THE MEDICAL RECCED. 
535 
oiled silk, and served to shape the patch of skin in- 
tended to be raised from the forehead for closing .the 
opening. The pattern was laid upon the forehead, so 
that the patch of skin to be raised should retain its 
connection above and corresponding to the left supraor- 
bitar notch, where it would derive its support directly 
from the branch of the ophthalmic artery emerging 
from the orbit. The pattern was laid on, not vertically, 
but obliquely, so that its long axis inclined to the right 
side at an angle of about forty-five degrees with a hori- 
zontal line. An incision was now carried through 
the entire thickness of the skin around the edge of 
the pattern, and the included patch of skin dissected 
up from the pericranium, except below where it 
was to retain its connection. The dark line, c, a, h, 
Fig. 1, marks the boundary of the patch. A narrow 
strip of skin, covered partly by the eyebrow, interven- 
ing between the patch just raised and the upper and 
inner margin of the opening, was divided across at its 
lower end, c, d, and dissected up to make room for the 
patch. The patch was next brought round edgewise 
from left to right, and applied over the opening, thus 
making a circuit of a little more than a quarter of a cir- 
cle. It was secured in its new place by two pin sutures 
inserted at opposite points near its base, and one at its 
extremity; these were wound with figure of eight 
turns of cotton yarn, and between them fine thread 
sutures were inserted close to each other. The nar- 
row bridge of skin raised to allow the patch to be 
brought into place, was transferred to the bare surface 
upon the forehead from which the patch had been 
dissected up, and was found sufficient to fill it 
up, so that no bare surface was left uncovered. Fine 
sutures were employed to complete this adjustment 
and terminate the operation. Tepid water dressings 
were directed to be kept applied to the parts. The 
subsequent progress was favorable. Primary union took 
place throughout the whole circuit of the transferred 
©rigtnai Communications. 
A CASE OP PLASTIC OPERATION 
PERFORMED FOR THE 
CLOSURE OF AN OPENING IN THE RIGHT SU- 
PERIOR NASAL FOSSA. 
SURGEON TO NEWYORK HOSPITAL AND ST. LUKE'S HOSPITAL. 
By GURDON BUCK, M.D., 
Margaret Kelley, set. 21, native of Ireland, unmar- 
ried, admitted into New York Hospital, March 3d, 
1869. Patient, now in the enjoyment of good health, 
states that about nine years ago, after scarlet fever, a 
dark spot appeared on the upper part of the nose, on 
the right side, and occasioned the opening which still 
exists. Its situation and shape are accurately repre- 
sented in the accompanying figure, taken from a photo- 
graph. It is of an elongated ovoid form, one inch and 
a half in its vertical diameter, and three-quarters of an 
inch in its longest transverse diameter. It opens 
largely into the right nasal fossa, its outer margin ap- 
proaches close to the inner canthus of the right eye. 
The skin at the margin is everywhere supple, and dips 
somewhat into the cavity. The interior surface, as far 
as it is visible, is healthy in appearance. The voice is 
unaffected. The disfigurement occasioned by the 
opening being very conspicuous, patient is naturally 
anxious to have it, if possible, removed. She keeps it 
constantly covered by a patch of adhesive plaster. 
Operation, March sth, under ether. 
The skin at the margin of the opening was every- 
where detached and everted, a process requiring 
extreme care, owing to the thinness of the skin, espe- 
cially at the inner canthus of the eye. An exact pat- 
tern of the shape of the opening was then cut from 
Fig. 3. 
patch, except about one-fifth of its circumfe- 
rence, which bordered on the inner canthus 
of the eye, where union failed in conse- 
quence of the opposite edges of the wound 
becoming inverted. To remedy this defect, 
a second operation was performed April 6th, 
The ununited edges were pared afresh, and 
two pin sutures inserted with special care to 
evert the edges and hold their cut surfaces 
incontact. Additional fine thread sutures 
were also necessary to complete the adjust- 
ment. A perfectly successful result followed 
this operat’on. The transplanted patch in its 
new situation formed a rather conspicuous 536 
THE MEDICAL RECORD. 
bulging ridge, particularly across the upper part of the 
nose, where the twist had taken place. To remedy this 
disfigurement, a third operation was performed on the 
17th April. A prism-shaped slice of skin was excised 
from the summit of the ridge along its entire length, and 
the edges accurately brought into coaptation and secured 
with fine thread sutures inserted close together. This 
operation did well, and accomplished what was in- 
tended, the levelling of the surface, and a great im- 
provement of the appearance of the face. On the 4th 
May, patient was discharged, much gratified with her 
improved condition. (See Fig. 2.) 
Nov. 8. He was again seen by Dr. Roosa. There 
was an abscess in the anterior wall of the meatus, just 
behind the tragus. This was opened, and a considera- 
ble quantity of thick pus evacuated. The meatus was 
as thoroughly as possible cleansed by syringing, and 
the use of pledgets of cotton. 
Nov. 15. The swelling had so far diminished that 
the drum-head could be properly examined. It was 
covered with bits of wax and epidermis, which were 
removed by gentle syringing. The hearing distance 
was twelve inches. A week later Dr. Roosa pronoun- 
ced the patient cured so far as the ear was concerned, 
all signs of irritation having disappeared, no tinnitus 
remaining, and the hearing function being restored to 
its normal condition. A gargle of alum and chlorate 
of potassa was used for his pharyngeal trouble. 
