Class S F 9 1 1 B()()k^i-_2 ('iOp)i1ght X'.' COPYRIC.llT DKPOSIT. A. MiANXJAL OF OPERATIVE VETERINARY SURGERY BY A. LIAUTARD, M.D., V.M. Dean and Professor of Anatomy, Surgery, Sanitary Medicine and Jurisprudence in the New York American Veterinary College ; Officier du Merite Agricole de Fraiice ; Member of the Societe Centrale de Medecine Veterinaire (Paris) ; Honorary Fellow of the Royal College of Veterinary Surgeons {Londoji) ; Correspotiditig Member of the Academy of Medecine of Br ux- elles ; Honorary Member of the Societe VHerinaire d' Alsace-Lorraine, etc. Author of'Vade Mectim of Equine Anatomy,'" "How to Tell the Age of Domestic Animals," ^'Atiimal Castration,'" "Lameness of Horses," Translator of ^'Bouley on Hydrophobia," of " Zundel on Diseases of the Foot"; Editor of the " Ameri- caii Veterinary Review," etc., etc. WITH NEARLY 600 ILLUSTRATIONS New York WILLIAM E. JENKINS VETERINARY PUBLISHER AND BOOKSELLER 851-853 Sixth Avenue 1906 SF3I . Li LIBRARY of CONGRESS Ont CoDy RiRTived JUL 24 1906 pjiPKfil tntry LASS Cl XX;c. No. COPY B. Copyright, 1S91, 1906 by A. Liautard, M.D., V.M. A// Rights Reserved printed by the Press of William R. Jenkins NEW. YORK \ TO Dr. a. CHAUVEAU, Member of the Institute {Paris), General Inspector of the Veterinary Schools {France), Professor to the Museum of Natural History {Paris), As a humble token of the high appreciation of his scientific labors in behalf of Veterinary and Comparative Medicine, this work is, with kind permission, dedicated by THE AUTHOR. PREFACE. If an apology should be deemed necessary for any apparent tardiness in the execution of the special undertaking of which the present work is the result, it will not be very far to seek, but may be readily found by a reference to the various and unceasing vocations in which the author of the Manual of Operative Veterinary Surgery is habitually engaged. The labor of its preparation has, in fact, been alternated and shared with that of other literary engagements of an imperative and unremittent char- acter, and the onerous and exhaustive duties pertaining to his collegiate functions, to say nothing of the demands of an extensive practice. Engaged for years in the work of teaching this special department of veterinary medicine, and having abundant opportunities, which have not been neglected, of realizing the diflBculties which the student who earnestly strives to perfect himself in his calling is obliged to encounter, I formed the determination long since to do what lay in me to facilitate his acquisi- tion of knowledge; and it was then that I projected the present volume, and began the accumulation of material by the compilation of data and arrangement of memoranda, with the recorded notes of my own experi- ence, the fruit of a long and extended practice before referred to ; and of course a careful study of the various authorities who have illustrated and organized our copious veterinary literature. Moreover, haste in the pub- lication, and a thorough digestion of the subject and the systematic order- ing of material, could not be very easily combined, and a little delay in the issue will prove no detriment to the value of the book. With his own kind permission, the work is dedicated to Professor A. Chauveau, General Inspector of the Veterinary Schools of France, as a token of my high appreciation of his services as a scientist, and in recog- nition of his standing among the lights of our profession ; and especially of my estimation of his excellent book on anatomy, in which he so ably lays the foundation of the knowledge which constitutes the indispensable condition of all success in surgical practice. VI PREFACE. I have been liberal with European authors, not only in freely cred- iting them with their discoveries and theories, and in many cases quoting literally their opinions and arguments, but especially so in adopting their illustrations and enriching the work with the artistic representations orig- inating in their's— an emphatic manifestation of my high estimate of their value and the skill of their execution. And it is thus that the names and accomplishments of Rigot, Bouley, Gourdon, Peuch, Toussaint, Cadiot and Zundel, of France ; of Brogniez and Degives, of Belgium ; of Hert- wig, Hering, MoUer and Hoffman, of Germany; of Lanzillotti-Buonsanti, of Italy ; and of Williams and Fleming, of England, will become famil- iarly known to our readers. But while I have in great part been guided in my work by the char- acter of that of our predecessors, I have not restricted myself to the lines observed by them, or exclusively respected the authority or prece- dents of European surgeons, but have sought to do justice to the progress of American veterinarians by honoring the contributions they have made to our surgical knowledge ; and it is due to accident alone, and to no in- vidious design, if any omission or oversight has been committed, by which any to whom credit should be awarded have failed to receive it. The chapters of the Manual which treat respectively upon "Frac- tures" and upon "Operations on the Foot" are reprinted from my own previous writings. Thus, in the first instance, the remarks upon frac- tures, with the kind permission of the Hon. Jeremiah M. Rusk, Secretary of the Department of Agriculture, are extracted from an article published in " The Special Report on Diseases of the Horse;" and in the second in- stance, touching the subject of operations on the foot, I have not hesitated to utilize my own translation of Zundel, produced as long ago as the year 1881. In both cases improvement has been made upon the previous treat- ment of these topics by the addition of numerous illustrative plates which accompany the text. In the chapter upon operations on the genito-urinary apparatus the reader is referred to my special work on the subject of " Castration," which is not included in the present volume. In completing the task undertaken in the preparation of the Manual, however perfect or imperfect may be the manner of its execution, while I have been influenced by a desire to effect something for the benefit of all classes of practitioners, including those of recent graduation, my ob- ject above all has been to facilitate the labors of the young student while industriously and anxioxisly toiling for the knowledge which is to qualify PREFACE. VU him for a successful career in a useful and honorable profession ; and if I shall have succeeded in this object, and the success shall be certified by the verdict yet to be pronounced, I shall feel fully satisfied and more than ever encouraged to persevere in my efforts to elevate the standard of vet- erinary science in America. No toil has been spared, no effort relaxed, in the prosecution of the design and desire to compel the approval of the judicious, and even to escape the strictures of the critical, and I have not failed to seek for aid and counsel from competent coadjutors. The entire text has undergone revision, with a view to the improvement of its idiomatic structure, by my esteemed friend, H. D. Holt, M. D., of Jersey City, N. J., to whom I am also indebted for the favor of supervising the proof and overlooking the issue and arrangement of the various chapters; and my publisher has exercised a true liberality in providing an external garment and garni- ture for the contents of the book, in all respects correspondent v\4th their value and interest. To that gentleman, therefore, are due my warmest acknowledgments for whatever of internal and external attractiveness may characterize the Manual of Operative Veterinary Surgery, and they are cordially and freely tendered. I have now only to express the hope that this contribution to the cause of veterinary progress may be as kindly received and favorably judged by my colleagues as it is honestly designed to effect its object by me, and that any shortcomings in the execution of the work may be len- iently regarded. And so it goes into the hands of the public, to share the fate of all human ventures, for better or for worse, as its fate may be. THE AUTHOR. CONTKNTS. FAOE. Inthoduotion 1 CHAPTER I. Means of Restraint 14 Means of Securing Solipeds 14 Derivative or Painful Method 14 Mechanical or Restraint Method 17 Standing Position 17 Recumbent Position 27 Casting with Hobbles 30 Securing the Legs ... 38 Casting with Ropes 44 Casting on the Operating Tables 47 Means of Securing other Domestic Animals 54 Bovines 54 Ovines and Caprines 62 Swine 62 Dogs and Cats 64 Sttbgioal Anesthesia 66 Local Anesthesia 67 General Anesthesia 70 Accidents of General Anesthesia 75 Accidents Licidental to the use of means of Restraint 76 Fractures 76 Injuries of Soft Tissues 19 CHAPTER II. Stjegical Diagnosis. Sight 81 Touch 86 Hearing 88 SmeU 88 Taste 88 X CONTENTS. CHAPTER III. Surgical Thkrapbutics. pagi. Dressings 90 Retentive Dressing 98 Uniting " 99 Suspensory " 99 Compressive Dressing 99 Dividing Dressing. 99 Expulsive " 99 Antiseptic " 100 Bandages. 103 Varieties of Bandages 105 CHAPTER IV. Elementary Opirations. Division 125 Incisions 125 Dissections 137 Puncture 138 Reunion 142 Position 144 Uniting Bandages 144 Sutures 146 CHAPTER V. Operations on the Skin and Cellular Tissue. Cauterization 158 Actual Cauterization or Firing 158 Transcurrent or Firing in Lines. 160 Firing on the Surface or " a la Qaulet " 171 Firing in Superficial Points 172 Objective Firing 174 Deep Cauterization 175 Rapid, Deep Cauterization 175 Inherent Firing 178 Subcutaneous Cauterization 180 Cauterization with the Thermo-Cautery 182 Cauterization in other Animals 183 Accidents of Actual Cauterization 184 CONTENTS. XI Operations on the Skin and Cellular Tissue — Continued. page. Exutories 186 Setons 188 Tape Seton 188 Regions to apply Setons 193 Rowel Seton 197 Trochiscus 198 Accidents or Sequelae of Setons 198 Ablation of Tumors 200 Excision 201 Ligature 205 Elastic Ligature 210 Removal by Tearing 211 Puncture 211 CHAPTER VI. Operations on Bones. Fractures. (Generalities) 212 Fractures of Different Bones 229 Dislocations 262 Amputations 266 Amputation of Members 268 " " Horns, 274 " " the Tail 277 Trephining 283 Periostotomy 291 Resection of Bones 293 CHAPTER VIL Operations on Muscles and their Annexes. Caudal Myotomy 296 Caudal Myotomy by Transverse Incisions 299 " " " Longitudinal " 300 " " " Mixed " 301 " " " Subcutaneous " 302 Accidents following Caudal Myotomy 306 Crural Myotase. Crural Myotomy 308 Complications of Crural Myotomy 311 Operations ripon Fibrous Tissues 312 yil CONTENTS. Operations on Musolks and their Annexes — Continued. page. Tenotomy 312 Plantar Tenotomy 312 Accidents Following 320 Carpal Tenotomy 321 Anti-Brachial Tenotomy 32C; Tarsal Tenotomies . 32^ Cunean Tenotomy 32;> Peroneo-Phalangeal Tenotomy 32G Tenotomy in Birds 327 CHAPTER VIII. Operations on the Digestive Apparatus. On the Teeth 32S Operative Dental Surgery 335 Leveling of the Teeth 335 Extraction of Teeth 343 Filing Teeth 35G Canine Dentistry 356 Operations on the Tongue 3" 8 Suture 36a Amputations. Glossotomy 361 Operations on Salivary Glands 361 Adenotomy 361 Maxillary Adenotomy 363 Operations on the (Esophagus 364 CEsophageal Catheterism 366 The Taxis 370- Crushing the Foreign Body 372 CEsophagotomy 373 Accidents Following 377 Qastrotomy. Rumenotomy 377 Incision of the Rumen 37S Enterotomy 380 Paracentesis 383 Hernia 385 Inguinal Hernia 394 Recent Inguinal Hernia 397 Accidents Following 411 CONTENTS. XIU Operations on Salivary Glands— Continued. page. Old Inguinal Hernia 411 Inguinal Hernia in Geldings 418 Crural Hernia 420 Perineal " 421 Pancreatic " 421 Pelvic or Internal Hernia of Oxen 421 Umbilical Hernia 425 Diaphragmatic Hemia 439 Ventral Hernia 443 Eventrations 447 Lapa/rotomy 449 CHAPTER IX. Opkbations on the Respiratory Apparatus. On the Guttural Pouches. Hyovertebrotomy 452 Laryngotomy. Arytenectomy 462 Fleming Method 463 Cadiot Method 468 Tracheotomy 477 Accidents Following 486 Thoracentesis 488 CHAPTER X. Operations on the Cibottlatory System. Bleeding. Venisection 492 Phlebotomy 493 Phlebotomy in Solipeds 496 " at the Jugular 497 " at the Cephalic 499 " on the Subcutaneous Thoraciq 501 " at the Internal Saphena oOl " on other Superficial Veins 50 ^ " in Large Ruminants 503 ** on the Jugular 504 " at the Subcutaneous Abdominal 504 " on Small Animals 505 Accidents Following Phlebotomy 506 XIV CONTENTS. Operations on the Circulatory System. — Continued. page. Arteriotomy 514 Arteriotomy at the Transversal of the Face 514 " " " Posterior Auricular 515 " " " Median Caudal 516 Ca/pilla/ry Bleeding 517 Bleeding at the Palate 520 " " " Coronet 521 " " Foot 522 Surgical Hemostasia 523 Temporary or Preventive 524 Permanent or Definite 526 Physico-Chemical Hemostatics 526 Surgical Hemostatics 530 CHAPTER XI. Operations on the Nervous Apparatus. Plantar Neurotomy 541 CHAPTER XII. Operations on the Genito-Ukinary Apparatus. Catheterism of the Urethra 558 Urethrotomy 558 Preputial Urethrotomy 561 Scrotal " 561 Ischial " 56S Cystotomy 565 Lithotrity 565 Amputation of the Penis 569 CHAPTER XIII. Operations on the Foot. Anatomy 576 Diseases and Defectuosities 583 Vices of Conformation 583 Instruments 589 G eneral Operations 590 Dressings 591 CONTENTS. XV Operations on the Foot— Continued. page. Diseases. Canker of the foot 591 Corns 607 Sandcracks 610 Calk , 627 Punctured Wounds of the Foot 629 Contracted Heels. Hoof Bound 640 Diseases of the Frog 66o Keraphyllocele 668 Laminitis 669 Navicular Disease 694 Quittor 702 Cutaneous Quittor 703 Tendinous Quittor 706 Sub Horny Quittor 711 Cartilaginous Quittor 714 CHAPTER XIV. Operations on the Eye and Ear. On the Eye. Operations on the Accessory Ocular Organs 739 Traumatic Lesions 740 Solutions of Continuity 740 Defective Congenital Conformations 741 Pathological Growth and Caries of the Membrana Nictitans. 743 Operations on the Lachrymal Apparatus 743 On the Caruncula 743 On the Lachrymal Ducts 744 On the Lachrymal Canal 745 Operations on the Essential Organs of Sight 746 Extraction of Foreign Bodies on the Surface of the Globe. . . 748 Paracentesis of the Cornea 748 Staphyloima 749 Cataract 749 Amputation of the Eye 754 Ocular Prothesis 755 On the Ear. Amputation 756 XVI CONTENTS. CHAPTER XV. PAGE. Diseases of the Withbbs 759 Excoriations 765 Warm (Edema '. 765 Hematoma 766 Core or Stickfast 760 Abscess 769 Wounds 770 Diseased or Fistulous Withers 771 Terminations of Diseased Withers 774 Diseases of the Poll 779 Excoriations, CEdematous Swellings, Core, Bloody Tumors. . 781 Cyst 781 Abscess 782 Poll Evil 784 TABLE OK ILLUSTRATIONS FIG. PAGE 1 The Twitch 15 2 Short " 16 3 Iron Barnacles 16 4 Wooden Barnacles 16 5 Gag 17 6 Cap, Cradle 19 7 SideBar 19 7a Plaited Rope 21 8 Securing the Hind Foot with Rope and Hobble 21 9 Securing One Hind Leg with Rope Only 23 10 Twitch, Side Bar, Surcingle ; Securing Hind Foot ; Fixing Rope on the Tail 23 11 Another Means of Using the Rope 23 12 Securing and Holding a Hind Leg with Rope 24 13 Securing Both Hind Legs with Hobbles 24 14 Securing all the Legs with Rope 26 15 Hippo-lasso 27 16 Stock 28 17 Winsot's Stock 29 17a Firing a Horse in Winsot's Stock 29 18 Laying a Horse Down in Winsot's Stock 29 19 English Hobbles 31 19a Self-locking Hobbles 31 20 Spring and String-hooks 33 21 Barnardot & Buttel Apparatus 33 23 Horse About To Be Cast 34 23 Horse Thrown and Secured with Buttel Apparatus 36 24 Improved Hobbles of Dneubourg 37 25 Neurotomy — 1st Position 39' 26 " 2d '* —1st Step 39 27 " 2d " —2d " 4a 23 . " 3d " — Securing Upper Hind to Upper Fore Leg 41 29 " 4th " — Securing Under Fore on Upper Hind Leg 43 30 " 5th " — Securing Under Hind on Upper Fore Leg 43 31 " 6th " 43 XVIU TABLE OF ILLUSTRATIONS FIG. PAGE 32 Side Bar Hobbles 44 33 Cross Hobbles 44 34 Application of Rohard Method 45 35 Animal Secured by Rohard Method 46 36 Wall Bed 48 37 Daviau's Table— Full Back View 49 38 " " —Front View • 50 39 " " — Animal in Position 51 40 Hodgson's Table 53 40a Same in Oblique Position 52 40b " • ' Horizontal Position 52 41 Securing Cattle 54 48 To Prevent Cattle from Kicking 55 43 Italian Nose Clamp 56 44 English Nose Clamp 56 45 English Nose Clamps 56 46 Square Rings for Cattle 57 47 Ring of Rolland 57 48 Alsatian Ring 58 49 Rings with Eyelets 58 50 Puncture of the Septum with Trocars 58 51 Rings with Points 58 52 French Rings 59 53 Ring of Rueff 59 54 Various Guiding Sticks 60 55 Vigan's Apparatus 60 56 Steer Placed in Stocks 61 57 Twitch for Swine 63 58 Gag for Swine 63 59 To Prevent Swine from Digging 63 59a Another Method 64 60 To Prevent Dogs from Biting 64 61 Mouth Speculum for Dogs 65 62 Keeping Mouth of a Dog Open. 65 63 Collar Nippers for Dogs 65 64 Richardson Atomizer 68 65 Syringe of Pravaz 69 66 Apparatus of Def ays 71 67 Cox's Chloroform Bag. ". 71 68 Gresswell's Chloroform Bag 72 69 Carlisle's " Inhaler 72 ZV i Simple Speculum Oris 82 72 Brogniez Speculum Oris 82 73 Green's " " 83 74 Gi'ange's " 83 75 Reynal's Mouth Reflector 34 TABLE OF ILLUSTRATIONS xix FIG. ■ PAGE 76 Nose Speculum 84 77 Eye Speculurcs 84 78 Ophthalmoscope 85 79 Examination of Dog's Ear 85 80 Vaginal Speculum 86 81 Straight, Curved Directory — Silver Probe 87 82 Dieulafoy's Aspirator. 87 83 Single and Double Roller Bandage , 1'4 84 Manner of Rolling a Bandage 95 85 Bandage Roller 95 86 How to Apply a Bandage 96 87 Safety Pins 100 88 Dissecting Forceps , Kfl 89 Bull-Dog Forceps 101 90 Straight Dressing Forceps , 101 91 Curved Dressing Forceps 101 93 Syringe for Dressing 101 93 Ball of Oakum 102 94 Pad of Oakum 102 95 Square Compress 103 96 Long Compress 1 03 97 Triangular Compress 103 98 Neck-Tie Compress 103 99 Maltese-Cross Compress 103 100 Malf Maltese-Cross Compress 103 101 Double Compress 103 103 Treble Compress 103 103 Graduated Compress 104 104 Perforated Compress 104 105 Plates on Shoes 104 106 Berns' Moistened Pads 106 107 Simple Frontal Bandage (full view) . . 107 108 " " " (side " ) 107 109 Compound Frontal Bandage (full view) 107 110 " " " (side " ) 107 111 Monocular Bandage (full view) 108 112 " " (side ") 108 113 Binocular " (full ") 109 114 " " (side ") 109 115 Ear " (full ") 109 116 " " (side ") 109 117 Bandage for the Ears (side view) 110 118 " " " " (full " ) 110 119) 120 [ Bandages for Dog Ill 121 ) 122 Parotids Bandage 110 TABLE OF ILLUSTRATIONS FTG. PAGE 123 Bandage for Superior Border of Neck IV^ 124 " " Anterior and Lateral Parts of the Neck 113 125 " "Withers 113 126 " " Back 113 127 " " Loins and Croup 114 128 " " Hip 115 129 " " " Separate 115 130 " " Inguinal Region and Perineum 116 131 " " " " " " Separate 116 133 " "Abdomen 117 138 " "Chest 117 134 " "Breast 117 135 " "Shoulder llS 136 " " Shoulder, Isolated 118 137 " " Shoulder Joint Proper llf> 138 " "Elbow lia 139 " " " Isolated 120 140 " " Forearm 120 141 " "Knee 131 143 " "Stifle 121 143 " " LegApplied 122 144 " " " Isolated 122 145 " " Hock and Cannon Applied 123 146 " " " " " Isolated 123 147 Straight Bistoury 126 148 Convex " 126 149 Concave " 126 150 Blunt " 136 151 Bistoury Cache (Castrating Knife for Females) , 126 152 Sage Knives 127 153 Scissors 128 ]gg I Bistoury held as a Pen 128 >- Bistoury held as a Bow of a Violin 139 Bistoury held as a Table Knife 129 Sage Knife held with One Hand 130 " Two Hands 130 Using Finger as Director 134 Sharp's Tenaculum 135 T-shape Incision 137 V-shape " 537 Crucial " 137 Semi-Lunar Incision 137 156 157 157a 158) 159) 160 161 162 163 164 165 166 167 TABLE OF ILLUSTRATIONS xxi ••lO. PAGE 168 L-shape Incision 137 169 X-shape Incision 137 170 Elliptic Incision 137 171 Dissecting Forceps 138 172 Bull-Dog Forceps 138 173 Various Shapes of Lancets 139 174 Manner of Holding a Lancet 139 175 Trocar and Canula 140 176 Various Forms of Trocars 141 177 Exploring Needles 143 178 Bandage for Transversal "Wound 145 179 " " Longitudinal Wounds 146 180 Various Sutured Needles 149 181 Grooved Needles for Metallic Sutures 150 182 Trelat's Needle 150 183 Riverdin's Needle 150 184 Simpson's Needle 150 185 Needle Holder of Mathieu 151 186 Suture Forceps 151 187 Needle or Pin Holder 151 188 Simple or Interrupted Suture 152 189 Looped Suture 152 190 Glover's Suture 153 191 Dossiled Suture 153 192 Quilled Suture 153 193 Suture with Adhesive Bandage 153 194 Single Pin Suture. 154 195 ) - gg >• Twisted Sutures 155 197 Zigzag " 155 198 Suture of the Furrier 155 199 T Suture 156 200 X Suture 156 201 Various Cauteries , 161 202 Old-fashioned Drawings 162 ■203 Firing a la Prange 163 204 Various Forms of Drawing in Firing 163 205 Firing in Dots and Points 1 73 206 Abadie Cautery 175 207 Bianchi Cautery 176 208 Foucher Cautery 177 209 Cautery with Changing Points 178 2iO Bourguet Cautery 179 211 Autothermic Cautery 179 212 Cauteries of Nancio 181 213 Firing a la Nancio 181 214 Paquelin Cautery 182 XXU TABLE OF ILLUSTRATIONS no. PAOK 215 Paquelin and de Place Cautery 18 > 216 Seton Knot 189 2171 218 I 219 y Seton Needles 189 220 I 221 J 223 Frog Seton Needle IPQ 223 Quill Suture Needle 190 224 Kowel Seton 197 225 Ecraseur of Chassaignac 2C2 226 " with Chain 203 227 " " Wire 20:> 228 " " Chain or V\'ire 200 229 " ofReynal .' 20-1 229a Haussnian Ecraseur 204 230 Tapestry Ligature 205 231 Treble Ligature 206 232 Female Needle 206 233 Male Needle 206 234 1st Step of the Ligature by Four 207 235 2d " " " " " 207 236 3d " " " " " 207 287 4th " " " " " 207 238 The Tumor Divided in Four 208 239 The Ligatures Secured 208 240 Thread and Needle for Subcutaneous Ligatures 208 241 1st Step 208 242 2d " 209 243 3d " 2( 9 244 4th " 209 245 5th " 209 246 The Ligatures in Position 2C9 247 The Ligature Secured 2( 9 248 Ligature Carrier 210 249 Complete Fracture ,. 21"^ 250 Incomplete " 212 251 Transverse Fracture of the Radius. 213 252 Oblique " " Femur 213 253 Fracture of the CommonBone, with Callus 219 254 Apparatus for Fracture of the Nasal Bone 230 255 Apparatus for Fracture of the Bones of the Face Applied 231 256 Fracture of the Lower Jaw 232 257 Splint for Fracture of the Lower Maxillary 233 258 " " " " Branches 234 259 " " " ■' Maxillary 234 260 Fracture of the Bodv of a Dorsal A'ertebraj 235 TABLE OF ILLUSTRATIONS xxiii FIG. PAGE 261 United Fracture of the Spinous Processes of Dorsal Vertebrae .... 236 261a Comminuted Fracture of a Dorsal Vertebrte at the Annular Portion 236 262 Fracture of the Axis in an Animal SufEering with Osteo-Porosis . . 237 263 United Transversal and Longitudinal Fractures of the Ribs 238 264 Fractures of the Ossa Innominata 241 265 Transverse Fracture of the Scapula 244 266 Bourgelat Apparatus for Fracture and Dislocation of the Shoul- der Joint 245 267 The Same in Place 245 268 Delwart's Bandage for Fracture of the Scapula 246 269 Another Bandage with Iron Splints 246 270 Comminuted Fracture of the Humerus 247 371 Oblique Fracture of the Humerus with Displacement and Partial Union 247 271a Consolidated Fracture of the Body of the Humerus 248 272 Fractures of the Radius 248 273 " " Ulna 249 274 Bourgelat's Iron Splint for Fracture and Ligation of the Forearm, 250 275 Fracture of the Femur 251 276 " with Shortening 251 277 " of the- Tibia 254 278 Bourgelat's Iron Splint for Fractured Tibia. 254 279 Splint and Dressing for Fractured Cannon Bone 255 280 " " " on Lower Part of Foreleg 256 281 Bourgelat's Splint for Fracture of the Cannon and Phalanges 256 282 Longitudinal Fractures of the Os Suffraginis 257 283 Comminuted Fracture of the Os Suffraginis 257 284 Animal with Fracture Below the Knee with Splints and Support, Resting in Slings 258 285 Fracture of Os Sesamoids : 260 QQ- [■ Amputating Knives , 267 288 Amputating Saw 267 289 Wooden Leg after Amputation 273 290 Cnarlier's Method of Amputation of Horns in a Calf, 1st Step 276 291 " ■' •' '• " " " " 2d " .... 277 292 Tail Cutters 278 293/ „ ,, ^._ 09Q \ Spring Tail Cutters 280 297 Tail Cautery 281 298 Old-fashioned Trephine 285 299 Bichat's Trephine 285 300 Single-Handed Trephine 285 301 Operation of Trephining. Modus Operandi 286 XXIV TABLE OF ILLUSTRATIONS FIG. PAGE 303 Bone Scrapers and Elevators 287 303 ) nr^A \ Parts of the Head where Trephining is Performed 288 305 Common Points of Selection for Trephining 289 306 Scissors 292 307 Bistoury 292 308 Periostome 292 309 Seton Needles 293 310 Various Forms of Saws 293 311 Chain Saw 294 312 Bone Forceps 294 313 Gouge 294 313a Chisel 294 313b Mallet 294 314 Anatomy of the Perineal, Anal and Caudal Regions 298 315 Bistoury for Caudal Myotomy 299 315a How to Hold the Bistoury and Make the Incision 299 316 Transversal Incisions in Caudal Myotomy 300 316a Caudal Myotomy by Longitudinal Incisions 300 317 Operation by Mixed Incisions (Vatel's Method) 301 318 Caudal Dermatome 303 319 Caudal Myotome , 303 330 Brogniez's Mode of Operation 302 321 Simple Method to Keep the Tail Elevated 304 322 Brogniez's Apparatus to Elevate the Tail 304 323 Elevating the Tail with Pulleys 305 324 Bartlet's Apparatus, Separate and in Position 3ft6 325 The Biceps Femoris in Cattle. Normal Position 309 326 The same over the Trochanter 309 327 Gouze's Bistoury 311 328 Section of Carpus, Metacarpus, Suspensory Ligament 314 329 Straight Tenotomy Knife 316 330 Curved Tenotomy Knife 316 331 Shoe with Prolonged Toe, for Club Foot 318 333 Movable Toe-Cork 318 333 Long-Toe Shoe ; 318 334) 335 >- Various Apparatus Recommended after Tenotomy 319 336) 337 Cunean Branch of the Flexor Metatarsi 324 338 Tarsal Tenotomy. Cunean Tendon Exposed 325 339 Tarsal Tenotomy. The Tendon Raised 325 340 Samples of Tooth Rasps 336 341 Brogniez's Odontritor 339 342 Prange's Odontritor , 339 343 Brogniez's Tooth Chisel 340 344 Gowing's Chisel 340 TABLE OF ILLUSTRATIONS XXV FIG. PAGE C House's Molar Cutter 1 I Moller's ^^^i Liautard's Cutter '' ^'^'^ I SchefBer's Extractor and Molar Cutter 345a Hamlin's Molar Cutter. .' 342 346 Samples of Tooth Forceps 343 347 Garangeot's Keys 344 348 Lecellier's Tooth Forceps for Molar 345 349 Garangeot's Keys, Modified by Delamarre 345 350 Speculum of Lecellier 346 351 Plasse Molar Extractor (full view) 347 352 The same (side view) 347 353 "Wendenburg Forceps 349 354 Pillwax's Forceps 349 355 Gowing's Forceps 349 356 " Modified by Bouley 350 357 Bouley's Tooth Keys 351 358 Gunther's Forceps 352 359 Bourrel's Method of Filing Dog's Teeth 357 360 Tooth Scrapers 357 361 Tongue Suspensory 360 362 Anatomy of the ffisophagus and Jugular Vein of the Horse 365 363 Baujin's Probang " 367 364 Ordinary Whalebone Probang 367 365 Brogniez's Gag 368 366 The ffisophagus Drawn Outward and Raised with the Scissors. . . . 375 367 Large Trocars 378 368 Brogniez's Gastrotome 379 369 Trocars for the Caecum 381 370 Brogniez's Enterotome 381 371 Holding the Trocar in Paracenthesis 384 372 Muscles of the Inferior Abdominal Region 386 373) 374 [ Formations of Hernias 388 375 ) 376 Cylindrical Hernial Sac 389 377 Spheroidal " 389 378 Conical " 389 379 Pyriform " 389 380 Hernial Sac in Clusters 389 381 } 382 \ Multilobular Hernial Sacs 389 383 Strangulated Inguinal Hernia 391 384 Anatomy of Inferior Inguinal Ring and Testicular Sac 395 384a Herniotome - 406 385 Herniotomes of Colin 406 386 Narrow Blunt Bistoury for Herniotomy 408 XXVI TABLE OF ILLUSTRATIONS FIG. PAGE 387 Bistoury Sliding in Grooved Directory 408 388 Holding Bistoury Upon Grooved Director 409 389 Straight and Curved Clamp 416 390 Sharp Hook for the Section of the Testicular Cord 424 391 Clamp of Bordonnat '. 434 393 Nippers of Benard 436 393 Plate and Nippers of Marlow 437 394 Ventral Hernia 444 395 Anterior-Posterior Section of the Head 453 396 Parotid Region — Superficial Layer 454 397 " Middle Layer 455 398 Hyovertebrotome 457 399 Tracheal Tampon Cainila 463 400 Razor-shaped Knife 463 401 Bent Knife 463 402 Hook to Secure Cartilage. 463 403 Special Forceps 464 404 Curved Scissors « 464 405 Retractor 464 406 Electric Lamp 464 407 Left Section of Larynx 466 408 Blunt Bistoury 468 409 Carved Scissors 468 410 Sping Tenaculum, or Dilator 468 411 Hooked Forceps 469 470 471 472 473 474 475 476 477 412] 413 414 I 415 ' ^^g VArytenectomy. 417 I 418 I 419 J 420 Anatomy of Tracheal Region 478 421 Ordinary Tracheotomy Tube 480 423 Tube of Dieterichs 481 423 Gowing's Tracheotomy Tube 481 424 Spooner's " " 481 425 Vachette's Tube 482 426 Tube of Pradat 482 427 Tube of Brogniez ^ 483 428 Tube of Leblanc, mounted 483 429 Tube of Renault 483 430 Tube of Peuch 483 431 Tube of Imlin 484 432 Tube of Trasbot 484 433 Trachea, Open for Introduction of Tube 484 434 Trocar Paracento injecteur de Reul 489 TABLE OF ILLUSTRATIONS XXvii FIG. PAGE 485 Ordinary Fleam, with Three Blades . 49o 436) 4;i7 >■ German and English Spring Fleams 494 438) 439 Fleam of Brogniez 494 440 Bleeding Stick 494 441 Manner of Holding the Fleam 49 1 442 Suture after Bleeding 496 443 Anatomy of Jugular Vein and (Esophagus in the Horse 497 444 Anatomy of the Cephalic Vein 500 445 " " Internal Saphena Vein 502 446 Phlebotomy on the Jugular 50 1 447 Position of the Facial Vein in Sheep 5C5 448 Anatomy of the Posterior Auricular Artery in Cattle. . , 515 449 Anatomy of the Posterior Auricular Artery in Swine 517 450 Cii"culation of the Palate 52q 451 Lancet to Bleed at the Palate 521 452 Apparatus to Apply Pressure to Stop Bleeding at the Palate 521 453 Shoe for Bleeding at the Toe 522 454 The Adstrictor of Brogniez 525 455 Tourniquet 525 456 A Variety of Artery Forceps 534 457 Cooper Needles, or Tenaculum 534 458 Applying the Ligature 535 459 Straight Knot 536 4G0 Improperly-made Knot 536 461 Artery Forceps for Torsion 539 4S2 Plantar Nerves in Digital Region 548 463 Plantar Nerve on the Posterior Face of the Phalang.'s 549 464 Blunt Tenaculum, with Elastic Band ... 551 465 " 551 466 Right and Left Neurotomes 551 467 Catheter 556 468 Female Catheter 557 469 Anatomy of the Perineal, Anal and Caudal Regions 559 470 Secure for Ischial Urethrotomy 563 .ig i Forceps to Remove Foreign Bodies from the Bladder 564 473 Tube of Troeber 465 474 Lithotritor of Guillon , 466 475 Crushing Forceps of Bouley 567 476 Bivalve Speculum C68 477 Penis in Normal Condition 570 477a Amputated Penis, with the Urethra Protruding 574 477b Stump of Amputated Penis, with Stitches Uniting Urethra and Skin 575 478 Longitudinal Section of the Digital Region 577 XXVlll TABLE OF ILLUSTRATIONS FIG. PAGE 479 Plantar Nerves in Digital Region 578 480 Arteries of the Digital Region 579 481 Portion of the Keratogenous Apparatus 580 483 Section of the Hoof 580 483) 484 [ Sage Knives 589 485 i 486) 487 >• Drawing Knives 590 488) 489 Clasps 623 490 Forceps of Vachette 623 491 Cautery of Vachette 6-23 492 Clasps Applied in the Thickness of the Wall 623 493 Toe Crack Secured with Clasps 623 494 Quarter Crack Secured with Clasps 623 495 Operation by Thinning Process 626 496 Operation for Complicated Toe Crack. 626 497 Dressing for Complicated Toe Crack 626 498 Short-branched Shoe 653 499 Foot Prepared for Charlier Shoe 653 500 Foot Shod ; Charlier's Method 653 501 Hinged Shoe 655 502 Articulated Shoe. 655 503 Shoe of De la Broue 656 504 Vatrin's Shoe 656 505 Shoe with Ears 657 506 Jarner's Spreader 657 507 Laf osse Desencasteleur 658 508 Spreading Shoe 659 508a A Better Form 659 509 Hatin's Shoe 659 510 Foures' Shoe 660 511 Defays' Contrary Vise 662 512 " Improved " 663 513 Mericant's Desencasteleur. . .^ 663 514 Jovard Desencasteleur 6G3 515 Chronic Laminitis 677 516 Chronic Laminitis, Last Stage 678 517 Foot Affected with Chronic Laminitis. . , , 679 518 Chronic Laminitis, with Keraphylocele 679 519 Changes of Structure of the Os Pedis 684 520 Local Cold Douche Application 689 521 Apparatus of Mathew for Cold Water Application 690 523 Cartilaginous Apparatus of the Horse's Foot 714 524) 525 > Spots of Necrosis in Cartilaginous Quittor 717 526) TABLE OF ILLUSTRATIONS XXIX FIG. PAGE 527 Direction the Groove Should Take to Remove the Quarter in Oper- ation for Cartilaginous Quittor 737 528 Truncated Shoe for Dressing in Cartilaginous Quittor or Compli- cated Corn 733 529 Deplas' Shoe for the Same 734 -^1 C ^^rious Steps in the Application of the Dressing After Ojieration 532 ) ^°^ Cartilaginous Quittor 735 533 Dressing Completed , 735 534 Eyelids Elevator 740 535 Bistoury for the Excision of the Encanthis 744 536 Probe of Bowmann 745 537 Knife of Weber 745 538 Section of the Horse's Eye 747 539 Lanceolated Bistoury 748 540 Tricuspid Stylet of Leblanc 750 541 Brogniez Diaptator 750 542 Forceps of Waldon 750 543 Scarpa's Needles 751 544 Operation of Cataract by Displacement of the Lens 751 545 Knife of Beers 752 546 Operation of Cataract by Flap Upward 753 547 Kystitome 753 548 Knife of Graafe 753 549 How to Protect the Eye 755 Artificial Eye— Side and Full View 755 550 ) 551 ) 552 ) 553 { Brogniez Apparatus for Amputation of the Ear 757 554 Apparatus of Brogniez in Position 757 555 Nippers of Garsault 757 556 " to Amputate Dogs' Ears 758 557^ 558 559 5- Anatomy of the Withers I 1% 763 560 , 561 J 562 Transverse Section of the Region of the Withers 764 563 Section of the Neck on a Level with the Poll. . 780 INTRODUCTION. Under the designation of operative surgery is understood tliat department of medical science and practice which includes the external and instrumental manipiilations reqmred in the treat- ment of surgical diseases and accidental injuries or deformities; or perhaps it might be succinctly defined as surgical scieiice me- chanically applied. The two branches — the science and the art — which constitute the study of operative surgery cannot, of course, be dissociated in a treatise on the general subject, and it will therefore be neces- sary, as we proceed with the detail of our observations, to give due consideration to the etiology, the symptomatology, the pathol- ogy and other characteristic features of certain diseases, in their relations to the indications of treatment and the manipulations which they involve at the hands of the surgeon. Viewed from the standpoint of comparative importance in re- spect to the value of the results of human and veterinary surgery, as relating to the vital status of the patients who become respect- ively the subjects of both — the human being and the quadruped races — veterinary surgery must of course consent to occuj)y the subordinate place; a fact, however, by no means tending to dis- parage the value or the just estimation of the calling of the scien- tific veterinarian. In human surgery the one paramount result held up to view is the prolongation of the Hfe of the patient. This is a consum- mation to be achieved regardless of any considerations of cost or trouble, while in veterinary surgery the prime motive is the res- toration of the patient's interrupted ability to fulfil his function as an animated machine for supplying a certain amount of valu- able force. For these reasons the scope of veterinary practice is Z INTKODUCTIOM. a circumscribed one, in comparison to that of human surgery, by having the aim and being brought to the test of mere economic utility. While the human life is prolonged at any cost, moreover, the treatment of the animal is always supplemented and influ- enced by the consideration that if curative efforts fail, the suffer- ings of the patient may be terminated by the administration of a prescription which will at once release him from pain and de- prive him of life, with the full sanction both of self-interest and benevolent feehng. Another element which operates to define the sphere of the veterinary surgeon is the natural disinclination of the owner of a sick or disabled animal — perhaps a man of limited pecuniary resources — in a tedious and unpromising case, to add to the ex- pense of surgical attendance the cost of the unremunerated "keep" of his disabled and improductive servant. It ought to be true, as a matter of course (perhaps it is so in point of fact), that no man of intelHgence and integrity will as- sume the duties and responsibilities of surgical practice without the due preparation and equipment, which is only to be acquired by conscientious study and competent knowledge of medical science at large. Especially and indisjoensably a surgeon must be an accomplished anatomist. His knowledge must be thorough and practical in the several divisions of anatomical science — he must possess a familiar Sbcquamtance -with, descriptive anatomy ; he must be fully instructed in surgical anatomy or the anatomy of regions ; he must have mastered the last chapter in pathologi- cal anatomy ; and if there are any other kinds of anatomy, he must master them all, and then he wUl have become an ayxatomist in fact, and qualified to practice surgery. Yes; a surgeon must be an Anatomist. And it ought to go without saying, that only a surgeon should practice surgery, whether his patient be biped or quadruped. No untrained layman should presume to wield the knife and the cautery with their associated arsenal of weapons and other appli- ances for the subjugation of the enemy whose assaults it is the special province of the sou'geon to repel. An ignorant operator may easily become, himself, a more dangerous "lesion" than some of those which he presumes to treat. The man who can cut into the living, and usually hypersensitive, flesh of a suffering animal, without knowing what tissue or organ he is attacking, what artery INTEODUCTION. 