NEW SERIES, VOL. VIII APRIL, 1930 No. 1

-- -

CHRONIC LEG ULCERS TREATMENT WITH UNNA’S PASTE BOOT

R. A. CUTTING, M.D., PH.D.

NEW ORLEANS, LA.

0 F ALL the cases coming under the

care of the surgeon perhaps none is more aggravating than the case of

chronic Ieg uIcer. Patients presenting chronic Ieg uIcers are frequentIy in rather good health except for their IocaI lesions, and may even fee1 in no way incapacitated for the reguIar duties of a more or less active Iife. Leg uIcers, however, are Ioathe- some Iesions, particuIarIy to a person of sensitive disposition, and any reIative Iack of physical incapacitation shown by the victim may be more than offset by a deIeterious effect on his psychoIogica1 reactions. Patients with incapacitating lesions of far Iess actua1 significance than these usuahy take to bed as a matter of course and are content to remain at rest unti1 such time as nature shah have had a chance to establish the process of repair; patients with chronic Ieg uIcers, however, tend to become restIess when confined to bed and sometimes, taking matters into their own hands, may insist upon ambula- tory treatment. Such treatment failing, they tend to drift from one surgeon to another without finding permanent reIief, uItimateIy Iose confidence in the medical profession at Iarge, and soon faI1 easy prey to patent medicines and to various forms of actua1 quackery.

No singIe measure can be advocated as a therapeutic panacea for all chronic leg uIcers, since these uIcers vary so wideIy

in their etioIogy, but, combined with appropriate accessory therapy, there nev-er has been devised a more efficient treatment than the Unna’s paste boot or stocking. Unna’s paste is no new substance, having been devised by the Hamburg dermatoIo- gist, PauI Unna, who was born in 1850; the method of fashioning this paste into a boot or stocking is also not new, having been used extensiveI\.; for the purpose in question by many able surgeons both past and present. The author, furthermore, wishes to discIaim a11 credit for originaIity in the detaiIs of preparing and applying the device, since, in the description of the technic which is subsequently given, he foIIows a method which has been recog- nized and practiced with success by many individuaIs for severa years. He feels, however, that the device has not received the general recognition which its vaIue justifies and beIieves that if the rationale of its use and the method of its preparation were more generahy known it would be more frequentIy provided, and patients consequently wouId not onIy be spared much suffermg, both physical and mental, but wouId aIso be sav-ed many days of economic usefulness.

Complicating the Iuetic ulcer, the pres- sure uIcer, and the mycotic uIcer, and tending to reach its acme in the varicose uIcer, is almost invariably a certain degree of Iocal venous stasis and associated tissue

* From the Department of Surgery, TuIane University Xkdicnl School, New Orleans, La Submitted for pubkation January 6, 1930.

713

744 American Journd of Surgery Cutting-Chronic Leg UIcers APRIL, 1930

edema. MaIignant uIcers, neuropathic uIcers, and tuberculous ulcers frequently show varying degrees of the same phenom- enon. This stasis and edema is not, of course, the exciting cause in the develop- ment of any of these lesions, not even the varicose uIcer, which does not deveIop in the absence of trauma, but when once such Iesions have become established the stasis and edema may be sufficient to hinder seriousIy or even actuaIIy to prevent the process of compIete repair. The process of repair consists not onIy of the deposition of new tissue, but of the remova of devitaI- ized and partiaIIy autoIysed debris. When- ever the venous return from an injured area is so disturbed that this remova of tissue debris is interrupted, the IocaI tissue spaces, the Iymphatics and the venous capiIIaries become cIogged, arteria1 bIood is mechanicaIIy prevented from reaching the scene, such adjacent tissues as are stil1 vita1 tend to be deprived of their oxygen suppIy, and IocaI acidosis and progressive death of tissue ensues. UnIess some method of breaking this vicious circIe be invoked the best that can be anticipated is a sort of equiIibrium be- tween the forces of destruction and the forces of repair in accordance with which aIternateIy now the one and now the other is in the ascendancy, the resuIt being an “ indoIent ” Iesion which stubbormy re- fuses to hea1.

