by a layer of coagulable lymph, poured out during inflammation, and often very difficult to be distinguished from it; but the union does not take place until the blood is expelled, or removed by absorption. That the coagulable lymph, after the red parts of the blood have been absorbed, effects the union, without increased vascular action, is quite improbable. The coagulating fluid which effects the union of wounds is not merely lymph poured out in the state in which it circulates, but it is the product of inflammation, which, to a certain extent, accompanies the reunion in every stage of its course. That the blood has nothing to do with the union is shown by the appearances which are observed in extravasation of blood into cavities, especially of the belly. The same objection applies also to the union of broken bones, without increased vascular action, which has been put forward by DZONDI (a).

[The opinion above stated as to union by the first intention, a term which, according to JOHN THOMSON, was first employed by GALEN, is that of JOHN HUNTER, and the objections to it are substantially those of THOMSON. It may also be inferred, though not so distinctly stated, that ASTLEY COOPER does not believe in the union by the first intention, or more correctly, by blood. In speaking of wounds, he (b) directs "the coagulated blood to be completely sponged away from the surface and edges of the wound, the edges to be brought together, and a strip of lint or linen moistened with the blood, to be placed on the part in the direction of the wound, when the blood by coagulating glues the edges together in the most efficient and natural manner; adhesive plaster is to be applied over the lint, with spaces between to allow of the escape of the blood or serum ;" and then immediately he adds:-" In a few hours inflammation arises, and fibrin becomes effused upon the surfaces and edges of the wound, by which they become cemented." (pp. 150, 51.) Upon the same subject TRAVERS makes the following pertinent observations:-"Is the blood," asks he, "when effused from wounded surfaces, a medium of organised adhesion ? or capable of becoming so? I answer in the negative: the question turns upon a delusion. If the wound be so small as that the effusion of blood is restrained by the adaptation of its sides, whether naturally falling together, or artificially compressed, the separation of its colouring matter is shown by a plentiful oozing of sanies at its mouth and the formation of a crust. If, on the other hand, the wound would be of such form or size as to present co-aptation, or be attended with loss of substance, the coagulum of coloured blood being in proportion, acts as a foreign body, and must be dislodged prior to healing. Hence the difference in the time, and often in the mode of healing, of a small gaping wound left to itself, or a wound with loss of substance, and that of a larger wound, whose sides are immediately brought and maintained in contact. Thus the agglutination of the lips of a small wound, by a thin layer of blood, a merely temporary expedient, is no bar to the union, but the contrary, both in respect of hæmorrhage and union, though never forming the permanent bond. In truth, no wound of any dimensions, however favourably situated for the adhesive process, and rapidly united, has not, when fresh, a layer or pellicle of blood coating its surface; not admitting of removal by abstersion, but insusceptible also of healthy organization. The separation and deposit of fibrine takes place distinctly, and after an interval. This is marked even in cases of simple division of the solid, but in loss of substance occupies many days; being step by step, and only just a-head, or in advance of vascularization." (pp. 81, 2.) "The fibrine effused in a state of solution in the liquor sanguinis, only becomes susceptible of organization, i. e. capable of permanent incorporation with the living solid, when separated from the other constituents of the blood. It is incapable of organization if effused in combination with the blood-corpuscles, as in extravasation or hemorrhage. This observation is not contradicted by the appearance of vessels in a coagulum, which serves as a spurious plasma or bed for the reception of the blood-corpuscle, and the shootings of the pseudo-capillaries in an arborescent form; and which, whether confined by cellular membrane or a layer of sponge, admits of no further advance towards vital organization, or the attainment of the self-preserving and adapting principle.” (p. 162.)

1. If the wound be simple and the parts not bruised, the edges brought into close contact, and the inflammation not proceeding so far as suppuration, but only to the secretion of albuminous lymphatic fluid, the edges of the wound become connected together, and, as the vessels shoot in from either side, the union is perfected. This kind of healing is called the Quick Union (1) (Reunio per primam intentionem, Lat.; Schnelle Vereinigung, Germ.; Réunion par premiere intention, Fr.)

(a) Lehrbuch der Chirurgie. VOL. I.

