Abstract:
A method and device for treating wounds  10  of tissue  11  is disclosed. The method has the steps of applying a porous pad  12  upon the treatment surface of the tissue  11 ; covering the treatment surface and the porous pad  12  with a foil or sealing cover  14  for isolating the treatment surface and the porous pad  12  from the atmosphere; filling the volume under the foil or sealing cover  14  with fluid  100  and purging air from the volume under the foil or sealing cover  14  thereby fluid  100  saturating said porous pad  12 : applying an acoustic shock wave treatment through the foil or sealing cover  14  or surrounding tissue  11  or a combination thereof sending acoustic shock waves  200  through the volume to the treatment surface and underlying tissue  11  and thereafter pulling a vacuum to create a sub-atmospheric pressure under the foil or sealing cover  14  wherein the combination of the applied acoustic shock waves  200  and sub-atmospheric conditions stimulates healing of the treatment surface and underlying tissue  11 . Preferably the acoustic shock waves  200  are unfocused or a wide area focused shock wave pattern. More preferably the shock waves  200  are sufficiently low energy or amplitude to avoid the sensation of pain during the treatment process thereby eliminating the need for anesthesia or localized numbing of the treatment area.

Description:
TECHNICAL FIELD 
       [0001]    The invention concerns an improved process and device for wounds using a combination of a vacuum bandage and acoustic shock waves. 
       BACKGROUND OF THE INVENTION 
       [0002]    The treatment of deep wounds historically involved salves, solutions or solid medicament carriers in impregnated wound coverings. These treatments at best were ineffective and often due to the toxic secretions emanating deep in the wound resulted in further tissue damage or injurious reactions and infections. 
         [0003]    Vacuum bandages over a wound were disclosed in German patent DE 4012232 A1 wherein the wound is covered by a thin semi-permeable foil. A supply line and a removal line are provided under the foil in the wound area. Active substances can be applied to the wound surface under the foil via the supply line by means of a syringe. After the desired application period the active substances can, in certain cases together with the wound secretion, be suctioned out via the removal line by means of a vacuum source. The supply line is provided with a self-acting closing safety valve, which is opened by the introduced syringe for introduction of the fluid active substances. Likewise there is provided on the removal line a closure or blockage mechanism, which closes off the output side during the application period of the active substance. 
         [0004]    In this known installation bandage the active substances are applied directly upon the wound surface and suctioned off from the wound surface. The active substance can thus only be applied in imprecise doses and in particular in the case of large wound surface areas an even effect upon the entire surface is difficult to achieve. A long time continuous effect can not realized. 
         [0005]    From U.S. Pat. No. 4,382,441 it is known, for treatment of wound surfaces, to lay a padding or dressing made of a porous material upon the wound surface and to sealingly cover this. The active substance to be applied is continuously conveyed through the padding, for which a fluid supply connection and a fluid removal connection communicate with the padding. The capillary effect of the porous padding optimizes the distribution of the supplied active substance over the entirety of the surface of the padding in contact with the wound surface. 
         [0006]    The porous padding is substantially form-stable and also the sealing cover is preferably form-stable. The fluid active substance is conveyed through the padding in a continuous stream, whereby a stream distribution results, in which the fluid active substance flows essentially along the area between the fluid supply connection and fluid removal connection, while the edge areas of the padding are barely perfused. Thus, in these edge areas the active substances are only exchanged in small amounts and, further, in the edge areas accumulations of wound secretion are only insufficiently removed. Beyond this the relatively form stable padding does not lie in all areas equally against the wound surface, so that also hereby an even application of the active substance and an even removal of the wound secretion is compromised. A continuous effect is not envisioned or intended. 
         [0007]    A solution to the above mentioned deficiencies in deep wound treatments was proposed in US patent application 2007/0021698 A1, the summary of which is repeated as follows. The invention was concerned with the task, of providing a process and device for application of active substances to a wound surface, which guarantees a high effectiveness of the applied active substance over the entire wound surface, makes possible an optimal dosing of the active substance, and enhances the wound healing process. 
         [0008]    The basic idea of the invention was to lay a padding or bandage of an elastic compressible porous material upon the wound surface and to cover the wound surface and the padding with a sealing layer or foil, which closes off the wound and the padding against the atmosphere. The supply line and the removal line are respectively provided with controllable closure devices which at the appropriate time are so controlled, that the introduction of the active substance and the suctioning off of the active substance and in certain cases the wound secretion are separated from each other in time. Between the time interval in which the closure device of the supply line is opened and the active substance is supplied, and the point in time, in which the closure device of the removal line is opened in order to suction out the active substance and the wound secretion, there is programmed or provided an treatment dwell time interval, in which both closure devices are closed and the active substance statically has an effect upon the wound surface. After the suctioning off of the active substance and the wound secretion there was, besides this, a time interval programmed in which the closure mechanism of the supply side remains closed and a vacuum is maintained in the area of the wound. For this the closure mechanism of the suctioning side can remain open, so that via the vacuum source a constant vacuum is maintained in area of the wound and the wound secretion is suctioned off. The closure mechanism of the removal side can also be closed, so that the vacuum produced initially can be maintained. It is also possible in this phase that the closure mechanism of the removal side is temporarily controlled to be open, in order that the vacuum is reestablished, in case this drops below a pre-determined value. 
