Journal of the Royal Society of Medicine Volume 85 December 1992
Treatment of leg ulcers
I H J Bourne MD FRCGP
'Richmond', Thorndon Approach, Herongate, Brentwood CM13 3PA
Keywords: leg ulcers; oedema; leg elevation; inelastic bandage boots
Summary A system of treatment of venous leg ulcers by leig elevation, dry gauze dressings and inelastic bandagf,e boots is compared with regimens in which a series olf elastic bandage boots are applied to squeeze oedem;a from swollen ulcerated legs.
45.00
40.00 0
-e ******.
*-
*---*......--**-.
..
35.00
30.00
Introduction Many authors agree that oedema must be dealt wit] by elevation of the leg before bandages are applied but the methods, height, and duration of elevation an type of bandage vary. After a study of the elastiiic properties of 14 different types of bandage, Wright 1i concluded that there was no single ideal bandag ,e and that a combination of bandages was require d depending on the ankle circumference and the degre be of compression required.
Patho-physiological basis of treatment When a patient is supine and the affected leg is raise Ed to a height of 20 inches for 3 hours, a considerabl le volume of oedema flows through the skin towards th4Le buttock2. This was demonstrated by serial circumferrentiometry of the leg of a patient using the apparatuLS shown in Figure 1. A 59-year-old woman was admitte Ed
'; I
7
*ti
Figure 1. Apparatus used for serial circumferentiometry
25.00 _ 24.00 11.10
_ 11.40
12,10
Figure 2. Reduction in
_ 12.40 13.10 13.40 14.10
leg
14.40
circumference
to Hammersmith Hospital for treatment of a post deep vein thrombosis ulcer on the right leg. A Thomas splint was adapted to hold three inelastic tapes which encircled the ankle, calf, and thigh. One end of each tape was fixed to the left-hand bar and the other to a syringe piston on the right-hand bar connected to a sphygmomanometer pump. The tapes were tightened to a constant pressure every 30 min and marks made on each tape, from which serial circumferences were charted. Figure 2 shows the graphs of the measurements obtained by serial circunmferentiometry in the patient referred to in Figure 1. The ankle: The graph shows that during the first 2% hours the circumference of the ankle decreased steadily. During the following hour the ankle circumference did not diminish because all oedema had drained from the foot. The calf After the first hour the calf circumference was slightly increased because the quantity of oedema fluid flowing from the foot was greater than the amount leaving the calf owing to the greater pull of gravity at the higher level. During the next 2% hours the calfbecame progressively thinner. The rate ofloss was approaching nil at the end of the period. The thigh During the first hour the thigh circumference did not alter, because the amount of oedema arriving from the lower leg was equal to the amount draining towards the buttock. During the next halfhour more fluid left the thigh than arrived from the lower leg. Subsequently the thigh circumference did not alter because the amount of seepage from the lower leg was equal to the outflow to the buttock. The buttock: Since the vascular supply of the buttock was unaffected and there was no cardiac disease it is assumed that the oedema fluid was absorbed into the blood stream in the buttock. The graphs in Figure 2 show that under the influence of gravity a considerable quantity of oedema is drawn through the subcutaneous layers ofthe skin of the elevated swollen leg to the healthy tissues of the thigh and buttock, where it is absorbed into the circulation in the normal vascular bed2. Oedema fluid is drawn into the ankle veins of the elevated
733
734
Journal of the Royal Society of Medicine Volume 85 December 1992
lower limb at a pressure of minus 9 mmHg. The remove the bandage, and seek advice if the foot lateral channel of all venules and veins resist becomes discoloured and painful4. Walking regularly compression by bandages and during elevation of the causes contraction of the calf muscle pump and leg, thus ensuring vital blood-flow when the veins increases the resorption of oedema, in spite of the appear to be flattened3. Examination of dissections absence of normal valve function in some of the deep at the Royal College of Surgeons confirmed that veins. venules and veins always drain into the lateral Patients were also advised about the rearrangement channels of larger veins. Exceptionally, there are of bedom. and living-roomfurniture to facilitate leg sinusoidal channels between superfilcial and deep elevation. For instance an upturned chair withpillows main veins. on a crepe-bandage sling across its hind legs can be Elevation of the oedematous leg of the patient for used on the bed during the day. Pillows on a settee 3% hours resulted in considerable dispersion of can be used to raise the leg. Patients with dyspnoea oedema. This fact is of importance in the preparation can be taught a V-shaped decubitus with the heart of patients for treatment with inelastic bandage and feet raised to the same