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 ■c) SKw,W^-«-^- 
 
 C\-].4- 
 
 A SECOND SERIES 
 
 OP 
 
 
 CASES OF SKIN TRANSPLANTATION 
 
 BY THIERSCH'S METHOD. 
 
 By JAMES BELL, M. D. 
 
 {Reprinted from the Montreal Medical Journal, June, 1893.) 
 
 '^v.. 
 

 P"^ 
 
 A SECOND SERIES OF CASES OF SKIN TRANS- 
 PLANTATION BY THIERSCH'S METilOD.* 
 
 By Jav.es Bell, M.D. 
 
 Surgeon to the Montreal General Hjspital ; Associate Professor of Clinical SurKery 
 
 MoQill University. 
 
 In December, 1887, just five years ago, I read a paper be- 
 fore this Society entitled, " The Treatment of Ulcers by the 
 Transplantation of Large Pieces of Skin after Thier.^ck's 
 Method" I then described the operation in considerable detail 
 and gave full clinical reports of the first six cases on which I 
 had operated, — (the patients were also presented for examina- 
 tion) . To-night I venture to offer some further observations 
 upon this operation, based upon th. reports of thirty-six cases 
 operated upon in the hospital 'lince that time. These cases are 
 taken from the hospital books, and this series includes only 
 those in which an operation was definitely undertaken for the 
 purpose of healing a wound or ulcer. Minor cases in which 
 the area to be covered was estimated at less than two square 
 inches, and all those cases in which skin was transplanted in 
 the course of another operation, as in the removal of small can- 
 cerous or lupoid ulcers from the face, webbed fingers, plastic 
 operations, etc., are not included. Case 31 is an exception 
 to the first part of this statement and was included here on 
 account of the great age of the patient (71 years). The area 
 to be covered for chronic ulcer in this case was about one and 
 a half square inches. , 
 
 Age — In age the patients range, as will be seen from the 
 
 ♦ Read before the Montreal Medico-Chirurgioal Society, Dec. 23, 1892. 
 
mit^^ 
 
 8 
 
 ; 
 
 appended tabulated statement, from 10 to 74 years, there 
 being six patients under 30, five of whom were operated upon 
 for ulceration due to burns, and one for ulcerations caused by 
 a machinery accident, seven patients between 30 and 40, two 
 of them due to burns, seven between 50 and 60, eight over 60, 
 and three whose ages are not noted, bui all of whom were over 
 40 and operated upon for chronic ulcer. 
 
 Lesions — Twenty-five patients were operated upon for chronic 
 ulcers of the legs, in six of whom both legs were operated upon 
 at the same time. Two were operated upon for acute ulceration 
 of the arms following burns i.e., within a few months of the acci- 
 dent ; one for extensive burns of the face, neck, hands and 
 arms, three for chronic ulcers following burns, i.e., ulcers 
 which for months or years ha I ceased to make any progress 
 towards healing, and three for contracted keloid cicatrices 
 following burns. These cicatrices were dissected away and skin 
 transplanted. Ona was in the axilla binding the arm to the 
 side, one in the poplitdal space flexing the leg to a right angle, 
 and one in the lower part of the face and neck flexing the chin 
 upon the breast and everting the lower lip. The first two of 
 these were operated upon in two stages, that is, the scar first 
 removed and the limb replaced in its normal position of exten- 
 sion, and the skin transplanted some weeks later, when the deep 
 irregular spaces had become filled up with granulation tissue. 
 Of the two remaining cases, one was operated upon for 
 destruction of skin, muscle and periosteum of tibia by machinery, 
 and one was transplanted after removal of a large epithelioma- 
 tous ulcer of the leg. 
 
 Results — In thirty-three of the thirty-six cases here reported 
 the ulcers were completely healed — that is, covered with a good, 
 sound skin in three weeks after operation. The three cases, 
 28, 33 and 36, in the appended table in which healing was not 
 completed in three weeks will be referred to individually 
 later on. 
 
