the pericranium as low down as the bony margin of the orbit. The upper lid was thus liberated and brought down so as to allow its tarsal margin to be adjusted in contact with that of the underlid. Before proceeding further, a transverse fold of the redundant conjunctiva, lining the upper lid, was excised as far back from its tarsal margin as possible. With the descent of the upper lid, the inverted V-shaped patch of skin, which had been raised from the forehead, was suture inserted on either side, together with additional brought down and secured at a lower level by a pin thread sutures above the pin sutures. The surface left bare on the forehead by the descent of the patch was closed by approximating the opposite edges of the wound and securing them in contact by thread sutures. To relieve these last sutures from tension, side, the one over the left temple being three inches, while the other, toward the middle of the forehead, was only one inch in length. The edges of these incisions yawned wide apart, and the desired relief was thus obtained. The bare surfaces left were coated with a collodion crust, formed by applying, first, a

H. C. W., æt. four years and seven months, a resident of New Jersey, of sound constitution and enjoying good health, was extensively burned when sixteen months old by overturning upon himself a kerosene study lamp. At the expiration of about four-parallel incisions were made through the skin on either teen months the burnt surfaces had mostly healed. The parts involved in the cicatricial contractions which resulted from the burns were the left half of the face and scalp, and the dorsal surface of the left hand and forearm. When I first examined him, in February, 1872, his condition was as follows:-The left half of the scalp, as far back as the occipital region, was bare, and the surface presented a pale, shining, cicatricial aspect; the skin, however, was pliable, and moved freely on the underlying parts. The left ear, though diminished in size by the loss of its rim, retained its natural shape, and was not adherent to the scalp. The skin covering the left half of the forehead and temple, though cicatricial on its surface, was still movable on the subjacent parts. The outer half of the left upper eyelid was everted to an extreme degree, and spread out upon the eyebrow; the inner half of its tarsal border alone came into contact with the lower lid. The conjunction covering the everted portion of the lid being relaxed and swollen, filled up the space between the lids when closed, and thus protected the cornea, which otherwise would have become opaque from constant exposure. The eyelashes, as well as the tarsal edges of both lids, had escaped injury. The eyebrow was denuded of hair. The eyeball itself had sustained no damage, the cornea retaining its natural lustre, and vision being unimpaired. The surface of the left cheek and side of the nose was cicatricial, and the contraction consequent thereupon had drawn the underlid away from contact with the eyeball, but without producing any eversion of its tarsal margin. The left angle of the mouth was somewhat drawn upward by a vertical fold of cicatricial skin upon the cheek immediately above it. In consequence of the condition of the lids of the layer of dry lint, and then over it a second layer of left eye, patient habitually held his head inclined for- lint saturated with collodion, which soon stiffens and ward and to the left side, so as to avoid direct ex-adheres closely to the surrounding surface. In order posure to bright light, and had thereby acquired a to hold the tarsal edges of the lids more exactly in peculiar expression of countenance (see Fig. 1). A de- coaptation, a beaded silver-wire clamp suture * scription of the left hand and forearm will be reserved passed in a vertical direction through both lids towards to a subsequent part of the narrative. the outer canthus, and out of the way of the cornea, and left in situ for three days. Wet dressings were avoided, and a layer of woven lint of double thickness was kept applied to the parts. Moderate febrile reaction followed the operation, but subsided on the third day. On the fourth day the last sutures were removed. Sloughing, however, had already taken place, and had involved about three-fifths of the trans

On the 6th of February, 1872, an operation was performed in the presence of Dr. James A. Davis, the family physician, from Bloomfield, New Jersey, Drs. John Beekman and Thomas Satterthwaite, and Prof. A. C. Post, M.D.

First Operation.-The object of this operation was to restore the upper lid of the left eye to its normal relations and functions. It was attempted as follows:-Two incisions were started from a single point high up on the forehead, above the middle of the left eyebrow, and continued downward in lines diverging from each other and terminating, one at either canthus of the eye. The inverted V-shaped patch of skin, included between these incisions, was dissected up from

FIG. 1.

was

at one end, and strung, first, with a small perforated disk of leather, and *This suture is constituted as follows: A flexible silver wire, knotted then with a smooth, round, glass bend, is armed at the other end with in contact, and then a second bead is strung upon the wire. The parts a suitable needle. This is passed through the parts that are to be held are now supported in contact, while the wire is drawn upon and the second bead pushed on to its place, and secured there by winding the

end of the wire two or three times around a friction match, which is then to be cut short with strong scissors.

these manipulations was manifest when patient returned in October to spend the winter in the city with his family.