6 he is likely to sever, what nerve to woTind, what organ to lacerate, what function to paralyze ; who would essay the operation of neu- rotomy without knowing where to look for the plantar nerve ; who would undertake a case of vaginal spaying in ignorance of the location of the flying ovaries; or who would operate for strangu- lated hernia unaware of the mode of avoiding the infliction of injury upon the posterior abdominal artery — such a man, if to be found, should simply be subjected to an odium which should ostracise him from honorable and equal association with others of his species, besides being held criminally amenable to the law providing penalties for the perpetrators of cruelty to animals These reflections may be unnecessary, but it is all too true that oiu' domestic animals too often become the victims of worse than brutal masters, who take advantage of their helplessness and inferiority to ioflict upon them cruelties so gross and aggravated that right-feeling men are often compelled to blush to call them fellows. It is no excuse for this that it is done through the agency of a pseudo-surgeon : such a plea merely doubles the number of the wrong-doers. In oifering these suggestions, and in formulating the informa- tion which follows, derived from the experiences of many studious and observant men, and which in their aggregate and connected form constitute the substance of this volume, it is assumed that it is only from competent and qualified minds that the apprecia- tion which it hopes to merit and to receive must come, and we trust that to the extent of its justice and truth it will not be withheld. "With the skill of the expert anatomist must be associated, of course, the necessary mastery of therapeutics and a familiar knowl- edge of special and general pathology, and all should be supple- mented by a knowledge of the theory and practice of the farrier. The science and the application of the laws of hygiene, so generally, indeed almost wholly, ignored by our fathers, and so largely a discovery of the present time, will never be overlooked or depreciated by the genuine siu'geon ; and while possibly the effects of meteorological influences may have become of less importance than they were considered to be La times gone by, a careful ob- servance of their phenomena will never be a useless item of acqui- sition. The fullest attention to the theories and apphcation of what may be denominated the science of antisepsis, and the adap- 4 INTKODUCTION. tation of antiseptic measures, now so universally and unintermit- ting an adjunct to all medical and surgical practice, and so utterly indispensable in the departments of dressing and nursing, and so often an available and valuable aid in the very act of operating, must be considered now to have become an incorporated and con- stituent department of the domain of surgery, and medicine as well, and the cultured veterinarian will of course so regard it in his practice. Without being necessarily a practical worker at the anvil, the surgeon, as we have intimated, must acquire a familiar acquaint- ance with the theories and the art of the farrier. No one can place too high an estimate upon the importance of the position occupied by the foot among the anatomical regions where lesions may be expected to occur, and whereas the shoe becomes practi- cally identified with the Hving member, and is, in use, a portion of the hoof itself, by the act of nailing the shoe and the hoof together the inference becomes palpable. An occasion may easily arise when a serious blunder in treatment may be traced to a previous blunder in diagnosis, which again may be referred to an earlier blunder still, which has consisted in neglecting to examine the foot, and the shoe which has injured it. What is the status, in respect to his market value, of a horse with poor feet, or whose good feet have been ruined by bad shoeing ? So the veterinary stu'geon, though not requii*ed to be able to make a set of shoes, should be expected to know how they ought to be made and fast- ened. And when a special shoe is required for the correction of a deformity, or as indicated in some diseased condition of the foot, it will of coiu-se become the exclusive province of the surgeon to dictate the w^hole process of forging and fastening, and to see that his instructions are not ignored. Besides the special scientific attainments to which we have referred, there are many other qualifications which must enter into the character of the good and skillfvil surgeon, in order to round it into true symmetry and proportion. Bouley remarks that "he must not only be a man of science, but a man of art," meaning, we suppose, that he should not only possess knowledge, but know how to make it available. First, he must possess the faculty of knowing how to gauge the necessity of his interference, with its manner and its duration; or, on the other hand, whether any interference is necessary, and whether the true indication is INTRODUCTION. not to refrain entirely from active measm'es. The result of his decision will afford a good test and gauge of the extent to which he has profited by his clinical and theoretical study. He is a sound philosopher who can wisely determine when to let alone, in opposition to the temptation to do something. The acquisition of manual dexterity is an accomplishment of prime importance and shovdd be acquired, and can only be earned by diligent practice upon the cadaver, or, what perhaps is more effectual, besides being in itself real work, by utilizing every op- portunity of performing minor operations, under suitable instruc- tion, upon actual patients. Of course, exjDertness without practice is impossible. It is not fully correct, perhajjs, to speak of manual dexterity in the singular number. The dexterity required should be bi-manual or ambi-dexterity, and any snrgeon who has not mastered the art of using both hands indifferently, though he may have learned all else pertaining to his profession, lacks yet one thing. Cases will continually arise in which the inability to change hands may interrupt the progress of an operation and involve the practitioner in great inconvenience, if not embarrassment, and possibly prejudice the case itself. Courage and coolness, with patience, are essential quahties of temper in an operating surgeon. To become alarmed and lose his balance on the occurrence of some untoward incident, or the ap- pearance of some unlooked-for abnormal development or compli- cation, or to give way to a spirit of impatience because of unex- pected delays, or, especially, to resent the fractious movements of the suffering animal, writhing under the knife or the glowing cautery, is both unprofessional and unmanly. The terms cour- age, coolness, patience and kindness should describe his state of mind while operating. The whole axiom of Asclepiades, cito, tuto and J ucu7ide, re- veals the entire scheme of conduct proper for the sui-geon under all circumstances. Every movement of the surgeon should be prompt and precise. Indeed, by operating rapidly he shortens the duration, and consequently the sum of the inevitable pain, and thus diminishes the anguish of a long and torturing infliction on behalf of the patient. The maintenance of his own self-possession will make him master of the situation, and assure a neat and ar- tistic finish to his task, with no unnecessary divisions of tissues, no mistaking of localities, and generally with no betrayals of 6 INTRODUCTION. doubt and hesitation or awkward and aimless manipulations, such as mark the attempts of the tyro and the novice. The confidence and facility with which each movement is accomplished will not fail to imj^ress favorably those who are spectators of the opera- tion, and to react favorably and profitably for the operators. Although, of course, the qualities of accuracy, neatness and rapidity must favorably impress the spectator, as well as benefit the patient, it must not be forgotten that the true success of the surgeon must find its evidence in the favorable result which finally crowns his work. If that is assured, it is but a small matter whether it is or is not applauded while in progress — the applause will foUow, in any case. We quote from Bouley, in the Dictionnaire de 3Iedecine et de Chirurgie VHerinaire, where he remarks, on another important practical point: "The operative function of veterinary surgery requires, on the part of the man who practices it, a certain cor- poreal vigor, associated with sufiicient agility to be able effectually to overcome the resistance of animals under torture, and counter- act the efforts and avoid the injuries they are always so prompt and often so dexterous to inflict upon those who are causing them pain. The veterinary surgeon must be cool-blooded and patient, never losing his presence of mind while directing the manipula- tions, often so difiicult and so dangerous, which are necessitated at his hands, especially when the large domestic animals are under treatment. He must then — always, in fact — be prepared for all difficulties and eventuahties that may arise, whether before, during or after an operation, and he must inspu-e confidence in his assist- ants by using full precautions for their safety and for his own, in his defensive dispositions against the dangers to which they are exposed." A surgical operation, as elsewhere described, is a mechanical action, practiced with more or less rapidity upon the living body, according to certain rules, either with the hand alone, or assisted by instruments, with a therapeutical or a proj^hylactic object in view, whether primarily necessary or facultative, of a prophylactic nature. It is especially as therapeutic measures that oj)erations are necessitated in the treatment of diseases and injuries; as, for ex- ample, in the case of the removal or extii'pation of diseased or altered parts, whose morbid action injuriously affects the general INTKODUCTION. 7 health or prevents recovery from a pre-existing disease. This class of operations includes the opening of abscesses, the extirpa- tion of gangrenous parts, or of necrosed or carious bone ; or again, for the modification of the natui-e of a traumatic lesion, in order to stimulate cicatrization, as in the opening of a fistulous tract, or the resection of an ulcerated surface ; or when the economy is to be reheved from the presence of a foreign body, or the abnormal product of a natural function, as in cases of oesophagotomy, or of calcuU of the bladder, or of the saUvary ducts. Operations have also their prophylactic uses, especially in the various forms of in- oculation and vaccination as anticipatory and preventive of infec- tious diseases. They find their further obvious indications, again, in remed^dng physical lesions when appUed to fractiu-es, dislo- cations, deformities, and the endless Ust of accidental injimes, wounds and hurts of every kind and degree. And, finally, they have their justifiable use in mutilating the larger domestic animals, designed for purposes of labor as beasts of burden or di*aught, in improving their adaptability by castration or spaying, or as prop- erly termed, "altering." Thus the general piu'pose of an operation is to palliate, cure or assist in the recovery of surgical diseases ; to prevent diseases, and especially such as are known to be contagious; and so to modify the condition of the domesticated animals as to enhance their usefuhiess and value to theii* human owners. In medical nomenclature, operations are variously designated according to the methods and characteristic manipulations attend- ing their performance, and the objects which they are designed to accomplish. Thus: (a) It is a light operation when superficial tissues or those of secondary importance are involved, like that of venesection, or the simple puncture of a vein. On the other hand, it becomes serious when it is performed upon important organs, or involves extensive and cornpHcated structures, as that for the reduction of strangu- lated hernia; the removal of the lateral cartilage of the foot in a case of quittor; the operation for chronic champignon, etc., etc. (I)) Operations are also dry or bloodless when accompanied by little or no hemorrhage; and sanguinari/ or bloody when, on the contrary, much hemorrhage attends any of their various steps. (c) Again, they are simple or complicated according to the extent and midtiplicity of the tissues or regions forming their 8 IXTRODUCTIOX. seat ; simple if performed by a single manipulation, complicated when requiring several distinct or separate stages for their exe- cution. {d) Operations are called regular or determinate when per- formed according to riiles in relation to the disposition of the parts, and, in general, upon sound structures ; and they become irregular or casual when the manipvilations are extemporized to meet the emergencies of the case, the necessity of the situation and the imanticipated comphcations which may arise while opera- ting, as particularly in cases of the removal of tumors. (e) They have also received various designations indicative of the time chosen by the surgeon for then- performance ; or made imperative by the circumstances of the case ; or according to the object specifically in view : thus they are urgent or of necessity when a fatal event woiild be the alternative of delay, and imme- diate treatment becomes imperative, as the condition of the patient's survival, as in operation for the reduction of strangu- lated hernia, or that of tracheotomy in a case of threatening suf- focation; and in cases beyond hope of complete recovery, they may become necessary, indispejisahle, useful or palliative, according to the degree in which they may be made available as a means of rehef, and may tend to the temporary respite of the sufferer, and in some degree improve his value by measurably enhancing his ability to continue to labor with some degree of comfort before he is overtaken by a final and total disabHity. There is another class of operations which justly deserves to be totally discountenanced and ignored, and in fact are fit objects for penal prohibition. They are known as operations of fantasy or fashion. They are without real utHity; are abortive attempts to improve upon the symmetry of nature ; are devised simply to satisfy a mere whim of affectation; are iu wretchedly poor taste; and probably subject their \ictims to a more aggravated and pro- tracted species of torture than any other form of wound known to veterinary surgery. There are sometimes conditions, however, in which they may lose their alleged aesthetic pretext and their ar- tistic character, and the object of their performance may be regarded as properly within the legitimate and beneficial sphere of professional work. The settlement of the point of the time, ia connection with any piece of surgical work, is not always one of mere secondary INTRODUCTION. importance in deciding the matters pertaining to the details of an operation. "When there is any option in the case it pertains wholly to the surgeon to determine the question. And when the period of abeyance has terminated by his decision in fixing the day and hour when the contemplated treatment is to be appHed, the optional time becomes changed to the selected time. Of course it is not always left to the option of the practitioner to select the moment for the accomplishment of his task. He must be gov- erned by the nature of the case, and may be left without the opportunity of exercising any discretion in the matter. The urgency of the occasion may be extreme, with no interval allow- able for dehjDeration or choice, and the only available time, the peremptory present, must be accepted as that of necessity. The operation being now obhgatory, and the case understood, the surgeon's next thought is the choice of the locality of the operation, and that being finally decided, the point of selection has been reached. The case may easily present such features that this point becomes too obvious for hesitation by becoming that of selection as well as that of necessity, as indicated by the seat of the lesion or diseased process. With traumatic cases, there is, of course, but a single point of interest — it is '(h.Q p>oint of injury ! In surgical pliraseology the terms method and procedure are often used convertibly. There is between them, however, a dis- tinction which, for the sake of precision, must not be lost sight of. By method should be understood the piincipal and primordial mode by which the operation is performed, while by procedure is meant the special modifications and successive stages by which the manipulations of the operation itself are regvdated. For ex- ample, in the removal of a vesical calculus there is one method by Hthotrity and another by extraction, and with both are involved the insertion of instruments into the urethral canal, one being the ptrocedure with the catheter, and the other the procedure by the injection of tepid water. Castration with clamps is a method, when compared to double subcutaneous twisting {Mstournage) or to torsion; and it is performed by iy^o procedures, that by covered and that by uncovered testicles. There are several important points which demand special at- tention at the hands of the surgeon before beginning an operation. Having finally reviewed the situation, and especially having men- tally rehearsed the anatomical disposition of the region and the 10 INTRODUCTION. pathological character of the lesion, with the necessary details of the work before him, not forgetting to anticipate possible acci- dents and compHcations ; and being assured that his arsenal of instruments, dressings, etc., is ample and in good and available order, with a liberal provision of sponges, antiseptics, etc., and duj)licates of such of the instruments as are liable to be broken or otherwise disabled, the condition of the patient should then be ascertained. It will, of course, have been thoroughly understood by the siu'geon previously, but it is always among possibilities that even at the aj^pointed moment for operating, some changes may be discovered or some new circumstances developed which may modify or contraindicate the entire proceeding. Some final preparation of the patient is always necessary. One item of this consists in clipping the hair from the skin over the seat of the operation, and thoroughly cleansing the part. In some cases it is necessary to soften the tissues by means of poul- tices, baths or wet bandages. There is also a constitutional and general preparation which must not be neglected, with a view to so modify the organism as to improve the ability of the animal to withstand the shock of the operation. If weak and debilitated, his strength and condition must be improved; if of an irritable and nervous disposition, precautions must be taken to control it. A comparatively low diet is almost always a salutary measure, and sometimes even complete diet an essential prelimiaary to an ojDeration, and the surgeon must assure himself that they have been proj)erly taken into consideration. In many cases the surgeon needs the co-operation of assistants, either professional men or laymen. The aid rendered by a profes- sional brother or by a student of medicine will of course be such as will be assigned to him by the responsible surgeon, and cannot be specified here — it will vary with every case. The facility and success of an operation will be greatly promoted by their intelli- gent and sympathetic aid, which will be quite of an indispensable character. In enlisting feTymen as assistants, it will of covu-se devolve on the surgeon to instruct them as fully as possible in the natui-e of the services expected from them ; and in making his selection of indi-viduals it will be an important point gained if he can obtain those who are accustomed to the management of ani- mals, and who are expert in handling and successful in controlling them. INTKODUCTION. 11 There is still another party to be considered while referring to the study of "preparation." It is neither the animal, the siii'geon, the assistants, the instrument case, nor the lint and bandages. It is the owner of the ailing animal. And to ".prepare" him for the event is oftentimes a performance requiring a larger amount of judgment, tact, knowledge of human nature and patience than the average man jjossesses. On the one hand there are those of the optimist class who have quite an unwarranted opinion of the power of surgery, and who, in despite of the most unfavorable prognosis, insist upon a resort to the knife, even upon inadequate occasions. And on the other hand are those who interpret any suggestion which involves a solution of continuity professionally proposed, however artistically consummated, as only a mild form of sentence of death to the patient. But however antipodean may be their views in other respects, they are in common quite assured that for an operation which fails to restore the dilapidated patient to a condition a Httle better than new, whatsoever may have been the accident or lesion which he may have encountered, and whatsoever may have been the skill and inteUigence exhibited in the treatment of his wounds or ailments, the only legitimate and orderly conclusion is a suit at law for malpractice. It is the function of the doctor to cure disease ; if he treats disease without Cluing it, he is an incompetent; this is the irrefragable logic! Though the Hving animal had failed to return any remuneration for his subsistence, and for the care lavished (?) on him during the peiiod of his disabihty, yet when reduced to the state of a cadaver he should be compelled, if possible, in an indirect way to net his bereaved owner a sum Hkely to prove largely anod}Tie to the poignancy of the grief which the loss of so much property had excited. But aside from this, the owner of the living property, the value of which is about to be jeopardized, is entitled to a full and candid statement of the nature of the case, with its possibihties and its dangers, and it is in the interest of the surgeon himself to observe perfect frankness with his employer — not, however, to the extent of compromising his position as doctus in the case, or foregoing his self-respect by making concessions upon points of scientific acquisition to a layman, however generally intelligent or specially interested. The surgeon mu^t assert himself as the representa- tive and exponent of an honorable and learned profession, able 12 INTEODTJCTION. and prepared to acqmt himself of liis just responsibilities; and, indeed, it is in this assumption by him, with the conceded assent of the owner, that the vii'tue of the contract lies, which binds the two parties with equal force, moral and legal. This point, being understood and settled, should be looked upon as furnishing the best preparation which the owner can ac- quire, and he will need no other when he is thus made to under- stand that he must have full confidence in the skill which he has called into reqviisition, and must be guided by its impUed guar- antee that every possible precaution will be taken to carry the patient through his trouble ; and that if accidents of any nature should occur*, when not incurred through carelessness or error, the risk is the owner's, and he alone must assume it. Such an rmderstanding on the part of the owner will impose upon the honorable surgeon an imperative sense of the conscientious care with which his task should be performed, while at the same time it will reheve his mind from the pressure of a possibly embarrass- ing anxiety while engaged in his work, and it cannot fail to be of advantage in various ways to all the parties concerned. IVIinor matters, such as the condition of the weather, the time of day, the selection of a place, the position which the oper- ator must assume for himself, with that which he assigns to the patient — these are points which are also to be carefully taken into consideration. They have, one and all, more or less influence on the facilities of execution of an operation, and perhaps also on the results that may follow it. CHAPTEE I. MEANS OF RESTRAINT. The final preliminary before operating upon animals, is to place the patient in such a condition of restraint as will assure the entire safety of the surgeon and his assistants from injury likely to result from the violent struggles of the terrified and suffering creature. The severity or the duration of the operation furnishes no accurate measure of the necessity of the restraint, or of its continuance or degree. Any unusual or violent aggressive treatment will excite his fears, and consequently his opposition, and whether the occa- sion be a painful and protracted dissection, or the simple apphca- tion of a dressing, the surgeon may usually rely on the strenuous resistance of the patient. It is of Httle account that there are differences of dispositions in horses, as in men. With any un- reasoning animal the case is the same, and with the excitement, the anxiety, and no doubt, a vague terror of something unknown impending, too often quite explainable by the treatment to which he has been long accustomed at the hands of an unfeeling owner, he is prompted by the mere instinct of self-presei'vation to defend himself with such means as nature has taught him to use. The necessity of enforcing a passive condition in the animal being thus apparent, it ought not to be necessary to say that the means of accomplishing it should be employed with reserve and moderation, especially when they are painful in themselves, and that no man claiming to be the possessor of humane instincts will permit himself to increase the severity of their application by supplement- ary ill treatment, in the infliction of "punishment," upon the alarmed and suffering brute, a course which is quite likely, more- over, to be as ill judged as it is otherwise reprehensible, from the fact that in most instances its effect is contrary to its intention, in aggravating the evil it would remedy. It should never be forgotten how easily the most fractious and timid animal may sometimes be controlled by kindness and patience, and his agitation soothed by 14 MEANS OF KESTKAINT. the sound of a familiar voice with which he has become accustomed to associate acts of gentleness and friendliness. Under any cir- cumstances, a habit on the part of the surgeon, of brutal treatment, the exhibition of a bad temper, in the indulgence of fits of anger, leading to acts of cruelty in the infliction of unnecessary pain on his dumb and helpless victim, is not only in every way useless, as being of no possible advantage in any direction, but tends to a degree of moral harm in those who are thus culpable for which no counterbalancing benefit can be imagined, and which certainly can never facHitate the remedial effect — but quite the reverse — of the pending operation. A benignant method of controlling animals for the special purpose for which treatment by the surgeon is invoked, is not, however, alone sufficient, and it is thus that a resort to effective means of physical restraint becomes unavoidable. These are of two kinds : one consists in inflicting upon some given part of the body, more or less remote from the seat of the operation, a severe and continuous pain, which, by a j)rocess of derivation, reduces that which is incident to the steps of the operation, by distracting or diverting the consciousness from the influence of the new suffering, against which he feels resistance would be in vain, to that of which he is sensibly cognizant, and thus the animal submits himself, with a comparatively voluntary surrender. The other kind consists of restraints proper, and are constituted of mechanical devices for securing immobility by the process of overcoming opposition by means of a dominating physical force. Theu' use is not affected by the position of the subject, and they are therefore applied in both the upright and decubital posture. The first comprehends the derivative or painful method of Peuch and Toussaint's division; the second, the method by direct me- chanical restraint. MEANS OF SECURING SOLIPEDS. A. — Derivative or Painful Method. This method is in very common use, and usually proves to be sufficiently effective to secure a degree of quiet and passivity in the patient for the safe performance of many light operations. Under some circumstances it is used in connection with the means SECURING SOLIPEDS. 15 of direct restraint. The instruments mostly employed in the first method consist of the twitch, the old fashioned barnacle, and the gag. Fig. 1.— The Twitch. The twitch is the instrument most commonly used and, un- fortunately, too commonly abused. In horses, it is sometimes applied on one of the ears, and sometimes on one of the Hps ; and is very severe in its action, wherever apphed. In applying it, the operator, passing his right hand through the loop of cord of the instrument, grasjDs the tip of the upjDer or the mass of the lower lip, leaving the loop to sHp over his fingers close to the skin which it then encloses, and with his left hand turns the handle of the instrument until the cord is sufficiently shortened to form a true Hgation of the tissues which it circum- scribes. The pain caused by this constriction may be graduated by the rotation of the handle of the instrument. . When in place it is either held by an assistant or tied on the halter. If the animal proves to be especially refractory under the infliction, the assistant should be cautioned against? aggravating the trouble by forcibly di'agging upon or jerking the instrument, violence of that nature becoming in some instances the cause of severe injuries to the musciilar or nervous structures of the Hi^s, "We have ourselves met with several cases of labial paralysis resulting from such an improper and repeated appHcation of the twitch. Some- times the length of the wooden portion of the instrument is con- siderably reduced, varying in its appHcation in such a way that when the open loop is placed on the lip the wooden part which takes the place of the handle is placed on the lips through it, and the cord is twisted by turning it. The barnacles are formed of two articulating branches, made of either wood or iron, with sundry notches at one end and a ring at the other to fit into the notches. The degree of pressure i-e- quired is regulated by shifting the ring until the proper notch is 16 MEANS OF KESTEAINT. Fig. 2.— Short Twitch. ascertained. The iron instrument is severe in its effects, probably more so than the twitch, but is less easy of application. In apply- ing the barnacles, the surgeon grasps the upper lip, and placing Fig. 3.— Iron Barnacles. each of the branches severally on opposite sides of the organ, brings the ends together, immediately fixing them in place at the desired point of pressure, and secures them by fitting the ring into the proper notch. Fig. 4. — Wooden Barnacles. The wooden barnacles are made with circular sharp ridges cut in both branches in order to intensify the pain, the ends, when they are approximated, being seciured by means of cords. The gag is a means of derivation used principally in Central Europe. It consists of a cord about one-quarter of an inch in diameter, which is placed in the mouth, and passing upward on each side of the face, is tied on the top of the head. This is twisted to any degree of tightness by means of a small, roujid piece of wood, which is passed between the cheek and the cord, the result being excessive traction upon the commissure of the lips and great SECURING SOLIPEDS. 17 Pig. 5.— The Gag. pain to the animal. Lacerations of the commissure, or wounds of the skin at the poll are to be anticipated if this manner of punish- ment is not guardedly used. There are besides these some milder appliances which must not be overlooked. Among them is the repeated pricking of the tip of the nose with a pin, and the introduction of foreign bodies, such as musket balls in the ears. The origin of this last method dates back to 1607, when little round stones were recommended for the same object. When musket balls are used, holes should be drilled through them for the insertion of a string, in order that they may be withdrawn when necessary. JB. — Mechanical or Mestraint Method. The means employed in this method vary according to the po- sition, whether upright or recumbent, in which it is desirable to confine the animal during an operation. STANDING POSITION. The necessity of imposing restraint upon the patient while under treatment in the standing position arises not alone from the danger of injury to the operator and his assistants, from the biting and kicking of the excited animal, but because he is so thoroughly impartial in the distribution of his attentions that he even requires protection from his own violence, and his own flesh must be guard- ed from the contact of his own teeth. They are usually resorted to in order to facilitate operations of comparatively trifling importance, and which are not of a par- ticularly painful nature, or are of easy and rapid execution, or 18 MEANS OF RESTRAINT. under circumstances when the animal can be controlled by being- merely held by the head against a wall, or with the hind quarters in a corner, or perhaps tied to a wall, a post, or a tree. Certain minor precautions are necessary on these occasions. For exam- ple, the groiind on which they stand must be smooth, though not sHppery ; of a good holding character, and neither too hard or too damp, in order to avoid falling, or slipping, or other possible ac- cidents. Attention to these matters will be of great benefit to the operator by leaving him a good foothold, with facilities for free- dom of movement, and more at hberty to guard himself against his patient, unexjpected changes of attitude. The means by which the movements of the head are kept under control are the halter, the hridle, the hridoon and the cavesson — instruments which need no description here. If the animal is left unconfined, the assistant having passed the rope of the halter or bridoon through his mouth, holds him close to his head, j^laces himself in front of him, or slightly on one side, and being atten- tive to every movement the animal may attempt, anticipates it, by pulling the head downwards if the animal is about to rear, or rais- ing it upwards to prevent him from kicking with his posterior legs, or inclining it to one side or the other, as the animal moves it in one or the other direction. An animal should never be tied with the halter-rope in his mouth or over his nose. There is danger in both methods of se- rious accidents, in case of a violent backing or jerking of the head. In one case the result might be a section of the tongue, and the other might involve a fracture of the maxillary. For simi- lar reasons the bridle is also dangerous. The height at which the head should be secured must vary with the movements attempted by the horse. Thus, to prevent him from rearing or striking with his fore legs, it should be placed low, but high when it becomes necessary to guard against his elevating his posteriors in order to kick with his hind legs. To protect his head against possible self-inflicted blows result- ing from his defensive sti'uggles, and to prevent him from seeing surrounding objects likely to alarm him, are precautionary items of not a little importance, and the employment of the mask or cap (Fig. 6C) is very effectual for that purpose. Fractious patients, dangerous to handle and difiicult to control, often become perfectly quiet and thoroughly docile on finding themselves involved in dark- SECURING SOLIPEDS. 19 Fig. 6.— C, tho Cap. O, the Cradle. ness, and submit to the necessary manipulations of the surgeon with- out further resistance. When a proper cap is unobtainable a bridle with blinders can be substituted, or a blanket placed over the head. Biting the attendants may be prevented by applying a muzzle, Fig. 7.— The S!d- Bar. 20 MEANS OF EESTRAINT. and he may be protected from his own teeth by the use of the cradle (Fig. 60) or beads, or the side bar (Fig. TAB). With the cradle around his neck, the horse is prevented from carrying his head on either side ; its use, however, must be carefully watched lest the friction of the cord, which secures it in place upon the superior border of the neck, should cause severe comphcations by chafing or even cutting through the skin. Peuch and Toussaint have reported one case of fatal tetanus from this cause, but no such accident ought ever to occur, for the means by which it may be avoided are easy and obvious, protecting the border of the neck with pads. The side bar prevents the flexure of the neck toward the side upon which it is placed, and when in use during an operation is apphed on the side occupied by the operator. It is used both singly (on one side only), and doubly (on both sides). The danger of accidents arising from the tmrestrained mobility of the head of the animal being thus guarded against, those which may be caused by striking and kicking with the feet are next to be considered. In many instances it may be sufficient to simj^ly raise the foot from the ground, and to keep it thus suspended by holding the leg in a position of flexure (Fig. 6). No violent measures are necessary in order to obtain such con- trol over the movements of the horse as are consequent upon com- peUing him to support his weight on three legs only. The method of raising the foot and keeping it oif the ground is a matter too familiar to every stable hand to need detailed instructions. But a little art may be necessary, with a httle compulsion added, to induce him to continue to sustain the role of a tripod long enough for the purpose of the operator. But this cannot always be de- pended on, and therefore when he betrays an evident unvrillLug- ness to submit quietly to such a confinement of the foot, the com- pulsion of the ropes or straps must be resorted to. For the fore leg the strap is attached below the fetlock and passed around the forearm, and either buckled or held in place by an assistant. When the rope is used it is passed around the coronet, the leg flexed and the rope either passed round the forearm and secured in the same manner as the strap, or thrown over the withers and held by an assistant on the opposite side of the horse. For the hind legs the rope, plaited rope or jilate-lonye, is necessary with the hobble. These are applied in different ways. SECURING SOLIPEDS. 21 Fig. 7«.— Plaited Kope. In tlie first method a hobble is j)laced on the coronet of the foot to be raised, with the buckle outward, and the ring looking backward] then a loop made at the flat end of the plate-longe is Fig. 8.