Page Ten P H Y S I O T H E R A P Y January, 1955. VARICOSE ULCERS A study of their underlying causes and etiology with special emphasis on the Physical treatments employed. by H. W. EDWARDS. Being the adapted text of a thesis for the degree o f B.Sc. (Physiotherapy).' University o f the Witwatersrand. June, 1954. HISTORY OF TREATMENTS. A S early as the 14th Century, varicose ulceration was diagnosed. . Guide Chauliac noted the influence o f fat on its causation. Ointments and lotions were the earliest forms o f treatment and included those used by Indian healers, miracle men and professional quacks, as well as those employed to-day by the medical profession. Ulcers have been treated for decades by physical means. Brodie in 1846 used a medicated elastic bandage; N oble in 1924 suggested rubber sponges and Dickson Wright used a large adhesive felt pad with a thin bandage to flatten out the edges o f the ulcer. Galvanism and Zinc iontophoresis were then introduced. Until 1930, however, most treat­ ments were unsatisfactory. They involved prolonged bed rest with loss o f income and blockage o f hospital beds. Hot dressings and various plasters were the next develop­ ment and o f these, Unna’s Paste was thought to be the most efficient form of treatment until a few years ago. Viscopaste and Ichthopaste bandages were then introduced and served to lessen the risk o f dermatitis. Treatment was then completely revolutionized, based fundamentally on tight bandaging from toes •; to knees, covering the septic discharging ulcer and causing the patients to be ambulatory. These new ideas were known only to a few including an old herbalist woman in Lancashire, with an enormous practice. These methods have been developed and are commonly employed to-day with the addition o f Ultra-Violet Light treatments. Although ultrasonic therapy has only recently been considered as useful in the treatment o f varicose ulcers, the biological effect o f ultrasonic waves was first discovered in 1917 by Langevin. He found, by chance, that fish ex­ posed to a powerful irradiation field from an under-water ultrasonic emitter were paralysed. However, the first successful attempts to employ ultrasonics therapeutically were made by Pohlman, Richter and Parow in 1939. Intense propaganda in favour led to undue hope and finally disappointment, but recently research has laid down the principles o f the therapy and better apparatus has made cure more possible. PART I. ULCERS OF THE LEG. 1. CLASSIFICATION. (a) Non-Infective Ulcers: . Interference with the vitality o f the part by injury, lack o f circulation or deficient innervation. (b) Inefective Ulcers: Direct action o f specific infection. (c) Ulcerated or malignant tumours: Originating in or invading the skin. Varicose ulcers are classified under non-inefective ulcers although secondary infection is usually present. 2. DIFFERENTIAL DIAGNOSIS. An ulcer is an indolent raw area which tends to persist and is more often than not infected. To differentiate varicose ulcers from other ulcers o f the leg, it is important that careful histories be obtained. Previous ulcers and sites, miscarriages, time o f existence o f ulcers, whether multiple or single, whether painful or not, are all facts which should be recorded. The types o f ulcei commonly occurring in the leg which should be distinguished from varicose ulcers are:— (a) Syphillitie Ulcers: These ulcers are generally multiple and occur chiefly in the outer, upper part o f the leg. They have a characteristic “punched out” appearance with raised hard edges. Old and new ulcers are always present and they are practically painless. A Wasser- mann blood test is done. (b) T.B. Ulcers: These occur in the legs mostly near the joints and are multiple or single. Often seen in children with evidence o f the disease elsewhere. The ulcers have a soft base with undermined edges, grey slough and a thin watery discharge. They are most painful. (c) Mycotic Ulcers: There is a “ringworm” arrangement in this type o f ulcer and they are multiple. They start as blisters which burst, become infected and finally tend to heal in the centre. The skin o f patients with varicose veins is susceptible to this infection. (d) Factitious Ulcers: Occur chiefly in hysterical women. A “Glove and Stocking” anaesthesia is present. They are rare and usually in a position easily accessible to the . patient. (e) Traumatic Ulcers: These are not usually mistaken for varicose ulcers. They commonly occur over the shin bone and show other signs o f trauma. Other conditions simulating ulcers but which rarely are, include: Raynaud’s diseases, Diabetes, Tropic disease and Cancer. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) ■,n..arv. 1955. ___________________ P H Y S I O T H E R A P Y __________________ ____________ Page Eleven 3 DESCRIPTION o f v a r i c o s e u l c e r s . It is claimed that the term varicose ulcer is a misnomer, nee there are many causative factors other than damage to the deep venous system. The term has arisen due to the close association o f this condition with varicose veins. Strictly speaking, however, these ulcers due to venous stasis and thrombosis should be termed gravitational ulcers. In fact any ulcer due to a faulty flow o f venous blood may be termed a gravitational ulcer. However, for the purpose o f this discussion, all are included under the general heading of Varicose Ulcers, as popularly accepted. Varicose Ulcers are by far the most common ulcers o f the lower extremities. ,They occur in the lower one third o f the leg, are generally single, sometimes multiple and may be large or small. Such ulcers are generally associated with varicose veins and there is usually a well marked area of inflammatory reaction which at times will spread for several inches beyond the open ulcer. There is localised oedema together with brown pigmentation o f the skin and sometimes a history o f phlebitis. The area o f the ulcer is deficient in muscular support and collateral circulation. The edges are usually sloping in appearance and the base is covered with large, coarse granulations and a profuse, grayish discharge. They may be one o f the most severe, disabling and painful conditions occurring in late middle life and most com­ monly in obese persons. The “indurated leg” which is a term referring to the swollen limb, seat o f brawny oedema, is a precursor of ulceration, eczema and chronic invalidism. PART II. FACTORS UNDERLYING THE FORMATION OF VARICOSE ULCERS. 