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Bier's hyperemic treatment in surgery, medicine, and the specialties; a manual of its practical application online

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slip a small rubber band over the base of the finger, as shown
in Fig. 63. Then, after putting on the glove again, the
operation can be proceeded with.* Later a second rub-
ber band may be applied in order to increase the passive
hyperemia. Of course, the constriction must not be
painful. It will be advisable for the physician to always



♦ If gloves and finger-cots are not or can not be worn, the rubber
band should at least be slipped over.



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OBSTRUCTIVE HYPEREMIA AS A PROPHYLACTIC. 127

cany in his pocket a small box containing rubber cots and
bands. They should also be kept ready (sterilized) for
emergencies at our hospitals.

In case of the infliction of a deeper wound on the fingers,
as also in the event of injury to the first phalanx, meta-
carpal or carpal region, obstructive hyperemia with the
bandage around the arm should be employed, as soon as
the operation or dissection has been finished.

The same prophylactic hyperemic treatment is advisable,
perhaps indicated, in poisoned wounds of different charac-
ter, e, gr., those inflicted by mad dogs and poisonous snakes.

It has been suggested to use the suction cups as soon as Rabies,
ever possible after the infliction of the wound. If the
extremities are involved, obstructive hyperemia by means
of the bandage may be added. Of course, this does not
exclude additional treatment at a Pasteur Institute.

Snake-bites have been effectively sucked out by mouth Snake-bites.
from time immemorial. This practice retains its value up
to the present day. Tight constriction above the wound
has also been extensively practised, the idea being that
this will prevent the poison from promptly entering the
circulation, while the living tissues meanwhile reduce the
virulence of the poison.

Obstructive hyperemia works similarly. The edema,
soon developing with the continued use of the elastic
bandage, materially dilutes the poison, thus rendering it
less deadly. An assortment of suction cups and elastic
bandages rightly belongs to the outfit of people living in
territories infested by these venomous reptiles.

In the direction of prophylaxis probably lies the widest
field of usefulness of artificial hyperemia. It is but natural



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128



bier's hyperemic treatment.



To Avoid
Vomiting after
Superficial
Ether
Anesthesia.



To Prevent
the Annoying
After-effects
of Spinal
Anesthesia.



Hyperemesis
Gravidarum.



that it will here be gradually more extensively made use
of in various directions.

Obstructive hyperemia has lately been recommended
as a means of preventing vomiting and dizziness following
the inductive stage of general anesthesia by means of sul-
phuric ether. The elastic neck bandage applied rather
tightly immediately after the completion of the operation,
and worn for one-half to one hour, has prevented the
above-mentioned symptoms. Of sixty-two patients thus
treated at the dispensary clinic, none had any annoying
after-effects, except one, and this patient had been under
the influence of the anesthetic for twenty minutes.

Explanation of the phenomenon : The artificial hyper-
emia reduces the effect of the poison upon the brain.

Bier has used the neck-band to overcome the dis-
agreeable effect of spinal anesthesia on the central nervous
system. His explanation is that the artificially increased
intracranial pressure prevents the cerebrospinal fluid,
with the injected drug, from remaining in extended con-
tact with the upper portions of the cord and brain and
presses it downward. This reasoning has been confirmed
by the experiments of other investigators.

Among all the conditions producing vomiting through
irritation of the brain, that causing the continued vomiting
in pregnant women should be first studied as to its possible
amenability to obstructive hyperemia.



Compound
Fractures.



APPENDIX.
COMPOUND FRACTURES.

The expert may use Bier's hyperemia to advantage
also in cases of compound fracture.



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COMPOUND FRACTURES. 129

The question that usually arises in these cases is: Shall
we temporize, or shall we at once proceed to revise the
fracture; that is to say, lay open the fragments, clean,
shape, unite, etc., and then treat the wound according to
indications? As a rule, the former course is decided upon for
the less severe cases, the latter for the more serious cases.

Obstructive hyperemia, begun as soon as the woimds
have been properly attended to and protected by a loosely
applied aseptic dressing, with the limb placed on splints,
seems destined to shift the borderline between these two
modes of treatment in favor of the conservative plan.

