F L A G E L L A T I O N AND F R E E G R A F T I N G

By THOMAS GIBSON, F.R.C.S.E., F.R.F.P.S.G.

Glasgow Royal Infirmary

THERE is no more fascinating tale in the early history of plastic surgery than that of the use o f pre-operative beating as a means o f "increasing the vitality " of a graft. Gnudi and Webster (195o) refer to it briefly, but it deserves a more detailed recording, not only for its intrinsic interest but as a possible pointer to the solution of the still intractable problem of massive free grafts.

DUTROCHET'S LETTER

The story begins on 2ISt March 1817, when a letter appeared in the Gazette de Santd over the signature " H. Dutrochet . " Th e author was Rdn6 Joachim Henri Dutrochet (1776-1847), who in later life made many observations on the anatomy and physiology of plants and animals, ~ -~, and has been described as " one of that numerous group o f scientists who present material before the scientific minds of the period are prepared to receive i t " (Mettler and Mettler, 1947). His letter, under the title " Examples ~ - of Reunion of Parts completely separated from the Body," was sufficiently sensational to be ab- stracted immediately in several other journals and later quoted, inaccurately and in an abbreviated form, in several works on grafting (see below). Unfortunately the only available Engl ish translations (Gnudi and Webster, 195o; Rogers, 1959) are taken from Blandin (1836), whose version is not only incorrect, but leaves out completely the second case, and therefore appears much more plausible than the original. Here is Dutrochet 's letter in full [writer's translation] : -

CHAPEAU PRES CHATEAU REGNAULT, 5 Mars 1817.

SIRS, The number of your interesting Gazette dated ISt March offers two examples

of reunion of parts totally separated from the rest of the body. This physiological phenomenon is well attested to-day, and one can report similar occurrences without exposing oneself to the ridicule which has been so unjustly shown to Garengeot. 1 Those which I am about to present to you are admittedly almost unbelievable but they are attested by an eye-witness, by a man too far above the common rut to allow himself to

1 Garengeot in 1731 reported a case in which a nose was bitten off in a fight, trampled underfoot, and subsequently reattached with complete success.

195

196 BRITISH JOURNAL OF PLASTIC SURGERY

be fooled by vulgar gossip, in fact by General P , my brother-in-law, who has for a long time been commander-in-chief of the troops of Daoulot-rao-Scindiah, sovereign of the Maharattas of Berar.

Amputation of the nose is a common punishment in India and every effort has been made to find means of correcting the hideous deformity which results. Two operative methods are in use to restore the amputated nose. The first consists of building on to the nose a portion of the skin of the forehead, following the procedure which you have described in your number of ISt September 1816, and which has been employed with so much success by M. Carpue, member of the Royal College of Surgeons of London. The second method consists in grafting, in place of the amputated nose, a piece of skin and subcutaneous tissue taken from the buttocks [original italics].

An officer in the army of General P had taken a particular aversion to one of his artillery warrant officers, and took advantage of the General's absence and of a minor offence which the warrant officer had committed, to have the latter's nose cut off. The unfortunate mutilated man had recourse to Indians known for operative restoration of the nose. Here is the procedure which they used.

The nasal amputation was already old, and the wound was beginning to cicatrise ; they refreshed the edges of it and then chose a place on the buttocks which they beat with blow after blow of an oM shoe [original italics] until this repeated percussion had produced considerable swelling. Then they cut from the swollen area a piece of skin and subcutaneous tissue of a triangular shape which they brought to the wound on the nose and fixed there with agglutinative plasters. This animal graft succeeded marvellously, and General P has had this man in his service for a long time since the operation.

Here is an even more extraordinary occurrence which reached me from the same source. General P , passing through a friendly countryside, had severely forbidden any form of pillage. A man captured on a marauding trip was brought to him, and he caused one of his ears to be cut off in the field. The man was a Brahmin, as are almost all the writers attached to the Indian armies, and this infamous punishment caused a great uproar which was appeased by gifts of money. However the man was still anxious to replace the ear, which had been thrown away and lost. The ear of a pariah was bought, cut off and grafted in place of the Brahmin's ear, and this graft succeeded. I t may be mentioned in passing that in these circumstances necessity appeared to make the Brahmin forget the horror which pariahs usually inspire in them.

Many operative attempts have been made with grafts on animals; I have myself made many experiments of this kind on rabbits ; none of them succeeded. This lack of success is probably due to the cause which you have indicated. (See the number of

ISt March.) H. DUTROCHET, D.M.