The treatment of the left hand was now to be undertaken. Its distorted condition had resulted from the same burn which disfigured the face, and was as follows:-The surface of the entire forearm and dorsum of the hand was cicatricial. The skin on the dorsum of the forearm was thickened and contracted longitudinally, while in the direction of the circumference it was lax and could be gathered up into folds. The hand and all the fingers were drawn up to an extreme degree in the direction of extension; the thumb and index finger, however, to a much greater degree than the other fingers. To such an extent were they drawn backward that at their metacarpo-phalangeal articulations the articular surfaces no longer confronted each other, but the phalanges rested upon the dorsal surfaces of the ends of their supporting metacarpal bones. The fingers were maintained in their distorted position by separate corded folds of cicatricial skin proceeding from the dorsum of each and converging at the wrist, where they were continuous with and formed a part of a broad fold of skin, which extended up on the forearm toward the elbow. The middle, ring, and little fingers were drawn backward to an equal degree, and remained in contact with each other; while the index finger, being drawn further backward than its fellows, was also widely abducted from the middle finger. The thumb was drawn the furthest backward of all, its first phalanx riding upon the dorsum of its metacarpal bone. The phalanges being all capable of flexion upon each other, the fingers still performed useful service. Flexion and extension at the elbow-joint, as well as pronation and supination of the forearm, remained unimpaired.

FIG. 2.

Preparatory to an operation on the hand, a guttered splint, made of tin, was adapted to the palmar surface of the forearm and lengthened out at the wrist by the addition of a flat piece, bent flatwise in the direction of flexion, and adapted for the support of the hand. On the 24th October, 1872, a fourth operation was performed.

Fourth Operation.-The second, third, and fourth fingers being similarly involved, their treatment only was to be attempted in the present operation, which was executed as follows: By flexing the fingers and putting on the stretch the cicatricial folds on the dorsum of the hand, a broad longitudinal fold of skin was also rendered tense and salient upon the forearm above. This was transfixed at its base, near the middle of the forearm, while gathered up between the thumb and fingers, and a tongue-shaped flap of skin formed by cutting downward toward the wrist and outward through the surface. The detached flap receded toward the elbow, and the three fingers could be flexed to a right angle at their metacarpo-phalangeal articulations; the phalanges themselves, however, could not be flexed upon each other, owing to the resistance of the edges of the wound just made upon the forearm, which became very tense and unyielding whenever flexion was attempted. These edges were therefore freely divided across at selected points till there remained no longer any resistance, and complete flexion of all the phalanges could be effected. No tendons or muscles were exposed; the surface laid bare consisting of adipose and connective tissue. A single vessel only required to be ligated. Here and there a suture was inserted to hold the detached skin in place, but without any attempt to procure adhesion. The limb was then placed upon the splint prepared for it, and the three fingers were secured by adhesive plaster to the flat piece that joined the splint, at an angle of flexion opposite to the wristjoint. The raw surface, which involved the dorsum of the hand and lower two-thirds of the forearm, was coated with collodion crust. After completing this operation, advantage was taken of the anaesthetic condition of the patient to perform another operation for the further improvement of the lids of the left eye. The outer half of the tarsal edge of the upper lid was still disposed to evert, and this disposition was promoted by the presence of a small mass of granulation growth in the conjunctival cul-de-sac at the outer canthus. The commissure of the lids had also become lengthened in a marked degree, so as to exceed the length of the commissure of the lids of the other eye by about one quarter of an inch. The mass of granulation growth was first excised by seizing it with a fine-clawed forceps and clipping it off at its base with a scissors curved flatwise. The attempt was next made to bring about permanent adhesion between the tarsal edges of the lids at the outer canthus. While the lids were held wide apart and the ball of the eye was protected by a wet rag, a cautery iron, with a ball-shaped end of the size of a pea, heated to redness, was buried in the cul-de-sac of the conjunctival cavity at the outer canthus and applied thoroughly to both tarsal edges of the lids for a distance of nearly two lines from their junction with each other. Compresses wet with ice-water were immediately applied, and afterwards frequently renewed. On coming out from the anaesthesia patient did not appear to suffer from this severe application. No febrile reaction followed, He passed a good night without an anodyne, and the next day sat up with his arm supported in a sling. Scarcely any redness or swelling of the hand or forehead supervened. On the fifth day, Oct. 29, the collodion crust came off from the wrist and forearm, leaving a healthy granulating surface which thereafter was dressed with simple cerate, the limb being kept upon the splint. A moderate degree of inflammation followed the application of the actual cautery to the conjunctiva and tarsus. No injury was sustained by the cornea or ball of the eye. Superficial eschars separated, and healthy suppuration followed. Upon the forearm portions of cicatricial skin which had

