Edward Adams

Dressings. These may be either dry or wet.

Dry dressings consist of gauze and bandage or of cotton and collodion (the cocoon dressing.)

The most convenient form in which sterile gauze can be obtained is in small squares in individual envelopes. Large packages are contaminated with the first opening and are inconvenient.

The cocoon dressing is occlusive and should never be applied over an infected area. It is applicable to sensitive areas for protection, and to operated areas not liable to infection.

Protective varnishes, such as collodion, compound tincture of benzoin, or pure ichthyol, are useful where little protection is indicated.

Wet dressings. Two distinct therapeutic actions may be derived from the wet compress, depending upon whether or not an impervious covering is employed. These actions are antiphlogistic and hyperemic, and these in turn may be either antiseptic or astringent. The wet dressing, without a covering, is cleansing and heat reducing, because of evaporation. There should be frequent replenishment of the solution in the treatment of any infected wound or where it is desirable to reduce inflammation.

A wet dressing with an impervious covering is contraindicated in the presence of pus, the warmth and moisture of such a dressing being congenial to the growth and to the multiplication of bacteria.

It is evident, therefore, that a wet dressing with an impervious covering can safely be employed only in conditions where the skin is unbroken, such as sprains and bruises.

The two general therapeutic actions, aside from those of causing hyperemia, are antiseptic and astringent. For the relief of pain and for the reduction of inflammation, wet dressings are the most effective form of treatment because (1) they are aseptic; (2) they permit free drainage; (3) no new granulations are disturbed in changing the dressing.

A great many different solutions are used and among these are:

1. sterile water;

2. ordinary saline solution (a teaspoonful of salt to a pint of water);

3. saturated solution of boric acid (prepared by dissolving a teaspoonful of boric acid powder in a pint of water);

4. Thiersch’s solution (prepared by dissolving 15 grains of salicylic acid and 90 grains of boric acid in a pint of water);

5. Burow’s solution (a solution of aluminium acetate prepared by dissolving 675 grains of alum and 270 grains of lead acetate in a pint of water.U.S.P. formula);

6. solution of bichloride of mercury (varying in strength from 1 to 3000, to 1 to 10000);

7. 2 per cent. solution of creolin or lysol;

8. U.S.P. lead and opium wash;

9. aqueous solution of ichthyol (varying from 5 to 50 per cent. according to the indications);

Put the chlorinated lime in a 12 litre flask with 5 litres of ordinary water and let stand over night. Dissolve the sodium carbonate and bicarbonate in 5 litres of cold water; then pour this into the flask and shake it vigorously for a minute and let it stand to permit the calcium carbonate to settle. After half an hour, siphon off the clear liquid and filter it to obtain a perfectly limpid product. The antiseptic solution is then ready for surgical use: it contains about 0.5 gm. per cent. of sodium hypochlorite with small amounts of neutral salts. It is practically isotonic with blood serum. Never heat the solution, and always keep it from the light. If in an emergency it is necessary to triturate the chlorinated lime in a mortar, do so only with water, never with the solution of the soda salts.

This solution has been used extensively abroad in the treatment of infections and wounds and has given splendid results.

(A proper quantity of Dakin’s solution for office purposes would be about one-tenth of the prescription above given.)

DUSTING POWDERS

These are employed either as antiseptics or as astringents or for both purposes. Their use is limited, and they are employed only where the secretion is scanty.

Among the various powders used are: aristol, dermatol, boric acid, orthoform, calomel, protonuclein, zinc oxide, alum, scarlet red, etc.

Thymoliodide, or aristol, is a splendid antiseptic powder and enjoys the advantage over iodoform of being inodorous.

Iodoform should only be used in tubercular conditions.

Dermatol, or bismuth subgallate, combines the astringent and mildly antiseptic qualities of bismuth and gallic acid.

Boric acid is mildly antiseptic.

Calomel should only be used in syphilitic conditions.

Zinc oxide and alum are both astringent.

Scarlet red (5 per cent.) with boric acid (95 per cent.) is indicated for the stimulation of granulations.

