LARYNGEAL DIPHTHERIA. TWO SUCCESSFUL CASES OF TRACHEOTOMY IN THE SAME FAMILY

G STEVENS
1889 The Lancet  
IN an inaugural dissertation published by Dr. Hahn of the Kiel University,l a detailed account having been given of a number of plastic operations from my clinique, in which Wolfe's method2 of transplanting skin-flaps from distant ,parts without pedicles had been employed, it may be ot some interest to the readers of THE LANCET to have my views as to the merits of that operation. Hahn reports thirteen cases in which skin defects had been supplied, mostly with satisfactory results, by Wolfe's
more » ... ults, by Wolfe's method of transplantation. These defects were the result in three cases of the existence of cancer of the face, in one of extirpation of nevus pigmentosus, and in four of rhinoplasty from the forehead. Wolfe's flap was in three cases -taken directly for the purpose of partial rhinoplasty, and in two others for the formation of eyelids. The defects varied -from 1 cm. to 5 cm. in diameter. Adhesion of the flaps took place in from five to ten days. Some entirely healed at once, and the transplanted flaps differed from the neighbouring skin only in retaining for some time a paler colour. In most cases there were exfoliation of the cuticle and necrosis of small spots of dermis, but without in the least prejudicing the successful result of the operation. Entire failure only resulted in one case, in which there existed the most unfavourable condition of the patient's skin. The following cases may serve as examples of the operations on the face. Fig. 1 represents a case of cancer rodens of the nose in a FIG. 1. FIG. 2. young girl seventeen years of age. The right wing of the nose was destroyed, and the nostril almost closed, being only kept open by a drain. By two arched incisions the cicatricial tissue was removed, and the defect covered by a .skin-flap from the upper arm. In six days adhesion was perfect. Fig. 2 shows another case of cancer rodens. MadameK——, , wife of a lieutenant-colonel, was first attacked in 1876, and for seven years recurring attacks caused most excruciating pain. Various surgeons were applied to, and all sorts of means (homoeopathic included) adopted without avail. I resolved in 1883, by which time the bridge of the nose was almost entirely covered with cancer, to remove the diseased tissue, and to cover with a flap from the left arm. The flap united perfectly in ten days, and since then there has been 'no return of the disease. Fig. 3 illustrates the following case. G-, five years of .age, daughter of a landed proprietor, was very much disfigured by a nævus pigmentosus. Attempts had been made to remove the nævus in three sittings, but it returned. In 1884 I removed the whole nsevus, and covered one-half of the place with a flap from the left arm, and the other with a flap from the forearm. Within seven days adhesion had taken place, and in about three weeks the appearance of the laps was normal. The advantages of transplantation by Wolfe's method are 1 Ueber Transplantation ungestielter Hautlappen nach Wolfe mit Berüchsichtigung der ubrigen Methoden. Kiel, 1888. 2 Wolfe: Diseases and Injuries of the Eye, p. 417. Churchill, 1881. the following. 1. His method enables us at once and completely to cover fresh wounds. 2. We can replace skin with cicatricial tissue by true skin, which offers greater resistance to external deleterious effects. 3. It gives better cosmetic results than any other method of transplantation, and this is specially important in operations on the face. The only disadvantage which this method has is that the flap is liable FIG. 3. to subsequent shrinking, but this can be obviated by making it larger than is necessary, so as to provide for the shrinkage. Wolfe's method is peculiarly applicable to plastic operations, and cases in which we have to deal with large wounded surfaces in the face, incapable of being closed with sutures. In such cases it is to be preferred to any other method. ON Oct. 29th, 1888, Master H-, aged fifteen years, the eldest child of a family of four boys, was brought to me in the following condition. His nostrils were red, raw-looking, and slightly scabby at the margins, and the submental glands were enlarged. The lad looked pale, and had chronically enlarged tonsils. On Nov. 8th the next boy, Noel, nine years of age, was ill of sore throat and slight peevishness. His tonsils presented a few yellowish-white soft spots. Improvement soon followed appropriate treatment, but some unusual pallor remained. On the 10th of the same month, the next younger boy, Frederick, aged three years and a half, had a similar illness. The pharyngeal signs soon cleared up, but eventually the child developed croupy symptoms. On Nov. 15th, the youngest boy, Harry, aged a year and ten months, a finely grown fat child, fell ill. He likewise had soft yellowish-white spots on the tonsils. On the 17th the pharynx in this case appeared free, and the child was apparently pretty well. I therefore discontinued visiting, but enjoined the mother to examine the children's throats daily, and to report to me at once if croupy cough came on. Accordingly, on Nov. 20th I was sent for, as the baby (Harry) had a croupy cough. The pharynx remained clear of deposit or membrane. I now asked Dr. Langton Hewer of Brownswood Park to see the child, and later in the day, at about 9.30 P.M., with his very kind and cordial assistance, I opened the trachea. Needless to say, the breathing had assumed a dangerous and suffocative type before the operation. The tissues were incised in a deliberate manner, and hardly any blood was lost. A Hilton's silver tube was used at first, and red rubber ones after about two days. The operation afforded complete relief, and some hours' sleep followed. Membrane and dirty sticky fluid were ejected,
doi:10.1016/s0140-6736(01)91312-1 fatcat:uixkyboxura4zbinqr47vtccs4