VI

A Case, disproving the Doctrine, that the Surfaces of a Wound in a State of Suppuration will not Reunite by the first Intention. By WILLIAM BALFOUR, M. D. Edinburgh.

WILLIAM CUNNINGHAM, aged 18, a labourer, applied to

me, on the 30th July, with a severe wound in his left thumb, which he received eighteen days before from the tackle of a pulley, while working in a quarry. The whole of the nail was torn away, and the pulp or fleshy part of the thumb, as far back as the first joint, was separated from the bone, with the exception of a semicircular piece of about half an inch in length, and very thin, on the finger side. The lad, unfortunately for him, applied immediately for medical aid, and, for upwards of a fortnight, the wound was kept open by the insertion of dressings to the bottom, with the view, I presume, of effecting & cure by the slow process of granulation.

When the patient came to me, which was eighteen days after' the accident, there was a trace of adhesion having begun at one angle of the wound, but which now appeared completely at a stand; there was no appearance of granulations in the bottom of the wound; the deruded parts had a peach-blossom colour; the pendulous surface a honeycomb appearance; and the whole wound discharged a thin and very fœtid matter.

I washed the parts with many successive ablutions of cold water, pressing the pendulous portion at times like a bit of sponge. I now attempted to bring the surfaces into contact, as if the wound had been recently inflicted; first, by a piece of rag applied circularly, and then by another longitudinally, or over the point of the thumb. Next day the discharge appeared through the dressings, which I removed, when the parts separated. The discharge was of a better colour and consistence; there was no fator; and the superior surface bled at many points without being touched. This circumstance encouraged me to another attempt. I bound up the wound, therefore, after washing it carefully, in the same way as the day before. On the third day the parts adhered. I did not remove the dressings again till the fifth, and then on account only of the great discharge that showed itself, when I found my labour to be in vain. I now weighed deliberately every circumstance that might tend to defeat my purpose, and found that my anxiety to bring every point of the jagged edge of the pendulous portion

into perfect contact with the opposite, was the cause of my disappointment. I found that, at the third dressing, I had drawn the longitudinal strap, or that over the point of the thumb, too tight, which caused the parts further back, or the pulp of the thumb, to recede from its opposite surface. I therefore now omitted that bandage, and contented myself with securing the apposition of the two surfaces by a bandage applied spirally. This plan succeeded to my utmost wish. Next day adhesion had taken place to a degree sufficient to prevent the part that formerly hung down from separating, as formerly, from the thumb. This was proved by my being under the necessity of removing the dressings, on account of matter that continued to issue from the denuded parts of the thumb, and the irregular edge of the wound. I now considered my object as accomplished, for no further discharge took place from the interior of the wound; the surfaces remained in perfect contact; new skin began immediately to shoot across from both edges; and, in a week, the reunion was so firm and complete, that very consi derable force would have been requisite to tear the parts asunder.

That the reunion in this case was by the first intention; that is, by a direct communication of vessels, without the intervention of granulations, there cannot be a shadow of doubt. It is not possible that granulations could have sprung up in twentyfour hours, sufficient to close a wound in which the whole pulp, or fleshy part of the thumb, was separated from the bone. Healthy granulations are of slow growth; and there were none begun when the patient came under my care.

On the contrary, the wound was rapidly degenerating into a putrid state. It had been open eighteen days before I saw it; but when I succeeded in bringing and retaining the surfaces in perfect contact, adhesion took place immediately, as if the injury had been recently inflicted.

By this case I have demonstrated, that the doctrine, so far as I know, universally held, of the surfaces of wounds being incapable of reunion by the first intention, after having passed into a state of suppuration, rests on no foundation: a discovery this, fraught with the most beneficial consequences to mankind; and in which the pathologist must observe, that the secretion of pus in a wound can be instantly suspended, and the action of the vessels producing it changed.

I am aware, that, in the cure of wounds, the most approved practice is, to bring and to retain the parts as nearly in contact as possible. By these means, much less new matter is required for filling up the cavity, than if the sides were allowed to res

main at a distance: The cure is, therefore, rendered more durable and complete; and the cicatrix is rendered much more sightly.

But these are the only objects and advantages that have ever been proposed by the practice. There is not, in all the authors whom I have consulted, the most distant hint to be met with, of the practicability of reuniting wounds by the first intention, after suppuration has taken place. I am therefore warranted to call the preceding case new. And, in this, I am supported by a late publication, which may reasonably be supposed to contain all that is known on the subject, and which has, as follows. • Of wounds, in which it would be in vain, and, of course, improper, to attempt reunion by the first intention, we have an example in such as have existed for some time before recourse has been had to art for their cure, and in wounds, the edges of which have become inflamed, and which seem to be passing into the state of suppurating sores.'-Dr Thomson's Lectures on Inflammation, p, 281,

VII.

