THE 
BOSTON MEDICAL AND SURGICAL 
JOURNAL. 
VOL. XVI.] Wednesday, March 8, 1837. [NO. 5. 
RHINOPLASTIC OPERATION. 
[Communicated for the Boston Medical and Surgical Journal.] 
The history of the patient who was the subject of this operation, we 
shall give very briefly, as follows. 
J. T. 28 years of age. Three years ago last spring, while playing 
very roughly with one of his companions, he received a violent blow 
on the nose, which dislocated the cartilage, driving it at the same time 
over to the left side. Some inflammation came on in the nose at the 
time of the accident, which very shortly subsided ; and as he was out 
of town, and at a distance from medical advice, nothing was done to 
replace the cartilage, which remained in the situation into which it had 
been driven by the blow. 
In the following spring, while pursuing his ordinary occupations, a 
small red spot appeared on the right cheek just below the eye ; this 
very soon increased in size, the inflammation gradually spread, first 
attacking the lip, and from thence extending to the nose, which became 
red, swollen, and finally ulcerated. 
It will be unnecessary to go further into the details of the case ; suf- 
fice it to say, that in the course of eighteen months the whole nose, 
cartilages, septum, bones, he. were successively attacked, and finally 
completely destroyed. The ulceration had also extended to the cheek 
of the opposite side. Subsequently to this, cicatrization gradually took 
place, leaving the patient in the state in which I saw him, six months 
after his recovery from the disease. 
At this period, having accidentally come across a description of the 
‘Taliacotian operation in an old magazine, he applied to know whether 
anything of a similar kind could be done to remedy his frightful deform- 
ity. The following was his state as he appeared on the first examination. 
The nose, as described above, had entirely disappeared, leaving in 
the place it originally occupied an opening about an inch in diameter, 
bordered by a firm cicatrice ; the septum of the nostrils was destroyed, 
and the two nasal cavities thus thrown into one ; externally a small cica- 
trix descended from the lower and left edge of this opening to the angle 
of the mouth. In the course of the efisease the four front teeth had 
been lost, and this, together with the absorption of the alveolar process- 
es, had caused a sinking of the upper lip, which had fallen an inch 
below the level of the lower one. An opening also existed between the 
lip and upper jaw, through which a probe might be passed from the 70 
Rhinoplastic Operation. 
mouth into the nasal cavity. The sense of smell was quite lost, and he 
was subject to an occasional running of the tears over the face, arising 
undoubtedly from the too sudden contact of the air with the fcchrvmal 
ducts. » "H? % 
A thorough examination of his case having been made, and nfidVijy 
there was fto^j^itive obstacle aaajnst. the possibility of the success 31 
an operation, the difficulties of*such an operation as would be require* 
were distinctly stated to him, the improbability of its succeeding so as to 
restore the organ in such a manner that the deformity should not be 
known, that the new nose might become very much flattened, and per- 
haps on the appearance of cold weather gangrene might take place, and 
finally, that even his life might be endangered by it. I felt it my duty 
to state the case plainly, having seen all these accidents occur from the 
operation, and death in two cases being the consequence, from severe 
erysipelatous inflammation of the scalp. 
Notwithstanding all these objections, he said that he was ready to in- 
cur any risk which would give him the least chance of having the de- 
formity under which he labored obviated, as life in his present state was 
hardly desirable. 
His case was certainly a hard one. A young man, in the prime of 
life, in other respects of a good face and appearance, was, by this fright- 
fid calamity, not only entirely cut off from society, but prevented from 
gaining the means of subsistence. 
Having determined to submit himself to an operation, it was thought 
expedient to delay it a few weeks, in order to watch the case a little, and 
prepare him for it by a course of diet and regimen. 
At the end of six weeks his health had materially improved, and as he 
still persisted in the determination of having an operation performed, 
preparations were made to do it as soon as possible, as on account of the 
approach of cold weather, no time was to be spared. At this period he 
was seen by my friend Dr. Peace, of Philadelphia, who was present 
with me at one or two operations of the kind practised by Dieffenbach 
in Pa ris, and he declared, as his opinion, that the appearance of the pa- 
tient offered every chance of success. The favorable circumstances 
were—the healthy state of the integuments surrounding the opening of 
the nasal fossa, the great height of the forehead, the whiteness and deli- 
cacy of the skin, and, added to this, the good state of his health. All 
the preparations having been made, the operation was performed on the 
seventh of September. 