level. Patients were told boots. When the leg is raised to this height the to sleep on a level bed 'at night and that'ihere was veins never become completely flattened because the no need to place blocksinder it end of the 'bed. lateral channels of collapsed veins remain open3. The At the weekly follow-iappoinmnts the bandage pressure exerted by a gently-applied inelastic bandage was renewed only if it'was soil'ed and foul-smelling, on an oedema-free leg is'nil, apart from the atmosor after 4 weeks to assess progress. After healing pheric pressure of the surrounding air. Any pressure patients were advised to elevate the legs at every generated when the patient stands or walks will be opportunity for the rest of their lives, and to wear of physiological origin and harmless. Ulcers -heal strong elastic stockings and strong lace-up shoes5 quickly because oedema is prevented from recurring. A simple gauze dressing in which a dry scab can form Results is an effective aid to natural healing. New epithelium Cure was achieved in 77.4%'of cases' at the end of one grows under the adherent scab, and ;healed skin ia year, these,patients were stil healed at' the end of the observed when the swab detaches itse. Non-stretch secondyear. The average period'oftrtment leading to cure w 5&6 months. The average length of hi restraining bandage boots applied withouttension ean be left undisturbed for up to 4-week4. Diabetic leg Xof the grop was 3.4 years. None had'been treated ulcers respond dramatically, to high.leg elevation previously with high elevation of the leg before treatment. Sequestra are .extruded and surgical bandaging5?6. These results have been confirmed by intervention can be avoided5. Travers et at7. In contrast it is not possible to regulate the pressure New healthy epithelium grew under the dry scab exerted on an oedematous leg by an elasticated wwih foamed in the mesh of the gauze. Any.organisms bandage boot, which may be too tight or not tight present-at t}e onset of treatment dieo6'drought. enough. It often becomes stretched, soggy and loose, Failures -were due to neglect of daily lieg-raismng, needing frequent replacement. In some regimen the social factors, back pain, aithrodesis, arhritis of the surface of the ulcer is covered with a wet dressing, ,hip-joint, cardiac or respiratory disease 6r'l IQ. which accentuates the oedema.. Dermatitis is a, Patients with large ulcers and grossly swollen legs frequent consequence. of appliation- of allergenic did badly. pastes and adhesive, materials to the affected leg. There is a need for non-allergenic pastes and adhesive Discussion materials of the side of the bandage next to the skin. In an editorial of the September i991 issue of-the
Patients and methods
,Jarnal-of the Royal Society of Medici'pe K G Harding states that 'It may be surprisinto r any people involved in the clinical care of pat1ents to find that a condiX&n which oci%wth e frquency of diabetee mellitus has reiei*ed such scait ktention that many of the treatments' prescribed ar-at bst probably not beneficial and at worst p6tentially
A series of 106 patients, 80 at Hammermith -Hospital and 26 in general practice in Hornchurch, Esoex, were treated with high elevation during the tweekend followed by the application of inelastic bandage boots. Some patients were bandaged at home by a community nurse. Those patients who attended- the iharmful'". hospital clinic were advised to keep the leg raised I have been informed by consultant colleagues tt until the time for setting out for the clinic. A few patient, generally refuse to co-operate in a leg-isg patients were admitted to Hammer8mith hspital regimen befoe bandages are applied. In my experiene during the weekend for high elevation treattant, and and that of G( colleagues and district nurse,- most the thinned legs were banaged on Mo_day with an patients accept the leg-raising discipline. inelastic bandage boot. Only plain gauze was placed Although Aihas been known sinceiHippocrates that. on the ulcer. compressiqn and rest in bed promotes baling of The bandage was applied evenly from toes to knee, venous ulcers, the effect of high elevationu ofthe leg using half-turns to negotiate the- ankle asd conical bfoeebandaging has notbee.nsm kmiy ze_ lower leg. This sometimes resulted in th adhesive Prasad et a; have stressed 'the pIg ance 9s surface ofthe bandage facing outwards at some places. of oedema in .venous $dce"9i rot f a patient with an Advantage was taken of this by covering the bandage In, 1939 Trueta boot with protectivecrwpe bandagew.whjWh adhered ulcerated leg is allowed togt up the granulatw and was less likely toalipd-wn. ItcQdkrmoved, =beoe congested, the cells fill with water,he woulna drips, and the tissues become an idelcltura washed and renewed;. Each patient was given a..pa- phlet -detailing : medium'. It follows thit to-baLndage an ulceratedleg instructions for periods, f high-elevation and regular, bqforre:aAempting to disperse oedema is to impede walking, and advising the patient to lower the leg, optpwal regrowth of epitheliiun.
