James Peter Warbasse.

Surgical treatment; a practical treatise on the therapy of surgical diseases for the use of practitioners and students of surgery (Volume v.1) online

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Columbia ^nibersiitp

College of ^fjpgiciang anb ^urgeong

3Evef erence Itifararp


A Practical Treatise

on the Therapy of Surgical Diseases for the Use of

Practitioners and Students of Surgery



Fellow of the American College of Surgeons

American Medical Association

American Academy of Medicine

New York Academy of Medicine

Surgeon to the Wyckoff Heights Hospital, Brooklyn, New York

Formerly Attending Surgeon

to the'Methodist Episcopal Hospital, Brooklyn, New York






Copyright, 191 8, By W. B. Saunders Company

ReprintiMl .luiic, 11)1!)

Ilcprintod Soptoinlicr, 1919

Reprinted April, 1920


' The most important part
of my business is to know
what ought to be done."













Digitized by the Internet Archive

in 2010 with funding from
Columbia University Libraries











This work has been written in the interest of the surgical patient. The
object has been to place in the hands of the surgeon the means for rendering
help in every surgical condition under all circumstances. The aim has been
to make this information easily accessible, and its application practical.

In most surgical diseases there is an ideal course of treatment which may
be pursued and which represents the highest possibihty of surgery. The
author has endeavored to present this maximum of treatment. Every
consideration has been given to direct the surgeon toward the ideal of
perfection. In many instances its application requires especial skill and
knowledge. The author is aware that circumstances may surround both the
patient and the surgeon which make impossible the applying of the ideal
measures, or render such attempts inexpedient. As an admission of these
circumstances this work presents alternatives of treatment which may be
employed if the best thing possible cannot be done.

The fact that the author has had constantly in mind the interest of the
patient, as the object of supreme consideration, has comipelled the concession
that there are differences in surgical ability in the applcation of treatment.
As the purpose of this work is not to glorify surgery, but to cure surgical
patients, this fact is frankly faced. In surgical diseases the mortality
varies with the skill of the surgeon. The author has attempted to adapt
to this fact the therapeutic advice which he gives. Thus, in many conditions,
both operative and nonoperative treatments are described; and in some
diseases operative procedures are given which should be carried out by the
experienced surgeon only, and methods are described which are adapted to
the less experienced surgeon but to which the experienced operator need not
report. All this is made necessary by the fact that in the treatment of
surgical conditions there is not only a pathological hazard which is capable
of modifying the outcome of the disease, but a surgical hazard as well.
As the pathology of surgical diseases is a variable factor in every case, so also
is the surgical treatment which the patient may command a variable factor.

These are not altogether unhappy circumstances. The average surgeon
is capable of most efiicient administration of the principles of treatment;
and above and beyond the average surgeon is a great class of experts whose
capabilities, in reheving suffering, prolonging hfe, and restoring to efficiency
the damaged and diseased, are the marvel of this age, and represent the
most beneficent expression of human handicraft.

The author hopes for the day when all surgeons who are entrusted with
the lives of human beings shall be so equipped that they can apply the ideal
treatment in all cases which come to their hands, and when all patients with
surgical diseases can command access to the environment which shall provide
them the surest guarantee of recovery.

Surgery is an art based upon a complex of sciences. It is always in a
developmental stage. Accordingly the author has endeavored to inspire
the reader with the spirit of originahty, to teach him not only how to do,
but to suggest to him new fines of action, to set him thinking on the problem
of treatment from his own standpoint. The hope of surgery, fike afi learning,



lies in emancipation from the thraldom of authorit>-. In this work many
expedients will be found to be briefly mentioned for the purpose of sug-
gestion, in order that the reader may be impelled to originality. For this
reason much of the normal anatomy of the parts is given, and anatomical
illustrations are freely employed.

It is assumed that the surgeon who turns to these pages for help is familiar
with the fundamentals of surgical pathology and diagnosis.

Prophylaxis is regarded as a part of pretreatment, and prognosis is so
intimately associated with the results of treatment, that each is accorded
as much attention as possible.

While large consideration has been given to new methods, nothing has
been introduced for the sake of novelty. In the presence of the newer modes
of treatment, the fact has not been lost sight of, that there are old methods
and old agents of surgical therapy which have survived the trials of time and
which are destined to outlive the newer things which are now vaunted in
their places.

In a work such as this, written wholly by a single individual, the literature
of the special departments of surgery must needs have been freely consulted.
Duplication and overlapping of subjects has been avoided by individual
authorship. By the use of cross-references much space has been saved,
and, it is hoped, the working value of the publication increased.

The author has seen fit to make certain variations from the current
classifications. Among these it will be noted that the treatment of infected
wounds is discussed under inflammations.

It will be observed that there are comparatively few references to the
discoverers of methods and of instruments. This is because the more the
author has searched the literature the more he has been struck by the fallacy
of our proper-name nomenclature in surgery. Most instruments and pro-
cedures, bearing proper names, were used before the time of the individual
whose name they bear. All of them are the product of a long series of
antecedent workers. No surgeon is isolated. Surgery is harmonized by
the spirit of mutual aid. Each surgeon's work is composite. The opera-
tion he is performing, however original it may seem, is but a small part
his own.

The author has endeavored to give credit to surgeons and to literary
references wherever it has seemed called for. He desires that in quoting from
this work others shall not attribute originality to ai)parcntly new methods
which are not connected with some surgeon's name. Although many
operations and methods of treatment, so far as is known to the author,
are here described for the first time, they are all based upon well-known
surgical principles, common to all surgeons. The author has avoided, so
far as possible, attributing to others originality which cannot be- confirmed,
and desires that the same consideration shall be shown to him.

That this work may prove a practical source of strength to the surgeon
in his encounters with disease, and that it may contribute to the promotion
of the highest ideals of surgery, is the purpose which has prompted its

James Pktkr Warbasse.
384 Washington Avenue,

Brooklyn, New York.



General Principles of Surgical Treatment ^7

Ancestral and Personal Peculiarities °

Nourishment ^i

Fresh Air 22

Nursing ■

Asepsis and Antisepsis '

Infection ^g


Surgical Materials, Their Preparation and Sterilization 33

Ligatures and Sutures •^^

Dressing Materials ^

Sponges and Pads ^

Drainage Materials ^|

Surgical Accessories ^

Bandages •••■•; A

Solutions, Applications, and Antiseptics 5/

Caustics Ji

Surgical Instruments Z^

Operating Tables • ^l

Emergency Instruments and Surgical Expedients °7

Care and Sterilization of Instruments ^9

Anesthesia and Anesthetics 9

General Anesthesia ^°^

Rectal Anesthesia . ^^

Intravenous Anesthesia ^^^

Hypodermic Anesthesia ^^

Pharyngeal Anesthesia 3

Laryngeal Anesthesia ~^

Intratracheal Anesthesia ^5

Hypnotic Anesthesia ^^

Local Anesthesia ^ '

Spinal Anesthesia. ■ • •_ ^.^2

Epidural Sacral Anesthesia ,

Parasacral Anesthesia ...._. ^g

Intravenous General Anesthesia • ^,^

Wounds and Operations ^.^

The Operating Room ^.

Operating Personnel . ^9

Preparation for Operation _l^

General Preparation of Patient '

Local Preparation of Patient I'

Special Preparation of Patient „

The Making of Surgical Wounds J°4

Accidental Wounds ^.g

Closure of Wounds _^^'

Drainage of Wounds ^^^

Dressings • ^^.^

Complications of Wounds ~

Shock 218

Special Wounds . ^^

Postoperative Treatment I

Inflammations 228

Acute Inflammations

Artificial Hyperemia 9

Infected Wounds ' ' ' " A^'

Physiologic Treatment ^^




Antiseptic Treatment 242

Chronic Inflammations 243

Surgical Fex-ers and Infections 255

Vaccines, Serums and Antitoxins 255

Septicemia 259

Pyemia 260

En-sipelas 262

Tetanus 264

Gas Bacillus Infection 270

Anthrax 271

Actinomycosis 272

Glanders 273

Hydrophobia 273

Snake Bite 274

Bites and Stings of Insects 275

Tuberculosis 276

Syphilis 283

Fistulas and Sinuses, Ulceration and Gangrene 304

Fistulas 304

Sinuses 3°5

Ulcers 3°8

Gangrene 3^5

NuTRiTrvE Disturbances 321

Scurvy, Rickets, Acromegaly 321

Giantism, Dwarfism, Cretinism 322

Tumors 323

Blood and Blood-\'essels 334

Hemorrhage 334

Proctoclysis 344

Hypodermoclysis 344

Infusions 346

Transfusion 348

Special Arteries 360

Arteries 37^

Aneurism 3^0

Occlusion and Ligation of Arteries 4°!

Veins 446

Wounds of Veins 446

Phlebitis. 447

Varicose Veins 448

Thrombosis and Embolism 454

Coagulability of Blood 45^

Lymphatic System 460

Wounds . _ 460

Inflammations 461

Lymphedema 462

Lymphoma 464

Leukemia 466

Diseases of Bones 467

Inflammations 467

Caries and Necrosis 4^8

Osteomyelitis 469

Tuberculosis of Bone 469

Tumors 47°

Deforming Diseases 47 1

Fractures 472

Genera! Considerations 472

Immediate Treatment 472

Reduction 474

Irnmobili/ation 476

Splints 477

I'lastcr-of-Paris 477

Traction and Extension 4o5

Massage Soo

Operative Treatment 502

Bone Grafting 509


Joint Fractures -jg

Compound Fractures ^jo

Fracture Dislocations ! ! ! C2i

Ambulant Treatment ^22

Treatment of Complications ^24

Fractures in the Newborn ^20

Special Fractures ' . ^-22

Dislocations 610

General Considerations ' ^j.^

Complications g^.

Compound Dislocations . . 612

Old Unreduced Dislocations . . 612

Habitual and Recurrent Dislocations . . 612

Congenital Dislocations 61^

Special Dislocations . . ! 618

Diseases of Joints .'.... ' 6=:o

Sprains gro

Dislocation of Cartilages ■ . . 5^2

Internal Derangements 6^^

Wounds of Joints grf

Synovitis and Arthritis ...".'.'.'.' 5^7

Tuberculosis of Joints 66^

Tuberculosis of Special Joints 55^

Syphilis of Joints '.'.'.'.'.'.'.'.'.'.'.'. 6^

JNIeuroses of Jomts gg^.

Malpositions due to Contractures . . 682

Ankylosis . . . 686

Operations on Bones and Joints . . . 688

Operations for Inflammations of Bone . . . 602

Bone-cavity Filling ..." 701

Resection of Bone for Tumors . . . ' -06

Arthrectomy . 710

Osteoplastic Operations 7io

Osteotomj' of Long Bones 711

Excisions and Resections of Bones . 717

Operations on Joints ' ;: ;:

Arthrodesis ■ ] ^^l

Excisions of Joints 7^1

Arthrotomy ! ^ It-
Prevention of Ankylosis 7^5

Operations for Ankylosis . I-7

Transplantation of Joints . . . 767

Osteoplastic Joint Operations . . . 768

Operations to Lengthen Bones . ' " ' ' '

Technic of Bone Grafting . . 772

Muscles, Tendons, Fascia and Bues^ . ' Irr

Muscles .'.■.".'.■.■.■.■ Ill

Tendons ^ -

Repair of Tendons 706

Lengthening of Tendons 700

Reconstruction of Tendons g^^

Shortening of Tendons . . 804

Tendon Grafting got

Tenotomy o^

Prevention of Adhesions 816

Tenosynovitis . . . 817

Ganglion g^o

l^'^'^ •■;;:::;:;::::::;: 818

Bursae g^.

Skin and Its Appendages 820

Traumatisms 820

Burns 821

Infections g

Hypertrophic Diseases ' . g ^

Atrophic Diseases ' . . 84?

Neuroses o


16 cox TENTS


Glandular Diseases
Hair and Nails . .
Animal Parasites .
Cosmetics ....


Contusions .







Compression 3^1

Operations on Nerves 3^2

Suturing gr.

Bridging ...'.'........'.'.'.'.'.'.. S55

Transplantation 3^5

Implantation ' S??

Stretching ................... 860

Neurectomy 35j;

Neurotomy 36j

^eu"tis_ '.'.'.'.'.'.'.'.''.'.'.'.'.'.'.'.'.'.. S61

Neuralgia 862

Neuralgia of Special Nerves 86^

Tumors of Nerves 880

Diseases of Special Nerves 331

Index of N.\mes p^j

Index of Subjects '.'.'.*".'.".'.'.". ". . ', '. ". ". ". *. ". goe



Surgical treatment is the oldest branch of surgery. It was developed
empirically into an art long before there was understanding of pathology and
diagnosis. At the present time it no longer stands alone; its perfection now
rests upon basic knowledge. The most important prerequisite for success-
ful treatment is an understanding of the normal and pathological anatomy
and the nature of disease. The surgeon who would equip himself best to
treat surgical disorders must first understand their causes, pathology, and

Surgical diseases are those which involve the external parts of the body
and those which are amenable to manual treatment. The aid of the natural
forces of repair is invoked in all diseases, but surgical diseases are those in the
treatment of which the aid of manual art is required. The province of the
surgeon is a large one, touching and overlapping all of the other departments
of medicine. The peculiarity of surgery is that the surgeon himself is a part
of the treatment.

Surgical diseases are not made up so largely from the self -limiting class as
are medical diseases. The natural tendency of most of the medical, or so-
called internal diseases is toward spontaneous recovery. Diseases which
have not this tendency, but for which something mechanical can be done, are
placed in the surgical class. The domain of surgery is constantly enlarged by
the addition of diseases which are found to be not amenable to medical
treatment. Abscess of the lung, the neuralgias, blood disorders, and many
of the abdominal diseases are examples. On the other hand there are, per-
haps, no diseases which have passed from the distinctly surgical to the med-
ical category.

We should not make the mistake to draw too positively a line of division
between these two classes of disorders. The same principles of constitutional
treatment and general care of the patient apply in surgical as in medical
diseases; and the same factors influencing the course of disease are to be con-
sidered. In order to secure the best results in surgical treatment, the surgeon
must not only apply himself to the specific ailment of the patient, but he must
give the individual as a whole his best consideration.

When a person suffering with a surgical malady comes under the care of a
surgeon, the one guiding principle which the surgeon should have always
before him is to do what is best for the patient, to the end that he may be
cured most quickly and completely. In doing this, the surgeon has a right
to abstain from impairment of his own ability to perform the same service for
others. The surgeon should treat one patient at a time, and give his best
concentrated effort to that patient, irrespective of the prospects of pay or
appreciation. By so doing he may expect to secure the most substantial

Race. — In the treatment of surgical diseases there are certain conditions
which influence the course of disease, and with which the surgeon should be

VOL I— 2 17


familiar. Among these are racial diferences. In the temperate climates
the negro is particularly susceptible to tuberculosis, and fistula in ano; and
carcinoma of the breast and uterus develop more commonly than in Arian
women. On the other hand appendicitis, piles, intestinal infections, gall-
bladder infections, and enlarged prostate are less prone to occur in the negro.
The negro as seen in temperate climates is less resistant to disease and injury
than are the whites, and the death-rate is higher at all ages.

In the surgery of the head it should be borne in mind that the skull of the
African negro is much thicker than that of the white. Mulattoes or mixed
breeds present the weaknesses of both races and more deficient resistance
than either. Carcinoma is less apt to occur among Indians, and still less
apt to develop among the Chinese. Among the American Indians and
Mexicans most all carcinomata occur in the breast or womb.

The Jewish people present extraordinary resistance to bad hygiene; they
bear surgical operations well; those living under the stress of city life are
prone to the development of piles and other rectal affections and to infections
through the portal system, probably entering through anal fissures and abra-
sions. Injuries and operations are borne particularly well by the peoples
which live exclusively, or nearly so, on a vegetable diet — the Chinese, Japa-
nese, Indians, Mohammedans, and the peasantry of Europe.

Ancestral and Family Peculiarities. — These are transmitted and often
have an important bearing upon the resistance of the individual in recovering
from disease. Hemophilia is one of these conditions, and its history should
be inquired for. There are certain diatheses which are peculiar to families
and which, cropping out during the treatment of surgical diseases, should
be recognized and account taken of them. Diabetes, gout, certain nervous
diseases, palsies, degenerative changes in the nervous system, insanity and
epilepsy belong to this class.

Sex. — The peculiarities of sex are also to be considered. Among the
young these differences are slight, but among adults it is noteworthy that
women bear pain better than men; they also suffer less from confinement in
bed; their physical resistance on the whole is less than that of men; they are
more susceptible to nervous disturbances arising as sequelae to operations and
injuries. Dementia following traumatism is probably more common in
women. Good cosmetic results are more important to women than to men.

Occupation.— The occupation of the patient has a bearing on surgical
treatment. The strength and suppleness of the laborer's or mechanic's
hands and limbs are most important to him; whereas, often with the business
man, the item of time required for a cure is a more important factor. The
occupation of the patient must often determine whether time shall be saved
or whether the best possible surgical result shall be secured. Questions of this
nature come up in the treatment of destructive injuries of the extremities and
in extremely chronic diseases. The loss of a member is sometimes of less
importance to the patient than the loss of the time which would be necessary
to effect a cure.

Habits. — The previous habits or diseases of the individual often have an
influence upon the treatment of surgical cases. Wounds heal more slowly in
the syphilitic, and in such patients the surgeon owes it to himself and his
assistants to take care lest they become infected. Patients who have hab-
itually taken much alcohol present many peculiarities. They take general
anesthetics with greater difficulty anrl rlanger; they must be guarded more
carefully against congestion and acute failure of the internal eliminating or-
gans; they suffer most from the dangers of deficient nourishment after opera-
tion or injury; they are [)rone to develop delirium tremens; and their general


resistance in every respect is lower than that of non-alcoholic individuals.
This is not only true of the confirmed drunkard who shows plainly the out-
ward signs of alcoholic degeneration, but also of the more moderate drinker
who apparently is healthy and who first shows the damaging effects of alcohol
after some injury or surgical disease.

Resistance. — The natural physical resistance of individuals to surgical
disease is very variable. Some individuals possess great physical resisting
power while others seem to have but meager vitality. Traumatism and dis-
ease generally ' are resisted better by persons of healthy ancestry, by those
who have lived hygienically, and by the more primitive or simple people who
have not yet come under the influences of so-called civilization. The more
highly cultivated types are depressed more by the shock of injury and opera-
tion, and they are more susceptible to the damaging effects of infections,
with the exception of those infections to which ancestral habituation has
rendered them immune. The more closely to the soil races have lived, the
greater is their resistance to disease and injury when compared with those
who have lived in the environment and occupations peculiar to towns and
cities. A preexisting defect in a single organ often becomes a matter of seri-
ous concern in the presence of surgical disease; and thus the surgeon may be
called upon to pay especial attention to the heart, or the kidneys, or the lungs
when the other parts of the body are functionating well. The obese are
notoriously deficient in vital resistance.

Age. — The age of the patient is also a matter for consideration. Children
are particularly susceptible to shock. They have, however, greater recupera-
tive elasticity. While more easily depressed, they seem to recover from
more profound states of depression than adults.

The tissues of children are more tractile than those of adults, and deformi-
ties which in adults require cutting can often be cured by being fixed in an
over-corrected position.

Light chloroform or ether anesthesia is best for children. Morphin,
cocain, and spinal anesthesia are objectionable.

Old age presents the peculiarity of specific weaknesses of special organs,
particularly the circulatory system. The psychic element in the treatment
of the aged is most important. Their prejudices, habits, and whims should
not be antagonized. During sickness is a dangerous time to attempt the
inauguration of reforms in old people. During illness their previous habits,
so long as not positively prejudicial to health, should be continued.

Immediate Conditions.- — Besides the above remote conditions, there are
ertain immediate conditions which influence the treatment and course of
urgical diseases.

Nourishment. — Special nourishment is required in certain diseases, but in
all surgical cases the patient's nourishment should be regarded as a part of the
treatment. In general, the nourishment should be simple and adequate.
The two extremes should be avoided. The patient should not be put upon a
starvation diet, as was once the custom, nor should he be "fed up" to the
degree of overfilHng his intestine. Of the two evils the latter is, perhaps, the
greater. His nourishment should be kept up to the highest standard com-
patible with the absence of harmful excess, for the reason that in infective
diseases salutary leukocytosis depends upon good nourishment, and in the
reparative processes healthy [tissue-building requires nourishing food. In
order to secure the best general results the food should combine the neces-
sary proportions of proteid, hydrocarbon, mineral salts, and water, to which
may be added vegetable acids as the taste of the individual may require.
Vitamins and the chlorophyl of fresh vegetables are also essential for the best


nourishment. The simplest forms in which these foods may be found are the
best. Eggs, milk, dry bread, butter, simple vegetables and a little meat are
the most desirable foods. Butter-milk, and the juices of the orange, lemon

Online LibraryJames Peter WarbasseSurgical treatment; a practical treatise on the therapy of surgical diseases for the use of practitioners and students of surgery (Volume v.1) → online text (page 1 of 106)