         [0009]    The dwell time interval, in which the padding is impregnated or soaked with the active substance and the active substance was applied with a continuous effect upon the wound surface, was selected corresponding to the nature of the active substance, its dosing and the indications given by the condition of the wound surface. In the vacuum time interval, in which no active substance is applied and only the wound secretion is suctioned off, the bodily immunological repair and immune processes of the tissue can proceed unhindered, so that the wound healing is optimized. Thus, active treatment phases and healing phases alternate temporally one after the another. In the treatment phase the wound system is actively engaged by means of the active substances, such as for example antibiotics or antiseptics, in order to fight or combat infections and the like. Since such active substances as a rule besides the desired main effect also have undesired side effects, the active substances are suctioned off subsequent to the active treatment phase and with them the wound secretion, which contains the decomposition products produced during the active treatment phase with their, in certain cases, toxic agents. In the subsequent vacuum time interval the body&#39;s own immunological healing process can proceed optimally, without being compromised by the undesired side effects of the active substances and the decomposition products produced during the combating of the wound infection. 
         [0010]    Preferably the closure mechanisms of the supply line and removal line are temporally so controlled, that the introduction of the active substance begins slowly and with a minimal volumetric stream. Thereby it is prevented, that wound pain is caused or increased by a too-sudden and rapid introduction of active substance. Likewise, the opening of the closure mechanism of the removal line is temporally controlled in such a manner, that the vacuum increases only gradually. A too rapid, sudden vacuum leads likewise to substantially wound pain. 
         [0011]    The padding provided upon the wound surface is comprised of an elastic compressible porous material, preferably a PVA-sponge (polyvinyl alcohol-sponge), wherein a flexible foil is employed for covering. If a vacuum is produced in the foil-covered wound area, then the foil lies tightly upon the wound and compresses the padding. Thereby the padding lies over its entire surface equally tightly on the wound surface. This improves the suctioning off of the wound secretion during the vacuum time interval. Should the inlet opening be opened for introduction of the active substance, then the porous padding suctions the active substance in, whereby it expands on the basis of its elastic resilience. Thereby it is achieved, that the padding evenly absorbs the active substance in the manner of a sponge. The active substance is evenly distributed over the entire surface of the padding and acts upon the entire wound surface in an even manner. This is improved thereby, that the padding in the vacuum phase lies tightly against the wound surface. The even distribution of the active substance over the entire surface is not impeded or hindered during the active treatment phase, since after the end of the introduction, during the active treatment time interval, a static condition exists, in which the introduction and removal lines are closed. 
         [0012]    Since the wound treatment can extend over a longer period of time, for example over several days, it can occur, that in particular during a longer vacuum phase the pores of the padding slightly adhere or become glued together. Such adhesion increases the resistance against the introduction of active substance. Thereby the introduction of the active substance by gravity can be impeded. In such a case it is purposeful, at the beginning of the introduction of the active substance, to first rinse the porous padding clean. For this, at the beginning of the introduction of the active substance, first a small volume of a fluid active substance is introduced under pressure, in order to rinse through the pores of the padding and to dissolve adhered areas. The introduction under pressure can advantageously be achieved by a syringe, which is connected to the inlet. Via piston pressure of the syringe a first dose of active substance can be employed for rinsing under pressure, before the introduction of the active substance occurs by gravity. In certain cases it is also possible, that the amount of the fluid active substance necessary for the entire introduction period is supplied by means of the syringe. 
         [0013]    The process and vacuum wound covering device as described therein US application 2007/0021689 is incorporated herein by reference in its entirety. The use of this form of device provides a unique and heretofore unused opportunity for more rapidly initiating the healing process in such difficult large and deep wounds. 
         [0014]    Historically vacuum bandages employed a sponge which by its cellular open pore nature exhibited numerous air pockets. 
         [0015]    Applicants of the present invention have developed a new family of unfocused or wide area unfocused acoustic shock waves that can transmit wave patterns with either a wide area focal region or with no focal point or a focal point lying outside the wound area, preferably external of the patient&#39;s body. The acoustic wave patterns provide both a germicidal effect on the tissue upon which they impinge, and also are known to accelerate healing. These wave patterns are best transmitted through a fluid gel to the applicator head and the patient&#39;s skin directly. With covered wounds as described above, transmission through the bandage was considered impossible due to the residual air pockets and therefore the use of such shock waves was not contemplated as complimentary to vacuum wound treatments. 
         [0016]    A subtle heretofore unappreciated, but remarkably simple adjustment of the use of such vacuum bandage devices as described in the prior art provides the basis for the present invention. 
       SUMMARY OF THE INVENTION 
       [0017]    A method and device for treating wounds of tissue is disclosed. The method has the steps of applying a porous pad upon the treatment surface of the tissue; covering the treatment surface and the porous pad with a foil or sealing cover for isolating the treatment surface and the porous pad from the atmosphere; filling the volume under the foil or sealing cover with fluid and purging air from the volume under the foil or sealing cover thereby fluid saturating said porous pad: applying an acoustic shock wave treatment through the foil or sealing cover or surrounding tissue or a combination thereof sending acoustic shock waves through the volume to the treatment surface and underlying tissue and thereafter pulling a vacuum to create a sub-atmospheric pressure under the foil or sealing cover wherein the combination of the applied acoustic shock waves and sub-atmospheric conditions stimulates healing of the treatment surface and underlying tissue. Preferably the acoustic shock waves are unfocused or a wide area focused shock wave pattern. More preferably the shock waves are sufficiently low energy or amplitude to avoid the sensation of pain during the treatment process thereby eliminating the need for anesthesia or localized numbing of the treatment area. By using acoustic shock waves the treatment of the shock waves creates a germicidal effect on the porous pad and the treatment surface of the tissue and a fluid drain system provided within the volume under the foil or sealing cover can remove tissue toxin and other contamination products during a fluid purging process thereafter the drainage vacuum can be applied to the entire volume under the sealing cover to provide continual drainage of body fluid and secretions that are created in the areas of the damaged tissue. This greatly improves the healing process of the tissue and reduces the chances for infection, furthermore to further reduce the chances of infection the step of introducing a medicament, antiseptic or antibiotic into the volume under the sealed cover prior to activation of the shock waves can be used to stimulate absorption or covering of the treatment surface tissue during and after the shock wave treatment. 