A piece of pasteboard, cut in the shape of the letter V, that is, of a 
triangular form, and with a projection from its base, corresponding to the 
columna of the nose, was placed upon the forehead, and a trace made 
around it with the nitrate of silver ; this being used in preference to ink, 
as recommended by Lisfranc, in order that it might not be liable to be- 
come effaced by the blood. A trace was also made around the opening 
of the nasal fossa, at the points where it would be necessary to remove 
the integuments for planting the new skin taken from the forehead. 
This was done the night previous, in order to prevent any undue delay 
on the day of the operation. Rhinoplastic Operation. 
71 
All unnecessary articles of clothing being removed, the patient was 
placed on a table in a recumbent position, bis face towards the window, 
and the offerator behind so as to have the full command of the head. The 
traces made by the nitrate of silver were about two thirds of an inch 
apart between the eyebrows, each side of the triangular portion of skin 
y»s three inches and a quarter in lengthy with a base of three and a half 
wches, and the projection for the columna of the nose, which was to be 
taken entirely from the scalp, previously shaved, was an inch and a half 
long and two thirds of an inch wide. 
The head being firmly supported by two assistants, the incision was 
commenced between the eyebrows, and the flap of skin dissected up so 
as entirely to isolate it from the skin of the forehead, except where, for 
the purpose of nutrition, it was left adherent at the root of the nose. 
The incision on the left side between the eyebrows was extended a little 
farther down than on the right, the better to facilitate the twisting of 
the flap. This incision included the skin, subcutaneous cellular tissue, 
and a portion of the occipito-frontalis muscle, care being taken not to 
raise the periosteum, from fear of necrosis. 
The flap thus dissected and twisted round to the left side, was care- 
fully wrapped in a compress of linen cloth, and before the operation was 
proceeded farther in, attention was given to diminishing the large wound 
made in the scalp. Little hemorrhage had taken place, and the tem- 
poral arteries which had been cut, very soon retracted and ceased bleed- 
ing. The angles of the wound were first brought together by the twist- 
ed suture, two pins being employed on either side. Its edges between 
the eyebrows were also approximated in a similar manner; by this 
means the wound in the forehead was diminished at once to less than 
half its original size ; it was still farther reduced by the use of a few 
strips of adhesive plaister, and a little scraped lint filled up the remain- 
der of the wound. Some lint spread with cerate was spread over the 
whole surface, a pledget, and the whole secured by a bandage round 
the head. 
The next object was to fix the borrowed skin in its place. In order 
to do this, it was necessary to freshen the borders around the opening of 
the nasal fossa, the traces of which, as stated above, had been previously 
made with nitrate of silver. For this purpose a short narrow knife, some- 
what similar to a cataract knife, was used, and a strip of integument a 
third of an inch in breadth, removed, including all that portion which 
had been at all indurated during the cicatrization of the ulcerations. 
The knife was also passed between the lip and upper jaw, in which 
existed, as before stated, an opening large enough to pass a probe, and 
the adhesions between the two, for the space of an inch, entirely cut 
away. This was done for the double purpose of giving the columna of 
the nose a more deep and firm adhesion, and, in the inflammation which 
would subsequently ensue, to close up the unnatural communication be- 
tween the mouth and nasal cavity. 
The flap was now brought down into its place, its angles a little 
rounded with the scissors, the better to simulate the alae of the nose, and 
the whole secured in its place by pins and points of the interrupted su- 72 
Rliinoplastic Operation. 
ture. From that portion o( the skin which was to form the columna of 
the nose, the epidermic side was pared a little, so that it might form an 
adhesion not only underneath to the jaw, but on its sides to lh£ quadran- 
gular wound made for it in the upper iip. 
A little scraped lint was now placed under the ends of the pins, and 
a strip of oiled lint introduced into each nostril to prevent adhesion ; aA 
other strip was placed upon the nose to preserve its temperature. 
dressings were secured by a band of adhesive plaister fixed to the fare- 
head above, and partially divided in the middle, so that it might descend 
on each side of the nose to the lip. 
