ON SKIN-GRAFTING, WITH A REPORT OF SOME INTERESTING CASES. BY LAURENCE TURNBULL, M.D., PENNSYLVANIA. HISTORY OF THE OPERATION. ONE hundred years have passed since the celebrated anatomist, John Hunter, was successful in transplanting the spur of a young chicken from its leg to its comb, as well as into the comb of a second bird, where it lived and grew; and no one made use of this valuable fact until a French surgeon, M. Reverdin, of Paris, in October, 1869, succeeded in transplanting a small portion of skin from one part of a man's body to the granulating surface of a large sore, under which treatment the ulcer healed. By the aid of time, position, local stimulation, and mechanical support, in healthy individuals, almost every variety of ulcer or granulating sore will heal, or be covered with skin; but in some instances, after weeks, months, and even years of treatment, there comes a time when this healing will cease, in spite of all the most approved efforts on the part of the surgeon and earnest efforts and co-operation of the patient. The new process of skin-grafting was in the first instance applied to these difficult and chronic sores. At a later period the process of skin-grafting was extended. to supply defective plastic, and other operations where, from contraction of the flap of skin in healing, the parts are not covered, or to prevent contraction, which is so apt to follow deep-seated burns, and prevent great deformity in the act of healing. Another important application is, where it is necessary to remove cancer, chancroid, lupus, or in syphilitic ulcers on the face, or any exposed part of the body; the skin-graft fills the removed part with smooth tissue, and is often of the utmost importance in its cosmetic effects. PHYSIOLOGY OF SKIN-GRAFTING. It has been found, by careful experiments, that by planting cells of healthy epithelium at various points on the granulating surface of a healthy sore, centres for the development of new skin are formed, and by multiplication and extension of these patches a sufficient amount of healthy skin can be cultivated to cover a very large amount of the surface of the body. M. Reverdin asks the question: "Is the growth of skin due to the effect of contact or neighborhood, or is it due to proliferation of the transplanted elements?" To make this skin-grafting a success, it should include some superficial dermis or rete mucosum, with some of the deep living cells which are found in the epithelial layer which possess conditions for propagation when placed in the natural pabulum, the healthy blood. If these cells continue healthy, they commence soon a process of proliferation, but no fat-cells are to be introduced, nor must there be simply scarfskin, which latter, being formed of horny, flattened scales, without nuclei, is incapable of growth. Original plan of operating of M. Reverdin. A small piece of epithelium, including some of the superficial dermis or rete mucosum, is taken from the healthy cutaneous surface on the inside of the arm, thigh, or face, by a fine forceps, and snipped out with a sharp scissors-each part not larger than the size of half a grain of hemp-seed. A small puncture in the raw surface is then made, and the small fragmeut of skin is carefully and accurately placed in it and protected by adhesive plaster. Some suggestions in reference to the success of the operation. The new skin-graft should be kept in position and not interfered with for several days; it should be lightly covered with a layer of cotton-wool and a bandage, for the purpose of maintaining its warmth and vitality. If the grafts are placed on an ulcer on the extremities, the patient must be kept in bed for a few days. Mr. Bryant, of Guy's Hospital, lays the graft on the surface of the ulcer, and states that he has not found any difference in the result. 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.1 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 apparent 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. |