         [0018]    To achieve the desired treatment, the vacuum treatment device adapted for transmission of acoustic shock waves is described. The vacuum treatment device for application to tissue has a porous pad for applications upon a treatment surface of the tissue. An air tight, but water vapor permeable foil or sealing cover for covering the treatment surface and the porous padding which seals and isolates the treatment surface from air. At least one fluid supply line for supplying fluid to the treatment surface and the porous pad; at least one fluid removal line for removing the fluid from the treatment surface and the porous padding, the removal line being connected to a vacuum source where the introduction of fluids through the supply line in combination with removal of fluids and entrapped air through the removal line, thereby fluid saturates the porous pad and treatment surface and wherein the fluid saturated volume under the foil or sealing cover enables an acoustic shock wave applicator head to be acoustically coupled to the foil or sealing cover, the foil or sealing cover and adjacent tissues, or the adjacent tissues for the transmission of acoustic shock waves to the treatment surface through the fluid saturated porous pad. 
         [0019]    Preferably the acoustic shock wave device transmits either convergent, divergent, near planar or otherwise unfocused shock waves to the treatment surface and underlying tissue or alternatively wide area focused acoustic shock waves to the treatment and underlying tissue in such a condition that makes it unnecessary to administer additional anesthesia or numbing of the tissue prior to the application of the acoustic shock waves. 
         [0020]    The padding is preferably made of an elastic compressible porous material, preferably a pored PVA foam material. 
         [0021]    In addition to the above the preferred device also includes a controller, a supply side valve, a return side valve and a supply side fluid pressure infusion pump wherein the controller can actuate the supply side valve, the return side valve, the vacuum or the pressure infusion pump to provide the fluid filled infusion of said porous pad or the drainage of said porous pad and treatment surface or a combination thereof for simultaneous fluid infusion and vacuum drainage. After a fluid infusion, the return side is either closed or restricted and there is created a fluid filled reservoir or volume directly under the foil or sealing cover void of air. When this area is completely purged of air it is possible to transmit acoustic shock wave treatments through the foil or sealing cover, the tissue adjacent the foil or sealing cover, or a combination of the two passing through the fluid saturated pad to the treatment tissue and underlying treatment surface. The return side can be closed and a vacuum source applied to create a sub-atmospheric pressure to the treatment tissue which in combination with the acoustic shock waves to stimulate the tissue. Furthermore medications can be applied to the porous pad and upon such application the transmission of acoustic shock waves will increase the ability of the treatment surface area to absorb such medications thereby effectively providing a better medicant coverage than otherwise would be achieved. These devices being effectively germicidally treated by the acoustic shock waves can remain on the patient without changing the bandage or dressing nearly as often as is normally required. The removal of the bandages often times creates additional trauma to the wound area causing the entire area to require additional healing as the wound or treatment area is being cleaned and re-bandaged. The use of acoustic shock waves limits the number of times this is necessary and therefore provides a better opportunity to provide a healing for the patient. 
       Definitions 
       [0022]    “apoptosis” is the biological process of controlled, programmed cell death, by means of which cells die by a process of condensation without the release of cell contents into the surrounding milieu. 
         [0023]    A “curved emitter” is an emitter having a curved reflecting (or focusing) or emitting surface and includes, but is not limited to, emitters having ellipsoidal, parabolic, quasi parabolic (general paraboloid) or spherical reflector/reflecting or emitting elements. Curved emitters having a curved reflecting or focusing element generally produce waves having focused wave fronts, while curved emitters having a curved emitting surfaces generally produce wave having divergent wave fronts. 
         [0024]    “cytoplasm” The part of a cell that contains the CYTOSOL and small structures excluding the CELL NUCLEUS; MITOCHONDRIA; and large VACUOLES. 
         [0025]    “Divergent waves” in the context of the present invention are all waves which are not focused and are not plane or nearly plane. Divergent waves also include waves which only seem to have a focus or source from which the waves are transmitted. The wave fronts of divergent waves have divergent characteristics. Divergent waves can be created in many different ways, for example: A focused wave will become divergent once it has passed through the focal point. Spherical waves are also included in this definition of divergent waves and have wave fronts with divergent characteristics. 
         [0026]    “extracorporeal” occurring or based outside the living body. 
         [0027]    A “generalized paraboloid” according to the present invention is also a three-dimensional bowl. In two dimensions (in Cartesian coordinates, x and y) the formula y n =2px [with n being ≠2, but being greater than about 1,2 and smaller than 2, or greater than 2 but smaller than about 2,8]. In a generalized paraboloid, the characteristics of the wave fronts created by electrodes located within the generalized paraboloid may be corrected by the selection of (p (−z,+z)), with z being a measure for the burn down of an electrode, and n, so that phenomena including, but not limited to, burn down of the tip of an electrode (−z,+z) and/or disturbances caused by diffraction at the aperture of the paraboloid are compensated for. 
