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Treatment of granulating wounds with delayed healing
TREATMENT OF GRANULATING WOUNDS WITH DELAYED HEALING* NELSON W. NEW
CORNELL,
M.D.
YORK
T
HE stages of repair in a wound which 2. Irritation by rough, unsuitabIe dressheals by granuIation tissue are as ings, or irritating chemicaI agents which foIIows : may be used in the dressing. I. An abundant exudation of smaI1 3. UnheaIthy or devitaIized condition of round ceIIs, whose function is to remove patient’s tissues, as in badly bruised or dead or damaged tissues, and aIso to break Iacerated skin, or in Iocations where there up, disintegrate, and finaIIy absorb any is persistent venous congestion, which bIood cIot . prevents access of heaIthy bIood. An 2. The invasion of the wounded area exampIe of the Iatter is we11 demonstrated by fibrobIasts from the tissues composing by varicose uIcers. the parts. 4. Constitutiona disease, such as 3. VascuIarization by protapIasmic buds Bright’s disease, diabetes, syphiIis, scurvy growing out from the capiIIaries. These or aIcohoIism, severe anemia. soon become canalized and Iined with 3. Infection. endotheIia1 ceIIs. The capiIIary Ioops thus 6. Foreign bodies. formed give the granular appearance to The treatment of wounds which wiII the deveIoping tissue. not hea due to the formation of granula4. Cicatrization and epitheIization: In tion tissue is: this stage the fibrobIasts become spindIeI. ConstitutionaI: in which any severe constitutiona disease is sought for and shaped with coIIagenous materia1 around treated accordingIy. In diabetes, for examthem. This gives to the wound contractiIe properties which tend to make the wound pie, diet and the proper administration of smaIIer and aIso Iift the underIying tissues insulin are used. 2. LocaI: toward the surface, making the wound of medicina1 agents (a) AppIication Iess in depth. This property of contraction aIso acts to constrict the vesseIs in the which may cut down excessive growth of or may stimuIate inactive granuIations, granuIation tissue, causing, them to disappear. When the entire surface is covered growth or cIear up a Iow-grade infection. (b) SurgicaI: Wh ere a cicatrizing base with epitheIium the wound may be conof a granuIating area is preventing it from sidered as heaIed. healing, excision may be done and the There are numerous conditions under freshened edges Ioosened and brought which granuIation tissue grows, which together, or skin grafting done as indicated. may aIter the character of the granuIations to such an extent that the wound wiI1 not In cases of venous congestion due to varihea1. Some of the more common of these case veins the Iatter may be excised, or treated by the injection method, i.e., conditions are : injection of the veins. I. Lack of rest in the part affected. Rest First of a11 in granuIating wounds is an essentia1 factor in the treatment which do not hea1, constitutiona diseases of granuIating wounds, and if the tissues shouId be ruIed out, but if found shouId be are constantIy being stretched it is quite properIy treated. often impossibIe to heaI them. For example, Next, one often encounters an exubergranuIating areas over extensor and flexor ant overgrowth of normaI pink granulations surfaces of joints are most diffrcuh to heaI which have grown so far above the surface if the part is not immobiIized. * Submitted for publication November 23, 1929. 338
Ni \\’\LHI~-slo,.. V111, NC,. I
CorneIl-GranuIating
of the adjacent skin Ievels that it is impossibIe for epithelium to grow over the granulating bed. In these cases, repeated “burning down ” to skin Ieve by the application of siIver nitrate caustic stick at intervaIs as indicated, \viII usuaIIy suffice to cause a rapid epitheIiaIization of a wound. Not infrequently the granulating bed may present heaIthy granulations but be of such a diameter that it is quite impossible for the epithelium to push across the space In these cases pulling the edges of the wound into closer proximity by adhesive strips is often sufficient. Another very exce1Ient use of adhesive in this type of wound is placing 41 inch strips of sterile adhesive around the edges of the wound extending out into the granuIating bed from the skin edge. In twenty-four hour’s time the advance of epitheIium under the strips can be recognized by the naked eye and by a continuation of the same process often very Iarge granuIating areas are covered over by new skin. An exampIe of excessive overgrowth of health>- granuIations is we11 iIIustrated by a patient who had a scalp wound which would not heal, folIowing a fracture of theskull. When I saw her several months later there was a mass of granulations tissue piIed high so that it resembIed a medium-size mulberry as to size and appearance. As it was clipped off with scissors a small sized artery was found extending up into it. Following the remova of this mound of granulation tissue, the healing-o\-er process took place rapidIy. A chronic Iow grade infection may cause an exuberant growth of unheaIthy granuIation tissue. The granuIations then take on a paIer or grayish appearance which heap up and overhang the skin edges. There is usuaIIy a considerable whitish purulent discharge and the wound refuses to heal. This type of granulation is best treated by u-et dressings unti1 the infection is overcome, fohowed by use of the caustic stick, together with some mildly disinfecting and stimmating agent, such as baIsam of Peru, dichloramine T. mercurochrome ointment, etc.
