Bandages used for binding differ significantly among themselves. According to Galen, their variations can be attributed to six main factors: material, shape, length, width, construction, and components.
The materials used for bandages can be classified into three categories: membranous or skin-based, which are particularly suited for fractured nasal cartilage; woolen, which are appropriate for inflamed areas that do not require tight binding; and linen, which is ideal for secure applications. Within the linen category, some are made from flax, while others are crafted from hemp, as noted by Hippocrates.
The structure of bandages also varies. Some are made from materials that are inherently strong and dense, such as membranous bandages, while others, like linen bandages, are woven. When selecting linen for bandages, it is preferable to use fabric that has been previously worn and repurposed, as this results in a softer and more pliable material. However, it is crucial that the linen possesses sufficient strength to resist tearing when stretched, ensuring it can effectively contain and repel any fluids that may leak from the affected area.
Moreover, bandages should not be hemmed or stitched, nor should they have any lace or seams. Hems and seams can create pressure points that may harm the underlying flesh, while lace can lead to uneven pressure distribution. The areas touched by lace will experience greater compression, whereas the fabric itself will be more forgiving, causing inconsistent binding.
Additionally, it is essential that the bandages are made from clean cloth, allowing for the possibility of moistening or steeping them in solutions appropriate for the condition being treated. This prevents the bandages from corrupting or worsening the medicinal liquid.
Linen bandages should be cut lengthwise rather than crosswise, as this construction ensures a firmer and stronger hold while maintaining uniformity in width throughout the length of the bandage.
Bandages also differ in shape. Some are rolled, and nothing should be sewn onto them, as they must be of an appropriate length for the intended application. Others are cut or divided pieces, which may be used to bind the breasts or other areas, while some are sewn together, comprising multiple branches that end in various shapes, particularly those designed for the head.
In terms of length and width, bandages come in a variety of sizes; some are shorter, while others are longer, and similarly, some are broader, whereas others are narrower. However, it is difficult to establish definitive measurements for the length and width of bandages, as these should vary according to the size and thickness of the body parts they are intended to bind. Generally, both length and width should be tailored to fit the specific area of application, whether it be the head, neck, shoulders, arms, chest, groin, testicles, rectum, hips, thighs, legs, feet, or toes.
In discussing the components of bandages, we refer to one part as the body, which denotes the appropriate length and width, while the ends, whether they run lengthwise or crosswise, are referred to as the heads, according to Galen’s terminology.
According to Hippocrates, there are two key considerations for the proper application of bandages or ligatures: one pertains to the affected body part, and the other to the nature of the injury itself.
Regarding the affected area, when bandaging the leg, it is essential to wrap it lengthwise. If wrapped across the width, the bandage will loosen as soon as the patient begins to walk and extend their leg, as the muscles will assume a different position. Conversely, when bandaging the arm or elbow, it should be secured in a flexed position, turned toward the chest. If the arm is bandaged while extended, the ligature will loosen upon the first bend due to the change in muscle configuration, as previously mentioned.
Thus, it is important to remember that the affected part should be bandaged in the position we wish it to maintain.
Regarding the indication derived from the disease, if there is a hollow ulcer that is sinuous and filled with numerous channels, discharging a significant amount of sanies, the ligature should begin at the bottom of the sinus and extend to the opening of the ulcer. This principle should be applied regardless of whether the sinus is sealed at the top, bottom, middle, or sides of the ulcer. By following this method, the impurities contained within will be effectively drained, and the widely separated edges of the ulcer will be brought together. Failure to do so may allow the accumulated filth to erode surrounding tissues, exacerbating the ulcer and potentially rendering it incurable by damaging the underlying bones with the corrosive sanies.
Some ligatures serve as remedies in their own right, effectively restoring disjoined parts to their natural unity. Others are not intended for their own sake but are designed to secure medications with healing properties. These ligatures can be categorized into two types: those that are actively applied, referred to by Hippocrates as “Deligatio operans,” and those that are completed and termed “Deligatio operata.”
