"pLASTER ITS HJSTORV MANUFACTURE AND USES HE SI YE "pLASTER ITS HISTORY MANUFACTURE AND USES |t)Wuw The Purpose of this Booklet There is a constant demand for a publication showing methods of using- adhesive plaster. This booklet there- fore has been published in response to this demand for such information and data. Some general information about adhesive plaster, including its history, is also contained in these pages. Many ingenious surgeons have con- tributed to this account of the varied uses of adhesive plaster. The illustra- tions have been mostly made direct from actual photographs and are so arranged as to show the methods so clearly that they may readily be fol- lowed with but little explanatory text. Little of the information given here- in makes any claim to newness. Most physicians are more or less conversant with many of the procedures indicated. The illustrations are chiefly useful as reminders of methods and technic to be followed. It is our hope and belief the booklet will be helpful. JOHNSON & JOHNSON. The History of Adhesive Plaster If you boil together, water, olive oil and lead oxide (litharge), glycerin is set free and gives a distinctly sweetish taste to the water. Oils are glycerides of fatty acids. Olive oil is composed of glycerin and oleic acid. The lead combines with the oleic acid of the olive oil and the result is the formation of a yellow mass variously called lead plaster, diachylon plaster or Emplastrum Plumbi. This is a very old formula and its history goes back many centuries. The old name diachylon is of Greek origin. Directions for its preparation, run through many old formula books and through all the pharmacopoeias, ancient and modern, and are still retained in the present U. S. P. (revision IX) under the title Emplastrum Resinae or Rosin Plaster. This is simply a mixture of the old diachylon plaster with rosin and yellow beeswax. It is still made on a manufacturing scale and sold in the United States under various names and while largely displaced by the more convenient rubber-base plasters, yet it still has some adherents who claim it to be superior for certain purposes, to the present-day rubber plasters. In so far as irritating properties are concerned, the old diachylon plaster has been claimed to be not only abso- lutely free from them but on the contrary, distinctly soothing in many conditions and was used as a direct wound-dressing. Adhesive plasters made of rubber-base were originally at times irritating to some persons under some conditions and it was a matter of long labor to over- come this tendency. Up to about the year 1898 the only known form of rubber-adhesive plaster was the original yellow-colored variety and on account of the occasional cases of irrita- tion of the skin upon its long-continued application, it was the privilege of Johnson & Johnson, in co-operation with several leading American surgeons, to enter into a long series of experiments with the object in view of eliminat- 3 4 The History of Adhesive Plaster ing the irritating character. Among other materials, ox- ide of zinc was experimented with as an ingredient likely to produce a plaster with less irritating qualities, and finally after many experiments and failures, a plaster- mass was devised incorporating, among other ingredients, twenty per cent of this material. In order to produce the desired result, however, it was found necessary en- tirely to revise all former ideas of plaster-making, and finally a plaster of almost no irritating quality was pro- duced and marketed under the name “ZO” Adhesive. So complete has been the displacement of the old lead plaster by rubber-base plasters that when the term is used, adhesive plaster made of rubber is supplied with scarcely a thought that there may be another kind. Everywhere rubber-base plaster, either plain or perfor- ated, cut in varying widths and lengths, is employed. The modern adhesive plaster has been so modified as to admit of a larger range of application than could possibly have existed if use had been confined to the old diachylon. The ingenuity of surgeons and of others has found many and novel uses for this plaster. The old plaster was not adhesive at a temperature anywhere near that of an ordi- nary room nor of the body. It requires heating over a flame to melt the coating of plaster-mass just before ap- plication ; hence the modern adhesive which will “stick” anywhere and to anything at such temperatures as com- monly are found, is obviously a vast improvement over the old variety. The question is often asked: Of what is the modern rubber adhesive plaster made ? A comprehensive answer to this question, is that it is made by mixing with rubber, a dough made of pitch, gums, waxes and powdered orris root. That is the essential base of all first-class modern rubber adhesive plaster, whether medicated or not. Because of its immense advantages the use of rubber- base plasters has caused the re-enthronement of adhesive plaster as one of the most important adjuncts of modern surgery. Suggestions for Preservation and Use To preserve adhesive plaster, keep it in a cool dark place. Protect it especially from direct sunlight. Protect from direct exposure to air. Its keeping qualities are wholly dependent upon these conditions. When a little is used from a large roll, wrap the roll and replace in its box or can and close the lid. Clean skin. The skin must be clean and dry before application and much better adhesion is secured if it is carefully freed from grease. Perspiration and the salts which its evaporation leaves on the skin, may produce a considerable irritation under adhesive plaster if the appli- cation is of long duration. Avoid hair. The hair should be shaved from the skin where the plaster is to be applied if good adhesion is to be expected and especially is this good advice from the view- point of the patient, when removal is attempted. Narrow strips. On irregular surfaces, as joints, etc., it must be borne in mind that a number of narrow strips can be applied in a much better and neater fashion than fewer strips of greater width. Economy. In using from a spool, it is more economical to apply the end and unroll from the spool, similarly to the usual procedure of applying a roller bandage. This will entail much less loss than will the practice of cutting off numerous lengths, judged to be correct for the pur- pose. Large rolls. In handling large rolls, when applying large sheets of plaster to the ribs, etc., annoyance from the sticking together, face-to-face, of parts that may acci- dentally touch each other, will be