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Miss PATRICIA HoRNSBY-SMiTH (parliamentary secre-tary, Ministry of Health) spoke warmly and pleasantly ofthe new approach we are making to this problem, of thewaiting-list for our mental hospitals, and the over.

crowding in them, and of the E million which the Ministe]has allocated to the provision of more beds in mentahospitals and mental-deficiency hospitals. But stafis the first necessity. The public, and particularlyparents, must be helped to understand that mentanursing can provide as satisfying a career as any othe:kind of nursing : and that it is a matter of treatmentnot of custody.

Management of Burns

* The members of the subcommittee are : Mr. R. J. V. BATTLE,Mr. PATRICK CLARESON, Mr. RAINSFORD MOWLEM, Mr. ROWLANDOSBORNE, and Mr. A. B. WALLACE. They are glad toacknowledge assistance from Mr. A. D. R. BATCHELOR andMr. R. L. G. DAWSON.

A series of six articles prepared by a subcommittee of theBritish Association of Plastic Surgeons *

IV. TECHNICAL PROBLEMS OF FREESKIN-GRAFTS

INSTRUMENTS

FOR most purposes the Blair type of razor of wafersteel fitted into a light handle is the best. The Humbymodification gives control of the thickness of skin cutand Bodenham’s variation reduces maintenance costs byusing detachable blades. All these can be sterilisedwithout loss of cutting power by boiling for two minutes.They are used in conjunction with one or more graftingboards to flatten the skin of the area chosen as the donorsite for the graft. For all ordinary purposes the thighsmake the best donor sites, though the inner aspect of theupper arm is useful for small grafts or when it is particu-larly desired to avoid hair. If these areas are not avail-able, the chest, abdomen, or back can be considered,although free-hand skin-graft cutting from these sites isnot easy. Before using the razor, the surgeon positionsthe limb so that it presents him with the maximum flatsurface. A board of wood in his left hand steadies andflattens the surface, whilst the razor is moved with a

gentle sawing movement until it begins to bite. The twohands move slowly along the limb, the board and theleading edge of the razor being 1/2 in.-3/4 in. apart.

Padgett’s dermatO’lne, although rather more complicatedin its use, has the advantage that it cuts an accuratelycalibrated graft and that it will remove such a graft frompractically any surface whether concave or convex. Theinstrument consists basically of a half-cylinder, 4 in.wide and 8 in. long. The clearance between the drum andthe knife is adjustable. The application of a specialcement to the drum and to the skin of the donor areaenables the two to adhere, so that the graft when cutcovers the drum. The procedure can be more difficultthan it sounds, in that neither the depth-gauge nor thecement are foolproof ; and thin grafts cannot be removedfrom the drum without a special technique.The electric dermatome cuts strips to a maximum width

of 3 in. and their length is limited only by the donor areaavailable. No cement is necessary and a mineral oil, suchas paraffin, provides adequate lubrication. There is noother instrument to touch this one in the treatment ofextensive burns, for it will remove very thin grafts andits donor areas are good’and trouble free. Furthermoreit can take skin swiftly and surely from any part of thebody. Very little experience in its use is required toensure proficiency.

TYPES OF GRAFT

The grafts most often used for the early resurfacingof burns are of intermediate thickness. Such grafts can

" take " in spite of some mild surface infection and theyleave better donor areas than do thicker grafts. When,however, complete excision of a burn can be carried out,and the base thus converted into a clean wound, a moredefinitive repair may be indicated, and for these a thickertype of graft is permissible. These thicker grafts aresimilarly used for the correction of scar contractures atlater stages in the repair.

After the cutting of a partial thickness graft, the donorarea epithelialises rapidly and should be healed withinten to fourteen days. There is, however, seldom anyindication to disturb the dressing in less than fourteendays. If by accident the fat beneath the skin in thedonor area has been exposed, then it should be immedi-ately covered, either by direct suture or by the applicationof a small graft from elsewhere. This accident willrender the area unsuitable for further grafting andhealing will be delayed. In most instances, however,donor areas can be used a second time within twenty-onedays ; but subsequent grafting is facilitated if only onelimb is used at a time, and though this is not alwayspossible, it should be borne in mind.

