Elliptical Bandage Technique

roller which came over the median line of the head back again to the rear, so that its right edge will rest on the middle of the first turn. It is again caught under the encircling turn at the occiput, is carried to the front on the opposite side, and continues to travel from before backward in an ellipse that is constantly increasing until it blends with the encircling turn upon the sides of the head. Each successive turn of the elliptic should leave abont one-third of the turn that preceded it uncovered in the centre. Of course the ends will meet at the same point, before and behind, where the reverses are made. The Knotted Bandage—(Fig. 9) Is useful to arrest hemorrhage from wounds of the Fie, 9.—The knotted bandage for compression in wounds of temporal or other vessels of scalp. | A CHAPTER IN MINOR SURGERY. 19 Take a piece of cork or wood, about an inch in diam- eter, and one-quarter of an inch in thickness, and wrap it with lint to make a compress. Apply this to the pleeding point, and lay over it the centre of a double- headed roller, carrying the turns around the head, above the ears. They are then crossed over the compress, one end is carried under the chin, the other over the top of the head, and they are again crossed on the opposite temple. Having carried the rollers again around the head and crossed them firmly over the compress, the ends are pinned securely and cut off. A horizontal slip may then be pinned to the anterior, middle, and pos- terior slips of the knotted bandage, beginning in the median line on the forehead, then back to the centre of the middle slip, and then to the slip underneath the occiput, to prevent any possibility of slipping. How to Apply Plaster-of-Paris Dressings. To prepare bandages for plaster dressings, first sift the plaster very carefully, to remove lumps and particles of trash, and as the bandage is being rolled rub the plaster well into the meshes of the cloth, until its tex- ture is covered. It is only necessary to rub the plaster upon one side of the roller, and that must be the side that is being turned in as the bandage is rolled. A few minutes before they are to be applied the bandages are placed into a basin of warm salt water, and left until the bubbles of air cease rising to the sur- face. They are then completely saturated, and must be taken out, squeezed as dry as possible, and applied im- mediately, as heretofore described. 20 A OHAPTER IN MINOR SURGERY. A half-pint of salt to two gallons of water is about the proper quantity. Plaster that has deteriorated by exposure can be ren- dered anhydrous by heating in a closed oven. The manner of covering the limb before applying this dressing will be explained hereafter. Plaster Dressings in Fractures of the Humerus. Bandage the hand and forearm, and by the proper extension and counter-extension adjust the fragments. The operator now puts a dry roller, free from plaster, around the humerus and shoulder by figure-of-8 turns, extending this as far as it will be necessary to use the fixed dressing. A thin undershirt can be used for this first covering just as well, its function being only to pre- vent the plaster from getting next to the skin, where the hairs of the limb would become entangled in it as it “set,” rendering its ultimate removal unnecessarily painful. The forearm is bent at right angles to the humerus, the fractured ends held in apposition by an assistant, and the prepared rollers are applied from the wrist up to the neck as in figure (5). It is best to apply about nine thicknesses of bandage (equal to three rollers) to the injured limb, while for six inches above and below the point of fracture double this amount is required. If for any reason there is a scarcity of plaster or bandages, a lighter dressing may be made strong by laying strips of zine, copper, or tin, cut about one inch in width and one foot in length, parallel with the axis of the limb, and working these in with the plaster throughout the entire circumference of A OHAPTER IN MINOR SURGERY. 21 the extremity. The centre of the strips should be op- posite the point of fracture. It is generally advisable after each separate bandage is applied to cover it with dry plaster, which is then moistened by the hands and moulded to the limb. If the fracture is near the lower extremity of the humerus it will suffice to carry the plaster dressing to the axilla, but if the upper half, or neck, is broken, the dressing must go over the shoulder to the root of the neck. Plaster Dressings for the Leg and Thigh. The most easily managed and simply constructed ap- paratus for making the necessary extension and counter- extension, in fractures of the lower extremity, is made as follows: Into each end of a table, about five feet long, two holes are bored, and into these, two perpendicular pieces are fitted, two feet long and about two inches in diame- ter, while