Surgery, with Special Reference to Podiatry Part 26

CHAPTER XVIII

+THERAPEUTIC MEASURES+

+HYPEREMIA+

+Hyperemia+ as a therapeutic agent was described by Bier and is of two kinds, _active_ and _pa.s.sive_. The former is the same as the _arterial_, while the latter is the _venous_. Between the blood of active and pa.s.sive hyperemia there are important physical and chemical differences, the one containing much free oxygen with but little carbonic acid and alkali, while the other presents the exactly opposite character.

In active hyperemia normal elements of the blood are kept in active motion, while in the pa.s.sive form they are allowed to escape, more or less, into the tissues.

Hyperemia possesses a great many properties:

1. Power to diminish pain.

2. Bactericidal action.

3. Absorptive property.

4. Solvent action.

5. Nutritive power.

6. Suppression of the infection.

Hyperemia may be produced in three ways; _first_, by means of the elastic bandage or band; _second_, by cupping gla.s.ses, and _third_, by hot air. The first two produce venous or pa.s.sive hyperemia, and the third, arterial or active hyperemia.

+Pa.s.sive Hyperemia.+ This obstructive hyperemia is produced by means of a thin, soft rubber elastic bandage, two or three inches in width, better known as the Esmarch, or Martin bandage. When this is applied moderately tight around a limb about six or eight turns, one layer overlapping the other, pressure is evenly distributed over a comparatively wide area, causing the subcutaneous veins below the constriction to swell; the extremity becomes somewhat bluish red in color, also larger and edematous, giving a feeling of warmth to the touch.

The rubber bandage, properly applied, should not cause any uncomfortable feeling and there should be absolutely no pain present.

At all times one must be able to feel the pulse below the site of the bandage. If the bandage is applied too tight, the skin of the limb looks grayish-blue and there appear whitish, or vermilion colored spots, which grow larger and larger, as long as the too tightly drawn bandage is on. Paresthesia and pain, with disappearance of the pulse, can also be noted.

The two cardinal rules to be observed in the application of the bandage are: (1) absolutely no pain with the application of the bandage; (2) the pulse at all times must be felt below the bandage.

In cases which require the bandage to remain in place from sixteen to twenty hours each day, it will be necessary to first apply a soft flannel bandage underneath the rubber one in order to prevent pressure necrosis.

Frequently changing the location of the bandage up and down the extremity, and treating the skin with alcohol rubs, will also be helpful to patients with a tender skin. The elastic bandage must always be placed upon a healthy area, proximal to the diseased part.

All dressings should be removed while the compressing bandage is on, in order that the part may become hyperemic.

Wounds or sinuses are covered with sterile gauze and kept in place with a towel, fastened with a few safety pins.

In acute inflammation, septic wounds and phlegmons, the increased inflammation is apt to frighten the beginner, but this is a desired phase of the treatment.

As a prophylatic against infection, it cleanses the wound, produces a local immunization and reaction before the infection has a chance to work; the earlier the bandage is applied the more remarkable is the effect.

For incised wounds of the foot with division of the muscles and tendons, if the tissues are not too seriously injured, the muscles and tendons should be united and the skin closed with interrupted sutures sufficiently far apart to allow free excretion. No drainage is employed and a slight compressing dressing is applied. The elastic bandage is applied very lightly, producing only a slight venous engorgement and the bandage should remain on from ten to eighteen hours a day.

As soon us the symptoms of acute inflammation subside, the time of application of the bandage is reduced. If signs of suppuration are present, the wound should be promptly opened and the pus evacuated.

The knife takes care of the pus; hyperemic treatment fights the infection.

In gonorrhoeal arthritis of acute or chronic nature, and in cases of tuberculosis of the bones and joints, the pa.s.sive form of hyperemia is especially indicated.

The use of cupping gla.s.ses is limited to abscesses, furuncles and sinuses.

+Active Hyperemia+, or arterial hyperemia, is produced by means of hot-air boxes such as the Tyrnauer electric apparatus, or the gas apparatus of Betz.

Active hyperemia increases the arterial blood to any part of the body, thus favoring the absorption of chronic exudates, infiltrates, adhesions, etc. Dry, hot air permits the use of a high degree of temperature without injury or pain to the respective part.

For neuritis of the foot, ulcers, especially diabetic, perforating and varicose, and for the stiffness following a chronic inflammation, or after a fracture, the arterial form of hyperemia gives good results.

+COLD+

+Cold+, or the rapid abstraction of heat, is a remedial measure that is nearly always available and is possessed of very great power for good in selected cases.

When cold is applied for its limited and local action, it is always used with two objects in view, namely, (1) to cause localized contraction of the blood vessels, which through inflammation are engorged, so that the parts are swollen and reddened; or (2) temporarily to anesthetize or benumb the nerve terminals, for the immediate relief of pain, in the hope that the temporary paralysis may ultimately result in such changes as to produce a cure.

Cold, in some form, is a popular remedy for a sprain, or any injury likely to be followed by inflammatory processes. A very useful remedy for the sprain of an ankle, when it is a recent accident, is to let the patient sit with the foot elevated, with a cloth wrung out in ice water, and an ice bag applied over the affected part.

In the treatment of localized pain or inflammation, cold is used in a number of ways, largely depending upon the will of the physician and the means of the patient. The simplest, cheapest, and perhaps the best method of using cold, is to place cracked ice in a rubber bag, the latter to be thoroughly watertight, lay it over the inflamed part, surrounding it with a towel so as to prevent the moisture, which appears on the surface from condensation, from wetting the clothing.

+HEAT+

+Heat+ is used locally for a number of purposes in the same manner as cold, and the choice of heat or cold in the treatment of any acute form of inflammation depends almost entirely upon the wish of the patient, who generally can tell at once which will give him the greater comfort.

In sprains of the ankle, nothing compares to a hot foot-bath prolonged for hours, the object being to decrease the pain and swelling, thereby regaining the use of the limb.

The high degree of heat which can be borne by gradually increasing the temperature of the water by the addition of small quant.i.ties of scalding water, is extraordinary, and the favorable results obtained are in direct ratio to the height of the temperature.

Between these soakings, the part should be dressed with lead and opium wash, and rubbed with ichthyol ointment or camphor liniment.

Hot-water bottles or bags are also used locally for the relief of congestion and pain.

+THE HIGH FREQUENCY CURRENT, OR VIOLET RAY+

+The Violet Ray or High Frequency Current+ is one which is in a rapid state of to-and-fro vibration and is applied through vacuum gla.s.s attachments or electrodes, which are excited to a beautiful violet color. The discharge may appear to the eye to be a single spark, but it is made up of a number of successive sparks, following each other with such extreme rapidity that they are said to oscillate (change directions) millions of times per second, a speed that the eye cannot note. The rapid oscillations have the effect of producing the following phenomena:

1. the high frequency current is unipolar, that is, does not require a complete circuit.

2. gla.s.s does not insulate the high frequency current as it does ordinary electricity.

3. the high frequency current generates enormous quant.i.ties of ozone during its flow.

4. the current does not produce any pain.

5. the high frequency current produces a cellular ma.s.sage.

The contractile effect is expended upon the individual cells making up the tissues, instead of on individual muscles.

If a sedative effect is desired, keep the electrode in contact with the part; if a stimulating effect is desired, hold the electrode away from the surface; the farther away, the longer the spark.

A uniform spark of any length can be produced by administering the current through layers of toweling, or through the clothing; the length of the spark depends upon the thickness of the layers.