         [0028]    “lactate dehydrogenase (LDH)” A tetrameric enzyme that, along with the coenzyme NAD+, catalyzes the interconversion of lactate and pyruvate. In vertebrates, genes for three different subunits (LDH-A, LDH-B and LDH-C) exist. 
         [0029]    “mitochondria” Semiautonomous, self-reproducing organelles that occur in the cytoplasm of all cells of most, but not all, eukaryotes. Each mitochondrion is surrounded by a double limiting membrane. The inner membrane is highly invaginated, and its projections are called cristae. Mitochondria are the sites of the reactions of oxidative phosphorylation, which result in the formation of ATP. They contain distinctive RIBOSOMES, transfer RNAs (RNA, TRANSFER); AMINO ACYL T RNA SYNTHETASES; and elongation and termination factors. Mitochondria depend upon genes within the nucleus of the cells in which they reside for many essential messenger RNAs (RNA, MESSENGER). Mitochondria are believed to have arisen from aerobic bacteria that established a symbiotic relationship with primitive protoeukaryotes. 
         [0030]    “necrosis” A pathological process caused by the progressive degradative action of enzymes that is generally associated with severe cellular trauma. It is characterized by mitochondrial swelling, nuclear flocculation, uncontrolled cell lysis, and ultimately CELL DEATH. 
         [0031]    A “paraboloid” according to the present invention is a three-dimensional reflecting bowl. In two dimensions (in Cartesian coordinates, x and y) the formula y 2 =2px, wherein p/2 is the distance of the focal point of the paraboloid from its apex, defines the paraboloid. Rotation of the two-dimensional figure defined by this formula around its longitudinal axis generates a defacto paraboloid. 
         [0032]    “phagocytosis” The engulfing of microorganisms, other cells, and foreign particles by phagocytic cells. 
         [0033]    “Plane waves” are sometimes also called flat or even waves. Their wave fronts have plane characteristics (also called even or parallel characteristics). The amplitude in a wave front is constant and the “curvature” is flat (that is why these waves are sometimes called flat waves). Plane waves do not have a focus to which their fronts move (focused) or from which the fronts are emitted (divergent). “Nearly plane waves” also do not have a focus to which their fronts move (focused) or from which the fronts are emitted (divergent). The amplitude of their wave fronts (having “nearly plane” characteristics) is approximating the constancy of plain waves. “Nearly plane” waves can be emitted by generators having pressure pulse/shock wave generating elements with flat emitters or curved emitters. Curved emitters may comprise a generalized paraboloid that allows waves having nearly plane characteristics to be emitted. 
         [0034]    A “pressure pulse” according to the present invention is an acoustic pulse which includes several cycles of positive and negative pressure. The amplitude of the positive part of such a cycle should be above about 0.1 MPa and its time duration is from below a microsecond to about a second. Rise times of the positive part of the first pressure cycle may be in the range of nano-seconds (ns) up to some milli-seconds (ms). Very fast pressure pulses are called shock waves. Shock waves used in medical applications do have amplitudes above 0.1 MPa and rise times of the amplitude are below 100 ns. The duration of a shock wave is typically below 1-3 micro-seconds (μs) for the positive part of a cycle and typically above some micro-seconds for the negative part of a cycle. 
         [0035]    Waves/wave fronts described as being “focused” or “having focusing characteristics” means in the context of the present invention that the respective waves or wave fronts are traveling and increase their amplitude in direction of the focal point. Per definition the energy of the wave will be at a maximum in the focal point or, if there is a focal shift in this point, the energy is at a maximum near the geometrical focal point. Both the maximum energy and the maximal pressure amplitude may be used to define the focal point. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0036]    The invention will be described by way of example and with reference to the accompanying drawings in which: 
           [0037]      FIG. 1  is an exemplary embodiment of the device according to the invention, to which an acoustic shock wave applicator head can be coupled directly to the outer covering of the device. 
           [0038]      FIG. 2  is a modification of the device of  FIG. 1  showing independent supply line and drainage line, as shown in a top view. 
           [0039]      FIG. 3  shows the exemplary device of  FIG. 1  being used in combination with a shock wave applicator; the applicator head is illustrated showing how the acoustic shock waves penetrate through the sealing cover into the underlying tissue area. 
           [0040]      FIG. 4  shows the alternative modified device of  FIG. 2  used in combination with a shock wave applicator; the applicator head is illustrated showing how the acoustic shock waves penetrate through the sealing cover into the underlying tissue area. 
       
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
       [0041]    The present invention as described below employs a vacuum wound bandage device  1 ,  1 A in combination with an acoustic shock wave applicator device. 
         [0042]    The vacuum wound bandage device  1 ,  1 A can be of any particular size or shape but unlike conventional bandaging, the vacuum wound bandaging device  1  must be designed to easily transmit acoustic shock waves. 
         [0043]    Prior to the present invention all such devices notoriously had a sponge or otherwise porous pads filled with entrapped air. Those skilled in the art of acoustic shock wave therapies recognized that such bandaging would act as a sound wave absorber or dampener, making it virtually impossible to use shock waves to treat such covered wounds. 
         [0044]    Furthermore, severely damaged tissue  11  in these deep wounds, if exposed to focused high energy shock waves caused additional hemorrhaging and a strong sensation of pain, thus making the use of conventional acoustic shock waves as a treatment unacceptable to the patient and the attending physician. 
