THE BIRMINGHAM MEDICAL REVIEW. DECEMBER, 1888. ORIGINAL COMMUNICATIONS. ON THE VALUE OF PLASTIC METHODS AND THEIR PLACE IN SURGERY.* BY SIR WILLIAM MACCORMAC, M. A., F.R.C.S., PLASTIC Surgery may be defined as that branch of our art which attempts to remedy some deformity, or to restore, as well as may be, some lost function or portion of the body, chiefly by transplantation or implantation of tissue taken either from some near or distant part or from the body of another person. Dieffenbach, in an introduction to the work of Zeis on Plastic Surgery, published in 1838, just fifty years ago, states: "I regard it as unnecessary to say anything in praise of that section of surgery which has for its object the restoration of bodily defects. It is one of the highest achievements in the whole domain of surgery." "Er ist die hochste Bluthe der ganzen Chirurgie." Thus wrote one who had himself done much to perfect plastic surgery; and his words may well serve as an excuse, if an apology be needed, for bringing this subject to your notice. Many great surgeons have developed or shown great interest in this branch of our profession. Taliacotius, whom we know as the father of the art in Italy, enjoyed in his day the highest * Paper read before the Midland Medical Society, Nov. 14th, 1888. Q consideration, In Germany we may mention the names of Von Anmon, Graefe, Dieffenbach, Langenbeck, Blasius, Rust, Textor, Beck, Benedict, Bunger, Chelius, Dzondi, Fricke, Heidenreich, Reiner, V. Walter, and Zeis; in France those of Blandins, Delpech, Lisfranc, Jobert, Malgaigne, Percy, and finally Dupuytren, who, during the last years of his life, restored many lost noses. In England, Carpue, Tyrrel, Liston, Ferguson, Syme, as well as many others, paid much attention to plastic surgery. The subject is as wide as it is interesting, and I can only discuss a very limited portion of it. I do not propose to refer to congenital so much as to cases of accidental defect, and more particularly to the method of rectifying these defects by means of transplanted portions of skin. We cannot, as a rule, remedy defects in the more complex structures of the body; we cannot restore the continuity of a divided muscle, an artery, or a vein; no organ can be restored. We cannot replace a lost eye, although the attempt has been made, but the cornea of a rabbit has been transplanted into the opaque cornea of a man, in the hope of forming a window for the otherwise sound eye to see through. Lost portions of the eyelids, of the cheeks, of the nose, the lip, or the ear can be made good. We may also close abnormal openings. We can remedy the deformity following after burn or accidental injury. The common practice amongst barbarous and semi-barbarous nations of cutting off the nose as a punishment seems to have given the earliest stimulus to one branch of plastic surgery, and the frequency of this form of mutilation in India gives the descriptive name of "Indian operation" to one form of rhinoplasty. The Kooma caste, a sort of inferior Brahminical priests, seems to have had the monopoly of the operation, and to have practised it from remote ages. Galen mentions that the Egyptian priests used to manufacture noses for those who had lost their own. In Sicily, at the end of the fourteenth century, Branca seems to have known the art, as it is written of him, "Si tibi nasum restitui vis ad me veni." The MS. recording the fact is in the Dominican Library at Palermo, and the art was continued with the members of his family for a lengthened period. They practised it in a small Neapolitan town, the method they employed appearing to be the use of a flap taken from some poor person. Caspar Taliacozzi was born in Bologna in 1546. He was a most distinguished Professor of Anatomy and Medicine in the university of that town, which, as you know, has lately celebrated its eighth centenary. To him is certainly due the scientific practice of rhinoplasty, and his manner of operating has, since that time, been called the "Italian method." In 1597 his work "De Chirurgia Curtorum per Insitionem" was published in Venice, and he died shortly after, in 1599, having enjoyed an immense repute during his life. Taliacozzi claims to be the first to use flaps of skin taken from a distant part of the body, but Franco and others had already done the same. In the works of Fabricius Hildanus we find that Griffon, a surgeon of Lausanne, restored a lost nose in 1592 by means of a flap of skin taken from the arm. The case was that of a girl, who is said to have cut off her nose to spite some soldiers of the Duke of Savoy whose attentions were too pressing. She was a pretty, modest maiden, and sought thus to escape their blandishments. Griffon's operation was so successful that the new nose, it is stated, was almost perfect. Griffon is said to have learnt Taliacozzi's