We shall content ourselves with saying that it is a grand work, condensing into small space the results of the labors of physicians and scientists. the world over. As a book of reference it is invaluable, and should be in the library of every progressive phy

sician.

The publishers have done their work in a highly creditable manner by presenting the profession with well-arranged, well-printed, and superbly finished volumes. The price ($15) is a very reasonable one, being within the limit of every physician.

The Function of the Lachrymal Puncta. By Geo. M. Gould, A.M., M.D. Reprint: Medical News.

Inert Tubercle Bacilli: Other More

Dangerous Organisms in the Sputum and Lungs. By F. J. Thornbury, M.D.

Everybody's Medical Duty: An address to the Unitarian Club of Philadelphia. By Geo. M. Gould, A.M., M.D.

A Method of Infection, Treatment and Prophylaxis of Ophthalmia. By Geo. M. Gould, A.M., M.D. Reprint: Medical News.

In conclusion, we feel like urging all who can to buy this work. It will The Necessity for Early Correction be money well spent, and the returns in Congenital Club-Foot. By H. Auwill far outweigh the cost to the pur-livered at the Jefferson Medical College gustus Wilson, M.D. A Lecture deHospital.

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Brochures Received. Influenza and the Latest Bacteriological Researches. By F. J. Thornbury, M.D. Reprint from Medical Record, June 4, 1892.

The Treatment of Tuberculosis of Bones and Joints by Parenchymatous and Intra- Articular Injections. Nicholas Senn, M.D. Reprint: Annals of Surgery, January, 1892.

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epidermis and dead tissue. An hour or two before operating, the skin of the thigh, from which the grafts are to be taken, must be sterilized, and wrapped in towels soaked in bichloride-solution. The patient is anæsthetized, and the soft upper layer of granulations cover

A Paper read before the Academy of Medicine, ing the ulcer completely scraped away

May 30, 1892,

BY

LEONARD FREEMAN, B.S., M.D.,

CINCINNATI.

A year ago I had the pleasure of bringing before you a case of skingrafting, according to the method of Thiersch. I propose to again call your attention to this interesting subject. It is in general the most satisfactory process of skin-grafting which has ever been employed, and has a most extensive applicability; and yet, for some reason, it has not come into the general use which it deserves.

with a sharp spoon, until firmer tissue is reached beneath. This layer is sometimes surprisingly thick, but it must all go, although a considerable depression may result. The thickened margins of the ulcer may also be scraped and trimmed away, and the entire surface leveled off as far as possible. Some endeavor to sterilize the ulcer at this point, they affirm with success, by the use of strong antiseptics, such as I : 1,000 bichloride. Thiersch counsels against this as endangering the vitality of the grafts, and recommends the employment, for purposes of irrigation, of nothing stronger than a 0.6 per cent. By means of the Thiersch-method solution of common salt. Hemorrhage it is possible to cover with epithelium is nearly always readily checked by ulcerating surfaces or fresh wounds of elevation and pressure by means of almost any character or extent in from pledgets of gauze, which Kleinknecht ten days to three weeks. And further: prefers to soak in peroxide of hydrogen. embarrassing cicatricial contractions can A piece of rubber protective between be prevented; and the stoppage of sup- the gauze and the bleeding surface prepuration and other septic processes, vents the tearing away, when the preswhich follows a successful skin-graft, sure is removed, of the clots which seal may be instrumental in saving life. Its the mouths of the vessels. It is better cosmetic value, in many cases, can to check the hemorrhage thoroughly, so scarcely be over-estimated. that the surface remains "dry."

tive, macerating and often destroying the delicate layers of transplanted skin. With the gauze dressing this is easily avoided, as the pus passes through the gauze and is either absorbed, or else may be washed away at once.

of the knee. With a backward and for- | accumulates beneath strips of protecward sawing motion it is easy to remove a thin shaving of epidermis an inch or so wide and several inches in length. It is not necessary, and perhaps not desirable, to include the entire thick ness of the skin, but only sufficient of it to cut through a number of papillary vessels and leave a lot of bleeding points.

The grafts thus obtained, being as thin as paper, fold into a bunch upon the razor as they are being cut. The end of the graft is now slid off the edge of the razor with a probe onto one side of the scraped ulcer, and held there while the razor is slowly moved across the raw surface, spreading out the graft in its course, in the same way that a nurse spreads a sheet beneath a bedridden patient. If the edges become turned under at any point, they must not remain so, but must be pushed backward and forward with a probe until they are unfurled and in their proper positions. The entire graft must then be smoothed out and pressed close to the underlying surface.

In a similar manner other strips of skin are shaved off and placed on the raw surface, until it is completely covered. It is better that the grafts not only slightly overlap each other, shinglewise, but that the margin of the ulcer itself should also be covered. But the process is often successful when this point is not strictly observed-new epidermis rapidly covering in the narrow, granulating strips between the grafts; although some contraction is then liable

to occur.

Thiersch considers it highly desirable, in order to preserve the vitality of the grafts, to apply a moist dressing, and this I have always done, except in one case, which proved a complete failure.

