THE
ESSENTIALS OF BANDAGING;
INCLUDING THE
MANAGEMENT OF FRACTURES AND
DISLOCATIONS,
WITH DIRECTIONS FOR USING OTHER SURGICAL
APPARATUS.

ILLUSTRATED BY 122 ENGRAVINGS ON WOOD.

BY

BERKELEY HILL, M.B. Lond., F.R.C.S.,

Instructor in Bandaging, &c., in University College, Assistant Surgeon to University College Hospital, and Surgeon to Out-patients at the Lock Hospital.

SECOND EDITION, REVISED AND ENLARGED.

LONDON:

JAMES WALTON,

BOOKSELLER AND PUBLISHER TO UNIVERSITY COLLEGE,
137, GOWER STREET.

1869.

LONDON:
BRADBURY, EVANS, AND CO., PRINTERS, WHITEFRIARS.

PREFACE TO THE SECOND EDITION.

In laying a Second Edition before the public, I have decided not to alter the scope of this little work, but simply to endeavour to increase its usefulness, by remedying omissions, and by adding new instructions where such appeared desirable. I have ventured to insert, as an Appendix, lists of the preparations requisite for the sick room and for the operating room before the ordinary operations of surgery are performed; also, lists of the instruments and appliances requisite, or possibly useful, in performing forty-nine different operations on the human body. It is hoped that, by giving the surgeon a list, such as most operators draw up in manuscript for their private use, whereby they may check their preparations before proceeding to operate, some trouble may be saved.

14, Weymouth Street, W.
November, 1869.

PREFACE TO THE FIRST EDITION.

The descriptions and directions for using surgical apparatus in the following pages, are those originally prepared for oral delivery in a short course of practical lessons in bandaging and the application of surgical apparatus, given by me in University College Hospital. No attempt is made to include all efficient modes of treating surgical injuries: it is merely proposed to supply the student or practitioner with instructions by which he may refresh his memory when about to employ the ordinary surgical appliances.

The drawings are by Mr. R. W. Sherwin, who has taken much pains to furnish exact representations of the apparatus, as it was applied by myself for his delineation. The directions for giving chloroform have had the advantage of Mr. Clover’s revision before publication.

14, Weymouth Street, W.
October, 1867.

CONTENTS.

THE

ESSENTIALS OF BANDAGING,

&c.

CHAPTER I.
BANDAGING.

General Rules.—Ordinary bandages are strips of unbleached calico 6 or 8 yards long, having a breadth of ¾ inch for the fingers and toes, 2¼ inches for the head and upper limb, 3 inches for the lower limb, and 6 inches for the body. These, when tightly rolled for use, are termed rollers. Besides these rollers for general use there are special bandages, such as rollers of muslin for using with plaster of paris, of stocking-webbing when elasticity is needed; four- and many-tailed bandages for particular fractures, &c. Messrs. J. & J. Cash, the cambric frilling makers of Coventry, now make a very firm light bandage of unbleached cambric woven in the necessary widths and lengths for use; these are very cool and pleasant, and a decided improvement on the ordinary calico strips generally used.

Position of the Operator.—He should place himself opposite his patient, not at the side of the limb to be bandaged; the limb too should be bent to the position it will occupy when the bandage is completed.

Before applying any kind of apparatus, the surgeon should see that the limb is carefully washed and dried.

How to hold a Roller.—When applying a roller it is best to begin by placing the outer surface of the roller next the skin (see fig. 1, page [3]), for it then unwinds more readily, and the first turns are more easily secured; moreover the bandage should be carried from the inner side of the limb by the front to the outer side, for the muscles are thus more firmly and pleasantly confined than by turns passing in the opposite direction; of course this observation supposes the hand and forearm to be in their usual position of semi-pronation.

Varieties of Turns.—In carrying a bandage up a limb, it is necessary, in order to support the parts evenly, to employ a combination of three different turns. The simple spiral, reverse, and the figure of 8.

The simple spiral turn is used only where the circumference of the part increases slightly, as the wrist; but when the limb enlarges too fast to allow the fresh turn to overlap the previous one regularly, the turn must be interrupted, and the bandage brought back again by reverse, or by figure of 8.

Fig. 1.—Figure of 8 turn.

To reverse the bandage, the thumb of the unoccupied hand is placed on the lower border of the bandage while the roller is turned over in the other, and then passed downwards to overlap and fix the previous turn evenly. At the moment of reversing, the bandage should be held quite slack, and not unrolled more than is necessary to make the reverse. All the reverses must be carried one above the other along the outer side of the limb, and only employed where really necessary.

Figures of 8 are made, as their name implies, by passing the roller alternately upwards and downwards as it enwraps the limb (see fig. 1). They are adopted where the enlargement is too great and irregular for reverses to sit evenly, over the ankle and elbow joint for instance.

THE HEAD.

Bandages for the Head.—A roller is commonly applied in three different ways to the head. 1st. For keeping simple dressings in place.

Apparatus.—1. A roller 2 inches wide, and of the usual length.

2. Some pins.

A turn is first carried round the head, over the brows and below the occipital protuberance, and fastened by a pin; this being done, the roller is carried across the dressing, and getting into the line of the first turn, is passed round the head again, then across the dressing, and round the head by horizontal and oblique turns alternately, the former to fix the latter, and prevent their slipping off the dressing (see fig. 2). In the figure the oblique turns have been doubled, and would fix dressings on each side of the head.

