UPPER EXTREMITY.
Bandage for the Fingers and Thumb.
Apparatus.—A ¾-inch wide roller.
The fingers are bandaged to prevent œdema when splints are tightly attached to the fore or upper arm. A roller ¾ inch wide is passed once round the wrist and then carried over the back of the hand to the little finger; then wound in spirals round it to the tip and returned up the finger, completed by a figure of 8 round the wrist and the root of the finger, and returned to the wrist before being brought across the back of the hand to the next finger, to which it is applied in the same manner till the four fingers are covered. It is a good precaution to place a shred of cotton wool between each finger before carrying the figure of 8 turn round the root; it prevents the bandages from chafing the tender skin.
The thumb is bandaged rather differently: the roller is commenced in the same way round the wrist, but the first turn is carried at once beyond the last joint, turned once or twice round the last phalanx, and continued by reverses to the metacarpo-phalangeal joint; the ball of the thumb is then covered by figures of 8 round the thumb and wrist. This is called the spica for the thumb.
Fig. 13.—Spica for the Thumb.
This plan is sometimes employed to compress bleeding wounds of the ball of the thumb, and is applied without previously covering the phalanges, as in fig. 13.
The Hand and Arm.
Apparatus.—1. A roller 2¼ inches wide for an adult, but narrower for a child.
2. Some cotton wool.
A little cotton wool should fill the palm before applying the roller. The bandage commences with figures of 8 carried round the hand and wrist. The roller is first passed across the back of the hand from the radial border of the thumb to the root of the little finger (see fig. 14), and then across the palm, reaching the back of the hand between the thumb and forefinger.
Fig. 14.—Commencing to bandage the hand.
When the hand is covered by these figures of 8 the bandage is passed up the forearm by reverses placed over the extensor muscles till the elbow is nearly reached. Before going further a dossil of cotton wool is placed in the bend of the elbow, and on the inner condyle; the joint is bent to the degree that will be required by the splint, and the patient told to grasp some part of his dress, or the sleeve of the other arm, that he may not unconsciously extend the joint again while the bandage is being rolled round it.
The elbow is covered by first carrying the roller round the joint, so that the point of the olecranon rests on the centre of the turn (see dotted lines, fig. 15). The bandage is then continued in figures of 8, passing above and below the first turn until the elbow is covered in and the bandage of the forearm is completed.
Fig. 15.—Bandage covering the elbow. The first turn over the point of the elbow is shown by the dotted lines.
Fig. 16.—Spica Bandage for the shoulder.
The arm is covered by spirals and reverses till the armpit is reached. Before bandaging the shoulder the armpit is protected by cotton wool or a double fold of soft blanket; the roller is then carried in front of and over the shoulder, across the back to the opposite axilla, where also some wool should be placed, then across the chest to the top of the shoulder again, and under the armpit to the front (see fig. 16). These figures of 8 are repeated as often as necessary to complete the covering. The bandage is applied in this method for dressings; but when pressure is needed the first turn may be carried at once to the root of the neck, and each succeeding turn made to overlap below the last, until the point of the shoulder is gained, as in fig. 37, p. [55]. These are called the spica for the shoulder.
Wound of the Palmar arch.—Bleeding from this wound can usually be stopped by pressure on the bleeding point, when this fails an attempt should be made to tie the vessel at the wound, and if this be impracticable the arteries of the forearm must be deligated.
For compression the following is necessary:—
Apparatus.—1. Petit’s tourniquet.
2. Straight wooden splint.
3. Rollers 2 inches wide, and ¾ inch wide for fingers.
4. Pad and cotton wool.
5. Lint.
6. A slip of a wine cork.
7. Scissors and needle and thread.
8. Lunar caustic.
Step 1. First apply the tourniquet to the brachial artery, to control the hæmorrhage while the apparatus is being adjusted.
Step 2. Make a graduated compress by folding a sixpence or slip of a cork in two or three thicknesses of lint, trim the lint into circular disks and prepare a dozen similar disks of increasing size; lay these one on each other to form a round cone about one inch high with the piece of cork at the apex, and fasten them together by a thread.
Step 3. Clean and dry the wound, then rub its surface carefully with nitrate of silver, to lessen the suppuration.
Step 4. Bandage the fingers and thumb, and prepare the splint, which should be straight, as broad as the forearm, and long enough to reach from the elbow to the tips of the fingers; it should be lightly padded.
Step 5. Envelope the wrist with a little wool; next lay the graduated compress on the wound, the small end downwards, and press it firmly in with the left thumb, while the splint is applied to the back of the hand and forearm. These are then fixed by a roller carried in figures of 8 round the hand and wrist across the compress until that is tightly pressed into the wound and the splint fixed to the limb. The roller is then carried along the forearm, a fold of wool laid in front of the elbow, the tourniquet removed and the roller carried to the axilla while the forearm is raised, flexed across the chest, and fastened to the side.
This apparatus is worn without being disturbed for three or four days if bleeding do not return; but at the end of this time it should be examined; if painful or if discharge ooze out at the wound, the bandage should be removed and readjusted less firmly than before, a piece of wet lint replacing the graduated compress.
Venæsection.—Bandage and bleeding at the bend of the elbow.
Apparatus.—1. Lancet.
2. Tape.
3. Pledget of lint.
4. Dish.
5. Staff.
In opening a vein at the bend of the elbow, the median basilic is selected, simply because it is usually the largest, but any branch that is superficial, and well filled with blood, may be opened.
The patient should sit or stand, in which positions, syncope, one of the objects of bleeding, is attained by the abstraction of a less amount of blood than in the horizontal posture.
The surgeon places a graduated bleeding dish on a chair or stool within his reach, and a pledget of lint in his waistcoat pocket; he next gives the patient a heavy book, or staff to grasp in his hand. The arm being bare to the shoulder, a tape, ¾ inch broad and 1¼ yard long, is tied round the arm tight enough to impede the venous, but not the arterial flow.
The surgeon standing opposite his patient and grasping the arm to be bled with his left hand, so that his thumb controls and steadies the swollen vein, takes his lancet between the right forefinger and thumb; then going through skin and vein at one stroke, carries the lancet upwards for about ¼ inch along the vein. The puncture of the lancet should be quite vertical, and the extraction also made quite vertically, that the slit in the vein may correspond to the slit in the skin.
Fig. 17.—Adjusting the tape after bleeding.
This being done, the operator lays aside his lancet, and takes up the dish, holding it so that the blood shall flow into it: when the dish is placed, he lifts his left thumb from the vein cautiously or the sudden spirt of blood will fall outside the dish and be lost. When the desired amount is drawn, the operator compresses the vein again with the left thumb, and setting down the dish, puts the pledget of lint over the wound. He keeps the pledget in place with his left thumb, while he releases the tape round the arm and places its middle obliquely across the pledget. His left thumb presses the pledget on the wound, while the right hand takes the end of the tape which is farthest from his left, and passes it under the forearm below the elbow to his left fingers, which grasp it tightly. He then takes the other end with his right hand (see fig. 17), and bringing it round the arm above the elbow, carries it across the pledget: as he does this, he replaces his left thumb on the compress with his right forefinger, which he keeps there while he brings up the end of the tape he has already in his left fingers, and throws it over the arm above his right forefinger, then passing his left hand below the right forefinger, he catches the same end of the tape again and draws it back. The two ends thus locked in a loop over the compress, are secured by tying them in a bow outside the elbow and the operation is finished (see fig. 18).
Fig. 18.—The bandage completed.