desirable, be safely made longer by extending the original incisions before it is finally separated.

For the most part, freshly fashioned flaps from the immediate neighbourhood of the defect have hitherto been employed, but recently many excellent cases have been published where nourished flaps were employed. Billroth appears to have been the first to use a granulating flap taken from one leg to cover in and heal an ulcer on the other one, and Gussenbauer and Czerny successfully employed such flaps for the same purpose, while attempts made to cover ulcerating surfaces with fresh flaps met with little success.

Wagner gives cases where he transplanted flaps from the thorax to the arm and forearm, from one leg to the other, and from the back to the ankle; and he also employed them in cases of recent injury.

Salzer and Czerny have used the skin of the thorax to transplant into cicatrices on the hand and fingers. Von Hacker transplanted a flap from the thorax to the popliteal space for a cicatrix after burn in a child of six. The contraction of the scar had bent both knees to an angle of nearly 45°, and prevented them being extended beyond a right angle. There was no sound skin left on either lower limb which could be utilised. The cicatricial tissue in the ham was first divided, and afterwards dissected away from the tendons and popliteal space. Two horizontal and parallel incisions were then made from the axillary line towards the sternum, eight inches long and nearly three inches apart, the skin and subcutaneous structures were separated from the muscular layer, and after a little trouble, the foot first, and then the leg, were passed under the bridge of the skin. The margins of the flap were sutured above and below to the separated edges of the cicatrix in the ham, the wound of the thoracic wall united as far as practicable with button sutures, and iodoform dressing applied.

A gutta-percha breastplate, with a hole in the centre for the leg, served to steady the parts and the dressing.

On the twelfth day the flap was divided on the outer side;

on the eighteenth day it was separated on the median side, and thus successfully transplanted to the ham.

A similar operation was done on the opposite side, and in this instance the complete separation was effected by the twelfth day; the result was permanently succeessful and the patient stood erect and walked with comfort, and both limbs could be completely extended at the knee.

In another case a flap was transplanted from the upper arm to the neck in case of burn; on the twelfth day the flap was onethird divided, and on the seventeenth day completely cut through.

For a cicatricial contraction at the elbow it is suggested that after dividing all the cicatricial bands from the tendons, a doubly attached flap taken from the thigh may be utilised to fill the gap. The hand and forearm are passed beneath the flap as far as the elbow, and the flap, which is made of suitable proportions, adjusted in the gap. The margins can be attached by sutures, and the extremities separated in succession after a sufficient interval.

In order to fill a most unsightly gap in a girl's cheek, Dr. George F. Shrady, of New York, lately told me of a case in which he had practised the following very ingenious and, so far as I know, quite novel and original method of what may be called the mediate transference of a flap of skin from the arm to the cheek, by using a finger as a medium to transport the flap from one position to the other. I am indebted to Dr. Shrady's courtesy for these details, as the case is as yet unpublished.

The arms are folded in front in such a manner as will allow the hand to rest easily with its palmar aspect against the lower portion of the opposite arm above the elbow; the other hand adapts itself in an easy position beneath the opposite elbow. This position is a comfortable and natural one, and can be well borne for a considerable time, when the limbs are subsequently bound together by plaster of Paris bandages.

The bearings having been noted, a suitably sized flap is

R

dissected from the outer aspect of the arm above the line of the margin of the outspread forefinger, the base of the flap downwards and the tongue up, or if found more convenient this may be reversed. The skin of the radial margin of the forefinger is then split for a sufficient length to fit the margin of the flap, and the latter, when the hand is in position, is stitched carefully to the split in the finger. This necessitates the curling downwards of the flap so that its raw surface presents outwards. "My purpose," Dr. Shady writes, "in curling the flap was to have the skin surface form the lining of the cheek. The presenting raw surface on the cheek was afterwards covered by sliding skin flaps from the neighbouring parts. In other cases it will be more convenient to have the cutaneous surface presenting externally, and this may be effected by dividing the flap at its inferior extremity.

