JEFFRIES: Plastic Operations without Pedicle.
11I3
the advantages of the best form of tilting-mirror; and a good series, and very convenient arrangement of lenses, in a very light, simple instrument, which will be comparatively inexpensive. In justice to Queen & Co., of Philadelphia, who have made for me the sample shown, it should be said, that this is the first attempt to embody my idea; that the instrument was constructed directly from my drawings without the intervention of any model; and that it was prepared somewhat hurriedly. These facts must be held to account for any slight mechanical imperfections it may present. NOTE.-The instrument hias since been altered, to permit the ready removal of the lens-slides for cleaning. Five lenses instead of four have also been placed in each slide, giving the following comb)inations: Plus 0.5, I 15 2, 2.5 3, 3.5, 4, 4.5, 5, 6, 7, 8, 9, IO, and I I dioptrics. Mlinus 0.5, I, 2, 3, 4, 5, 6, 7, 8, 9, 10, II, 12, 13, 14, 15 i6, 17, andl IS dioptrics.
SOME SUGGESTIONS ON PLASTIC OPERATIONS WITHOUT PEDICLE. By B. JOY JEFFRIES, M.D., BOSTON.
THE increasing number of successful flap operations without pedicle reported, induces me to make known some thoughts that have occurred to me before I have had opportunity of testing them myself, though having prepared to do so. Certainly no operator but would gladly get rid of the necessary wound of the arm in obtaining the flap, both on account of the wound -itself, its healing, etc., but more especially on account of the delay in the dissecting it up, its preparation, etc. Experience has shown that we cannot depend on obtaining a dissected flap from another person, as and wizen we want it. It has also shown that the taking the flap from the
114
JEFFRIES: Plastic Operations withiout Pedicle.
patient's arm or elsewhere is a serious drawback to their willingness to undergo the operation. The piece of skin thus removed does not seem to answer all its purpose. It would be natural that one of more consistence, more vascular and more vital, so to speak, would attach itself with greater certainty and be more easily manipulated. The absence of fat on the under and hair on the upper surface would be very desirable. The prepuce, it seems to me, offers us the best kind of skin for transplanting; thin, delicate, vascular, with no fat or hairs. As it does not shrink on removal, like other portions of the skin, we can better measure the amount required to be sacrificed. We have a double surface in the part taken off. If our patient is a male, and not a Jew, he may afford us the necessary material with a less disagreeable subsequent wound than that on the arm. If a female, our flap may be got from a male, or, as I would propose in all cases, from circumcised children. The Jewish rite is often enough performed in our centres of ophthalmic surgery to give us ample opportunity of thus obtaining it. I do not find on inquiry that there is anything connected with the rite which would prevent the proposed use of the removed foreskin. As this has a double surface, it would probably answer our purpose as to size. It certainly is the most delicate piece of skin obtainable. I have never heard of its use or the suggestion of its use as a flap. I would draw attention to one other point. Whilst in many cases one would hardly risk an operation without a flap in releasing the lids, etc., are there not some when the flap could be dispensed with ? Certainly nature dispenses with it subsequently, as an inch wide flap disappears to a line wide mark. This does not of course disprove the necessity of its presence during healing. But in reading over carefully the reports from various operators, I thought whether what the flap as used did in some cases was more than retard the healing, and thereby, by letting the parts accommodate themselves, so to speak, with the help of the attached lids, prevent the otherwise natural contraction. I have noticed what others have also spoken of, at least at society meetings, viz., how long you can keep an open wound
BULL: Unilateral Temporal Hemianopsia.
I I5
in statu quo by carbolized oil without carbolic poisoning or other symptom. Would it not be possible to do this, at any rate, with some of the lesser wounds we have after loosening the lids aind when these latter are attached to each other? The continued existence of the flap is evidently not necessary, and it seems to me possible to gain what it gives us by what I suggest. DISCUSSION.
DR. WEBSTER.-I was lately reading what Juler says on this subject, and he recommends the foreskin, as Dr. Jeffries has done.
TWO CASES OF UNILATERAL TEMPORAL HEMIANOPSIA. BY CHARLES STEDMAN BULL, M.D., NEW YORK.