(b) Surgical Lectures edited by TYRRELL, vol. i.

U

[(1) The reader will probably be struck with the peculiarity (to us) of the designation, "quick union," applied to the immediate and more simple mode by which divided animal structures unite; but it is the expression used by the author, and as his translator I have no right to vary it, merely because it is a phrase to which our ears are not accustomed. It is also to be noticed that CHELIUS employs the expression "quick union as synonymous with "union by the first intention," as may be seen in the preceding note, when he enumerates the kinds of union mentioned by HUNTER and MECKEL. But this is incorrect, as it is evident by the term "quick union" he means the union by adhesion of HUNTER and other English surgeons, and not "union by the first intention," which although enumerated by HUNTER as one form of union, has long since been discarded in this country.-J. F. S.

The adhesive inflammation, in connexion with wounds, is thus described by JOHN HUNTER:-"It first throws out the blood, as if the intention was to unite the parts again. The newly cut or torn ends of the vessels, however, soon contract and close up, and then the discharge is not blood, but a serum, with the coagulating part of the blood, similar to that which is produced by the adhesive state of inflammation, so that they go through the two first processes of union; therefore the use of the adhesive inflammation does not appear so evidently in these cases as in spontaneous inflammation." (p. 368.)

Although the account of adhesive inflammation given by ASTLEY COOPER is not so complete as that given by modern writers, who have had the opportunity of employing the microscope, yet it is well worthy of attention; and it is to be borne in mind, that although the publication of his opinions are only comparatively of modern date, yet are they the same which he had for years taught in his class-room. "When an incision is made," says he, "into a part which has been affected by adhesive inflammation, viz., the cellular membrane, a quantity of serum is found effused around the inflamed part, and in the part itself a yellow and semi-transparent substance having the appearance of jelly, though different in its nature. (p. 97.) When adhesive matter has been formed, blood-vessels soon enter it, and in a short time it becomes organised; the vasa vasorum are elongated by the force of circulation, and enter the newly formed substance, sending out minute ramifications. On cutting into adhesive matter within twenty-four hours after it has been deposited, small bloody spots may be seen, marking the future situation of the vessels which nourish it; but it is not till ten days after it has been formed, that any considerable portion of adhesive matter becomes entirely organised; for if injected, you will not completely succeed through every part of the newly formed substance, until ten days after the injury, and not even so soon in certain structures. When vessels elongate, they have not the character of arteries in general; they take a serpentine and tortuous course. It has been thought that the new vessels originated in the effused substance; but they are formed by the elongation of the vasa vasorum of the surrounding arteries, which become dilated, lengthened, and serpentine; and the degree of vascularity will be in proportion to that of the part subjected to the adhesive process." (pp. 99, 100.) The process of union by adhesion, according to the modern views generally held, is thus briefly described by BENNETT (b):

"When an incision has been made in the skin, blood flows from the divided capillaries, until they are obstructed partly by their own contractility, and partly by the coagulated blood blocking up the cut extremities. The early phenomena of inflammation now manifest themselves, the capillaries become distended and engorged with blood, and at length exudation or the essential phenomenon takes place. After a time, which varies according as the blood more or less abounds in fibrin, the cut surface is glazed as it is called, that is, the exudation has coagulated on the surface, and is transformed into plastic lymph. If now the parts are accurately brought together, little more exudation takes place. Cells are formed which rapidly pass into a fibrous formation and healing or union by the first intention is the result." (p. 61.)

"The exuded matter," says WHARTON JONES (c)," from being at first serous, comes at last to contain a greater or less quantity of fibrine or fibriniform matter (oxyprotein), and in this state is a clear viscid fluid, usually called lymph. As this fluid is the same as the plasma of the blood, it of course has the same properties, physical and chemical. It may remain fluid, or coagulate; and having coagulated, the serum may or may not be separated. In the latter case, the exuded matter is gelatiniform; in the former, the coagulum is consistent or diffluent, according to the proportion of fibrine or oxyprotein contained in the exuded matter. The serum which is separated, may either be soon removed by absorption or collect. Examined microscopically, the recently exuded matter appears (a) Lehrbuch der Chirurgie, § 209. (b) Treatise on Inflammation.

