1850 The Lancet  
in addressing the assembled pupils, remarked that out of the various materials with which noses might be replaced, the patient had chosen his own skin, and that he had thought it right to comply with his request; the more so as he was a favourable subject for the operation, since the destruction of the organ had originally been caused, not by an idiopathic disease, but by a blow. The operation, as far as it had now gone, was only done in the rough; there was a great deal to shape out yet until
more » ... he new organ should be brought to a proper form. Mr. Fergusson observed, that this would be an extremely painful proceeding, were it not for the great boon conferred by chloroform, and that Mr. Liston had performed the same operation soon after the ansestbetic use of ether had been introduced. The patient, seven days after the operation, was attacked by erysipelas; he was delirious at intervals, particularly at night; the eyes and cheeks swelled considerably, and the new nose turned of a dull reddish colour. Still the wound of the forehead went on contracting and granulating nicely. The delirium became soon so violent, that the patient was at one time hardly prevented from tearing off the new nose; it was therefore found necessary to use the straight jacket, and to give him a male watcher. He, however, became gradually quieter, and about eighteen days after the operation he was more calm, dozing almost incessantly; his face assumed a more natural and sane expression, but when spoken to he gave no answer, and appeared to be deaf. The treatment of the erysipelas and violent symptoms consisted principally in stimulants, as chloric ether and ammonia, opium, wine, &c. The nose, however, and the forehead, were looking very well; the latter was fast cicatrizing, and the former seemed to have adhered firmly, especially at the root. The opening into the frontal sinus above mentioned remains patent, and seems not disposed to fill up. Twenty-two days after the operation the patient was removed into the physicians' ward, where, after having given a great deal of trouble with delirium tremens, he is now progressing very favourably. We had a few days ago an opportunity of seeing this patient, and were highly gratified at observing the firm manner in which the transplanted flap had grown to its new situation. The nose, though in an unfinished state, looks remarkably well, the man having of course quite a different physiognomy. If it were not for the falling-in of the incisive portion of the upper jaw, the patient would certainly not have to complain of his looks. It would thus appear that the rhinoplastic operation has in this case endangered the patient's life; and though erysipelas had a great share in these hazardous results, it cannot be denied that this apparently slight operation is not exempt from danger; neither are the statistics encouraging. Out of two patients, Blandin almost lost one; Lisfranc had one death; and Dieffenbach has recorded two fatal cases out of six. The Italian method, where the flap is taken from the arm, would primd facie seem less liable to the complications mentioned above; but it is so inconvenient that it has been very justly abandoned. The French method, introduced by Larrey, in which the cheeks furnish the materials, has advantages in some cases, but is likewise liable to accidents. (We had recently an opportunity of witnessing the latter method applied at St. Bartholomew's Hospital by Alr. Lloyd; we shall lay the case before our readers when the patient's progress has been a sufficient time under observation.) We look forward with great interest to the further operations Mr. Fergusson may judge proper to perform upon this patient-viz., whether he will form a septum from the upper lip, as proposed by Liston, or remedy the falling-in of the apex by the method he has himself followed with success in a former case-viz., by bringing the cheeks more in the mesial line, and giving, as it were, a new foundation to the nose; though perhaps a newly-made organ will not be so favourable to this mode of operation as to the plan proposed by Liston. CHARING-CROSS HOSPITAL. Ossific Tumour in the Ischiatic Region. (Under the care of Mr. HANCOCK.) It is very interesting to remark what various results trifling blows or falls will have upon different individuals. Not the least extraordinary consequence of slight violence is the formation of ossific tumours; not exactly true exostosis, but deposits of bone in swellings, the effect of a certain amount of contusion in different parts of the frame. Every one recollects the boy so frequently mentioned by Abernethy in his lectures, with whom a trifling blow on any part of the body would invariably lead to the production of an exostosis; and this disposition to form bony tumours was not confined entirely to the skeleton, for after a blow on the muscles, a sort of osseous deposit would take place in them; in fact, as we are told by Mr. Samuel Cooper, the margins of the axillae had become ossified; the great pectoral muscle, and the latissimus dorsi, were both turned into bone at their edges, so that the patient was completely pinioned. Though Mr. Hancock's patient, as will be seen by the sequel, has not so marked a tendency to ossific formation, she affords a good example of this peculiar propensity. It would appear that the subject of this case, a woman about forty years of age, had, three years ago, a fall backwards, while lifting a pail, which brought her to the ground with some violence in a sitting posture. The patient heard a snap in the ischiatic region at the time of the accident, and soon afterwards she perceived a tumour, the size of a marble, in the situation of the ischium. This had gradually increased to the present time, was now about the bulk of a large orange, and could be felt under the glutscus maximus. For the last six weeks she had experienced a great deal of pain after standing for a while, the suffering was soon increased when she sat down, and, latterly, she could not assume the sitting posture unless she used a pillow to diminish the pain which she was undergoing. On examination, there was observed a hard, irregular tumour, the size of an orange, as stated above, the attachments of which seemed to be to the inner surface of the ischium, commencing at its tuberosity, and extending for a short distance along the ramus of the same bone. Acute lancinating pains were excited on pressing the integuments against the inner surface of the tumour. On the 13th of March, Mr. Hancock proceeded to the extirpation of this tumour at the patient's urgent request; she was placed under the influence of chloroform (very effectually by means of a simple piece of lint moistened with chloroform, and lightly held over the face, as is usual in this hospital), and after a longitudinal incision over the glutseus muscle and a little dissection, the tumour was removed. The exact situation of the latter was found to be internally to the biceps and posteriorly to the triceps muscles, very near to the tuberosity of the ischium. When a section of the tumour was made, the external portion was seen to be formed of loose fatty tissue; but the greater and internal portion was cornposed of ossific deposit, radiating in various directions, forming innumerable osseous needles intersecting each other. Mr. Hancock, in giving to the pupils assembled in the theatre a sketch of the case, stated that he suspected that the growth of this tumour had been connected with a rupture of the biceps; before the operation there had been a doubt whether the tumour was encysted, or connected with a bursa, or whether it was an osseous growth from the ischium. It was well known, added Mr. Hancock, that foxhunters are apt in leaping to meet with a sudden rupture of the adductor longus; a tumour was the result of such a rupture in a case under Mr. Hancock's care in private practice; this growth created no inconvenience, except in riding, when the adduetors were of course compressed; but in the present case the tumour was situated so near the ischium, that sitting became almost impossible, and pain very excruciating from pressure on the sciatic nerve. I This patient has since progressed remarkably well, and is on the point of leaving the hospital. ST. THOMAS'S HOSPITAL Large Inguinal Hernia. (Under the care of Mr. SOUTH.) M. Amussat, a clever surgeon of Paris, strongly advocates forced taxis in strangulated hernia; his mode of procedure consists in placing the patient on a hard mattress, and in applying continuous pressure in the right direction on the sac. As one person could not endure the fatigue of constantly pressing upon the tumour, assistants relieve each other, and it has happened, in favourable cases, that this method was followed by successful results. It cannot, however, be denied, that this rather violent way of effecting reduction is not exempt from danger; and we have to report a case of hernia with enormous protrusion, lately under the care of Mr. South, which shows, in a very clear manner, that continued and per-
doi:10.1016/s0140-6736(02)89130-9 fatcat:azs34o7s7fhsjbo2hmudwwoy7a