CORNE LL UNIV ERSITY THE Ifflnm^r Uptprmarg Bltbrar^ FOUNDED BY ROSWELL p. FLOWER for the use of the N. Y. State Veterinary College 1897 This Volume is the Gift of Dr. W. L. Williams. 5577 Cornell University Library SF 911.W721912 Surgical and obstetrical operations ...E 3 1924 001 129 133 The original of tliis book is in tlie Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924001129133 SURGICAL AND OBSTETRICAL OPERATIONS W. L. WILLIAMS Professor of Surgery and Obstetrics In the New York State Veterinary College, Cornell University Embodying portions of the OpERATIONSCURSUS of Dr. Pfelffer, Professor of Veterinary Science in the University of Glessen THIRD EDITION, REVISED AND ENLARGED 1912 CARPENTER & COMPANY ITHACA. N. Y. Press of Andrus Sl Church Ithaca, N. Y. Copyright, 1912 BY CARPENTER & CO, SF <^'ll Vila i'Hi^ PREFACE TO THE THIRD EDITION. The author caused to be published in 1900 a booklet entitled : " A Course in Surgical Operations by W. Pfeiffer and W. L. Williams," consisting of an authorized transla- tion of Dr. Pfeiffer's Operating-Cursus with such changes, additions and omissions as were deemed desirable. Three years of constant use, with such criticisms as came to the author from others, served to point out desirable changes of so sweeping a character as to demand a practically new treatise specially adapted to American conditions, and to render the continuance of a formal joint authorship inex- pedient and in 1903 the author published a more extended volume under the present title, followed by a large second edition in 1906. In this third edition the author has con- tinued to draw freely upon Dr. Pfeiffer's Operations-Cursus in the preparation of the text which in many chapters is practically copied therefrom, including the illustrations with grateful acknowledgement of his profound obligations. On the other hand nothing has been copied or extracted except it could be freely adopted as the author's own view, releas- ing Dr. Pleiffer from all responsibility for the character of any of the contents. The volume is primarily designed for the use of the au- thor's classes in laboratory surgery and embryotomy in which the student performs the surgical operations described, on animals procured for the express purpose, under chloroform anaesthesia whenever possible, after which the subject is destroyed while still anaesthetized ; at the same time it has been aimed to render the volume of the greatest possible value to the practitioner consistent with this plan. The operations included under this scheme are necessarily limited to those which can be reasonably well performed on com- paratively sound animals of little value and regularly pro- curable for laboratory purposes. The list covers a wide iv PREFACE TO THE THIRD EDITION. range and is designed to give to the student as thorough training as is practicable in a laboratory course and includes well nigh all the more important varieties of confinement, anaesthesia, disinfection, sutures, bandaging, dressing and other adjuncts to operative work. The chapter on trephin- ing of the facial sinuses has been dealt with at much greater length in the present edition in order to fully and clearly describe the author's method of operating. The operation for the surgical relief of roaring in horses has undergone a complete revolution since the publication of our second edition in 1906 and the technic therefor which we had begun to develop in 1905 and tentatively inserted in the second edition has undergone phenomenally rapid changes until now it would appear that the technic had acquired a certain degree of permanency, though still too new to expect it to remain unchanged. The introduction of the ventricular burr by Dr. J. H. Blattenberg and various suggestions in the details of technic by Prof. Hobday of England and others has materially aided in bringing the operation to its present state of reliability and caused the operation introduced by us in 1905 to become accepted throughout America and Europe to the exclusion of other methods. We have accordingly omitted the chapter on arytenectomy from this edition, as an obsolete operation and have inserted an entirely new chapter upon the opera- rion for roaring in which we have endeavored to bring the technic thoroughly up to date. Generally but one method of operating is described, the one chosen being that which in the author's experience has proven the most valuable in actual practice, and no opera- tion has been introduced purely for practice but each one has been tested and known to have practical value. When two methods of operating are given, they are inserted because each has definite points of superiority over the other and one method may be specially applicable in a PREFACE TO THE THIRD EDITION. v given case, another in a different patient where the same operation is to be performed as for example, a milk cow is best spayed through the vagina while a heifer must be operated upon by an incision through the abdominal walls. Considerable stress has been laid upon the surgical anato- my of the parts involved in each operation ; some uses of the various operations are mentioned ; some of the chief dangers of each are pointed out and in some cases references to literature upon the operation or the diseases for which the operation is designed, are cited. Figures i, 2, 6, 7, 9, 10, 11, 15, 16 and 17 and Plates Nos. XII, XIV, XVI, XXIII, XXIV, XXVII, XXVIII, XXIX, XXXI, XXXIV, XXXV, are from Dr. Pfeiffer's Operations-Cursus ; and the remaining Plates and figures were either drawn under the direction of the author by Mr. C. W. Furlong, formerly instructor in Industrial Draw- ing and Art in Sibley College, Cornell University, or were made from original photographs. W. I/. Williams. Cornell University, March, jgi2. CONTENTS. I. I. OPERATIONS ON THE HEAD : Extraction of Teeth ^ 1..J. i Repulsion of Teeth .'i^-fv ;^^^ 8 Trephining the Facial Sinuses JIl'^.Z-Sl—l—-- 'o Trephining of the Frontal Sinuses 'L 19 Trephining the Superior Maxillary Sinuses I! 32 Trephining the Inferior Maxillary Sinuses 'L 41 Trephining the Nasal Fossae „_^ 45 Poll EviLQB£ ration ^ L__^^^!!j--. Z^^j.^ ^^-^-^— 53 Ligation of the Parotid Duct 2l_v--^ -- 61 Entropium Operation 4—- 62 Staphylot-omy-^ zr^itS^ , 63 Trifacial Neurotomy L.c Js- 64 II. OPERATIONS ON THE NECK : Opening the Guttural Pouches ^> 70 Tracheotomy /__ *_'i 76 The Operation for Roaring .3L'.'-?__Ll . j_! 'j.l^X-.Ul.'i^S .^r> 78 Intra-tracheal Irrigation d 87 Intravenous Injection ^jlc-i-'i.-. 71 88 a. Phlebotomy with Fleams 91 b. Phlebotomy with Lancet, 92 c. Phlebotomy with Trocar ^ .___, 93 Ligation of the Carotid Artery ,— L- -: ^.-^i^'-S.-d)^ 93 CEsophagotomy ><.__. 'J_ 98 III OPERATIONS ON THE TRUNK AND ON THE GENITAL ORGANS : Ipuncture of the Chest ^/2\%l.'h.' 100 'Puncture of the Intestine 'L ^-7 10 [ Subcutaneous Caudal Myotomy .___ //...-^j?.!?_ 103 iCaudal Myectomy for Gripping of the Reins __/!_l\^i'_ii 105 Amputation of the Tail l^J li.±J'7:._'^A tog Urethrotomy ^_/j_i__^lZ _'_':'!:./ 114 Amputation of the Penis I--i-l_ _>—'_. _:j^_.rb^l__^ 117 Vaginal Ovariotomy in the Mare ._'_'_ .__^ 123 Vaginal Ovaiiotomj'in the Cow ^ 130 Ovariotomy in the Cow by the Flank C' j,. CONTENTS vii ■Ovariotomy in the Bitch by the Flank ^^— i>I-- - 134 Ovariotomy in the Bitch by the Linea Alba C'. 141 Ovariotomy in the Cat ^ _^__i:) 142 'Castration of Cryptorchid Horses ^'lfL?:_'Lll_— • 143 11 IV. OPERATIONS ON THE EXTREMITIES : Tenotomy of the Flexor Tendons of the Foot fl.L—-. 154 Tenotomy of the Peroneal Tendon (Stringhalt Operation) ''lA. 157 Tenotomy of the Cunean Tendon (Spavin Operation) -__A.W._ 159 Neurotomy L! 161 Digital Neurotomy lilii^!j:A. 167 • Plantar Neurotomy i'_j__ji..ii. 169 Median Neurotomy _''_^_ A-£^_ 174 Ulnar Neurotomy ??J.!:'_-'_r*Ji.u.ij.l^^„ 179 'Sciatic Neurotomy '_: __2__'!'__i_'- 185 jAnterior Tibial Neurotomy '' \y_ ^ 191 KResection of the Lateral Cartilages :L c.i-l.I'.J- 196 plesectiou of the Flexor Pedis Tendon '1 /__:i^-__ 202 |Amputation of the Claws of Ruminants !.L..^^£. L-k.-'tl 204 [Bayer's Sutures ^__j;_?j..4_ii 209 II. EMBRYOTOMY OPERATIONS : i/^1 1. C / l^ephalotomy U. _. 212 Decapitation 0. 214 .Subcutaneous Amputation of Ant';rior Limb u. 2 15 TAmputatiou at the Humero-radial Articulation -^--0 218 ijDetruncation ^hijTp 218 Destruction of the Pelvic Girdle, Anterior PresentatioUi&.i'/^. 222 (Amputation of the Limbs at the Tarsus Zll^LjC^tri': 226 Intra-pelvic Amputation of the Posterior Limbs, Breech Pre- sentation -._l_-._ '--^- i:i\IJ^- 230 Evisceration of the Foetus ^/. 239 INTRODUCTION. Man}' details must be omitted in the succeeding text which are of importance in each operation, but which, if inserted, would render the volume unwieldy in size for the purpose designed. These details are in a measure alike in each case, and it is assumed that the student has already familiarized himself with them. The more important of these may be summa- rized as follows : 1. The subject should be securelj^ confined in each case as directed, because the method designated has been found effective in the operation under description, and serves to fix the relations of the parts in such a way as to conform to the surgical anatomy of the region as outlined in the text. It is to be constantly borne in mind that a change in the atti- tude of the animal may cause profound alterations in the relations of parts which displacement may greatly embarass the operator, or even prevent his carrying out the operation according to the technic given. In securing an animal for operation the whole body should be confined in a way that will sufficiently control movements and will insure safety to the patient and operator ; the part to be operated upon must be so fixed as to properly limit its motion and in a position to afford the greatest facility for the carrying out of the operation according to the technic given. 2. Anaesthesia should be carefully carried out everywhere possible, because in addition to the humane sentiments in- volved, the resulting perfect control of the animal is an essential in aseptic or antiseptic surgery. The student should make a careful study of anaesthesia in these exercises and acquire invaluable experience and confidence for their use in actual practice. X INTRODUCTION. 3. Disinfection must be scrupulously applied in every de- tail since upon its effectiveness must rest the verdict of success or failure as measured by modern surgical thought. The operator's finger nails should be well trimmed, smoothed and cleansed, and his hands and arms thoroughly scrubbed with a stiff brush in hot water and soap for a period of fifteen minutes, and all dirt and old epidermal scales removed. The parts should then be disinfected. This may be accom- plished by immersing the hands in a hot concentrated solu- tion of permanganate of potassium for ten minutes and then decolorizing them in a strong solution of oxalic acid in boiled water. Or the hands may be disinfected after the washing with soap and water by immersing and scrubbing them for ten minutes in a i to 1000 solution of corrosive sublimate, but in order to make this thoroughly effective the solution needs be alcoholic, or the hands should first be immersed in alcohol, ether, or other substance capable of dissolving fats and permitting the disinfectant to penetrate to every part without being obstructed by sebum or fat. Great care should be exercised by the student not to touch any object with his hands after they have been disinfected for the operation, unless such object has also been disinfected or sterilized, or in case it becomes necessary to touch objects not sterile, the disinfecting process should be repeated before proceeding further with the operation. This constitutes one of the most difficult of all details for the beginner to acquire, and each failure should be remedied by repeating the process over and over until the habit of maintaining effectual asepsis is acquired and fixed. The operative field should always be carefully shaved be- fore beginning the operation, and the shaved area should always be ample, so as to insure against contamination from adjacent hairs, as well as to give a clear view of the field. The area should then be disinfected in a' reliable INTRODUCTION. xi manner, that advised for the operator's hands serving as a type. Whenever circumstances will permit the operative field should be kept in an antiseptic bath or pack for twenty- four hours prior to the operation in order that the deeper parts of the skin, especially the hair follicles and sebaceous glands, shall become thoroughly disinfected, a process well nigh impossible in a short period. The suturing, dressing and bandaging of the wound should be carried out carefully in every case and no opera- tion left without completing it in the best manner possible. The student should make each operation as real as possible and not omit any detail even if he thinks he already knows it sufficiently well, as the repetition of a supposedly familiar detail serves an important purpose in the fixing of a habit which is inestimably more valuable to the surgeon than any theoretical knowledge of technic. The safe surgeon is he who has so accustomed himself to the technique of asepsis and antisepsis that he carries it out rigidly in an automatic manner and is thus free to concen- trate his entire attention on the surgical problems before him. The student who consults his interests will go yet farther and prior to undertaking any operation on the living subject will study the regional anatomy of the part on the cadaver and learn therefrom all that he can of the structure of the part which he must finally complete upon the living animal. No dissection of the cadaver can ever teach true surgical structure as the dead tissues can not be hke the living, but such dissection can and does give great aid and should be pursued as far as it can lead and enough will still remain to be learned on the Hving subject. It is to be constantly re- membered that anatomy deals with the structure of the dead body while surgical operations are performed upon the living structures : they are not alike. xii INTRODUCTION. The student should further take occasio)i to study in con- nection with each operation the object or objects for which it is performed in practice, its effect on the diseased or other parts, the untoward results to be anticipated, etc. Suggestions occur from time to time in the text designed to aid the student in these lines and help weave connecting bonds between the operation, its objects and results. Surgical operations may in themselves be valueless or worse and acquire value only when properly correlated to •disease and skillfully performed. Surgical and Obstetrical Operations. I. SURGICAL OPERATIONS. I. OPERATIONS ON THE HEAD. TOOTH OPERATIONS. Prefatory remarks. The grinding teeth of the horse consisting of three premolars and three molars in each row are of such dimensions and attachments that their removal in case of disease or defect often presents difficulties of no small degree. These teeth attain their greatest size at the time of erup- tion and most of each tooth remains firmly imbedded in its alveolus while a very shallow crown projects into the buccal cavity. The teeth are gradually pushed out of their alveoli as their crowns are worn away by attrition as age advances and the proportion of the intra- to the extra- alveolar part gradually decreases until in very old animals the alveoli be- come obliterated and the last vestige of what was once the apex of the fang rests insecurely in the buccal mucosa. The facility with which teeth may be extracted increases as the age of the animal, being as a rule easily drawn with forceps in old, while in case of freshly erupted teeth in young horses it may be almost or quite impossible to extract them with forceps of any kind, except in those cases where they have become somewhat loosened as the result of disease or accident. When aberrations in development occur, lead- ing to the formation of dental tumors or odontomes the possibility of extraction by means of forceps is frequently wholly excluded. In cases where dental disorder has led to empyema of the facial sinuses, even if the tooth may be drawn by means of forceps, further operation is generally 2 EXTRACTION OF TEETH. necessary, in order to assure a prompt recovery, by the removal of the effects of the disease of the tooth. The removal of molars may therefore involve extraction ■with forceps, trephining the dental alveolus and repulsion of the tooth and trephining of the sinuses because of em- pyema or other pathologic conditions referable to the dental affection ; consequently all of these should be studied as related topics. 1. EXTRACTION OF TEETH. Plates I and II. Instruments. Extracting forceps, fulcra of various sizes, mouth speculum with abundant lateral working room, ■ exporte ur forceps, toothpick, splinter forceps, reflecting lamp. Technic. In simple cases with a quiet animal the pa- tient may be sufficiently confined by being backed into a corner or very much better by securing in stocks. In com- plicated cases or very resistant animals it is best to place the patient upon the operating table or in default of this, cast and secure in lateral recumbence on the sound side. Apply the speculum and identify the diseased tooth by manual exploration ; determine if the tooth is of unnatural size or form, if it is loose, if the gums are separated from the neck at au}^ point, if it is out of line with the other teeth in the row, if it is painful to the touch, if it be split, etc. An external tooth fistula or a tumefaction over the affected member may aid in distinguishing it. Aid may also be had by illuminating the mouth with a reflecting electric or other lamp. Remove any accumulations of partially masticated food by means of the toothpick or fingers. In applying the forceps, have an assistant draw the tongue out at the commissure of the lips on the side oppo- EXTRACTION OF TEETH. 3 site to the affected member and introducing one hand into the mouth, place the index finger on the posterior border of the diseased tooth and with the other hand, push the opened forceps backward upon the dental row until they reach the diseased member, then firmly grasp it with the instrument, pressing the jaws down as deeply as possible against the alveolus. In many cases the diseased tooth can be clearly seen, especially with the aid of the reflecting lamp, and the forceps may be readily applied by sight, which is frequently preferable to the sense of touch. Withdraw the free hand from the mouth, grasp the forceps handles firmly and loosen the tooth in its alveolus by establishing and maintaining as long as necessary a gentle to and fro lateral movement. The tooth is thus loosened in its alveolus by causing it to revolve very slightly back and forth on its long axis, thereby spreading the alveolar cavity. When the tooth has become well loosened, the fact is indi- cated by its revolving with the forceps and by an audible crepitant sound caused by the passage of air bubbles to and fro through the blood and lymph in the alveolus. Maintain the forceps in position with one hand and with the other introduce the fulcrum to a point where the depression on its superior surface will receive the projecting rivet-head of the instrument or in an otherwise secure position affording a safe support, while the inferior surface rests evenly upon the crown of a tooth anterior to that which it is desired to extract, as is shown in Plate I. The fulcrum needs be held firmly in place in order to prevent it from gliding away under pressure. In extracting the first premolars there is no opportunity for resting the fulcrum on teeth anterior thereto and con- sequently forceps have been made with fulcra beyond the forceps jaws resting upon teeth more posteriorly situated. This is not essential. If the tooth is thoroughly loosened. Plate I. Extraction of Teeth. Sagittal section through the oral cavity, show- ing plan for extracting the third inferior pre- molar, viewed from within the mouth. A Forceps jaws applied to third premolar. B Fulcrum resting upon first premolar. CC, Plates of mouth speculum resting upon incisor teeth. EXTRACTION OF TEETH. 7 as it should be, one hand placed in the interdental space with the dorsal surface against the jaw and the volar grasp- ing the instrument, will serve as an effective fulcrum. In other cases an iron or steel fulcrum is not essential, but a stick of hard wood of proper size and form acts quite as efficientl}' and may even keep its position better because the teeth upon which it rests sink into it somewhat. On the whole the fulcrum is not so important as some have considered it, since, after a tooth is loose enough to be drawn with its aid, a very trifling additional loosening will permit it to be easily lifted from its alveolus without it. The tooth fang is extracted by forcing the handles of the forceps toward the jaw in which it is located, so that as it is gradually drawn out the forceps tend to pivot on the fulcrum in a way to permit the tooth to emerge from its alveolus in the direction of its long axis. By referring to Plate II it will be seen that the long axes of the different teeth vary, that of the molars being obliquely forwards from, fang to crown towards the incisors, while the crowns of the premolars are directed obliquely backwards toward the molars. The slant of the teeth is most marked at the ends- of each arcade while at the middle they acquire an almost perpendicular position. In drawing the last molar the back of the forceps will! generallj' strike against the opposite dental arcade before the tooth has completely emerged from its alveolus and ini order to complete its removal it may be necessary to take a deeper hold with the extracting forceps or withdrawing these complete the operation with the aid of exporteur forceps, or still better frequently with the hand. In young horses where the teeth are very long we have found it im- possible to complete the extraction until the tooth had been divided transversely by means of the tooth cutting forceps. The dangers in the extraction of teeth are chiefly : I. The transverse fracture of the tooth, leaving the fang still fixed in the alveolus, a danger not infrequently un- .■8 REPULSION OF TEETH. avoidable when the crown has become greatly weakened by disease so that it lacks the necessary power of resistance ; under most other conditions transverse fracture ma}' be largely guarded against by the careful securing of the patient in a manner to effectively prevent sudden throwing of the head while the forceps are applied, and by using good judgment in the amount of force exerted while loosening the tooth in its alveolus. As stated above we should not expect to be able to extract with forceps the teeth of very young horses which have not become partly detached by disease or in which the fangs are the seat of odontomes. 2. Fracture of the alveolar walls is an accident which may generally be prevented by proper care in the application of force and the avoidance of any attempt to extract a tooth when the existence of an enlargement of the fang is apparent or suspected. 3. The tooth may slip from the forceps into the pharynx and be swallowed, an accident avoidable by inserting the hand into the mouth as the tooth begins to emerge from its alveolus, and if need be, grasp it with the fingers. 