a strong horizontal bar connects the two upper ends. One of these uprights is smoothed, rounded, and padded, to prevent injury to the perincum, The foot of the injured side being nicely bandaged (as in Fig. 6), the patient is placed upon the table, astride the padded upright (see Fig. 10), and with the perineum against it, and is suspended by a strap passed over the horizontal bar and underneath the sacrum, being elevated from the table sufficiently to allow free man- ipulation of the bandages under the back. The head and shoulders are supported upon pillows, the foot of the uninjured limb rests upon a stool, a clove hitch or double loop is thrown around the ankle, and to this a block and pulley is attached, the opposite end of which 22 A CHAPTER IN MINOR SURGERY, is fastened to the wall. Extension is then applied, until by measurement from the anterior superior spinous pro- cess of the ilium to the lowest point of the inner malleo- lus, the two legs are found to be of exactly the same length. The leg and thigh is then covered with a dry roller, or a trousers’ leg, or piece of soft blanket, and the plaster rollers are applied as described in the dressings for fracture of the humerus, Accessory splints of zine, copper, tin, or hoop-iron may be worked in, in the same Fi. 10.—Extension and counter-extension apparatus, for applying plaster-of-Paris dressings in fractures of the lower extremities. manner as there described, only they should be cut longer for the leg. When the fracture is near the neck of the femur, these strips must extend well up on the abdomen. When the bone is broken near the condyles, the plas- A CHAPTER IN MINOR SURGERY. 23 ter rollers need be carried no higher than the peri- neum. This same apparatus, so simple that any man of ordi- nary intelligence and mechanical ingenuity can, with the proper wood, a hatchet, saw, and auger prepare it in half an hour, is all that is required to put up a fracture of the lower extremity, be that fracture anywhere between the ankle and the hip-joint. In fractures of the tibia or fibula, or of both bones near the ankle, the dressing need not be carried higher than the knee ; while if in the upper part of these bones the rollers must be carried to the perineum. In case of compound fracture, a fenestrum can be cut over the point of injury. The patient should be guarded against carelessly al- lowing any urine to become infiltrated beneath the dressing, as such an accident will contribute greatly to his or her annoyance. ‘When it becomes necessary to remove the plaster, it ig opened on one side with an ordinary shoe-knife, and then pulled off. It is usually advised in works on surgery to put the patient under the influence of an anmsthetic, so as to completely relax the muscles of the fractured limb. With all due deference to these older gentlemen, the author is decidedly of the opinion that it is not essen- tial to the success of the operation.* * In January, 1875, my friend Dr. L. M. Yale, Snrgeon to the Charity Hospital, New York, and I dressed a fracture of the femur near the trochanter, by the above method without the use of any anesthetic, The patient was very muscular, weighing 180 Ibs., and suffered so little during the operation, that he smiled and made jocose 24 A CHAPTER IN MINOR SURGERY. If after the extension is complete the limbs are of the same length, angsthesia is believed to be unneces- sary. The opinion of the patient as to the amount of pressure most comfortable to the limb is of no little value to the surgeon. The author has had constructed the apparatus shown in the annexed cut (Fig. 11), which is not costly, is easily Fra. 11.--The author’s apparatus for extension and counter exten- sion, in treating fractures of the leg and thigh with plaster-of-Paris dressings. (a) Leather straps which pass under the perineum and over each thigh. (®) Webbing strap upon which the sacrum rests, This strap is un- keyed and drawn from underneath the dressing when it is com- pleted, as are the leather atraps marked (2). made, and can be done up in a very convenient pack- age for transportation (see Fig. 12). remarks throughout the séance. He recovered completely in three weeks, was not confined to bed more than ten days, and has by the closest measurements only three-sixteenths of an inch shortening. have geen and sasisted also in dressing fracture of the humerus without anmethesia. A CHAPTER IN MINUR SURGERY. 25 It consists of two poles of ash or hickory, five and a half feet long, and two inches in diameter, turned per- fectly round and smooth. Fra, 12.