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.