Fig. 2.—Bandage for retaining dressings in position, showing two sets of oblique turns.

Knotted Bandage.—This is used when pressure on the superficial temporal artery is required.

Apparatus.—1. A roller 8 yards long, 2 inches wide, one-third being rolled into one head, the rest into another head.

2. Some lint.

3. A piece of a wine cork one-third of an inch thick.

4. Needle, thread, and pins.

The cork is folded in a double thickness of lint; over this are placed six or eight more folds of lint of gradually increasing size, and the whole are kept in shape by a stitch passed through them and through the cork. This forms a graduated compress, and is then laid on the wound small end downwards.

One head of the roller is taken in each hand, its middle laid over the compress on the injured temple, say the right; the ends are carried round the head, one just above the eyebrows to the left temple, and the other backwards below the occipital protuberance, to the same point; the ends are then crossed and changed from one hand to the other to be brought to the wounded temple. Here they are again tightly crossed, one end being carried under the chin and by the left side to the vertex, there meeting the other end, which has passed over the head, in the opposite direction (see fig. 3); at the right temple the ends are again crossed or “knotted,” but this time they are passed horizontally round the head. Having done this the ends are pinned and cut off, or if necessary the knots repeated before fastening; the first pair, if tightly drawn, usually suffice as well as several.

Fig. 3.—Knotted Bandage.

The Capelline Bandage is rarely required, but is used when the restlessness of the patient renders it difficult to keep dressings or ice-bags in place.

Apparatus.—1. A double-headed roller, 2 inches wide and 12 yards long.

2. Some pins.

Fig. 4.—Capelline Bandage.

The middle of the roller is laid against the forehead just above the brows, and the ends passed behind the occiput, where they are crossed, and while one continues the circular turns round the head, the other head of the bandage is brought over the top along the middle to the front, passing under the encircling turn, which fixes it. It is then carried back to the occiput, on one side of the first transverse band, when again fixed behind by the circular band it is brought forward on the opposite side of the first, and fixed in front. This arrangement is repeated until the head is covered in a closely fitting cap (see fig. 4).

In beginning this bandage, it is necessary to keep the first circle low down, close to the brows in front, and below the occipital protuberance behind, or the cap will not fit firmly over the skull.

A Shawl Cap is readily improvised with a silk or cambric handkerchief folded diagonally into a triangle; the base of the triangle is then carried over the brow, the apex let fall behind the occiput, where the ends cross, and catching in the apex, come round to the front to be tied on the forehead.

Fig. 5.—Shawl Cap.

The Four-tail Bandage.—Instead of applying the handkerchief in the manner just described, it may be split from each end to within six inches of the middle, and so converted into a broad four-tail bandage; the middle is laid on the top of the head, the hinder ends tied under the chin, and the forward ones behind the nape of the neck (see fig. 6). Or a piece of calico, 1½ yards long and 4 or 6 inches wide, is split from each end 3 inches short of the centre—one pair of tails being rather wider than the other. If used on the face, the middle is put against the point of the chin, the two narrow tails are carried backwards to the nape, crossed, and pinned together on the forehead above the brows. The two broader tails are carried upwards in front of the ears, where they turn round the two narrow tails, to be either tied or pinned at the vertex. Four-tail bandages are used elsewhere, as in the axilla, to keep poultices in place, &c.

Fig. 6.—Four-tail Bandage.

To retain Ice Bladders on the Head.—This is done by folding a thin napkin over the bladder, which is then laid against the head or part to be kept cool, and the ends of the napkin are pinned tightly down to the pillow at each side. In this way the bag cannot slip, and its weight is at the same time prevented from pressing on the head.

To compress the Jugular Vein after bleeding.—After venæsection of the external jugular vein it is requisite to keep a compress of lint on the wound. This is done by fastening the bandage on the neck with two simple turns, then carrying it in a figure of 8 round the neck, over the compress and under the axilla of the opposite side, then round the neck again; if the figure of 8 is passed pretty firmly, sufficient pressure is made in this way without interfering with the circulation through the vessels, and the turns round the neck of course must not be tight.

THE TRUNK.

To bandage the Breast.

Apparatus.—1. A roller 3 inches wide and 8 yards long.

The roller is first carried once round the body below the breast, beginning in front and passing towards the sound side. When the bandage is fixed, the roller ascends over the lower part of the diseased breast, to the opposite shoulder, and comes back by the arm-pit to the horizontal turn; it is then passed round the chest to fix the oblique turn. Having done this, it again is carried up over the breast and shoulder, and round the body in alternate turns until the breast is fully compressed, each turn over the breast being carried higher than the preceding one, and each turn round the body overlapping the oblique turn to keep it in place (see fig. 7).

Fig. 7.—Bandage for a Breast.

To bandage both Breasts.—This is readily done by first bandaging one breast and then, carrying the roller over the shoulder of the side already bandaged, bringing it across the sternum and under the second breast on to the horizontal turns, which it follows alternately with the oblique ones, as was done in bandaging the first breast. The only difference is, that in compressing the first breast the bandage was passed obliquely upwards, for the second it is carried obliquely downwards over the breast.

Spica Bandage.

Apparatus.—1. A roller or 2½ or 3 inches wide.

