hammer ; the strokes should not be conducted vertically, but as obliquely as
possible (tangentially) in order not to cause pain to the patient. If the cap-
THE TREATMENT OF WOUNDS
119
Fig. 192. Case containing Plaster of Paris Knife
AND Scissors
sule of plaster of paris is so thick that it can be bent apart to the required
width only with great difficulty, a flat groove is chiselled on the opposite
side ; in this groove the
capsules can move as
on a hinge.
Moreover, instead of
a hammer, a small flat
saw (^plaster of paris
saw) may be used for
obtaining smoother mar-
gins for the cut.
Removable plaster of
paris dressing. Very fre-
quently a plaster of paris dressing is applied with the intention of having it
worn for some time as a removable support (tutor), for instance, after resec-
tions, especially of the knee joint, or as a plaster of paris corset in the treat-
ment of scoliosis. In this case, it is more important that the dressings
should fit well and be light and durable. For a cover of the surface, it is
best to use tricot, which fits well all the contours of the body. Commercial
tricot hose is used for the most part ; it must be twice as long as the dress-
ings to be applied ; one-half serves as an under layer for the plaster of paris
dressings ; the other is turned over the set dressings as a cover.
For such tutors only plaster of paris bandages are used. They are
applied according to Sayre as follows : —
The bandages, about 5 to 8 centimeters wide, are applied as smoothly
as possible around the limb in spiral turns; reversed turns are avoided by
cutting the bandage at the place involved; during the application, each turn
is well nibbed together with the following. This is best done by an assistant,
who follows with both hands the descending bandage and strokes it firmly
to the limb ; thereby greater firmness and a more complete agglutination of
the several layers are effected; the thickness of the dressings should rarely
exceed half a centimeter.
When the dressing has nearly set, the bandages are divided with a very
sharp knife, in a straight line previously marked, and the tricot is divided
with a pair of scissors. In order to prevent injury to the patient, which
might easily occur, it is well, before applying the dressings, to place a strip
of pasteboard, or of wood, or something similar, under the tricot at the place
where the cut is to be made ; a longitudinal roll of cotton or a cord may be
used instead {Szynianowski). After the dressing has been cut, the margins
120
SURGICAL TECHxNIC
of the splint are carefully turned aside far enough to enable the limb to be
removed from it and is then set aside for drying. After 2 to 3 days, it is
covered with tricot. Along the margins,
the tricot is sewed together with the inner
layer so that the whole dressing becomes
lined ; laces or strips of leather and buckles
should be attached to the edges of the slit
made in the dressing — preferably by an
instrument maker (Fig. 193).
Common cotton jackets and trousers,
which serve for a lining, or long knee-stockings, of which one is used for an
under layer and the other for a cover, are generally cheaper than the tricot
material. Especially with stockings, plaster of paris boots, which look very
well, can be applied (for corrected flat feet, club feet resections, etc. ).
Plastic plaster of paris splints {Beely) are made of rolls of hemp, flax,
jute, or straw which has been made soft by beating {Anschiitz). Having
been dipped in the thin plaster of paris cream, they are applied to the limb
Fig. 193. Plaster of Paris Tutor
FOR THE Knee
Fig. 194. Beelv's Plastic Plaster of Paris Splint
(previously lubricated and wrapped with a moist muslin bandage). The
bundles of fibre, only about i centimeter thick, are applied one after
another, covering each other, and finally the surface is smoothed with
plaster of paris cream. These removable plaster of paris splints are
especially well adapted to the treatment of compound fractures. If the
limbs are to be suspended in them, it
is well to insert in the paste, at sev-
eral places, hooks and eyes of wire
(Fig. 194).
Such splints may be applied with
Breiger's plaster of paris cotton in a
still more convenient and cleanly
manner; for instance, for radius frac-
tures, Braatzs spiral splint, which holds the hand securely in flexion and
abduction, without limiting the movement of the fingers (Fig. 195).
Fig.
195.
Bkaatz's Spiral Splint for Radils
Fr.\ctlre
THE TREATMENT OF WOUNDS
121
STRENGTHENING PLASTER OF PARIS BANDAGES
In order to make the plaster of paris bandages more durable, a thicker
layer of plaster of paris cream may be applied ; by this means, however,
the dressings unfortunately become awkward, clumsy, and heavy. It is
more practical to give it greater firmness by inserting strips of wood
{Volcker's "tapetenspan " or shoemakers' shavings — Neudorfer), narrow
splints of veneered wood, strips of tin or wire, without making it thereby
essentially heavier.
