The happy medium is to push the granulations apart and insert the graft, and not to draw blood by the puncture so as to displace the delicate graft.

To facilitate the detachment of pieces of skin, Mr. Bryant has devised an instrument in which the forceps and scissors are combined, and which accomplishes the object at a single movement, and takes away a portion of skin, which is again to be cut in three or four smaller pieces.

Another method, suggested by Dr. J. T. Hodgen, and adopted by Dr. R. J. Levis, one of the surgeons of the Penn. Hospital, consists in penetrating the cuticle with a very delicate sewingneedle, elevating a small point of skin and shaving off the minute elevation and upper stratum of dermis.

The same results can be accomplished by means of a pair of scissors such as are employed for removing a portion of the iris (termed iridectomy scissors) by separating the blades with slight pressure against the skin, and cutting the piece of skin within the blades. Then on the thumb nail it can be cut up in smaller pieces.

What has been the success of skin-grafting.

Of twenty-two carefully watched cases I find that eleven were perfectly successful, eight partial successes, and three were absolute failures. This I consider a very good result, and there are no good reasons why this important and valuable operation should be so much neglected. It is a most simple operation, which any one with care can perform. But we must not expect too much from a few grafts, and must have patience to wait long enough for the results, and employ an abundance of grafts; fifty, seventy-five, or even a hundred will be required if the surface is large, as sometimes only a few will succeed. Yet these few may perform important work by covering the denuded surface and removing a horrid deformity. It must be remembered that skin-grafting, like all surgical operations, is liable to entire failure when every care has been taken; an east wind, or erysipelas, or the system of the patient running down, may prevent the grafts from growing, or sloughing may ensue and cause them all to disappear.

I will not occupy further time with details of ordinary cases, but will select two which are of special interest.

CASE VII.' on my list is that of an extensive burn, the result of a railroad accident occurring in Indiana in December, 1871. The scalding involved the entire front of the body. On January 12, 1872, the subaxillary, mammary, and submammary regions of both sides presented a healthy surface of granulations, the full depth of the skin having sloughed off. After allowing nature to do all that was possible, there were grafted one dozen points in the granulating surface from the calf of his brother's leg, inserting the grafts nearly one inch apart. Repeated the grafting every second or third day until January 22, when the whole surface except two points was covered with new skin. The number of grafts used was about seventy-five, fifty of which grew; each of them forming an island of skin extending, meeting, and uniting without leaving any mark of union. The grafts were cut of the full depth of the skin and twice the size of a mustard-seed, and, held in a sharp-pointed dressing forceps, were pushed down into the granulations, and the forceps loosened, the granulations closing over and burying the grafts from sight. On the first daily dressing after the insertion, there was no appa rent effect. On the second, the granulations at the point were slightly paled. On the third dressing there appeared a slight circular flattened depression four lines in diameter, the granulations forming a ridge around the patch. From the fifth to the sixth dressing these patches took on the appearance of true skin, and at once began spreading, reaching almost one inch in diameter before coalescing. The extension was first by a circle of granulations becoming pale in color, then flattening and taking on the appearance of true skin. When the patient was last seen, Oct. 24, 1872, the skin presented a uniform smooth appearance, there being no deformity nor disposition to contraction of cicatrix so common after such injuries, recovery being complete.

CASE XIX. on my list is one of the most remarkable cases on record. The woman was exhibited and the history given me by the surgeon, Dr. I. R. Hayes (at Tralee, Ireland). On May 24th Dr. Hayes was called to see Mrs. S., aged 36, who was found insensible, lying with her head and face on the hearth, where a turf fire had burnt out. The upper part of the cheek and eyelids of the right side were vesicated; the forehead and side of

1 Indiana Journal of Medicine, July, 1873. Dr. I. M. Green.

the head also suffered; and a portion of the skin over the parietal bone was charred, as may be seen in Fig. 1. She was quite unconscious, and continued so until the following morning. For three or four days she was greatly depressed, but free from pain.

Reaction having set in, she suffered very much from pain and sleeplessness, which was relieved by full doses of opium. She appeared to improve until about the sixteenth day, when suddenly she became slightly delirious, and suffered from nausea and occasional vomiting, with paralysis of the left side. The face was free from the paralysis. These symptoms passed off in ten days, and her health gradually improved. The injured parts of the face, upper part of the ear and eye, which are seen in Fig. 3, had sloughed away and cicatrized, and she was able to go about doing her household work. About October 1st the bones had separated at the sutures in a line extending from the mastoid portion of the temporal to the posterior angle of the parietal, along the lambdoid and sagittal sutures to the superciliary ridge, and outwards to the outer angle of the frontal bone. On VOL. XXXI.-56

October 3d Dr. Hayes removed the bones, including the whole parietal and half the frontal, as seen in the Figs. 1 and 2. The under surface of the bone was covered with a thick curdy matter. The depressions of the arteries and the honeycombed character of the bone from the suppuration are well seen in Fig. 2, which is a view of the internal surface.

No pulsation could be felt over the meningeal arteries, and a quantity of fetid pus welled up from between the hemispheres. The dura mater, which was covered with granulations, continued to secrete pus freely.

Finding the ulcerated surface was not cicatrizing, about December 2d Dr. Hayes grafted skin on five places on the dura mater; three of them were successful and two failed (one was scraped epidermis). The cicatrization commenced from those which took, and ultimately covered the whole of the exposed

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beautiful progress of the grafting. When the skin-grafts were put on, Dr. Hayes placed a pad of lint over them, and bound it with a strip of adhesive plaster. The following day her left side,