4. ANATOM Y OF THE VENOUS SYSTEM. (a) Anatomy. The Venous System o f the lower leg consists o f super­ ficial and deep portions. The deep veins are those situated deeply among the muscles and bones and which collect the blood from the deeper tissues about the foot and ankle, carrying it upward. It then beccomes the popliteal vein at the lower edge o f the popliteal space. This vein continues as the popliteal until it enters Hunter’s canal, where it is called the femoral vein. When it passes under Poupart’s ligament, it becomes the external iliac and later, at the brim o f the true pelvis, unites with the internal iliac to form the common iliac vein. The superficial venous system o f the lower leg, consists o f the long and short saphenous veins. The long saphenous forms over the inner side o f the foot and ankle, passes upwards medial to the edge o f the tibia, past the medial condyle o f the femur, along the inner side o f the lower thigh and then joins the femoral vein o f the deep system, through the foramen ovale two inches below Poupart’s ligament. The short saphenous collects blood from the back and external border o f the foot and back o f calf. It joins the popliteal vein in the upper edge o f the popliteal space. These systems are connected by collateral anastomosing veins, an extensive network resting in the superficial fat. The superficial veins are connected with the deep veins in the lower leg and thigh by communicating veins. All these veins, superficial, deep and communicating are supplied with valves with their cusps facing upward and inward. This tends to prevent the reflux o f blood and maintains the blood column above them. These valves are usually o f the bicuspid type. (b) Embryology: Valves first develop in the embryo at 3+ months and by 5 months are completely developed. They are usually located at the entrance o f the saphenous into the femoral and popliteal veins .and are found distal to the opening o f a tributary. There is no definite regularity in their location. (c) Histology: The wall o f a vein is made up o f three layers:— (i) Intim a: layers o f cuboidal epithelium lining the inner walls with elastic interna beneath. (ii) M edia: large amounts o f muscle tissue interspersed with fibrous tissue and scattered elastic tissue. (iii) Adventitia: consists almost entirely o f fibrous elements with small amounts o f muscle tissue. Throughout the media and adventitia are scattered the vasa vasorum o f the vein wall. With abnormalities in the venous system, degenerative changes occur in the lining coats o f the vein. 5. PHYSIOLOGY O F THE VENOUS SYSTEM. The normal circulation in the venous system is from the extremities towards the heart in a proximal direction; both in the superficial and deep veins. This is aided by:— (i) The contraction o f the left ventricle which is a force from behind driving the blood along the veins. (ii) The negative intrathoracic pressure which exerts a suction effect or pull upon the column o f blood in the large veins of the abdomen. The blood is also forced upward during inspiration for when the diaphragm descends it increases the intra-abdom- inal pressure. This increase in pressure is trans­ mitted to the blood in the veins and since the valves prevent the blood from passing downwards it is propelled upwards. (iii) Abdominal and Limb Muscles: In standing, the abdominal muscles contract and offer a firm support for the large veins o f the abdomen. If this was not so blood would collect in these veins and the flow to the heart would be reduced. The muscles o f the limbs perform a similar function. Furthermore, the contraction o f muscles when walking forces the blood upward towards the heart with a pumplike action. The valves prevent any back flow. The vascular system o f the leg has been described as being similar to a U-shaped glass tube. The aorta and large arteries being one limb, the capil­ laries, the bottom and the large vein trunks and vena cava the other limb. When filled with fluid, the system is in equilibrium. If the blood is introduced into one side, an equal amount must flow out o f the other, i.e. when the heart pours blood into the aorta, an equal amount must flow from the vena cava, into the right side o f the heart. Thus venous return is accomplished irrespective o f the body’s position. However, in the erect position there are gravi­ tational influences and a large quantity o f blood accumulates in the lower parts of the leg. The human “ U-tube”, un­ like those o f glass does not have rigid and impermeable walls. The vessels have elastic coats which are apt to give way under high pressure, the lumen widens and blood accumulates with resultant venous stasis. To dispel this surplus, the body relies on the contraction pf the muscles of the calf. When these muscles contract as in walking, they act as a peripheral heart, squeezing blood from the lower leg into the popliteal and the femoral veins. The valves prevent the back flow. 6. PATHOLOGY OF VEINS A N D ULCERS. Loss o f valve .function, followed by dilation o f the vein walls, is the first step in the formation pf varicose veins. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page Twelve P H Y S I O T H E R A P Y January, 1955. When the valves do not function properly, the blood sqeezed out o f the lower leg, will return as soon as the muscles relax. N o amount o f walking or muscle movements will prevent the blood from stagnating. Pierre Delbet gives the mechanical explanation that it is back pressure from the iliac veins, causing the valves at the sapheno-femoral junction to give way and permit reverse flow. Apparently the valves degenerate throughout adult life and there is evidence o f a general connective tissue weakness in the body which is progressive with age. As a result o f this loss o f valve function, venous stasis occurs and oedema develops. If prolonged for weeks or years changes such as induration and ulceration occur and aching and pain result from anoxaemia. These changes constitute the picture observed in lower leg ulcers. They are rarely found alone and are nearly always accompanied by chronic pitting oedema and brawny, indurated skin. The patient complains o f dull aching or bursting pain whenever the lefg is vertical. These symptoms constitute the components o f a “lower-leg-stasis syndrome” . Grave circulatory disturbances underly this syndrome. In an investigation carried out by Gunnar Bauer, the femoral and popliteal veins were found to be in a patho­ logical condition. The salient feature was an almost com­ plete absence o f normal functioning valves. The presence o f varices in the superficial system pre­ disposes towards the development o f thrombophlebitis o f the deep system. This inflammatory condition is asso­ ciated with hard clot or thrombus formation which is, tender and painful. The tissues become indurated with an intense cellulitis. With the stagnation o f blood in the varicose veins the blood is poorly oxygenated and more susceptible to in­ fection. If there is a continued congestion o f the skin, a dermatitis and later eczema may develop with possible ulcer formation. , Ulcers occur largely in the skin. There is an inflammatory reaction o f the tissue beneath and gangrene and separation o f superficial layers o f skin. At times the area resembles a carbuncle. N o one bacterial organism can be held as the specific cause o f ulceration. 7. ETIOLOGY A N D CAUSATION. In the case o f Varicose Ulcers, persistent oedema or induration is usually present in the dependent parts and the tendency to ulceration is aggravated by:— (i) Some obscure reflex mechanism as a result o f trauma. (ii) The presence o f infection. (iii) Muscular inactivity. (iv) Varicose Veins. Venous stasis, with resulting stagnation o f fluid in the tissues, is the basic factor producing the lowering o f tissue resistance and secondary ulceration. The potential difference between blood in the veins and the fluid in the tissues is equalised. Stasis results, tissues become waterlogged and their resistance to infection or trauma becomes lowered because o f impaired nutrition. Secondary infection by pyogenic organisms is always present. The surrounding skin becomes indurated and purplish brown. The immediate cause o f tissue breakdown, is often trivial. It may be embolic and due to infected teeth, tonsils, haemorrhoids, etc. If not cared for, infected veins may increase, an ulcer results and may penetrate deeper. The ulcer cycle always causes much damage to circulation and nutrition o f the tissues and leaves them more susceptible to future ulceration. Often after years o f ulceration and healing, a continuous potential state o f gangrene exists. Ulcers developing in this case are truly trophic. Occupations involving a lot o f standing, particularly those o f barbers, laundresses, dentists and blacksmiths, reduce the pumping effect o f muscular contractions, with resultant stagnation. (a) Causation of Ulcers: Ulcers are the end result o f the predisposing patho­ logical conditions which have been operating for many years—obesity, stasis, lack o f muscle tone in leg muscles, lack o f exercise, standing and non-function o f vein valves. Medical diseases may be aggravating factors and trauma the exciting cause, with supervening infection. (i) Varicose Veins: Varicose Veins are common antecedents and may be due to trauma, phlebitis, burns or fractures with resultant retrograde venous flow. Varicosity dimin­ ishes free return o f blood and leads to congestion, lack o f nutrition and ulceration. The back pressure in the reversed venous circulation is considerable. When the patient is standing the venous pressure can be between 90 mm. and 170 mm. Hg. This stagnant column o f blood causes oedema and the surrounding tissues are affected. Even a mild degree o f trauma in such an area, initiates the formation o f an infected varicose ulcer. (ii) Previous Thrombosis: A main causative factor in ulceration is a previous thrombosis o f deep veins o f the leg, which may affect the iliac, femoral and popliteal veins. There may be phlebosclerotic and similar idiopathic changes. In 1949 a series o f cases studied by Annings showed: 88-6%—due to.deep varicose thrombosis. 11-4%—due to varicose veins. (iii) Congenital weakness: Congenital weakness o f the vessels may be an important cause and there is apparently a heriditary factor not to be overlooked. The vein walls are sufficiently strong enough during the early years, but under the stress and strain o f later life, with back pressure from the iliac veins and straining from heavy work, the walls dilate with loss of valve function. (iv) Trauma: Usually injury to a vein heals rapidly, but such conditions as phlegmasia alba dolis following preg­ nancy or exposure to cold, where there is deficient circulation or pyogenic infection, without free drainage, an ulcer may result. Any slight trauma may cause an abrasion when the skin is weak and varicose. The ultimate formation o f an ulcer is a question o f mechanics. The foot and lower leg become engorged and waterlogged, the dependant parts are acted upon by gravity, the nutrition is impaired and the skin breaks