2. Some pins.

Fig. 8.—Spica for the Groin.

Lay the end on the groin to be bandaged, carry the roller between the great trochanter and the crista ilii round the pelvis to the other side, passing there also between the crista ilii and trochanter; next take the roller downwards in front of the pubes to the injured groin, then outwards round the thigh below the trochanter to the gluteal fold, and pass it up between the thighs to the groin, where the figure of 8 is completed. A second and a third are to be passed in the same way, carrying them exactly one over the other, round the body and below the buttock (see fig. 8); at the groin they should overlap, each lying a little above the preceding turn. A pin, when the necessary number of turns is completed, fastens down the end.

Hernia Spica.—The spica bandage is usually required to keep dressings and compresses in place over wounds after operation for strangulated hernia, sinuses, &c., in the groin; when the figure of 8 has been put on the first time it may be cut across in front; and, the dressings being changed, the ends may be fastened together by pins. If additional strips are laid across and fastened to the figure of 8 underneath, the required pressure is obtained, and much tedious lifting of the patient is saved (see fig. 9.)

Fig. 9.—Hernia Spica.

Body bandage for tapping the Belly in Ascites.—This is made of two thicknesses of stout flannel, 2 feet wide in the middle, where it forms a continuous sheet for 18 inches, but beyond that it is split into 3 tails, 6 inches wide and 3 feet long. In the middle line, 4 inches below the centre, is a round hole 2 inches across, through which the surgeon reaches the skin to insert the trocar.

When in use, the middle of the bandage is placed in front with the hole in the mesial line of the body, and midway between the umbilicus and pubes; the ends of the right side are passed behind the back to the left, interlacing with those from the left side. When all is ready, an assistant standing on each side of the bed pulls steadily on the ends to keep up continuous pressure on the abdominal viscera as the fluid escapes. After the fluid is evacuated the ends are wound firmly round the body in front, while the puncture in the wall of the belly is closed by a fold of lint attached with a strip of plaster.

The T Bandage is used to apply dressings, compresses, &c., to the anus or perinæum. A roller 3 inches wide is fastened by a couple of turns round the pelvis, and then fixed by a pin at the middle line in front. From this point the roller is carried tightly over the dressings to the corresponding point behind, and returned once or twice more until sufficient pressure is gained, when it is fastened off.

The Strait Jacket is made of jean or stout canvas. It is cut long enough to reach below the waist, around which a strong tape is carried to be drawn tight and tied after the jacket is put on. The sleeves are several inches longer than the arms, and their ends can be drawn close by a tape which runs in the gathers; a similar tape confines the garment round the neck, and it is tied behind by tapes down the sides. When the jacket is to be put on a patient it is first turned inside out, then one of the nurses or assistants thrusts his own arms through the sleeves, and facing the patient, invites him to shake hands; having thus obtained possession of the patient’s hands he holds them fast while a second assistant, standing behind the patient, pulls the jacket off the first assistant on to the patient, whose hands are thus drawn through the sleeves before he perceives the object of the manœuvre; the jacket is next tied round the neck and behind, the tapes of the sleeves are carried round the body, drawn tight till the arms are folded across the chest, and fastened to the bed on each side, or tied round the body.

Manacles for Delirious Patients.—Instead of the strait jacket a double leathern muff is now generally used to restrain unruly patients. It irritates them less, and is far more easily applied.

Fig. 10.—Manacles for confining the arms of delirious patients.

In wearing it the arms are crossed in front, and a strap drawn tight round both wrists. Each hand is thrust into a stout leathern glove, or muff, connected with the wrist-strap, and capable of being tightened over the fingers by a strap and buckle across the glove.

To suspend the Testicles.—Suspensories are made specially for this purpose. The best are fastened round the neck by a loop of elastic tape, but a very efficient one can be improvised with a pocket handkerchief and a piece of bandage. The bandage is tied tightly round the hips for a girdle, the handkerchief is folded three-corner wise, and its longest side slipped behind the testes, the ends being passed over the girdle (see fig. 11), and tied again behind the scrotum. The loose apex of the handkerchief is drawn up in front over the girdle and pinned to it, which is all that is required (see fig. 12).

Fig. 11.—Shawl Suspensory for the Testes, in the first stage of application.

Fig. 12.—Suspensory for Testes completed.

When the patient is recumbent, the testes may be supported by a strip of diachylon plaster 2 feet long and 4 inches wide, passed across from hip to hip underneath the scrotum and testes, which lie supported on a shelf.

Another way of raising the testes is to place a soft pincushion between the thighs, and allow the swollen gland to rest on the cushion.

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.

THE LOWER EXTREMITY.

For adults the most useful width for the rollers is 3 inches, and the length the ordinary one of 8 yards.