avoided by removing the face-cloth only as the application of the plaster pro- ceeds. It is quite difficult to separate layers of plaster that have made contact face-to-face. Constriction. Applying plaster to an extremity nat- urally constricts it to some extent. Therefore wrap from 5 6 Suggestions for Preservation and Use the tips inward, elevate the limb or slit the whole dress- ing after application is completed. Bandaging. Wherever possible cover the application of adhesive plaster with a neatly applied bandage. This as- sists in retaining it in position, keeps it neat and clean and prevents the possibility of its unrolling and sticking to the clothing and bed linen. Waterproofing. Wherever it is desirable to water- proof adhesive plaster, it is easily accomplished by paint- ing the back of it, after application, with collodion. Shel- lac or any other kind of varnish may be used if preferable. To a limited extent a plaster dressing so treated may be immersed in water and washed with impunity. Removal. The removal of adhesive plaster is a matter frequently discussed. We have often recommended the application of alcohol to the inner surface, while peeling back the plaster from the skin. This is quite successful if carefully and properly done, as alcohol absolutely des- troys the “stickiness.” The most successful alternate method and the one most generally used is simply to peel the plaster back from the skin and it should be turned clear back and not pulled up at right angles to the skin. A rapid “snappy” motion will usually succeed with less discomfort to the patient. The adhesive mass is soluble in any of the usual rubber- solvents such as gasoline, benzol, chloroform and ether, and these are excellent for cleansing off any edges, specks or patches left after removal of the plaster. If any of these are attempted as a means of removal of the plaster itself, it will be found that if the cloth is moistened with any of them, this cloth can be lifted right off but leaves the sticky mass upon the skin. This mass can now be gradually dissolved by repeated moistening with the solvent. With extremely sensitive cases this method, while slow, may be found advisable. Gasoline is one of the best of these solvents and is scarcely irritating at all. Of course, it is inflammable. Specifications for Adhesive Plaster During the period of feverish buying by the Govern- ment at the time of the World War, dissatisfaction was experienced with some of the zinc oxide adhesive plaster purchased by the U. S. Army and Navy. Specifications were therefore sought for, with a view of establishing a standard of manufacture that would supply these depart- ments of the Government with a satisfactory product. The specifications of the United States Army were as follows:— Composition—Adhesive plaster to be made of a composition containing not less than 30% of pure ground para rubber and not less than 20% of oxide of zinc free from lead and lead compounds. The mass to be free from nodules and evenly spread not less than 5 ounces not more than 6 ounces per square yard on a cotton cloth backing having not less than 150 threads to the square inch and weighing not less than 4 ounces, nor more than 5% ounces per square yard. Adhesiveness—Adhesiveness on hard wood of 5 square inches of plaster as determined by special appliance at- tached to tensile strength machine after plaster has remained 30 minutes at 37 degrees C. shall not be less than 40 pounds. Adhesiveness on hard wood of 5 square inches of plas- ter as determined by special appliance attached to tensile strength machine after plaster has remained 6 hours at 75 degrees C. shall not be less than 40 pounds. These specifications were found to be of distinct ad- vantage and are still in use. The description of “composi- tion” is satisfactory and those for the adhesive test are also excellent as far as that one made at 37 degrees C. is concerned, but the test at 75 degrees C. does not work out in a very satisfactory manner. 7 The Manufacture of Adhesive Plaster The earlier processes for spreading adhesive plaster fol- lowed the methods used for diachylon plaster. The mass was dissolved in gasoline or other solvent to attain the desired fluidity and was then spread on the cloth by means of a scraper or knife and the solvent was then allowed to evaporate. This procedure does not produce a satisfac- tory plaster and the best plaster today is spread by means Fig. 1 of heat and pressure only. The cloth backing is fed through a pair of massive steel rollers that are hollow and supplied with interior connections for both steam and cold water so as to allow accurate temperature control. At the same time the plaster mass is rolled in a thin film upon and into the cloth. The result is a smooth homogeneous mass spread evenly and at the same time pressed into the mesh of the fabric so as to be firmly adherent thereto. This requires very massive and expen- sive machinery and the greatest of care and good judg- ment, but if properly done, plaster so produced is of fine quality. Also the quality of the plaster depends to a large ex- tent upon the care, skill and experience used in selecting, 8 The Manufacture of Adhesive Plaster 9 preparing and mixing the materials which are used to make the mass. Rubber, perhaps the most important ingredient, at least the basic one, is procurable in so many varieties and conditions that it has become hardly a name for a thing, at all. Only the highest grade natural Para rubber should be used and it is a requisite that it be thoroughly cleaned, washed, dried and conditioned for a period of several months before it is used in plaster- making. So with the pitch, gums, resins, waxes and pow- Fig. 2 dered dry materials, all must be pure and of the highest grade and carefully selected and prepared for the purpose. In plaster-making too much heat or too little is ruinous in result. Poor mixing and especially a poor grade of rubber or one improperly prepared, may produce a plas- ter, fine in appearance, but after a year sadly lacking in adhesive qualities. On the other hand, an equally disas- trous condition may take place in it so that the mass will have become too sticky, soft and utterly useless. Surgical and Orthopedic Uses of Adhesive Plaster In surgery, adhesive plaster plays a most important part. It is at once a covering, a dressing, a more or less water-proof protective and a substitute for or addition to the suture. It is well established that the judicious use of adhesive plaster tends to simplification of wound- dressing and that by its aid many cumbersome wrappings