been detatched from their underlying connections its supporting metacarpal bone. In order still further sloughed. Nov. 5.-The exuberant granulation growth to liberate the thumb, and reduce the dislocation, a has required the energetic application of solid nitrate longitudinal incision of the skin was carried between of silver at every daily dressing. Forcible flexion of the the metacarpi of the thumb and index finger upward fingers and wrist has been daily practised: this, though to join the incision across the wrist, and the skin was a severe process during its performance, was not follow- dissected up on the dorsal surface of the metacarpus ed by any lasting pain afterwards. of the thumb. All resistance was at length removed,

It now became apparent that a great advantage would have been gained, by liberating the index finger and restoring it to its normal relations at the same time with the other three fingers; it was accordingly decided to do it without further delay. The operation was performed on the 5th of November.

Fifth Operation.-Two incisions, beginning one at the commissure between the thumb and index finger, the other between the index and middle fingers, were carried through the skin, upward, in converging lines, until they met at a point above the cicatricial fold of skin which held the finger extended. After these had been made, the index finger could be fixed at its metacarpo-phalangeal articulation, but not at its phalangeal articulations. By dissecting up the skin on the dorsum of the first phalanx from its underlying connections, the power of flexing the finger at these articulations was fully restored. The index finger was then brought down by the side of its fellow, where it was secured, and thereafter treated in common with them. The cauterized surfaces at the outer canthus of the left eye being now in a state of healthy suppuration, and all swelling having subsided, the tarsal edges of the lids were secured in exact contact by a silver wire-beaded suture (see page 473) inserted in a vertical direction through both lids, at a distance of half an inch from their tarsal edges, and at the same distance from the outer canthus. Two fine thread sutures were also inserted at the edges, after first scraping them with a dull-edged knife. The thread sutures were removed on the third, and the wire suture on the eighth day. Permanent adhesion was thus secured between the tarsal edges for a distance of nearly three lines from the outer canthus, thus shortening the commissure so as to correspond with that of the other eye. Early in the month of January, 1873, the wound surfaces on the dorsum of the hand and wrist had healed. The manipulation of the wrist and finger-joints had been continued daily with decided benefit, and the limb had been kept constantly secured to the splint. The thumb, not having yet been subjected to any treatment, remained unchanged. To remedy this deformity was the object of the

Sixth Operation.-Feb. 12, 1873. By stretching the thumb in the direction of flexion, a longitudinal fold of cicatricial skin was brought into prominence upon the radial border of the wrist and forearm. At first broad and embracing the root of the thumb, this fold grew narrow as it extended obliquely upward on the palmar surface of the forearm, in the middle of which it became corded, and continued so to the elbow. This fold in the process of its formation had evidently drawn up the thumb into its distorted position, and was still the chief obstacle in the way of its performing complete flexion. This fold was divided, while held on the stretch, by a transverse incision passing onethird around the wrist, and at a distance of one inch above the joint. The tissue creaked under the knife, and the edges of the wound receded wide apart, but without affording much relief to the thumb. The subjacent aponeurotic layer was also found tense and resisting, and had to be divided across. Some degree of flexion was thus obtained. It was now ascertained that the proximal end of the first phalanx was dislocated, and rested on the dorsal surface of the end of

still keep it in the splint at night, and continue the manipulations daily on the hand and also on the face." Figs. 3, 4, 5, showing the results of treatment, are from photographs taken in Florence in January, 1874. 46 West 29th st., May 26th, 1874.