If patients with these indoIent uIcers can be persuaded to remain in bed for a period of weeks, associated infection of the ulcerating area being controIIed meanwhiIe by the use of hypertonic saIine solutions and heat, appropriate accessory treatment aIso being provided in the form of antisyph- iIitic treatment for the Iuetic ulcer, forma1 operation upon, or the injection of scIeros- ing soIution into varicose veins, in connec- tion with varicose uIcers, the exhibition of massive doses of iodides by mouth in mycotic uIcers (grs. 30-100 t.i.d.), and the Iike, there are very few cases of chronic leg uIcer which will not eventuaIIy proceed to compIete heahng. Genera1 bodiIy rest

undoubtedIy pIays some part in the pro- duction of this healing, since it allows a concentration, so to speak, of the entire excess of body energy on the affected area, but the IocaI reIief of bIood and tissue fluid stasis is much more fundamenta1 and important, and is undoubtedIy the factor primariIy responsibIe for the good cIinica1 resuIts obtained by the non-ambuIatory treatment.

Much has been written on the ambuIa- tory treatment of varicose uIcer, which, of course, is the chronic Ieg uIcer ordinariIy presenting stasis and edema in its most characteristic form, and aImost without exception, when reduced to their essentials, the methods invoIve the appIication of IocaI mechanica support to the part. The muItipIicity of devices used to produce such support, though indicating that none of them perfectIy reaIize the end for which they were designed, nevertheIess bear mute testimony to the correctness of the principIe invoIved. Most practitioners of experience have seen certain chronic uIcers hea under the simpIe expedient of 1ocaI support by criss-cross adhesive pIaster strapping; IocaI elastic pressure as obtained by the use of inflatable rubber bags or baIIoons, or by the resiIient porous rubber sponges of ordinary commerce, shouId aIso produce exceIIent results in certain seIected cases. Such devices, however, wouId seem to have a rather Iimited scope of usefuIness, since the usua1 indication is for a much more extensive support than they can easiIy be made to achieve. In reIativeIy few cases is stasis Iimited to the area of the Iesion, and when ulcerations are of considerabIe extent or, though reIativeIy smaI1, have existed for consider- able periods of time, stasis and edema are very apt to be not IocaIized at a11 but generaIized beIow the knee. The idea1 mechanica treatment wouId therefore seem to be some form of support which wouId exert gentIe and equal pressure over the entire surface of the foot and Ieg, and which, accordingIy, wouId assure for the ambuIatory patient essentially the

\.I IV SHRIE.S VOL. VIII, No. j Cutting-Chronic Leg Ulcers American Jnurnd of Surgrry I-45

same condition which is obtained in the attendant who prescribes the mode of case of the recumbent patient, an extremity treatment. UnfortunateIy patients advised de\ oid of venous and Iymph stasis. to use the elastic roIIed bandage rsreIy

The eIastic stocking can be made to receive from it the amount of benefit serve this supportive function fairIy weI1, which they might reasonably be expected but is subject to certain almost compIeteIy to enjoy. unav,oidabIe disadvantages: The Unna’s paste boot is subject to

I. W’hen produced in quantity and none of these disadvantages, whereas, bought by the patient ready-made eIastic at the same time, it affords better support stockings are apt to fit poorIy; when made than either the elastic stocking or the to order they are reIativeIy expensive. eIastic bandage.

2. Even though initiaIIy carefuIIy and I. The boot is a custom made, buiIt-up

accurateI?- fitted to the individual patient, affair, which conforms exactly to the

the device may very soon become quite shape of the part, because it is applied Iike

worthIess, due either to Ioss of eIasticity a cast. The materials from which the boot is

of the stocking or to actus changes in made are reIativeIy inexpensive and can

the shape and size of the limb as the case be easiIy obtained and prepared by aImost

progresses toward healing. any practitioner, nearIy anywhere, and

3. In order to be reaIIy effective the in the absence of elaborate technica

stocking must be apphed before arising facilities.

in the morning, i.e. after the recumbent 2. The boot does not stretch, and when

attitude assumed during the night has it ceases to fit accurateIy, due to changes in

relieved the affected part of much of its the shape and size of the part, it can,

fluid stagnation, and it shouId be appIied without compunction, be removed and

after the extremity has been heId for a repIaced with another because of its

number of minutes nearIy vertica1 in inexpensiveness.

order to faciIitate stir1 further reduction in 3. Being moIded to the part it cannot be

size. Patients of Iimited intelligence usuaIIy repIaced by the patient after it has been

fair to appreciate the necessity for atten- removed, and, accordingly, the patient

tion to this part of the technic, and a11 is compIeteIy under the control of the

patients tend to become careIess in observ- surgeon at a11 times; the apparatus

ing instructions; occasionaIIy they may functions perfectIy regardIess of the pa-

even negIect to wear the apparatus for days tient’s inteIIigence or cooperation.