For the first type, to ensure a proper binding, the ligature should be tightly rolled. The surgeon must hold it firmly and straight in their hand, avoiding a careless grip, as this will facilitate a more effective application. Additionally, care should be taken to position the ends of the roller— and their fastening—away from the affected area; it is preferable for them to be placed above, below, or to the side. It is also crucial to avoid tying any knots directly on the affected region, particularly on areas where the patient typically leans, rests, or lies down, such as the back, buttocks, sides, joints, or the back of the head. When fastening or suturing the rollers, the ends should be doubled to enhance their strength; otherwise, even if wrapped tightly, they may not remain secure, especially if they are wide.
For the second type of ligature, the surgeon must reflect on its intended purpose and assess whether it has been executed properly, neatly, and elegantly, to the satisfaction of both the surgeon and any observers. It is the hallmark of a skilled practitioner to perform every task with care and precision.
In cases of fractures, luxations, and all forms of bone dislocations, as well as in wounds and contusions, it is essential to begin your bandaging with two or three tight wraps around the affected area. If possible, these initial wrappings should be applied more snugly than in other regions to better stabilize the displaced bones and to facilitate the expulsion of any fluids that may have accumulated there. This compression also serves to prevent the ingress of additional fluids that might be on the verge of entering the site.
In the context of fractures, which invariably occur alongside contusions, blood may escape from its vessels due to the violence of the injury, leading to the accumulation of blood under the skin and resulting in discoloration. Initially, the affected area may appear red, but it will subsequently turn black and blue as the blood undergoes corruption. Therefore, after the initial windings, it is crucial to extend the bandaging well beyond the broken or dislocated area. Failing to do so may inadvertently draw more blood and fluids into the injured site, resulting in the formation of abscesses and other serious complications.
It is important to note that while blood typically flows downward, the fluids under pressure can travel in two directions: from above downward and from below upward. You should aim to redirect these fluids back into the body and the abdominal cavity rather than allowing them to flow toward the extremities. The extremities lack the capacity to handle such an influx of material and are not sufficiently robust to bear the burden without risking further complications.
When this accumulation of fluids is successfully pushed back into the body, it is then regulated and contained by the inherent strength and vitality of the internal organs, aided by the body’s natural heat.
According to Hippocrates, two primary types of ligatures are essential for surgeons to securely hold bones—whether fractured or dislocated—once they have been restored to their natural position.
The first type is called Hypodesmides, or under-binders, while the second is known as Epidesmi, or over-binders. In some instances, only two under-binders are utilized; however, three are more commonly employed. The initial under-binder should be positioned directly over the fracture and wrapped around the area three to four times. Following this, the surgeon must carefully evaluate the configuration of the fracture, as the binding approach will vary according to its specific shape.
The ligature must be applied directly opposite the most pronounced side of the dislocation or fracture, ensuring that the protruding bone is pushed back into its proper position and securely held in place. For example, if the right side of the fracture protrudes more, the ligation should begin there and extend toward the left side. Conversely, if the left side is more prominent, the binding should start on the left and wrap toward the right.
In this context, it is advantageous for a surgeon to be ambidextrous, skillfully using both hands to execute a variety of ligations. When rolling the first ligature, it should be directed upwards, toward the body, for the reasons previously outlined.
It is important to note that this method of ligation is not exclusive to fractures; it also applies to luxations. When a bone is dislocated, the side from which it has shifted should be bound more loosely and gently, while the side towards which it has moved should be bound more tightly. This technique ensures that the bone is both corrected and effectively stabilized.