Solutions. Among the various solutions used are silver nitrate, in various strengths, zinc and copper sulphate, ichthyol, balsam of Peru, nitric acid, sulphuric acid, trichlorand monochloracetic acid.

Silver nitrate is employed for its astringent action, as are also the copper and zinc sulphates.

Balsam of Peru is used for its stimulating action.

The stronger acids are employed for their escharotic qualities.

“Red wash” (made up from the following formula: zinc sulphate 20 grains, compound tincture of lavender 30 minims, distilled water to make 8 ozs.) has a powerful astringent action and promotes cicatrization, especially when there is a tendency for the granulations to become exuberant.

In the treatment of chilblains, a strong astringent is desirable to constrict the diluted capillaries.

The stronger lotio alba of the national formulary, containing equal parts of the saturated solutions of zinc sulphate and potassium sulphuret, is markedly astringent and has a drying effect upon the skin.

STYPTICS

Styptics. These may act either by causing clot formation in the cut arteries, or by causing the retraction of their edges. In the latter class are included such drugs as hydrastine and adrenaline.

The disadvantage of using these drugs lies in the fact that secondary hemorrhage is possible when their constrictor action is over. The styptics causing clot formation are therefore to be recommended. They should be non-irritating, antiseptic, and styptic, at the same time. Such a preparation is practically unknown.

Peroxide of hydrogen on a pledget of cotton, placed over the bleeding area, may effect a clot formation.

The U.S.P. liquor ferri subsulphatis, better known as Monsel’s solution, is the best and most effective styptic that we have. Monsel’s solution, however, is not antiseptic and entrance of bacteria into the wound is possible, unless, it is applied with a sterile applicator or is dropped directly upon the wound from the bottle.

The U.S.P. tincture of iodine in equal parts of water, applied to the bleeding area may, besides sterilizing it, stop bleeding.

Should none of the above effect a stoppage of the bleeding, other means must be sought. A bit of sterile gauze pressed quite firmly against the area, should next be tried. If this fails, a wooden applicator, prepared with Monsel’s solution may be employed. A cotton wound applicator, unless dipped into a strongly antiseptic solution, contains millions of bacteria from the fingers. The use of the ancient styptic stick of alum, copper or silver is discountenanced everywhere as uncleanly.

SOLVENTS

Solvents. Under this heading, those substances which are known to soften tissue will be considered.

Sodium hydroxide, up to a saturated strength, or an ointment of salicylic acid, 5 per cent. to 50 per cent., depending upon the density of the tissue to which it is applied, are the ones commonly used.

These two drugs have the power to macerate dry, hard tissues.

Experience is necessary for the proper use of tissue solvents as the length of time that they are allowed to act is of as much importance as the strength of the solution.

Sodium hydroxide solution can be instantly neutralized with any acid and for this reason is preferable.

OINTMENTS

Ointments. In the list of ointments, the much vaunted virtues of advertised compounds are usually found.

Ointments and oils are used in the treatment of wounds and ulcers, either to stimulate granulations or to soften thick epidermis.

Ointments should never be used where there is a profuse discharge, as eczema is a complication which very often follows such treatment.

A great many different kinds of ointments are used and among these are:

One of the oldest as well as one of the best applications is balsam of Peru, which has a powerful effect in increasing the growth of granulations, but often after this has occurred the granulations are apt to become exuberant with little tendency to cicatrization.

The ointment which has given the best results is scarlet red, an aniline dye, which is known chemically as a sodium salt of a disulphonic acid derivative. Scarlet red (Biebrich) was originally prepared as a dye for wool and silk, and is so named because of the fact that it was first manufactured in the town of Biebrich. It was first used for medicinal purposes in 1907 in an 8 per cent. strength; because this strength was found to be too irritating, it was alternated with a bland ointment every 24 hours. It is now used only in strengths varying from one-half to five per cent., for the latter has proved to be as strong as necessary. When applied to granulating surfaces, scarlet red is sometimes absorbed in sufficient amount to color the urine a bright red, and a number of acute cases of nephritis have been reported from its use.

