Historical Roots of the “Avoidable-Unavoidable” Pressure Ulcer Controversy

Some years ago while browsing in an antiquarian bookstore I opened a volume entitled Lectures on the Diseases of the Central Nervous System by Jean Martin Charcot published in 1877. Among the yellowed pages was an illustration of a necrotic sacral pressure ulcer, and my heart started pounding. I had come across one of the earliest descriptions of pressure ulcer pathogenesis. I excitedly purchased the book, and subsequently learned that I held in my hand the beginnings of the modern “avoidable-unavoidable” controversy on pressure ulcers and published my findings in two articles in the Journal of the American Geriatrics Society.

Dr. Charcot was one of the greatest physicians of the 19th Century, and described medical and neurologic syndromes that still bear his name. He worked in Paris where he headed the Salpêtrière, a chronic disease hospital that gained notoriety during the French Revolution when it was the site of an infamous massacre of French aristocrats. Charcot believed that pressure ulcers were an unavoidable result of damage to the brain or spinal cord because of “neurotrophic fibers” that connected the skin directly to the central nervous system. Charcot wrote:

“I have often been a witness to this fact, occurring among the aged persons in this hospital, and I have been many times able to satisfy myself that pressure on the spot occupied by the eruption did not here play an essential part.”

Charcot had an illustrious opponent by the name of Henri Brown-Sequard who tried to disprove Charcot’s neurotrophic theory of skin ulceration with experiments on small animals. In 1853 Brown-Sequard wrote:

“On guinea pigs, upon which the spinal cord was cut in the dorsal region, and on pigeons, upon which the spinal cord was destroyed from the fifth costal vertebra to its termination, I have found that no ulceration appeared when I took care to prevent any part of their bodies from being in a continued state of compression, and of washing them many times a day to remove the urine and feces…”

This was an amazing and unique time when two of the greatest minds in medicine were concerned about bedsore pathogenesis, but unfortunately pressure ulcers dropped off the medical map for over a century. It took the demographic change toward an aging society to revive the discussion on pressure ulcers and cause the medical profession to refocus on their importance. This demographic change was ushered in by improvements in public hygiene and medical advances that prolonged the human lifespan and allowed people to live longer with multiple comorbidities.

Today there is renewed controversy as to whether pressure ulcers are avoidable or unavoidable, particularly in the “pay for performance” era. Most authorities agree that pressure ulcers are a quality indicator, yet few will say that all pressure ulcers are avoidable. The expert consensus published by the National Pressure Ulcer Advisory Panel stated that “not all pressure ulcers are avoidable.” In 2010, the Centers for Medicare and Medicaid Services (CMS) enacted a “no-pay” policy for hospital acquired pressure ulcers on the assumption that pressure ulcers are reasonably preventable using currently available clinical practice guidelines.

Certainly there are medical factors that cause certain pressure ulcers to be unavoidable. Some believe that the key to unavoidability is in the process of dying, and you can read more about the Kennedy Terminal Ulcer and Skin Changes at Life’s End (SCALE). I believe that these arguments have validity, but there are also factors apart from the dying process that lead to unavoidable pressure ulceration including forced immobility, pre-existing illnesses, and hemodynamic factors that impact adversely on blood supply to skin and soft tissues.

Jean Martin Charcot was a visionary and pioneer in the medical field. He was one of the first to use photography in his medical work, and studied hysteria and hypnosis decades before the psychoanalytic era was ushered in by his student Sigmund Freud. He also started the controversy on avoidable and unavoidable pressure ulcers a century and a half before these wounds became commonplace in today’s medical practice.

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Download my article:  The Unavoidable Pressure Ulcer: A Retrospective Case Series.

Related posts:

Cluttering up the Pressure Ulcer Staging System
New Research Sheds Light on Hospital-acquired Pressure Ulcers.
Determining the Avoidability of Pressure Ulcers.
New Pocket Guide to Pressure Ulcers.
Wound Healing Products:  From Ancient to Modern Mythology.

References for this post:

 

Levine, Jeffrey M. Historical Perspective: The Neurotrophic Theory of Skin Ulceration. Journal of the American Geriatrics Society (JAGS) 40: 1281-1283, 1992.

Levine, Jeffrey M.  Historical perspective on pressure ulcers:  The Decubitus Ominosus of Jean-Martin Charcot.  Journal of the American Geriatrics Society (JAGS) 53: 1248-1251, 2005.

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Dr. Jeffrey M. Levine has authored numerous articles on topics related to healthcare of the elderly. These include medical history, prevention and treatment of chronic wounds such as pressure ulcers, elder neglect and abuse, and physical restraints. He has also edited a book on legal and regulatory aspects of nursing homes.