at a time. 4. Being composed partIy of zinc oxide

4. The eIastic stocking is difficult to and being reIativeIy impenetrabIe to secre-

keep clean when used in the treatment tions, it can be used directIy over open

of an uIcer because of aImost unavoidable uIcers and does not speediiy become

contamination by secretions, and any objectionabIe through absorption of secre-

attempt to modify the device by cutting tions. When soiIed it is not washed and

hoIes or windows in it to aIlow treatment repIaced, but cut away and discarded.

of the uIcer without removing the stocking The Unna’s paste boot is never fenestrated,

defeats the entire purpose of the treatment, consequentIy it provides uniform support

since it abolishes support over the area over the entrre extremity.

where it is most needed. Unna’s paste consists of 4 ingredients

The elastic roller bandage would be of (there seems to be no good reason for

more vaIue to patients than it is were it modifying its composition by the addition

not so difficuIt to appIy singIe-handed and of other substances) :

were the patient’s inteIIigence and under- Zinc oxide, 4 parts

standing of the anatomy and physioIogy Gehtin. 4 parts

invoIved as compIete as that of the medica GIycerine. IO parts water... 10 parts

746 American Journd of Surgery Cutting-Chronic Leg UIcers APRIL. 19x0

The formuIa is easy to remember since it consists of four parts of each of the two sohd constituents and ten parts of each of the two Iiquid constituents.

The onIy substances entering into the formula which may possibly have some function other than a supportive one are the zinc oxide and the gIycerine. Zinc oxide is cIassified pharmacoIogicaIIy as an astringent; it is possibIy a very feebIe antiseptic. Inasmuch as it is of IittIe or no value when used by itseIf on indolent uIcers, the presumption is that its value when used as one of the ingredients of an Unna’s paste boot is not dependent upon its pharmacoIogica1 action. The same line of reasoning may be used for gIycerine. GIycerine is cIassihed as a mild antiseptic; it is aIso somewhat hygroscopic. Its antiseptic properties are so slight, however, that it is used as an ingredient in certain culture media, and its hygroscopic proper- ties apparentIy have IittIe to do with its usefulness in connection with the Unna’s paste boot, as the boot does not become noticeabIy damp, and secretions even from open uIcers penetrate it 0nIy reIativeIy sIowIy. Furthermore, there seems to be no apparent reason why the combination of zinc oxide and gIycerine or indeed the combination of a11 four ingredients, zinc oxide, geIatin, gIycerine and water shouId act essentially in any except a mechanica manner; certainIy the mixture when appIied as an ordinary dressing to indoIent uIcers produces no such spectacu- lar resuIts as when appIied in the form of a weWitting boot or stocking.

The appIication of an Unna’s paste boot is accordingIy believed to accompIish, by a mechanica appIiance, for the ambuIa- tory patient exactIy the same state of affairs as is accompIished for the recumbent patient by posture. The only advantage which the bed patient has over the ambula- tory case with a we&apphed Unna’s paste boot is genera1 bodiIy rest, an advantage which is probabIy of IittIe actua1 impor- tance in the average case of chronic Ieg uIcer.

The theoretica vaIue of the method is ampIy attested by the practica1 resuIts, Given 2 patients with similar Iesions and treated exactly aIike except that one is put to bed and kept there whiIe the other is treated with an Unna’s paste boot and aIIowed to go about his daiIy duties, the Iatter wiI1 improve aImost exactly as fast as the other and wiI1 be a much more contented and gratefu1 patient.

In appIying an Unna’s paste boot it is important to observe strictly the foIIowing technic, since modifications, however we11 meant, may make the difference between compIete success and utter faiIure.

Previous to the appIication of the boot in cases in which open uIcers are present on the Iower extremities or in which edema is extreme, a day or two, occasionaIIy severa days, of hospitaIization with rest in bed and eIevation of the part may be desirabIe in order to relieve edema and control gross infection. Patients with fou1 ulcers shouId be put immediateIy into a hot bath. In the contro1 of infection there is no agent which compares in efficiency with the use of hot, moist compresses of magnesium suIphate solution of about IO per cent strength. Such a soIution is suff~-

ciently hypertonic to prevent maceration of tissues and aIso to withdraw from the tissues pIasma and tissue fluids which in their passage outward serve most effr- cientIy to wash away bacteria and minute particIes of decomposing tissue and to bring antibodies into the affected area. Magnesium suIphate itseIf possesses the weII-known property of acting as a IocaI anesthetic when appIied to denuded surfaces.