Wounds
American
Jwrrd
of Surga-.y
339
Foreign bodies in a wound, such as an unremoved suture, spicuIe of dead bone, a smal1 piece of gauze or rubber drain, or in hand infections a piece of dead will cause an overgrowth of tendon, grayish, unhealthy appearing granulation healing follows remova tissue. Prompt of the foreign substance. In contradistinction to exuberant granuIations, there are the underdeveIoped or insufficient granu1ation.s. Provided constitutiona1 disease has been ruIed out, this type of granuIation tissue needs stimulating. Balsam of Peru is probabIy foremost among the non-irritating stimuIants. There are numerous others, such as dichIoramine T, Durante’s solution, etc. Physical agents are aIso useful The simpIe therapeutic Iamp consisting of a heat-giving buIb appIied for fifteen minutes three times daily is most efficacious in promoting growth of sIuggish granulations. Other Iight therapy such as the infra-red, or ultraviolet lights are useful but shouId be used with extreme caution and by an experienced person. HeIiotherapy, which is cheapest and most often accessibIe, is oftentimes comSubnormal granulation pIeteIy forgotten. tissue when exposed to the direct rays of the sun is always benefited by the exposure, and healing is hastened. The patient can do this frequentIS at home between visits to the doctor. It must be impressed upon the patient, however, that the exposure shouId be direct and not through a window pane. Constricting by voluminous dressings shouId be avoided, the aim shouId be to give as free an access of air to the granuIating area as is compatibIe with good wound asepsis. Under the class of deficient granuIation tissue as a cause of wounds not heaIing, probabIy the foremost offender is the varicose vein uIcers in the Iower extremities. Due to the constant venous congestion these uIcers at times wiII actuaIIy spread instead of healing. The most ef‘ficient non-operative method in this type of case is the appIication of the so caIIed
340
American Journal of Surgery
Farr-LocaI
Anesthesia
(a11 cotton eIastic) bandage. This is appIied in the morning before the patient gets out of bed, and is worn a11 day. Many of the smaIIer sized ulcers of this type wiI1 hea quickIy under this treatment. Elastic stockings shouId never be used as they constrict at the top and the bottom, adding to the venous congestion rather than relieving it. They aIso can be extremeIy uncomfortabIe. For the Iarger, Iong-standing, more caIIous uIcers with cicatrized base, surgica1 remova of the veins is indicated, or better stiI1, the injection method which is fast dispIacing the surgical procedure. Wounds caused by chemica1 burns, severe bruises, etc., which cause a deep Ioss of tissue and heavy “scab ” formation, ACE
are best treated by wet dressings of saIine unti1 the sIough comes away. Among the miIdIy stimuIating ointments for this group of sluggish wounds is 3 per cent ammoniated mercury, boric acid and zinc oxide ointments. In concIusion it may be said that wounds which wiI1 not hea1, due to the formation of granuIation tissue, far1 into two great cIasses, the overgrowing granuIations and the deficientIy growing granuIations. In the first group a cutting-down of the overgrowth or remova of the cause of this overgrowth is indicated. In the second great group the granulations must be stimuIated and encouraged by the application of the physica and physioIogicaI principIes indicated.