This dressing consists simply of a quantity of crumpled gauze, wet with sterilized 0.6 per cent. salt solution. I have been in the habit of covering this with first a layer of sublimate gauze, to ward off too rapid infection, then a layer of cotton and a sheet of oiled silk, to check evaporation, and lastly another protecting layer of cotton.

Thiersch contended that the dressings should be moistened every few hours; but others, including McBurney and Halstead, have shown that it is sufficient if the moist dressing be renewed every second day, and I have sometimes let it go much longer than that.

Fomin, of St. Petersburg, prefers the dry method of dressing, as do also Hübscher (Beitr. z. Klin. Chir., Bd. IV) and Jungengel. Fomin resterilizes the ulcer with strong bichloride after scraping, washes with distilled water, dusts the grafted surface, as does Jungengel, with iodoform, and applies an ordinary dry antiseptic dressing. The whole operation is done under local cocaine-anesthesia alone. Hübscher resterilizes the scraped ulcer and sometimeş uses boric acid and vaseline as a dressing. Fowler prefers the potassiomercuric-iodide as an antiseptic. All these operators report good results.

In dressing the grafted area, strips of rubber protective are usually laid on first; but I prefer another method which I devised some years ago. It consists in covering the grafts with a single, smooth, closely applied layer of gauze. The slightly bleeding surface, from This may be pinned around the limb, which the grafts were taken, is washed or held in place by strips of adhesive with bichloride and covered with an plaster at a distance from the margin of ordinary aseptic or antiseptic dressing, the ulcer. The grafts are thus held which may usually be left in place unfirmly in place, and the layer of gauze til new epithelium has formed-say two need not be removed until they have or three weeks. McBurney recombecome solidly attached; although the mends that the thigh be dressed with dressing above may be changed as often the salt solution. He claims that healas may be necessary. Pus generallying takes place quicker and with less

pain. I have tried this plan, but could | chances of carrying germs into the see no diminution in either the pain or deeper tissues. But in this way the the time of healing, while the danger of infection is certainly increased.

Eight to ten days are required for the grafts to become united, and during this time, at least, it is perhaps desirable to keep up the moist dressing, although some surgeons advise changing to the dry iodoform-dressing in five days. When the wet dressings are finally discontinued, I have found it well to apply some sort of ointment, such as aristol ointment or simple vaseline. This prevents the drying and cracking of the new skin, and the adherence of the dressings.

In a

granulations can not be followed into the inequalities of the floor of the ulcer, and it is questionable whether asepsis is thus promoted.

As has been mentioned, the majority of operators, including Thiersch, do not use antiseptics, at least after the ulcerating surface has been scraped, for fear of damaging the capillary circulation. Others, however, report numbers of cases in which strong antiseptics have been employed with the best results, and with the desirable effect of preventing suppuration. When antiseptics are used, it is best to wash them away with distilled water or salt solution before the transplantation is made. In my experience, plain, sterilized water has answered every purpose just as well as salt water.

Quite often, on examining the transplanted surface, a few days after the operation, or at the end of ten days or two weeks, the grafts will appear not to have taken-they will apparently have disappeared, or will seem to ad- It is generally accepted, and no here to the overlying gauze and be doubt correctly, that the grafts should pulled away with it, leaving the surface lie as close to the tissues beneath as of the ulcer with a whitish, macerated possible, without the interposition of appearance. This does not necessarily any blood. Witherspoon (Weekly Med. mean failure. It generally means that Rev., 1890), however, claims that a the outer layers of epidermis, those re- stratum of blood-clot is not only harmceiving little or no nutrition, have sep- less but desirable, as it fills up inequalarated from the rest of the graft, leav-ities, prevents suppuration (!), and ing the rete malpighii behind. furnishes nutriment to the grafts. But few more days the surface will again blood-clot, on the one hand, is pecubecome covered with epithelium. liarly liable to decomposition, and Garré has shown, on the other, that nutrition is obtained by the capillaries. of the deeper layer of granulations joining with or penetrating those of the grafts. Hence, Witherspoon's statement is not supported by theory, at least. It is, of course, true that a slight amount of blood-clot must exist beneath the transplanted skin; but, as Jungengel has said, if the layer is a little too thick the superficial epithelium exfoliates; and if much too thick the entire graft dies.

With infected surfaces, particularly old ulcers, suppuration nearly always occurs, especially if salt-solution only has been employed; germs will remain deep down among the granulations. But, up to a certain point, the cleaner the ulcer and its surroundings, the longer will suppuration be delayed; and at the end of five days, according to McBurney and others, it can do but little harm. This last statement I have repeatedly found to be true; and also that the formation of pus much sooner than this does not always indicate failure-indeed, Halstead mentions a satisfactory result obtained by transplantation onto the already profuse suppurating surface of a burn.

McBurney shaves off the upper layer of granulations, instead of scraping it away, in order to obtain a smoother surface and to lessen the

In order to avoid this objectionable stratum of blood, McBurney employs. an Esmarch strap during the operation, and claims that the results are very satisfactory. In the few cases in which I have seen this done, I had reason to think that hemorrhage took place beneath the grafts after the strap was removed, leading to their separation from