Of these materials, the strips of wood are most preferred, on account of
their lightness and cheapness ; hence, for the
WOOD SHAVING PLASTER OF PARIS DRESSINGS
the following rules may be observed : —
{a) On the humerus (in fractures of the humerus and inflammations of
the shoulder joint).
The arm, bent at a right angle in the elbow and abducted, is carefully
wrapped with flannel bandages as far as and above the elbow joint ; from
there the arm and the shoulder are wrapped with cotton bandages. Next,
the whole arm from the wrist to the shoulder is wrapped with a plaster of
Fig. 196 Fig. 197
Wood-shaving Plaster of Paris Dressing on the Humerus
paris bandage, brought to the side of the chest, and supported by a mitella,
Next, the middle portion of a long "tapetenspan " (strip of wood) is applied
under the elbow ; its two halves are carried along the anterior and posterior
122
SURGICAL TECHNIC
sides of the arm, and its ends are allowed to cross each other over the
shoulder. A second long strip of wood is applied along the outer surface
of the arm from the wrist to the side of the neck (Fig. 196). Finally, the
strips of wood, the arm, and the mitella are enveloped in plaster of paris
bandages, applied according to Desanlt {Â¥\g. 197).
{b) Fractures of the forearm and inflammation of the elbow joint.
After the arm, bent at a right angle at the elbow, has been wrapped
with cotton and next with plaster of paris bandages, two long strips of
Fig. 199
WooD-sHA\'iNG Plaster of Paris Dressing on the Forearm
wood like reins are applied around the joint, of which one takes its course
along the anterior and posterior sides of the forearm, while the other
ascends around the elbow to the arm. Two strips are added for the
superior and inferior surfaces of the arm, and all four are fastened with a
plaster of paris bandage (Figs. 198, 199).
In more serious injuries and after resection of the elbow joint, the (fenes-
trated) plaster of paris dressing may be applied, with the joint at a flexion
THE TREATMENT OF WOUNDS
of an obtuse angle and the forearm in semi-supination.
201 show the arrangement of the strips in such a case.
123
Figures 200 and
Fig. 201
WooD-SHAVixG Plaster of Paris Dressing after Resectiux of the Elbow Joint
(c) Fracture of the leg.
The plaster of paris dressing in fractures of the leg has recently become
materially limited ; at the present time it is used only in fractures of the
shaft, of the tibia or the malleoli, or of the bones of the foot. In fractures
of the femur, the treatment by extension yields better results. In severe
injuries of the pelvic bones, and especially in order to secure immobilization
for the hip joint in inflammation, or to give a firmer support to the leg for
after-treatment after resection of the head of the femur, the plaster of paris
dressing is still largely used. Likewise, as a light support (tutor) after
resection of the knee or ankle joint.
If a plaster of paris dressing is to be applied on the leg, to encircle at
the same time the pelvis, the patient must be placed in such a position that
the posterior side of the pelvis also becomes freely accessible ; an ordi-
nary Volkmanji pelvic support is not sufficient, since it covers too much
space. It is better, therefore, to use the pelvic supports mentioned for that
purpose. They can be screwed to the table {yon Esniarch, von Bardeleben
-^ Figs. 202, 204) upon which the patient is placed, with the sacrum resting,
while one (or two) assistants hold his legs, and by making traction upon
them the perineum of the patient is drawn toward the iron pole, wrapped
with cotton (counter extension). For the support of the heel during the
124
SURGICAL TECHNIC
application of the dressings, an adjustable heel support (Fig. 203) may be
used. The back is supported by a padded pelvic support or a high pillow,
so that the patient is suspended in a horizontal position about 8 inches
above the table.
Fig.
202. Von Esmarch's
Pelvic Support
Fig.
203. Von Esmarch's
Heel Support
Fk;. 204. Von Bardele-
ben's Pelvic Support
Next, the leg and then the pelvis are wrapped with cotton bandages
over which a plaster of paris bandage is applied. Then a long strip of wood
is applied along each of the four sides of the leg ; the ends are held in posi-
tion by assistants (Fig. 205). The strips are fastened temporarily with a
plaster of paris bandage in serpentine turns (Fig. 206), and over them
several broad plaster of paris bandages are applied, surrounding the pelvis
in figure-of-8 turns ; a layer of plaster of paris cream is spread upon them.