(c) Quoted at the head of the division.

quite amorphous, without any trace of organization, except that, when coagulated, it may be more or less indistinctly fibrous and covered with oil globules, appearances which, however, have nothing in common with the organization which afterwards ensues. The corpuscles which the fibrinous matter, very soon after exudation, is found to contain, have been alleged to be the colourless corpuscles of the blood which have escaped from the vessels; but this is not the case. As already said, none of the corpuscles of the blood pass out along with the exuded fluid as long as the vessels are entire. The corpuscles in exuded matter are new formations, developed after exudation, developed in it, in fact, as in a blastema." (p. 271.)

Of "healing by the first intention or adhesion" JONES says:-" In this case the matter exuded on the cut surfaces becomes forthwith, and all of it converted into tissues-cellular tissue and capillaries-by which the divided parts are reunited. An epithelium or epidermis is then formed on the surface in the ordinary way, and cicatrization is completed." (p. 280.) The formation of the cellular tissue is thus described by the same writer:-"There are formed numerous round nuclei (exudation corpuscles) in the cytoblastema, which elongate, becoming slender and arrange themselves one after another in rows. At the same time the cytoblastema is resolved into flat fibres from 1-5600th to 1-3700th of an inch broad. On the surface of these flat fibres lie the nuclei which become partly absorbed, partly coalesce to form nucleus and elastic fibres. The broad fibres either remain at this stage of development, in this state resembling the fibres of the middle coat of the arteries, or they split into finer fibrils, begin to curl, and become true cellular tissue. Mr. GULLIVER, appealing to the fibrous structure which fibrin presents immediately on coagulation, has been led to express doubts as to the universality of the application of SCHWANN's doctrine. Mr. GULLIVER is quite correct when he says, that he could never see any satisfactory evidence that the fibrils of fibrin are changed cells. Direct observation clearly shows that the fibrin is at once formed into fibres in the act of coagulating. But Mr. GULLIVER is not correct in adducing the fibrous structure of fibrin as an argument against the development of fibres from cells." (p. 273.) The development of new vessels, in fact, is in itself a process of organization which presupposes the development or organization of other tissues. New vessels are not formed for the purpose of "vitalizing" "effusions of the organizable materials of the blood," for such effusions are already vitalized. It is from such effusions that the new blood-vessels themselves are developed, and that along with the development or organization of other tissues, such as the cellular. The blood-vessels are formed in order to fetch and carry away the materials concerned in the nutrition and further development of these tissues. All the best observations on the development of new vessels hitherto, tend to the establishment of the proposition, that it takes place in this way. At the same time that the new cellular or other tissue is being developed, cells are formed, which coalesce with and open into each other, and form net-works of capillary vessels, at first quite separate from and independent of the old vessels of the part, with which they only afterwards enter into communication, as Mr. HUNTER supposed." (pp. 274, 275.)

LAWRENCE observes:-" An objection has been taken to the employment of the term inflammation, in reference to that process by which a recent wound is united; for, in fact, under favourable circumstances, we find the union will take place without the occurrence of any great vascular disturbance of the part. Often you will not be able to notice any swelling, redness, heat, or pain; not any of those circumstances which are considered necessary to establish the presence of inflammation. In fact, if those circumstances occur, that is, if inflammation takes place in the part, recognisable by the circumstances which we ordinarily observe as characterizing it, the union by adhesion is disturbed and affected. The occurrence, therefore, of inflammation, in its obvious and distinctly recognisable character, interferes with and prevents the accomplishment of adhesion." (p. 522.)