During the whole of this long and painful operation the patient kept 
up his courage, and not a cry was uttered, nor the least struggle made 
that could at all impede the motions o! the operator. Not much blood 
was lost, and his strength was so little exhausted that he was able to run 
up stairs to his chamber. He was ordered to go to bed immediately, to 
keep perfectly quiet, and a watcher left with him, who had directions, in 
case of his falling asleep, to prevent him from either rolling over on his 
side, or raising his hand to the nose so as to derange the dressings ; also 
to wake him immediately should he breathe through the nose. To have 
arrow-root or gruel and lemonade, for nourishment. 
On visiting him in the afternoon he was found comfortable ; the 
new7 nose was warm, and had bled a little from the edges which formed 
the nostrils, both showing the circulation was not at all impeded. 
Sept. 10th. Passed a good night, slept well, pulse seventy-nine, com- 
plains of no pain, the nose of about the natural temperature". The gen- 
tleman who watched with him thinks that the lint on the right side of 
the nose was occasionally raised a little during expiration, when the pa- 
tient slept soundly ; he awoke him once or twice on this account. A 
purgative was ordered of the sol. sulph. magnes. and liquid farinaceous 
diet. A piece of cork was confined betw’een the teeth, so as to keep 
the mouth open, it being hoped that this might prevent him from closing 
his lips during sleep and breathing through the nose. 
11th. Quite as well, passed a quiet night, has a good appetite, pulse 
eighty. Watcher says that he occasionally made a motion to raise his 
hand to the nose, but, as if instinctively aware of the impropriety' of it, 
withdrew it again without touching the dressings. The introduction of 
the cork into the mouth had entirely effected its object, by preventing 
the passage of air through the nose. 
12th. The first dressing took place four days after the operation, and 
the following was found to be the state of the parts. 
The dressings on the forehead, after being well soaked were first re- 
moved. The angles of the wound were found to have united through- 
out, so that two of the pins were at once dispensed with. Union had 
also taken place in its lower part, just above and between the eye brows ; 
the lemainder of the wound, that is, its central part, in which union by 
the first intention could not take place, was suppurating well, and filled 
with healthy granulations. 
The nose was next attended to. Upon the lint being removed, which 
had become very much hardened and caked in by the coagulated blood, Jlhinoplastic Operation. 
73 
it was found that entire union had taken place on both sides. The alae 
of the nose and lower ed;;es could not easily be seen without making 
use of too much violence in removing the dressings, which at present 
was not thought necessary. The columna was curved inwards, and the 
sutures concealed. The nose was of the natural color and temperature, 
and the circulation through it seemed uninterrupted. 
Two strips of lint dipped in oil were laid over the cicatrix on each 
side of the nose, and no other dressings used. The patient was allowed 
to sit up a little, and to take any article of food ol the liquid kind he 
might fancy. 
On the 1:3th he was quite as well, with the exception of a little oedema 
of the upper eyelids, arising, undoubtedly, from the pressure of the 
bandages and other dressings on the forehead. One ol the pins was 
removed Irotn the forehead on the 13th, and another, the only lemaining 
one, on the following day. The dossils ol lint which had been placed 
in the nostrils still remained there, firmly caked in by the drying ol the 
pus, blood, &c. These were not removed until the 19th, when their 
places were supplied by two pieces ol hollow sound. Some difficulty 
was found in the introduction of the tube into the right nostril, which 
had become partially filled with granulations. 
On the 14th a quantity ol hair began to appear on that portion of the 
skin forming the columna ol the nose, which, as will be remembeieo, 
was taken from the scalp; this hair, from time.to time, required to be 
removed with the scissors. He was put upon a nourishing diet, with tne 
caution to use the jaws as little as possible. He stated that occasionally, 
when lie swallowed, he had a sensation as though lie would sw allow 
his nose.” 
15th. The remaining pins were removed from the side of the nose, 
and the two sutures which confined the al;e ; and on the litli, ten dajs 
alter the operation, the two ligatuies, which confined the columna in 
its place, were also removed. 