UNILATERAL TEMPORAL HEMIANOPSIA, WITH CENTRAL SCOTOMA OF THE OTHER EYE. COL. N , aged sixty-six, a retired officer of the army, was first seen in consultation by me on June 28th, I884, and gave the following history: In the summer of I849, while at one of the military posts on our western frontier, he was struck by lightning while standing at the door of his tent. He fell to the ground and remained unconscious for several hours. When he regained his consciousness, he discovered that he wa§ blind in both eyes, but this condition rapidly improved, so that at the end of a few days he had regained his sight, and in a short space of time had the perfect possession of all his faculties. He remained perfectly well in every respect till i857, nearly eight years later, when the muscles of the left thigh and leg began to atrophy, and almost simultaneously there suddenly appeared a temporal hemianopsia of the right eye. The paresis and atrophy of the muscles of the left lower extremity slowly but steadily progressed till I859,
11I3
the advantages of the best form of tilting-mirror; and a good series, and very convenient arrangement of lenses, in a very light, simple instrument, which will be comparatively inexpensive. In justice to Queen & Co., of Philadelphia, who have made for me the sample shown, it should be said, that this is the first attempt to embody my idea; that the instrument was constructed directly from my drawings without the intervention of any model; and that it was prepared somewhat hurriedly. These facts must be held to account for any slight mechanical imperfections it may present. NOTE.-The instrument hias since been altered, to permit the ready removal of the lens-slides for cleaning. Five lenses instead of four have also been placed in each slide, giving the following comb)inations: Plus 0.5, I 15 2, 2.5 3, 3.5, 4, 4.5, 5, 6, 7, 8, 9, IO, and I I dioptrics. Mlinus 0.5, I, 2, 3, 4, 5, 6, 7, 8, 9, 10, II, 12, 13, 14, 15 i6, 17, andl IS dioptrics.
SOME SUGGESTIONS ON PLASTIC OPERATIONS WITHOUT PEDICLE. By B. JOY JEFFRIES, M.D., BOSTON.
THE increasing number of successful flap operations without pedicle reported, induces me to make known some thoughts that have occurred to me before I have had opportunity of testing them myself, though having prepared to do so. Certainly no operator but would gladly get rid of the necessary wound of the arm in obtaining the flap, both on account of the wound -itself, its healing, etc., but more especially on account of the delay in the dissecting it up, its preparation, etc. Experience has shown that we cannot depend on obtaining a dissected flap from another person, as and wizen we want it. It has also shown that the taking the flap from the
114
JEFFRIES: Plastic Operations withiout Pedicle.
patient's arm or elsewhere is a serious drawback to their willingness to undergo the operation. The piece of skin thus removed does not seem to answer all its purpose. It would be natural that one of more consistence, more vascular and more vital, so to speak, would attach itself with greater certainty and be more easily manipulated. The absence of fat on the under and hair on the upper surface would be very desirable. The prepuce, it seems to me, offers us the best kind of skin for transplanting; thin, delicate, vascular, with no fat or hairs. As it does not shrink on removal, like other portions of the skin, we can better measure the amount required to be sacrificed. We have a double surface in the part taken off. If our patient is a male, and not a Jew, he may afford us the necessary material with a less disagreeable subsequent wound than that on the arm. If a female, our flap may be got from a male, or, as I would propose in all cases, from circumcised children. The Jewish rite is often enough performed in our centres of ophthalmic surgery to give us ample opportunity of thus obtaining it. I do not find on inquiry that there is anything connected with the rite which would prevent the proposed use of the removed foreskin. As this has a double surface, it would probably answer our purpose as to size. It certainly is the most delicate piece of skin obtainable. I have never heard of its use or the suggestion of its use as a flap. I would draw attention to one other point. Whilst in many cases one would hardly risk an operation without a flap in releasing the lids, etc., are there not some when the flap could be dispensed with ? Certainly nature dispenses with it subsequently, as an inch wide flap disappears to a line wide mark. This does not of course disprove the necessity of its presence during healing. But in reading over carefully the reports from various operators, I thought whether what the flap as used did in some cases was more than retard the healing, and thereby, by letting the parts accommodate themselves, so to speak, with the help of the attached lids, prevent the otherwise natural contraction. I have noticed what others have also spoken of, at least at society meetings, viz., how long you can keep an open wound
BULL: Unilateral Temporal Hemianopsia.
I I5
in statu quo by carbolized oil without carbolic poisoning or other symptom. Would it not be possible to do this, at any rate, with some of the lesser wounds we have after loosening the lids aind when these latter are attached to each other? The continued existence of the flap is evidently not necessary, and it seems to me possible to gain what it gives us by what I suggest. DISCUSSION.
DR. WEBSTER.-I was lately reading what Juler says on this subject, and he recommends the foreskin, as Dr. Jeffries has done.
TWO CASES OF UNILATERAL TEMPORAL HEMIANOPSIA. BY CHARLES STEDMAN BULL, M.D., NEW YORK.
UNILATERAL TEMPORAL HEMIANOPSIA, WITH CENTRAL SCOTOMA OF THE OTHER EYE. COL. N , aged sixty-six, a retired officer of the army, was first seen in consultation by me on June 28th, I884, and gave the following history: In the summer of I849, while at one of the military posts on our western frontier, he was struck by lightning while standing at the door of his tent. He fell to the ground and remained unconscious for several hours. When he regained his consciousness, he discovered that he wa§ blind in both eyes, but this condition rapidly improved, so that at the end of a few days he had regained his sight, and in a short space of time had the perfect possession of all his faculties. He remained perfectly well in every respect till i857, nearly eight years later, when the muscles of the left thigh and leg began to atrophy, and almost simultaneously there suddenly appeared a temporal hemianopsia of the right eye. The paresis and atrophy of the muscles of the left lower extremity slowly but steadily progressed till I859,
