CHAPTER III.
GENERAL RULES FOR THE APPLICATION OF HYPEREMIA.
- OBSTRUCTIVE HYPEREMIA BY MEANS OF THE ELASTIC BANDAGE.
As has been said before, this is the older and principal method.
This obstructive hyperemia is produced by means of a soft rubber bandage, same as is used for the production of artificial anemia in the case of bloodless operations on the extremities.
In slightly obstructing the return of the blood from the extremity to the heart with the aid of such a soft rubber bandage, the principal point to be observed is that the circulation be never entirely interrupted. What must be our aim is to retard the return of the blood from the extremity under treatment, in this way increasing the quantity of blood normally contained therein, but in no way to interfere with the influx of the blood through the artery. The bandage must be applied firmly enough to slightly constrict the lumen of the thin-walled veins, but not sufficiently so to compress the more resistant walls of the arteries.
One must at all times be able to feel the pulse below the
place surrounded by the elastic bandage. 26
OBSTRUCTIVE HYPEREMIA BY ELASTIC BANDAGE. 27
This rule cannot be emphasized too strongly. Nearly all beginners are apt to apply the bandage too tightly.
Yet, it is not difficult to find the proper measure of compression. The patient's own feelings are the best guide, for the degree of obstructive hyperemia is a correct one, if the patient is not in the least annoyed by the bandage applied. As soon as the latter unduly constricts, pares- thesias will be noticed in the part subjected to hyperemia; then pain will set in. Objectively this mistake can be recognized by the too rapid turgescence of the subcu- taneous veins; furthermore, the extremity will assume a bluish-red appearance; a little later there will be red blotches and small subcutaneous hemorrhages will become noticeable. If the constriction is continued, the part becomes cyanotic in appearance and the pulse disappears. As soon as any of these symptoms become evident, the bandage should be removed, and less tightly reapplied a little later.
Let it be said again, that there must be no increase of pain, while the bandage is in place. The patient should be requested to inform the physician as soon as pain sets in or already present pain becomes worse. The bandage then should be changed and put on more loosely.
The technique is correct, if there is absolutely no increase of pain and if there is visible hyperemia of the part subjected to the treatment.
On the other hand, the elastic bandage must not be applied too loosely. This would produce a mere obstruc- tion to the return of the lymph, the accumulation of which alone is not wanted. The portion distal to the bandage must appear bluish or bluish-red—never white.
28 BIER'S HYPEREMIC TREATMENT.
The freedom from pain must extend also to the area surrounded by the bandage. Bier employs a soft rubber bandage, 24 inches wide, which he winds around the limb about six to eight times, one layer overlapping the other
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Fig. 1.—Demonstrating the application of Bier’s clastic bandage around the arm. The flannel bandage is used for padding. This is rarely required. The bandage is 2} inches wide and is applied so as to have one layer overlap the other by } inch. The end is fastened with a pin, but can just as well be tucked under (Fig. 2) or tied with tapes, which are stitched on to the end of the bandage (Fig. 3). The distal part of the extremity shows a distinct obstructive hyperemia. The patient suffers no pain and no annoyance.
by about one-half inch. In this manner the pressure is evenly distributed over a comparatively wide area. The end may be fastened with a safety-pin (Fig. 1) or tucked
OBSTRUCTIVE HYPEREMIA BY ELASTIC BANDAGE. 29
under (Fig. 2) or tied with tapes, which are stitched on to the bandage (Fig. 3.) * Only in cases which require the bandage to remain in
Fig. 2.—This illustration shows the application of the elastic bandage around the arm, with its end tucked under,
place for longer periods, say twenty to twenty-two hours per day, will it be necessary or desirable to first apply a
*Rubber bandages are sometimes very slippery, causing the turns to become loosened, although the end is properly tied with the tapes. In such a case it is advisable to secure the end besides with two strips of adhesive plaster, or moisten the lower surface of the last turn with water.
30 BIER'S HYPEREMIC TREATMENT.
soft flannel bandage underneath the rubber bandage, in order to avoid pressure necrosis (Fig. 1.) Frequently changing the location of the bandage up and down the
Fig. 3.—Shows elastic bandage in place around the arm, its ends tied with tapes which are attached to the bandage. This is the style of bandage usually found upon the market. If the bandage is to re- main on for a number of hours, it is advisable to apply a strip of ad- hesive plaster, to guard against the tapes’ becoming undone. Note the engorgement of the subcutaneous veins of the forearm in Figs. 1 to 3, showing the effect it is desired to produce by the bandage.
extremity, and treating the skin with alcohol rubs, will also be helpful in patients with tender skin.
OBSTRUCTIVE HYPEREMIA BY ELASTIC BANDAGE, 31
With the bandage in place, the distal part of the extrem- ity must feel warm, not cold.
It is not easy to produce a warm or hot obstructive hyperemia in a healthy limb; nor does one always succeed in increasing the temperature of a tuberculous joint in this manner. But every focus of acute inflammation subjected to obstructive hyperemia will quickly show increased warmth. First we notice a marked redness, then heat and a swelling. On seeing the swelling increase, the practitioner often becomes frightened, but there is no reason for alarm. According to Bier, this phenomenon is to be looked upon as a welcome, salubrious reaction.
The first effect observed in conjunction with this arti- ficially exaggerated inflammation, is the diminution of pain, becoming more and more noticeable with the appear- ance of the edema.
This disappearance of pain is best demonstrated in acutely inflamed joints; e. g., a gonorrheal joint. The best proof for a perfect technique is our ability to make passive motions with such joints, about one hour after the appli- cation, without creating pain.
The elastic bandage must always be placed upon a healthy area, proximally to the seat of the disease. It should never touch the latter.
For affections of the upper and lower extremities it has been made a rule to always apply the bandage around the arm or thigh even though hand or foot be the seat of the disease. It is of no consequence that in such cases the elbow or knee-joint are incidentally also subjected to
hyperemia. It never causcs an exudation into the healthy
joint, not does it ever produce varicose veins. The reason