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SKIN GRAFTING 
 
SKIN GEAFTING 
 
 FOR SURGEONS AND 
 GENERAL PRACTITIONERS 
 
 BY 
 
 LEONARD FREEMAN, B.S., M.A., M.D. 
 
 PROFESSOR OF SURGERY IN THE MEDICAL DEPARTMENT OF THE 
 UNIVERSITY OF COLORADO, SURGEON TO ST. JOSEPH'S HOS- 
 PITAL, THE NATIONAL JEWISH HOSPITAL, AND THE 
 CITY HOSPITAL, DENVER, COLORADO 
 
 WITH ®i ILLUSTRATIONS 
 
 ST. LOUIS 
 
 C. V. MOSBY COMPANY 
 
 1912 
 
■^ 
 
 &h 
 
 Copyright, 1912, by C. V. Mosby Company 
 
 Press of 
 
 C. V. Mosby Company 
 
 St. Louis 
 
 ©CI.A332140 
 
CONTENTS 
 
 CHAPTER I. 
 
 PAGE 
 
 Terminology — Early History 1-6 
 
 Definitions — Early History. 
 
 CHAPTER II. 
 
 Comparative Vitality of Grafts from the Old and from 
 the Yotjng — Heterogeneous Grafting — Dangers of 
 Transferring Disease — Influence of the Patient's 
 General Condition upon Skin Grafting — Surgical 
 
 Cleanliness 7-12 
 
 Grafts from the Old and from the Young — Heterogene- 
 ous Grafting — Transmission of Disease — The Patient's 
 General Condition — Death from Skin Grafting — Sur- 
 gical Cleanliness. 
 
 CHAPTER III. 
 Tee Method of Reverdin 13-32 
 
 Preparation — Where to Obtain Grafts — Size of Grafts — 
 Method of Cutting Grafts — Placing the Grafts — Legal 
 Questions — Dressings— Wet and Dry Dressings — Chang- 
 ing Dressings — Process of Healing — After-treatment. 
 
 CHAPTER IY. 
 The Method of Thiersch — Its Use in Special Cases . . 33-67 
 General Technic — Hemorrhage — Curetting — Preparation ■ 
 of Granulations — Methods of Cutting Grafts — Placing 
 the Grafts — Grafting in Two Stages — Thin vs. Thick 
 Grafts — Anesthetics — Dressings — "Splinting" Grafts — 
 Treatment of Wounds After Removal of Grafts — "Ac- 
 cordion Grafts" — Proper Time for Grafting — After- 
 treatment — Application of Thiersch Grafting — Thiersch 
 Grafting in Special Cases — Heterogeneous Thiersch 
 Grafting — Statistics. 
 
CONTENTS 
 
 CHAPTEE V. 
 
 PAGE 
 
 The Wolfe-Krause Method 68-73 
 
 Preparation — Technic — Adjustment of Grafts and Dress- 
 ings — After-treatment. 
 
 CHAPTER VI. 
 
 The Method of Hirschberg — Skin-Periosteum-Bone 
 Grafts 74-76 
 
 CHAPTER VII. 
 
 The Transplantation of Mucous Membrane — Anomalies 
 
 in Skin Grafting — Sponge Grafting 77-83 
 
 Mucous Membrane — Anomalies in Skin Grafting — 
 Sponge Grafting. 
 
 CHAPTER VIII. 
 
 Grafting from Animals 84-89 
 
 CHAPTER IX. 
 
 Grafting in Lupus, in X-ray Burns, on the Cranium, 
 and in Connection with the Eye and Ear .... 90-104 
 Lupus — X-ray Burns — Grafting on the Cranium — The 
 Eye— The Ear. 
 
 CHAPTER X. 
 Local Anesthesia in Skin Grafting 105-107 
 
 • CHAPTER XL 
 
 Histology and Pathology * 108-121 
 
 Adhesion and Nutrition — Color — Mortality — Sensation 
 — Cicatricial Contraction — Exfoliation — Depressions — 
 Production of Epithelium — Independent Longevity of 
 Epithelium — Epithelial Stimulation — Grafting from Ne- 
 gro to White Man — Cheloids. 
 
 CHAPTER XII. 
 
 Brief Comparison of Different Methods of Skin Graft- 
 ing . 122-125 
 
ILLUSTRATIONS 
 
 FIGURE PAGE 
 
 1 Incisions through indurated border and floor of callous ulcer 18 
 
 2 Cutting a Reverdin graft 21 
 
 3 Cutting a Reverdin graft 22 
 
 4 Cutting grafts from pellicle of new skin at border of healing 
 
 ulcer 23 
 
 5 Reverdin grafts in place 24 
 
 6 Reverdin graft in place at the end of planting 25 
 
 7 Strip of rubber tissue with punched-out drainage holes . . 27 
 
 8 Strip of gauze pinned about the leg for holding grafts in 
 
 place 28 
 
 9 Cutting Thiersch grafts from thigh 34 
 
 10 Thiersch graft partially cut 35 
 
 11 Showing how Thiersch grafts should overlap each other . 36 
 
 12 Thiersch grafts in place 36 
 
 13 McBurney's hooks for stretching skin 41 
 
 14 Halsted method of cutting large Thiersch grafts .... 42 
 
 15 Sliding Thiersch graft from razor on to surface of ulcer . . 44 
 
 16 Placing Thiersch grafts from razor 45 
 
 17 Wire cage in place in open method of grafting 49 
 
 18 Wire cage in place in open method of grafting 50 
 
 19 Wire cage for open method of grafting 50 
 
 20 Method of "splinting" grafts with netting 52 
 
 21 Accordion grafts 54 
 
 22 X-ray dermatitis of hip 94 
 
 23 X-ray burn of hand 94 
 
 24 Points for insertion of local anesthetic in skin grafting . .106 
 
SKIN GRAFTING 
 
 CHAPTER I 
 . TERMINOLOGY— EARLY HISTORY 
 
 Definitions. 
 
 Skin grafting should not be confused with plastic surgery 
 (anaplasty), as is frequently clone. The former refers to 
 operations in which portions of skin or of epithelium are 
 entirely severed from their original connections and used 
 to fill in defects elsewhere ; while the latter should be 
 limited to procedures where flaps of skin are employed 
 which are merely loosened from the underlying tissues and 
 slid from one point to another, or are provided with pedi- 
 cels through which nutriment is furnished until union 
 takes place. 
 
 The simplest form of plastic work consists in "mobiliz- 
 ing" the integument adjoining a wound in order to relieve 
 tension and facilitate the application of sutures. The 
 most complicated is perhaps that introduced by Schrady, 1 
 in which a skin-flap is made to adhere to the denuded side 
 of a finger, so that when the original connections are sev- 
 ered the flap may be conveyed, attached to the finger, to 
 any portion of the body— the digit serving as a sort of 
 movable pedicel. 
 
 1 Medical Record, Jan. 24, 1891, p. 117. 
 
 1 
 
SKIN GRAFTING 
 
 Transplantation is another term for skin grafting. Im- 
 plantation means practically the same as transplantation 
 (Gould), although its use is often limited to operations in 
 which dead organic or inorganic substances are employed. 
 D ermanoplasty (Esmarch) and dermepenthesis are some- 
 what obsolete synonyms for skin grafting. The w^ord flap 
 should be confined to plastic surgery, and the word graft, 
 to transplantation. 
 
 Transplantation is sometimes designated as the first or 
 older Indian method, in contradistinction to the second 
 Indian method, often called simply "Indian method," in 
 which a pedunculated flap, with more or less twisted pedi- 
 cel, is taken from the adjacent tissues. In the Italian 
 method, the flap is obtained from one of the extremities 
 which can be brought in contact with the field of opera- 
 tion — for instance, the arm in rhinoplasty. 
 
 When grafts are composed of epithelium alone, whether 
 in the form of large or of small pieces, or of so-called 
 "epidermal dust," they are known as epidermal grafts; 
 when comprising both epidermis and a portion of the true 
 derm, as der mo-epidermal grafts; and w T hen made up of 
 the entire thickness of the skin, whether including the 
 subcutaneous connective tissue or not, as total cutaneous or 
 "whole-thickness" grafts. 
 
 Vegetable grafting, termed instition, by Kiister, has little 
 in common with skin grafting, in spite of a superficial 
 similarity. Vegetable grafts grow upon their hosts from 
 first to last as separate individuals, something in the 
 nature of parasites. Skin grafts, on the contrary, become 
 a portion of the tissue into which they are transplanted. 
 Such experiments, however, as the one made by John 
 
EARLY HISTORY 
 
 Hunter, a hundred years or more ago, of transplanting the 
 spur of a cock to the comb of the same fowl, has a strong 
 resemblance to vegetable grafting. 
 
 When grafts are obtained from the patient himself, they 
 are preferably called aidodermic ; when from another in- 
 dividual, lietero-, homo-, or isodermic; and when from 
 animals, zoodermic — the methods being known as auto- 
 plastic, heteroplastic, and zooplastic. 
 
 Early History. 
 
 Surgery is usually regarded as a modern science, and yet 
 the ancient Hindus, perhaps two thousand years ago, per- 
 formed many difficult operations as successfully as we per- 
 form them now. Particularly is this true of some forms 
 of plastic surgery and of skin grafting. 
 
 It was the custom in India to punish certain offenses by 
 cutting off the nose. As an almost necessary consequence, 
 there appeared at an early date men skilled in plastic 
 surgery, who belonged, strangely enough, to a low and 
 despised class, the tile-maker's caste. Their work is said 
 to have been excellent, even superior in some respects to 
 that done at the present time. One of the most remark- 
 able achievements of these pioneers in surgery was the 
 replacement of the nose by a graft from the thick skin 
 of the gluteal region, a feat which even now cannot be 
 repeated with certainty. When we consider that the sub- 
 cutaneous fat was included and that no support could have 
 been had from underlying tissues, the success obtained 
 seems little short of marvelous. The temptation is great 
 to ascribe some virtue to the secret "cement" employed, 
 
4 SKIN GRAFTING 
 
 but we know so little of the actual technic that speculation 
 in this line is not of much value. 
 
 Tt was once thought that pieces of skin transplanted from 
 one individual to another grew vigorously or withered as 
 the original possessor's health became good or bad. Hence, 
 it may be imagined that the man bearing such a graft 
 must often have been very solicitous as to the physical 
 welfare of the donor. 
 
 It is probable that skin grafting, like some other arts, 
 was largely lost sight of during the middle ages, although 
 here and there a more or less authentic account of an 
 isolated case has been preserved. For instance, it is re- 
 lated by Sancassani (1731 to 1738), that a female street- 
 vender, in order to prove the efficacy of a certain salve, was 
 accustomed to cut a piece of skin from her leg, pass it 
 around the audience upon a plate, and then replace it in its 
 original position, covering it with salve. Such perfect 
 union took place that the site of the operation was scarcely 
 discernible. 
 
 About the end of the eighteenth century some account 
 of the Indian methods of grafting was brought to Europe 
 by travelers. The statements, however, were credited by 
 few, and those who did believe were generally disap- 
 pointed when they tried the experiment themselves. 
 Nevertheless Van Helmont 2 states that Tagliacozza, a 
 Bologna surgeon famous for his achievements in rhino- 
 plasty, constructed a nose for a patient in Brussels from 
 the skin of the arm of a workman; but Tagliacozza has 
 been credited with so many wonderful things that it is 
 difficult to sift the true from the false. 
 
 2 Opera Omnia, 1682. 
 
E^KLY HISTORY » 
 
 The skin from the back of a student's hand is said to 
 have been used by Dzondi in the formation of a woman's 
 nose, and Biinger 3 succeeded in getting a portion of a 
 graft from the thigh to adhere in a similar operation. 
 
 And yet, while disbelief was almost universal, it must 
 have been generally known among medical men that cer- 
 tain parts — such as noses and fingers^ when accidentally 
 severed from their connections — were capable of becoming 
 reunited under favorable circumstances. In fact, records 
 of such cases are not uncommon in the writings of various 
 ages, and one would imagine that the conception of skin 
 grafting, based upon such a foundation, would have been 
 almost unavoidable. John Bell, 4 however, scornfully 
 mentions two instances, regarding them as fabrications; 
 and yet they may well have happened. The first was 
 described by Garengeot as follows: 
 
 A soldier, reeling out of a tavern drunk, along with some of his 
 companions, got into a quarrel, in which one of them bit his nose off, 
 threw it into the gutter and trode it under foot. He picked up his 
 nose, flung it into Mr. Gallin's, an apothecary's shop, ran after the 
 fellow who had done it, and when he returned, Mr. Gallin washed the 
 nose at the well, stuck it with plaster in its place, and in two days 
 after it was firmly united. 
 
 The second instance was related by Sir Leonard Fiora- 
 vanti : 
 
 In that time when I was in Africa there happened something 
 strange and this was it. A certain gentleman, a Spaniard, that was 
 called Seignior Andrew Gruitiero, of the age of twenty-nine years, upon 
 a time walked in a field with a soldier, and had words with him and 
 began to draw. The soldier seeing that, struck him with the left 
 hand and cut off his nose, and then it fell down in the sand, and 
 then I happened to stand by and took it up, and washed away the 
 
 3 Graf e and Walther's Jour., 1823. 
 
 * Principles of Surgery, London, 1826. 
 
6 SKIN GRAFTING 
 
 sand, and stitched it on again very close and dressed it with our 
 balsam um artificiato', and bound it up and so let it remain eight 
 days, thinking that it would have come to matter, nevertheless, when 
 I did unbind it, I found it fast conglutinated, and then I only dressed 
 it once more, and he was perfectly whole. 
 
 A unique feature of this interesting narration is the fact 
 that the sand was removed from the severed part by 
 urinating upon it — certainly an easy method of procuring 
 a supply of sterile salt solution ! 
 
 So firm was John Bell in his belief that no portion of the 
 body could grow on again after it had once been completely 
 removed, that when confronted by a man who had chopped 
 off the end of a finger and successfully replaced it, Bell 
 tried to explain the circumstance by supposing that "so 
 small a piece of the finger may have rotted after it was 
 bandaged, the remaining flesh upon the point of the finger 
 growing up to supply its place." What would this eminent 
 surgeon have thought had he come in contact with a case 
 similar to one reported by Finney 5 in which a finger be- 
 came reunited after being completely severed from the 
 body some seven hours, or the case observed by Kelley 6 
 where the soft parts of a nose grew in place after having 
 been separated an hour? As early as 1836, Hoff acker, 7 
 surgeon to a students' duelling corps in Heidelberg, suc- 
 ceeded in reuniting numerous severed portions of noses and 
 a piece of a lip. 
 
 5 Johns Hopkins Hosp. Bull., Oct.-Nov., 1892. 
 
 6 Times and Register, Phila., Aug. 16, 1890. 
 
 7 Med. Annalen, 1836. 
 
CHAPTEE II 
 
 COMPARATIVE VITALITY OE GRAFTS FROM 
 THE OLD AND FROM THE YOUNG— HETERO- 
 GENEOUS GRAFTING— DANGERS OF TRANS- 
 FERRING DISEASE— INFLUENCE OF THE 
 PATIENT'S GENERAL CONDITION UPON 
 SKIN GRAFTING— SURGICAL CLEANLINESS 
 
 Grafts From the Old and From the Young. 
 
 It has often been stated that grafts taken from the old, 
 especially when including the entire thickness of the skin, 
 do not grow so well as those removed from younger individ- 
 uals, even when the transplantation is made from the 
 patient's own body. Most of these assertions, however, are 
 based upon an article by Dobson, 1 whose experiments were 
 limited to but one graft in one case. More recently others 
 have made similar claims, with somewhat more ground for 
 their assertions, and Sullivan 2 says that experience has 
 taught him that skin from babies, particularly those at 
 the breast, is possessed of superior vitality. Ivanova has 
 utilized this idea in grafting from the bodies of dead 
 infants. 
 
 Many successful graftings are, nevertheless, done upon 
 individuals well advanced in years ; and not only that, but 
 they are done under unfavorable conditions, as in ulcers 
 of the leg. Even admitting that grafts from the young 
 
 1 Medical Times and Gaz., Oct. 29, 1870. 
 
 2 Med. Rec, Jan. 9, 1897, p. 48. 
 
8 SKIN GRAFTING 
 
 may show a somewhat greater vitality than those from the 
 old, there is not sufficient difference in this regard to 
 warrant either a refusal to operate upon old people or an 
 attempt to invariably employ in such cases skin taken 
 from the young. 
 
 Heterogeneous Grafting. 
 
 There is no doubt that grafts thrive best when obtained 
 from the patient's own body, but nevertheless grafting 
 from others may be successful, although many of the mar- 
 velous cases described in the daily press are either exag- 
 gerated or have been reported too soon to be scientifically 
 reliable. Although the grafts may apparently flourish at 
 first, many of them, even when derived from blood rela- 
 tions, are apt ultimately to disappear in two or three weeks, 
 with or without suppuration. 3 This was exemplified in 
 one of the writer's cases, in which a large bum was covered 
 by grafts partly obtained from the patient's thighs and 
 partly from those of his mother. Every one of the auto- 
 dermic grafts survived while all of the isodermic transplan- 
 tations ultimately perished. 
 
 Davis 4 has recently reported forty cases of isodermic 
 Thiersch grafting with nineteen complete successes, sixteen 
 partial successes, and but ixve failures. In his opinion, 
 "isodermic grafts are quite as successful as those from the 
 same individual under similar favorable conditions," but 
 the experiences of many others do not warrant so optimistic 
 a conclusion ; and it is undoubtedly safer, from all points of 
 view, to transplant from the patient's own body. Heter- 
 ogeneous grafting shoul'd always be done when possible 
 
 3 Lexer, Zent. f. Chir., 1911, -No. 29, p. 23. 
 * Ann. Surg., 1909, Vol. 50, p. 542. 
 
TRANSMISSION OF DISEASE \) 
 
 under local anesthesia, in order to avoid danger to the 
 donor of the skin. Schaefer 5 thinks that heterogeneous 
 transplantations do best when donor and recipient are of 
 about the same age, but the accuracy of this view may well 
 be questioned. 
 
 Transmission of Disease. 
 
 There is no doubt, that diseases of various kinds can be 
 transmitted in skin grafting from one individual to an- 
 other ; and in fact, this has been done in numerous in- 
 stances: Syphilis is most to be feared. Deuvel 6 reports 
 the case of an old gentleman with a large ulcer following 
 erysipelas, which was grafted from a number of different 
 persons, including his son. The patient soon developed 
 syphilis, originating in the grafted area. Upon investi- 
 gation, the son was found to be afflicted with the disease in 
 its secondary stage. Such unfortunate accidents may be 
 guarded against, however, by obtaining a preliminary 
 Wassermann reaction. 
 
 Czerny 7 mentions two cases, which are, however, not 
 convincing, in which tuberculosis was thought to be trans- 
 mitted by grafts obtained from legs which had been am- 
 putated for white-swelling of the knee. The patients 
 developed phthisis, although no signs of the disease had 
 existed before, and the family histories were clear. 
 
 Smallpox is said to have been inoculated through skin 
 grafting in at least one instance; and as far as the other 
 acute infectious diseases are concerned, the list is probably 
 limited by lack of opportunity only. 
 
 5 Tr. Internat. Med. Cong., 1887. 
 
 6 Union Med., Dec. 11, 1881. 
 
 7 Verhand. d. Deut, Gesell. f. Chir., 1886; Cent, f. Chir., 1886, No. 24. 
 
10 SKIN GRAFTING 
 
 Halm 8 has shown, by an experiment for which he has 
 been severely censured, that cancer may be transplanted 
 from one portion of the body to another. He grafted an 
 area of skin from an inoperable carcinoma to the surface 
 of a wound made elsewhere, thus producing a malignant 
 growth at the point of implantation. Similar experiments 
 have since been repeated many times by others, and auto- 
 inoculations have often been observed following operations 
 for cancer. 
 
 The Patient's General Condition. 
 
 This is not of so much importance as a contraindication 
 to grafting as might be supposed. On the contrary, the 
 correction of a local septic process by transplantation can 
 materially assist in the regaining of health and strength. 
 Wounds may heal and grafts grow in a satisfactory manner 
 upon those whose physical status is much below par, unless 
 some specific poison be present. 
 
 Erysipeolas can cause grafts to dissolve even after adhe- 
 sions have taken place ; hence transplantations should not 
 be made for perhaps six or eight weeks after the disease 
 has disappeared, as streptococci are capable of existing for 
 a long time within the tissues. Any acute fever, especially 
 one of the exanthemata, may act in a more or less unfavor- 
 able manner. 
 
 It can scarcely be doubted that diabetes and nephritis 
 exercise a somewhat unfavorable influence ; and yet success- 
 ful grafting has been done in the presence of these condi- 
 tions, and they need not deter us from operating in the 
 absence of other contraindications, although, for obvious 
 
 8 Ber. Klin. Woch. No. 21, 1888, p. 413. 
 
HSTFLTJEOSrCEl OF DISEASE 11 
 
 reasons, local rather than general anesthesia shonld be 
 chosen. 
 
 Of all constitntional disorders, syphilis is probably the 
 most disturbing, so much so that it has been claimed that 
 grafting shonld never be attempted when this disease is 
 present, and Hartley 9 cites several cases which he thinks 
 show that grafts will not adhere until syphilis has disap- 
 peared from the system. Much depends, of course, upon 
 the stage of the trouble, and upon whether the surface 
 which is to receive the grafts is directly syphilitic. 
 Wounds often heal readily in syphilitics, and there would 
 seem to be no reason why grafts should not grow ; in fact, 
 they frequently do so, as has been demonstrated by the 
 writer and by others. Nevertheless, it is wise to subject 
 the patient to a preliminary course of antisyphilitic treat- 
 ment lasting at least three or four weeks, particularly if 
 the disease is active. Grafting on genuinely specific ulcers 
 is not to be thought of, as it will almost certainly be fol- 
 lowed by failure. 
 
 Death From Skin Grafting. 
 
 A case in which death followed the transplantation of 
 skin to the surface of a large burn is reported by Dunn. 10 
 He suggests that a fatal toxemia was produced by dis- 
 turbance of the granulations ; but suppuration had been 
 in existence for a year, and it is possible that amyloid 
 disease may have been responsible for the accident. The 
 urine was not examined. 
 
 It is well established that skin grafting is an extremely 
 safe procedure. The small mortality which accompanies 
 
 9 N. Y. Med. Jour., Aug. 27, 1892, p. 247. 
 
 10 Northwestern Lancet, Apr. 15, 1893. 
 
12 SKIN GRAFTING 
 
 it being due to extraneous causes and not to the operation, 
 itself. 
 
 Surgical Cleanliness. 
 
 This is of much importance, because the more nearly the 
 surface to be grafted approaches an aseptic condition the 
 greater is the likelihood of success ; and if the skin from 
 which the cuticle is obtained is not cleansed, infection may 
 result with more or less disastrous effects. 
 
 Just as in other surgical operations, the cutaneous sur- 
 face should be shaved, scrubbed, and rubbed with alcohol. 
 Strong antiseptics, such as bichlorid of mercury, are un- 
 necessary ; but if they are used, they must be washed away 
 with care, as the presence of even a small quantity may 
 interfere with the vitality of the grafts. For this reason, 
 the iodin method is not often employed in skin grafting. 
 
 The edges of cutting instruments, such as razors and 
 knives, are injured by. boiling ; hence they are best sterilized 
 by placing them in pure carbolic acid, afterward rinsing 
 them in alcohol, which in turn is removed with salt solution. 
 
 Although asepsis is undoubtedly desirable, it must not be 
 supposed that it is always necessary to success. Trans- 
 plantations will often adhere in the presence of the most 
 profuse suppuration, providing the granulations are in 
 reasonably good condition. In fact, in the grafting of 
 ulcers and granulating wounds, it is seldom possible to pro- 
 cure even an approximately aseptic surface, although more 
 or less successful attempts are often made in this direction, 
 as described in detail under the various methods of graft- 
 
CHAPTEE III 
 THE METHOD OF REVERDIN 
 
 Skin grafting is really one of the oldest procedures in 
 surgery; and yet, so far as modern times are concerned, 
 we knew little or nothing about it until Dec. 8, 1869, when 
 J. L. Keverdin, 1 an interne of La Charite, in Paris, made 
 his famous report on the subject to the Societie de Chirurgie, 
 in which he claimed that bits of skin, completely severed 
 from their original connections, would adhere and grow 
 upon granulating surfaces. Others had reported similar 
 experiments prior to this, however, to which scant attention 
 had been paid. 
 
 The principle was so audaciously new that many medical 
 men of prominence in England and upon the Continent 
 sneered at the discovery and greatly underrated its value, 
 claiming that it was a painful operation which made new 
 wounds and distracted attention from legitimate treatment 
 of the old ones. Even David Page, 2 president of the Royal 
 Medical Society of Edinburgh, with the usual fatuity of a 
 medical prophet, said that skin grafting was "not likely to 
 occupy a permanent position in minor surgery." 
 
 Pollock 3 was among the first to adopt Reverdin's dis- 
 covery in England, being rapidly followed by Bryant and 
 others. Hodgen 4 and Munoz were two of the earliest 
 
 1 Bull de la Soc. de Chir., Dec. 10, 1869. 
 
 2 Brit. Med. Jour., Dec. 10, 1870 — Archiv. Gen. de Med., 1872. 
 
 3 Trans, of the Clin. Soc, London, 1871. 
 
 4 St. Louis Med. and Surg. Jour., July, 1871. 
 
 13 
 
14 SKIN GRAFTING 
 
 writers on the subject in America. In France, Reverdin's 
 claims were soon abundantly established, and skin grafting 
 became very popular. 
 
 From sneering indifference, the surgical world then 
 passed to overcredulity, in which exaggerated notions were 
 held regarding the possibilities, of the discovery. It was 
 frequently stated that the new skin was identical with 
 normal cuticle, and that one need have no hesitation in 
 making the most extraordinary promises in this regard, 
 even in operations about the face and other exposed por- 
 tions of the body. We now know, however, that the limi- 
 tations of the method are great, and that its use should be 
 restricted to certain cases only where the cosmetic results 
 are of minor importance. 
 