—The same, ready for transportation. These are supported by two legs at each end, each leg being made of the same strong material, forty-one inches long, and having a strong piece of iron curved overits upper end, and fastened on each side, forming a loop or eye, through which the parallel bars fit snugly. The lower ends are smaller, somewhat pointed, and fit into a hole in a cross-piece, extending between the two legs of one end, to prevent spreading. Where the legs cross in the centre they are mortised, so as to fit into each other, and have an iron screw-bolt running through them at this point to fasten them firmly together. This bolt should be left long enough, so that the nut, when loosened, will allow the legs to be freed from the mortises, and fold up, like a pair of scissors, into a small space for convenience of packing. The legs in position are spread until they leave the parallel bars twenty-two inches apart, from inside to in- side, and thirty-two inches from the ground. A series of webbing-straps, eight in number, two inches in width, with a‘sewed loop at one end and a buckle loop at the other, are fastened on the poles at proper distances. The body of the patient rests upon these, and they can be slid up or down, tightened or 26 A CHAPTER IN MINOR SURGERY. loosened by the buckle-strap to suit the convenience of the operator. The one of these straps upon which the sacrum of the patient rests must be well removed from the others, and differs from the rest in not having the sewed loop at the end, but instead a loop made by passing a strong iron spike through eyelets worked in the proper places, so that the spike can be withdrawn and the strap pulled from under the plaster dressings, which have overlapped it, as the roller travels from the thigh around the sacrum to the front of the abdomen. The counter-extension is made by means of two long perineal straps passing from the iron loop, on each side of the patient’s head, around the perineum, and back, to be fastened at the starting-point. To prevent the litter from slipping when the extension is applied, a strong cord should be fast- ened between the end nearest the patient’s head and the adjacent wall. The counter-extension is made from two iron hooks, in the soles of a pair of skeleton shoes (Fig. 13), which Fra. 13,—The author's extension shoes: modification of those in use at Bellevue Hospital. A CHAPTER IN MINOR SURGERY. 27 are.strapped to the patient’s feet, and can be approxi- mated or separated by means of an adjustable bolt pass- ing between them. After the dressing is complete, the patient rests in ) ET TEN iia Fie, 14 —The author's method of dressing fracture of the patella by s the fixed (plaster-of-Paris) method. 28 A CHAPTER IN MINOR SURGERY. perfect comfort and safety upon this litter, until the plaster is completely solidified. The use of this apparatus avoids all danger to the patient from accidental slipping or breaking of the ex- tension or counter-extension fixtures, the parts being perfectly supported by the webbing straps; it is not painful, since the weight of the body is distributed over such an extensive surface and is not confined toasingle loop of wire or bandage, as was formerly used ; and it can be strapped into such a small package that it is transported without inconvenience. Fracture of the Patella by the Plaster Method. , The author’s method of dressing fracture of the pa- tella by the fixed apparatus is as follows (see Fig. 14) : Having bandaged the foot of the injured limb, the patient is laid upon a table, with the leg elevated at almost a right angle to the plane of the body, and the heel is placed in a notch cut in the end of an upright, which is nailed to the table. This position relaxes the rectus femoris muscle, and allows the upper fragment to be brought in contact with the lower one. A piece of adhesive plaster (moleskin is best) is then cut as represented in Fig. 15. It should be cut wide enough to lap over the anterior half of the thigh, and about eighteen to twenty inches in length. Apply this to the limb so that one of the three tails shall fall on each side of the upper fragment, and one over its centre. Throw a few turns of a roller around the plaster above the patella to aid in holding it in position, make the necessary traction, and when the two frag- ments touch, secure the plaster to the leg below by an A CHAPTER IN MINOR SURGERY. 29 additional roller. A dry roller or other covering is then applied, and the plaster rollers are adjusted as high as the perineum. Fra, 15,—Adhesive strip for retaining fragmenta in position. In half an hour the leg can be taken down, and the patient is at liberty to go where he chooses. There is no necessity for his remaining in bed for weeks ina fixed position, with nothing else to do but brood over his own misfortunes. If the moleskin plaster is not available, the surgeon can use a roller bandage, about three inches wide, as follows: Lay the centre of the double-headed roller just over the upper border of the upper fragment, car- ry it under the leg, and tie in a loose single knot. The two ends are then carried around the upright piece, canght in a couple of notches cut in it, and when the fragments are approximated by the extension and