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CHAPTER 30
most helpful in assessing the value of any local treatment recommended in the literature,
such as poultices of carrots and turnips, linseed oil, bread (Paget, 1873), scarlet red, zinc
oxide, tulle gras, or tincture of benzoine (Munro, 1940), fomentations (Riddoch, 1917),
tannic acid (Latimer, 1934), aluminium, gold leaf (Gallagher & Geschichter, 1964; Oden,
1967), hyaluranidase (Davenport, 1962), animal collagen (Wanke & Grozinger, 1965;
Stoop, 1970), negative air-ions (Ursu, 1970) and others. Unfortunately, most of these
local procedures advocated do not give exact data and, therefore, comparative assessment
of their value is impossible.
Amongst the various local treatments advocated, the ultra-violet treatment needs
special mention, as it is still widely used by physiotherapists in the treatment of sores.
From my own observations on pressure sores in paraplegics, I came to the conclusion
that it has no advantage over any other local treatment unless at the same time the prin
ciple of avoiding pressure and the application of proper dressings, as outlined above, are
strictly observed (Guttmann, 1970). It must be remembered that in pressure sores one
deals with devitalized tissue. Therefore, a proper dosage of local applications of ultra
violet to the devitalized tissues is difficult and often impossible but there is no doubt that
stronger doses have resulted in burns (personal observation).
The uncertainty of the value of so many local treatments has recently been aptly
summed up by Dr Dollfus by quoting Dr Vilan of Paris, 'You can put anything you like
on a pressure sore, except the patient'.
It has already been mentioned that one obstacle in the healing of pressure sores is
intractable spasticity, particularly in complete transverse lesions of the spinal cord, which
not only delays the rate of healing but makes later plastic repair of the sore difficult if not
impossible. Major operations to deal with this complication, such as laminectomy with
posterior or anterior rhizotomy to transform the spastic lesion into a lower motor neurone
(i.e. flaccid) one, is, in these septic cases, most hazardous, as the profound surgical shock
following such a major operation naturally increases the immediate danger to life of these
often seriously ill patients. However, today such operations can be avoided altogether,
as they can easily be substituted by intrathecal alcohol injections (Guttmann, 1953).
SURGICAL REPAIR
Epithelialization by pinch graft or 'postage stamp' grafts
The combination of surgical excision of sloughs and conservative management after
wards, as outlined above, has proved highly successful in our cases throughout the years.
Sores of gigantic size and great depth could be healed and the resulting scar was, as a
rule, a third of the original size of the sore (Fig. 112). As mentioned above, epithelializa-
tion of large sores over the sacrum can be accelerated surgically by skin grafts once the
granulations have reached the level of the surrounding skin. We prefer pinch grafts to
'postage stamp' grafts as they take more readily. Pinch grafts are obtained by inserting the
point of a wide-bore surgical needle into the skin of the donor area and removing a cone
of the skin. Fig. 213 demonstrates the way of epithelialization following pinch grafts. The
epithelium spreads irregularly from the centre of the pinch graft and confluent with the