 It is often asserted that Hamilton, of New York, con- 
 ceived the idea of skin grafting in 1847, and put it into 
 execution on January 21, 1854, many years before Rever- 
 din published his experiments, and Parmenter 5 even goes 
 so far as to designate the process the "Hamilton-Reverdin 
 Method." But if Hamilton's reference to his own opera- 
 tion is referred to, 6 it is at once evident that what he per- 
 formed was not a Reverdin operation, or even skin graft- 
 ing at all, in the proper sense of the term, but merely a neat 
 piece of plastic work in which he partially covered a crural 
 ulcer with a pedunculated flap from the other leg. Hamil- 
 ton, however, stated the important principle that it is un- 
 necessary to cover a granulating surface completely in order 
 to procure cicatrization, the new skin having a tendency to 
 increase in area and fill in the deficiencies. He designated 
 his procedure elk o plasty. 
 
 5 Surgery by American Authors, Roswell Park, 1896. 
 
 6 N. Y. Med. Jour., Sept. 1871, p. 225; N. Y. Med. Gaz., Aug. 20, 1870. 
 
THE METHOD' OF REVERMN 15 
 
 Preparation. 
 
 Some attention must be paid to the surface to be grafted, 
 in Reverdin's method, in order to insure reliable results, 
 although, this is of less importance than in other procedures. 
 With fresh wounds and "healthy" granulating surfaces 
 little preparation is requisite, but under more unfavorable 
 conditions it is quite necessary. 
 
 Bryant 7 recognized that it was possible for epithelium 
 to grow upon an unhealthy granulating surface. In fact, 
 the majority of Eeverdin grafts are applied in the pres- 
 ence of more or less pus, and they have been known to 
 thrive even upon the ulcerating surfaces of cancers 
 (Kraske). It is nevertheless true that the healthier the 
 granulations the greater the chance of success. One would 
 hesitate before grafting upon tuberculous ulcers or those 
 directly due to syphilis, and certain other conditions 
 should be regarded in a similar manner. Ulcers in which 
 the granulations are large and pale ("indolent," "exuber- 
 ant," "succulent,") are unfavorable, as are likewise those 
 presenting patches of necrotic tissue. 
 
 The granulations should be of medium size, vascular, 
 and of a fresh red color; not large and "flabby" or small, 
 hard, and "irritable," as is sometimes found in ulcers pos- 
 sessing little tendency toward healing. One of the best 
 indications of fitness for the reception of grafts is the for- 
 mation of a pellicle of new skin around the borders of an 
 ulcer. It has been claimed by some that grafting should 
 never be attempted unless such a pellicle exists, but this is 
 undoubtedly going too far. Nevertheless, excavated ulcers 
 
 7 Guy's Hosp. Reports, 1872, p. 237. 
 
16 SKIN GRAFTING 
 
 and those with undermined edges do not usually present 
 surfaces fitted for transplantation. It has been asserted 
 that no pus should be present. Desirable as such an aseptic 
 condition undoubtedly is, in the majority of instances it is 
 unnecessary or practically impossible of realization. 
 
 It is generally sufficient, then, that suppuration is not 
 too profuse, and that the pus is "laudable" in character; 
 but if actual or at least relative asepsis is desired, it may 
 be secured by mopping with pure carbolic acid, scraping 
 away the granulations down to the firm tissues beneath, and 
 then dressing with a layer of gauze, over which is smeared 
 sterile boric acid ointment. In twenty-four to forty-eight 
 hours a healthy granulating surface suitable for grafting 
 is obtained. 8 Painting with tincture of iodin is also 
 effective. (See chapter on Thiersch Grafting.) 
 
 The cicatricial tissue, which often surrounds the 
 margins of old ulcers and lines their bases, encapsulating 
 them, as it were, interferes decidedly with the vascular 
 supply and may render skin grafting difficult if not im- 
 possible. Sometimes this tissue is so dense that suitable 
 granulations refuse to form, and the surface of the ulcer 
 remains comparatively smooth and bloodless, as though 
 scooped out of cartilaginous material. Inflammation of 
 the surrounding skin or of the ulcer itself is also prejudi- 
 cial to success. 
 
 If the circulation be impaired by cicatricial tissue or 
 by varicosities, or if marked inflammatory changes be pres- 
 ent, complications which are more likely to occur when 
 the ulcer is on one of the lower extremities, the patient 
 should remain in bed until the part regains as far as pos- 
 
 8 J. S. Davis, Internat. Jour. Surg., June, 1910. 
 
THE METHOD OF REVERDIN 17 
 
 sible its normal tone. This may require from a few days 
 to several weeks. 
 
 Gauze compresses wrung out of warm salt solution or 
 weak bichlorid of mercury are of use in allaying inflam- 
 matory processes. Carbolic acid should not be employed, 
 for this purpose, as its prolonged contact with tissues having 
 at the best a deficient vitality may do more harm than 
 good, as has been sufficiently demonstrated in connection 
 with gangrene of injured fingers produced by weak solu- 
 tions (2 per cent). Moderate pressure, applied evenly 
 with a roller bandage, is generally of value. 
 
 When all necrotic tissue has disappeared, and acute in- 
 flammation has been allayed, the granulations should be 
 prepared for reception of the grafts, providing the con- 
 ditions are not already satisfactory. This is best done 
 in most cases by cauterization and compression, em- 
 ploying stick nitrate of silver or tincture of iodin for the 
 former and a. roller bandage for the latter. Between the 
 cauterizations, which should take place every two or three 
 days, compresses wet with bichlorid, liquor sodse chlor- 
 inata, or 0.5 per cent chloral, may be placed upon the 
 ulcer, or else boric acid, aristol, or acetanilid salve, or per- 
 haps these substances in the powdered state. Iodoform 
 gauze saturated with balsam of Peru sometimes does good 
 service. Where there is a tendency to acute eczema, dry 
 dressings with talcum powder are often preferable. A 
 daily washing of the part in warm soapsuds may be de- 
 sirable when there is considerable discharge. 
 
 When induration and fibrous thickening of the borders 
 of the sore exist, absorption may be induced by compres- 
 sion applied with imbricated strips of adhesive plaster or 
 
18 SKIN GRAFTING 
 
 by means of a coin bound rather firmly against the part. 
 Sometimes a few radiating incisions through the ring 
 of callus down to the softer tissues beneath are of service 
 in relieving tension and favoring vascular supply (Fig. 
 1). These incisions may at times be continued through 
 the thickened floor of the ulcer itself, and are usually not 
 very painful owing to the obtunded sensibility of the tis- 
 sues. A number of small parallel incisions are valuable 
 
 Fig. 1. — Incisions through indurated border and floor of " callous ulcer." 
 
 for the purpose of loosening up the indurated floors of cer- 
 tain old ulcers. 
 
 For the purpose of cleaning up old ulcers and stimu- 
 lating their granulations, Eichard Harte often employs an 
 aseptic flaxseed poultice, held firmly in place by the elastic 
 pressure of a thin rubber bandage. 
 
 Any strong antiseptics which may have been used for 
 cleansing must be washed away before transplantation is 
 begun, for fear of injuring the vitality of the grafts. 
 
 Where to Obtain Grafts. 
 
 When possible, the grafts should be obtained from the 
 patient's own body rather than from another, not only be- 
 
THE METHOD OF REVERDIN 19 
 
 cause they are apt to grow better, but because there is less 
 risk of conveying disease. "Whether there is any advantage 
 in employing skin from a region corresponding to the one 
 operated upon is doubtful, although this point has been 
 insisted upon by Lewis, 9 Agnew, 1 . Hueter, 11 and others. 
 Donnelly, for some unexplained reason, prefers grafts 
 from a portion of the skin subject to slight motion, such 
 as the insertion of the deltoid muscle. 
 
 There is an object, however, in grafting from the inside 
 of the arm or thigh, or the side of the chest or bend of the 
 elbow ; for in these situations the skin is thin and soft and 
 comparatively free from hairs or glands. But practically 
 skin from any convenient part of the body may be em- 
 ployed with almost equally good chances of success — even 
 the delicate new skin from the borders of ulcers which have 
 begun to heal (see p. 23). The anterior surface of the 
 thigh is often selected. 
 
 Lucas 12 considers that "the prepuce of a child possesses 
 a germinal vitality which renders it peculiarly serviceable 
 for grafting," in addition to suppleness, thinness, and vas- 
 cularity. He claims that preputial grafts will adhere 
 when those from other parts fail, even on unhealthy gran- 
 ulating surfaces. However this may be, the suggestion is 
 of value in cases where sensitive patients, children for in- 
 stance, strongly object to grafting from their own persons; 
 but great caution must be exercised in order to avoid the 
 carrying of disease. The material can be obtained in 
 abundance in children's hospitals, just where it is most 
 needed. 
 
 9 Phila. Med. Times, March 21, 1874, p. 389. 
 
 10 Med. and Surg. Reporter, Nov. 28, 1874, p. 424. 
 
 11 Allgem. Chir., 1889. 
 
 12 Lancet, Oct. 4, 1884, p. 586. 
 
20 SKIN GRAFTING 
 
 Pusey 13 claims many advantages for the loose re- 
 dundant skin of the scrotum ; but in the Eeverdin method, 
 at least, it is difficult to understand how anything can be 
 gained by procuring grafts from this situation or from the 
 prepuce, although it might be otherwise in the method of 
 Wolfe. 
 
 Before cutting the grafts, whatever be the situation 
 selected, the skin should be carefully cleansed, and the in- 
 struments sterilized; for, although the wounds are small, 
 they are nevertheless wounds, and should be guarded 
 against infection. 
 
 It is probably neither necessary nor desirable to irritate 
 the skin by brushing or beating, with the idea of increasing 
 its supply of blood and serum, as was practiced by the 
 Hindus. Fowler, Ilirschberg, Granbury, and others have 
 nevertheless recommended this, while Berger applies a 
 mustard plaster or a poultice for the same purpose. 
 
 Size of Grafts. 
 
 The grafts should be small, about the size of a grain of 
 wheat, as originally recommended by Eeverdin. JSTot that 
 larger ones will not grow, as was early demonstrated by 
 Oilier and others, but one of the principal claims of the 
 Eeverdin method is that pain and scars are reduced to a 
 minimum, which would not be true if the grafts were 
 unnecessarily large. In addition, small grafts generally 
 answer the purpose as well as larger ones, and the latter 
 are apt to produce unsightly lumps. If the portions of 
 skin are originally too large, they may be spread upon the 
 thumb-nail and divided. 
 
 13 Lancet, Oct. 18, 1884, p. 676. 
 
THE. MEiTHOB OF REVERDIN 
 
 21 
 
 Method of Cutting Grafts. 
 
 Grafts are most easily cut by elevating a small fold of 
 skin with a pair of mouse-tooth forceps and dividing it 
 with scissors curved on the flat or with a knife or razor 
 (Figs. 2 and 3). Iridectomy scissors are convenient for 
 the purpose. The entire epithelium and a portion of the 
 corium, perhaps one quarter to one half of a line in thick- 
 ness, is thus obtained. None of the subcutaneous cellular 
 
 Fig. 2. — ■ Cutting a Reverdin graft. 
 
 tissue and fat should be included, as it does not possess 
 sufficient independent vitality. The epidermis alone is all 
 that is really necessary, although better results are per- 
 haps obtained if a portion of the corium be included. 
 Reverdin employed the term "greffe dermique" which 
 Poncet changed to "greffe dermoepidermique/' thus more 
 correctly expressing what is really meant. 
 
 An insignificant oozing of blood results. The trifling 
 amount of pain can be obviated, if necessary, by partially 
 
22 
 
 SKIN GRAFTING 
 
 freezing the skin with chlorid of ethyl or by anesthetizing 
 the cutaneous surface by the injection of novocain. (See 
 chapter on Local Anesthesia in Skin Grafting. ) When par- 
 tial freezing is resorted to, the necessary number of grafts 
 may all be cut at once and placed until needed in warm 
 physiological salt solution, or raw-side down upon a warm 
 piece of glass, which prevents the edges from curling under. 
 
 Fig. 3. — Cutting a Reverdin graft. 
 
 The little wounds are, from the method of cutting, more 
 or less elliptical, which favors rapid healing, with the for- 
 mation of a small, almost punctate, white scar. Sutures 
 are unnecessary. An ordinary aseptic or antiseptic dress- 
 ing should be applied, dry or moist, according to preference. 
 A good one consists of boric acid ointment covered with 
 rubber protective. The neglect of this precaution may per- 
 mit the development of erysipelas or other infectious 
 troubles. 
 
THE METHOD OF EE.VEEDIN" 
 
 23 
 
 Satisfactory grafts may often be cut by pressing a pair 
 of curved scissors firmly against the skin and snipping off 
 the portion which protrudes between the blades. 14 Some' 
 prefer to elevate a fold of skin by transfixion with a fine 
 needle, bnt this offers no advantage over forceps. Special 
 skin grafting scissors were introduced by Bryant and by 
 Smith, but they are entirely unnecessary. 
 
 Souchon 15 has recently emphasized an old and useful 
 
 Fig. 4. — Cutting grafts from pellicle of new skin at border of healing ulcer. 
 
 method of obtaining small grafts by cutting them with 
 scissors from the thin, new epithelium as it "floats" out 
 from the skin-edges of a healthy granulating surface which 
 is beginning to heal (Fig. i). 
 
 The surface to be grafted is nearly always granulating 
 and covered with more or less pus. ' The method of Rever- 
 din, however, is also applicable to fresh wounds, although 
 
 "W. H. Marcy, Med. Rec, Aug. 18, 1894, p. 206. 
 15 J. A. M. A., July 17, 1909, p. 207. 
 
24 SKIN GRAFTING 
 
 other procedures, such as those of Thiersch and Wolfe, 
 give better results. 
 
 Placing the Grafts. 
 
 There is no object in scraping away the granulations, as 
 is often done in the process of Thiersch. In fact, the only 
 excuse for using the Eeverdin method is its comparative 
 painlessness and insignificance as an operation; and this 
 advantage would disappear if so harsh a procedure as cu- 
 retting were resorted to, and little if anything would be 
 gained. 
 
 All that is necessary, then, is to wash away the pus as 
 
 Reverdin grafts in place. 
 
 thoroughly as possible with salt solution or sterilized 
 water, using cotton sponges if desired, but avoiding hem- 
 orrhage. Mild antiseptics which do not coagulate albu 
 min may be employed without injury, providing they ar<> 
 subsequently removed with some neutral solution, but it is 
 questionable if any benefit is derived. A suppurating, 
 granulating surface cannot be sterilized by the brief use 
 of ordinary antiseptics, and it is likely that positive harm 
 is done by lowering the vitality of the superficial cells. 
 
THE, METHOD OF REVERDIN" 
 
 25 
 
 Certainly no benefit can result from irrigating with anti- 
 septics after transplantation, as has been suggested. 
 
 As soon as the grafts are cut, they are placed at once, by 
 means of forceps or needle, upon the surface to be grafted, 
 with their raw sides down (Figs. 5 and 6). Edges which 
 have a tendency to curl under are carefully unfurled by 
 pressing upon the bit of skin with a probe and shoving it 
 
 
 Fig. 6. — (I) Reverdin graft in place at the end of planting; (II) Sixteen 
 days later (Ehrenfreid and Cotton). (From Boston Med. and Surg. Jour- 
 nal, Vol. CEXI, No. 26, 1909.) 
 
 carefully from side to side. Adhesion to the granulations 
 immediately takes place, especially if no blood or other 
 fluid be present, slight pressure with a moist pledget of 
 gauze assisting the process. Roberts and others claim that 
 exposure of the ulcer to the atmosphere for a time before 
 and after operating causes the surface to become sticky and 
 facilitates adherence, but this can seldom be required. It 
 is unnecessary to fasten the grafts in place with fine sutures 
 (Hueter), or to bury them beneath a trap-door in the gran- 
 
26 SKIN GRAFTING 
 
 illations, as was advocated by Eorth, 16 Dunn, 17 and 
 others. 
 
 Each graft is capable of enlarging to but a limited extent, 
 perhaps the size of a silver dime, and it cannot stimulate 
 the borders of the ulcer effectually at a greater distance 
 than half an inch. If a single graft is placed in the center 
 of a sufficiently large ulcer, it will produce an island of 
 skin only, and in addition it does not seem to grow so well. 
 
 Hence the transplanted pieces should not be farther 
 apart than half an inch, and better closer than this. They 
 should also not be at a greater distance from the edges of 
 the ulcer. 
 
 If the grafts are sufficiently close together, there is no 
 object in placing them in regular rows or geometrical 
 figures. Should the number be limited, it is wiser to thor- 
 oughly cover a comparatively small area than to scatter 
 the material over too extensive a surface. The use of 
 scarlet-red ointment may hasten epithelial formation over 
 the remainder of the ulcer, 1S but it should not come in 
 contact with the grafts. 
 
 Legal Questions. 
 
 Legal complications have arisen from skin grafting in 
 one or two instances at least. One of these occurred in 
 Atlanta. A boy, thirteen years old, brought his little 
 cousin to a physician's office, with an affection requiring 
 the transplantation of skin. The boy willingly consented 
 to have the grafts removed from his own arm, which was 
 accordingly done. The father immediately brought suit 
 
 16 Med. Rec, Jan. 9, 1886, p. 36. 
 
 17 St. Louis Med. and Surg. Journal, July, 1895. 
 
 18 Von Schmieden, Zentralbl. f. Chir., 1908, p. 153. 
 
THE METHOD OF KEIVEBIHN" 
 
 27 
 
 upon the grounds that the action was unjustifiable and 
 brutal, and that he had not been consulted. The case was 
 promptly decided for the defendant, as was also another 
 in Cincinnati, in which a man who was paid to furnish 
 grafts claimed that too much skin had been taken and 
 sued the surgeon for damages. 
 
 Dressings. 
 
 Some sort of dressing should be employed for the sake 
 of protection from dirt and accident, not, however, because 
 a dressing is essential to the vitality of the grafts, which 
 will thrive just as well when enclosed in some box-like 
 
 Fig. 7. — ■ Strip of rubber tissue Avith punched-out drainage holes 
 
 covering, or when not covered at all 19 (see chapter on 
 Thiersch Grafting). 
 
 It is usually recommended to place rubber protective 
 next the grafts to prevent their adherence and displace- 
 ment- when the dressings are changed. This should be 
 cut into strips, perhaps half an inch in width, which are 
 placed side by side, or criss-crossed, like basket-work, or 
 punched full of holes, in order to furnish exit for the secre- 
 tions (Fig. 7). Strips of transparent sheet gutta-percha 
 may be used, and their ends allowed to project on the 
 sound skin, where they will adhere if moistened with a 
 
 19 Yemans — Leonard's Med. Jour., 1888. 
 
28 SKIN GRAFTING 
 
 little chloroform. If more convenient, there is no ob- 
 jection to the employment of goldbeater's skin, oiled silk, 
 isinglass plaster, tin or silver foil, etc. Marcy 20 prefers 
 to use ordinary adhesive plaster, which may often succeed 
 on the principle that epithelium will grow in spite of al- 
 most anything. 
 
 All of these methods possess the disadvantage of caus- 
 ing more or less maceration which may jeopardize the 
 vitality of the new skin. A preferable and much simpler 
 device consists in spreading a single layer of gauze over 
 the grafted surface and pinning it around the limb, or 
 
 Fig. 8. — Strip of gauze pinned about leg for holding grafts in place. 
 
 fastening it to the skin in a number of places with collodion 
 (Fig. 8). This was suggested by McCarthy, 21 and later 
 independently by the writer. 22 Bidwell 23 uses gauze of 
 spun glass, which would seem to be an ideal material for 
 the purpose. The meshes of the specially prepared netting 
 employed by Davis are so wide that it is more suitable for 
 "splinting" large Thiersch grafts than for holding in place 
 the small pieces of epithelium under consideration (see p. 
 51). While the superjacent dressings are changed, the 
 gauze remains permanently in place until healing is com- 
 plete. Absorption of the discharge is thus permitted, and 
 
 20 Med. Rec, Aug. 18, 1894. 
 
 21 Med. Press and Circ, Apr. 13, 1881, p. 311. 
 23 Cincinnati Lancet-Clinic, 1885. 
 
 23 Lancet, July 21, 1894, p. 130. 
 
THE. METHOD OF REVERm^ 29 
 
 the condition of the grafts is easily ascertained at any time 
 without disturbing them. 
 
 Bryant insisted upon the use of a separate piece of lint 
 over each graft, but. this is perhaps more troublesome than 
 advantageous. 
 
 Wet and Dry Dressings. 
 
 Whether the main dressing is dry or moist is usually 
 of little importance, but no powerful antiseptic should be 
 employed. It is customary to dust various non-irritating 
 powders over the grafted surface, such as iodoform, boric 
 acid, acetanilid, aristol, etc., but their value is question- 
 able, simple sterile gauze often being equally serviceable. 
 If a powder is used, care must be taken that it does not 
 form a crust, beneath which pus may accumulate and de- 
 stroy the grafts. 
 
 If the operator prefer, an ointment containing any of 
 the powders mentioned above will give good results if the 
 discharge is not excessive. Scarlet-red ointment (see p. 
 56) may be useful in hastening the epithelialization of 
 uncovered portions of a granulating surface, but it should 
 not come into contact with the grafts themselves, at least 
 until they have become firmly adherent, for fear of causing 
 their destruction. 
 
 Bovinine has often been employed — so-called ''grafting 
 in blood" — with the idea that additional nutrition is thus 
 furnished to the grafts during the process of adhesion, but 
 the utility of the method is somewhat questionable. The 
 material may be spread upon the grafted surface like but- 
 ter upon bread. 
 
 A pad of gauze covered with cotton completes the dress- 
 
30 SKIN" GRAFTING 
 
 ing, which is held in place under moderate pressure with 
 a bandage. 
 
 In case a wet dressing is chosen, the powder or salve is 
 omitted, a pad of gauze wrung out of warm normal salt 
 solution or boric acid being used instead. An outside cov- 
 ering of oiled silk will prevent too rapid evaporation and 
 render moistening of the dressings unnecessary oftener 
 than perhaps once in twenty-four hours. 
 
 Changing Dressings. 
 
 If the field of operation were always aseptic, it would 
 be unnecessary to change the dressings at all during the 
 process of healing; but unfortunately this can seldom be 
 the case, as a certain amount of suppuration is nearly al- 
 ways present. It is, therefore, desirable to remove all 
 but the lowermost layer of gauze, or protective, as the case 
 may be, every twenty-four to forty-eight hours, prolonged 
 soaking in warm salt solution being necessary when the 
 dressings have a tendency to stick. Gentle irrigation is 
 then in place, although the surface must not be rubbed for 
 fear of displacing the transplanted cuticle. 
 
 AVhen there is considerable discharge, and protective has 
 been used, it should frequently be changed as well as the re- 
 mainder of the dressing; but when the discharge is not 
 great, it can often be left in place for from five to ten days. 
 
 It is difficult to avoid a certain amount of musty or even 
 more offensive odor, and at times the dressings become 
 green in color from the presence of Bacillus pyocyaneus; 
 but success is not often seriously jeopardized by these 
 occurrences. 
 
 Instead of employing dressings of various kinds, the 
 
THE METHOD OF REIVEBDIN 31 
 
 "open method" may be used, as is often done in Thiersch 
 grafting, the grafts being directly and freely exposed to 
 the air beneath a protecting wire-gauze cage (see p. 49). 
 The presence of much discharge, hoivever, is apt to render 
 the procedure unsatisfactory, owing to the formation of 
 thick crusts. 
 
 When grafting is done near a joint, particularly in chil- 
 dren, some form of splint should be applied to prevent 
 motion of the part. The lower extremity, especially where 
 varicose veins exist, should be elevated in order to favor 
 circulation. 
 
 Process of Healing. 
 
 In the course of twenty-four hours the grafts seem to 
 swell, appearing whiter, thicker, and softer ; and in two or 
 three days those which have "taken" become pinkish in 
 color with a reddish areola. Then a thin, pearl-gray 
 epithelial pellicle begins to grow out from their borders 
 and from the adjacent edges of the ulcer, like ice from 
 the shores of a pond. The bits of skin which turn brown 
 are probably dead, while those which are yellowish white 
 will lose their superficial layers of epidermis at least. 
 This exfoliation of epidermis is common and usually occurs 
 in three to five days. It does not mean that the grafting 
 has failed, as the deeper layers remain, and that which 
 has been lost is soon reproduced. 
 
 The new epithelial pellicle is not attached to the granula- 
 tions at first, but rests like fine tissue-paper upon their 
 flattened surfaces, from which it may easily be lifted, and 
 perhaps utilized for further grafting (see p. 23). Soon 
 long fine processes or "roots" grow down into the granula- 
 
32 SKIN GKRAFTTNG 
 
 tions, anchoring the epithelium, and "bridges" are often 
 thrown out, connecting the grafts with each other or with 
 the borders of the ulcer. 
 
 After-treatment. 
 
 When cicatrization is complete, the part must be pre- 
 served from injury for several weeks, until a certain 
 amount of resisting power has been attained ; for ulcers 
 cured by the Reverdin method, especially those of the 
 lower extremities, are prone to break down on slight provo- 
 cation. If there is a tendency to dryness and exfoliation, 
 an ointment should be used containing some unirritating 
 substance, such as boric acid. 
 
 The new skin is not by any means equal to ordinary skin, 
 although it is much better than mere cicatricial tissue. It 
 contains no hair bulbs, sweat glands, or sebaceous follicles. 
 The grafts regain a certain amount of sensation in the 
 course of time, although it is often imperfect and long in 
 making its appearance, slowly progressing inward from the 
 periphery. 
 
CHAPTER IV 
 
 THE METHOD OF THIERSCH— ITS USE IN" 
 SPECIAL CASES 
 
 There is no process of skin grafting so simple, so re- 
 liable, and so generally applicable as the method of 
 Thiersch, 1 and yet it has never received the thorough recog- 
 nition to which it is entitled. Granulating surfaces or 
 fresh wounds of almost any extent may be covered with 
 epithelium in from ten days to three weeks ; embarrassing 
 cicatricial contractions are avoided ; and the prevention of 
 suppuration and other septic processes may be instru- 
 mental in saving life or limb, to say nothing of shortening 
 the period of convalescence. In many cases the cosmetic 
 value can scarcely be overestimated. 2 
 
 General Technic. 
 
 If a suppurating area is to be grafted, the adjacent skin 
 should be scrubbed, all crusts and hairs removed, and the 
 surface on which the grafts are to lie irrigated with normal 
 salt solution. The patient is anesthetized, and the granula- 
 tions are then scraped away with a spoon down to the 
 comparatively firm tissue beneath, which is sometimes 
 suprisingly deep. Oozing is checked by pressure and by 
 
 1 XV. Kong. deut. Gesell. f. Chir., Berlin, 1886. 
 
 2 As regards priority, Oilier (Bull, de l'acad. de Med., 1872) was in the 
 habit of cutting grafts 10 to 15 mm. wide and 2 to 4 cm. long, resembling 
 in every way Thiersch grafts ; but unlike Thiersch, he did not scrape away 
 the granulations before making the transplantation. Fischer (Zeit. f. Chir. 
 Bd. 13, 1880, p. 193) also shaved from the surface of a limb, thin strips of 
 skin identical with those used by Thiersch. 
 
