The treatment of ulcer of the leg

THE TREATMENT OF ULCER OF THE LEG* BEVERLY

DOUGLAS,

M.D.

Associate Professor of Surgery, Vanderbilt University NASHVILLE, TENNESSEE

c,c

I

T is easy to get a Ieg uIcer to hea1. It is hard to obtain a kind of heaIing that wiI1 last” (Leriche, Fontaine and Maitre’). With this statement, which I take the Iiberty of transIating, these authors open a recent articIe. I fee1 that it is so apt that I begin the present discussion with it aIso. I agree with them in feeling that with the oIder methods of treating uIcers recurrence is the ruIe. Yet on the basis of our findings, I have the conviction that with the majority of Ieg uIcers treated conservativeIy and aImost a11 of those in which radica1 excision and proper grafting are empIoyed, permanent cure wiI1 resuIt. The importance of cIeanliness and protection to the heaIed uIcer area and of immediate return to the out-patient department, shouId injury or spontaneous infection occur, has been emphasized to the patients in our series at discharge from the clinic. After healing, if eIastic adhesive has been empIoyed, the application of the bandage is made one more time and a dry eIastic cloth bandage is then substituted. If it is thought desirable, this is Ieft on continuousIy for support. Through these measures recurrence has been Iimited Iargely to those cases in which injury is the principa1 cause. We readily recognize the fact that with older methods of treatment a type of healing is usuaIIy obtained which resuIts in unstabIe conditions at the site. The epitheIia1 Iayer is thin and usuaIIy devoid of hair, sebaceous and sweat gIands and papiIIae over an extensive area. Methods, whether conservative or radica1, shouId aim at producing better circuIatory conditions of the extremity as a whole and a thicker, healthier and therefore more durabIe skin

Iayer. Often this is impossibIe due to the tremendous amount of scar which has been deposited in the zone around the periphery and under the base of the uIcer. GENERAL

CONSIDERATIONS

According to aImost a11 authors, the incidence of varicose uIcer is on the increase. This fact is probabIy due to modern Iiving conditions, incIuding Iong hours of standing stiI1 or sitting down. Referring to England, A. Dickson Wright2 recentIy said, “No one reaIizes what a terribIe curse Yaricose uIcer is to the Iower cIasses of this country; it is much more prevaIent than is imagined, because most of the sufferers, tired of receiving no reIief from the medical profession, settIe down to endure their compIaint with occasiona extravagances in the form of quack remedies. In every Iarge town of the midIands may be found an institution, under the supervision of unquaIified peopIe, for the treatment of ‘bad legs.’ ” Such is the picture of this country aIso in many IocaIities. The unhappiness and economic Ioss in these cases is very regrettable, the more so because aImost invariabIy the uIcers wiI1 respond to the proper treatment. In other words, they are curabIe. In five articIes3’415j6J between 1929 and 1936 I have endeavored to point out the modern advances of treatment and to stress the great curability of uIcer of the Ieg. In this briefer articIe, it wiI1 be my purpose again to refer to and re-emphasize some of these points, to add recent deveIopments and to appIy certain pertinent facts concerning the genera1 probIem of wound healing to this particuIar fieId. As great as the advancements have been, there are already indications of stiI1 more changes.

* From the Department of Surgery, Vanderbilt University. 429

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Definition. UIcer of the Ieg is to be considered as a speciaI type of wound found in a speciaI Iocation. In general terms, an uIcer may be defined as an open wound due to the Ioss of skin or of skin and subcutaneous tissue through trauma, infection, new growth, circuIatory deficiency, or a combination of two or more of these factors. The term uIcer impIies that the wound is reIativeIy wide transverseIy in proportion to its depth-too wide to hea per primam. The foIIowing chief causes of uIceration of the leg are recognized: I. Trauma: injury in the form of mechanical force, extremes of temperature, heat and coId, concentrated chemicaIs, Roentgen ray or radium. 2. Infection: syphiIis, tubercuIosis, amebiasis cutis, carbuncIe, maIignant pustuIe. 3. Neoplustic growth: rodent uIcer, MarjoIin’s uIcer. 4. Circulatory disease: varicose veins, Iimited gangrene of arterioscIerosis, scorbutic uIcers, ma1 perforant, bed sores. The circuIatory changes may be primary or secondary to trophic changes as for exampIe after division of a nerve. 3. Combinations of the preceding four causes: ExampIes are syphiIis supervening in a varicose vein case, MarjoIin’s uIcer in which a squamous ceI1 epitheIioma forms in the chronic uIcer from a burn, bedsorei in which mechanica trauma (friction), circuIatory stasis (pressure) and infection a11 pIay a part. This Iist is by no means a fuI1 one, but at Ieast wiI1 serve to show the muItipIicity of causes to which uIcer may be attributed. Such terms as “Iuetic,” “varicose,” “epitheIiomatous” shouId properIy be reserved for those cases where the etioIogy is definiteIy proved. Leriche rightIy condemns the indiscriminate use of the term “varicose uIcer ” in a11cases in which varicose veins are seen somewhere on the uIcerated Ieg. The various forms which uIcers assume when due to various diseases are we11 iIIustrated in Boyd’s “PathoIogy.“s

of the Leg

LOCATION

OF

ULCERS

Leriche et a1.l point out the fact, which I have frequentIy had occasion to verify, that varicose uIcer is most commonIy found aIong the interna surface of the Ieg over or above the interna maIIeoIus where the skin is stretched over the bone as if upon a saddIe. A typica uIcer due primariIy to varicose veins is shown in Figure I. Friction or other injury from a shoe has Ied the British to caI1 these uIcers “boot ulcers” or “stocking uIcers.” The factor of scratching with the fingers because of a chronic itching of course aIs pIays its part. Varicose uIcer usuaIIy starts as a singIe Iesion. SyphiIitic uIcers are usuaIIy muItipIe unIess the Iesion is due to gumma formation. They are generaIIy Iocated in some part of the upper two thirds of the leg. I have seen as many as forty uIcers from this cause present on a singIe extremity. (Fig. 2.) The persistent muItipIe uIcerations due to infection by staphyIococcus aureus in those uIcers due to trauma have no special site of prediIection depending as they do upon pureIy casua1 factors. This condition is known as ecthyma. It is simiIar to impetigo, but is more chronic in nature and not so contagious nor infectious. Strangely enough, Goodman9 finds that most varicose uIcers are Iocated on the Ieft rather than the right leg. He found that far more of the patients with ulcer on the right Ieg had positive Wassermann tests than those with uIcers on the Ieft Ieg. In our series4 at Vanderbilt Hospital the incidence of Ieg uIcer is about three-fifths as great as that of acute appendicitis. ETIOLOGY

Commoner Causes. A study of the literature shows that opinions are at variance concerning the proportiona incidence of uIcer of the various types. Varicose veins must stiI1 be considered by far the commonest cause of Ieg uIcer. Various estimates are given; in many of them this condition is estimated as causing

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FIG. I. Varicose veins with ulceration of leg in a man of seventy years. A, before operation. Dilated vein indicated by arrow. B, successful sieve graft in ankle region. (Note that perforations have ahead!, almost entirely epitheIiaIized.) c, heaIed resuIt fifty-seven days after operation, with small deep graft at top. (From DougIas, in South. 1l4. J., 24: 5, 1931.1

FIG. 2. MuItipIe

biIatera1

Iuetic uIcers. A, before treatment. B, healed condition treatment and Iocal use of eIastic adhesive.

following

antiIuetic

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as high as go per cent of Ieg &em. The percentage wouId probabIy be cut down greatIy if Wassermanns were drawn on every patient. In Goodman’s series of sixty-four cases, syphiIis was proved to exist in thirteen. This does not indicate, however, that syphiIis was the cause of uIcer in each case. As the present nationa fight against syphiIis proceeds, it seems obvious that the proportion of uIcer due to other causes wiI1 increase. In a recent articIe, Leriche and his associates1 IogicaIIy ask the question as to what conditions shouId be incIuded under the term “uIc&e variqueux” or varicose uIcer. After recounting the histories of two cases in which they performed a tota remova of the internal saphenous vein for large uIcer of the Ieg, they state that in both cases heaIing of the ulcer was accomplished but the uIcers recurred without any return of the varices. They are right in proposing that the term “varicose uIcer” be reserved for those uIcers which deveIop on a Iimb showing varicose veins and through the tissues of which varicose veins with the chemica1 extend. Stagnation changes in the tissues accompanying it should be demonstrated before the term “varicose uIcer” shouId be used. Trauma from burns or other causes is another common cause of Ieg uIcer. In sixty-six cases of uIcer which came to them for surgica1 treatment, Brown et aI.” found burns of the Ieg the commonest cause and OsteomyeIitis next. Other causes of Iower incidence incIuded varicose veins, radium, x-ray and other trauma, OsteomyeIitis, phIebitis, hemoIytic streptococcus gangrene of the skin, and syphilis. De Takats and Curtis fee1 that hereditary factors and familia1 predisposition are important in Ieg uIcers. Rarer Causes. Among the Iess common causes of Ieg uIcer in our series may be mentioned those due to maIignant degeneration of a scar, to radiodermatitis, MarjoIin’s uIcer, aIs0 rodent uIcer and eIephantiasis. The fil.ariaI form of the Iatter is common in the tropics.