2. REPULSION OF TEETH. Plate II. Uses. The removal of molars, pre-molars, tooth fangs from which the crowns have been broken away, alveolar odontomes, etc., which can not be removed safely by means of the forceps. Instruments. Mouth speculum, razor, con vex sc q|p f]g | - trephine, bone gouge, Luer's shar p bone forceps, (rongeur forceps) light and heavy bone chisels, mallet, tooth punch, curette, compression artery forceps, scissors, needles, thread, absorbent cotton, antiseptic gauze, extracting forceps, splinter forceps, tenacula, metal probe. REPULSION OF TEETH. g Technic. Secure the animal in the lateral recumbent position with the affected side up. The operating table affords by far the best means for securing for the conven- ience and safety of operator and patient. If the sinuses are so involved as to make po.ssible the inhalation of pus, blood or other injurious matter, perform tracheotomy in ample time to avert danger. Aneesthetize locally or generally as required. Shave and disinfect the operative area and trephine according to the method described in the following chapter, down through the alveolar plate immediately over the fang of the afEected tooth. Avoid dulling the trephine by striking it against the tooth fang. If an external fistula exists the identity of the affected tooth is best determined by passing a metallic probe through it against the diseased fang ^Yhile one hand is passed into the mouth and the location of the probe more fully ascer- tained. Care should be exercised in trephining to not injure the adjoining teeth. After removing the disc of bone isolated by the trephine, control all hemorrhage and then enlarge the opening and remove the bony ti.ssues till the tooth fang is bared its entire width. Insert a scalpel or bone chisel between the external face of the bone and the soft tissues at the oral margin of the trephine opening and with one hand in the oral cavity with the fingers resting upon the alveolar border on the lateral side of the tooth to serve as a guide, push the scalpel or chisel along between the bone and soft tissues until it emerges from the gums alongside the affected tooth and extend this separation backwards and forwards until the soft tissues are completely detached from the alveolar wall over the entire area of the diseased member. When operating upon the superior molars, the fangs of which are covered by the zygomatic ridge, the chisel or scapel cannot be pushed directly from the trephine opening into the mouth between the soft tissues and the bone because the line is concave instead of direct. In these cases it is 1.2 en dt <: O ^ B a. ^^ > 05 ^ 2 'C -3 !" ^ -3 o pq ■ - S ■ S ■- >^ >-> ;-< w ?< '5< cfl CD a a REPULSION OF TEETH. ij best to detach the soft parts from the zygoma only at first and then remove the alveolar plate of the ridge with the bone forceps or chisel, after which the line into the mouth is direct and the instrument can then be readily pushed be- tween the soft and osseous tissues for the remainder of the distance and the separation completed. In operating upon the inferior molars covered by the masseter an opening through the muscle may be made near its lower border large enough to admit the trephine or the muscle may be detached at its point of insertion to the inferior maxillary bone and two parallel incisions carried upwards a short distance, permitting the raising of a flap, or what is generally best for the second and third molars, a curved incision is made at the antero-inferior border of the masseter muscle parallel to the parotid duct and satellite vessels and just posterior to them and the muscle lifted up and drawn backwards sufficiently to expose the bone im- mediatel}' over the tooth fang. With a light, narrow bone chisel cut away and remove the external alveolar plate over the entire extent of the tooth, from the oral margin of the trephine opening into the mouth cavity. Hold the chisel so that the outer edge is inclined from the affected tooth toward the adjoining one, thus making a bevelled channel through the alveolar plate tending to loosen the isolated section of bone by driving it outwards. Drive the chisel for a short distance on one side, then upon the other, and thus break the alveolar plate away in small sections and avoid an extension of the fracture to neighboring alveoli and damage to adjacent teeth. Care should be taken that the bone chisel is sharp otherwise extensive fractures of the bone may occur. With gouge and chisel remove all remnants of bone over the lateral side of the tooth laying it completely bare as shown in Plate II. The soft tissues of the part should not be disturbed beyond the excision of the circular piece, corresponding to 14 REPULSION OF TEETH. the disk of bone removed by the trephine and the detaching of them from the portion of bone to be chiseled away. When the tooth has been bared so that every part of its lateral surface can be seen or felt, the punch may be placed against the end of the fang, a few firm, quick blows given with the mallet, so directed that the force is in a line with the long axis of the tooth, and the organ driven into the mouth where it is seized by the forceps or the hand and removed. If it is not readily and safely dislodged in this way, place the heavy bone chisel against it and with the aid of the mallet comminute the tooth by breaking it trans- versely and splitting it longitudinally, in which process the fragments are generally loosened from the alveolar walls and <;an then be readily removed with the aid of the gouge, or heavy dressing or splinter forceps. Remove carefully all fragments of tooth or of loosened bone, cleanse and disinfect the wound, pack with iodoform gauze and dress daily. In cases where a fistulous opening remains after repulsion of molars without the removal of the alveolar wall, or if a tooth has been drawn by means of the forceps and the alveolus fails to heal, the bony plate should be removed in the above manner. Dangers. Wounding of the adjoining tooth is to be avoided chiefly by carefully locating the fang of the affected one and placing the instrument as exactly as possible over its centre, by using a trephine not exceeding 2 to 2.5 cm. in •diameter and cautiously sawing through the compact layer of the external plate only, removing the cancellated tissue with the gouge and extending the opening in the desired -direction after the outlines of the tooth fang have been clearly determined. If an adjoining fang is wounded, the tooth should be removed as it will not heal but will result in a permanent tooth fistula. Fracture of the alveolar walls of the inferior maxilla may occur during the removal of the external alveolar plate -with the chisel or of the repulsion of the tooth with the REPULSION OF TEETH. 15 punch. The first is to be averted by care in having the chisel sharp, by observing the precaution of making a bevelled cut through the bone, by using only moderate blows and driving the instrument alternately for a short distance on each side. The second danger of extensive fracture may be averted by being cautious to see after each stroke on the punch that it has not slipped inward along the median side of the tooth, pressing the internal plate away from the tooth and tending to produce a longitudinal fracture nearly or quite as long as the dental arcade. Careful digital exploration in the mouth may discSver this fracture while still "simple" but a stroke or two more will convert it into the very much more serious "compound" fracture opening into the oral cavity. Keeping one hand constantly in the mouth at the point of impact is always desirable as a precautionary measure. Transverse fracture of the tooth while yet in situ by means of the bone chisel, as above described, is a great safe- guard against this injury by lessening the force required in repulsion and by the removal of the tapering fang, which then leaves a more secure base for the punch to act upon. It should never be forgotten that the impact from the punch must always be as nearly parallel to the long axis of the tooth as is possible. The fracture of the superior maxilla and bony palate is not so probable as the preceding and is preventable by mod- erate care in the denuding of the tooth before punching, by comminution of the tooth in proper cases, by the careful ad- justment of the punch and applying the force in the proper direction. Literature. Odontomes, Sir Bland Sutton, Jour. Comp. Med. and Vet. Arch, Vol. XII. p. i ; A CHnical Study of Odontomes, W. ly. Williams, Am. Vet. Review, Vol. XV, p. I ; Notes on Odontomes, do ; Am. Vet. Rev. Vol. XXIII, p. 82 and Oest. Mon. Thierheilkunde, Bd. XXIV, s. 122. 1 6 TREPHINING OF THE FACIAL SINUSES. TREPHINING OF THE FACIAL SINUSES. Plates III-XI. Prefatory Note. The facial sinuses of the horse consti- tute an exceedingly intricate and extensive group of cavities, communicating more or less freelj' with each other or with, the exterior through the medium of the upper air passages, of which they are to be regarded as a part. Their arrangement and relations permit them to frequently become the seat of, or central figure in many forms of disease which require for their differential diagnosis, amelioration or cure, the operation known as trephining. Their extent and relations to each other and to surrounding parts varies- greatly with age and may be profoundly changed as a result of disease, amounting not infrequently in the frontal, superior and inferior maxillary sinuses ceasing to exist as- separate cavities and becoming merged into one vast diverti- culum. The general po.sition, extent and relations of these are indicated by Plates III-XI. It is to be noted that in cross sections the superior and inferior maxillary sinuses appear to be reversed in relation. ,to their^ nomenclature. It is difficult to make a cross sec- tion of these sinuses in such a manner that the antero- inferior extremity of the superior sinus does not show below and external to the inferior one. The inferior maxillary sinus is inferior in the sense that it is nearer to the nasal opening so that with the head in a vertical position or in a longitudinal section the inferior sinus is below the superior, while if the head be placed horizontally or a cross section made, a small portion of the superior sinus may show below the inferior. The uses of trephining are in a measure common to all the .sinuses and are chiefly for the relief of empyema of the cavities involved, necrosis of the bony or cartilaginous walls,, tumors of various kinds, especially dental in the young and TREPHINING OF THE FACIAL SINUSES. 17 malignant growths in the old, foreign bodies in the sinuses, differential diagnosis of diseases of this region, etc. Veterinarians trephine the sinuses by two fundamentally different plans ; with, and without excision of the cutaneous disk corresponding to the piece of the bone removed. The first is generally used in Great Britain and North America, while the last is the prevailing method in continental Europe and other parts of the world. The reason assigned for these variations in method are conflicting. To us there seem to be adequate reasons for preferring the excision of the cutaneous disk. We regard as the chief considerations in an operation the following : the avoidance of infection ; the prevention of pain during the operation or the after- treatment ; the reduction of the scar to a minimum ; rapidity and certainty of recovery ; convenience in operating and dressing. Inevitably a septic operation, the degree of infection is largely dependent upon the area of the wound, the facilit}'^ for maintaining cleaniness and the degree of disturbance to the tissues while being dressed. The wound area in the bone is alike in all cases but that in the skin varies greatl3^ If we compare the usual European technic with that given below we would find the wound area ap- proximately 2.2 sq. in. in the European method, while in the latter we have only about .44 sq. in. or proportionately the wound area in the soft tissues in the two operations would be as 5 : I . It is very evident that the technic given below affords immeasureably better facility for maintaining cleanliness in the wound and with a minimum amount of insult to the tissues in the process of dressing. The amount of pain caused in the operation which should be eliminated by local anaethesia depends chiefly upon the extent of the skin incision which is essentially equal in the two plans .so that the only difference would be in the 1 8 TREPHINING OF THE FACIAL SINUSES. dissection of the skin from the bone in the European operation. The pain caused in dressing must be greater in the European method because the detached, overhanging skin must be moved and disturbed each time causing pain and inviting infection. The question of pain in dressing must always be seriously considered as it not only affects the time required for dressing and its efficacy, but has an important relation to the docility of the animal after re- covery, some horses having their dispositions permanently ruined by the irritation due to the oft repeated painful dressing of wounds. The cicatricial contraction of the tissues of the horse is so great that the removal of a circular disk of skin J^ to i^ in. in diameter on the face does not leave a visible scar so that the question of blemish falls back upon that of infection, which, as we have asserted above is far more probable by the continental European method. The rapidity and certainty of recovery are dependent upon the considerations above discussed. The removal of the cutaneous disk is certainly easier and quicker than the other method. The convenience for dressing is evidently superior by the English and American method. The opening of the sinuses into the nostrils is based upon the surgical principle that suppurating cavities should be provided with ample drainage from the most dependent part. The direction to leave the external wound open, at first thought seems antagonistic to general surgical princi- ples but it should be remembered that the wound consists only of the incision through the skin, connective tissue and bone penetrating a suppurating cavity, and that any object which we can place in this opening can only serve to dam back the secretions of the cavity and can not prevent them from coming in contact with the wounded surface. It must further be regarded that the respiratory mucosa of the upper air passages are not irritated or injured in any TREPHINING OF THE FRONTAL SINUSES. 19 manner so far as we can observe clinically by the direct ad- mission of air into them through a trephine, or other artificial opening, but on the contrary the suppuration in a sinus is constantly aggravated by the retention of the pus and ex- clusion of air and recovery facilitated by thorough drainage and aeration. 3. TREPHINING OF THE FRONTAL SINUSES. Plates m-XI. Uses. Fracture of the bony walls, necrosis, tumors. The ample communication below with the superior maxillary sinus (See FE, Plates V and VI) prevents the accumulation of pus or fluids in the frontal sinuses even if formed therein unless the former becomes filled and the contents back up into the latter. In empyema of the frontal sinuses, trephining can not give relief, but calls for a repetition of the operation on the maxillary sinuses. Instruments. Razor, scissors, convex scalpels, artery forceps, tenacula, probe, trephine, curette, gouge, Luer's sharp bone forceps (rongeur forceps), hammer, chisel, probe-pointed bistoury, dressing forceps, disinfecting and dressing materials. Technic. The operation may be performed upon the standing animal with the aid of local anaesthesia of the skin the bone having virtually no sensation. Restless animals may be further secured with the twitch, in the stocks, upon the operating table or by casting on the sound side. Clip and shave the hair from the region of the frontal bone at that point which the operator has reason to believe is nearest the center of disease. The highest point at which the sinus may be trephined is indicated by F in Plate III. The most central portion of the cavity is reached by trephin- Plate III. Trephining the Facial Sinuses. F, highest point at which an opening may be made into the frontal sinus -without wounding the cranium and brain ; N, opening into nasal sinus ; SM, opening into superior maxillary sinus ; IM, opening into external portion of in- ferior maxillary sinus ; IM', opening into the median portion of the inferior maxillary sinus. TREPHINING OF THE FRONTAL SINUSES. 23 ing on a level with the inferior border of the orbital cavity on the lines FE, Plates V and VI. Trephining at this point gives the operator access to the superior maxillary sinus, SM, Plates IV-VI, through the fenestrum, FE, Plates V and VI. The lowest and generally most essential point for trephining is at ST, Plates IV and V, where the opening affords free drainage externally from the most de- pendent part of the cavity and at the same time offers ample opportunity for securing dependent nasal drainage by breaking through the superior turbinated bone at ST, Plates IV, V and XI. By consulting Plates VII-IX, it will be seen that after reaching the level of the nasal septum, a trephine opening immediately against the median line like that at F, Plate III would wound the septum and superior turbinated bone and penetrate the nasal cavitj'. Consequently the operator must avoid making the trephine opening in this region near the median line, but must keep ij^ to 2 inches laterally therefrom. With a heavy convex scalpel make a circular incision at the desired point as large as the area of the trephine, directly through the skin, subcutem and periosteum down to the bone and remove in one piece the entire mass of encircled soft tissues by seizing the skin with a tenaculum and forcibly separating the periosteum from the bone with the scalpel or bone chiseK Control the hemorrhage. With the center-bit of the trephine extended place it accu- rately upon the denuded area perpendicular to the surface of the bone and grasping the handle firmly turn it to and fro until the bit has penetrated the bony plate and the saw has cut a distinct groove to serve as a guide when the center- bit should be retracted and the operation continued until the disc of bone is detached, being careful to maintain the trephine perpendicular to the surface. The operation is facilitated by grasping the shaft of the trephine between Plate IV. Trephining of facial Sinuses, Right side of face, viewed laterally, showing extent and relations of the sinuses. O, orbital cavity ; SM, superior maxillary sinus ; IM', median portion of inferior maxillary sinus ; NC, nerve conduit of superior maxillary trunk of the trifacial ; IM, lateral portion of inferior maxillary sinus ; F, frontal sinus ; ST, opening through superior turbinated bone for the establishment of drainage from the frontal and superior maxillary sinuses into the nasal passage ; IT, opening through inferior turbinated bone for the establishment of drainage from the median portion of the inferior maxillary sinus into the nasal cavity. TREPHINING OF THE FRONTAL SINUSES. 27 the thumb and fingers of one hand, constituting a support in which it may turn back and forth. The pressure under which the trephining is carried out must not be too great or the instrument may become wedged and broken. When the bony plate which has been isolated begins to loosen, remove the trephine and break, or pry out the piece of bone with the bone gouge or chisel. Smooth any uneven edges of bone with a heavy scalpel or by re-inserting the trephine and using it as a rasp. The abnormal contents of the sinus may now escape through the opening or be re- moved with the curette, forceps or scissors, and the cavity irrigated with an antiseptic fluid. Leave the trephine wound entirely open and irrigate the sinuses daily with antiseptics. The frontal, being in free communication below with the superior maxillary sinus, the irrigating fluids may fall directly into the latter until it becomes filled. The superior turbinated bone of the same side forming the median wall of the frontal sinus, it is commonly perforated by necrosis, in cases of serious disease establishing a communication be- tween the frontal and nasal cavities, through which pus and irrigating fluids readily escape into the nostril. It has been assumed that pus or other contents in con- siderable quantity might pass from the superior maxillary sinus into the nasal cavity through the normal communi- cating slit between the two cavities but a careful study of anatomical arrangement of these parts, opposite N, Plates VII-X, shows very clearly that it is impossible as the margins of the slit acts as a valve and closes it when pressure is applied from within. In order to prevent the aspiration by the patient of the contents of the sinuses, whether pus, blood or irrigating fluids, and to facilitate their escape from the nostril, any irrigation on the recumbent animal should be carried out with the poll elevated and the head flexed. Plate V. Trephining of Facial Sinuses, Oblique lateral view of the face with the sinuses exposed. SM, superior maxillary sinus ; IM', median portion of in- ferior maxillary sinus ; NC, nerve conduit of superior maxil- lary division of trifacial nerve ; IM, lateral portion of inferior maxillary sinus ; F, frontal sinus ; FE, fenestrum of com- munication between the frontal and superior maxillary sinuses ; ST, artificial opening through the superior turbi- nated bone at the lowest part of the frontal sinus establishing a free communication with the nasal passage ; IT, artificial opening through the inferior turbinated bone at the bottom of the median portion of the inferior maxillary sinus, affording drainage into the nasal passage. L-Ft TREPHINING OF THE FRONTAL SINUSES. 31 By studying Plates IV-X it will be seen that any collec- tion of pus or other pathologic contents in the frontal sinus at F would result in poor drainage so far as may be obtained by trephining through the external wall only. The drainage, whether the contents have formed within the frontal sinus itself, or have entered it through the fenestrum, FE, Plates V and VI, from the superior maxillary sinuses should be completed by making an artificial communication through the turbinated bone between the frontal sinus and the nasal fossa at ST, Plates IV, V and XI. This is to be accomplished by breaking through the thin walls of the turbinated bone by means of a probe or other suitable instru- ment and enlarging the opening sufficiently with the probe- pointed bistoury or with the finger. In locating the exact point for making this opening in the turbinated bone it is advisable to pass a slightly curved heavy probe, a pair of long curved uterine dressing forceps or some other slightly curved and somewhat rigid instrument up the nostril to the operative region and having an index finger in the sinus against the median wall, the movements of the sound can easily be felt and the wall be broken down either by pushing the sound up into the sinus or thrusting the finger downwards into the nasal paissage. In order to prevent aspiration of pus, blood or other fluids after the perforation of the highly vascular turbinated bone, the animal must be allowed to get up immediately or if under general anaesthesia a trachea tube should be inserted sufficiently early to avoid danger. Thread a long probe with a heavy suture about 75 cm. long and inserting it through the trephine opening into the nasal passage draw it out through the nostril and removing the probe, attach a strip of gauze 75 cm. long to one end of the suture, draw it out through the nostril and tie the ends together on the side of the face to prevent dislodgement. Retain the gauze in position for about forty-eight hours to 32 TREPHINING SUPERIOR MAXILLIAR Y SINUSES. insure the permanency of the opening through the turbi- nated bone. In case of severe hemorrhage the nasal and sinusal cavities may be tamponed for twenty-four hours with a long strip of gauze which may be secured if necessary by suturing to the lips of the trephine wound. In practice the operation can be best carried out generally with the animal in the standing position the operative area being first anaesthetized by the use of cocaine or by inducing artificial oedema. In the standing position we largely avoid the danger of aspiration of fluids and the hemorrhage is greatly lessened. 