Since, in such dressings of the hip, the weakest point is the groin, in which
THE TREATMENT OF WOUNDS
125
by imprudent movements and especially in rising a fracture may easily be
produced, it is advisable sufficiently to strengthen the layer of plaster of
paris at this place, if necessary, by incorporating a strip of tin or something
similar. Wooden strips are here less useful, since they too are flexible on
Fig. 206
Fig. 207
Wood-shaving Plaster of Paris Dressings for the Leg
their surface. Finally, the projecting ends of the chips are cut off, the
margins of the dressings are smoothed, and in any existing wounds or fis-
tulae, a fenestra is made at the corresponding place (Fig. 207).
i^z//^-/ places the patient on two iron rods (gas pipe), which are connected
near one end by a movable crossbar as long as the hand. The end is put
126 SURGICAL TECHNIC
on the edge of a table, and the patient is placed upon the rods in such a
manner that only the head and the chest rest on the table, while the abdo-
men and the legs are balanced by the diverging rods. After the dressings
have been applied, the rods are withdrawn from under the layer of bandages.
The preparations recommended by several surgeons for position and
extension in this dressing are rather complicated and cannot be carried out
everywhere.
The plaster of paris dressing for the knee must, if it is to be effective,
extend to the thigh and the leg from the trochanter to the ankle.
In fracture of the shaft or the malleoli of the leg, the dressings should
extend from the toes to the knee joint. Since, especially in this region, ow-
ing to the strong muscular contraction, there may result very great displace-
ments of the fragments, which cannot always be balanced by the strength
of the assistant who makes the extension, it is advisable to attach to the
foot a loop by which the broken limb is drawn up vertically by a pulley,
whereby the body of the patient makes the counter extension. In this posi-
tion, all displacements become adjusted; the position can be maintained
without any trouble until the plaster of paris dressing has completely set.
FENESTRATED PLASTER OF PARIS DRESSINGS
At a point corresponding with the location of small wounds or fistulous
openings, the plaster of paris dressings must be supplied with correspond-
ing openings {fencstrac), to make these places accessible for suitable treat-
ment, for inspecting the wound at any time, and for securing free drainage
for the secretions (Figs. 201, 207). These places are either left free at the
time of applying the plaster of paris bandage, by making reversed turns or
by cutting out the dressing at one margin of the fenestra to be formed and
continuing the bandaging at the other side, or with a sharp knife fenestrae
are made after the splint has been applied by cutting out a piece correspond-
ing in size to the cutaneous defect.
In order to reach the right place, it is advisable to place upon the region
of the wound, covered thickly with dressing materials, some object which
forms a projection and upon which the cuts can be made without hesitation ;
for instance, a cotton compress, a tampon, cork, small basin, potato, etc.
To prevent secretions of the wound from infiltrating between the skin
and the plaster of paris dressings, the margins of the fenestrae must be
firmly padded with eominon cotton ; this ring of cotton may be made still
more waterproof by brushing it with collodion, varnish, shellac, or putty.
THE TREATMENT OF WOUNDS
127
Varnished paper does not occlude the wound so well as adhesive plaster, if
it is used from the start for making fenestrae. For this purpose, make of it
tubes in length of a finger, turn over one end nicked at several places, and
apply upon the wound, so that they rest upon the skin like chimneys ; next
apply the plaster of Paris dressing in the usual manner, so that the lumen
of the tubes remains free, and line the uppermost layers with the end that
projects over the dressing.
But if the wounds are so large that through a correspondingly large
fenestra the firmness of the dressings would become diminished, for instance,
after severe compound fractures, or if the whole contour of the limb has to
remain free at one place, in order to renew the dressings as often as neces-
sary, as, for instance, after resection of the joints, then the plastic dressings
are applied in two halves, which are connected with one another by means
of a strong arch (stirrup bridge). This is, then, an
INTERRUPTED PLASTER OF PARIS DRESSING
In the antiseptic treatment of wounds, this dressing need hardly ever be
used, since the dressing is rarely changed, and since, moreover, a sufficient
substitute is offered by the simple wire splints and wooden splints. In
former times, however, on account of the frequent change of the dressings,
they were more in demand and were essentially instrumental in saving time
and work for the physician and pain for the patient. If, therefore, in cases
of sepsis or suppuration of the joints, the surgeon desires to proceed conser-
vatively, they may be recommended even now as very convenient dressings,
rendering the frequent change of dressings possible in a short time and
without any special assistance.