down. The persistence o f an ulcer is still a question o f mechanics together with added low-grade bacterial infection. Thus only by elevating the foot or by tight bandaging can the waterlogging fluid be driven from the foot and the ulcer given a chance to heal. Recently it has been suggested that the causation may be associated with a calcium im­ balance o f the body. (b) Symptoms: The most important symptoms associated with varicose veins and ulcers are the infiltrations o f abnormal effusions o f fluid into the tissues, often resulting in the formation o f connective tissue and other changes. It may be muscular infiltration, causing pain and stiffness o f joints, but the common area is the calcaneo-malleolar region, spreading to the back o f the small o f the leg. Pereosteal infiltrations o f the tibial surface and sub-cutaneous or cutaneous in­ filtrations on the inside o f the knee are extremely painful. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Januaryj?^ P H Y S I O T H E R A P Y Page Thirteen There may be oedema o f the whole leg, which is tense and shiny with pitting on pressure. The leg feels heavy. Causes o f these infiltrations may be partly central, partly peripheral and sometimes interm ediary. (i) Causes o f Central Origin: These are due basically to weak heart, after operations, nephritis, asthma and emphysema. Fevers such as typhoid, pneumonia and rheumatic fever necessitate long bed rest with reduced muscular movement. Hence the original cause o f infiltration in distal parts o f the leg is hastened. (ii) Intermediate Causes: Badly fitting elastic stockings and tight garters, are contributory factors. Fear o f draught and cold has an influence on the state and, function o f the lower limbs. (iii) Peripheral Causes: Fractures may cause severance o f important vessels or their involvement in callus formation. Plaster bandages and prolonged immobilisation may inhibit the circulation. Sometimes the treat­ ment o f a fracture is compromised or essentially delayed by infiltrations in the ankle region. These limit the mobility o f the foot, with resultant atrophy o f the calf muscles and discomfort. Trauma plays a definite part, causing distortion o f the area and accompanying infiltration. Obvious nutritional disturbances o f the skin, such as pigmentation, atrophy and induration, are early indications o f tissue breakdown. Phlebitis and peri-phlebitis o f small veins may be present. Ulcers are limited in depth by the superficial and deep fascia and always appear deeper, because o f the swollen margins. Pain is a prominent symptom o f varicose ulcer, and sometimes it can become so severe, that the patient is forced to bed. Necrosis o f the skin and discharge from the ulcer', affords relief. The terminal nerve filaments which supply the ulcer area, are not broken down, but are held under pressure in the area o f cellulitis and congestion. They are acutely eroded and inflamed, and are thus hypersensitive. When a patient is on his feet, there is increased congestion of the tissues and fluid stagnation with consequent in­ creased pressure on the terminal endings. Severe pain results. (c) Varicose Veins: There is a close association o f varicose veins with ulcer development, thus it is necessary to consider in some detail, the basic etiology o f varicose veins. Some authorities m aintain th a t the etiology o f ulcers is a trophoneurotic distrubance, a condition resulting secon­ darily to the developm ent o f varicose veins. Definition: A varicose vein is defined as one which has undergone dilation, elongation and tortuous changes in shape, with thickening o f the wall. Furthermore, there is no power in the vein to carry blood to the heart, as the valves are in­ competent. Etiology: It was found by Lake, Pratt & Wright in 1942, that 67% of women had varicose veins who had not been pregnant, although there was a higher incidence in women who had. This was possibly due to the fact that women have softer and less supportive surrounding tissues to the walls of veins, and that at times o f pelvic congestion, back pressure is more marked in venous circulation. Recent evidence has shown that the absence o f Vitamin C may have a direct bearing on the development o f varicose veins. Causative Factors: (i) Age—rare under 18 years. (ii) Sex—commoner in women than men, but not to any great extent. Probably less noticeable in men, because they hide their legs. (iii) Pregnancy—responsible for many cases arising in 3 ways: (a) Obstruction to return o f blood from legs, due to gravid uterus. (b) Toxaemia sometimes damages veins. (c) Sometimes a phlebitis which in turn causes superficial veins to become varicose. (iv) Infective diseases— general lowering o f tone of muscular system. (v) Occupation—constant standing in bad atmospheres and light with undermining of general health. (vi) Tight garters and similar restrictions. (vii) Endocrine deficiency. Sicard considers a deficiency o f ovarian stimulation in the female and hypophyseal secretion in the male a factor. The whole venous system is hypotonic, due to lack o f hormones. He also considers a lack o f sympathetic stimulation to the vein wall, which leads to dilation. (viii) Absence o f Vitamin C. (ix) Hereditary factor and a .congenital weakness of vein walls. The symptoms associated with varices, include a heavy feeling in the leg; paraesthesia o f the skin o f lower ex­ tremities, and oedema o f legs and ankles. Varicose veins do not always cause indolence or sepsis. The deep and superficial induration accompanying varicose veins, is probably due to interstitial fibrosis, from organisa- ion o f oedema. Chronic phlebitis and periphlebitis of venules, may be the possible cause. p a r t m . THE TREATMENT OF VARICOSE ULCERS. INTRODUCTION. 