The Foot is usually bandaged without covering the heel, and the bandage is begun as follows:—

The roller being held in the right hand for the right foot, or in the left hand for the left foot; the unoccupied hand takes the end, and passing it under the sole, brings it up on the back of the foot just behind the toes, where it is made fast by carrying the roller outwards over the back. When one turn is completed, the bandaging is continued by reverses until the metatarsus is covered, then one or two figures of 8 round the foot and ankle carry the bandage to the leg, where it proceeds upwards by spiral turns round the small of the leg, and by reverses up the calf. The reverses lie at equal distance up the leg, on the muscles, not over the bone, that the skin be not pinched between the crease of the bandage and the bone. When the calf is passed, the roller is continued by figures of 8 above and below the knee, until that joint is covered in, then by reverses up the thigh to the groin, where the bandage terminates by a spica round the body (see page [9]). This is the ordinary bandage for the lower limb. There are some varieties for particular parts, these are:—

To cover the Heel.—Holding the roller as for the foot, pass the end behind the heel, bring it out by the outside over the front of the ankle-joint, and complete the turn with the roller. In doing this, the point of the heel must catch the middle of the bandage. If the foot is a long one, the roller should be three inches broad; but a narrower bandage is more easily fitted on a small foot. After the first turn, the bandaging is continued by carrying the roller in figures of 8 round the foot and ankle, passing alternately above and below the first turn until the ankle is covered as in fig. 19.

Fig. 19.—Covering the Heel.

To bandage a Toe.—Take two turns round the foot, with a bandage one inch wide, then go round the toe to be raised, and back again round the foot. This figure of 8 lifts a toe above the rest if taken from the dorsal, and depresses it if taken from the plantar surface.

The Knee is bandaged by beginning with a simple turn round the leg above the calf, then carrying the roller across the patella to the thigh above the knee: and next entwining it in a circular turn round the thigh before descending over the patella to the leg below the knee, where this is repeated until the knee is covered.

To bandage a Stump.—The flaps are first supported by two or more strips of plaster, one inch wide and ten or twelve long, carried from the under surface of the limb over the face of the stump, and a slip of wet lint and oilskin is applied to the wound. The muscles and soft parts are next confined by a bandage. This is first fixed by simple turns below the nearest joint, and brought downwards in figures of 8 round the limb till the end of the stump is reached, which is next covered in by oblique and circular turns carried alternately over the face of the stump and round the limb, as is shown in fig. 2 for bandaging the head. Or, if a double-headed roller be used, in the manner directed for the capelline bandage on page [5].

Extending a Stump.—When the soft parts fall away from the bone they may be drawn down by attaching a weight by cord and pulley, as described for extending the hip-joint (see fig. 80). The stump should be lightly bandaged and the cord fastened to its upper and under surface. The weight is very small at first, and should be increased from time to time as required.

Many-tail, or 18-tail Bandage, or bandage of Scultetus.—A roller is cut into short lengths long enough to encircle the limb and to let the ends overlap 2 or 3 inches; these are applied separately, the lowest first, the next overlapping it, and the next overlapping the second until the requisite number are applied. Sometimes the tails are attached to each other before they are applied. To do this, the tails are laid out on a table, so that the second overlaps one-third of the width of the first strip, and the third strip overlaps the second, and so on. When all the tails are arranged, a strip is laid across their middle and fastened to each tail by a stitch; but this is not a necessary part of the bandage, and it prevents single tails from being removed. This bandage is used in compound fractures and other wounds, as the soiled strips can be replaced without raising the limb to pass the roller under it.

Elastic Socks and Stockings are made to support varicose veins of the legs. They are woven of india-rubber webbing with silk or cotton. The latter are the lowest priced and often even the most comfortable to wear. The stockings should fit carefully everywhere, especially at the small of the leg, where they generally are too slack, while they cut at the upper end below the knee.

CHAPTER II.
STRAPPING.

Strapping is a method of supporting weak or swollen joints and other parts. Sheets of calico, wash-leather, or white buckskin, spread with lead or soap plaster, are prepared for this purpose. A sheet should be rubbed with a dry cloth before using, to remove adherent dust, &c. It is then cut into strips varying in width between ¾ inch and 2 inches, according to the evenness of the surface to be covered: narrow strips fit best over joints and irregular surfaces. When applied to a limb, the strips should be about one-third longer than its circumference. Each strip or strap is first warmed by holding it to a fire, or by applying its unplastered side to a can of boiling water; when hot, the strip is then drawn tightly and evenly over the part. If the surface to be strapped be irregular, it is best to dip each strip of plaster in hot water before applying it, being thus quite supple the strap fits the limb more exactly. When the limb is thickly beset with hairs, it is a good plan to shave the part where the plaster will lie before putting on the straps.

Strapping the Breast.—Strapping is put on the breast in the same way as the bandage (page [8]). The straps should be not more than 2 inches wide, and long enough to pass forward under the axilla and breast from the lower angle of the scapula on the same side as the injured breast, across the chest as far as the spine of the other scapula. The strips are then warmed and laid on alternately over the breast and across the chest, until the former is fairly supported.

Strapping has this advantage over a bandage—its circular strips do not pass round the chest completely and thereby hamper the breathing as the roller does.

To strap the Testicle.

Apparatus.—1. Strips of soap plaster spread on calico, or better, on wash-leather, ½ inch wide and 12 inches long.

2. A can of boiling water.

3. Razor and soap.

Fig. 20.—Strapping the Testis.

First, shave the scrotum; then tighten the skin over the testis with the left thumb and forefinger passed above it; take a strip of plaster 6 inches long and ½ inch wide, and encircle the cord tightly with it; next pass another strap of the same width, 9 or 10 inches long, from the back of this ring, over the testicle to the front, drawing it tight also (see fig. 20). The strapping is continued by laying fresh straps over each other until the whole testis is covered in. Lastly, take a strip 15 or 20 inches long, and, beginning at the ring above, wind it round and round the testicle until all the vertical strips are confined in place by this spiral strip.