can be discarded. Hamilton’s adhesive plaster dressing for fracture of the patella is shown herewith (Fig. 3). A figure of eight Fig. 3 adhesive plaster strap applied about patella, and padded splint on two retention straps above and below to im- mobilize leg and hold splint. Fig. 4 In the Schmauss method as shown (Fig. 4), the two retaining strips one and one-half to two inches wide are placed in a figure of eight manner. The first is adjusted to hold the lower fragment up in place. The second strip is used to hold the upper fragment down against the lower. The third, a wide strip, is applied to cover the 10 Strapping for Knee Sprains 11 patella and all intervening tissue between the two retain- ing strips, so as to overlap on to them. The object of this is to prevent tilting up of the fragments and to prevent constriction or swelling of (or effusion around) the patella. Dr. Epstein’s method of strapping for traumatic syno- vitis of the knee is shown in Fig. 5. Fig. 5 A spiral adhesive plaster dressing for injury to the lateral ligaments is illustrated in Fig 6. The two dots indicate the two ends of the internal lateral ligaments. Fig. 6 Strapping of the knee for sprains in inflammatory pro- cesses and rheumatic pains is explained by reference to Fig. 7. Adhesive'straps one and one-half inches wide Fig. 7 12 Strapping for Knee Sprains encircle knee, each strap slightly overlapping the other and crossed on the exterior surface in a half figure of eight. The principle of reinforcement is utilized in strapping localized effusions as obtained in tendon sheaths, in bur- sae, in sprained or ruptured ligaments or muscles, in Fig. 8 Fig. 9 Fig. 10 The technic of ad- hesive plaster strap- ping reinforcement, as used by Finley R. Cook, M. D., is illustrated in Figs. 8, 9, 10 and 11. Another double figure eight reinforcement strapping is shown in Fig. 12. Fig. 11 Fig. 12 haematomata and effusions in joints. For example, in strapping the knee for effusions, only one narrow strip is carried completely around the knee direct over the patella, making only moderate pressure on the vessels in the popliteal space, which at the same time affords a point d’appui for the remaining strips which pass two-thirds around the limb, meeting at a common point on the cen- tral strip beneath the hamstring tendons. This layer Strapping for Ankle Sprains 13 makes an elliptical-shaped bandage, which exerts pressure on the tendons and lateral ligaments and does not inter- fere with the use of the joint. The second layer consists of several strips passing upward and downward obliquely over the anterior aspect of the knee, along the lateral borders of the patella. The third layer, the reinforcing strips, are shorter and pass over the point in a transverse manner. Lastly, strapping with the use of the parts is an excellent form of massage. This may be the most im- portant function of strapping. Fig. 13 Fig. 14 Fig. 15 Fig. 16 Fig. 17 An interesting method of strapping the ankle joint is shown: Fig. 13, the first vertical and horizontal straps and Fig. 14, the completed dressing covering affected side—on the normal side the straps only cover the heel. In the well-known Gibney method of strapping the ankle joint in sprains, one and one-half inch strips of adhesive plaster are applied in the manner illustrated, 14 Strapping for Ankle, Foot and Toe Fig. 15 showing the first layer, Fig. 16 the second, and Fig. 17 the front view of completed dressing. Dr. Lexer’s method of applying adhesive plaster is explained in Fig. 18. Fig. 18 Figs. 19 and 20 make plain the Keppler method of strap- ping for weak foot, the first showing the two long lateral strips and the second the completed dressing. Fig. 19 Fig. 20 Dr. Dewey’s suggestion for holding roller bandage in place is as per Fig. 21. A method of retaining dressing on toe so as to obviate bandaging of the whole foot, as used by Dr. Brickner, is indicated by reference to Fig. 22. In Fig. 23 is illustrated Dr. Epstein’s technic for treat- Bandage Fastening. Flat-Foot Strapping 15 ment of flat foot. The patient is seated, the operator seated in front of him, the heel of the patient resting on the operator’s knee. Two eighteen inch strips (2 inches wide) of adhesive plaster are made adherent overlapping Fig;. 21 Fig. 22 Fig. 23 Fig. 24 at one end and almost entirely divergent at the other. The small end of this bandage is applied to the ankle 16 Strapping Flat-Foot, Ulcers, Varicose Veins under the external malleolus, the plaster brought under the arch of the foot so that the wider end reaches the inner side of the leg at a level with the head of the fibula. The foot is adducted. A retaining strap is placed trans- versely across the calf at the upper end of the dressing, while another is placed horizontally around the ankle above the malleoli. A one-inch strip is now wound in a Fig. 25 Fig. 26 Fig. 27 figure of eight around the arch and ankle in the following fashion: Beginning under the external malleolus, down under the sole, up over the arch to the dorsum of the foot, around the tendo-achilles, around the ankle, over the dorsum and under the arch again. About six turns are thus consumed. In Fig. 24 is pictured a method of using adhesive plas- ter for dressing ulcers of the leg by direct strapping. After application the notches are cut into the plaster to allow drainage. Adhesive plaster is used for strapping the leg for ulcers Strapping Varicose Veins. Eversion of Foot 17 and varicose veins. To relieve the tension the straps are divided after application. Fig. 25 illustrates front view and Fig. 26 the back view, and also shows method of splitting the dressing to relieve tension. A suggestion has been made for the use of adhesive plaster for the repair of wounds after removal of varicose veins. See Fig. 27. Fig. 28 Fig. 29 Adhesive plaster straps may be used to maintain inver- sion of foot before applying plaster of paris dressing. Fig. 28 suggests a method of accomplishing this. In Fig. 29 we have a proposal for adhesive plaster dress- ing for the correction of eversion of the foot in infants. A two-inch band is placed about the foot and along the tibia. On each of the strips a hook is sewn to which the tension strap, also of adhesive plaster, is hooked. A method of using adhesive strips to close wounds after removal of tumorous growth of foot is explained by 18 Strapping for Foot Wounds, Hammer Foe reference to Figs. 30 and 31, the first before operation and the second after operation. Adhesive plaster has been applied for the relief of hammer toe (Fig. 32) as shown in Fig. 33, the applica- Fig. 