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THE TUBED PEDICLE IN PLASTIC SURGERY.
320 at the first operation I performed on A.B. V., the burnt seaman, the operation taking place on Oct. 3rd, 1917. These tubed pedicles progressed so well that the second stage operation, division of pedicle towards its base for use on the face, was performed on Oct. 17th, 1917 (Mr. Audi alteram partem." H. C. Mallison for me). Captain J. L. Aymard’s case, B. C. H., was operated on Oct. 18th, 1917, when he HELMINTHIC INFECTIONS AND PELLAGRA. designed an original flap for making the nose and at the To the Editor of THE LANCET. same time "tubed" it, in the same way as was my I am to blame in not informing Captain Aymard SIR,-May I be allowed a few words of comment upon case. the last paragraph of Lieutenant-Colonel P. S. Lelean’s at the time he published his rhinoplasty case in your that he was not the first to get on to the principle letter published in your issue of July 17th? Colonel paper " Lelean writes that if the deficiency factor is only a of tubing " the pedicle. I am, Sir, yours faithfully, contributory factor to a determining cause yet to find, H. D. GILLIES. the suggestion that the latter is to be sought in a Queen’s Hospital, Sidcup, August 3rd, 1920. helminthic infection (such as with Ascàris) is equally difficult of acceptance. Now, so far as regards the suggestion made recently by myself in this connexion, THE CLINICAL DIAGNOSIS OF DIPHTHERIA. I have not considered the helminthic infection as the To the Editor of THE LANCET. determining cause and the deficiency factor as only a contributory one. The matter is rather the other way
Correspondence. "
SIR,-I
round.
nave louuweu with
great
interest
the
recent
the above subject. Being able to lay claim to considerable practical experience of both sides of the problem-the clinical and the bacteriological-I make bold to set forth some views on the subject. If it were always remembered that there can be no such as infallibility, clinical or bacteriological, there factor, perhaps especially important as a predisposing thing would be no occasion for " exclusive advocacy " by the considered most a dietetic cause; (in deficiency being holders of opposing views. In this matter of diphtheria cases, at all events) as the actual determining cause. diagnosis there is no time fQr opposition and argument. As I wrote :There is urgent need for cooperation and agreement. "There is, of course, no intention of suggesting here that helminthic infections, by themselves alone, constitute the specific The clinical manifestations of diphtheria cannot be such infections are known to be prevalent systematised with absolute certainty. However sure cause of pellagra ; in many districts and countries where pellagra never, or only rarely, each of us may have been of his ability to dogmatise occurs." upon faucial lesions, sooner or later admission had to May I illustrate by a rough analogy ?° Chronic, local be made of a mistaken diagnosis. I think such must irritation or stimulation is known to be often a most represent the experience of all fever workers. How important contributory or predisposing cause of malig- could it be otherwise ?’? So equally must bacteriological nant disease; but this alone is not regarded as the dogmatism be impossible where diphtheroid organisms immediate determining cause-of malignancy, because a are in question. Many times the clinician must be malignant growth does not necessarily supervene upon disagreeably surprised by the variety of bacteriologists’ such a condition. opinions where B. diphtheriæ, B. hofmann, and diphIn the case of pellagra what I had in mind was that, theroids are under judgment. as regards the extent of their responsibility, the two Some such considerations may have been in Osler’sx factors might perhaps stand in relation to one another mind when he remarked thatin this way. The greater the adverse effect of " The clinical and bacteriological conceptions of