8. The treatment o f varicose ulcers has been classified under three headings: ■ SURGICAL, MEDICAL and PHYSICAL. As after care and the patient’s co-operation are so im­ portant in effecting a permanent cure, they have been included under a separate heading. In the treatment o f any case o f varicose ulcer, two con­ ditions must be recognised. (i) The primary condition or etiological factor present, is the stagnation o f blood in the parts. This lowers the resistance o f the tissues to infection. (ii) With venous stasis, slight trauma may be the im­ mediate cause o f ulcer development. Treatment is therefore aimed at correcting the reflux blood flow, promoting a better circulation and protect­ ing the area from future trauma. Supportive measures are therefore indicated, to aid the venous and lymphatic circulation in the lower leg, directly about the site o f ulceration. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page Fourteen P H Y S I O T H E R A P Y January, 1955. Early treatment and continued after-care, are essential to heal ulcers and keep them healed. It is important to realise, however, that to treat the ulcer without treating the veins or other underlying cause, is a waste o f time. In fact, untreated diabetes, syphilis, kidney disease and septic foci, will often prevent healing. There are certain prophylactic measures which help to minimise the risk o f ulceration. These include:— (i) Avoidance o f sepsis. (ii) Early passive and active movements post-operatively. (iii) Early diagnosis o f deep vein thrombosis, and the use o f anti-coagulant drugs. (iv) Weight reduction. A. EXAM INATION OF PATIENT. As in all other cases when a patient with an ulcer presents himself for treatment, a careful examination is made. The history is investigated, to find out the etiology o f the condition. Previous thrombophlebitis, pregnancies, date o f first ulceration, recurrence, disability caused and persistence are noted. The amount o f oedema and swelling o f feet are determined. Complicating factors, such as diabetes, nephritis, etc. are looked for. Each ulcer case is considered separately, and a different diagnosis should be made. This is important to verify that the ulcer is varicose, and to avoid incorrect treatment. B. CHOICE OF TREATMENT. Surgery is indicated where there is an obvious offending vein, when a resection or ligation may be performed, or injections administered. In the case o f large, sluggish ulcers, an excision o f the whole area may be made, and /or skin grafts implanted in the ulcer area, to hasten healing. As a general routine, conservative measures should always be practised, before resorting to more drastic means. The direct application o f any particular solution or ointment, has no value in itself in bringing about recovery. Unnas’ Casts have for years been considered the most effective form o f treatment, but are now slowly being replaced by less cumbersome physical methods. The modern ambulatory treatments, are gradually taking precedence over all methods, as with the patients’ full co-operation, ulcers should heal in two or three weeks, as against the months o f incapacity with other forms o f treatment. There is a more marked improvement in the circulation and in the general health of body and mind. 9. SURGICAL TREATMENT. Surgical treatment can be divided into two parts:— (1) Surgery affecting the veins, which has an indirect effect on the healing o f the ulcer, and (2) The direct application o f surgery to the ulcer area. A. Aims o f Treatment: (a) To attempt to correct the defective circulation present. (b) To hasten healing. (c) To try and prevent any possible back flow o f blood. B. Methods o f Treating the Veins: (a) “Bloodless stripping operation on the internal saphenous vein. (b) The removal o f varicose veins, which in many in­ stances, prevents the onset o f ulceration and induration. (c) Ligation o f sections o f the great saiphenous vein along its course, usually below the sapheno- femoral opening. ,A short setion o f vein between the ligatures is resected. In addition, multiple incisions may be made at a distance o f 1-in. or so from the ulcer, thus ligating all varices feeding the area. Areas o f good tissue are left, however, between the incisions to supply nourishment to the part. This ligation o f the great saphenous vein at the foramen ovale, can be followed immediately, or at a later date, by injection o f offending veins. This is the more modern form o f treatment employed. . (d) The injection treatment o f varicose veins: The principle o f injection into a vein, is to inflame and damage the inside wall, so that the vein becomes a solid cord which has no inside passage. This cord becomes more and more fibrous, and is finally absorbed. - The injection used is sclerosing, not clotting, so no danger o f embolism exists. Various drugs and techniques are used. The treatment is indicated in the case o f : (i) Varices which have developed the complications o f ulcer, eczema, etc. (ii) Tortuous veins o f the calf and leg, so large and painful as to be disabling to the patient. Injections are absolutely contra-indicated in the case o f distended, superficial varicose calf veins, which are secondary to the obliteration o f deeper veins, by attacks o f phlebitis. Injection cures only the offending veins, and does not affect the patient’s tendency to have, and to develop varicose veins. Even after healing, the area readily breaks down due to inattention to veins, and no instructions as to the wearing o f elastic stockings or bandages. The surgeon always injects into an aseptic state. Usually a few days in bed with the limb elevated, and hot saline packs, relieve the inflammation and oedema, prior to injecting. (e) Division o f the Popliteal Vein: Blocking o f the large avalvular vein trunk, at its lower end in the popliteal region, prevents any possible back flow. Contractions o f the calf muscle, drives the blood through numerous fine-calibred channels into the veins in the