The strapping should be re-applied the second or third day, as the testicle by that time will have shrunk within its case.

Fig. 21.—Strapping an Ulcer.

Fig. 22.—Strapping the Ankle.

Strapping Ulcers and Joints.—Cut strips of plaster one-third longer than the circumference of the part to be strapped; if that is irregular, as the ankle or wrist, they must be narrow: commonly the width varies between ¾ inch and 1½ inch. The strips are warmed, the middle passed behind the limb, the ends crossed in front (see fig. 21) and drawn tight, but with sufficient obliquity for the margins of the strip to lie evenly. The strapping is begun as low down the limb as requisite, and continued upwards by laying on more strips, each overlapping about two-thirds of the preceding strap. When the process is finished, the ends should meet along the same line, and all the uppermost ones be on the same side.

The ankle is strapped differently. Strips are prepared about ¾ inch wide; one is carried behind the heel and its ends brought forward till they meet on the dorsum of the foot; a second, encircling the foot at the toes, secures the first; a third is again carried behind the heel above the first, and is fixed by a fourth round the foot. This is continued until the foot and ankle are firmly supported (see fig 22).

Strapping a Joint with Mercurial Ointment.

(Scott’s Bandage.)

Apparatus.—1. Mercurial ointment.

2. Diachylon plaster.

3. Lint.

4. Spirit of camphor.

5. Cotton wool.

6. Freshly scalded starch, or solution of gum.

7. Binder’s millboard.

Spread the ointment on a piece of lint large enough to cover the joint, and to extend four or six inches above and below it; then wash the joint with warm water and soap and dry it carefully; next sponge it well with the spirit of camphor for five minutes. Tear the lint into strips and wrap it round the joint; then strap the part firmly from below upwards over the lint with strips of diachylon plaster, each overlapping the preceding. Lastly, envelope the joint in a thin layer of cotton wool, and roll a bandage soaked in starch over all. If the patient wears no other kind of splint the bandage may be strengthened by laying a piece of millboard well softened in boiling water along each side of the joint before the starch bandage is applied. As the enlargement of the joint shrinks, this application must be renewed, usually every fortnight is often enough.

CHAPTER III.
FRACTURES.

HEAD AND TRUNK.

Fracture of the lower Jaw.—The External Splint and Bandage.—A method requiring the lower jaw to be firmly fixed against the upper one while the broken bone knits.

Apparatus.—1. One and a half yards of bandage four inches wide.

2. A piece of gutta-percha, sole leather, or binder’s millboard.

3. Dentists’ silk or wire.

4. Boiling hot, and cold water.

Step 1. The fracture is first reduced. While the apparatus is being fitted, the recurrence of the displacement is prevented by the hands of an assistant, or by lacing the teeth together with stout silk or wire. It is well also to wet the patient’s chin with a sponge and cold water, to prevent the gutta-percha from sticking to his beard while it is soft.

Step 2. A piece of gutta-percha is prepared 2½ inches wide and long enough to reach from one angle of the jaw to the other when passing in front of the chin. This is softened thoroughly by immersion in boiling water, and when quite pliable should be quickly removed from the hot and plunged for a moment into cold water: if a towel be previously laid in the hot basin, the gutta-percha can be lifted on it without stretching. It should be laid on a table, and its surface sponged with cold water to prevent it sticking to the skin, it is then slit from each end into tails 1 inch and 1½ inch wide, leaving 2 inches uncut at the centre. So prepared, the splint is applied to the jaw with the middle pressing against the chin, the narrower ends being carried horizontally backwards to the angles of the jaw; the broader part is next bent up beneath the chin, its ends overlapping the horizontal ones. While the splint is still soft, the surgeon presses it firmly upwards that the gutta-percha may mould itself accurately to the chin. When set, the splint is removed, trimmed, and punched with holes here and there for evaporation. A covering of wash-leather may be added, if desired. When the splint is finished, it is replaced on the chin. If sole leather or pasteboard be used instead of gutta-percha, they must be prepared in the same way, but allowed to remain on the chin twenty-four hours that they may set before the final trimming and adjustment.

Step 3. A bandage, 4 inches wide and 1½ yard long, and slit from each end to about 2 inches from the centre, is then applied to the splint, and a small pad of folded flannel should be placed at the nape of the neck to protect the skin from the crossed bandage. When all is ready, the two upper ends are carried behind the neck, crossed, drawn tight, and tied or pinned on the forehead; the lower ends are carried upwards, taking a turn round the first pair at the temples, and fastened at the vertex (see fig. 23).

Fig. 23.—Outside splint for fracture of the lower jaw.

The ligatures that may have been used on the teeth can now be removed, or if they cause no pain, they may be left for a week or two.

It is a useful precaution to place a piece of soap plaster spread on soft leather, under the chin and along the throat, to protect the skin from the chafing of the splint while it is worn.

Sometimes the jaws close too nearly to allow food to be taken between them. It is then necessary to place a thin wedge of softened gutta-percha, 1½ inch long, ½ inch wide, and about ⅓ inch thick, between the molars on each side. The gutta-percha must not be softened much, or when the bite is taken the teeth will pass through it. These plugs should be omitted unless absolutely required, as the fragments keep a better position without them.