Therefore, the ligature must be applied on the side toward which the bone has shifted, ensuring that it is more loosely and gently wrapped here, rather than being tightly compressed with bolsters or rollers. This allows the bone to be more inclined to move back toward the opposite side of the luxation. If the ligation is not performed in this manner, it tends not to be successful because the area becomes relaxed and displaced from its natural alignment, thereby posing a significant risk of the bone being forced out of its corrected position. Hippocrates himself was so concerned about this issue that he advised pulling the realigned bone slightly more toward the side opposite to the direction of the initial displacement than its natural position might suggest.
Returning to our earlier discussion on the three types of ligatures: after applying the first under-binder, we proceed to the second ligature. We start this at the fracture and wrap it around once or twice. As previously mentioned, we must avoid forcing too much blood back toward the extremities, focusing instead on directing it toward the body and internal organs.
For this reason, the ligature should be applied from the top downward, gently tightening it to expel the blood contained within the wounded area. When you reach the end of that section, you should then reverse the direction, rolling it back upwards with the remaining length. Alternatively, you can use the third under-binder, starting where the second one ended, and roll it from the bottom upwards.
Once these under-bindings are in place, proceed with the application of your bolsters, followed by the over or upper-bindings, which are typically two, but sometimes three.
The first of these ligatures features two ends and is wrapped from both the right and left sides. This method not only secures the initial under-binder and bolsters but also aids in restoring the muscles to their original configuration. The subsequent two bindings, each featuring a single end, are designed to be applied in opposite directions to the under-binders. Specifically, if one is wrapped from below upwards, the other should be applied from above downwards, ensuring they counteract each other.
This technique of ligation, once promoted by Hippocrates, is no longer widely used in modern medical practice. Therefore, it is necessary to outline the method currently in favor. Today, over-binders are not employed; instead, the role of the previously mentioned over-binders is fulfilled by what we call the third under-binder. This is wrapped from below upwards, contrary to the direction of the first and second under-binders. If the initial binders began on the right, this one starts on the left and finishes where the first under-binder did.
Applying this binder with consistent pressure is crucial, as is ensuring that the spirals and turns are more loosely spaced. The primary function of this third roller in the ligation process is to return the muscles to their natural form, which may have been slightly modified by the tension from the first two ligatures.Always remember to adjust the tightness of your ligatures according to reason, the patient’s comfort, and the need to prevent inflammation of the swelling. Additionally, the individual’s body type should dictate the level of compression: those with more delicate physiques cannot tolerate as much pressure as those with sturdier builds.
In cases of fractures and dislocations, overly tight bindings can force bodily humors into the extremities, leading to severe and often significant edema. To treat this, the ligature must be loosened, and the swollen areas should be rewrapped from below upwards. This method helps to redirect the accumulated fluid back toward the center of the body, as there is no other effective way to alleviate the swelling.
Failing to address this issue may lead to neglecting the proper treatment of the underlying condition in favor of merely addressing the symptoms—something no surgeon should overlook when necessary. For this reason, Hippocrates advised that bandages be loosened every three days and that the affected area be bathed in warm water. This practice helps dissolve and disperse the humors that have settled in response to intense pain, thereby preventing itching and other related symptoms.
Once the risk of complications has passed, the ligation can be loosened, either sooner or later than usual, and should be applied with less tension than before. This allows blood and healing fluids, which may contribute to the formation of a callus, to flow more freely to the affected area.
It occasionally occurs that a fracture is accompanied by a wound. In such cases, it is advisable to secure the area with a ligature; otherwise, there is a significant risk of swelling, inflammation, and other complications resulting from excessive fluid accumulation from nearby tissues. However, it is not appropriate to use binding techniques that involve multiple convolutions or wrappings. Since the wound requires daily dressing, the area must be disturbed each day, necessitating the loosening of the tightly wound ligature. This process can cause pain and impede the healing process, which relies on rest.
Instead, the binding should consist of a single layer wrapped around the wound using a roller made from a cloth that is folded two or three times, fashioned like a bolster, and sewn together as conveniently as possible. The size of the roller should be sufficient to encompass and cover the entire wound, for reasons that will be elaborated in our Treatise on fractures.
