The Roller Bandage

PART I THE ROLLER BANDAGE any bandage material wound upon itself into a compact Tolf is known as a roller bandage (Fig. 1). When the strip is wound upon itself from both ends toward the center, thus forming two cylinders, a double roller is formed (Fig. 2). Fig. 1.—Single roller. Practically any material capable of being wound upon itself into a compact roll may be used in making a roller bandage. The materials generally used are muslin, gauze, flannel, flannellet, rubber, or woven elastic, that most frequently em- ployed being muslin. This is strong and firm, has sufficient body to make its application uniform throughout, and is 12 THE ROLLER BANDAGE 13 comparatively cheap. The muslin roller should be used exclusively by the beginner in bandaging when practising the various fundamental (page 30) and special (page 40) bandages, and especially when learning to make a roller bandage by hand. Gauze is soft and pliable and can be pulled into place read- ily, is lighter in weight and is cooler than muslin, can be sterilized, and lends itself readily to saturation with an anti- septic solution. It is the best material to use in bandaging Fig. 2.—Double roller. the eye, the ear, and the fingers, but it is too light and flimsy to be used when a firm bandage with pressure is required. It is very difficult to make a good gauze-roller by hand. The full width of the material as woven should be made into a compact cylinder, preferably by machinery, and this cylinder should be cut into the desired widths by means of a sharp knife. Flannel is a soft, pliable bandage material that adapts itself readily to uneven surfaces. It is of special value in eye bandages (page 66) and as a soft protective beneath a plaster- 14 BANDAGING of-Paris cast. Its cost, however, practically prohibits its general use. Flannellet is a splendid substitute for flannel in every par- ticular, and is very much cheaper. Fig. 3-—Esmarch’s rubber bandage. Rubber (Fig. 3) is used as a bandage material when it is desired to render a part bloodless, as in Esmarch’s method, or where pressure is desired in the treatment of certain joint affections, leg ulcers, etc. Fig. 4.—Smooth web elastic bandage. _ Fig. 5. —“‘Rubberless” elastic bandage. Woven elastic material may be used in place of a rubber bandage in the treatment of joint affections, and especially for support in varicose conditions of the lower extremities. An MAKING A ROLLER BANDAGE 15 elastic woven bandage may be self-applied with better effect than would result from the self-application of muslin or gauze. The material may be interwoven with rubber (Fig. 4) or be rubberless (Fig. 5). MAKING A ROLLER BANDAGE A machine-made roller bandage may be purchased at almost any drug-store; those made of gauze, rubber, or woven material should not be made, as a rule, by the operator. Anyone, however, who expects to use bandages must know how to make them by hand and by the bandage machine. The beginner should practice this task with muslin rather than gauze or flannellet, and with narrow rather than wide strips. A piece of unbleached muslin, the full width of the bolt and 5 or 7 yards long, should be obtained. One end of the piece is cut with scissors into strips the width of the desired bandage, the first and last cuts being a little more than the width of the selvedge, and the strips are torn down about 1 foot. The operator and his assistant face each other, with the piece of muslin between them. Beginning with the selvedge at one side, they take hold of alternate strips and tear the piece through its entire length. The strips will be rumpled, owing to the pulling, and must be straightened out, and all ravel- ings must be removed from either edge of the strips. To Roll a Bandage by Hand.—Lay the strip on the anterior surface of the thigh. Fold the first 10 or 12 inches on the succeeding portion; fold the folded portion on itself repeatedly, shortening the fold each time, until the last one is about 2 inches long. Roll the folds on themselves with the thumbs and index-fingers, using as much pressure as possible, to make the core hard. After the folds have been rolled, place the roll on the upper part of the anterior surface of the thigh, and while the strip is held taut and smooth with the left hand, run 16 BANDAGING the roller downward under the fingers and palm of the right hand, with as much pressure as possible. Repeat this pro- cedure two or three times until the roll is large enough to be held between the thumb and index-finger and firm enough to withstand considerable pressure from end to end without bending. Hold the roll between the thumb and index- or second finger of the left hand, with the unwound portion of the strip leaving Fig. 6.