muscle o f the thigh, and no back flow occurs. This operation is preferred as a routine now by Gunnar Bauer, at Mariestad Hospital, Sweden. Out o f 245 cases treated, 180 had open ulceration and 33 had a history o f repeated ulceration. All cases responded and healed in a time shorter than with conservative treatment. A t the same time as dividing the popliteal vein, those veins with a retrograde blood flow were dealt with, either by dividing, injecting or stripping. It was found that the use o f anti-spasmodic drugs and repeated sympathetic blocking, was o f little or no value, but lumbar sympathectomy caused rapid healing. C. Surgery Applied to Ulcer Area: (a) Skin Grafting: In time, most ulcers heal, but when the ulcer has begun to heal and is clean, the burying o f skin grafts in the granulations in the ulcer hastens a cure. The graft is not undertaken until all coarse, watery granulations have disappeared, infection cleared up and the ulcer bed covered with fine epithelial granulations. Preliminary bed rest is often advocated, to reduce the oedema and clear up sepsis. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) J anu ary, 1955. P H Y S I O T H E R A P Y Page Fifteen The skin from which the graft is to be taken, must be thoroughly cleaned. This area is usually the thigh, and the graft is taken under local anaes­ thetic. For ambulatory treatments, small pinch grafts are implanted in the ulcer area and hasten epithelia- lisation. When a large Thiersch graft is used, the ulcerated scar is sometimes excised because with oedema, scarring and induration, fibrous tissue forms causing a dimished blood supply, which lessens the chance o f a graft taking. Firm pressure is maintained over the graft for some time post-operatively. (b) Autohaemic Treatment: This method o f treating ulcers was described by Nade. Blood was drawn from the patient’s ante- cubital vein. This was applied by dropping or blowing it into the ulcer surface, and spreading it into a film which is allowed to clot. O f 15 cases treated, 9 were cured, 2 improved and 4 were un­ changed. Further investigation is being carried out on ulcers by irradiating them, with strong doses o f ultra violet light, before applying the blood. (c) Excision o f Area. Some surgeons excise the whole ulcer area, and let the wound heal by granulations. Any form o f surgery is definitely contra-indicated where any infection is present. Badly infected and necrosing ulcerations, must be cleared up and pre­ ferably healed, before any operation performed. Operative treatment may cause an ulcer to heal, but the patient still has much oedema and swelling o f the lower legs, and still requires support for the extremity. Future trauma to the area, may and probably will cause re-ulceration. The patient has little chance o f permanent healings After operative treatments too, patients generally remain in bed from 2—3 weeks and there is a distinct possibility o f post-operative embolus and death, especially in obese patients. 10. MEDICAL METHODS. In addition to giving support to the dependant extremity, and o f correcting the pathological circulation present, the local application o f soothing, healing preparations has been accepted. A. Unnas’ Cast and Adhesive Strips: Unnas’ cast and adhesive strips have been the most popular and accepted as the most efficient form o f treat­ ment, until the past few years. It used to be the best hope o f the surgeon ,in treating this condition. Many doctors to-day advise that the cast be applied directly over the large, open, weeping, badly infected ulcer area, and changed every two or three days. Formula fo r Unnas' Paste: Zn. Oxide ... 30 parts. Phenol ............ 2 Gelatin ............ 30 Glycerine ... 50 Water ........... 90 „ The gelatin is soothing to the skin, and acts as a medium to carry any medicant with which it is mixed. The glycerine is sedative and soothing and helps to take care o f excessive perspiration, due to its affinity for water. The Zinc Oxide is mildly antiseptic. Ichthyol and other drugs are often incorporated. The solution is made up, mixed thoroughly and set aside to cool, to form a semi-solid mass. The con­ tainer is placed in hot water to soften and warm the paste. It is applied from the knees to the toes. The leg is wrapped in a cotton gauze bandage, applied evenly with no ridges over the tibia. The heel is left uncovered. Over the layers o f bandage, another layer o f Unnas’ paste is applied, and rubbed into the bandage. This repeated and allowed to cool. Several layers o f gauze may be used. To-day bandages are prepared which have the Unnas’ paste rolled in. Ichthyopaste and-viscopaste bandages are the most common, and are easier to apply. Support is thus given to the extremity, and if maintained, the patient can be assured that the ulcer will heal. These pastes are only applied when the ulcer is practi­ cally healed, according to McPheeters and Anderson. The first cast is removed at the end o f one week. The area is inspected and unless other conditions have developed, a new cast is applied. This is left on for two weeks, then removed and a new one applied. This is left on for two, three or four weeks. The Unnas Cast is clumsy and unsightly. The method o f strapping with adhesive strips, applied, directly to the ulcer area for support, has given good results. The limb is strapped with strips o f adhesive, one after the other, beginning at the toes and working upward. Each succeeding strip o f adhesive, overlaps the .one below, until, the foot, ankle and lower leg are strapped well above the ulcerating area. The strips are applied snugly. This is similar to the application o f the Unna paste, and the basic principle of both these methods is practically the same. The adhesive strapping is left on, and allows the wound to become bathed with its own pus secretion, until it finally oozes through between