Observations, with Cases, illustrative of a New, Simple, and Expeditious Mode of Curing Gout. By WILLIAM Balfour, M. D. Edinburgh.

IN my Observations, with cases, illustrative of a new, simple, and expeditious mode of curing rheumatism and sprains, there is the following.

• Note VIII.-Whether there was a mixture of gout in this gentleman's case or not, it is impossible, with absolute certainty, to ascertain. He denied that ever any thing of the kind was known in his family; and yet the painful swelling of the joints of some of the toes, strongly indicated something of this nature. I certainly gave it as my decided opinion that there was no gout present. But, whether right or wrong in so doing, one thing is certain, that the pain and swelling of the joints of the toes yielded as readily to percussion and compression as did the pain and swelling of those parts which were, without doubt, affected with rheumatism. If, therefore, there was any mixture of gout in Sir T-s's case, then percussion and compression are a remedy for gout equally as for rheumatism. I

see nothing, indeed, in the nature of things, why they should not be as beneficial in the one disease as in the other. In Madame Rey's case I applied percussion and compression indiscriminately, to parts affected with rheumatism, and to parts which were suffering from gout; and with immediate and great advantage to both. It is my intention to prosecute this subject further.'

Soon after the above work was published, which was in the middle of February last, Madame Rey was attacked, early one morning, with a most violent paroxysm of gout, in one of her great toes. She called her servant, and ordered her to compress and beat the part. This was done with moderate force, which excited the pain to a most torturous pitch. In a fit of despair, Madame Rey commanded the girl to use all her force, which was attended with immediate and complete relief from pain. No derangement of the system, or of any internal organ, followed; nor has she had (22d August) any return of the complaint in her extremities.

To these facts, which, as they did not come under my personal observation, but which are not the less true, I have not given in the form of a case, I have great pleasure in adding the following, as quite decisive of the justness of the opinion expressed in the preceding Note, with regard to the probability of compression and percussion being applicable, with the best cffects, in gout.

CASE Ì.

On the 2d of July I was requested to visit Mr N. M. aged 40, and of a full habit of body, whom I found labouring under a severe fit of gout. About ten or twelve days before I saw him, he had taken a very quick ride of about ten miles, by which he was greatly overheated, and took not the least care of himself afterwards. About two o'clock next morning, he awoke with violent pain in the balls of both great toes, reaching upwards along the upper part of the foot to the ankles; and, in the back part of the leg, to where the gastrocnemius muscle terminates in its tendon.

When I first saw him, the balls of the toes were still much swelled, pained, red, tense, and shining; and motion of the joints impracticable. The whole upper part of the foot, particularly about the roots of the toes and outer ankles, was oedematous. The legs were generally swelled as high as the calf; and along the tendo Achillis, especially at its commencement, very painful. The patient was very lame. He described himself as having had a paroxysm every night, from the commence

ment of the complaint,-as the pain and heat were, in the nighttime, intolerable. Had taken no medicine; pulse 80; no appetite.

I applied compression to the balls of the toes; friction to the oedematous parts; percussion to the ankles; and friction and percussion to the legs,-surrounding all the parts, afterwards, with a roller. The patient walked better immediately. Ordered a brisk purgative of decoction of senna and Epsom salts.

3d-Medicine operated smartly. Underwent the same treatment, this morning, as yesterday, with increased advantage. 4th.-All the symptoms declining; and walking greatly improved.

5th.-Put on his usual shoe on one foot, this morning, after the operation, without being desired.-Is altogether so much better as not to need my attendance any longer.-I notwithstanding made two or three more calls, to ascertain the permanency of the cure.

This is the first case of pure regular gout, in which I applied compression and percussion; and it is the first instance, so far as I know, of any attempt to alleviate, or to cure gout by mechanical means. My almost instantaneous, and complete, and permanent success, surprised me; but it surprised my patient more, he had suffered so long before I was called, from a conviction that no earthly power could be of any avail in gout; and it was in compliance only with the solicitations and entreaties of his friends, that he submitted to call medical aid at all. By the time, however, that I had made him the third visit, he was of quite a different mind.

CASE II.

Mr J. O, solicitor, aged 47, of a cholerico-sanguine temperament, and full habit of body, called at my house on the 10th of June, very lame of both feet, occasioned by pain in the soles and ankles. Pain had been increasing for some days, and had now reached a height that threatened to incapacitate the patient from walking altogether. I applied percussion to the parts affected for a few minutes, and then a thin flannel bandage. He immediately walked much better.

As this gentleman was not in the habit of carrying a stick, but had one on this occasion from dire necessity, and on which he leaned much when he came in, I had the curiosity to look after him when he went away, to observe how he managed. He walked a few yards at first with much the same caution as when he came in, and then took his stick by the middle, and carried