— Securing the Hind Foot with Rope and Hobble. passed around the neck ; the rope is then carried along the back, and with a single turn around the tail, is passed through the ring of the hobble, from withiu outward. Pulling on the rope raises the foot and carries it backward, where it is held by the assistant. Second. — Sometimes the hobble is dispensed with, and the rope is passed from the neck straight to the coronet, where a double twist is made, and the foot controlled as before (Fig. 9). Third. — In other cases, the plate longe is secured to the tail, instead of around the neck, conditioned of course upon whether the tan is svifficiently long and furnished with hair of the strength 22 MEANS OF RESTRAINT. Fig. 9. — Securing one Hiod Leg with Rope only. necessary. When matters are favorable in this respect, the operator proceeds as follows : a loop being made at some distance from one end of the rope, it is laid flat on the top of the tail, close to its origin, and the short end being twisted around that extrem- FiG. 10.— A, The Twitch. B. Side Bars. C, Surcingle. D, Securing Hind Foot E, Fixing the Kope on the TalL 8ECUEINO 80LIPED8. 23 ity with from two to four turns, and the remaining portion passed through the loop, and the other, or longer portion of the rope, drawn taut, the knot is tied and the plate-longe thus firmly secured. As in the two previous methods, by drawing upon the longer end of the rope the foot can readily be raised and held in position, either with or without the hobble. There are occasions, when, although it may not be required to have the leg and foot held up for the purposes of the opera- tion, it still becomes necessary to do so in order to prevent the animal from using his feet as weapons of combat, or to restrain him from motion. The plate-longe, and the single or double side-line, with one or two hobbles, are then put in use, for the purpose of either raising the leg from the ground and compelling the animal to stand on three, or again to prevent motion in the posterior biped. Por example, in one case the flat part of the plate-longe is Fig. 11.— Another Means of Using the Rope. passed with a loop around the coronet of the leg to be kept steady, the rope is then carried forward between the fore legs, then on the side of the neck opposite to that of the leg to which the plate-longe is fixed, over the %vithers, back to that side, and twisted around itself behind the elbows, as it passes between the fore legs (Fig. 11). 24 MEANS OF r.nSTRAINT. Xa other cases a large loop of the plate-longe is thrown over the neck, and the rope carried back to the coronet of the foot to Fi'i. 13.— Securing both Hind Legs with Hohbles. SECURING SOLIPEDS. 25 be secured, and by one or two twists around itself, is brought backward, where it is held by an assistant. Sometimes a single hobble is placed on the coronet, and the rope of this side-line runs through its eye, which is turned forward (Fig. 12). To prevent the animal from kicking with both hind legs, a King hobble, carrying the chain, is put on one leg, and the chain passed through the eye of another hobble placed on the other hind leg, and the rope carried forward and secured as in the case of raising one single foot, viz., between the fore legs, on either side of the neck, over the withers and then after being twisted around itself back of the elbow, held by an assistant (Fig. 19). In some instances a double side-line is used, the loop being thrown over the neck, and the ropes carried backward, one towards each hind leg, and passed through the eyes of hobbles placed on them, and returned forward, where they are secured with a slip-knot to the loop of the side-line on each side of the neck. For the same purpose, of securing the two legs of a biped, whether anterior or posterior, LeGoff has invented a pecviliar apparatus, consisting of a Y-shaped rope, single at one end and bifurcated at the other, each of the three ends having a running noose or loop. If the two hind legs are to be secured the loops of the bifurcated portion are placed on the coronets of these legs, and the loop of the single portion secured on one of the fore legs. If on the contrar'y, the fore legs are to be confined, the arrangement is simply reversed. Another excellent method of limiting the movements of the animal to prevent him from kicking, and keep him quiet, is to take a plate-longe, and beginning on one of his sides, at the girth, for examjDle, pass it forward across one forearm, a little below the elbow, in front of him, on the other side across the other fore- arm ; then backward across the thigh, or a little below it, then passing it back of the animal, to the first side across the other thigh, to return to the starting point (Fig. 14). Passing the rope through the eye of the flat extremity of the plate-longe, the legs can be comparatively well kept together. To prevent the rope from dropping too low, it is thrown over the back and secured on itself on the other side by a knot. This joart of the rope over the back supports the two horizontal portions which run on each side of the animal and keeps them in place. This mode of restraint is but a simplification of the apparatus 26 MEANS OF BESTRAINT. Fig. 14.— Securhig all the Legs, with Rope all around the Animal. invented by Raabe and Lunel — the hippo-lasso (Fig. 15). This apparatus is called the straight jacket for horses, by the inventors, and is composed of a strong breast-piece or Dutch collar, and a breeching, placed over the withers and the croup. The breeching carries on each side, firmly sewn on, a long strap, and at each point, B, an iron eyelet. The breast-piece at B, carries also on each side an iron eyelet, and on the front strap a strong buckle. To place it in position, the Dutch collar is thrown over the neck and the breeching laid over his rump. Both straps of this part of the hippo-lasso are passed forward through the iron eyelet of the breast-piece at B, back through that of the breeching at B, and then forward again to be buckled, more or less tightly, at b. The length of the strap of the Dutch collar piece which passes over the neck, and that of the croup, must be regulated in such a manner that the horizontal position of the lasso is for the fore legs, but a little below the forearm, and between the stifle and the hock for the hind legs. The hippo-lasso is an excellent means of restraint, and may even be utilized for vicious animals upon which operations would otherwise be impossible, except by throwing them. In shoeing SECURING SOLIPEDS. 27 Pig. 15.— Hippo-lasso of Raabe & Lunel. A^cious and clipping nervous horses it has given most excellent results. Among other varieties of apparatus used for controlling animals iu the standing position, are the various machiaes known as stocks or travis. They are of many forms, and consist of heavy wooden frames, firmly secured ia the ground, with peculiar arrange- ments for supporting the animal in slings, if necessary. They are padded on the inside, for security against injuries and have on one of their narrow sides a system of ii'on bars, against which to secure the feet when the animal is raised from the ground. The stock illustrated in Peuch and Toussaint's work (Fig. 16), will give a good general idea of one of the most approved forms of this means of restraint. The stock of E. Winsot (Figs. 17, 17a and 18) is another form, which can be used for securing the animal in either standing or laying position. RECUMBENT POSITION. Notwithstanding the many advantages attending the applica- tion of the means already described, devised for securing the immobihty in the standing position of animals undergoing sur- gical treatment, there are circumstances in which their efficiency becomes wholly lacking. Sometimes it is because of the invincible restiveness of the animal, but more often because of the serious nature of the pending operation, which may require for its safe MEANS OF EESTRAINT. Fig. 16.— The Stock. performance a degree of deliberation and an amount of dissection of the most painful character, with which only the most absolute passivity, if not complete unconsciousness, is compatible. In this class of cases the recumbent position in the patient becomes sim- ply an indispensable requirement. To throio or cast a horse signifies simply to apply the force necessary to compel or induce him to lie down, and to continue in that position during the pleasure of the surgeon. The forms of compulsion by which the desired result is to be effected are next to be considered. It would be improper to construe the word "throwing" as SECUEIXG HSiLlPEDS. 29 Fig. 17a.— Firing a Horse while Secured in Winsot's Stock. Fig. 18.— Laying a Horse Down with Winsot's Stock. 30 MEAI^S OF RESTRAINT. literally designating the act of violently casting down, as in a wrestHng match. On the contrary, it must be qualified as refer- ring to a method of so manipulating the patient and directing his movements as to bring about a change of posture with all the appearances of a voluntary act on his part, which indeed it essen- tially becomes. The preparation of the hed upon which the animal is thrown, and of its location, will require some judicious attention from the surgeon. A convenient place, with sufficient space to allow per- fect freedom of movement about the patient, such as a large yard, a barn or an open field will fulfil the requirements. The ground should be smooth, and, if possible, soft — a pasture lot or farm- yard, or a manure heap often oifering good facilities for the pur- pose in country practice. In any case it should always be covered with a layer of straw, sawdust or tan bark of sufficient thickness to prevent a violent concussion when the patient falls, and ought to be sufficiently wide to allow him to fall as nearly in its center as possible. Its dimensions should be approximately from nine to ten feet square. An important point in its construction is that it should be free from any hard foreign substances, such as stones, bones, pieces of wood or iron, etc., for fear of contusions or other similar lesions against any parts of the body of the patient. Several methods are in use for throwing a horse, among which are the peculiar apparatuses known as the hobbles. The roijes and the operating tables are also used. The previous preparation of the animal for the operation ought not to be forgotten. This usually consists in a fast of not less than twelve hours, and wiU always be found to be a good measure. A. — Casting xoith Hobbles. These are of various kinds. Some are made of leather, others of rope, but they are aU constructed upon the same principle. The English style, invented by Bracy Clark and afterwards improved, which are in most general use, present so many advantages in their f acihty both of appHcation and removal from the legs after the op- eration, that we shall limit our consideration to them alone (Fig. 19). A set is composed of four hobbles, a chain and a spring hook. Each hobble is formed of two straps of leather of unequal length, the shortest (a) having attached on one end a strong buckle (^), SECUKING SOLIPEDS. 31 Fig. 19— English Hobbles. A, Hobble Unbuckled, B, King Hobble. C, Hobble in Position, witb Rope tUrougb the Eye. and at the other an iron eyelet, naiTow and somewhat elongated (n), the eyelet of the longest (b) being somewhat square in form (e), in order to allow the ring (w) to pass through it, and having in its Fig. 19a.— Self-locking Hobbles of Prof. Barker. 32 MEANS OF RESTRAINT. length a number of holes to allow it to be buckled with the short strap. Three of each set are of this construction. The fourth, which is the mahi^ chief or king hobble, differs from the others in the form of the iron eyelet of the shortest strap. In this hob- ble it is made of a peculiar shape, and with a small slot, through which the chain is passed and secured by a pin screw running through it. The chain belonging to this set measures four or five feet in length, and has spliced at one end a casting rope some fifteen feet long. At the other end the link of the chain is flattened and made to sUp easily through the slot of the main hobble. Fig. 20.— Spring and String-IIooks. There are many forms of spring-hooks used. In our own practice we use two strong spring padlocks, as being of easier appHcation and less liable to liberate the animal by becoming loosened or breaking. Besides the set of hobbles, a long plate-longe and a Bemardot & Buttel aj^paratus are necessary. This consists of a wide and strong surcingle, having on both sides two straps, joined together in front, and a strong halter, which from the nose-band carries another strap, which passes in front of the head, between the ears, through an iron ring on the pole-band of the halter, and is to be buckled to the single strap of the siorcingle. By shortening this straj), the head and neck are placed and kept in as much exten- sion as may be desired. Prehminaries being completed and instruments ascertained to be inefficient condition, the horse is placed at the side of the bed; and we may here repeat that the manipulations which are next to succeed are not designed to throw him off his feet with a violent SECUKING SOLIPEDS, 33 Fig. 21.— Bernardot & Buttel Apparatus. shock, but simply to place him in a posture of such discomfort, and so to disturb the center of gravity that lying down becomes an instinctive act, and is done voluntarily, in order to avoid the act of falling ; it may be termed a voliintary compulsion. When brought to the bed, a caj) is placed over his head, and all the hobbles are applied, simultaneously if possible, by four assistants acting in concert. They should carefully observe that the large buckle of each hobble is placed on the outside of the leg, and that the eyes of the straps are turned toward the center of gravity of the animal, those of the front hobbles looking back- ward, and those of the hinder hobbles looking forward. The chief hobble must be placed on the fore or hind leg of the side opposite to that on which the animal is to he. The application of the hobbles on a timid and restive horse is not always an easy matter. Remembering, ]3erhaj)s, some similar experience at some former period, he rebels, resists and kicks as a natural consequence. If speaking soothingly and kindly, and employing the usual tranquilizing and assuring processes, with the raising of one of the fore feet, fails to quiet and control him, a twitch is placed on his nose and left on untU, at a j)reconcerted moment, the hobbles are put in place ; quickly, but as noiselessly as possible, the chain is passed thi-ough the ring of the chief hob- ble — on, say the fore leg for facility of descrijDtion — then through the i-ing of the other fore leg, back to the ring of the hind leg of 34 MEANS OF RESTRAINT. the same side, through the ring of the other hind leg, and back to the slot of the main hobble, where it is secured by the pin- screw. The Bernardot & Buttel apparatus is then put in place and buckled by an assistant, with the surcingle on the side of the patient 02:>2)osUe to that on which he is to be made to lie. Previ- ous to this, another assistant will have passed a long rope around the body of the animal a Httle back of the withers, and with stiU another holds it on what will be the under side when the patient lies down. StUl another assistant is placed at his head, to aid the one who holds it, while yet another grasps the tail, and two others seize the casting rope. The second step of the operation is to reduce the animal's base of support as much as possible, by bringing the four feet together. To do this, the operator, standing in front of the as- sistants who hold the casting rope, has each hind leg in succession raised shghtly from the grormd and carried forward by the assist- ant having it in charge, a gentle traction being made at the same time upon the casting rope, in order to shorten the length of the chain passing through the hobbles, the assistants at the head meanwhile gently backing the animal still more to reduce his area of support, untn the equilibrium is so nearly lost that the animal Pig. 22.— Horae about to be Cast. SECURING SOLIPEDS. 35 instinctively abandons the effort to keep his feet, and assumes the recumbent posture in order to avoid the shock of a heavy fall. H. Bouley recommends that the first movement in this final step should be an attempt to back the horse, in order to move the fore legs first, and then to bring the hind legs forward, if the base of support is still too broad. The twitch should now be removed ; in fact, the most prudent plan would be to remove it the moment the hobbles are in place The final step of the act of Hteral throioing or casting being accomplished, the last indication remaining to be fulfilled is to secure the patient in the most favorable position for the surgeon to perform the important work of which all that has been under- taken has been but preliminary. It is properly the permanent (for the time being) adjustment of the body in such a manner as to allow the surgeon the best possible access for all his manipula- tions to the region which is to be the seat of his dissections and other operative movements, without any unsteadiness or opposition. Bouley's directions for this purpose are that the operator, watching for the right moment, as the horse begins to totter, gives orders to the assistants having charge of the ropes acting on the body, the tail and the head, by a prompt and simultaneous action, to pull in the direction of the side on which the animal is to lie, and to those at the casting rope' to pull firmly but not harshly in the opposite direction, while he himself pushes the body of the animal towards the bed. By this arrangement of opposing tractions the casting is easily effected ; but unless the assistants act in perfect concert, and especially if the casting rope be di'awn too rapidly and suddenly, the animal will be raised from the ground with a sudden lift, to fall so heavily on the bed as to possibly subject him to the risk of sustaining severe injuries. Bouley remarks on this point: "An animal is properly cast only when, bending his knees, he lies down softly and easily on his side, bringing to the ground successively the shoulder, the ribs and the hind quarters; or again w^hen, the fall beginning from behind, the order is exactly reversed." Once down, the forcible traction upon the chain brings the four legs in close proximity, the spring hooks or padlock passing thi-ough the link nearest to the ring of the hobble through which the chain passes, coming out last. To provide against the possi- 36 MEANS OF EESTRAINT. ble breaking of that portion of the chain which embraces the four hobbles, Peuch & Toussaint advise the passing of the casting rope and chain a second time through the rings of every hobble before it is seciu'ed with the spring hooks. The animal being down, the straps of the Bernardot & Buttel apparatus are buckled, and the head well extended on the neck. The use of this apparatus con- siderably diminishes the difficulties involved in the contention of the head. Before its introduction, two assistants were requii'ed to keep it in extension and comparatively motionless ; and even then the results were not always easily reached nor accidents avoided, whereas, with this halter and surcingle arrangement a single strong assistant is sufficient to secure control of the head; Fig. 33-— Horse Thrown and Secured by Bernardot & Buttel Apparatus. SECURING SOLIPEDS. 37 and it has the advantage, besides, of " preventing fractures of the vertebral column, ruptui'e of the diaphragm, and rupture of in- ternal viscera." In some exceptional cases the surgeon will be obliged to im- provise his hobbles. This may be done by fastening four ropes of suitable length around the coronets, allowing sufficient room for the passage of the casting rope between the hobbles and the skin, or again placing an iron ring through these loops of rope, which are secured by a knot on the outside of the leg, as suggest- ed by Mr. Dneubourg. The removal of the hobbles and of the other apparatus em- ployed in casting the animal, demands similar care and attention to that which was required to put them on. "While the Bernardot & Buttel surcingle is unbuckled, the assistant loosening the Fia. 24. — Improved Hobbles of Dneubourg. straps of the cap, and ready to remove it at a moment's notice, the operator placing himself facing the soles of the feet, in order to be out of danger, cautiously unscrews the screw-pin which fastens the chain to the principal hobble, and removes it, when all the hobbles becoming loose, are removed, and the animal being freed from aU restraint, is allowed to rise. While the animal is rising it wiU be but prudent in the by- standers to allow him aU the scope he may choose. The action is sudden and somewhat violent, and he may move his hind legs 38 MEANS OF RESTRAINT. witli a sudden jerk which may throw the hobbles off with force suf- ficient to severely hurt some unguarded spectator upon whose per- son they might infringe. We have been witness to such an oc- currence, when they were thrown a distance of twenty feet, with violence sufficient to inflict, possibly, dangerous injuries. An animal thrown and secured as has been described is in a suitable position for the majority of operations, such as those about the head and neck, of the body, or of the upper part of the legs. But in many cases, it is necessary to fix a leg in a peculiar position either to expose a given region of the body, or when the Hmb itself becomes the seat of operation. The action of se- curing the animal in the recumbent position is one of great im- portance, and none of its details ought to be overlooked. And there are several points to which we have already referred in our introduction, which may be again noticed with advantage. Bear- ing in mind the accidents which may resulb from keeping the horse in a state of painful passivity, and his instinctive struggles to free himself, not to mention the painfulness of the constrained posture itself, the inference is palpable that it is incumbent on the surgeon to release the suffering patient from his trying constraint at the earliest moment consistent with the proper completion of the operation. Again, in securing the legs, care must also be taken that, although a given position of a leg may facilitate the movements of the operator, it is not justifiable if there is another mode of securing the same object by means more comfortable and less dangerous to the patient, as well as easier for the surgeon. An exjDcrience of many years has taught us that six j^rincipal modes of fixing an animal's leg, fulfil all necessary requirements, and that the special purposes and effects of these are such as to forbid their modification. In considering these six specific modes, it will promote facility of description if the reader wUl follow our references to the dif- ferent legs on a sort of mental diagram which by a mode of ab- breviation by initials wiH designate — supposing the animal to be thrown on the near side — the near anterior as N.A.; the off anterior as O.A.; the near hind as N.H.; and the off' hind as O.H. First position — Exposing the inside of the N.A. leg. — A loop of the plate-longe is secured on one of the fore legs, above the knee, say the off leg, carried in front of the near leg, under it, back and between the fore legs, always above the knee, to retm-n SECURING SOLIPEDS. 39 Fig. 25.— 1st Position. Neurotomy. to the starting point, aroiind the off leg again, back to and be- tween the legs, thus forming a complete figui*e 8. This is re- peated twice or three times, when a turn around all the crossings of the rope between the legs ties up all the twists of the rope and a double slip-knot is made on the forearm of the off fore leg. Both legs thus secvired, the near leg is released from the hobble, and carried forward by an assistant pulling on it with a rope tied around the foot. For reasons ah-eady stated, we consider this position as the only one justifiable for neurotomy on the inside of the off leg, or for tenotomy. Firing on the inside of the coronet for ringbone, or along the tendons, might also be performed in this position. Second position — Securing the off fore on the off hind leg. — The loop of the ]Dlate-longe is placed on the O.A. leg about the middle Fk;. :l'6.— 2d Position. Ist Step. 40 MEANS OF RESTRAINT. of the cannon region, from tliere carried backwards over the O.H. leg, above the hock, between both hind legs, and forward, be- tween the fore legs and reflected back over the forearm, about its middle, when it is given to an assistant stationed at the back of the animal. An assistant is placed in front of the animal, kneeling on the bed, and prevents the rope which passes in front and over the forearm from slipping down too rapidly. The leg being released from the hobble, the operator holding it carries it backward, while the assistant at the back pulls slowly but steadily on the rope, the action of this lever of the first kind, with its fulcrum on the O.H. leg, the resisting power at the foot of the animal and the moving power at the forearm of the off, moves and draws the leg backward until it reaches the cannon bone of the hind leg. At that moment, steadily holding every- thing in place, the rope that is passing above the hock on the near hind leg is allowed, cautiously, to slip below the hock, and the near fore leg is then brought to the middle of the near hind cannon bone, where it is secured with a double figure 8. Other sur- geons secure the fore leg above the hock as in the plate we borrow from Peuch and Toussaint (Fig. 27). The danger of injury to the tendo- Achilles has caused us to change that position to the one Fig. 27.— 2d Position. 2d Step. SECURING SOLIPEDS. 41 above described. In this position the inside of the N.A. leg is ex- posed, and it can be fired, either for disease of the knee or of the tendons and bursae. All operations upon the foot of the O.A. can be performed except those requii'ed on the inside of that foot, such as those for inside quarter-crack, complicated suppurating com or inside cartilaginous quittor. Fig. 28.— Sd Position. Securing Upper Hind to Upper Fore Leg. , Third position. — Securing the off hind upon the corres])onding fore leg. — In this the rope is first secured in the middle of the off hind cannon region, carried forward and over the forearm, above the knee, in front of the forearm, back between the fore legs, between the hind legs and over the near hind leg, above the hock, to the assistant stationed at the back of the animal. Re- moving the leg from the hobble, and piilling on the rope the near hind leg is brought, by the same method, to the middle of the off fore cannon, where it is secured with a figure eight twist of the rope. In this operation the inside of the near hind leg is ex- posed from the hock down, and in that position, operations on the inside of the hock can be performed, such as firing for spavin, thorough-pins, curbs, and cunean tenotomy, as well as firing on the inside of the tendons, or even tenotomy. As far as the off hind leg is concerned, only operations on the foot are justified, with the exception of those on the inside of that part of the leg. Fourth ptosition — Securing the near fore on the off hind leg. — The rope is secured by a loop on the middle of the cannon of the near fore leg, which rests du-ectly on the bed, carried backward over the off hind leg above the hock, back between the hind legs, 42 MEANS OF EESTEAINT. Fig. 29.— 4th Position. Securing Under Fore on Upper Hind Leg. forward under tlie forearm of the near fore leg, between the fore le^s and back to the assistant at the back of the animal. In this action it again becomes a lever of the first kind, with the fulcrums above the hock, the resistance at the lower part of the near fore leg and the moving power at the forearm. The leg is drawn from its deep position to a superficial one, and secured with a figure eight on the middle of the near hind cannon, and not above the hock, for reasons already considered. This posi- tion is only justifiable for operations on the inside of the near fore foot, such as complicated quarter- crack, complicated suppu- rative corns, inside cartilaginous quittor, and the like. The pe- cuhar awkwardness of this position, in which the leg is carried in excessive adduction subjects the animal to the danger of severe Fig. 30.— 5th Position. Securing Under Hind on Upper Fore Leg. SECURING SOLIPEDS. 43 lesions in the axillary region, and it is justifiable only in the cases specified. Fifth position — Securing the near hind on the cannon of the off fore leg. — The rope is first tied up by a loop on the middle of the near hind cannon bone, forward over the forearm of the off fore leg, between the fore legs, and back to under the near hind leg, between the hind legs and to the back of the animal, where it is held by an assistant. The leg is again drawn from under him, is steadily brought to below the knee of the oif foreai-m and secured as in the other positions. In this position the only operations to be performed are those on the inside of the digital region, or rather of the foot of that leg. Fig. 31.— 6th Position. Sixth position — Securing the off hind leg near the neck or shoxdder of that side of the body. — The rope is tied up by a loop around the coronet of the off hind leg, that is below the fetlock, carried forward toward the siiperior border of the neck, under the neck and then toward the inferior border of that region, back over the whole length of the animal to the front of the hind legs, between these and over the tibial region of the off hind leg, where an assistant holds it to the back. Other assistants, pulling on the rope, and making it sHde as it passes on the borders of the neck, 44 MEANS OF KESTRAINT. the operator carries the leg forward until it reaches the outside sur- face of the shoulder, or the lateral parts of the neck, where the rope is secured by a double twist and knot around the coronet of the near hind leg displaced. This awkward and painful position is for operations in the inguinal region, including castration, in- guinal hernia, removal of champignon, amputation of the penis, or removal of tumors. When the operations which have necessitated these various positions have been completed, the leg which has been restrained should be returned into its proper hobble, and this should be done slowly and carefully, avoiding any unnecessary motions or noises, and the animal relieved of his means of restraint as in all other operations. Fig. 32.— Side Bar Hobbles. In a few instances, however, aside from these various modes of securing individuals, the surgeon has recourse to the side bar hobbles, which carries a hobble of its own at each end, one hobble being fixed on a fore, the other on a hind leg. Some of the Enghsh veterinarians are using the cross hobbles, Fig. 33.— Cross Hobbles. which has the advantage of being adapted for use upon legs diametrically opposite, such as the near fore and the off hind legs, and vice versa. H. — Casting with ropes. The hobbles are not the only kind of apparatus devised for throwing horses, nor are they all made according to the English pattern, although the same general principles pre- vail in all." Ropes in the form of side lines, either single or SECTJEING SOLIPEDS. 45 double, are often substituted for hobbles, and for many varieties of these special claims are made by their inventors, or by those who give them theii' preference, and use them in then* practice. Without entering into the consideration of the comparative merits of these various methods, which vary, not only in nearly every country of the world, but even in different sections of the same country, there is a mode of their appHcation, upon which we have a word of comment to offer. This is the mode with a single, and that with a double rope. (1st.) With a single rope. — This is the simplest mode of casting, but it is also the least safe. It is the oldest of the methods in use, but has in our days been more or less modified and improved. The method of Kohard seems to be as perfect as any of them. In this, a rope from twenty to twenty-five feet in length is necessary. The horse being placed near the bed where he is to be thrown, is held in the ordinary manner. If he is to he on the near side, the operator is placed on the right, near the shoulder with the rope, in which is a knot about six feet from its end, which Eohard calls the ring knot (a), and immediately below it is another, called the stopping knot (b), through which the rope will run. "In this way," says Rohard, "there is a large loop FiG. 34.— Applicatiju of the Rohard Method. 46 MEANS OF KESTEAINT. formed, which is thrown over the neck, while both knots made he a httle below the point of the shoulder." Taking with the free portion of the rope, a twist round both forearms, passing behind them first, then forward across the near fore leg, in front of both fore legs, and backward across the off fore leg, over the rope, it is carried across the abdomen, to the near hind coronet, which it surrounds from without inwards, to be brought back to the posterior part of the withers on the near side, where the operator takes hold of it. Then by degrees slowly pulling on the rope, and making the animal raise his near hind leg by quietly urging him, this leg is carried forward, with a uniform movement, until at one moment, the animal attemj)ting to resist or struggle, the assistant at the head carries it toward the bed, the operator pressing with his body against that of the animal, until he slowly settles down without injury on his side. To fix the leg definitely, Fig. 35.— Animal Secured by the Kohard Method. one begius by the near hind leg. Making a double twist of the rope around the coronet' of that leg, this is carried towards the loop which passes around the neck, and is there secured by a double knot (a), and carried back to the off hind leg, which is then carried far forward and secured to the same collar loop, with a single knot (7)). To release the animal, it is merely necessary to untie the stopping knot, when the rope becomes loosened from the legs. SECUKING SOLIPEDS. 47 (2d. ) With double side lines, or tico ropes. — This is dene by means of a long rope, doubled in its middle, and having a knot made in such a way as to form a loop large enough to be drawn over the head and neck of the animal ; the two ends below the knot are then passed in front of the chest and between the fore legs, carried, one to each hind leg, around the coronet, turning it once around the main rope, and passed on the collar loop from within outwards, to strong assistants standing on each side of the animal. By steady pulling both hind legs are carried forward, untd the animal loses his balance and settles on his haimches, when a strong effort of the assistant at the head brings him down on the bed. The hind legs are secured to the collar loop with the ends of the rope, and the fore to the hind legs in the same manner. The various methods of casting which we have been consider- ing, with hobbles and with ropes are, as we have before said, not the only plans recommended. Almost every country ( f Europe, while also using the hobbles, has a fashion of its own in which the ropes are utilized, and as to the fact of their widespread, if not universal use, it would seem that not a few veterinarians of exten- sive practice have originated and employed special methods of their own devising, for which they claim more or less superiority. Among those recommended in this countr}^ we may mention the apparatus of Mr. Miles, which he has used for years in his exten- sive practice as castrator. Dr. Wm. Dougherty, of Baltimore, has sent us a set of rope-hobbles and side-line, which upon personally testing we are able to recommend as possessing important points of excellence, especially in casting young colts for castration. For further hght and broader information on this subject we must refer our readers to the standard authors by whom it has been discussed in the French, German, Danish and Russian tongues, feeling at the same time quite confident that the general rules which we have suggested and illustrated for the performance of the operation of casting are sufficient to guide any intelhgent operator through all the steps of the proceedings. C. — Casting on the Operating Table. The necessity of employing such a number of assistants in throwing a horse, with the difficulties often encountered in con- ducting all the steps of the operation, and the accidents which 48 MEANS OF EESTRAINT. too often accompany its execution, have led to the invention of other means of accompHshing the object in which the objections to the old method are sought to be obviated. It was with this view that the operatiag-beds of Lafosse in France and Hart in "Wurtem- FiG. 36.— Wall-bed of Fromage de Peugre burg were contrived. The wall-bed of Fromage de Feugre pos- sessed many advantages, but was abandoned on account of its comphcated structure. Of late years, however, several other forms of operating tables have been devised, of which one espe- cially is highly commended by European authors. It is that of Mr. J. Daviau which consists of a broad and heavy table, furnished with pads, surcingles, hobbles, ropes and other necessary appurten- ances for securing the animal, and which is moved by a pecuhar crank arrangement which permits its adjustment in any required position, from the horizontal to the vertical, and by which it may be turned down flat upon an iron frame. The apparatus is placed solidly on the ground, or can be made movable by a set of low wheels attached to the heavy wooden frame upon which the table and the crank are supj)orted. Mr. Daviau claims for his invention: 1st. That it obviates "all the compHcations " accompanying the ordinary system of throw- inw. 2d. It allows " the easy and comfortable rising of the horse " after the operation, without danger. 3d. It gives entire security to the operator, who can perform his task alone and without the SECUBING SOLIPEDS. 49 50 MEANS OF RESTKAINT. SECURING SOLIPEDS. 51 52 MEANS OF RESTRAINT, Fig. 40.— HodgBon & Magee's Table. Back View ; showing the working of pulley to draw the table down. SECUKING SOLIPEDS. 53 need of assistant. 4th. No assistants are needed to be exj)osed to danger, and the responsibility of the operator is diminished. 