If the wound is oriented lengthwise, the bolsters and splints should be applied to the sides of the wound to help bring the edges together and expel any debris. Conversely, if the wound runs across, we should avoid using bolsters and splints. According to Galen, these could widen the wound and push purulent matter back into it, which is undesirable.
In every case of fracture or dislocation, it is essential to address areas that are depressed, hollow, or thinned, especially near joints, by padding them with bolsters or cloths. This ensures that the affected part is evenly supported on all sides by splints, thereby securely holding the bones in place. For instance, when binding the knee, it’s necessary to fill the hollow behind the knee to facilitate a more effective and expedient ligation. Similar padding is required under the armpits, above the heel, near the wrist, and in any other areas that exhibit significant unevenness due to cavities.
After applying the binding, always ask the patient if the bandage feels excessively tight. If the patient indicates discomfort from the tightness, the binding should be loosened slightly. Overly tight bindings can cause pain, heat, excessive fluid discharge, gangrene, or even tissue death. Conversely, a binding that is too loose is ineffective as it fails to maintain the desired positioning of the parts.
A properly adjusted bandage should ideally result in mild swelling the following day—a sign that blood is being gently squeezed from the injured area. If the swelling feels hard, the bandage might be too tight; if there is no swelling, it may be too loose. Should a hard swelling develop from an overly tight bandage, it must be loosened immediately to prevent severe complications, and the area should be treated with warm Hydraeleum. A new, slightly looser bandage should then be applied and maintained until the pain and inflammation subside, ensuring that nothing heavy is placed on the affected area during this time.
If the patient is robust and the injury is recovering well, the bandage should remain snug for the first three to four days. If, from the third to the seventh day, the bandage appears looser and the swollen area has reduced, this is generally a positive sign indicating the effective reduction of swelling through proper compression and fluid drainage.
In cases of bone fractures, precise and tighter bandaging at the fracture site promotes better alignment and fusion of the bone. However, areas away from the fracture should be bound more loosely. After the seventh day, the bandage should be tightened a bit more than before as the risk of inflammation and pain decreases.
However, these guidelines for the three types of bandages do not apply to every part of the body, such as the jaws, collarbones, head, nose, and ribs. Since these areas are not cylindrical and elongated, bandages cannot be wrapped around them like they can be on the arms, thighs, and legs. Instead, bandages should only be applied to their outer surfaces.
From what has been previously discussed, it is clear that ligatures play a crucial role in restoring dislocated or separated tissues and in bringing together those that are apart. They are particularly useful in cases of fractures, wounds, contusions, tendon ulcers, and similar conditions where continuity is disrupted and requires the support of bandages for repair. Additionally, bandages serve to keep tissues apart that would otherwise fuse together unnaturally, such as in burns where fingers and thighs might adhere to one another, or where the armpits could stick to the chest and the chin to the breast, unless properly prevented by effective ligation.
Moreover, bandages can help rejuvenate emaciated parts. For instance, if the right leg is wasting due to lack of nourishment, the left leg can be wrapped starting from the foot and extending up to the groin. Similarly, if the right arm is deteriorating, the left arm can be bound tightly, beginning at the hand and ending at the armpit. This technique allows a significant portion of blood from the bound limb to return to the vena cava, which then redistributes it into the nearly empty vessels of the atrophied area. However, it is important to ensure that the binding of the healthy limb does not cause pain, as painful ligation can lead to increased blood flow and muscle tension, necessitating rest and recovery for that limb.
Ligatures are also effective in controlling bleeding. This is evident when a vein is opened with a lancet; applying a bolster and a ligature can promptly halt the blood flow. They are particularly beneficial for women immediately after childbirth, as binding the womb with ligatures helps expel excess blood and stimulates the expulsive faculties, preventing the womb from becoming distended with gas.