On emergency, when gutta-percha, leather, or pasteboard are not at hand, the jaw may be set, and then kept in position by a four-tail bandage, made from a pocket-handkerchief, until more complicated apparatus can be prepared.

The apparatus must be worn five weeks before it is laid aside and mastication permitted.

Interdental Splints.—In cases of unusual difficulty, interdental splints may be employed. To fashion some of these, the mechanical skill of a dentist is requisite, unless Morel Lavallée’s plan is resorted to. He applied a mould or socket to the line of the teeth, and kept it in place by pressure underneath the jaw. He first brought the fragments into apposition by means of threads and wire. Then he took a piece of gutta-percha, about ⅓ inch thick and ½ inch broad, and long enough to extend, when bent along the lower jaw, from one wisdom molar to the other. This was softened in water, and pressed on the teeth; next a well-padded horse-shoe plate was placed under the chin, reaching from one angle of the jaw to the other, and two wires were passed through the side of this plate opposite the angle of the mouth; these were drawn through the plate by a screw nut; their upper ends being curved into hooks with sharpened points. The points catch into the gutta-percha; by screwing up the nuts, the chinplate was raised, and the teeth driven up and bedded into the splint.

This method, however, has its disadvantages. If the fracture take place behind the first molar, the bearing on the upper fragment is too slight to keep it down in its place.

In the New York Medical Journal for September and October, 1866, Mr. Gunning, of that city, has published a mode of applying caps fitted to the teeth for fracture of the jaw-bone. External support is abandoned wherever it is possible. In simple fractures, the caps or interdental splints, being accurately fitted, require no fastening to the teeth.

The jaw should be adjusted in its splint as quickly as possible after the accident. The fragments are first brought into their true position. Gaps through loss of teeth at the line of fracture, are filled by plugs of hard wood, and the fragments kept in place by wiring the teeth together tightly. Continued strain on the teeth causes much pain; hence all means for keeping the fragments in place while the splint is being fitted should be removed when that is accomplished, though ligatures used solely to support loosened teeth may be left, as there is no traction upon them. Stumps, and teeth loose before the accident are best taken out, if they interfere with the arrangement of the splint.

Fig. 24.—Vulcanite Interdental Splint to fit the arch of the teeth of the lower jaw, seen upside down. The holes marked a pass through to the upper surface, to allow water to be injected between the splint and the teeth, while it is worn, for cleaning.

The next thing is to take a mould of the lower jaw in wax softened by heat, holding the wax in an ordinary dentist’s tray. From this mould a plaster cast of the jaw is made. If the line of teeth be uneven in the cast, it is to be sawn through, the pieces raised to the right level, and cast again. In this cast a vulcanite plate is made exactly fitting the teeth (see fig. 24). The margins of the mould or splint should be carried down below the line of the gums, to grasp the jaw beyond the alveolar border; and when the fracture takes place behind the teeth, its outer side should be prolonged backwards as far as the muscles will allow, to prevent the displacement of the anterior fragment outwards which muscular action produces in these fractures. Holes should be made in the top of the splint, to permit a stream of water to be sent between the splint and the teeth daily, for cleanliness. Also, in difficult cases, a hole should be cut opposite a tooth in each fragment, for ascertaining from time to time that each part continues in its proper position while the splint is worn.

Metal is used for the plate by English dentists, instead of vulcanite. It can be made thinner, and is less brittle than the latter.

The perfect fit thus secured suffices, in simple fracture, to keep the parts in close apposition; while the movements of eating and speaking are very little interfered with.

Fig. 25.—Showing the method for supporting externally the jaws in the splint, when the teeth are not fastened to it by screws, E. Upper wing; G. Lower wing; H. Mental band to keep the jaw up in the splint; I. Neck-strap to keep the band back; K. Balance-strap to hold skull-cap in place. The upper wings are of course dispensed with, when a single splint only is used.

When the displacement is considerable the fragments are held in place by riveting one or more teeth to the cap, or, when circumstances prevent support being obtained in this way, external support is supplied to the splint by steel wings, fixed into the splint at the angles of the mouth (see fig. 25), and carried outside the cheek to the angles of the jaw. A piece of stout jean or canvas, cut to fit under the chin, is then connected with these wings, and also fastened by a tape behind the neck.

If the case require that a bearing be made on the upper jaw as well as the lower one, as in fracture of both jaws in edentulous persons, the two splints are articulated behind, so that they may open and shut with the lower jaw. Each piece then carries a wing, the lower one supporting a chin-piece, and the upper one being connected by strings attached at the temples to a close-fitting skull-cap. The skull-cap is prevented from slipping forward by connexion with a strap fastened to both shoulders.

A fractured Rib is very well treated by strapping the injured side alone, without enrolling the chest in a tight bandage, which harasses the patient by impeding respiration.

Apparatus.—1. Diachylon plaster.

2. Can of boiling water.

Fig. 26.—Strapping a broken Rib.

Strips of plaster long enough to reach from the spinal column to the sternum, and 2 inches wide, are to be firmly drawn round the injured side. The first strip should be carried as high as can be managed under the arm-pit. The next strip overlaps it about an inch (fig. 26), each succeeding strip overlapping and fixing the preceding one until the lower ribs are covered in. The arm should then be bandaged to the side, and supported in a sling.