5th. Economy of time. 6th. Economy of material and space for the performance of the ordinary operation of casting. In this country several forms of tables are in use. Those of Dr. Tiffany, Price and others, all of which are constructed somewhat upon the same principles with respect to the action of an iron crank to control the position of the table. Doctors Hodgson & Magee, both veterinarians of New York, have invented a table which for simphcity seems to surpass any one we have yet seen (Fig. 40). Like the others, it has slings, ropes, hobbles, pads, etc., but dif- fers from them in two important particulars. The first is the manner in which the table is lowered and raised ; the second, the manner in which the hobbles are secured and made immovable. In the middle of the superior border of the table, and directly below it on the posterior face, are two sohd iron rings. In the ceiling of the operating room, or on the cross-piece of the frame in which it is enclosed, and directly opposite that in the border of the table there is another. Another is fixed in the floor some dis- tance back of the frame upon which the table rests when in a horizontal position. To these riags two systems of pulleys are attached, one connecting that in the ceiling with that in the bor- der of the table ; the other connecting the ring on the posterior face of the table with that in the floor. Besides this, under the table are two strong iron eyelets through which chains are passed, which at one end are secured to the hobbles by openings through the table, and at the other are secured from slipping through the ring by a wide T arrangement, secured on the last link. These chains measure the distance which exists between the rings on the floor and the table when in a horizontal position. When the horse is brought alongside the table and tied up with the sUngs, the halters and head-straps securing him, and the hobbles being in place, the roj)e of the upper pulley is pulled by an assistant, and the table moved slowly into the proper position. The rope being then fastened to the ring in the floor, the table is immovable. Upon the completion of the operation the rope is gradually slackened, while an assistant pulls on the rope of the base of the table which is thus restored to the vertical position. 54 MEANS OF RESTRAINT. MEAITS OF SECUKING OTHER DOIHESTIC ANIMALS. (a) BoviNES. — With these animals benignant measures are of little avail. Kindness may in some possible cases — but they will be rarely met with — succeed to a hmited extent, but to trust to the influence of the treatment so often effective with an intelligent and docile equine, such as the petting caress, the soothing tone of voice, or the kindly glance of a human eye, with even the jDlacid and mild-eyed milch kine, will be only an act of misplaced con- fidence. To blind them, to induce dizziness by turning them rapidly in a small cu'cle, may at times produce good results, but even then these measures will be more reliable if combined with more palpable agents of restraint. Cattle may be kept quiet in the standing position by raising their heads, by passing the index finger and thumb of one hand into the nostrils, with the arm over the face, and raising the tip of the head upward, while the other hand, grasping one of the horns, moves the top of the head downward, the resistance of the animal being overcome by pinching the nose with the hand which grasps it with more or less force. By this means the head of the animal is fixed, and the operator guarded against injury from the horns, and the movements more or less hmited. While maintain- ing this position, the cavity of the mouth can be examined and even short and simple operations rapidly performed. Another device for preventing the animal from using his horns as a means Fig. 41.— Securing Cattle. SECURING OTHER DOJIESTIC ANIMALS. 55 of contention is to tie a long roj^e around their base, j^assing it along the neck and the back with one loop around the ribs and another ftu'ther back around the flanks, and when reaching the tail secuiing it there by a knot at the base of that member. The head is thus kept elevated, and he is restrained from motion by the pain experienced by the tail when the rope is tightened by his attempt to flex it. This assures his passiveness (Fig. 42). The practice of shielding the sharp points of the horns with smooth, metallic balls is one which tends largely to diminish the power of the animal for doing harm, by obviating to a great ex- tent the danger from punctured wounds to which those who han- dle them are exposed. The best mode, however, of securing cat- tle while standing, is by tying the head up to a post or a tree, or again by yoking an individual with his mate or another animal of the same species. Kicks must also be guarded against. Those by the fore legs are avoided by raising one foot and tying it on the forearm, thus compelling the animal to stand on three legs. But the hind legs of cattle are the most dangerous from their abihty to kick in so many directions, whether backward, forward or outward. Several methods are recommended by which to guard against this form of danger. Among these may be mentioned the passing of the tail forward between the hind legs and then outward, car- rying it towards the stifle of the leg from which the kick may pro- ceed, and holding it firmly with a backward pull ; thus surround- FiG. 42.— To Prevent Cattle from Kicking. 5G MEAXS or RESTKAIXT. ing- or tying tlie leg with the tail. Again, to pass a twitch round the leg above the hock, and to turn it until the tendo-Achilles pressed upon, is brought in contact with the posterior face of the leg. A looj) of rope twisted upon a stick will answer the same j^urpose. The use of hobbles, single or double, or of the side lines to seciu-e the hind legs, has also been recommended, as with solipeds, with the difference that the horns furnish a strong means of support, which is entirely lacking in the soHped. A method approved by some of controlling the motion of the animal is to pass a rope on one hind leg above the fetlock, and to carry this leg well forward, or even to raise it from the grovmd and to tie it by the rope to the forearm of the sam.e side above the knee or around the horns. The use of a long bar of wood held under the abdomen by two assist- ants in front of the stifles ; keeping the animal pressed against a wall by means of a wooden bar, with which an assistant pushes firmly against the stifle of the side opposite to that upon which the operator stands ; binding the animal against a wall with a rope fixed to a ring in front of the chest and one behind the hind quar- ters — all these are simple means employed to keej) cattle quiet in the standing position. Some individuals, however, and especially bulls, are altogether intractable, and require more severe and effectual modes of p\ni- ishment. These are applied upon the muzzle of the animal in his nasal septum by nippers or clamj)s, or with rings. Nippers are of divers forms. One true, single clamp is commonly used in Italy, and has been modified in England ; another is in use in Hol- 3J Fig. 43.— Italian Nose Clamp. Fig. 44,— Modified English Nose Clamp Figs. 45 A and B.— Modified English Nose Clamps. SECUEING OTHER DOMESTIC ANIMALS. 57 land, which is a true screw-clamp ; another, which is preferred in France — are a few among the varieties of this single instrument for the appHcation of pressure upon the septum nasi. They are generally secured on the front of the face by ropes or straps. They are effectual appHances, and by their aid the head can be kept up and the animal controlled without difficulty. Among the lings the simplest are most commonly in use. They are made ia two parts, articulated at one extremity, and united at the other when in place by a rivet or screw. They vary much both in form and size. Some (though still known as rings) are square ; others Fig. 46.— Square (?) Kings for Cattle, are round and eUiptical. The ring of Rolland, the Alsace ring, and some of simpler construction carry an auxiliary ring at some part of their circumference with which to secure them on the'face of the animal by means of ropes or straps. These rings are applied after the perforation of the nasal septum with a trocar or a punch-nip- pers, making an opening of a size corresponding to that of the ring. Sometimes the perforation is made with a hot iron, the Fig. 47.— Ring of RoUand. animal being properly secured and tied to a tree, or placed in a yoke with the head elevated, the operator making a quick punc- ture through the cartilage, and introducing the ring and riveting it. The hemorrhage soon ceases spontaneously. In order to dispense with the punch, trocar, and the pimcture with the hot iron, rings of a special construction have been in- vented. These also consist of two parts, and are also articulated. 58 MEAXS OF EESTRAINT. Fig. 50.— Puncture of the Septum with Trocars. Fig. 51.— Rings ■with Points. SECURING OTHER DOMESTIC ANIMALS. 59 one of the joints lia\dng' a sharp point with, which the ring is pushed through the cartilage. A simple form represented in Figure 51 shows the point passing thi'ough an eye at the other extremity of the ring to be bent over it in order to close the in- strument. The ring used in some parts of France is contrived Fig. 53.— French Rings. somewhat on the same plan, but is more complicated. That of Rueff is a kind of broken circle, which, when closed, forms a per- fect ring in which the branches are kept together by a small screw. Fig. 53.— Ring of Rueff. The rope which is attached to the nasal ring is not always suffi- cient to drive or control bulls, and conductor sticks armed at the end with iron hooks of various shapes are recommended. The apparatus of Vigan is a very simple one, but it fulfils all require- ments and suffices for the restraint of the most vicious animals. It consists of a wooden pole with an ii'on prolongation having a wide ring by which to hold it, and at a short distance from this a hook to be inserted into the nose ring. Back of this is a strap to secure around the horns the bar over the top of the head as it passes between the horns. At the other extremity is an iron stifle through which a surcingle is passed to be tied around the body of the animal. Painful, and stUl easy to apply, this apparatus is not only a powerful means of restraint, but is sufficient to prevent any motion of the head. 60 MEANS OF KESTEAINT, Pig. 55.— Vigan's Apparatus. SECUBING OTHER DOMESTIC ANIMALS. 61 Fig. 56.— Steer Placed in Stock. The use of stocks for tlie control of bovines is often also re- quired. These are used principally ia shoeing oxen, but are available for some operations which require greater passiveness than can be obtained by the appHcations of the simj)ler means above described. It is only in exceptional cases, and when an operation is likely to be unusually painful and prolonged, that the recumbent position is required with bovines. The casting of cattle may be effected with or without hobbles, but in either case special care is necessary to provide a sufficiently thick bed to protect the head, and guard against the possible danger of fracturing the horns. A long board placed transversely across the neck, with an assistant seated on each end, affords an excellent means of controlling his efforts and struggles. "When hobbles are used, they must be of smaller size than those used for horses, and should be placed above the fetlocks. To cast bovines without hobbles, either of two methods, one invented by Rueff of Germany, and another described by Gwell and Hertwig, wiU answer the ptu'pose. In the fii'st, the Rueff method, a rope some thirty-six feet long is required, in the middle of which a loop is made and fixed round the base of the horns. The two free ends are then passed between the fore and the hind legs, each being twisted from within outwards, around one of the coronets, and brought back to the loop at the base of the horns, through which they are passed to assistants, one on each side, with du'ections to pull backwards. The feet are thus brought dose together, and the animal seats himself on his hind quai'ters, 62 MEANS OF EESTKAINT. and finally stretches himself on the bed. If he struggles, the traction on the ropes only expedites the fall. If he pushes for- ward, or attempts to kick or even only moves his feet, the running of the rope is so much more facilitated. In the other mode, a rope about the same length and carrying in one extremity a loop which is thrown over the horns, is passed backwards along the superior border of the neck, as far as about its middle, where a loose loop is made ; then carried backwards at the side of the vertebral column, where another loop is made, be- hind the shoulders, and a third one around the abdomen, on a level with the flank, where an assistant holds it backwards by the side of the sacrum. If the animal is to be thrown on the left side, the rope must pass on the right of the base of the tail, and vice versa. Two assistants pull on the rope, while another holds the head and tries to bring the animal down. The traction on the ropes tight- ens the three looj)S, and under the efiect of this force the animal is made to he down quietly. It facihtates the operation to lubri- cate the roj)e with a little grease or soap. In order to avoid comj)Hcations from lacing the ropes too tightly about the body, it is always indicated to subject the pa- tient to a moderate fast previous to casting by this mode. (^>) OviNES AND Caprines. — Although these animals are timid and comparatively lacking in strength, they are at times capable of struggling violently and becoming dangerous, and they can- not be subjected to surgical treatment without being cast. This is done by grasping both legs of one lateral biped, the right fore and hind legs, for instance, and laying him over on the opjDosite side, the left, and vice versa. If all the legs are to be secured, those of each lateral biped are first tied, and with the two cords a straight knot is made, binding all together. If the seat of oj^eration is the head, the animal is held by an assistant, who sits with the body of the animal between his legs, with its back close to his own body, holding the fore legswithhis hands, and controlling the hind qviarters between his legs. In some cases when the operation is hght, the oj)erator holds the an- imal himself without help. (c) Si^TNE. — Securing a good hold of this animal is not always an easy task, and it sometimes requii-es not a little skill and cun- ning to do so. "When seized, two assistants are necessary to cast him, especially if he is of large size, and when down, either a muz- SECURING OTHER DOMESTIC ANIMALS. 63 Fig. 57.— Twitch for Swine. zle must be put on his snout to prevent his biting, or a pecuHar twitch placed between his jaws and twisted over the upper one. If an examination or operation is to be made about the mouth, a wooden gag placed between the jaws and held with cords, will be found of great utiHty. The various oj)erations performed upon 3 Fig. 58.— Gag for Swine. the noses of swine, to prevent them from digging the ground, may be considered to some extent as means of restraint. The incision of the snout, which consists in making several transverse cuts through it; the nasal tenotomy, though not so successful; the appHcation of rings through the nose, by the same methods as Fig. 59.— To Prevent Swine from Digging. 64 MEANS OF EESTKAINT. riG. 59a.— Another Mode. those used in cattle, are simple means whicli only need mention, be- ing more frequently performed in fact by raisers and breeders of swine, and indeed rather belonging to their special domain than to that of the professional veterinarian. L '^' Fig. 60.— To Prevent Doga from Biting. {d) Dogs and Cats. — Dogs can be prevented from biting by muzzhng them, or with a cord or band wrapped first around the lower jaw, and then around both, and secured over the neck behind the ears. To examine the mouth in the absence of a speculum, as the one represented in Figure 61, the mouth may be held oj)en by cords passed around each jaw behind their tusks, and puUing them apart. If the animal is dangerous or ugly, the collar nippers SECURING OTHER DOMESTIC ANIMALS. 65 Fig. 63.— Collar Nippers for Dogs. become very handy, in order to liold them by the neck and keep them under control, whether for operation or for administration of medicines. Cats are most difficult to handle. They bite and they scratch, and they are often unconquerable until they are fuUy subjected to general anesthesia. In many instances, the co-operation of a good assistant, accustomed to handling them, may be found necessary. They may sometimes be made amenable to treatment by grasping them by the neck behind the ears, and close to the head with one hand, and securing the fore paws with the other, while a second assistant holds the hind legs, or it may become necessary to have the four paws tied tightly together, and only the head held by the assistant. We have heard of the utilization of a man's boot as a means of feline restraint, particularly in the castration of the male, or " Tom," the head and body of the animal being thrust into the leg 6G MEANS OF RESTRAINT. of the garment, leaving only the posterior portions exposed and accessible to the operator. This may not be a scientific device, but its effectiveness can hardly be doubted. SURGICAL ANESTHESIA. A resort to the various means of restraint, which we have been considering, is sufficient in a majority of cases to bring under perfect control such animals as require to be subjected to surgi- cal treatment. But there is a class of cases in which they become inadequate to meet the great requirements of inducing in the pa- tient a condition in which a great diminution, or the entire suspension, of sensibility and consciousness, with aU power of muscular reaction, is established thi'oughout the organism. This result is obtained through the characteristic action of the special therajoeutical compoimds, known as anesthesia. It is not merely as a more effectual means of securing control over refractory jDatients that their administration is justified. It is also prompted by a projDer humanitarian feeling in cases in which severe and prolonged suflering accompany the operation. In veterinary surgery, the indication for anesthesia, has not, to the same extent as in human, the avoidance of pain in the patient for its object, and though the duties of the veterinarian include that of avoiding the infliction of unnecessary pain as much as possible, the administration of anesthetic compounds aims prin- cipally to facilitate the performance of the operation for its own sake, by depriving the patient of the power of obstructing, and perhaps even frustrating its execution, to his own detriment, by the violence of his struggles, and the persistency of his resist- ance. To prevent these, with their disastrous consequences, is the prime motive in the induction of the anesthetic state. That it per- fectly succeeds in fixing the patient in the attitude most favor- able for the siu'geon in the execution of the various parts of his task, needs no affirmation, nor need we attempt to measure the value of the discovery, which has proved itself to be such a price- less benefaction to the world. There are special cases where anesthesia is more particularly necessary than in others, and where absolute immobility of the patient is essential, and entire muscular relaxation indispensable. Thus it is indicated in the reduction of fractures or dislocations in SURGICAL ANESTHESIA. 67 the large domestic animals ; in cases of delicate manipulation and dissection with sharp instruments, as in the operation for strangulated inguinal hernia; in the reduction of other hernial tumors, in the performance of neurotomy; in operations upon the eye, and in the removal of tumors of certain kinds. It is also indicated in certain operations upon the foot, which are always accompanied with great pain, such as that for the extirpation of a portion of the quarter of the foot, in the removal of the cartilage affected with necrosis (quittor); or again, in deep punctured wounds of the sole, where the resection of the plantar aponeurosis becomes necessary, or the bones are scraped with the knife. The anesthetic condition is also very favorable for the reduc- tion of displaced organs, as of a prolapsed rectum, or uterus, or bladder. In operations upon the teeth, in some cases of parturition, in castration, in iiring, or even in the aj^plication of hobbles, the induction of the anesthetic state has often been of great benefit in quieting nervous animals, and subduing them to a condition of passiveness, which relieved the movements of the surgeon from all embarrassment and uncertainty. As with human patients, anesthetics are contra-indicated in animals subject to diseases of the heart or of the lungs. A full stomach is also always a contra-indication of their administration, especially in solipeds, which are lacking in the abihty to reheve it of its contents by vomiting. Anesthesia may be either local or general, according to the area of its effects. Local, when apphed to the skin over a limited surface, to which its effects are confined ; and general, when ad- ministered by inhalation, and through the respii'atory organs in- fluencing the entire economy. In local anesthesia the effects are obtained either by the pulveri- zation of the proper substance upon the region where it is required to take effect, or by the subcutaneous injection of special agents. General anesthesia is usually produced by the inhalation of the vapors of ether or of chloroform. LOCAL ANESTHESIA. The special indications for this are so numerous that they may almost be considered as general, if not universal, and its applica- tion is so simple and easy a process, and its effects usually so cer- 68 MEANS OF KESTKAINT. tain, that it would become the practitioners of our day to utilize it more frequently and extensively than they do. It is available as well as useful in the simplest oj)erations, and may be employed in the opening of abscesses and cysts ; in the puncture of cold abscesses with the hot irons; in the puncture of the cornea; in neu- rotomy ; in simple incisions of the skin ; in the removal of small tumors, etc., etc. We have used it with the best results in ui-eth- rotomy, in caudal myotomy, in amputation of the tail, and the removal of mammary tumors in dogs, etc. Bouley long ago rec- ommended its application to surgical diagnosis, in cases of doubt- ful lameness, an expedient which has recently been introduced into this country by several veterinarians, for the differential diagnosis of shoulder and foot lameness. We have remarked that the anesthesia can be produced in several ways, though two are principally in use. Among these properly termed minor and secondary expedients, are the apphca- tion of cold water or ice, and cooling or freezing mixtures, and pressure upon the blood-vessels and nerves, which have for years been among the adjunct and agencies of surgical practice, but have given place in recent times to methods more potent and more certain in their effects. Notwithstanding this, however, some mention of their nature and quahties, and the methods of utihzing them will not be out of place, if only as a matter of gen- eral reference, and a case might arise in practice when the infor- mation might become practically valuable. 1st. JPulverization of an Anesthetic Liquid. — The apparatus employed for this process is the invention of Dr. Eichardson, and though the spraying tube has been from time to time more or Fig. 64.— RichardBon Atomizer. LOCAL ANESTHESIA.. 69 less modified, the mode of its employment continues unchanged ; though any substance susceptible of easy pulverization may be employed. Ether is the agent most frequently chosen. Eigolene has given us great satisfaction in our own practice. In impinging upon the sldn in a state of excessive division, the rapid evaporation of the liquid lowers the temperature of the surface with which it comes in contact, and it is this process of refrigeration which diminishes the local sensibility, and, as the effect increases, overcomes it entirely for the time being, or so long as the spray continues to be thrown upon the part. Some slight objections, however, may be alleged against this mode of producing insensibility, arising from the special proper- ties of the fluid employed, and for this reason the mode by sub- cutaneous injection is somewhat to be preferred. 2d. Subcutaneous Injections. — Both ether and chloroform have been recommended, and extensively used, in this manner, but without doubt the salts or compounds of cocaine possess ad- FiG. 65.— Syringe of Pravaz. vantages over either of them. An epidermic syringe, or that of Pravaz, is generally used for the purpose, with a solution of from four to twenty per cent, strength, according to cii-cumstances. If used on a tumor a certain quantity of the solution, jDcrhaps twenty drops, is injected luider the skin at two or three points around its circumference, the desired effect following, and the parts being ready for the operation within from eight to ten minutes, more or less, according to the strength of the dose administei-ed. Either of these modes of local anesthesia is harm- less, and may be employed without risk or fear of complications. 70 MEA]srs or eestkaint. GENEEAXi ANESTHESIA. The three principal agents which recommend themselves by the efficiency and certainty of their action in producing general anesthesia, are ether, chloroform and chloral hydrate. Their adaptation varies, however, with the animals subjected to their administration. Chloroform and chloral are chiefly used for the larger animals, principally horses, while chloral and ether are re- served for the smaller kinds, with which chloroform is so generally dangerous, and even so often fatal, that its use with them is almost entirely discarded. Insensibility by Anesthetic Vapors. — The modes adopted for the inhalation of the vapors of chloroform are numerous, but among them all the merit of simphcity shordd probably be award- ed to that which is recommended by Bouley. This consists in the introduction into each nostril of a small sponge, or a ball of oakum, saturated with the ether or chloroform, and held in place by the hands of assistants. The inhalation of the vapors, which are thus mixed with air, proceeds rapidly, the sponges being recharged as soon as they become exhausted, and returned to the nostril, until the object in view is accompHshed. But while this mode is a vei*y convenient one, we conceive it to be liable to certain objections. First, unless the pouring of the liquid is very carefully per- formed and in such quantity that the sponge is not over-saturated, ' there is danger that a large portion of it may be wasted, by run- ning off, either on the bed, or possibly, into the nostrils, causing, in the latter case, great irritation of the mucous membrane. And if the anesthesia is to be continued for a considerable length of time, the effect produced upon the delicate membrane of the nose may be sufficiently serious to end in the sloughing of the parts. It must certainly have been with the view of avoiding this complication that Defays invented the inhaler shown in figm-e 66 with its wide raaige of appHcation, from the dog to the horse. Many veterinarians have adopted an arrangement consisting of a strong leather muzzle with large openings at its bottom and sides for the free admission of the atmospheric air, the sponge or oakum charged with the chloroform or ether being placed in the bottom of the muzzle, which is fixed upon the animal's head in the GENEKAL ANESTHESIA. 71 Fig. 66. — Apparatus of Defays. ordinary way. This is a very convenient, though quite a simple contrivance, but English veterinarians, and among them Mr. R. Cox, recommend in preference a chloroform-bag, in the form of an ordinary bag, made of strong canvas, both ends of which can be closed by a running string, one being tied around the nose Fig. 67.— Cox's Chloroform Bag in Position. while the bag is secured by cords to the halter or to the straps of the cap. The chloroform is introduced into the bag by means of a thin piece of cloth saturated with the liquid. The chloroform nose-cap recommended by Mr. Gresswell also answers a very good purjDose, and in fact, possesses advantages which render it superior to the apparatus of Mr. Cox. It is not so portable in its form, but is more durable in its construction. In fact, it produces the features of the ordinary stable muzzle which we have ah'eady mentioned. The apparatus of Carlisle is also one of EngUsh invention, for which great merit is claimed. We have used it, and the trial has shown it to possess many features of marked superiority over the others. The quantity of liquid required to bring a large animal under complete general anesthesia cannot be positively ascertained. 72 MEANS OF RESTRAINT. Fig. 68.— Gresswell's Chloro- form Nose-Bag. Fig. 69.— Carlisle's Chloroform Inhaler. While it has often been induced by the inhalation of a single ounce, there are cases in which two, three, or even more have been necessary. An essential point to consider is that the chloroform should be absolutely pure. Mixtures of two or more drugs have also been employed, usually ether and chloroform, with or without the addition of alcohol, but the result of all ex- perimental tests has been, with us, to establish the conviction, that as yet, chloroform used singly has proved itself to be the most effective and the safest of all. The administration of chloroform of course pre-supposes, besides all the other conditions and preliminaries of an operation, such as previous fasting, the preparation of the bed, and other incidental steps, the act of throwing the patient. When the effects of the inhalations begin to become manifest, the first physiological change noticed is an extreme agitation, accompanied with coughing. The animal struggles more or less violently, the irritation and tickling of the throat j)roduced by the vapors upon the laryngeal mucous membrane, giving rise to a spasmodic motion of the glottis, and whether the patient be a GENERAL ANESTHESIA. 73 large or a small animal, he exerts his strength to rid himself of the apparatus and regain his freedom of motion. These manifestations are, however, but of short duration, and are soon followed by a state of passiveness, the respu-ation be- coming easier, the cough disappearing and his energy subsiding ; and in short, he is subdued. The eye then assumes its character- istic expression, its brilHancy is lost, it is wide open, the pupils slowly dilate, the gaze becomes fixed, the sensibility of the cornea is lost, and the light ceases to effect it. The mouth becomes more or less loaded with saUva; the pulse, which must be carefully noted by an assistant, becomes slow and weak, the respiration returns to its normal condition ; the state of complete anesthesia has been reached, and the jDatient, in happy unconsciousness, is ready for the surgeon. The time required to reach this condition varies with the sub- ject, and especially with the quality of the drug administered. The average period is from one to five minutes in small animals, and from ten to fifteen in the large. In some few cases, however, half an hour may elaj)se before complete insensibility is produced, and again animals are encountered with peculiar idiosyncrasies, which remain entirely refractory, and successfully resist every attempt to reduce them to insensibility ; a statement equally true when applied to human patients. The duration of the Anesthesia. — Some animals remaining under the influence only for a few minutes, sometimes from fifteen to thirty or forty, it becomes necessary to prolong the insensibil- ity by renewing the inhalation, and they must, therefore, be con- tinued until the completion of the operation. Recovery from the anesthetic state does not always take place immediately and per- fectly. As the effect begins to subside, the animal, having parti- ally regained his senses, begins to move his eyes, raises his head, perhaps allows it to fall back slowly on the bed, lying flat on his broadside ; then his legs begin to move, and presently he attempts to spring suddenly to his feet. He may succeed in doing so, but again, his muscles may not have yet recuperated their power of full action, and there may be danger of his experiencing a heavy fall on the bed. His condition is one of drunkenness, and he re- quires to be watched, and, if necessary, aided, in order to prevent him from injuring himself by efforts beyond his strength while in a state of weakness of which he is unaware. 74 MEANS OF KESTKAINT. The symptoms of general anesthesia by chloroform, which we have detailed, are those of ordinary cases. There are, however, other symptoms which the vigilant operator will not fail to look for, which are of great importance as indicative of the dangers, and premonitory of some of the casualties incident to the situ- ation. These we reserve for subsequent consideration. Anesthesia by the Administration of Chloral. — While this drug and its compounds, as sometimes used, produces in some cases a condition of insensibility quite as complete as that ob- tained by chloroform or ether, yet there are cases in which only a less comjilete degree of success can be secured, though still suffi- cient to be of great assistance to the surgeon as well as of rehef to the patient. That the intra- venous injection of chloral has been shown to be the best of all modes of obtaining anesthesia, is an admitted truth, but unfortunately it is a method of introducing it into the system which will scarcely ever become sufficiently prac- ticable to be available outside of the laboratory. Efforts to over- come the difficulty referred to have not been wanting, however^ and Messrs. Cadeac and Mallet have experimented with chloral by combining its action with that of muriate of morphine. By first injecting subcutaneously a certain quantity of a solution of mor- phine, and following it after a few minutes by a rectal injection of a solution of chloral, they have obtained complete anesthesia in a very short time. For a horse they have used eighty centi- grammes to one gramme of the morphine, and from eighty to one himdred grammes of chloral; and, for a dog, ten centigrammes of morjDhine and twenty grammes of chloral The administration of chloral in the form of balls, as commonly practised by many veterinarians, in doses varying from one to one and a half ounces, given on an empty stomach, and from one to two hours before the operation, is undoubtedly good practice. We have not personally had the opportvmity of testing it in cases of long and tedious dissections, but the benefit we have often de- rived from it in short, though painful operations, justifies us in recommending it, not only for this very object, but in any case, where, from any possible cause, an animal is hkely to receive severe injuries during his struggles to liberate himself. ACCIDENTS OF GENERAL ANESTHESIA. 75 ACCIDENTS OF GENEEAL ANESTHESIA. Notwithstanding the caution observed in the use of ether or chloroform, and however pure these articles may be, accidents must be exj)ected during their administration. They are not always of a serious nature, but they may at times have fatal results. Among those of minor importance is the cough which becomes at times quite troublesome, but may be readily subdued by a tem- porary arrest of the inhalation ; vomiting, which often occurs in small animals, but which can be guarded against by causing the patient to fast long enough to insure an empty stomach before being etherized, and spasmodic contractions, of which the exis- tence, when undoubtedly present, is often overlooked. Among those of more serious nature are syncoj^e, either cardiac or res- piratory. Cardiac syncope is a very serious accident, and in a majority of cases proves fatal, especially in large animals. It is sudden in its manifestation, and often unobserved until at too late a period of the operation. It is due to a gradual diminution, followed by an arrest of the muscular contractions of the heart, and as far as our observation extends is always associated with pre-existing heart disease. The application of cold douches, of heart stimu- lants, ammonia given by inhalation or internally, are the first in- dications in these cases. Respiratory syncope, which is far less dangerous, arises from the influence of the laryngeal nerves upon the activity of the res- piratory centers. Its access is sudden, being caused by the arrest of the respiration. There is no convulsion, though the intoxica- tion produced by the anesthetic vapors is sudden in its effects, and is generally detected only by careful watching. The appUcation of electricity, that of the electro-puncture, and especially persevering efforts to effect artificial respiration, may sometimes saye the animal, provided the trouble is not connected with the complete arrest of the contractions of the heart. In view of these possible incidental conditions, some general rules suggest themselves tending to their avoidance. Great care and exactness in gauging the doses of the anesthesia, with such caution in their administration as to produce a slow and gradu- ated effect, is one point. Free allowance for the introduction of air with the vapors inhaled ; close attention to the state of the 76 MEANS OF BESTEAINT. circulatory and respiratory apparatuses, and the manner in which their functions are executed, by noticing the heart-beat and watch- ing the piilse and the movements of respiration at the flanks, are other points of importance. Another point is the need of bearing in mind that an animal submitted several days in succession to general anesthesia be- comes more and more susceptible to its effects, and therefore more exposed to the dangers they imply. ACCIDENTS INCIDENTAL TO THE USE OF MEANS OF RESTEAINT. We have already considered some of the accidents which are likely to interfere with the successful apphcation of the means of restraint, and especially with reference to the final act of the pre- liminary series which occur at the moment of throwing the animal and depositing him on his bed, particiilarly such as may follow the neglect of properly protecting the head with the cap or blinkers, or by an unnecessarily prolonged use of the twitch, or from the sudden and violent movements of the animal himseK. These can usually be obviated by proper forethought and watch- fulness. But the most careful attention cannot always assure immunity from miscarriage and casualties. Thus, a common mis- hap, and one which cannot be anticipated nor prevented, is the sudden and heavy fall of the animal just as his equilibrium is lost. The lesions which may follow this casualty may have their seat either in the hard or soft structures, and are of the most serious character, not only including, at times, fractures and dislocations, and lacerations of the soft tissues, including the muscles, but may affect the viscera, and even the blood vessels and the nerves — in this last case involving the parts in all the evils of local paralysis and its disabilities. (a) Fkactukes. This form of injury may have its seat in the vertebral column, the ribs, and the bones of the extremities. 