         [0045]    This basically led to a complete belief that a combination was totally incompatible and unworkable by those skilled in the art of treating such sever wounds. 
         [0046]    In US publication 2007/0021698 A1 published Jan. 25, 2007 a vacuum bandage is disclosed entitled “Process and Device for Application of Active Substances to a Wound Surface” the description of which is incorporated herein by reference in its entirety herein. In this application the primary function is to provide a device which facilitates the use of medications, antiseptics and or antibodies to the covered wound via a supply line and wherein the wound can be exposed to sub-atmospheric pressure to stimulate healing. 
         [0047]      FIGS. 1 and 2  show a vacuum wound bandage device  1 ,  1 A respectively which is described as follows. 
         [0048]    For treatment of a large surface area deep wound  10  a padding  12  is applied. The padding  12  is comprised of a porous elastic compressible material, preferably of an open pored PVA foam material. The padding  12  is cut or trimmed to correspond to the contour of the wound  10 . The wound  10  and the padding  12  are covered over by a foil  14  and sealingly closed off. The foil  14  is so cut, that it covers over the padding  12  and the wound  10  and extends beyond the edges of the wound. The foil  14  is sealingly secured to the skin surface about the wound circumference, for example, it is adhered. 
         [0049]    The foil  14  is flexible and is comprised of a synthetic or plastic material, which permits the diffusion of water vapor, however, provides an air-tight enclosure. 
         [0050]    In the padding  12  there is introduced a drainage tube  16 , a so-called Redon-tube, which is perforated in the end area lying in the padding  12 . The not perforated area of the drainage tube  16  is covered over by the foil  14  and extends out therefrom. 
         [0051]    In the illustrative embodiment of  FIG. 1  there is introduced in the proximal end of the drainage tube  16  a T-shaped branch or manifold piece  20 . On its one connection of the manifold  20  a hose is attached as supply side  22 , which leads to a known infusion container  24 . On the other connection of the manifold  20  a hose is attached as removal  26  which leads to a receptacle container  28  onto which, via a connection line  30 , a vacuum source is connectable. Such a receptacle container  28  is likewise known per se. 
         [0052]    The supply line  22  has associated therewith a closure mechanism  32  and the removal line  26  has a closure mechanism  34  associated therewith. The closure mechanisms  32  and  34  are continuously adjustable between a closed position and an open position and are operated via a controller  36 . 
         [0053]    In the here shown illustrative embodiments the closure mechanisms  32  and  34  are respectively constructed as hose clamps, which include a receptacle, in which the hose of the supply line  22  or, as the case may be, the removal line  26 , can be introduced. A plunger is, as indicated by arrows in the figure, controlled electromagnetically, pneumatically, hydraulically or in an otherwise known manner by the controller  36 , in order that the introduced hose is pressed against a side wall and with squeezing is closed off or in order that the cross-sectional area of the hose is continuously unimpeded. 
         [0054]    In certain cases a pressure sensor  38  can be introduced in the wound area under the foil  14 , which senses the pressure existing under the foil  14  and reports this to the controller  36 . 
         [0055]    In the infusion container  24  a fluid active substance is pre-supplied, which can be introduced to the padding  12  and therewith to the wound surface via the supply line  22  and the drainage hose  16  in the case of opened closure mechanism  32  and closed closure mechanism  34 . In the case of the closed closure mechanism  32  and opened closure mechanism  34  the active substance and the wound secretion produced in the wound  10  can be suctioned off via the removal line  26  into the receptacle container  28 . 
         [0056]      FIG. 2  shows a variation of the device  1 A, which in comparison to the illustrative embodiment of  FIG. 1  differs therein, that the padding  12  introduced in the wound  10  has introduced therein two hoses  16  and  18 . The hose  16  is connected with the supply line  22 , while the drainage hose  18  is connected with the removal line  26 . A branching is thus unnecessary. 
         [0057]    In the illustrative embodiment according to  FIG. 1  the hose  16  forms a hose dead-end, in which on the one hand the active substance can be introduced and out of which on the other hand the active substance can be suctioned out. Thereby during the introduction of the fluid active substance gas bubbles can be trapped in the drainage hose  16 , which would interfere with the introduction of the active substance. This difficulty cannot occur in the embodiment according to  FIG. 2 , since any gas bubbles trapped in the hose  16  would be suctioned out via the drainage hose  18 . The embodiment according to  FIG. 1  however has the advantage, that only one hose must be introduced under seal under the foil  14 . 
         [0058]    A particular advantageous feature of the exemplary vacuum wound device is the closure mechanisms  32  and  34  are controlled by the controller  36  to be closed and in the wound there exists a vacuum of approximately 10 to 80 kPa. On the basis of this vacuum the foil or sealing cover  14  is pressed against the wound surface, wherein the elastic padding  12  is compromised. The controller  36  directs the closure mechanism  32  to open, so that the fluid  100  can flow out of the infusion container  24  via the supply line  22  and the hose  16  into the padding  12 . During the inflow the padding  12  suctions itself to fullness with fluid  100 , whereby it expands on the basis of its elastic spring resilience. The porous padding  12  is suctioned full of fluid  100 , whereby under the foil  14  a certain over-pressurization exists, which is preferably determined by the height of the infusion container  24  with respect to the wound  10 . In certain cases a pressure controlled pump can be introduced in the supply line  22  controlled by the pressure sensor  38 . 