At this period, the following was the state of the paits. The wound 
in the forehead, from the adhesion by the first intention which had taken 
place, and subsequent contraction, had diminished to a third it> oiiginal 
size, and the small triangular space which remained, together with that 
portion of the scalp from w hich the columna of the nose had been taken, 
was filled with healthy granulations. From the wound to the root of 
the nose was a lineal cicatrix two inches in length, and continuous with 
the cicatrix on the left side. Adhesion of the integuments had taken 
place on both sides of the nose ; at the right alae, however, the union 
was not quite so peifect as at the left ; that is to say, the whole thick- 
ness of the skin did not appear to have united. To assist the union, 
the skin of the (lice which lay under it was slightly scarified with the 
point ot a lancet. 
The columna of the nose was a little curved backward, and its edges 
had retracted inwards upon themselves. 1 he inside ol the no>e was 
suppurating well, and at its upper part adhesion seemed to have taken 
place between the two bleeding surfaces which had been opposed to each 
other. The tip of the nose was well defined, and its edges were curved 74 
Rhinoplastic Operation. 
inwards so as well to simulate the natural appearance of the alae, and 
just above the alae, apparently from atmospheric pressure, a depression was 
taking place, forming their superior boundary. This was assisted by the 
patient making an occasional pressure with his fingers at these points. 
He feels well, has a good appetite, and sits up all day. He breathes 
freely through the tubes placed in the nostrils, which require to be daily 
removed in order to clear out any obstructions which may collect in 
them. 
At the end of a month the wound in the forehead had contracted to 
about a quarter of its original size. Adhesion of the nose was perfect 
at all its points. The openings of the nostrils were regularly rounded, 
and simulated well the natural appearance. The tip of the nose is well 
preserved, and a regular curve takes place from its root to the end of 
the organ. 
At the end of six weeks he was able to go out and walk about during 
the evening, but as the weather became cold he was advised to confine 
himself to the house, as cold evidently had a very great effect in re- 
tarding the cicatrization of the wound in the forehead. By reference 
to the second figure on the plate which accompanies this paper, a pretty 
correct idea will be formed of the state of things six weeks after the 
operation. 
At the end of two months it was thought time to proceed tothe second 
operation, which was required to remove the twist existing at the root 
of the nose. It will be easily conceived by referring to the plate, that 
underneath the pedicle which connected the nose with the forehead, a 
small portion of sound skin existed, and that of course no adhesion had 
taken place between this portion and the pedicle lying over it. The 
method usually adopted by operators has been to cut the pedicle, after 
sufficient union of the nose has taken place below to justify the separa- 
tion of it from its source of nutrition, and to fix it down at the root of 
the nose, in a transverse incision made for it at that point. 
To this method there are some serious objections. First, the danger 
of inflammation in separating the pedicle ; second, of sloughing of the 
organ on the vessels being cut which have hitherto supplied it with 
blood ; and lastly, the very perceptible transverse cicatrix left after the 
operation. The method resorted to in the present case is liable to none 
of these objections, except, perhaps, the first one, in which the danger 
is much diminished. 
This operation was as follows. An incision was made, commencing 
at the internal angle of the eye, and extending to that part of the base 
of the nose where adhesion had not been able to take place ; a corres- 
ponding incision was also practised on the pedicle. The skin being well 
dissected up from its adhesion, a small portion of integument was removed 
from the upper angle of the wound, where it had become wrinkled from 
the twist in the pedicle. The edges were brought together by three 
points of tbs? interrupted suture. The same operation was to be per- 
formed at a future day on the other side, where, however, the opening 
was of about half the size, and not so perceptible. Union took place, 
throughout, by the first intention. Some trouble was experienced, how- Rhinoplastic Operation. 
75 
ever, by the formation of a small abscess in the new cicatrix, which 
suppurated and discharged itself. 
The third drawing, executed four months after the operation, when 
the cicatrization had become complete at all points, gives' a very good 
idea of his present appearance. He now declares himself entirely well, 
no secretion takes place from the nostrils, and on looking into those 
cavities a new skin is found to line them throughout. The nose it- 
self has contracted gradually, so that by the first contraction cl the in- 
teguments, and the subsequent contraction from suppuration, it has de- 
creased to almost two thirds the size of the flap which was taken bom the 
forehead. Contraction also seems to be going on in its longitudinal axis, 
so that the distance between the tip of the nose and the mouth, daily in- 
creases. This will be much more perceptible, and the whole physiogno- 
my of the nose much improved, when the four front teeth, which have 
been lost, are replaced. This will bring out the under lip, and at the 
same time raise the tip of the nose. The cicatrix in the forehead has 
become very small, and is gradually assuming the color of the surround- 
in0- integuments. The scalp from which the columna was taken is lost 
incite hair. The nose is quite firm, of a good form, and the cicatrix on 
each side hardly perceptible; at the root of the nose on the left side, and 
at that portion which formed the pedicle, a small fissure still remains, 
which is for the present concealed by a strip of court plaister. 