of the Leg HemoIytic streptococcus gangrene of the skin described by MeIeney12 is another rarer cause of uIcer of the extremities, as is a diphtheroid organism cIoseIy reIated to the Kiebs-LoeRIer baciIIus.13 Many other of the rarer causes of uIceration are summarized in a recent report by White,14 who caIIs attention aIso to epidermophytosis (ringworm) of the foot with secondary uIceration of the leg, nodular uIcerative syphiIis (tertiary Iues), erythema induratum with muItipIe ulcers (which he feeIs is due to tubercuIosis) aIso to the extragenita1 venereal uIceration which can occur on the extremities, such as chancroid, granuIoma inguinaIe and IymphogranuIomatosis of NicoIas-Farre. He aptIy mentions factitia1 or seIf inflicted uIcers, and those due to IocaIized aIIergy, injury from industria1 pursuits such as those due to chrome Iime, fumes of hydrochIoric acid, hydroffuoric acid and shaIe oil. He aIso mentions sickle-ceI1 anemia, typhoid encephaIitis, and muItipIe scIerosis as a few genera1 conditions which may cause uIcers. We have had occasion to treat uIceration of the Ieg from overdoses of bromides in a chiId. This drug, Iike the iodides, may cause uIcers which have a vegetative appearance. WhiIe this Iist is not compIete nor exhaustive by any means, one may obtain from it an idea of how often Ieg uIcer is a primary condition and how often the complication of other disease. Every effort shouId be made to find the specific cause of uIceration if such be present, since dehnite treatment may then be instituted which wiI1 resuIt in rapid cure. The IocaI appearance may be heIpfu1 but rareIy reveais the etioIogy. Much may be determined, however, by a study of the uIcer edge. Luetic uIcers are usuaIIy punched out and crater-like. TubercuIous uIcers frequently have overhanging edges. Epitheliomatous uIcers show a hard thickened epitheIia1 edge. For the reasons given above (Leriche) one shouId not consider the mere presence of varicose veins as being diagnostic of varicose uIcer but shouId insist that insuffrciency of the venous

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circuIation be demonstrated at the site both by circuIatory and laboratory studies. Many patients with varicose veins deveIop u1cer.s onIy after they have contracted syphiIis. LOCAL

PATHOLOGY

The Iocal tissue reaction which results in loss of substance to variable depths wiI1 depend upon the nature of the specific cause. In alI, prevention of further compIications wiI1 greatIy enhance the rate of heaIing and shorten the heaIing time. IndividuaIization wiI1 Iead to specific therapy both as to infection and to veins. Ochsner and Garside15 point out the foIlowing IocaI tissue changes in varicose uIcers: stagnation and anoxemia with increase in water content and corresponding decrease in oxygen content, an increase in IocaI N.P.N. and acid bodies and decrease in arteriaI suppIy. AI1 of these deIeterious changes Iay the part open to compIications resuiting from minor trauma or infection. DougIas4 has suggested the foIIowing form of outIine for the usua1 cIinica1 course of certain types of uIcers when inadequateIy treated : “ I. Origin and Course of Varicose Ulcer. Varicose veins (with or without phIebitis), passive congestion, edema, minor injury causing uIceration, secondary infection, cicatrization of edge and base, causing further impairment of circulation. ResuIt, unstabIe healing or extension of the uIcer. “2. Origin and Course of Syphilitic Leg Ulcer. Luetic obliterative endarteritis of capiIIaries, stasis, uIceration. ResuIt, if treated, earIy healing with atrophic scar. ResuIt, if improperIy treated, secondary infection, cicatricia1 change, chronic ulceration. “3. Origin and Course of Leg Ulcer Following Lymphatic Stasis. Superficial infection, acute Iymphangitis, chronic Iymphangitis with Iymphatic stasis, brawny induration with IocaI circuIatory deficiency, minor injury, uIceration, cicatricia1 change, chronic uIceration.

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“4. Origin and Course of Ulcer Following Trauma. Burn or other trauma, infection, heaIing by cicatrix (contractures if over joints), IocaI impairment of circuIation, injury, chronic uIceration with or without maIignant change. “It is interesting that practically all of the Ieg uIcers which come to us for treatment wiI1 faI1 according to their causes into one of these four groups. Likewise, one by using it may easiIy classify each according to its particuIar cIinica1 course of development or regression. “One fact stands out from it. This is the large rBIe that IocaI circuIatory changes pIay in causing an uIcer to become chronic or intractabIe to treatment. In the case of most uIcers the vicious circIe of vascuIar deficiency, uIceration, healing by scar tissue with stiI1 greater vascuIar deficiency, is repeated over and over again with frequent insuIts from trauma and infection, to make a cure without radica1 operation more and more hopeIess.” OnIy at the beginning may uIcers be considered to be due to one cause. At first there may be a primary cause of uIceration and if this is removed or even attenuated there may resuIt a rapid cure, but the primary cause as a ruIe very soon becomes mixed with other factors. Legs which certainIy from the condition of the veins shouId be uIcerated often escape this unfortunate occurrence because of the carefu1 and cIeanIy habits of some individuals whiIe in others who subject themseIves to in jury through force or scratching a reIativeIy slight degree of varicosity may mean a sentence to earIy and long continued uIceration. SYMPTOMS

In acute uIceration on the leg from any cause the symptoms are those of acute infection. In chronic uIcers pain and other symptoms are practicaIIy absent if infection and edema are controIIed. One does, however, find pain in two conditions. The first is associated with MarjoIin’s ulcer or

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maIignant squamous ceII degeneration of an oId uIcer site, usuaIIy from a burn. The second condition is that of erethistic or painfu1 uIcer. This consists of a chronic, very painfu1 uIcer at the ankIe joint. The pain is usuaIIy more severe at night than during the day and may best be treated by running a probe IightIy over the entire surface of the uIcer in order to find one or more spots which wiI1 be indicated as the chief cause of pain. The sensitive nerve Mament is then cocainized and touched with fuII strength carbolic acid. TREATMENT

General Principles. In a previous articIe3 I stated two principIes which if faithfuIIy foIIowed wiI1 resuIt in the cure of aImost a11 so-caIIed intractabIe or chronic uIcers. At present after several years I am even more certain of their fundamenta1 importance. Experimenta and cIinica1 evidence at VanderbiIt and eIsewhere have reinforced the soundness of both. Brieffy they are: I. CarefuIIy determine the cause or causes of uIceration and treat each. 2. Substitute good for unheaIthy tissue by getting rid of infection and by encouraging heaIing either through protective measures or by grafting with the addition of protective measures. The extremities and more particuIarIy the Iower extremities have two rather unique etioIogic factors which are of great significance and which must be understood to make any treatment rationa1. The first is that, the Iegs being dependent, there may be present various degrees of impairment of the venous return, resuIting in stagnation and deficient metabolism in the skin and subcutaneous tissue, IocaI anoxemia and acidosis, with a decrease aIso in arterial suppIy. In addition to this, there are edema and Iymph stasis which frequently resuIt in a stiI1 further impairment of the bIood circuIation. The second unique factor is that the skin over the tibia and, we may add, over the maIIeoIi is stretched, as recentIy pointed

of the Leg out by Leriche, as upon a saddle, so that in addition to being in poor circuIatory condition it is particuIarIy subject to trauma such as that from rubbing of shoes, bIows against objects, etc. To this the dirt of the street on socks is commonIy scratched and rubbed in by fingers. Thus the “stage is al1 set” for ulceration. On the other hand, bad as these vicious circular factors may appear, it must be admitted that there are two factors anatomicaIIy and functionaIIy pecuIiar to the extremity which aid tremendousIy in the treatment of uIceration. First, unIike that of most organs, the circuIation of the Iower extremity, be it arteria1, venous or Iymphatic, may be modified with ease (periarteria1 sympathectomy, excision of varices, “pavaex,” anastomosis of superficia1 to deep Iymphatics [KondoIeon]). Second, the Iimb as a whoIe may be treated (bandaging with eIastic adhesive, 0ccIusive pIaster cast [Orr treatment for osteomyelitis], transparent rubber or composition jackets).33’34 Technique of Treatment. Treatment of underIying causes of uIceration is a primary principIe to be strictIy adhered to. Varicose veins may be treated either before or after the uIcer is heaIed through IocaI measures. ShouId eIastic adhesive be used to strap the uIcer, injection of veins may be performed whiIe the Ieg i’s being supported and the uIcer covered by the bandage. Details of varicose vein treatment wiI1 be omitted here because of space requirements. As wiI1 be shown, the genera1 condition of the patient has an important bearing on the heaIing of uIcers and shouId be determined by a thorough physical and laboratory examination. A baIanced diet with the necessary vitamins wiI1 combat anemia and vitamin deficiency and hasten the healing process. causative organism is If a specific indicated by intensive study, treatment shouId be aimed at it. SyphiIis shouId be as intensiveIy treated. GranuIoma inguinaIe and tubercuIosis wiII need appro-

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treatment as we11 as priate genera1 intensive IocaI measures. EIephantiasis shouId be treated by anastomosis of the superficia1 and deep Iymphatics according to the method of KondoIeon or some modification of it. In chronic osteomyelitis, dead bone must be removed and granuIation tissue aIIowed to form before strapping or grafting. A reasonabIe degree of periostitis underneath the ulcer base is to be expected as a usual bony reaction. It wiI1 rareIy need attention. In hemolytic streptococcus gangrene of the skin, MeIeney12 advocates wide incision to drain pockets “as far as subcutaneous necrosis extends but no farther.” Brevity forbids the mention of many other genera1 measures. GENERAL