 In th« criticisms which followed the reading of my first paper 
 on this subject, the opinion was expressed that the skin thus re- 
 produced would not last, but that the old areas of ulceration 
 
^ 
 
 ' 4 
 
 would soon be in the same condition as before operation. I 
 could not then answer this objection from personal experience, 
 but I can now say most emphatically that such is not the case. 
 In proof of this statement I have here to-night the first patient 
 on whom I operated in August, 1887. On three different 
 occasions since the operation he has developed small ulcers 
 upon the same leg, which absolutely refused to heal until 
 they were scraped and skin grafted upon them. In every 
 instance, moreover, the ulcer appeared, not upon the skin which 
 had been transplanted and which remained perfectly normal, 
 but just outside the border of the transplanted area. Three 
 cases of this series (2, :^2 and 25) returned for operation a 
 second time. In all three the ulceration had begun in the ol(f 
 skin outside the originally transplanted area and at the time of 
 operation in each case more than half of the originally trans- 
 planted skin remained sound, while extensive ulceration had 
 occurred outside its border. Cases 2 and 3 were first trans- 
 planted from an amputated leg, the operation beginning in the 
 first one hour and in the second two hours after the removal of 
 the limb ; no result. Case 2 of my first series was a profes- 
 sional beggar and returned to the hospital since I reported his 
 case with ulceration of his leg, which, like the preceding cases, 
 was much more extensive in the surrounding skin than in the 
 previously transplanted area. He declined to have his leg 
 operated upon a second time, as he depended upon this ulcer- 
 ated condition to secure him his livelihood from a sympathetic 
 public. Case 28 was that of a man aged 41 who came to 
 hospital twenty-nine days after having been burnt with ignited 
 varnish. His whole face, neck, forearms and hands were ex- 
 tensively and in places deeply burnt. He was delirious and very 
 ill (thought to be suffering from iodoform intoxication). One 
 eye was destroyed and the other seriously damaged. On this 
 account Dr. Buller was associated with me in the treatment of 
 the case. Seven weeks after admission I proceeded to transplant 
 skin, and in order to give Dr. Buller an opportunity to complete 
 the treatment of the eye, I transplanted skin from the patient's 
 thighs to his forearms and hands, while Dr. Buller transplanted 
 
 
^— p 
 
 6 
 
 1 
 i 
 
 
 a small area in the itnmediato vicinity of the eye. In three 
 weeks the parts transplanted were completely covered with skin ; 
 a normal result. As I had at the first operation pretty well 
 denuded his emaciated thighs and calves, and the face and neck 
 were still to be dealt with (with the exception of the limited 
 area around the eye transplanted by Dr. Buller), 1 advised 
 the patient to secure some person who would allow the skin to 
 be taken from his thighs and transplanted to the patient's face. 
 As he was a private patient and able to pay he adopted my 
 suggestion, and four weeks later the face and neck were trans- 
 planted with skin in this way. The young man from whom the 
 skin had been taken was sent into the ward to allow of the 
 healing of the thighs, when it was found that he was very ill 
 and feverish. He had only been cursorily examined and had 
 not been under observation at all before the operation. Further 
 examination showed that he was in the second week of typhoid 
 fever, from which he recovered after a very severe illness. My 
 patient in the meantime became ill and feverish, and the skin 
 which had been transplanted necrosed and separated within ten 
 days, and considerable areas of ulceration again appeared upon 
 the hands which had been perfectly healed. Some weeks later 
 another man was secured and skin transplanted again. The 
 final result, especially as far as the face was concerned, was 
 not perfectly satisfactory, as the skin only took in places and a 
 great deal of contraction followed. In this connection it is in- 
 teresting to note that Herr Sick, first assistant in Schede's Klinik, 
 Hamburg, records a case (Centralblat fur Chirurgie, No. 44, 
 1892), in which skin transplanted to the head of a ten-year-old 
 girl from the thighs of two healthy young men, healed com- 
 pletely, but in the course of three weeks it broke down and as 
 completely disappeared. A second attempt to cover the defect 
 with skin from a sister of the patient of about the same age was 
 unsuccessful, and only at the third operation, when the skin was 
 taken from the patient herself, was the operation successful. 
 
 Case 35, operated upon two weeks ago and still in hospital, 
 is that of a ten year old girl suffering from contraction of the 
 chin upon the chest and great eversion of the lower lip by 
 
 ..■!:. 
 
6 
 
 cicatricial tissue, the result of a burn. Only a little more than 
 half of the skin transplanted has taken in this case. The im- 
 perfect results in these two cases I attribute to the great diffi- 
 culty in dressing the wound in this situation (the face), so as to 
 retain the strips of skin in position and maintain asepsis, — in 
 fact the latter is impossible in the immediate neighborhood of 
 the mouth and nostrils. 
 