Journal of the Royal Society of Medicine Volume 85 December 1992
Whenever possible the nurse bandaged the patient at home, or at 09.00 h at the surgery, to ensure that minimal oedema was present6. Leg Ulcer Clinics were held in the morning. If this could not be arranged the patient was advised to stay in bed with the leg raised for at least 3 hours until the last moment before travelling to the clinic. The patient should not be kept sitting for an hour or two in the waiting room before treatment. If the patient cannot cooperate in a"weekend leg-raising regimen and is treated at home, elevation for at least 3Shoursbefore bandages are applied is the minimum requirement4. In some cases admission to hospital for leg drainage treatment from Friday until Monday is advantageous and economical. Non-stretch nonadhesive bandages can be washed and dried during the weekend while the patient rests with the legs raised. Strong elastic stockings were provided after the ulcer was cured. These cannot easily be put on a swollen leg; this is another reason to encourage the, patient to keep the leg as slim as possibleby elevation every spare moment during every day. Patients who are unsuitable for treatment byhigh elevation of theP leg may be treated by intermittent tompression with inflatable boots and elastic bandage bootsP'. Before and after surgical treatment for concomitant varicose disease the affected leg should be elevated to eliminate oedema. The role of compression banages and elastic stockings In the early stages of treatment4 when there is gross oedema, compression bandages skilfully applied after leg elevation are beneficial in that they contintte the process of dispersing oedema12. The pitfallslof compression therapy- have- been emphasized by Allen'3. When the affected leg retains its normal size and shape compression may interfere with arterial blood flow, especially in the elderly patient with arteriosclerosis. At this stage retention bandages are preferable. Elastic stockings are useful but often difficult to put on. Compression bandages are expensive
and require special skills. They are not usually available in developing countries. References1 Wright D. Report of the Spring Meeting of the Venous Forum. Phlebology 1989;4:211 2 Bourne IHJ. Verification of a hypothesis concerning the path along which oedema fluid drains away from an elevated swollen leg with the patient supine. In: Negus D, Jantet G, eds.- Phiebology. London: John Libbey. 1986:278-81 3 Bourne IHJ. An investigation into the function of apparently flat and empty superficial veins observed in the leg of a patient undergoing treatment by high leg elevation. In: Negus D, Jantet G, eds. Phlebology. London: John Libbey, 1985:282-4 4 Boune IMJ. Drainage of oedema in treatment of leg ulcers.. BMJ 1972;i:581-3 5 Bqurne IHJ. Treatment of gravitational ulcers and oedema 'of the lower limb bypostural drainage and inelastic compression bandages. MD Thesis, London University, 1972:236,250,2526i, 16ue IHJ. Treatment' of grvitational ulcers and oedema of 'the lower limb by postural drainage and inelastic compression basndages.- MD Thesis, London
University1972:288-98 7 Travers JJP1 Dalziel KL;Makin GS. Aeent of, new, one-layer adhesive bandaging method in maintaining prolonged limb co;npeession and effects on yenous
healing. PhlebologI 1992;7:59-63
8 Harding KG. Leg ulcers. Jf R Soc Med 1991;84:516 9 Prasad A, Ali-Khan, Mortimer P. Leg ulcers and oedema: a study explbring the 'prevalence, aetiology, and possible significance of oedema in venous ulcers.