30 Fig. 31 Fig. 32 Fig. 33 tion of adhesive straps serving to keep the toe straight. Adhesive plaster strips have been used to advantage in treating ingrown toe nail. Fig. 34 shows method of traction by the strip which draws the flesh away from the nail and allows packing of the wound. Strapping for Ingrowing Toe-Nail 19 Dr. Lesser’s technic in operation for ingrowing toe nail, referring to Figs. 35 and 36, is as follows: After asepsis is complete and an Esmarch hemostatic bandage is applied, an incision is made, on both sides of the toe, separating the skin only as far back as the lower third of the nail or further if necessary; lay back the flaps and hold them back with wet sterile saline gauze. (As the vitality of this portion of the body is low, the sterile saline pad is preferable to dry dressing.) Next remove the tissue lateral to the nail. Begin the incision Fig. 34 Fig. 35 Fig. 36 at the distal end of the toe about 10 m. m. under the lateral margin of the nail, and continue it in a line ob- liquely outward to meet the point where the skin flaps are attached, taking care that the flap is not cut. The removed tissue is wedge-shaped, the base having been taken from the front of the toe and the point at the place where the skin flap ends. After all bleeding is stopped lay the flaps on each side under the nail, and suture them or hold them there with narrow strips of sterile adhesive plaster. Stretch a plas- ter strip about 2 c. m. back of the flap to the same dis- tance on the other side around the front of the toe. Should the nail have been septic before the operation, place the strip of plaster low enough toward the plantar surface to allow the insertion of a small strip of iodoform gauze under the lateral margins of the detached nail; place the ends of the drain over the first layer of dress- ing. Use two layers of iodoform gauze dressing if the wound must be drained, the first under the ends of the 20 Corns. Bunions. Strapping the Instep drainage gauze and the second over everything (each layer to be three or four ply). Cover all with a piece of gutta-percha tissue and tighten with adhesive plaster. Illustrated herewith are three interesting suggestions Fig. 37 Fig. 38 for using adhesive plaster in the care of the feet, Fig. 37 a method of strapping for bunions, Fig. 38 a suggestion for corn on sole of foot, and Fig. 39 illustrates a procedure for strapping for fallen instep with a cushion on sole of foot, also made of adhesive plaster. Barwell’s method for talipes varus is as follows: Cut a piece of adhesive plaster into the shape of a fan, which is split into four or five strips converging towards the apex of the fan. The apex of the triangle is passed through a wire loop with a ring in the top, brought back upon itself and secured by sewing (Fig. 40). The plaster is firmly secured to the foot in such a manner that the wire eye shall be at a point where we wish to imitate the insertion of the muscle and that it shall draw evenly on all parts of the foot when the traction is applied. Secure Fig. 39 Strapping for Talipes Varus 21 this by other adhesive strips and a smoothly adjusted roller. The origin of the artificial muscle is as follows: Cut a strip of tin or zinc plate, in length about two-thirds of Fig. 40 Fig. 41 Fig. 42 that of the tibia, and in width one-quarter of the circum- ference of the limb. This is shaped to fit the limb as well as can be done conveniently. About an inch from the upper end fasten an eye of wire. Care should be taken not to have this too large as it would not confine the rubber to a fixed point. The tin is secured upon the limb in the following man- ner: From stout adhesive spread on moleskin cut two strips long enough to encircle the limb and in the mid- dle of each make two slits just large enough to admit the tin; then cut out a strip of adhesive plaster twice as long as the tin and a little wider. Apply this smoothly to the side of the leg on which the traction is to be made. Lay upon it the tin placing the upper end level with that of the plaster (Fig. 41). This is to be secured by fastening 22 Talipes f arus. Strapping for Extension the two strips just mentioned around the limb, then turn the vertical strip of plaster upwards upon the tin. A slit should be made in the plaster where it passes over the eye in order that the latter may protrude. The roller bandage should then be continued smoothly up the limb to the top of the tin. The plaster is again reversed and brought down over the bandage and the whole secured together by a few turns of the roller. A small chain a few inches in length containing a dozen or twenty links for graduating the adjustment is then secured. Into either end of a piece of ordinary rubber tubing two to six inches in length and one-quarter inch in di- ameter hooks are fastened by a wire or other strong ligature (Fig. 42). ' Fig. 43 There is an important field for the use of adhesive plas- ter in strapping for extension purposes. Herewith is il- lustrated (Fig. 43) a suggestion for the proper method of doing this work. In Bryant’s Extension method in treating fracture of the thigh, both the injured limb and the sound limb are flexed at a right angle with the pelvis, fixed by light splint and fastened to a bar above the bed. The weight Strapping for Extension 23 of the body produces counter extension and the patient can easily be cleansed. See Fig. 44. Fig. 45 Detail of foot-box used by Dr. Barety. See also Fig. 46. Fig. 44 An interesting event in surgical practice has been the publication of a thesis by Dr. Raymond-Jean-Theo- phile Steibel, Doctor of the Faculty of Medicine in Paris, entitled, “La Veritable Extension Continue par VAppariel de Jean Paul Barety.” In this thesis Dr. Steibel gives an extended explana- tion of the apparatus and the methods of Dr. Barety in cases of the facture of the femur and coxalgies. Inci- dentally the publication pays great tribute to Dr. Jean Paul Barety of Nice, France, who prior to his death had devoted his life and his ingenuity to the improve- ment of apparatus for continuous extension. Notwith- standing his untimely death at the age of twenty-five, his biographer states that “the essential qualities of a 24 Strapping for Extension man of French science were in Jean Paul Barety. His work deserves the highest consideration. His death was cruel for his friends and cruel for science.” The following has been translated from the thesis cited: “Adhesive plaster is an essential part of all forms of apparatus for continuous extension. It is through the medium of adhesive plaster that one can exercise