4. TREPHINING THE SUPERIOR MAXILLARY SINUSES. Plates III-X. Uses. Empyema, diseased teeth, odontomes or other tumors. Instruments. Same as for the frontal sinuses. Anatomically there are two maxillary sinuses, superior, SM, and inferior, IM, Plates III-X, having a thin im- perforate bony partition between them. This partition shifts somewhat in position with age and in case of disease undergoes profound changes in location and is frequently totally obliterated in cases of empyema, dental cysts and other affections. If the sinusal partition be present, good drainage of the superior sinus may demand the surgical destruction of the partition so that some authors advise trephining directly upon the partition in ordei to open the two cavities simultaneously. In extensive disease of either sinus the partition between the two frequently becomes obliterated so that there remains but one sinus to open ; in limited disease the opening of both cavities is ill advised. In extensive disease the existence of a partition may generally be ignored in operating and TREPHINING SUPERIOR MAXILLARY SINUSES. 33 the trephine opening be aimed at the probable focus of the malady and, should this fail to reach the desired locality, the proper location for the opening may now be determined by digital or other examination through the first opening. A second operation should then be made to directly reach the seat of the affection and if need be, yet a third to secure proper drainage. Shave and disinfect as much of the area as may be re- quired bounded above by the inferior border of the orbital cavity, laterally by the zygomatic ridge, inferiorly by the lower end of the zygoma and medianwards by the middle line of the face. Determine the proper point for operation by percussion or otherwise. If it be desired to enter the superior maxillary sinus only, SM, Plates III-X, locate the opening beneath the orbital cavity and in front of the zygo- matic ridge, SM, Plate III, or at any point directly beneath this to midway between SM and IM, Plate III, at about the level of the dotted line IM'. The trephining is carried out as described for the frontal sinuses on page 19. After the trephining has been com- pleted remove any purulent collection or tumors or carry out any other neces.sary operation in the affected sinuses and after cleansing, if the trephine opening does not insure perfect drainage of the lateral sac, either lower it by cutting away its inferior border with the bone forceps or make a second trephine opening at the necessary point. Since empj^ema of the superior maxillary sinuses is due in the vast majority of cases to infection derived from diseased teeth or dental alveoli it is essential after the sinus has been opened that the operator search carefully and minutely over the alveoli of the molars for naked, eroded tooth fangs or for fistulse leading down into the dental alveoli. If dental disease is recognized the trephining of the sinus is to be supplemented by repulsion of the offending tooth as described on page 8. ♦3 Plate VI. Trephining of Facial Sinuses. Frontal view of right side of face with sinuses exposed. SM, superior maxillary sinus ; IM', median portion of inferior maxillary sinus ; IM, lateral portion of inferior maxillary sinus ; F, frontal sinus ; FE, communication between the frontal and superior maxillary sinuses. SM TREPHINING SUPERIOR MAXIILARY SINUSES. 37 Under the influence of disease the sinuses may extend far beyond their normal location or may contract or become largely obliterated by being filled with new bone or soft tissue. The median portion of the superior maxillary sinus on the inner side of the bony conduit of the trifacial nerve, NF, Plates IV-X, can not always be completely drained through the opening SM, Plate III, and provision for this must then be made by trephining into the lower part of the frontal sinus and thence breaking through the superior turbinated bone, ST, Plates IV-V, into the nasal passage or at times it may be feasible to break through the inner wall of the superior maxillary sinus on the median side of the nerve conduit into the nasal cavity. If the inferior maxillary sinus is also involved good nasal drainage may be had by breaking down the intersinusal partition and then penetrating the inferior turbinated bone at IT, Plates IV-V, and inserting through this opening a long and thick strip of gauze which is brought out through the nostril and the ends tied together on the side of the face to prevent displacement. Retain this in position, renewing daily until the permanency of the opening is assured. It generally occurs in extensive empyema of the sinuses that an opening in the turbinated bone takes place b}' necrosis and in some cases affords the desired drainage while in the majority the pathologic opening is so placed that it is incomplete. Leave all wounds entirely open and irrigate daily with antiseptic solutions. Dangers. Care must be exercised to not injure the superior maxillary division of the trifacial nerve, NF, Plates IV-X, either in trephining or after the sinuses have been opened. The bony conduit of this nerve is in rare cases entirely resorbed by pressure from dental cysts or other causes, leaving it stretched across the cavity as a white nacrous cord, intensely sensitive. Any injury to this nerve Plate VII. Trephining of Facial Sinuses. Cross section of the right half of the head of a horse at the posterior border of the last molar. F, frontal sinus ; IM, lateral portion of inferior maxillary sinus at extreme posterior or superior part ; IM', median portion do. ; N, nasal cham- ber opposite the communication between it and the superior maxillary sinus ; NF, conduit of superior maxillary branch of the trifacial nerve ; SM, superior maxillary sinus ; M^, fragment of last molar. IM-- TREPHINING INFERIOR MAXILLAR Y SINUS. 41 causes intense pain and renders the animal very resistant to the necessary manipulations in the after care of the wound and may leave the patient pernamently nervous about the handling of its face. Hemorrhage is generally not severe and may occur from the skin, where it may be readily controlled by compression or ligation ; from the intra-osseous vessels, where it may be checked by pressure with absorbent cotton, by pushing a small portion of cotton into the channel of the vessel with a needle or tenaculum or by plugging the vessel with a conical piece of wood ; from the wounded turbinated bones where it may be stopped by packing with gauze. These tampons should be removed after twenty-four hours. 5. TREPHINING THE INFERIOR MAXILLARY SINUS. Plates III-XI. Uses and Instruments. Same as in the preceding. Anatomical Outline, The inferior maxillary sinus is an exceedingly irregular cavity, differing in details of form and extent in individuals and at various ages. As shown in the illustrations its disposition might be compared to a pair of saddle bags hanging over the nerve conduit, the lateral and median chambers not very unlike in extent. As suggested in Plates IV-V, the floor of the lateral cavity is broken up by irregular bony septa, which in some cases cut the sinus up into quite separate cavities. Sometimes it extends downwards barely below the end of the zygoma, at other times it reached down below the infra-orbital foramen. There is hence no rule by which the operator may at all times make his opening precisely at the lower extremity of the sinus. Technic. The general technic is the same as for the frontal and superior maxillary sinuses, but two trephine Plate VIII. Trephining the Facial Sinuses. Cross section of the left side of the head of an aged horse at the second molar, seen from the front. F, frontal sinus ; N, nasal sinus, oppo- site the communication between the nasal and inferior maxillary sinuses ; IM, lateral portion of inferior maxillary sinus ; IM', median portion of inferior maxillary sinus ; SM, superior max- illary sinus ; NF, superior maxillary division of trifacial nerve in its bony conduit ; SZ, subzygo- matic artery ; P, palatine artery ; M2, second molar. TREPHINING THE NASAL FOSSAE. 45 openings should always be made. The first opening should be made close against the median side of the zygoma near its lower or nasal extremity, Plate III, IM, and the inferior border lowered sufficiently with the bone forceps to provide thorough drainage for the lateral compartment of the sinus. The second opening is to be made on the median side of the nerve conduit, NC, Plates IV-V as indicated at IM' in Plate III. The location may be accurately determined by palpating with the index finger through the first opening at IM, Plate III. This compartment can not be well drained upon the face through either of the trephine openings and a third opening, penetrating the inferior turbinated bone at IT, Plates IV-V, is essential to ideal results by affording free drainage into the nasal chamber. The opening through the inferior turbine is made in the same manner as described for the opening through the superior turbine from the frontal. Thorough search should be made throughout the sinus for the causes of disease, teeth, etc., these removed and followed by after treatment the same as advised for the two preceding operations. 6. TREPHINING THE NASAL FOSSAE. Plates VII-X. Uses. Operations upon the septum nasi, or the tur- binated bones, or the removal of tumors or foreign bodies from the nasal passages. Instruments. Same as for the frontal sinuses (page 19). Technic. The trephining, N, Plate III, is carried out by the method described above, in the nasal bone, close by the median line of the face and according to indications at any point from a level of the dotted line, SM, Plate III, to the juncture between the nasal and pre-maxillary bones near the upper extremity of the false nostril. Plate IX. Trephining the Facial Sinuses. Cross section obliquely downwards and back- wards through the right half of the head of a two-year old colt at the first molar. F, frontal sinus ; N, nasal passage at point of communica- tion with the inferior maxillary sinus, IM ; IM', median portion of inferior maxillary sinus ; SM, extreme lower end of superior maxillary sinus opened;, [Mi, first molar; M2, second molar; P, palatine arterj- ; SZ, sub-z}'gomatic artery. TREPHINING THE NASAL FOSSAE. 49 A study of Plates VII-X will show that the trephining of these cavities requires great care in order to avoid wound- ing either the highly vascular septum nasi or even more vascular turbinated bones. The operation should be im- mediately against the septum since otherwise the superior turbinated bone may be wounded or an important intra- osseous artery in the nasal bone, just above its union with the superior turbinated, as shown in Plate IX, may be severed. If the turbinated bone is penetrated the frontal, and through it, the superior maxillary sinus is opened and ex- posed to .infection with all its consequences. Special care is accordingly necessary that the trephining should not be carried too deeply, that the bone be barely penetrated, and that the osseous disc be carefully removed in order to avoid the wounding of the turbinated bone, which lies in close proximity to the nasal bone. The operative area is narrow and the trephine used should not exceed 2 cm. in diameter. Whenever possible the operation should be carried out on the standing animal which decreases the hemorrhage and the danger from aspiration of fluids. The hemorrhage may be further controlled in operations upon the septum nasi and turbinated bones by spraying the parts with adrenaline chloride and cocaine. Even in the standing animal, if extensive operations are to be carried out on the very vascular septum nasi or on the turbine, it is advisable to preform trachetomy before trephining, and retain the trachea tube in position until all danger has passed. When the animal is confined in the recumbent position the patient's safety demands that tracheotomy be performed in almost all cases before any operation is begun upon the septum nasi or turbinated bones. After tracheotomy, anaesthesia may be maintained by means of an ordinary funnel with its tube bent at right angles and inserted into Plate X. Trephining of Facial Sinuses. Cross section of the left side of the head anterior to the last molar, and through the widest part of the inferior maxillary sinus. M', last superior molar ; SM, superior maxillary sinus at its antero-iuferior extremity ; IM, in- ferior maxillary sinus, lateral portion ; IM', do. median portion ; N, nasal fossa ; S, sound lodged in lachrymal duct ; NF, trifacial nerve ; F, frontal sinus. Nl-I IM- — SM POLL EVIL OPERATION. 53 the trachea tube while the chloroform is dropped on a towel spread over its mouth. After completing any required operation upon the septum, turbinated bones or other parts, hemorrhage may be controlled by packing one or both nasal fossae with single strips of gauze of sufficient size and carefully securing them by sutures to the sides of the trephine wound or otherwise. 7. POLL EVIL OPERATION. Instruments. Clipping shears, razor, sharp scalpels, one dozen compression artery forceps, probe-pointed bistoury, probe, Luer's bone forceps, bone gouge, curette, suture and dressing material. Technic. Clip the foretop and mane and shave the forehead and the top of the neck back to a distance of 8 or 10 cm. or as much farther as may be required to pass beyond and behind the supposed extension of disease, and disinfect the area. Confine the animal in lateral decubitis preferably upon the operating table, place under complete anaesthesia and remove the halter or other headgear. With sharp scalpel make a longitudinal incision on the median line of the head and neck beginning at a point presumably posterior to the diseased area and carrying it over the poll down onto the forehead for a distance of 4 or 5 cm. below the foretop. Continue this incision through the skin, the subcutem, the adipose tissue, AT, Plate XI, and either through, or passing around . alongside the neck ligament, LN, into the diseased area beneath the latter. Dissect the ligamentum nuchse away from the adjoining tissues as far back as diseased, divide it obliquely upward and backward as indicated at AA, and detach anteriorly from the base of the occiput. Be careful to remove every j^ U a OJ pi & u o ;_( t+-. ^a en .2 a c xn OJ o o '-*-> p. to .Q 'pi u ij '5 a o CO «i -a 1 oj a I-T « 3 a M S <; 3 S +-> g ja ;h 1 t^ -M a a O ■a P< ^ ^ n 1 h. s u W u a ,B , 1 a (!■ a a a 1*, a a o '3 a a •h) o a u o 1*) '3 01 a J 1 ^ ■4-J _a 1 a 2 .s a o tn a a >> "o a ^ a o T s 4-1 & ^ OJ be ., ^ Si a 'a a o a .2 'u -t-' >2 ■TS ■a ■^ a ^ -2j a « .2 Hi a 5 d S POLL EVIL OPERATION. 57 portion of the ligament in the area indicated and all calca- reous deposits or other diseased tissues. With L,uer's forceps groove a channel about 2 cm. wide from behind to before directly upon the median line, through the occipital protuberance to the depth of about 2 cm. mak- ing the bottom as near as possible on a level with the wound in the soft tissues as indicated by the dotted line, AA. Using Luer's forceps as a curette detach all vestiges of the neck ligament from the base of the occiput and leave the bone bare and smooth. If the Luer or ronguer forceps are not available the grooving of the occiput may be accom- plished with a strong curved bone gouge. Or the grooving of the occiput and curetting away of the attachments of the neck ligament to the base of the occiput may be very effectually accomplished with a hoof knife. Be careful to avoid penetrating the cranial cavity or the occipito-atloid articulation. If the operator is not perfectly clear regarding the anatoni5' of the parts he would do well to have before him a sagittal section of the head of a horse which may serve as a guide. In curetting the ligamentous attachments from the occiput the operator should keep the index finger of the left hand at the bottom of the wound, against the occipito-atloid ligament in order to protect it from injury. The operation is rendered safer also by rigid control of the hemorrhage to which end he needs an ample number of compression artery forceps. Control the hemorrhage, cleanse and disinfect the wound, pack with iodoform gauze and suture for its entire length except the anterior part, where the tampon should slightly protrude, and dust the margin of the wound with iodoform and tannin. Remove the tampon after foity-eight hours and dress anti.septically daily. The sutures may or may not be removed according to conditions. In carrying out this operation our chief aim should be to remove all diseased parts, to afford perfect drainage anteriorly, to secure and maintain antisepsis, and to keep the wound directly on the median line from which no visible scar will result. Plate XII, Ligation of the Parotid Duct. Fig. iXSegment of the left ramus of the in- ferior maxilla of the horse seen from the right and beneath, sp, usual operative field ; a, ex- ternal maxillary artery ; v, external maxillary vein ; st, si, parotid duct. Fig.| 5j Life size of operation field on external side of maxilla ; a, external maxillary artery ; z', external maxillary vein ; st, parotid duct ; »/, masseter muscle. LIGATION OF THE PAROTID DUCT. 6l 8. LIGATION OF THE PAROTID DUCT. Plate XII. Objects. The destruction of the parotid gland in case of fistula from wounds or abscesses. Instruments. Razor, convex scalpel, straight probe- pointed scalpel, tenaculum forceps, ligation forceps, tenacula, needle holder, probe, suture and dressing material. Technic. In case of salivarj' fistula insert a probe toward the gland through the fistula into the duct and with a sharp scalpel lay the duct free for a distance of from i to 2 cm. on the glandular side of the fistulous opening. If the fistula has its location on the side of the cheek, cast the horse and shave and disinfect the region on the inferior maxilla where the artery, vein and parotid duct turn around its inferior border. When the operator glides his finger over the vascular region forward and backward there is felt a resistant cord, the pulsating external maxillary artery about 3 mm. in diameter. Between this and the oral border of the masseter muscle make an incision about 4 cm. long parallel to the artery through the skin and skin muscle. Pick up the loose connective ti.ssue with a pair of forceps and excise it. Immediately behind the external maxillary artery, a, Figs, i and 2, Plate XII, is the external maxil- lary vein, V, and behind this and immediately at the border of the masseter muscle lies the parotid duct, si. In case of salivary calculi which cannot be removed through the mouth or of cystic dilation of the parotid duct, make the cutaneous incision at the affected point, open the canal, and after the removal of the calculus, etc., close the duct wound by means of intestinal sutures in such a way that the external surfaces of the lips of the wound in the wall of the duct are brought in contact, or ligate the duct on the proximal side of the point of operation and destroy the gland. 62 ENTROPIUM OPERA TION. Ligation of the duct is accomplished by passing a strong silk thread beneath the duct by means of a curved aneurism needle, carrying the ligature around the duct and tying with a surgeon's knot. The parotid duct may also be previously split and an internal wound made at the point of ligation. Close the skin wound by means of a continuous suture and cover the operative surface with iodoform collodion or with wound gelatine. 9. ENTROPIUM OPERATION. Instruments. Razor, scissors, convex scalpel, tenaculum and ligation forceps, tenacula, needle holder, needles, thread, absorbent cotton. Technic. Quiet adult horses may be operated upon in the standing position with the aid of local anaesthesia, other horses and small animals should be secured in lateral re- FlG. I. Entropium operation on the superior and inferior eyelids of the dog. cumbency preferably upon the operating table. Shave and disinfect the skin of the inverted eyelid. Grasp the skin of the eyelid midway between the inner and outer canthi with the forceps and elevate a skin fold parallel with the border of the eyelid to such a height that the inverted member assumes its normal position. Pass a finger into the STAPH YL O TOMY. 63 -conjunctival sac to make sure that the conjunctiva is not drawn into the skin fold. Clip the fold off with the scissors immediately below the forceps, removing an oblong piece. Between the border of the eyelid and that of the wound the skin should be left intact for at least .5 cm. Ligate or compress any bleeding vessels and close the wound by means of interrupted sutures. The wound may be covered with iodoform collodion or wound gelatine or dusted over with iodoform-tannin. It is usually unnecessary and inadvisable to cover the parts with hood or other appliance since so long as the wound is healing properly the animal will not disturb it. 10. STAPHYLOTOMY. Object. An operation devised by Dr. M. H. McKillip for making a manual exploration of the Eustachian tubes, guttural pouches, larynx, pharynx and posterior nares ; and for operations upon these structures. The form and extent •of the soft palate of the horse is such as to render it ex- tremely difficult to make a manual exploration of the parts above and behind it, and impossible to make a visual ex- amination except with the aid of the expensive and compli- x:ated rhino-laryngoscope, which only aids in diagnosis while -staphylotomy combines with this operative advantages, per- mitting the free introduction of the hand into the laryngo- pharyngeal region. Instruments. Mouth speculum, short curved probe- pointed bistoury with a ring to fit the middle finger. Technic. Cast the patient or secure on the operating table in lateral recumbency and turn the nose upward. Adjust the mouth speculum and open the mouth as wide as possible ; draw the tongue well out with the left hand while the right carrying the knife on the middle finger is passed 64 TRIFACIAL NEUROTOMY. carefully through the fauces uutil it hooks over the posterior border of the soft palate. The knife is then gently drawn forward making an incision along the median line of the soft palate from its posterior, free border to its attachment on the palatine bone. The hand is then withdrawn and the speculum removed for a few minutes to permit the patient ta rid its pharynx of any blood clots or mucus that may have accumulated. Readjusting the speculum as before, the right hand is again passed through the fauces and now that the palate is divided a manual exploration may perfectl3f" reveal the presence of any abnormality in the region. 11. TRIFACIAL NEUROTOMY. Plate XIII. Object. The relief of involuntary shaking of the head- Instruments. Razor, scissors, convex scalpel, tenacula, aneurism needle, compression artery forceps, needles, thread, absorbent cotton, a strong piece of muslin 12 cm. square. Technic. Secure in lateral recumbency, preferably upon the operating table, and produce complete anaesthesia. Re- move the halter, bridle, or other headgear. • Shave and disinfect an area 8 to 10 cm. square over the infra-orbital foramen. Locate by touch the infra-orbital foramen, lOF, Plate XIII, below the levator labii superioris proprius muscle and displace this slightly upward toward the median line of the nose until the foramen can be clearly felt below the muscle. With the scalpel begin an incision somewhat superior to the foramen and near its nasal border and make a wound downward and forward in the direction of the commisure of the lips about 5 cm. long through the skin, muscle and connective tissue down to the nerve and control hemorrhage with the greatest care. If the larger branches of the glosso-facial vessels are severed they should be ligated TRIFACIAL NEUROTOMY. 