A second mode of treating fractured ribs, is to take a flannel roller 6 inches wide, and 8 yards long, and carry it firmly round the chest in successive spirals, beginning at the armpits, and passing down till the waist is reached. The turns of the roller may be kept from slipping down by throwing across the shoulders two strips of bandage like a pair of braces, and stitching each turn to the brace in front and behind. The arm should be confined to the side as in the other method. This plan has the inconvenience before mentioned of interfering with respiration.

In Fracture of the Pelvis, the fragments are kept in position by a broad roller carried several times round the pelvis and fastened.

THE UPPER EXTREMITY.

Fracture of the Metacarpal Bones.

Apparatus.—1. A piece of gutta-percha.

2. A roller 2 inches wide.

In treating this fracture it is important to keep the broken bone in place without confining the wrist or fingers.

A pattern of the palm and dorsum of the hand is cut out of paper, which is doubled round the radial side, letting the thumb out through a hole of convenient size to clear it (see fig. 27). The piece of paper is then laid on a sheet of gutta-percha ¼ inch thick, and the requisite quantity cut off; a hole as big as a pea is next punched in the gutta-percha in the middle, about 1 inch from the lower border, or at a point corresponding to the hole in the paper for the thumb. The fragments are then pushed into place and held so by an assistant, while the surgeon softens the gutta-percha in boiling water; when thoroughly soft, he draws the thumb through the little hole punched in the gutta-percha, and moulds the splint to the palm and back of the hand, bringing the ends of the gutta-percha together at the ulnar side of the hand; the fragments are held carefully in position till the splint is set. The splint is afterwards removed and trimmed. A few holes should be punched in it after it is moulded to allow perspiration to escape. The splint may then be covered with wash-leather, and a pair of straps with buckles stitched on to keep it in place. It is worn for three or four weeks, or until the fragments are united.

Fig. 27.—Gutta-percha Glove for fractured Metacarpal Bone.

Should gutta-percha not be at hand, another plan is effectual.

Apparatus.—1. A firm ball of tow large enough to fill the palm, stitched in old linen.

2. A roller 2 inches wide.

The broken bone is first replaced; then the hand and fingers bound on to the ball by carrying the roller around them until they are all immoveably confined.

This plan has the disadvantage of confining the whole hand for the fracture of one metacarpal bone; the gutta-percha allows free use of all but the metacarpal bones.

Broken phalanges are treated by bandaging them on to a slip of wood long enough to reach into the palm; the slip must be well padded, that the somewhat concave anterior surface of the digit may accommodate itself on the flat splint. If more than one finger be injured, and the fracture be compound, the splint should then reach up the palmar aspect of the forearm and hand. Fingers should be cut in it to correspond with the fingers to be fastened to the splint.

Fracture of the lower end of the Radius.—Colles’ Fracture.—The displacement in this fracture is mainly due to the lower end of the radius and the carpus being carried backwards while the shaft projects in front.

Apparatus.—1. A straight splint of wood. A second splint, curved at its lower end.

2. Pads and cotton wool.

3. A roller 2 inches wide.

4. A sling.

5. A strip of plaster.

The objects to be attained in treating this fracture are to press the lower fragment forwards and to draw (adduct) the hand towards the ulnar side of the limb. For this purpose a straight and a curved splint are used.

No bandage should be placed under the splints in treating any fracture of the shaft of the radius or ulna, lest the broken ends be pressed into the interosseous space.

Step 1. Prepare the splints. The straight splint should reach, when the arm is bent, to a right angle with the thumb upwards, from a little below the inner condyle to the lower end of the upper fragment or shaft; the curved or pistol splint extends from the outer condyle to the joint of the first and second phalanges. The width of both splints should slightly exceed that of the forearm. The bend of the lower end of the pistol splint should be abrupt, and directed towards the ulnar border opposite the wrist, where the margin of the splint should make an obtuse angle of about 1½ right angles (see fig. 28).

Fig. 28.—Pistol Splint for fracture of the Radius near the lower end.

Pads used with these and other wooden splints are made of layers of cotton wool, carded sheep’s wool, tow, or folds of old blanket. These materials should be stitched in old linen or calico, and covered outside with oiled silk where likely to be stained with the discharge from wounds.

The pads must be thicker below than above, to keep the splints parallel along the forearm; and that of the pistol splint is thickest opposite the carpus, to push the lower fragment forwards.

Fixed deformity opposite the wrist is usually present from impaction of the fragments; moderate extension may be employed to remove this, but forcible or continued efforts give great pain and do harm, by further straining the already wrenched ligaments. After these preparations the splints are applied.

Step 2. Put a very little cotton wool in the palm and across the root of the thumb, before the roller is begun, lest it chafe the carpus in front. The curved splint, with the barrel or longer part inclined downwards below the forearm, is next attached to the back of the hand by a roller carried in figures of 8 round the hand and root of the thumb, but not above the wrist (see fig. 29). This is made fast by a pin.

Fig. 29.—Fracture of the Radius.

Step 3. Raise the straight part of the outside splint till parallel to the forearm, thus adducting the hand to the ulnar side; and fix the splint by a strap of plaster an inch wide carried round it and the forearm below the elbow.

Step 4. Apply the inside straight splint next, keeping the front of the carpus and of the lower fragment exposed. Draw the two splints together by simple spiral turns of a roller, begun just below the elbow and carried down to the lower end of the inside splint, there fasten it off.