Its application to granulating surfaces causes healing, not by the formation of scar tissue, but in every case by producing a high grade of normal skin (this can be demonstrated by sections), which very soon becomes freely movable on the underlying tissue. The return of sensation in the healed area takes place from the periphery inward, instead of upward from the underlying tissue.

Scarlet red ointment should be applied in the following manner: after thorough cleansing of the part with tincture of green soap and water, then ether and finally 93 per cent. alcohol, the ointment should be spread in a thin layer over the entire surface on a piece of sterile gauze, and over this an ordinary dry sterile dressing. If the ointment is applied too thickly it may cause granulation tissue to break down, and for this reason it should be spread in a thin layer upon the granulating surface or its edges. Usually the dressing should be left undisturbed for from 24 to 48 hours, then reapplied, as indications warrant. The patient should invariably be informed that the dressing will be stained red, so as to forestall unnecessary alarm, due to the belief that a hemorrhage has occurred. He should also be apprised of the fact that stains on the linen are hard to eradicate. In removing the dressing, if it is adherent to the granulations, some peroxide of hydrogen should be used to loosen it. The skin about the granulating surface is best cleansed by benzine as this removes all traces of scarlet red better than any other solution. The three formulas that are recommended are the following:

The first is indicated where its use is desired over a large area and for a long time; the second, where an astringent action is required because the granulations are profuse; the third, where the granulations are sluggish and require stimulation.

The ointment in a 10 per cent. strength is not recommended because it is too irritating.

In cases of chronic leg ulcers, especially those associated with enlarged veins, it is impossible to effect a cure until the chronic congestion of the limb is relieved and the blood supply of the part approaches the normal.

Often all that is necessary is a gauze, muslin or flannel bandage, properly applied over the dressing and extending from the ankle to the knee.

A rubber bandage when applied with moderate, even pressure, has for its purpose the relief of congestion, but in a great many cases the rubber has an irritating effect on the skin.

When the granulations are almost on a level with the surrounding skin, and also when there is considerable thickening of the edges of the ulcer, the best means of keeping up an even pressure and causing absorption of the thickened margins, as well as of hastening the epithelial growth, is to apply zinc oxide adhesive plaster in strips, one-half to one inch in width. These strips should overlap to the extent of about one-third of their width; should extend about three-fourths of the way around the limb, and should be evenly and smoothly applied. They should be started about one inch below the ulcer and should run from two to three inches above it.

BANDAGING

Bandaging of Leg. The final stage after the dressing has been put on, consists in the application of the bandage. A bandage possesses advantages over strapping in being less irritating to the skin; in being more quickly put on and taken off; in being more easily removed without disturbing the surface, and in more completely allowing the formation of the granulations.

The bandage is also superior to a laced stocking, as the latter does not properly embrace the foot.

The bandage material can be either gauze, muslin or flannel. The last is considered the best because this material is thin, yielding and elastic and yet almost any degree of compression can be exercised with it.

In edematous swelling in general, the flannel appears very suitable, as it is soft to the skin and accommodates itself to the greater or less distension of the limb, arising from the increase or diminution of the fluid. The bandage should be at least six yards long, if required for an ordinary adult, and the width should be from two to three inches. Every portion of the limb, from the toes to the knees, should be equally and evenly compressed. Compression is of such absolute importance that without it everything else will be comparatively ineffectual. This being so, very much will depend on the manner in which the bandage is employed.

Without practice, it is not easy to properly apply a bandage to the leg, and probably this difficulty is the chief reason why preference is often given to adhesive plaster, as this sticks wherever it is put.

The blistering and excoriation often produced by strapping, and the time consumed in its application, are sufficient reasons for acquiring skill in the art of bandaging; an art whose comforts and advantages are appreciated by the patient.

Before using, the bandage should be rolled up very tightly, so that it may be grasped easily and held in the hand firmly without slipping. In putting it on, unwind only that portion which is being applied to the limb, because if it be loose in the hand, or if a considerable piece be unrolled at a time, it cannot be applied firmly or smoothly. The bandage should always be carried up to the knee, even if the ulcer or wound be seated on the lower part of the leg or on the foot itself, as the object of its application is not merely to cover the ulcer but also to support the vessels of the limb. If the bandage be discontinued on any part of the leg, it is liable to become loose and fall down.