55 or twisted. It is even better to ligate or compress these vessels prior to severing them. Hold the lips of the wound apart with two tenacula or by placing a strong suture through each wound margin and through the skin at a point 6 to 8 cm. distant and tying the sutures tightly, dilate the wound thoroughly and dissect away the connective tissue from the nerve until every part of it is clearly in view. Pass an aneurism needle beneath the nerve trunk and lifting it from the bone make a search for a small artery which usually passes along beneath it through the foramen and if this can be found either ligate it immediately at its point of emergence and again 5 cm. lower down and divide between the two ligatures or separating it from the nerve protect carefully against injury. With a probe-pointed bistoury or scissors sever the nerve at the foramen and grasping the distal end dissect away about 5 cm. of the trunk and excise. Be very careful to include all branches and especially one or two superior or dorsal twigs which are dire^qted upward just as they emerge from the foramen. After the hemorrhage has been brought under complete control and all blood clots have been removed cleanse the wound carefully, dust over with iodoform and close with continuous sutures. In order to protect this first wound during the operation upon the other side take the piece of muslin mentioned among the needs for the operation, and folding it several times in a square, place it over the wound and suture it firmly at each corner to the skin. Turn the animal to the opposite side and repeat the operation on the other nerve except the application of the square piece of muslin which is here unnecessary. If circumstances will at all permit it is far safer to operate upon only one side first, allowing this to heal and then operate upon the other side. As soon as the animal stands, remove the protective piece of muslin from the first wound, disinfect both wounds, dust 5 Plate XIII. Trifacial Neurotomy. IvL, levator labii superioris proprii muscle ; lOF, infra-orbital foramen ; NF, superior max- illary division of the trifacial nerve. TRIFACIAL NEUROTOMY. 69 them over with iodoform and tannin or cover with wound gelatine and leave undisturbed to heal by primary union. Avoid halter, bridle or other fixtures which might injure the wounds after the operation. In some cases the operation may be performed upon the standing animal under local anaesthesia and whenever this is possible it is greatly to be preferred since the hemorrhage is far lessened and the danger from sepsis reduced, but with most affected animals the standing operation is impractic- able. Dangers. The chief danger in the operation is from in- fection, which sets up a severe neuritis in the proximal end of the nerve, aggravates the symptoms and causes much suffering. In order to prevent infection the aseptic precau- tions need be unusually strict in every detail and the anaes- thesia profound. Carefully avoid wounding the neighbor- ing vessels and control completely any hemorrhage that occurs in order to avoid a hematom in the wound, which always invites infection. Literature. Involuntary twitching of the head relieved by trifacial neurectomy. W. ly. Williams, Jour. Comp. Med. and V. A., vol. XVIII, p. 426. Involuntary shaking of the head and its treatment by trifacial neurectomy, do. Am. Vet. Rev., vol. XXIII, p. 321 and CEst. Monatsch. Thierheilkunde, Bd. XXIV, s. 211. ^l.co'lQ ¥- i J -^y^'k^^yM^^^ II. OPERATIONS ON THE NECK. 12. OPENING OF THE GUTTURAL POUCHES. Plate XIV. Instruments. Razor, Scissors, convex sharp-pointed and straight probe-pointed scalpels, artery forceps, tenacula, probe, trocar, curette, drainage tubing, suture and dressing material. Technic. I. Viborg's method. The operation is possible on the standing animal, but generally the patient must be cast or placed on the operating table and secured in lateral decubitis with the head extended. By extending the head and compressing the jugular vein there is brought out the triangle immediately behind the posterior border of the in- ferior maxilla and below the parotid gland comprised be- tween the posterior angle of the inferior maxilla, the terminal tendon of the sterno-maxillaris muscle and the external maxillary vein. In this so-called Viborg's triangle after the removal of the hair and the disinfection of the skin which is maintained stretched, make a 5 cm. long incision through the skin and skin muscle immediately beneath the aforementioned tendon and parallel to it. In case of pronounced swelling in Viborg's triangle the operator must determine the location for the incision by the position of the sterno-maxillaris muscle. The skin, subcutem and cervical fascia having been incised to a sufficient extent, force a passage with the finger or with closed probe pointed scissors or other blunt instrument through the loose connective tissue on the median side of the parotid gland, to the guttural pouch and penetrate it at its lowest point with the finger or trocar. In order to open the empty guttural pouch as an exercise operation it is desirable to grasp a portion of its wall by means of forceps. Through the operative wound a drainage OPENING OF THE GUTTURAL POUCHES. 71 tube can be introduced into the pouch, and fixed in position by sutures. The opening can be enlarged in an antero- posterior direction to the extent of 5 to 8 cm. or large enough to admit the operator's hand. Through this enlarged wound, the operator may palpate the Eustachian tube and other portions of the interior of the pouch and perform desired operations. A far more common operation in veterinary practice than the opening of the guttural pouches, is the opening of strangles abscesses of the sub-parotid lymph glands, lying between the inner face of the parotid gland and the external face of the guttural pouch. The operation here used is the same as Viborg's for the guttural pouch but does not penetrate that cavity because the inner wall of the abscess has pushed the external wall of the pouch inward so that the former largely occupies the usual location of the latter. The dyspnoea generally prohibits casting the animal and necessitates operating in the standing position. In some cases the dyspnoea is so severe as to demand tracheotomy before the opening of the abscess can be undertaken because the excitement aggravates the difficult respiration to the point of suffocation. II. ChaberV s method. Secure the horse in the lateral re- cumbent position, remove the hair and disinfect the skin beneath the wing of the atlas. Make an incision about r cm. in front of the lower half of the wing of the atlas and parallel to it, about 6 cm. long extending through the skin and skin muscle down to the parotid gland. The incision is facilitated by rendering the skin tense with the left hand! and care is to be taken not to wound the auricular nerve which passes directly along the atlas. Then draw backward the posterior lip of the wound and separate with blunt in- struments the posterior border of the parotid gland from the atlas, to which it is bound by loose connective tissue, and draw it forward with tenacula. At the bottom of the Plate XIV. Opening of the Guttural Pouches (Hyoyertebrotomy) According to Viborg and Chabert. Head and neck of recumbent horse viewed from the side, sm, stylo maxillaris^^muscle ; /, parotid gland ; /, guttural pouch ; k, larynx ; st, sterno-maxillaris muscle ; r, rectus capitus anticus major muscle ; c, external carotid artery ; e, external maxillar)' artery ; i, internal maxil- lary artery ; v, external maxillar}' vein ; .j, probe ; a, wing of atlas. OPENING OF THE GUTTURAL POUCHES. 75 opening thus formed there is seen the stylo-maxillaris muscle, sm, Plate XIV, lying against the median side of the parotid gland covered only by the aponeurosis of the mastoido-humeralis muscle. With the handle of the scalpel inclined toward the wing of the atlas penetrate in the direction parallel to the long axis of their fibers the aponeu- rotic expansion of the mastoido-humeralis, and the stylo- maxillaris muscle. The puncture is thus located between the ninth and tenth nerves on one side and the internal carotid artery on the other. Since the wall of the guttural pouch rests against the median side of the digastricus or sterno-maxillaris muscle it is opened by this incision. The operator inserts an index finger along the blade of the knife at first and then withdrawing the instrument passes the other index finger also into the penetrant wound and by forcibly parting these, dilates it. The abnormal contents are then removed by means of forceps, curetting and irriga- tion. In order to prevent adhesion of the wound lips in the firmly stretched stylo-maxillaris muscle, introduce a strong drainage tube into the pouch and fix it to the external borders of the wound by a suture. III. DietericK" s method. This operation is effected at a point between I and II, the opening of the pouch being made immediately behind the stylo-maxillaris muscle. In order to accomplish this the cutaneous wound over the wing of the atlas must be prolonged below it. After detaching the posterior border of the parotid gland the operator searches in the loose areolar tissue with the index finger of the left hand for the vascular angle which is formed by the occipital, internal carotid and external carotid arteries which may be detected by pulsation — the same is located at a depth of from 8 to lo cm. Place the volar surface of the finger in the vascular angle and push a sharp scalpel along its dorsal side to the pouch which here becomes opened on its posterior lateral surface. 76 TRACHEOTOMy. This method has the advantage over Chabert's that for the removal of hard contents (chondroids) the opening can be readily dilated, even to such an extent that the entire hand may be passed into the air sac and the opening of the Eustachian tube be explored as in Viborg's operation. 12. TRACHEOTOMY. Fig. 2. Instruments. Razor, scissors, convex scalpel, tenacula, tenaculum and ligation forceps, trachea tube, and suture material. Technic. In the superior third of the cervical region, in the neighborhood of the fourth to the sixth tracheal ring, shave and disinfect the skin on the anterior surface of the neck to the extent of lo cm. long bj' 5 cm. wide. The operation is best performed upon the standing animal with the head extended. In lateral decubitis the operation is carried out with some difficulty, and generally the operator fails to get the incision on the median line. The operator stands before the right shoulder of the horse with an assistant opposite him. Render the skin tense along the median line of the trachea with the left hand and then make a drawing cut 5 to 8 cm. long from above to below with the scalpel. The incision should be made carefully upon the median raphe of the skin which is virtually destitute of sensation and requires no anaesthesia. After the skin muscle is cut through, in order to avoid hemorrhage, separate the two sterno-thyro- hyoideus muscles by means of tenacula along the median raphe in the white strip of connective tissue. The opening into the trachea may be made in a variety of ways. The quickest and most crude method is to slit it from above downwards through two or three tracheal rings, and press- TRACHEOTOMY. 77 ing the several ends apart insert the tube through the open- ing. Since the tracheal rings are incomplete, being open on their dorsal surfaces, cutting through the ventral portion divides each ring into two separate parts and their being pushed apart, distorts them and tends to the causation of chondritis and collapse of the trachea, a danger which in- creases with the duration of time that the tube is maintained in position. It is therefore most suitable for hurried opera- tion in impending suffocation where the tube will probably be needed for a short time only. Tracheotomy, s, sterno-thyro-hyoideus muscle ; t, trachea ; sch, mucous membrane of the posterior wall of the trachea ; /, interannular ligament. A second method of operation, illustrated in Fig. 2, con- sists in making a transverse incision through the inter-annu- lar ligament between the two last exposed tracheal rings the length of the diameter of the tube to be inserted. Make a perpendicular incision upward from each end of this at a point I to 1.5 cm. from the median hne through one or two tracheal rings, according to the size of the tube. With forceps or tenaculum grasp the segments of partially de- 78 THE OPERATION FOR ROARING. tached cartilage and remove them by cutting through the inter-annular ligament. A third and to us preferable method is to insert a narrow bladed scalpel transversely at about the lower third of the lowermost bared tracheal ring and cutting outwards and upwards in a curved line, pass through the first inter-annu- lar ligament and continue into the succeeding segment until near its superior border, when the incision is curved down- ward to eventually reach the starting point, the isolated section of the trachea being securely grasped with a pair of forceps before its excision is completed. By this method no tracheal ring is severed. The trachea tube is to be removed and cleansed daily as long as its use is necessary, and when discontinued the wound should be left open and dressed antiseptically. 13. THE OPERATION FOR ROARING. Plate XV. Figs. 3-5. Instruments. Razor, hypodermic syringe, scalpels, tenaculum, artery forceps, laryngeal speculum, two long curved dressing forceps, hard rubber syringe with long pipe, ventricular burr, reflecting lamp, razor-shaped scalpel, long curved scissors. The following technic has for its aim two fundamental objects which are to be kept constantly in mind : I. It is aimed to bring about a prompt, firm, complete and permanent adhesion of the arytenoid cartilage and vocal cord against the inner face of the thyroid cartilage in the normal position of forced inspiration, so that no air can become impacted into the ventricle to force the vocal cords and arytenoid cartilage downwards and inwards to obstruct the free ingress of air. THE OPERA TION FOR ROARING. 79 2. It is aimed to complete the operation without wound- ing a cartilage either in the essential operation when re- moving the ventricular mucosa, during the invading incision through the crico-thyroidean membrane, and later, should dyspnoea occur, by inserting the laryngeal tube through the existing incision instead of performing tracheotomy. Technic. Docile animals are readily operated upon in the standing position. The animal should be confined in stocks, or otherwise, in such a manner that his head may be securely held in an elevated and extended position. The safety of the operator further demands that the patient shall be so secured that he can neither rear nor strike. Resistant animals need be cast or confined upon the operating table. General anaesthesia upon the recumbent animal is usually unnecessary, and is only demanded in those cases of unusual resistance to confinement, where the patient may injure itself by its violent struggles. Ordinarily ample anaesthesia, whether from the stand- point of surgical efficiency or of sentiment, is obtainable by the use of local anaesthetics, preferably of cocaine and adrenaline. Shave and disinfect the operative area, and inject sub- cutaneously a sufficient amount of the local anaesthetic. Make a longitudinal incision over the larynx through the skin and fascia as accurately as possible on the median raphe, commencing opposite to the anterior extremity of the thyroid cartilage and extending downward and back- ward to the region of the first tracheal ring. Separate the sterno-thyro-hyoideus muscle on the median line with the scalpel blade or handle as preferred. Control the hem- orrhage. If the operation is performed upon the standing animal with the aid of cocaine and adrenaline, the incision is virtually bloodless. Locate the crico-thyroidean ligament, triangular in form, bounded anteriorly and on both sides by the thyroid cartilage ^^te\v^ Operation for Relief of Roaring. Fig. I. Longitudinal section through the ventricle of the larynx ; A, arytenoid cartilage ; TA, anterior fasiculus of thyro-arytenoideus muscle ; TA', posterior bundle thyro-arytenoid- eus ; VC, vocal cords ; V, laryngeal ventricle ; ^T, thyroid cartilage ; E, epiglottis. Fig. ^. Sagittal section of the larynx. C, cricoid cartilage. Other lettering same as Fig. i. Fig. 2. n r- THE OPERATION FOR ROARING. 83 and posteriorly by the cricoid ring. Error may occur here and the space between the cricoid and first tracheal rings be mistaken for the crico-thyroidean ligament. This is readily obviated by careful digital palpation, which reveals the triangular crico-thyroidean ligament with its rounded apex directed forward and its lateral borders sharply defined by the hard borders of the alse of the thyroid cartilage, while the base of the triangle rests upon the more elastic anterior border of the cricoid cartilage. Fig. ^ Laryngeal dilator in position. Having carefully identified the crico-thyroidean ligament, place the back of the scalpel against the anterior border of the cricoid cartilage, accurately upon the median line, the point directed obliquely backwards toward the cavity of the trachea. Push the scalpel through the ligament into the 84 THE OPERA TION FOR ROARING. laryngeal cavity, and carry the incision forwards on the median line to the body of the thyroid cartilage. Detach the slotted piece from the laryngeal retractor (Fig. 4) and insert the closed retractor into the incision through the ligament, the ratchet end of the speculum being directed toward the trachea, the curved spurs on the jaws of the retractor resting within the cricoid ring. Open the dilator to the full extent of the crico-thyroidean space. Insert the hook of the slotted piece into the cavity of the thyroid cartilage and secure in position by means of the thumb screw. Illuminate the cavity of the larynx. In the standing animal, when facing good light, the natural illumination suffices. The illumination may be improved with the aid of a hand mirror. Excellent illumination is always available by means of a reflecting electric lamp. With a good lamp the illumination may be perfectly controlled in a dark room or in the dark- ness of night. When the animal is cast and turned upon his back, the light rays should enter the larynx from above obliquely downward and forward. If the operation is being done in the open field by sunlight, the patient's head should be directed away from the sun, or good illumination fails. Observe the motion of the arytenoid cartilages, and determine, if not previously done, whether the unilateral or bilateral operation is to be performed. Inject into the larynx and laryngeal ventricle or ventricles a sufficient quantity of a solution of cocaine and adrenaline to blanch and anaesthetize the mucosa. The ventricles are more con- veniently injected if the syringe nozzle is bent near the tip. The ventricles commonly contain some mucus, which interferes with the securing of the mucosa and should be taken up and removed by means of a small piece of absorbent cotton pressed into the ventricle with the long curved dress- ing forceps. When the ventricular mucosa has been effectively anaes- thetized introduce the burr into the ventricle and draw the THE OPERATION FOR ROARING. 85 sheath on the burr shaft away from the burr for the distance of about I cm. Press the burr gently against the bottom of the ventricle, hold the canula to prevent its revolving, and give the burr one or two turns to the right until the re- sistance indicates that the mucosa is securely engaged. The canula is now pushed against the burr and gentle traction applied to the handle, revolving the burr and canula ^-' Fig. \ Fig. S. Laryngeal dilator. Ventricular burr, modified after Blattenberg. now and then a trifle, until the everted mucosa from the bottom of the Ventricle appears beyond the mouth of the ventricle. Grasp the everted portion of the mucosa securely with the long curved dressing forceps and then continue traction with these until the ventricular mucosas has been completely everted. Then cut away the everted mucosa by excising it with the razor-shaped scalpel or by means of 86 THE OPERATION FOR ROARING. long scissors at approximately the point indicated by the dotted line in Plate XV. If the right side of the larynx appears to be affected also, or if for other reasons it seems desirable, repeat the operation upon the right ventricle. (The operation may also be performed without the use of the ventricular burr, but it is more difficult, especially upon the standing animal. The technic is the same until the removal of the ventricular mucosa is reached, when, instead of the burr, the mucosa of the ventricle at its arytenoid border is grasped with the forceps, tension is applied, and the mucosa is incised along the arytenoid border and thence along the summit of the vocal cord. The incision is con- tinued at the point indicated by the dotted line in Plate XV until the ventricular mucosa has been isolated from that of the larynx in general. Cautiously exerting tension with the forceps upon the incised border of the ventricular mucosa, dissect it away from the loose underlying areolar connective tissue either with the Moeller razor-shaped scalpel or with a scalpel handle.) However the mucosa is removed the operator should take care that the removal is complete, since any remnant incautiously left behind in the ventricle may prevent the desired adhesion of the arytenoid to the thyroid cartilage or a small patch of mucosa being left deep in the ventricle might permit adhesion of other parts, imprisoning the mucous islet and ending in a mucous cyst. When the mucosa has been removed from one or both ventricles, all blood coagula should be wiped away, any shreds of tissue removed and the denuded tissues painted over with tincture of iodine. The application of the tincture of iodine is best made with the long curved dressing forceps carrying a small pledget of cotton saturated with the drug. The operator needs have care in this application lest the horse in forcible expiration blow some of the iodine in his face and eyes. THE OPERA TION FOR ROARING. 87 If the patient has been cast, anaesthetized and turned upon his back, turn him upon his side, remove the confining apparatus, and, while he is recovering from the anaesthesia, keep the laryngeal incision open and the larynx free from blood. The hemorrhage from the operation is the greatest when it has been performed under general anaesthesia, less if cast and the operation performed under local anaesthesia and by far least of all when it is performed upon the stand- ing animal with the aid of cocaine- adrenaline anaesthesia. As soon as the operation has been completed upon the standing animal, the head may be released and the patient returned to the stall. It may be allowed to eat or drink at convenience. The same is true of the patient cast for the operation, and only local anaesthesia applied. Patients cast and chloroformed should be prevented from eating or drinking for some hours and should be fed sparingly for three or four days. During the first 48 hours after operating, especially after the bilateral operation, the patient should be closely watched in reference to dyspnoea either from hematoma in the ventricles or from edema or emphysema of the parts. If dyspnoea becomes at all apparent, tracheotomy should be promptly performed, or what we greatly prefer, a laryngeal tube should be inserted and fixed securely to the margins of the external wound by means of stout sutures, and further security given by passing strong tapes about the neck and. tying firmly. Ordinarily the ventricular wounds should not be disturbed', after the operation. The external wound should be dressed anti.septically daily till healed ; a period of about three weeks. Horses used for ordinary work purposes may usually be returned to their work after five to six weeks. S8 INTRA VENOUS INJECTION. 