trac- tion of the limb and on its quality depends the greatest Fig. 46 Extension Apparatus Used by Dr. Barety part of the success. The inherent defects of the adhe- sive plaster used up to the present time are sufficient in themselves to explain why the process of traction by adhesive straps has been so often criticized and aban- doned. The adhesive often used in a little time caused erythematous excoriation of the skin, rendering it nec- essary to suspend the application of the extension. “Diachylon plaster, the principal element of all so- called adhesive plasters, has a very complicated formula. The formulas laid down in the treatises on pharmacy do not allow of any purification of the ingredients, nor do they assure the sterility or the cleanliness of the product. It necessarily follows that the prolonged ap- plication of this product to the skin during weeks and months causes all kinds of irritation, itching and even suppuration. This undoubtedly is the principal cause Strapping for Extension 25 that has led to the abandonment of this system of trac- tion. “Suggestions have been made for the use of trusses and dressings more or less complicated, often constrict- ing and usually expensive and at times intolerable for the patient. “Jean Paul Barety, realizing this condition and at- tributing to it the fault of the adhesive plaster, deter- mined to find a different product prepared with more system and less harmful. He first sought to simplify the old formula but without success. The products first used by him lacked adhesiveness, their application was modified by the surrounding temperature, a thousand precautions were necessary in order to make their ap- plication successful. During these investigations, Dr. Barety received one morning by chance a sample of American adhesive plaster of the manufacture of Johnson & Johnson, New Brunswick, N. J., designated as ‘ZO’ Adhesive Plaster. Dr. Barety made use of this plaster and the results were such that from that day he no longer used any other adhesive. “Three years ago we made investigations to ascertain what was the composition of this product, its method of manufacture and utilization. The results of these inves- tigations we are happy to make known as giving the best results. From the manufacturer we have learned that in the preparation of ‘ZO’ Plaster, improvements have been made not only in the quality of the rubber used but in the preparation of the other substances which make up the compound, and in these processes the impurities and harmful elements which make up the ordinary adhesives of commerce have been elimi- nated. The perfection of processes not only assures the adhesiveness of the mass but the efficiency of the plas- ters and produces a product which, at no matter what the temperature, the adhesiveness is quite rapid and the heat of the body is sufficient to increase without do- ing away with any of the qualities of the product. 26 Strapping for Extension. Hand Strapping “In the course of our studies we have tested some of the other products which we here cite. The table here shown is the result of applying the adhesive strips on a cylinder of thin rubber, the hollow of which was filled with fine sand, a depression being made on the surface in the axis of the cylinder. Sample Surface application in square centi- Traction in Adhesive- ness in square centi- Nos. meters grams meters 1 30 4.750 158.33 2 20 6.500 325 3 20 8.980 449 4 40 5.890 147.25 5 25 7.600 344 6. . . . 20 5.900 295 “In the course of our observations, and as a result of these additional tests, we have been able to make on the different adhesive products, we have never found a pro- duct whose fabrication is as perfect and as constant in its quality as ‘ZO’ Adhesive Plaster. Each time we have used this adhesive plaster we have always been able to establish our traction as strong as we have ever seen it, without ever being subject to the annoyance of slip- ping or non-adhesiveness or having to resort to any procedure. Finally, in the use of ‘ZO’ Adhesive Plaster we have never had any erythema or excoriation, nor have we ever been subjected to the necessity of ceasing the application of the extension. In a word, ‘ZO’ is a pei feet product and all surgeons who have attempted to apply the apparatus devised by Dr. Barety for con- tinuous extension for fractures of the thigh or coxalgia have the greatest interest and the greatest satisfaction in using this product, which is no other than No. 3 in the table shown.” In Fig. 47 is illustrated the use of reinforced strips encircling hand and thumb, for sprains, inflammation, etc. Adhesive plaster for dressing in fractures and dislo- cation of metacarpal bone is well depicted in Fig. 48. Strapping for the Hand and Fingers 27 Reinforced adhesive plaster strapping of the carpo- metacarpal and metacarpophalangeal articulation of thumb is portrayed in Fig. 49, the first layer passing around the thumb over the hand to the starting point. Fig. 47 Fig. 48 Fig. 49 Fig. 50 In Fig. 50 is indicated a simple dressing of wounds with adhesive plaster. An adhesive dressing in fracture of phalanges is shown 28 Strnpping for Fingers. Splints in Fig. 51. A splint is used on the finger and this to- gether with the finger is strapped firmly with the adhes- ive plaster. Another method of retaining dressings on the finger Fig. 51 Fig. 52 Fig. 53 Fig. 54 by use of adhesive strips is portrayed in Fig. 52. This method also does away with the necessity for bandaging the entire hand to keep the dressing in place. In bandaging the fingers Dr. Brickner advises only Strapping fur Fingers 29 sufficient bandage to hold the required dressing. See Figs. 53 and 54. The last turn of the roller is made at the end of the dressing and here it is tapered by turning in the corners. Fig. 55 Fig. 56 Fig. 57 Fig. 58 A strip of adhesive plaster not over one-fourth of an inch wide, and about twice the circumference of the finger is applied, not constrictingly, once around, to hold the end of the bandage. Another narrow strip of plaster is passed up one side of the dressing, over the tip and down the other side, and its ends are held down by a second turn of the first strip. Such a bandage is less unsightly, less uncomfortable, less wasteful than that usually ap- plied; it covers only as much of the finger as is neces- sary, and the exposed joints are unimpeded (the last a matter of no small importance). 