DESMURGY

Desmurgy is a doctrine of bandages. It is an independent section of general surgery. It is the teaching of applying bandages with the purpose of treatment of injuries and some diseases. The term “desmurgy” means a branch of practical surgery which studies the applying bandages. It includes two concepts:

The bandaging material, which is applied directly to the wound (dry, damp, ointment bandages).

The external part of a bandage, which is applied for the fixingof the bandaging material on the wound.

A bandage in a wider understanding means a complex of agents applied with the purpose of protection of wounds or pathological cells from the influence of the environment for a more or less longacting term.

In a narrow sense, a bandage means a material (bandage, plaster, etc.), which is applied on a wound for fixing the bandage material with medical agents. Finally, the term “bandaging” means a process of applying or changing medical bandages with its fixation.

The beginning of using bandages dates from the ancient times. Hippocrates wrote about the application of dry bandages and aseptic bandages (cloths moistened with wine, alum, copper salts) and about ointment bandages (moistened with oils), drainages etc. Sponge and dry leaves were used as bandages, for fixing the bandage — sticky plaster, pitches and external cotton bandages. In ancient India cotton, vegetative fibers, etc. were used as bandage material. On Scythian bowls (ІV–ІІІ century AD), founded in the area of Kerch, there is a picture with a man who is bandaging a wound.

In the works of Celsius, bandages moistened with vinegar are mentioned. Galen applied the drainage bandages with bronze tubes.

Avicenna used gypsostarch bandages for treating fractures for the first time. In the middle ages, bandages with tampons (Roter and Roland), with turunda (Goy de Sholiak) were applied. The XVІІІ century was the start of the use of adhesive (plaster) bandages. The art of desmurgy reached the greatest development in the ХІХ century, in the first place due to a number of wars at that period, and secondly due to existing concept concerning protection of a wound against harmful influence of the environment (special medical-protective bandage of J. Lister, 1867).

M. I. Pyrogov’s contributed much to desmurgy. He repeatedly touched technique of bandaging in his book “Beginning of general field surgery development,” in which he presented his experience of plaster bandages application on the battle-field.

The classical principles developed by the end of the ХІХ century were assumed as the basis of modern desmurgy. New achievements in science, though they did not pass over this ancient sphere of medicine, nevertheless did not change it substentially. Bandages are the basis of desmurgy till now.

There are some general tendencies in the desmurgy development. First, trying to make a complex of agents for applying bandages, the purpose of which is help with the work of the medical personnel during mass admission of victims.

Second, the application of glue preparations (BF-6, furoplast) for protecting wounds against undesirable external influence during treatment or providing the fixion of bandage material (cleol, collodium).

Third, the replacement of traditional bandaging material with ductile one, which provides, simultaneously a protective effect and the introduction of antiseptics directly to the damaged place due to medical additions to plastic mixes (armored cellulose bandage).

Fourth, the replacement of existing gauze bandages with tubular bandages, net rollers, which provide fast and reliable fixion of bandage material. The purpose of wounds bandaging:

— protection of the wound against harmful external influence;

— prevention of reinfections of wounds;

— sometimes stoppage of bleeding from the wound;

— fight against wound infection by agents with adsorbing and hygroscopic properties.

In his book “Physical antiseptics”, M. Ye. Preobrazhensky (1894) proved that the bandage material, which absorbs the contents of the wound well, is one of the best ways of discharging infection from the wound.

If the purpose and influence of bandaging to the wound is known, it is easy to come to conclusion, which bandaging material is the most suitable and corresponds to the following requirements:

— it does not irritate the wound or adjoining tissue;

— it does not change its properties during sterilization;

— it does not lose qualities during a long-term preservation;

— it has a convenient form and, most important, — high absorbability.

Thus, the most suitable material for bandaging is cotton, gauze and lignin. These three kinds of bandages have been proven in surgery.