"The flap grew nicely to the cheek, and when separated from the finger maintained its vitality. It was allowed to grow, with its upper portion only attached for some time, and then the sides and lower portions (previously free) were stitched into position. As a result of a subsequent operation for covering the granulating surface, the lower portion of the original skin flap sloughed, but enough remained to make a very presentable and useful cheek." Dr. Shrady thinks the result proves that the principle is a good one. It is easy of application, comfortable for the patient, and establishes the fact that the hand can be used as a means of intermediate transplantation to almost any part of the body within reach.

259

A PERSONAL EXPERIENCE OF HAY-FEVER.

BY BERTRAM C. A. WINDLE, M.A., M.D.,

PROFESSOR OF ANATOMY IN THE QUEEN'S COLLEGE, BIRMINGHAM.

As one divorced from the active practice of medicine I should have more than a passing hesitation in offering my opinions as to any disease to a meeting of men much more familiar than I am with any subject of which I might treat. But as the most suitable individual to capture a thief is allowed to be a member of the confraternity, it is perhaps legitimate to suppose that a sufferer from hay-fever, who has made the cure or alleviation of his disease a subject of considerable thought and experiment, may be able to offer a few suggestions to his more fortunate and unafflicted brethren which may be of use to them in dealing with this troublesome ailment, the number of whose victims appears annually to be on the increase. I do not propose entering into any elaborate or detailed account of the observations of others as to the disease, feeling that if any value attaches to this paper it will be due to its dealing with my own personal observations on the subject. I should also state at the outset that my remarks relate only to that ailment popularly known as "hay-fever," and not to spasmodic sneezing fits caused by ipecacuanha, linseed meal or other substances.

As to the cause of the disease I have no doubt in my own mind that pollen of some kind or another, almost certainly that of some grass or grasses, is to blame. Whether the action of this substance is mechanical or chemical I know not; but repeated observations which I shall not linger to detail have convinced me that in pollen we have the cause of the trouble. When once fully established, however, I think it probable, if not certain, that dust of any kind, or other stimuli such as bright sunlight, may produce paroxysms of sneezing. This may readily be accounted for by the hypersensitive condition of the mucous membrane produced by the complaint.

Pollen, however, is not the only thing necessary for the production of hay fever. Were this so we should all be sufferers since the grains are all around us. Like the tubercle-bacillus the pollen requires a suitable nidus or surface on which to work. I have for some years made enquiries with a view to ascertain what causes the condition of mucous membrane suitable for the action of the pollen to take effect; in so doing I have been struck by the number of cases in which sufferers were also of a gouty tendency, or at least had a gouty family history. This is so in my own case, and though not universally so, yet the great majority of those persons as to whose history I have made inquiry have afforded similar evidence. It has been stated that gout predisposes to a tenderness or susceptibility to injury of the mucous membranes, rheumatism to a similar condition of the serous. That is, for example, that the cause which will set up a bronchitis in a gouty person will produce a pleurisy in a rheumatic. The generalisation is perhaps to sweeping, but has, I think, speaking with all deference, a certain amount of truth, and adds additional weight to my hypothesis, which, by the way I do not remember ever having seen raised in any of the numerous papers which I have read upon the subject. The class of cases in which hay-fever is met with, again, is of some importance in this connection. It is, I believe, unknown amongst the working classes, and gout as Sydenham has told us attacks more rich men than poor, more wise men than fools.

I should not omit to mention that nasal polypi in some cases have predisposed to the disease, and their removal has effected its cure.

I have no experience, as yet, I am thankful to say, of the asthmatic form of hay-fever and the catarrhal is so well known that I need not delay over its symptoms. It is accompanied by several troublesome and annoying complications, amongst which I may mention irritation of the conjunctiva with inflammation and sometimes chemosis of that membrane, a perfectly maddening itching of the back of the soft palate, and an extension of the same torture to the mucous membrane of the Eustachian tube.