30 Fingers. W rist-Sprains. Olecranon. Radius A suggestion of Dr. Brickner for the use of adhesive plaster in treating paronychia is illustrated in Fig. 55. This permits cleansing and drainage. In Figs. 56, 57 and 58 are shown methods of strapping Fig. 59 Fig. 60 with adhesive plaster for sprain of wrist. All are stand- ard procedures in common use and need no description here. For fracture or dislocation of olecranon, adhesive plas- ter has been used as in Fig. 59. Dr. Lexer’s idea for an immobilization dressing of area in fracture of radius and which still allows active motion, is indicated by reference to Fig. 60. Fig. 61 Fig. 62 Strapping Humerus, Elbow. Fastening Bandages 31 An interesting suggestion has been made (Fig. 61) for the application of adhesive plaster for extension and traction in fracture of the humerus. Note the weight hanging by means of a loop of plaster. Fig. 62 is sufficient description of the use of a padded wooden triangle used in the axillary, the same being held in position by adhesive plaster, in fracture of the humerus. In dislocation or sprain of elbow a two-inch strip of adhesive plaster may be used as shown in Fig. 63. Fig. 63 Fig. 64 Fig. 65 For the prevention of slipping of roller bandages, two suggestions have been brought forward. One, Fig. 64, is described thus:— Fix a roller bandage with three turns at the wrist; make turns until elbow is reached. Apply three adhe- sive strips one-half inch wide and to extend one inch beyond proximal and distal turns to the exterior or dorsal region of arm and apply gauze over it. Another, Fig. 65, consists simply in fastening the end of the bandage to a piece of adhesive plaster to apply to skin surface at starting point. 32 Colics Fracture. Wound-Closing, Shoulder-Strapping Dr. Beck’s suggestion for adhesive plaster as applied to Colle’s fracture as shown in Fig. 66 includes the use of a round pencil or similar object to prevent adherence of ulna to radius. Fig. 66 Fig. 67 Fig. 68 Fig. 69 Dr. T. M. Bull used dumb-bell-shaped adhesive plaster for drawing wound edges together. This gives greater tension possibility (Fig. 67). In Fig. 68 is illustrated strapping of shoulder with reinforcement in sprains and dislocations, compression and massage. Front view. Fig. 69 shows one-inch strips drawn from a line on level of axillary fold to middle of scapula behind. Back view. A method of placing half figure of eight reinforcing straps for sprain and dislocation is excellently portrayed Strapping for Fracture of Clavicle 33 in Fig. 70. Cotton or gauze is placed in axillary fold. In Stimson’s dressing for dislocation of the outer third of the clavicle, three-inch plaster is used. See Fig. 71. In Sayre’s dressing for fracture of clavicle, Fig. 72, Fig. 70 Fig. 71 Fig. 72 two straps of adhesive plaster are used three inches wide and long enough to reach one and one-half times 34 Strapping for Fracture of Clavicle around the body—one strap encircles the arm below axilla and is carried around the back and across the chest. The other strip goes from the hand on the chest to the scapula. Another method of plaster strapping for fracture of the clavicle, a figure of eight strapping, is shown in Figs. Dr. Bellamy describes and illustrates his method of dressing- a fracture of the clavicle, as follows: (1) A strip of adhesive plaster is cut out to resem- ble a claw, a little smaller than the size of the patient’s hand, extending into a strap of the size of the wrist, this claw to be stuck to the skin about one inch in front of the pit of the invalid’s shoulder, and should extend on an angle across the back, over a fulcrum between the scapula well around the front of the chest, thereby hold- ing the shoulder backward and upward. (Fig. 75.) (2) A strap about two inches wide, depending on the size of the patient, will, when folded, encircle the tip of the elbow and be attached to the front and back of the chest, elevating the shoulder about one inch higher than Fig. 73 Fig. 74 Strapping for Fracture of Clavicle 35 the opposite one, and the hand of the injured side will be free and will rest over the upper part of the front of the chest (Fig. 76). (3) A strap of similar width, i. e., a fixation strap which will cover the lower part of the elbow and extend around the chest so as to hold the arm in a position simu- lating Kocher’s second position for dislocated shoulder, thereby tightening the pectoralis muscle and holding the inner fragments in place (Fig. 77). Fig. 75 Fig. 76 Fig. 77 (4) A triangular band of cotton and gauze sufficiently large to keep the arm at the proper angle when hanging by the side; this angle can best be judged by noting the uninjured arm and shoulder. (5) A pad of cotton and gauze sufficiently large to act as a fulcrum for the strap is very important. When the dressing is properly applied the shoulder will be drawn upward, and backward; the position is im- perative if the fragments are properly approximated. In using adhesive plaster the gauze covering should be stripped from the plaster only where it is to adhere. Dr. Romer’s method for treating fracture of the clavi- cle is illustrated in Figs. 78 and 79. Three strips of firm adhesive plaster, each an inch and one-half in width, applied from above the nipple to below the angle of the scapula. The middle strip covers the 36 Strapping the Clavicle, the Sternum seat of the fracture and should be first applied; the lat- eral ones, slightly overlapping it, should extend about an inch and a half on either side. In addition to these strips it is advisable to apply another which encircles the shoul- der-joint. To prevent chafing or the plaster adhering to the hairs a thin layer of wool should be placed in the axilla. Fig. 78 Fig. 79 Fig. 80 Fig. 81 A dressing for fracture of sternum consists of two-inch adhesive strips to encircle chest with one reinforcing Ribs. Adhesive Corset. Appendix. Celiotomy 37 strap crossed in front at site of fracture as per illustra- tion in Fig. 80. An adhesive plaster swathe for fracture of rib is shown in Fig. 81. Initial end is fixed at the spine, held taut and to go three-quarters of the way around the body. The plaster is to be wide enough to extend six inches on either of fracture. Fig. 82 Fig. 83 Fig. 84 In Figs. 82, 83 and 84, are illustrated three methods of using adhesive plaster for fracture of the ribs. Two- inch strips overlapping each other are used. An adhesive plaster corset can be used for the mainte- nance of dressings and easy examination of a wound. This corset can be made for any required size. The edge for the insertion of the string is overlapped to pre- vent adhering, holes being punched in and the string drawn in like shoe laces. To make it neater, hooks may be sewn on as in a lace shoe, thus avoiding holes in the plas- ter. Fig. 85 represents the corset when open for exami- nation of the wound, and Fig. 86 when closed. Fig. 87 is a suggestion for an adhesive plaster support, used after appendicectomy, the strip used being four or five inches in width. In Fig. 88 we have a method of application of adhesive plaster for support after celiotomy. 