14. INTRA-TRACHEAL IRRIGATION. Objects. The washing out of oils or other insoluble or irritant substances accidentally introduced into the trachea and bronchi while drenching or otherwise, and the disin- fection of the trachea and bronchi. Instruments. Same as for tracheotomy, and a gravity irrigating apparatus fitted with 3 m. of rubber tubing about I cm. in diameter, 5 liters of .6 per cent, sodium chloride solution at a temperature of 37 to 39" C. In cases of suppurative bronchitis, peroxide of hydrogen may be added to the solution. Technic. Operate on the standing animal. Perform tracheotomy (page 76). Elevate the gravity apparatus containing the irrigating fluid i to 2 m. above the patient, have the animal's head slightly elevated, insert the free end of the rubber hose in the trachea tube and let the fluid flow into the trachea in a moderate stream until it is filled and the animal makes expulsive efforts, when the inflow is stopped and the animal permitted to lower his head and expel the fluid, then raise the head again and repeat until the fluid is expelled clear. Repeat the operation according to requirement. 15. INTRAVENOUS INJECTION. Fig. 6. Instruments. Scissors, hypodermic syringe. Technic. The operation is performed on the standing animal on either jugular vein at about the juncture of the upper and middle thirds of the neck ; to most operators the right jugular is the more convenient. At the place desig- nated the subscapulo-hyoideus muscle lies between the jugular vein and the carotid artery and affords some pro- tection against injury of the latter. After clipping the hair, INTRAVENOUS INJECTION. 89 the skin should be carefully disinfected preferably with tincture of iodine. The vein lies in the jugular groove between the mastoido-humeralis and the sterno-maxillaris muscles covered only by the skin and skin muscle. Stand by the shoulder of the horse and compress the jugular with the thumb as shown in Figure 6 or with the second to the fourth fingers, in which case the ball of the thumb rests on the mastoido-hutiieralis muscle, in a way that the vein becomes filled above the point of compression in the Fig> 6. Intravenous Injection. shorn area and stands out as a swollen cord. In the case of fleshy necked horses efficient compression is more readily attained if the head is somewhat elevated and extended by an assistant. If the vein cannot be made prominent in this way the compression should be alternately applied for a time and then withdrawn suddenly, when the course of the vein reveals itself by a wave-like movement along the jugular groove. go INTRAVENOUS INJECTION. In cattle digital compression of the jugular is not usually efficient in causing distension. It is more practical to dis- tend the jugular by passing a looped cord around the base of the neck and drawing it tightly. The very conical neck of the cow tends to cause the cord to slip forward and loosen, which may be obviated by having an assistant grasp the cord at the top of the neck and hold it in place. A very efficient method for distending the jugular of the cow is to stretch a strong cord tightly between two posts at the heighth of the base of the neck, lead the animal against it and secure the head firmly to a post in front of the animal sufficiently tight to cause the lower part of the neck to press firmly against the cord. Just above the point of compression the vein is the most fully distended and firmly fixed. After testing the hypo- dermic needle to see that it is open hold it between the second and third fingers while the thumb covers its basal opening and thrust it through the skin, cutaneous muscle and jugular wall, in the direction of the vein obliquely for- wards and upwards i to 2 cm. deep, so that the point of the needle enters the vessel at its most distended part. In this way it is easy to prevent injury to the median wall of the vein. If the vein has been properly punctured blood will flow from the needle upon the removal of the thumb. If the vein is not entered at the first attempt the needle should be partly withdrawn and then pushed in again in a slightly different direction. Be careful that the hypodermic syringe contains no air. The material to be hijected should be warmed to approxi- mately the body temperature. The syringe is then connected with the needle and the contents slowly discharged into the vein. In withdrawing the needle be careful to press the skin firmly against the underlying part. The omission of this precaution frequently results in the formation of a subcutaneous hematome. PHLEBOTOMY. gi 16. PHLEBOTOMY. Fig. 6. Instruments. Razor or scissors, fleams, lancet, phle- botomy trocar, spring lancet, pins, suture material. Technic. a. Phlebotomy with fleams may be performed on either jugular vein. The operation is preferably carried out on the standing animal, but is not difficult when the patient is recumbent. The point of operation is at about the boundary line between the upper and middle cervical regions, because it is here that the subscapulo-hyoideus muscle which separates the jugular vein from the carotid artery is most voluminous and consequently affords the greatest protection to the latter. At this point clip or shave and disinfect the skin. Grasp the extended blade of the fleam at the hinge with the thumb and index finger of one hand, while the third and fourth fingers compress the jugular vein at a point far enough below that the fleam blade rests upon the shaved part. In fleshy-necked animals the course of the vein may be clearly made out by causing its repeated distension and relaxation. In some very heavy necked horses, or in very restless animals, efficient distension of the jugular is best obtained by cording the neck as described under " Intravenous Injection." It is well to be careful that the point of the fleam blade is not allowed to prick the skin prematurely and render the animal restless. The instrument should be held perpen- dicular to the surface and parallel to the long axis of the vein. The most elevated point of the vessel should be struck by the blade in such a way that the skin, subcutan- eous muscle and jugular wall are penetrated parallel to the long axis of the vessel. Drive the fleam blade into the vein by a short, sharp blow with a small stick of heavy wood. The extension on the fleam blade prevents its being driven too deeply. The size 92 PHLEBOTOMY. of the blade to be used depends upon the thickness of the skin and other tissues covering the vein. If the vein is opened, dark red blood escapes from the wound in a large stream. If the operation does not succeed at the first effort, one should select an undamaged portion of the skin for a second attempt so that the opening into the vein may be direct and clean. When the vein is opened lay the instrument aside. The compression of the vessel must be continued in order to insure the flow of blood, to prevent aspiration of air and also to provide that the lips of the skin wound shall not be- come displaced in relation to that of the vein by which the escape of blood would be impeded or stopped. The flow of blood may be favored by inducing masticatory movements by the animal. The amount of blood withdrawn varies between 3 and 8 liters, according to the size of the animal and the object to be attained. The wound may be closed by an interrupted or a pinned suture. For the latter, relieve the compression on the vein and grasp the lips of the skin wound between the finger and thumb and stick the pin perpendicularly through the middle of them a few mm. from their borders. Apply a noose of silk ligature, previously prepared, over the pin and close and tie the loop. In applying the pin' and loop, take care not to elevate the skin from the underlying part, which tends to the production of a hematome. b. With the lancet the operation is preferably performed on the right side of the neck. Compress the vein as illus- trated in Fig. 6, and hold the lancet between the thumb and index finger in such a manner that it can only penetrate as far as into the vein, and then push it in quickly just in front of the compressing thumb through the skin, subcutem and venous wall as deep as the fingers holding the lancet will permit. Hold the blade perpendicular to the long axis of the vein, and avoid directing the point dorsalwards, which would LIGATION OF THE CAROTID ARTERY. 93 endanger the superior wall of the vessel or cause the lancet to glide over the wall and not enter the vein. When the lancet has entered the vein, extend the wound somewhat toward the head by flexing the hand dorsally. In cattle it is necessary to compress the vein by means of a cord tightly drawn around the neck, the operator taking the same posi- tion as in the horse while an assistant holds the animal by the horns or nose, or the vein may be still more effectively distended by causing the patient to press against a tightly stretched cord with the base of the neck as advised for intravenous injection on page 88. Close the wound as in a. Phlebotomy with the spring lancet is carried out in a similar manner, the jugular being compressed in the same way, and the lancet, with the spring set, placed over the vein in such a way that the opening will be made in the same direction and manner as with the fleams. The lancet blade is then released and penetrates the vein. The com- pression below is continued as in other cases. c. Phlebotomy with the trocar is performed in the same manner as has been described for intravenous injection. So long as the flow of blood continues the compression of the vein must not be intermitted. The phlebotomy trocar should be about 5 mm. in diameter. 17. LIGATION OF THE CAROTID ARTERY. Plate XVI. Objects. The control of hemorrhage from wounds or the prevention of hemorrhage during the removal of tumors or other operations in the parotid region. Instruments. Scissors, scalpel, tenacula, aneurism needle, mouse-toothed forceps, ligation forceps, suture material. Technic. The operation is possible on the standing animal with the aid of cocaine or other local anaesthetic but 1 '^ Plate XVI. Fig. I. — a. Ligation of the common carotid artery ; /), QJsophagotomy. Fig. 2. — Ligation of the common carotid' artery ; i\ common carotid artery;/, jugular vein ; v, vagus nerve; i, sympathetic nerve ; r, recurrent nerve ; p, cervical panniculous carno- sus muscle ; ;//, .sternomaxillaris mus- cle ; sf. levator humeri muscle. Fig. 3. — QJsophagotomy. t:, com- mon carotid artery ; /, jugular vein ; o, 0' , (esophagus ; 5, sympathetic nerve ; t, trachea ; st, mastoido-hum- eralis (lavator humeri) muscle. Fig. 1. Fig. 2. ^ ir LIGATION OF THE CAROTID ARTERY. 97 it is preferable to confine the patient in laternal recumbency and anaesthetize. The operation is made at the same point as for phlebotomy and the same cutaneous wound, «, Plate XVI, may be used for this purpose. The incision should be .at least 10 cm. long extending through the skin, fleshy pahniculus and subscapulo-hyoideus muscles and then a passage forced with the fingers to the trachea. At the region of the neck indi- cated, the carotid passes along the border between the lateral and dorsal surfaces of the trachea, accompanied dorsally by the vagus and sympathetic nerves and ventrally by the recurrent. (In Fig. 2, Plate XVI, the vagus and sympathetic nerves, v and s, are pushed out of their normal position and appear ventrally to the carotid.) Pass the index finger over and behind the carotid until the trachea is reached, and encircling the inner and lower sides of the artery, force a way through the surrounding areolar tissue and draw the vessel out through the wound. As a rule the carotid is still loosely surrounded by connective tissue, which comes from the deep fascia of the neck and in which also the three above mentioned nerves are found. These nerves must be carefully separated from the carotid and must on no account be included in the ligature. Ligate the carotid twice with an interval of about 2 cm. between the two ligatures and divide the artery midway between them. The second ligature is necessary in order to prevent hemorrhage from the distal end through collateral anasto- moses and it is es.sential to sever the artery in order to avoid its rupture by the stretching of the undivided carotid dur- ing movements of the neck where the nutrition has been cut off at the point of ligation. Provide drainage for the wound and suture the muscle and skin. gS OESOPHAGOTOMY. 18. OESOPHAGOTOMY. Plate XVI. Instruments. Razor, scissors, convex scalpel, straight probe-pointed bistoury, tenacula, artery forceps, absorbent cotton, suture material. Technic. The operation can be carried out on the standing or the recumbent animal. At its origin the oesophagus lies above the trachea somewhat to the left of the median line and as it decends it gradually deviates farther until in the lower cervical region it lies down along the left side of the trachea. The operation is performed at any point between the pharynx and chest where the lodgment of a foreign body or other condition may demand it. When the oesophagus is empty the operation is best performed in the lower third of the neck at b, Fig. i, Plate XVI. An incision lo cm. long through the skin and skin muscle is made on the left side between the anterior border of the mastoido-humeralis muscle and the jugular vein. With the two index fingers divide the loose connective tissue down to the oesophagus, which lies between the left scalenus muscle, trachea and jugular vein. Along the supero-external border of the trachea runs the carotid artery, accompanied dorsally by the vagus and sympathetic and ventrally by the recurrent nerves. The oesophagus feels like a round muscle within which one can distinguish a firmer cord, the mucous membrane. When brought into view the organ has a pale red color, and it, with the trachea is surrounded by the deep fascia of the neck. Pass one finger around the oesophagus from behind, draw it away from the trachea, force a passage through the deep fascia of the neck and draw it out through the external wound. After making an incision through the oesophageal muscle and mucous mem- brane introduce a probe pointed bistoury or a scissors blade OESOPHAGOTOMY. 99 into the lumen of the oesophagus and split its wall. The mucous membrane is white and lies in thick longitudinal folds. When there is a foreign body in the oesophagus the operation is performed at the point where it is lodged, in the manner described and the incision should be made only large enough to permit its removal. In diverticuli of the oesophagus an ellipical piece of the mucous membrane which has been overstretched is cut out. The oesophageal wound is closed by a laminated suture, that is, the mucous membrane is united by means of an intestinal suture and the muscular wall closed over this. The skin and muscular wound may either be left open or closed with the Bayer suture and bandaged, with a drainage tube in the lower angle. III. OPERATIONS ON THE TRUNK AND GENITAL ORGANS. 19. PUNCTURE OF THE CHEST. Fig. 7. Objects. The relief of hydrothorax or pyothorax. Instruments. Razor, scissors, trocar, i ni. of rubber tubing of the same size as the trocar, vessel for receiving the escaping fluid, dressing material. Technic. Operate upon the standing animal, the point of operation in the horse being the seventh intercostal space on the left side, and the sixth on the right. Dogs may be Fig. 7. ( Puncture of the chest ; puncture of the intestine. laid upon the table. The anterior ribs are so covered by the shoulder that they cannot be counted from before back- wards and must be enumerated from behind forwards. In the horse there are usually eighteen ribs and in the dog fourteen. Counting ii or 12 intercostal spaces from behind PUNCTURE OF THE INTESTINES. loi we reach in the horse the point of operation on the left and right sides respectively. Clip or shave the designated inter- costal area immediately above the thoracic vein. Grasp the trocar firmly with the thumb and index finger of one hand at such a distance from the point as will permit the canula to enter the chest. After the skin over the seat of operation has been drawn aside by the hand, place the trocar at the anterior border of the rib with the point inclined slightly forward and with a sharp blow with the palm of the other hand drive the instrument through the skin, cutaneous and intercostal muscles, internal thoracic fascia and pleura into the pleural sac. When the resistance ceases, the thoracic cavity has been entered. Remove the stilette and permit the pus, lymph, or other fluid to escape. This flow is at first continuous, but later becomes rythmic, synchronous with respiration. The intermission of the flow during inspiration permits air to enter the pleural cavity unless precautions are taken against it ; this is most readily obviated by slipping one end of the rubber tubing over the exposed part of the canula and placing the other extremity in the receptacle for the fluid where it will be submerged. This will not only prevent aspiration of air into the chest but will act as a siphon to aid in the withdrawal of the fluid from the pleu- ral cavity. In the absence of the tubing the entrance of air may be avoided by closing the canula with the finger after each expiration. 20. PUNCTURE OF THE INTESTINES. Figs. /-S'. 2_'f, ' *'' Object. The relief of intestinal tympany. Instruments. Razor, scissors, trocar. Technic. Puncture of the intestine is preferably per- formed on the standing horse but may be carried out on the recumbent animal. The point of operation is in the right I02 PUNCTURE OF THE INTESTINES. flank about equi-distant from the last rib, the extremities of the transverse processes of the lumbar vertebrae and the external angle of the ilium in the standing horse ; at the uppermost point of the abdomen in the recumbent animal, that is, at the most prominent part of the distension. After the skin at this place has been clipped or shaved and disin- fected gasp the trocar with the index finger and the thumb of the left hand and holding the instrument perpendicular to the body surface, give it a firm, quick blow with the palm of the right hand and drive it through the abdominal wall into the intestine. With a properly constructed trocar of the dimensions suggested in Figure 8 no preliminary puncture with the lancet is required or advisable. The cutting end of the stilette should be very long, tapering and sharp so that it will cut as freely as a lancet. By performing the opera- tion as directed the trocar ordinarily punctures the caecum. Fig. ^. %J^^ Intestine trocar with sheath. Outside diameter of caniila 3 mm., length of canula, 16 cm. Withdraw the stilette and permit the gas to escape through the canula. The canula may become occluded by particles of ingesta entering it and these should be removed by reinserting the stilette. The intestine first punctured may collapse and the flow of gas cease while the tympany continues in other parts ; this may be overcome by reintro- ducing the stilette and pushing the trocar through the distal wall of the bowel and into the intestine beyond. If this does not succeed, the trocar may be withdrawn and reinserted in a neighboring area or if need be on the opposite side of the animal. SUBCUTANEOUS CAUDAL MYOTOMY. 103 In withdrawing the canula replace the stilette and press the skin against the abdomen with the thumb and finger of one hand while the trocar is drawn out with the other. This tends to prevent particles of ingesta from following the canula out of the intestine and becoming lodged at some point in the track of the wound to set up inflammatory processes there. Before introduction, the trocar should always be rendered sterile but should not bear irritant antiseptics, which be- coming lodged in the wound tend to irritate the tissues and produce abscesses. Puncture of the intestine is so often extremely urgent that deliberate aseptic precautions are not always practicable and trocarization only too frequently results in abscesses in the abdominal wall. Its prevention must depend chiefly upon the disinfection of the skin and instrument. It becomes important to use an instrument which is clean in advance. If the one one shown in Fig. 8 is well disinfected after using and the sheath is filled with alcohol before it is screwed on, the instrument will remain sterile until it is again unsheathed when the alcohol will quickly evaporate and leave the trocar aseptic. 21. SUBCUTANEOUS CAUDAL MYOTOMY. Fig.^. Object. The correction of curved tail. Instruments. Sharp straight tenotome, bandage. Technic. The point or points of curvature and their extent are to be carefully noted by having the animal trotted away from the operator. The curvature is generally due to unequal development of the two levator or extensor muscles. Fig. q.-e, though quite rarely the depressors,/, may be implicated. JO| SUBCUTANEOUS CA UDAL- MYOTOMY. Confine the animal in stocks, or in default of these, con- trol by means of a twitch and sideline. Cleanse and disin- fect the tail and have it sharply bent by an assistant in the opposite direction to the curvature. Locate the longitudi- nal furrow between the levator and depressor muscles on what has now become the convex side and at the lower margin of the levator and just above v. Fig. 9, insert the tenotome at the most prominent part of curvation, the incision being parallel with the muscular fibers, and push Fig.S. % ^ Transverse section of the tail, n, caudal vertebra ; c, sacro- coccygeus lateralis muscle ; e, sacro coccygeus superior ; f, depressor longvis and brevis muscles (sacro-coccygeus infer- ior); i, intertransversales muscles ; a, coccygeal artery ; .r, su- pero-lateral coccygeal artery ; /, infero-lateral coccvgeal ar- tery ; V, caudal veins (dorsal, ventral, lateral) ; sch, caudal fascia ; h, skin. the instrument entirely through the muscle to the vertebra, then turning the cutting edge upwards, at the same time advancing the point toward the median line, sever the entire muscle. The superior lateral caudal artery, s, Fig. 9, bleeds pro- fusely if severed, and wounding of it may usually be avoided by withdrawing the tenotome a trifle in passing that point. CAUDAL MYECTOMY. 