 33 
 
34 
 
 SKIN" GEAFTING 
 
 elevation, where practicable. After removing the blood 
 and debris with warm salt solution, the surface is ready 
 for the grafts. 
 
 These are best obtained from the anterior surface of the 
 thigh and are conveniently cut with a sharp razor. An 
 assistant makes the surface as tense as possible by means 
 of a hand on either side of the limb, or by grasping the 
 thigh from below, while the operator, standing with his 
 
 Fig. 9. — ■ Cutting- Thiersch grafts from thigh. 
 
 back to the patient's feet, cuts toward himself, with his left- 
 hand stretching the skin in front of the razor in the direc- 
 tion of the knee (Fig. 9). Pieces of gauze beneath the 
 hands will prevent them from slipping. With a side- 
 to-side sawing motion it is not hard to remove thin shav- 
 ings of epidermis, from half an inch to an inch or more 
 in width and several inches in length, the manipulation 
 being easier with firm skins than with flabby ones, and 
 
THE METHOD OF THIERSCH 
 
 35 
 
 rather difficult with the thin cuticle of young children and 
 old people. Both skin and razor should be kept wet with 
 salt solution. 
 
 It is -neither necessary nor desirable to remove the entire 
 thickness of the skin, but simply a paper-like layer, leaving 
 a number of bleeding points from division of capillary ves- 
 sels in the ends of the papillae. Although the procedure 
 
 Fig. 10. — Thiersch graft partially cut — note position of assistant's hands on 
 each side of thigh, with gauze pads to prevent slipping. 
 
 is simple enough, it should be practiced upon the cadaver 
 before being tried upon the living. 
 
 The delicate strips of skin fold up on the razor as they 
 are cut (Fig. 10), and as soon as a sufficient length has been 
 obtained, a slight inclination of the instrument away from 
 the thigh will readily sever the graft from its connections. 
 - The grafts are then spread smoothly upon the area to be 
 covered, so that they overlap each other shingle-wise, and 
 
36 
 
 SKIN GRAFTING 
 
 also overlap the edges of the Wound, completely concealing 
 the raw surface (Figs. 11 and 12). When the sections are 
 
 ife 
 
 Fig. 11. — Showing how Thiersch grafts should overlap each other and the bor- 
 ders of the ulcer. 
 
 large, they may advantageously be "buttonholed" with a 
 pair of scissors or extensively perforated with a punch 
 
 Fig. 12. — Thiersch grafts in place — granulating wound of buttock. 
 
 in order to facilitate drainage (Davis). If too much skin 
 has been obtained, the redundant portions may be replaced 
 
THE! METHOD OF THIERSCH 37 
 
 upon the raw surface from which they were removed, where 
 they will readily adhere. 
 
 Hemorrhage. 
 
 In order to control hemorrhage which may follow the 
 curetting, Thiersch at first employed an Esmarch strap, 
 leaving it in place until the grafts and dressings had been 
 applied, but he afterward discarded the procedure as being 
 unnecessary and possibly harmful. Others, however, have 
 taken up the idea, thinking, perhaps, that it was new, and 
 have used it extensively. In general, there is little objec- 
 tion to the employment of the strap, and it is at times of 
 advantage, although following its removal undesirable 
 oozing may take place beneath the transplanted skin. 
 
 There seems to be no reason for agreeing with Fischer, 
 who says that skin will grow better when removed from a 
 bloodless part and applied to one equally bloodless, a view 
 curiously at variance with the ideas of those who advocate 
 irritation and congestion of the skin before grafting. 
 
 Pressure with moist pledgets of gauze, perhaps saturated 
 with peroxid of hydrogen or a solution of adrenalin, nearly 
 always controls bleeding in a few moments, especially if 
 the part be elevated and the pressure applied over a piece 
 of rubber protective, in order to prevent tearing the clots 
 from the mouths of the small vessels when the compressing 
 material is removed. An effective method is to apply a 
 thin rubber bandage around the limb or body and directly 
 over the raw and oozing surface. Kushmore 3 advocated 
 the use of a high-frequency electric current for the purpose 
 of coagulating the blood and causing the grafts to adhere. 
 
 3 Ann. Surg., 1904, Vol. 40, $>. 404. 
 
38 SKIN GKAFTING 
 
 but this is of doubtful advantage and has never been ex- 
 tensively adopted. It is much better to twist a vessel than 
 to tie it, as ligatures are prejudicial to success. The sur- 
 face should be rendered as "dry" as possible, in order to 
 favor adhesion and growth of the new cuticle. 
 
 Curetting. 
 
 With Thiersch, the removal of granulations was one of 
 the principal features of his original method. He claimed 
 that the more or less large and soft, superficial granula- 
 tions, during their slow transformation into connective tis- 
 sue, were the cause of cicatricial contraction, and that this 
 contraction could be avoided by scraping away the granula- 
 tions until firmer tissue was reached. He also thought that 
 grafts grew better when this was done. This advice was 
 universally followed until it was demonstrated by Schnitz- 
 ler and Ewald 4 that it is unnecessary to remove healthy 
 granulations and that grafting can be done directly upon 
 their unaltered surfaces with the production of a movable 
 skin, and without appreciable subsequent contraction. It 
 should be mentioned, however, that numerous operators 
 have been unable to obtain reliable results without curet- 
 ting, and it will certainly always be in place where it is 
 desirable to remove unhealthy granulations or diseased 
 tissues. In any case, the results are probably more univer- 
 sally satisfactory, when the granulations are removed. 
 
 It has been claimed that where scraping is not resorted to 
 an anesthetic, either local or general, is unnecessary, because 
 of the comparatively slight burning pain produced by the 
 cutting of the grafts, which is said to be made still less by 
 
 4 Cent. f. Chir., No. 7, 1894, p. 148. 
 
THE METHOD OF THIERSCH 39 
 
 the use of the- Esmarch strap. These statements, however, 
 by no means always hold good, the pain being often quite 
 severe. 
 
 Instead of scraping with a curette, Sick 5 simply rubs 
 away the granulations with a bunch of gauze, or a stiff 
 nail-brush may be used. Halsted, McBurney, and others 
 prefer to shave the surface with a scalpel or an amputating 
 knife, claiming that a smoother surface is obtained devoid 
 of partially separated and bruised portions of tissue, which 
 tend to become necrotic and interfere with the vitality of 
 the transplanted skin. 
 
 Warm salt solution, upon which Thiersch has laid so 
 much stress, is to be recommended for irrigation, but it is 
 not necessary, as ordinary sterilized water answers almost 
 the same purpose, both during the operation and subse- 
 quently. A four per cent solution of boric acid can also be 
 used if desired. Thiersch and many others speak de- 
 cidedly against the employment of antiseptics after the 
 curetting, has been done, claiming that the superficial 
 necrosis thus produced interferes materially with the ad- 
 herence of grafts; but there is no doubt that strong anti- 
 septics may be freely employed both before and after 
 curetting, 6 providing they are subsequently washed away 
 with some neutral solution. Their utility, however, is 
 questionable, as asepsis cannot thus be obtained. 
 
 Preparation of Granulations. 
 
 Granulating surfaces should be prepared with even 
 greater care in Thiersch grafting than in the method of 
 Eeverdin. (See chapter on The Method of Eeverdin.) 
 
 5 Arch. f. Klin. Chir., Bd. 43, p. 387. 
 
 G C Hiibscher, Beitr. z. Klin. Chir. Bd. 4, 1888, p. 395. 
 
40 SKIN GRAFTING 
 
 When considered advisable, the procedure of Wilcox may 
 be used : 7 The evening before the operation, the part is 
 thoroughly cleansed with green soap and hydrogen per- 
 oxid and put up in a compress wet with 1 per cent 
 formaldehyde (the ordinary 40 per cent solution being 
 taken as the unit), which is left on over night. The gran- 
 ulations, tendered dark, red, and dry, are then scraped 
 away down to the firm vascular tissues beneath, an Esmarch 
 bandage being wound directly over the raw surface, when 
 possible, in order to control oozing by means of pressure, 
 the rubber having no tendency to stick when removed. 
 
 Davis 8 recommends cleansing and drying the ulcerated 
 surface on the previous day, painting it with tincture of 
 iodin, and then dressing it with balsam of Pern (2 to 6), 
 which is allowed to remain until the operation, when it is 
 washed away with normal salt solution. 
 
 These methods are said to have the advantage of render- 
 ing the part aseptic, and they probably do so, in the ma- 
 jority of instances at least ; but they are seldom necessary. 
 
 Methods of Cutting Grafts. 
 
 The grafts may be removed from any convenient portion 
 of the body, the anterior surface of the thigh being nsually 
 chosen, although Franke prefers the outer side, as it can 
 be made tense by adducting the limb. Davis claims that 
 grafts should always be obtained from the right thigh when 
 possible, because phlebitis is more apt to follow when the 
 left limb is employed, but this somewhat theoretical as- 
 sumption is generally disregarded in practice. 
 
 McBurney stretched the skin between two "hooks" sup- 
 
 7 Ann. Surg., May, 1904. 
 
 8 Ann. Surg., Dec. 1910, p. 721. 
 
THE METHOD OF THIERSCH 41 
 
 plied with teeth, which catch the skin transversely to the 
 long axis of the limb. (Fig. 13.) Mixter 9 employed an 
 instrument consisting of an oblong fenestrated steel plate 
 with several short, sharp pins projecting from its slightly 
 concave surface to prevent slipping. When this is pressed 
 firmly against the thigh, the skin projects through the 
 fenestrum and may be flattened with a roller and shaved 
 off with a specially constructed knife. 
 
 Fig. 13. — McBurney's hooks for stretching skin. 
 
 Some operators prefer razors which are flat on one side, 
 and others use an amputating knife, a small scalpel, or the 
 blade of a microtome ; but there is really nothing more con- 
 venient than an ordinary sharp razor. The complicated 
 apparatus of Mixter is not necessary, although it produces 
 strips of skin with smooth edges ; but this can be accom- 
 plished, if desirable, by outlining the graft with a scalpel 
 before shaving it off. A safety razor can sometimes be em- 
 ployed to advantage. 10 Whatever instrument is used, its 
 
 9 Boston Med. & Surg. Jour., Dec. 31, 1891. p. 700. 
 "Doolittle, J. A. M. A., Mar. 26, 1898, p. 716. 
 
42 
 
 SKIN GRAFTING 
 
 blade should be kept moist with salt solution, or with a 
 mixture of glycerin 25 parts, alcohol 25 parts, and water 
 50' parts. 11 
 
 Halsted, of Johns Hopkins, 12 employs very large grafts, 
 especially following operations for cancer of the breast. 
 
 Fig. 14. — Halsted method of cutting large Thiersch grafts. (From Johns 
 Hopkins Hospital Reports, Vol. XV, p. 316.) 
 
 In cutting them, he places a sand-bag beneath the thigh, 
 so as to give a broader surface, and stretches the skin be- 
 tween two small boards, like shingles, held crosswise to 
 the limb, with their edges pressed firmly against the sur- 
 
 11 E. Barker, Practitioner, Oct., 1888. 
 12 Ann. Surg., 1909, Vol. 50, p. 542. 
 
THE METHOD OF THIERSCH 43 
 
 face. One of these boards is pulled upward by an as- 
 sistant, while the other is pulled downward by one hand 
 of the operator (Fig. 14). An amputating knife is used 
 to sever the grafts, which are spread raw side upward on 
 rubber protective or silver-foil, upon the surface of a board, 
 before transferring them, together with the protective, to 
 the wound. The procedure requires some technical skill. 
 There is no danger of the subsequent development of 
 hairs in the transplanted cuticle, as has been affirmed by 
 Thompson, because in Thiersch grafting the bulbs are left 
 behind. It is desirable, however, to shave the part to 
 prevent the severed hairs from getting beneath the grafts 
 and interfering with their union. The skin should be 
 surgically clean, as in any other operation. 
 
 Placing the Grafts, Etc. 
 
 The strips of epidermis are so thin that they fold up 
 on the razor and may be carried directly to the surface 
 to be grafted without first floating them out in water and 
 transferring them upon a spatula or piece of glass, as is 
 often done. The edge, of the razor with its folded graft 
 is placed near the border of the ulcer, and the end of the 
 graft slid from the blade and held by a probe against the 
 skin (Figs. 15 and 16). The razor is then slowly moved 
 across the ulcer, spreading out the strip much as a nurse 
 spreads a sheet beneath a patient. The edges, which are 
 often more or less turned under, must be carefully un- 
 furled by sliding the grafts back and forth with a probe. 
 The new skin should be gently pressed in place with a 
 pledget of moist gauze in order to promote adhesion and 
 disperse air-bubbles and blood. 
 
44 
 
 SKIN GRAFTING 
 
 Jungengel has shown that if a layer of clot be present 
 beneath the grafts which is a little too thick the outer layers 
 of epithelium are apt to exfoliate, and if very much coag- 
 ulated blood exists, the entire graft may perish. It has 
 been said that a certain amount of clot is of value in that 
 it promotes nutrition and prevents suppuration, but this 
 statement has not been confirmed. 
 
 Some surgeons prefer to cut at once all the grafts they 
 
 Fig. 15. — Sliding Thiersch graft from razor on to surface of ulcer. 
 
 expect to use, placing them in warm salt solution. An as- 
 sistant then spreads them raw side up on strips of sterile 
 protective or on moist toilet-paper, by means of which they 
 are transferred to the field of operation, the protective re- 
 maining in place as the first layer of the dressing. This 
 has its advantages where, owing to the locality to be 
 grafted, the simpler method already mentioned cannot be 
 employed. McNaught rolls the strips of skin upon a 
 probe, by means of which they may easily be transported 
 and accurately adjusted; or they can be spread upon a 
 
THE METHOD OF THIERSCH 
 
 45 
 
 sponge and applied as a goldbeater applies gold leaf (Bruce 
 Clarke). 
 
 If the grafts are large, they should be perforated at fre- 
 quent intervals in order to provide means of exit for fluids, 
 which might otherwise accumulate beneath them and 
 cause their disintegration by separating them from the 
 underlying surface. This can be accomplished after the 
 
 Fig. 16. — Placing Thiersch grafts from razor — granulating wound of buttock. 
 
 grafts are in place by snipping out small pieces with a pair 
 of curved scissors, or the - grafts may first be spread on 
 strips of rubber protective and perforated with a punch or 
 with scissors. 13 This seems like an excellent method, but 
 Yogel claims that when it is used it is desirable to employ 
 a moist dressing for several days to prevent closure of the 
 openings by dried secretions. 
 
 13 Davis, Internat. J. Surg., May, 1910. 
 
46 SKIN" GRAFTING 
 
 Grafting in Two Stages. 
 
 Wentscher 14 and Porter advocate the performance of 
 Thiersch grafting in two stages, at least in certain cases, 
 especially where bleeding cannot be promptly checked. 
 At the first sitting, they scrape the nicer and cnt the neces- 
 sary grafts, putting them in salt solution at room-tempera- 
 ture, where they may be kept without injury for many 
 hours. At a second sitting, the new skin is placed in posi- 
 tion, no anesthetic being required. In this connection, it 
 is interesting to note that Lynngren has successfully grafted 
 pieces of epithelium kept for three months in sterile ascitic 
 fluid, and that dried epidermis has "taken" after as long 
 as 418 days. 
 
 Thin vs. Thick Grafts. 
 
 There is some difference of opinion as to whether it is 
 desirable to use thin grafts or thick ones, some going so 
 far as to recommend the employment of the entire thick- 
 ness of the skin (Fowler, Moullin, Cheyne, etc.). When 
 this is done, however, it is better to dissect out the grafts 
 and suture the resulting wound according to the method 
 of Wolfe. Fowler 15 contends that more than the papillae 
 should be removed with the razor, but that no fat should 
 be included, the idea being to obtain the stroma con- 
 taining the horizontal network of vessels. Kellock 16 
 suggests a sort of combination of Wolfe grafts with 
 Thiersch grafts, cutting them so that the whole thickness 
 of the skin remains in the center surrounded by a thinner 
 
 "Berl. Klin. Woch., No. 43, 1894. 
 
 15 Ann. Surg., 1889, p. 179. 
 
 16 Lancet, Nov. 25, 1899. 
 
THE METHOD OF THIERSCH 47 
 
 area, the latter being shaved off first. The technic, how- 
 ever, is complicated and has not been generally adopted, al- 
 though Porter strongly recommends it in grafting areas 
 from which x-ray burns have been excised from the hands 
 (see Grafting in X-ray Burns). 
 
 It is perhaps well to avoid grafts of exceeding thinness ; 
 but nevertheless, when moderately thin ones are placed by 
 the side of those which are quite thick, the former seem 
 to be as satisfactory for most purposes as the latter'. In 
 general, a good graft may be said to be but little thicker 
 than the paper upon which this is printed. 
 
 Little or no scar results from the removal of these thin 
 slices of epithelium, at most a thin, white, almost imper- 
 ceptible cicatrix, although the seat of the operation remains 
 brownish in color for weeks. Different sets of grafts may 
 be removed from the same area, providing sufficient time 
 elapses between the operations to allow a new growth of 
 epithelium to occur. 
 
 Anesthetics. 
 
 It has been claimed that a general anesthetic, especially 
 ether, was detrimental to the vitality of grafts, and pa- 
 tients have been needlessly tortured on this account. Ex- 
 perience has' demonstrated that a, general anesthetic has no 
 appreciable effect upon the transplanted skin, and the 
 operation is often sufficiently painful to justify its em- 
 ployment, in spite of the statements of Fowler, Plessing, 
 and others to the contrary. (See chapter on Local Anes- 
 thesia in Skin Grafting. ) 
 
48 SKIN GRAFTING 
 
 Dressings. 
 
 It has been abundantly demonstrated that it is unneces- 
 sary to keep the grafts moist as emphasized by Thiersch ; 
 in fact, they seem to do better in many cases when the 
 dressing is a dry one — simply a sprinkling of iodoform 
 or boric acid and a covering of gauze and cotton, as in 
 the treatment of ordinary wounds, and there is really no 
 great need for a powder at all. There are those, however, 
 who speak against a dry dressing, claiming that the desic- 
 cated secretions interfere with the escape of fluids between 
 the grafts, which accordingly accumulate and elevate the 
 new skin at various points, thus leading to its destruction. 
 Moderate pressure is beneficial, but too tight bandaging 
 may cause sloughing. 
 
 If a moist dressing is preferred, it is unnecessary to 
 change it, if a heavy one and protected by oiled silk, 
 oftener than every day or two, as has been shoAvn by Mc- 
 Burney, Halsted, and others ; although Thiersch contended 
 that a fresh dressing must be applied every two hours, 
 or the old one moistened at least. 
 
 A sterilized non-irritating ointment of some kind (boric 
 acid, iodoform, etc.) makes a satisfactory dressing and 
 is used by some, while others prefer bovinine, from the 
 somewhat questionable idea that it furnishes nutriment to 
 the grafts prior to their firm adhesion. Instead of salt 
 solution, the layers of gauze may be moistened with steri- 
 lized olive oil, which will not require such frequent re- 
 newal, or with a 4 per cent solution of boric acid. Dun- 
 ham 17 thinks it advisable to remove a moist dressing at 
 
 17 Ref. Handb. Med. Sci., Supplement. 
 
THE METHOD OF THIERSCH 
 
 49 
 
 the end of six days and allow the grafts to become dry, 
 claiming that they are thus rendered tougher. 
 
 Strips of rubber protective, silver foil, tin foil, gold- 
 beater's skin, etc., are ordinarily used next the grafts, or 
 simply a layer of gauze, as described on page 28. Other 
 
 .•£11111 
 
 : If »? i 
 
 
 - 
 
 \ 
 
 I 
 
 
 i 1 
 
 : jssa 
 
 8 
 
 
 
 Fig. 17. — Wire cage in place in open method of grafting — side view. 
 (From International Journal Surgery, May, 1910.) 
 
 successful methods of dressing have been suggested, in 
 one of which everything is lifted clear of the new skin by 
 means of small strips of board elevated on cushions of 
 cotton; or "cages" made of wire gauze may be employed, 
 their rough edges being bound with adhesive plaster — the 
 "strainers" used in kitchens are convenient (Figs. 17, 18, 
 and 19). 
 
50 
 
 SKIN GRAFTING 
 
 Fig. 18. — Wire cage in place in ' ' open method ' ' of grafting — front view. 
 
 Fig. 19. — Wire cage for open method of grafting — edge bound with adhesive 
 
 plaster. 
 
THE METHOD OF THIERSCH 51 
 
 Much has heen claimed for this "open method/' and 
 it certainly gives excellent results, sometimes succeeding 
 where other procedures fail. Goldmann 18 emphasizes the 
 point that the primary fixation of the grafts, which takes 
 place by filbroblasts and capillaries in from 12 to 24 hours, 
 is the most important thing, This, he says, is best accom- 
 plished by the open method, and after it has once occurred, 
 the further character of the dressing, whether dry or moist 
 or by means of ointments, is of little significance. 
 
 A "dry cage" can be converted into a "moist chamber" 
 by covering it with wet gauze, or salt solution can be 
 dropped directly upon the grafts from an irrigator; but 
 there would seem to be nothing gained by this. 
 
 ' 'Splinting" Grafts. 
 
 Davis 18a holds down or "splints" the grafts with curtain 
 netting, having a mesh of about % of an inch (Fig. 20). 
 In order to give the material stability, he soaks it in 30 
 parts of gutta-percha dissolved in 150 parts of chloroform. 
 It can be sterilized by placing it between layers of gauze, 
 and treating it for 36 hours in 1 :1000 bichlorid, changing 
 the fluid every 12 hours. It can then be kept permanently 
 in this solution, which must, however, be thoroughly rinsed 
 away before the material is used. Book-muslin impreg- 
 nated with varnish may also be used, or silk netting treated 
 with paraffin. 19 In employing these "'splints," they must 
 overlap the sound skin, and may remain in place from 4 
 to 10 days, the overlying dressings being meanwhile 
 changed as often as may seem necessary. 
 
 18 Zentralb. f. Chir., p. 793, 1906. 
 
 18 a Am.. Surg., 1909, p. 416. 
 
 19 Parry, Am. J. Surg., July, 1909, p. 243. 
 
52 
 
 SKIN GRAFTING 
 
 Bernhard 20 advocates exposure of the newly grafted 
 area for a short time to the direct rays of the sun; while 
 Schepelmann 21 douches the new skin for several weeks 
 with hot air, by means of a special electric instrument, 
 
 Fig. 20. — Method of "splinting" grafts with rubber-impregnated curtain- 
 netting (Davis). (From Johns Hopkins Hospital Bulletin, XXI, p. 41.) 
 
 claiming that better and more permanent results are thus 
 obtained. 
 
 Thies 22 covers the grafts with a thick layer of fine sand, 
 which has been sterilized by boiling in a 1 per cent solution 
 of sodium carbonate and then dried. He considers that 
 
 20 Deut. Zeitschr. f. Chir., 1905, B. 78, p. 574. 
 
 21 Med. Klinik, 1911, p. 1048. 
 
 22 Zent. f. Chir., 1911, p. 458. 
 
THE MEITHOD* OF THIERSCH 53 
 
 this method has a number of advantages, among which are 
 the removal of fluids by capillary suction, the splinting of 
 the grafts, and the prevention of coagulation of the dis- 
 charges by the alkalinity of the material. The sand should 
 be changed frequently. 
 
 If the grafted surface is near a joint, it is best to prevent 
 movement by means of an ordinary splint. It is well to 
 examine the transplanted skin, especially if about the face, 
 in 24 hours, in order to make sure that nothing has slipped 
 because of vomiting, etc. If everything is in place at 
 that time, it will remain so. If a graft has become dis- 
 placed, it is best to remove it and apply another at once, 
 which can usually be done under local anesthesia with but 
 little inconvenience to the patient. 
 
 Treatment of Wounds After Removal of Grafts. 
 
 The raw and slightly bleeding surface of the thigh, from 
 which the grafts have been taken, can be dressed as one 
 would dress an ordinary wound. McBurney, however, 
 prefers a covering of gauze moistened with normal salt 
 solution, believing that healing will thus take place more 
 readily and with less pain; but others have been unable to 
 notice a difference in this respect. An excellent method 
 is to use sterile boric acid ointment and rubber protective, 
 thus avoiding drying and sticking of the dressing, which 
 causes considerable discomfort. Frequent changing of 
 such -a dressing is unnecessary. 
 
 Much more pain is usually felt in the thigh than in the 
 part to which the grafts have been applied ; in fact, even 
 when considerable pain is present in an ulcer, it is apt to 
 cease when transplantation has been done. 
 
54 
 
 SKIN" GRAFTING 
 
 "Accordion Grafts." 
 
 Lanz 23 has suggested a method by which the wound 
 from which the grafts were obtained can immediately be re- 
 covered. This is accomplished by shaving off a large 
 Thiersch graft and stamping slits in it with an appropriate 
 
 FIG.3 
 
 Fig. 21. — " Accordion grafts " (Lanz). (From Zentrabl. f. Chir., 1908, p. 3.) 
 
 die, so that it may be drawn out, like an accordion, to 
 twice its original length (Fig. 21). It is then divided, 
 one half being used to cover the wound from which the 
 graft was cut, while the other half is placed on the sur- 
 face to be grafted. This ingenious procedure should be 
 of much service — by shortening the tedious healing of a 
 large raw surface, by promoting drainage, and by furnish- 
 
 23 Zentralbl. f. Chir., 1908, p. 3. 
 
THE: METHOD OF THIERSCH 55 
 
 ing a means of obtaining more material in cases where 
 the surface to be grafted is large and the available skin 
 small in amonnt. Under local anesthesia the extent of the 
 operation will also be lessened — a point of some importance 
 to the patient. Such grafts should be "splinted" firmly 
 in place by gauze or by netting (see p. 51). Instead of 
 using a specially made die, the grafts may be spread upon 
 a sterile board and nicked with a sharp knife. 
 
 Proper Time for Grafting. 
 