diphtheria are at helminthic intoxication (and this may not be the same present not in full accord. On the one hand, there are cases of as the heavier infection the would the less itself), thing simple sore-throat which the bacteriologists, finding the Klebsbe the degree of dietetic deficiency which would suffice Löffler bacillus, call true diphtheria. On the other hand, cases of to produce suprarenal inadequacy and pellagra, and membranous, sloughing angina, diagnosed by the physician as are called by the bacteriologists pseudo-diphtheria or vice versa. With reference to the Turkish prisoners, I diphtheroid, diphtheroid angina. The term diphtheroid may be used for the stated in the summary of my report that the occurrence present to designate those forms in which the Klebs-Löffler bacillus of Ascaris eggs was very general, not only amongst the is not present. Though usually milder, severe constitutional disturbance and even paralysis may follow these so-called pseudopellagrins but equally amongst those who were liable diphtheritic processes." at any time to become pellagrous. Just at the time I Surely the foregoing is a laboured attempt to make was at Kantara, the incidence of pellagra was becoming distinction where there is no difference. It frequently very high; and had not the labour been knocked off, happens that a patient suffering from local and general one would hesitate to say how many of the " apparently characters of healthy " Turks would not have gone on to show a symptoms and having all the clinical for as many days as diphtheria, cultures "negative" I not condition. do therethink, manifestly pellagrous are required to rid the throat of the false membrane. fore, that my suggestion is so difficult of acceptance. Is it known whether any of the prisoners of our Is it to be wondered that " clinical and bacteriological l.E. F. and E.E.F. in Turkish hands showed symptoms conceptions of diphtheria are not in full accord " ?The of pellagra?And, if so, whether the cases occurred explanation of the apparent inconsistency is simple. A consideration of the histological structure of the false among the British or the Indians, or both? Because will, demonstrate the mechanical impossicertainly the Indians would be more generally infected membrane with helminths than the British. At any rate, as a bility in given cases of a swab, lightly rubbed upon the first step I think it would be worth while for workers in surface, reaching the underlying diphtheria bacilli. The parts touched are swarming with pyogenic cocci, pellagrous areas to endeavour to ascertain whether which, on culture by the bacteriologist, must give a there is a distinct correlation between cases of pellagra , ’ "negative field." The cold scientific fact is that the and the occurrence of helminthic infections. particular swab submitted for examination is " negative. I am, Sir, yours faithfully, The cool conclusion that the patient involved has no H. M. WOODCOCK. July 31st, 1920. diphtheria organisms in or about the fauces, hence cannot be suffering from diphtheria, is unscientific, THE TUBED PEDICLE IN PLASTIC SURGERY. and only serves to create a situation of professional embarrassment. To the Editor of THE LANCET. Scientific procedures cannot altogether supersede SIR,-The operating books, surgical records, and ward clinical observations. They must serve as valuable sisters’ report books of the Queen’s Hospital show the aids, and, if accorded that function, but not relied on following statement of fact. The first occasion on which the pedicles of a face flap were definitely tubed occurred 1 The Principles and Practice of Medicine, pp. 192-193.
As will be clear, I think, to readers, both of my section of the Pellagra Report on the Turkish Prisoners’ of War, and of my letter published in your issue of May 28th, the question is whether a helminthic infection is to be regarded as an essential contributory
correspondence
on
......
.
’
.
Correspondence. "
SIR,-I
round.