Fig. 208. Stirrup Plaster of Paris Dressing for the Knee
Thus the region of the wound may be bridged over at two sides by
strong arches of sheet iron, the straight ends of which are incorporated in
128
SURGICAL TECHNIC
the plaster of paris dressings (Figs. 208, 209). For lessening the elastic
motion of these iron arches, wrap them with hemp or jute dipped in plaster
of paris cream. With these plaster of paris hemp splints alone, a stirrup
dressing can be constructed {Beely — Figs. 210, 211), which can be easily-
suspended by means of a few eyelets fastened in the plaster of paris.
Fig. 209. Stirrup Plaster of Paris Dressing for the Elkow
Fig. 210. Peelv's Plaster of Paris Hemp Splint for the Knee. I.
An interrupted splint can also be made with the straight wooden laths
bridge, especially if the limb has to be made accessible only on one side.
After the regular plaster of paris dressing has been applied, above and be-
low the injured place, both parts are connected by pieces of lath (poles),
which are incorporated in the dressings with cotton or tow compresses
saturated with plaster of paris ; in addition, they are fastened with plaster
of paris bandages (Fig. 212).
Similar is Pirogojf's bridge plaster of paris dressing, which has proved
to be very good, especially as a temporary dressing; a piece of coarse
THE TREATMENT OF WOUNDS
129
Fig. 211. Beely's Plaster of Paris Hemp Splint for the Ivkee. H.
Fig. 212. Bridge Plaster of Paris Dressing with Wooden Laths
Fig. 213. Pirogoff's 1 I df Paris Dressing
SURGICAL TECHNIC
liiijiijm
Fit;. 216. Von Esmakch's Plaster of Paris Suspension Splint for Resection
OF the Elbow Joint
Fig. 217
THE TREATMENT OF WOUNDS
131
Fig. 21J
Fig. 219. Von Esmarch's Plaster of Paris Suspension Splint for Resection
OF THE Wrist
Fig. 220
132
SURGICAL TECHNIC
Fig. 221
^dm
% I
kmM.»#s«®
Fic. 222. Watson's and von Esmarch's Plaster of Paris Suspension Splint
FOR Resection of the Knee Joint
Fi(j. 224
THE TREATMENT OF WOUNDS
133
sackcloth (sleeve, trousers) is dipped in a plaster of paris cream and applied
on the lower side of the limb as a strong plaster of paris splint ; on the upper
side, above and below the wound, two large tow compresses (straw, hay),
saturated with plaster of paris cream, are appHed, and over them the wooden
lath is fastened like a bridge upon its pillars with broad linen strips of
plaster of paris bandages (Fig. 213).
Still more convenient and also lighter are the so-called resection splints
in connection with sttspension wires (plaster of paris suspension splints),
which are securely fastened to the limb by plaster of paris bandages. This
mode of dressing was first employed for the knee joint by Watson ; after-
wards, for the other joints, by von Esmarch.
The splints are made narrow at the place destined for the resection and
form a small connecting bridge, while the wire belonging to it forms an arch
at this place.
This dressing is applied in the following manner : —
After the diseased joint has been dressed antiseptically and the whole
limb bandaged with cotton bandages, the well-cleansed splint is covered with
two moss pads, which allow the small bridge between them to remain free.
Fig. 225. Von Esmarch's Plaster of Paris Suspension Splint for Resection
OF Ankle Joint
The latter is wrapped with india-rubber cloth, made sterile, or is protected
in some other manner from the contact of secretions ; next, the splint is
fastened on the lower side of the limb with plaster of paris bandages, and
thus the region of the joint remains completely free. With the last plaster
134
SURGICAL TECHNIC
of paris bandage, the suspension wire is fastened with plaster of paris cream
at the anterior surface of the limb, and as soon as the dressing is completely
dry, the limb is held by the frame in free suspension. Figures 214-225
show these splints for various joints. Instead of wooden splints, in case of
necessity, splints similarly shaped may be cut from strong tin or bent to-
gether from telegraph wire (Figs. 226-228).
Fiu. 227
â– iyr>- >n>///t) 'i t> i ii>i i t //njl>/n'rr7r
Fig. 228
Von Esmarch's Suspension Splints made of Telegraph Wire
Von Volkniann' s wooden dorsal splint (Figs. 229, 230), which is firmly
applied with plaster of paris or starch bandages at the superior surface of
the limb, affords the diseased joint a firm support and is especially suitable
for all cases in which large wound surfaces, fistulae, or decubitus are on the
lower side of the limb.
