or sits on the perineal strap ; the foot hangs
suspended in the air and the diseased joint is
Fig. 287. Taylor's ExTEN.sa.N ^^^^ relieved from the weight of the body.
Apparatus This original apparatus has undergone numerous
Fig. 2S8. Fastexing the Adhesive
Plaster Strips
THE TREATMENT OF WOUNDS 1 59
improvements and has been largely changed {Sajre, Schaffer, Whitehead,
and others j.
TEMPORARY DRESSINGS
If the ordinary articles of dressings so far described are not available for
dressing wounds, arresting hemorrhage, immobilizing fractures of bones, the
physician or the trained layman (Red Cross nurse, Samaritan) has to extem-
porize a dressing quickly with luhatever material is at hand. Such emer-
gencies occur often enough in time of peace (it is said that in Prussia alone
considerably more than 100,000 serious injuries occur annually). Especially
important, however, is the art of improvising rapidly and well in time of war.
After large battles, with the murderous destructions which the most recent
firearms cause and the infinite number of wounds, even the largest supply of
materials for dressings becomes exhausted, and the otherwise ample number
of trained persons becomes insufficient at least for the moment.
In the treatment of wounds, the first principle to be observed is not to
touch the wounds winecessarily, especially with iinclean (non-aseptic) hands,
to forego all indiscreet examinations, probing, removing of foreign bodies,
and not to apply any dressings which are not known to be surgically clean ;
for to leave the wound open and unprotected from every dressing (the open
treatment of wounds) is less hazardous than to cover it with unclean mate-
rials. Slight hemorrhages also are more easily arrested by means of the
scab which forms in the open air. In the neighborhood of inhabited places —
in houses, however, with scanty means — an aseptic dressing can be made by
boiling water for some time ; with this, the wound is cleansed from all im-
purities ; next, it is covered with a clean (washed and ironed) cloth (handker-
chief) and this dressing is fastened with another cloth. If no aseptic dressing
materials are at hand, they may be obtained in a very simple manner by
boiling some pieces of gauze, etc.
Wound douches for a sufficient irrigation of the wound may be made with
vessels open on the top (cooking utensils), into which the end of a rubber
hose, weighted with a stone or some similar object, is lowered, while suc-
tion is produced at the other end ; or by making a glass douche according to
Fig. 28. Funnels and cans can also be used for this purpose.
For bandages may be used strips of table cloths, sheets, and shirts. The
cloth bandages may be made of a napkin or a handkerchief. An arm sling
may be improvised, in want of cloths, from the skirts of a coat, the sleeves
of a coat or a shirt cut open, or the uninjured sleeve fastened to the breast
i6o
SURGICAL TECHNIC
with safety pins (Figs. 289-291). In the case of women place the arm into
the apron thrown over the shoulder.
Fig. 289
Cloth Bandage of Skirt
OF Coat
Fig. 290
Bandage of Coat Sleeve
CUT OPEN
Fig. 291
Bandage of Sleeve fast-
ened BY Safety Fins
When hemorrhages cannot be arrested by means of a firmly applied
dressing, then, first of all, elevate the limb ; in case of necessity, compress
the bleeding artery above the wound with the finger or with a tourniquet
quickly improvised. In serious injuries of the large vessels, constrict the
whole limb between wound and heart with an elastic tube, suspender, or a
bandage which is subsequently moistened.
If bones are fractured, in addition to the greatest gentleness and cir-
cumspection possible in touching and moving the injured person, splints
should be quickly procured.
For temporary splints may be used : —
(a) Wooden splints, rulers, laths, poles, boards (Fig. 292), strips of wood,
trellis of flower pots (Fig. 293), flexible wooden covers (like Gooc/is flexible
wooden splints — Fig. 140). Useful, also, are twigs or small brandies, tied
together in bundles (Fig. 294), or arranged side by side smoothly, fastened
by tying them together with transverse pieces of wood (Fig. 295), or wdth
THE TREATMENT OF WOUNDS
i6i
Fig. 292, Tejiporary Splints for Fractured Leg
Fig. 293. Splint of Trellis of Flower Pot
Fig. 294. Splint of Small Branches tied in Bundles
Fig. 295. Flat Splint of Twigs arranged Side by Side
l62 SURGICAL TECHNIC
twine in the form of a chain (Fig. 296). In a similar manner, the smooth
bark of straight trees (willows, beeches), or the dried leaves of banana
trees, or thin, flexible veneering may be used. Also, the splint cloth (illus-
trated in Fig. 142), which can be cut, may easily be prepared; in lack of
some adhesive substance, strips of wood, twigs, etc., are sewed to the
material.