 There is no reason -for deferring skin grafting until 
 granulation has set in, as is habitually done by some, as 
 the grafts take just as well or better when applied to fresh 
 wounds, thus saving the patient the considerable annoy- 
 ance, not to say danger, of a second anesthetization. If, 
 for instance, an operation is to be done in which the wound 
 will be too large to permit approximation of the edges, as 
 in cancer of the breast, a thigh is sterilized and wrapped 
 in a surgically clean towel. As soon as the major opera- 
 tion is completed, the grafts may be cut, immediately put 
 in place, and an ordinary dry dressing applied, the entire 
 procedure occupying but a few minutes. 
 
 When granulation has once begun, it is well to wait until 
 the process has become thoroughly established and all 
 sloughing tissue has disappeared, which, according to 
 Thiersch, and others, requires five or six weeks ; but this is 
 unnecessarily long, two or three weeks usually being suf- 
 ficient. 
 
 It is important that the granulations should be in good 
 condition, especially if the operation is to be done without 
 scraping. It is sometimes possible, however, to graft un- 
 
56 SKIN GRAFTING 
 
 healthy ulcers, and Kraske has succeeded in covering the 
 ulcerating surfaces of malignant tumors, although the new 
 skin is apt soon to disappear. Better results are, of course, 
 obtained when the conditions are more nearly normal, a 
 favorable sign being the appearance of a pellicle of new 
 skin at the borders of the ulcer. 
 
 After-treatment. 
 
 From seven to ten days are required for grafts to become 
 firmly fixed; and unless suppuration or some other acci- 
 dent occurs, the lowermost layer of gauze or protective may 
 be left in place for two weeks. To avoid danger of loosen- 
 ing the delicate adhesions of the new skin, the coverings 
 should be soaked off with warm salt solution ; although 
 occasionally, when healing has been perfect and dry dress- 
 ings have been employed, they slide off as though no defect 
 in the skin had been present. 
 
 Some mild ointment should subsequently be used to pre- 
 vent dryness and cracking of the tender epithelium, which 
 must be guarded from injury or sudden changes of temper- 
 ature for several weeks. Particularly is this true of crural 
 ulcers and those which have a tendency to reappear after 
 grafting. 
 
 It often happens, especially under moist dressings, that 
 the outer layers of epidermis die and become macerated, 
 so that when the dressing is removed the grafts apparently 
 come away with it, leaving a grayish, sodden surface be- 
 hind. This does not necessarily mean failure, for in a 
 few days the epithelium will generally be replaced from 
 the remaining rete Malpighii. 
 

 THE METHOD OF THIERSCH - 57 
 
 Schmieden 24 claims that scarlet-red ointment stimulates 
 the growth of epithelium to a remarkable degree, and this 
 opinion has been confirmed by many others. The method 
 may be used to advantage in Thiersch grafting where for 
 some reason the entire area has not been covered by skin, 
 but care should be taken that the ointment should not come 
 in unnecessary contact with the grafts, especially before 
 they have become firmly adherent, as it might cause their 
 destruction. 
 
 Application of Thiersch Grafting. 
 
 It is astonishing to what useful purposes Thiersch 
 grafting may be applied in the treatment of various lesions 
 — such as old ulcers, including the intractable crural ulcer, 
 fresh wounds with loss of skin, defects remaining after 
 plastic operations, or after the removal of tumors, nevi, 
 cicatrices, etc., and extensive bums, especially where sub- 
 sequent contractions are feared. Debilitating suppurative 
 and septic processes may be checked by this means, and 
 sometimes life saved. Amputation may occasionally be 
 avoided. The offensive ulcerating surfaces of inoperable, 
 malignant tumors may be skinned over, as demonstrated 
 by Kraske. Tuberculous affections of the skin may be cut 
 and scraped away, and the defects filled in with Thiersch 
 grafts. Flat nevi may at times be shaved off and re- 
 placed by new skin, causing comparatively slight disfigure- 
 ment: Even obstinate cases of lupus erythematosus have 
 been successfully treated in this manner. The grafts will 
 adhere to periosteum, to bone from which the external sur- 
 face has been removed, to tendons, fascia, dura mater, 
 muscle, etc., and mucous surfaces may also be grafted — -for 
 
 ^Centralbl. f. Chir., 1908, p. 153. 
 
58 SKIN GRAFTING 
 
 instance, the vagina, either with sections of mucosa, or with 
 skin. 
 
 Urban asserted that transplantation could not be made 
 on surfaces having a tendency to perish when the cover- 
 ing of soft parts is removed, for instance, bone, tendons, 
 aponeuroses, and cartilage; and this is to a large extent 
 true, although not strictly so, as has been abundantly 
 proved. It must not be forgotten, however, that skin 
 grafts can never be covered up within the tissues, for in- 
 stance, as a substitute for a tendon sheath or a lost portion 
 of peritoneum or dura mater, because of the impossibility 
 of obtaining reliable asepsis. 
 
 A few of the writer's cases, briefly reported, will serve 
 to illustrate the applicability of the Thiersch method: 
 
 The hand of a boy had been badly crushed. The entire dorsum 
 was occupied by a granulating surface which presented little tendency 
 to heal. If healing had occurred, there would have been much de- 
 formity from contraction. The dressings were all removed on the 
 ninth day after the transplantation, and the grafts found adherent. 
 The superficial epithelium came off over a small area, but was soon 
 reformed. The patient was seen as late as two years after the opera- 
 tion, the new skin being in excellent condition, perfectly pliable and 
 free from contraction. 
 
 In another instance several crural ulcers were grafted that had 
 existed eight or ten years, the patient spending considerable time in 
 the hospital during that period. At the end of ten months the ulcers 
 still remained healed, with no puckering of their surfaces. The 
 patient was a heavy drinker and did the work of a hostler. 
 
 An interesting case was one in which the right foot had been badly 
 crushed in a railroad accident. The member was finally saved, but 
 with the loss of a large amount of skin over the inner side of the 
 foot and ankle and posterior portion of the sole including the heel — • 
 an area somewhat larger- than the entire hand. A Wladimiroff- 
 Mickulicz operation was discussed, but it was determined to try skin 
 grafting first. The grafts adhered without difficulty, and the wound 
 was soon well ; although a small ulcer in the vicinity which was not 
 grafted failed to heal for several weeks thereafter. This might be 
 considered an instance in which Thiersch grafting saved a foot from 
 amputation. 
 
THE METHOD OF THIERSCH 59 
 
 An extensive burn of both feet and the anterior surfaces of both 
 legs in a little girl had caused such extreme contractures that the 
 feet were drawn up almost against the tibiae. The physician in 
 charge, after dissecting out the cicatricial masses and straightening 
 the limbs, attempted to fill in the large remaining wound surfaces 
 with pedunculated flaps from the adjacent uninjured regions of the 
 legs. The flaps, however, sloughed, leaving the child's condition 
 worse than before. The raw surfaces were then scraped and covered 
 with Thiersch grafts, which all grew vigorously. The child was 
 heard from six months or more after the operation; there had been 
 no contraction, no ulcers had formed, and the result was satisfactory. 
 A large epithelioma was removed from the frontal region, leaving 
 the dura exposed over an area the size of a saucer. This was grafted 
 at once, using the dry method. The result was perfect, notwith- 
 standing that the wound was thoroughly septic. After several weeks 
 the patient was again seen, and the grafts found in good condition. 
 Every surgeon knows what a tedious process the healing of such a 
 wound is under ordinary circumstances. 
 
 In the case of a young lady, a fairly large nevus (port-wine stain) 
 disfigured the lower eyelid and the upper portion of the cheek. This 
 was excised down to the subcutaneous tissues, and the edges of the 
 wound brought together as far as possible with sutures, leaving an 
 opening as large as a silver half-dollar, which could not be closed 
 without danger of drawing dowm the margin of the lid. The gap was 
 filled with a single moderately thick graft and covered with a wet 
 dressing. The transplantation succeeded, and in the course of time 
 the skin became pliable. At the end of eight or nine months not 
 the slightest puckering of the lid had resulted. Although the graft 
 could still be easily detected, it continued to approach month by 
 month more nearly to the appearance of the surrounding skin. 
 
 Failure resulted in the case of a young and healthy man with a 
 large ulcer of the leg occupying the site of a sear due to a crush. 
 The ulcer had existed for years with no tendency toward healing. 
 In operating, the tissues were found so dense and fibrous that a 
 properly soft and bleeding surface could not be obtained, even by 
 criss-crossing the floor of the ulcer with incisions. The grafts ap- 
 parently dissolved under the wet dressing. It would undoubtedly 
 have been better to have dissected out the entire cicatrix before graft- 
 ing- 
 
 In a case of epithelioma of the nose, the tissues were peeled from 
 the bony framework, leaving only the periosteum. Grafts placed 
 upon this surface "took" without difficulty, the process of healing 
 being greatly shortened and the disfigurement lessened. 
 
 In excising an epithelioma from the bridge of the nose, a circular 
 piece of skin the size of a silver quarter was removed. In two or 
 three weeks the graft, which was at first considerably sunken, became 
 
60 SKIN" GRAFTING 
 
 elevated to the level of the surrounding surface. There was no con- 
 traction and but a slight rounded cicatrix at the border of the trans- 
 planted skin. 
 
 In another case, quite an extensive area of tuberculous skin was 
 removed from the inferior maxillary region of a small boy. A 
 Thiersch graft filled in the defect quite satisfactorily, although some 
 contraction took place about the edges. In such a case the surgeon 
 operates with a freer hand and a better chance of eradicating the 
 disease when he is conscious that the loss of tissue can readily be 
 replaced. 
 
 Thiersch Grafting in Special Cases. 
 
 Accidental wounds are frequently permitted to gran- 
 ulate before transplantation is done, as it is- often impos- 
 sible to render them surgically clean and, in addition, the 
 patient may be bleeding excessively or in a condition of 
 shock. If everything is reasonably favorable, however, 
 grafting should be done at once, as it may prevent subse- 
 quent infection. 
 
 Burn's. — As a matter of course, granulation is always a 
 first requisite in burns. If the part can be kept aseptic, 
 the new skin may be applied in about six weeks, and the 
 time should even be longer if extensive sloughs must sepa- 
 rate (Urban). Judicious grafting in large burns of the 
 third degree cannot be too strongly urged, in order to pre- 
 vent long-continued and exhausting suppuration, unsightly 
 scars, and embarrassing contractures. 
 
 Dunham 25 succeeded with a thick Thiersch graft in 
 bridging over a finger-joint exposed by a burn, but this 
 was a piece of good fortune which cannot frequently be imi- 
 tated, the covering over of hollow spaces being a matter 
 of plastic surgery rather than of transplantation. 
 
 The Nose. — The results of Thiersch grafting about the 
 
 25 Ref. Handbook Med. Sci., Supplement. 
 
THE METHOD OF THIERSCH 61 
 
 nose are reasonably good, even when the entire covering 
 of the organ has to be removed, providing the mncosa re- 
 mains uninjured. When, however, so flimsy a framework 
 as the mucous membrane alone exists, it is better to plug 
 the nostrils with cotton so as to obtain a firmer basis. The 
 grafted alee are at first quite thin, but in the course of 
 time they become thick enough to be presentable. 
 
 It is sometimes desirable to use pedunculated flaps of 
 skin in repairing defects about the nose or lips involving 
 the entire thickness of the part. When this is done, their 
 raw surfaces may be covered with Thiersch grafts, either 
 at once or after granulation has taken place, in order to 
 prevent contraction. In replacing a portion of the cheek, 
 for instance, a flap may be dissected from the neck, sup- 
 ported on a piece of gauze for ten days or two weeks, and 
 grafted before insertion in its new position. The wounds* 
 from which these flaps are taken may also be grafted when 
 necessary. . 
 
 In the worst form of acne rosacea the cutaneous sur- 
 face of the end of the nose becomes irregularly hyper- 
 trophied, so that the grotesquely enlarged organ has a 
 swollen, red, and nodular appearance. Such unsightly 
 noses can sometimes be pared down to a proper size, and 
 the surface at once grafted, the results being often cos- 
 metically good. 
 
 Xew Growths, — The Thiersch procedure has a wide 
 field of usefulness in filling the defects left by the removal 
 of malignant tumors, particularly carcinoma of the breast. 
 With an effective method of grafting at his disposal, the 
 operator does not fear to excise an amount of skin which he 
 would otherwise hesitate to do, and it is in the skin that 
 
62 SKIN GRAFTING 
 
 the majority of relapses occur. Kraske 26 found it pos- 
 sible to graft the ulcerated surfaces of inoperable car- 
 cinomata, thus preventing septic infection and offensive 
 discharge ; but it is questionable if such a course is worth 
 while, as the grafts soon break down and disappear. 
 
 In excising hairy moles, it is necessary to be sure that 
 the hair bulbs are completely removed; otherwise hairs 
 force themselves through the new epidermal covering, as 
 happened in a case reported by Gnarch. 27 
 
 Hands and Fingers. — In injuries and burns of the 
 hands, grafting is of immense service in the prevention of 
 unsightly scars and annoying contractures. The Thiersch 
 method may even be used with considerable success upon 
 the palmar surface, although better and more durable re- 
 sults are obtained, especially when the knuckles and wrist 
 are involved, by means of pedunculated flaps from various 
 portions of the body, or by the Wolfe-Krause method. 
 Skin grafts may be employed with satisfaction in opera- 
 tions for syndactylism. 
 
 Scabs, and Contractures. — One of the most useful 
 applications of Thiersch grafting is in the prevention and 
 removal of deformities, due to extensive scars and con- 
 tractures. Where possible, it is usually preferable, for 
 the sake of nutrition as well as for cosmetic reasons, to 
 dissect out the cicatricial tissue entirely. In contractures 
 about the neck, for instance, where the chin is drawn down 
 toward the sternum, the entire scar should be removed prior 
 to the application of grafts. It should be noted, however, 
 that pedunculated flaps or Wolfe-Krause grafts are often 
 
 26 Munch Med. Woch., Jan. 1, 1889. 
 
 27 Verhand. Internat. Med. Cong. Berlin, 1890, p. 224. 
 
THE METHOD OF THIERSCH 63 
 
 more serviceable and sightly than are Thiersch transplan- 
 tations. 
 
 Grafting- on Bone. — Following sequestrotomy and 
 other bone operations nmch time is often consumed in heal- 
 ing. A few judiciously applied skin grafts will, however, 
 frequently hasten convalescence, although they are less 
 likely to "take" than under most other circumstances. 
 Even the entire orbit may be lined with epithelium after 
 the removal of a malignant growth, as was successfully 
 done by von Noorden. 28 
 
 In some cases, where a smooth, clean surface can be ob- 
 tained, transplantation may be done at once, although it 
 is often preferable to wait until granulations have ap- 
 peared, perhaps four to six weeks. When a gutter has 
 been chiseled in the bone, it may be necessary to shove 
 the grafts through quite a small opening, and much dif- 
 ficulty may be experienced in adjusting them smoothly. 
 They may sometimes be held in place by packing the cavity 
 with small pledgets of gauze. Even when success is but 
 partial, the remainder of the surface is often stimulated 
 to rapid healing. After the removal of exostoses, the bone 
 may at once be covered with new skin with considerable 
 assurance of a good result. 
 
 Chronic Empyema. — In this troublesome affection it is 
 sometimes necessary to remove portions of the chest wall 
 in such a manner as to leave a large granulating cavity 
 which is very slow in healing. Tillmanns, in 1890, dem- 
 onstrated that such surfaces can be successfully grafted, 
 and since then, the operation has been repeatedly done by 
 others. 
 
 2S Berl. Klin. Woch., 1892, No. 41. 
 
64 SKIN" GRAFTING 
 
 Bedsores, after the breaking-down process has ceased, 
 can sometimes be provided with an epithelial covering, 
 either with or without preliminary cnrettement, thus sav- 
 ing time, disfigurement, and annoyance. 
 
 Chronic leg ulcers present such a severe test of any 
 form of grafting that methods will often fail which uni- 
 formly succeed elsewhere. Urban, however, is so confident 
 that Thiersch grafting, when properly carried out, will be 
 effective in these cases, that he says amputation should 
 never be resorted to even in the most extensive lesions ; but 
 his elaborate method requires so much time, care, and pa- 
 tience that it can scarcely be considered advisable except 
 in aggravated cases. Three to four months are necessary, 
 six to eight weeks of which must be spent in preparation 
 alone, and during the entire time the patient must remain 
 in bed ! 
 
 It is advisable in many instances to completely excise 
 ulcers of the leg, almost as if they were malignant growths, 
 before transplantation is attempted, especially if much in- 
 duration is present; and failures would undoubtedly be 
 much less frequent if this were more often resorted to. 
 Excision is of course inevitable if lupus or epithelioma 
 exists. 
 
 The cause of the ulcer must be carefully considered, for 
 upon this may depend the character of the operative pro- 
 cedure. In various ulcers, for instance, the enlarged, veins 
 should always receive attention, either by obliterating them, 
 by means of one of the various procedures employed for 
 that purpose, or by applying a suitable support to the leg, 
 in the shape of a bandage, an elastic stocking, or a Murphy 
 
THE METHOD OF THIERSCH 65 
 
 corset. Prolonged rest in bed will of conrse improve the 
 nutrition of the limb, but the old condition returns as soon 
 as the patient resumes his feet. Syphilis is always a con- 
 traindication to operation until appropriate treatment has 
 been used for a sufficient length of time to insure local free- 
 dom from the disease. 
 
 Following a transplantation for leg ulcer, the patient 
 should remain in bed for some time, as a sudden afflux of 
 blood to the part often injures the tender grafts, and an 
 elastic flannel bandage should be worn for several months, 
 reaching from the toes to the thigh. Some mild ointment 
 should occasionally be applied to the grafted area in order 
 to prevent excessive dryness, and great care must be exer- 
 cised in the avoidance of injury to the limb. 
 
 Urban lays much stress upon massage in the after-treat- 
 ment. This should be begun in the vicinity of the ulcer 
 upon the tenth day, and the longer it is continued the bet- 
 ter. The new skin may be rendered pliable without actu- 
 ally touching it by carefully pulling and massaging the 
 skin in its vicinity. 
 
 • Mucous Surfaces. — Thiersch grafting has been success- 
 fully done in the mouth, the vagina, the urethra, the eye, 
 and the ear, although the chances of success are not so good 
 in these situations as elsewhere. The statement made by 
 Thiersch is not strictly true, that it is impossible to graft 
 upon surfaces connected with mucous cavities, Schnitzler 
 and Ewald having succeeded even upon a granulating sur- 
 face, following the removal of an epithelioma from the in- 
 side of the cheek. The new skin soon conforms more or 
 less to the characteristics of the surrounding mucous mem- 
 
66 SKIN GRAFTING 
 
 brane, although not becoming identical with it. Hairs or 
 glandular elements never develop, partly because of the 
 thinness of the grafts. 
 
 It is occasionally possible to form a new urethra, in oper- 
 ations for hypospadias, or to replace lost portions of the 
 urethral canal by means of Thiersch grafting, the grafts 
 being wound around a catheter, which is left in situ until 
 adherence has taken place. 
 
 Heterogeneous Thiersch Grafting. 
 
 As in other forms of transplantation, skin taken from 
 the patient himself grows better than that obtained from 
 others, even from a blood-relation. When, however, it is 
 necessary to employ the heteroplastic method, local anes- 
 thesia (see Chap. X) should always be used, if possible, in 
 order to avoid danger to the donor. In extensive burns 
 occurring in children, for instance, it may be advisable to 
 obtain grafts from another, usually the mother or the 
 father. When this is the case, the two individuals may be 
 placed side by side, the grafts removed under local anes- 
 thesia from the parent being transferred directly to the 
 unscraped granulating surface on the child without causing 
 pain to either of them. 
 
 Statistics. 
 
 In order to give some idea of the proportion of successes 
 obtained in Thiersch grafting, the following statistics are 
 quoted : 
 
 Eancrede 29 estimates that seven out of ten operations 
 succeed ; but if the cases are at all well selected, the pro- 
 
 29 Ann. Gyn., Feb., 1892. 
 
THE METHOD OF THIERSCH 67 
 
 portion should be greater than this. Thorndike has col- 
 lected 123 cases with 102 successes (82.9 per cent). 
 Jungengel's statistics show 119 transplantations with 100 
 successes. Yon Eiselsberg 30 reports 37 operations on 
 fresh wounds with 33 good results, and 13 operations on 
 granulating wounds with 11 good results. Plessing 31 tab- 
 ulates 78 graftings with 58 successes (75 per cent) and 12 
 partial successes. Out of 544 cases of grafting by various 
 methods, collected by Davis from the reports of the Johns 
 Hopkins Hospital, 341 were completely successful, and but 
 17 were absolute failures. 
 
 30 Wien. Klin. Woch., 1889, Nos. 34 and 35. 
 3 1 Arch. f. Klin. Chir., Bd. 37, p. 53. 
 
CHAPTER V 
 THE WOLFE-KRAUSE METHOD 
 
 The credit for introducing the use of grafts filling the 
 entire cutaneous defect and comprising the whole thick- 
 ness of the skin, without including fat or cellular tissue, 
 is due to J. R. Wolfe, an oculist of Glasgow. His first 
 experiments were made in connection with the conjunctiva, 
 portions of which he shifted, without pedicels, from one 
 part of the eye to another. He soon began to employ the 
 conjunctiva? of rabbits in repairing defects in the human 
 eye, announcing his method before the Glasgow Med. and 
 Chir.' Soc, in 1872. In 1875, he published his experi- 
 ments in skin grafting for ectropion, 1 being closely followed 
 by Wadsworth, who introduced the procedure in America. 
 Von Esmarch was among the first to apply the operation to 
 any extent in general surgery. 2 
 
 Grafts composed of the entire thickness of the skin had 
 been used frequently enough, however, prior to their em- 
 ployment by "Wolfe, not only by the ancient Hindus, but 
 in modern times as well, although the subcutaneous tissues 
 were nearly always included. Jacenko 3 was probably the 
 first to successfully employ grafts devoid of fat, and in 
 1872, Le Eort reported a successful operation in a case of 
 ectropion. 
 
 Wolfe was probably correct in believing that the avoid- 
 
 iBrit. Med. Jour., Sept. 18, 1875. 
 
 2 Wien. Med. Woch., 1885, Nos. 29 and 30. 
 
 3 Ber. Klin. Woch., Xo. 8, 1871. 
 
 68 
 
THE WOEFEKKRAUSE METHOD . 69 
 
 ance of fatty tissue was an important feature of his method, 
 as it is apt to undergo necrosis and to interfere with nutri- 
 tion. This has been denied, however, by many, including 
 Hirschberg 4 and Taylor, 5 and there is no doubt that suc- 
 cess can often be obtained without this precaution ; in fact, 
 free masses of fat alone are not infrequently transplanted 
 from one locality to another, in order to fill up unsightly 
 depressions, a substitution for the mammary gland having 
 even been provided in this manner. Wolfe's original 
 method has been modified, and the technic so much im- 
 proved by Fedor Krause, that it is often referred to as the 
 Wolfe-Krause Method. 
 
 Preparation. 
 
 If an ulcer is to be operated on, its preparation must 
 be undertaken with even greater care than in the Thiersch 
 process (see Chap. IV). After curetting away the granu- 
 lations, there should be no hesitation in excising the cal- 
 lous borders and base, so as to obtain as free a circulation 
 as possible ; and in some cases — for instance, in old crural 
 ulcers — it may even be advisable to chisel away a layer of 
 thickened and diseased bone from the face of the tibia. 
 Rather than employ ligatures on the wound surface, it may 
 occasionally be preferable to delay operating for a day or 
 so and apply compression, afterward soaking off the com- 
 press so as not to renew the bleeding; or direct pressure 
 with an Esmarch bandage may be used (see p. 37). 
 
 Contrary to former belief, it has been demonstrated 
 (Davis 6 ) that good results can be obtained by placing 
 
 *Verhand. d. Deut. Gesell. f. Chir., 1893. 
 
 3 Practitioner, Dec, 1882, p. 428. 
 
 6 Internat. Clinics, 1905, Vol. 1, p. 81. 
 
70 SKIN GRAFTING 
 
 whole thickness grafts directly on a healthy granulating 
 surface, without preliminary curettement. The granula- 
 tions should be cleaned the day before the operation, how- 
 ever, and a mild antiseptic dressing applied. Such grafts 
 are at first higher than the surrounding skin, but they soon 
 come down to the common level. Although it is question- 
 able if success is as certain as when the granulations are 
 removed, it is nevertheless well to know that under certain 
 circumstances the operation may be simplified in this 
 manner. 
 
 Technic. 
 
 The grafts are best cut in the shape of a spindle, so that 
 the defect produced by their removal can be closed by 
 sutures, although in fleshy individuals it may be necessary 
 to dissect the fat from the bottom of the wound before it 
 can easily be united. 
 
 The arm or the thigh is usually chosen, but owing to the 
 fact that the skin retains almost indefinitely its original 
 character of fineness or coarseness, it is well to use on 
 the face grafts from the inside of the arm. Aside from 
 this consideration, it is of little moment, contrary to 
 Hirschberg, where the grafts are obtained, or whether the 
 blood plexus is highly developed or not, and it is unneces- 
 sary to produce an artificial hyperemia by preliminary 
 irritation of the cuticle. Davis suggests using skin from 
 the abdomen obtained in the course of a laparotomy. 
 Hueter and Krause claim that hairs may be transplanted 
 by this method, although they are apt to be deformed and 
 rather few in number. An eyebrow, for instance, might 
 thus be replaced from the pubes. 
 
THE. WOEFErKRAUSEl METHOD 71 
 
 The graft should be carefully outlined by an incision. 
 Then one end is seized with forceps, and the whole flap is 
 freed with the knife, the edge of which is turned toward 
 the surface so as to remove the fat, although the retention 
 of a small amount will do no serious harm. At least one 
 third should be allowed for shrinkage, which is always 
 great, owing to the elasticity of the skin. In order to 
 avoid touching the raw tissues more than is necessary, 
 which is detrimental to their vitality, it is best to fold the 
 end of the spindle under as soon as enough is loosened, so 
 as to bring the two raw surfaces together and permit han- 
 dling of the graft by its epithelial covering only. Rough 
 handling should be avoided with the greatest care, such as 
 tight pinching with forceps, rubbing with gauze, or un- 
 necessary traction before the graft is completely divided. 
 
 Young 7 excises the subcutaneous fat along with the 
 grafts, afterward trimming it off with curved scissors while 
 the flap is spread on the palm of the hand or is curled over 
 a finger. He claims that less time and trouble are thus 
 required and that the resulting wound is more readily 
 closed. Adipose tissue soon reforms beneath the trans- 
 plantation, in sufficient amount to fill up inequalities and 
 render the skin pliable. 
 