THE R6LE OF LOCAL ANESTHESIA IN OFFICE PRACTICE* ROBERT
C
EMMETT
FARR,
MINNEAPOLIS,
MINN.
M.D.
ONSIDERED from the standpoint cian does, genera1 practice or specialization, of anesthesia aIone, the off&e equiprura1 or urban, there is one fundamenment of different physicians varies ta1 principIe that shouId aIways be his wideIy. ObviousIy what might appIy to one guide. The interests of the patient shouId would have no appIication to others. transcend a11 others. Even the appIication Few physicians reaIize the ease with which of the sIogan “the greatest good to the must never be aIIowed greatest number” any offIce may be equipped with the necesto interfere with the appIication of this sary paraphernaIia required for the routine principle. Every individua1 patient shouId empIoyment of IocaI anesthesia. Once receive the benefits to be derived from the equipment is instaIIed and the fundafolIowing this maxim. Time, expedience, mentaIs of technic mastered, the bugaboo decreased income, the physician’s comfort that the use of IocaI anesthesia is a comand every conceivabIe factor must be fades into obscurity. pIicated process considered secondary in importance to the Furthermore, when the physician has his offIce so equipped and reaIizes the patient’s interests. Advantages. With the above consideraadvantages that may accrue from the tions in mind there are many advantages routine use of IocaI anesthesia in offIce to be gained by the empIoyment of IocaI practice, he wiI1 be surprised at its many anesthesia whenever it is indicated. Inciadvantages and, as a ruIe, wonder how dentaIIy, its use corresponds in a marked he formerIy carried on without this impordegree with the patient’s interests, expeditant adjunct. RegardIess of the type of work a physiency and many other important points. * Submitted for pubIicn1tion December 12, 1929.
CORNELL,
M.D.
YORK
T
HE stages of repair in a wound which 2. Irritation by rough, unsuitabIe dressheals by granuIation tissue are as ings, or irritating chemicaI agents which foIIows : may be used in the dressing. I. An abundant exudation of smaI1 3. UnheaIthy or devitaIized condition of round ceIIs, whose function is to remove patient’s tissues, as in badly bruised or dead or damaged tissues, and aIso to break Iacerated skin, or in Iocations where there up, disintegrate, and finaIIy absorb any is persistent venous congestion, which bIood cIot . prevents access of heaIthy bIood. An 2. The invasion of the wounded area exampIe of the Iatter is we11 demonstrated by fibrobIasts from the tissues composing by varicose uIcers. the parts. 4. Constitutiona disease, such as 3. VascuIarization by protapIasmic buds Bright’s disease, diabetes, syphiIis, scurvy growing out from the capiIIaries. These or aIcohoIism, severe anemia. soon become canalized and Iined with 3. Infection. endotheIia1 ceIIs. The capiIIary Ioops thus 6. Foreign bodies. formed give the granular appearance to The treatment of wounds which wiII the deveIoping tissue. not hea due to the formation of granula4. Cicatrization and epitheIization: In tion tissue is: this stage the fibrobIasts become spindIeI. ConstitutionaI: in which any severe constitutiona disease is sought for and shaped with coIIagenous materia1 around treated accordingIy. In diabetes, for examthem. This gives to the wound contractiIe properties which tend to make the wound pie, diet and the proper administration of smaIIer and aIso Iift the underIying tissues insulin are used. 2. LocaI: toward the surface, making the wound of medicina1 agents (a) AppIication Iess in depth. This property of contraction aIso