T h e first part of the letter is perhaps plausible, but the second case is palpably absurd and brands the whole communicat ion as little more than a traveller 's tale. T h e early abstractors (J. Med. Chir. Pharm. Paris (1817), 39, 9 r ;1 Hufe ld ' s Journal des practischen Heilkunde (1817), 44, IO6 ; Salzb. med.-chir. Ztg. (I818), i , I74) ment ion both cases in an abbreviated form, but later writers entirely omit the case of the pariah's homograft ear (Percy and Laurent , 1819 ; Blandin, 1836). Both paraphrase the account as if General P himself had written it, and Percy and Laurent add entirely new details about inserting cylinders of wood to keep the nostrils open ; in addition b o t h give the instrument of flagellation as a pantoufle (slipper) and not as a savatte (an old worn-out shoe), a much harder implement .

1 This reference has been quoted on several occasions as if under the authorship of Leroux, who was the editor of the journal which was commonly known as Leroux's Journal.

F L A G E L L A T I O N A N D F R E E G R A F T I N G 197

This method of making new noses with free grafts, which came to be known as " the second Indian method," was never described before Dutrochet's letter and, so far as I am aware, has not been heard of in India since. A possible clue to its origin is given by Liston (1827) ; in his " case in which a new nose was restored" he says: " This curious operation (i.e., forehead rhinoplasty) is occasionally practised in India by native practitioners. Dr M. Whirter, who paid great attention to their surgery during a long residence in the East and whilst engaged in journeys into the most remote and unfrequented parts of the country, informs us that these operators are in the habit of pummelling the integuments of the forehead with the heel of their slipper so as to incite the circulation before performing their incision."

Whatever the truth may b e , the important point is that the story was widely publicised in a variety of journals at the time and was well known to Professor Bringer of Marburg, who actually used it on a patient. His report of this case is so well detailed, documented, and attested that it commands belief.

THE ASTONISHING CASE OF PROFESSOR BUNGER

Christian Heinrich Bringer (I782-I842), Professor of Anatomy and Director of the Anatomical Institute in Marburg University, was one of the first surgeons ever to carry out a bilateral ligature of the common carotid artery (Hirsch). Probably his only publication in a medical journal, however, is his paper entitled " Successful Attempt at Forming a Nose from a Fully Separated Piece of Skin from the L e g " in the Journal der Chirurgie und Augenheilkunde of 1823.

It tells of a 33-year-old woman, Wilhelmina M., who had lost the whole of her nose from a scrofulous condition which was probably lupus, although it might have been syphilis. The lesion had destroyed not only the cartilaginous nose, but the skin over the nasal bones as far as the inner canthus on each side and had spread upwards between the eyebrows and on to both cheeks. Some years previously the patient had heard Bringer speak about the Tagliacotian rhinoplasty, and he had told her that he might have been prepared to make her a new nose if the disease were not so widespread. In 1817 she heard news of successful rhinoplasties in Berlin (yon Graefe, 1818) and in England (Carpue, I816), and turned up at Bringer's unit, assuring him that she had no fear of pain and desiring most ardently that he make the attempt.

" It seemed to me so desirable to be able to relieve the distress of such a brave girl, once known for her almost perfect beauty and now carrying such a heavy burden ; but to begin with I could perceive no possibility of this even after much reflection. My final decision was that I would excise the diseased areas of skin from her cheek and thus check on her capacity for healing."

He began by excising from the right cheek a piece of tissue the size of a four-groschen piece (2- 5 cm. diameter). Two weeks later when this seemed to be healing well, a portion the size of a thaler (3"4 cm. diameter) was removed from the left cheek. These healed so well that he then excised the affected skin on the upper lip and that covering the nasal bones. Unfortunately, neither forehead nor cheeks could supply sufficient skin for a nasal reconstruction, and he thought that an arm flap would not readily reach the corners of the eyes. He considered using a flap from another person, but there were too many difficulties to be overcome. All that remained, therefore, was the " second Indian method." He

198 BRITISH JOURNAL OF PLASTIC SURGERY

had great doubts about the procedure, but felt that the loss of the skin from the patient's leg would be no great disability and that, apart from the pain she would suffer, no great harm would be done.

The operation took place on 26th June 1819, and Bringer was assisted by his colleague Professor Ullman. He had decided against the use of the buttock because of the resultant discomfort in sitting or lying, and the difficulties of dressing the

area. Instead, he chose an area on the anterolateral aspect of the thigh, and this was whipped for some time with a leather strap until it was red, swollen, and bloated.

