glorious womanhood of our decaying country to answer to the call for motherhood; calling on her to deny herself personal freedom, yea, to sacrifice her life, if need be, on the altar of maternity, that posterity may be perpetuated in endless variety. No consideration is taken of the consequences following. No heed is paid to the cries of distress and suffering of the numberless hordes born to homes of poverty and crime. No mercy is shown to the aching heart of the mother whose maternal love must suffer the distress of creating deformed and helpless children. No account is take of the blight brought on society by the ruthful propagation of the defective citizens. Where is the voice of justice; where is the spirit of honor? Oh, sentiment where is thy sense of reasoning? When it becomes a question between sentiment and honor, honor will prevail! Finally the most clinching argument lies in the fact that already the intelligent and better classes of our people are voluntarily practicing artificial limitation. Progress is inevitable in any society that is alive and striving. Elementary ideas starting many generations before, continue to develop larger and larger until they become a fixed practice in the lives of the people. Such is the case with the growth of family limitation. Little by little the truths of science reveal the nature of life and the higher ethics until now by common consent this regulation is becoming the rule of practice.

This being true, society should demand the repeal of the Federal law that brands as immoral and criminal the giving of any information in the method of preventing conception. If our profession accepts this view of the situation they should address themselves to creating the public sentiment that will insure this repeal, and to this end I present these few remarks.

The Rockefeller Institute has announced a new method of treatment for tetanus, and patents to the invention of a special apparatus used in the treatment have been thrown open. Most of the deaths among wounded soldiers are due to the tetanus germ, which thrives in the highly cultivated soil of Europe, and the disease is almost invariably fatal. Dr. F. J. Meltszer, who has been given the credit of the new method, found that an injection of a solution of Epsom salts into the membrane of the spinal cord produces a relaxation of the muscles for several hours, and gives time for other medicine to take effect.

DACTYLOCOSTAL (OSSEOUS AND CARTILAGINOUS) RHINOPLASTY.*

EDWARD G. BLAIR, M. D., Kansas City, Mo.

The term rhinoplasty is here used in its most comprehensive sense and includes restoration from the three gross deformities that are common in the nose: first, entire absence of any external nasal tissue and septum; second, preservation of the skin and cartilages covering the nose but collapsed from the entire loss of septum and columna; and, third, from loss of upper lateral cartilages and partial loss of the septal cartilage and nasal bones - the very common "saddle nose." The procedures which are here offered for the correction of these deformities are to some considerable extent susceptible to interchange under modification and the methods applicable to all the minor defects in the nose.

In the correction of the condition where entire loss of nose exists, these essentials must be attained: an integument, practically free from scar, covering the half of a pyramid diagonally sectioned and projected from the face, with two openings in its base for nostrils and with septum. If these features exist, it is surprising how little or how much passes for a nose. It is unnecessary to refer to the ancient methods of the French, Italian, and Hindu schools except to say that none of those operators produced even the first requisite.

In 1886, beginning with Keonig, the German surgeons began the use of osteoperiostitic flaps for projection, but these were lacking in the other essentials and for the most part were unwieldy.

The methods here presented for the total absence of a nose embraces the use of a finger, out of which the essentials are first constructed before attachment to the face. The ring finger of the left hand is selected, split throughout its entire length on the anterior surface, and cross-sectioned at the proximal flexion through the tendons down to the bone. The skin and subcutaneous tissue of one side is laterally dissected well around to the dorsum; a similar dissection of the other side carries with it all the tendinous tissue, leaving the front of the phalanges bare of soft tissue and the finger trebled in dorsal width, to maintain which the margins are sutured to a plate of celluloid applied on the back. The distal joint is excised for ankylosis. To further maintain this width and furnish the foundation

*Presented before the Medical Society of the Missouri Valley, March 27, 1914; and before the Jackson County (Mo.) Medical Society, April 28. 1914, with exhibition of cases. Text and illustrations from "Surgery, Gynecology and Obstetrics," Chicago, December, 1914.