To be successful, the treatment has to be applied faith-
fully for twenty hours each day; regular and careful
examination has to be made in order to detect any possible
retention of serum, or pus formation. As the pain decreases,
the position of the fragments is gradually corrected, always
imder continuance of the loose aseptic dressing. As
soon as the time for a threatening infection has passed, a
plaster-of-Paris splint with one or more cut-outs is applied
and the hyperemic treatment discontinued.

One of the most dreaded of compound fractures is that S'^*^*"!®^?^,,

^ Base of SkuU.

of the base of the skull. Intracranial hemorrhage and

meningitis here endanger the patient's life.

Of all the methods of treatment known and used nowa-
days, prophylactic hyperemia of the head with the elastic
band around the neck, started immediately after the
injury, seems to promise the best results in these cases,
as it is most apt to prevent meningitis. Nor is it to be
feared, in view of the absorbing qualities of hyperemia,
that it will produce or increase intracranial bleeding.

Case, — Boy, twelve, falls down high stairs, striking
9



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130 bier's hyperemic treatment.

head-first upon stone floor; unconscious; severe hemor-
rhage from mouth and nose. Six hours later admitted
to hospital; still dazed; streaks of coagulated blood adhe-
rent to pharynx. Immediate head hyperemia. Con-
sciousness returns rather quickly; no fever; no meningeal
complications. Subperiosteal blood effusions become ab-
sorbed in comparatively short time. Discharged after
two weeks.

Case. — Boy, thirteen; run into, and thrown a distance
of several feet by automobile. Brought to hospital by
ambulance. Unconscious. Severe hemorrhage from right
ear; slight facial palsy on right side. Fracture of right
thigh. Rupture of right drum membrane clearly visible;
bloody oozing. Immediate head hyperemia by means
of the elastic neck-band, eleven hours out of every twelve.
Iodoform guaze tamponade of external meatus of right
ear; splint to thigh. Consciousness soon begins to re-
turn, though not fully; patient remains in sort of slight
stupor for several days. On third day after beginning
of treatment, discharge from ear turns serous. Slight
fever, which gradually drops to normal. No intracranial
complications. Head hyperemia slowly reduced. Dis-
charged cured.

Tliis probably salubrious prophylactic effect from the
use of the elastic neck-band in fractures of the skull and
base of the skull is to be expected, it seems, rather in
cases associated with a rupture of the drum membrane
or the nasopharyngeal mucosa, viz., in cases in which
there is an external exit for drainage.

If no such external rupture is evident, it is suggested
that the surgeon promptly trephine the skull at a suitable
place, introduce one or two split drainage-tubes in the
epidural space, and then immediately start hyperemic
treatment. It goes without saying that further intra-



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TUBERCULOSIS. 131

cranial operative work should be promptly carried out, if
needed.

The rather rapid awakening from stupor after injury
to the head under the influence of head hyperemia is very
interesting and deserves further study. It was rather
conspicuous in the following:

Case, — Man, laborer, forty years old, hit by a fellow-
worker on right frontal bone with hammer. Flesh wound,
no fracture, semi-unconsciousness. Neck-band. Wide
awake after two hours.

It remains to be seen, what benefit the treatment brings
in cases of concussion of the brain.

Comparative statistics of cases, treated by this and the
other methods, would be best adapted to definitely estab-
lish the merits or demerits of this proposed prophylactic
treatment.

It need hardly be added that compound fractures are
hospital cases, and physicians will do well to urge their
patients to enter a hospital or clinic, where they have the
advantages of strict asepsis and continuous observation
by competent physicians and nurses.

CHRONIC INFECTIONS.

Tuberculosis.

I. Tuberculosis of Joints. — Tliis section is of especial
interest, inasmuch as it was the treatment of this trouble
that gave birth to the use of hyperemic treatment. The
prmcipal studies in regard to the peculiarities and effect
of this therapeutic agent have been made on patients
afflicted with tuberculous joint-disease.

After a most interesting development, the treatment
of tuberculosis of the joints by means of artificial hyper-



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132 bier's hyperemic treatment.

emia has been brought to such a stage of perfection that it
may now be looked upon as one of our most important
aids in the conquest of this class of diseases.

It is to be emphasized right here that artificial hyperemia
requires longer to effect a cure than operative treatment,
a drawback which it has in common with all other conserva-
tive methods. He who desires to be cured quickly would
probably better submit to resection or amputation.

