In 1855 the editor of the Western Lancet, Dr T. Wood, published an article in his own journal on the subject of plastic (reconstructive) surgery. This clinical sub-discipline was still in its infancy, but a handful of surgeons had achieved wonders in treating severely disfigured patients. The leading American expert was Thomas Dent Mütter, who had spent a year studying the new techniques of plastic surgery in Europe. One of the important insights that he brought back to America with him was that if the patient’s own tissue were used to repair a defect, healing was much more likely to occur if the graft retained its own blood supply. To repair a burn, for instance, a flap of skin from a nearby part of the body could be dissected free and used to cover the damage, with the graft left attached by a ‘pedicle’ of tissue to its original site.
Mütter succeeded in treating numerous ‘monsters’ – patients with severe deformities, previously deemed inoperable – and achieved lasting fame. At his death in 1858 his collection of anatomical specimens became the nucleus of the Mütter Museum, which remains the foremost medical collection in the United States. In this case, Dr Wood employed an operation first described by Dr Mütter and named after him.
Dr Wood’s report begins by reflecting on the dangers of plastic surgery, and why it is so fraught for the surgeon:
A very slight cause may prevent union by the first intention, and if this union fails to be effected in a few hours, all is lost; this operation is not, like most other operations that fail, simply unsuccessful, but it may aggravate the deformity, and perhaps leave the patient without hope of aid from surgical skill.
Every operation was, to some extent, a gamble. One which, in this case, paid off:
Miss U , eleven years of age, had received a severe burn when she was about four years old, on the front and right side of her breast and neck, which on healing left a cicatrix [scar] extending from near the nipple to the base of the jaw vertically, and laterally from the angle of the jaw on the right side, to an inch beyond the median line towards the left. The concavity between the chin and breast was completely filled by strong dense bands of skin, that drew down and permanently fixed the chin to within one inch of the sternum. This contraction of the skin of the neck, distorted the features very much—her mouth was kept open, and the front teeth in the lower jaw projected nearly horizontal, (having been gradually changed in their direction by the continual drawing on the gums,) and the nostra, and the eye-lids on the right side were drawn down out of their natural shape…The band running from the chin to the sternum completely destroyed the power of rotation of the head and neck, and the body was necessarily moved when she attempted to look at objects on either side of her person.
These were significant disabilities, and Dr Wood decided that they were worth treating. He elected to operate using Mütter’s operation:
Assisted by my friends, Dr. P. G. Fore, and the late Dr. P. S. Conner, the patient was brought under the influence of chloroform. The bands were completely cut across, and all the modular tissue that restrained the movements of the head and neck, was carefully dissected out. This left the neck and head free in their movements; but when the head was placed in the erect position, we had a denuded space, five and a half inches long, by four and a half wide, to be covered with integument borrowed from the shoulder. For this purpose a flap was raised from the surface of the trapezius muscle, and turned across the neck, where it was carefully stitched into the wound.
The trapezius is a large muscle which extends from the top of the neck and shoulder to the small of the back.
Cool water dressings were used, and at the end of the second day after the operation, everything looked well, and the entire flap appeared to be united; but on the third day a violent attack of erysipelas ensued, which extended over the left side of the neck and face, apparently originating in a small piece of the old cicatrix that was left at the extreme left of the wound.
Erysipelas is a skin infection caused by a streptococcal bacterium. It is not surprising that it occurred, since at this date only basic hygiene would have been observed in the operating theatre – there was as yet no aseptic regime. Luckily the treatment they chose for this complication was probably the best available at the time.
The entire inflamed surface, including the flap, was painted over with a solution of the nitrate of silver, in the proportion of thirty grains to the ounce of water. This application promptly arrested the inflammation, but about one-fifth of the flap was loosened from its adhesions, and finally sloughed, the remaining four-fifths were unharmed and permanently healed in.
The one-fifth of the flap which had been affected by infection eventually healed, although this caused a new scar which became tight and had to be relieved by a further small incision. This additional minor procedure was entirely successful.
The appearance of the case, both before and after the operation, is very accurately illustrated in the frontispiece by our artist. The daguerreotype, of which the second figure is a copy, was taken about eighteen months after the operation, and it will be seen that there is not a trace of the great deformity left. The teeth have resumed their natural direction, the mouth is closed, and the contour of the chin and neck is perfect. She now enjoys as complete freedom in the movements of the head and neck as if no accident had happened to her.
If the result was as good as the image suggests, this operation was remarkable indeed.