THE TREATMENT OF WOUNDS
Fig. 229
135
Fig. 230. Vo.x Volkmaxn's Dorsal Spun'
Fig. 221
Fig. 232
Von Esmarch's Iron Arch Splint for Resection
OF THE Wrist
136
SURGICAL TECHNIC
But if the whole contour of the limb is to remain free, a dorsal and a
volar splint may be connected by strong wire arches {von EsviarcJi). These
iron arch splints are especially suitable for the wrist joint and ankle joint;
they are fastened with plaster of paris bandages and are light and com-
fortable (Figs. 231-234).
Fig. 2.\x
^HsTP^^*^?
Fig. 234
Von Esmarch's Iron Arch Splint for Resection of the Ankle Joint
For the elbow joint, my double splint, which can be easily constructed, is
very useful (Figs. 235, 236). In changing the dressing, the interrupted
padded arch splint upon which the arm rests is lifted from the lower board.
My divided iron suspension splint for the clboiv joint is very convenient
but somewhat large and heavy ; it consists of three folding sphnts, the arms
of which, movable on hinges, are fastened to an iron pole ; in applying the
dressing, the middle splint is removed (Figs. 237, 238).
THE TREATMENT OF WOUNDS
137
Fig. 235
Fig. 236
Von Esmarch's Double Splint for Resection of the Elbow Joint
138
SURGICAL TECHNIC
Fig. 237
Fig. 238
Von E.sMAKCH'ii Divided Iron Suspension Splint for Resection of
Elbow Joint
POSITION DRESSINGS
These serve for a comfortable and secure position of the injured limbs,
either alone or in connection with other dressings.
They essentially lessen the sufferings of the patient, especially in exten-
sive and serious wounds. But since they are rather heavy and bulky, they
are not so well adapted to transportation as to hospital treatment.
For military service, the most practical are those which are not too heavy,
nor too complicated and expensive, and which can be made by any mechanic
from a drawing;.
THE TREATMENT OF WOUNDS
139
If, in serious injuries of
the leg, other conveniences are
not available, then as the sim-
plest temporary position use
the side position according
to Pott (Fig. 239); that is,
place the patient's leg on pil-
lows, with the half-bent knee
and hip joint on the exter-
nal side ; the muscles thus
become relaxed and im-
pediments to circulation are
avoided.
If the injured person is to
be transported in this posi-
tion, the pillows are fastened
around the limb with cords.
For the further transpor-
tation of such severely injured
persons, especially when both
lower extremities are injured,
Bonnef s wire breeches are use-
ful (Fig. 240). This splint
consists of a well-padded wire
frame, in which the broken
limbs are fairly well immo-
bilized. Openings can be ^ig. 239. Pott's Side Position
made in it, for bandaging the wound without moving the limb from its posi-
Fig. 240. Bonnet's Wire Breeches
tion. At the foot end are appliances for extension. This apparatus is very
I40
SURGICAL TECHNIC
comfortable for the patient, but too expensive and bulky, and hardly
answers the present requirements of surgical cleanliness.
Fig. 241. Wire Breeches flattened for Packing (according to von Esmarch)
Of woven wire cloth (wire gauze), which can be purchased, wire splints
can be made, which are lighter than Boiincfs and so flexible that they
occupy but little space when flattened (Fig. 241). Moreover, they can be
more readily cleaned.
r\
DorBi.E Inclined Plane
The double inclined plane (planum inclinatum duplex) is especially suit-
able for serious injuries and fractures of the leg ; it is constructed either, as
Figure 242 indicates, according to Petit' s fracture box, or more simply, as
THE TREATMENT OF WOUNDS
141
Figure 243 indicates, of a few boards provided on their lateral margins with
wooden pegs by which the margins of the cushion upon which the leg rests
are pressed against it.
Fig. 243
Fig. 244
Von Esmarch's Double Inclined Plane
If the wound is on the posterior side of the limb, a piece is sawed out
of the board on that side (Fig. 244). Two longer wooden pegs, between
which a bandage is stretched in figure-of-8 tours, serve as a support for the
foot.
By means of Dobsoiis wooden
frame (Fig. 245), placed under
the mattress in the region of
the knee, a practical double in-
clined plane for both legs can
be extemporized.
Von Renz's abduction box
(Fig. 246) is especially adapted
to cases of compound fractures p.j^__ ^^^^ Dobson's Wooden Frame
of the femur, in which the
upper fragment is in a strongly abducted position. Since the splint can
142
SURGICAL TECHNIC
Fig. 246. VuN Rent's Abduction Bux
Fig. 247. Petit and Heistek's Fracture Box
THE TREATMENT OF WOUNDS
143
easily be made by any carpenter, it might prove valuable in practice in
small places situated at some distance from large cities, where the physi-