In pregnant women, ligatures can provide comfort by supporting the weight of the fetus, especially when it is positioned low in the pelvis, making movement difficult. The binding of the womb, often referred to as the navel ligature, not only alleviates discomfort but also elevates the fetus, allowing for greater mobility.
Additionally, ligatures have important applications in revulsion and derivation, as well as in securing medications applied to specific areas such as the neck, chest, or abdomen.
Finally, ligatures serve three primary purposes during the amputation of limbs, such as arms and legs. First, they help lift and hold the skin and underlying muscles, ensuring that after the operation, these tissues can fall back into place to cover the ends of the severed bones, facilitating healing and reducing pain in the residual limb. Second, they help control bleeding by compressing veins and arteries. Third, by applying a tight binding, ligatures can obstruct the flow of animal spirits, effectively numbing the area beneath them and reducing sensation in the affected part.
Bolsters serve two primary functions. Firstly, they are used to fill the natural hollows and uneven areas of the body, ensuring uniform thickness throughout. Examples of such cavities include the armpits, clavicles, hams, and groins. Additionally, there are body parts that taper towards their ends, such as the arms nearing the wrists, legs approaching the feet, and thighs leading to the knees. To address these variations, these areas should be padded with bolsters and linen cloths to achieve uniformity in size from one end to the other.
The second function of bolsters is to protect and preserve the initial layers of bandaging—specifically the first two or three rolls or under-binders—that are applied directly to a fractured area. Depending on their purpose, bolsters are applied differently: crosswise when used to fill cavities and even out thickness, and lengthwise or vertically when used to safeguard the underlying bandages.
Furthermore, bolsters can be utilized to prevent the discomfort and complications that may arise from overly tight bandaging of newly aligned bones. For adequate thickness, a cloth folded three or four times is typically sufficient, though the precise dimensions of length and width should be adjusted based on the specific body part and the condition being treated.
Having discussed the uses of ligatures and bolsters, it is important to address other devices that help hold bones in place, such as splints, junkes, cases, and similar items.
Splints can be crafted from a variety of materials, including past board, thin splinters of wood, leather (similar to that used for shoe soles), tree bark, or plates made from lead or other flexible yet firm materials. It is crucial that splints are lightweight to avoid causing discomfort to the injured area. Their dimensions—length, width, and quantity—should be tailored to fit the specific body part they are intended for. Additionally, splints should be shaped straight or curved depending on the anatomy of the limb they are applied to. Care must be taken to ensure that they do not extend too far over bony prominences, such as the ankles, knees, and elbows, to prevent excessive pressure that could cause harm. Furthermore, splints should taper at the ends and be thicker in the middle, where they rest on the broken bone.
The primary purpose of splints is to securely immobilize fractured or dislocated bones after they have been properly aligned. To achieve this, it is essential that there are no thick bolsters beneath them and that they are not placed over excessive layers of bandaging, as this would inhibit their ability to apply the necessary pressure.
Junkes are constructed from sticks the size of a finger, wrapped in rushes and then covered with linen cloth. They are primarily used for fractures of the thighs and legs. Cases, on the other hand, are made from lightweight wood or plates of lead and serve to maintain the correct alignment of bones when a patient needs to be moved from one bed or room to another or requires assistance in using the restroom.
Lastly, if there is a need for stronger support on the fractured or dislocated limbs, these cases can prevent the bones from shifting in any direction—whether the patient is asleep or awake, willing or unwilling. They are especially beneficial when the bones have not yet healed completely or are loosely bound to avoid pain, inflammation, or complications such as gangrene. In such cases, the bones may shift or separate due to the unevenness of the bedding.
Collectively, these devices—cases, junkes, and others that aid in the stabilization and support of broken or dislocated bones—can be referred to as “Glossocomia,” in alignment with Hippocrates’ terminology. For a young surgeon who is yet to gain practical experience in these techniques, understanding these concepts may be challenging. However, I have endeavored to provide a clear description of their forms and functions, so that he may grasp their purpose until he can observe or practice these procedures himself.