STORAGE OF SKIN

Any graft, either autogenous or homogenous, that isnot immediately required can be stored for later use. Itshould be spread on wide-meshed ’ Vaseline’ gauze andfolded on itself so that the raw surfaces are together,rolled into a compact bundle, enclosed in a swab moistenedin normal saline, and finally placed in a small sterile

specimen jar or tube. This is sealed and placed beneaththe ice-box in a refrigerator, where it should be kept at aconstant temperature of 32°-34°F. Such grafts can

usually be used with satisfactory results up to about threeto four weeks after cutting.

HOMOGRAFTS

The transference of skin from one person to anothermeets with unqualified success only when the two areidentical twins. In other cases, such grafts have limitedvalue only. Though the initial take of these grafts seemssatisfactory, they remain viable for only fourteen to

twenty-one days. After this they ulcerate, separate, andare lost. Apparently the recipient becomes sensitive tothe foreign transplant, for a second application from thesame donor usually lasts for a much shorter period, and athird transplant may never adhere at all. It has beenshown, however, that if homografts are placed in marginalcontact with autografts, they can assist epithelialisation.It appears that epithelium from the autografts invadesand replaces the homografts. It is also suggested fromboth clinical and animal experiments that multipledonors are preferable to single donors, since the reactionof the recipient to multiple grafts from several donors isless violent than it is to grafts from a single donor.

Homografts are especially useful in small children andin those adults in whom donor areas are insufficient to

provide early complete skin cover by autografts.

GRAFTING OF GRANULATING AREAS

Only the simplest type of grafting procedures are

indicated in granulating areas. The granulations mustbe free from excessive discharge and slough and theirsurface should be smooth and pink. Such areas are

rarely bacteriologically clean, and the organisms com-monly present are :

(a) -haemolytic streptococci.-The proteolytic enzyme pro-duced by these organisms can digest any free epithelial graftand their presence on a granulating area is the commonestreason for failure.

(b) Staphylococcus aureus.-These organisms are danger-ous to the survival of a graft because of the quantity ofdischarge they produce from the surface of the area to begrafted.

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(c) Gham-negative bacilli.-Pyocyaneus and proteus are

often found together. They produce a profuse and offensive’discharge, which is likely to be responsible for failure of thegraft. They are essentially organisms which thrive best onmoist wounds, so that any treatment which tends to

produce a dry surface is a help. After grafting, dryness isencouraged either by avoiding all dressings or by their earlyremoval.

; The sensitivity of any or all of these organisms variesvery considerably and the uncontrolled use of an anti-biotic is valueless. The local or parenteral applicationof an antibiotic of known efficacy against the particularcontaminant is, however, useful during the forty-eighthours before and after operation.

TECHNIQUE OF GRAFT APPLICATION

Grar‘u.lat2ng AreasWhen discharge is profuse in spite of all treatment, the

epithelium is best applied as patches or strips of aboutpostage-stamp size, which will survive independently ofone another. These patch grafts are made by cutting upsheets of thin or intermediate split grafts. The generalplan of the operation is as follows :The donor site of the graft must be prepared as before anyoperation.First step.-The graft is cut as the first step in the operation,

in order to avoid contamination of the donor area. Thedonor area is dressed with vaseline gauze, dressing gauze,cotton-wool, and a sterile bandage.Seemd step.-The area to be grafted is now exposed. If the

granulating area is relatively clean and the granulations arehealthy and flat, there is no need to remove them. If theyare pale, exuberant, and discharging unduly, they may beremoved by dissection to expose a healthy base. Hsemostasiswith iced saline packs is then necessary before applicationof the grafts. The grafts are then applied with their rawsurface towards the granulations. In general, grafts should beplaced almost touching each other. Where the supply ofskin is unequal to the demand, they can be spaced out to theirown width apart or separated by homografts one fromanother.

Third step.-The entire grafted area is covered with wide-meshed vaseline gauze and dressing gauze. This layer can beseparately fixed by painting the healthy skin round the areawith ’Mastisol,’ so that the first turn of the bandage iscemented to the skin.

A thin layer of wool is applied and pressure maintainedby a crêpe bandage. If a limb is being grafted, immobili-sation with a plaster slab is advisable. The hand, ofcourse, is normally immobilised in the position of function,although, in young children with burns of the palm,extension of the fingers can be prolonged without

subsequent loss of the power of flexion.