{b) Straiv splints. Stalks of straw in as good condition as possible
are tied together in bundles (Fig. 297). Two of these straw splints are
wrapped into both ends of a cloth, placed under the limb in such a manner
that they come to lie close to the limb on both sides, and can be fastened
to it by means of boards {straw splint — Fig. 298). Also, straw, reeds, or
rushes can be sewed into mats (von Beck), and the limb can be enveloped
with them and a bandage applied over them ; when rolled up on each side
they can also be used for lateral splints (Figs. 299, 300). Door mats, lino-
leum, strips of carpet, etc., can be used in the same manner.
(r) Pasteboard splints can be easily prepared everywhere according to
the models mentioned on page 128. In lack of pasteboard, old book
covers, maps, boxes, or layers of newspapers, pasted together, may be
used.
{a) With a pair of strong scissors, tin can be cut into any desired form
of splints (Figs. 156, 157). A piece of roof gutter makes a very practical
splint.
{e) Wire splints are prepared from strong wire taken from fences,
enclosures, or from woven wire gauze, which can be purchased. In time of
war, the use of telegraph wire, from lines broken during battle, is of espe-
cial importance. With a strong pair of pincers and a file, even with little
experience, simple splints may be quickly prepared. They are light, clean,
and transparent. Figure 301 shows Porte}'' s splint, which can be easily made.
Figure 302 shows a protecting frame for wounded limbs. The construction
of other splints from wire presents greater technical difficulties (see Figs.
164, 165).
(/) Objects which the wounded man has on his person sometimes
furnish very useful material for splints.
Articles of clotJdng (for instance, coats, trousers, cloaks, bootlegs) may
be employed. A military cloak, for instance, is rolled up on both sides and
fastened to the limb by a belt or a cloth (Fig. 303). The sleeves, filled with
straw, moss, or earth, can be used as splints. A boot cut open lengthwise
and in front in its middle portion, the leather of the leg of which is wrapped
about a piece of wood applied exteriorly, provides a foot splint, which,
THE TREATMENT OF WOUNDS
163
Fig. 296. Splint of Transverse Pieces of Wood fastened with Twine
Fig. 297. Straw Splint
Fig. 298. Straw Splint
Fig. 299. Straw Mat for Splint
164
SURGICAL TECHNIC
Fig. 300. Reed Mat for Splint
Fig. -;oi. Porter's Wire Splint
Fig. ^02. Protecting Frame for Wounded Limb
Fig. ^q-;. Military Cloak used as Splint
THE TREATMENT OF WOUNDS 165
like Volkmami' s T, prevents the lateral movements of the injured foot
(Fig. 304).
Fig. 304. Boot cut open lengthwise used as Foot Splint
Weapons like swords, cutlasses, bayonets, sabres, scabbards, muskets,
rammers, lances, leather, felt of the saddle, spokes of wheels, canes,
umbrellas, and parasols may be used for splints without any further prepa-
ration (Figs. 305, 306, 307, 308).
i^g) In cases of great emergency, when nothing at all is at hand, the healthy
leg is used as a splint for the injured one, and the thorax for the diseased arm.
Often there are to be had neither tables nor practical position apparatus
for applying the bandages. The military model is excellent as an operating
and dressing table (Fig. 309). Upon this, by a kind of double music stand,
two men can be dressed at the same time. By means of boards and pillows
this arrangement can easily be fixed to any large common table. Position
appliances and means of sitspension for injured limbs may easily be made
with wire and strips of cloth (Figs. 310, 311). A double inclined plane is
made by two laths nailed together at an obtuse angle, a Heister's fracture
box, by placing the leg upon a very low bench, the legs of which have been
sawed off in a manner that accomplishes the object. A suspension apparatus
for a fractured leg can be made by means of several triangular cloths, which
as slings are carried across a transverse pole. It can be prepared in a still
simpler manner if the stocking is cut open anteriorly and if two rods are fast-
ened to its margins. These are hung up on a stronger rod or pole (Fig. 312).