Meanwhile he excised all the diseased tissue of the nose ; this caused great pain and was followed by such copious bleeding that it was a full hour before he could cut the skin from the leg.

A paper pattern was made of the desired size and shape, but in order to get easy closure of the wound he cut out more skin than was necessary in the form of an ellipse 4 in. long by 3 in.

broad. This was trimmed to shape and from the under surface he removed more than half of the thickness of the fat to get a more exact junction at the edges.

" I had been finished with this for some time and the chalk-white graft had long since lost its own warmth, but ever and anew the blood began to well from the corner of the eyes." In the end he decided to put the graft in position and insert one or two stitches at the inner canthi to control bleeding, but even then a full hour and a half passed before bleeding stopped. Many years later Ullman told Bringer's successor Zeis how he (Ullman) had held the graft in his hand during this period (Zeis, 1863). Finally the graft was stitched around the whole circumference. A dressing of fine woolly lint was fixed with adhesive plaster, and a loose piece of linen attached to the forehead covered the whole face as far as the mouth.

Bringer was very depressed at the end of the operation. " The whole undertaking appeared to me as a mockery and I already reproached myself with having in all probability tortured such a heroic patient in vain. The piece of skin was now lying in the shape of a complete nose but looked alarmingly pale and corpse-like."

Its appearance next day did nothing to raise his spirits ; the face was swollen and the scar flushed, but the graft was still chalk-white. On the second post-operative day he and Ullman went to see the patient " in the pretty firm conviction that all would now be decided and certainly not in the interests of the patient; there would be nothing further to do but remove the graft." But all was changed.

F L A G E L L A T I O N A N D F R E E G R A F T I N G 199

" How strongly I could have wished that this morning besides Professor Ullman, myself, and various relatives of the patient, several other professional men might have enjoyed the sight that greeted us when we opened the lint. We doctors simply stared at each other and at first could not believe our eyes when we caught sight of the graft, so chalk-white the previous day--but now gleaming scarlet and swollen over the greatest part of the surface ; only the lower portion which was to form the septum and the ala~, and a narrow margin about ~ in. broad all around the stitched edge of the graft showed a suspicious bluish tinge."

, i

" ~ ~ ~ q

Bringer was most encouraged, removed a few stitches, and had a warm decoction of cinchona, savin, and camphor dropped hourly through the lint. Next day the red colour had paled and the bluish areas had increased in extent with small blisters forming over them and were obviously gangrenous. He removed all the stitches.

On the fourth post-operative day he was overjoyed to find that the gangrene had spread no farther and was showing a line of demarcation. By the eighth day there had separated almost completely a half-moon-shaped piece comprising the tip, the columella, and the ala~, and when this portion was removed the free edge appeared healthy and covered with good granulations. What is more, it projected at the front and sides a good finger-breadth beyond the edge of the nasal bones [writer's italics]. There had been a marginal loss all around the sutured edge which separated about two weeks later. As Bringer points out, the graft had obviously taken from the under surface and not from the edges. On three occasions small purulent blisters formed on the flap, but when opened these soon healed. Continuous decoctions of cinchona and chamille by day and zinc salve by night with an occasional application of balsam of Peru finally produced complete healing at the end of the fifth week. A well-formed scar surrounded the graft, but the lower free edge protruding beyond the nasal bones had curled around them towards the nasal cavity. Finally, little fine hairs began to grow.

Although the graft had proved largely successful, the essential part had been

200 B R I T I S H JOURNAL OF PL AS TI C SURGERY

lost and the patient was still without a nose. Bringer waited a whole year, and then with an arm flap of the Tagliacotian type and small flaps from the cheek ~he finally succeeded in giving her a new nose. He gives few details, but ends his paper with the hope that he will shortly publish the final details with the necessary illustrations. He never did, and we are without any authentic pictorial representations of this most remarkable case.

There can be no doubt from the detailed description and from Ullman's ~corroboration that this case record was authentic, and it seems extraordinary that so few attempts were made to follow it up. Dieffenbach did many experiments with free grafts, but most of these failed. He writes, however, in the preface to h i s " Chirurgische Erfahrungen " (1829) : " Among the very many transplantations which I have done in animals, a few isolated grafts healed and survived in cases where before the graft was cut its vitality had been increased by artificial stimuli like beating, squeezing, rubbing with spirit or blistering." It was not until I893, however, that Hirschberg developed the method further.