1st. Fractures of the Vertebral Column. — In the list of frac- tures, those of this region of the body are the most frequent. The numerous reports of cases which are made public by veterin- ary writers furnish sufficient evidence of the facihty and frequency of their occurrence, even when the most careful attention has been ACCIDENTS DUE TO RESTEAINT. 77 bestowed on all the details of the work of casting. The very peculiar circumstances under which these spinal fractiu-es some- times take place, baffling calculation, and occurring when least expected or prepared for, illustrate the responsibility which the veterinarian assumes, and the culpabihty with which he would become chargeable by undertaking the work without due caution and preparation, or without notifying the owner of the animal of all the hazards and difficulties attending the case in all its steps and stages. As will be seen when we come to the consideration of this special lesion in the chapter on fractures, the symptoms which accompany this accident are distinguished, as to one feat- ure, by the suddenness of their appearance, which takes place at the moment of the infliction of the injury or immediately after. But the most important of the characteristics of the case is the grave fact that the fracture is almost always of the comminuted kind. This is held to be due to the excessively powerful mus- cular contraction, resulting in the over-arching of the vertebral column simultaneously with pressure from the abdominal organs, caused by the sudden extension of the anterior and jDosterior bipeds, bound together with hobbles, the violence of the struggle so powerfully pressing the vertebrae together as to result in the yielding of their spongy structure; and the crushing or grinding of the bone is the consequence. This theory of the production of fractures of this character has been adopted by the majority of Euroj^ean veterinarians, es- pecially by those of France, where it is understood as "Bouley's Classical Theory." In 1889, however, another theory was pro- pounded and defended by Mr. Moussel, of Alfort, differing en- tirely from that of Bouley, in which he claims that the kind of fracture in question is not caused by an over Jiexlon of the spine, but, on the contrary, is the effect of an excessive extension! result- ing from greater contraction of the ilio-spinahs muscle. According to Dickerhoft, " three factors are active in the cau- sation of these fractures. In the first place, the animal must have some object as a^J»oiM^ il cq^pui for one hind leg; that point must be connected with either one of the other extremities or directly with the trunk. * * * Secondly, the horse must make his vertebral column tense by the contraction of the spinal extensor muscles. * * * Thirdly, the horse must, simultaneously with the extension of the hind leg and that of the vertebral column, draw its pelvis 78 MEANS OF KESTKAINT. to one side. * * * But no one of these three elements, in itself, will produce a fracture; they must all concva-." Whatever may be the value of these theories, the fact that at post-mortem examinations fractures have been discovered, in some cases in the annular portion, and in others in the body, seems to prove that any one of them is equally apphcable with another. To prevent these fractures, therefore, becomes the principal object of the surgeon at the critical moment when the animal is thrown. This involves a strict attention to the rides which we have laid down for his guidance in the various steps of the act of casting ; and, moreover, to have recourse, as often as possible and as the indications suggest, to the aid of anesthetic agencies, and by no means to ignore the value or neglect the use of the apj)a- ratus of Bernardot & Buttel. 2d. Fractures of the Ribs. — These fractures are undoubtedly frequent, as the result of heav;^'^ falls upon a badly-made bed — too hard or too thin, or perhaps concealing hard substances, as stones or the like. 3d. Fractures of the Pelvic Rones. — There are but few cases on record of this kind of injiu-y, but they are possible, as the re- sult of carelessness in the preparation of the bed or improper casting, or powerful muscular contraction. 4th. Fractures of the Bones of the Extremities. — Though prob- ably less common than those last referred to, these lesions are not unknown in veterinary practice. They occur principally in the diaphyses of bones, or near to, or at the epiphysis, and are often in- complete in their nature. Delafond describes a case of fracture of the femur taking place during the application of the clamps while undergoing the operation of castration ; and another case is recorded of which the trochanter of the femur was the seat. Eey has reported a case of fracture of the cubitus taking place as the animal, when freed from the hobbles, made a violent effort to spring from the bed ujDon which he had been thrown to be fired for a chronic enlargement. These fractures of the extremities may be avoided by careful attention, not only at the time of throwing the patient, but in placing him in position and in properly securing him, and giving him judicious assistance in regainiag his feet. 5th. Dislocations. — These accidents are of very rare occur- rence. One case, however, is recorded of a dislocation backwards of the humerus, complicated with fracture of the cubitus. INJURIES TO SOFT TISSUES. 79 (b) IxjuFtiES TO Soft Tissues. 1st. Lacerations of Muscles cuid tlie'ir Annexes. — These are the result of the distorted positions into which the extremities are forced while undergoing operations. They may be discovered immediately, or may be developed a few days after the operation. Inflammation of the olecranean and pectoral muscles, of those of the croup, and of the anterior part of the shoulder have been re- ported. Bouley has seen a rupture of the aponeurosis of the great and of the small oblique muscle of the abdomen, and one rupture of the flexor metatarsi. A case of laceration of the diaphragm is recorded by Bouley, Jr. In one of our own patients, laceration of the olecranean muscles was followed by such severe comphcations, that it became necessary to destroy the patient. 2d. Ruptures of the Viscera. — These are of rare occurrence, being generally prevented by the precaution of refraining from throwing the animal, vmtil assured of an empty digestive canal by previous fasting. Accidents, however, have been witnessed by Gohier, who has noticed their occurrence upon the rectum near the anus. This horse had drunk freely of water before being cast. Bouley, Jr., has seen a case of rupture of the diaphragm. Rey has known one of the heart, Schaak one of laceration of the humeral artery, and even the giving way of the vena cava, in a case of a nervous animal upon which means of restraint were being appHed to dress a small wound. The patient suddenly fell, and, struggling violently, died ; and at the post-mortem the abdomen was found full of blood, and the vein torn back of the kidneys. 3d. Injuries to Nerves. — These are accompanied with loss of power, usually temporary, but sometimes permanent. The posi- tion in which it is sometimes necessary to fix an animal, as in the diagonal, is that in which they are most likely to occur. The symptoms of paralysis which are then manifested, betray them- selves when the animal has just risen from the bed, when, upon being called upon to move, the leg is discovered to be unable to caiTy its weight, flexing upon its various bony levers, and render- ing locomotion impossible. Sometimes these symptoms are of but short continuance, and disappear under the influence of strong stimulating frictions. The leg was, according to the popular phrase, "asleep," because of a temporary arrest and sluggishness of the cu'culation. But in other cases, the condition is brought 80 ilEANS OF BESTEAINT. on by a true lesion of the nerves, the brachial, the lumbar plexus, or some of their branches having undergone some traumatic hurt which may prove more or less refractory to treatment. 4th. Asphyxia. — According to Peuch and Toussaint, this ac- cident may result from the ignorance of assistants, who, in con- trolling the animal and keeping him down on the bed, have com- pressed the nostrils too tightly ; or again it may be caused by the excessive pressure of the throat straps of the halter, or of the rope which encircles the neck when a horse is placed in position for castration. To explain the causes of this accident should be, with an intelligent operator, sufficiently to hint the means of prevent- ing its occurrence. Conclusions. — A review of the matters we have been considering in this chapter may not be out of place, nor unjDrofitable, even at the risk of being, perhajDS, a little repetitious. In view of the oc- currence of these accidents, and appreciating the responsibility assumed by the surgeon when about performing an operation upon a more or less valuable animal, he cannot but be conscious of the obligations which impose themselves upon him to take every precaution to avoid them. He should therefore guard against their eventual contingency, by closely inquiring concerning the condition of his patient, and by satisfying himself that every part of the apparatus of restraint is in good order ; should avoid rough treatment and employ anesthesia when possible, and never put an animal in a constrained position for treatment when an operation can be otherwise performed more advantageously and easily and comfortably to his patient, and he should never allow him to re- main in his restrained and compulsory recumbent position longer than is strictly necessary. And above all, he should never under- take an operation without having fully acquainted the owner of the animal of the possibihty of accidents. The fact of thus ex- plaining matters to an owner, and of obtaining his intelligent con- sent does not, of course, relieve the surgeon of his responsibility, but rather, on the contrary, confirms and increases it by thus add- ing a new, though an implied pledge to his employer to devote his most conscientious endeavors and exercise his best skill in the matter, in token of his appreciation of the confidence placed in his skill and faithfulness. CHAPTER n. SURGICAL DIAGNOSIS. The first query to be settled in examining a diseased animal is whether the ailment with which he is attacked is merely a case of disordered function, requiring only the administration of the proper drugs to restore the usual" order of things, or a case de- manding the operative skill and expert ministrations of the sur- geon, with bistoury and cautery and suture. The decision of this query involves a thorough knowledge of anatomy, and is compara- tively more difficult, as well as more important, than the mere medical diagnosis of diseases pertaining to internal pathology. Errors in surgical diagnosis are always both more dangerous and more important than those of a mere medical character, inasmuch as they are likely to be more readily exposed, and to involve a greater amount of responsibihty on the part of the surgeon. To insure the certainty of his diagnosis, the surgeon must caU into exercise aU his resources of knowledge and experience, and employ all his faculties of observation and discrimination, with such instrimiental aid as may serve to facditate and confirm his conclusion, as to the nature of the cases before him. He must especially employ all his organs of sense in the investigation. A single sense is sometimes sufficient to diagnosticate the character of some special lesions, but more commonly each sense is an auxihary of the others, and all are complementary to each. In fact, the surgeon is not justified in reaching a conclusion as to the detection of an affection, which is discovered by the sight, or touch, or smell, or hearing, alone, but to escape the possibHity of error, he is bound to confirm his discovery by the corroboration of another, or what is still better, of all the others, if possible. In these cases, as in others, the eye is the most valuable and comprehensible of the organs. 1st. Sight. — Visible changes of contoiu', or color, or other deviations from the usual appearance of tissues, or of regions, are of course first made known through the sight of the eye. De- formities, unless of very minute dimensions, with abnormal 82 SURGICAL DIAGNOSIS. growths, prominent swellings and changes of direction in the bony levers, belong to the same category, and if these are not suf- ficiently distinct or conspicuous, and seem likely to escape the visual observation of the surgeon, a careful measurement may de- cide the point. The eye must also discern the changes occurring in the various visible membranes, as for example, the heightened redness of a congested membrane, and the paleness of an anaemic subject. Again, if there is abnormal motion in a part, as in fractures and dislocations, it is to the eye that the disclosure is first made. This application and study of the use of his eye will be very serviceable to the surgeon in the examination of the external sur- face of the body, but when examinations within the organism, or within its cavity, become necessary, however strong a light he may have at his disposal, he will be compelled to have recourse for assistance to the speculum, to hold the parts open. There are many forms of this instrument. The speculum oris, for the mouth, has very numerous shapes, some of them very sim^Dle, as in Figures 70 and 71, and some com- FlGS. 70 & 71.— Simple Speculum Oris. Fig. 72.— Brogniez Speculum Oris. plicated, as in Fig. 72, the speculum of Brogniez. Green's spec- ulum is an American invention, simple, safe, comfortable to the patient, and of easy manipulation (Fig. 73). Grange's mouth speculum is rather clumsy and heav;^' (Fig. 74). These instruments are generally employed for solipeds. Placed between the jaws, they open the mouth forcibly, and keep it so as long as they con- tinue in place. Sometimes, however, the mouths of these animals, as well as those of ruminants, can be held open without them, by putting SIGHT. 83 Fig. 74. — Grange's Speculum. the tongue out of one side of the mouth with one hand, while the cheek is pulled out in the opposite direction with the other. This same manipulation may answer for large ruminants, provid- ing the head is kept elevated by an assistant. In swine, a gag (See fig. 58) made of wood, is often used, and the speculum rep- resented in figure 61 answers well for dogs. At other times, however, with these animals, the mouth is kept open by separat- ing the jaws with tapes passed around each, and pulled apart. 84: SURGICAL DIAGNOSIS. Fig. 75. — EeynarB Mouth. Keflector. Reynal is the author of an instrument which facilitates the examination by the eye of some parts of the mouth. It is pohshed on both surfaces, and acts as a reflector, and, when in- troduced on the iaside of the cheek, will help to detect diseased spots on the teeth, which would otherwise escape discovery. The Fig. T6. — Xose Speculum. speculum to dilate the nostrils and examine the nasal cavities, also acts as a reflector, but fails, we think, to fulfill the object, for lack of sufiicient dimensions. It is made somewhat on the principal of the vaginal speculum used in human medicine, and acts in the same manner. Fig. 77.— Eye Speculums SIGHT. 85 Fig. 78.— Ophthalmoscope. The speculum to keep the eyelids apart will be found of great assistance in the examination of that organ, so sensitive to the light when in a state of disease, and so constantly kept closed on that account. It is, in fact, this speculum which renders the use of the ophthalmoscope practicable for the examination of the in- ternal structures of the ocular globe. Some of the various patterns of the speculum used in human Fig. 79.— Examination of Dog's Ear. 86 SURGICAL DIAGNOSIS. surgery for the ear, will be found available in tbe examination of the external auditory canal, especially in dogs. The dilatation of the vagina and the anus is scarcely ever needed in veterinary surgery, and instruments are there- fore not required; nor is the endo- scope, so useful in human sur- gery, of any value in veterinary practice from the impossibility of using it upon animals. To realize the value of these optical aids in the examination of cavities, a strong light is indispensable. Sometimes the ordinary solar rays will be sufficient, but at others reflected and concen- trated artificial light will be necessary, as in the use of the oph- thalmoscope to examine the eye, or to detect the conditions of the deep posterior parts of the nasal ca"\^ties. {b.) Touch. — The taxis is the surgical sense ^:)«r excellence, and is probably the more valuable and rehable of all the means of investigation possessed by the surgeon, the sight itself not ex- cepted. Nothing else so accurately detects the changes in the proportions, in the consistency, in the elasticity, or even in the nature of tissues, and its discoveries may be made serviceable at every stage of an operation of importance and delicacy. But to attain a reliable certainty in the exercise of this tactical skill, the finger ends must, equally with the eye, be thoroughly educated to perform their functions with accuracy and discrimination. A change in the aspect, form and contour of a region which easily escapes detection by an ordinary observer, wiU become instantly evident to the well-drilled digital extremities of the ex- perienced operator. The object requiring examination is not always, however, within reach of any portion of the hand, and resort must be had to instrumental aid in the exploration of parts deeply situated, or of fistulous tracts, and for this purpose the 2^fobe is brought into requisition. It is usually of metallic material, generally silver, or of lead, or may be made of gutta percha or whalebone, or other TOUCH. 87 Fig. 81.— Straight, curved Directory— Silver Probe. suitable, flexible substance, and either straight or curved as the S probe. The director is also a probe, heavier than the ordinary kind, and having a small groove running its length on one side. It is used as a kind of guide to prevent the deviation of the bis- toury from its proper course, and to conduct it to the bottom of a wound. Exploring needles are used with advantage in the detection of the nature of abnormal growths, the small and narrow wound which they make being sufficient to ascertain the nature of the liquid which may be present, without danger of comphcations. The Dieulafoy aspirator affords another means of exploration and discovery of deep-seated parts, inaccessible in the ordinary way. Fig. 82.— Dieulafoy's Aspirator. bo SURGICAL DIAGNOSIS. (c) Hearing. — The indications obtained througli the media of the sight and the touch may be usefully supplemented, and are often completed by those which address the sense of hearing. The gui'gling sound in Uquid or gaseous tumors, the peculiar bruit in aneurisms, caused by the current of the blood; the con- tact of a stone in the bladder when touched by the exploring catheter; the peculiar glou-glou of the entrance of air into a vein; the characteristic crepitation of fractiu-es, and the whisthng of a roaring horse — these, and other signs, convey their information with unmistakable distinctness to the auricular sense. {d) Smell. — The exercise of the olfactory sense in the formation of a surgical diagnosis is more limited than those just con- sidered, and yet there are conditions in which it may be of great importance. The odor, sui ge?ieris, of gangrene and of necrosis are promptly detected, and at once recognized, and the existence of other pathological conditions, as of urinary or stercoral fistulous tracts, and certain affections of the feet, are betrayed by the pungent and aggressive appeal to the olfactory organs. (e) Taste. — As free from anything like fastidiousness in respect to offensive contacts and surroundings, as the sui'geon must unavoidably become, he di'aws a line ; he insists upon a strict monopoly of his gustatory sense for his own internal uses, and only investigates the domestic animals in an ahmentary way, when entii'ely healthy individuals are reduced to a post-mortem condition by the butcher, and served in the form of beef, mutton and pork, properly cooked. But if the surgeon should desire much valuable aid from the exercise of the physical senses in form- ing his diagnosis, he will commit a serious error if he allows himself to be entirely and exclusively guided by them. Strictly speaking, a direct diagnosis may sometimes be arrived at by a care- ful collation of the results of his researches, but he will often, also, be obliged to modify or go beyond these conclusions, and make an indirect diagnosis besides. There are two ways of making a positive surgical diagnosis : one which may be called the direct, or diagnosis by confirmation ; another known as indirect, or by exclusion. The former is by ulterior investigations, confirming a previous diagnosis made upon the basis of a single and prominent symptom ; the latter by the elimination of all diseases, which, though they may have some TASTE. 89 resemblance to that which has been suspected, yet are excluded by the presence of some specific and incompatible symptoms. It is only by carefvd induction and cautious reasoning, that the surgeon can settle the question of his diagnosis, and insure such a true and tangible conclusion, as can only be reached when there is a perfect correspondence between the suggestions derived from the testimony of the physical organs, and the calm deduc- tions of the logical faculty, aided by a disciplined and well fiu'- nished memory. CHAPTER m. SURGICAL THERAPEUTICS. This title refers to one of the most extensive and important departments of surgical practice, upon which, indeed, as to its proper administration, depends in a great measure the success of the operative sMll, of which it is the supplement and consummation. It comprehends the bandaging and dressing of traumatic injuries. DRESSINGS. Gourdon says that " a dressing is a mode of local, periodically repeated, treatment, producing a continued action, following or- dinarily the performance of operations, and consisting in the methodical application upon the surface of wounds of special apparatuses, which complete the effect of the operation, and co- operate in the recovery." The value of the skill and proficiency to be acquired by dili- gent study and observation in this comprehensive and indispen- sable art, need not be stated ; that it is entitled to be so denomin- ated no one acquainted with the niceties of its details and the judgment and experience entering into their ^performance, need be told. Nor can the dependence of the surgeon, for the good results which he hopes to secure in his department of duty, upon the faithfulness and intelligence of the nurse, who is to co-operate with him in perfecting the healing process, be easily overrated. An incompetent or unfaithful nurse, may spoil the best work of a good surgeon. To protect a wound from immediate contact of surrounding bodies, to shield it from injurious atmospheric effects, malarious or otherwise ; to keep aloof all putrid and virulent mat- ters ; to secure the absorption and neutralization of their morbid products; to control the cicatrizing process in the ulcerated parts ; to apply topical treatment, according to indications, as the curative processes develop ; to produce a mechanical action, such as dilatation or compression, according to the instructions DKESSINGS. 91 of the surgeon, and the indications of the case. Such is a fair, though brief synopsis of the duties of the nurse, upon whom it devolves to give effect to the rules of surgical therapeutics. A well-applied dressing may become the first step toward assuring the success of an operation, those following it — even when only methodically executed — being mere continuous degrees of the one well-begun action. A well-apphed dressing may sup- ply the defects and amend the errors of an improperly performed operation; and, on the other hand, a bad dressing may jeopardize the success of a well-executed operation by interfering with the process of cicatrization, and in other ways delay the recovery of the patient, and even prevent it entu*ely, by causing unfavorable complications. The appHcation of all dressings is subject to certain general rules, from which no deviation is allowable. As in every action in life, the first step should be that of preparing all the necessary means and appHances for the work, and the last, before beginning the actual manipulation, shordd be to ascertain that nothing more remains to be provided, at the risk of a serious interruption and delay, and loss of time in a search for some missing article of necessity. On such a point the merest hint shoiild be sufficient, and, indeed, even a hint should be unnecessary with a practical and thoughtful person; but, unfortunately, all persons are not practical and thoughtful. The next step for the surgeon is to secure for himself and his patient a favorable arrangement in respect to light and room. There must be nothing interposed before the eye, or that can limit the free movement of the hand and the arm — a most obvious sug- gestion. Before applj^ng a dressing, the wound should be thoroughly cleansed and freed from blood, pus, the remains of pre\dous dressings, and, in a word, of any foreign or other substances capable of becoming sources of irritation. This is best done with water alone, but its effect is frequently greatly improved by combining with it some of the compounds, such as carboUc acid, sanitas, creoline, etc., which have proved their value as antiseptic agents. It may be applied by carefully passing a fine sponge or a ball of oakum over the siurface of the woiind, or it may be used more freely in larger ablutions. Crusts or scabs, if any, may be removed with the scissors or scraped away with the spatula, but 92 SURGICAL THERAPEUTICS. the finger-nails must by no means be used for such a purpose) for the twofold reason that it is both filthy and dangerous. Handle the wound only as much as is necessary; all needless taxis irritates — the inference is obvious. If the wound is deep, injections can be combined with the lotions in cleansing it. With the first dressing, there is probably only blood to wash away, and that should be done thoroughly, not overlooking any portion that may have di'ied in the hau' and on the skin. The essential condition of cleanhness appHes not only to the wound, but also to the material used for the dressing, and soiled cloths or bandages, and dii'ty tow or oakum must be rigorously rejected. And, while insisting on strict cleanliness in the instruments and dressing material, it will hardly be decorous to the surgeon to omit him from the category, and to remind him of the propriety of looking to his own condition, and especially to that of his hands. In all his manipulations it should be a matter of conscience with the surgeon to treat his patient kindly. Rough handhng, loud scolding, threatening or jerking, with a restless animal, to punish him for an instinctive and natural attempt to move under the infliction of paia, will not only be of no service, but, on the contrary, will increase his fright and render him all the less docile and willing to submit in quietness. In applying the various parts of the dressings, unnecessary pressure should be avoided, esj)ecially on soft tissues ; and when it is indicated, it should be appHed by slow degrees, and as uni- formly as possible, packing the wound upon its entire surface, and completed only as the dressing is nearly ended. Assistants shovdd be enjoined to observe the same rules. The dressing should be appHed, not hastily, but rapidly; not with the idea of saving time, simply with a view to lose none. The fact of avoid- ing any waste of time, by working without needless pause, has, moreover, the excellent efi^ect of curtailing the sufferings of the patient, and sparing him much needless pain. It is always important to watch the effect of the various arti- cles of dressing as they are appHed, in order to be certain that they cause no pain either at the time, or at a later period by then* shape, the roughness of their surface, or their unskillful applica- tion ; and above all, that they cause no interference with any of the essential functions of the economy, as the respiration or cii-- DRESSINGS. 93 collation. TMs last especially may be impeded by excessive pres- sure. To avoid this, bandages applied upon one of the extremities of the body should be so placed as to direct the pressure from the periphery toward the center. If appHed in the opposite direction, more or less strangulation might result, causing considerable swelling below the bandage. In fact, all unnecessary or exag- gerated pressure is liable to cause inflammatory swellings, erysip- elous engorgements, or local gangrenes. The maintenance of an equal and regular pressure will obviate aU danger of deformities of parts, and when methodically applied upon iiTegular wounds, wherever needed, will serve to restore or preserve them in the natural contour of the region. Neatness and finish should be studied as much as possible, but not, of course, at the expense of any of the special and essential objects of the dressing. Besides these general rules there are others relating to minute points and touching the various elements, which, as a combined whole, constitute the completed transaction, such as those relating to the topical treatment, to the material used, to the rollers or bands, and to the bandages proper. The medicinal compounds used for topical treatment are either api^lied alone or through the medium of other materials. They are of various natures and con- sistencies, from that of the almost impalpable vapor used for spraying, to the liquid forms in the numerous watery solutions, alcoholic tinctures, and oils or Hniments, to the hard and other solid compounds in the various astringent, absorbing, stimul- ating or caustic powders, or the soft pharmaceutical mixtures, the cerates, the pomades, the ointments, the plasters, poul- tices, etc. The apj)Ucation of the material used shovdd receive attention from the surgeon. An invariable rule should be to avoid all ir- regularity, roughness and unevenness, and to be careful that the exterior appHcation rests upon a regular and uniform surface. For this reason it should be the order, in applying this material, always to begin by using the smallest portions, increasing gradu- ally to the largest, thus filling first the small iafractuosities and making an even surface, to be covered with larger ones and thin pads, then with thicker ones, and finally with those of the widest dimensions, which should bear a margin extending somewhat be- yond the outlines of the wound. The entire dressing is to be 94 SURGICAL THEEAPEUTICS. maintained in position by means of compresses, rollers or band- ages, as the case may require. Kollers are long bands of muslin, linen, or ticking, or broad tapes, wbich are used principally in dressing wounds of the ex- tremities, or of regions liable to much motion. Their length and width vary, according to the requirements of the case. The sur- geon will do well to assure himself of the dimensions of these, and to ascertain that the rollers are of ample length, with some- thing to spare, which excess in length can be cut off. Deficiency in the length of a roller will interfere with a perfect completion of its application. If too wide, it may prove difficiilt to apply it neatly, while if too narrow it may have a tendency to act like a hgature, and make even pressure difficult, besides being more Hable to slip and become loosened. Rollers are apjDlied either dry or moist. AVhen moist, they become loose in droning, and their action becomes insufficient. Dry rollers ought, therefore, to be preferred. Bands or rollers are prepared in two ways, either by being rolled on one or on both of their extremities, and are therefore called the single or the double roller. In applying it, the extrem- PlG. 83.— Single and Double Roller Bandage. ity is first folded tightly to make a small cylinder, which is held by its extremities between the thumb and index finger of the left hand, resting by its width between the same fingers of the right ; and while the fingers of the left hand turn the small central cylin • der, the band is roUed upon it to its end. Eolling on both ends is done in the same manner. When half of it is rolled, a pin will secure it and prevent it from becoming slack until the other half is made ready to be used. In roUing the bands, slight traction should be made at intervals by the thumb of the right hand, while the fingers of the left keep the central cylinder steady — the object of which is to have the roller firm, hard and sohd. In large estabhshments, or even in private practice where great numbers may be required, the use of the small aj^paratus represented in Figure 85 will be found very advantageous, the DRESSINGS. 95 Fig. 84.— Manner of Roling a Bandage. band being rolled upon the central rod with facility, and when removed having the necessary quaUties of a well-rolled bandage. The general manner of applying a roller bandage is very simple. Placing with one hand the end of a single roUer, or the middle of a double one, upon the part to be covered, and keeping it steadily in position, the other hand holding the mass of the bandage with Fig. 85.— Bandage Roller. 96 SUKGICAIi THEKAPEUTIC8. the roll turned upward, gently draws on it away from the start- ing point, unrolls it, and with it surrounds the entire region in returning to the starting point. This process is continued until the band is exhausted, when it is secured by pins or by strings. Thus appHed, it may be laid in a circular manner, when the turns rest exactly upon each other, or in a spiral manner when they overlap each other in part of their width, or in a crossed or figure of eight manner, when the turns cross each other to meet always at a given point. If they are applied upon cylindrical siu-faces, the folds generally He smoothly and evenly upon each other as they are successively formed, but if the region is of conical shape or otherwise irregular in form, one of the borders will adapt itself more readily to the parts than the others. Hence the formation of bulging parts or pockets, which render the smooth and proper application of the bandage very difficult, and may interfere with its sohdity. This is avoided by giving to the roller an oblique half twist, which, while it changes the gaping border in its posi- tion, prevents the slackening of the bandage and removes the pocket. This is principally required in the bandaging of the lower part of an extremity (Fig. 86). The application of bands on double rolls is also subject to the Fig. 8a.— How to Apply a Bandage. DRESSINGS. 