The position appliances in Figs. 243, 245, 246, 251, which can be made
rapidly by any carpenter, are especially serviceable.
i66
SURGICAL TECHXIC
Fig. 305. Joined Bayonets used as Splint
Fig. 307. Scabbard used as Splint
Fig. 308. Mr^KET used as Splint
THE TREAT.MEXT OF WOUNDS
i6:
Fig. 309. Dressing Table (Militan- rvlodel)
Fig, 310. Von Volkmann's Suspension Appailitus foPv Injured Aiai
Fig. 311. Von Bardeleben's Wire Suspension Apparatus for Fractured Leg
Fig. 312. Cubasch's Suspension Apparatus of Stocking cut open
l68 SURGICAL TECHNIC
ANTISEPSIS IN WAR
It is the urgent demand of humanity to have every wounded soldier, even
in war, enjoy the protection and the blessings of the antiseptic treatment of
wounds.
To be able to fulfil this demand it is necessary that: —
(a) Not only all military surgeons be perfectly familiar with the anti-
septic treatment and the practical application of the same,
(d) But also that all persons of the hospital corps (litter bearers, Red
Cross nurses) are versed in the principles of antisepsis, and are competent
to render efficient first aid.
(c) Not only the field hospitals and the hospital corps, but also the
wagons for medical supplies of the troops, the knapsacks for the dressings,
and the pouches of the hospital assistants must be sufficiently provided with
antiseptic material for dressings.
(d) In time of war, every soldier should carry with him a packet of anti-
septic dressings from which, in case of necessity, an aseptic protective dress-
ing can be temporarily suppHed.
These demands have been amply met by the supplement of Military
Hospital Regulations of 1886.
In accordance with them, the following antiseptics and dressings are
used: —
Carbolic acid, sublimate, iodoform, and materials for dressings charged
with these chemicals. Carbolized gauze (see p. 24), subHmate gauze (see
p. 26), iodoform gauze, 25% (see p. 33), carbolized and sublimate wound
cotton (prepared like gauze). These materials made up in larger and
smaller packages are compressed by machinery into a very small space, are
fastened together, and wrapped in paper. (The large packages contain i
kilogram of cotton; the smaller, 100 grams.) In addition, they contain
sublimate catgut, sublimate silk, antiseptic sponges and tampons, moss
pasteboard, wood wool, cambric bandages 5 meters long, muslin flannel,
gauze, triangular cloths, etc.
In field hospitals amply provided with all requisites, the treatment of
wounds and the manner of operating do not essentially differ from those
practised in large clinics in time of peace. The case is different, however,
at the first dressing station and on the battle-field itself, where, on account of
rapid changes of position, with the modern art of rapid warfare and with
the far-reaching new guns, a change of dressing stations must very fre-
quently occur. On account of the accurate aim of present weapons, more-
THE TREATMENT OF WOUNDS 169
over, the number of the wounded in a short time becomes so great that not
only the surgeons but also the materials for dressing at hand soon become
insufficient.
Here, where strict antisepsis cannot be performed, at least the first prin-
ciple in the treatment of every wound should govern all action: ''Do no
harm."
Omit, therefore, every examination of the wound with fingers or instru-
ments that are not surgically clean (aseptic).
Only in the case of dangerous hemorrhage is it justifiable to make an
exception to this rule ; for in such instances prompt action is the essential
feature of the treatment.
In no case should bullets be extracted without the strictest aseptic pre-
cautions. A bidlet that has penetrated the body produces in itself only little
injury. Many bullets become encysted without causing any subsequent
harm.
Experience teaches that even very serious internal injuries (of bones,
joints, tendons, nerves, lungs, heart, brain, etc.) produced by the bullet in
its course, can heal without any suppuration or fever and without any fur-
ther complications, provided no germs of putrefaction have entered the
wound at the time.
Hence, the work of the hospital corps should be limited solely: —
(i) To apply temporary dressings; that is, to cover the recent wound
amply with antiseptic materials, in order to prevent germs of putrefaction
from entering it.
(2) To secure for the injured parts of the body a condition of rest {im-
mobilization by means of cloths, splints, etc.).
(3) To transport the injured thus treated as quickly as possible to the
place where the wound can be treated in a strictly antiseptic manner.
If the wound of the soldier, provisionally dressed, presents after his arri-
val at the field hospital no symptoms necessitating a direct examination
(fever, pain, hemorrhage, extravasation of the secretions), it is better to
leave the wound tuitoucJied and not even to remove the first protective dress-
ing ; for many gunshot wounds heal thus under the scab without any disturb-
ance of normal wound healing.