The health of the*patient has never been better, his sense of smell is 
returning, and the tears no longer run over the face, and he, as well as 
his friends, congratulate themselves both on the moral and physical ef- 
fects of the operation. He is now able to make his appearance during 
the daytime, which he lias not done before during the last two years, 
and no person would observe anything remarkable in the nose, without a 
minute examination, when it would be difficult to explain the remarka- 
ble anatomical changes which have taken place. 
Remarks.—In an operation like the present, of comparative rarity in 
this country, it will not perhaps be considered amiss, if a few remarks 
are offered on some of the most interesting points connected with its 
history, and of the chief difficulties which may occur to prevent its 
success. 
The operation of Rbinoplastie is originally of very ancient date. For 
various reasons, however, it had fallen into most unmerited disrepute un- 
til of late years, when it has been again revived in Europe by the bril- 
liant successes of Graffe, Dieffenbach, and Labat on the Continent, and 
Liston in Great Britain. Dieffenbach, in his late visit to Paris, where, 
with the accustomed liberality of the French, all the hospitals were 
thrown open to him for practising his celebrated operations for the resto- 
ration of parts, has, perhaps, done more than any other operator to- 
wards giving it its proper standing in surgery. 
In the most ancient operations of this kind, the lost organ was restored 
at the expense of the integuments in its immediate neighborhood; ad- 
vantagebeing taken of the extensibility of the skin of the cheeks, the 
integuments were dissected up on both sides of the nasal fossa, brought 
forward, and united in the centre by points of the interrupted suture. 76 
Rhinoplastic Operation. 
In case of the extensibility of the integuments not being sufficiently 
great, incisions were made on both sides in front of the ears, so as to di- 
minish the tension of the skin at these parts, the wounds thus made 
being afterwards allowed to fill up by granulation. This operation, 
however, did not, as will be easily perceived, restore the form of the 
lost organ, and the only advantage gained was a (lap of skin to cover 
the existing deformity. 
The operation which was afterwards adopted, and which at present 
bears the name of the author, was that of Taliacotius, which consisted 
in taking the skin required, from the arm, or, in some cases, from the 
body of another person. The given shape of the nose being marked 
out on the place determined upon, the flap was dissected up, except at 
its base, and the integument thus taken was confined in a place prepared 
for it around the nasal fossa. In this operation, it was required that the 
arm, in case it was taken from that part, should be confined in contact 
with the face, for the space of ten or fifteen days, or until union had ta- 
ken place ; and it was not until then that the arm was released from its 
situation. The disadvantages of this method are at once manifest; the 
length of time required to keep the limb in this painful situation, so 
as in some cases to produce partial paralysis, and the danger that ensued 
in the too early separation of the transplanted skin from its source of 
nutrition, were, of themselves, reasons of sufficient weight to cause this 
method to fall into disuse. 
The operation which has attained the most celebrity, is that which 
goes by the name of the Indian Method, in which the flap is taken from 
the forehead. This has been most frequently practised in France and 
England, and it is this method, which, it will be perceived, has been 
adopted, with some modifications, in the present case. 
Having thus briefly referred to the history of the operation, some re- 
ntal ks will now be made on the chief difficulties which occur in the 
course of it, and the means taken to obviate them. 
No operation, perhaps, requires more attention to the nice points of 
detail, than that now under consideration ; and it is on these that the 
ultimate success of the operation, in a great measure, depends. For in- 
formation on this subject, we cannot do better, than by referring to the 
work of M. Labat, one of the most valuable monographs on rliino- 
plastie for reference yet published. The author, after having referred 
to the occasional trouble which he experienced from hemorrhage while 
dissecting up the flap of skin from the forehead, goes on to state, “ But 
an inconvenience much more embarrassing, and to which it was neces- 
sary to be resigned, from the impossibility of remedying it, was occa- 
sioned by the great quantity of blood, which, entering the throat, was 
violently expelled from the mouth every time that the pain of the opera- 
tion forced the patient to cry out. But what was much more trouble- 
some still, was its being repeatedly received in the eyes of the operator, 
so as once or twice to oblige me to discontinue the operation for the 
space of some seconds.” 