The laborer dependent upon his wages for a living for
himself and family will probably be earlier able after an
operation to resume his work than if treated by hyperemia.
And it must be admitted that our present refined methods
of resection, particularly if Mosetig's iodoform fillings
or E. Beck's bisnmth paste be employed for the resulting
cavity, insure a quick and usually good functional result,
at least in the wrist-, elbow-, and ankle-joint. Yet this
mutilating treatment could not be the final aim of scientific
surgery; and we now have something better in Bier's
hyperemic treatment, which aims to restore perfect func-
tion without sacrificing any part of the limb or joint itself.

It is true a great deal of patience and perseverance
are required to attain this end, as it takes many months
(about twelve to fifteen) of treatment and careful medical
supervision; but the final result in most cases amply
repays both patient and surgeon.

It is diflScult to give a correct explanation for the curative
effect of artificial hyperemia in tuberculous cases. The
best seems to be, that gradually connective (scar-) tissue
takes the place of the tuberculous, and that connective
tissue does not represent a soil in which the tubercle
bacillus can flourish. It dies, and therewith its pathologic
sequelae come to an end.



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TUBERCULOSIS. 133

In the treatment of surgical tuberculosis obstructive hyper- Form of Hy-
peremia.
emia only, by elastic bandage or suction glasses, is used;

never hot air.

The elastic bandage is used far more extensively than
suction glasses. It can be nicely applied in tuberculous
inflammations in the greater number of joints of the ex-
tremities, including the shoulder.

It is to be regretted that, so far, the hip-joint cannot
be subjected to this treatment, the impossibility being given
by the necessity of employing venous hyperemia only.*

As a rule, a tuberculous joint is treated with obstructive Duration of Ob-
hyperemia twice a day for one hour, although this rule J|^*^^ ^"
may have to be modified in some instances. If observa-
tion shows that a somewhat longer duration of treatment
gives a better result, also as regards relieving the pain,
the time may be extended to twice two hours per day.

In severe and rapidly progressive cases a still longer
duration of obstructive hyperemia, twice per day, may
become necessary.

In cases of hot abscess-formation with fever, due to
mixed infection of the sinuses present, the treatment will
have to be extended to twice eleven hours per day. After
the acute stage has passed, the shorter periods of treatment,
with nine to eleven hours intermission, are resumed.!

♦ See page 36, foot-note.

t Originally Bier advised obstructive hyperemia for eleven hours of
each twelve for tuberculous cases. It was seen, however, in course of
time, that a persistent chronic edema appeared, which often gave rise
to the development of erysipelas in fistulous (open) cases. The cause
for the setting in of such unwelcome complication evidently is the
edema-fluid, the bactericidal power of which had been used up.

Since employing the obstructive hyperemia twice per day for one to
two hours only, a complicating erysipelas has not been observed by
Bier again.



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134 bier's hyperemic treatment.

This shows that here, as elsewhere, we have to individ-
ualize. At times a period of continuous improvement
is followed by one of comparatively little improvement
in spite of most painstaking application. In such an
event it may be advisable to discontinue the treatment
for a while, say from six to eight days, after which the
resumed treatment will often yield more satisfactory-
results.

To understand this, it must be borne in mind that
obstructive hyperemia acts like a powerful drug, the dosage
of which must be adapted to the individual case.

But, as has been stated above, the general rule in un-
complicated cases of tuberculous joint disease is, to apply
the elastic bandage twice, one hour per day. During
this time the induction of a "strong hyperemia '' should
be the aim, that is to say, that part of the extremity
which is distal to the bandage should turn a bluish-red,
without, however, becoming painful.

The possibility of a good result from such brief applica-
tions of the elastic bandage twice per day, is certainly a
great boon to patients belonging to the working classes.

They can apply the treatment in the morning before
going to work and again after their return at night, mean-
while carrying the arm in a sling,, making themselves
useful with one arm, or performing some light work with
both, as soon as some improvement has set in. If the
lower extremity be involved, they can apply for work
that can be done mostly in a sitting posture. In this way
they can at least earn some money and will not be an
absolute burden to the community or their families during
the long course of the treatment. Of course, it would be



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TUBERCULOSIS. 135

far better if such patients did not have to work, but could
enjoy outdoor life.

The bandage must always cover a perfectly healthy part Technique.
of the extremity f not too close to the diseased joint. In tuber-
culous affections of the elbow and joints below the same
the bandage is best applied around the arm. (Fig. 75.)