It is desirable also that the patient should not wear a garter above the bandage, as anything unequally tight in the course of the veins is calculated to obstruct the free passage of the blood.

The firmness with which the bandage is put on is, of course, chiefly for the purpose of gaining the good effects of compression on the structures beneath, but besides, it contributes very much in making the bandage remain in its position when applied. Encircle the limb with it in a loose, careless manner, and it will fall down almost immediately the patient begins to walk about. Tight bandaging is extremely well borne if performed in a complete and methodical way, beginning at the lowest portion of the foot around the first joints of the toes and ending just below the knee.

The proper application of the bandage is of such great importance, especially in the treatment of varicose ulcers of the leg, that it should, when possible, always be done by the doctor himself. It is difficult for the most skilled layman to put a bandage on his own leg. The real practical difficulty lies with those patients who live at a distance from the doctor and who can only visit him once a week or at ten day intervals. These must be taught to dress and bandage the limb, and generally some friend or relative will learn to superintend the details.

The length of time which elapses before the bandage and dressings are removed and reapplied must necessarily be determined by the circumstances of each case. When the ulcer is very extensive and the discharge proportionately great, it may be advisable to dress the leg every day at the beginning of the treatment. Generally speaking, an ulcer of the leg is disturbed too often. To take off a dressing and put on another, even though done with the greatest care, interrupts the healing process and the natural steps to cure. Let the dressing remain on until some uneasiness points to the propriety of taking it off, for the purpose of allowing the escape of the discharge. Delay the removal of the dressings as long as possible without carrying the forbearance too far. Avoid extremes of waiting too long or of meddling too soon. Taking the average case, an interval of three days may in general be safely permitted.

Spiral Bandage of the Great Toe. In applying this bandage, the initial extremity of the roller is secured by two or three turns around the ankle and the bandage is carried obliquely across the dorsum of the foot to the base of the toe to be covered, and next to its tip, by oblique turns; a circular turn is then made and the toe is covered by ascending spiral or spiral reverse turns until its base is reached, from which point the bandage is carried obliquely across the dorsum of the foot and finished by one or two circular turns around the ankle. The end of the bandage may be secured by a pin or may be split into two tails and secured by tying.

Spica Bandage of Great Toe. This bandage is applied by placing the initial extremity of the roller upon the ankle and fixing it by two circular turns; the roller is then carried obliquely over the dorsal surface of the foot to the distal extremity of the great toe; a circular turn is next made and the bandage is carried upward over the back of the great toe to the ankle, around which a circular turn should be made; ascending figure of eight turns are then made around the great toe and the ankle, each turn overlapping the previous one, two-thirds, and each figure of eight turn alternating with a circular turn around the ankle. These turns are repeated until the great toe is completely covered with spica turns and the bandage is completed by circular turns around the ankle.

French Bandage of the Foot. In applying this bandage the initial extremity of the roller should be fixed on the leg just above the ankle and secured by two circular turns around the leg; the bandage should be carried obliquely across the dorsum of the foot, to the metatarsophalangeal articulation, at which point a circular turn should be made around the foot; the roller should then be carried up to the foot, covering it with two or three spiral reverse turns; after this a figure of eight turn should be made around the ankle and instep; this should be repeated once to cover the foot, with the exception of the heel, and the bandage continued up the leg with spiral reverse turns.