 An essential feature, according to Krause, is absolute 
 dryness, surgically speaking, which he thinks is conducive 
 to rapid healing. There must be no douching and no mois- 
 ture about the hands or instruments or about the surface 
 upon which the grafting is to be done. He is probably 
 correct in this, although there are others who do not agree 
 with him. 
 
 7 Glasgow Med. Jour., Oct., 1907. 
 
72 SKIN GRAFTING 
 
 Adjustment of Grafts and Dressings. 
 
 The grafts, cut into smaller pieces if desirable, are 
 pressed firmly in place in order to remove blood and bub- 
 bles of air, and if too much moisture is not present, they 
 will adhere as if giued fast. Subsequent bleeding beneath 
 the surface is fatal. Sutures are detrimental and are 
 never necessary, except occasionally about the eyelids and 
 lips, although they were at first invariably employed by 
 Wolfe. 
 
 The entire wound must be completely covered with as 
 large sections of skin as possible, because wherever there 
 is an open space more or less of a cicatrix results. If this 
 is not practicable, the operation may be completed with 
 Thiersch grafts. 
 
 It was at first customary to keep the new skin warm by 
 applying artificial heat ; but this was found' to be detri- 
 mental rather than beneficial, as decomposition was thus 
 favored. Either a dry or a moist dressing, as described 
 under the Thiersch method, may be used, but the former 
 is usually preferable, nothing but ordinary sterilized 
 gauze and cotton really being necessary. The grafts 
 should be inspected in three or four days in order to open 
 blisters, etc., the gauze being soaked off with warm boric 
 acid solution if strips of rubber protective have not been 
 employed. After this, sterilized borated vaselin can be 
 used. 
 
 After-treatment. 
 
 Inequalities of the surface soon fill out as they do under 
 Thiersch grafts. If the outside layers of the new skin 
 exfoliate much, a moist covering can be used to hasten the 
 
 '•''■■. 
 
THE WOLFEhKRAUSK METHOD 73 
 
 process, and the lost epithelium replaced by Thiersch 
 grafts, if necessary. Even when the surface rises in 
 blisters and assumes a bluish color, failure should not has- 
 tily be assumed, as the necrosis is often superficial and of 
 comparatively slight importance. 
 
 Healing should be complete in from three to six weeks, 
 success being aided by massage and other measures as in 
 the Thiersch process. Without actually massaging the 
 grafts themselves, they may be loosened quite early by 
 manipulating the skin in their vicinity. 
 
 With proper care whole thickness grafts may be em- 
 ployed wherever the Thiersch method is applicable, even 
 upon tendons, bones, and aponeuroses ; but its greatest use- 
 fulness begins where that of the Thiersch graft ends — that 
 is, where an especially thick and durable covering is re- 
 quired — although the technic is much more exacting and 
 the chance of failure greater. Davis, 8 however, has re- 
 ported 19 cases of grafting with the whole thickness of the 
 skin with but one partial failure, which is certainly en- 
 couraging. 
 
 8 Ann. Surg., 1909, Vol. 50, p. 542. 
 
CHAPTEK VI 
 
 THE METHOD OF HIRSCHBERG— SKIN-PERI- 
 OSTEUM-BOKE GRAFTS 
 
 In the original "Indian method/' as used by the ancient 
 Hindus in rhinoplastic operations, grafts were employed 
 comprising the subcutaneous fat ; and nearly all the trans- 
 plantations which were done up to the time of Wolfe, with 
 the exception of that introduced by Reverdin, were pat- 
 terned after this method, as is most' plastic work at the 
 present time. 
 
 Hirschberg x has attempted to revive the Indian method, 
 but has met with little response from other surgeons. He 
 claims that better results will be obtained by transplanting 
 the subcutaneous adipose tissue along with the cutis, and 
 supports his assertion by calling attention to cases in which 
 pieces of fat alone have been used to fill up various defects 
 in the tissues, even to the replacement of the entire mam- 
 mary gland (Czerny). It is interesting to note, however, 
 in this connection, that Pitschke has called attention to the 
 necrosis of adipose tissue which often follows surgical oper- 
 ations, causing troublesome fistulse, thus showing that the 
 vitality of fat is not great. 
 
 Hirschberg 2 lays great stress on the amount of blood 
 and other fluids which the graft contains at the time it is 
 transplanted, with the idea that it subsists until new vessels 
 
 1 Verhand. d. deut. Gesell. f. Chir., XII Kong., 1893. 
 
 2 Verhand. d. deut, Gesel. f. Chir., XXIV Kong., 1895. 
 
 74 
 
 ■HH 
 
THE METHOD OF HIRSCHBEEG- 75 
 
 are formed almost entirely upon the nutritive material al- 
 ready within its substance ; and in this connection DiefTen- 
 bach, Thiersch, and Hanfr have shown that for some time 
 after the removal of a thick portion of cuticle there is more 
 or less perceptible motion of its fluids. 
 
 Hirschberg also believes that not a little depends upon 
 the locality from which the skin is derived, some portions 
 of the body being richer in vessels than others, which ac- 
 counts, he thinks, for the comparatively ready reunion of 
 severed portions of noses and fingers. The success of the 
 Hindus, he attributes partially to the fact that they usually 
 grafted from the gluteal region, where the skin is very 
 vascular. 
 
 Hence, he advises artificial irritation of the skin by 
 means of rubbing it, or beating it with a piece of rubber 
 tubing, until the surface becomes red and swollen ; and in 
 order to further increase the congestion of a limb, an Es- 
 march strap may be lightly fastened about it. The gen- 
 eral opinion is, however, that but little if any benefit is 
 derived from the production of artificial hyperemia in skin 
 grafting. 
 
 Sutures are often desirable in the method of Hirschberg, 
 as the grafts will not adhere readily without them. As a 
 matter of convenience, he often places them in position be- 
 fore entirely detaching the flap. 
 
 Morrow 3 has utilized the Hirschberg method by remov- 
 ing -small defects from the face and other regions with an 
 instrument known as "Keyes' cutaneous punch," and filling 
 the hole thus left with a button comprising the entire thick- 
 ness of the skin together with the subcutaneous fat, which 
 
 3 Trans. Am. Derm. Assoc, 1891. 
 
76 SKIN GKAFTTNG- 
 
 is removed in the same manner from some other region. 
 He claims that hair may easily be transplanted in this way. 
 
 Skin-Periosteum-Bone Grafts. 
 
 It should be mentioned that grafts are occasionally em- 
 ployed which include not only the skin and subcutaneous 
 tissues, but also the periosteum and even a portion of the 
 bone itself. The technic, however, is very exacting, and 
 asepsis must of course be absolute. The indications for 
 this method of transplantation are not numerous and are 
 confined mostly to certain rhinoplastic operations and to the 
 filling in of defects in connection with the skull and scalp. 
 
 In outlining the graft, which is usually obtained from 
 the anterior surface of the tibia, the incision is made di- 
 rectly down to the bone, a more or less thin layer of which 
 is then removed with a sharp chisel without disturbing its 
 connection with the super j acent periosteum and skin. The 
 tibial wound is then closed by undermining and suturing 
 the surrounding integument. Better results are usually 
 obtained when a section of bone is included than when the 
 periosteum alone is employed. 
 
CHAPTER VII 
 
 THE TRANSPLANTATION OF MUCOUS . MEM- 
 BRANE— ANOMALIES IN SKIN GRAFTING— 
 SPONGE GRAFTING 
 
 Mucous Membrane. 
 
 The first systematic transplantation of mucous mem- 
 brane, other than the conjunctiva, was done by Wolfler, 
 who grafted urethras, after the excision of strictures, with 
 strips of mucosa from a prolapsed rectum, from the cervix 
 of a prolapsed uterus, or a uterus which had been removed 
 from the body. Subsequently he similarly obtained good 
 results with the stomach of the frog, the esophagus of the 
 rabbit, etc. In one of his cases the condition of the new 
 urethra was perfect at an autopsy made six months after 
 the operation. Beigel x also did some excellent work in 
 this line, and Fenwick 2 repaired a defect in a human 
 urethra with a portion of the urethra of a sheep. 
 
 It should be mentioned in this connection that the 
 urethra has recently been satisfactorily replaced with por- 
 tions of the internal saphenous vein as well as with the 
 ureter and the vermiform appendix, removed from other 
 individuals during the course of necessary operations. 
 
 Wolfler claims that mucous membrane adheres as well 
 as skin, but this has not been the experience of others. 1 1 
 
 1 "Die Krankheiten des Weibl. Geschlechtes, " 1875. 
 
 2 Lancet, Feb. 8, 1896, p. 3.53. 
 
 77 
 
78 SKIN" GRAFTING 
 
 can be shaved off as in Thiersch grafting, or may be 
 stripped off in its entirety. 
 
 Hirschberg, in 1874, made the first transplantation of 
 buccal mucous membrane to the conjunctiva. Since that 
 time the experiment has been frequently repeated. To 
 Wolfe, in 1872, is due the credit of grafting from the con- 
 junctivae of animals to that of man, and of bringing the 
 procedure into general use. 
 
 Czerny showed that mucous membrane from the mouth, 
 with flat epithelium, and from the nose, with cylindrical or 
 ciliated epithelium, soon comes to resemble epidermis when 
 grafted upon a raw skin surface. Sick 3 has observed that 
 the same phenomenon occurs in connection with vaginal 
 mucosa. 
 
 Most writers, following the teaching of Virchow, main- 
 tain that skin transplanted to a mucous surface becomes 
 transformed into mucous membrane. It is certainly true 
 that in most cases it very largely conforms itself to its 
 surroundings, losing its hairs and other distinctive fea- 
 tures. Thiersch, 4 however, denies that this change takes 
 place, citing as proof a case in which he used a skin-flap in 
 manufacturing a soft palate. So much hair grew upon the 
 part that the patient was compelled to continually shave 
 the inside of his mouth ! 
 
 In operations for hypospadias Thiersch grafts have been 
 successfully employed to line the new urethra, by wrapping 
 them around a catheter, which is left in position until ad- 
 hesion has taken place. 5 They have also been used within 
 the larynx after the excision of a stricture. 6 • 
 
 3 Archiv. f. Klin. Chir., Bd. 43, p. 387. 
 
 ±Beitrage z. Cent. F. Chir., 1888, No. 24. 
 
 5 Nove-Josserand, Rev. de Chir., 1903, Vol. 1, p. 403. 
 
 6 Alapy, Zentralbl, f. Chir., 1900, p. 1313. 
 
ANOMALIES IN SKIN GRAFTING 79 
 
 Anomalies in Skin Grafting. 
 
 Kibler, 7 Parmenter, 8 and Granbury 9 insist that shavings 
 from callosities of the palms of the hands or soles of the 
 feet furnish particularly good material for grafting, having 
 the advantage of being easily obtained without pain or 
 other inconvenience to the patient. From three to six or 
 more grafts, as thin as tissue-paper, may be cut from 
 the same surface at intervals of three or four days. In the 
 experience of Kibler and others over 80 per cent of the 
 transplanted pieces of epithelium have lived, the results 
 being excellent. 
 
 Granbury recommends preliminary friction of the callus, 
 imagining that the vitality of the grafts is increased and 
 union hastened. Experience has proved, however, that in 
 other situations irritation of the skin prior to transplanta- 
 tion is of little or no value, and it is difficult to see why it 
 should be otherwise where callus is concerned. 
 
 Hodgen 10 was successful in grafting with shavings from 
 corns, preferring this material to that otherwise obtained. 
 Leale n had good results with warts, his method being to 
 separate the growth into its component vascular "epithelial 
 rods," which were scattered over the ulcerated surface. 
 He attributed his success to the superabundant tendency to 
 growth, which verrucosities are supposed to possess. Hod- 
 gen has also transplanted from mollis, but it is difficult to 
 imagine why this should ever be done, particularly as there 
 is some danger of transferring malignancy in this way. 
 . The fact that pieces of old, dried, and often loose 
 
 7 Jour. Am. Med. Assoc, Aug. 8, 1891, p. 224. 
 
 8 Park's Surgery, 1896. 
 
 9 Texas Sanitarian, Sept. 1894. 
 
 10 St. Louis Med. and Surg. Jour., July, 1871. 
 "Med. Rec, Vol. 14, p. 188, 1878. 
 
80 SKIN GRAFTING 
 
 epidermis could be used in grafting was also demonstrated 
 by Hodgen, his experiments being confirmed by Lnsk. 12 
 When desirable, almost unlimited quantities of epithelium 
 can be obtained by the application of a canthakides blis- 
 ter, as was first suggested by the writer, 13 and afterward 
 by Morris 14 and by Lusk. It is unnecessary to dry the 
 epidermis, as is recommended by Lusk, but it can be used 
 at once, as it is cut from the blister, small pieces furnishing 
 better results than large ones (Morris). It is true that 
 "blister grafts" are not as durable as those obtained by 
 other methods, and that they are best adapted for use on 
 certain small wounds and granulating surfaces, although 
 Lusk, by using very small pieces, claims to have obtained 
 good, durable, elastic skin. 
 
 Schweninger observed that when hairs were placed upon 
 an ulcer a growth of epithelium resulted; but von Nuss- 
 baum showed that this occurred only when the root sheaths 
 were present, and that the hairs themselves were of no im- 
 portance. The process, then, amounts simply to a trans- 
 plantation of epithelium, and is of little practical value. 
 
 Howard 15 claims to have grafted ulcers with bits of 
 muscle, which grew well and stimulated the remainder of 
 the surface to rapid cicatrization. This does not mean, 
 of course, that epithelium can develop from muscle as has 
 been asserted. 
 
 It has long been known that scrapings from the surface 
 of the skin, so-called "epithelial dust," will adhere to 
 granulations or to fresh wounds and grow as do larger 
 grafts. Reverdin tried the experiment and reported 
 
 12 Med. Rec, Dec. 7, 1895, p. 800. 
 
 13 Denver Med. Times, May, 1895, p. 428. 
 
 14 Lectures on Appendicitis and Notes on other Subjects, N. Y., 1895. 
 
 15 N. Y. Med. Jour., Sept., 1871. 
 
ANOMALIES IN SKIN GRAFTING 81 
 
 against it, as did also Czerny, Reclus, and others, although 
 Fidder and Hodgen claimed to have had good results, espe- 
 cially the latter, who employed scrapings from the sole of 
 the foot. It would seem probable that the less the sup- 
 puration the greater the chance of success, as the tiny grafts 
 would not be so likely to become macerated or washed away. 
 
 In this connection the method of Mangoldt 16 possesses 
 some merit. He carefully disinfects the skin and scrapes 
 it with a scalpel until a sort of paste is procured, formed 
 of epithelial scales and a little blood. This is smeared 
 upon the surface of the ulcer, to which it readily adheres, 
 owing to the coagulation of the blood, forming a brick-red 
 layer. In five to seven days the blood vanishes, leaving 
 new pinkish skin, which becomes firm in about three weeks. 
 A fine mosaic is seen with a lens, but to the naked eye it 
 is smooth epidermis. Mann, of Dresden, has utilized the 
 method in open wounds following operations upon the 
 mastoid. 
 
 Grafting from dead bodies or from amputated 
 limbs is easily done and has frequently been resorted to ; 
 but the danger of carrying disease is positive and cannot be 
 disregarded, while failures are much more frequent than 
 in autodermic methods. Czemy reports cases of tubercu- 
 losis, communicated by grafts obtained from a leg removed 
 for white swelling of the knee, and there is always danger 
 from syphilis. 
 
 Girdner 1T claims that the method is original with him, 
 but the credit probably belongs to Steele, of Bristol, who 
 made successful transplantations from amputated limbs in 
 
 16 Deut. Med. Woch., Nov. 28, 1895, p. 798. 
 17 Med. Rec, July 30, 1881. 
 
82 SKIN" GEAFTING 
 
 several cases. Ivanova 18 has transplanted with much suc- 
 cess from the bodies of infants, one and one-half and two 
 hours after death. In grafting from amputated limbs, 
 Symonds 19 sometimes employed the Thiersch method and 
 at other times that of Wolfe. Tillmanns, in his work on 
 surgery, advances the questionable idea that in transplant- 
 ing from the cadaver the operation must be performed be- 
 fore rigor mortis sets in. 
 
 Each of the above-mentioned means of obtaining grafts 
 is of scientific interest, and may be of practical use in 
 certain cases ; but none of them is of so much general value 
 as the method usually employed. Grafting with hairs, 
 moles, or Avarts would scarcely be considered under ordi- 
 nary circumstances. 
 
 Sponge Grafting. 
 
 Sponge grafting, introduced by Hamilton, in 1881, is 
 essentially different in principle from skin grafting, never- 
 theless a brief consideration of the subject will not be out 
 of place. It was formerly in quite general use. Sponge 
 does not grow fast to the surface as does skin, but acts 
 merely as a stimulating support for the granulations, fin- 
 ally undergoing complete absorption. The procedure is 
 much inferior in its results to the transplantation of cuticle, 
 and is now seldom employed. 
 
 A fine Turkey sponge is selected, soaked in dilute 
 nitrohydrochloric acid until all calcareous particles have 
 been dissolved, and then placed for a time if desired in a 
 
 18 Ann. Surg., Vol. 12, 1890, p. 354. 
 
 19 Brit. Med. Jour., Dec. 14, 1889, p. 1331. 
 
SPONGE GRAFTING 88 
 
 solution of potassium hydroxid. Very thin slices, which 
 are the most serviceable, can be cut with a sharp knife, or, 
 more conveniently, with a microtome, and sterilized by boil- 
 ing, or in a 5 per cent solution of carbolic acid, which is 
 afterward removed by washing. 
 
 The sponge is then spread upon the granulations, which 
 have been rendered as nearly aseptic as possible (see the 
 method of Reverdin), and dressed much as if it were a 
 transplantation of skin. The granulations soon acquire 
 new energy and push their way into the interstices of the 
 sponge, which often almost disappears beneath them, so 
 luxuriant is the growth. Cicatrization proceeds more rap- 
 idly than under ordinary circumstances, providing that 
 sepsis and decomposition do not become too prominent, 
 which is not infrequently the case. 
 
 Robinson combines sponge grafting with the transplanta- 
 tion of skin, small bits of which he places beneath the layer 
 of sponge. He claims that the filling up of ulcers and the 
 formation of epithelium go on side by side with unusual 
 rapidity. 
 
 The transplantation of fascia, 20 muscle, nerves, brain- 
 tissue, blood-vessels, omentum, bones, joints, and even of 
 entire organs, has recently assumed much prominence in 
 surgical literature, but the consideration of these inter- 
 esting subjects is scarcely in place in connection with a 
 monograph on skin grafting. 
 
 20 Davis, Ann. Surg., Dec. 1911. — Zeit. f. Chir., 1911, pp. 23 to 36. 
 
CHAPTER VIII 
 GRAFTING FROM ANIMALS 
 
 The idea of obtaining grafts from animals, thus avoid- 
 ing pain and inconvenience to the patient, is certainly 
 attractive. If it could be demonstrated that such trans- 
 plantations were sufficiently often successful, and that the 
 new skin was as satisfactory as that obtained by other 
 processes, zoografting would be the method of choice. Un- 
 fortunately the procedure is at best uncertain, so much so 
 that Reclus has classed it among "laboratory experiments," 
 rather than among useful operations. Colrat laid down 
 the general rule that such grafts usually become absorbed, 
 granulations sooner or later growing through them, al- 
 though they may seem to thrive at first. This is un- 
 doubtedly going too far, as numerous instances have been 
 recorded where the method has been of great service. 
 
 Cousin makes some interesting comparisons between the 
 value of grafts obtained from man and from animals. He 
 made 165 transplantations from frogs, chickens, guinea- 
 pigs, and rabbits, out of which he had but 15 successes. 
 In 122 human grafts, however, good results were ob- 
 tained in 115. 
 
 Success has varied much in the hands of different opera- 
 tors ; so much so that by some the method has been abso- 
 lutely condemned, and by others praised beyond all reason. 
 A partial explanation of this lies in the fact that many 
 
 84 
 
GRAFTING FROM ANIMALS 85 
 
 results have been reported too soon, before time and ex- 
 posure had tested the resisting powers of the new skin. 
 
 Zoografting possesses an advantage over transplantation 
 from another person in avoiding the danger of transmitting 
 disease ; and where it would otherwise be necessary to call 
 upon the patient's friends for epidermal donations, it is 
 perhaps most in place. Even in these cases it is question- 
 able whether it would not often be better to run the small 
 amount of risk and obtain human skin from the bodies of 
 recently dead infants, amputated limbs, circumcisions, etc., 
 or from living individuals. 
 
 One of the first recorded instances of grafting from an 
 animal, to man, and certainly one of the most remarkable 
 in medical literature, is said to have occurred in the seven- 
 teenth century. A surgeon replaced a defect in the scalp 
 and skull with a skin-periosteum-bone graft from a dog; 
 but under threat- of excommunication, the Church com- 
 pelled the unfortunate operator to remove the transplanted 
 tissues, which had already grown in place. 
 
 Zoografts have been obtained by various operators from 
 frogs, chickens, lizards, pigs, dogs, cats, rabbits, guinea- 
 pigs, the lining membranes of eggs, etc. Frogs furnish, 
 perhaps, the most reliable and most easily obtainable mate- 
 rial, although Miles 1 considers it to be the least desirable of 
 all. 
 
 Grafting- from frogs was performed by Allen, in 
 1884, 2 and by Baratoux and Dubousquet-Laborderie 3 a 
 few years later. The skin of the abdomen is usually em- 
 ployed, but that from the back or any other portion of the 
 
 1 Edinburgh Med. J., Sept., 1895. 
 
 2 Lancet, Nov. 15, 1884. 
 
 3 Le Prog. Med., Nov. 15, 1887. 
 
86 SKIN GRAFTING 
 
 body answers the purpose equally well. Smith 4 affirms 
 that the dorsal skin is thicker and grows more satisfactorily 
 than that from other parts. Small pieces can be removed, 
 or long strips, which may afterward be divided if desir- 
 able. ]STesterovsky 5 pinches up a fold of skin with forceps 
 and snips off a piece the size of a finger-nail, which is a 
 rapid and satisfactory method. Fowler 6 skins the entire 
 frog, legs and all, in strips % to % i ncn wide. 
 
 In order to render everything as aseptic as possible, 
 the frog, after a preliminary scrubbing, may be immersed 
 as far as the neck for five minutes in a solution of corrosive 
 sublimate (Nesterovsky), or allowed to swim about indefi- 
 nitely in a solution of boric acid (Polaillon). 
 
 The cuticle of frogs, as well as that of other animals 
 and of man, may be preserved apart from the body for a 
 number of hours; hence grafts wrapped in some water- 
 proof tissue with moist gauze, to prevent drying, may 
 safely be carried to patients at a distance (Allen). 
 
 The new skin soon becomes pinkish and so nearly trans- 
 lucent that one must observe rather closely at times to de- 
 tect its presence; in fact, it occasionally seems almost to 
 disappear, and then to reappear as a delicate film through 
 which the red surface beneath can easily be seen. Should 
 the grafts even vanish entirely, cicatrization is said to be 
 promoted. The pigmentation, so universally present with 
 frogs, disappears in a few days, — five, according to Smith ; 
 ten, according to Fowler, — but, nevertheless, for some rea- 
 son the new skin remains somewhat darker than the sur- 
 rounding cuticle. 
 
 4 Boston Med. and Surg. Jour., Jan. 24, 1895. 
 
 5 Brit. Med. Jour., June 1, 1889, p. 1246. 
 "Ann. Surg., Vol. 9, 1889, p. 179. 
 
GRAFTING FROM ANIMALS 87 
 
 A soft, pliable covering is produced, which, were it only 
 durable, would be all that could be desired ; but unfortu- 
 nately it has a tendency to ulcerate and disappear, which 
 renders frog's skin inferior to that obtained from the 
 human body. Even under the most favorable circum- 
 stances, great care must be given the soft and immature 
 cuticle for at least three months. 
 
 Redard 7 was the first to use the skin of chickens for 
 grafting, and for a time this material became quite pop- 
 ular, although, like other forms of zoografting, it is now 
 seldom resorted to. The soft, nude cuticle on the under 
 surfaces of the wings was selected, and the fat carefully 
 removed. When the grafts survived, they ultimately came 
 to resemble to a great extent the normal surface of the 
 body. 
 
 Altamirano 8 successfully grafted an ulcer with 20 pieces 
 of cock's wattle:. The circulation in these structures is 
 so vigorous that one would expect comparatively good re- 
 sults. 
 
 Miles, of Edinburgh, 9 and a few months later, M. E. 
 Van Meter, of Colorado, 10 employed with considerable 
 success the skin of puppies, Miles using the greyhound, 
 and Van Meter the Mexican hairless puppy, which pos- 
 sesses a particularly soft and white integument. The 
 cuticle of a young pig has been utilized with satisfaction 
 by Raven n and Hubscher. 
 
 Miles 12 has also transplanted from rabbits and kit- 
 tens. His method is to shave the abdomen, and if neces- 
 
 7 Arch. Roum. de Med. et de Chir., Jan., 1888. 
 s Satellite of the Ann. Univ. Med. Sci., Oct., 1889. 
 9 Lancet, Mar. 15, 1890, p. 594. 
 
 10 Annals Surg., Aug., 1890, p. 136. 
 
 11 Brit. Med. Jour., Nov. 3, 1877, p. 623. 
 
 12 Edinburgh Med. Jour., Sept., 1895. 
 
88 SKIN GRAFTING 
 
 sary the flanks, and remove the cuticle in strips from one to 
 six inches in length and from one-half to one inch in width, 
 avoiding the subcutaneous cellular tissues. It is perhaps 
 unnecessary to curette the granulating surface, but it should 
 be healthy. The grafts are pressed down firmly, with 
 their edges together, and the dressing should not be dis- 
 turbed for from forty-eight to seventy-two hours, and then 
 with the greatest caution. Superficial sloughs and pustules 
 may form. The latter should be opened at once. Gran- 
 ulations which show a tendency to grow through the new 
 skin and destroy it should be removed with a sharp spoon. 
 The color of the grafted skin soon becomes satisfactory, and 
 sensation develops ; hair does not grow, and there is no con- 
 traction. Miles reports four successes in 10 cases and only 
 two absolute failures. 
 
 As a matter of interest only, it should be mentioned that 
 skin has been successfully grafted from man to the lower 
 animals. 
 