         [0059]    The opening of the closure mechanism  32  of the supply line  22  in the introduction time interval T 1  is controlled by means of the controller  36  in such a timed manner, that the volumetric flow of the fluid active substance only increases slowly. A sudden opening of the closure mechanism  32  would result in a very rapid influx of the active substance. This can result in wound pain to the patient, in particular since the fluid active substance as a rule does not correspond to the body temperature of the patient. 
         [0060]    During the vacuum phase in certain circumstances the pores of the compromised padding  12  can adhere or stick together. Such an adhesion prevents the influx of the active substance under only gravity, which is determined by the height of the infusion container  24  with respect to the wound  10 . Such a possible adhesion of the pores can be rinsed clean thereby that during the opening of the closure mechanism  32  first a certain volume of the fluid active substance is introduced under pressure. For this a suitable volume of the active substance can be introduced by means of a piston syringe via the supply line  22 . The piston syringe is therefore preferably connected to the supply line  22 , for which for example a three-way cock or valve can be associated with the supply line  22 , onto which the piston syringe is connected. 
         [0061]    As soon as the padding  12  has suction-filled itself with fluid active substance, the closure mechanism  32  of the supply side  22  is closed at time T 2 . For a treatment dwell time interval T 2  the closure mechanisms  32  and  34  of the supply line  22  and the removal line  26  remain closed, so that the active substance contained in the padding  12  can act upon the surface of the wound  10 . The duration of the treatment dwell time interval T 2  can be predetermined by the controller  36  and is based upon the type and condition of the wound  10  and according to the type and concentration of the active substance. When the active substance during the time interval T 2  has had a sufficient effect or action upon the wound surface, then at time T 3  the closure mechanism  34  of the removal line  26  is opened. Thereby via the vacuum existing through the connection line  30  the fluid active substance is suctioned out of the padding  12  and the wound  10  via the hose  16  (in  FIG. 1 ) or as the case may be the drainage hose  18  (in  FIG. 2 ). At the same time the wound fluid  100  or secretion is suctioned out, which has accumulated in the wound  10  in the treatment dwell time interval T 2  and which contains decomposition and breakdown products produced through the action of the active substance. 
         [0062]    The opening of the closure mechanism  34  is timely so controlled by the controller  36 , that the flow-through cross-section of the removal line  26  opens only slowly and the vacuum in the padding  12  and the wound  10  only increases gradually, through the continuous line. An immediate and complete opening of the closure mechanism  34  would lead to a very rapid pressure drop in the area of the wound, which would be associated with wound pains for the patient. 
         [0063]    Should at time T 4  the original vacuum again be achieved, which in certain cases can be monitored by the pressure sensor  38 , so the fluid active substance can again be completely removed from the wound  10  and the padding  12 . The vacuum is then maintained for a vacuum time interval T 4 . Thereby as a rule the closure mechanism  34  remains open, so that the vacuum is continuously maintained by the vacuum source  30 , and the produced wound secretion is continuously suctioned off into the receptacle retainer  28 . It is also possible, that the closure mechanism  34  is closed or temporarily closed and only opened for short period of times when the vacuum monitored by pressure sensor  38  must be regenerated. 
         [0064]    All of this is fully described in US patent publication US 2007/0021689, which has been incorporated herein by reference in its entirety. 
         [0065]    Now with reference to  FIGS. 3 and 4 , the above exemplary vacuum bandage device  1  or  1 A, can be used in a new and rather unique way in combination with an acoustic shock wave applicator device  50 . 
         [0066]    With reference to  FIGS. 3 and 4 , the shock wave applicator  50  connected to a power generating source (not shown) via a connecting a cable  52  can be used in combination with either the wound vacuum bandaging device  1  or  1 A or any other bandaging device wherein the porous pad can be completely and totally fluid  100  saturated and wherein any ambient air underlying the foil or sealing cover  14  can be effectively removed. The exemplary devices  1  and  1 A provide ideal ways in which fluid  100 , either under gravity or otherwise pressurized fluid  100  can be introduced under the sealing foil  14  and prior to the introduction of the fluid  100 , a vacuum pulled depresses the sealing cover  14  to compress the porous pad  12  such that as the vacuum is shut off and the supply line is opened the fluid  100  enters and re-saturates the porous pad  12 , the entrapped air is evacuated from under the sealing cover  14  through the drainage line and as this is accomplished and all air is removed above the wound area such that the pad  12  and the entire volume area under the sealing cover  14  is completely fluid  100  saturated making it possible to apply acoustic shock wave treatments. 
         [0067]    Historically acoustic shock waves were provided using a focusing element that would redirect the waves to converge to a point such that converged waves would have the highest energy at the focal point or focal region of the emitted waves. These acoustic waves had sufficient energy to break up concrements such as kidney stones, however, when used on tissue  11  or bone this could create localized hemorrhaging and a severe introduction of pain. It is well appreciated that the introduction of pain into large, deep wounds is not desirable. It is also well understood that new advances in acoustic shock waves have been achieved whereby tremendous healing potentials can be achieved using unfocused or low energy acoustic shock waves  200  that virtually eliminate the sensation of pain or localized hemorrhaging. With these advances it is now possible to use an acoustic shock wave applicator  50  on a deep wound  10  as described above wherein the acoustic shock waves  200  can be transmitted into the affected tissue  11  without the introduction of pain, but while still providing a germicidal effect and a more rapid healing of the treatment area. Another beneficial feature of using unfocused shock waves  200  is that the transmission occurs over a larger area and therefore the treatment can be accomplished with minimal moving of the applicator  50 , therefore the applicator  50  being pressed upon and acoustically coupled to the foil or sealing cover  14  will not cause injurious pain to the patient. 