105 Wounding the skin over the muscular incision is avoided by placing the thumb of the left hand over the line of in- cision so the knife will be recognized as soon as the muscle and caudal fascia are cut through. Remove the knife in the same manner as introduced. Release the horse and have him trotted again. If the operation is sufficient, the tail should curve i?i about the same degree as before, but in the opposite directiofi. If this has not been attained examine carefully and sever any remaining bundles of muscle, and this not sufficing repeat the operation as before at another point 5 or 6 cm. above or below the first, severing the muscle again. Or if the depressor appears implicated, sever it in a similar manner. In extreme cases the entire lateral half of the caudal muscles, tendons and aponeurosis may be severed. Apply an antiseptic pad to the wound and retain it by a moderately firm bandage, which serves at once as an occlu- sive dressing and effective hemostatic. Remove the band- age after 24 hours. By this plan of operation it is not ^,, intended to tie the tail to the side of the animal during the^"0"= time of healing but when bandaging immediately after t'he operation, the tail should be held away from the side toward which it formerly curved so that the bandage may tend to prevent the return of the organ to its former position. V--V' "'■*■" -r 22. CAUDAL MYECTOMY. Objects. For the prevention of the gripping of the reins by the tail. Instruments. Elastic ligature, straight bistoury, ten- acula, absorbent cotton, bandages. Technic. Confine the animal in lateral decubitis or in stocks, cleanse and disinfect the parts and apply the elastic ;k ' 'h b 'S' Caudal Myectomy To Prevent Gripping of the Reins. DC, Depressor cocc}'geus longus muscle ; T, tourniquet. AMPUTATION OF TAIL. 109 ligature as close as possible to the root of the tail. Have an assistant hold the tail upwards, i. e., dorsalwards, and tightly stretched. Make an incision 15 to 20 cm. long, over the middle of the inferior surface of each depressor longus muscle, beginning close -against the elastic ligature and ex- tending toward the apex, severing at once the skin and caudal fascia down to the muscle. Let an assistant retract the lips of the incision with tenacula while the operator dissects the depressor longus muscle, DC, Plate XVII, from the adjacent tissues at either side, sever it by a transverse incision close against the ligature and dissect away the en- tire muscle down to the lower end of the wound and there excise it. Repeat the operation on the opposite side. Make two elongated tampons of absorbent cotton, of the size and form of the muscles removed, saturate these with i-iooo sublimate solution, insert neatly in the wounds and over this to aid in securing antisepsis and to equalize the pressure apply a pad of absorbent cotton, saturated with sublimate solution, covering the wounds and encircling the tail and secure by a moderately firm bandage as closely as possible to the elastic ligature. Remove the ligature, when hemorrhage may ensue, which is to be controlled by the ap- plication of a second bandage extending higher up on the tail. Remove the bandage in 24 hours and dress as before for a second day after which treat as an open wound. Care should be taken to not apply the bandage too tightly or leave it in place for more than 24 hours, since otherwise necrosis of the tail is liable to occur and necessitate amputation. 23. AMPUTATION OF THE TAIL. Plate XVIII. Objects. The treatment of malignant, or incurable dis- eases of the tail. Instruments. Elastic bandage, scalpel, razor, artery forceps, bone cutting forceps, suture material. 3 7/'s V ' ^ ^ •% t7 Amputation of the Tail. • Fig.i. — Tail amputated showing flaps un- sutured ; B, Bandage securing hairs turned Yy/jipffiard-out-of operator's way. 7S Fig. i. — Operation completed showing su- tures ; B, Bandage applied to secure hairs of tail upwards out of operator's way. Fig. 1. / AMPUTATION OF THE TAIL. 113 Technic. The animal may generally be operated upon in a standing position secured in the stocks or with the aid of the side line. Local anaesthesia may be applied by in- jecting cocaine or other drug deeply upon the nerve trunks as well as just beneath the skin. The animals' attention may be attracted by means of the twitch if found necessary. The point of amputation is determined by the location of the disease. Over the area of operation clip the hair, shave and thoroughly disinfect. Apply the tourniquet or elastic bandage at the base of the tail so as to render the operation bloodless. Above the seat of operation turn the hair upward toward the root of the tail and secure it there by means of the bandage, B, Fig. i, Plate XVIII. Locate as accurately as possible the position of a joint at the point where it is desired to operate and with the scalpel begin an incision on the median line on the upper side of the organ about i cm. above the articulation and carry this obliquely outward for a distance of 4 to 6 cm. according to the size of the tail and then continue it downward, backward and inward along the side and inferior surface until directly opposite to the place of beginning. Make a similar incision upon the opposite side of the tail, cut through all the connective tissue and muscles down to the bone and then disarticulate with the aid of the scalpel. Search for the arteries and control the hemorrhage by torsion or ligation. The vessels will be more readily found by loosening the tourniquet so as to permit the blood to flow. Some operators prefer to begin the incision at the side of the tail instead of upon the dorsal surface and in that way have a dorsal and ventral flap instead of right and left as. indicated in Fig. i, Plate XVIII. The excision having been completed the flaps are brought together by means of strong silk or silk worm gut sutures as shown in Fig. 2. The 114 URETHROTOMY. LITHOTOMY. sutures should be begun at the apex of the two flaps and comparatively deep. Disinfect the stump thoroughly and if the hair is suffici- ently long it is well to draw it down over the wound, to which an antiseptic covering has been applied, and retain the dressing in position by tying a cord around the hair just beyond the point of amputation. 24. URETHROTOMY. LITHOTOMY. Figs. 10-11. Objects. For the removal of calculi from the bladder or urethra or performing other operations on these parts. Instruments. Catheter, convex scalpel, scissors, artery and compression forceps, tenacula, lithotome, lithotomy forceps, lithotrite, absorbent cotton, drainage tube, suture material. Technic. Urethrotomy may be performed on horses in a standing position, the hind feet being secured with hobbles. It is best, however, to operate under anaesthesia with the patient in lateral or dorsal recumbency, either on the operat- ing table or cast, being careful to secure as gently as possi- ble, having first emptied the bladder if practicable, since rupture of an overdistended viscus maj' readily occur during violent struggles by the animal. The point of operation will depend upon the location of the calculus or other obstacle. If it is found in the pelvic portion of the urethra or in the bladder, the operation is made at the ischial notch, Fig. lo. First the penis is drawn out from the prepuce and the catheter introduced into the urethra and pushed upward until it has passed the ischial notch. After disinfection of the skin, render it tense and make a 5 cm. long incision on the median line at the ischial arch through the skin, bulbo-cavernosus muscle, spongy portion of the urethra, and the urethral mucous membrane URETHROTOMY. LITHOTOMY. 115 down to the catheter, Fig. 1 1 , k. In order to prevent infil- tration of urine after the operation, special care is to be taken to make the lower end of the wound slanting in such a manner that the deeper margin is higher than the superficial. After the catheter has been drawn back away from the ischial arch, introduce the lithotomy forceps into the urethra or bladder, grasp the stone and draw it outward in its natural direction. The grasping of the stone with the forceps is Urethrotomy at the ischial notch. materially aided by means of the left hand introduced into the rectum. One must avoid grasping, along with the stone, the mucous membrane of the bladder. Partial filling of the bladder with a tepid aseptic solution will aid in grasp- ing the calculus and in avoiding the implication of the bladder walls. By careful rotary movement and pushing the forceps backward and forward the operator can deter- mine before traction is exerted if the forceps can be with- ii6 URETHROTOMY. LITHOTOMY. drawn easily and without much resistance through the neck of the bladder. If the stone is so large that it cannot pass the neck of the bladder lithotripsy may be performed. This operation re- quires time and patience, since as a rule it is not possible to encompass the entire calculus with the forceps. That is, the narrowness of the neck of the bladder prevents the sufficiently wide opening of the forceps. The stone con- Fig. 41. Urethrotomy (life size), h, skin; a, retractor penis muscle; b, bulbo- cavernous muscle ; c, spongy urethra ; u, urethra ; k, catheter. sequently must be gradually broken off at its periphery and the individual pieces of calculus removed. The character of the surface of the stone has an evident bearing upon the practicability of lithotripsy. The surgical dilation of the pelvic urethra with the lithotome is usually far more practical than the crushing of the stone. Introduce the instrument and divide the urethra upward on the median line as the instrument is withdrawn. AMPUTA HON OF THE PENIS. 1 1 7 In order to prevent injury to the rectum it should be emptied of feces before the operation is undertaken. After the re- moval of the stone, the operator may push the catheter again over the ischial arch and unite the lips of the wound in the urethral mucous membrane by means of intestinal sutures. Flush the bladder and urethra by means of a warm, 3 per cent, boric acid solution injected through the catheter and then withdraw the latter. Finally, suture the skin wound and insert a drainage tube or iodoform gauze in the lower angle. Or the whole wound may be left entirely open and dressed daily with antiseptics. In case the pelvic urethra has been divided the suturing of the external wound is of questionable utility. (For student practice on an anaesthetized horse, intro- duce a stone into the bladder through the urethral wound and practice grasping and removing it with the lithotomy forceps. ) 25. AMPUTATION OF THE PENIS. - Plata XIX amf Fii? 32. Instruments. Scalpel, elastic ligature, strong silk suture, strong piece of tape i m. long, artery and compres- sion forceps. Technic. The operation is carried out on the recumbent animal under local or general anaesthesia, the upper hind foot being drawn backward or upward or otherwise so fixed as to not obstruct the field of operation. The point of operation is determined by the character of the disease and the object to be attained. It may be made at any point from the glans penis to the attachment of the corpus caver- nosum to the ischium. If possible amputate in front of the preputial ring. « ° S -f, 3 s ^^^^ 17 v-i - .^ . O O O g: .** no'-' .. o •|afo 2J^ s! i e 1 .0 1 s 0. stage o: tourniq a; S, S: bra ; L, ileted op E ^ tn ^ -M P4 ^ Firsi ed a ireth Ure Com M 3 g g/bjo u .^ -M 3 P -f 1^ cij ta 3 S i. u 4* "^5^V^^^^^- AMPU7A TION OF THE PENIS. 121 After the penis has been drawn out, and the preputial region carefully cleansed and disinfected, an assistant grasps the organ just behind the preputial ring and holds it firmly. A catheter is then introduced into the urethra and pushed upwards beyond the point where it is designed to amputate the organ and a temporary elastic ligature, T, is then applied Fig. 127 Amputation of the penis, showing needle inserted for a suture. V, Dorsalvessels of penis ; A, Fibrous tunic of the corpus cavernosum ; S, Skin ; CC, Corpus cavernosum ; CS, Corpus spongiosum of urethra ; U, Urethra, above the assistant's hand around the penis, or a piece of tape is looped around it above the hand and is made to serve both as a tourniquet and as a means for holding the penis. Or the penis may be grasped in front of the ligature with double tenaculum forceps and held. 122 AMPUTATION OF THE PENIS. Apply a small cord just behind the glans penis, L, Fig. I, Pate XIX, and then make a triangular incision on the ventral surface of the organ about 4 cm. long by 3 cm. wide, the base of the triangle being forward as shown in Fig. I ; carry this incision through the skin, S, the corpus spongiosum, CS, and along the corpus cavernosum, CC, down to the urethra, U. Dissect away the tissues in the triangular area without opening or wounding the urethra and when this has been completed make a longitudinal incision from near the apex of the triangle to its base through the urethral walls to the catheter. Beginning at the apex of the triangular wound insert a series of inter- rupted sutures as shown in Fig. 2, Plate XIX in such a manner that they pass through the urethral wall and the skin so that when tied the wounded surfaces are completely hidden and the urethral mucous membrane is brought into apposition with the integument. Continue these sutures down to the base of the triangle after which remove the catheter and excise the organ by a cut extending in a slightly oblique direction from below upwards and forwards. Take a straight needle armed with the silk suture and passing it through the margin of the urethral wound, the adjacent fibrous capsule of the corpus cavernosum and across but not through the erectile tissue, insert it again into the superior portion of the fibrous capsule and carry it out through the adjacent dorsal vessels and the skin as shown in Fig. 12, and, bringing the ends of the sutures together, tie in such a way that the urethral mucous membrane and the margin of the skin are brought into immediate contact and the blood vessels securely closed in such a manner as to guard against hemorrhage. By this plan when the sutures are tied, the cut borders of the fibrous envelope are brought together over the erectile tissue, thus preventing hemor- rhage from that tissue also. Insert as many sutures as- may be required to completely and securely close the wound VAGINAL OVARIOTOMY IN THE MARE. 123 and finally leave every part wholly covered with epithelium. By this plan it is hoped to avoid stricture of the urethra in the process of healing. Remove the tourniquet and release the patient. 26. VAGINAL OVARIOTOMY IN THE MARE. Figs. 13-14. Objects. The alleviation of vice when related to ovarian irritation or disease. Instruments. Colin's scalpel, ratchet ecrasure, 55 cm. long, vaginal tensor. Preparation of patient. It is highly important that the animal should be kept on a scant laxative diet for at least 24 hours and preferably longer prior to the operation, so that the alimentary canal shall be somewhat empty and thus decrease the intra-abdominal tension and relieve the operator from much annoyance due to the pressure of the viscera. Technic. The vagina of the mare is unique in its physiological behavior. Under venereal excitement or the introduction of the operator's hand or of tepid water the organ has the* power of " ballooning " or dilating to a degree not so marked in other animals ; the vaginal walls become erected, hard, and stand apart from each other, filling the pelvic cavity, resting firmly against the pelvic bones and ligaments at every part except at the points where the bladder and rectum intervene and these organs are pressed out fiat and occupy a minimum amount of space. In the quiescent state the vaginal walls are in contact and from the perinaeum forward to within about 10 cm. of the uterine os, the vulva and vagina are connected above with the rectum by the pelvic connective tissue, while anterior to this point the vagina is covered by peritoneum, and it is 124 VAGINAL OVARIOTOMY IN THE MARE. in this area that the incision needs b.e made in the operation. The ballooning of the vagina profoundly alters the relation of this operative area, and changes it from the horizontal in the quiescent organ to the perpendicular in the ballooned condition. These variations permit of two methods of operating : I. On the ballooned organ without anaesthesia and with the animal confined in the standing position. II. On the quiescent organ in the recumbent position under anaesthesia : I. Without anaesthesia. Secure in the stocks with the head elevated, a rope over the back to prevent rearing, Fig. tsr special spraying ecraser, 55 cm. long. // t,- Fig. "«r" Colin's scalpel. straps beneath the body to prevent lying down, straps or ropes before and behind the animal to prevent backward and forward movements, all four feet pinioned to the floor, and the tail firmly secured and stretched to a beam above. Apply a bandage to the tail extending for a distance of 12 to 15 inches from the base of the tail in order to secure the tail hairs out of the way of the operator. With soap, water and brush cleanse the tail, perineum and vulva thoroughly, being especially careful to remove all VAGINAL OVARIOTOMY IN THE MARE. 125 detachable masses of sebum ; 50 per cent, alcohol may be used sparingly to aid in removing this. Too free a use of alcohol excoriates the delicate skin. Cleanse the clitoris carefully. Follow the washing with a free application of i: 1000 aqueous sublimate solution to the external parts and for a short distance inside the vulvar lips and to the clitoris. Do not introduce irritant disinfectants into the healthy vagina nor deeply into the vulva as it may cause severe straining during and subsequent to the operation and by in- juring the vulvo- vaginal mucosa favor subsequent infection of the vaginal wound. Wash away the sublimate solution with a tepid 0.6 per cent, soda bicarbonate solution, and fill the vulvo-vaginal canal with the same. After thorough disinfection of the hands and arms remove the disinfectants by washing in sterile soda solution, which at the same time renders the hand unctuous and readily introduced through the vulva. Armed with the guarded sterilized scalpel, Fig. 14, intro- duce the right hand into the vagina promptly and when it is well " ballooned " unsheath the knife and placing it just above the os uteri parallel to the long axis of the uterus and a few mm. to the right or left of the median line in order to avoid a loose fold of mucous membrane generally existing there, the blade being held vertical, that is the cutting sur- face parallel to the longitudinal muscular fibers of the vagina, and guarding the possible extent of its introduction with the thumb and fingers, push it directly forward in a straight line with a quick thrust through vaginal mucosa, the muscular walls and the peritoneum, until the disap- pearance of resistance indicates that the latter has been penetrated. This is the most critical step in the operation. If the hand is introduced into the vagina immediately after the injection of the sterile saline solution the vagina will generall}' be found " ballooned '' or will quickly become inflated under manual movements. If the solution is thrown 126 VAGINAL OVARIOTOMY IN THE MARE. out the vagina may collapse and closely invest the hand, in which case more of the liquid should be injected when it will again dilate. If the hand is introduced without the knife, withdrawn and then introduced with it, it will be frequently found that the vagina has collapsed and needs a second filling with the fluid. Patience until dilation is accomplished and promptness to act when attained are prime requisites to success. The knife should be pushed through the vagina quickly making a clean wound the width of the blade, when the latter is to be withdrawn and laid aside. It should be re- membered that in this "ballooned" state, the anterior wall of the vagina is but 2 or 3 mm. thick and easily pene- trated. Introduce the hand again, push one finger into the incision, then a second and third, and eventually holding all the fingers in the form of a cone push the entire hand into the peritoneal cavity. Immediately below the incision and continuous with the tissues involved in the wound lies the uterus with a transverse diameter of 4 to 6 cm. With the palm of the hand downward, trace the uterus forward a distance of 15 to 18 cm., where it ends abruptly in two cornua of about the same size as the body, which are given off horizontally at almost right angles. Trace these to the right and left for a distance of 14 or 15 cm., where they end obtusely, and 3 or 4 cm. bej'ond this in a direct line, resting upon the anterior border of the broad ligament is the dense oval ovary varying in size from 2.5 to 7 cm. in diameter. Prepare the ecra.seur for use by withdrawing the chain until the loop is of barely sufficient size to admit of its being readily slipped over the ovary. Grasp this loop and the end of the ecraseur tube in the hand, carry the instrument to the ovary and drop the loop over it from above. Pass some of the fingers beneath the ovary and push it up through the chain loop and grasp it there with the thumb VAGINAL OVARIOTOMY IN THE MARE. 127 and index finger. Holding the ovary with one hand tighten the chain quickly with the other, examine to make sure that a loop of intestine is not caught, draw the ovary well through and get a large portion of the oviduct, and crush off promptly, holding to the gland until carried out through the vulva. Remove the other ovary in the same way. Generally it is most convenient to remove the left ovary with the right hand and vice-versa but each may be re- moved with either hand. Wash away any blood from the external parts, apply sublimate solution freely to the vulva, perineum and tail. Keep the patient quiet for five or six days, and feed lightly on a laxative diet. II. In operating under anaesthesia the animal should be cast or confined upon the operating table in lateral re- cumbency preferably with the posterior part of the body somewhat higher than the anterior so as to avoid visceral pressure in the pelvic cavity. Place the animal under com- plete anaesthesia. Prepare the parts in the same manner as already described. Carry the knife into the vagina in the manner previously described and render the roof of that organ tense by pushing the os uteri downward and forward with the hand or by means of a vaginal tensor or speculum. It is important that the vagina be held well down toward the floor of the pelvis so as to carry it away from the rectum, posterior aorta and iliac arteries while the incision is being made. The incision is now to be made just above and be- hind and a trifle to one side of the os uteri in essentially the same manner as under I, except that when the vaginal tensor is used the cut is made upward and backward instead of directly forward. The remainder of the operation is identical with what we have described under I. Under anaesthesia the vagina is flaccid and can not be made to "balloon." 