The principles and practice of modern surgery

by Roswell Park

Postoperative suppression of urine, which may occur even after catheterization, may be treated by giving 0.08 to 0.15 Cg. of sulphate of sparteine every three or four hours (McGuire).

SKIN GRAFTING.

The whole method of skin grafting is based on the fact that if epithelium be removed from any portion of the body and planted on favorable soil elsewhere it will take root and grow, reproducing only itself and no other kind of tissue. It is closely analogous to sewing seed upon a favorable soil, or even to sodding. Furthermore it is not necessary that epithelium be furnished from the individual upon whom it is to be implanted; it may come from another of the same species or even from a different species. Thus the skin of the frog has been used for grafting upon human beings, and even the lining membrane of the egg. Nor is it necessary that the epithelial cells should be apparently alive when thus employed. Very thin shavings of human skin which have been dried, or have been kept from decomposing by some antiseptic, have been successfully used; nevertheless the ideal method consists in taking what is needed from the individual who needs it.

The term skin grafting is now applied to the employment of very thin layers of the epidermis, i. e., as thin as can be shaved off with a sharp razor, and it does not apply to the autoplastic methods of skin transplantation.

Hamilton, of Buffalo, and Reverdin, of Geneva, a number of years ago independently discovered that minute particles of healthy skin might be implanted upon healthy granulations and that from such minute grafts epithelium would be produced and a fresh epidermal covering be afforded. This method was in use for years and was a great advance on what had previously been done. Then Hamilton, of Edinburgh, suggested the use of thin slices of clean sponge, in order that thereby a trellis might be offered for the growing and climbing granulation tissue; this served a good purpose in many cavities. But the greatest advance came when Thiersch demonstrated that large areas might be covered with skin shavings, and that thus in a few days there would be accomplished that which took weeks or months by older methods. His original plan comprehended only the use of these grafts upon granulation tissue; later it was found that they might be applied to fresh raw tissue, even to denuded bone. Thus originated the so-called Thiersch method of skin grafting.

The surface to which these grafts are applied must be thoroughly cleansed as well as the surface from which they are removed. If an ulcerated surface is to be prepared for grafting it should be scraped thoroughly with a sharp spoon; all sloughing or suspicious tissue should be carefully removed, and all oozing allowed to subside. Not until the surface is prepared is it advisable to remove the grafts. These are best removed by putting upon the stretch the skin of the selected area, so as to render it taut and as nearly flat as possible. The razor used for the purpose should be sterilized and sharp. Salt solution may be allowed to drip upon the razor while the surgeon is using it. It is rarely practicable to remove a strip over 5 Cm. wide or 25 Cm. long. The endeavor should be to remove only the superficial layer of the skin, and when properly done this removal should be followed by but a trifling oozing of blood. If bleeding be profuse the layer removed has been too thick. Grafts of sufficient number and size are removed to nearly cover the desired area. The more completely it is covered the more acceptable will be the final appearance of the surface. If the grafts adhere, we may confidently rely upon their furnishing enough fresh epithelium to fill in the irregular defects between the edges. The grafts when cut should be raised with a razor and a spatula and gently spread out upon the prepared surface, and so pressed and treated that no air bubbles are retained beneath them. If the surface be dry enough they will adhere to the very thin coagulum of blood which glazes it, and after a few moments it will take friction to disturb them.

Should the margin of the surface to be grafted be old and indurated it is best to trim off any depression that exists, so that the new skin may not be let in below the surface of the surrounding skin.

The dressing should consist of a layer of sterilized oiled silk, gutta-percha tissue, or green protective, laid on in strips, in order that excessive fluid may escape between them. A little antiseptic powder may be dusted upon the grafts, if such be the choice of the surgeon, but if the operation has been properly managed this will hardly be necessary. Careful regulated pressure should be made outside of the protective, by cotton and a suitable dressing, and then the part, if a limb, may be bound upon a splint in order to ensure physiological rest. Silver, tin, or aluminum foil also make a good protective, and, on theoretical principles, are even better than the textile materials.

Some surgeons leave these dressings for several days. I have found it an advantage to remove them within thirty-six hours, as sometimes the grafts appear to be macerated in the fluids and to lose their first cohesion to the prepared surface. The main thing about the dressing is that it should be non-adhesive and restful. After three or four days, when the grafts have completely adhered, any ointment dressing may be used. It may happen that only a portion of the entire number of grafts serve their purpose, and that others fail to do their work. Even when the failure has been apparently considerable it will often be seen that individual epithelial cells have adhered and later will grow. The unhealed portions of such a surface now fall within the definition given earlier of an ulcer, and should be subjected to the same treatment.

Grafting may be repeated as often as seems to be necessary. The best surfaces from which to take the grafts are usually the outer aspects of the arms and thighs. The places from which they are removed need only the simplest antiseptic dressings. If the grafts have been of sufficient thinness the scars left by their removal are scarcely permanent and rarely disfiguring.