White cotton, which is applied for bandaging, consists of long and thin fibers. In order to make cotton suitable for bandages, it is necessary to degrease it. After degreasing, it is necessary to bleach the cotton a chloral bath and leave it for some time in the open air. After that, it should be washed with a weak solution of hydrochloric acid to neutralize the reaction. Then, it should be washed out with water and dried. A lump of such cotton drowns in water because it absorbs water quickly.

Grey, not degreased cotton, is used in the medical practice for the protection of a sore place against the external influences, for compresses, for putting under a plaster bandage, etc.

The other widespread bandage material — gauze — has got its name from the city of origin (the city of Gauze in northern France) where it was made for the first time. Gauze is a soft cotton fabric made of degreased cotton. There are many kinds of gauze; medical practice uses 2–3 kinds, which should satisfy a number of requirements.

For bandaging, only degreased gauze, which is capable of absorbing liquids, is suitable.

Two sorts of gauze are used in the medical practice: bandaging gauze that is less dense, which contains 7×8 strings on 1 cm2, and bandaging gauze that is more dense, which contains 14×14 or 17×17 strings by 1 cm2. The first one absorbs liquids faster; the second — slower, however it is stronger than the first one.

Lignin is mechanically and chemically processed wood of conifers and leaf-bearing trees. The color of lignin is white-yellow. It soaks up wet, pus, and easily undergoes sterilization.

The shortcomings of lignin are the following:

It is not sufficiently elastic and breaks into fine pieces.

During long preservation, it loses its elasticity and crumbles.

It easily breaks under the influence of wound secretion.

When wet, it turns into a continuous layer.

Taking this into account, lignin is applied to such wounds that are in need of changing often.

Types of bandages (according to type and purpose):

Simple, soft, protective or medical.

Preasure (hemostatic).

Immovable (immobilizing), transportable and medical.

Extendable (bandages for stretching).

Correctable — for unloading bones and joints, correction oferroneous positions.

Depending upon the material, which is used for fixing, the following ones are distinguished:

Soft bandages (bandage, contour, cravat, sling-like, etc.).

Hard bandages (transport and medical splints, orthopaedicdevices, artificial limbs, corsets).

Bandages which harden (plasters, zinc-gelatinous, starch, bandages made of polymeric materials).

SOFT BANDAGES

Soft bandages are divided into:

Bandage:

— gauze bandages;

— knitted tubular (reticular) bandages;

— elastic textile bandages.

Adhesive:

— synthetic glues (cleol, collodion, BF);

— adhesive plaster.

Cravat.

Sling-like.

Contour:

— standard contour (suspensors, bandage, retalast, bandage);

— individual contour (made in case of need).

Bandages. Bandage — a long strip of gauze or other material is intended for fastening a bandage or immobilization support-motor apparatus (when the bandage is saturated with substances that harden — plaster, starch).

Gauze bandages till nowdays are the basic material used for bandaging. They have different width (5–20 cm) and length (5–7 m). Narrow bandages are used for bandaging finger and hand, wide ones — for bandaging the stomach, pelvis, breast, hips.

Bandages after aseptic procedures can be used repeatedly. They are soaked in a 3% solution of hydrogen peroxide with 0.5% solution of detergents, washed and sterilized in an autoclave. Bandages are washed in soapsuds at the temperature of 35–37°С, rinsed and dried.

Medical knitted tubular (reticular) bandages are intended for fixing bandaging material at any part of the body. They are produced as a roll. Unlike to usual bandages, they are not winded arouned but pulled on a damaged site of the body. Eventually, it fixes the bandaging material without impeding mobility of joints.

Elastic textile bandages are applied mainly in traumatology and sport medicine.

Adhesive bandages are applied for the protection of open damages and superficious inflamatory processes. They provide fixation of the bandaging material applied over the wound.

Cleol consists of rosin — 40 g, 96% ethyl spirit — 33 g, ether — 25 g, and sunflower oil — 2 g.