Bacteriologically Glean AreasThere is at present a tendency to favour early excision

of burned areas. The surgeon is then faced with a cleanarea to graft as opposed to the granulating area describedabove. It must, of course, be remembered that theseareas are potentially infected and that systemicchemotherapy may be necessary.Hsemostasis is essential but may be difficult to secure.

The ideal to be aimed at is a graft which is immediatelyadherent and therefore requires no suturing or pressurebandages as a protection against subsequent displace-ment. Indeed, grafts will take without dressings, butthey are unlikely to do so if the surgeon is pressed fortime, if reactionary haemorrhage is probable, or ifmovement of the part is uncontrolled.The graft is spread, raw surface uppermost, on tulle gras.

If it has been impossible to cut one single sheet of skin

sufficiently large to cover the entire defect, smaller pieces maybe overlapped to produce the necessary area. The entiresheet of gauze is picked up, turned over, applied to the raw,area and- fixed in position by marginal sutures.

Accurate pressure is applied to the graft by layers of woolwrung out in an emulsion of flavine and paraffin or in saline.The ends of the marginal stitches should be left long andbrought out over this pack and tied together, so that thegraft and pack are fixed firmly to the raw area. The dressingis completed by a generous layer of gauze and wool andcovered by a crepe bandage. It may often be desirable toimmobilise a limb by a light plaster slab.

Special AreasDental composition-e.g., Stent’s--can be used to

good effect, particularly where there is a fixed base, as,for instance, on the forehead. It is the method of choicein eyelid grafting, and it is useful in grafting the upperlip, but in these situations the soft tissues have to bestretched round the mould and held by careful stitchingover it.

The wax is sterilised by immersion in 1 : 25 carbolicsolution and then washed and heated in water at 1400F. Whenmalleable, sufficient is taken to make an impression of theraw surface, and it is then cooled in position with a jet of £ice-cold saline. The mould is removed, dried, and covered withgraft, the raw surface outwards. A thick graft tends to curlaway from the mould and may have to be stuck to it withmastisol. The mould covered with graft is then applied andstitched carefully into position. One or more stitches may beinserted when the mould is first made (in at one side, over themould, and then to the other) and the two ends can thenimmediately be tied over the mould. These stitches hold themould in position during the insertion of others, which should,is possible, be made to pick up the sheet of graft on either sideof the mould, as well as the skin edges. The usual pressuredressing is necessary.

’

Postoperative DressingsThese dressings will be undertaken to ensure the

survival of the largest possible area of the graft. Allgrafts survive by plasmatic circulation for the. first

forty -eight hours after application. Thereafter the ingressof capillaries begins and is almost complete in five to tendays, depending upon the thickness of the graft. Themaintenance of pressure dressings, however desirable asa protection, is not essential after capillary ingrowth hasbegun. If the graft has been applied to an uninfectedarea, the initial dressing may be left in place until

complete stability is achieved-i.e., seven to fourteendays. All that will then be needed is the excision of anyredundant graft overlapping the normal skin marginsand the daily application of a thin layer of vaseline orlanoline until surface desquamation is complete andnormal flexibility is re-established.

If, however, the graft has been applied to an infectedsurface the extent of final survival represents a balancebetween the initial " take " and the amount of autolysiscaused by the infected purulent discharge which soonreaccumulates. It may therefore be desirable to removethe primary dressing after forty-eight hours. This mustbe done with extreme care to avoid dislodging the grafts.All non-adherent grafts and tags are cut away, and alayer of tulle gras, from which excess vaseline has beenremoved, is applied. Over this, an appropriate dressing,such as sodium hypochlorite, can be used, but if repeatedapplications are necessary it is inadvisable to remove theprotective tulle gras at each dressing.A useful alternative, particularly in children, is to

leave the graft exposed. Crusting between the graftsmay be removed by irrigation, which may, where

possible, be carried out in a bath. This regimen iscontinued until epithelialisation becomes obvious andit may then, if desired, be changed for the closed

dressing technique.When the primary take of any graft is inadequate to

ensure early complete epithelialisation, nothing is gainedby delaying regrafting for longer than the time necessary

, to produce a clean recipient area.

R. J. V. BATTLEM.B.E., M.Chir. Camb., F.R.C.S.