FACTORS

AFFECTING

HEALING

OF

ULCERS

Since uIcers are a11wounds of a particuIar configuration, a knowIedge of genera1 factors which may hasten or retard heaIing wiI1 prove very important in their treatment. This is a fieId in which, aIthough much research has been undertaken, IittIe has proved concIusive or fina1. Some of the factors which certainIy affect heaIing are age, diet, distant infection and hormones. The facts concerning these and many other factors have been fineIy summarized by Arey16 and Andersonl’ in recent articIes. Carrel, Du Nouy and Iater Howes and Harvey have shown that the rate of heaIing is inverseIy proportiona to the age of the patient. The Iatter authors have shown that this is due to the earIier onset of fibropIasia. These authors and others agree. on the opinion that a high protein diet favors heaIing by shortening the tota time required for wound repair. ConverseIy, Ravdin and Thompson’8 experimentaIIy demonstrated that hypoproteinemia resuits in retardation of healing in dogs. Carbohydrate metaboIism does not seem to be so important except as it assumes disease proportions as, for instance, in diabetes. Vitamin A and c deficiency are imDortant in wound heaIing. Arev recounts

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the experiments of severa authors, especiaIIy Saitta,lg in supporting his beIief that a vitamin A deficiency which has existed for a long time delays wound repair. According to this Iatter author and Anderson, treatment with vitamin A, even though onIy IocaIIy, acceIerates repair. This was later confirmed by TaffeI and Harvey. In genera1 it may be said that the effect of diet on wounds has not yet been put on a satisfactory clinical basis. Much carefu1 work is yet needed. Lanman and IngaIIs,20 through experimenta1 studies, showed that partiaIIy scorbutic animaIs have Iowered tensile strength in wounds and that asymptomatic scurvy is of importance in causing a deIay of heaIing in humans. Horn and Sandor, in 1934, showed the favorabIe influence of saIves and oiIs containing vitamin A appIied directIy to human traumatic wounds. As stated by them, both epitheIization and granuIation formation were speeded and through the more rapid growth of the latter, secondary infections were restrained. Often patients with Ieg uIcer are suffering from infection eIsewhere. For exampIe, syphilis may exist in a patient with a varicose uIcer. CarreI has shown that distant infection, experimentaIIy produced, retards healing. The effect of uIcers on the body as a whoIe is usuaIIy negIigibIe except in severe cases where infection causes certain changes in metaboIism, incIuding a higher basa1 rate during the destructive phase (Schneider and Straaten22). Dickson Wright has shown that Ieg uIcers cause a mental change in patients which is even reflected in their countenances. Their sad expression he terms the “ulcer facies.” In the past this has been due to the Iittle hope of cure which standard Ieg uIcer treatment afforded. With modern methods of therapy, cure is the rule, and the menta1 outIook of the patient need no Ionger be forIorn, but shouId be and usuaIIy is one of optimism. The first consideration, then, wiI1 be found in discoverinp the cause of uIceration.

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It is certain that secondary anemia shouId be treated by diet, iron tonics, and if necessary, bIood transfusions. Likewise endemic or nutritional edema, a fairIy common condition, shouId be treated by a diet high in caIories and in proteins. This edema, regarded by Youmans as of IittIe importance except “as an indication of a more fundamenta1 disorder,” most commonIy invoIves the Iower extremities and may aggravate any uIceration present. Its importance as a cause of sIow heaIing is found in the fact that diet too Iow in proteins may retard healing of uIcers. The work which has been done in periarteria1 sympathectomy indicates that an increase in the circulation of the whoIe bIood to a part wiI1 resuIt in a more rapid heaIing. From findings in Raynaud’s disease, one concIudes that the opposite is true in the case of decreased arterial suppIy. The purpose of inffammation with its increased bIood ffow to a part up to a certain point is to speed up the heaIing process. The conditions for fuIfiIIing the second basic principIe wiI1 be found by studying the fundamentaIs of the mechanism of cIosure and in making heaIing the more rapid by providing conditions worked out aIong these lines. Areyl6 hoIds that “the chief bioIogica1 factor responsibIe for the extension of epitheIium over the denuded area is the ameboid movement of the neighboring ceIIs themseIves.” He feeIs that the mitosis and ceI1 proIiferation have graduaIIy Iost advocacy in the face of carefu1 studies. From cornea1 studies with Covode he states that there is found an actuaI decIine in mitotic frequency during the first days foIIowing an injury. Studies by Loeb, Arey, Marchand and Werner24 a11 show the movement of epitheIium over mammaIian wound surfaces and concIude that “this must be the resuIt of an active wandering since mitoses were not increased during the earIy stages and especiaIIy did they not occur in the border zone.” Arey states that “in view of a11 the avaiIabIe information the primacy of ceI1

of the Leg migration in the epitheIization of wounds cannot be doubted, even though the contraction advocated by CarreI ( rg 10) and Burrows (1924) may Iessen the diameter of the origina Iesion markedIy in some Iocations.” He concIudes that two factors are of importance in the rapid restoration of epitheIia1 continuity: (I) contraction, important in mobiIe skin which is IooseIy attached to the deeper structures, and in which it can and does affect both epidermis and corium as a unit; and (2) ceI1 movement apparentIy by amebism, mitosis for the most part coming Iater after epitheIization is compIete. It is to be noted that a11 opinions embrace the importance of epitheIization in the zone surrounding the wound and of contraction in reducing the size of the wound so that epitheIization may compIete the work of contraction and so of healing. Arey, in speaking of the heaIing attained through scab formation, states that the extension of epitheIium from a11 sides is in progress even on the first day. “The granuIar and horny Iayers of the nearby epidermis disappear and resoIve into a homogeneous syncytia1 Iayer of characteristic rod-Iike form.” This covering sheet Loeb has designated as “the upper protopIasmic Iayer.” It migrates fastest of a11 the epitheIia1 components and rapidIy makes a covering to the whoIe scab; even at thirtysix hours this process is we11 aIong to compIetion. He makes a statement which we consider very important to our work from the standpoint of both conservative and radica1 “If the Iesion be smaI1 enough treatment: and the suppIy of ceIIs large enough, the mitotic phase may never become detectable as such. In wounds so Iarge that theadjoining epitheIium cannot suppIy sufficient ceIIs within a comparativeIy short time ceIIuIar proIiferation then enters before epitheIization is compIete and ceI1 movement and proliferation go on simuItaneousIy.” If we appIy these facts to our studies on the heaIing of hoIIow rings of skin of flattened doughnut shape, appIied to a granu-

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or of pseudopodia except in a direction Iation tissue of a dog, we wiII reaIize that inward. It is IikeIy that the cause of this they are pertinent to the present discussion diffIcuIty of centrifuga1 spread is that Iike of heaIing.7 InvariabIy the centra1 circuIar HLALlNG OFRING OFSMlN ONA GRANVLATING SURFACE

o-as-?.*

I-+S-?i.

I-L.-L.

FIG. 3. Greater rapidity of centripeta1 healing than of centrifugal healing. Size of outer edge of ring of skin has remained same while inner edge of ring has compIeteIy healed. (Tracings on cellophane.)

A

B

FIG. 4. Diagrammatic representation of centripeta1 and centrifugal heaIing. A, centripeta1 healing. The numerous epitheIia1 ceIIs at the edge of a granuIating wound are extending inward toward the center to cover the quadrant. Here seventeen cells must account for covering the space of iifty-four. B, centrifuga1 heaIing, representing a “pinch” graft on a granulating surface. A few ceIIs at the edge of the graft must extend outward and connect up with the next Iine of ceIIs in order to accompIish heaIing. Here seven ceIIs must account for covering the space ordinariIy covered by fifty-four. This is the sIower and less sure process of heaIing. In this diagram the factor of contraction is not taken into account. It is assumed that the skin graft at the center is too far from the periphery of the wound for the Iatter to grow in to it.

areas hea compIeteIy (mainIy due to contraction) Iong before epitherization has begun to proceed outward from the outer border of the graft. (Fig. 3.) ApparentIy the spread of the synctia1 membrane is diffIcuIt by the mechanism of ceI1 migration

the spokes of a whee1 the pseudopodia-Iike process wouId become further and further apart as their spread proceeded peripheraIward. The membrane formed by them wiI1, therefore, not remain intact unIess processes aIso spread at right angIes or tangen-

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tiaIIy to the radiaI Iines and joined up opposite portions of the outgrowing processes. It is not hard to conceive that this

FIG. 5. SmalI heaIed recurrent postphlebitic ulcer treated by circular strapping with eIastic adhesive. Note uIcer area covered with several layers of epithelium, ceIIs of which have desquamated and stuck to plaster. This is the final stage of healing when mitosis is active in the epitheIia1 Iayer which has spread over the wound.