But if such symptoms appear as necessitate examination, the dressings
must be removed immediately and the wound subjected to energetic anti-
septic treatment. For this purpose (apart from major operations, amputa-
tions, resections, etc., which may be found necessary), it is above all things
necessary to enlarge the wound and establish drainage followed by thorough
I/O SURGICAL TECHNIC
disinfection with effective antiseptic preparations (such as sublimate, iodo-
form, chloride of zinc, etc.); after this, the antiseptic dressings should be
applied (see secondary antisepsis, p. 66).
If a dressing station is near at hand, the stretcher bearers have no more
important duty to perform than to transport the wounded as gently and as
rapidly as possible to such a place.
Only in cases where medical assistance is not near at hand or where no
materials for dressings can be had should the materials which the soldiers
carry with them be used either by the wounded themselves or by the
stretcher bearers (especially in smaller cavalry divisions).
THE SOLDIER'S ANTISEPTIC DRESSING PACKAGE
According to the Military Sanitary Regulations of 1886, each soldier in
time of war is supplied with a dressing material consisting of two antiseptic
muslin compresses, 40 centimeters long and 20 centimeters wide, a cambric
bandage 3 meters long and 5 centimeters wide, a safety pin, and waterproof
material 28 centimeters long and 18 centimeters wide, for covering.
Concerning the composition of this first aid dressing as well as concern-
ing practical utility to supply the soldier with such a package for field service,
very different opinions prevail among military surgeons. Some consider
the same entirely unnecessary.
I have heard, however, from many experienced military surgeons, that,
during campaigns in distant countries (in the war against the Boers, in the
Ashantee war in Egypt, in the Caucasus), the surgeons in dressing the
wounded often had to depend entirely on the first aid package which each
soldier carried with him. In our last war, especially among the cavalry,
very often no other material for dressing was at hand than that which could
be found in the pockets of the soldiers ; in my opinion, therefore, humane
principles demand that each soldier shall carry with him in the time of
war a practical first aid package of antiseptic dressings, with which his
wound can be dressed antiseptically, if other material for dressing is not
at hand.
For many years I have been occupied with the subject of what the first
aid package of the soldier should contain and how the material should be
packed to be of the greatest practical use. In the year 1869 I published a
little pamphlet under the title "The First Dressings on the Battle-field,"
which contained, as a supplement, a triangular cloth with an engraving rep-
resenting the application of Major' s triangular cloth on the battle-field.
THE TREATMENT OF WOUNDS 171
During the Franco-Prussian war, many antiseptic dressing packages
were made in Kiel by the relief society, according to my directions, and
were distributed among our soldiers. These contained, in addition to the
triangular cloth with safety pin, two small packages each, filled with car-
bolized cotton, and a gauze bandage, all wrapped up in parchment paper.
When it was afterward found that carbolic acid evaporated rapidly, I
used in its place salicylated cotton ; and since the salicylic acid after carry-
ing the package for some length of time fell out from the meshes of the
cotton, I substituted a roll of jute of chloride of zinc and afterward pack-
ages of sublimated sawdust.
But since, on the part of the military authorities, the objection was made
to me that it was not advisable to give to the soldier going to war a picture
in which the "horrors of the battle-field" were represented, I had another
triangular cloth made of the cheapest cotton material, on which only six dif-
ferent naked iigures are printed, from which figures the various modes of
applying the cloth for dressings can be seen. This cloth is now used uni-
versally as a means of instruction for first aid, not only in our Samaritan
schools, but also by the large ambulance associations of England and
America (Fig. 102).
In the composition of these packages, I have always endeavored to fol-
low the progress of antisepsis; hence, my latest package, named "Tem-
porary Dressing for the Battle-field," contains, in addition to this cloth, two
compresses of sodium chloride sublimate gauze (10 centimeters wide, 100
centimeters long), each wrapped in glazed paper, and a sodium chloride
sublimate cambric bandage (10 centimeters wide, 2 meters long), so that,
with the antiseptic material contained in the package, even large wounds
can be dressed.
The whole, greatly compressed and wrapped in very durable waterproof
india-rubber material, presents a package 1.5 centimeters thick and 10 cen-
timeters square, weighing exactly 100 grams. The following directions for
use are printed on the same : —
" For simple gunshot wounds, apply on each opening of the wound one
of the compresses, after the glazed paper has been removed. For larger
wounds, unfold the compresses and endeavor to dress the whole surface of
the wound with the antiseptic gauze. Hold the gauze in place by a circular
bandage. The triangular cloth serves to protect this dressing still further,
and at the same time it serves a useful purpose in supporting the injured
limb, and in applying temporary splints, illustrated on the cloth."