97 rules we have given. The completion of the process by the appli- cation of the final dressings and proper finishing steps can scarce- ly be subjected to rules which could not well be framed to meet the varieties in the features and circumstances of the diversified cases constantly occurring in practice. The only strictly general rule that can be established, is, that when a bandage is placed on the outside of a dressing, it must always, first of all, be fixed at the points which are the most essential to secure it and maintain it in its proj)er place. The proper time for the removal or change of a dressing, is a question which depends for an answer upon the consideration of the nature of the wound, the season of the year, the age and con- dition of the patient ; in fact upon all the various circumstances which in the judgment of the surgeon may influence the progress of the cicatrization. On general principles, the first dressing is not to be removed until the suppurative process is thoroughly estabUshed, which is towards the fourth or fifth day. But there are cases where special circumstances indicate an earlier or a later removal. For example, if the dressing has been applied to control the hemorrhage of a divided blood vessel, from twenty-four to thirty-six hovirs are generally sufiicient to obtain the obHteration of the vessel. Again, while it is justifiable to leave the dressing of a foot, which has been subjected to an operation, for eight, fifteen, twenty, and even twenty-five days without changing, and especially in these days of antiseptics when so much is possible in the way of com- bating the suppurative process, there are no doubt cases where it must be looked after earher, as where there is an exhibition of increased pain, instead of the abatement which might be justifi- ably looked for if the operation and the dressing had been properly executed j the increase of pain indicating some compli- cations which early exposure might easily have controlled. There are, however, conditions where the removal of a dressing is in- dicated in some more than in others, as, for instance, when sup- pui-ation is abundant. In these cases, to prevent the retention of the pus in the wounds, and to diminish the danger of its pres- ence, or of its absorption, or facilitate its escape, drainage tubes must be used, or the dressing changed. The removal of a first dressing usually involves an attention to minute details not subsequently required, the various parts 98 SURGICAL THERAPEUTICS. which compose it being often impregnated with blood and glued together by concreted pus, causing, if removed carelessly, the laceration of tissues, tearing of granulations, hemorrhages, etc. It must especially be ascertained whether adhesions exist between the material of the dressing, and if they are present they must be thoroughly soaked by means of compresses wet with tepid water, or a warm water bath, if the di-essing is upon a region which allows it, as, for instance, one of the extremities. When this is done, the various constituents of the dressings may easUy be removed, one by one, but care and deliberation will still be necessary. The smaller particles should be removed with the forceps, not the fingers. If the location allows it we even prefer to wash these away by irrigation, with a stream of luke-warm water, or by soaking thoroughly in a foot bath. The wound is to be cleaned out carefully, by soaking or sopping away the pus with fine sponges, avoiding all rubbing upon the granulations or caus- ing them to bleed. Then studying all the indications, to be dis- covered in the condition of the wound, and avoiding aU unneces- sary manipulations, and attentively removing all causes likely to interfere with the repairing processes, the dressing is to be re- placed with all the original precautions. As little time as possi- ble, consistent with thoroughness, should be occupied in this process. The wound should be uncovered only as long as necessity requii-es, the materials for the di-essing being all easily accessible without delay or hindrance, being prepared in advance and carefuUy inspected. The effects looked for in the application of dressings can be divided into general and special, these varying in their natiu'e, according to the object which the surgeon has in view. The first and principal object is to protect the wound from exposure to the action of the atmosphere, and also against contact with foreign bodies, thus to relieve the pain, diminish the inflammatory irritation, and accelerate the cicatrization. It also prevents the retention, by their absorption of the sujDpuration and serosity which form on the surface. They also expedite recovery by maintaining the natural warmth of the body in the region. The special effects of dressing, vary according to the special action produced by their application, and these may be considered under several heads. {a) Retentive dressing. — This is designed to keep parts in their EETENTIVE DEESSING. 99 normal condition and situation, and thus aid in their union or con- solidation, without deformity. It is principally appHed in cases of fractures or dislocations, but finds also its main indication in maintaining ui their proper place the medicinal substances which are the active agencies of cure. {b) Uniting dressing. — That which is made with sutures or adhesive plaster, to hold the 2:)arts in their proper position, and maintain their perfect co-ajjtation. (c) The suspensory dressing, which is a variety of the reten- tive dressing, and serves to support organs of soft texture in some parts of the body, such as the testicles, or the mammae, which by their position are exposed to traumatism by their sit- uation, their weight, and by pulling and bruises. Susjyensories, is the name given to these special bandages ; they are commonly used in diseases of the testicles, and of the udder. {d) Com2)ressive dressings. — These are devised to produce more or less active pressure upon a too active granulating sur- face ; to arrest hemorrhage, to change the vitahty of some tissues of a morbid nature, or to control the projection of abnormal bony growths. (e) The dividing dressing is the opposite to the uniting. It is of common use in cases where too rapid closing of wounds is to be prevented. It is apphcable in "infundibuliform surfaces, in deep fistulous tracts, and in wounds which are the seat of foreign elements, pathological or other. It operates by keeping the superficial opening of the wound dilated, by means of tents, sponges, etc. {/) ^xjyulsive dressing. — The object of this dressing is to assist the exit of pus from the surface of wounds. A simple dress- ing, by its absorbing proj)erties, is somewhat of an expulsive na- tiu'e. The presence of a single tent of an absorbing quahty, as small balls, or padding of absorbent cotton; the aj)plication of drainage tubes ; all these facilitate not only the escaj^e of the secretions, but also the discharge of the morbid products. The di'ainage is obtained by the introduction into the wound of India rubber tubing, of various dimensions, perforated at intervals upon their length, and kept in j)osition by safety pins inserted through them and the skin, at suitable points. These tubes, when extend- ing through the depth of a wound, embracing its whole length, and projecting through a counter opening, as well as through the LOFC. 100 SUKGICAL THKRAPEUTICS. Fig. 87.— Safety Pins. natural ones of the wound, form an excellent means for contin- uous irrigation, in the treatment of fistulous withers, comphca- ted poll evil and other diseases. {g) A7itise2)tiG dressing. — Is intended to prevent the entrance of micro-organism into wounds, to neutralize their morbific ef- fect, to check their development, and thus prevent their septic in- fluences from taking effect. The application of the Lister dress- ings, with the care required in the preparation and aj)plication by the surgeon ; of the instruments and materials included in the arsenal of pharmaceutical 'resources, comprising the antiseptic sprays ; the various acids, boracic, carbolic, and salyciUc ; the alkaline sulphites and hyposulphites; permanganate of potash; solutions of bichloride of mercury and of creoline; antisej^tic gauze and absorbent cotton — all these, and more constitute dress- ings essentially germicide, which cannot be too confidently recommended to the attention and adoption of the veterinary surgeon. The application of the wadding dressing, so highly recom- mended by some, has given, in our hands very satisfactory results, in many cases. Wadding well j^repared and properly applied, forms an almost invincible obstacle to the introduction of micro-organisms, and according to Pasteur, by its direct action upon the pus renders fermentation impossible. The instruments necessary for the adjustment of dressings, are generally speaking, numerous and varied. They consist of forceps of all kinds, the ordinary dissecting, the buU-dog, the straight, and the curved dressing forceps ; scissors, directors, ANTISEPTIC DRESSING. 101 Fig. 88.— Dissecting Forceps. Fig. 92.— Syringe for Dressing. spatulas, the S. probe, and others ; syringes, and sometimes atomizers, and also razors, enter into the list of those generally needed. The materials used to form the base of the dressings vary : charpie, wadding, wool, moss and sponges, are employed. Their costliness as respects their commercial value, is probably the reason why they are not more generally adopted in the practice of veterinarians. Oakum is the material, par excellence, 102 SURGICAL THERAPEUTICS. for the application of dressings in veterinary surgery, and is even commonly used in human surgery. We are almost tempted to claim for it the distinction of having been especially created for the benefit of vfounded horses, its various and valuable quahties so obviously fitting it for the uses to which it is appropriated in the equine clinic. It is excellent as a defense against the contact of external bodies, and in preserving a uniform temperature in the parts covered by it. From the sponginess of its consistency it readily soaks and absorbs the fluids which form upon the surface of a wound, while the tar with which it is more or less impregnated confers upon it slight antiseptic properties, which assist in the stimulation, and are in themselves favorable to all the processes of cicatrization. To be of good quality, it must be clean, soft to the touch, and free from any foreign substance. Sometimes it is cut into small portions for use, but more generally in strips, or in such other special shapes as may be required. It is made into halls by spreading out little masses of the fibres, which after being separated from each other, are rolled between the hands, into the required forms and sizes. They are exceedingly convenient in Fig. 93.— Ball of Oakum. constituting the first steps of this application of a dressing. It is also made into ji^af?s or cushions, by stretching the fibres parallel, into any given width and length, and folding them into the simil- itude of a small mattress. This must be soft, and free from lumps, or fragments of wood, and of an even thickness through- FiG. 94.— Pad of Oakum. out. These are made also of various dimensions, the widest and thickest being used to cover the outside of the wound. It is also shaped into dossils, rolls, and tents, or jylugs, the adaptation of which remains yet to be considered. BANDAGES. 103 BANDAGES The catalogue of means and appliances for dressing is by no means exhausted in those akeady mentioned. Among them are the various forms of compresses, the rollers, the splints, the plates and the means of drainage, with the various forms of rolled ban- dages, wide bandages and mechanical bandages. (a) Compresses. — These are pads made of linen, of various sizes and shapes, and folded to any degree of thickness required, which are sometimes appHed immediately upon the wound, but usually upon the oakum. They are not, however, of frequent use in veterinary surgery, except under special indications. They may be square, long, triangular, shaped like a neck-tie, or like a Maltese cross, either complete or half, double or treble-tailed, and generally patterned and graduated according to the form required Fig. 95.— Square Compress. Fig. 96.— Long Compress. Fig. 97.— Triangular Compress. Fig. 98.— Neck-Tie Compress. Fig. 99.— Maltese Cross Complete. Fig. 100.— Half Maltese Cross Complete Fig. 101.— Double Compress. Fig. 102.— Treble Compress. lOi SURGICAL THERAPEUTICS. Fig. 104.— Perforated Compress. Fig. 103.— Graduated Compress- by the case. They are commonly used in their entire thickness, but are sometimes made with a hole in their center, and then receive the name of ^yerforated or fenestrated. {b) Rollers have already occujDied our attention. (c) Splints. — These are long, flat, and more or less rigid strips of wood, or other material, designed to be added to other dress- ings, to give them some peculiar form or position, and to consoli- date and strengthen them by increasing their rigidity. They are usually appHed upon the extremities or superior j^arts of the body, and are composed not only of wood, but of hard leather, paste- board, tin, gutta-percha, etc., etc., and maintained in position by bands or adhesive mixtures. They must be carefully and accu- rately ajiplied in order to avoid chafing or excoriating the skin, and are often padded, and theu" borders made especially smooth and uniform. {d) Plates. — These are small pieces of metal or wood, used principally in the surgery of the foot, to keej) in place dressings of the plantar region, which require more or less pressure upon \: 7 Pig. 105.— Plates on Shoes. BANDAGES. 105 their surfaces. Tliey consist of separate parts or sections, repre- senting together the entire surface of the sole, one section sHding on each side, between the foot and shoe, and are kept in place by a third and narrower section, introduced transversely between them and the shoe, towards the heel. It is important to ascertain, be- fore applying them, that sufficient room exists between the sole and the shoe, and also that the wall is not in such close contact with the shoe at the heels as to prevent the introduction of the cross pieces. (e) 3Ieans of Drainage. — The conduit most commonly used is a vulcanized india-rubber tube, which is introduced into wounds to facilitate the escape of purulent and other discharges, and to keep them in a cleanly state. They are of various dimensions, as to the length and diameter, to accommodate those of the purulent cavity, and are perforated at the side throughout their length, in order to collect and receive all the impuiities that may be present. Instead of tubes, long tents of oakum are sometimes introduced into a wound, for the purpose of absorbing the impurities, and to serve as a means of drainage also. {f) Iloller Bandages. — These are the simplest of bandages. They are applied with one or several rollers. We have already mentioned their division into cii'cvdar, spiral, figure 8, etc. () have loops through which the bands pass to cross each other under the maxillary bones, and extend upward on each side of the head to be tied over the poll. The bands (d) are fixed on the breast-band of a Dutch collar, and (,/■) is attached to the surcingle (Fig. 123). 9th. Bandage for the Anterior and Lateral Parts of the Neck. — This bandage is octagonal, with a band at each angle. The anterior are tied on the forehead or on the throat-strap of the Fig. 124.— Bandage for the Anterior and Lateral Parte of the Neck. BANDAGES. 113 halter, tlie middle ones over the dorsal border of the neck ; the posterior cross each other over the withers, and are secured to the surcingle, as are also the two lower (Fig. 124). 10th. Bandage for the Withers. — This is square, truncated at its posterior angles, and having in the middle of its anterior and posterior border a fold to adapt it to the height of the withers. There are five bands. The anterior are secured forward, above Fig. 125.— Bandage for the Withers. the breast, the posterior are passed around the thorax and tied together, the other sewed on the middle of the posterior border extending along the spine and attached to the crupper. Fig. 126.— Bandage for the Back. 114 SURGICAL THERAPEUTICS. 11th. Bandage for the Bach. — This bandage is composed of a long, square piece, truncated on its two posterior angles, and has six bands, one at each angle. The two in front are tied to- gether after passing around the chest, the middle ones after sur- rounding the abdomen toward the umbilical region and the pos- terior are united after forming a kind of crupper in passing under the tail (Fig. 126). 12th. Bandage for the Loins and Croup. — This band- age is of a form similar to the preceding, and of sufficient size to cover the croup posteriorly. It is truncated on both posterior angles, and each border, except the anterior, has folds to allow the bands to adapt itself to the rotundity of the region. At each Fig. 127.— Bandage for the Loins and Croup. angle is a band, the posterior passing around the abdomen, and carried backward and upward to be tied over the loins. The pos- terior then turns from without inwards, over the round of the hip, crossing obhquely the internal face of the thigh forward to the stifle, and passing over the external face of the thigh to the mid- dle bands on a level with the hip-joiat, where they are tied. Two extra bands may be attached to the front border and tied to the surcingle, if thought necessary, to prevent the bandage from slip- ping backwards. 13th. Bandage for the Hip (Figs. 128, 129).— This is formed of a piece of cloth the length exceeding the breadth by one-half, or in the proportion of three to two, and so enveloping the hip and part of the croup that the inner border runs along the peri- nseum, and the outer on the external face of the thigh and leg. BANDAGES. 115 Fig. 128.— Bandage for the Hip. Fig. 129.— The same separate. This border {f, d) forms a fold about four inches wide at its base, and the inferior {d, e, c) has two which, like the first, form an exact adaptation to the parts. Eight bands belong to this band- age — three upon the posterior border (a, a, a) at its superior part, which are fixed to the crupper, the superior border having one {h) long enough to reach to the surcingle, and the inferior border having three {d, e, c). The bands d and e pass around the leg and cross each other at g, the band d being fixed to the crupper, while e extends to the surcingle forward. Band e crosses obhquely to the inner face of the thigh, passes upward along the 116 SURGICAL THERAPEUTICS. flank, and is tied to the surcingle. The band/* is fixed upon e, as seen in the illustration, Fig. 128 at h. 14th. Bandage for the Inguinal Region and Perinmum. — This is applied to the testicles or to the mammae. It is a long, triangular bandage, with its base placed forward, and is provided Fig. 130.— Bandage for the Inguinal Region and Perineum. Pig. 131.— The same separate. with four bands, one at each angle of the base. These are passed around the flanks to be fixed on the loins, the two posterior on the apex of the triangle to draw along the perineum, and passed over, and on each side of the ta,il, crossing each other to join the first one, to which they are tied. 15th. Bandage for the Abdomen. — This should be oblong in shape, its length double its breadth, and having folds on each of its long sides to adapt it to the convexity of the body. The bands are six in number, two of which are fixed on the loins, two on the back, and two over the withers. A seventh is sometimes added, which passes around the base of the neck and prevents the band- age from sHpping backwards (Fig. 132). 16th. Bandage for the Chest. — This is square, with a prolon- gation in front to go between the fore legs, and which is notched on the front to adapt itself to the chest behind the elbows. The bands are six, one at each angle, and two on the prolongation in front. These are fixed in pairs, over the back, the loins and the withers (Fig. 133). BANDAGES. Fig. 134.— Bandage for the Breast. 118 SURGICAL THERAPEUTICS. 17th. Sandage for the Breast. — This resembles the preced- ing, except that the narrow prolongation is attached under the chest to the surcingle, or," surrounding the forearm, goes to the withers. The others are tied over the withers and on the sides of the chest to the surcingle (Fig. 134). 18th. Bandage for the Shoidder. — This is cut in the form of a trapezium, to cover the shoulder and the arm. It is applied some- what obhquely, and has on its front borders (Fig. 135) folds to adapt it to the convexity of the anterior part of the arm. Of its Fig. 135 — Bandage for the Shoulder. f Fig. 136.— Same, isolated. BANDAGES. 119 seven bands, c, c are fixed on the withers at the origin of the neck, ef, passing first around the forearm and joining c c, as it passes on the opposite side, and d, g, h are secured to the surcingle. 19th. Bandage for the Shoulder Joint. — This bandage is square and truncated on its suj)erior angle, and is provided with several folds to adapt it to the convexity of the shoulder. The Fig. 137.— Bandage for tho Shoulder Joint Proper. bands are six, three anterior and three posterior. The first two are appHed around the neck, the thu'd on a ring at the surcingle ; the other three also going to the surcingle, either directly or in passing around the inside of the forearm. 20th. Bandage for the JBRbov\ — This bandage is of an ir- regular shape, with folds on its lateral and lower borders, to adapt Fig. 138.— Bandage for the Elbow. 120 SURGICAL THERAPEUTICS. Fig. 139.— Same, isolated. it accurately to the j)oint of the elbow. Five bands serve to con- fine it, /' going directly to the withers where it is tied with i, pre- viously passed under and around the thorax on the opposite side, g and h are seciu-ed to the breast-band of a Dutch collar, k jDasses around the forearm on the inside, from behind forward, and passes in front of the breast to be also secured to the Dutch collar. 21st. Bandage for the Forearm. — This is of an irregular tri- angular sharp, with the apex truncated, and the base notched to accommodate itself to the axilla and the fold of the elbow. When appHed, the apex of the triangular, which forms a short border, is turned downward and the base upward in the axilla. Two bands sewed to each angle of the base are fixed to the breast-band Fig. 140.— Bandage for the Forearm. BANDAGES. 121 of the Dutch collar, and the borders are secured by little tapes on the outside of the forearm. Sometimes these borders are fastened together by laces inserted obhquely. 22d. Bandage for the Knee. — This is square, notched on its superior border and in the center, both of which are provided with a small piece to form a gusset, in which the bony projections of the knee are secured. A double, ordinary band, or, what is better, an elastic strap attaches it to the breast-band, while smaller tapes serve to tie it to the back of the knee. Fig. 141.— Bandage for the Knee. Fig. 142.— Bandage for the Stifle. 23d. Bandage for the Stifle. — This is of a triangular figure, the base of which should be four times longer than its height. It has three bands, one at each angle. That of the superior angle passes along the flank, and is attached to the crupper strap at the loins ; that of the inferior angle twists forward and inward on the thigh, and connects with the crupper at the base of the tail, whUe the thii'd band turns around the crupper, crosses the internal face of the thigh from behind forward, passes in front of the stifle, and terminates backward at the same point with the preceding band, after twisting around that of the superior angle. 122 SURGICAL THZr.APEUTICS. 24tli. Leg Bandage. — This is the comphcated device repre- sented in Figs. 143 and 144. It has four bands on its superior border, (Fig. 144 a, 5, c, d') and the lateral borders have five or six tapes. The bandage has three gussets, two of which, c Fig. 143.— Bandage for the Leg Applied. and d, are on the superior border, and one, ^, on the inferior, and the two lateral borders have each one a fold. To put the bandage in place, the band d is passed along the flank upward and tied to the crupper strap, c, j)assing from within outward on the inside Fig. 144.— The same, isolated. BANDAGES. 123 of the thigh, to be fixed on the round of the crupper. A and b cross each other at the lower part of the leg, a httle above the tendo-Achilles, in order to allow a to pass from the inside to the outside of the leg so as to become attached to the stircingle, while b is secured to the round of the crupper. The small tapes are, of course, tied together in couples. 25th. bandage for the Hock and Cannon. — This requires a piece of cloth of sufficient dimensions to completely surround the hock and cannon down to the fetlock. Its superior border is Fig. 145.— Bandage for the Hock and Cannon, applied. ~%^ Fig. 146.— The same, isolated. notched for the fold of the hock, and a gusset is made in its lower extremity for the fetlock. Four straj)S proceed from its superior border to be secured to the bandage of the leg, and the ends of the small tapes of its lateral borders are tied together in paii-s in front of the leg. {g) Mechanical Bandages. — This is the distinctive name of a class of dressings which are not only a f)assive means of protec- tion to the parts upon which they are appHed, but from which also proceeds a direct or positive action, by co-operating in the recovery of lesions, if indeed it is not the true operating cause which brings it about. Rollers and wide bandages some- 124 SUEGICAL THERAPEUTICS. times act as mechanical bandages. But the name is more par- ticularly applicable to certain more or less complicated apparatus- es, whose special mechanical action has the effect of producing some defined therapeutical result. The metaUic plate used in the reduction of some forms of hernia; the metallic spring apparatus used in applying pressure upon special regions, as, in orthopedic surgery, or in the reduction of fractures or dislocations, like those invented by Bourgelat, Brogniez, Defays, and others, are of this class, inasmuch as all of these possess the constituent properties which are understood to characterize the agencies belonging to the category of mechanical bandages. These will be subjects for our consideration when we treat of the various conditions in which they are indicated. CHAPTER IV. ELEMENTARY OPERATIONS. Under this term are understood those of a simple nature, as perhaps an incision or puncture, or the insertion of sutures, and other implicated manipulations, but which form the foundation and belong to the operative generalities of the domain of major surgery. They will be treated under the two principal heads of division or dieresis, and reunion or synthesis. DIVISION. This is a very common svu'gical step, of which the object is the separation of tissues from each other. Gourdon has recog- nized six principal modes by which to divide tissues, viz.: by in- cision, dissection, puncture, resection, ligature and cauterization. Varying, somewhat, from this view, and considering resection as an operation specially appropriate to bony structures, and liga- ture as adapted to the cellular tissues, and classifying cauteriza- tion as principally a means of puncture, we prefer, with Peuch and Toussaint, to reduce the consideration of these modes of division to three, viz.: incision, dissection and puncture. A. — Incisions. Any methodic division of soft tissues made with a sharp instrument is an incision. The basis of the majority of siu'gical operations, their purpose is to allow the escape of the contained fluid from a cavity, to enlarge the size of a wound, to make counter openings, to extract foreign bodies, to remove pathologi- cal growths, to destroy abnormal adhesions, to expose tissues to be operated upon or tumors to be removed, to facilitate the re- duction of displaced organs, etc., etc. The bistomy, the scalpel, the sage knife and the scissors are the cutting instruments most commonly used for making incisions. Sometimes, however, the amputation knife, the tenotome, the hemiotome, with lancets, or 126 ELEMENTARY OPERATIONS. even drawing knives, take their place. Drawing knives, however, are better adapted to excise the horny, or other similar hard struc- tures, than to cut upon soft tissues. Fig. 147.— Straight Bistoury. Fig. 148.— Convex Bistoury. Fig. 149.— Concave Bistoury. Fig. 150.— Blunt Bistoury. Fni. 151.— Bistoury Cacli6 (Castrating Knife for Females). In form, the bistoury is either straight, convex or concave, and usually is jDointed, but the use of blunt or guarded instru- ments is often indicated. The bistoury cache is also employed in some special operations. A bistoury is generally mounted with a single blade, though sometimes several blades are mounted together on one handle, and can be closed upon it in the manner of an ordinary pocket knife. But when strict antiseptic INCISIONS. 127 rules are observed in the operations, the blade is held firmly on the handle, and cannot be closed. Sage knives^ which are much used in operations upon the foot, are but convex bistouries, single or double, curved upon their length, and, according to the disposition of the cutting edge, are called right, or left, or double. The blade is generally firmly Fig. 152.— Right, Left aud Double Sage Knives. riveted in the handle, to render it more solid and better adapted to the incision of the comparatively harder tissues. When made to close as an ordinary pocket knife they are less solid, and more difficult to keep in good condition. The scissors vaiy also in shape, and are sometimes straight, sometimes curved, and with either blunt or pointed ends. Be- sides these cutting instruments, directors are often used as guides to cany the knife in the desu-ed direction, and obviate errors and accidents in operating. The bistoury is held in different 128 ELEMENTARY OPERATIONS. Fig. 153. — Various Shapes of Scissors. positions, according to circumstances, as we shall proceed to point out and classify. 1st. Held as a writing pen. — That is, with the handle resting on the back of the hand, the thumb, index and medius finger on each side of the blade, the other two fingers resting on the skin. Figs. 154 and 155.— Bistoury held as a Writing Pen. In this position the edge of the blade may be turned either down- ward or upward. The division mentioned by Goiu'don, with the fingers extended or flexed upon the blade is scarcely, and at best but a variety. 2d. The instrument may be held as the bow of a violin, or the thumb on one side of the articulation of the blade, with the handle and all the fingers on the opposite side, the index on the back of the blade, the medius on the articulation ojjjDOsite the thumb and the other two fingers on the side of the handle. None of the fingers must be allowed to divert the instrument from being carried horizontally upon the tissues. In this position the edge of the blade may be tiirned either downward or upward. INCISIONS. 129 Figs. 156, 157, 157a.— Bistoury held ae a Bow of a Violin. 3d. The bistoury can be held as a table knife. The thumb and the medius being placed on opposite sides, at the junction of the blade and the handle, the index resting upon the back of the Figs. 158, 159.— Bistoury held as a Tahle Knife. blade, the other fingers holding the handle in the hollow of the hand. As in the preceding positions, the edges of the blade may be either turned downward or upward. "Whatever position may be given to the instrviment, it is to be held firmly, and with a steady hand. Sage knives are generally held by grasping the handle full in the hand, or, as when holding a bistoui-y as a table knife, sometimes with one hand only, and at others with both, according to the indications and the amount of firmness and steadiness required. The manner of holding scissors is akeady known. The only variation likely to be found 130 ELEMENTAKY OPERATIONS. Fig. 160.— Sage Knifo held with One Hand, Fig. 161.— Sage Knife held with Two Hands. needful, is that in some cases it is liandier to grasp tliein from above and in others from below. There are some general rules which are important to observe in performing the simplest operation. These relate to the condi- tion of the instrument, to the preparation of the parts, and to the direction and dimensions of the incision. The condition of the instrument must be such that the soft tissues may be divided with but little pressure. It must cut and not tear. Therefore, besides their state of thorough cleanliness, they must be very sharp and their edge entirely smooth and free of indentation, which would cause them to act as a saw and pro- duce an iiTegular and ragged incision, more painful to the patient, and more difficult to heal. It has been recommended to dip them before using in oil or warm water, but these precautions can be dispensed with. The region upon which the incision is to be made must be thoroughly cleaned, the hairs being clipped short, and sometimes even shaved. In these days of antisepsy, it is proper to soak it weU, after it is washed, with some antiseptic solution. To make a clean incision, the skin must be well stretched with the hands, the instrument firmly held, and the division made by a steady move- INCISIONS. 131 ment, to avoid the possibility of extending the incision beyond the necessary Limits. The direction and size of incisions require careful consider- ation. They must run as nearly parallel with the direction of the muscular fibres and the large blood vessels and nerves of the region as the condition of the part will permit. Their direction should also correspond to that of the long axis of the part or tumor undergoing operation, and in such a manner that the retraction of the skin will not tend to separate the borders of the wound. Sometimes, according to the unavoid- able natural motions occurring in a region, the normal folds of the skin shoidd be considered. A vertical incision is always pre- ferable, as more readily allowing the escape of liquids, pus or otherwise, which may have accumulated. As much as possible, and generally, incisions should be made with a single stroke, and of the full length and depth requu^ed by the further steps of the operation. Besides diminishing the suf- fering of the animal, such an incision will greatly facilitate all the subsequent manipulations of the operator. Incisions are made by four principal methods : first from without inwards; second, from within outwards; third by sub- cutaneous division ; and fourth by the sHcing, scraping or shaving method. In the first two modes the instrument may be turned in five directions. (a) Totcards the operator, by beginning at the farthest point aud moving the instrument in the direction of his own person. (b) From the operator, by reversing the former movement. (c) From left to right and transversely, the instrument being held with the right hand. {d) From right to left, or in the opposite direction, with the instrument in the left hand. (e) From ahove downvmrds, in a vertical or slightly obHque du'Bction. Incisions from left to right and from above downwards are the most convenient, and for this reason the sirrgeon practices them as much as possible. 1st. Jneisions from without imoards. — These incisions are carried from the surface of the skin towards the deep structures underneath. They may be made with any kind of bistoury, but the convex is to be preferred. 132 ELEMENTAKY OPERATIONS. The skin should be well stretched by various movements of the hand, or of the operator, or his assistants, and held tense and smooth, unless it is already sufficiently expanded by the effect of the existing lesion underneath it. Then the operator, holding the instrument in the first or third position, carries the instrument, with the edges and the point turned down- ward, to the spot on the surface to be divided, and penetrating thi'ough the skin to the depth desired, completes the incision to its proj)er length. This mode of incising the skin answers for the majority of cases, but there are others when the skin has to be divided care- fully and by layers. Incisions are then made with the convex bistoury, held in either position with its edge downward, carried perjDendicularly over the skin and often by repeated light strokes. These two procedures answer when the part to be operated upon offers a certain sohdity. Otherwise the incision can be made in a third manner, viz.: by taking hold of a fol3. of the skin, held at one end by an assistant, at the other by the operator, and completing it by a transverse section through the fold, made from the apex to the base. The objection to this mode of dividing is that the incision can never be thoroughly limited. 2d. Incisions from within outwards. — In contrast with those akeady considered, these incisions are made from the deep parts toward the supei-ficial, and thi'ough the thickness of the skin. The Straight Bistoury is here the preferable instrument, either alone or assisted by a guide or conductor, which may be the grooved probe, the dii'ector, or the finger of the surgeon. Either with or without, these incisions can be executed in various ways. Without the .Director. — With the bistoury held as a writing pen, with the blade turned upward, first the point of the instru- ment, and then the entii-e blade is thrust perpendicularly through the tissues ; then lowering the handle of the instrument until it forms with the skin an angle of forty-five degrees, the instru- ment is moved in an oblique direction in such a way as to stretch and divide the skin, until at the end of the incision the bistoury is brought back to a perpendicular direction to complete the incis- ion in a neat manner. This incision can be made toward or from the operator, according to the case. It will facilitate the action of the instrument if the skin back of the hand that holds it is stretched with the free hand of the operator. INCISIONS. 133 Another manner of incision from within outward is to make a fold of the skin, as ah'eady described, and by pushing the straight bistoury through its base, and turning the edge, completing it by a single stroke upward to the summit. When an incision already existing must be enlarged, the bistoury, held in the second posi- tion, is introduced flatwise under the skin as far as is necessary ; then turned to bring the edge uj)ward and pushing the point through the skin by drawing the instrument outward, the flap of skin between the two openings is di^dded at one stroke. A foiu'th procedure is known as the incision with flaps. It is principally used in amputations. With the left hand the surgeon grasps a fold of skin, pushes the bistoury held in the first position, but flatwise, through its base, and in drawing it out obliquely by a sawing motion cuts out a semi-circular flap of the required dimensions. With the Director or Guide. — Incisions in this mode are made to remove compressions caused by strictures, or to estabhsh a free exist to pus by a counter opening. Either the finger or the grooved probe or the director may be used as a guide to the in- strument. In all cases there must already exist a natural or acci- dental opening to allow the introduction of the director. Several modes of procedure are employed according to conditions and ob- jects in view. In one, the director being introduced into the tract to be enlarged, as far as the point where the incision must end, the bistoury, held in the first or second position, with the edge turned upward, is made to slide into the groove of the director, forming with it an acute angle, and pushed in its whole length, dividing the tissues untU it reaches the end of the groove, when it is withdrawn in the perpendicular position. A second mode is to carry the bistoury flatwise alongside the director, and when reaching its end to turn the instrument with the edge upward, first thrusting the point through the tissues and tegument, and completing the incision by withdrawing the bistoury outward and toward the operator. In a third procedure, which is that of mak- ing counter openings, the probe or dii-ector is introduced into the wound, and at its deep end, to push toward the skin until it raises it from the inside or can be felt through it ; an incision from with- out inward is then made at that point, and the director being ex- posed, the bistoury is engaged in its groove and pushed alongside, dividing the tissues at will in length and in depth, and estabHshing 134 ELEMENTARY OPERATIONS. a broad communication between tlie original opening and the one just formed. By using the sharp end of an S probe, j^assing it alongside the director previously engaged, and pushing it through the side, the making of the incision from without inward may be avoided, as described above, and the groove of the S probe may be used as that of an ordinary director. Sometimes, however, when the original opening allows it, the finger is introduced into it and used as a conductor. In this case, a blunt bistoury is preferable, as less dangerous to the operator than the straight instrument, or the curved form may be used. This may be made to slide with the back of its blade, or again flatwise, along the palmar face of the finger until the bottom of the wound has been reached, and then turning the knife, the tis- sues are divided by carrying the bistoury either toward or from Fig. 162.