HIRSCHBERG'S MODIFICATIONS

In April of that year he presented to the 22nd Congress of the Deutsche Gesellschaft frir Chirurgie a paper entitled " On the Take of Fully Detached Skin Grafts retaining the whole of the Underlying Fat." He argued that free skin grafts died from lack of blood and should therefore be put into a condition of hypera~mia before being cut. He quoted Thompson's experiments (1893) to show that trauma, such as beating or rubbing, paralysed the muscular coats of the veins and enabled them to take up more blood.

His method of achieving hypera~mia was very thorough. He first exsanguinated the arm with an Esmarch's bandage and applied a tourniquet. Then, with a thin rubber tube folded on itself several times, he whipped the donor site for a period of two to three minutes. The selected area was either on the outer side of the upper arm or the radial side of the forearm, and on this he marked out a quadrilateral portion of skin somewhat larger than the defect to be covered. Three sides of this portion were cut through and the flap so formed was raised from the deep fascia, leaving it still attached distally. Sutures were placed through the three sides, leaving the needles attached so that the graft could be quickly stitched into the defect. When all was ready the tourniquet was released.

One can imagine the result. " Within a few minutes the skin had become red, and so swollen from the erection of the skin papillze that it took on a ridged appearance." When the bleeding was controlled he cut rapidly through the base of the flap with scissors, and then had a free graft of skin and fat with the vessels fully congested.

He used these grafts in four cases of turnouts of the face and scalp, which had been excised to leave a quadrilateral defect. In two instances the base was pericranium; in two, bare skull was exposed. Their subsequent behaviour was the same in each case. " The grafts, which looked pale in the first hours after their application, looked normal the next day and remained so fresh and alive-looking until the fifth or sixth day that all my colleagues who saw them considered it out of the question that anything could still disturb the healing process. Between the fifth and seventh day, however, a bluish discoloration crept

FLAGELLATION AND FREE GRAFTING 20I

over the greater part of the graft up to a zone around the edge. Becoming ever darker this superficial part of the skin either separated itself as a crust by the fifteenth or eighteenth day with a small amount of discharge, or the separation

Y

was assisted with scissors. Underneath was the pale red, lightly ridged dermis over which the skin grew in a few days." The final result was either normal-looking skin or a slightly red appearance similar to that after a superficial burn.

WRITER'S COMMENTS

The five cases described--and so far as I am aware no further cases of flagellated grafts have been published--seem to provide prima facie evidence that preliminary beating of the donor ske will permit skin with a layer of subcutaneous fat to survive. In theory there are at least three possible reasons why this may be so :--

i. As Hirschberg pointed out, the trauma will cause a paralysis of the muscularis coat and prevent the spasm of the vessel walls which usually occurs when a graft is cut. Hynes (I954) has shown that this spasm may not relax until twenty hours have elapsed ; after beating, however, the vessel mouths on the cut surface will be patent and ready to form early anastomoses with vessels in the bed.

2. The vascular network in the beaten graft is full of blood. This may well be important since, whenever blood from the bed starts to enter the graft, movement of the contained cells will begin and the development of an early circulation will be encouraged. In massive grafts in which the vessels are collapsed and empty, blood entering the graft must first fill the whole vascular system before a circulation can be established; dilatation of the dying vessels and complete stasis of the contained red cells is the usual result.

3. Marked oedema accompanies the congestion following beating. Until a circulation is developed, the cells of a graft depend for their nourishment on the intercellular fluid, and the great increase in this may b e o f value in tiding the cells over the initial period of starvation.

It is freely admitted that all these points are arguable. Furthermore, traumatising tissues in the way described seems to contravene the most fundamental

2 0 2 B R I T I S H J O U RN A L OF P L A S T I C SURGERY

of our surgical principles. At the same time the writer was sufficiently impressed with the possibilities of the method to try it out in a small series of cases.

Experimental work of this kind in man is infrequently justifiable and very difficult to control. Unfortunately none of the lower animals with the possible exception of the pig has a subcutaneous structure resembling that of man, and animal experiments were not possible. The series of cases in which flagellated grafts have been used is still too small for firm conclusions to be drawn, and the cases will not be detailed here, but certain important points have emerged and are worth recording.