The modern tendency in the treatment of infection is aImost entireIy away from the use of antiseptic in any case, but in preparing patients for the appIication of an Unna’s paste boot one shouId par- ticuIarIy avoid antiseptics, since uIti- mateIy the entire invoIved area is to be seaIed over.

Patients may be considered ready for the application of the boot whenever the

area surrounding the uIcer no Ionger should not be heated much above the shows the cIassica1 e\-idences of inflamma- meIting point of the glycerine, since it is tion ilocal heat, redness, swehing, and subsequently applied directly to the skin

FIG. I. Method of preIiminary draining of venous blood FIG. 2. Proper position of foot and leg during appiica- and tissue fluids from foot and Ieg just prior to application of Unnn’s paste boot. Part is kept elevated for at Ieast five minutes.

tion of boot; foot is heId by toes. First turns of bandage at base of toes and just below knee are:in pIace.

tenderness) and when during a period of observation of twenty-four hours the foot and Ieg are found to undergo but IittIe decrease in size.

At this time and prior to the application of the boot, if the uIcer is a varicose ulcer, the injection of the regiona varicose veins may be begun. One or more injections may be conveniently made at this first treatment, the boot being subsequentIy appIied and worn, and at the time of subsequent appIications of the boot addi- tiona1 injections may be made.

and wiII require cooIing before it can be appIied if initiaIIy heated to too high a temperature. Furthermore, an excessive amount of heat or unduIy proIonged heat interferes with the subsequent “set- ting” of the paste.

Having controIIed infection to a reason- able extent and !having drained the limb of excessive edema, the Unna’s paste boot is appIied in the foIIowing manner:

The boot is best appIied to the patient after at Ieast one night of rest in bed, before he has been ahowed out of bed in the morning, and after at Ieast five minutes of elevation of the part (Fig. I). If hairy, the patient’s foot and Ieg shouId receive preIiminary shaving. In any case the foot and Ieg shouId, of course, be scrupuIousIy cIean.

The ingredients of the Unna’s paste are mixed together,* pIaced in the inner com- partment of an ordinary doubIe boiler or rice cooker, and Iiquefied by means of heat. The proper consistency of the paste just prior to use shouId be that of thick cream or thin batter, and the mixture

The appIication proceeds with the pa- tient Iying on a tabIe or bed in dorsa1 decubitus, the leg being flexed upon the thigh and the thigh being flexed upon the abdomen; an attendant steadies the foot by grasping the patient’s toes.

* In case the geIatin to be used is of the solid or “flake” variety, and best in any case, the gelatin and water may be aIlowed to stand in contact over night; compIete liquefaction of the mass with heat on the foIIowing morning, addition of the gIyccrine and then of the zinc oxide, with constant stirring, foIIow.

The position in which the Ieg and foot are heId prior to and during the apphcation of the boot are most important both from the point of view of the efhcacy of the treatment and the patient’s subsequent comfort. The flexion of Ieg on thigh and thigh on abdomen reIaxes the caIf muscIes of the leg and makes possibIe the apphca-

748 American Journal of Surgery Cutting-Chronic Leg UIcers APRIL, 1930

tion of a snugIy fitting appIiance; the dorsiffexion of the foot ensures subse-

are permitted. At those pIaces at which foIding or “reverse turns ” wouId be re-

quent comfort in waIking and guards quired, the bandage is simply cut across

FIG. 3. Method of applying Unna’s paste with ordinary paint or varnish brush. Gauze roIIer bandage is heId in position ready to cut. Bandage is cut across and started again at different angIe in order to avoid making of “reverse turns.”

against any tendency to the production of foot-drop.

The first step in the actua1 apphcation of the boot consists of making a turn and a haIf of loose-meshed gauze roIIer bandage about the foot at the base of the toes and FIG. 4. Unna’s paste boot completed. Note difference

another turn and a haIf about the Ieg in size between two limbs. Circumference of treated

just beIow the knee. The bandage shouId foot and leg is much smalIer than that of opposite extremity, even disregarding thickness of boot.

be about 2 in. in width. (Fig. 2.)