 E. Aievoli 13 made use of thin sections of the testes of 
 rabbits for purposes of grafting in four cases, assuming 
 that the testicle possesses a greater cellular activity than 
 other portions of the body. The results were undoubtedly 
 good, but it does not follow that they were better than could 
 otherwise have been obtained. 
 
 The lining membrane of an egg furnishes a material 
 for grafting which is easy to obtain and is sometimes effica- 
 cious, although the results are not so durable as they might 
 be, in spite of the views of Watson and others to the con- 
 trary. Amat 14 achieved some success in this way in cases 
 
 "Cent. f. Chir, No. 14, 1891, p. 289— Med. Rec, Aug 6, 1892, p. 164. 
 "Arch. d. Med. et de Pharm. Milit., Mar., 1895 — Medicine, Oct., 1895. 
 
GRAFTING FROM ANIMALS 89 
 
 of extensive burns. Small pieces were placed 12 to 15 
 millimeters apart and covered with sections of tin foil 1 
 cubic centimeter square. An ingenious application of the 
 method has been used by Berthold, in closing perforations 
 of the tympanum (see grafting in connection with the ear). 
 The procedure has been of value in filling defects in the 
 conjunctiva, such, for example, as are produced by the re- 
 moval of a pterygium. 
 
CHAPTER IX 
 
 GRAFTING IN LUPUS, IN X-RAY BURNS, ON 
 THE CRANIUM, AND IN CONNECTION WITH 
 THE EYE AND EAR 
 
 Lupus. 
 
 This is a stubborn tuberculous affection of the skin, 
 almost as difficult to eradicate as epithelioma itself. It has 
 been cauterized, curetted, and salved from century to cen- 
 tury until the patience of all concerned has been tried to 
 the utmost. Where other measures failed, the problem of 
 scientific and satisfactory operative cure, with a minimum 
 of disfigurement, was at last solved by von Esmarch in 
 1885, who excised the diseased tissue and filled in the de- 
 fect by skin grafts. - It remained for Urban, however, 1 in 
 1892, to develop this form of treatment and bring it into 
 general use. 
 
 It is true that lupus had occasionally been removed pre- 
 vious to this, and the defects filled in with new skin; but 
 scraping instead of excision was nearly always resorted to, 
 and plastic surgery relied upon to fill the gap. 2 Some- 
 times, however, a Reverdin grafting was done 3 with fair 
 results, although contractions took place and unsightly scars 
 remained. Recurrence was frequent by either method. 
 
 In many instances Thiersch grafting is satisfactory, 
 
 iDeut. Zeitschr. f. Chir., Bd. 34, 1892, p. 187. . 
 
 2 Blasius, Oppenheim's Zeitsch., Bd. XIX — Friedberg, Chir. Kim., Jena, 
 1855. 
 
 3 Roux, Revue Med., Apr. 15, 1885. 
 
 90 
 
GRAFTING IN" LUPUS 91 
 
 while in others it may be better to resort to the Wolfe- 
 Krause method, in which the entire thickness of the skin 
 is employed. The former is more easily and quickly ac- 
 complished, and perhaps more certain of success ; while the 
 latter is at times preferable on account of the superior 
 durability of the new skin and its greater resemblance to 
 the surrounding surface. Where it is desirable to trans- 
 plant hairs, in the replacement of an eyebrow, for instance, 
 the procedure of Krause is indicated, although not always 
 successful. Of course ; where the raw surface can easily 
 be covered by flaps, or by undermining the skin and sutur- 
 ing, this should be done, but it is not often practicable, 
 owing to the situation or the extent of the disease. 
 
 It should be mentioned that all authorities do not agree 
 upon the operative treatment of lupus. Some cling to the 
 older methods, and maintain that various combinations of 
 scraping and cauterization are to be preferred. For in- 
 stance, Schutz 4 and Brooke 5 speak unfavorably of excision 
 and subsequent grafting, maintaining that it is "too de- 
 pendent for its success on either unknown or unpreventable 
 factors ; and in private practice it is not easy to get patients 
 or their friends to submit to the loss of a second slice from 
 another part of the body. Further, the cosmetic effects are 
 doubtful, and the removal of the disease by excision is un- 
 certain." 
 
 In reality, however, if the operation is properly done, 
 recurrences are much less frequent than by other methods, 
 as has been abundantly demonstrated ; and in addition, one 
 who is affected with lupus and who appreciates the stub- 
 
 *Arch. Derm. u. Syph., Bd., XVII, Heft 1, 1894. 
 5 Med. Chron., Apr., 1894. 
 

 92 SKIN" GRAFTING 
 
 bornness of the disease should be as willing to have it ex- 
 cised and the surface grafted as if it were carcinoma, 
 especially as the chances of speedy recovery with compara- 
 tively slight disfigurement are greater than are offered by 
 other procedures. 
 
 As in malignant growths, everything depends upon 
 thorough excision ; and if this is not accomplished the oper- 
 ation is a failure. The encircling incision should lie at 
 least 2, and better 3, millimeters within the sound skin; 
 and the entire cutis, including most of the subcutaneous 
 cellular tissue, must be removed. The reason for this ex- 
 tensive dissection lies in the fact that small foci, invisible to 
 the naked eye, frequently exist far from the apparent bor- 
 ders of the diseased area, and may be left behind unless 
 considerable apparently sound tissue is sacrificed. Bruce 
 Clarke 6 considers that the outlines of the disease may be 
 more exactly defined by a preliminary injection of tubercu- 
 lin. 
 
 A different knife from the one used in removing the lupus 
 should be employed in cutting the grafts, in order to avoid 
 the somewhat remote possibility of transferring the disease. 
 It is also well to be careful in regard to fingers and sponges. 
 
 If the lupus is very • extensive, there may be reason for 
 operating in two or more stages. In such cases a part only 
 is cut out, and the wound grafted. Eight or ten days must 
 elapse before the operation is repeated ; and it is then well 
 to remove a portion of the grafts which have already been 
 applied, which may have been invaded on their edges by 
 tubercles. 
 
 As the entire thickness of the skin is excised in the oper- 
 
 6 Lancet, Mar. 18, 1893. 
 
GRAFTING IK" X-RAY BURNS 93 
 
 ation, the thin Thiersch grafts sink quite decidedly below 
 the surface. This hollow fills up, however, in two or three 
 weeks ; and in ten or twelve weeks the new skin approaches 
 the color of that which surrounds it, although it may re- 
 main somewhat paler. The only situation in which much 
 shrinkage occurs is about the eyelid, when nearly all of 
 it has been removed. Almost the entire skin of the nose, 
 especially that over the bony framework, can be cut away 
 and replaced by either Thiersch or Wolfe grafts with quite 
 good results. 
 
 Care must be taken that the grafts are not shifted during 
 the vomiting which often follows anesthesia. About the 
 neck a plaster casing may be required to secure the neces- 
 sary quietude, and it may even be desirable in certain situa- 
 tions to apply no dressing at all, or merely strips of pro- 
 tective, or a single layer of gauze, or a wire-mesh "cage" 
 (see p. 49). 
 
 X-ray Burns. 
 
 With the introduction of the Roentgen-ray came the so- 
 called x-ray burn — a peculiarly stubborn form of chronic 
 dermatitis, in which there is atrophy of the various con- 
 stituents of the true derm, often with areas of epithelial 
 proliferation, resembling papillomata, and a strong ten- 
 dency to bacterial invasion, ulceration, and malignant 
 degeneration (Fig. 22). There is but little inclination 
 toward spontaneous healing, so that it is sometimes neces- 
 sary to excise the diseased area, especially if there is a 
 possibility of malignancy. When this is done, transplanta- 
 tion of skin may be required, by either the Thiersch or the 
 Wolfe-Krause method (Fig. 23). 
 
94 
 
 SKIN GRAFTING 
 
 It has been the experience of the writer that when the 
 thinner grafts are used, they may in time undergo degen- 
 
 Fig. 22. — X-ray dermatitis of hip treated daily for one year by unskilled 
 operator for tuberculosis of hip. Areas of malignant degeneration (Dr. 
 H. G. Stover). 
 
 erative changes similar to those for which they were orig- 
 inally applied, hence, when practicable, it is better to 
 
 1 2 
 
 Fig. 23. — (1) X-ray burn of hand. (2) Same after skin grafting. (From 
 Journal Medical Research, Vol. XXI, No. 3, 1909.) 
 
 employ transplantations from the whole thickness of the 
 skin. Because of their greater durability, Wolfe-Krause 
 
GRAFTING IN X-RAY BURNS 95 
 
 grafts should always be preferred about the knuckles, the 
 wrists, and the tips of the fingers. In operating it is neces- 
 sary to remove all the burned area, if possible, as the 
 disease will otherwise tend to i reappear around the edges 
 of the grafts. 
 
 According to Porter, 7 especial care must be used in these 
 transplantations. For instance, hemostasis must be abso- 
 lute, the dressings should be applied with moderately firm 
 pressure, and the hand, for this is the part usually affected, 
 should be kept somewhat elevated for at least two weeks. 
 It is best to bevel the borders of the wound and cut the 
 grafts to fit exactly, in one piece, with their edges thinner 
 than their centers to correspond with the bevel. 
 
 When rubber protective is used as a covering, it should 
 be removed in from 24 to 3 G hours; and if there are any 
 collections of serum or blood, the grafts must be incised, 
 and the fluid pressed out. The edges of the transplanta- 
 tions are then smeared with lanolin. 
 
 From the experience of others, it seems unlikely that 
 this elaborate technic has many advantages over other 
 measures, because, if the diseased area is completely ex- 
 cised, as it should be, the surface to be grafted does not 
 differ from that of an ordinary wound. The writer has 
 certainly had good success with the methods in common 
 use. About the hands it is often difficult to check oozing. 
 When this is the case, instead of prolonging the anesthetic, 
 the grafts may be preserved on rubber protective in an 
 aseptic jar containing moist gauze and applied without 
 anesthesia on the following day (see p. 46). When the 
 oozing is not excessive, however, it may almost always be 
 
 7 J. A. M. A., Jan. 23, 1909, p. 323. 
 
96 . SKIN GEAFT1NG 
 
 stopped by placing the grafts in position and applying 
 temporary pressure (seep. 37). 
 
 Grafting on the Cranium. 
 
 Occasionally a woman's long hair is caught in a revolv- 
 ing belt in some factory, and the scalp more or less com- 
 pletely stripped from the skull, everything down to the 
 pericranium being torn away, sometimes from the back of 
 the neck to the eyelids and from one ear to the other. If 
 these extensive wound surfaces are left to themselves, heal- 
 ing will go on for a certain distance around the edges, 
 accompanied by much contraction; but if the central por- 
 tion ever heals, which is doubtful, the delicate cicatrix 
 will require many months for its formation and will read- 
 ily break down again. Hence the problem of successful 
 skin grafting upon a denuded cranium becomes one of con- 
 siderable importance. 
 
 The Reverdin method has been most often employed, 8 
 but Thiersch grafting gives much better and quicker re- 
 sults and should be the operation of choice, although whole 
 thickness grafts are occasionally applicable, especially when 
 they can be obtained from the lost scalp, large portions of 
 which may thus be utilized at times. 
 
 Schaef er 9 has written an excellent article on the use of 
 Reverdin grafts in these cases. He concludes that the 
 grafts should be thick, even to comprising some of the 
 subcutaneous connective tissue, should be placed close to- 
 gether, and should be taken as far as may be from the 
 patient's own body. The aim should be to obtain a cutane- 
 
 8 Originally, perhaps, by S. C. Bartlett, Am. Jour. Med. Sci., Oct. 1872, p. 
 573. 
 
 9 Trans. 9th Internat. Med. Cong., Vol. Ill, p. 166. 
 
GRAFTING OH" THE: CRAjSTUM 97 
 
 ous covering for the bone containing at least a good share 
 of glandular elements and as movable as possible. He 
 states that : "The most reliable skin is formed by grafting 
 about the circumference of the wound, say one or two rows, 
 producing a narrow strip 1 centimeter wide, and waiting 
 until the blood-vessels are well developed in it ; then plant 
 another series close to the last one. By this plan, contrac- 
 tion in the marginal tissue takes place in advance of the 
 subsequent graftings, diminishing the liability for an ulcera- 
 tive process to occur by means of such contraction." The 
 grafts are also more likely to grow well, as much of their 
 nourishment is derived, according to Schaef er, from the bor- 
 ders of the wound. 
 
 Because of the poor blood supply afforded by bare bone, 
 it is often better not to operate at once, but to wait until 
 granulation has become well established, when transplanta- 
 tion may be clone directly upon the uncuretted surface. 
 In order to prevent drying out and exfoliation of the bone 
 during the interval of waiting, it should be covered with 
 moist dressings or with rubber protective (Davis 10 ). 
 
 Scalping by Indians is luckily rare at present, but in the 
 early times many an inhabitant of the border towns carried 
 on the crown of his head a section of white and denuded 
 bone which refused to become covered, even with granula- 
 tions. Sneve calls attention to an almost forgotten 
 method which was once employed in the cure of these trou- 
 blesome cases. An unknown French surgeon was the in- 
 ventor of the process, which was first described by 
 Robertson. 12 
 
 10 Ann. Surg., Dec, 1910, p. 721. 
 
 11 Med. News, Mar. 4, 1893, p. 239. 
 
 12 Nashville Journal of Medicine and Surgery, Apr., 1855. 
 
98 SKIN GRAFTING 
 
 With a drill, a number of holes are bored close to- 
 gether through the outer table of the skull, through which 
 granulations push their way in the course of four or five 
 weeks and coalesce upon the outside. In order to prevent 
 the drill penetrating too far, a piece of cork may be fas- 
 tened % inch from the end. Use may occasionally be 
 found for this old method at the present time in certain 
 cases. 
 
 A positive danger, however, is sepsis, which is peculiarly 
 apt to be grave in connection with the diploic structures (in 
 a case reported by Pond 13 the patient's temperature went 
 up to 105°), but with proper precautions the danger can 
 be reduced to a minimum. 
 
 The Eye. 
 
 Much attention has always been given to grafting in con- 
 nection with the eye, and most of the early skin transplan- 
 tations were made upon the lids for the purpose of correct- 
 ing ectropion. Von Grafe is said to have succeeded as 
 early as 1818. These operations were given a definite 
 footing, however, by Wolfe, of Glasgow, in the years be- 
 tween 1872 and 1875. His first experiments were made 
 by shifting small pedunculated flaps from one portion of 
 the conjunctiva to another; but although he was success- 
 ful in this, the range of applicability was so small and the 
 available material so limited that he soon began to obtain 
 grafts from the conjunctivas of rabbits. 14 
 
 Von Wecker, it is true, has transplanted from one human 
 conjunctiva to another, but opportunities for this exist 
 practically only when another eye is to be enucleated un- 
 
 13 Med. Rec, Dec. 16, 1893, p. 772. 
 "Glasgow Med. Jour., 1873, p. 220. 
 
GRAFTING ON THE EYE 99 
 
 less one desires to experiment with the cadaver. Mncons 
 membrane from the prolapsed rectum of a child has also 
 been used. 
 
 Wolfe's cases of symblephaeon were probably the first 
 ever remedied by transplantation from animals, and his 
 operations were almost uniformly successful. He was 
 closely followed by Raymond, Brettauer, 15 Becker, 16 von 
 Wecker, and many others, both in this country and abroad. 
 His method, given in his own words, is as follows ir : 
 
 I first separate the adhesion by means of blunt-pointed scissors, 
 so that the eyeball can move in any direction. The conjunctival sac 
 and cornea, are cleared of nodules., so as to obtain an even surface. 
 Two rabbits are then put under chloroform, one being kept in reserve 
 in case of accident. 
 
 I take from the rabbit that portion of the conjunctiva which lines 
 the inner angle, covering the "membrana nictitans" and extending 
 as far as the cornea, on account of its vascularity and looseness. If 
 the palpebral opening is too narrow, I enlarge it at the external angle, 
 and introduce a ligature through the whole thickness of the free 
 border of the lower lid, and by means of the ligature the lid is drawn 
 open and kept steady, and the conjunctival cul-de-sac exposed. Into 
 the middle of the flap to be removed a black silk ligature is intro- 
 duced, a knot is tied, and the ligature cut short. This knot is in- 
 tended to mark the epithelial surface of the membrane, for without 
 it the flap is apt to curl up, and leave us at a loss how to adjust it. 
 
 Xext I mark the boundary of the conjunctiva of the rabbit which 
 I wish to transplant, by inserting four black silk sutures which I 
 .secure with a knot. The ligatures having been put on the stretch, I 
 separate the conjunctiva to be removed with scissors, and by means 
 of a fine spatula I spread it upon the back of my left hand. The 
 four ligatures are then cut off, and the conjunctiva trimmed to the 
 proper size. It should be larger than the lost substance. 
 
 I now return to the patient and see that the bleeding has sub- 
 sided and that the parts are in a fit condition to receive the trans- 
 planted flap, which has in the meantime become dry like a piece 
 of parchment, and adherent to the dorsum of the hand. It is then 
 lifted by means of a spatula and transferred to replace the lost con- 
 junctiva of the patient. It is secured in its place by six or eight 
 
 15 Nagel's Jahresbericht der Ophth., 1873, p. 250. 
 
 16 Wiener Med. Woch., 1874, No. 46. 
 
 17 Lancet, Dec. 14, 1889, p. 1219. 
 
100 SKIN GRAFTING 
 
 ligatures, or even more if necessary. This is a very difficult process 
 requiring delicate manipulation, and the assistant must keep the 
 flap in place by a spatula while it is being stitched in its new place. 
 Both eyelids are closed with lint and a bandage, and kept so for 
 four days. The ligatures are left in for six or eight days. 
 
 At the present time surgeons lay much less stress upon 
 the employment of sutures. 
 
 In ectropion, after incision of the cicatrix and correc- 
 tion of the deformity, von Wecker rilled in the wound with 
 small grafts ; but this is. not advisable, as considerable con- 
 traction will almost certainly occur. The method of 
 Thiersch, and particularly that of Wolfe, will give much 
 better results. It is at times not advisable to dissect out 
 the cicatrix in these affections, as this would involve too 
 much loss of tissue, but this is a point for judgment in in- 
 dividual cases. It is generally sufficient to make a hori- 
 zontal incision in the scar at least .5 centimeters from the 
 border if possible, and of sufficient depth to permit the lid 
 to be brought into place, a more or less oval wound of con- 
 siderable size resulting. 
 
 In order to avoid movement and consequent disturbance 
 of the transplanted skin, the lids may be united by several 
 stitches, without paring the edges, which are allowed to 
 remain for from four clays to a week. If it is preferred, 
 the lower lid may be attached to the superciliary region or 
 the upper lid to the cheek by one or two sutures sufficiently 
 tense to keep the tissues smooth and immovable. Both eyes 
 should be bandaged. • 
 
 Thiersch grafts require no sutures, and it is not only un- 
 necessary to stitch fast the Wolfe grafts in the great ma- 
 jority of cases, but it is positively harmful, on account of 
 traumatism and tension. When something seems to be re- 
 
GRAFTING ON THE EYE 101 
 
 quired to hold them in place, Argyll-Robertson 18 uses what 
 he calls "tethering" or "cradle" stitches, which bind down 
 the graft by passing back and forth across its surface, 
 getting their points of fixation within the skin on either 
 side. This method, however, is seldom necessary. 
 
 Where nothing is left but the margin of the lid and the 
 conjunctiva, perfectly satisfactory results may be obtained 
 by either the Thiersch method or by that of Wolfe. 
 
 Douthwaite 19 reports a case in which an , attempt was 
 made to replace a lost portion of an eyelid with a section 
 of lid from another individual. There seemed to be some 
 show of success until the result was ruined by an accident 
 occurring on the third day. 
 
 In ectropion Knapp 20 recommends a skin grafting 
 operation in which the skin is obtained from the lid itself, 
 a strip being removed' from the loose folds between the 
 margin and the eyebrow, where it will not be missed, and 
 inserted in a longitudinal slit in the intermarginal space. 
 Le Fort obtained- grafts in a similar manner for use in 
 cases of symblepharon. Woodruff 2 1 inserts a Thiersch 
 graft obtained from the red margin of the lower lip. 
 
 Symblepharon can be successfully treated by means of 
 cutaneous Thiersch grafts, as well as with mucous mem- 
 brane from the lip, conjunctiva from the eyes of rabbits, or 
 grafts from the skin of the lid. 
 
 Hotz 22 employs Thiersch grafts obtained from behind 
 the ear as a substitute for conjunctiva, especially after the 
 removal of a pterygium. For a long time the graft re- 
 
 18 Practitioner, 1893, p. 160. 
 
 19 China Med. Miss. Jour., June, 1892. 
 
 20 Oph. Rev., July, 1895. 
 
 21 Ann. Oph. and Otol., July, 1893. 
 
 22 Jour. Am. Med. Assoc, Sept. 10, 1892; Ann. Oph. and Otol., 1893, Vol. 
 II, No. 2; Ann. Oph., Jan., 1897, p. 10. 
 
102 SKIN GRAFTING 
 
 mains as "an opaque white strip covered by a thick coat of 
 soft epidermic cells/ 7 but finally "loses its cutaneous char- 
 acter, and can be distinguished from the ocular conjunctiva 
 by very close inspection only." He concludes that "the 
 skin grafting method can prevent the recurrence of ptery- 
 gium, and that it leaves no unsightly mark upon the eye- 
 ball. It is a comparatively simple operation, and the 
 grafts so seldom fail to grow fast to their new bed that I 
 feel much disposed in the future to employ this method 
 in all kinds of pterygia, small and large." 
 
 After dissecting the pterygium from the cornea and 
 globe, he does not divide its base, but allows the growth 
 to retract into the corner of the eye where it remains. A 
 large wound in- the conjunctiva results from upward and 
 downward retraction. The graft is made considerably nar- 
 rower than the longitudinal diameter of the wound, in order 
 that it may riot push out over the cornea, which it is in- 
 clined to do, but it reaches the conjunctiva at both ends 
 vertically. Both eyes should be bandaged for 48 hours. 
 
 Successful operations by the method of Hotz have been 
 reported frequently. Eversbusch 23 has also used Thiersch 
 grafts upon the ocular conjunctiva, while Le Fort has em- 
 ployed Wolfe grafts from the thin, loose skin of the lid. 
 The writer has suggested that the lining membrane of an 
 egg, or the epithelium raised by a blister, might possibly 
 be employed to advantage in replacing portions of the con- 
 junctiva. 
 
 The entire internal surface of thei orbit may be covered 
 with epithelium by the Thiersch method, as was done by 
 von Noorden, 24 following the excision of an extensive car- 
 
 23 Munch. Med. Woch., 1887, Nos. 1 and 2. 
 ^Berl. Klin. Woch., 1892, No. 41. 
 
GRAFTING on the ear 103 
 
 cinomatous growth. After the removal of the globe, em- 
 barrassing contractions in the socket, which interfere with 
 the wearing of an artificial eye, can sometimes be pre- 
 vented by judicious grafting. 
 
 Numerous attempts have been made to replace a dam- 
 aged comea in man with the cornea of an animal. For 
 this purpose the rabbit has usually been selected, although 
 Gradinego 25 employed the ordinary barn fowl. Most of 
 the cases do reasonably well for a few days, but the new 
 cornea soon becomes cloudy and useless, at least in part, 
 so that the operation has been discarded by many. Its 
 consideration is hardly in place in the present connection. 
 
 The Ear. 
 
 Skin grafts have been employed to close perforations 
 of the: tympanum, Berthold 26 being the pioneer in this 
 direction. He designates the operation myringoplasty, 
 and reports some lasting cures, 27 in one of which the graft, 
 which had grown thinner than when first applied, lay 
 deeper than the level of the drum. When the tympanum 
 is entirely gone, it is sometimes advantageous to freshen 
 the granulated mucous membrane in the vicinity and cover 
 it with an appropriate graft, but this does not mean that 
 a new drum has been formed. 
 
 In 1886, Berthold achieved considerable success in the 
 temporary closure of perforations of the tympanum with 
 portions of the vitelline membranes of hen's eggs. These 
 grafts will often stay in place for months, and in some cases 
 they probably grow fast, as they become more or less pink- 
 
 25 Lancet, June 29, 1889, p. 1319. 
 
 26 Monatschr. f. Ohrenheilkunde. Nov., 1878. 
 2 -Ber. Klin. Woch., June 9. 1890. p. 523. 
 
104: SKIN GRAFTING 
 
 isli and cannot be displaced by inflation of the internal ear ; 
 in fact, it is otherwise difficult to understand how they can 
 remain so long in position. 
 
 The teehnic of the procedure is simple. The portion of 
 fresh membrane, cut to an appropriate size, is placed in 
 position with a pair of forceps and smoothed out with cot- 
 ton on a probe ; or it may be picked up on the end of a 
 medicine dropper by means of slight suction, and rede- 
 posited in proper position by forcing a little air from the 
 instrument. 
 
 The troublesome granulating surfaces resulting from 
 operations upon the mastoid may be successfully covered 
 with Thiersch grafts as suggested by Siebenmann, 28 as may 
 also fresh wounds, even when the bone is extensively ex- 
 posed. Mann 29 employs for this purpose scrapings of 
 epidermis mixed with blood, according to the method of 
 Mangoldt (see p. 81). The wound is tamponed with 
 iodoform gauze for five days, and then cauterized with 
 nitrate of silver, bone and all, every two or three days until 
 a good granulating surface is obtained, which will be in 
 about two weeks. An anesthetic may then be given, and the 
 surface curetted, although this is not essential, after which 
 the epithelial paste is applied and covered with rubber pro- 
 tective, which is held in place by inserting into the cavity 
 pellets of gauze the size of a pea. When possible, the 
 dressing should be left undisturbed for a week or more. 
 
 28 Schmidt's Jahrbuch, B. 248, No. 12, p. 266. 
 29 Deut. Med. Woch., Nov. 28, 1895, p. 798. 
 
CHAPTER X 
 .LOCAL ANESTHESIA IN SKIN GEAETING 
 
 Skin grafting is essentially a minor operation; hence 
 whenever possible it should be clone under local anesthesia, 
 thus sparing the patient the discomforts and dangers of 
 chloroform or ether, although it should be understood that 
 disappointment may result with children and with those 
 who are especially nervous, apprehensive, or hysterical. 
 