Spica Bandage of the Foot. In applying this bandage, the initial extremity of the roller should be fixed just above the ankle and secured by two circular turns; the bandage should then be carried obliquely over the dorsum of the foot to the metatarsophalangeal articulation; a circular turn around the foot should be made at this point and the bandage continued upward over the metatarsus by making two or three spiral reverse turns; it should then be carried parallel with the inner or the outer margin of the sole of the foot, according as it is applied to the right or left foot, directly across the posterior surface of the heel, and from this point it should be conducted around the outer border of the toe and over the dorsum, crossing the original turn in the median line of the foot, thus completing the first spica turn. These spica turns should be repeated, gradually ascending, by allowing each turn to cover three-fourths of the preceding one, until the foot is covered, with the exception of the posterior portion of the sole of the heel; the turns should cross one another in the medium line of the foot and should be kept parallel throughout their course. Bandages for the Foot and Leg. Whenever possible the patient should be kept in bed, or, at least, in the recumbent position with the leg elevated, but when circumstances do not permit of this the veins can be supported in various ways. Elastic stockings are excellent but expensive, and not durable. Bandages of rubber cloth, or woven bandages rendered elastic by the character of the mesh, or Martin’s plain rubber bandage may be employed. The last named is put on smoothly but not too tightly, for in walking the leg swells, so that a uniform pressure is established. As the rubber prevents evaporation it acts like a wet compress, stimulating the granulations, but very often producing eczema around the ulcer. The rubber bandage should be washed carefully at night with soap and cold water and must be kept clean. In one patient a firm elastic stocking of vulcanized rubber will give the greatest ease and comfort, while in another the resulting irritation will prove unbearable. As regards the flannel bandage it has already been described at some length.

The essential feature of ambulatory treatment is a good dressing to prevent congestion, and Unna’s paste is ideal for this purpose. The paste necessary for the bandage is prepared as follows: first dissolve four parts of the best gelatin in ten parts of water by means of a hot water bath. While the fluid is hot add ten parts of glycerine and four parts of powdered white oxide of zinc; stir briskly until the mixture is cold. Another formula for the paste, and the one recommended, consists of the following: white gelatin, 2-1/2 ounces; water, 8 ounces; zinc oxide, 2-1/2 ounces, and glycerine, 4 ounces; prepared as above. The paste should always be melted before use by placing the receptacle in a hot water bath or in an ordinary copper sterilizer, such as that employed for boiling instruments. A small tin can be used, and a piece of paste about four inches square is cut into fine pieces and put in the can. This is placed in the sterilizer, into which is poured water to a depth of about two inches, so that the can is but slightly immersed. No top should be placed on the can. An ordinary stove or gas range can be used for heating purposes. A very important fact to remember is that no water is to be put into the can with the paste.

The leg is next cleansed, and after the paste has been thoroughly melted it is applied from the base of the toes to the knee, as hot as the patient can comfortably tolerate it, by means of an ordinary small paint-brush. Then a layer of gauze bandage (two to three inches in width, according to the limb) is applied, then a layer of paste, and in this manner two or three thicknesses of bandage are used, depending on the case. In thin people, it is necessary to use only one or two layers of bandage, whereas in stout persons several layers may be required. After the last application of the paste, some non-absorbent cotton is spread on the bandage, giving it the so-called “moleskin” plaster finish. Another way of finishing the dressing is to dust some ordinary talcum powder on the last layer of the paste, giving the bandage the appearance of a plaster-of-Paris dressing. If there is an ulcer, a window can be cut out, thus providing for the drainage of the secretions. The length of time this dressing should be left on depends on a number of conditions, especially the amount of secretion, and whether the patient has to remain on his feet very much. Ordinarily, the bandage can remain on for one week, but indications may be such that it need not be removed sooner than the tenth day, and in some instances it can be kept on for three or four weeks. To remove it, an ordinary bandage-scissors is used to cut the dressing, and it peels off without disturbing any of the granulations on the ulcer.

PROMOTION OF NEW EPITHELIAL GROWTH AND CICATRIZATION

The value of nitrate of silver and red wash as stimulants of the healing process has already been mentioned. They are also of value in producing cicatrization and in promoting the covering of new epithelium over the ulcer or wound. If the solid stick of nitrate of silver be applied very lightly to the edges just inside the pale bluish line of advancing epithelium, so as to produce a white film on the surface, this slight cauterization will be found to aid in strengthening and cornifying the new, delicate and previously invisible epithelial cells and in preventing them from being washed away by the discharge from the ulcer. The solid stick of nitrate of silver is also of benefit in destroying the exuberant granulations which project above the surface of the surrounding skin; often, by piercing these flabby granulations in several places with the solid stick held perpendicular to the surface, cicatrization is hastened. After the granulations are level with the surrounding skin the covering of the ulcer or wound with new epithelium is hastened by the application of some smooth surface along which the epithelium can spread. For this purpose zinc oxide plaster or some thin rubber may be used.