acts to constrict the vesseIs in the which may cut down excessive growth of or may stimuIate inactive granuIations, granuIation tissue, causing, them to disappear. When the entire surface is covered growth or cIear up a Iow-grade infection. (b) SurgicaI: Wh ere a cicatrizing base with epitheIium the wound may be conof a granuIating area is preventing it from sidered as heaIed. healing, excision may be done and the There are numerous conditions under freshened edges Ioosened and brought which granuIation tissue grows, which together, or skin grafting done as indicated. may aIter the character of the granuIations to such an extent that the wound wiI1 not In cases of venous congestion due to varihea1. Some of the more common of these case veins the Iatter may be excised, or treated by the injection method, i.e., conditions are : injection of the veins. I. Lack of rest in the part affected. Rest First of a11 in granuIating wounds is an essentia1 factor in the treatment which do not hea1, constitutiona diseases of granuIating wounds, and if the tissues shouId be ruIed out, but if found shouId be are constantIy being stretched it is quite properIy treated. often impossibIe to heaI them. For example, Next, one often encounters an exubergranuIating areas over extensor and flexor ant overgrowth of normaI pink granulations surfaces of joints are most diffrcuh to heaI which have grown so far above the surface if the part is not immobiIized. * Submitted for publication November 23, 1929. 338
Ni \\’\LHI~-slo,.. V111, NC,. I
CorneIl-GranuIating
of the adjacent skin Ievels that it is impossibIe for epithelium to grow over the granulating bed. In these cases, repeated “burning down ” to skin Ieve by the application of siIver nitrate caustic stick at intervaIs as indicated, \viII usuaIIy suffice to cause a rapid epitheIiaIization of a wound. Not infrequently the granulating bed may present heaIthy granulations but be of such a diameter that it is quite impossible for the epithelium to push across the space In these cases pulling the edges of the wound into closer proximity by adhesive strips is often sufficient. Another very exce1Ient use of adhesive in this type of wound is placing 41 inch strips of sterile adhesive around the edges of the wound extending out into the granuIating bed from the skin edge. In twenty-four hour’s time the advance of epitheIium under the strips can be recognized by the naked eye and by a continuation of the same process often very Iarge granuIating areas are covered over by new skin. An exampIe of excessive overgrowth of health>- granuIations is we11 iIIustrated by a patient who had a scalp wound which would not heal, folIowing a fracture of theskull. When I saw her several months later there was a mass of granulations tissue piIed high so that it resembIed a medium-size mulberry as to size and appearance. As it was clipped off with scissors a small sized artery was found extending up into it. Following the remova of this mound of granulation tissue, the healing-o\-er process took place rapidIy. A chronic Iow grade infection may cause an exuberant growth of unheaIthy granuIation tissue. The granuIations then take on a paIer or grayish appearance which heap up and overhang the skin edges. There is usuaIIy a considerable whitish purulent discharge and the wound refuses to heal. This type of granulation is best treated by u-et dressings unti1 the infection is overcome, fohowed by use of the caustic stick, together with some mildly disinfecting and stimmating agent, such as baIsam of Peru, dichloramine T. mercurochrome ointment, etc.