Pr(jcess of spread

of ceIIs in a membrane in an outward direction wouId be much more difI?cuIt to accompIish than a spread inward or CentripetaIIy, in which ceI1 migration or pseudopodia1 processes would automaticaIIy cause ceIIs to be placed more and more in contact with each other as they reached nearer and nearer toward the center. When, however, a nearby edge of growing epitheIium is present, then a joining up of the two edges is probabIy effected by surface tension or by positive chemotaxis which may cause the two edges to draw or ffow together and finaIIy to form one membrane.24a This expIanation is readiIy seen also to be borne out cIinicaIIy in the case of sieve grafts. In the case of this type of graft, smaI1 isIand areas of intact skin are punched out at the donor site and Ieft behind as an integra1 part of the thigh or other part of the body as the fuIl or whoIe thickness graft of the skin is Iifted. The latter, a sheet of skin perforated with hoIes

of the Leg Iike a “sieve” is then sewed into the uIcer defect. One might suppose that the edges of the isIands of the donor site being undisturbed skin (an integra1 part of the body), wouId grow out very rapidIy and that the rate of heaIing of the isIands wouId be far more rapid than that of the hoIes of the compIeteIy Iifted or transpIanted skin. InterestingIy enough, this is not true. The perforations in the graft are usuaIIy found to be heaIed at a time when the epitheIium of the island edges has onIy spread out about 2 to 3 mm. UnIess the isIands are placed quite close, which wouId enabIe epitheIium to grow virtuaIIy inward or toward the next isIand, instead of outward for an extensive distance, heaIing, whiIe it wiI1 occur, wiII require about doubIe the time of heaIing of the perforations. Since conditions are otherwise nearIy idea1 at the donor site (good tissue, no infection) and often anything but idea1 at the recipient area (transplanted tissue, scar tissue and infection often present) we con&de that the main difference is that in the case of the donor site we have diffIcuIt conditions mechanicaIIy for heaIing to take pIace, viz., isIands far apart with edges of Iimited migration of ceIIs or size, centrifuga1 pseudopodia formation or (Iater) proliferation by mitosis, whiIe in the case of the perforations in the graft edges which are Iarge with a smaI1 area to cover, mechanical conditions are better from the Here the heaIing is ceIIuIar standpoint. centripeta1 from the start. CeII ,migration or pseudopodia formation and Iater proIiferation by ceI1 mitosis are a11 carried out under idea1 conditions. Figure 4 is diagrammatic but it gives an idea of the differences between centrifuga1 and centripeta1 spread of epitheIium in heaIing. The effect of mitosis in the fina stage of heaIing is shown in Figure 5. We have reached the same concIusion from cIose observation of smaI1 deep or “pinch” grafts. The epitheIia1 edge of skin surrounding a granuIating wound which has been covered with these grafts will grow or migrate centripetaIIy or inward at a

NEW

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No.

Douglas-UIcer

2

rate so far surpassing in velocity that of the edge of the outer grafts that we have found that it is purposeIess to pIace the Iatter closer than I cm. from this edge. On the other hand, the grafts must be pIaced cIose, viz., I~:?to 9’4of a centimeter apart at most, or the healing of the wound wiI1 proceed extremeIy sIowIy. In the Iatter case the migration of ceIIs or growth-in other words the heaIing-is centrifuga1 unti1 the epitheIium reaches another graft. At this time the rea1 beginning of centripeta1 heaIing wiI1 be attained by the formation of circles between any three or four grafts. (Fig. IB.) ShouId the grafts be pIaced free at distances apart of I to 2 cm., the sIow centrifugal phase of heaIing wiI1 consume a time which wil1 greatIy proIong healing and even make it impossibIe. It must be borne in mind that in a11 cases contraction wiI1 pIay a greater or Iess rGIe in reducing the distances between the grafts and between them and the epitheIium of the wound edge. APPLICATION CONCERNING

OF

KNOWN

WOUND

FACTS

HEALING

TO TREATMENT

If we are to appIy our knowledge of epitheIia1 heaIing in wounds to Ieg uIcers, severa indications at once seem to stand out. First, since epitheIia1 ceIIs must flow or migrate as we11 as proIiferate to cover a granuIating wound in heaIing, it foIIows that the epitheIium of the edge must be at Ieast reasonabIy heaIthy and strong in order to accompIish heaIing. If the edge is too thin or is badIy infected or irritated, we shouId expect IittIe in the way of healing. In our practice we find that an epithelia1 edge at the periphery of an uIcer may Iook very bad yet proceed to spread. In such cases the type of heaIing is weak and recurrence is the rule. In those cases in which skin has lost some of its normaI components (for exampIe, sweat and sebaceous gIands and hair foIIicIes), its strength is weakened, it is “unheaIthy” skin. In reaIity it is scarred skin and is subject to various irritations and infections.

of the Leg

American

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439

Brown, Byars and BIaiP have iIIustrated this with three photomicrographs of the edges of leg ulcers. The first shows the edge of a varicose uIcer open most of the time for twenty years. One sees “practicaIIy no epithelia1 activity either in fiIing up keratin or attempting deep invasion.” In the second, which is one of scar epitheIium adjacent to an uIcer, one sees “thin ffat epitheIium without hair, gIands or papiIIae” but with a heavy keratin Iayer indicating marked ceIIuIar activity as a response to wound stimuIus. The next photomicrograph shows how scar epitheIium, in contradistinction to the normal, may easiIy be lifted off its base by trauma or hemorrhage, thus causing re-uIceration. In simiIar photomicrographs of excised tissue forming uIcers, we have shown how the number of norma skin structures (hair foIIicIes, sweat and sebaceous gIands, etc.) becomes Iess as one approaches the actua1 epitheIia1 edge of the uIcer. I exhibited these at the Southern Medical Association meeting in 1930 in order to emphasize the necessity for radical, wide and deep excision of scar in selected cases. In order to obtain heaIing with strong and heaIthy skin, of course the ideal wouId be radica1 treatment by excision and grafting. ExcIuding this as unnecessary except in advanced cases, the indications are (a) to combat infection in the uIcer and surrounding skin edge and prevent secondary infection; (b) to provide against further injury to the base and edge of uIcer; (c) to avoid exuberant granuIation and excessive scar tissue formation; (d) to favor contraction of edges, and (e) to favor heaIthy epitheIization. Th ese points may be regarded as cIoseIy reIated indications mutuaIIy interdependent. AppIied together to ulcer treatment, they mean “steady and stabIe heaIing.” While they are cIoseIy related, ulcers differ greatIy in requirements. Thus in one uIcer infection may predominate, in another frequent injury may pIay an important r6Ie, etc. We shaI1, therefore, consider them separateIy.

440

American Journal of Surgery

DougIas-UIcer

(a) Treatment of Infection. We have already caIIed attention to the importance of diet and other genera1 measures in heaIing and consequentIy in overcoming infection. The estabIishment of infection shouId be prevented if possibIe as soon as an accident occurs by thorough shaving of the wound edges foIIowed by their steriIization and cIeansing with ether. Large abrasions which may Iead to uIceration may then be strapped with eIastic adhesive. We have obtained rapid proIiferation or migration of epitheIium by this method if the wound is shaIIow and reIativeIy cIean. There are many methods of treating uIcers after infection is estabIished in them. The chief point to keep in mind is to honestIy individuaIize each case in order to determine if possibIe the specific organism responsibIe for the infection. In streptococcus hemolyticus gangrene of the skin, cultures wiI1 reveal the organism. Its treatment has aIready been described.12 UIcer due to diphtheroid baciIIi wiI1 readiIy respond to treatment (Barber et aI.13) with autogenous vaccine and IocaI application of permyase jeIIy. Diphtheria. In a recent communication MeIchior l38 states that the appearance of granulations with Klebs-Loefher baciIIus infection was deceptive with smaI1 whitish spots sometimes minute, more often a dirty unheaIthy aspect with markedly deIayed heahng. The granuIations formed an almost smooth surface and were vioIet coIored, in pIaces grayish or yeIIow, edges He found the onIy treatment atonic. efficacious in eight to fifteen days was powdered methyIene. Graham reports that he has had two cases of empyema with the same infection. I have seen two diphtheritic uIcers of the extremity which cIeared up with IocaI and genera1 administration of antitoxin. Ulcers due to micro-aerophiIic hemoIytic streptococcus infections are to be treated by wide excision and the appIication of a suspension of zinc peroxide in water as a paste to a11parts of the wounds, especiaIIy pockets sealing the wounds, laying fine meshed

of the Leg

FEBRUARY,1939

gauze washed in the suspension over the uIcer surface and finaIIy seaIing this in with fine meshed gauze impregnated with zinc oxide ointment.13b Infections due to other anaerobes may be treated in the same way. In secondary uIceration of the Ieg foIIowing ringworm of the foot, primary attention shouId be focussed upon treating the epidermophyton infection. The troubIesome infection of uIcers from B. pyocyaneus may be controIIed, according to Brown et aI.,ll “by frequent painting with strong soIutions of the dyes (gentian violet and methyIene bIue) or by proprietary mercurials pIus the copious use of soap and They fee1 that acetic acid and water.” hydrogen peroxide are of IittIe vaIue in such infections. When none of the above organisms can be demonstrated, but onIy the usua1 pyogenie ones, any one of a number of antiseptics may be tried. These, however, in our experience shouId rareIy be considered as curative, except in the case of smaI1 uIcers, for after infection is reasonabIy taken care of the probIem of epithelization remains. Rather they shouId be regarded as preparatory for further conservative or radica1 measures. Boric Acid Packs. In most of the Iarge uIcers which we see for the first time, after shaving and cIeansing with soap and water we appIy steriIe dressings covered with a layer of cehophane and gauze bandage over aI1. CarreI tubes are incorporated in this between the skin and the gauze. Irrigations are then done at four hour intervaIs with saturated soIution of boracic acid whiIe the patient is awake. A warm water bottIe at about 105’ F. is kept over the uIcer site for as Iong at a time as convenient. The CarreI tubes may be omitted and moistening of the dressing done with a medicine dropper or syringe through one or more smaI1 hoIes cut in the ceIIophane. Normal saIine may be substituted for the boric. GrossIy, uIcers and surrounding tissues have cIeaned up rapidIy under this routine. In stil1 dirtier and more malodorous cases the CarreI-Dakin technique