—Rolling a bandage by hand. the upper surface. Grasp the body of the roll between the thumb and flexed second finger of the right hand, with the unwound portion of the strip running over the extended index- finger and in such a position that pressure may be made upon it by the thumb and finger (Fig. 6). Hold the roll firmly between the thumb and finger of the left hand and supinate the right hand, allowing it to slide around the roll. Decrease MAKING A ROLLER BANDAGE 7 the pressure made on the axis of the roll by the left thumb and finger and pronate the right hand, exerting sufficient pressure on the body of the roll to make it turn on its long axis. Repeat these movements until the entire strip has been made into a compact cylinder, taking care to remove all ravelings as the roll is made. After the knack of rolling a bandage has been learned, the operation can be made more rapid by pro- nating and supinating both hands simultaneously, the left hand revolving the cylinder while being supinated, the right while being pronated. Fig. 7A bandage roller. A loosely rolled bandage will not unroll smoothly under such tension as is necessary to make it lie snug against the part. As a roller made by hand is with difficulty made compact enough to overcome this defect, it should be made by machine, although it is essential that everyone using roller bandages should be able to roll them fairly well by hand. Machine Rolling.—The machine used for rolling bandages, called a “bandage roller,” consists of a winch with a series of 18 BANDAGING parallel bars through which the strip of bandage material is passed before being wound on the rod, or shaft, of the winch (Fig. 7). Usually three parallel bars are sufficient to fulfil their purpose—viz., to prevent infolding of the edges by mak- ing the bandage material lie perfectly flat as it is wound on the shaft of the winch. This shaft is square or hexagonal in Fig. 8.—Bandage roller with adjustable guide. shape and tapers slightly from the crank end. On many machines there is an adjustable guide which slides on the shaft and parallel bars. The machine is clamped to a table (Fig. 8). When using the bandage roller, pass the end of the strip of material from behind forward between the lower two parallel bars, and from before backward between the upper two, MAKING A ROLLER BANDAGE 19 close to the crank side of the winch. Hold the crank handle as close to the side of the upright as possible, turn the end of the strip over the shaft, close to the right upright, and hold it in place with the left hand, and with the right turn the crank in the direction taken by the hands of a clock, so that the strip will be fed to the upper surface of the shaft. As soon as the shaft grips the material, transfer the left hand to the strip below the parallel bars. If there is a guide on the machine, move it forward until it touches the edge of the strip. Turn the crank with the right hand and make sufficient traction G d ¢ a Fig. 9.—Roller bandage: a, Initial extremity; b, outer surface; c, inner surface; d, 9 y: , upper edge or border; ¢, lower edge or border; f, body; g, terminal extremity. with the left to insure a tight roller. After the entire strip has been wound, hold the roller firmly with the left hand and make three or four turns with the crank to tighten the roll. Make two or three reverse turns with the crank while the roll is held fast, and withdraw the shaft from the bandage. Turn in the corners of the end of the strip and fasten the end with a pin or piece of adhesive plaster. A roller bandage (Fig. 9) consists of a body, an initial ex- tremity, the part first unwound from the body, and a terminal extremity or end. The strip composing the body has an inner 20 BANDAGING and an outer surface, the former lying in contact with the body, and an upper and a lower edge or border. Width and Length of the Roller Bandage.—Roller bandages vary in width from 3 inch to 6 inches. Narrow bandages, not more than 1 inch wide, should be used when bandaging the fingers; the very wide ones may be used when bandaging the trunk. The most commonly used rollers range in width from 1 inch to 3 inches, with gradations of } inch, and in length from 5 to 7 yards. No definite length can be assumed for any bandage, as it is impossible to calculate the various turns that may be required to properly fulfil the objects of the bandage. A sufficient number of turns must be made in every instance to properly bandage the part, whether such turns require 3 or 10 yards. PLASTER BANDAGES Plaster-of-Paris bandages have superseded, in general use, all other forms of hardening bandages when a fixed dressing is required. Silicate of soda, starch, and paraffin are simi- larly used occasionally. They form a lighter dressing than the plaster, but are more difficult to apply, are more expen- sive, and are not more efficient. Plaster-of-Paris rollers may be bought in any drug-store, hermetically sealed in a tin box. As a rule they are too tightly rolled and not readily saturated with water, as they must be before being applied, and, therefore, are not so effi- cient as those made by the operator or his assistants. The requisite materials are a strip of some meshed goods, such as