128 VAGINAL OVARIOTOMY IN THE MARE. DANGERS. W^ounding of the rectum is scarcely possible under the first method if care is taken not to attempt the incision until the vagina is well "ballooned," and then making the stab- wound directly forward. If made upwards when the organ is so erected the accident is highl}' probable, and with the undilated vagina where it is necessary to cut upwards the danger is ever present. Its prevention demands that in the first method, the operator await the complete " ballooning " and then make his incision as directed. In the second method, the accident is to be prevented by being careful to push the vagina down away from the rectum and hold it away while the incision is being made. If the wound in the rectum passes through the pelvic connective tissue behind the peritoneum it is of little consequence, but the operation should be abandoned ; if the bowel is opened into the peritoneal cavity the accident is generally fatal. Wounding of the iliac arteries, which generally pro- duces prompt death from hemorrhage, results from the in- cision being made upwards instead of forwards when the vagina is " ballooned " or from a failure to hold the roof of the vagina down and away from the part while making the incision in the flaccid organ as is the case with the recumbent animal under anaesthesia. It is most likely to occur with timid operators who become nervous, especially when the vagina does not " balloon " promptly or the mare is not well secured. The accident is wholly unnecessary if the operator will await the " ballooning " in the first operation while by the second method it is prevented by proper care in holding; the vagina downward and forward during the incision. When it has occurred it is generally beyond remedy though in some cases the prompt intravenous injection of adrenaline chloride may stay the hemorrhage and save life of the patient. VAGINAL OVARIOTOMY IN THE MARE. 129 Wounding of the uterus may occur when the incision is directed downward and may greatly embarrass the operator and confuse him by passing the hand through the incision into the uterine cavity. It is to be avoided in the first operation (without anaesthesia) by carefully directing the incision straight forwards. When the accident occurs it is of little consequence beyond the embarra,ssment and may be overcome by again dilating the vagina with fresh injections of the soda solution and making a new incision, or if pre- ferred the first cut may be corrected by placing an index finger against the peritoneum at the upper part of the wound, and wilh a sudden and vigorous thrust break through into the peritoneal cavity, or the error may be corrected by again using the scalpel and directing the in- cision properly. If it is attempted to rupture the peritoneum with the finger it must be done by a sharp thrust since otherwise a large section of the membrane will be pushed away from the subjacent tissues. Incomplete penetration of the vaginal wall is liable to occur if the scalpel is dull or the vagina imperfectly "bal- looned " and flaccid, or if the operator is unduly timid. It is best prevented by avoiding the causes as related, and once it has occurred it is generally best to again "balloon" the organ in the operation without anaesthesia and make a new incision either to the right or left of the first. It may be overcome also by thrusting the index finger through the peritoneum as described in the preceding paragraph or completing the cut with the scalpel. The mistaking of a ball of feces for the ovary has oc- curred to inexperienced operators and the fatal error of re- moving the portion of the rectum surrounding the fecal pellet committed. The blunder is uncalled for ; the fecal ball is movable in the bowel, the intestine is far more massive than the broad ligament, and the ovary is to be definitely identified by its being lodged in the broad ligament just 9 I30 ]'AGINAL OJ'ARIOTOMY IN THE COW. be5'ond the end of the coriiua, which is continuous with the uterus. If, therefore, one traces the uterus forward to the cornua, thence along each of these to their extremities and along the borders of the broad ligament to the ovary, as above directed, the error will not occur. The incision may be made too low and pass beneath the broad ligament. It is to be avoided by being careful to keep close to the median line and above the os uteri. If it occurs the operation may be completed from beneath with- out very great difficulty only that the ovary now lies above the hand and must be drawn down from on top the broad ligament in order to fix the ecraseur upon it. Infection constitutes always the most serious danger and is to be avoided by properly securing the animal, by the avoidance of irritant antiseptics in the vagina, bj' rigid anti- sepsis at every stage, and by carrying out the mechanical parts of the operation deliberately, vigorously and neatly. If infection should occur it will generally take the form of pelvic cellulitis with abscesses and rectal stricture. Enemas of a normal salt or soda solution affords the surest relief of the stricture and impaction in front of it. The abscesses must be watched and opened early into the vagina or rec- tum, and the case treated internally and locally according to general surgical principles. 27. VAGINAL OVARIOTOMY IN THE COW. Objects. Increasing the fat- or milk-producing qualities and the cure of nymphomania or other ovarian disease. Instruments. Colin's scalpel, vaginal dilator, Miles' spaying shears, spaying ecraseur. Technic. Confine the cow in the standing position in the stocks, secure the head firmly and pass two boards be- neath the abdomen and sternum to prevent lying down, and a rope over the middle of the back to prevent arching of the spinal column and straining. VAGINAL OVARIOTOMY IN THE COW. 131 Wash and disinfect the tail and the perineum and flush out the vagina with a 0.5 per cent, sohition of carbolic acid or lysol at a temperature of about 100° F. Insert the vaginal dilator with one hand and push the prolongation at the anterior end into the os uteri. With the other hand elevate the handle of the dilator and depress and push for- ward the uterus, thus rendering the roof of the vagina tense and pushing it downward away from the rectum Carry the scalpel into the vagina with the right hand and resting it in the oval of the dilator make an incision through the roof of the vagina, beginning at a point 8 to 10 cm. posterior to the OS uteri and extending backward on the median line for a distance of 2 or 3 cm. Be careful to make the incision entirely through the mucosa, muscle and peritoneum at the first cut, since any failure to complete it tends to cause the peritoneum to separate from the muscular coat and form a pocket between them, while the serous membrane being ver^f elastic renders it difficult to complete the incision. Introduce two fingers through the incision, and reaching over the side of the vagina to the right or the left, the right or left ovary respectively is recognized lying immediately against the lower part of the vagina, just at the anterior border of the pubis, in a mass consisting of the cord-like Fallopian tube and the fimbriae of its pavilion. The ovary may be distinguished as a firm oval mass 2 to 4 cm. in length and I to 2 cm. in its lesser diameter attached to the broad ligament. If not promptly recognized by the sense of touch, trace the vagina and uterus forwards with the fingers from the vaginal incision to the cornua and follow them as they bend forward and downward, and then backward and up- ward to the oviducts, until the ovary is reached where it is attached to the broad ligament, just beyond the fimbriated end. Grasp the ovary between the fingers and draw it through the incision into the vagina. Introduce the scissors or emasculator with the other hand, and when the ovary is 132 J'AGINAL OVARIOTOMY IN THE COW. reached open them barely suflScient to admit the ovarian attachments between the blades and cut the gland away along with a portion of the broad ligament. Or introduce the ecraseur and drawing the ovary through the loop of the chain and holding it securely until the instrument is tightened, crush it off in this way. It is essential that plenty of the broad ligament and ovi- duct be excised with the ovary to insure the entire removal of the latter, because the accidental leaving of the smallest particle of ovarian tissue will cause a development of this into abnormally large cystic ovisacs, and will tend to in- crease instead of decrease nymphomania. Should the animal be pregnant the ovary on the gravid side is dragged downward and forward out of reach of the operator's fingers, and if it is desired to complete the operation it may be necessary to enlarge the vaginal wound and introduce the entire hand, when the ovary can be reached and re- moved. Generally no after care is necessary. The Dangers are similar to those of the mare. The iliac arteries may be wounded in the same manner as in the mare and is preventable by being careful to push the vaginal roof well downwards awa}' from the rectum and sacrum. In rare instances fatal hemorrhage follows the cutting off of the ovaries with the scissors especially in cows sterile be- cause of diseased ovaries accompanied by a want of tone. For this reason it is safer in cows sterile from diseased ovaries to use the ecraseur but even this instrument is not wholly proof against hemorrhage and fatalities have been rarely recorded after its use so that some veterinarians have advised ligation of the arteries instead, but this is a complex process which requires much time for its accomplishment. Another danger appears in the presence of the rumen, the supero-posterior portion of which when filled with food projects into the pelvic cavity and if the cut is directed for- wards a stab wound readily penetrates its walls with fatal results. Make the cut upwards and backwards. OVARIOTOMY IN THE COW BY THE FLANK. 133 28. OVARIOTOMY IN THE COW BY THE FLANK. Instruments. Clipping shears, convex scalpel, spaying shears, or ecraseur, heavy needle and thread. Uses. Same as the preceding, applicable to heifers or to cows in which the vulva is too small to admit the operator's hand or in case of diseased vagina or uterus. The animal may be secured as in the preceding or con- fined in lateral recumbency with the hind legs extended backward and the anterior limbs forward. To accomplish this loop a rope about the two fore feet, another about the two hind feet, and drawing upon these, cast the animal and secure it in recumbency with the legs extended and body stretched by fastening the ropes to two strong posts about 8 to 10 m. apart. The operation may be performed in either flank. Clip the hair from the upper part of the flank, disinfect an area 15 to 25 cm. square and make an incision about 12 cm. long beginning at a point equi-distant from the anterior tuberosity of the ilium, the ends of the transverse processes of the lumbar vertebrae and the last rib and extend it down- wards perpendicularly severing the skin and subcutaneous muscle. Divide the external oblique muscle in the direction of its fibres by means of the scalpel handle or the fingers and repeat the process upon the internal oblique after which puncture the peritoneum with the scalpel. Some operators cut directly through the entire abdominal wall at a single stroke, but this comes to the operator only by experience. Force one hand through the opening into the peritoneal cavity and search for the ovaries at the same point and by the same method as in the preceding operation, that is, locate the uterus within the pelvic cavity, between the rectum and bladder and trace it, the cornu, and broad ligament to the ovary. The uppermost ovary can be drawn out through the wound and cut off with the scissors or ecraseur ; the lower one must be held with one hand and 134 OVARIOTOMY IN THE BITCH. the instrument introduced along the arm and when the ovary is reached, apply the scissors or ecraseur and cut or crush it off. The beginner must always remember that the positive means for identifying the ovaries is by tracing the uterus from the vagina along its cornua to the oviduct and thence to the organ in the broad ligament. Cleanse the wound and close the skin incision with continuous sutures. 29. OVARIOTOMY IN THE BITCH BY THE FLANK. Plate XX. Instruments. Spaying knife, suture material. Techic. Confine the animal in lateral recumbency, preferably upon the right side for a right handed operator, the head somewhat depressed, the limbs extended and the body well stretched. Clip, shave and disinfect a sufficient area in the exposed flank at a point just anterior to and be- neath the external angle of the ilium. With one hand grasp the skin fold of the flank and render the skin of the region tense, while with the other holding the spaying knife like a pen make at first a drawing incision from below upward about 2 to 3 cm. long, ending above at a point slightly be- low the external angle of the ilium, the incision extending through the skin and subcutaneous tissues ; without remov- ing the knife from the wound elevate the handle and with a quick thrust make a stab wound extending through the external and internal oblique muscles and peritoneum at a single cut. The operator can determine when the peritoneal cavit}' has been entered by the disappearance of resistance. Introduce an index finger into the peritoneal cavity, and as soon as this has been entered follow directly along the peritoneum upward and backward toward the angle of the ilium where the uterine cornua lie covered over by the broad ligament. The internal generative organs of the OVARIOTOMY IN THE BITCH. 135 bitch are unique among our domesticated animals. The uterus, U, Plate XX, is small and physiologically unim- portant, the cornua, RUC and I^UC, are ample in size and constitute physiologically the uterus. The distance from the cornual extremity, LUC, to the ovary, O, which is occupied by the Fallopian tube is very brief so that the cornua and ovary are well nigh in contact. The ovary, O, O, is very small, smooth and completely hidden in the pavilion which here constitutes a sac having a very small longitudinal opening of 2 to 5 mm. The most remarkable feature of the apparatus from a surgical standpoint is the great development of the broad ligament which is broader than the distance from the lumbar region to the abdominal floor, while the uterus and uterine cornua are stretched between the vagina, V, and the ovary, O, so that they are suspended in the sub-lumbar region resulting in a double fold of the broad ligament hanging down like a curtain be- tween the parietal peritoneum and the uterus and cornua on either side. The broad ligament of the bitch is conse- quently suspended at one point from the sub-lumbar region, at the other from the uterus, so that instead of that organ being suspended by the ligament the relation is reversed and the ligament is suspended from the uterus, or rather uterine cornua. In Plate XX the right broad ligament, BL', is laid out upon the side exposing the right uterine cornu, RUC, while on the left side the ligament is divided at about its center and the posterior portion, BL', is laid out on the flank, while the anterior, BI,, is left in its normal position con- cealing a portion of the cornu, LUC. Unlike our other domesticated animals, the broad ligament is heavily loaded with fat which gives it an appearance very similar to the omentum, but the net-work is far less conspicuous or want- ing, the omentum also extends back into this region so that the two are in contact. 1^ Ovariotomy in the Bitch. Abdomen of a non-pregnant bitcli lying on the back with the abdominal floor removed and the omentum pushed away. TT, the two pos- terior teats ; B, bladder ; V, vagina ; U, uterus ; LUC, LUC, left uterine cornua with a portion of its broad ligament, BL, lying across it ; RUC, right uterine cornua with its broad ligament, BL', turned outwards exposing the full length of the cornua. On the left side the ligament is divided so that the anterior half rests in its nor- mal position while the posterior half, BL', is turned back. 0,0, ovaries; R, rectum; K, left kidney ; AA, a line indicating the level of the external tuberosities of the ilia. O VARIO TOMY IN THE BITCH. 1 39 The ovary being indistinct and hidden is diiScult to iden- tify directly, and the cornua being covered over by the duplicature of the broad ligament is not readily reached, so that the finger generally comes in contact first with the broad ligament of the uppermost cornu hanging loose in the peritoneal cavity : engage this between the end of the finger and the abdominal wall and draw it out through the wound, grasp it and continue drawing upon the folds of the ligament, especially upon the median or under-most portion until the naked cornu appears through the opening, seize it and draw out the anterior portion until the ovary follows, then grasp the latter with the thumb and index finger of one hand and the ovarian ligament with the same members of the other and tear the ligament through between them by linear tension. Extend the tear through the broad liga- ment as high toward its lumbar attachment as is convenient and backward to the neighborhood of the uterine bifurca- tion. Draw upon the exposed cornu until the point of bi- furcation appears, when the other branch is to be grasped and drawn out through the opening. In young puppies the securing of the second cornu is very difiicult and requires great care to prevent the rupture of the first. The object may be facilitated by pressing the upper flank of the bitch downward, thereby greatly diminishing the transverse diameter of the abdomen. The succeeding operation (30) avoids this difficulty in a large measure. Should the distal cornu be ruptured and with its ovary drop away from the operator, it becomes nec- essary to turn the animal over and make a second incision on the opposite side, somewhat further forward. When the second cornua has been secured draw it out as far as prac- ticable and holding it tense insert an index finger along it until the ovary is reached, which is recognized by its slightly greater size and density succeeding the brief neck represent- ing the Fallopian tube between the end of the cornu and I40 OVARIOTOMY IN THE BITCH. ovary, while beyond it can be felt the ovarian ligament. Engage the ligament between the end of the index finger and the abdominal wall, and with a firm and vigorous move- ment, using the finger end and nail as a curette, rupture the ovarian ligament by drawing the finger toward the in- cision, and with the aid of tension upon the cornu draw the ovary out through the abdominal incision and divide the broad ligament as before. Remove the cornua with the attached ovaries by rupturing them transversely near the bifurcation by means of linear tension. If the bitch be pregnant and especially if far advanced the uterine cornua will lie upon the abdominal floor, much enlarged and very much more flaccid than the nongravid uterus and feeling very much like intestines. The change in the position of the uterus has caused the unfolding of the duplicature of the broad ligament so that it no longer covers the cornu. In such cases the operation is performed in the same way except that rupturing the blood vessels by linear tension does not insure against hemorrhage and it is neces- sary to ligate the ovarian and uterine arteries with catgut or silk. In cases of pregnancy the entire cornua should be drawn out and a strong ligature placed around the uterus or vagina, and the ovaries, uterine cornua and their con- tents be removed en masse. Release the upper posterior limb and close the cutaneous wound by a continuous suture. Dangers. Rupture of the uterine cornu alluded to above. It is always to be remembered that the leaving of one ovary in position even though the other gland with the two cornua and uterus are removed, induces intense oestrum and renders the animal if anything more disagreeable than before the operation. The ureter may be mistaken for the cornu but is smaller, is closely attached to the abdominal walls, and does not have the broad ligament with its large deposit of fat. The kidney is far larger than the ovary, more exposed, and located more anteriorly. O VARIO TOMY IN THE BITCH. 1 4 j The iliac arteries are at times caught and ruptured by the finger but the blunder is uncalled for except through nervousness of the operator. , Instances of puncturing the bladder in making the in- cision have been reported. If the bitch has been led out and caused to urinate prior to operating, the accident is made practically impossible. 30. OVARIOTOMY IN THE BITCH BY THE LINEA ALBA. Plate XX. Instruments. Same as in the preceding. Technic. Confine in the dorsal position with the head sharply declined. Shave and disinfect an area on the median line about 6 cm. square extending forward from the pubic brim. Make an incision on the median line about 4 cm. long beginning just in front of the pubic brim and extend- ing forward cutting entirely through the skin, the linea alba and peritoneum. Insert an index finger and identify the uterus or broad ligament by its location and form. The finger usually comes in contact first with the urinary bladder which may more or less obstruct the passage to the uterus according to its degree of distension. When empty as shown at B, it offers practically no obstruction. When very much distended it may be evacuated by gentle pressure with the fingers. The operator should be careful not to draw the bladder out through the incision as its replace- ment may prove difiicult and its puncture with a hypo- dermic needle or an enlargement of the abdominal incision may be necessary in order to bring about its return. Push the bladder aside if necessary and just above it and below the rectum the uterus should be readily distinguished and either it or the broad ligament caught by the finger and brought out through the incision after which the operation proceeds 142 OVARIOTOMY IN THE CAT. in the same manner as by the flank method. By passing an index finger forward to reach the lower surface of the rec- tum in front of the uterus and then drawing it backwards the finger passes between the former and the cornua and the latter are picked up. It has a distinct advantage over the flank method in that in puppies there is not so much difficult}' in bringing out the ovaries, nor the danger of the rupture of the cornua and the ovary being retained. By the use of retractors in the abdominal incision the operator is enabled to see the uterus in position and grasp it by means of forceps, obviating the necessity for introducing the finger into the peritoneal cavity. The sutures must extend entirely through the abdominal wall and be carefully placed in order to prevent hernia. Interrupted sutures are preferable. If the operation has been properly performed no bandage is necessary and the patient will not disturb the sutures. If asepsis has not been strictly followed infection may occur and the consequent irritation cause the patient to tear the sutures out, which may lead to protrusion of the intestines or other abdominal viscera. If the sutures do not include the deeper layers of the abdominal wall hernia is liable to occur and require a second operation. 31. OVARIOTOMY IN THE CAT. Instruments. Same as for the bitch. Technic. The cat may be spayed by either the flank method or through the linea alba. The point of inci,sion in either case is the same as in the bitch but owing to the smaller size of the animal it is necessary to make the wound quite small. The abundance of fur renders it essential that an ample area be shaved and the surrounding hair be saturated with a disinfectant and carefully brushed away CASTRATION OF CRYPTORCHID HORSES. 143 from the operative area. The cat being more subject to infection than the bitch the aseptic precautions must be of the strictest possible character. The operative area must be thoroughly disinfected and cleansed and equal care must be taken not to introduce irritant disinfectants into the wound. A great danger also exists in the tendency of the muscle layers of the abdomen to readily become separated by pressure from the finger and form a pocket in which wound discharges accumulate and constitute a dangerous seat for infection. Great care must therefore be taken to make a clean incision directly into the peritoneal cavity and to avoid separating the peritoneum from the muscles or the muscular layers from each other. The uterus and ovaries of the cat are naked and far more easily distinguished than in the bitch, there being no extra deposit of fat in the broad ligament. The sutures are to be applied to the wound in the same manner as in the bitch. 32. CASTRATION OF CRYPTORCHID HORSES. Plates XXI and XXII. Instruments. Scalpel, emasculator. Technic. Confine the animal by casting in the dorsal position with the hocks well flexed and both posterior limbs completely abducted .so as to fully expose the inguinal region. Or secure upon the operating table on the side opposite to the retained gland and abduct the upper pos- terior limb by drawing it upward by means of a pulley. Cleanse and disinfect the inguinal region. Anaesthize. Make an incision about 10 to 12 cm. long through the skin and dartos directly over the normal position of the scrotum, parallel to the median raphe about 4 or 5 cm. distant from it. Insert the two index fingers in the wound, press them into the areolar tissue toward the external inguinal 144 CASTRATION OF CRYPTORCHID HORSES. ring and drawing them apart separate the tissues sufSciently to permit the entrance of the hand. With the fingers held in the shape of a cone bore a passage in the areolar tissue through the external abdominal ring and con- tinue in a direction approximately toward the external angle of the ilium until the aponerosis of the small oblique muscle near the crural arch is reached. Unless rectal ex- ploration has shown that the testicleis within the abdomen^ take care in traversing the inguinal space between the ex- ternal and internal rings that the gland is not passed by unrecognized (inguinal cryptorchidy) lying in this regioQ covered by peritoneum and the cremasteric fascia. Some- times the epididymis has descended to the scrotal region while the testicle remains within the abdomen, thus result- ing in a long, narrow inguinal canal. Pass the hand upwards, outwards and forwards along the aponeurosis of the small oblique until the crural arch is reached slightly anterior to the crural ring in which the pulsating femoral artery can be felt, and palpate at this point in the muscular wall for the internal inguinal ring which varies greatly in different individuals but usually reveals itself to the fingers as an oblong slit or ring about one inch in length covered only by peritoneum. Through this usually extends a portion of the gubernaculum testis or of the vas deferens. Examing Plate XXI, the peritoneal view of the internal ring is shown crossed by the dotted line, V, of the upper or right testicle, into which extends a short distance the tail of the epididymis. In the lower or left testicle the ring has been opened and the gland lies in a position correspond- ing to the right and showing the epididymis and vas defer- ens lying in the processus vaginalis, P. The surgical rela- tion of the parts is further illustrated in Plate XXII, where the testicle is completely withdrawn into the peritoneal cavity and spread out over the right flank. The processus CASTRATION OF CRYPTORCHID HORSES. 