In some old chronic cases, healing is prevented by the fact that the base of the ulcer cannot contract owing to its being bound down by fibrous scar tissue. This binding down of the base and edges of the ulcer also tends to cut off the blood supply, and therefore in this additional manner healing is hindered. For the relief of this condition a number of procedures have been devised. Mattress sutures, introduced through the normal skin beyond the edges of the ulcer and passing beneath it, out through the skin on the other side, is one method. By tightening these sutures, over a button or metal plate, the ulcer can be lifted from the underlying tissues. Another method, called “starring of the ulcer,” consists in a series of radiating incisions through the base and edges of the ulcer, the part from which the incisions radiate corresponding with its centre. In this and in the following operations, in order to obtain a favorable result, it is necessary that the incisions pass completely through the cicatrical tissue which forms the base and edges of the ulcer into normal tissue. “Cross-hatching” of the base of the ulcer by means of a series of incisions at right angles to one another, and at a distance of about one-half inch apart, is often of value in aiding the healing of a chronic ulcer, the continued existence of which and failure to heal having been due to its thickened, adherent base and edges. Circumcision of a chronic ulcer consists in making a circular incision around it through the normal skin. A modification of this method consists in making a series of overlapping, short, curved incisions surrounding the ulcer, instead of a single circular incision. In these last two methods it is necessary that the incisions be made through normal skin, and that the wounds be made to gape, if necessary, by packing them with gauze.

When the ulcer or wound is of considerable size, it is often impossible to secure healing even by these methods. It may for a time appear as if it were going to heal, and a pale blue line of newly formed epithelium may spread out from the edges, but instead of the epithelium continuing its progress, at a subsequent dressing it will be found to have disappeared. In these cases, as well as in those in which the size of the ulcer would necessitate a long delay for a cure or in which the subsequent contraction of the scar would produce deformity, skin grafting, skin transplantation, or some form of flap operation is indicated.

SKIN GRAFTING TO OBTAIN A SOUND SCAR

A very important object in the treatment of all ulcers is to obtain a sound scar. In ulcers affecting the lower extremity in elderly people, the scar resulting from spontaneous healing is weak and readily breaks down if the patient does much standing or walking. The patient is therefore frequently obliged to give up work in order to get the ulcer re-healed, or must be content to employ means which merely prevent its extension and relieve some of the discomfort. When the best possible scar is desired, and when it is important to avoid marked contraction, it is necessary to adopt some method of skin-grafting.

There are three plans by which rapid healing of an ulcer may be brought about: Reverdin’s epidermis grafting; Thiersch’s skin grafting, and the use of the whole thickness of the skin.

Reverdin’s Method. In this procedure small thin portions of the superficial layer of the skin are snipped off with a curved scissors. Pieces about the size of a hemp seed are planted on the surface of the granulations at short distances from one another. Epidermic growth occurs from each of these little points, and the result is that numerous small islands of epithelium form over the surface of the ulcer. If the grafts be close enough together and the conditions be favorable to healing, these islands soon coalesce and thus rapid cicatrization is obtained. The grafts should not be too far apart, because they appear to have only a limited power of reproduction.

With a view to obtaining a sounder scar, thicker and more extensive portions of the skin must be taken and the grafts must be applied close together. There are two ways of doing this: either by using the whole thickness of the skin or by employing Thiersch’s method, in which about half the thickness of the skin is shaved off.

The procedure where the whole thickness of the skin is employed need not be described, partly because the results are not satisfactory and partly because all the conditions for which it was introduced are better fulfilled by Thiersch’s method.

Skin grafts may be taken either from the patient himself or from another individual. When the patient is much debilitated, the cutaneous epithelium shares in the general malnutrition and under these circumstances a graft from a healthy subject might succeed better than one taken from the patient.