Step 5. Put a narrow sling under the forearm between the elbow and the wrist to support the limb comfortably.

When the apparatus is finished the position of the broken fragments should be visible (see fig. 29) and not concealed by bandage. The hand should also be quite free of the sling, lest it be drawn from its proper adducted position. The fragments are in good position when the hollow on the anterior aspect of the wrist and the prominence on the corresponding posterior surface are removed.

The Gutta-percha Gauntlet is another plan of treating fracture of the lower end of the radius that may often be adopted from the first, and may always replace the wooden splints and bandage when the swelling has subsided. It was contrived by Mr. Heather Bigg, and permits the patient to use his hand to some extent while the bone is uniting.

Apparatus.—1. A piece of gutta-percha ¼ inch thick, wide enough to enwrap the metacarpus and wrist, and long enough to reach up the lower half of the forearm. Two thirds across the width, and about 1 inch from the lower end, a small round hole is punched. The sheet is then softened in hot water, and applied to the hand, the thumb being thrust through the hole punched to receive it, which rapidly enlarges when soft. The gutta-percha is then adjusted to the hand and forearm, its borders meeting at the ulnar side of the limb, rather nearer the inner border of the arm than is depicted in fig. 30.

Fig. 30.—Gutta-percha Gauntlet for Colles’ Fracture.

If the fracture is recent, it must be reduced while the splint is soft by extending the hand and holding the parts in the required position until the gutta-percha is set. Before removing the splints superfluous edges should be marked, and, when the splint is off, trimmed away with a knife. Holes must also be punched at frequent intervals that the perspiration may escape. The splint is next lined with wash-leather, and fitted with a pair of straps and buckles to keep it in place.

By this plan the fingers are left free, and some motion allowed also to the thumb. The only joints kept immoveable are those of the carpus and wrist.

Apparatus of some kind must be worn three weeks continuously; then for a fortnight longer, while it is removed every day to allow passive motion of the fingers and gradually of the wrist also to be practised. Care should be taken to warn the patient that pain and stiffness last long in these fractures, lest he blame the surgeon because he does not quickly recover full use of his arm.

Fracture of the Shaft of one or both Bones of the Forearm.

Apparatus.—1. Two straight wooden splints.

2. Pads and wool.

3. 2-inch wide roller.

4. Sling.

The treatment is the same whether one or both bones are broken. Caution has been already given against bandaging the forearm underneath the splints.

Step 1. Prepare two straight wooden splints; one to go in front of, and one behind the forearm. The posterior or outside reaches from the external condyle to the end of the metacarpus; the anterior or inside splint from a little below the internal condyle only as far as the wrist, keeping clear of the ball of the thumb. The splints should be slightly broader than the forearm, and well padded; towards the lower end the padding should be thicker than above. The forearm is bent to a right angle and the thumb put upwards.

Step 2. Reduce the fracture by gentle slow extension at the wrist; this being effected, apply the splints to the forearm, and let an assistant hold them while the bandage is rolled on.

Step 3. When a little wool has been wrapped round the hand and wrist, fasten the dorsal splint by figures of 8 carried round those parts; then draw the two splints together by simple spirals continued to the elbow (see fig. 31).

Fig. 31.—Fracture of both Bones of the Forearm.

Step 4. Support the forearm in a sling, to complete the apparatus.

The splints are worn three weeks; after this, passive motion may be practised daily, and the splints finally abandoned ten days later. But a sling is still required some ten days after the splints are laid aside.

When the ulna alone is broken, an anterior splint reaching from the inner condyle to the tips of the fingers often suffices without a second one.

When the shaft of the radius is broken high up (a rare accident) the displacement is sometimes very difficult of reduction unless the wrist be well supinated. To preserve this position it may be necessary to use a wooden angular splint, and to fix the vertical part to the arm behind the elbow, while the horizontal part is carried along the back of the forearm.

Fracture of the Olecranon.—This fracture, if seen early before effusion takes place, may be put up at once, but if delay till the joint is swollen has occurred, the limb must be kept quiet on a pillow, or on a splint in an easy position with evaporating lotions, until the effusion is absorbed, before any means can be taken to restore the position of the olecranon. Though the straight position of the elbow is usually employed, it is not essential for even very close union of the fragments.

In treating this fracture the following plan is useful.

Apparatus.—1. Straight hollow splint.

2. 2-inch rollers and finger rollers.

3. Pad, wool, and lint.

4. Strapping plaster.

5. Pins.

Step 1. Bandage the fingers; wrap the hand in cotton wool and bandage it. When the wrist is passed, fasten the bandage for a time by a pin, and straighten the arm.

Step 2. Push the olecranon down as close as possible to the rest of the ulna, and put a dossil of lint over it. Place the middle of a strap of plaster an inch wide and 16 inches long, on the lint, and carry its ends round the forearm in a figure of 8; to some extent this alone fixes the fragment.

Step 3. Continue the bandage up the forearm by reverses, keeping the elbow straight; and pass the joint by figures of 8 carried over the compress of lint and the forearm, to draw down the olecranon (see fig. 32). When this is secured, prolong the bandage to the deltoid, to confine the action of the triceps muscle.

Step 4. Pad lightly a hollow splint about 2 inches wide, reaching from the axilla nearly to the wrist, and apply it along the anterior aspect of the limb, then fix it by a second roller. This completes the apparatus.