of the septum, a flap of skin and subcutaneous tissue is turned back from the chest wall, as was done by Baldwin,† larger in dimensions than the split surface of the finger, and left attached; up to this attachment the opening is immediately sutured. The finger is now brought into contact with the chest flap, raw surfaces together and sutured at the margins. This position is kept for one week by adhesive slings, at the end of which time section of the flap from the chest is made under local anestheia, and its amalgamation with the widened finger is allowed to grow to the state of perfection. When this is reached, the half of the finger carrying the tendons is again split from the margin to and beyond. the median line throughout it length in a flat plane and beneath the tendons. This flap then is flatly turned over on its other half as the leaf of a book, exposing the double raw surface, over which one Thiersch skin-graft is immediately applied. When this has healed, a free comb of tissue projects from the middle of the finger-made up on one side of chest-wall flap, on the other of Thiersch graft with tendinous and subcutaneous tissue in between.

As soon as these newly fashioned tissues become pliable, and before too much shrinkage occurs, the finger is applied to the face in the following manner: The margin of the facial opening is incised throughout its entire circumference well inside the nasal

Fig. 2. A, rib-cartilage; B, rib; C, silver wire anchorage into jaws of split finger; D, chest-wall integument.

+ Surg., Gynec. and Obst., 1912, xv, 720.

cheeks is freely lifted with a periosteal elevator and is carried well up to the frontal bone above. A small flap is now turned cavity. The contiguous soft tissue on the up from the floor of the nasal cavity and left attached at the median line: a similar flap is sought in any available tissue inside the cavity above. In the finger, the nail. and dorsal tissues are removed back to the distal knuckle and the bone made bare; the margins are freshened by turning a small Lane flap from above downwards as far in length as the middle knuckle, the flaps slipped under raw edges of the facial tissue with the integumental surface toward the nostril. Similarly freshened margins are made on the finger comb to be attached to the nasal flaps above and below. The bare unguinal phalanx is now passed under the edges of the soft tissues above and anchored

B

Fig. 3. A, complete nasal integument; B, flap turned from inside nose; C, flap turned up from floor of nasal cavity; D, dorsal flap of skin turned down from finger: E, bone of finger; F, granulating surfaces unexposed.

by a suture passed through them and the phalanx and tied over a piece of gum tubing. The marginal face and finger tissues are sutured with simple interrupted sutures of silk. A cross-section of these assembled tissues is seen in Fig. 1.

The finger is held in contact with the face as illustrated in a plaster cast. The length of time it should be kept so is not determined by days, but, after five days, by tourniqueting the finger with a small rubber band, shutting the blood supply from the hand, and observing the circulation from the face. The opinion is now well established that this procedure done each day for from fifteen to thirty minutes under inspection stimulates the establishment of the facio-finger circulation and reduces the length of time in the cast. In the original case amputation was made in nineteen days; but it was recognized that it could have been separated in fourteen. Another physiological observation worthy of note is that at the end of ten days the patient voluntarily said, "My finger down to there (meaning the middle knuckle) feels like my nose, the rest of it like my finger." When the circu

Group 1 is a case in which there is an entire absence of a nose (Photograph 1), even to the extent of partial destruction of the nasal bones and vomer with marked retraction of the contiguous tissue of the face into the nasal opening, a condition doubtless due to hereditary syphilis. Our procedure was to supply this defect by splitting the two distal phalanges of the ring finger and suturing them to a celluloid plate applied to the dorsum (Photograph 2), then applying this to a flap of skin turned back from the chest-wall (Photograph 3), and after seven days detaching; subsequently splitting this tissue thus obtained longitudinally to the middle of the finger, turning this over and applying a large Thiersch skin-graft, thus making a comb of soft tissue, the beginning of a septum (Photograph 4); then removing the nail, the distal joint already having been stiffened, and suturing the finger to the freshened edges of the facial tissue, holding it in place by a fixed plaster cast (Photograph 5). After nineteen days amputation of the finger from the hand was performed; the proximal phalanx was split and set into the superior maxillary bone at right angle to the portion sutured to the face to form the base of the nose. Through slits of the split phalanx rubber tubes were inserted to maintain the nostrils