The difficulty which the author here complains of, was remedied in 
the present instance by a very simple means. Instead of placing the Iihhioplastic Operation. 
77 
patient in an upright position, he was made to lie upon his back on a 
table, the operator behind him ; the blood was thus conducted off 
on each side ol the face, instead of passing over the nasal fossa 
and mouth, and entering the throat. To guard against any possibility 
ol this accident taking place, plugs were confined in the opening of the 
nasal cavities, during the dissection of the Hap, and the time occupied in 
closing up the wound on the forehead. When the tiperalion was com- 
menced around this opening, and the entrance of the blood was unavoida- 
ble, the patient, who maintained sufficient coolness throughout, was request- 
ed to keep the blood as long as possible in the mouth, and an assistant 
directed to clear out, with a small sponge, what had collected, as occasion 
required. 
We give the account of another trouble, in the author’s own lively 
description, which, fortunately, was avoided in the present instance. 
“ But an accident of much more gravity, and which placed me in a 
very critical position, presented itself at a moment, when, after having 
detached from the forehead the Hap of integument, I was about to bring 
it down into the place it was destined to occupy. Previous to making 
this twist of the new flap, it was thought necessary, as I have before 
stated, to prolong the incision on the left side as far as the medium line 
of the root of the nose, in order to facilitate the torsion of the pedicle ; 
the patient experienced, at this moment, such a violent pain by the 
inevitable division which it was necessary to make of some of the rami- 
fications of the frontal branch of the ophthalmic nerve of Willis, that 
he escaped from the hands of the assistants, rushed towards the door, 
and was determined not to undergo the remaining part of the operation. 
At this moment, the physiognomy of L. presented a most frightful as- 
pect ; his forehead covered by a large wound, the borders of which, re- 
tracted by pain, had greaily augmented its extent, and all the rest of the 
face, his neck, and garments, inundated with blood. But a sight which 
was much more horrible to behold was the flap of palpitating integuments, 
which at every moment were jerked from one side of the face to the 
other.” 
In the present instance, no particular suffering was observed by the 
extension of the incision down between the eyebrows; and in case of 
any difficulty of this kind, the complete command in which the patient 
was held, from the position adopted, would have prevented any of the 
evils complained of by M. Lnbat. 
One of the greatest difficulties of the operation, and that which, in 
its consummation, occupied the most time, was the passing of the pins 
which were to close the wound in the forehead, and to confine the new 
nose in its situation. To remedy this as much as possible, the pins to be 
employed, which were the long pins, generally used by naturalists, were 
previously sharpened ; and for introducing them, a little instrument was 
constructed, somewhat similar to the aneurismal forceps of Dr. Physick, 
made with a small groove to receive the head and upper third of the 
shaft of tfie pin. With this instrument the pins were readily seized, 
and pushed through the skin, and the ligature being applied, their ends 
were cut off by the scissors or cutting pliers. Rhinoplastic Operation. 
78 
At that part of the flap which was to simulate the alae of the nose, 
as it was necessary that the integuments should be directed inwards, 
the pins, of course, could not be used, and here a plan recommended by 
M. Labat was adopted, which was followed by partial success. A 
thread being passed first through the integument ol the face, and then 
through the flap, at about two lines distant from their edges, the ligature 
was so tied as to produce, as it were, a fold at that point ; and the bet- 
ter to effect this object, a small piece of adhesive plaister, rolled up into 
the form of a cylinder, was confined under the threads, so as to make a 
strong compression on the wound and to force the edges into their places. 
This succeeded completely on one side ; on the other, however, the 
union, at first, was not so entire, the skin adhering only by about hall its 
thickness. 