38 Strapping for Umbilical Cord and Hernia Dr. Garrison’s method of applying adhesive plaster dressing for retaining umbilical hernia in infants is illus- trated in Fig. 89. In Fig. 90 is shown a standard method of dressing for umbilical cord. The gauze as applied, is twice as wide Fig. 85 Fig. 86 Fig. 87 Fig. 88 as shown in the cut. There is a hole through the center of one half and after the cord is drawn through the hole, the other half is folded over the cord. The pad then as- sumes the appearance shown and the adhesive straps are applied. Adhesive plaster straps have been used to approximate wound edges instead of using sutures. Fig. 91 illustrates Wound Closing. “Sealing" Abdominal Dressings 39 this and also the large adhesive plaster straps through which tape is drawn for the retention of final cover dress- ing. In Fig. 92 is illustrated the so-called “sealer” of Dr. Evans as used in dressing laparotomies or celiotomies. Fig. 89 Fig. 90 Fig. 91 Fig. 92 Two-inch adhesive strips are placed in three sections. The upper one is placed one inch below the ensiform pro- 40 Adhesive Plaster in Wound Closing cess across the abdomen; the second across the umbilicus, and the third strip one inch above the shaved pubes. Two strips, two inches wide and ten inches long are now used, the upper one, lapping the edge of the dress- ing one inch and the abdomen one inch. This secures the Fig. 93 Fig. 94 upper edge of the dressing firmly. There is then attached a strip to the lower edge of the dressing and on the pubes one inch. This also secures this portion of the dressing and they both prevent the hand-borne infection, with which we are all so familiar. The curious, investigating, time-killing patient’s hands cannot find access to his wound and thereby contaminate and infect himself. The bellows action upon respiration is prevented; in so doing air and cuticle, etc., cannot reach the wound. Dr. Grant describes a simple dressing which he uses as a substitute for the suture. This dressing is particu- larly adapted to contusions and lacerated wounds of the head (Fig. 93). The dressing consists of strips of adhesive plaster, some ordinary old-fashioned dress hooks and some rubber bands. Adhesive Plaster in Wound Closing 41 The plaster should be either one-half or three-quarters of an inch in width. One or two hooks are used as may be necessary. More than two hooks to a strip does not work satisfactorily. Make two holes for each hook to be used, the holes to Fig. 95 be about one inch from the end of the strip of plaster, and one-quarter of an inch apart, The rings on the back ends of the hooks are to be open so as to better catch in the plaster. Turn the free ends of the plaster back on itself and make a double thickness under the hooks. The plaster may be as long as is necessary to make proper tension, and it should be brought to within from one-half to an inch of the edge of the wound (Fig. 94). When it is firmly fastened, begin lacing the rubber band from one hook to its fellow on the opposite side, drawing as tight as may be necessary to bring the lips of the wound together. If necessary, a gauze pad may be placed under the hooks. For some time before his death Dr. Robert H. M. Daw- barn was using experimentally, in his work in the City Hospital of New York and in other institutions, a unique method of wound closure. Dr. Dawbarn used as a method of wound closing Michel clips and adhesive plaster, alternately applied (Fig. 95). He used this method for every conceivable operation, with signal success and satisfactory cosmetic results. 42 Adhesive Plaster■ in Wound Closing For suturing the subcutaneous tissue the skin edges are closely proximated, with small forceps, and every inch along the line of incision a Michel clamp is attached. Between each clamp the skin is drawn together by adhe- sive strips (Fig. 96) which are sterilized over an alcohol Fig. 96 Fig. 97 Fig. 98 Adhesive Plaster in Wound Closing 43 flame (Fig. 97). This gives a minimum of adhesive sur- face directly over the wound, with a maximum of traction of the skin. The Michel clamps are removed after twenty-four hours, and the strips after ten days. The strips of adhesive are made by taking a large strip of adhesive plaster from three and one-half to five inches wide, laying it on a glass plate, adhesive face downward (Fig. 98). Over this in the center, a smaller reinforcing strip, from one and one-half to two and one-half inches wide is laid for the purpose of giving additional strength. The pattern of the strips is laid out in lead pencil and then cut out. He demonstrated that this method of wound closure preserves the integrity of the skin, prevents stitch ab- scess, does away with the painful removal of stitches and leaves a very small scar. In Fig. 99 is portrayed a method of closing the wound after breast amputation, using sterilized adhesive plaster. Surgeons are called on frequently to operate on the anal region at a time when no assistance is available. Under such circumstances it is difficult to secure proper exposure. Dr. Brun utilizes two adhesive strips about five and one-half inches (14 cm.) long by two inches (5 cm.) wide, according to the size of the patient’s buttocks. (See Fig. Fig. 99 44 Adhesive Plaster for Anal Exposure 100). To one end, which has been folded upon itself, is attached a long strip of tape or bobbin. The other end is divided into three equal strips about three inches (7.5 cm.) long. The middle strip is then made a half inch (1.3 cm.) shorter. Fig. 100 The patient is put in the lithotomy position, knee chest position or bending over the table. The middle strip is attached at the side of the anus (the region being shaved), and the superior and inferior strips are fastened above and below. This procedure is repeated with the second strip on the opposite side. The patient now pulls the buttocks apart while the surgeon ties the tape at the head piece of the operating table, Adhesive Plaster for Burns and Skin Grafting Dr. Arthur S. Vosburgh was apparently the first to use adhesive plaster as a direct application to burns. His explanation of the method was before the New York Surgical Society as reported in the Transactions under date of February 28, 1912, viz: “Dr. Arthur S. Vosburgh presented a man upon whom skin-grafting was done following the excision of a car- buncle on the back of the neck. The method employed was as follows:—The grafts were covered with zinc oxide adhesive plaster which was first sterilized in formalin vapor. These strips of plaster were placed close together, leaving a very small interval between them to allow for the escape of secretion. They were left in situ for a pe- riod of from six to eight days, the superficial dressings being changed as required. “In commenting upon the method, Dr. Vosburgh said . . . The success of the operation depends primarily on the maintenance of cellular vitality; the grafts must quickly establish nutritional relations with the area cov- ered and it was obvious that once placed in position the transplanted skin or epidermis should not be moved. Formerly, the grafts were covered with rubber tissue, sil- ver or gold foil, or wide meshed tulle rendered non- absorbent with sterile paraffin, and a dry or moist sterile gauze, held in place by bandages, completed the dressing. Later, operators found that leaving the grafts exposed to the air, gave much better results, and this would be the ideal method were it not for the danger of the grafts becoming dislodged through some movement of the pa- tient, intentional or otherwise. Attempts have been made to protect the grafts with a wire cage or some similar device, but the range of usefulness of this method was limited. “Dr. Vosburgh said that having observed the behavior of epithelium in chronic ulcers that were covered by zinc 45 46 Strapping for Burns and Grafts oxide adhesive plaster, he was led to apply this dressing directly over skin grafts. He had employed the method in a number of cases during the past year where it seemed impossible or at least improbable that any other form of dressing could be maintained in position, and it had proven successful on the back, the nates and in regions about joints. The speaker said all observers agreed that the superficial layers of skin grafts were exfoliated, and this often led the uninitiated to fear that the graft had failed. It was the separation of the graft into layers that rend- ered the success of this method possible. Dr. Charles A. Parker, of Chicago, in the Journal of the American Medical Association, July 3, 1915, speaks of the need for quick healing in order to avoid great de- formity and scar tissue which usually follows extensive burns. In burns involving the whole thickness of the skin the throwing off of the slough, which must take place before epidermidalization occurs, may take two or three weeks. When the slough is removed he treats the wound with adhesive strips in the following manner: After separation of the slough, ribbons of adhesive plas- ter from one to one and one-quarter inches wide and long enough to encircle the limb and lap slightly were placed around the limb from ankle to perineum, leaving no granu- lations exposed (Fig. 101). To be more explicit, the first band was put around the ankle partly on good skin and partly on the burn, and the ends overlapped an inch or so. The next strip slightly overlapped the upper border of the first one, just enough to keep it from slipping on the wet tissues, and was carried around the limb like the first one. The third followed the second in a similar man- ner and so on till the area was entirely covered and had enough stability to stay in place and serve its function in keeping in the serum and preventing cells dying from dryness. Over this were placed several layers of gauze to take up the secretion that worked out through between the strips at various places, although no arrangement was made for drainage. At first narrow slits were left Strapping for Burns and Grafts 47 open for drainage; but the granulations quickly occupied these areas, became exuberant and bled, and otherwise in- terfered with the healing; so the spaces were dispensed with entirely, with a much smoother course to the heal- ing. Every day the gauze was changed as it became soiled. Fig. 101 Twice a week—on my visiting days—the adhesive plaster was changed. This was easily accomplished by getting the blunt point of scissors under it at one end of the leg and cutting across all strips from the bottom to the top or the top to the bottom of the leg, when the plaster would fall from the leg as it was not adherent to the moist or granulating surface. This adhesive dressing prevents exuberant granulations and, as he says, “allows a continuous growth of epithelium from the margins.” This mechanical effect is an import- ant one, as anyone who has had to control this condition knows. It does not adhere to the exposed surface, which is moist; it can be removed with little injury to new tis- 48 Extension Support for Burned Limb sues, bleeding rarely occurring. It prevents tissues grow- ing into the gauze mesh. Dr. Reat suggests the method shown in Fig. 102 and reports the case of an extensive burn (involving all the anterior portions of the body) where the skin, the subcu- Fig. 102 taneous connective tissues, muscles and fascia of the pal- mar surface of the arm were all destroyed. The dorsal or upper portion of the arm was sound. Adhesive plas- ter was applied on the portion which had not been burned, from dorsum of hand to deltoid muscle, then loops of plaster were attached to the long strip with tapes through the loops. The arm was lifted up out of its slough and suspended by a semicircular form placed over and par- allel with the arm, bringing the under surface to view. The recovery was rapid. Therapeutic and General Uses of Adhesive Plaster There are some things in medicine which will stand forever and those things are based upon rationalism. If we consider, for instance, a local injury such as a sprain or an inflamed joint, the indicated treatment must be protection, compression, limitation of motion and mas- sage, no matter by what agent these factors are produced. The idea of rational medicine is the employment of agents which perform these functions in the most effective and Fig. 103 Fig. 104 Fig. 105 most simple manner, and therefore the consensus of opinion declares adhesive plaster strapping to be the correct me- dium. As this is true of sprains and inflamed joints, a careful analysis with a receptive attitude and a due regard for therapeutic rules, soon manifests an un- limited number of conditions in which the same functions are necessary for relief and cure. Illustrated herewith is the adhesive plaster belt of Dr. Rose for the treat- ment of gastroptosis, enteroptosis, mov- able kidney, and many other causes of P