There is not the slightest doubt that, treated in this way, free skin grafts with an underlying layer of fat of approximately the same thickness as the skin will survive, though small areas of superficial or even whole skin loss often occur and may spoil the cosmetic result. Such grafts are practically free from any tendency to contract and have been used with advantage around the neck. It may be, of course, that unbeaten grafts of the same thickness will survive equally well, but the whole tradition of plastic surgery is against leaving any fat adhering to a full-thickness graft. I f the thickness of the fat layer is increased, the take becomes quite unreliable and the vascularisafion of the surface skin patchy and irregular.

In one instance a free graft with a layer of fat about i cm. thick was transplanted to the raw area left after excision of a leg ulcer. Ten days later no blood had reached the skin, which looked necrotic and was therefore excised. The underlying fat, however, was richly vascular and had completely survived transplantation. It readily accepted a split-skin graft and a very stable healed leg resulted. This case suggested that preliminary flagellation might enhance the take of free fat grafts which have a notoriously poor survival, and a small series of these have been carried out. Some have undergone absorption, but many have survived unchanged. The series is still too small, however, for any conclusions to be drawn.

It will be realised that the great stumbling block of the method is its empiricism. There is no indication in the literature of the force to be applied or how long to continue. A soft endotracheal tube has been used in my cases, and the first appearance of bruising has been taken as the end point. The amount of trauma which will cause bruising, however, varies greatly in different subjects and at different ages, and one can never be certain that the desired result has been obtained.

Methods of achieving the same result without flagellation have been considered. Dieffenbach (1829) suggested rubbing with spirit, or blistering with mustard plaster. Le Fort (1872) also used mustard plaster, while Rous (1946) rubbed the donor site with ether. Heat in various forms would have a similar result, but all these methods have their maximum effect on the skin capillaries, whereas the vasodilatation and congestion should be equally distributed throughout the skin and subcutaneous fat. Recently Stark (I959) has shown that this result may be obtained by histamine driven deeply into the tissues by electrophoresis, and this is a possible answer to the problem.

There may or may not be something in it ; but it is hoped that this account of a little-known chapter in medical history will stimulate further research into one of our major unsolved problems, the survival of the massive free graft.

The illustrations are imaginary and are the work of Mr R. G. Campbell.

FLAGELLATION AND FREE GRAFTING 203

REFERENCES

BLANDIN, P. F. (1836). " De L'Autoplastie." Paris : Urtubie. BONGER, C. H. (I823). J. d. Chit. u. Augenh., Berlin, 4, 569. CARI'UE, J. C. (I816). " An Account of Two Successful Operations for Restoring a Lost Nose

from the Integuments of the Forehead." London : Longmans. DIEFFENBACH, J. F. (1829). "Chiruxgische Erfahrungen besonders fiber die Wiederherstellung

zerstorter Theile des menschlichen KOrpers nach neuen Methoden." Berlin : Enslin. GARENGEOT, R. J. C. DE (I731). " Trait6 des op6rations de chirurgie," 2nd ed. Paris:

Huart. GNUDI, M. T., and WEBSTER, J. P. (195o). " The Life and Times of Gaspare Tagliacozzi."

New York : Herbert Reichner. GRAEFE, C. F. VON (I818). ~ Rhinoplastik." Berlin : Reimer. ttlBSCH, A. (1884-88). " Biographisches Lexikon." Vienna and Leipzig: Urban and

Schwarzenberg. I-IIRSCHBERG, M. (1893). "Deutsche Gesellschaft ffir Chirurgie," Verhandlungen, 2z Congress,

pt. ~, p. 52. HYNES, W. (1954). Brit. J . plast. Surg., 6, 257. LE FORT, g . (I872). Bull. Soc. Chit. Paris, Ser. 3, I, 39. Quoted by Gnudi and Webster

(I950). LISTON, R. (1827). Edinb. reed. surg. J., 27, 2zo. METTLER, C. C., and METTLER, F. A. (1947). " History of Medicine." Philadelphia and

Toronto : Blakiston. PERCY, P. F., and LAURENT, C. (I819). Dictionnaire des Sciences mddicales, 36, 87. ROGERS, B. O. (1959). Surg. Clin. N. Amer., 39, 289. Rous, P. (I946). J . exp. Med., 83, 383. STARK, R. B. (1959). Plast. reconstr. Surg., 24, 19. THOMPSON, W. H. (1893). Arch. Anat. Physiol., Lpz., p. lO2. ZEIS, E. (1863). " Die Literatur und Geschichte der plastischen Chirurgie." Leipzig:

Engelman.