Fig. 10. made a crescentric incision through the mucous membrane, and down in fact to the bone, commencing the incision nearly opposite the superior extremity of the opening and continuing it until it reached a point nearly opposite its inferior. A strip of mucous membrane about three lines and a half in breadth, was thus separated except at its extremities from the adjacent parts. A similar incision was then made on the opposite side, (see dotted lines, Fig. 10.) The lips of the little wound were next detached from the subjacent bone to the extent of one line on each side, and then folded, as it were, upon themselves, thus leaving a gutter into which I inserted a small cylinder of soft buckskin. Making the incisions, detaching the lips of the wound and introducing the buckskin occupied but a minute or two, giving the patient little or no pain, and causing no hemorrhage worth mentioning. The first step of the operation was thus completed and the patient ordered to keep perfectly silent. Fearing that the motion of the tongue might displace the buckskin I had prepared a sort of flat obturator mounted upon a piece of elastic wire, the end of which I intended to wrap round a tooth, and by this means keep the plate firmly applied over the wound and thus prevent the escape of the buckskin cylinder; but I found this instrument unnecessary inasmuch as the swelling of the wound was sufficient to accomplish the object in view. Inflammation followed by suppuration speedily supervened, and on the removal of the cylinder seventy-two hours after its introduction a fine crop of healthy granulations was discovered at the bottom of the wound; these rapidly increased in size and soon filled up the space between the lips of the incisions, rendering the introduction of any foreign body for the accomplishment of this object needless. In six days after the first operation and when the granulations were in full vigour, I performed the second series of incisions, which were carried between the extremities of the other two, and treated in precisely the same manner. (See Fig. 10.) In six days from the execution of this second operation I found the opening in the palate surrounded by a strip of granulations, and in a proper condition for the last and by far the most difficult step of the whole attempt, the detachment and approximation of the flaps. Having provided myself with two scalpels, half an inch in length by two lines in breadth, cutting on both sides and slightly curved near the points, several very small and nearly crescentric needles, a delicate pair of Physick's forceps, two or three delicate hooks, small dressing forceps, and well waxed ligatures of silk of one thread, with sponges, &c. &c., I proceeded to the performance of the operation. The head being properly placed, I commenced by detaching the mucous membrane all around, dissecting from the margins out to the granulations, which being very yielding, allowed me without difficulty to bring the flaps together, at or near the centre of the opening. To accom Fig. 11. plish this, a pair of small forceps was employed, and while the flap was held tense by an assistant, I passed the ligature first through the flap on the left side, at its centre and about a line from its edge, and then allowing that to escape from the forceps, the opposite one was made tense and the ligature passed through it at a point directly opposite the little wound in the other; the ligature was then tied, and the flap above, or that next the anterior portion of the mouth brought into the concavity formed by the approximation of the two lateral flaps and attached by a ligature on each side. The lower was next brought to its proper position and there held by similar stitches. The opening in the palate was thus completely "covered in," and presented the appearance seen in Fig. 11. The usual after treatment was pursued and in three weeks from the date of the last operation my patient was perfectly relieved of every vestige of his deformity. The ligatures were cut away on the fourth, fifth and sixth day and nothing of consequence occurred during the period of confinement. This operation, though tedious, is nevertheless a very useful modification of staphyloplasty and may be resorted to in almost all those cases in which the wound fails to unite throughout, after the usual operation of staphyloraphy; and too much credit cannot be ascribed to Dr. Mettauer for the suggestion of the operation by granulation.* I believe, however, that the case just reported is the first example of the combination of the operation "par glissement du lambeau," and that by granulation. My reason for not making all the granulating wounds at one operation was the fear of cutting off an adequate supply of blood to the margins intended for flaps. By postponing the second operation until the first wound was filled up with granulations and the circulation between them and the adjacent flaps firmly established, I avoided all danger of sloughing from a want of blood. Time, in such cases, being a matter of minor consideration, I did not think myself warranted in running any risk of failing in the operation by an attempt to economise it. CASE III. James Williams, a young man 18 years of age, applied to me in December 1840 for the purpose of having an operation performed for the closure of two openings, (the result of previous inflammation and sloughing,) one of which was situated entirely within the velum, and the other just above it, but located in the hard palate. Both openings were on the right side and separated from each other by a narrow strip of mucous membrane and bone, and pre * Amer. Journ. Med. Sci., Feb. 1838, p. 325. Fig. 12. sented each one a callous margin. That in the velum readily admitted the extremity of the forefinger and was ovoid in shape, the other was larger and nearly round. The usual accompaniments of such defects were present, and for the relief of these an operation was desired. The common operation by interrupted suture was practised on the opening in the soft palate, which united perfectly in about two weeks, and as soon as this was accomplished and the patient had rallied from the effects of the operation I commenced the treatment of the other, the method employed being that described in the report of the case of Mr. Richards. The result was most fortunate and fully justified the confidence placed in this novel operation. ART. VI.