— Using the Finger as a Director. the operator. This jDrocedure is more appHcable when the fistu- lous head is not deep, but it is preferable to the use of the ordin- ary director as being a much better instrument of diagnosis, and safer as a director of the bistoury. 3d. Suhcuta7ieous Incisions. — The usefulness of this mode of dividing tissues is best demonstrated by its appHcation to cases of tenotomy and myotomy, or the puncture preceding the injec- tion of tincture of iodine according to some methods. It requires special instruments, made with narrow blades or with fine trocars, which, when introduced through the skin, leave a very small open- ing, the division being made under the Ugaments, with sj^ecial care to avoid its di\'ision beyond the point where the instrument has been introduced. Suppuration seldom follows this operation if it has been projoerly performed, and, accordingly, the cicatrization is very rapid ; the great advantage obtained by this mode of incision cannot be overlooked. INCISIONS. 135 4tli. Tncisio7is hy Slices — Scraping or Shaving Incisions. — These incisions are made by dividing the tissues in successive lay- ers. Three varieties of operation are practiced, differing accord- ing to the density of the tissues acted upon. In the first, which is appHcable to hard structtu^es, the bistoiuy, or, preferably, the sage knife is required. The instrument is held full in the hand, as a table knife, or, again, as the bow of a violin, and is passed flatwise over the surface of the tissues, and layers of various thicknesses removed from it ; and sometimes the tissues are sufficiently hard to require the strength of both hands for the management of the instrument. Fig. 163.— Sharp Tenaculum. In a second mode, appHcable to soft tissues, a convex bistoury and a pair of forceps or a sharp tenaculum are necessary. Rais- ing with either of these a thin layer of the tissue to be divided, the bistoury is carried sHghtly flatwise over the surface and a piece of it is cut, scraped, or shaved off, the operation being repeated until the desired depth has been reached. A third mode is applied in cases of growths which are to be cut off at their base. To do this, the growth is raised as much as possible, by means of the forceps or tenaculum, and the amputation is accompHshed with a few sawing movements of the instrument. The forms which incisions may receive are of two principal kinds — the simple and the compound. Simple incisions are those which are generally made with one stroke of the bistoury, and generally from without inward, and are either straight or curved. The straight., or simple, are indicated for the exposure of regions, the opening of abscesses, etc., etc. They are not as applicable to the removal of tumors, especially of those which have large bases. The curved incisions vary in their circular shape, and differ also from the straight in the modus operandi., as they require a stretching of the skin to be made in various directions, as that of the bistouiy is changed over the cutaneous surface. Compound incisions are formed by the union of several simple incisions, their number varying much, but they may be reduced 136 ELEMENTARY OPERATIONS. to the following kinds: the T and V shaped, the crucial, the elHptic, and the semi-lunar. The branches of these compound in- cisions are made in the same manner as for the simple kind ; when two incisions are to meet at a given point, the second one must be made, not to begin, but to terminate at that point ; when two incisions are to unite, one above the other, the lower one is to be made first, to avoid the flow of blood from the upper, which would cover and conceal it ; and when two incisions are to meet at their extremities, it is proper that the ends of the second incision should start a short distance beyond the commencing point of the first, and terminate with a similar space from the end of the first in- cision. In other words, the junction of the extremities of the two incisions must never be by a perfect acute angle. The angle must always have a slight prolongation formed at one extremity, by the extension of one, and at the other by that of the other incision. These rules are not absolute, but may be changed as circumstances may require. In the T-shaped incision, a straight cut is carried perpendicu- larly upon the middle of another. In the V-shaped, there are . two straight incisions meeting at an acute angle by one of their extremities, this angle, as we have just said, having a small pro- longation on one of its lines at then* junction. The V-shaped in- cision may open in every direction. Sometimes the two incisions are made to meet at a right angle, to form the L-shaped incision. In the crucial incision, two straight cuts are made to meet at their middle, usually at a right, sometimes at an acute angle, forming an JC-shaped incision. This is made in three steps, first, a simj)le straight cut ; second, the first part of the second incision as in the T-shaped form, and third, the second part of the second incision ending, not beginning, at the point of junction of the in- cision made in the first two steps, and in such a manner as to be the continuation of the incision made on the second step. This incision may also be made in two cuts, when the skin is hard and adherent to the deeper tissues, by making the second incision with one stroke of the knife, passing at the middle of the first. The elliptic incision is made with two curved cuts, so united at their extremities as to leave between them an eUiptical space. The semi lunar or crescentic incision is formed by two curved ones, the circumferences of which are turned in the same direction, leaving between them a form like that of the new moon. INCISIONS. 137 Fig. 164.— T-8hape Incision. Fig. 165. — V-Bhape Incision. Fig. 166.— Crucial Incision. Fig. 167.— Semi-Lunar Incision. Fig. 168.— L-shape Incision. Fig. 169.— X-shape Incision. Fig. 170.— Elliptic Incision. B. — Dissections. Dissection is the separation of the cellular tissue from the various parts to which it is united. The scalpel, the bistoury and the scissors are among the necessary instruments, sometimes replaced or assisted by the fingers or a strong du-ector. With the scalpel, or the bistoury, the handle is also utilized, and frequently the blunt extremity of the scissors, while again in some cases the cellular connections are separated with the fingers or the blunt end of a director. To these instruments are added forceps, either the common dissecting, or the bull-dog form. Three procedures are involved, viz.: the/>ee dissection, the limited, and the dissec- tion by slices or shavings. 138 ELEMENTARY OPERATIONS. Fig. 171.— Dissecting Forceps. Fig. 172.— Bull-Dog Forceps. (a) Free dissection is that of a flap of skin from the tissues beneath, to which it is only slightly adherent. Holding the skin with the fingers, or the forceps, with one hand, and having the bistoury or scalpel in the other, the skin is raised as much as possible and separated from the other tissues with a single stroke of the bistoury, held as a pen or as a violin bow, the operator drawing it towards him as much as possible. In the dissections of flaps of skin, as those in the V, the T, the crucial, and the cres- centic incisions, the strokes of the bistoury extend in length as they approach the base, or the adherent portion of the cutaneous flap. In the straight or elliptic incisions, on the contrary, the strokes are longer at the beginning. When the cellular tissue is very loose, its separation from the skin is made with the fingers or the blunt end of the scissors. This mode, called enucleation, is often employed for some special forms of tumors, as the fibroid, or fatty. {h) Limited Dissection. — The steps of this process are the same as those of the preceding, excepting that the siu-geon proceeds by small strokes in order to avoid going too deeply into the tissues, and leave the skin of a sufiicient thickness. (c) Dissection by Slices or Shavings. — The skin being divided, and the subcutaneous tissues raised with the forceps, the bistoury, held flatwise, excises horizontally each layer of the structure by a sawing movement. C. — Puncture. Properly speaking, this is a simple, special operation, designed to penetrate into hollow j)arts, to explore the nature of tumors, to DISSECTIONS. 139 examine the contents of natural cavities, or to provide for the escape of gases or fluids. It is, therefore, a solution of continuity of small dimensions, constituting often the first steps of an incision, but which forms also an essential operation. It can be performed with various instruments, as the lancet, the straight bistoury, the trocar, the exploring needle and their adjuncts, the aspirator, and the actual cautery. Fig. 173.— Various Shapes of Lancets. Puncture with the Lancet. — In form and shape the lancet greatly varies, but in general it may be considered as a compound bistoury, with a pointed and two-edged blade. The point may be either quite mde, or very acute, and is sometimes ciu'ved, with one edsre convex and the other concave. To use the lancet, the blade, open at a right angle with its handle, is held between the thumb and index finger, while the Fig. 174.— Manner of holding a Lancet. 140 ELEMENTARY OPERATIONS. handle rests on the back of the hand, with the fingers shghtly flexed. The joint, brought close to the skin, and perpendicular to it, is thrust by the extension of the fingers through the tegument and tissues underneath and then di'awn out perpendicularly, un- less it is desirable to increase the size of the incision, when the division is made by extending the incision from within outward. Puncture loith the Straight Bistoury. — The bistoury, for this purpose, must be finely j^ointed and sharj). Held as a writing pen, with its edge upward or downward, or as a table-knife, accord- ing to the thickness of the tissues, and its action limited by having the fingers at a given distance from the point, it is pushed per- pendicularly and more or less rapidly at once to the necessary depth. It is then di'awn out, unless the incision is to be enlarged, which is done by a motion from within outward by the blade. Sometimes the instrument is pushed into the tissues in an obHque, instead of a perpendicular direction, when it is not desirable to have communication between the oi^ening of the skin and the one dii-ectly beneath it. This constitutes the first step of the subcutaneous incision. Fig. 175.— Trocar and Canula. Puncture with the Trocar. — This instrument is composed of two parts. A rod, secured to a firm handle at one extremity and terminating at the other in a tri-faced point, is one ; this rod fits into a canula, blunt at one end and having at the other a cup- shaped flange, which is the other part. The canula is long enough to receive the entii-e length of the rod, except the tri-faced jDoint, which projects beyond it. The two parts are fitted closely together. Trocars are of various size and form, being both straight and ciuwed. That which is used for hyovertebrotomy is the longest of all ; those used for rumenotomy are quite large in diameter ; the enterotome is, on the contrary, quite small. DISSECTIONS. 141 Fig. 176. — Various Forms of Trocars. To punctvire with the trocar, the operator will assure himself that it is in good condition, and that the rod can readily be with- drawn from the canula when necessary. Holding the instrument ia such a manner that the handle, grasped by the thi-ee fingers, rests in the palm of the hand, the thumb is apphed on the canula near its point of union with the handle, and the index extended on the outside of it, to limit the play of the instrument ; the trocar is pushed through the tissues in a pei-pendicular direction, and until a sensation of resistance is no longer felt. When introduced, the canula is held in place with one hand, while with the other the rod is slowl}^ drawn straight out, or by a sHght rotary motion. If the design of the operation has been the evacuation of the Uquid contents of a tumor, as the fluid escapes the growth dimin- ishes, and it becomes necessary to insert the canula further in the cavity or turn it in different directions, to ensui*e the removal of the entire contents. Yet it is necessary to be careful not to press the orifice of the canula against the walls of the sac, a condition Hkely to prevent the escape of the fluid. To remove the canula, moderate pressure is applied with one hand on the skin around the seat of the punctui-e, while the other 142 ELEMENTAEY OPERATIONS. withdraws the instrument by its pamllon, drawing it in a line parallel to the division in which it was introduced. Exploring needles, or trocars, which are but small directors with a lanceolate blade at one end, and a small groove on one side, are also used for making punctiu'es, and then- adaptation as Fig. 177.— Exploring Needles. very small trocars, with aspirators (principally that of Dieulafoy) find frequent use in our surgery. These instruments have ah'eady been considered in the chapter upon surgical diagnosis. The Puncture with the Actual Cautery. — The conical cautery is the one used in this mode of operation. It varies in diameter and in length. The instrument is heated to a white heat, appUed perpendicularly upon the skin and pushed in until the sense of resistance is no longer felt, when it is withdrawn. The condition of white heat of the instrument is of great importance. Though apparently an act of great severity, the oj^eration finds numerous appHcations in oiu* surgical practice, principally for the puncture of deep-seated cold abscesses. It has great advantages over the puncture with the bistoury, inasmuch as there is no hemorrhage to fear from its use ; because the opening made by the cautery remains unclosed a longer time, and because the inflammation is modified in its nature, and the process of resolution thus assisted by the caloric thrown in. The use of local anesthesia, by the injections of cocaine, will remove from this mode of puncture the rough side of its appHca- tion by rendering the operation entirely painless. KEUNION. This term signifies the readjustment and consolidation of tis- sues which had been disintegrated and divided — otherwise, simply the reuniting of separated parts, and theii' restoration to a nor- mal condition. This process is otherwise referred to as that of cicatrization, a natural property of organic tissues, which, though it may be aided and guided by the surgeon, can be controlled by REUNION. 1J:3 Mm only to the extent of preventing accidents and maintaining natiu'al conditions. The j)rocesses, the order, and the rapidity of the formation of cicatrization are not the same with different tis- sues, and certain distinctive terms have therefore been adopted by which to denote the modified ways by which the piu'pose of nature is effected. Thus we have immediate reunion or adhesive injiammation or xiyiion by the first intention, by which separated parts sohdify upon simple contact, as varying from union by the second intention, or by granulation and suppui'ation ; followed by iDiion by the third intention, when, together with the processes of the second intention, there is added one of mortification and the elimination of dead structure. This subdivision accords strictly with the order of nature, as it may be constantly observed, the phenomena of separation involving a regular gradation of de- tail in the active forces emj^loyed in the recujjerative efi^ort, from the simplest and most efficient in the union by first intention to that which is, in fact, a struggle between the elements of growth and preservation and the tendency to dissolution and death, as ex- hibited in the thii'd degree. Before proceeding to the direct discussion of the means used to assist the vis conservatrix in the reunion of divided jDarts, there are some general considerations of which the surgeon must never lose sight. They are not of the less importance because they are matters of an obvious and secondary character, and refer mainly to what may be termed matters of minor detail. Where immediate reunion is looked for, the wound must be fresh and clean, and entii-ely free from clots of blood or foreign substances. The edges must be smooth and even, and if there are any ragged portions they must be carefully excised. In addition to this, where there is a granulating surface the granulations must be carefully inspect- ed and their healthiness assured, and the surgeon must search care- fully to ascertain that there are no fistulous tracts present. In any case the haii' must be clipped short around the edges, the skin thor- oughly washed, and, what is a point of primary importance, the exact coaptation of the oj)posite edges carefully ascertained and secured. The means employed to maintain the contact of the edges of a wound, and assist in its closure are, according to Goiu'don, of four kinds — 2^osition, uniting bandages, adhesive plasters and sutures. 144 ELEMENTAEY OPEKATION& A, — Position. Tliis is more a preparatory step toward obtaining reunion than a true means of securing it, and to have its full effect and assm-e all its benefits, must be accompanied by the judicious appHcation of plasters or bandages. By position is tmderstood such an atti- tude of the patient as will tend to keep in coaptation the sides of the wound, as opposed to a jDOsture which would, if left unguard- ed, disturb the immobihty which is indispensable to the comple- tion of a symmetrical union. The natural restlessness of the pa- tient under the circumstances, even irrespective of the ordinary habHity to the sHghter causes which divert his attention and ren- der immobihty impossible, forbid the idea of entire passivity. And yet there are some cases where it is possible, or at least must be attempted. This may be illustrated by the hj'pothetical case of a lacerated wound, forming a V shaped flajD of skin, with its base turned upward. By taking advantage of this condition, and keeping the apex of the V downward, the position of the flap will itself assist in closing the wound, the edges having a natural ten- dency, from the contractive character of the fibres, to form, and to maintain the desirable contact. But if, on the contrary, the flaj) has its base tvu-ned downward, the difiiculty of keeping it in its proper position will be greater, proportionately to the tendency of the edges of the flaj) to drop away from those of the skin. Taking advantage of the position of this peculiar wound, and assisting it by the application of bandages or other means, will materially facilitate the closure of the wound. B. — Uniting Bandages. Though these are not so frequently required in veterinary as in human surgery, they are very efiective in bringing together and retaining the edges of wounds, especially in the extremities, where in both transverse and longitudinal wounds they fulfil their pur- pose very satisfactorily, especially where only the skin is involved. If the injury extends to the muscular substance, however, they are both more difficult to apply, and less serviceable in their ef- fects. In wounds of a transverse character, two bandages of a length equal to that of the injured leg, and as wide as the great axis of the wound, are required. One of these is di\ided into UNITING BANDAGES. 145 Pig. 178.— Bandage for Transversal Wound. three or four strips in one-half of its length, the other having in its middle an equal number of longitudinal slits, smaller than those of the first, these two being fixed parallel to the axis of the leg, one above the other below the wound, by several turns of rollers, and by passing the strips of one through the corresjDond- ing sHts of the other, the edges of the wound will, by opposite traction upon the bandages, be necessarily brought together and supported in that position (Fig. 178.) The same method answers for longitudinal wounds, though simpler in structure ; this bandage, consisting of a single band of a width equal to the length of the wound, and prepared with strips and corresponding sHts, as just described, at a distance of about three-quarters of the cu'cumference of the leg. Thus prepared, and compressive pads placed on each side of the wound, the bandage is manipidated as in the other cases, and when it is all properly adjusted, is further secured by rolling it around the leg over the strips (Fig. 179.) C. — Adhesive Sticking ok Agglutinating Plasters. These descriptive terms refer either to certain special mixtures which are appHed either directly, and alone upon the solutions of continuity, or spread upon linen, in the form of the ordinary 146 ELEMENTAEY OPERATIONS. Fig. 179.— Bandage for Longitudinal Wounds. surgeon's plasters. They are better adapted for use, with the smaller, than with the larger animals, answering all the require- ments with the former class. They are comj)osed of various in- ingredients, differently combined, such as black pitch, with resin, Venice turpentine, etc., and oils, to improve their flexibility, and aid their curative quahties. Venice turpentine, alone, is sometimes spread over the bandages, also a mixture of tar and Burgundy pitch. Pitch, alone, when melted and mixed with cut oakum or tow, forms a good adhesive mixture. The ordinary adhesive, or diachyton, or lead plaster, used in human medicine, is of great value in the surgery of small animals, and we have used it with great satisfaction with both large and small patients, appljiag it in long strips, rolling them around the affected region in two or three thicknesses. CoUodion has also been highly recommended. Either alone, or apphed with thin Unen, or what is better, with wadding, it forms over the sur- face of a wound, not only an adhesive plaster, but also a protec- tive dressing. Plasters are, in some cases, used alone as means of reunion, and ia the treatment of fractures, they form a powerful adjunct in controlling the displacements of fragments of bone. They are, however, also frequently used to reinforce other means of reunion, and especially deep sutures. D. — Sutures. In all the category of sui-gical detail, there is nothing so effec- tive, or indeed indispensable, as the suture, properly apphed, for SUTURES. 147 the retention of breaches of continuity, whether the sewing be done by means of linen or silk thread, animal fibre, metallic wire, needles, pins or other instruments. By no other means can the parts be held in the necessary coaptation to insure a perfect reunion. The sutiu^e is available for various purposes. Besides contributing materially to the coaptation of the edges of a wound, and thus aiding to secure a cicatrization by first intention, it pre- vents the contact and introduction of air into a wound, arrests and prevents hemorrhage, keeps in place lacerated fragments of deep wounds which could not be controlled by bandages alone, assists in the closure of artificial openings, such as may take place in the walls of the abdominal cavity, and prevents the escape of any portion of its contents, and assists in the closing of natural openings. But, though principally usefvd in effecting the objects enumerated, the essential indication of the suture appears in the re- union of solutions of continuity, and, partictdarly, in regions where the natural movements of the parts tend necessarily to prevent the borders of the wound from remaining in undisturbed contact, for a period sufficient to obviate the danger of serious blemishes of cicatrization. But whUe the suture is of no less advantage in fresh injuries, it is also indicated as well in suppurating wounds, with the precaution of leaving room for the free escape of j^atho- logical secretions. Sutui-es are contra-indicated, when a wound becomes the seat of extensive inflammation, or occupies a broad surface, or is ir- regular, or accompanied by loss of tissue ; or when the parts are the seat of sevei-e contusion, or contain foreign bodies or mortified tissues in their depths. There are other cases also, where their employment is contra-indicated, as when their object is likely to be defeated by the uncontrollable movements of the jD^tient. Causes of failure may also sometimes be found in the irritation arising from the material of which the suture is formed, cutting its way loose. By this accident, a wound which, if not interfered with, woiild have left but little if any cicatrix, and would have required but a short time to heal, becomes transformed into a large, ugly, granulating surface, that is likely to leave a compara- tively bad looking cicatrix in the end. The application of these retentive stitches falls under the general rules relating to the disposition of the edges of the loound, and the special placing of sutures. In reference to the first point, 148 ELEMENTAEY OPERATIONS. the first consideration to be noted is, that the wound must, of course, be thoroughly cleaned, and free from blood or foreign bodies. Then the borders of the wound must be fresh, or, if old, blackish, or beginning to granulate, must be sHghtly excised by thin scraping, and the edges brought as closely in contact as possible. To apply the suture, the needle is to be held and used precisely like an ordinary sewing needle. If the skin is thick enough to requii*e it, a thimble can be used. Sometimes special needles with handles are made, and sometimes forceps may be needed to grasp the needle, and push or pull it through the integument. The needle should pass through the skin as nearly perpendicularly as jjossible, since, if introduced too obUquely, the tractions upon the skin maj- be sufficiently uneven to involve the possibility of tearing out the stitch. In placing the sutiu-e, nerves, tendons and blood vessels must, of course, be avoided. The suture shovdd embrace a good hold of the skin to secure a greater traction and better approxi- mation of the parts ; the distance between the stitches must be such that no gaping can take place ; they must be disposed at regular distances apart. When the needle is introduced from without inward, the skin is raised with the fingers of the left hand, or, better, witla. a forceps ; if introduced from within out- ward, pressure is to be made upon the skin with the fingers or the blunt blade of a pair of scissors, near the point of exit of the needle. Generally, the suture is begYUi at the middle of the wound, in which case the edges are made to meet more accurately and regu- larly. This rule, however, will find numerous exceptions. All the stitches should be placed before any are tied, and they must be tied only sufficiently tight to keep the edges together ; other- wise they may cut through the skin. If not sufficiently tight the wound vnh be left gaping and cicatrization will be interfered with. The knots ought to be i:)laced as much as possible on one side of the wound and towards the most dependent part, to avoid their being soiled by the suj^puration. The material used for sutures varies much. Strong Uneu thread, silk, metallic wires of silver, lead or tin, and in some cases narrow and thin elastic cords or bands are used, according to the circumstances. Metallic wires have the advantage of being less irritating, and can remain in the thickness of tissues without giv- SUTURES. 149 ing rise to excessive inflammatiou or ulceration if the swelling should be extreme. Elastic cords or bands have an important advantage in their property of yielding to the inflammatory swell- ing, as it develops itself while avoiding dangerous or unnecessary traction. Fig. 180.— Various Sutured Needles. Suture needles are made in countless forms and numbers, straight and curved, and of different lengths and dimensions, but having, all of them, flat points. When metaUic. sutures are used, their extremity is grooved to receive the wire in such a manner that its double thickness will not interfere with its passage through the skin. 150 ELEMENTARY OPERATIONS. '1 Some needles are armed and protected witli handles, as tliose of Trelat, of Riverdin, and of Simpson. Sometimes their lanceo- lated part has the eye pieced in its center ; in others, the eye is merely a notch, closed by a repulsor, moved by sHding through the handle. Generally, the hand is sufficient to push the needle through the skin, but at times, as has been mentioned, forceps or needle-holders are necessary, such as the needle-holder of Mat- thieu, an ordinary forceps or an ordinary pin-holder. The com- mon wire dressing pin is also included among suture implements, SIMPLE OR INTERRUPTED SUTURE. 151 Fig. 186.— Suture Forceps. Fig. 187.— Needle or Pin Holder. but is not always efficient from lack of rigidity, when a stronger and less flexible implement becomes necessary. Sutures are of many kinds, some being superficial, others deep, and otherwise classified, according to the requu-ements of their apj^Ucation, into single, as when the thi'ead or wire alone main- tains the reunion, or compound, when it requires other and acces- sory means, such as needles, pins, quills, etc., etc. 1. The simple or interrupted suture (Fig. 188) is formed of dis- tinct stitches between the borders of the wound, each being tied 152 ELEMENTARY OPERATIONS. Fig. 188.— Simple or Interrupted Huture, Fig. 189.— Looped Suture. separately. It is made in two ways. By a first procedure, with a needle holding a long thread, the surgeon holding both edges of the wound, passes it through both at once, cutting the thread and making each stitch entirely distinct, and t}dng then only when they are all in place. He begins with the center stitch. In the second procedure, a separate thread is prepared for each stitch, having a needle at each end, which is passed through the skin from within outward, and, as before, each stitch is tied independently of the others. Often, only a single needle is used, making the first half of the stitch from without inward, and the second half from within outward. This suture is used for recent wounds, and those in which there is extensive laceration of the integument. 2. Looped Suture (Fig. 189). — This is an interrupted suture, in which the threads, instead of being tied uj) separately over the wound, ai'e twisted together on each side, without being tied, in order that each thread may be removed independently of the others, if necessary. The cords are then twisted together, and sometimes tied and sometimes not. It was formerly recommended for intestinal wounds, and is but Uttle used at the present time. 3. Uninterrupted or Glover'' s Suture (Fig. 190). — This is a con- tinuous suture, of which the stitches successively cross the wound from both within and without. In making it, the thread is knot- ted at the end, and the needle pushed through the skin at one ex- tremity of one of the borders of the wound, from without inward, and then dii'ectly opposite it through the other edge, brought to DOSSILED SUTURE. 153 the Urst iu crossing the wounds obliquely, and this is repeated until the lower end of the edge, opposite to that at which the suture was begun, is reached, when the thread is stopped by a knot. Before secuiing the last stitch, care must be taken to re- move any possible wrinkles between the stitches. f.?ee^J Fig. 190.— Glover's Suture. <= =& /""^^^^i^'^ Fig. 191.— Dossiled Suture. 4. Dossiled /Suture (Fig. 191). — This is a variety of interrupted suture, in which the thi'ead is doubled, and at one end carries a Httle baU or dossil of hnt or oakum. Passed through one edge of the wound from without inward, it is brought outside of the wound, and cut the necessary length. Another similar thread is passed through the other border in a similar way, and, when cut, both threads are tied together in the center of the w^ound. This sutiu'e is often used for the piu*pose of holding in place the substances (wadding, oakum, etc.) that may be placed in the wound, or to prevent the return of a hemorrhage. It is a strong adjuvant of other hemostatic measures. 5. Quilled tSuture (Fig. 192). — This is formed by a series of in- tennipted stitches, supported on each side by a short piece of quill or wood, or metallic pin, which must be longer than the great axis Fig. 192- Quilled Suture. Fig. 193.— Suture with Adhesive Bandage. ISi ELEMENTARY OPERATIONS. of the wound. To apply it, a double thread, with the ends knot- ted, is passed through the edges of the wound, and several stitches made in succession, as in the regular simple interrupted suture. When these are in place, the support (qviill, pencil or otherwise) is passed through the lap of each double thread on one side of the wound. Drawing this first quill close to the skin, the threads are sejDarated, and, between them, a second quill appHed on the other border of the wound, and secured in place by a knot. This suture is recommended for wounds of the abdomen. Peuch and Toussaint recommend it after the removal of mammary tumors in bitches. Sometimes elastic cords are used, in preference to or- dinary threads, as being less putrescible, and yielding better to the inflammatory sweUing, etc. Director Degive frequently employs the elastic suture witfi ad- hesive bandages (Fig. 193). Two adhesive bandages, of dimensions proportionate to that of the wound, are glued on each side of it. These carry near the border, in the neighborhood of the edges of the wound, small holes, through which elastic rings are passed. These rings repre- sent the threads used in the other mode of procedure, and through these rings the quills or pins are placed, which will rest on the outside of the bandages and keep them in place. 6. The single 2)in suture is a simple opera- tion for small wounds, commonly used as the last step of the operation of bleeding, and by which both edges of the wound are brought Fig. 194.— Single Pin together with a pin, and secui-ed by a special Suture. double loop or hitch called the bleeding knot. 7. Twisted /Suture (Figs. 195, 196). — This is frequently used for wounds of the eyehds or of the nostrils. It consists in placing through the borders of the wound as many pins as may be neces- sary^, and holding them by twists of thread. Ordinary pins are generally used in veterinary surgery. The pins are secured in different ways. In one case, the twists are so made as to form a series of figure 8s, placing them two or three times successively, first around the pin at one extremity of the wound and repeating the movement with each pin. In an- other way, instead of making a figui-e 8, the threads are turned around the pins at each stitch, suiTounding all with a circular thread. ZIGZAG SUTURE. 155 Fig. 195.— Twisted Suture. FiG. 196.— Another. Some veterinarians, in making this compound pin suture, prefer the use of elastic rings to that of the circular or figure 8 threads. We have personally used these rings with very satisfactory results. 8. Zigzag Suture (Fig. 197). — This is a continued suture in which the thread is made to cross and re-cross from one border of the wound to the other. The jjrocedure is as foUows: a needle carrying a long thread is passed through one edge of the wound from without inward, and through the other in a straight direc- tion from within outward. Starting with the same thread, a sec- ond stitch is taken at some distance from the first, and on the same side of the wound on which the first was ended, a second stitch is made by passing the needle from without inward, and back from within outward, to reach the side of the wound where the first stitch was started at an equal distance from it. The re- maining stitches are, of course, made in the same manner. This suture has been recommended for the treatment of um- bilical hernia in sohpeds. 9. Suture of the Furrier. — This is performed with a needle and a long thread, which is alternately passed through the edges of the wound from without and from within. It is also a continuous Fig. 197.— Zigzag Suture. Fig. 198.— Suture of the Furrier. 156 ELEMENTARY OPERATIONS. Fig. 199.— T Suture. Fig. 200.— X Suture. sutiu'e, in wliich. the coaptation of the borders of the wound is regular and exact. It is principally applicable when the borders of the wound have a tendency to overlap each other. 10. T future (Fig. 199). — This is the peculiar stitch used to brinsr together the borders of a T or crucial incision. A thread is O o used with a needle at each end, each of which is passed through from without inward, in one of the angles of the T, and brought from within outward beyond the transverse incision of the T when being unthreaded and laid aside. The sutiu'e is completed by tying the two ends of the thread together. The same suture could be made with a single needle. The same procedure is required for the crucial incisions. 