Thiersch’s Method. In employing this method the skin which is to be used for the grafting must first be shaved and disinfected in the usual manner, as has been previously described. The presence of hairs on the grafts seems to interfere materially with their union.

Preparation of the Ulcer. Preliminary. It is of no use to graft a sore which is actually ulcerating; it must be brought into a healthy condition, and healing must have commenced before transplantation is likely to be successful. The best criterion that healing is taking place is the presence, at the edges, of the dry line which indicates recently formed epithelium. Some surgeons wait for a considerably longer time before grafting in order to get a firm layer of granulations, but experience shows that it may be safely resorted to as soon as healing begins around the edge. A second essential is that the ulcer shall be clean. If the discharges be septic, the graft, which is, after all, merely a piece of dying tissue, will become impregnated with decomposing pus and may rapidly become loosened, die, and undergo decomposition. The methods of rendering the ulcer aseptic have already been described.

Operative. The following is the method of procedure: after the patient has been placed under an anesthetic, the granulations over the whole surface of the ulcer are forcibly scrubbed off with a firm nail-brush, or are evenly scraped away, taking care, however, to remove only the soft layer of granulations and not to go through the deeper one of newly formed fibrous tissue into the fat. A surface is thus left which is smooth, highly vascular, and firm, and which consists of the deeper layers of granulation tissue that have already become organized into fibrous tissue. In cases of ulcer of the leg it is also advisable to remove those portions of the edge which have already become covered with new epithelium. If the transplantation be limited to the parts actually unhealed, the result is disappointing as a rule, for while the part grafted remains sound, the margin where spontaneous healing had occurred, is apt to break down, and thus a narrow line of ulceration appears at the edge of the ulcer.

After the layer of granulations has been removed and the newly healed edge of the ulcer has been cut away, the bleeding must be arrested completely before the grafts are applied. The most rapid method is to pour a few drops of adrenalin chloride (1 to 1000) solution over the raw surface, when the oozing ceases immediately. If adrenalin be not at hand the following plan will be found satisfactory: any spouting vessel is clamped and a large piece of sterilized gauze or thin sheet rubber is applied over the raw surface of the wound; outside this, several sponges are placed and a sterilized bandage is bound firmly over them. If the sore be small and an assistant be available, he may apply the pressure. Pressure is employed indirectly through the protective in this way, because if it were made directly upon the surface of the wound by means of the sponges, bleeding would recommence when the latter were removed, as they stick to the raw surface.

While the bleeding is being arrested the surgeon cuts his skin grafts from any part of the body, as he thinks fit As a rule they are taken from the front of the thigh, but the side of the abdomen may be selected. The area from which the grafts are to be cut is disinfected, and the surgeon grasps the limb from behind with his left hand in such a way as to make the skin over the front of the thigh as tense as possible; in doing this he pushes the soft parts well forward so as to make the anterior aspect of the limb as flat as possible. The skin is further put on the stretch vertically by an assistant, who pulls it upward and downward. These precautions are important, as without them it is almost impossible to cut a graft of even width. The razor, which should have a very broad blade, is dipped into a boric acid solution and is kept constantly wet with it whilst the grafts are being cut. Unless this be done, the graft adheres to the blade and may be either partially or wholly cut through before a sufficient length can be obtained. The razor is made to penetrate through about half the thickness of the skin, and then, by a lateral sawing motion, the grafts are cut as broad and as long as possible. After a little practice it is easy to cut them about two inches in breadth and about four or five inches in length.

If one graft be insufficient, it is best to slide it off the razor and leave it on the bleeding surface; in this way it is kept warm and moist. Some surgeons put the graft into warm saline solution, and it is said to then spread out more easily afterwards. Small skin grafts can be cut under local anesthesia.

Application of Grafts. When a sufficient number of grafts have been cut, the bandage, sponges and protective are removed from the raw surface of the ulcer and the grafts are applied to it if the bleeding has stopped, as is generally the case. The raw surface usually has a thin layer of blood-clot upon it, and this should be wiped away.