 The most satisfactory technic is perhaps the following: 
 Have in readiness two syringes which will stand steriliza- 
 tion by boiling — one, an ordinary hypodermic syringe with 
 a small sharp needle, and the other a larger instrument, 
 holding an ounce or more, with a moderately long needle. 
 Also an anesthetizing solution consisting of : 
 
 • Novocain 0.25 gram. 
 
 Xornial salt sol 50.00 grams. 
 
 Adrenalin 3 gram. 
 
 This may be designated Sol. No. 2, and when diluted 
 with an equal volume of salt solution, forms Sol. No. 1. 
 
 The adrenalin must be fresh, and the solution prepared 
 just before using. Boiling does not injure the novocain, 
 but this should be done before the adrenalin is added. As 
 much as 60 or 90 grams of No. 2 can be used in adults 
 without danger, while No. 1 can be injected in almost any 
 reasonable quantity. 
 
 Select an area upon the arm or thigh large enough to 
 
 105 
 
106 
 
 SKIN GKAFTING 
 
 obtain from it easily all the grafts required, and anesthe- 
 tize a number of spots along its vertical center, an inch or 
 so apart, with Sol. No. 1 (Fig. 24). This is done by 
 thrusting the needle of the small syringe just beneath the 
 epithelium, and parallel to its surface, without penetrating 
 entirely through the skin. When the piston is pressed, a 
 small, white elevation, or wheal, appears, which is imme- 
 diately anesthetic. 
 
 Then through these anesthetic spots the operative field' 
 
 Fig. 2i. — Points for insertion of local anesthetic in skin grafting. 
 
 is subcutaneously infiltrated by means of the larger syringe, 
 injecting the fluid, in the direction of the arrows (Fig. 24), 
 first to one side and then to the other. This should be done 
 Avhile the needle is being pushed forward in order to avoid 
 depositing the liquid within a vein. Massage of the part 
 will produce a more thorough distribution. 
 
 It is necessary to wait for from 5 to 15 minutes before 
 the operation is begun, in order to obtain satisfactory an- 
 esthesia, and this time can be occupied in completing tbe 
 
LOCAL ANESTHESIA 107 
 
 surgical cleaning of the part. It is interesting to note 
 the blanching of the skin due to vascular contraction under 
 the influence of the adrenalin, the lessening of absorption 
 thus obtained not only increasing the efficiency of the novo- 
 cain, but decreasing its general poisonous effects. 
 
 Sol. No. 1 may be used almost ad libitum for this infil- 
 tration. Sol. JSTo. 2, however, acts more promptly and 
 thoroughly, but the quantity employed should never greatly 
 exceed two ounces. Anesthesia usually lasts from half an 
 hour to an hour or more. 
 
 Some years ago Halsted, of Baltimore, introduced a 
 method for producing anesthesia of the antero-lateral por- 
 tion of the thigh in skin grafting, by freezing or cocainiz- 
 ing the external cutaneous nerve below the anterior superior 
 iliac spine. The procedure, however, is rather difficult 
 and uncertain and does not compare practically with the 
 method just described. 
 
 Thiersch grafts may also be cut, more or less painlessly, 
 after freezing the skin with ethyl chlorid; but consider- 
 able discomfort is experienced at the moment the tissues 
 congeal, and the anesthesia is too transitory to be com- 
 pletely satisfactory, hence the method is not in general 
 favor. 
 
CHAPTER XI 
 
 HISTOLOGY AND PATHOLOGY 
 
 Much work in the histology of skin grafting has been 
 done by Garre, 1 Goldmann, 2 Abraham and Bidwell, 3 
 Thiersch, 4 and others. Most of the investigations were 
 made with especial reference to the method of Thiersch ; 
 but they apply equally well to Reverdin grafts, which are 
 really small Thiersch grafts, and to a considerable extent 
 to other forms of transplantation. 
 
 Adhesion and Nutrition. 
 
 Epithelial grafts, and those containing in addition more 
 or less of the true skin, become adherent to granulations 
 or fresh wound surfaces much as does the layer of epi- 
 thelium which floats out on the surface of an ulcer from 
 its borders. 
 
 For a time its existence can be said to be parasitic ; any 
 extraneous nutrition which it may receive being obtained 
 by a species of imbibition from the subjacent tissues, and 
 from the disintegration of leucocytes which rapidly accu- 
 mulate beneath the grafts and work their way in a few 
 hours into the interstices and into empty vessels, where 
 they are still to be seen in considerable numbers at the 
 end of eight weeks (Karg). The process was accurately 
 observed in grafts five, to eight days old by Armaignach, in 
 
 1 Cent. f. Chir., 1890, p. 226; Beitrage z. Klin. Chir., 1889, SonderaMruck. 
 
 2 Beitrage Z. Klin. Chir., Bd. XI, Heft. 1, p. 229. 
 
 3 Medical Week, 1894, p. 186. 
 
 4 Verhand. d. deut. Gesell. f. Chir., 1874, p. 69. 
 
 108 
 
 nBHOM^mi 
 
HISTOLOGY AXD PATHOLOGY 109 
 
 1877. 5 The leucocytes, together with exuded fluids, assist 
 also in cementing the new skin in position, as in the heal- 
 ing of an ordinary wound. In the course of eighteen hours 
 (Thiersch), delicate vessels, consisting of endothelial walls 
 alone, from capillary loops of the granulations and from 
 vessels which form parallel to the surface, force their way 
 into the severed capillaries of the graft, sometimes, pos- 
 sibly, directly joining with them; while others pass into 
 the tissues in various directions. The old vessels quickly 
 degenerate (Garre). 
 
 The intermediate layer of leucocytes, together with any 
 coagulated blood which may be present, soon disappears, a 
 layer of fibroblasts appearing in its place, and a delicate 
 subcutaneous connective tissue rapidly forms. Garre has 
 discovered a thin panniculus adiposus as early as the 
 twenty-second day. 
 
 The grafts become firmly adherent by the tenth day, and 
 the circulation is established sufficiently well to maintain 
 their vitality, although it is many weeks before the repara- 
 tive process is complete. Inflammation and stasis are the 
 factors which most often contribute to breaking down of 
 the new skin by interfering with its nutrition. 
 
 Color. 
 
 The grafts are at first dead white in color, although those 
 comprising the entire skin may be of bluish or reddish 
 appearance owing to stagnated blood. Later on they as- 
 sume a pinkish hue as the circulation becomes reestab- 
 lished, which is about the sixth day or even earlier. 
 Rarely, as mentioned by Krause, the vessels dilate until an 
 
 5 Rev. de Sci. Med., Vol. 9, 1877, p. 325. 
 
110 SKIN GEAFTIWG 
 
 unsightly vascular network occupies the place of the new 
 skin. 
 
 Transplanted skin tends to assume more and more the 
 color of its surroundings, differing in this respect from a 
 cicatrix, which increases in whiteness with its age, due to 
 the presence of contracting fibers in the scar which slowly 
 cut off the circulation. 
 
 Enderlen 6 claims to have demonstrated that extensive 
 degenerative changes always take place in transplanted 
 skin, the only portions which survive being the lowermost 
 epithelial layer, some glands and vessels, and perhaps a few 
 connective tissue cells, but this is disputed by others 
 (Braun) . Regeneration of epithelium proceeds from these 
 structures, but the new cutis arises from the adjacent and 
 subjacent tissues. 
 
 Movability. 
 
 Thiersch grafts gradually become movable, often in six 
 or eight weeks, and may be shoved from side to side and 
 even elevated in folds. This movability depends upon the 
 presence of elastic fibers (Zenthoefer), which Garre has 
 found as early as the tenth day, and Goldmann in abun- 
 dance at the end of four months, the old fibers disappearing 
 and being replaced by new ones. Urban maintains that 
 movability is more apt to be present if grafting is done 
 upon a fresh wound surface. 
 
 Grafts comprising the entire skin are, of course, more 
 pliable than those which are thinner, while the skin pro- 
 duced by Reverdin grafting is but little looser than an 
 ordinary cicatrix. Cicatricial tissue contains no elastic 
 
 6 Centralbl. fur. Chir., No. 28, 1897, p. 7. 
 
 HMHMM 
 
HISTOLOGY AND PATHOLOGY 111 
 
 fibers, and consequently, wherever a space is left between 
 two grafts, the cuticle will be more or less bound down at 
 that point. Inflammation retards the formation of elastic 
 fibers and may stop it altogether. 
 
 Sensation, etc. 
 
 Sensibility to touch and to variations of temperature 
 returns slowly, and may always remain somewhat below 
 normal. It begins near the edge of the graft and appears 
 last at the center. 7 Two or three months are generally 
 required for its complete return. 
 
 In Reverdin and Thiersch grafting the hairs and glan- 
 dular elements of the skin are absent ; but in thicker grafts 
 this is not true, although the hairs are apt to be deformed 
 and to fall out easily. 
 
 In spite of many assertions to the contrary, Braun 8 
 maintains that in autoplastic transplantations, where the 
 conditions are favorable, the entire graft maintains its 
 vitality, whether it comprise the entire thickness of the 
 skin, or the epithelial layers only. Other observers, how- 
 ever, claim that the more superficial layers invariably die 
 and are afterwards regenerated. 
 
 Cicatricial Contraction. 
 
 That some contraction often goes on beneath any sort 
 of skin graft cannot be denied, especially if granulations 
 have been present and have not been thoroughly removed. 
 This- contraction is considerable in the Reverdin method, 
 where the grafts are small and far apart, and it is quite 
 noticeable when strips of skin are not placed near enough 
 
 7 Stransky, Wien. Klin. Woch., 1899, Nos. 2 and 3. 
 8 Zent, f/Chir., 1911, No. 29, p. 35. 
 
112 SKIN GRAFTING 
 
 to each other in the method of Thiersch or of Wolfe. 
 Thiersch contended that contraction is due to the trans- 
 formation of the upper layer of large, soft granulations 
 into connective tissue, and that the thorough scraping away 
 of these granulations would prevent its occurrence. 
 
 Examinations made by G-arre and by Goldmann demon- 
 strated that even four to eighteen months after a Thiersch 
 transplantation no cicatricial tissue could be detected be- 
 neath the grafts ; but this is probably not true in all cases. 
 Since then it has been shown that transplantation can often 
 be made directly on a granulating surface with almost as 
 good a result as if the most thorough curetting had been 
 performed. 
 
 It seems probable that septic processes have much to do 
 with cicatricial contraction, and that the prevention of sup- 
 puration by the application of new epithelium is a matter 
 of prime importance. The statement of Meyer 9 that 
 Thiersch grafting is always accompanied by marked con- 
 traction if the entire thickness of the skin has been lost 
 is not strictly true if the grafts have been placed so as to 
 properly overlap each other, although slight shrinking may 
 often be noticed, especially when a considerable portion 
 of a loose structure, such as the eyelid, has been replaced. 
 
 The surfaces even of Wolfe grafts may sometimes become 
 wrinkled in the course of time from contraction beneath. 
 An irregular, brownish pigmentation may also occur, or 
 the graft may remain cyanotic from enlarged vessels. 
 These unusual phenomena cause embarrassment to all con- 
 cerned, unless the patient has been previously warned. 
 
 9 Deut. Med. Woch., No. 16, 1894. 
 
 fcabMfc,t€ 
 
HISTOLOGY AND PATHOLOGY 113 
 
 Exfoliation. • 
 
 Exfoliation of the epidermis may occur in any form of 
 transplantation, and depends largely npon nutrition, hence 
 the sooner the circulation becomes thoroughly established 
 the sooner will the epithelium cease to scale off. Accord- 
 ing to Jungengel, a layer of clot of a certain thickness will 
 always cause exfoliation, and if too thick the graft will 
 die. Circulatory disturbances may also give rise to the 
 formation of blisters, which may contain more or less 
 blood. 1ST one of these accidents necessarily mean that the 
 transplanted skin will not live, for if the rete Malpighii 
 remain, the lost epithelial covering will soon be reproduced. 
 
 Depressions. 
 
 A remarkable thing about grafting according to Thiersch 
 and Wolfe is the readiness with which depressions fill up 
 to a level with the surrounding skin. This also depends 
 largely upon nutrition, and is commensurate with it. On 
 the nose a depression as deep as the skin is thick may 
 smooth out in two or three weeks, and on the forehead, in 
 from four to six weeks ; but in the case of a badly nourished 
 leg a hollow may always remain. When Wolfe grafts pro- 
 ject above the skin, as they often do when placed upon 
 granulations, they soon become depressed to the general 
 level. 
 
 It is quite evident from the above that definite healing 
 of the new skin does not take place for weeks or even 
 months, and that it should not be too much exposed to 
 injury before considerable time has elapsed. 
 
114: SKIN" GRAFTING 
 
 Production of Epithelium. 
 
 It was formerly maintained that the new epithelium 
 appearing between skin grafts, especially in the Keverdin 
 method, was produced directly from the embryonic cells 
 of granulation tissue, by what Gubler has termed catabiotic 
 action. In other words, these cells merely receive a sort 
 of stimulus from the transplanted material, which mani- 
 fests itself not only in proximity to the grafts, but also 
 at the borders of the ulcer. This idea has been sup- 
 ported by many eminent authorities, including Keverdin, 
 Billroth, Cornil and Eanvier, Rindfleisch, Reclus, and 
 others. 
 
 Bryant was among the first to assert the untruthfulness 
 of the theory, basing his opinion upon the fact that a por- 
 tion of skin which he transplanted from a negro to a white 
 man increased considerably in size. Since then it has been 
 abundantly demonstrated that epithelium is always repro- 
 duced from epithelium or endothelium and never from con- 
 nective tissue or anything else, and that the "islands" of 
 epithelium which occasionally appear near the centers of 
 large granulating surfaces arise either frorn isolated hair 
 follicles and glands, or from stray epithelial cells which 
 have been accidentally transplanted. The process of cell 
 division (caryocinesis) has been observed and studied in 
 grafts. 
 
 Epithelium seems to possess a strong independent vital 
 ity which renders it almost parasitic. Other tissues 
 possess this also, but to a far less degree ; for, if such were 
 not the case, accidentally severed portions of fingers, ears, 
 and noses could not be replaced, as has been so often done, 
 
 ■.'"...•.;■■•'■.,.' vf? 
 
HISTOLOGY AND PATHOLOGY 115 
 
 and the transplantation of bone, nerves, tendons, brain- 
 tissue, etc., would be impossible. 
 
 Independent Longevity of Epithelium. 
 
 Martin 10 made a number of experiments to determine 
 the length of time during which grafts could live when 
 separated from the body. The longevity increased with 
 the decline of the temperature, the best results being 1 ob- 
 tained near the freezing point, when vitality was main- 
 tained for 96 hours. The time could be increased to 108 
 hours, however, by keeping the grafts in a confined space 
 instead of in the open air. An amputated limb, for in- 
 stance, if kept in a refrigerator, can be used for grafting 
 purposes at least 21 hours after its removal from the body. 
 
 It is more than probable that these experiments of Mar- 
 tin do not show the duration of vitality of the grafts so 
 much as they do the time of beginning decomposition under 
 varying circumstances. In other words, if the pieces of 
 epithelium had been maintained in an aseptic condition, 
 vitality might have been greatly if not indefinitely pro- 
 longed. 
 
 Since the researches of Martin, numerous experiments 
 have demonstrated, clinically and otherwise, that skin 
 grafts may be conserved for varying lengths of time before 
 their transplantation (Thiersch, Minnich, Menzel, Brewer, 
 etc.). Hoclgen n and Lusk 12 have shown that dried epi- 
 thelium, even when detached from the body, will retain its 
 vitality, and Lusk 13 was able to preserve such desiccated 
 fragments indefinitely and use them successfully in graft- 
 
 10 Thesis, Paris, 1873. 
 
 11 St. Louis Med. and Surg. Jour., July, 1871. 
 
 12 Med. Rec, Dec. 7, 1895, p. 800. 
 
 13 Internat. Jour. Surg., Feb. 1897, p. 39. 
 
116 SKIN GRAFTING 
 
 ing. This is not surprising when we remember that no 
 greater enemy to bacterial growth exists than dryness. 
 
 The experiment reminds one of the dried grain preserved 
 for so many centuries in the pyramids of Egypt, which, 
 under the influence of heat and moisture, is capable of ger- 
 mination and reproduction. It naturally suggests itself 
 whether the epithelium of a mummy would not do likewise 
 under favorable circumstances. 
 
 This independent vitality accounts, to a certain extent, 
 for the comparative readiness with which epithelium may 
 be transplanted, and for the manner in which it grows 
 over, or "floats" out, upon a granulating surface; but we 
 must also recognize an ability to imbibe sufficient nourish- 
 ment for at least temporary maintenance without direct 
 vascular communication with the underlying tissues. 
 
 In this connection another interesting fact, first noticed by 
 Klebs, is the power possessed by epithelial cells to "wan- 
 der" from the borders of an ulcer out on the granulating 
 surface, which may help to explain the independent islands 
 of skin which sometimes appear. 
 
 Epithelial Stimulation. 
 
 Undoubtedly the epithelium at the edge of an ulcer is 
 stimulated to renewed growth by the presence of grafts 
 within a reasonable distance, and the grafts also stimulate 
 one another; the greater the number of grafts, and the 
 closer they lie to each other, the greater the stimulation. 
 
 This can be accounted for by assuming that growth is in- 
 hibited by the presence of bacteria and their poisons, as 
 well as by defective circulation and nutrition. When a 
 graft begins to adhere and develop, it destroys the bacteria 
 
 HHH^HUHI^^BHIJHlH 
 
HISTOLOGY AND' PATHOLOGY 117 
 
 over a certain area and weakens those in its immediate 
 vicinity, besides increasing the flow of nutritive fluids. 
 These phenomena turn the balance in favor of the epithe- 
 lium as against -the germs. 
 
 It has been claimed by some 14 that this "stimulation" 
 is greatest shortly following transplantation, and hence bet- 
 ter results are obtained in the method of Eeverdin by 
 grafting in successive stages and by placing a row of grafts 
 near the margin of the granulating surface at each sitting. 
 There is little evidence, however, to support this assertion. 
 
 Grafting From the Negro to the White Man. 
 
 Under ordinary circumstances no one would think of 
 transplanting the skin of a negro to a white man, or the 
 reverse ; so that the question as to whether or not the skin 
 will retain, under such conditions, its original color is of 
 scientific interest only. The experiment has been tried a 
 number of times (once resulting in a lawsuit), but the 
 reports have been strangely conflicting. 
 
 That skin removed from an individual of one race and 
 grafted upon a member of a different race will grow with- 
 out difficulty was demonstrated by Maurel, 15 who per- 
 formed many experiments in this line, although Thiersch 
 claims that, while skin from the negro will grow perfectly 
 well upon a white man, white skin will not do well upon 
 the negro. Fowler 16 says that when white skin is trans- 
 ferred to a negro the white color remains. 
 
 Bryant 17 records an apparently convincing case m 
 which a number of small pieces of negro's skin were grafted 
 
 14 Charles Steele, Brit. Med. Jour., Dec. 10, 1870. 
 15 Gaz. Med., 1878, p. 349. 
 
 16 Ann. Surg., Vol. 9, 1889, p. 179. 
 
 17 Figs. 52 & 53, p. 136, Bryant's Surgery. 
 
118 SKIN GRAFTING 
 
 upon the leg of a white man. These increased to twenty 
 times their original size within ten weeks, and coalesced 
 to form a comparatively large patch of black cuticle. 
 Hodgen confirmed Bryant's conclusion, when the deeper 
 portions of the epithelium were transplanted, but not when 
 superficial epithelial scales were alone employed. The 
 writer once transferred a portion of black skin from 
 the thigh of a negro to the comparatively white sole of the 
 patient's foot. At the end of about three weeks, when the 
 man was lost sight of, the graft still retained its dark 
 color. 
 
 Eeverdin, and also Coste, declare that black grafts soon 
 lose their characteristic color upon a white man, from ab- 
 sorption of their pigment; and Maurel, whose experience 
 was large, stated that pigmented grafts must be trans- 
 planted to individuals whose skins are rich in pigment if 
 they are to retain their color. 
 
 Thiersch, in his investigation of the subject, came to 
 the conclusion that skin of one color when transplanted to 
 individuals of another color always changed its hue. 
 Girdner 1S noticed a gradual transformation from black 
 to white in the skin transplanted from a negro to a white 
 man. Maxwell 19 transferred a small graft from his own 
 arm to the face of a colored man; "from the size of a 
 canary seed, it increased to the extent of about a half inch 
 in its greater dimensions and was of irregular form, with 
 narrow points extending into the surrounding black sur- 
 face." Presently dark lines appeared in the white skin, 
 and in the course of three months it was as black as the 
 remainder of the negro's countenance. 
 
 is Med. Rec, Oct. 25, 1890, p. 468. 
 
 19 Phila. Med. Times, Oct, 8, 1873, p. 37. 
 
 MHHiHi 
 
HISTOLOGY Am> PATHOLOGY 119 
 
 A study of the subject has been made by Karg, 20 who 
 concluded that white skin gradually became black upon a 
 negro, and vice versa. He showed that pigment was 
 carried to and from the epidermis by the phagocytic action 
 of large star-shaped connective-tissue cells lying on the 
 border between the corium and epidermis and that it was 
 finally removed by wandering corpuscles. Karg contended 
 that the pigment was formed in the rete, although Thiersch 
 believed that its formation took place still deeper. Of 
 some value in this connection is the undisputed fact that 
 the skin of frogs when transplanted soon loses its pigmenta- 
 tion and almost becomes transparent. 
 
 The majority of testimony seems to indicate that the 
 color of grafts finally changes to that of the skin into which 
 they are transplanted ; but this transformation takes place 
 slowly, and may not be completed for many weeks. We 
 should expect the time to vary considerably, as the activity 
 of the pigment cells depends largely upon the nourishment 
 of the epithelium in general. Those who claim that this 
 change does not take place may have reported their cases 
 too soon; and in the absence of evidence to the contrary, 
 we shall have to assume that this is true. 
 
 Cheloids. 
 
 Occasionally a cheoloid growth springs up between the 
 grafts or around the borders of the transplanted area. 
 This has been particularly mentioned by Murray, Lange, 
 Kammerer, McBurney, and Fowler. 21 Sometimes this is 
 a true cheloid, but more frequently merely redundant 
 cicatricial tissue due to spaces being left between the 
 
 20 Arch, f.; Anat. and Phys., 1888; Cent. f. Chir., 1888, p. 944. 
 
 21 N. Y. Med. Jour., Feb. 4, 1893. 
 
120 SKIN GRAFTING 
 
 grafts, which become the seat of irritating bacterial infec- 
 tion. 
 
 McBurney is inclined to hold the dry dressing responsi- 
 ble for these cicatricial overgrowths, and recommends the 
 employment of a moist covering for the grafts for at least 
 two weeks. This idea is scarcely tenable, however, as the 
 same formation often occurs under wet dressings. The 
 causes of true cheloid are not at all clear, but they are 
 probably the same in connection with skin . grafting as 
 under other conditions. 
 
 Fowler records a case in which he removed from the 
 arm a cheloid which had followed vaccination, and grafted 
 the wound with frog's skin. The growth promptly re- 
 turned. Two more attempts were made, one with the skin 
 of a chicken and the other with cuticle from the patient's 
 own thigh, but each time the cheloid again made its ap- 
 pearance ; and following the last operation a growth of the 
 same nature sprang up in the thigh from which the graft 
 was obtained, which discouraged the operator from fur- 
 ther interference. 
 
 A peculiar case was observed by Pilcher, 22 in which, as 
 soon as the patient got out of bed following a transplanta- 
 tion, an eruption resembling purpura, eventually forming 
 blisters, appeared, not only upon the grafts but upon the 
 surface from wdiich they were obtained. As soon as the 
 bed was resumed, the eruption disappeared, but developed 
 a second time when the patient attempted to walk about. 
 
 Intense itching occasionally appears after a few days at 
 .the seat of a transplantation, which can often be relieved 
 by massage. 23 
 
 22 N. Y. Med. Jour., Feb. 4, 1893. 
 
 23 Garre, Brit. Med. Jour., Mar. 9, 1889, p. 560. 
 
HISTOLOGY ANH PATHOLOGY 121 
 
 An epithelioma was seen by Dunham 24 on the leg of a 
 woman of 53, following Reverdin grafting of an old ulcer. 
 Such an isolated case signifies little, however, as epithe- 
 liomata occasionally develop in crural ulcers where no 
 transplantation has been attempted. 
 
 24 Med. Bee, Aug. 3, 1895, p. 170. 
 
CHAPTER XII 
 
 BRIEF COMPARISON OF DIFFERENT METH- 
 ODS OF SKIN GRAFTING 
 
 The simplest of all is the method of Reivebdin. It is 
 easy of execution, causes but little pain, and is but slightly 
 suggestive of a dreaded "operation" ; but the results are not 
 always satisfactory. The new epidermis is often but little 
 better than ordinary scar tissue, having a marked tendency 
 to contraction, and breaking down under comparatively 
 slight provocation. This is particularly true when the 
 grafts are small, thin, and far apart.- If, on the other 
 hand, they are too thick, the new skin will be more or less 
 "humniocky" on its surface. In addition, the alternation 
 of the darker grafts with the lighter intervening cicatricial 
 areas often produces a mosaic appearance which is some- 
 times quite objectionable. Movability is seldom obtained, 
 because the epidermis is bound down by connective tissue 
 between the grafts and cannot be loosened by massage. 
 
 Hence transplantation according to Reverdin should be 
 reserved for cases in which for some reason it is inexpedi- 
 ent to employ another method, and where the rapid closure 
 of a granulating surface is desired without much reference 
 to anything else. Examples of such instances are : ( 1 ) 
 When the patient refuses to have the skin removed from 
 his own person, and it becomes necessary to procure it 
 
 from another individual; it can then be snipped out in 
 
 122 
 
COMPARISON OF METHODS 123 
 
 small pieces where a more extensive operation would be 
 refused. (2) When, after the different operations with 
 their several advantages have been explained, the patient 
 chooses the method in question on account of its compara- 
 tively trivial nature. (3) When, in very old or weak or 
 nervous people, a general or a local anesthetic would be 
 undesirable. 
 
 Much of course depends upon the situation of the lesion 
 and its nature. A loss of tissue upon the face naturally 
 requires more consideration for cosmetic reasons than, an 
 ulcer of the leg, and the chance of embarrassing contrac- 
 tures about the joints and neck must be avoided even at 
 the expense of much inconvenience and some danger. Un- 
 der the various circumstances just mentioned, one may re- 
 sort to dead bodies, preferably those of .infants, or to 
 amputated limbs; or obtain the necessary. material from a 
 case of circumcision, or from the skin of some animal. 
 And just here is where a real use may be found for epi- 
 dermis obtained from warts, corns, callosities, blisters, 
 etc., and for "epidermal dust," although we must not ex- 
 pect the results to be very brilliant. 
 