 Case 33, a feeble old man aged 65, with very weak circula- 
 tion and suffering from asthmatic attacks, was operated upon 
 November 18th, 1892. He had suffered from a chronic ulcer 
 for thirty years, but about July last it became painful and 
 began to grow hard about the edges. On admission to hospital 
 the hard nodulea about the edges were examined microscopi- 
 cally and pronounced to be epithetical cancer. The whole ulcer 
 was dissected out, wide and deep, and skin immediately trans- 
 planted. The area covered was 9J by 6 inches. The strips 
 of skin have all taken, but granulation points crop out between 
 the strips in places and show much les,s tendency to heal than 
 in ordinary cases. In transplanting a surface so large and so 
 uneven as this was after dissection, it was impossible to place 
 the skin so accurately as not to leave some little spaces uncov- 
 ered. These are the spaces which still show granulation 
 between the strips of skin. On the whole nineteen-twentieths 
 of the surface was covered with healthy skin at the end of three 
 weeks, and this case only differs from the others in that there is 
 apparently not the same tendency to rapid extension of normal 
 epithelial growth from the edges of the transplanted strips. 
 
 Case 34, a boy aged 13, met with an elevator accident on 
 the 3rd of October last, whereby the skin, fascia, part of the 
 tibialis anticus muscle, and a large portion of the periosteum, 
 from the middle third of the antero-lateral surfaces of the tibia 
 were torn off and stripped down to the ankle. These parts were 
 replaced as well as possible, but their vitality had been des- 
 troyed and sloughing followed. When the sloughs had been 
 removed the leg was dressed carefully from time to time until 
 the bared surface of the tibia was covered with granulations. 
 Skin was then transplanted in the ordinary way on the 22nd of 
 
 '• 
 
I 
 
 November last. The dressing was removed on the eighteenth 
 day after operation, when the wound, which measured 10} 
 inches in its greatest length by 0} in its greatest breadth, and 
 completely encircled the leg at its inferior extremity, was founJ 
 to be completely healed. 
 
 Case 36 may be briefly mentioned as a type. A young man 
 aged 18 had both his legs burnt by falling into boiling soap in 
 August, 1889. Healing progressed rapidly for a time and then 
 became gradually slower and slower, until, for more than a year 
 before admission, no progress whatever had been made, and an 
 ulcer remained on the posterior surface of each leg about the 
 junction of the middle and lower thirds. Thirteen days after 
 operation the skin was found to have taken perfectly. I am 
 enabled to present this patient for your inspection on this the 
 sixteenth day after operation. With regard to the operation 
 itself, it id sufficient to say that perfect asepsis, a broad-bladed 
 and sharp razor, and ordinary manual dexterity, are the essen- 
 tials to success. No preparation of the patient nor the part to 
 be operated upon is necessary beyond the cleansing processes 
 which are necessary in every operation. 
 
 Several of the patients here reported were taken from the 
 out-patient department with filthy clothing and skin, and foul- 
 smelling ulcers, direct to the operating room (having of course 
 had a bath and thorough cleansing of the parts to be operated 
 upon). A single dressing of dry sublimated gauze, which is 
 usually removed at the end of the third week, is the only after- 
 treatment necessary. When this is removed the newly devel- 
 oped skin is protected for a couple of weeks with a pad of gauze 
 and a bandage. In those cases in which skin was transplanted 
 to the face and a single dry dressing was impossible, the wound 
 was kept moist with normal salt solution as recommended by ; 
 Thiersch. This form of dressing is far more troublesome and 
 less satisfactory than the dry dressing. All the cases here 
 reported have been operated upon at a single operation, — that 
 is the ulcer was scraped or dissected out and the skin applied 
 immediately. In cases where it is necessary to dissect out a 
 large area of skin (such as case 32) it would undoubtedly be 
 
8 
 
 better to apply a gauze dressing for twenty-four or forty-eight 
 hours to stop the oozing of blood, which is considerable, and 
 transplant the skin at a second operation. 
 
 Note. — Cases 82 and 85, which were not completely healed 
 when the foregoing was written, have recovered perfectly, — the 
 former in six weeks and the latter in five. 
 
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