cheese-cloth, mosquito-netting, or crinoline (crinoline being far superior to the others), and a highly calcined or anhydrous gypsum, generally known as plaster of Paris. This is an impure, earthy alabaster which has been deprived of its water of crystallization by heating. If exposed to the air, PLASTER BANDAGES az especially in the presence of moisture, it readily takes up some of this water of crystallization and becomes lumpy, and in that condition is of no value to the surgeon. The plaster must be kept dry, and must be smooth and free from all granular particles when used. To make a plaster-of-Paris roller, take a strip of crinoline 3 or 5 yards long and 3 or 4 inches wide, lay it lengthwise on any flat surface, but preferably on a large, flat pan, and fill the meshes with the plaster, using either a flexible spatula or the fingers to rub it in. As the crinoline becomes thoroughly impregnated, roll it loosely into a cylinder. If the roller is not to be used immediately, it should be wrapped in tissue- paper and placed in an air-tight vessel. When exposed to the air the plaster is changed into a granular, sandy material through its absorption of moisture, and in that condition will not make a compact solid when applied as a cast. Baking in a hot oven for a half-hour will greatly improve the quality of old or exposed plaster rollers. Plaster-of-Paris bandages may be made by drawing the strip of crinoline, under a roller, through a mass of gypsum in any deep vessel, the strip being loosely wound as it emerges from the plaster. Such rollers are not so satisfactory as those made by rubbing the plaster into the meshes, as the plaster is not so evenly distributed. When a plaster roller is to be applied it must be immersed in water, lying on its side rather than its end, as the latter position will allow more of the plaster to drop from the meshes. When bubbles of air cease to rise from the roller, it should be picked up by both ends and the surplus water should be removed by compressing the cylinder from end to end or by a twisting motion. Less plaster will be displaced by this method than by compressing the roller and forcing the water out of the ends. If the roller is allowed to remain too long 22 BANDAGING in the water the plaster will “set” in fine particles like sand; such a bandage is of no further value. The ultimate “setting” of the plaster is not due to a chemical change in the gypsum, but is simply a change from its calcined to its hydrous or crystalline form. The part to which the plaster is to be applied should be shaved, cleaned, and made dry. It should then be covered with stockinet (Fig. 10) or a flannel or flannellet bandage. Bony prominences should be protected by a layer of cotton. The operator may wear rubber gloves or smear the hands with vaselin, which will prevent the plaster sticking to the skin. Fig. 10—Tubular stockinet. The plaster bandage is applied with the same turns used in the application of the ordinary roller, with the exception of the “reverse.” The turns should not be made taut, because the strength of the resulting “cast” does not depend upon the tight bandage, but upon the plaster reinforced by the crino- line. The short figure-of-8, the rapid ascending spiral, and rapid descending spiral turns are most frequently used. If there should be gapping of any of the turns, a “dart” should be folded in the gapping portion. If it is advisable to open the cast immediately after its application, a strip of zinc about 1 inch wide and long enough to extend beyond either end of the cast should be laid, length- wise of the part to be covered, on the protecting stockinet or bandage. The cast may be incised without endangering PLASTER BANDAGES 23 the underlying skin by cutting on this strip, which should later be removed by traction on one end. Fig. 11.—Engel’s plaster-saw. If the cast is not opened at the time of application, it may be removed when desired by means of the plaster-saw (Fig. 11), the plaster-knife (Fig. 12), and the plaster-shears (Fig. Fig. 12.—Merrill’s plaster-knife. 13). The easiest way to cut through the plaster is to make a groove with the saw or knife and apply peroxid of hydrogen, vinegar, or dilute hydrochloric acid along the groove. This Fig. 13—Reed’s plaster-shears. application will soften the plaster so that it may be cut easily with the knife or saw. Repeated applications of the acid or 24 BANDAGING peroxid will make the cutting easier. The last few layers, with the underlying protective, should be cut with the blunt- pointed scissors and the protective should be removed with the cast, to the inner surface of which it will adhere. APPLICATION OF THE ROLLER BANDAGE Underlying Principles.