A FEW REMARKS REGARDING CERTAIN

the previous operations. Patient did well after this, as he had done after the previous operations. The same process of forcible flexion and stretching was employed upon the thumb as had been used upon the fingers with such good results. In order to reduce the size of the thumb and improve its shape, it was kept tightly wound with strips of adhesive plaster. The commissure between the thumb and index finger was also kept crowded up towards the metacarpus by strips of adhesive plaster applied tightly over a saddle-shaped compress made with several thicknesses of woven lint. On the 1st of May a spot of the size of a finger-nail, on the wrist, at the root of the thumb, was all that still remained unhealed. Under the constant use of the manipulations already described, and the wearing of the splint, the thumb and fingers had regained their WITH A FEW SUGGESTIONS CONCERNING THE TREATnatural shape and freedom of motion, and were gradually recovering their power to grasp objects. thumb, however, in consequence of its greater degree of distortion, originally had not recovered the power

FIG. 5.

The

of flexion so perfectly as the other fingers. The face had also much improved; the commissures of the eyelids were alike in length on both sides, and the tarsal edges of both lids of the left eye were perfect in their adjustment to each other. A spot upon the forehead, above the left eyebrow, of the size of a thumbnail, was covered with a growth of hair that required to be shaved two or three times a week. It was a portion of the hairy scalp, and formed the extremity of the patch of skin which had been transplanted from the right to the left half of the forehead. On the 10th of May he accompanied his family on a visit to Europe. From that time to the present (January, 1874) the daily manipulation of the fingers has been kept up regularly, and the splint has been worn at night only, the hand being left free in the daytime to be exercised in every possible way. The father, in a recent letter, says: "His hand has improved, and he now uses the thumb quite a good deal; in fact for all practical purposes it is about as useful as the other. We

ABNORMAL CONDITIONS OF THE SUPE-
RIOR AIR-PASSAGES, AND SOME OF
THE CAUSES OF CHRONIC INFLAM-
MATION OF THESE PARTS.

MENT.

BY W. H. BENNETT, M.D.,

NEW YORK.

1ST. I think it may be demonstrated that dust from ordinary sources, as met with in the air which all of us breathe, and not referring to any particular calling, enter the larynx and trachea in considerable quantities, under certain circumstances, and may remain adherent to the walls of these organs many hours, and even a whole day.

2d. A healthy mucous membrane covering the nares, pharynx, and larynx is less frequently met with in the city of New York than is commonly supposed; certainly in every third adult it will be found diseased at some point, and in children above the age of ten naso-pharyngeal catarrh is exceedingly frequent.

3d. Although the apparent effect of a foul stomach is only visible on the tongue (coated tongue), the irritation is equally felt by the whole mucous surface in the immediate vicinity, and it is frequently impossible to cure a chronic catarrh of these parts without treating the stomach also.

4th. A partial constriction or obstruction of either of the nasal passages, or at the anterior nares, has, to a certain extent, the same effect upon the parts immediately behind it as a stricture of the urethra, or at the external meatus, has upon the parts immediately behind it.

5th. Although it is impossible to make a diagnosis of incipient phthisis solely from the condition of the larynx, we may nevertheless be greatly assisted in our diagnosis by the appearance of this organ.

6th. The chink of the glottis may be so nearly closed, if the narrowing take place gradually, as to present an opening scarcely a line and a half in diameter when stretched to the utmost, and yet sufficient air will find entrance to the lungs to prolong life for the time being, and even for some days.

7th. All diseased membranes absorb moisture from the air in damp weather, but particularly the mucous membrane of the superior air-passages, which may become considerably swelled from this cause, the vessels dilated, the circulation sluggish, and the secretion markedly increased.

To return to my first statement regarding the entrance of dust particles into the larynx and trachea: I have seen several cases where the interior of these organs was discolored in spots, here and there, by a black deposit, and in two of these cases the patient had not been exposed for some hours to an atmosphere of dust. I am confident as to the nature of the deposit, for I took the precaution to wash out the larynx, collect the sputa, and examine it under the microscope. Every one of these several cases suffered from catarrh