Collodion includes 4 g of colloxiline, 76 g of ether, 20 g of 96% ethyl spirit. Collodion and still better glue BF-6 can be used for protection of aseptic postoperative wounds without gauze, rendering sterile glue on the surface of a small wound (protective film).

Plaster. It is used for the protection of fresh noninfected wounds as a way of the bandaging material fixation. Adhesive plaster is used for connection of the edges of wounds. In pediatric surgery — for plaster stretching with fractures of tubular bones.

Cravat bandages. It is a piece of material of a triangular form. It is used for the bandaging material fixation, in particular while rendering first aid.

Sling-like bandages. These are strips of gauze or any other fabric incision on both sides, intended for holding the bandaging material on the nose, chin, and occipital area.

Contour bandages. They are made of pieces of material according to the profile of a closed bandaged part of the body. Contour bandages are fixed with the help of sewed tape. Sometimes for fixing the appendix, contour bandages of the stomach are used. Elastic reticular bandage (retalast) is made of rubber, braided by a cotton string. This reticular looking like a stocking (from 5 up to 20 m) seven sizes (0–6) is applied for fixing bandage material on any body area.

Technique of Applying Soft Bandages

The strict following certain rules while applying a soft fixing bandage provides the fullfillment of bandaging requirements:

The patient should be in a convenient position; he can lay orsit, if the damaged part of the body is approximately at the level of the breast of the rendering aid person.

A bandaged part of the body while applying a bandage isimmobile. The endings should be in a physiological position, which provides maximal relaxation of the muscles.

The operator should be in front of the patient, to see any reaction to pain which is caused by the bandage.

The bandage is applied central (in the direction from periphery to the thorax) and begins with a fixing turn.

During typical application, the bandages should be held in theright hand and the free end (beginning) — in the left.

Unroll the bandage from left to right, without taking hands offof the surface which is being bandaged.

Each following turn should cover from half up to two-thirds ofthe width of the previous turn.

The demands to a finished bandage are following:

The bandage should reliably fix the damaged area until thefollowing bandaging.

The bandage should be put on firmly but not tightly; it shouldnot give feeling of discomfort to the patient.

The bandage should be even, without any wrinkles and nicelooking.

The bandage should make even pressure upon the corresponding part of the body and be immobile.

The knot at the end of the bandage cannot be on the damagedarea of the body.

Basic Types of Bandages

Circular bandage. It is convenient when bandaging circularsurfaces. Each following turn covers the previous one. Sphere of application: the lower third of the shoulder, ankle joint. A disadvantage is that the circular bandage can turn around, displacing the material.

Spiral bandage. It is applied on the extremities, trunk, andthorax. The bandage is very simple and is quickly applied, but it can easily slip down.

Spica bandage. It is applied for fixation of a great amount ofbandaging material on the extremities.

Cross bandage. It is applied on the body surface which differin form (volume). The bandage forms a figure 8. It is applied on the occipital area.

Spiral reverse bandage. It is applied on the humeral joint, shoulder girdle and the areas under the armpits.

Turtle bandage (diverges and converges). It is applied on largejoints (knee, ulnar, talocrural).

Turning bandage. It is applied on the stump after an operation(amputation) of the extremities, hands or feet.

Т-shaped bandage. It is applied on the perineum or axillary area.

Tipes of Bandages According to Localization

Bandages on the head and neck are applied during bleedings. For closing the forehead, temporal and occipital areas, circular bandages are applied.

For closing the whole hair area of the head the Hippocrates’ cap and night-cap are applied, bridle — on the chin area, sling-like bandage — on the nose, forehead, occipital area, cross — on the occipital site.

Bandages on the thorax, humeral zone and the upper extremities. For this purpose, spica and cross, cravat and spiral bandages are applied. The Dezault’s and Velpeau’s bandages are used with clavicle fracture, bruise or dislocation of the shoulder.

The bandage on forearm and shoulder is a spiral turtle one; on the 1st finger — a spica one; on the other fingers — spiral bandages like a mitten.