NEW SERIES VOL. XLIII,

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DougIas-UIcer

is carried out. EspeciaIIy is this routine foIIowed if operation is contempIated. AzochIoramide preparations or other antiseptics which aid in dissoIving necrotic tissue may be substituted if desired. A singIe cautious appIication of 95 per cent pheno1 to a dirty, necrotic, granulating uIcer base, folIowed almost immediately by aIcoho1, wiI1 often cIean up the necrotic base so much that it wiI1 appear red at the next visit. Care must be taken not to spiI1 the carbolic on the skin. Anderson,” in a very recent quantihas shown that the few tative study, antiseptics which decreased the number of surface organisms in wound heaIing at a norma rate, were ineffective in the presence of tissue necrosis and exerted no beneficia1 effect on the rate of wound repair. He found, however, no contraindication to the use of usua1 antiseptics since no evidence was obtained to show that their chemica1 action on wound tissue ceIIs was excessive. Evidence has recentIy been presented5 to show that Dakin’s soIution of hypochIorite, whiIe antiseptic, may be miIdIy toxic and sIightIy retard heaIing. Gentian violet was first advocated for the treatment of joint infections, then Iater for burns by Firor and AIdrich. I have used it with good resuIts to provide an antiseptic membrane in burns, where a I per cent aqueous soIution was empIoyed. A series of three articIes has appeared in the New England Journal of Medicine, advocating its use for uIcers of the Ieg.26 In the Iatest of these, a preIiminary report, Thurmon and Chaimon advise the use of 2 per cent aqueous soIution. It is appIied three times a day for two to three days when a hard crust wouId have formed. The crust is dried in the air and no bandage applied. Patients were kept ambuIatory and crusts renewed onIy if Ioose. They describe fifteen uIcers treated by this method in which heaIing was very prompt and scarring minimaI. Maggot Therapy. We shaI1 mention onIy in passing the Iarge voIume of work

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441

which has been done by Baer2’ and many others on the steriIization of wounds, especiaIIy OsteomyeIitis wounds, with steriIe maggots. In its pIace it gives exceIIent resuIts, but since it requires a specia1 set up for its use and does not aIIow ambuIatory treatment, it is of IittIe vaIue in Ieg uIcers. Cod Liver Oil Therapy. The beneficia1 effects of cod Iiver oi1 in chronic uIcers have been described and the Iiterature summarized by Epstein2* in a series of cases 31 in number. In part of them he used the oiI with equa1 parts of anhydrous IanoIin and in the other the anhydrous IanoIin aIone. There was a very smaI1 difference in the two series in favor of the cod Iiver oil preparation. The action of cod Iiver oi1 and other such preparations is thought to be due to its vitamin content. To vitamin D is attributed mainIy the stimuIation of epitheIia1 proliferation, to D and A together the rendering of bacteria in wounds non-toxic and the stimuIation of the heaIing process. Epstein feeIs, and we agree, that “cod Iiver oil aIone does not constitute sufficient treatment,” and that it shouId not suppIant therapy aimed at basic etioIogic factors. Cod Liver Oil and Allantoin Therapy. RecentIy Salzman and GoIdstein2g have described the treatment of a few cases of chronic uIceration with the daiIy appIication of a combination of cod Iiver oi1 and aIIantoin extracted from maggots, which they term codaIItoin. The two are combined in proportions of 45 per cent cod Iiver oi1 and 2 per cent aIIantoin with pheno1 0.5 per cent and prepared in a IanoIin base. AIIantoin is so-caIIed because it is a characteristic component of the fetal aIIantoic secretion. While their resuIts appear to be convincing and very promising, one is Ieft to wonder in a compound preparation how much of the effect is due to the weak phenoI. They warn against using pheno1 in Iarge uIcers on account of the danger of absorption of too much of it. So often the presence of Iive maggots is a source of discomfort and embarrassment

442

American Journal of Surgery

Douglas-Ulcer

to the patient that we agree with these writers in feehng that if ahantoin is the substance IargeIy responsibIe for their beneficia1 effects, it shouId be used in their pIace. This aIso permits the treatment to be ambulatory. (b) Provision against Further Injury to Ulcer. It has Iong been our beIief that uIcers and other wounds shouId be regarded as fractures of the skin and Iikened to fractures of bones. If the same principIes of rest, protection and Iater massage and gradua1 Ieaving off of pressure and graded resumption of the standing posture as emphasized by OwenslO be carried out, heaIing, other factors being equal, wiI1 be more rapid and stable. This Iatter procedure wiI1 pay dividends especiaIIy in the case of heaIing over the knee or ankIe joints and particuIarIy in the case of skin grafts. No surgeon wouId think of treating a fracture of a bone without spIinting and putting the fragments at rest to accompIish union, yet uIcers are often treated by methods which favor further injury by bIows, drying, rubbing of gauze on epitheIia1 edges, sticking of gauze to granuIations and secondary infection. The Orr treatment of osteomyeIitis30 by drainage and rest in a cast aIone emphasizes these points. (c) Avoidance of Exuberant Granulations and Scarring. If steriIity can be rapidIy attained, granuIations wiI1 not grow exuberantIy to form “proud fIesh.” In generaI, the formation of a membrane, as in the gentian vioIet or tannic acid treatment, also wiI1 prevent this from occurring. In case exuberant granulations occur, strapping with eIastic adhesive (described beIow) wiI1 Aatten them down to the IeveI of the epitheIium in a few dressings. They may aIso be cauterized with silver nitrate stick, a procedure which we fee1 shouId be rarely practiced since the better methods described are’ avaiIabIe. Since the Aattening down of granuIations to the epithelial IeveI of the ulcer edge enabIes the Iatter to grow more smoothIy, an uIcer aIIowed to heal under the eIastic adhesive wiI1 have Iess tendency to scarring and keIoid formation.

of the Leg The exception to this is found in very dirty uIcers. Here more scar wiI1 form if the secretions are heId in. Proper drainage must be afforded in these by fenestration of the eIastic adhesive. (Fig. IO.) (d) Stimulation of Normal Contraction. Carrel, DeheIIy, Depage, Du Nouy, and others have shown the importance of contraction of the uIcer edges during cicatrization as a factor which reduces the size of wound to be covered with epithelium. According to Arey, contraction pIays a tremendous part in the heaIing of wounds Iarger than 15 mm. in diameter. My studies5 have shown quantitativeIy through experiments on dogs and humans how traction with eIastic adhesive may reduce the size of wounds. This may, of course, be accompIished Iess sureIy by adhesive skin straps which are graduaIIy Iaced cIoser and cIoser together. This Iatter method is Iess efficient since it is very diffIcuIt to maintain adherence of the straps for any Iength of time. When eIastic adhesive is used on edematous Iegs, it must be made tighter and tighter as the sweIIing subsides. The shrinkage of the leg wiI1 aIso reduce the size of the uIcer in proportion. Over joints no more than the usua1 normal contraction must be produced by strapping, or contracture and Iimitation of function may result. (e) Promotion of Rapid and Healthy Epithelization. It is our opinion that if measures are taken to accompIish (a) to (d), incIusive, epitheIization wiI1 spontaneousIy proceed with IittIe heIp. We have mentioned IocaI vitamin appIication through cod Iiver oi1 preparations as being suggested as a means of stimulating epitheIization. In generaI, we prefer this if necessary to other chemicals like scarIet red as possibly giving a more nearIy norma epitheIia1 spread and therefore more stabIe healing. Strapping. Morison and Car1 Beck many years ago strapped the edges of ulcers in various manners with ordinary flamed zinc oxide adhesive strips. In 1932 the writer’ pubIished a report of a case of Ieg uIcer treated by circuIar strapping with

NEW SERIES

VOL.

XLIII,

No. ?.