         [0068]    As shown in both  FIGS. 3 and 4  an acoustic gel  51  is preferably used to help facilitate the transmission of the acoustic waves  200 , as shown the applicator  50  has a side firing head  54  wherein the waves are transmitted in such a fashion that the physician can hold the applicator while the waves are being transmitted onto the treatment surfaces. Alternatively the applicator could be provided with an end firing lens such that the physician would hold the applicator longitudinally and the transmission of waves would occur directly outward from the applicator head. In either case it is desirable that with a wide focused area shock waves be produced at low energy to minimize the sensation of pain and to reduce the convergence to a maximum amplitude that is far less than those found in focused shock waves that use a narrow focal point. Alternatively either planar or divergent or convergent waves wherein the focal point is outside the tissue  11  area or body such that the patient does not require additional anesthesia or numbing of the wound site area. 
         [0069]    As shown and as described above, it is preferable that the application of the shock waves  200  occur when the foil or sealing cover  14  is in a distended or slightly outward position as created when the vacuum valve is closed and the fluid supply line is allowed to fill the area with fluid  100  causing a slight distension or ballooning of the cover  14 . This bowing of the cover gives evidence that the entire wound area is fluid  100  filled greatly enhancing the ability to transmit the acoustic shock waves  200 . Once the acoustic shock waves  200  have been applied the vacuum treatment device can be used as described above wherein during the healing time a slight vacuum can be pulled such that the decomposing tissue  11  and fluid  100   s  within the wound and bandage are pulled under vacuum allowing sufficient drainage to the wound site area as is currently the practice. 
         [0070]    Assuming the entire wound area is within a projected area of the wave transmission, a single transmission  200  dosage of wave energy may be used. The transmission dosage can be from a few seconds to 20 minutes or more dependent on the condition. Preferably the waves are generated from an unfocused or wide area focused source. The unfocused waves can be divergent, planar or near planar and having a low pressure amplitude and density in the range of 0.00001 mJ/mm 2  to 1.0 mJ/mm 2  or less, most typically below 0.2 mJ/mm 2 . The focused source preferably can use a diffusing lens or have a far-sight focus to minimize if not eliminate having the localized focus point within the tissue  11 . Preferably the focused shock waves are used at a similarly effective low energy transmission or alternatively can be at higher energy but wherein the tissue  11  target site is disposed pre-convergence inward of the geometric focal point of the emitted wave transmission. 
         [0071]    These shock wave energy transmissions are effective in stimulating a cellular response and can be accomplished without creating the cavitation bubbles in the tissue  11  of the target site. This effectively insures the tissue  11  or organ does not have to experience the sensation of hemorrhaging so common in the higher energy focused wave forms having a focal point at or within the targeted treatment site. 
         [0072]    If the target site or wound is larger than the emitted wave pattern the target site may be such that the patient or the generating source must be reoriented relative to the site and a second, third or more treatment dosage can be administered. The fact that the dosage can be at a low energy the common problem of localized hemorrhaging is reduced making it more practical to administer multiple dosages of waves  200  from various orientations to further optimize the treatment and cellular stimulation of the wound site. Heretofore focused high energy multiple treatments induced pain and discomfort to the patient. The use of low energy focused or un-focused waves at the target site enables multiple sequential treatments. 
         [0073]    The present method does not rely on precise site location per se, although can be used in combination with such known devices as ultrasound, cat-scan or x-ray imaging if needed. The physician&#39;s general understanding of the anatomy of the patient should be sufficient to locate the target area to be treated. This is particularly true when the wound is within the surgeon&#39;s line of sight and this permits the lens or cover of the emitting shock wave applicator  50  to impinge on sealing cover  14  or adjacent tissue  11  directly or through a transmission enhancing gel  51 , water or fluid medium during the shock wave treatment. Ideally the foil or sealing cover  14  may be transparent or at least translucent such that any entrapped air bubbles can be observed and removed from under the foil or sealing cover  14  prior to transmitting the shock wave treatment. The treated area can withstand a far greater number of shock waves based on the selected energy level being emitted. For example at very low energy levels the stimulation exposure can be provided over prolonged periods as much as 20 minutes if so desired. At higher energy levels the treatment duration can be shortened to less than a minute, less than a second if so desired. The limiting factor in the selected treatment dosage is avoidance or minimization of cell hemorrhaging and other kinds of damage to the cells or tissue  11  while still providing a stimulating stem cell activation or a cellular release or activation of VEGF and other growth factors. 
         [0074]    Due to the wide range of beneficial treatments available it is believed preferable that the optimal use of one or more wave generators or sources should be selected on the basis of the specific application. Wherein relatively small target sites may involve a single wave generator placed on an adjustable manipulator arm. A key advantage of the present inventive methodology is that it is complimentary to conventional medical procedures. In the case of any operative surgical procedure the surgical area of the patient can be bombarded with these low energy waves to stimulate cellular release of healing agents and growth factors. This will dramatically reduce the healing process time. Most preferably such patients may be provided more than one such treatment with an intervening dwell time for cellular relaxation prior to secondary and tertiary post operative or post trauma treatments. 