A point of especial interest in this case is its causa- 
tion. As the membrana tympani remained intact 
throughout, as even after the swelling had subsided 
small particles of wax still adhered tenaciously to the 
surface of the drum-head and of the walls of the mea- 
tus, and as no other cause could be assigned for the 
inflammation, we could not avoid the conclusion that 
it was due to the impacted cerumen acting as a foreign 
body. 
Similar cases are very rare. Troltsch does not men- 
tion impacted wax as one of the causes of otitis ex- 
terna, though he says that sometimes it sets up irrita- 
tion in the walls of the canal and the outer surface of 
the membrana tympani, and the translator informs us, 
parenthetically, of a case in which it caused “acute 
inflammation and perforation of the drum ” (page 83, 
2d edition). 
This is the only case of the kind that has occurred 
in this hospital during the two and a half years of its 
existence, during which time about eleven hundred 
and fifty ear cases have been treated. 
New York, No. 46 West 29th street. 
Exports 0f hospitals. 
MANHATTAN EYE AND EAR HOSPITAL. 
A CASE OF ACUTE INFLAMMATION OF THE 
EXTERNAL AUDITORY CANAL, CAUSED 
BY IMPACTED WAX. 
Reported by D. Webster, M.D., 
D. H., aged 28, laborer, presented himself at Dr. 
Roosa’s clinic, at this hospital, Nov. Ist, 1870. Five 
days previously his right ear was attacked with pain, 
tinnitus, and deafness, which symptoms had gradually 
increased up to date. He had slept but little for the 
last two nights, in consequence of the severity of the 
pain. He could hear the ticking of an ordinary watch 
at the distance of only one inch. 
Upon examination we observed a little puffiness of 
mastoid process, some swelling back of the angle of the 
lower jaw and of the walls of the meatus. There was 
also some pharyngitis. Through the aural speculum the 
external meatus was seen to be plugged with hard wax. 
This was removed by carefully syringing the ear with 
warm water. Some pus was found in the canal, and 
at first the membrana tympani was thought to be per- 
forated, but upon more careful examination it was 
found to be intact, though a complete examination of it 
was rendered impossible by the narrowing of the mea- 
tus consequent upon the swelling. 
Politzer’s method for inflating the middle-ear was 
practised, and the patient was directed to fill his ear 
frequently with warm water. 
Nov. 2. He said that the pain was so relieved, that 
he rested well last night, and complained more of a 
sensation o£ soreness than of pain. The tinnitus and 
swelling were undiminished, but the hearing distance 
had risen to ten inches. On using Politzer’s method, 
the patient felt the air enter neither ear, and when this 
was done again with the addition of the vapor of chlo- 
roform, as first practised by Dr. J. S. Front, it was felt 
only in the lefr. He was directed to continue the use 
of warm water. 
HOUSE-SURGEON TO THE HOSPITAL. 
Eeoteios curtr notices of Eooks. 
First Medical and Surgical Report of the Bos- 
ton City Hospital. Edited by J. Nelson Borland, 
Physician; David W. Ciieever, Surgeon. Boston: 
Little, Brown & Co. 1870. Byo., pp. 084. 
On the completion of the fifth year of the establish- 
ment of the Boston City Hospital, the trustees desired 
the medical staff to prepare an enlarged consolidated 
report. The duty of editing it was intrusted to a 
committee consisting of Drs. Borland and Cheever. 
All the departments have been represented, and general, 
medical, and surgical statistical tables have been added. 
The articles contained in this well-printed and bulky 
volume—made unnecessarily thick and unhandy from 
the heavy quality of the paper used—will compare 
favorably with those of the Hospital Reports published 
either at home or abroad. Some of them are of great 
value. The editors have been judicious in their selec- 
tion, and the chief contributors have done their work 
well. The first article is on peri nephritic abscess, by 
Dr. Henry J. Bowditch. Dr. David W. Cheever con- 
tributes Articles 11., IY., VIII., XL, and XIII., re- 
spectively on excisions of joints, on displacement of 
the upper jaw, on reproduction of the tibia, on en- 
cephaloid tumor of tonsil, occlusion of the vagina, and 
a surgical abstract. Article 111., cases of pneumonia, 
is by Dr. J. Nelson Borland. Article Y., treatment of 
acute rheumatism, is contributed by Dr. John G. 
Blake. Article IV., by Dr. Howard F. Damon, is on 
the treatment of skin diseases. A very valuable paper 
on typhoid and typhus fever, by Dr. J. Baxter Upham, 
is Article YII. The two following articles are, an 
Nov. 3. The swollen walls of the meatus had be- 
come more sensitive to the touch, and the pain had re- 
turned. He was treated with the warm aural douche, 
Politzer’s method again used, and the entrance-to the 
meatus stuffed with cotton in order to exclude the cold 
air. 
Nov. 5. The swelling had increased. Dr. Prout, 
who saw the patient for Dr. Roosa, made two incisions 
in the walls of the meatus—one backwards, the other 
upwards. Pus followed the knife in the latter. The 
pain caused by the incisions was immediately relieved 
by the warm.douche (Clarke’s aural douche).