lation is thoroughly established from the face, amputation is done at the metacarpophalangeal articulation, and the projecting phalanx is reflexed backward so that the middle articulation can be removed with a rongeur to ease the tension in the dorsal tissues and prevent the ischemia resulting from extreme flexion of this phalanx when it is set into the tissues covering the superior maxilla to secure projection. Before this is done the soft tissues of the phalanx are slit on each side close to the bone and carried to the face for suturing. The middle portion is set into a transverse incision made into the maxillary tissues down to bone and sutured in place. Freshened edges of the septal tissue are made and brought into contact as the flexion is made. There are now no raw surfaces exposed except the margins of the slits, and into these gum tubes are placed to allow for healing and formation of the nostrils.

If for any reason there is insufficient pro

Photograph 3.

(Photograph 6). Through a failure to observe properly the interference to the circulation brought about by this angular flexion of the knuckle most of the proximal phalanx sloughed. leaving a fair nose, as indicated in Photograph 7, with small contracted nostrils which might be considered a reasonably satisfactory result, but which was not satisfactory to us. who hoped for something better. To correct this deficiency. then, on November 7, 1913, the end of a cartilage of a rib was turned up and sutured to the split first phalanx of the middle finger. After ten days one and one-half inches of this rib and cartilage with thoracic skin and muscle covering was detached and allowed to thoroughly establish a circulation from the finger, as shown in Photograph 8; subsequently, the nose already obtained was split longitudinally and the wings turned back, exposing the bone of our former finger; over this then was superimposed the rib still carried by the finger and sutured to the wings which had been turned back. Ten days later the rib was amputated from the finger and the finger restored, the rib having splendid circulation supplied by its attachment to facial tissues. Photograph 9 shows result of rib-grafting. Febraary 16, 1914, after section from finger.

jection, or if from contraction more tissue is desired, the following plan may be utilized successfully: A flap of chest wall is again used similar in shape to that used. before, but made over a rib including its cartilage and all the tissues down to the pleura; the cartilage of the rib is sectioned and the free end in the flap turned up. The soft tissues of the middle finger of the left hand are now split in a flat plane anterior to the bony phalanx back to the distal flexion. Into the jaws of this incision the projecting rib cartilage is set and anchored by a silver wire inserted along one side of the nail inward and through the cartilage and out again on the other side, the ends being twisted over a piece of tubing placed over the nail. The skin of the upper jaw of the finger is sutured to the free end of the skin of the chest wall, and contact of the lower finger flap is made by the introduction of packing introduced to elevate the rib and prevent its reunion. After ten days, section

The

of the rib-flap was completed one and onehalf inches away from the point of finger contact. In this way the finger was made the carrier of chest wall, including skin, rib hand cartilage (Fig. 2), one and onehalf inches in length by one inch in width. This union was continued with the hand free on a simple splint until the vitalization and formation of the graft was what was desired. Three weeks' time was given to this, with only slight shrinkage. former finger nose was then split in the median line from a point above desired to the tip, down to the bone, and the nasal covering dissected off laterally, making two wings of soft tissue-former dorsum of the finger. Perfectly healthy bone and septum were revealed, but were somewhat retracted. The margins of the chest-wall graft were freshened, as were those of the widened finger, and this tissue was superim

posed on the exposed bone, with which its freshened, granulating under surface was brought into contact. Anchoring facial suturing and maintenance was the same as before. On the tenth day the finger tourniquet indicated the feasibility of sectioning the finger from the graft, which was done, leaving a vital rib implanted with chestwall skin, growing, a fixed part of the nose. The small fragment of cartilage left in the finger was removed and the finger restored.

When, in the case of a collapsed nose, a finger is used, as was done by Finney*, a primary plastic sectioning is done for the construction of the septum. Starting well over to the left side of the nasal covering a flap is dissected off on the inside of mucous membrane, with some effort to include portions of cartilage, and the dissection is carried well over to a point opposite and left

*Surg., Gynec. & Obst. 1907, v. 23.