Wounds
American
Jwrrd
of Surga-.y
339
Foreign bodies in a wound, such as an unremoved suture, spicuIe of dead bone, a smal1 piece of gauze or rubber drain, or in hand infections a piece of dead will cause an overgrowth of tendon, grayish, unhealthy appearing granulation healing follows remova tissue. Prompt of the foreign substance. In contradistinction to exuberant granuIations, there are the underdeveIoped or insufficient granu1ation.s. Provided constitutiona1 disease has been ruIed out, this type of granuIation tissue needs stimulating. Balsam of Peru is probabIy foremost among the non-irritating stimuIants. There are numerous others, such as dichIoramine T, Durante’s solution, etc. Physical agents are aIso useful The simpIe therapeutic Iamp consisting of a heat-giving buIb appIied for fifteen minutes three times daily is most efficacious in promoting growth of sIuggish granulations. Other Iight therapy such as the infra-red, or ultraviolet lights are useful but shouId be used with extreme caution and by an experienced person. HeIiotherapy, which is cheapest and most often accessibIe, is oftentimes comSubnormal granulation pIeteIy forgotten. tissue when exposed to the direct rays of the sun is always benefited by the exposure, and healing is hastened. The patient can do this frequentIS at home between visits to the doctor. It must be impressed upon the patient, however, that the exposure shouId be direct and not through a window pane. Constricting by voluminous dressings shouId be avoided, the aim shouId be to give as free an access of air to the granuIating area as is compatibIe with good wound asepsis. Under the class of deficient granuIation tissue as a cause of wounds not heaIing, probabIy the foremost offender is the varicose vein uIcers in the Iower extremities. Due to the constant venous congestion these uIcers at times wiII actuaIIy spread instead of healing. The most ef‘ficient non-operative method in this type of case is the appIication of the so caIIed
340
American Journal of Surgery
Farr-LocaI
Anesthesia
(a11 cotton eIastic) bandage. This is appIied in the morning before the patient gets out of bed, and is worn a11 day. Many of the smaIIer sized ulcers of this type wiI1 hea quickIy under this treatment. Elastic stockings shouId never be used as they constrict at the top and the bottom, adding to the venous congestion rather than relieving it. They aIso can be extremeIy uncomfortabIe. For the Iarger, Iong-standing, more caIIous uIcers with cicatrized base, surgica1 remova of the veins is indicated, or better stiI1, the injection method which is fast dispIacing the surgical procedure. Wounds caused by chemica1 burns, severe bruises, etc., which cause a deep Ioss of tissue and heavy “scab ” formation, ACE
are best treated by wet dressings of saIine unti1 the sIough comes away. Among the miIdIy stimuIating ointments for this group of sluggish wounds is 3 per cent ammoniated mercury, boric acid and zinc oxide ointments. In concIusion it may be said that wounds which wiI1 not hea1, due to the formation of granuIation tissue, far1 into two great cIasses, the overgrowing granuIations and the deficientIy growing granuIations. In the first group a cutting-down of the overgrowth or remova of the cause of this overgrowth is indicated. In the second great group the granulations must be stimuIated and encouraged by the application of the physica and physioIogicaI principIes indicated.
THE R6LE OF LOCAL ANESTHESIA IN OFFICE PRACTICE* ROBERT
C
EMMETT
FARR,
MINNEAPOLIS,
MINN.
M.D.
ONSIDERED from the standpoint cian does, genera1 practice or specialization, of anesthesia aIone, the off&e equiprura1 or urban, there is one fundamenment of different physicians varies ta1 principIe that shouId aIways be his wideIy. ObviousIy what might appIy to one guide. The interests of the patient shouId would have no appIication to others. transcend a11 others. Even the appIication Few physicians reaIize the ease with which of the sIogan “the greatest good to the must never be aIIowed greatest number” any offIce may be equipped with the necesto interfere with the appIication of this sary paraphernaIia required for the routine principle. Every individua1 patient shouId empIoyment of IocaI anesthesia. Once receive the benefits to be derived from the equipment is instaIIed and the fundafolIowing this maxim. Time, expedience, mentaIs of technic mastered, the bugaboo decreased income, the physician’s comfort that the use of IocaI anesthesia is a comand every conceivabIe factor must be fades into obscurity. pIicated process considered secondary in importance to the Furthermore, when the physician has his offIce so equipped and reaIizes the patient’s interests. Advantages. With the above consideraadvantages that may accrue from the tions in mind there are many advantages routine use of IocaI anesthesia in offIce to be gained by the empIoyment of IocaI practice, he wiI1 be surprised at its many anesthesia whenever it is indicated. Inciadvantages and, as a ruIe, wonder how dentaIIy, its use corresponds in a marked he formerIy carried on without this impordegree with the patient’s interests, expeditant adjunct. RegardIess of the type of work a physiency and many other important points. * Submitted for pubIicn1tion December 12, 1929.