On radiocarpal joint — a cross one, bandages on the stomach and pelvis — plaster and spiral bandages. On the pelvis, inguinal area, perineum — variaties of spica bandages.

On the calcaneal area — diverging turtle bandage. On the 1st toe — a turning one. On the upper and lower extremities, it is best to use bandages from medical reticular bandage (retalast).

HARD BANDAGES

Hard, or retentive, bandages are applied with the purpose to deprive of mobility the damaged area of the body, to provide it rest for a long time and at the certain position. They are applied for fractured bones of the extremities for transport or medical immobilization, as well as for inflammatory diseases of the extremities, in particular joints (tuberculosis of bones and joints). Immovable bandages are applied also after operations on bones and joints of the extremities with massive damage to the soft tissue.

Standard splints and standard fixing material, extending devices, artificial limbs, and orthopaedical devices belong to the hard (retentive) bandages. The correct way of hard bandages application is the same as for soft bandages, but they should be performed more diligently, because they are applied for 1.5–2 months and any mistake may bring fatal harm to the patient. It is necessary to watch the condition of the extremities closely in connection with a possibility of uneven pressure of the bandage and the formation of necrosis, especially where the bones stick out.

Transportable and Medical Splints

They are mostly used for immobilizing the extremities. Medical splints are applied in hospitals to treat fractured bones of the extremities. Splints should be rather strong and manageable, provide reliable immobilization. They are made from cardboard, wooden plates (Diterichs’ splints), plastic, polyethylene (inflatable splints) or metal (Cramer’s and Esmarch’s splints,) for treating fractures by the stretching method.

Transport Immobilization

The basic requirements are following:

The splints should be sturdy, portable and simple.

They should immobilize two-three of the nearest joints.

The fixing splint should not constrain vessels and nerves.

With closed injuries, the splints should be applied over clothes. With open — for the first time, it is necessary to apply a sterile bandage to the wound. The splint should be applied strongly and prevent displacement of fragments, otherwise large vessels and nerves can be damaged by bone fragments.

Transport splints are divided into fixing and distraction.

Fixing splints provide immobilization for parts of the body — standard ladder-like Cramer’s splints and Esmarch’s splints. Synthetic plastic splints, pneumatic inflatable splints are convenient. For the lack of special means, improvised means or improvised splints are used.

With a fractured clavicle cotton-gauze rings are applied. With a damaged spine and bones of the pelvis — long boards and shield, in damage to the hip — Diterich’s splints.

Extension splints have a direct relation to traumatology and will be described in details in the section “Fractures”. They create immobilization and at the same time provide stretching (medical metal splints and apparatus).

Artificial limbs and orthopaedic apparatus are produced in orthopaedic factories for long-lasting immobilization of the extremities (orthopaedic footwear or devices made of metal, plastic and leather).

Bandages which Harden

Plaster, zinc-gelatinous and starch, and also glutinous, of rare glass and bandages with polymeric materials belong to this group of bandages, which harden.

Plaster bandages are prepared from calcium sulfate, which is rubbed in bandages made of hygroscopic gauze. Nowadays, the medical industry delivers ready-made bandages for medical institutions; therefore a plaster mechanic at traumatology departments has more time, necessary for defining the quality of the plaster and preparation of the plaster bandage.

The quality of the plaster is determined as follows: in a tray a small amount of plaster powder is mixed with warm water in the ratio of 2:1. A ball is made of plaster solution, which must harden in 5–10 min and remain intact when dropped on the floor. If the ball breaks, the plaster is not suitable for use. Hot water accelerates the hardening process of plaster.

In traumatology, there are special plaster rooms for applying and removing plaster bandages. They are equipped with special inventory and instruments. Plaster bandage or longets are soaked in a basin with warm water and then wait for the excretion of air blisters to end. Each plaster bandage take out by both ends with two hands.