         [0075]    The underlying principle of these shock wave therapy methods is to stimulate the body&#39;s own natural healing capability. This is accomplished by deploying shock waves to stimulate strong cells in the tissue  11  to activate a variety of responses. The acoustic shock waves transmit or trigger what appears to be a cellular communication throughout the entire anatomical structure, this activates a generalized cellular response at the treatment site, in particular, but more interestingly a systemic response in areas more removed from the wave form pattern. This is believed to be one of the reasons molecular stimulation can be conducted at threshold energies heretofore believed to be well below those commonly accepted as required. Accordingly not only can the energy intensity be reduced but also the number of applied shock wave impulses can be lowered from several thousand to as few as one or more pulses and still yield a beneficial stimulating response. 
         [0076]    The use of shock waves as described above appears to involve factors such as thermal heating, light emission, electromagnetic field exposure, chemical releases in the cells as well as a microbiological response within the cells. Which combination of these factors plays a role in stimulating healing is not yet resolved. However, there appears to be a commonality in the fact that growth factors are released which applicants find indicative that otherwise dormant cells within the tissue  11  appear to be activated which leads to the remarkable ability of the targeted organ or tissue  11  to generate new growth or to regenerate weakened vascular networks in for example the vascular system. This finding leads to a complimentary use of shock wave therapy in combination with stem cell therapies that effectively activate or trigger stem cells to more rapidly replicate enhancing the ability to harvest and culture more viable cells from the placenta, a nutrient culture of said stem cells, or other sources. The ability to stimulate stem cells can occur within the patients own body activating the naturally occurring stem cells or stem cells that have been introduced to the patient as part of a treatment beneficially utilizing stem cells. This is a significant clinical value in its own right. 
         [0077]    This invention further provides germicidal cleaning of diseased or infected areas and for wound cleaning generally after exposure to vacuum wound bandaging devices. 
         [0078]    The use of shock wave therapy requires a fundamental understanding of focused and unfocused shock waves, coupled with a more accurate biological or molecular model. 
         [0079]    Focused shock waves are focused using ellipsoidal reflectors in electromechanical sources from a cylindrical surface or by the use of concave or convex lenses. Piezoelectric sources often use spherical surfaces to emit acoustic pressure waves which are self focused and have also been used in spherical electromagnetic devices. 
         [0080]    The design of sources with low pressure amplitudes and energy densities. First: spherical waves generated between two tips of an electrode; and second: nearly even waves generated by generalized parabolic reflectors. Third: divergent shock front characteristics are generated by an ellipsoid behind F 2 . Unfocused sources are preferably designed for extended two dimensional areas/volumes like skin. The unfocused sources can provide a divergent wave pattern a planar or a nearly planar wave pattern and can be used in isolation or in combination with focused wave patterns yielding to an improved therapeutic treatment capability that is non-invasive with few if any disadvantageous contraindications. Alternatively a focused wave emitting treatment may be used wherein the focal point extends preferably beyond the target treatment site, potentially external to the patient. This results in the reduction of or elimination of a localized intensity zone with associated noticeable pain effect while providing a wide or enlarged treatment volume at a variety of depths more closely associated with high energy focused wave treatment. The utilization of a diffuser type lens or a shifted far-sighted focal point for the ellipsoidal reflector enables the spreading of the wave energy to effectively create a convergent but off target focal point. This insures less tissue  11  trauma while insuring cellular stimulation to enhance the healing process. 
         [0081]    This method of treatment has the steps of, locating a treatment site, generating either convergent diffused or far-sighted focused shock waves or unfocused shock waves, of directing these shock waves to the treatment site; and applying a sufficient number of these shock waves to induce activation of one or more growth factors thereby inducing or accelerating healing. 
         [0082]    The unfocused shock waves can be of a divergent wave pattern, planar or near planar pattern preferably of a low peak pressure amplitude and density. Typically the energy density values range as low as 0.000001 mJ/mm 2  and having a high end energy density of below 1.0 mJ/mm 2 , preferably 0.20 mJ/mm 2  or less. The peak pressure amplitude of the positive part of the cycle should be above 1.0 and its duration is below 1-3 microseconds. 
         [0083]    The treatment depth can vary from the surface to the full depth of the treated wound. The treatment site can be defined by a much larger treatment area than the 0.10-3.0 cm 2  commonly produced by focused waves. The above methodology is particularly well suited for surface as well as sub-surface soft tissue  11  wound treatments. 
         [0084]    The above methodology is valuable in generation of new tissue  1 , vascularization and may be used in combination with stem cell therapies as well as regeneration of tissue  11  and vascularization. 
         [0085]    The methodology is useful in stimulating enforcement of defense mechanisms in tissue  11  cells to fight infections from bacteria and can be used germicidally to treat or cleanse wounds or other target sites which is a primary concern in the case of chemical or radiation burns resulting from such exposures to radiation or chemical agents and burns generally wherein the wound also includes decomposing burned tissue  11 . 
         [0086]    While the above listed indications cited above are not exhaustive nor intended to be limiting, it is exemplary of the wide range of beneficial uses of low energy and amplitude unfocused divergent, planar or nearly planar shock waves, convergent shock waves, diffused shock waves or a combination of shock wave types in the treatment of humans and other mammals that are exposed to wounds wherein vacuum bandaging devices are employed. 
         [0087]    It will be appreciated that the apparatuses and processes of the present invention can have a variety of embodiments, only a few of which are disclosed herein. It will be apparent to the artisan that other embodiments exist and do not depart from the spirit of the invention. Thus, the described embodiments are illustrative and should not be construed as restrictive.