Douglas-UIcer

eIastic adhesive in which the effect of on epithehzation was demonpressure strated. Here it was found on the removal of the bandage, the turns of which had been appIied unevenIy, that where “the turns of the bandage had pressed firmly against the tissues, the ulcers were heaIed. On the contrary, wherever the turns had been too Ioose, the granuIations were exuberant had not grown over.” and epithehum (Fig. 6.) This seems to demonstrate cIearIy the raIe of pressure in hoIding down granuIation tissue thus favoring epitheIization. Twyman31 expressed this view in an article in which he showed a picture of a bridge of epitheIium running across the center of a wound strapped with a narrow The epitheIia1 bridge strip of adhesive. corresponded in position and approximateIy in width to the strip of adhesive. He expresses the beIief that epitheIium proIiferates readiIy when it is subjected to a degree of pressure which restrains the growth of granuIations. Our further experience with the eIastic form of the pIaster abundantly demonstrates its vaIue in hoIding down granuIations to the IeveI of the skin, thus favoring epitheIization. No matter what antiseptic is used, if the smear and cuIture from a wound demonstrate a reduction in the number of organisms, heaIing wiI1 be more rapid. C arre1 and others have shown that the heaIing rate is retarded by infection. It must not be overIooked that the advancement of epithelium over the ulcer is itself a powerfu1 weapon in fighting infection. We see this fact demonstrated in the signa effect which pinch grafting has on a moderately infected granuIating uIcer. The spread of epitheIium on the wound shouId, therefore, be encouraged in every possibIe way. The spreading epithelial edge should be protected and kept on the same pIane as the granulations ahead of it in the ulcer base. No matter whether one beIieves in the spread of epitheIium by mitosis or by ceI1 movement (migration), it must be admitted

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American Journal of Surgery

443

that the membrane shouId be protected in order to insure rapid and stabIe heaIing. This brief review of the means at our

FIT,. 6. Effect of pressure on heaIing process. SeveraI ulcers were transected by a pressure crease. Portions of the ulcers where pressure was greatest (b,b) were found to be heaIed. Portions where plaster was Ioose found to be stiI1 gramdating (a,a).

disposa1 for treating uIcers brings us to the question-Is there a method of choice? The answer we beIieve is that each patient and each uIcer must be individuaIized. Since there are many underIying causes as we11 as many IocaI causes of uIceration, each case must be studied individuaIIy and the proper method chosen for it. A IittIe more than three years ago I published two articIes,“*’ giving results of studies on the effect of eIastic adhesive as a Iocal method of treatment upon a Iarge series of Ieg uIcers extending from January, rg3 I through June, 1934. After cIearing up underIying genera1 and IocaI causes of uIceration and treating I I per cent by radicaI operation, a11 but 3.3 per cent heaIed and only 4.4 per cent recurred. I presented evidence which demonstrated that when this material is properIy appIied, uIcers, even very oId ones, wiI1 heaI in genera1 at a rate more rapid than the idea1 rate of heaIing for recent wounds kept steriIe by diIute SOIU-

444

American

Douglas-UIcer

Journal of Surgery

tion of sodium hypochlorite as computed by CarreI, Hartman and du Nouy. After two additiona years in which the actuaI number of cases treated has materiaIIy increased, our resuIts are as satisfactory as ever and I feel satisfied that this materia1 is now beginning to occupy the pIace in the armamentarium of the fieId which I predicted it wouId and which it spIendidIy merits. The few persons in whose cases heaIing with the pIaster has not occurred have generaIIy been those in whom one or another of the indications for the radica1 measures described beIow was present, but who for economic or other reasons have refused operation. The properties to which I ascribed the effect of eIastic adhesive were that it is persistperfectly adhesive, semipermeable, ently elastic, bactericidal in eject, and hygienic. TabIe I shows the typica shortenTABLE SHORTENING

OF

HEALING ELASTIC

Totals. _____

.

.

12

15.0

65

10

41.5 17.5

51 38

7

-.

Averages.. --__----

* After Douglas,

ACCOMPLISHED

q 9.6 years

BY

ADHESIVE*

kE::~‘::.‘::::

Ulcer 3..

I TIME

--

--

74.0 24.7

ems.

in Surg., Gynec. @ Ok.,

$13.56

‘54 51.3

days

Oct.,

$ 4.52

1935.

ing of heaIing time which it accompIishes with great reguIarity. Experimental and cIinica1 evidence to prove its modes of IocaI action was presented in a second articIe. Some of these which were proved were that it provides moist heaIing, thus protecting antibodies from drying, is semipermeabIe and does not imprison secretions but obIiterates dead space, prevents recontamination or reinfection of the wound, favors epitheIization and contraction be-

of the Leg cause of its “ gIove-like” action and compression of exuberant granuIation tissue, and lastly that it protects growing epitheIium spIints and prevents distortion of the uIcer edges during movement and compresses the veins. A gIance at the indications or requirements (a) through (e) which we regard as necessary to obtain heaIing with strong and heaIthy skin wiI1 show that eIastic adhesive comes nearer to meeting a11 of them than any singIe material. As we have stated before, “it appears to be an effective combination of four methods previousIy empIoyed. . . . It combines, in one bandage, the protective and supportive quaIities of an Unna’s paste boot, the eIastic qualities of a rubber stocking, the porous quaIities of a gauze dressing, the non-sIipping fixative qualities of adhesive.” It is aIso very comfortable and economica1. I wish again to emphasize one point. Its vaIue in combating infection is due to its bactericida1 action. It is not essentiaIIy antiseptic. Its vaIue in comparison to routine warm soaks of boric is pIainly shown in Figure IO. This case was one of ecthyma or muItipIe uIceration of the skin resembling impetigo but probably due to a mixture of streptococcus and staphyIococcus, in which, in more than twenty cases strapping with a postage stamp size strip of eIastic adhesive left on for a week at a time has been foIIowed by IOO per cent heaIing with immediate cessation of the formation of new lesions. An articIe is in preparation reporting these cases in more detai1. The effect is undoubtedIy due to the IocaI action of antibodies within the confines of the uIcer pIus the fact that the infectious materia1 is not aIIowed to spread over the skin and contaminate new hair foIIicIes. FuII detaiIs of technique for using elastic adhesive may be found in a previous articIe.6 Here we mereIy reiterate a few points and more particuIarIy add a few new ones. In order to obtain best resuIts it is extremeIy important to folIow detaiIs of technique very exactly.

NEW SERIES VOL. XLIII,

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DougIas-UIcer

Preliminary Local Treatment of Ulcer. In case of marked suppuration the ulcer and surrounding skin is covered with copious gauze dressing which in turn is

FIG. 7. AppIication of pad cut to shape of depression on smaII, deep ulcers.

covered with ceIIophane over aI1. The Iatter is perforated in a few pIaces and especiaIIy over the uIcer irrigated with warm saturated boric acid or normaI saIine at four hour intervaIs. A warm water bottIe, as warm as can be comfortabIy borne, is appIied. The packs are changed every forty-eight hours unti1 gross cIeansing of the uIcer is accompIished. Technique of Applying Elastic Adhesive. CIeaning and shaving precedes appIication of eIastic adhesive. (Fig. 8.) With the heeI on the corner of a chair, a figure 8 is pIaced at the ankIe and one proceeds upward with considerabIe pressure, overIapping one-haIf to two-thirds the width of the pIaster to the pateIIa.* The bandage is changed at intervaIs of one week (first time) and two weeks thereafter. Over smaI1 deep uIcers the first turn is made Ioose above, or a smaI1 piece of pIaster is fitted into, the uIcer crater. Cotton or gauze is cut to fit in the dead space. (Fig. 7.) The bandage is then appiied as usua1. *We are constantIy asked how tightly the bandage should be appIied. The main difficulty arises from appIying it too IooseIy; it is difIicuIt to have it too tight except in arterioscIerosis. However, the turns must be very evenly applied so that there are no pressure ridges. (Fig. 6.) At each successive application the spiral edges of each turn of plaster are turned at a different Ieve in order to avoid such ridges.

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American

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At current prices we have shown that average cost of the dressing is Iess than one-haIf that of other dressings commonIy used for ulcers.

FIG. 8. Method of appIying plaster. HeeI’ eievated on corner of chair. First turn over forming Second turn dorsum of foot. figure eight around ankle.

Treatment of Ulcers in W’bicb Exudation If Iocal treatment with soaks Is Marked. is not effectua1 the threads of the elastopIast may be separated by insertion of scissor points a miIIimeter or two through the pIaster directIy over the proposed area of contact with the uIcer. Better stilI in such cases we make a few sIits with scissors (not over four or five) in the direction of the stretch of the pIaster with the latter foIded so that the adhesive side is out. This we term “fenestrated eIastic adhesive.” It provides exceIIent drainage, the sIits opening up just enough to reIease the exudate as it forms, the puI1 of the pIaster then cIosing the edges of the sIits together again. An uIcer so treated is shown in Figure g. I have used a biIatera1 or two way stretch erastic adhesive which I have devised and named equipIast on uIcers which have been especiaIIy refractory to treatment. AppIications of this, while more Iimited, wiIl be reported as soon as a suffIcientIy Iarge number of cases is treated. This is put on, stretched equally in every direction and covered with an eIastic cloth roIIer bandage. Treatment by Antiseptics under Plaster or Incorporated in Adhesive Coating. In very

446

DougIas-Ulcer

American Journal of Surgery

and persistent infections refra ctive of uIcer s, Dr. RaIph Larsen32 of our departmen1t has suggested and empIoyed ammoni-

of the Leg of wounds under this treatment and th lose with eIastic adhesive aIone. We see no reason why, since zinc peroxide pl iste

FIG. g. AppIication of fenestrated elastic adhesive to ulcer with copious drainage sIits cut with sharp scissors Iengthwise and folded with adhesive side toward bIades.

A

c

B

FIG. IO. E. W. BiIateraI strapping on bacteria. acid compresses, was hea1. Larger uIcer on with eIastic adhesive, (From DougIas, A&.