the strips o f plaster and saturates the dressing. The strapping is then removed, wound cleansed and restrapped. Adhesive bandages may give rise to dermatitis, and it is then advisable to apply Ichthyopaste, viscopaste or an Unna bandage. A Crebon bandage, made up o f lead plaster, colophony and soap, under the elastoplast, mini­ mises the risk of dermatitis. All bandages must be carefully removed to avoid destruction o f granulation tissue. B. Ointments and Lotions: , If the ulcer and tissues are badly inflamed and painful, the patient is put to bed with the application o f hot packs. These quieten down the inflammation, and the additional use o f a supportive bandage hastens healing. Mildly stimulating ointments and lotions are used, but these mainly prevent dressings from sticking to the granu­ lating surface. Any mild ointment, preferably a Zn. Oxide base with a mild stimulating, healing medicament is good. Iodine seems to be o f definite, positive value in the treat­ ment o f chronic ulcers, but does not help all cases. It has been found that the use o f hyaluronidase, in the treatment o f chronic ulcers, has been successful. The ulcers over the malleoli, were painful and disabling and o f long duration. They were resistant to all the usual therapeutic measures. Hyaluronidase is an enzyme, prepared from bovine testes, snake venom, bacteria and other sources, and is applied by iontophoresis and subcutaneous injections around the ulcer. Tissue metabolism is improved, and the passage o f necessary agents into the ulcerated area facili­ tated. The ulcer base, healed with red granulating tissue and healing was characterised by the near absence o f visible scar tissue formation. Inflammation disappeared, but oedema was still present, and this persistent oedema con­ tributed to the difficulty in final epithelialisation. Pain was relieved. It is to-day applied in powder form. It is, however, not so much the ointment applied to the ulcer surface, as the tight compression bandage, together with walking, that promotes healing. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page Sixteen P H Y S I O T H E R A P Y January, 1955. C. VACCINE TREATMENT. Some authors, Pondorff being the most prominent, believe in the vaccine treatment, and in the development from the bacteria present in the ulcer, o f an autogenous vaccine with which the patient innoculates himself against his own infection. He thinks the secretion from the ulcer area, which is retained by the Unnas cast or bandages, softens the indurated skin. A secondary absorption occurs through this softened skin, surface, and the patient becomes innoculated with his own vaccine. Few to-day agree with this theory. More recent treatment, is the introduction o f vaso­ dilating drugs through the skin, by means o f iontophoresis. These should, however, only be used as adjuncts to the supportive therapy, which is more corrective of the path­ ology present, and is the basic principle o f treatment. 11. PHYSICAL METHODS. Physical treatment aims at bringing about a return to normal activity, and is based upon recent findings con­ cerning the direction o f venous flow, when the patient begins to walk. When the patient is standing still, the veins are filled with blood, and the upward flow is almost neglible. Walking is thus encouraged because of the effect o f muscular contraction on the deep veins. Previously, patients were treated with prolonged bed rest, but this is contra-indicated as the muscles atrophy from inactivity, and the circulation becomes more sluggish. The types o f patient treated are those with healing or recently healed ulcers, or dry, scaling unhealthy skin, caused by disturbed venous return. The success o f treatment depends upon the patients’ co-operation and they must be made to understand all instructions concerning the care o f the leg. Written in­ structions on home care should be given as well. Patients should be made to report for re-examination at lengthening intervals, and must report any slight relapse. The length o f time spent on treatments, a minimum o f J hour, places heavy demands on hospital staff, but the results justify it. A .Aims of Treatment: (i) To prevent stagnation o f blood and tissue fluid under and around the ulcer, and hence improve the circulation. (ii) To reduce oedema present. (iii) To give support to dilated varices, mechanically holding their walls compressed. (iv) To counteract the effects of gravity. (v) To soften areas o f induration in the lower leg. (vi) To control infection and promote healing. (vii) To improve the nutrition o f the skin. (viii) To approach the patient psychologically, and en­ courage him to get well. (ix) To rehabilitate the patient. (x) To prevent recurrence o f the condition. B. Means of Treatment: Numerous methods are employed to-day. The Bisgaard method, however, seems to have taken precedence over most other forms o f treatment, and is used by many, even if in a somewhat modified form. Before proceeding to a detailed description o f this method, some o f the electrical means employed will be considered. (a) Short-Wave Diathermy: This method aims primarily at improving the circulation, clearing up infection and reducing oedema. If a faulty sensation and excessive congestion in the parts is present, an indirect heating in the form o f lumbar diathermy should be applied. A mild thermal, progressing to a thermal 'treatment is given, until the toes become warm. If sensation is normal and the part not congested, a cop- lanar treatment to the lower leg is given. The heating should be athermal, and applied for 5 minutes progress­ ing to 10 minutes. (b) Ultra-Violet Light: This method o f treatment is used in cases o f infection and extreme indolence. It aims at sterilising the floor o f the ulcer bed, improving circulation, promoting healing, and freeing the area from a foul odour. It can be