The bandage is wrung on each side in order to get the water out. The wrung bandage is circularly rolled up on the ends. Before applying the bandage, the skin is greased with Vaseline or a cotton stocking is put on, leaving the fingers open. The extremities are kept at the neutral position. For immobilization of the extremities during a fracture, an unpadded plaster cast is applied, in other cases — the protruding area of the extremity is covered with a cotton-gauze (padded bandage). A 5–6-layer bandage is solid enough. The condition of the extremity should be watched for two days after applying the bandage. If the extremity gets cold, pain occurs, the plaster bandage should be incision with scissors or a special saw. Each plaster bandage is marked with an indelible pencil. It contains the schematic image of the fracture or the inflammatory focus, the bandage application and removal date.

The plaster dries within 24 h. The bandage is dried with a mobile electric heater.

There are the following kinds of plaster bandages:

Circular dense ones — for immobilization of the extremitiesand trunk in fracture.

Fracture brace is applied on one joint or a certain segment ofthe extremity, which provides rest and immobilization during contusions, fractures, inflammatory processes.

Slab of plaster is applied with bruises, fractures and inflammatory processes. It can be posterior, palm (anterior) and P-shaped.

Slab of plaster and circulating bandage is a splint, which isfixed by circular plaster bandages in bones fractures.

Fenestrated and bridge-shaped bandages are used for the treatment of wounds with the immobilization of the extremities. For the reliability of the fixion of the extremities in the position of the hardening plaster bandages with spacer are used.

The hinged-plaster bandage is applied for training movementsin the joint.

Plaster corsets, collars, bandage-beds are applied in the treatment of orthopaedic diseases, chronic inflammatory diseases of the bones, during a definite period after a fractured backbone, etc. The plaster bandage is the optimal kind of bandages which harden. The zinc-gelatinous bandage is applied during the treatment of varicose ulcers of the lower extremities, which do not heal easily, purulent wounds, consequences of fractures.

The zinc-gelatinous mass of Unna is dissolved in a water bath; they soak with it the turns of bandages applied to the skin of the definit segment of the extremity. While applying the extension bandages, circular turns of the bandage (the first layer) are carried out; they are carefully saturated with paste, longitudinal strips of gauze are put on (the second layer) for extension traction, and they are fixed with circular turns (the third layer), diligently saturating the bandage with paste. The zinc-gelatinous bandage is prepared by the following recipe: zinc oxide — 100 g, gelatin — 200 g, water — 300 ml, glycerin — 400 ml.

Starch bandage is prepared from starchy gauze bandages. The technique for applying is similar to plaster one. Starch bandage is less solid, but its application is more easy.

Adhesive bandages made of rare glass (siliceous sodium), celluloid, and dextrin are mostly used when applying replacable bandages (corsets, splints, and removable joint-immobilizer).

Bandages made of polymeric materials (plastubol, bumetol, etc.) are applied by way of spraying aerosol with these substances on wounds, burns or postoperative wounds. For several seconds after spraying the aerosol, a transparent protective film, which provides not only function of the bandage but also visual supervision of the wound, appears. When introducing medical preparations into the structure of the aerosol, they also have a direct medical effect.

The bandage with villiage cheese and 1/8 part of liquid ammonia or 10% of KOH can be applied in the villiage because of the lack of other hardening agents.

Celluloid bandages are made as follows: celluloid is dissolved in acetone and glue, which was formed, and grease the gauze bandage.

Possible complications as a result of wrong application of a bandage which hardens: hypostases, decrease in muscular force and immobilization, impairment of blood circulation.

A student should know and be able to apply such bandages as: “night cap”, “Hippocrates’ cap”, bandage on the occipital area, on both eyes, Dezault’s bandage, “bridle”, Velpeau’s bandage, sling bandage, bandage on the mammary glands, occlusion bandage with damage to the thorax, spica bandage on the humeral joint, a “turtle-like” bandage on the ulnar joint and a “knight glove”.