—A perfect bandage is one that ac- complishes its object by a combination of turns so arranged that no unnecessary material is used; by turns so placed that none are required to cover underlying defects; by turns so applied that the pressure throughout is even and sufficient, but not more than enough to fulfil the requirements of the bandage. Perfection should be sought in every instance; careless, slovenly bandaging should never be permitted by anyone, although such is frequently seen. More perfect bandages would be applied if the operator would realize that the bandage should be allowed to follow its natural course as far as possible, this natural course being determined by the fact that it lies flat on the underlying sur- face, with both edges in contact with the surface and under an even tension. If this natural course should not agree with the one desired by the operator, it should not be changed or altered by tugging and pulling, as this would cause more pressure to be exerted by one edge than the other, but a “reverse” (page 35) should be made and the bandage thus started on a new course. A bandage should not “gap.” A gap is made when the bandage is so applied that while one edge is lying firmly against the part, the other edge is loose. As a result, the pressure exerted on the underlying structures is uneven. “Gapping” should be overcome in every instance by allowing the bandage to follow its natural course; if this does not agree with the one desired, a reverse should be made, as stated above, and APPLICATION OF THE ROLLER BANDAGE 25 the turn started in the direction required. Covering the gaps by subsequent turns, as is so frequently done, will hide these poorly made ones and possibly make the finished band- age more presentable, but it will not remove the defects of the covered turns. When a turn that gaps is covered by one superimposed, the loose portion of the former will be wrinkled or folded upon itself and will thereby cause markedly uneven, irregular pressure to be exerted upon the underlying tissues. Bandages should be applied, as far as possible, in the direc- tion of the venous circulation, so that any pressure that may be exerted by the various turns will have a tendency to empty the superficial veins rather than cause their engorgement. A rapid descending spiral bandage may be applied to a part without interference with the circulation, because the sub- sequent turns of the completed bandage will be made from the distal to the proximal end of the part, thus exerting press- ure in the line of the venous circulation. When a bandage does not cover an entire extremity, the portion distal to the bandage may become edematous. After swelling of the part begins, it progresses rapidly because of the increased tension of the lower border of the distal turn. For this reason, all bandages of the leg or forearm should in- clude turns around the foot and hand respectively. An ede- matous condition of the tissues will occur, likewise, if a portion of the part being bandaged is exposed. Most bandages are made secure by their proper applica- tion; therefore security should not be obtained by reduplica- tion of turns run in various directions. When proper appli- cation does not afford the desired security, strips of adhesive plaster should be laid across the various turns. They may be pinned or tacked with a needle and thread, but both meth- ods are inferior to the use of adhesive plaster. Ordinary pins should seldom be used, because they are easily displaced 26 BANDAGING and because they may prick the patient. Safety-pins do not present the same objections. A turn is made by carrying the bandage around or over a part. These rounds or turns are designated, according to their general characteristics, as the circular, the rapid ascending spiral, the rapid descending spiral, the slow ascending spiral, the slow descending spiral, the reverse, the recurrent, and the figure-of-8 turn. For convenience of study and practice they are grouped to form what are known as the “fundamental bandages” (p. 30). As they are the foundation of all special bandages, a thorough knowledge of their application is essen- tial to the mastery of the art of bandaging. Spacing is accomplished by overlapping the various turns. The spaces thus made should equal, with few exceptions, about one-third of the width of the bandage, two-thirds of the un- derlying turn being covered by the one superimposed, the remaining one-third being exposed or uncovered. It must be remembered that each added layer of bandage increases the pressure on the underlying structures. This pressure will be practically uniform throughout if the spaces are made equal and if the various turns are applied with an even tension. Crosses are made by reverse or figure-of-8 turns, the latter usually forming a series known as a spica. When they are made in bandaging the extremities, they should run in a straight line, parallel with the long axis of the part, and should be placed over a fleshy portion of the limb rather than directly over a poorly covered bone, such as the “shin-bone.” Crosses will run in a straight line if the spaces on either side are equal in width; if they are unequal, the line of crosses will be de- flected toward the wider space. Begin