By experiments, it was found that after prolonged storing even the subli-
172 SURGICAL TECHXIC
mate evaporated from the materials for dressings ; the materials themselves,
however, were found aseptic, so that this temporary dressing serves to meet
the indications of primary aseptic occlusion.
(The editor has devised a first aid package which is much more compact
and which contains as the essential component parts a teaspoonful of boro-
salicylic powder, compressed cotton, and a gauze handkerchief, to which are
added two strips of adhesive plaster and safety pins. Without the adhesive
plaster it is very difficult to hold the dressing in place.)
In what part of the uniform these packages should be carried, I do not
wish to offer an opinion. This is a matter for the military authorities to
decide. I would say, however, that the contents of the package may be
folded together to make a package twice as large but half as thick, so that it
could be sewed to one side of the breast of the uniform, thus serving for
padding.
Note. — H. Beckmann, a surgical instrument maker in Kiel, furnishes these aseptic
dressing packages for 12^ cents.
(A number of years ago the editor suggested that the first aid package
should be worn on the inside of the belt, as the belt is about the last thing
the soldier will part with on a forced march or in a pitched battle.)
NARCOSIS
During every major operation, and every prolonged and painful exam-
ination, especially when the relaxation of all the muscles is desirable or
necessary, the patient should be rendered unconscious, that is, he should be
placed under the influence of a general anaesthetic.
GENERAL ANESTHESIA
is produced by the inspiration of poisonous gases, of which chloroform and
ether are the anaesthetics most generally used.
CHLOROFORM AN.^STHESLA.
Chloroform, CHCI3 (discovered by Liebig, first used by Simpson, in 1847),
a clear, colorless liquid, very volatile, non-combustible, and of a characteristic
not unpleasant odor, is a poison, the inspired vapors of which produce a
paralyzing effect upon the ganglionic cells of the brain and the spinal
cord, sometimes causing cessation of breathing and of the heart's action.
The paralysis seems to advance in the brain from before backward, so that
THE TREATMENT OF WOUNDS
173
first the frontal lobes (consciousness) become involved, and finally the func-
tion of the medulla oblongata (respiratory centre) becomes extinct. At any
stage of anaesthesia death may occur suddenly from paralysis of the heart.
(The result of much experimentation and a large clinical experience
appear to prove that the toxic effects of chloroform usually involve the
respiratory centres.)
Pure chloroform should be free from ether or alcohol, and should contain
no methylic compounds (turns black on the addition of concentrated nitric
acid), no free chlorine (bleaches moistened litmus paper), no acids (reddens
blue litmus paper). If a few drops of chloroform are allowed to evaporate
on Swedish filtering paper, a rancid acrid odor of the residuum indicates
that the chloroform is impure or decomposed {Hepfs odor test). Since
chloroform easily decomposes on exposure to light and air, it should be kept
in yellow or dark bottles (25-50 g.) and be changed from one bottle to
another as little as possible, and then only in a dark room. Any part of
chloroform left over from one anaesthesia should not be used for another
anaesthesia, except, perhaps, on the same day. By the presence of illumi-
nating gas vapors are formed from the chloroform, which strongly irritate
and cause coughing (Chlorwasserstoffsaure.^). By free admission of air and
by saturating the room with steam (in a sterilizer), this inconvenience is
partly removed.
In the administration of chloroform various precautionary measures must
be observed : —
The stomach of the patient should be empty (no food during the last three
or four hours) ; during the operation, the patient should lie upon his back or
on one side with his head only slightly elevated, or best of all, perfectly hori-
zontal with his limbs slightly elevated ; he should not lie on the abdomen, be-
cause this position renders respiration more difficult ; he should not be in a
sitting position, because this renders syncope more likely to occur. All tight-
fitting articles of clothing (collar, belt, corset), which impede the respiratory
movements, should be removed or loosened ; neck and breast should be free
and the abdomen easily accessible. For all major operations it is best to
place the patient perfectly naked upon the operating table. But since
chloroform lowers the body temperature, the patient should be protected,
especially in prolonged anaesthesias, from taking cold. Hence, cover his
body with blankets, apply hot bottles or the " Warmetuch." Artificial
teeth, chewing tobacco, etc., must be removed from the mouth (danger of
asphyxia from aspiration) ; the bladder, rectum, under some circumstances