For the treatment of the shoulder-joint an elastic tube
is employed instead of a bandage; this is kept in place by
means of strips of muslin or gauze, fastened in a simple
way. (See Fig. 5.) Special care must be exercised in
the treatment of these cases, as the elastic tube necessarily
always encircles the same spot, and, hence, may give rise
to pressure necrosis of the skin.

In cases of tuberculosis of the knee, tibiotarsal articula-
tion, and the small joints of the foot the bandage is worn
around the thigh.

In stout patients the elastic bandage has to be wider —
3 to 3J inches (8 to 9 cm.) — and is best made to cover
a thin gauze compress or a layer of cotton, as otherwise,
owing to the tapering form of the thigh, it would be likely
to be pulled into a narrow band and cause pain.

In order to increase the effect of the bandage, a hot bath
of the parts of, say, ten minutes' duration may be helpful.

After the removal of the bandage the portion of the
extremity that was subjected to the elastic compression
is thoroughly massaged in order to guard against pressure
atrophy of the muscles. For the same reason the bandage
is never reapplied in exactly the same spot, but 1 to IJ
inches (3 to 4 cm.) further up or down, thus wandering
between the joint above and a place of safe distance from
the focus of the disease.



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136 bier's hyperemic treatment.

As a rule, all dressings (in the case of open tuberculosis)
are removed while the bandage is in place. The sinuses
are loosely covered with aseptic gauze, and the limb is
wrapped in a towel so as to retain its warmth.

In addition to the elastic bandage, suction glasses are
applied in these cases of open bone tuberculosis for forty-



Fig. 75. — This illustration shows the manner of application of the elastic
bandage in a case of fistulous tuberculosis of the elbow-joint.

five minutes per day, with the usual interruptions; that is
six to five minutes on and two to three mmutes off, but
best while the bandage is not in place. (Fig. 76.) Care
must be taken to select the proper size of glass.
By means of this local suction-hyperemia whatever



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TUBERCULOSIS. 137

purulent secretions and necrotic shreds may be present are
aspirated.

The joints are not put in fixation splints during treat-
ment. If but a minimum degree of mobility is left, the
patient is urged to gently but frequently exercise the joint,
in order to preserve and increase such mobility.



Fig. 76. — Shows the patient with tuberculosis of the elbow represented
by Fig. 75 with the suction glass in operation.

Only extremely painful joints are immobilized, but the
splint is left off just as soon as the sensitiveness subsides.

If no pain be experienced, the patient may use the Permissibility
affected limb to some extent. He may dress himself in Diseased Joints,
the presence of a diseased joint of the upper extremity.
He may be out of bed part of the time each day, with a



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138 bier's hyperemic treatment.

tuberculous knee- or foot-joint. But in the latter case
the joint must be carefully protected against overweight.
Pressure of the two diseased articulating surfaces is strictly
to be avoided. So long as these joints are in an inflamma-
tory stage, the patient has to wear a support of some kind
and use crutches or a cane. The best and safest way to
guard against unduly burdening the joints with the weight
of the body, is to apply a movable splint while the patient
is out of bed (Figs. 77 and 78) ; the active exercises to be
undertaken while he is in bed.

In order to avoid misunderstanding it should be stated
right here, that neither a systematic movement-therapy
nor brisement force is ever indicated. Such procedure
would surely make things worse. The patient must
know that traumatism of any kind is apt to again light up
the receding trouble.
Contrnctures. In the cases in which the local trouble has reached an
advanced stage, or contracture of the joint has set in,
gradual reposition is to be combined w^ith hyperemic
treatment. This has reference especially to the knee,
where the pathologic posture is usually obstinate and easily
leads to subluxation. An adhesive-plaster extension
splint is promptly applied in these cases and obstructive
hyperemia begun at the same time. The splint leaves
the knee fully exposed and remains in place until the
extremity is straightened. Then it is dispensed with and
brought into use again only in case of a return of the con-
tracture. (Fig. 79.)

Case. — Patient, sixteen, sick for six months; left knee
very painful, contracted at right angle; no abscess; slight
mobility i)reserved; muscles markedly atrophied. No



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TUBERCULOSIS. 139

fever. Obstructive hyperemia daily, two times two hours;
extension splint; gentle exercises permitted. Two weeks
later much less sensitive; mobility improved; swelling
reduced; knee almost straight. (See Fig. 79.)