145 vaginalis, P, is outlined by a dotted line into which is in- troduced a curved sound, S, along side of which lies the gubernaculum, G. The gubernaculum, it will be observed is divisible into three sections, a slender one, G, which by passing along behind the peritoneum escapes from the abdominal cavity at the postero-external commissure of the ring to extend to the scrotum. The second portion of this organ, G', is much thicker and extends from G to the epididymis at E, while the third division, G", extends from the epididymis to the testicle. In Plate XXII it is shown that the testicle under all ordi- nary conditions is inevitably attached through its guber- naculum testis to the postero-external commissure of the ring and that it has a second definite attachment to the seminal bladder through the medium of the vas deferens, V, and a third by means of the testicular artery, A. The gubernaculum and the vas deferens constitute the essential guides in locating and recognizing the testicle. By forming a hollow cone with the fingers about the in- ternal ring, the vas deferens, epididymis and gubernaculum tend to drop out into the processus vaginalis where they may be grasped with the fingers without the peritoneum having been ruptured. The vas deferens and epididymis present characteristics which are unmistakable to the trained touch consisting of a small firm cord (vas deferens) or a small mass of fine threads (tail of epididymis) which roll freely between the thumb and finger and give a sensa- tion which is unlike that produced by any other tissue in the body. Grasp the part firmly and tearing through the peritoneum seize the vas deferens and carefully draw it out through the external wound. (In teaching cryptorchid castration to the beginner we make our opening down to the internal ring and grasp the vas deferens between the thumb and finger without penetrating the peritioneal cavity and then yiV7 Castration of Cryptorchid Horse. Urino genital apparatus of 24 hr. colt. T, T, testicle ; A, testicular artery ; G, gubernaculum testis ; V, V, vas deferens ; B, urinary bladder ; UA, umbilical arteries retracted within abdomen ; P, processiis vaginalis ; UV, umbilical vein. CASTRATION OF CRYPTORCHID HORSES. 149 passing a pair of long uterine dressing forceps along the hand, fasten them upon the vas deferens. The student then completes the operation, using the forceps as a guide. He thus learns the relations and character of the parts and recognizes the internal ring with the peritoneum still stretched across it, intact.) In case the vas deferens can not be felt before rupturing the peritoneum, it may be broken through with the index finger and inserting the finger into the cavity, the gubernaculum is found attached to the postero-external border of the ring, and but a short distance therefrom the finger comes in con- tact with the vas deferens or with the tail of the epididymis where the gubernaculum crosses it at E, in Plate XXII. Having reached the vas deferens the operation is proceeded with as above. Thus far the operator has not concerned himself with the location of the testicle but relies wholly upon the vas deferens or gubernaculum, since when either of these is recognized the testicle is virtually within his power. He thus proceeds upon the basis that he is not to^Jwafthe testicle for the rea.son that it is not lost but that it has de- finite relations and attachments which permit of certain displacements of the organ itself but not of its attachments. Having drawn the vas deferens out through the wound tension is exerted upon it which tends to cause the testicle to follow but sometimes the gland is too large to pass the internal ring and the latter needs be dilated by inserting an index finger in it or the testicle needs be guided through the opening. We have described herein one method of castrating a cryptorchid horse where the cryptorchidy is due to an arrest in the development of the gland and of its descent. There are other methods employed which introduce variations at each .step, many operators making the incision over the external ring instead of near the median line. Other \ f^' Plate XXII. Castration of Cryptorchid Horse. Right inguinal region and testicle of 24 hrs. colt. P, processus vaginalis surrounded by a dotted line and containing a curved sound, S ; G, first portion of gubernaculum testis; G', second portion of gub- ernaculum testis extending to the epididymis, E ; E, epididymis ; G", gubernaculum extending from epididymis (globus minor) to the testicle ; T, testicle ; A, testicular artery ; V, V, vasa deferentia ; B, urinary bladder ; UA, umbilical arteries. \k<" CASTRATION OF CRYPTORCHID HORSES. 153 operators avoid opening the internal ring and penetrate the peritoneal cavity somewhat in front of and above the ring through the small oblique muscle. When one plan has been learned the variations are easily applied. There are other causes of cryptorchidy which in rare cases require a different procedure in order to extract the gland varying with individual cases but the essentials for the tracing and recognition of the testicle are the same. Prior to attempting the operation it is well to make a rectal exploration and determine as far as may be the loca- tion of the testicle, whether it be on the right or left side, and its character, should it be in any way pathologic. After the testicle is brought to the surface it may be re- moved with the emasculator or by such means as the opera- tor may prefer. Cryptorchid testicles when due to arrest in development are not vascular and there is little tendency to hemorrhage after exci.sion. Place an antiseptic tampon in the wound, pushing it well up against the internal ring and retain it in position by means of sutures for a period of 24 to 48 hours when it is removed and the wound dressed antiseptically. The operation for cryptorchidy in the smaller animals is essentially the same as in the horse except that the incision is to be made ordinarily through the flank as in spaying. The same attachments are to be our guide and the operation is to proceed upon almost parallel lines. IV. OPERATIONS ON THE EXTREMITIES. 33. TENOTOMY OF THE FLEXORS OF THE PHALANGES. Plate XXIII. Objects. The relief of contraction of the flexor tendons of the foot. Instruments. Razor, scissors, sharp tenotome, bandage material. Technic. Tenotomy is generally performed on the flexor of the third phalanx, seldom on the superficial flexor or flexor of the second phalanx. Confine upon the operating table with the affected member undermost and the foot fully extended. In default of a table confine in lateral recumbency and apply an exten- sion splint to the foot as shown in Plate XXIII. On the median side at the middle of the metacarpus or metatarsus the skin is shaved and disinfected over the tendon of the flexor pedis muscle. The location named lies between the lower extremity of the great carpal or tarsal sheath above and the superior extremity of the tendonous sheath of the fetlock below, .so that neither of these is wounded during the operation, but the tendon is severed at a point where it is invested by loose connective tissue which retains the divided ends in their normal line of direction, somewhat fixed, and favors their ultimate reunion. Grasp the metacarpus or metatarsus in this area from above and behind in such a manner that the thumb rests upon the median or upper surface, and the index and second fingers on the lateral or under side of the flexor pedis tendon. While the left thumb pushes the skin toward the bone, that is, forward, a sharp pointed tenotome held perpen- dicularly in the right hand is introduced with the cutting edge toward the hoof through the skin, subcutem and anti- brachial fascia down to the flexor pedis tendon. Immedi- c ■§ c '(/) P. ; • 5 t^ < .« "^ OJ 'U •~i ■i; o % ;i! R ^ ;-4 o ' >-, a a; a tn 1 3< o ^ ."J o o t*-i p! i^ '^ H ■3 SI .M P, B ^ en W o d ii S ■-3 rt 222 DESTRUCTION OF THE PELVIC GIRDLE. against the maternal vulva by making an incision through the skin and skin muscle. If practicable it is best at this point to remove one shoulder subcutaneously, (48), and fol- low by evisceration, (54), in order to give greater opera- tive room and increased mobility of the fetus. Insinuate the hand between the skin and the deeper structures and forcibly separate the integument from the fetal body back- ward until the last rib is passed, as shown at the curved line in Plate XXXVI. Force the finger tips through the abdominal wall behind the last rib and passing along the entire border of each posterior rib, separate the abdominal walls from the ribs and sternum. After the abdominal muscles have been detached, and the fetus has been evis- cerated, rotate the thorax upon its long axis which will cause a division of the vertebral column near the dorso- lumbar articulation and the anterior portion of the fetus falls away. Secure the two posterior feet with cords, unless this has already been done, spread the detached skin, which has been pushed back from the thorax, carefully over the amputation stump of the lumbar vertebrae, repel these by means of the hand while an assistant draws upon the cords attached to the feet, push the remnant of the fetal trunk into the uterus and advance the feet along the genital pass- ages, thus converting it into a posterior presentation. Ordinarily this would result in a dorso-pubic — which should be converted into the dorso-sacral position, when its extraction can be readily brought about. 51. DESTRUCTION OF THE PELVIC GIRDLE IN THE ANTERIOR PRESENTATION. Plate XXXVII. Object, [n somewhat rare instances perhaps most fre- quently in the cow the pelves of the mother and fetus be- come interlocked, the antero-external angle of the fetal ilium, r, becoming locked with the shaft of the maternal si i ^ ^ a _ •i-i 5 QJ a o o o rt J 1 Oh en s" 3 "o —I '^ lU nJ a Q) 'o 'c3 '3 1 o 5 M o TZJ '^ 1 a a" 1 a. .2 ;s CD U "erf 'd 1-1 en ;-) M o o "3 a u ej" c 1^ OJ Is 01 •2 a J) Vh Cfi .2 dJ > I— r OJ _o a 5 > SO 2 ^ '*J >! ;h o -*-• 1~( a (U ? to o rt ■•-' n 13 a a OJ 'tn en B ca !> CJ t4H w "3 3j 2 !«1 _g !3 t+H CJ 15 2 26 AMPUTA TION OF THE LIMBS A T THE TARSUS ilium I at C in such a manner that any safe degree of trac- tion fails to dislodge it. Technic. Remove one anterior limb subcutaneously, (48), and eviscerate, (54), through an opening made by the removal of two or three of the exposed ribs. Introduce the chisel through this opening and carry it back with the hand, place it against the shaft of the fetal ilium, I', have an assistant drive it through the shaft from before to behind and then withdrawing the chisel replace it against the pubic brim either at the .symphysis pubis or opposite the obturator foramen, and drive it through the pubis and ischium at either of these points. The coxo-femoral articulation is thus detached and isolated so that the entire limb may drop backward beyond its fellow, the remnant of the severed ilium, I', can drop downward or move in any direction and the entire pelvis thus loses its rigidity and undergoes great diminution in size so that it can readily be withdrawn. 52. AMPUTATION OF THE LIMBS AT THE TARSUS. Plate XXXVIII. Object. It sometimes happens in the mare, far more rarely in the cow that in the posterior presentation with the hind limbs retained at the hock owing to the unusual size of the fetus or its having been dead for some time, dry and emphysematous, that the deviation can not be overcome or its correction would entail an unnecessary amount of labor. In these cases it is frequently easier for the obstetrist and safer for the mother to amputate the limb at the tarsus. Technic. Pass a cord around the leg above the tarsus as indicated in Plate XXXVIII and have an assistant hold the leg steady by gentle traction. Introduce the chisel carefully guarded in the palm of the hand, and place it against the lower part of the tarsus as shown between T, T. The chisel should be placed as nearly as possible perpen- -^ ^«JC=!5— t2 cj CI. / ^ .^ "3 «s CU {-I .2 H ^fe ft a s >, -S ^ P CD O S 2 w 230 INTRA-PEL VIC AM PUT A TION. dicular to the long axis of the metatarsus. The proper direc- tion of the chisel may at times be greatly favored by placing the cord upon the metatarsus instead of the tibia thus forc- ing the tarsus toward the sacrum of the mother and tending to throw the metatarsus straight across the pelvic cavity. When the fetus is in the dorso-sacral position and it is desired to amputate the left limb, the chisel should be held in the palm of the left hand with its dorsal surface against the vaginal walls and the instrument carefully guarded and guided during the entire operation. The amputation should preferably be through the lower section of the tarsus but may be made through the head of the metatarsus. Do not drive the chisel entirely through the hock without removal as it may become caught and clamped between the divided bones, but drive for a few inches along the lateral side being sure that the skin at that point is severed along with the bone, then loosen the chisel by rotation and lateral motion and drive somewhat deeper into the tarsus until it is com- pletely severed. Withdraw the severed metatarsus and re- move any dangerous spicules of bone remaining on the stump and see that the latter is safely secured by a cord passing around the leg above the os calcis. Repeat the ■ operation on the other hock in a similar manner using the right hand to guide the chisel. Extend the two limbs into the passages by traction and effect a posterior delivery. 53. INTRA-PEL VIC AMPUTATION OF THE POSTERIOR LIMBS, BREECH PRESENTATION. Plates XXXIX-XL. Uses. The overcoming of dystocia due to a posterior presentation with the hind limbs completely retained in the uterus, the so-called breech presentation, in cases where the deviation can not be readily corrected. Technic. Introduce one hand armed with the embry- otomy knife through the maternal passages until the peri- ^ A -\V d m o s o o o •a 5 tn o "0 '2 3 "S ^H S 2 c fc OJ ■_3 c£ _o o o in oJ o 2 ri tfi tfi •c n ,o c <«>« 4J c en O p< 1-1 o g i_i (D a .0 a a .2 'u p. H a 3 a o o ai S ,13 Si u 3 3 Tj c u 5 -*-' a ca _0 tj a 5 OJ o o "3 h V •id o (U u ^ v^ fi- rt ,e >, "3 B Vh ^ s a o W tJ a a ^ a; CU 234 INTRA-PEL VIC AMPUTA TION. neum of the fetus is reached and make a free incision through that region involving the anus in the male fetus and the anus and vulva in the female and enlarge the incision sufficiently to admit the operator's hand into the fetal pelvis. Locate the great sciatic ligament and with the knife divide the ligament from end to end, thus enlarging the pelvic cavity and giving ample operating room. If the pelvis of the fetus is too small to admit the hand of the operator at all before severing the sciatic ligament, this may be accomplished by cautiously cutting from behind forward with Colin's scalpel or with the chisel. When this has been severed and sufficient operating room attained, carry the chisel with the hand and place it against the shaft of the ilium as shown between I' I' in Plate XXXIX as nearly perpendicular to the long axis of the iliac shaft as possible and keeping the hand in touch with the chisel blade, have an assistant drive it through the bone until it and its periosteum are completely severed. Revolve the chisel on its long axis and force the cut ends of the bone apart. Dis- engage the chisel and place it against the symphysis pubis or against the ischium opposite the obturator foramen and drive it through the ischium and pubis at this point. Using the chisel as a lever, separate the isolated portion of the pelvis as completely as practicable from the surrounding tissues, and with the fingers separate the muscles from the detached pelvic bone for a short distance from the severed ends on either side. Carry a cord in, pass the loop over the ends of the severed section and tightening it secure the iso- lated portion of the pelvis and have one or more assistants exert traction as indicated in Plate XL. The chief obstacle to the withdrawal of the limb is the great gluteus muscle which should be sought for, identified and torn through with the fingers at a distance of 5 or 6 cm. from its attachment to the great trochanter. Other important points of resistance are the attachment posteriorly of the skin, vulva and anus to the ischium through the medium s o OJ CJ ^-• cn CO 15 B9 bO ^H a ■S D hH (U i a g S U k. 3 <*M vh H u 2 t*l ^ 13 B . ^ c ^ a -j:^ at ^ pi & rt cfl 3 •i.« «) d s 2 ^ eg )~r k < n' .2 •15 d MH li 3 ft o 1 e Oh O d V m Ph"^ T 1 0) ft a 1 s J3 •S 5 12. CJ "S J5 V 0) ^d Id" 1 2 Q. g 1 '3 y 3 1>* o „ en M ft .Q t^ d 2 a % w CJ •t;.-- -S 238 INTRA-PEL VIC AMPUTA TION. of aponeurosis and anteriorly, chiefly on the median line, the prepubic tendon ; these are to be cut, if necessary, with the chisel or knife. Vigorous traction may now be applied by means of the cord, the operator in the meantime guard- ing the most advanced end of the detached piece of pelvis with the palm of his hand in order to prevent injury to the maternal organs. Sometimes this detached piece of the pelvis tears away from the femur when traction is applied and comes away alone. In such a case the cord is to be applied over the head and trochanter of the femur and traction again applied drawing the limb away in a reversed position, the skin being turned back or everted as it ad- vances until the region of the hock is reached where the integument does not so readily separate and only requires to be cut loose and the member allowed to come away. During the removal of the limb the operator is to con- stantly note the progress with his hand and sever by tearing or cutting any tendons or muscles which offer special obstruction to the operation. Repeat the operation upon the opposite limb in the same manner except that but one incision need be made through the bone, that is, through the shaft of the ilium. During the entire work the opera- tion is carried out subcutaneously or rather intra-fetally and the maternal parts are amply guarded against injury. The size of the fetal trunk may be further reduced if de- sirable, by evisceration, (54), and followed still further by the introduction of the chisel guided by the hand and the ribs, on one or both sides, severed one after another until the chest can completely collapse. Or the ribs may be yet more conveniently severed by introducing the sector in the body cavity, pushing it forward until the first rib is reached catching the spherical end over the rib and drawing back- wards, sever each rib in turn. If need be some of these may be removed and one of the anterior limbs caught by a cord around the scapula and extracted intra-fetally. The remnant of the fetus is to be extracted by means of a cord fastened about the lumbar region of the spine. EVISCERATION. 239 54. EVISCERATION. Evisceration of the fetus is frequently desirable in ob- stetric practice and has a variety of uses. It decreases the size of the fetal trunk considerably and permits its more ready passage through the genital canal, as in the anterior presentation ; with lateral deviation of the head it renders the fetal trunk flaccid through the removal of the viscera supporting the body walls and permits the body remnant to be bent or moved more readily for the correction of any mal- presentation ; it permits freedom of intra-fetal operations directed against other parts, as for detruncation, or for the destruction of the pelvic girdle in the anterior presentation, and when a fetus is emphysematous, evisceration permits the gases of decomposition to pass into the fetal body cavity and thence externally. The escape of gases is very greatly favored further by the cutting of the ribs. Technic. Evisceration may be variously performed, but is generally demanded in either the anterior or posterior presentation and a description of these will suffice. In the anterior presentation, unless the fetus is far ad- vanced through the vulva, evisceration is best performed by the removal of one or more of the anterior ribs. The ribs are generally best reached by the removal of the shoulder, as already described under subcutaneous amputation of the anterior limbs, (48). When the ribs have been laid bare in the manner described the operator can thrust the finger tips through the intercostal muscles in the first space and enlarge the opening thus made by tearing through the muscles up- wards to the spinal column and downwards to the sternum ; then grasping the posterior border of the rib near its middle, fracture it by means of a sudden and vigorous pull. The fractured ends may then be grasped and pulled, broken or twisted off. The chisel may be brought into use if required in order to divide the rib, the hand of the operator con- stantly guiding and guarding the chisel blade. The opera- 240 EVISCERATION. tion is then to be repeated if required, upon the second and third ribs in the same manner until an opening into the chest is secured ample in size for the introduction of the operator's hand. Force one hand through the opening and tear the medi- astium above and below from the thoracic walls, and then grasp either the trachea at its bifurcation or the heart and tear them away. The heart, which constitutes the greater bulk of the thoracic viscera, is best grasped in the palm of the hand, with the fingers engaging the aorta and pulmo- nary arteries. When the thoracic viscera have been with- drawn, thrust the fingers through the diaphragm and locat- ing the liver, isolate the diaphragmatic area to which it is attached, and engaging both with the fingers remove the two together. The liver constitutes, in a normal fetus, the chief intra-abdominal mass, occupying more space than all other organs combined. After the liver has been removed the intestinal tube, with its contents, is withdrawn without difficulty, as its attachments are feeble. The kidneys may also be removed. Evisceration in the posterior presentation is preferably performed through the pelvis, generally in connection with intra-pelvic amputation of the posterior limbs, (53). It may be performed without destruction of the pelvic girdle by making an incision through the perineal region and then severing the sacro-.sciatic ligament as directed under 53. When admission has been gained to the abdominal cavity introduce the hand and withdraw the alimentary tube, then rupture the diaphragm about the liver and tear away the latter organ in the same manner as in the anterior presentation. The liver is so friable that it cannot well be removed by grasping the organ itself, but comes away entire with the central part of the diaphragm. Remove the heart and lungs as above directed.