-Case of Congenital Tumour of the Eye Ball. By W. T. TALIAFERRO, M. D., of Maysville, Ky. MISS N. H., aged 15 years, delicate frame, florid complexion, chestnut hair, and blue eyes, visited me in May, 1838, for advice, with a congenital tumour on each eye arising from the sub-conjunctival coat. The tumours were of a delicate pink at their base, becoming brownish at their apices. They were discovered immediately after birth, and had had a steady gradual growth. At the time she visited me, the tumour of the left eye (see accompanying figure,) covered an oval base, about five lines in its long, and three and a half in its short diameter, and rose in a flattened conoidal shape to about six lines in height. Its long diameter ran nearly parallel with a line drawn from the inner to the outer canthus of the eye. It covered nearly the lower two-thirds of the pupil in a pleasantly shaded light. From the apex grew some ten or twelve hairs, about sixteen lines in length, a shade darker than the cilia. As the tumour grew from the outer and lower part of the cornea perpendicular to the globe, it bore the lower lid far downward and outward. The upper lid was drawn down and could be elevated but very slightly; the cilia of the upper lid came in contact with the globe and the tumour. Exposure to the wind or light, produced a free and slightly purulent discharge, rendering her situation exceedingly distressing. The tumour occupying the two lower thirds, and the superior lid the upper third of the pupil, she could distinguish no object clearly with this eye. The tumour of the right eye, (see figure,) in shape and situation, relative to the globe, was like to the left; its size about half that of the left, covering about the lower sixth of the pupil. The vision of this eye was good on a horizontal line and upward. The pupils of both eyes were larger than natural; the left about a third larger than the right. Her education had been impossible, and her situation altogether was most deplorable. "Al ways advised never to disturb the tumour, or the eyes would be inevitably destroyed." After having greatly reduced the activity of the circulation by medicine and diet, I removed the tumour of the left eye on the 1st of June, assisted by my talented friend and partner, Dr. E. D. Pickett, now of Mississippi. Present Drs. Duke, Marshall, Henry, Fox and Taylor. The dissection was made with Charrere's delicate cornea knife, curved scissors and hooked forceps. The operation was rendered tedious from the exceeding vascularity of that portion of the conjunctiva reflected over the tumour, which was supplied with numerous large tortuous vessels converging from either canthus. In its texture the tumour seemed as if composed of lamina, far separated by spongy cellular substance. It was very tough. From the pressure, probably, the external lamina of the cornea were almost entirely absorbed at the lower part, and greatly thinned and softened throughout the extent occupied by the tumour. In fact it was quite impossible to distinguish where the tumour ended and the cornea began; of course, therefore, the corneal texture was much encroached on. The treatment was a dressing of light pledgets, kept constantly wet with cold water, to the eye; aperients, and a gruel diet, &c. &c. In eight or ten days, an evident discharge was begun from the wound, as if for a reproduction of the tumour. This was again dissected off; cold applications made as before growth began again: argent, nitrat. two grs., aq. distillat. 3j, M. was used. Growth not checked; the solution of nitrate of silver was increased in strength to twenty grains to the ounce with little improvement; the solid argent. nit. was resorted to, and sulphate of cuper alternated; healthful healing began and continued steadily till the wound was well. In the latter part of June, the tumour of the right eye was removed, assisted by Dr. G. W. Bayless, Demonstrator of Anatomy in the Louisville Institute. Present Drs. Duke, Pickett and Marshall. Treated for a few days with pledgets wetted with cold water, and followed by the application of the solid nitrate of silver. Not a single bad symptom supervened. An opacity is left on each eye equal in extent to the bases of the tumours. The patient was kept in a pleasantly shaded chamber for about eight weeks, and restricted to a vegetable diet. One or two drops of a solution of ten grains of nitrate of silver in one ounce of water was daily applied to each eye. At the termination of the period just named, the sight of both eyes was perfect. The opacity in the right eye is scarcely perceptible, and in the left is only visible when the eye is turned upwards. The lids have resumed their normal position. In February last Miss H. was in excellent health, and most happy in acquiring an education. ART. VII.-An Examination of the Testimony relative to the Efficacy of the Hydrated Peroxide of Iron as an Antidote to Arsenic, with Directions for its Preparation and Exhibition. By T. ROMEYN BECK, M. D. Ir is now about six years since the use of the peroxide of iron was introduced to the notice of the public. It has been made the subject of numerous, and for the most part satisfactory, experiments on animals; it has been frequently exhibited to persons poisoned with arsenic, and in many instances with success; it is also a substance very easily prepared, and one that can always be kept on hand either by the physician or druggist. These circumstances might be supposed sufficient to establish firmly the character of any antidote, and I do not doubt but that it is thus viewed by those who have from time to time noticed the testimony adduced in its favour. But this has, in many instances, consisted of brief notices of successful cases or experiments, scattered through the selections and summaries of Medical Journals, and hence has possibly not made that impression which a collection of the whole would produce. With a view to promote that desirable object, and at the same time to urge an early exhibition of this substance in all cases of poisoning by arsenic, I have ventured to prepare the following observations. I propose to follow the following order. 1. A notice of the discovery. 2. The results of experiments on animals. 3. The efficacy of its exhibition on man. 4. The mode of its preparation and exhibition. I. The earliest notice that I have seen of the efficacy of peroxide of iron as an antidote, is contained in a letter addressed to M. Poggendorf, the editor of a German Scientific Journal by Dr. Bunsen, bearing date Gottingen, May 1, 1834.* In the same year Drs. Bunsen and Berthold jointly addressed a communication on the same subject to the Academy of Sciences at Paris.† It had been previously established by the experiments of Renault and others, * London and Edinburgh Philosophical Magazine, vol. vi, p. 237. |