Each graft is lifted with forceps or the fingers and applied with the cut surface downward, and then is carefully unfolded by means of two probes and stretched evenly over the surface. The grafts should overlap the edges of the skin and also each other, so that no part of the raw surface is left exposed, for granulations always spring up on the uncovered parts and are apt to destroy the grafts in their vicinity; moreover, a thin scar is left at these points which may break down subsequently. The graft is always thinner at its edges than at its centre, and it is these thin edges which overlap each other or the margin of the skin; there is no real sloughing of these overlapping portions.

The dressing should be left on the grafted surface for about five days; in some cases even for a week. If the wound be aseptic, no suppuration or decomposition takes place beneath it. Before being removed, the dressing should be thoroughly soaked with a 1 in 2500 sublimate solution, for otherwise it may stick at the edge and adhere to the graft, which may thus be peeled off, unless great care is taken. The parts should be gently cleansed with the same solution, and a dressing similar to that put on originally should be employed for about another week. At the end of that time the grafts are fairly, firmly adherent and then a 5 per cent, boric acid ointment is the best application.

It will be found that even at the first dressings the grafts present a pink color and are adherent to the deeper surface, though they are still readily detachable. In the course of about a week the old cuticle peels off, but no raw surface is left. Later on, there is a great tendency to the formation of new epithelium, cornification, and drying-up, and it is to avoid the latter condition that ointments are so useful; in fact, until the scar is absolutely sound, it is well to keep the surface covered with some greasy application, the best being the 5 per cent, boric acid ointment.

For many months the grafted surface is likely to scale or crack, and this might prove a starting-point for the occurrence of sepsis which would cause the newly grafted area to slough. It is important to keep the scar as supple as possible, and therefore it should be constantly anointed with cold cream, vaselin, or lanolin. Grafted surfaces upon the face, however, do not manifest this tendency for any length of time.

Time Required for Cure. It is important to know when the patient may be allowed to walk about after an ulcer of the leg has been skin-grafted. If he begins too soon, the grafts will almost certainly become detached. That this will be so is evident from a consideration of the mode by which the adhesion of the grafts takes place. At first they adhere to the surface of the sore, simply by means of the effused and coagulated length. Cells rapidly spread into this length and in the course of two or three days the space between the grafts and the raw surfaces is occupied by a mass of young cells. In this tissue, new blood vessels develop and penetrate into the graft, whilst, at the same time, the cells of the latter grow and assist in the development of the young tissue and of the blood vessels. Thus the graft becomes vascularized; but for a considerable time the tissue between it and the surface of the sore contains many young blood vessels with delicate walls, and therefore, if the patient stands erect and allows the pressure of the column of blood to fall on these vessels, they rupture, and bleeding occurs beneath the graft and leads to its detachment.

It requires a long time before the graft is firmly incorporated with the tissue beneath by the development of elastic fibres; indeed, it may be reckoned that this union is not complete until from three to six months have elapsed. The graft will, in all probability, be destroyed if the patient walks about within three months of the transplantation. Hence, unless that time can be devoted to the treatment, it is not worth employing skin-grafting for ulcer of the lower limbs. By this, however, it is not implied that it is necessary to keep the patient in bed for the entire time, but merely that the foot must not be allowed to hang down, nor must any weight be borne upon it.

At the end of about six weeks the patient may be allowed to get up and lie on a sofa or sit with the leg on another chair, but the limb must not be permitted to hang down. After about three months he may be allowed to get about, but in order to prevent the detachment of the grafts, he should be fitted with a knee-rest and peg on which he walks, the leg projecting out behind him. If possible he should not put his foot to the ground until six months have elapsed. In cases of sores on other parts of the body, when the erect posture does not cause congestion of the part, the patient may be allowed to walk about after the first three weeks.

Results. The scar which results after skin-grafting performed in this manner is of a satisfactory character, and ulcers which have been intractable for years may be closed satisfactorily by this means. In order to obtain anything in the nature of a permanent cure, however, the prescribed period of rest must be adhered to rigidly.