Phiebology 1990;5:181-7' 10 Trueta J. Treatment of war wounds and fractures. London: Ha.mish Hamilton, 1939:11,19 11 Pflug JJ. Intermittentdcompression inp the i~ianagement of swollen legs in general practice. Practitioner 1975;
#15:69473 12 Ruckley CV. Treatment of venous ulceration. Compression therapy. Phlebology 1972;7(suppl 1):22-6 13 Allen S. Go easy with compression. Phkebology 1992;7:89
(Accepted 30 October 1991)
735
Treatment of leg ulcers
I H J Bourne MD FRCGP
'Richmond', Thorndon Approach, Herongate, Brentwood CM13 3PA
Keywords: leg ulcers; oedema; leg elevation; inelastic bandage boots
Summary A system of treatment of venous leg ulcers by leig elevation, dry gauze dressings and inelastic bandagf,e boots is compared with regimens in which a series olf elastic bandage boots are applied to squeeze oedem;a from swollen ulcerated legs.
45.00
40.00 0
-e ******.
*-
*---*......--**-.
..
35.00
30.00
Introduction Many authors agree that oedema must be dealt wit] by elevation of the leg before bandages are applied but the methods, height, and duration of elevation an type of bandage vary. After a study of the elastiiic properties of 14 different types of bandage, Wright 1i concluded that there was no single ideal bandag ,e and that a combination of bandages was require d depending on the ankle circumference and the degre be of compression required.
Patho-physiological basis of treatment When a patient is supine and the affected leg is raise Ed to a height of 20 inches for 3 hours, a considerabl le volume of oedema flows through the skin towards th4Le buttock2. This was demonstrated by serial circumferrentiometry of the leg of a patient using the apparatuLS shown in Figure 1. A 59-year-old woman was admitte Ed
'; I
7
*ti
Figure 1. Apparatus used for serial circumferentiometry
25.00 _ 24.00 11.10
_ 11.40
12,10
Figure 2. Reduction in
_ 12.40 13.10 13.40 14.10
leg
14.40
circumference
to Hammersmith Hospital for treatment of a post deep vein thrombosis ulcer on the right leg. A Thomas splint was adapted to hold three inelastic tapes which encircled the ankle, calf, and thigh. One end of each tape was fixed to the left-hand bar and the other to a syringe piston on the right-hand bar connected to a sphygmomanometer pump. The tapes were tightened to a constant pressure every 30 min and marks made on each tape, from which serial circumferences were charted. Figure 2 shows the graphs of the measurements obtained by serial circunmferentiometry in the patient referred to in Figure 1. The ankle: The graph shows that during the first 2% hours the circumference of the ankle decreased steadily. During the following hour the ankle circumference did not diminish because all oedema had drained from the foot. The calf After the first hour the calf circumference was slightly increased because the quantity of oedema fluid flowing from the foot was greater than the amount leaving the calf owing to the greater pull of gravity at the higher level. During the next 2% hours the calfbecame progressively thinner. The rate ofloss was approaching nil at the end of the period. The thigh During the first hour the thigh circumference did not alter, because the amount of oedema arriving from the lower leg was equal to the amount draining towards the buttock. During the next halfhour more fluid left the thigh than arrived from the lower leg. Subsequently the thigh circumference did not alter because the amount of seepage from the lower leg was equal to the outflow to the buttock. The buttock: Since the vascular supply of the buttock was unaffected and there was no cardiac disease it is assumed that the oedema fluid was absorbed into the blood stream in the buttock. The graphs in Figure 2 show that under the influence of gravity a considerable quantity of oedema is drawn through the subcutaneous layers ofthe skin of the elevated swollen leg to the healthy tissues of the thigh and buttock, where it is absorbed into the circulation in the normal vascular bed2. Oedema fluid is drawn into the ankle veins of the elevated
733
734
Journal of the Royal Society of Medicine Volume 85 December 1992
lower limb at a pressure of minus 9 mmHg. The remove the bandage, and seek advice if the foot lateral channel of all venules and veins resist becomes discoloured and painful4. Walking regularly compression by bandages and during elevation of the causes contraction of the calf muscle pump and leg, thus ensuring vital blood-flow when the veins increases the resorption of oedema, in spite of the appear to be flattened3. Examination of dissections absence of normal valve function in some of the deep at the Royal College of Surgeons confirmed that veins. venules and veins always drain into the lateral Patients were also advised about the rearrangement channels of larger veins. Exceptionally, there are of bedom. and living-roomfurniture to facilitate leg sinusoidal channels between superfilcial and deep elevation. For instance an upturned chair withpillows main veins. on a crepe-bandage sling across its hind legs can be Elevation of the oedematous leg of the patient for used on the bed during the day. Pillows on a settee 3% hours resulted in considerable dispersion of can be used to raise the leg. Patients with dyspnoea oedema. This