Fig. 77. Fig. 78.

Fig. 77. — Shows a plaster-of-paris support, easily improvised by the
surgeon. A snugly fitting splint reaches from the ankles to the tuber
ischii. It carries at its lower end a stirrup, Ufting the foot above ground.
By splitting this splint open in front and behind, it is made movable.
It is lined with felt and applied to the extremity by means of a few
straps fastened by buckles. By taking its support on the pelvis, the
knee will not bear any weight. It is not fixated. A cork sole under
or in the shoe of the healthy side corrects the difference in length.
The apparatus is applied as soon as the knee has become straightened
and painless under the hyperemia treatment.

Fig. 78. — Illustrates the same idea as carried out by the instrument-
maker. The machine is worked from a plaster cast.



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140 bier's hyperemic treatment.

Daily examination to make sure that no cold abscess
be forming. After further three weeks knee-fungus
harder; flexion to right-angle possible, extension splint
removed; still in bed. Same hyperemic treatment two
times two hours daily. Two months after admission, out of
bed. Has bad effect; joint effusion; back to bed. After
another six weeks, up regularly with movable plaster-



hours, twice a day, the splint continuously. Atrophy of the ex-
tremity and fungous swelling of the knee are evident. There is
no tuberculous hydrops. Only light weights are used, 5 to 8 pounds in
adults, 2 to 3 pounds in children. To avoid any sudden stretching, a
safety roll is placed in the popliteal space, which is gradually reduced
in circumference.

of-Paris support (see Fig. 77), which is always taken off
on lying down. Four and a half months after admission:
knee swelling materially reduced; muscular atrophy less
marked; articular contours more normal. Hyperemic
treatment continued as before. Eleven months later
examination shows no more signs of tuberculous inflam-
mation. Can actively flex joint to right angle. (See Fig. 81.)
Knee configuration almost normal. (See Fig. 80.)

The Course of Improvement in such joints usually sets in in the course

der HyperwiSc" ^^ ^ number of weeks. Nights disturbed by pain give way

Treatment ^^ restful sleep. Swelling and pain recede. The contours

of the joint become more defined and mobility increases.



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142 bier's hyperemic treatment.

functional result. Hyperemic treatment with elastic
bandage. Two weeks later: can raise arm without assist-
ance of other hand; sleeps much better. Treatment
faithfully continued for nine months without interruption.
Then has useful arm; returns to work. Brilliant result.

In a number of cases a cold abscess forms, which, of
course, must be evacuated.

While an open tuberculous process represents a graver
form of the trouble, it has often been noted that a turn



Fig. 82. — This illustration represents a little girl with a serious
tuberculous affection of the metatarsus. Hyperemia is produced by a
suction glass of large size. A smaller glass covers a sinus at the neck,
being the result of a tuberculous glandular trouble.

for the better sets in as soon as this breaking down occurs.
The system seems to rid itself of the necrotic tissue by
way of suppurative softening, resulting in a cold abscess.
Tliis then is opened by means of a small incision, the pus
is allowed to escape, and the sinus is placed under artificial
suction hyperemia. (Fig. 82.) In favorable cases the



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TUBERCULOSIS. 143

secretions soon become serous under this regime, gradually
cease, and the sinus closes.
-Here, again, the same important rule for the successful



Fi;:. 83.— Showing daily scene at children's ward (lernian Hospital,
New York. The little jrirl has been taught to use the suction pump
herself. She works it as long as the slowly increasing vacuum in the
glass does not create pain. Some of her little playmates look on,
praising her sincerely.

carrying out of obstructive hyperemia applies: opening
of the abscess in order to evacuate the pus.



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144 bier's hyperemic treatment.

Yet, aspiration plus injection of sterilized iodoform-
glycerin-emulsion (five to ten per cent.) also remains a recom-
mendable procedure, in conjunction with Bier^s hyperemic
treatment, when dealing with the ordinary cold abscess,
principally in private practice. Such combined treatment
is advisable in cases in which the surgeon has not the time


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Online LibraryWilly MeyerBier's hyperemic treatment in surgery, medicine, and the specialties; a manual of its practical application → online text (page 7 of 18)