The following is the brief review, by BENNETT, of the several opinions now held in regard to the formation of new vessels:

"It is now well understood that the appearance of vessels in colourless tissues, as in the conjunctiva, is not owing to their being newly formed, but to the over-distension of those which were previously too transparent to be visible. In the exudation poured out on serous membranes or on granulating surfaces, vessels which had no previous existence are produced, and the manner in which this takes place is not yet definitely determined. Two views have been advanced: 1st, That new vessels are formed in connexion with the old ones, by the escape of a blood-corpuscle, hollowing out for itself a channel in the exudation, which subsequently becomes a vessel; 2nd, that the new vessel arises independently of the old one, from minute points, which become enlarged, and afterwards connect themselves with the old ones. This opinion, which was advanced

by JOHN HUNTER, is most consistent with the researches of SCHWANN, and the known mode of development of vessels in the embryo. DOELLINGER and KALTENBRENNER consider that new vessels may be formed in both stages. Their mode of arrangement in lymph have been shown by the injections of POCKELS, and in granulations by those of LISTON. The difficulty of the inquiry consists in ascertaining how the vascular walls are formed previous to that period when an injection can be thrown into them. The late observations of Mr. TRAVERS, on the injured web of the frog's foot, seem to confirm the first view above mentioned, whereas those of HASSE, HENLE, SKODA, and KOLLETSCHA, on the new vessels of lymph in man, tend to the conclusion that isolated extravasations of blood channel for themselves passages in the coagulated exudation, which subsequently become vessels, and unite with those previously existing. These isolated and star-shaped collections of blood I have frequently seen in recently effused lymph, but hitherto have never been able to satisfy myself that they constitute the first formation of new vessels. The whole subject demands renewed investigation.” (pp. 62, 3).]

2. But if the wound do not at once unite, there exudes, for the first few days, from the whole surface a reddish serous fluid, which becomes purulent: a delicate cellular substance is developed upon the surface of the wound which, by the shooting forwards of the capillary vessels into it, forms granulations; these at first are very delicate, and bleed on the slightest touch, but by degrees become firmer, draw together towards their middle, and thus diminish the extent of the wound; the granulations are covered with a delicate cuticle, and a whitish, skinny, imperspirable covering called a Scar (Cicatrix, Lat.; Narbe, Germ.; Cicatrice, Fr.) is produced. This is the cure of wounds by means of suppuration and cicatrization (Reunio per secundam intentionem, Lat.; Heilung der Wunden auf dem Wege der Eiterung und Vernarbung, Germ.)

In all the higher animal organisms the special reproduction of lost parts is dependent only on the production of cellular tissue, by means of which the bones may be partially reproduced by the deposit of phosphate of lime. The solution of continuity of other parts is, however, only replaced by a cellular deposit; which, indeed, may assume a tough fibrous structure, but never can acquire the organization of the lost or divided part. The opinions, in regard to the reproduction of nervous substance, however, are still very various, as will be seen hereafter.

["When the adhesive inflammation" says JOHN HUNTER, "is not capable of resolution, and has gone back as far as possible to prevent the necessity of suppuration, especially in those cases that might have admitted of a resolution, as in spontaneous inflammations in general, where there has neither been an exposed laceration of the solids, nor, as before mentioned, loss of substance, but where the natural functions of the part have only been so deranged that it was unable to fall back into a natural and sound state again; or, secondly, where it was a consequence of such accidents as the effects of the adhesion could not in the least prevent, (as in wounds that were prevented from healing by the first or second intention,) then, under either of these two circumstances, suppuration takes place. The immediate effect of suppuration is the produce of pus, from the inflamed surface, which appears in such cases, or under such circumstances, to be a leading step to the formation of a new substance called granulations, which are the third method, in the first order of parts, of restoring those parts to health." (p. 371.)

"Granulations are an accretion of animal matter upon the wounded or exposed surface; they are formed by an exudation of the coagulating lymph from the vessels, into which new substance both the old vessels very probably extend, and also entirely new ones form, so that the granulations come to be very vascular, and indeed they are more so than almost any other animal substance." (p. 477.)