fact is of importance in the preparation can be taught a V-shaped decubitus with the heart of patients for treatment with inelastic bandage and feet raised to the same level. Patients were told boots. When the leg is raised to this height the to sleep on a level bed 'at night and that'ihere was veins never become completely flattened because the no need to place blocksinder it end of the 'bed. lateral channels of collapsed veins remain open3. The At the weekly follow-iappoinmnts the bandage pressure exerted by a gently-applied inelastic bandage was renewed only if it'was soil'ed and foul-smelling, on an oedema-free leg is'nil, apart from the atmosor after 4 weeks to assess progress. After healing pheric pressure of the surrounding air. Any pressure patients were advised to elevate the legs at every generated when the patient stands or walks will be opportunity for the rest of their lives, and to wear of physiological origin and harmless. Ulcers -heal strong elastic stockings and strong lace-up shoes5 quickly because oedema is prevented from recurring. A simple gauze dressing in which a dry scab can form Results is an effective aid to natural healing. New epithelium Cure was achieved in 77.4%'of cases' at the end of one grows under the adherent scab, and ;healed skin ia year, these,patients were stil healed at' the end of the observed when the swab detaches itse. Non-stretch secondyear. The average period'oftrtment leading to cure w 5&6 months. The average length of hi restraining bandage boots applied withouttension ean be left undisturbed for up to 4-week4. Diabetic leg Xof the grop was 3.4 years. None had'been treated ulcers respond dramatically, to high.leg elevation previously with high elevation of the leg before treatment. Sequestra are .extruded and surgical bandaging5?6. These results have been confirmed by intervention can be avoided5. Travers et at7. In contrast it is not possible to regulate the pressure New healthy epithelium grew under the dry scab exerted on an oedematous leg by an elasticated wwih foamed in the mesh of the gauze. Any.organisms bandage boot, which may be too tight or not tight present-at t}e onset of treatment dieo6'drought. enough. It often becomes stretched, soggy and loose, Failures -were due to neglect of daily lieg-raismng, needing frequent replacement. In some regimen the social factors, back pain, aithrodesis, arhritis of the surface of the ulcer is covered with a wet dressing, ,hip-joint, cardiac or respiratory disease 6r'l IQ. which accentuates the oedema.. Dermatitis is a, Patients with large ulcers and grossly swollen legs frequent consequence. of appliation- of allergenic did badly. pastes and adhesive, materials to the affected leg. There is a need for non-allergenic pastes and adhesive Discussion materials of the side of the bandage next to the skin. In an editorial of the September i991 issue of-the
Patients and methods
,Jarnal-of the Royal Society of Medici'pe K G Harding states that 'It may be surprisinto r any people involved in the clinical care of pat1ents to find that a condiX&n which oci%wth e frquency of diabetee mellitus has reiei*ed such scait ktention that many of the treatments' prescribed ar-at bst probably not beneficial and at worst p6tentially
A series of 106 patients, 80 at Hammermith -Hospital and 26 in general practice in Hornchurch, Esoex, were treated with high elevation during the tweekend followed by the application of inelastic bandage boots. Some patients were bandaged at home by a community nurse. Those patients who attended- the iharmful'". hospital clinic were advised to keep the leg raised I have been informed by consultant colleagues tt until the time for setting out for the clinic. A few patient, generally refuse to co-operate in a leg-isg patients were admitted to Hammer8mith hspital regimen befoe bandages are applied. In my experiene during the weekend for high elevation treattant, and and that of G( colleagues and district nurse,- most the thinned legs were banaged on Mo_day with an patients accept the leg-raising discipline. inelastic bandage boot. Only plain gauze was placed Although Aihas been known sinceiHippocrates that. on the ulcer. compressiqn and rest in bed promotes baling of The bandage was applied evenly from toes to knee, venous ulcers, the effect of high elevationu ofthe leg using half-turns to negotiate the- ankle asd conical bfoeebandaging has notbee.nsm kmiy ze_ lower leg. This sometimes resulted in th adhesive Prasad et a; have stressed 'the pIg ance 9s surface ofthe bandage facing outwards at some places. of oedema in .venous $dce"9i rot f a patient with an Advantage was taken of this by covering the bandage In, 1939 Trueta boot with protectivecrwpe bandagew.whjWh adhered ulcerated leg is allowed togt up the granulatw and was less likely toalipd-wn. ItcQdkrmoved, =beoe congested, the cells fill with water,he woulna drips, and the tissues become an idelcltura washed and renewed;. Each patient was given a..pa- phlet -detailing : medium'. It follows thit to-baLndage an ulceratedleg instructions for periods, f high-elevation and regular, bqforre:aAempting to disperse oedema is to impede walking, and advising the patient to lower the leg, optpwal regrowth of epitheliiun.