D

muItipIe ukers of Iegs due to ecthyma. Effect of elastic adhesive UIcer on right Ieg (A), treated with moist, warm, saturated boracic not steriIe for nineteen days and required thirt.y-nine days to upper Ieft Ieg (B), treated o&y by strapping at wkekIy intervals was steriIe in nine davs and healed (D) in twentv-three davs.’ kg., 32: 756, 1936.)”

ated mercury ointment 3 per cent as a Iight coating for the uIcer directIy under the e Iastic adhesive. This seems to offer much hope. At present he and I are makil lg comparative studies by tracings

shouId not be used in the same mann er. The makers of a certain EngIish eIas ;tic adhesive have coated the cIoth with an emuIsion mixed with ichthyo1 for use in :rs. certain cases of eczema surrounding UICC

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We have ordered eIastic adhesive for tria1 in which the em&ion is mixed with ammoniated mercury and other substances. ResuIts have been so good with eIastic adhesive strapping aIone that we have been reticent about adding any drug to it unIess it can be definiteIy proved to benefit the heaIing process. Materials Used. In our work, both experimenta and cIinica1, we have used principaIIy two forms of pIaster, one made in the United States (eIastopIast), one in EngIand (tensopIast). Other simiIar pIasters made by good companies are being tried. a Local Strapping. In smaI1 ulcers postage-stamp-shaped strip of eIastic adhesive or a circuIar band or two around the Ieg wiI1 suffice. This is especiaIIy true where no veins are to be supported and in those cases in which there is IittIe exudation. In a11 the corners and edges shouId be bound down with ordinary adhesive strips. Contraindications. The contraindications to the use of eIastic adhesive are obvious-acute spreading infections where drainage is required, gangrene of the skin from arterioscIerosis and diabetes, projecting bony prominences such as a knuckIe of bone in fractures, and severe eczema sensitive to zinc oxide. Ordinary eczema is no contraindication to its use. Treatment by Transparent Rubber or Composition Jackets. This method, advocated by me in 1936~~ for wounds of the extremities, is now being perfected. By its use the very atmosphere surrounding the wound, i.e., temperature, humidity, soIution, or gaseous content, positive or negative pressure, and Iight conditions may be varied at wiI1 whiIe the wound is studied through the jacket under the naked eye and the tota exudate coIIected for study. Exact pressure may be appIied to skin grafts and no other dressing appIied. Among the successfu1 cases reported have been a graft of the popIitea1 space and four fuI1 thickness grafts of the hand in which takes were recorded with no other dressing.34 ResuIts are very promising but of course the method requires hospitaIization for use on uIcers and grafts of the Iower

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extremity. ResuIts with it have been reported in a recent articIe.33 Indications for Operation-Radical Treat-

1 I. Squamous ceI1 epitheIioma (MarjoIin’s uIcer) developing in scar thirtyfive years after burn. Onset of excruciating pain marked beginning of malignant change. Wide excision and sieve and smaII deep grafting resulted in heaIing. Recurrence three years Iater with amputation.

FIG.

ment. In a certain few cases, probabIy due to the fact that the protection to the wound with eIastic adhesive is very compIete, heaIing toward the end wiI1 be sIower even than the norma retardation on idea1 curves indicates it shouId be. We have made it a ruIe not to discontinue the pIaster as Iong as the tracing of the uIcer edge has shown the sIightest degree of reduction in size. At times alternation of the eIastopIast with dry dressings or moist warm boric acid soaks wiI1 add a stimuIus to which the wound edges wiI1 rapidIy respond.

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Ir:L eIephantiasis the healing has been SIOWbut progressive up to a year. Patience is re quired in these cases.

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repeatedIy recurred with minor injl .u-y. as “This Iist is not to be regarded exhaustive.”

FIG. 12. A, depthA of excision necessary

for cure ofyarge varicose uIcer. B, Iower haIF of ulcer heaIed after application of sieve graft. Upper and IateraI third heaIing after same treatment. A pedicle flap has been used to cover tibia1 crest. c, heaIed condition severa months Iater.

As we have stated before, “No absoIute rules shouId govern individua1 cases, our experience wouId seem to indicate that, in the foIIowing types of uIcers, conservative measures shouId yield at once to radica1 surgery through which aIone permanent cure wiI1 be reasonabIy assured: “ I. UIcers due to neopIasm. “2. UIcers in connection with eIephantiasis. “3. Very Iarge uIcers surrounded and underIaid by avascuIar scar tissue. “4. UIcers in which conservative treatment wouId invoIve too great a time Ioss and too great a risk of further disabiIity on account of recurrence (miIitary and industrial group). “5. UIcers which have faiIed to hea with conservative measures in tweIve months. “6. UIcers in the region of joints which wouId hea with scar contractures. “7. UIcers which after heaIing have SpontaneousIy recurred or which have

TECHNIQUE

OF

RADICAL

TREATMENT

By this term in the case of Ieg uIcers we impIy two operations, each of which as a ruIe shouId be performed in the hospita1. We have not changed our opinion concerning this point though in rare cases minor grafting may be done on ambuIatory cases in the out-patient department. RadicaI methods shouId incIude three phases of treatment.3~4~6~6 I. Preliminary Attention to General 07 Underlying Causes of Ulceration. During the period consumed by these measures the patient’s genera1 heaIth is Iooked after, a proper diet prescribed and such conditions as obesity, anemia and nutritiona edema are attended to. By the use IocaIIy of the CarreI-Dakin technique or some other empIoying chIorine antiseptic, the uIcerated area is freed of necrotic tissue and the bacteria1 count is reduced to a point indicating “surgica1 steriIity.” 2. Excision of All Scar Tissue. The ulcer wiI1 promptIy recur unless this is

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properly done. The dkbridement is usuaIIy performed under a genera1 anesthetic. Briefly the skin incision is carried peripheraIIy as wideIy as any evidence of scarring is found. The entire uIcer base is then attacked by turning the bIade of the scaIpe1 horizontaIIy and undermining it at the IeveI of the deep fascia. No cicatricia1 tissue must be Ieft. (Fig. 12.) Tendons may be exposed but shouId not be divided unIess Iengthening is necessary for contracture. BIeeding is to be controIIed by heat and pressure aIthough a few fine catgut ties are permissibIe. The skin is protected by vaseIine gauze strips overIapping the wound edges onIy 2 or 3 mm. Carrel tubes are pIaced evenIv over the wound in direct contact with- its surface. A thin Iayer of fine meshed gauze is placed entireIy over the tubes and wound and fluffy gauze added in many Iayers to compIete the dressing. Irrigations with Dakin’s soIution or other chIorine antiseptic are begun twenty-four hours later. The purposeof this second phase is dkbridement of scar and mechanica1 cIeansing, which favor better circuIation, through Iarger vessels. When-excision is carried as deepIy as it shouId be, it resuIts in an anastomosis of the superficia1 and deep Iymphatic vesseIs at the edges, which is aIso high17 beneficial. Many uIcers invoIve a consrderabIe portion of the Ieg. It is therefore better as a ruIe to divide the operation into two or three stages. One of our patients was cured after transpIantation of xog square inches of whoIe thickness skin to two Iegs. This was done in four stages by overIapping the successive grafting and excision operations respectiveIy. 3. The Repair of the Defect. The operation to suppIy skin or skin and subcutaneous tissue to the defect shouId usuaIIy be deIayed for four or five days. One important reason for this is that the products of trauma from the excision wiI1 have been absorbed or cIeared from the surface; the second, as pointed out by CarreI and DeheIIy, is that the deep cicatrix may contain encysted organisms, which may infect the surface of the wound at the time of excision when tissues are damaged and bIood

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clot is present to form an idea1 cukure We are aware that certain medium. surgeons advocate immediate grafting after excision of ulcers, whiIe others go to the other extreme of waiting as Iong as three or four weeks. We fee1 that the Iatter is usuaIIy unnecessary. The former, for the reasons given,6 is not safe, except in excision of heaIed scars, and not aIways even in these. Immediate grafting in Iarge wounds may proIong the operation to an undesirabIe length. It is usuaIIy advantageous not to disturb the Iower Iayers of gauze in contact with the wound unti1 the time of grafting. METHODS

OF CLOSURE

If a sharp tibia1 crest (a) Pedicle Flaps. is exposed without periosteum, holes shouId be bored in the bone to aIIow granuIations to cover its surface. This is a method practiced on the skuI1 in the case of scaIped persons by Vance in Tennessee in the Indian wars of Andrew Jackson’s time. A pedicIe flap of skin and subcutaneous tissue may then be swung from one of the margins of the wound into it (the ancient Indian method). This maneuver shifts tissue to a better position where it is more needed but does not gain tissue. It usualIy has to be combined with skin grafting. Figure 12 shows such a case. Deep defects over joints may aIso need covering with a flap. The use of pedicIe flaps from the opposite extremity (ItaIian method) has a very Iimited application. The reasons for this are frequentIy the presence of disease on the other extremity (varicose veins), irksomeness of holding the two Iegs in apposition, and extra time consumed. (6) Skin Grafts. For the detaiIed technique empIoyed in the use of the various kinds of skin grafts, reference is made to specia1 articIes and texts on the subject. Varieties. I. Thin Grafts.-OIIier Thiersch. These consist of thin Iarge sheets of skin, usuaIIy cut with a razor, the skin being held taut between the edges of two boards. This graft often faiIs from the standpoint of resisting infection and of preventing contracture.

