal tunic of the artery being effected in the 

 absence of inflammation. 



Such cases may carry conviction to the mind 

 of a superficial observer, but a more careful in- 

 vestigation will lead to an opposite conclusion. 

 My own observations induce me to think, that 

 of all the causes by which adhesive inflam- 

 mation of serous membranes maybe produced, 

 the most remarkable perhaps is an extravasation 



* Isid. Geoff. St. Hilaire, Hist, des Anomalies de 

 reorganization, t. i. p. 532. 



t On the Blood and Inflam. Ed. 1828, p. 319. 



of blood into their cavities, which appears to 

 excite just the precise quantity of inflammation 

 necessary for the production of adhesion. If 

 we examine the point at which such coagula 

 are maintained in contact with serous mem- 

 branes, before perfect union is established, we 

 shall find between the coagulum and the mem- 

 branes a stratum of exhaled matter, the exist- 

 ence of which would lead to the conclusion 

 that the clot has excited in the membrane as 

 much inflammation as is necessary for the pro- 

 duction of such exhalation. 



In solutions of continuity where blood has 

 been effused between the edges, it was main- 

 tained by John Hunter* that this blood was 

 the provisional bond of union ; this, I appre- 

 hend, is not the case. Whether protected from 

 the atmospheric air, which appears to exercise a 

 very decided influence in decomposing it, as in 

 some fractures, or directly exposed to it, as in 

 ordinary solutions of continuity, this coagu- 

 lum never, during the early periods, adheres 

 with sufficient firmness to attach to each other 

 the borders of a wound If, however, any por- 

 tion of the coagulum remain after a fibrino- 

 albuminous exhalation has been formed upon 

 the divided surfaces, it may become in this way 

 organised, and permanently adherent. 



After the preceding remarks, it will therefore 

 be held in this article that whenever an adhe- 

 sion has been effected between two surfaces, 

 naturally or artificially separated, that that 

 adhesion must have taken place through the in- 

 tervention of inflammation ; that inflammation 

 arrived at a certain height will be accompanied 

 byafibrino-albuminous exhalation; that if the 

 inflammation be carried beyond that point, a 

 purulent secretion may be established, and 

 when this is developed, union, by what is 

 termed the first intention, cannot occur ; granu- 

 lations are then developed, and union by what 

 is termed the second intention, may follow. 

 The process by which each kind of union is 

 effected I shall now proceed to describe in de- 

 tail. 



In all cases, whether two naturally separate 

 tissues are to be united, or whether a solution 

 of continuity is to be repaired, there appears to 

 be a certain uniformity in the means by which 

 the union is accomplished. Inflammation is 

 developed, and a material susceptible of or- 

 ganization is exhaled, which becomes the con- 

 necting medium. This matter in its greatest 

 state of simplicity is exuded under the form 

 of lymph, upon the surface of the parts to be 

 united ; it is coagulated, and transformed into 

 a soft pulp ; it gradually increases in density, 

 acquires a reticular or porous aspect, a first 

 rudiment of organization, and as a second de- 

 gree exhibits in its substance red spots, then 

 striae, which have the appearance of vascular 

 ramifications, and at last bloodvessels. 



It is hardly possible to collect this lymph in 

 a state of purity except in the canal of an artery 

 where it has been exhaled between two ligatures. 

 It is then presented under the form of a whitish 

 matter, of a soft and fibrinous consistence, which 



* Loc. cit. p. 253. 