The Unna’s paste, being of the proper

Support provided by boot is quite evident.

consistency and not too hot, is now with a pair of scissors and the winding is appIied directIy to the skin by means of 2 recommenced at the desired angIe. The in. paint or varnish brushes from the bandage, Iike the origina Iayer of region of the base of the toes to the bend Unna’s paste, extends from the base of of the knee, no portion of the surface being the toes to the bend of the knee and covers exempt, not even open uIcerated areas, the foot and Ieg, incIuding the hee1. A the paste being carried almost to, but second Iayer of Unna’s paste is now appIied not quite to the outer edges of the two over the Iayer of gauze bandage and over bands of gauze just previousIy appIied. this stiI1 another Iayer of gauze bandage. As soon as the initia1 Iayer of Unna’s (Fig. 3.) paste has been appIied to the skin surface In this way the boot is buiIt up to the and without undue deIay a layer or two of required thickness; usuaIIy about 5 Iayers the Ioose meshed roIIer bandage is appIied of gauze and 7 Iayers of Unna’s paste are directly over it. This Iayer compIeteIy required to provide a boot of suitabIe covers the area previousIy covered by thickness. The Iast Iayer of the boot the paste. No foIds of roller bandage, or should consist of Unna’s paste, and the “reversed turns ” as they sometimes called, entire hoot should be allowed to remain ___.~~ _ ~_

csposecl to the air until the surface has driecl or “set” to such a point that it is no longer sticky or “tacky” to the touch. The surface of the boot, when almost dry, may conveniently be dusted over with some suitable dusting powder, such as powdered talcum.

The finished boot conforms, of course, preciseIv to the shape of the foot and leg, because-it has been moIded thereto; and the Unna’s paste, when it has set, provides a support which is moderately eIastic, which is not heal-y or cumbersome, and which can be worn in compIete comfort and without being particuIarIy noticeable when covered bv the patient’s stockings (Fig. 4).

The patient may be aIIowed to dress and proceed with his reguIar duties as soon as the boot has become set and has been properIy powdered.

A single appIication of an Unna’s paste boot may suffice onIy in the simpIest cases; usually one or many reappIications are required, the period of time required for complete hearing of the uIcer being approxi- mateIg the same as that which wouId be required in the recumbent treatment.

The question of the frequency with which Unna’s paste boots shouId be changed is one of individual judgment. In those cases in which no open ulceration is present properIy appIied boots need not be changed for reIativeIy Iong periods of time, frequently severa months. The principa1 indications for the remova and reapplication are : (I) soiIing of the boot and (2) changes in the extremity such that the boot no longer fits and provides the support for which it was originally intended. In those cases in which extensive areas of uIceration exist and quantities of exudate are continuaIIy being discharged the boot may become soggy and require changing at much more frequent intervaIs, occnsionaIIy every three or four days. Perhaps in average cases the boot may be

aIIowed to remain for a period of three weeks or Ionger.

The reapplication of an Unna’s paste boot is a relatively simple matter. The boot is removed with scissors in the evening, the patient being given a hot bath with pIenty of soap and water. The patient is immediateIy put to bed and remains there until the boot is reapplied on the foIIowing morning. The renoplication is made preciseIy as in the original application.

One of the cardina1 principles in the appIication of the Unna’s paste boot and one which can never be disregarded is that no windows or doors shall be cut in it.

Furthermore, one shouId not discontinue the use of the boot too soon; otherwise the freshIy healed areas ma!- promptIy break down and uIcerate again. It is better to err on the side of conservatism and continue the treatment for some weeks beyond the time limit dictatecf by one’s first judgment and to reapply the boot subsequentry at the First sign of reappear- ance of the lesion.

The Unna’s paste boot, serving as it does a purely mechanica function, cannot be expected to take the pIace of essential therapy: antisyphiIitic treatment, iodides internaIIy, the recognized methods for the treatment of associated varicose veins, wide excision of maIignant tissue, and the Iike.

If the principIes of application as previously outlined are strictly followed and suitable accessory treatment is pro- vided, the apprication of the Unna’s paste boot provides a form of treatment which is nothing short of a reveIation to one who has tried man; of the other practical methods of treatment of chronic leg uhers. By use of this simple expedient many cases which previously were a source of vexation and disappointment wit1 be transformed to cases providing real satisfaction and pride.