method, for this surgeon's work was as yet unpublished, from an Italian travelling north. Taliacozzi recommended that a part of the patient's body, and not that of another person, should be used. The many stories afloat are based on the supposition that the new nose formed by skin taken from some one else retains, in some mysterious way, a sympathetic connection with its former possessor. The reference in Butler's Hudibras is founded on this belief. Van Helmont (1682) and others mention, on the authority of eye-witnesses, the mortification of the new nose coincidently with the death of the person who had furnished the material to form it. Edmund About's story of "The Notary's Nose" rests upon the same assumption. He tells amusingly how a sturdy Alsatian of no very regular habits supplied the needful amount of skin to reproduce the nose of a handsome notary, which had been sliced off in a duel, when it was immediately devoured by a dog standing by. In duels amongst the German students, by the way, the presence of dogs is strictly forbidden. The Alsatian got a round sum down and an allowance, upon which he lived so exceedingly well that, by-and-by, grog-blossoms appeared on the notary's nose. The horrified lawyer searched Paris for the man, to remonstrate at his conduct, and finally stopped his allowance. The grog-blossoms soon disappeared, but after an interval, the notary's nose was seen to dwindle, and finally it came to nothing, when it was discovered the Alsatian had just died of starvation, in consequence of the deprivation of his allowance. Thus matters stood until the end of the last century and the beginning of this, when news came from India that noses cut off as a punishment by the Indian princes were restored by native operators, and the relation of the case of a pariah thus operated upon, Cowasjee by name, is to be found in the Gentleman's Magazine, 1794. The English Consul in Poonah sent 400 miles for the man who, it was said, was the only operator in India at that time, and in whose family the business was, it appeared, hereditary. Two English surgeons of the Bombay Presidency were present, and the operation, as related by them, is much the same in detail as that of the Indian operation now practised. A model in wax is first taken which exactly represents the form of the lost portion of nose. This is then flattened out upon the forehead, and a line is drawn around it at a little distance from the margin. The shape and size of the flap are thus indicated. It is dissected up, leaving it attached by a pedicle between the eyebrows. The nasal stump is refreshed, the flap turned round and adjusted in its new position. Sutures were not introduced, but bandages and an earth-dressing applied. "Ghee" was also used as an application, and tents of On the twenty charpie were inserted to keep the nostrils open. fifth day the twisted pedicle attaching the nose to the forehead was cut through. There is, however, another plan attributed to the Indians, which consists in removing a large piece of skin from the buttock and applying it bodily to the nose after paring the stump. Bunger states that such efforts have proved successful. In 1803 Lynn performed the operation in England, but with out success. Carpue, in 1814, successfully operated on an officer who had lost his nose through syphilis, and a year afterwards he operated on Lieut. Latham, whose nose was sliced off by a sword-cut at Albuera, in Spain, while rescuing the colours of his regiment from the enemy. Carpue closely followed the Indian method, with great success in both cases.* Gräfe, in 1816, about the same time that Carpue published his cases, operated by the Indian plan on a soldier whose nose had been cut off by a sabre, but later on Gräfe adopted the Italian method, modifying Taliacozzi's plan in so far as to apply the flap dissected from the arm immediately to the nose, in place of allowing an interval to elapse as the Italian surgeon did, a modification which, in the opinion of many, was no improvement. † In Munich, Reiner, 1817, almost at the same time performed Indian rhinoplasty with complete success. A case of rhinoplasty is mentioned by Sir Gilbert Blane as being performed by Hutchinson in 1818. Davies restored a nose and upper lip in 1823. Very few other cases seem to have been either performed or recorded, except, perhaps, Syme's operation for filling a hole in the ala of the nose by transplantation of skin (Edinburgh Journal, 1835). Thus we may say was rhinoplasty, and with it plastic surgery in general, introduced in recent times to the notice of surgeons. "Potiora enim sunt, quæ necessaria, post hac quæ utilia, *"Two Successful Operations for Restoring the Lost Nose from the Integuments of the Forehead." (London: C. J. Carpue. 1816.) † C. F. Gräfe," Rhinoplastik," 6, Kupfer tafeln, Berlin. 1818. |