During the whole of the treatment, it was necessary to keep the open- 
ings of the nostrils distended by small tubes. The substance which 
seemed to answer the best for this purpose, was a portion of the barrel 
of a quill ; the end which was to remain in the nose, being stopped up 
with a little melted sealing wax, and a small aperture cut in the side 
through which the air could freely pass. These were ingeniously con- 
structed by the patient himself, who, after a time, was able to manage 
them without difficulty. The tendency to contraction at these points 
was very great, so that at one period, the tubes being left out during the 
night, it required considerable force to replace them. 
From the new nose being formed entirely of skin, it will perhaps be 
supposed, that the integuments composing it are flaccid, and the form 
of it easily destroyed. This, however, from reasons easily appreciable, 
is not the case. The integuments of the scalp being naturally of great 
thickness, by the suppuration which took place from the inner side were 
made to assume a firmness almost similar to fibro-cartilage; and at the 
root of the nose, the internal surfaces coming in contact, contracted ad- 
hesions so as to make the nose perfectly solid at that part. The size, 
also, of the colurnna, which doubled upon itself and contracting deep 
adhesions during the inflammation which took place, forms a round and 
solid pillar to support the tip of the nose. 
Great precautions had been taken to guard against exposure to the 
cold, which, by stopping the circulation, might at once defeat the whole 
object of the operation. As soon, however, as adhesion had taken 
place, it was perceived that no danger from this source was to be appre- 
hended ; and although during the winter he has slept in a room in which 
water has frequently frozen, and has been since repeatedly exposed 
during some of the coldest days, he finds that the temperature of the 
organ is never greatly diminished. 
"The cicatrization of the wound in the forehead was greatly retarded 
by the cold weather, and less than half the time would have been re- 
quired, had the operation been performed during a warmer season ; when 
it had diminished to a small size, and cicatrization, as frequently is the 
case in the filling up of large wounds, seemed to have been arrested, great 
benefit was found from the use of an ointment composed of six drops of 
creosote to an oz. of simple ointment. On the application of this to Large Doses of Calomel. 
79 
the wound, the effects were at once apparent. A small pellicle formed 
over its whole surface, which was shortly replaced by a firm, consistent 
cicatrix. 
In one or two cases operated upon by Dieffenbach, much swelling 
took place in the new formed nose the day after the operation, arising 
from the difficulty of the blood, which had entered by the arteries, being 
conducted off by the veins. In one case the nose became so enormous- 
ly distended, that it was feared the adhesions would be entirely destroy- 
ed, and it was only by the repeated application of leeches, 70 or 80 be- 
ing employed in the course of 48 hours, that this danger was finally 
avoided. In the present case, from the extension given to the incision 
on the left side, care being taken that traction should not be made too 
forcibly on the part, so as to compress the pedicle at its base, the circu- 
lation was, from the first, unobstructed. 
In the account of the foregoing case, it has been attempted to bring 
forward some of the most important points which might be of service as a 
guide to future operators ; and if the author has been so fortunate as to 
throw any new light, however small, on the operation, he will feel that 
he has rendered a service to science and to humanity. 
jBoston, March, 1837. J. Mason Warren. 
LARGE DOSES OF CALOMEL. 
To the Editor of the Boston Medical and Surgical Journal. 
Dear Sir—The author of “ Remarks on Itinerants,” in his third num- 
ber, speaking of mercury and its preparations, says he has used it after 
all other remedies had failed, in doses of a teaspoonful heaped up, once 
in six hours, for a week, as a vermifuge. He says his patient was a lit- 
tle girl, five years of age. Now, Sir, I wish to inquire whether calomel 
was the preparation he used, and if so, was the article genuine ? If he 
gave it internally, as is probable from the reading, what effects attended 
its operation besides the expulsion of one hundred and twenty-five 
worms ? In other words, did it, or did it not, produce much impression 
on the system ? 
If, Mr. Editor, you do not deem these interrogatories unimportant, or 
in other respects objectionable, I wish them to be proposed, through the 
Journal, to the author of those remarks. N. 
Vermont, Feb. 1 ‘3th, 1837. 
BOSTON MEDICAL AND SURGICAL JOURNAL. 
BOSTON, MARCH, 8, 1 8 37. 
STATE LUNATIC ASYLUM. 
The following are extracts from the report of the Chairman of the Leg- 
islative Committee on Charitable Institutions, which is a document high-