The formation of a new nose or under lip, when either of these has been removed by accident or some previous disease, was first practised in India by Branco, afterwards by Tagliacotius in Italy and Germany, and is now termed the Talicotian or rhino-plastic operation. Tagliacotius used to take a piece of skin off the arm or some other part of the body to make the new feature, upon which But ler has written a humorous stanza, and Addison an amusing paper. It is now performed by taking a piece of the integuments in the vicinity of the feature, from the neck when it is the under lip, and from the forehead when the nose. The latter ope ration is performed in the following manner:—A piece of leather is cut the shape of the nose, and placed upon it, or where the nose should have been; and, if any skin remains, it is removed, and the margins rendered raw by clean incisions; when all bleeding has ceased, the leather is then laid upon the forehead, and traced round either at once with the scalpel or pen and ink; this portion of the skin is then dissected off from its attachment to the oc cipito-frontalis muscle, taking along with it as much cellular substance as possible, and leaving a tolerable point of connection at the root of the nose; it is then gently twisted round, and laid upon whatever remains of a root or dorsum, making it correspond with the surface already ren dered raw for its reception, only a degree larger; and lastly, stitching it with two silk ligatures on each side of the nose, and one at the columna. If the skin to form the new nose has no support in consequence of the columna and cartilaginous sep tum being destroyed, it should be gently supported with dossils of lint inserted in each naris; but if there be enough of septum to prevent the skin hanging or dragging, no foreign body should be in serted, as all source of pressure or irritation ought to be carefully avoided. Whenever adhesion has been effected, the nose should be supported by sil ver tubes. The raw part on the forehead should be approximated with stitches as much as possible, and afterwards healed like any ulcerated surface. Whenever adhesion is perfect, and all irritation and tumefaction have subsided, the little twisted portion of integuments that formed originally the point of connection should be divided, and laid neatly down.
Before performing this operation, the surgeon should be satisfied there is no constitutional affec tion present, and in those cases where the nose has been destroyed by noli me langere, all tendency to this herpetic ulceration ought to have entirely ceased. If a small portion of the skin of the old nose remains, it had better be removed, as it will disfigure the countenance by a contrast of colours.
Suppuration is another termination of inflamma tion. Whenever the inflammatory action is more violent than what is necessary for the capillary ar teries to secrete coagulable lymph, these capil laries, modified and influenced by the nerves, form small suppurative papilla that secrete purulent matter, which theory of action constitutes suppura tion. When this ensues from acute inflammation, and the matter is circumscribed or confined in a sac, the disease is named acute abscess; for we have purulent matter, or a puriform fluid secreted by mucous membranes, which are the most subject to this termination of inflammation. It is also se creted in incised wounds, and in the skin or cutis vera after a scald with boiling water or the appli cation of a blister, In mucous membranes, such as the urethra, the capillaries are naturally endowed with the power of secreting a mucous fluid; and if these vessels are inflamed, they are easily and quickly modified by the nerves, to secrete a puri form fluid, as for example in Gonorrhon, occasion ally twelve hours after infection. In this case the
capillaries do not seem to form suppurative papil lae, as in common suppuration and ulceration. In the cut the capillaries perform the functions of ex halants naturally, so that when stimulated by a blis tcr, they are soon modified by the nerves to perform the function of secreting purulent matter; and if the irritation be kept up by blistering ointment, they soon form suppurative papillae. In incised wounds, the capillaries perform the same office as in ordinary suppuration; small suppurative papilla: being rapidly formed and then pus secreted. In all cases of suppuration there must be a precedence of inflammation, however slight in degree, even in scrofulous tumours or abscesses. All loose tex tures, as the cellular, when attacked with inflamma tion, are more prone to terminate in suppuration than condensed compact structures, because the blood-vessels have greater latitude to form suppura tive or ulcerative papilla.
The symptoms of suppuration are rigors or cold shiverings, which occur at irregular intervals, and are commonly followed by a hot fit and slight in crease of the preceding febrile symptoms, if the in flammation has been extensive; a total quiescence of the pain of the inflammation for a time, which is soon resumed if the hot applications are continued, especially if the suppuration be superficial. In a short while the pain returns, but changed to a dull, heavy, and constant feelings; the tumour becomes conical, with a white or yellow tinge at the apex, while the surrounding inflammatory colour is deep er and the skin more glistening; there is occasion ally more or less of an oedematous feeling, and matter is then distinguishable to the fingers. One of the best examples of an acute abscess, is the ter mination of an inflamed inguinal gland in suppura tion. Whenever the fluctuation of matter is per ceptible in a circumscribed acute abscess, a free incision should be made from the one end of the tumour to the other, with the bistoury; but in an extensive or diffused abscess, the most depending part should be selected to make the aperture. Un less a free incision is made in the circumscribed abscess, the matter is liable to loiter at one of the extremes, and form a sinus or sinuous ulcer or tube, which afterwards requires to be laid open, an event frequently exemplified in the syphilitic ab scess. Some authors recommend that abscesses should be allowed to break of themselves, while others recommend caustic instead of the bistoury, but the knife is preferable, as it inflicts less and more transient pain, makes an aperture proportion ate to the abscess, and prevents the disease making further progress. After the evacuation of the mat ter, poultices should be applied for the first twenty four hours, when the wound ought to be dressed with simple dressings, compress of tow, and a ca lico roller; and in the case of the groin being the seat of the disease, the bandage should encircle the body and the thigh in the figure of the digit 8. The periods of dressing an abscess must depend on the quantity of matter secreted. In ordinary cases, once or twice in twenty-four hours is sufficient.