given alone or combined with Short Wave Diathermy. ■ A first degree erythemal dose is given to the whole o f the surrounding area, and progressed by 25 % each day. A double fourth, degree erythemal dose is given to the ulcer area, with surrounding protection. This dose destroys bacteria and produces a vasodilation at the base o f the ulcer, with resultant increase of discharge from the wound. The treatment is given twice a week, or on alternative days, when Short-Wave Diathermy is used. Infra-Red may be applied over the wound, but is a super­ ficial heating and o f not much use. (c) Faradism Under Pressure: This method is used for gross oedema, and assists the mobility o f the joints. A dressing is applied over the ulcer. Two large pads, one under the sole o f the foot, and one under the calf, are applied and secured in position by a Bisgaard bandage. The treatment is given for 5 minutes, a rest and then 1 another 5 minutes, progressing to 15-20 minutes, with frequent rest periods. This treatment can be given daily. (d) Zinc Ionisation: This method is used for its drying effect on a weeping wound. It prevents infection, is slightly antiseptic, and aids the circulation. The ulcer is packed with ribbon gauze, soaked in a 1 % Zinc Sulphate solution. The active pad is then placed over and y-in. round the ulcer. The amount o f current used is 4 m.a. per sq. ins. o f wound, and the treatment given until the needle drops. The poles are reversed at the end of treatment, to facilitate an easy removal o f the pad. Treatment should only be given twice a week. A dry dressing is used to cover the wound in between treat­ ments. (e) Ultrasonic Therapy: The first successful attempts to employ ultrasonics therapeutically were made in 1939. Only recently, however, has research laid down the principles o f the therapy. Irradiation by ultrasonic waves, sets tissue particles in very rapid but small vibrations. The ultrasonic energy is absorbed in the tissues and converted into heat. Two effects are produced, viz.: thermal and mechanical. (i) Thermal effects: There is a rise in temperature o f several degrees. The organism responds to the stimuli by hyperaemia, limited only b'y increased heat dissipation at high temperatures. Biochemical reactions may be started or accelerated. The nature o f these waves is similar to those o f short wave Diathermy, but is confined more to the periphery, and hence more localised. (ii) Mechanical effects: There is a vibration in the tissues, but the nature o f these effects is not fully elucidated. There is possibly a rise in the permeability o f cell membrances, which begin or accelerate osmotic processes. It is thought to aid the thermal effect, in increasing metabolism and is said to have an analgesic and spasmolytic effect. These effects are beneficial in cases which need hyperaemia, stimulation o f metabolism, and analgesia or relief o f spasm. They are employed in inflammatory processes, because of the production o f hyperaemia in deep tissues. They often cause more rapid regeneration in indolent wounds, like varicose ulcers. (To be continued.) R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) January, 1955. P H Y S I O T H E R A P Y S O U T H A F R I C A N S O C I E T Y O F P H Y S I O T H E R A P I S T S . Members o f the Society receive Hospital Training. They are qualified to administer Massage, Remedial Exercises, Electrical, Ultra-Violet Ray and Hydro-therapy treatments. The Society was formed in 1924 and is the only body o f Physiotherapists in this country to receive the full recognition and support o f the South African Medical Association. S.A.S.P. Members do not advertise individually and pledge themselves to treat patients only under medical direction. All members o f the Society are eligible for enrolment on the National Register of the South African Medical and Dental Council. Names and addresses o f members practising in any district can be obtained from the General Secretary. S.A. S O C IE T Y O F P H Y S IO T H E R A P IS T S . President : Miss S. Oosthuizen, P.O. Box 6468, Johannesburg. General Secretary: Miss H. Baines, Physiotherapy Dept., P.O. Box 11151, Johannesburg. Registrar: Mr. A. Rothberg, W .N.L.A. Hospital, Eloff Street Extension, Johannesburg. General Treasurer: Miss H. M. Benford, 47 Lister Buildings, Jeppe Street, Johannesburg. Appointments Secretary: Mesdames Douglas and Benford 47 Lister Buildings, Jeppe Street, Johannesburg. Editor: Miss Lois Dyer. Journal Treasurer: Mrs. M. Levy, 105, Acacia R oad Blackheath, Johannesburg. All communications should be addressed to : MISS LOIS DYER, PHYSIOTHERAPY DEPARTMENT, GENERAL HOSPITAL, JOHANNESBURG. BRANCH SECRETARIES. Southern Transvaal: Miss C. Baker, Physiotherapy Dept., General Hospital, Johannesburg. Northern Transvaal: Miss F. de Bruin, Physiotherapy Dept., General Hospital, Pretoria. Natal & Zululand: Mr. M. Dunlop, King Edward Hospital, Durban. Northern Cape: Mrs. M. Thomas, 16, Atlas Street, Kimberley. Orange Free State & Basutoland: Miss E. B. Greig, Physio­ therapy Department, National Hospital, Bloemfontein. Cape Peninsula: Mr. M. D . Oliver, Room 33, Adderley House, 80, Adderley Street, Cape Town. |Port Elizabeth & Eastern Province: Miss M. N . Sugden, Guardian Buildings, Main Street, Port Elizabeth. East London & Border: Miss J. Scott-Russell, Physiotherapy Dept., Frere Hospital, East London. + + + A D V E R T IS E M E N T RATES OUTSIDE Back Cover ................ £12 10 INSIDE Front „ .................... .... £11 10 Back „ .................... £11 0 Whole Page ................ £10 10 .. i Front Cover ........... £6 0 .. i Back ,, ........... .... ... £5 15 .. i Page ............................ £5 10 .. i .... £3 5 A D V ER TIS IN G SPACE AVAILABLE A p p l y : Hon. Treasurer: Mrs. M . Levy, 1 0 5 , Acacia Road, Blackheath - Johannesburg. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )