C., H. & Co., Ford. Shoulder-joint, amputation at, by circular incision, flaps united. Shoulder-joint, amputation at, oval, Larrey. Fig. 372. C., H. & Co., Ford. 427 427 34 34 254 Fig. 368. C., H. & Co., Ford. 486 486 486 C., H. & Co., Ford. 402 C., H. & Co., Ford. 402 Shoulder-joint, disarticulation of, Dupuytren, flaps united. Fig. 369. Snare, polypus, nasal, Codman and Shurtleff's. Fig. 762. Snare, polypus, nasal, Sexton's. Fig. 761. Sound, tunneled, Gouley's. Fig. 648. Speculum, rectal, Allingham's. Fig. 618. Speculum, rectal, bivalve. Fig. 616. Speculum, rectal, Williams'. Fig. 617. Speculum, rectal, Thebaud's dilating. Fig. 625. C., H. & Co., Ford. 402 Spine, curvature of the, Sayre's apparatus for. Figs. 462–464. C., H. & Co., Ford. 298, 299 Staphylorrhaphy, freshening borders. Fig. 531. Tarso metatarsal articulation, amputations at. Fig. 386. Tarso-metatarsal articulation, amputation at, Hey's modification of Lisfranc's. PAGE Tarso-metatarsal articulation, amputation at, Skey's modification of Lisfranc's. Figs. 411, 412. Tarso-metatarsal articulation, disarticulation at. Figs. 387-391. Tenaculum. Figs. 59, 519. Tenaculum, application of, to vessels. Fig. 60. Tendon, dividing a. Fig. 220. Fig. 410. Fig. 416. Tendons, flexor, of fingers, linear guide to. Fig. 161. Tenotomes. Figs. 217, 218. Thigh, amputation of, bilateral flaps. Fig. 428. Fig. 386. New. 260 Esmarch. 261, 262 Gross. 270 Original. 269 S. Smith. 271 C., H. & Co., Ford. 35, 328 Packard. 35 C., H. & Co., Ford. C., H. & Co., Ford. 151, 152 Thigh, amputation of, Celsus' single circular incision. Figs. 442, 443. Fig. 441. Thigh, amputation of, circular-integumentary flap, conical cavity of stump. Thigh, amputation of, periosteal flap. Fig. 439. 495 Sayre. 152 Gross. 106 Fig. 440. Gross, modified. 284 Esmarch. 256 Toe, amputation at the metatarso-phalangeal articulation. Fig. 375. Esmarch. 255, 259 256 Toe, amputation of a single, at the metatarso-phalangeal articulation. Fig. 376. S. Smith. Toc, amputation of a single, at the metatarso-phalangeal articulation, lateral-flap method. Fig. 377. Esmarch. 256 Toe, amputation of a single, at the metatarso-phalangeal articulation, lateral-flap method, completion of operation. Fig. 378. Esmarch. 257 Toe, amputation of a single, at the metatarso-phalangeal articulation, squareflap method. Fig. 379. Toe, great, amputation of, at proximal end of metatarsal bone. Fig. 384. Toe, little, amputation of, and metatarsal bone. Fig. 385. Toe-nail, ingrowing. Fig. 467. Tongue, excision of, écraseur in position. Fig. 544. Tongue, excision of, Kocher's operation. Fig. 546. Tongue, excision of, Regnoli's incision. Fig. 545. Tongue, excision of, removal of a V-shaped piece. Fig. 541. Tongue, excision of, removal of a V-shaped piece, flaps united. Fig. 542. Tongue, the, drawing forward, during administration of anæsthetics. Fig. 9. Tonsillotome, Mackenzie's. Fig. 540. Tonsillotome, Tiemann's. Fig. 538. Tourniquet, abdominal, Brandis'. Fig. 449. Tourniquet, abdominal, compression pad and elastic band. Fig. 448. Tourniquet, abdominal, elastic ligature. Fig. 454. 13 337 338 337 Esmarch. 289 Esmarch. 288 Esmarch. 292 C., H. & Co., Ford. 287 PAGE Transfusion apparatus, Fryer's. Fig. 184. Transfusion, direct. Fig. 183. Transfusion, introducing tube. Fig. 182. Fig. 210. Transfusion, removing fibrin from blood. Fig. 186. Uranoplasty. Fig. 535. Urethra, tapping the. Fig. 752. Fig. 676. Urethrometer, Otis'. Fig. 748. Urethroplasty. Fig. 738. Urethroplasty, Nélaton's operation. Fig. 739. Urethroplasty, Rigaud's operation. Fig. 740. Urethrotome, Otis'. Figs. 749, 750. Urethrotome, Pect's. Fig. 751. C., H. & Co., Ford. 476, 477 C., H. & Co., Ford. 477 Urethrotoiny, operation of, drawing apart lips of the incision. Fig. 744. Original. 473 Urethrotomy staff, grooved, Syme's. Fig. 743. Variocele, Keyes' needle for. Fig. 179. Varicocele, treatinent by elastic traction. Fig. 178. C., H. & Co., Ford. 472 Wrist-joint, amputation at, flaps united. Fig. 354. Wrist-joint, amputation at, double flap. Figs. 355, 356, 358. Wrist-joint, amputation at, single palmar flap. Fig. 357. Wrist-joint, amputation at, double flap, appearance of stump. Fig. 359. Wrist-joint, excision of, Langenbeck's incisions. Fig. 268. Wrist-joint, excision of, lateral incisions. Fig. 264. Wrist-joint, excision of, Lister's incisions. Fig. 269. Esmarch. 244 Esmarch. 244 Esmarch. 245, 246 Esmarch. 195 Esmarch. 193 Stimson. 196 OPERATIVE SURGERY. CHAPTER I. GENERAL CONSIDERATIONS. Operative Surgery treats of the manual procedures necessary to properly accomplish the surgical object in view. The operation to be done is the execution of a verdict that is, or should be, based upon surgical principles and laws in a sense comparable to legal proceedings in the Courts of Justice. The surgeon, in most instances, however, holds the threefold position of judge, jury, and executioner. It is, therefore, very essential for the welfare of the patient that he properly interpret the surgical laws and principles relating to the case, in order that the verdict to follow may be just, and its execution cast no opprobrium upon himself or his profession. To be able to operate understandingly, requires not only a thorough knowledge of the principles of surgery, but a fair knowledge of the ways and means of accomplishing the desired purpose. It is not enough to be able to remove in a skillful manner an offending member or disease, but it is equally important for the surgeon to so prepare the patient and himself that no unanticipated complication can occur immediately prior to, during, or subsequent to the operation. Regarding the principles of surgery proper, the reader is referred to the many works upon that subject; since it is not the intention of the author to intrude upon this department of surgery, except in so far as it may be found expedient to apply them to the immediate safety of the patient during and subsequent to the operation. Prior to an operation, especially if it be one of any magnitude, it is essential that the following facts be ascertained: First. The physical condition of the heart, lungs, kidneys, brain, and great vessels. Second. If there be an acute surgical or other complication of the essential organs of the body, joints, serous cavities, etc. Third. If the patient be suffering from shock. Fourth. If the patient be anæmic or scorbutic. If he have syphilis, phthisis, epilepsy, diabetes, or be in danger of delirium tremens. Fifth. If he be willing and ready for the operation. Upon the healthful condition of the heart, lungs, brain, etc., may depend the expediency of giving an anesthetic, and the choice between them. If the kidneys be diseased, it may be inadvisable to operate upon the urethra or bladder, or even to give an anæsthetic; if the great vessels be dilated or atheromatous, much discretion must be employed in its selection and administration. It should not be forgotten, however, that the mental emotion and physical suffering attendant upon an operation, when performed without anesthesia, may be of greater moment than with its use. If the injury demanding an operation be recent, and the patient be suffering from a severe shock, it should be deferred until reaction is established. If the shock be out of proportion to the visible injury, a careful examination of the patient must be made to ascertain its cause. If a complicating injury be discovered, which of itself imperils the life of the patient, all idea of an immediate operation must be deferred. These thoughtful attentions will lessen the pungency of the oft-repeated satirical expression, "The operation was successful, but the patient succumbed." If the patient be already anæmic, or scorbutic, the loss of blood added to the shock of the operation may expose him to greater dangers than if the operation be postponed. Unfortunately, however, in a majority of cases, the conditions calling for operative interference are the prime factors which determine the degree of the blood changes, and will not, of themselves, admit of any delay. The existence of syphilis, phthisis, diabetes, etc., exerts a marked influence on the recovery, and their importance must not be underestimated in connection with this fact. If a patient be addicted to the continuous use of intoxicating beverages, and worse still, if he receive an injury during a prolonged debauch, it seriously complicates his case, not only directly from the previous effects upon his bodily vigor, but from the impending danger of delirium tremens. It is not necessary to the successful issue of an operation that the patient be ready and willing; yet, if such a fortunate combination be present, it will weigh heavily in favor of ultimate success. It is prudent, however, that he should be ready in a legal sense; that is, that his consent be gained. If the operation be a dernier ressort he should be given the opportunity of adjusting his business and spiritual affairs. If they be prematurely adjusted-if such be possible-the knowledge of it, and the quiet of mind resulting therefrom, will become valuable aids toward his recovery. Season of the Year.-Autumn and spring are the best seasons for |