nave louuweu with
great
interest
the
recent
the above subject. Being able to lay claim to considerable practical experience of both sides of the problem-the clinical and the bacteriological-I make bold to set forth some views on the subject. If it were always remembered that there can be no such as infallibility, clinical or bacteriological, there factor, perhaps especially important as a predisposing thing would be no occasion for " exclusive advocacy " by the considered most a dietetic cause; (in deficiency being holders of opposing views. In this matter of diphtheria cases, at all events) as the actual determining cause. diagnosis there is no time fQr opposition and argument. As I wrote :There is urgent need for cooperation and agreement. "There is, of course, no intention of suggesting here that helminthic infections, by themselves alone, constitute the specific The clinical manifestations of diphtheria cannot be such infections are known to be prevalent systematised with absolute certainty. However sure cause of pellagra ; in many districts and countries where pellagra never, or only rarely, each of us may have been of his ability to dogmatise occurs." upon faucial lesions, sooner or later admission had to May I illustrate by a rough analogy ?° Chronic, local be made of a mistaken diagnosis. I think such must irritation or stimulation is known to be often a most represent the experience of all fever workers. How important contributory or predisposing cause of malig- could it be otherwise ?’? So equally must bacteriological nant disease; but this alone is not regarded as the dogmatism be impossible where diphtheroid organisms immediate determining cause-of malignancy, because a are in question. Many times the clinician must be malignant growth does not necessarily supervene upon disagreeably surprised by the variety of bacteriologists’ such a condition. opinions where B. diphtheriæ, B. hofmann, and diphIn the case of pellagra what I had in mind was that, theroids are under judgment. as regards the extent of their responsibility, the two Some such considerations may have been in Osler’sx factors might perhaps stand in relation to one another mind when he remarked thatin this way. The greater the adverse effect of " The clinical and bacteriological conceptions of diphtheria are at helminthic intoxication (and this may not be the same present not in full accord. On the one hand, there are cases of as the heavier infection the would the less itself), thing simple sore-throat which the bacteriologists, finding the Klebsbe the degree of dietetic deficiency which would suffice Löffler bacillus, call true diphtheria. On the other hand, cases of to produce suprarenal inadequacy and pellagra, and membranous, sloughing angina, diagnosed by the physician as are called by the bacteriologists pseudo-diphtheria or vice versa. With reference to the Turkish prisoners, I diphtheroid, diphtheroid angina. The term diphtheroid may be used for the stated in the summary of my report that the occurrence present to designate those forms in which the Klebs-Löffler bacillus of Ascaris eggs was very general, not only amongst the is not present. Though usually milder, severe constitutional disturbance and even paralysis may follow these so-called pseudopellagrins but equally amongst those who were liable diphtheritic processes." at any time to become pellagrous. Just at the time I Surely the foregoing is a laboured attempt to make was at Kantara, the incidence of pellagra was becoming distinction where there is no difference. It frequently very high; and had not the labour been knocked off, happens that a patient suffering from local and general one would hesitate to say how many of the " apparently characters of healthy " Turks would not have gone on to show a symptoms and having all the clinical for as many days as diphtheria, cultures "negative" I not condition. do therethink, manifestly pellagrous are required to rid the throat of the false membrane. fore, that my suggestion is so difficult of acceptance. Is it known whether any of the prisoners of our Is it to be wondered that " clinical and bacteriological l.E. F. and E.E.F. in Turkish hands showed symptoms conceptions of diphtheria are not in full accord " ?The of pellagra?And, if so, whether the cases occurred explanation of the apparent inconsistency is simple. A consideration of the histological structure of the false among the British or the Indians, or both? Because will, demonstrate the mechanical impossicertainly the Indians would be more generally infected membrane with helminths than the British. At any rate, as a bility in given cases of a swab, lightly rubbed upon the first step I think it would be worth while for workers in surface, reaching the underlying diphtheria bacilli. The parts touched are swarming with pyogenic cocci, pellagrous areas to endeavour to ascertain whether which, on culture by the bacteriologist, must give a there is a distinct correlation between cases of pellagra , ’ "negative field." The cold scientific fact is that the and the occurrence of helminthic infections. particular swab submitted for examination is " negative. I am, Sir, yours faithfully, The cool conclusion that the patient involved has no H. M. WOODCOCK. July 31st, 1920. diphtheria organisms in or about the fauces, hence cannot be suffering from diphtheria, is unscientific, THE TUBED PEDICLE IN PLASTIC SURGERY. and only serves to create a situation of professional embarrassment. To the Editor of THE LANCET. Scientific procedures cannot altogether supersede SIR,-The operating books, surgical records, and ward clinical observations. They must serve as valuable sisters’ report books of the Queen’s Hospital show the aids, and, if accorded that function, but not relied on following statement of fact. The first occasion on which the pedicles of a face flap were definitely tubed occurred 1 The Principles and Practice of Medicine, pp. 192-193.
As will be clear, I think, to readers, both of my section of the Pellagra Report on the Turkish Prisoners’ of War, and of my letter published in your issue of May 28th, the question is whether a helminthic infection is to be regarded as an essential contributory
correspondence
on
......
.
’
.