Journal of the Royal Society of Medicine Volume 85 December 1992
Whenever possible the nurse bandaged the patient at home, or at 09.00 h at the surgery, to ensure that minimal oedema was present6. Leg Ulcer Clinics were held in the morning. If this could not be arranged the patient was advised to stay in bed with the leg raised for at least 3 hours until the last moment before travelling to the clinic. The patient should not be kept sitting for an hour or two in the waiting room before treatment. If the patient cannot cooperate in a"weekend leg-raising regimen and is treated at home, elevation for at least 3Shoursbefore bandages are applied is the minimum requirement4. In some cases admission to hospital for leg drainage treatment from Friday until Monday is advantageous and economical. Non-stretch nonadhesive bandages can be washed and dried during the weekend while the patient rests with the legs raised. Strong elastic stockings were provided after the ulcer was cured. These cannot easily be put on a swollen leg; this is another reason to encourage the, patient to keep the leg as slim as possibleby elevation every spare moment during every day. Patients who are unsuitable for treatment byhigh elevation of theP leg may be treated by intermittent tompression with inflatable boots and elastic bandage bootsP'. Before and after surgical treatment for concomitant varicose disease the affected leg should be elevated to eliminate oedema. The role of compression banages and elastic stockings In the early stages of treatment4 when there is gross oedema, compression bandages skilfully applied after leg elevation are beneficial in that they contintte the process of dispersing oedema12. The pitfallslof compression therapy- have- been emphasized by Allen'3. When the affected leg retains its normal size and shape compression may interfere with arterial blood flow, especially in the elderly patient with arteriosclerosis. At this stage retention bandages are preferable. Elastic stockings are useful but often difficult to put on. Compression bandages are expensive
and require special skills. They are not usually available in developing countries. References1 Wright D. Report of the Spring Meeting of the Venous Forum. Phlebology 1989;4:211 2 Bourne IHJ. Verification of a hypothesis concerning the path along which oedema fluid drains away from an elevated swollen leg with the patient supine. In: Negus D, Jantet G, eds.- Phiebology. London: John Libbey. 1986:278-81 3 Bourne IHJ. An investigation into the function of apparently flat and empty superficial veins observed in the leg of a patient undergoing treatment by high leg elevation. In: Negus D, Jantet G, eds. Phlebology. London: John Libbey, 1985:282-4 4 Boune IMJ. Drainage of oedema in treatment of leg ulcers.. BMJ 1972;i:581-3 5 Bqurne IHJ. Treatment of gravitational ulcers and oedema 'of the lower limb bypostural drainage and inelastic compression bandages. MD Thesis, London University, 1972:236,250,2526i, 16ue IHJ. Treatment' of grvitational ulcers and oedema of 'the lower limb by postural drainage and inelastic compression basndages.- MD Thesis, London
University1972:288-98 7 Travers JJP1 Dalziel KL;Makin GS. Aeent of, new, one-layer adhesive bandaging method in maintaining prolonged limb co;npeession and effects on yenous
healing. PhlebologI 1992;7:59-63
8 Harding KG. Leg ulcers. Jf R Soc Med 1991;84:516 9 Prasad A, Ali-Khan, Mortimer P. Leg ulcers and oedema: a study explbring the 'prevalence, aetiology, and possible significance of oedema in venous ulcers.
Phiebology 1990;5:181-7' 10 Trueta J. Treatment of war wounds and fractures. London: Ha.mish Hamilton, 1939:11,19 11 Pflug JJ. Intermittentdcompression inp the i~ianagement of swollen legs in general practice. Practitioner 1975;
#15:69473 12 Ruckley CV. Treatment of venous ulceration. Compression therapy. Phlebology 1972;7(suppl 1):22-6 13 Allen S. Go easy with compression. Phkebology 1992;7:89
(Accepted 30 October 1991)
735
