THE USE OF HYPEREMIA IN THE POSTOPERATIVE TREATMENT OF LESIONS OF THE EXTREMITIES AND THORAX

C. E. TENNANT
1915 Journal of the American Medical Association  
DENVER In calling attention to the use of hyperemia in lesions of the extremities and the thorax, it is my purpose to refer only to the use of that form of treatment known as suction or cupping. In order to be successful with it, it is necessary for a large portion of the extremity to be contained within the vacuum chamber. To successfully create and maintain a vacuum in so large a chamber as will completely envelop an extremity, it is necessary to attach some form of electrically propelled
more » ... cally propelled motor, which should be so adapted as to be thoroughly under control while creating the vacuum. Under such favorable conditions a sufficient vacuum may be maintained for a period which will allow of complete and uniform hyperemia of all of the extremity enclosed within the chamber. This means that the veins become fully engorged with new blood, the tissues bathed in the vital fluid, and bactericidal agents liberated, setting free a far more effective death dealing agent to bacteria than any chemical agent known to-day, to say nothing of the stimulating effect imparted to the tissues about the wound. There are several lesions of the extremities in which I have found the use of the suction hyperemia to give very satisfactory results. One of these lesions is chronic varicose ulcer in all forms. By this descrip¬ tion is meant the kind of varicose ulcer which often baffles all ordinary means of treatment and tries one's patience. These cases all require a certain preliminary treat¬ ment, and I am in the habit of instituting hot, moist dressings, and the soaking of the extremity in very warm water at frequent intervals, during each day for at least two weeks prior to operating. This, of course, is hyperemia in one of its various forms, but this method only prepares the tissues for the subsequent work. After this preliminary treatment the tissues become soft and engorged with blood, and the granu¬ lations bleed quite readily. The patient is then anes¬ thetized, the granulating surface thoroughly curetted, and the fibrous tissue cleared away with the scalpel. Incisions are then made in the fibrous and healthy tis¬ sues surrounding the ulcer, in order that blood may flow into the area which is to be grafted with new skin. After drying the tissues in the usual manner, large Reverdin grafts are taken from an adjacent portion of the extremity and placed in close proximity over the denuded surface of the ulcer. Narrow strips of guttapercha are now placed over this graft, running at right angles to one another, and over this one or two layers of rubberized mesh. On top of this are placed several layers of sterile moist gauze and the usual dressings are applied. The limb is now put in a light posterior plaster-of-Paris splint, and on the following day, without disturbing the dressings, the leg is placed in a large Bier's hyperemic boot and light suction applied. This treatment is continued about thirty min¬ utes daily for three days. After this the dressings are removed daily, the surface washed with salt solution and the leg placed in the hyperemic boot for thirty min-utes. The dressings are then reapplied, using first the guttapercha, then the rubber mesh and other dressings. Under this method of treatment I have, so far, had about 90 per cent, of my grafts hold, and the period of convalescence has not exceeded eighteen days. At the expiration of this time a roller bandage is applied, painting it while so put on with a soft brush immersed in a gelatin préparation of zinc oxid (Unna's paste.) This makes a firm, elastic stocking, which fits the limb snugly and will not slip. This is left in position for at least six weeks following the patient's discharge. At the expiration of this time I am in the habit of having the patient fitted with an elastic stocking, in order to prevent, as far as possible, the recurrence of these ulcers in other portions of the same limb. I have also been surprised and pleased with the results obtained by the use of this same vacuum hyper¬ emia in the treatment of infected compound comminu¬ ted fractures of the extremities. Where the bones are in good apposition and anywhere about or below the elbow or knee, whether in a wooden splint or a snugly fitting plaster-of-Paris dressing, these extremi¬ ties can be easily placed in the vacuum chamber, and daily suction hyperemia instituted. -Each time the treatment is applied, the lacerated tissues and ends of the bone are bathed in blood and serum, these acting as bactericidal agents. Daily applications soon control the infection present and eventually leave a clot of fibrinated blood between the ends of the bone, thereby aiding osteoblastic proliferations. This same clot also aids very materially in hastening repair in the soft tissues. This method, if used for a period of thirty minutes daily, commencing immediately after the injury or operation, would probably reduce the period of disability and convalescence about 50 per cent. While I1 still strongly advocate the use of the open air methods in the treatment of burns, I am also strongly impressed with the use of this same hyperemic vacuum in burns of the second and third degree. Unfortunately, up to the present, this treatment can only be successfully applied to burns of the distal extremity. For more than ten years I have been using hyper¬ emia as a routine treatment in all my thoracotomies for empyema.2 During this time I have had no cause to regret its adoption and have been strongly impressed with a number of good features in connection with the treatment, since it has given quite uniform results. First of these is the rapid and effective emptying of the chest cavity of pus and blood, which is accom¬ plished through a medium sized opening. Second, the early and successful expansion of the lung as demonstrated by the Roentgen ray. Third, the early closing of the drainage site and the absence of post¬ operative sinuses with their annoying complications. These all make for an extremely short convalescence, which it has been my invariable good fortune to experience. The site for the incision should be in the median line of the area of dulness, and at the most dependent portion. The incision should parallel one rib, of which 1 y2 or 2 inches should be resected. Two large drain¬ age tubes are then inserted into this opening, and copious dressings applied, the patient having been in
doi:10.1001/jama.1915.02570450010002 fatcat:3hi4qyi7lvcx5kobukrqkn7a3i