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2. Intermediate Thickness Grafts. Through the use of an ingenious vacuum cutting chamber and a special Iong, thinbIaded knife, BIair and Brown” have shown that it is possibIe to split the skin and to vary the thickness of skin grafts of the Thiersch variety at wiI1 so as to in&de more or Iess of the derma, producing, as they term it, a thin or thick “spIit” graft, which respectiveIy wiI1 incIude approximateIy one-third to three-fourths of the thickness of the derma. This is an exceIIent graft and has many important and usefu1 appIications. Its successfu1 use in grafting Ieg ulcers has been reported by Brown, Byars and BIair. l1 They used thick split grafts. The spIit graft requires a certain degree of ski11 and specia1 apparatus. The thinner variety wiI1 aIIow of a certain degree of contraction. The donor area heaIs without further grafting and may be used for further cutting of grafts. 3. Grafts of WhoIe Thickness. (a) SmaII deep or “pinch” grafts. Davis has pointed out the great usefuIness of smaI1 deep grafts (popuIarIy caIIed “pinch” grafts) for covering uIcers in hospita1 and in seIected ambuIatory cases. Reverdin, whose very minute grafts have faIIen into disuse, is responsibIe for deveIoping the method of cutting these grafts. They are cut by Iifting the skin up Iike a tent with the point of a sewing needIe and cutting smaI1 circuIar pieces from under it with a scaIpe1. These grafts often take in spite of a fairIy marked degree of infection. They give a heaIing which in appearance is Iike a mosaic but fairIy resistant. Another disadvantage is that they wiI1 fai1 to prevent contracture, a point important in the region of joints. (b) WhoIe thickness or WoIfe Krause Grafts are cut in any size by pattern to cover any defect. They consist of the fuII thickness of the skin down to but not in&ding the underIying fat. The donor area must be closed by suture or by further grafting. Like “ spIit ” grafts they must be sutured in place and pressure maintained over their surface for about three weeks after operation with a marine sponge,

of the Leg inffatabIe rubber tampon (Smith), anthraxtested Iamb’s WOOI, stiI1 attached to the Iamb’s skin, a materia1 which I suggested two years ago for this purpose and have found to be very vaIuabIe. (I) The “sieve” or perforated graft, a modification in which isIands of skin are punched out with a smaI1 round cupped stee1 die before cutting the fuI1 thickness of skin, was described by the writer in rg3o for use in Iarge defects. Since then exceIIent reports of resuIts have been received from many cIinics and many individuaIs. Some surgeons have reported its successfu1 use in ambuIatory cases. At present a report on a great many cases treated by this form of graft is in preparation. It has been demonstrated, on account of its drainage at every point throughout its extent due to its uniform perforations, to possess a degree of safety in the face of infection, which pIaces it in a category with smaI1 deep grafts. On the other hand, the type of heaIing obtained through its fuI1 thickness skin is stabIe and prevents contracture. The donor site wiI1 hea spontaneously in IOO per cent of cases without further attention except for a few dressings. We have here a sharp contrast to the WoIfeKrause graft which requires grafting of the donor area. Other techniques of skin grafting, such as the burying of “pinch” grafts or strips of skin by pushing or puIIing them into the granuIations have a Iimited use in uIcer surgery. They may be appIicabIe to certain cases but the advances recentIy attained through other methods of skin grafting have made these appear to have rather limited vaIue. The type of healing obtained in Ieg uIcers by the use of sieve grafts has proved over a period of years to leave IittIe to be desired in our cases. Because of ski11 or experience a surgeon may obtain better resuIts through the use of one kind of graft or another. This is entireIy permissibIe, within limits. He however, that there shouId not forget, are certain indications, such as safety, stabiIity of heaIing, and prevention of

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contracture, which must be folIowed to obtain the greatest measure of success. No one method wiI1 suit a11 cases. The effort shouId be made to individuaIize each patient and to choose the proper method of grafting for each. I fee1 very certain that “whoIe thickness skin ” grafting or a skin graft so thick that it deserves the name shouId be used without exception on an extremity over a knee or ankIe joint. (See Fig. I.) OnIy by so doing wiI1 contracture and consequent Ioss or Iimitation of function be avoided. CONCLUSIONS

UIcer of the leg, except in extremeIy advanced cases, is curabIe with IittIe Ioss of function and few recurrences through an individuaIization of the particuIar case in hand. Cure may be accompIished in a vast majority of cases by attention to underIying causes of uIceration, and by empIoying the IocaI conservative methods, experimenta and cIinica1 evidence for the vaIue of which is presented. The remaining smal1 percentage of cases may aImost a11 be cured by excision of the uIcer foIIowed by skin grafting. REFERENCES I. LERICHE, R., FONTAINE, R. and MAITRE, R. Extensive results of the treatment of leg uIcers by combination of periarteria1 sympathectomy and skin graft. J. de hr., 45: 44, 1935. 2. WRIGHT, A. DICKSON. Brit. M. J., p. 906, Dec. 13, 1930. 3. DOUGLAS, B. Practitioner’s Library, George Blumer, Vol. IV. Chant. I. D. ADnIeton. New York. 4. DOUGLAS, B. The radilal repair oi large skin defects with particuIar reference to leg ulcers. Smith, M. J., 24: 53, 1931. 5. DOUGLAS, B. The sieve graft-a stable transptant for covering skin defects. Surg., Gynec. CP Obst., 50: 1018, 1930. 6. DOUGLAS, B. Conservative and radical measures for treatment of uIcer of the leg. Part I. A study of techniques, indications and resuIts. Surg., G_vnec. @ Obst., 61: 458, 1935. 7. DOUGLAS, B. Conservative and radica1 measures for treatment of uIcer of the leg. Part II. A critica study of heaIing in experimenta and human wounds under eIastic adhesive plaster. Arch. Surg., 32: 756, 1936. 8. BOYD, W. SurgicaI Pathology. PhiIadeIphia, 1925. W. B. Saunders Co.

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g. GOODMAN, H. Ulcer of the Ieg. Arch. Dermat. ti Sypb., 6: 179, 1922. IO. OWENS, N. Varicose ulcers of the leg. New Orleans M. elpS. J., 89: 484. I I. BROWN. J. B.. BYARS. L. T.. and BLAIR. V. P. Repair of ;Iceratio& of the lower extremity. Surg., Gynec. @ Obst., 63: 33 I, 1936. I 2. MELENEY, F. L. HemoIytic streptococcus gangrene. Arch. Surg., 9: 317, 1924. 13. BARBER, H. W., GJUSEPPI, P. L., and KNOTT, F. A. Brit. J. Dermat. &+Sypb., 49: 360, 1937. 13a. MELCHIOR. Yearbook of Genera1 Surgery, 1938. _ Abst. from Presse mkd., 45: 1668, ,937: _ I 16. MELE~EY. F. L. Zinc oeroxide in the treatment of micro-aerophilic and anaerobic infections. Ann. Surg., 101: 997, 1935. 14. WHITE, C. J. The treatment of chronic Ieg uIcers. M. Clin. Nortb America, 21: 241, 1937. 15. OCHSNER, A., and GARSIDE, E. Chronic leg uIcers. Texas State J. Med., 25: 587, 1930. Chronic cutaneous ulceration of the Iower extremities. M. c~ S. J., 84: 594, 1932. 16. AREY, L. B. m’ound healing. Pbysiol. Rev., 16: 327, I 936. 17. ANDERSON, D. P. The problem of wound heaIing. Ann. Surg., 108: 918, 1938. 18. THOMPSON, W. D., RAVDIN, I. S., and FRANK, I. L. Arch. Surg., 36: 500, 1938. Quoted by Anderson.” 19. SAITTA, S. Scritti biol., 4 and 5, Ig2g-1930. Quoted by Arey.lB 20. LANMAN, T. H., and INGALLS, T. H. Ann. Surg., 105: 616, 1937. 21. HORN, Z., and SANDOR, S. Deutscb. med. Wcbnscbr., 60: 1018, 1934. 22. SCHNEIDER, A., and STRAATEN, T. Arch. f. klin. Cbir., rqg: 774, 1928. 23. YOUMANS, J. B. Endemic nutritiona edema in Tennessee. Soutb. M. J., vo1. 26, Aug. 1933. 24. LOEB, AREY, MARCHAND and WERNER. Quoted by Arey.16 24a. GOODPASTURE,E. W., DougIas, B., and Anderson, K. J. Exper. Med., 68: 891, 1938. 25. MEIXHIOR. Diphtheria in granuIating wounds. Presse mkd., 45: 1668, 1937. 26. THURMOX, F. M., and CHAIMON, H. Gentian violet treatment of leg uIcers. New England J. Med., 216: 11, 1937. 27. BAER, W. S. The treatment of chronic OsteomyeIitis with the maggot (larva of the bIow Ry). J. Bone u Joint Surg., 13: 438, 1931. 28. EPSTEIN, E. Local appIication of cod liver oil in skin ulcerations. Am. J. Surg., 36: 472, 1937. 29. SALZMANN,H. A., and GOLDSTEIN,L. Z. The treatment of suppurative cutaneous wounds and ulcerations with cod Iiver oiI and allantoin. Am. J. Surg., 40: 529, 1938. 30. ORR, H. W. Surg., Gynec. ti Obst., 45: 446, 1927. 31. TWYMAN, F. D. J. Missouri M. A., Ig: 257, 1922. 32. LARSEN, R. Personal communication. 33. DOUGLAS, B. The pneumatic jacket system of treating extensive wounds. J. Tennessee State M. A., ApriI, 1936, p. 160. 34. DOUGLAS, B. Treatment of everyday wounds. South. M. J., in press. L