"Immediately upon the formation of the granulations cicatrization would appear to be in view. The parts which had receded, in consequence of a breach being made into them, by their natural elasticity, and probably by muscular contraction, now begin to be brought together by this new substance; and it being endowed with such properties, they soon begin to contract, which is a sign that cicatrization is soon to follow. The contraction takes place in every point, but principally from edge to edge, which brings the circumference of the sore towards the centre; so that the sore becomes smaller and smaller, although there is little or no new skin formed. The contracting tendency is in some degree proportioned to the general healing disposition of the sore, and the looseness of

** *

the parts on which they are formed; for, when it has not a tendency to skin, the granulations do not so readily contract, and, therefore, contracting and skining are probably effects of one cause." (p. 483.) A principal use of the contraction of granulations is, that "it avoids the formation of much new skin, an effect very evident in all sores which are healed, especially in sound parts. * After the whole is skinned, we find that the substance, which is the remains of the granulations on which the new skin is formed, still continues to contract, till hardly anything more is left than what the new skin stands upon. This is a very small part in comparison with the first formed granulations, and it in time loses most of its apparent vessels, becomes white and ligamentous. For we may observe, that all newly healed sores are redder than common skin, but in time they become much whiter." (p. 485.)

The following is the very interesting and important history of the process of filling up a gaping wound, as described by TRAVERS:-"In a wound with loss of substance, which offers the most complete example of organization, the fibrine is very gradually deposited, little by little, at its margin, preserving at all points an uniform line of approximation to the centre. The margin is elevated, rounded, and opake at its base; its salient edge is thin, sharp, and transparent. This presents no appearance of vascularity during the process, but the circumjacent vessels are observed to multiply and extend their branches of communication or anastomosis. These processes go pari passu towards the healing of the breach; the fibrine becoming fuller and more opake where it adjoins the original texture, and in the same proportion encroaching upon the void space. The wound preserving its figure, continues to diminish as the surrounding parts become organised by the production of transparent capillaries from the nearest vessels, in forks and arches of communication one with another, parallel for the most part to the margin of the wound. These vessels are visible in fine striæ before circulation can be detected. A single globule is first observed to enter, and this is followed by more, which have only an oscillatory motion for many hours, a flux and reflux derived from the impulse of the circulation in the parent capillaries, which see-saw movement continues gradually gaining in the direction of the nearest neighbouring vessel, into which at length the pioneer globules enter in single file. The next stage is the abrupt and rapid occasional transit of a globule, or of several isolated globules in succession, through the new channels, just as drops of rain course one another down a window-pane in the same track.

"The conclusion of the process is a regular uninterrupted transition of a file of globules, by which a cross branch of communication is established. This is the simplest example, but the complications of anastomosis proceed in a similar manner. Instead of the meeting of parent vessels, one new vessel encounters another, and they join and divaricate at an angle; or one, meeting another current in an opposite direction, is reflected at an angle so acute as to be refluent upon itself to the vessel from which it emanated, or to contiguous ramusculi from the same parent; and thus arches and circles forming a mesh of anastomosis are established.

"The nascent blood-vessels appear in the first instance destitute of colour, by reason of the pancity of the blood-globules which they convey. When perfected, enlarged, and multiplied, they become the nourishing vessels, arteries, and veins of the new texture, the motion of the blood being, as they are arteries or veins, conformable to that of the original texture. The appearances of vessels striking directly across the newly deposited lymph to meet their opposites-of vessels seemingly engrooved in the lymph by a train of blood globules pioneering their track-of insular specks and zones in the fibrinous deposit, which generate and throw off pencils of vessels for anastomosis with each other and with those proceeding from the margin-are doubtless presented at different stages of the process; but, being the result of occasional and partial observations, have been inaccurately dated and explained. The whole business of organization is of and from the margin of the wound; and it is upon the margin, and its gradually developed organization and encroachment, that the healing action is first and last seen, i. e., until its obliteration by the cicatrix. There is no such thing as isolated or independent vascularization, although appearances exist that convey this impression, as will be afterwards shown. The centripetal or convergent arrangement is the presiding and consummating genius of the operation; but the inherent contractility of the fibrine, and the primary institution of a fuller and freer anastomosis of the nearest marginal vessels, modify the process of organization, and render the centre, as it is the most distant point, the last vestige of its completion. The loop, fork, or arch, consists of an arteria and vena "comites," so that the continuity of circulation keeps pace with the extension of vascularization. It is the opening out of the angle of reflection which presents these varieties of arrangement at different periods, and explains the purpose of its existence and uniformity." (p. 76–9.)