 Thiersch grafting- has a wider range of applicability 
 than any other method, and its results are quite uniformly 
 good, both functionally and cosmetically, and yet it must 
 give way to other proceedings under certain conditions, 
 where firmer and thicker skin is desirable which more 
 closely resembles the surrounding integument. 
 
 In such cases the WoefehKrause method should be 
 chosen. This is particularly true upon the palms of the 
 hands, the soles of the feet, the eyelids, and possibly about 
 the face in general, although Thiersch grafts answer the 
 
124: SKIN" GKAFTING 
 
 purpose fairly well in the last-named situation. The 
 thicker grafts, when they can be made to unite, un- 
 doubtedly furnish a more durable covering for old leg 
 ulcers, especially of the varicose variety, and to parts about 
 the joints. 
 
 The transplantation of hairs can be accomplished only 
 by taking the entire thickness of the skin, and even then the 
 result is apt to be unsatisfactory. 
 
 It is seldom desirable to employ grafts comprising the 
 subcutaneous fat, as recommended by Hirschberg. 
 
 The skin" of animals does not compare in vitality with 
 that derived from the patient's own body or from some 
 other person, and just where its employment would be 
 most serviceable — on the leg ulcers of old people, for in- 
 stance — it is next to useless. 
 
 Mucous membbane, from animals and from man, Can 
 be used to repair defects in the urethra, vagina, etc., and 
 the conjunctiva of rabbits makes an excellent substitute 
 for that membrane in the human species ; but it has been 
 sufficiently well shown that Thiersch grafts and skin flaps 
 will often answer the same purpose, 1 while they are more 
 easily obtained, are much more likely to be successful, and 
 they can be kept more nearly aseptic. If cutaneous grafts 
 do not actually become transformed into mucosa, they at 
 least come, in the course of time, to resemble it closely. 
 Even in the urethra, skin flaps and Thiersch grafts have 
 been used, although with the former epithelial exfoliation 
 is apt to lead to subsequent annoyance. 
 
 In the transplanting of skin and of mucous membrane, 
 it must always be borne in mind that heterogeneous graft- 
 
 iWitzel, Cent. f. Chir., No. 45, 1890. 
 
COMPARISON OF METHODS 125 
 
 ing is much less likely to succeed than autogenous, hence 
 the material should always be obtained from the patient 
 himself if possible. 
 
INDEX OF AUTHORITIES QUOTED 
 
 Abraham and Bidwell, 108 
 Agnew, 18 
 Aievoli, E., 88 
 Allen, 85, 86 
 Altamirano, 87 
 Amat, 88 
 
 Argyll-Robertson, 100 
 Armaignach, 108 
 
 Baratoux and Dubousquet-Labor- 
 
 derie, 85 
 Barker, E., 42 
 Bartlett, S. C, 96 
 Becker, 99 
 Beigel, 77 
 Bell, John, 5, 6 
 Berger, 20 
 Bernhard, 52 
 Berthold, 89, 103 
 Bidwell, 28 
 Billroth, 114 
 Blasius, 90 
 Braun, 110, 111 
 Brettauer, 9*9 
 Brewer, 115 
 Brooke, 91 
 Bryant, 23, 114, 117 
 Biinger, 5 
 
 Cheyne, 46 
 
 Church, 85 
 
 Clark, Bruce, 45, 92 
 
 Colrat, 84 
 
 Cornil and Ranvier, 114 
 
 Coste, 118 
 
 Cousin, 84 
 
 Czerny, 9, 74, 78, 81 
 
 Davis, 8, 16, 28, 36, 40, 45, 51, 
 
 67, 69, 70, 73, 83, 97 
 Deuvel, 9 
 
 Dieffenbach, 75 
 Dobson, 7 
 Donnelly, 18 
 Doolittle, 41 
 Douthwaite, 101 
 Dunham, 48, 60, 121 
 Dunn, 11, 26 
 Dzondi, 5 
 
 E 
 
 Eiselberg, von, 67 
 Enderlen, 110 
 Esmarch, von, 2, 90 
 Eversbusch, 102 
 
 Fen wick, 77 
 
 Fidder, 81 
 
 Finney, 6 
 
 Fioravanti, Sir Leonard, 5 
 
 Fischer, 33, 37 
 
 Fowler, 20," 46, 47, 86, 117, 119, 
 
 120 
 Franke, 40 
 
 G 
 
 Garengeot, 5 
 
 Garre, 108, 109, 110, 112, 120 
 
 Girdner, 81, 118 
 
 Gnarch, 62 
 
 Goldmann, 51, 108, 110, 112 
 
 Gould, 2 
 
 Grafe, von, 98 
 
 Gr anbury, 20, 79 
 
 Gubler, 114 
 
 H 
 
 Hahn, 10 
 
 Halsted, 39, 42, 48, 107 
 Hamilton, 14, 81 
 -Banff, 75 
 Harte, Richard, 18 
 Hartley, 11 
 
 Hirschberg, 20, 69, 70, 74, 78, 
 124 
 
 127 
 
128 
 
 INDEX OF AUTHORITIES QUOTED 
 
 Hodgen, 13/ 79, 80, 81, 115, 118 
 
 Hoffacker, 6 
 
 Hotz, 101, 102 
 
 Howard, 80 
 
 Hiibscher, C, 39, 87 
 
 Hueter, 18, 25, 70 
 
 Hunter, John, 3 
 
 Ivanova, 7, 81 
 
 Jacenko, 68 
 Jungengel, 44, 67, 113 
 
 K 
 
 Kammerer, 119 
 
 Karg, 108, 119 
 
 Kelley, 6 
 
 Kelloek, 46 
 
 Kibler, 79 
 
 Klebs, 116 
 
 Knapp, 101 
 
 Kraske, 15, 55, 57, 62 
 
 Krause, 70, 71, 109 
 
 Lange, 119 
 
 Lanz, 54 
 
 Leale, 79 
 
 Le Fort, 68, 101, 102 
 
 Lewis, 19 
 
 Lucas, 19 
 
 Lusk, 80, 115 
 
 Lynngren, 46 
 
 M 
 
 McBurney, 39, 40, 48, 53, 119, 
 
 120 
 McCarthy, 28 
 McNaught, 45 
 Mangoldt, 81, 104 
 Mann, 81, 104 
 Marcy, 28 
 Martin, 115 
 Maurel, 117, 118 
 Maxwell, 118 
 Menzel, 115 
 Meyer, 112 
 Miles, 85, 87, 88 
 Minnich, 115 
 Mixter, 41 
 Morris, 80 
 Morrow, 75 
 
 Moullin, 46 
 Munoz, 13 
 Murray, 119 
 
 N 
 
 Nancrede, 66 
 Nesterovsky, 86 
 Noorden, von, 63, 102 
 North, 26 
 Nussbaum, von, 80 
 
 
 
 Oilier, 20, 33 
 
 Page, David, 13 
 Parmenter, 14, 79 
 Parry, 51 
 Pilcher, 120 
 Pitschke, 74 
 Plessing, 47, 67 
 Polaillon, 86 
 Pollock, 13 
 Poncet, 21 
 Pond, 98 
 Porter, 46, 47, 95 
 Pusey, 20 
 
 R 
 
 Raven, 87 
 
 Ravmond, 99 
 
 Reclus, 81, 84, 114 
 
 Redard, 87 
 
 Reverdin, 20, 21 , 80, 114, 118 
 
 Rindfleisch, 114 
 
 Roberts, 25 
 
 Robertson, 97 
 
 Robinson, 83 
 
 Roux, 90 
 
 Rushmore, 37 
 
 Sancassani, 4 
 
 Schaefer, 9, 96, 97 
 
 Schepelmann, 52 
 
 Schmieden, 26, 56 
 
 Schnitzler and Ewald, 38, 65 
 
 Schrady, 1 
 
 Schutz, 91 
 
 Schweninger, 80 
 
 Sick, 39, 78 
 
 Siebenmann, 104 
 
 Smith, 23, 85 
 
 Souchon, 23 
 
INDEX OF AUTHORITIES QUOTED 
 
 129 
 
 Steele, 81, 117 
 Stover, H. G., 94 
 Stransky, 111 
 Sullivan, 7 
 Symonds, 81 
 
 Tagliacozza, 4 
 
 Taylor, 69 
 
 Thiersch, 39, 48, 75, 108, 109. 
 
 115, 118, 119 
 Thies,' 52 
 Thompson, 43 
 Thorndike, 67 
 Tillmanns, 63 
 
 U 
 Urban, 58, 60, 64, 65, 90, 110 
 
 Van Helmont, 4 
 Van Meter, M. E. 
 
 87 
 
 Virchow, 68 
 Vogel, 45 
 
 W 
 
 Watson, 88 
 
 Weeker, von, 98, 99, 100 
 
 Wentscher, 46 
 
 Wilcox, 40 
 
 Witzel, 124 
 
 Wolfe. 68, 78, 98, 99 
 
 Woodruff, 101 
 
 Young, 71 
 
 Zenthoefer, 110 
 
INDEX 
 
 Accidental wounds, Thiersch grafting in, 60 
 
 Accordion grafts in method of Thiersch, 54 
 
 Acne rosacea, Thiersch grafting in, 61 
 
 Adhesion in grafting, 108 
 
 Adjustment of grafts and dressings in method of Wolfe-Krause, 72 
 
 After-treatment in method of Reverdin, 32 
 
 of Thiersch, 56 
 
 of Wolfe-Krause, 72 
 Amputated limbs, grafting from, 81 
 Anaplasty, 1 
 
 Anesthesia, local, in grafting, 105 
 Anesthetics in method of Thiersch, 47 
 Anomalies in grafting, 79 
 Antiseptics in method of Reverdin, 18, 24 
 Aseptics in grafting, 12 
 Autodermic grafts, 3 
 
 B 
 
 Bacillus pyocyaneus, 30 
 Bedsores, Thiersch grafting in, 64 
 Blood, grafting in, 29 
 Bone, grafting on, 62 
 Bovinine, 29, 48 
 
 Burn, treatment of, by Thiersch grafting, 59 
 Burns, Thiersch, grafting in, 60 
 x-ray, grafting in, 93 
 
 O 
 
 Cage, wire-gauze, 49 
 
 Callosities, grafting from, 79 
 
 Cancer, transmission of, 10 
 
 Cantharides blister in grafting, 80 
 
 Case reports of Thiersch grafting, 58 
 
 Cauterization in method of Reverdin, 17 
 
 Changing dressings in method of Reverdin, 30 
 
 Cheloids in grafting, 119 
 
 Chickens, grafting from, 87 
 
 Chronic empyema, Thiersch grafting in, 63 
 
 Cicatricial contraction in grafting, 111 
 
 tissue in method of Reverdin, 16 
 Cleanliness, surgical, 12 
 Cock's wattle, grafting from, 87 
 Color in grafting, 109 
 Comparison of methods of grafting, 122 
 
 131 
 
132 • INDEX 
 
 Compression in method of Eeverdin, 17 
 Condition of patient in grafting, 10 
 Contraindications in grafting, 10 
 Contraction in grafting, cicatricial. 111 
 Contractures, Thiersch grafting in, 62 
 Cornea, grafting on the, 103 
 Corns, grafting from, 79 
 Cranium, grafting on the, 96 
 Curetting in method of Thiersch, 38 
 Cutting grafts, Halsted method of, 42 
 in method of Reverdin, 21 
 in method of Thiersch, 34, 40 
 
 Dead bodies, grafting from, 81 
 
 Death from skin grafting 11 
 
 Definitions, 1 
 
 Depressions in grafting, 113 
 
 Dermanoplasty, 2 
 
 Dermepenthis, 2 
 
 Dermo-epididermal grafts. 2 
 
 Diabetes as contraindication in grafting, 10 
 
 Disease, influence of. in grafting. 10 
 
 transmission of, 9 
 Dressings in method of Reverdin, 27 
 changing, 30 
 wet and dry, 29 
 
 of Thiersch, 48 
 
 of Wolfe-Krause, adjustment of, 72 
 
 E 
 
 Ear. grafting on the, 103 
 
 Ectropion, grafting in. 100. 101 
 
 Egof. lining membrane of. grafting from, 88 
 
 Elkoplasty. 14 
 
 Empyema, chronic, Thiersch grafting in, 63 
 
 Epidermal dust, 2 
 
 grafts, 2 
 Epidermis, exfoliation of, 31. 113 
 
 grafting from, 80 
 Epithelial dust, grafting from, 80 
 
 stimulation in grafting, 116 
 Epithelioma, treatment of, by Thiersch grafting, 59 
 Epithelium, longevity of, in grafting, 115 
 
 production of, in grafting. 114 
 Erysipelas as contraindication in grafting, 10 
 Esmarch strap. 35, 39, 69, 75 
 Europe, early history in, 4 
 
 Excision of hairy moles, Thiersch grafting in, 62 
 Exfoliation in grafting, 113 
 
 cf epidermis, 31 
 Eye, grafting on the, 98 
 
INDEX 133 
 
 Fingers, Thiersch grafting on, 62 
 
 Foot, crushed, treatment of by Thiersch grafting, 58 
 
 Frogs, grafting from, 85 
 
 G 
 
 Gauze for holding grafts in place, 28 
 Grafting, adhesions in, 108 
 
 anomalies in, 79 
 
 cantharides blister in, 80 
 
 cheloids in, 119 
 
 cicatricial contraction in, 111 
 
 color in, 109 
 
 comparison of method of, 112 
 
 depressions in, 113 
 
 epithelial stimulation in, 116 
 
 exfoliation in, 113 
 
 from amputated limbs, 81 
 
 from animals, 84, 124 
 
 from callosities, 79 
 
 from chickens, 87 
 
 from cock's wattle, 87 
 
 from corns, 79 
 
 from dead bodies, 81 
 
 from epidermis, 80 
 
 from epithelial dust, 80 
 
 from frogs, 85 
 
 from kittens, 87 
 
 from lining membrane of an egg, 88 
 
 from moles, 79 
 
 from mucous membrane, 124 
 
 from muscle, 80 
 
 from negro to white man, 117 
 
 from puppies, 87 
 
 from rabbits, 87 
 testes of, 88 
 
 from warts, 79 
 
 hairs in, 80 
 
 heterogeneous Thiersch, 66 
 
 histology of, 108 
 
 in blood, 29 
 
 in ectropion, 100, 101 
 
 in lupus, 90 
 
 in operations on the mastoid, 104 
 
 in perforations of the tympanum, 103 
 
 in pterygium, 101 
 
 in scalping, 97 
 
 in symblepharon, 99, 101 
 
 •in two stages in method of Thiersch, 46 
 
 in x-ray burns, 93 
 
 local anesthesia in, 105 
 
 longevity of epithelium in, 115 
 
 mortality in, 110 
 
 nutrition in, 108 
 
 on bone in method of Thiersch, 63 
 
134 INDEX 
 
 Grafting — cont'd 
 
 on the cornea, 105 
 
 on the cranium, 96 
 
 on the ear, 103 
 
 on the eye, 98 
 
 on the orbit, 102 
 
 pathology of, 108 
 
 production of epithelium in, 114 
 
 proper time for, in method of Thiersch, 55 
 
 sensation in, 111 
 
 sponge, 82 
 Grafts, accordion, in method of Thiersch, 54 
 
 adjustment of, in method of Wolfe-Krause, 72 
 
 autodermic, 3 
 
 cutting, Halsted method of, 42 
 in method of Reverdin, 21 
 of Thiersch, 34, 40 
 
 dermo-epidermal, 2 
 
 epidermal, 2 
 
 from prepuce of a child, 19 
 
 from the old and from the young, 7 
 
 from the scrotum, 20 
 
 Hamilton-Reverdin, 14 
 
 heterodermic, 3 
 
 heterogeneous, 8 
 
 homodermic, 3 
 
 isodermic, 3 
 
 placing the, in method of Reverdin, 24 
 of Thiersch, 43 
 
 primary fixation of, 51 
 
 Reverdin, 13 
 
 size of, in method of Reverdin, 20 
 
 skin-periosteum-bone, 76 
 
 splinting, in method of Thiersch, 51 
 
 Thiersch, 33 
 
 thin vs. thick, in method of Thiersch, 46 
 
 total cutaneous, 2 
 
 treatment of wounds after removal of, in method of Thiersch, 53 
 
 vegetable, 2 
 
 where to obtain, in method of Reverdin, 18 
 
 whole-thickness, 2 
 
 Wolfe-Krause, 68 
 
 zoodermic, 3 
 Granulations in method of Reverdin, 15 
 
 of Thiersch, preparation of, 39 
 Greffe dermique, 21 
 
 dermoepidermique, 21 
 
 H 
 
 Hairs in grafting, 80 
 
 transplantation of, 124 
 Halsted method of cutting grafts, 42 
 Hamilton-Reverdin method, 14 
 
 Hand, crushed, treatment by Thiersch grafting, 58 
 Hands, Thiersch grafting on, 62 
 Healing, process of, in method of Reverdin, 31 
 
no>Ex 135 
 
 Hemorrhage in method of Thiersch, 37 
 Heterodermic grafts, 3 
 Heterogeneous grafting, 8 
 
 Thiersch, 66 
 Hirschberg, method of, 74 
 Histology of skin grafting, 108 
 History, early, 3 
 
 in Europe, 4 
 
 in India, 3 
 Homodermic grafts, 3 
 
 Implantation, 2 
 
 Incisions, radiating, in method of Reverdin, 18 
 
 India, early history in, 3 
 
 Indian method of transplantation, 2, 74 
 
 Inflammatory processes in method of Reverdin, 17 
 
 Instition, 2 
 
 Isodermic grafts, 3 
 
 Italian method of transplantation, 2 
 
 K 
 
 Kittens, grafting from, 87 
 
 Laudable pus, 16 
 
 Legal questions in skin grafting, 26 
 Local anesthesia in grafting, 105 
 Longevity of epithelium in grafting, 115 
 Lupus, grafting in, 90 
 
 method of Reverdin in, 90 
 
 of Thiersch in, 90 
 
 of Wolfe-Krause in, 91 
 
 M 
 
 McBurney hooks for stretching skin, 41 
 Mastoid, grafting in operations on the, 104 
 Method of Hamilton-Reverdin, 14 
 of Hirschberg, 74 
 of Reverdin, 13, 122 
 
 after-treatment in, 32 
 
 antiseptics in, 18, 24 
 
 cauterization and compression in, 17 
 
 cicatricial tissue in, 16 
 
 dressings in, 27 
 changing, 30 
 wet and dry, 29 
 
 granulations in, 15 
 
 in lupus, 90 
 
 inflammatory processes in, 17 
 
 method of cutting grafts in, 21 
 
 on cranium, 96 
 
 placing the grafts in, 24 
 
 preparation for, 15 
 
 process of healing in, 31 
 
136 hsdbx 
 
 Method of Reverdin — cont'd 
 radiating incisions in, 18 
 size of grafts in, 20 
 suppuration in, 16 
 where to obtain grafts in, 18 
 of Thiersch, 33, 123 
 accordion grafts in, 54 
 after-treatment in, 56 
 anesthetics in, 47 
 application of, 57 
 
 case reports of, 58 
 curetting in, 38 
 cutting grafts in, 34 
 dressings in, 48 
 general technic of, 33 
 grafting in two stages in, 46 
 
 on bone in, 63 
 hemorrhage in, 35 
 heterogeneous grafting in, 66 
 in accidental wounds, 60 
 in acne rosacea, 61 
 in bedsores, 64 
 in burns, 60 
 in chronic empyema, 63 
 
 leg ulcers, 64 
 in incising hairy moles, 62 
 in lupus, 90 
 in special cases, 60 
 method of cutting grafts in, 40 
 on cranium, 96 
 on hands and fingers, 62 
 on mucous surfaces, 65 
 on scars and contractures, 62 
 on the nose, 60 
 placing the grafts in, 43 
 preparation of granulations in, 39 
 proper time for grafting in, 55 
 splinting grafts in, 51 
 statistics in, 66 
 thin vs. thick grafts in, 46 
 treatment of crural ulcers by, 58 
 
 of crushed foot by, 58 
 
 of crushed hand by, 58 
 
 of epithelioma by, 59 
 
 of extensive burn by, 59 
 
 of ulcer of leg by, 59 
 
 of wounds after removal of grafts in, 53 
 of Wolfe-Krause, 68, 123 
 
 adjustment of grafts and dressings in, 72 
 after-treatment in, 72 
 in lupus, 91 
 preparation for, 69 
 technic of, 70 
 Methods of grafting, comparison of, 122 
 Moles, grafting from 2 79 
 
 hairy, Thiersch grafting in excision of, 62 
 Movability in grafting, 110 
 
INDEX 137 
 
 Mucous membrane, transplantation of, 77, 124 
 
 surfaces, Thiersch grafting on, 65 
 Muscle, grafting from, 80 
 Myringoplasty, 103 
 
 N 
 
 Negro to white man, grafting from, 117 
 Nephritis as contraindication in grafting, 10 
 New growths, Thiersch grafting in, 61 
 Nose, Thiersch grafting on the, 60 
 Nutrition in grafting, 108 
 
 O 
 
 Old, grafts from the, 7 
 Orbit, grafting: on the, 102 
 
 Pathology of skin grafting, 108 
 
 Placing the grafts in method of Reverdin, 24 
 
 of Thiersch, 43 
 Preparation for method of Reverdin, 15 
 of Wolfe-Krause, 69 
 of granulations in method of Thiersch, 39 
 Prepuce of a child, grafts from, 19 
 Primary fixation of grafts, 51 
 Production of epithelium in grafting, 114 
 Pterygium grafting in, 101 
 Puppies, grafting from, 87 
 Pus, laudable, 16 
 
 R 
 
 Rabbits, grafting from, 87 
 
 testes of, 88 
 Reverdin, method of, 13, 122 
 
 after-treatment in, 32 
 
 antiseptics in, 18, 24 
 
 cauterization and compression in, 17 
 
 cicatricial tissue in, 16 
 
 dressings in, 27 
 changing, 30 
 wet and dry, 29 
 
 granulations in, 15 
 
 in lupus, 90 
 
 inflammatory processes in, 17 
 
 method of cutting grafts in, 21 
 
 on cranium, 96 
 
 placing the grafts in, 24 
 
 preparation for, 15 
 
 process of healing in, 31 
 
 radiating incisions in, 18 
 
 size of grafts in, 20 
 
 suppuration in, 16 
 
 where to obtain grafts in, 18 
 Rubber tissue for skin grafting, 27 
 
138 INDEX 
 
 s 
 
 Scalping, grafting in, 97 
 Scarlet red ointment, 29, 56 
 Scars, Thiersch grafting on, 62 
 Scrotum, grafts from the, 20 
 Sensation in grafting, 111 
 Size of grafts in the method of Reverdin, 20 
 Skin-periosteum-bone grafts, 76 
 Smallpox, transmission of, 9 
 Splinting grafts in method of Thiersch, 51 
 Sponge grafting, 82 
 Statistics in Thiersch grafting, 66 
 Stimulation, epithelial, in grafting, 116 
 Suppuration in method of Reverdin, 16 
 Surgical cleanliness, 12 
 Symblepharon, grafting in, 99, 101 
 Syphilis as contraindication in grafting, 11 
 transmission of, 9 
 
 Technic of method of Thiersch, 33 
 
 of Wolfe-Krause, 70 
 Terminology, 1 
 
 Testes of rabbits, grafting from, 88 
 Thiersch, method of, 33, 123 
 
 accordion grafts in, 54 
 
 after-treatment in, 56 
 
 anesthetics in, 47 
 
 application of, 57. 
 case reports of, 58 
 
 curetting in, 38 
 
 cutting grafts in, 34 
 
 dressings in, 48 
 
 general technic of, 33 
 
 grafting in two stages in, 46 
 on bone in, 63 
 
 hemorrhage in, 35 
 
 heterogeneous grafting in, 66 
 
 in accidental wounds, 60 
 
 in acne rosacea, 61 
 
 in bedsores, 64 
 
 in burns, 60 
 
 in chronic empyema, 63 
 leg ulcers, 64 
 
 in excising hairy moles, 62 
 
 in lupus, 90 
 
 in special cases, 60 
 
 method of cutting grafts in, 40 
 
 on cranium, 96 
 
 on hands and fingers, 62 
 
 on mucous surfaces, 65 
 
 on scars and contractures, 62 
 
 on the nose, 60 
 
 placing the grafts in, 43 
 
INDEX 139 
 
 Thiersch, method of — cont'd 
 
 preparation of granulations in, 39 
 splinting grafts in, 51 
 statistics in, 66 
 thin vs. thick grafts in, 46 
 treatment of crural ulcers by, 58 
 of crushed foot by, .58 
 of crushed hand by, 58 
 of epithelioma by, 59 
 of extensive burn by, 59 
 of ulcer of leg by, 59 
 
 of wounds after .removal of grafts in, 53 
 Total cutaneous grafts, 2 
 Transmission of cancer, 9 
 of disease, 9 
 of smallpox, 9 
 of syphilis, 9 
 of tuberculosis, 9 
 Transplantation, 2 
 Indian method, of, 2 
 Italian method of, 2 
 of hairs, 124 
 
 of mucous membrane, 77, 124 
 Treatment of wounds after removal of grafts in method of Thiersch, 53 
 Tuberculosis, transmission of, 9 
 Tympanum, grafting in perforation of the, 103 
 
 U 
 
 Ulcer of leg, treatment of, by Thiersch grafting, 59 
 Ulcers, chronic leg, Thiersch grafting in, 64 
 . crural, treatment of, by Thiersch grafting, 58 
 
 Vegetable grafting, 2 
 
 W 
 Warts, grafting from, 79 
 White man, grafting from negro to, 117 
 Whole-thickness grafts, 2 
 Wire-gauze cage, 49 
 Wolfe, technic in symblepharon, 99 
 Wolfe-Krause, method of, 68, 123 
 
 adjustment of grafts and dressings in, 72 
 
 after-treatment in, 72 
 
 in lupus, 91 
 
 preparation for, 69 
 
 technic of, 70 
 
 X 
 
 X-ray burns, grafting in, 93 
 
 Y 
 
 Young, grafts from the, 7 
 
 Z 
 
 Zoodermic grafts, 3 
 Zoografting, 84 
 
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DEC 20 1312 
 
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