11th. X Suture (Fig. 200). — This suture, which is recommend- ed after spaying sows, is made by taking a stitch thi'ough both edges at once, and carrying the thread obliquely across the wound, starting the second stitch on the same border of the wound as the first, and finishing in the same manner ; the thread is then again passed across the wound, and the ends tied together. 12th. JSIetallic Sutures. — These do not differ from the sutures which we have considered, excepting that metals are used instead of thread or silk. They are applied hke the others, and secured in the same manner, by knots or by twisting theu' ends together. The period for the removal of sutiu-es depends upon many circumstances, and varies according to the nature of the tissues involved, their thickness, and the species of the animals operated on. In horses and in dogs, suppuration occurs more rapidly than in ruminants or STvine, and on that account the sutui'es cannot be allow^ed to remain as long, without giving rise to the formation of pus. Moreover, in regions where cellular tissues and blood vessels are abundant, the pus is usually formed more rapidly than in those REMOVAL OF SUTURES. 157 of the opposite formation, and consequently sutures must be re- moved earlier. On general principles tliey should be taken out by the fourth or fifth day, or even sooner, if indications of complica- tion due to their presence are manifested. In removing sutures, it is necessary to proceed cautiously, in order to avoid breaking any adhesions that may have been formed. As a general rule, but one should be detached at a time, be- ginning at the least important point. The threads and needles should be cut close to the side oj^posite to that on which they are to be extracted ; they must be careftdly cleaned of crusts or dried pus and any roughness whatever, and the skin should be carefully held down as they are slowly drawn out. If the adhesion seems at any points to be too Ught, the sutures must be left in a few days longer. The application of adhesive mixtures, or of collodion, will strengthen a weak cicatricial tissue. When a suture has been applied, as weU as when it has just been removed, it is sometimes necessary, in order to prevent the animal from biting or rubbing the cicatrix, to bring the cradle or the side bar into requisition. CHAPTER V. OPERATIONS ON THE SKIN AND CELLULAR TISSUE. CAUTERIZATION. The theory of the cautery is the ii'ritation and disorganization of living tissues, either by the immediate contact of heat or of chemical substances, producing an analagous effect on the organ- ism. Cauterization is thus of two kinds, the actual and the pote^v- tial, according to the agent employed in its production. Potential cauterization, by reason of the nature of the agents employed, as well as of the method of employing them, belongs properly to the domain of therapeutics, and we shall therefore pass the subject by with a simple mention, to give our attention to what falls more jiarticularly under the head of operative siu-gery, the actual cautery. ACTUAL CAUTERIZATION OR FIRING. Firing is one of the most valuable of therapeutic agencies. It is also one of the oldest and best known among methods of sm-gi- cal treatment, in both human and veterinary medicine. It was practiced and recommended as far back as the times of Columelle, Absp'tus and Vegetius, when it was in high repute as a remedy for articular diseases, sprains and weakness of the loins ; but to- wards the 15th century, its popularity waned somewhat, and it seemed to have partially lost favor, until the days of Markam and Gray in England, and Solleysel in France, where it regained by degrees its former rej^ute. It now holds an established place among regular and methodical operations, and is one of the most important among our surgical resources, appHcable in many pathological conditions, and efficacious in most. The following long hst of ailments and lesions in which it may be indicated is given by Bouley. ACTUAL CAUTERIZATION OK FIRING. 159 (a) Diseases of Joints. — Exostoses around the borders of articular sui-f aces ; sprains of ligaments ; dilatations of sjTiovial bui'sse and iadiu'ations of their walls ; dislocations ; true or false anchylosis; deformities of the extremities from excess of work; congenital general weakness, etc. {h) Diseases of Bones. — Exostoses; periostosis; callus of complete or incomplete fractures ; caries ; necrosis. (c) Diseases of Tendons. — Partial lacerations ; chronic swelling after tenotomy. id) Diseases of Tendinous Sheaths. — Dilatation ; lacerations ; changes in the structure of their walls. {e) Diseases of JIuscles. — Atroj^hy; iaduration; pathological changes of structure. (/') Diseases of the Cellular Tissues. — Chronic oedematous swellings; induration; abscesses; cysts. {[/) Diseases of the Nervous Ajyparatus. — Paralysis; occult pains without visible lesions. (h) Diseases of the Lymphatic System — Chronic lymphangitis ; farcinous cords ; j^ustules or tumors. (^) Diseases of Veins. — Chronic phlebitis. (J) Diseases of Arteries. — Hemorrhages. {k) Special Diseases. — Carbuncular tumors ; gangrene; ulcers ; fistulas, etc. To epitomise and simphfy this long recapitulation, we may sa^^ Avith Gourdon, that the use of the actual cautery is indicated when its charactei-istic effect as an excitant and tonic is sought for in atrophy, or in diseases of joints; or again, as a modifying factor in chronic inflammation ; as a derivative, and as a physical or a preventive agent. It is contrcvindicated in cases where there exists an excess of vital irritation, or of inflammatory tendency, until the symptoms which attend such a state of the system have more or less sab- sided. Actual cauterization is divided into the superficial and the dee2y, the former being again subdivided into the mediate and the immediate. In the immediate the iron is apj)Hed directly to the skin, while in the mediate the action is supj)osed to be modified by the interj)osition of some kind of medium. The various modes of actual cauterization, according to Bouley, are systematically exhibited in the following table : 160 OPERATIONS ON THE SKIN AND CELLULAR TISSUE. ' Superficial. . Immediate . Mediate . Trauscurrent, in lines. On siu'face, a la Gaulet. In points or dots. By ignited bodies. By heated liquids. By radiation or objective. By the interposition of Idd skin or of a layer of lard. r Rapid. [ Inherent or disorganizing. Subcutaneous. Peuch and Toussaint have added the needle cauterization, and firing with the thermo-cautery. Overlooking several of these specifications, which are of little or no utilit}', such as the firing with the inter-position of ignited bodies, of heated liquids, kid skin, etc., we proceed to consider the various prevalent and estabhshed modes in daily practice and of general utilit}^ Transcurrent, or Firing in Lines. The Cautery. — The instrument used in aU these operations, while formerly made of different metals, is now made exclusively of iron, for which there are various reasons. It is not only because of its cheapness and excellence and the general quaUties which give it universal precedence in the arts, but for some reasons pe- culiar to the case. Thus, its changes of color when heated, render it easy to gauge, proximately, the degree of heat, and it also possesses the property of retaining heat longer than many other substances. The form of the cautery varies greatly. The style most com- monly in use resembles a small hatchet, of triangular, j)rismatic shape, thick at its base and with a thin border or edge, sometimes convex, sometimes straight, and more or less sharp, according to the indication. The handle is, of course, of wood or other non- conducting material, and in respect to the weight, reference must be had to facility of handling and power of retaining heat. The THE CAUTERY. 161 o Fig. 201.— Various Cauteries. lighter ones are usually preferred, not only on account of this facility, but as being less liable to produce too pronounced an effect. Heavy instruments, in consequence of the degree of heat they radiate, and their contact with a broader surface of skin, are hable to transform the firing into the condition of a mere burn. The size of the cautery will necessarily be regulated by the ex- tent of the region to be treated. The cautery must be perfectly smooth, on its surface as well as on its thin edge, and to ascertain that this is the case, before they are heated a file should be passed over both surfaces, and before being apphed to the skin they should be again inspected by the surgeon or an assistant, to be assured that the edge is clear and clean, and there is no roughness to cause a ragged and uneven hne on the skin. In heating the cautery, a charcoal fire is much to be preferred to that from the blacksmith's forge. The latter soon soils and blackens the instrument, while the former is smokeless and every way cleaner, besides being portable and always convenient. There is no uniform riile to govern the position in which the animal must be secured. While there are occasions when he can be treated while standing, and kejit under control by the simple means of restraint, in many, and indeed in a majority of cases, 162 OPERATIONS ON THE SKIN AND CELLULAR TISSUE. it will be everyway advantageous to have the patient thrown down and secured, in order that the region to be fired may be exposed as freely as possible — a point which has already been considered. The parts upon which the firing is to be made must be thor- oughly cleaned and especially free from scabs or greasy sub- stances. The hair is to be cHpped short whenever its length and thickness are likely to interfere with the action of the instrument ; yet the skin must not be shaved, inasmuch as a thin coat of haii' will always prove rather an assistance than othervnse, in drawing the first lines, by preventing the instrument from slij)ping. There was a period when animals were fired with a view to their alleged ornamentation, without any pretext of necessity aris- ing from disease, but simply in conformity to the behest of fash- ion (and possibly as a means of the identification of property), but this artistic firing for fashion's sake is now altogether discarded, and the burned-in shapes of fern leaves, stars, crosses, harps, etc., — -^ Fig. 202.— Old-fashioned Drawings. etc., have made room for firings inflicted for better reasons and with more beneficient and valuable results. And while the resvdts of these aesthetic and artistic firings made for purposes of embeUishment were usually ugly, un- sightly cicatrices, thickened and hairless, the operations of the present time leave as their sequelse but slight and superficial marks, which are hardly entitled to rank as blemishes, though in this connection must not be included the Prange firing (Fig. 203), which, with its peculiarity, is applied as the ordinary line firing, except that the hues are divided in small sections. Firing in lines miist be applied not only upon the diseased part, but must extend somewhat beyond it, and the lines must be made as nearly as possible parallel with the direction of the hair. FIEING IN LINES. 163 Fig. 204.— Various Forms of Drawing in Firing.* * The firing on the loins we think ought to be parallel to the median line instead of oblique. 164 OPERATIONS ON THE SKIN AND CELLULAK TISSUE. This rule we consider a very important one, altliougli it is known that European veterinarians, when operating in some special re- gions, entu-ely disregard it, firing in hnes running at right angles with the direction of the hair, though it is quite obvious that the result must be an irregularit}^ in the growth of the hah' and a wavy appearance, which can be entirely avoided by observing the rule we have referred to. A glance at Fig. 204 will give the reader an idea of the proper form for making the drawings and the directions of the lines. Not only should the lines run parallel with the dii-ection of the hah', but it is equally important that there should be no de-vdation in the width of the intervals between the Hnes. It would be im- possible to give exactly the distance which must separate them, as this depends upon the thickness of the skin, the condition of the patient and the effects to be produced. In drawing the lines it must be remembered that they ought to be of an even depth their entu*e length, but we do not think that this can be easily accompHshed wdth the instrument having the convex edge, while there should be no considerable difficulty in effecting it by a steady atid uniform manipulation with the straight edged u'on, and by merely raising the hand at the begin- ning of the hne and depressing it shghtly at the end. The cautery must never be passed in one hne against the growth of the hair, and by always dl•a\^^ng it toward himself the operator will avoid injuring the bulbs, and escape the danger of causing a subsequent abnormal growth of hau'. Nor should the cautery be passed twice in succession in the same hne. If the in- strument should shp out of its track before reaching half its length, the line should be abandoned and the next one proceeded with. To determine the lines correctly, and follow them accu- rately by the eye alone, requires a natural aptitude which all do not possess. It is an art, however, which, if possible, should be ac- quired, and as well as when existing naturally, cultivated and im- proved, by study and practice. But in the absence of the natural faculty, which it is so deskable for the surgeon to possess, resort must be had to the obviously reliable expedient of pre\dous mark- ing, by which a charcoal mark upon a Hght-haired, or a chalk mark upon a dark animal wiU obviate all risk of lack of sj-mmetry and want of regularity. The degree to which the cautery should be heated, as well as RULES FOE APPLYING THE CAUTERY. 165 the manner in -wliicli it must be moved ou the skin, is to be deter- mined by the steps of the operation. In beginning- the markings of the firing or the initial drmcing, the iron must be of a dark red color, just hot enough to burn the thin coat of hair left on the skin. By this method, any ii-regularity in the drawing can be re- moved and corrected by the passing of a second instrument. When the entu-e sui'face has been covered with the initial di-aw- ings, and ever^^hing is correct, the heat of the cautery can be shghtiy an 1 jn-ogrcssively increased as the operation apj)roaches the end. Ttu rapidity ^^■ith which the instrument is moved over a hne should vary inversely to the degree to which it is heated, the thickness of the skin, the consistency of the subcutaneous tissues, and also the stage of the operation. Generally, the movement of the cautery should be accelerated when the heat is greatest, when the skin is thin, when the tissues underneath are hard, and when the operation is nearly completed. Another important rule is not to apply too \iea,\j a pressirre upon the cautery when moving it over the skin. A sUght pressiu-e with a slow movemeat is harmless and even advantageous at the beginning of the operation, or w^hen the skin is thick, but it be- comes dangerous under the opposite conditions when the heat of the cautery is extreme. In such a case a true incision of the skin may be the result. Fu-ing is essentially a bloodless operation even when severely apphed, but it is only by the careful observ- ance of the above rules that hemon-hage dui'ing actual cauteriza- tion can be avoided. Its appearance during the oj^eration is, we beheve, the result of inattention, and caused by too hastily raising the heat of the instrument, or more often by excessive pressure uj^on it. The obsei'vance or neglect of these rules will demonstrate the difference between scientific and unscientific firing, and show that while one is true scientific surgery, the other is simply burning the skin. The first is applied by one who appreciates the value of the results he hopes to realize, while the other merely places a hot iron in contact with the skin, quite ignorant of the good or e\i\. results which may foUow the act. As the operation progresses, changes take place upon the lines, which give an indication of the strength of the firing. These objective changes consist iu a change of color in the lines, and an accompanying exudation from the skin. In the first degree, or light firing, the lines are not deep, and 166 OPERATIONS ON THE SKIN AND CELLULAR TISSUE. are of a golden yellow tint, having only a few isolated drops of serosity at their sides, the dermis not being extensible, and the skin between the hnes free from infiltration, the epidermis can- not yet be scraped with the finger nail. In the second degree or ordinary firing, the lines are of a Hghter color, or bright yellow, the drops of serosity are more abundant, the dermis is more ex- tensible, the skin between the Hnes is thickened with infiltration, and the epidermis is easily scraped off. In the third degree, or strong firing, the lines have a hght yellow color, the dermis is so thinned that the sHghtest traction of the portions between the lines, which then become wider, stretches it, the serosity is abund- ant and overruns the edges of the lines, and the skin between them is infiltrated and possibly covered with small phlyctenases or bhsters. To proceed further wOl be to produce a deep burn, which may be followed with serious comphcations, or at the least, leave large, unsightly cicatrices. The length of time required to produce these effects, and the frequency of the apphcations upon a given region, are points by no means easily determined. They are affected by many contin- gencies, which cannot be anticipated. According to Fromage de Feugrd, a cautery heated to a cherry color must be used in each line from ten to twelve times for a Hght firing, and from fifteen to twenty for more serious cases ; but Gourdon considers these fig- ures too high, and says that from five to six strokes will be suffi- cient for a firing of the first degree, from eight to nine for one of the second, and from twelve to fifteen for the third, or strong fir- ing. But these figures have no absolute value. The number of strokes wiU depend upon many conditions, such as the heat of the instrument, the state of the parts and the dexterity of the operator. The effects resulting from actual transcurrent cauterization may be divided into primitive and secondary. (a) J'rimitive effects. — The inflammation which follows the burning manifests itself by the appearance of a serous exudation, the serosity being in the form of small di'ops, in greater or less abundance, according to the degree of the cauterization. This serosity collects between and at the bottom of the lines, and con- tinues to flow for from twenty-four to forty hours, when it is re- placed by the formation of crusts or scabs, dry, yellowish, and ir- regular, and if the firing has been light, attached to the bottom or the borders of the Hnes ; but covering the entire cauterized sur- PRIMITIVE EFFECTS. 167 face between tlie lines, as well as at the bottom, if the firing has been sti'onger. These crusts of dry serosity remain adherent for a few days only, and from the sixth day to the eighth they begin to separate, but the dropping off of the cauterized portions of the skin requires a longer time, varying according to the degree of the firing. In the first degree they are ehminated by the formation of a new layer of epidermis. It is a process of dry desquamation by which they are exfoHated, and requires from two to three weeks for its accompUshment. In the second degree, when the thickness of the cauterized tissue is greater, the scabs proper are more adherent, and it requires a process nearly aUied to one of suppurative expulsion, which may consume a month before the final sloughing is accompHshed. In the thu'd degree, a regvilar process of suppuration is necessary for the* removal of the scabs, and its completion will require a period of not less than five or six weeks. After light firing, the marks left are scarcely detectable ; after the second degree, the hair grows over the Unes, but in an irregu- lar way, giving a somewhat roughened appearance to the part, while the strong firing leaves a thick and callous epidermis, and therefore a serious cicatrix. Besides these first and du-ect effects of the cautery, there are others which ought not to be overlooked. About the parts where the firing has been appHed, the skin and the subcutaneous tissues become the seat of extensive infiamma- tion, accom^Danied with pain and swelling, and in some animals this may assume a severe aspect. The swelling may extend until it involves the entire extremity, and this may seriously interfere with the act of locomotion. It, however, subsides and disappears as the process of the removal of the scabs advances, and when this has been accomplished, the swelling and pain will also have disappeared. (b) Secondary effects. These are slow in their development, and cannot be easily or well described, and they vary widely ac- cording to the objects for which the firing has been appHed. It may be said, however, on general jninciples, that the development of secondary effects cannot be expected except after a consider- able lapse of time, allowing at least several months, and in any case, only long after the objective effects have entirely disaj^peared. The treatment following the operation, is of a very simple character. For a few days, and until the secretion upon the 168 OPEBATIONS OX THE SKIN AND CELLULAK TISSUE. cauterized parts has dried and the scabs have begvm to slough, the animal must be restrained from lying down, and biting or rubbing himself, nor must this vigilance be relaxed, until the danger of breaking up the surface of the wound has ceased, with the temptation which was kept up by the continuation of the irri- tation, with the dropping off of the scabs and of the cicatrization. There is no necessity for interference with the sloughing of the scabs, or occasion for impatience to see them removed. After a period of time, which varies according to the severity of the op- eration, they win separate spontaneously, or with a little friction of the parts, or washing with tepid water and soap. A question of some importance in connection with this oper- ation, is that which refers to the use of oily or greasy substances in the treatment of the cauterized surface. In times past this was accounted to be good practice, and soothing embrocations were recommended and freely employed, but this treatment has become nearly, if not wholly, obsolete. At the most, vesicating prepara- tions are considered allowable, but even these only under special conditions, as when the cauterization has not been sufficiently strong. This practice is specially prevalent in the United States, where the operations of firing and blistering are almost always as- sociated. This combination has nothing objectionable, and in fact is justified by the apprehensions and opposition existing among Americans. Yet j)ractitioners must always remember, that if many cases where firing is indicated terminate unsatisfactorily, after both firing and blistering, it is because the true and local effects of the cauterization, by ordinary or strong firing, have not been produced, when they were necessary to obtain good results. The possibility of ugly cicatrices cannot be well avoided if j)i'oper firing is to be depended upon. In view of the fact that the effects of firing are not limited to those which visibly and immediately appear on the surface of the skin, but that others of importance are also to be anticipated, after a certain time, the question of the duration of the rest necessary for the patient after the firing, be- comes one of some importance. All w^'itten authorities on the subject agree in sajdng, that this rest must be a long one, reckoning it by months, though in some instances light exercise, or even hght work, may be allowed sooner. Generally speaking, however, the surgeon will be guided by the nature and history of his case, and especially by the extent SECONDARY EFFECTS. 1G9 of the cauterization. The patient will of course requu-e perma- nent and absolute rest for a few days, or until the serosity and the scabs have dried, but after that he may be allowed the liberty of a box-stall, or of the pasture, without interfering with the necessary oversight of his condition and progress. There are cases where moderate walking exercise could not be otherwise than beneficial in its effect upon the final result. Though, as we have said, the apphcation of greasy medica- ments may not be recommended, yet, as a substitute or alterna- tive, bhstering ointments may be used to supplement too light a firing. It is, in fact, not rare to find it necessary to follow the firing with a severe bhstering after the scabs of the first operation have fallen off. If this is done, however, it must not be until the more active effects have diminished, and the inflammation has subsided. It may sometimes become necessary to solve the problem of the duty of the veterinarian in cases where an animal requires the treatment of the cautery on two places on one leg, or on two legs, or perhaps on the entire four. Humane feehng alone ought to fm-nish a sufiicient guide in this matter. "VMien the operation is not only in itself so excep- tionally painful during its performance, but is followed by further suffering arising from the necessity of protecting the animal acainst himself, it should be considered sufficient to inflict the firings singly, and after the first infliction to repeat the torture only after a respite of several days. On this point we differ from the opinion expressed by some European writers, and cannot dis- cover the alleged benefit to be derived from any extra dispatch, in the absence of any urgent reason for considering it to be im- perative. Our conviction is strong that one firing ought not to follow another until the immediate effects of the first have sub- sided, and the animal has had several days to recuperate from the great strain he has been compelled to endure. The apphcation of transciu-rent cauterization is verj' often in- dicated in sohpeds, and we borrow from Bouley a Ust of the ordin- ary lesions for which it is most frequently emj)loyed. A. — Eegions of the Extremities. Coronet. — Indicated against ringbones, circular periostitis following phalangeal arthritis, or deep penetrating wound of the foot ; exostosis f olloT\ing fractures. Apphed in lines, parallel to the axis of the bone ; not too near to- 170 OPEKATIONS ON THE SKIN AND CELLULAR TISSUE. gether, to avoid sloughing of the skin ; never fire beyond the second degree ; avoid bui'ning the coronary band. Results : gen- erally efficacious, but necessary to repeat it. Fetlock. — Ai'ticular or tendinous windgalls ; exostosis ; perios- titis after sprains or arthritis ; indiu'ation of tendons ; cold infil- trations and induration of cellular tissue ; knuckling. Apphed in parallel Lines, vertical in front and shghtly obUque behind. Re- sults : not so satisfactory, though in many cases favorable. Cannon. — SpHnts ; callous and thick tendons ; cold infiltra- tion and induration of cellular tissue. Applied as in the fetlock. Results: generally very satisfactory; second firing is often re- quired. Knee. — Articular and tendinous synovial dilatations at any part of the joint ; hygroma; bony deposits. Applied in parallel lines, vertical in front or obhque on the lateral faces. Very ad- vantageous for synovial dilatations and hygroma; less so in exos- tosis. Forearm. — Bony growths of any kind ; muscular weakness, manifested by sprung knee. Lines parallel to the axis of the re- gion. Beneficial for exostosis ; doubtful in the other cases. Flboic-joifit. — Bony deposits ; dilatation of articular synovial sac. In parallel Hnes. Results very satisfactory. Arm. — Weakness of olecranon muscles. In hnes parallel to the hairs. Results very doubtful. Shoulder. — Muscular atrophy ; paralysis ; diseases of the artic,- ulation, dilatation of the coraco-radialis bursae; lameness of un- known nature, and located in that region, may involve the en- tire region, or it may only cover the scapulo-humeral angle. In the first case, apphed in Hnes parallel to the direction of the hau', extending from the upper to the lower end of the scapula, the firing has an oval shape ; in the second case, the firing is circular, and forms parts of two parallel hnes, slightly oblique to each other. Generally advantageous in atrophy and occult lame- ness, doubtful in paralysis, not so much in articular or tendinous diseases. Hock. — Articular or tendinous tumors, hygroma, dilatation of the bursse of the extensors of the cannon and flexors of the foot, bony growths, peripheric periostitis, cold infiltrations, and indura- tions of cellular tissue. Drawings of the firing at the hock vary, according as it may be desired to fire the entire joint or only part. REGIONS OF THE BODY. 171 In this latter case it is applied in vertical or oblique lines, form- ing a drawing as regular as possible. In the former case two ways are recommended ; in one the surface of the hock is divided into halves by a line drawn parallel with the tendo- Achilles ; all lines back of this one are parallel with it, and all those in front of it are parallel with the front of the hock, and therefore sHghtly obHque to the others. In the other method, a line is drawn from the point of origin of the tendo- Achilles vertically downward to the cannon bone, and upon this, obHque, feather-shaped lines are drawn on each side. Results, generally rather favorable in all the diseases of the hock. Leg. — Bony deposits, rupture of the cord of the flexor meta- tarsi; chronic swelling applied in lines parallel to the region. Results, very advantageous. Stifle. — Dilatation of femoro-patellar bursse, exostosis of the patella, luxation, pain remaining after bruises or wounds, liga- mentous fistulas of old standing. Apj^Ued in several parallel ver- tical hnes in front, and on each side oblique to them. Results, almost always successful. Thigh and Coxo-femoral Joint. — For similar lesions to those of the shoulder, atrophy, paralysis, occult lameness ; same appli- cations. Results about the same. B. — Regions of the Body. Loins. — Weakness of vertebral column due to paralysis ; sprain of the vertebral column, vertebral periostitis, occult pains. AppHed in lines parallel or obHque to the median line of the body. Results generaUy doubtful. Withers. — Chronic cysts, indurations following fistulous withers, old fistulas. A few lines paraUel with the vertebral col- umn, the others oblique. Results almost always beneficial. Hibs. — Acute or chronic pleuresy and pneumonia. In lines paraUel with the long axis of the ribs ; seldom used, the results are difficult to appreciate. Principally used by Nicholson and Maclean against contagious pleuro-pneumonia. Firing on the Surface, or a la Gaulet. This is so named after its inventor. The mode of operation is with cauteries which have their border, or the part which is appHed to the skin made to form a flat or slightly convex sur- face (instead of being thin and sharp), in order to remedy one of the principal objections to ordinary firing, that of leaving 172 OPEBATIONS ON THE SKIN AND CELLULAR TISSUE. permanent marks. It proposes to effect this by throwing upon the surface of the skin an even radiation of heat. The descrip- tion given by Mr. Gaulet is this: "The iron being heated to nearly a cherry color, a straight liae is made in the principal direction of the region to be fired, and immediately alongside of it another, and so successively until the entire surface is covered. The first lines are then crossed, transversely or obliquely, by others, which perhaps also touch each other, and at last, in order to have the entire surface evenly cauterized, the parts which have not been touched in tracing the original lines are also touched with the iron which then retains but one-half of the heat it pos- sessed at first." * * * " After twenty-four hours, or perhaps less, an inflamma- tory swelling takes place, and the skin is covered with small bUsters of serosity ; three weeks after, the crusts which have fol- lowed begin to drop off, and the hair is seen growing underneath them." According to Bouley, this method cannot be substituted for the ordinary cauterization. If applied Hghtly, its effects are not more severe than those of an ordinary blister ; but if apphed in a severe form, it is Uable to be followed by the sloughing of large portions of skin, and to leave behind cicatrices of the very worst description. It has, however, in the hands of Mr. Paul Bouley, given satisfactory results in its application upon the stifle, the jDoint of the shoulder, and the cyst of the withers, and with Mr. Naudin, in the treatment of chronic swelliags of the extremities. FiErNG IN Superficial Points. This form of cauterization is performed with instruments of conical or oHvar forms (see Fig. 201), having the point blunt and rounded, in order to rest on the skin without incising or penetrating it. The point must not be so long as to cool off too rapidly, nor so short as to be incapable of retaining a sufficient amount of heat. In this mode of firing, the points or dots are arranged in quintu- ples, a first series of points being marked in either a vertical, obHque or hoi'izontal line, equidistant from each other, and more or less close according to the indications ; a second series is marked on a parallel line, at a distance equal to that which sepa- rates the dots of the first series, and placing the first point on a line with the middle of the space separating the dots of the first FIRING IN SUPERFICIAl, POINTS. 173 series, thus alternating the application of the points in a third and fourth series, until the whole surface is covered. This makes a regular drawing, and leaves but little blemish afterward. The rules pertaining to the application of firing in straight lines are the same as in the cauterization in superficial points, and they apply to this also, but we believe this is to be better indicated in the firing of small surfaces, for bony deposits, ringbones, splints, spavins and side-bones, or generally in the treatment of circumscribed diseases. Fig. 205.— Firing in Dots and Points. Firing in points is always more effectual than that in straight lines, and being exempt from the danger of skin sloughs, it always leaves fewer blemishes. Moreover, in a majority of cases, it can be applied without casting the patient. These are points which should count largely in its favor. The principal objection to be urged against it is the greater length of time required to realize the full measure of its effects. ]\Ir. Prange has invented a mode of cauterization, which is verj^ similar to that in superficial points, but differing from it in the fact that instead of points, the ordinai'V flat iron is used. It is cauterization in Unes, but instead of being long and made with one stroke of the cautery, they are dirided into short lines (see Fig. 203), also aiTanged in quintuple, like the dots of the point firing. This method has not found favor with those who have experimented with it. 174 operations on the skin and cellular tissue. Objective Firing. In this mode of cauterization, the heat is transmitted, not by contact, but by radiation. It is a process rarely resorted to, and when it is used it is more as an adjunct to transcurrent firing, or as a simple mode of revulsion. It consists simply in bringing the heated iron in close proximity with the surface to be cauterized. Gaulet is reported to have obtained good results from it in the treatment of lolcers, grease and ophthalmia ; Leblanc in chronic diseases of the eye, and Laux in the treatment of chronic lameness of the thigh- According to Gourdon, it is indicated for the arrest of some internal hemorrhage of mucous membranes ; for the re- duction of prolapsus of the rectum and of the uterus ; in hernias ; to stimulate the cicatrization of ulcers, and against some chronic inflammation of mucous membranes, of the conjunctiva, the pituit- ary membrane, etc. The cautery used by Mercier is square, oval or circular, with the surface, which is to face the skin, unpohshed, while the other is smooth and polished, a disposition designed to graduate the firing by facihtating the radiation of the heat with the first, and diminishing it with the second. The special aim in this plan is to avoid the formation of a slough, and to attain it as perfectly as possible, the firing ought to be so managed, as to apj)roximate the point of disorganization as nearly as possible without reaching it. In operating, the surgeon, after satisfying himself of the con- dition of the skin and its subjacent coimections, moves the instru- ment to and fro over the part, carefully avoiding contact with the tegument. If the hair burns too quickly, it indicates an excess of heat, or that the instrument is too near the surface. The heat shovild be gradually increased from a brown to a cherry red color. The duration of the operation depends on the condition of the skin. When the epidermis can be easily scraped with the finger- nail, or is raised by the formation of small bUsters, and the fired surface becomes moist, and shows little drops of serosity, and the skin becomes thicker, denser, and more adherent to the subjacent tissues, the evidence is present that the proper degree of firing has been reached. The serosity increases immediately after the operation, and for some time continues to flow, until the surface is covered with OBJECTIVE FIKING. 175 its dried pellicles or crusts. On the second or third day an in- flammatory swelling is developed, and all the symptoms of ordin- ary firing are manifested, and after three or four weeks the reso- lution is complete. It the firing has been too severe, the serous secretion becomes very abundant, and the inflammatory swelling increases rapidly and becomes warm and painful. Towards the fifth or sixth day the skin becomes black, diies up, shrinks, is raised in large patches, and sloughs off, leaving a broad siu-face, covered with large granu- lations, very slow to cicati'ize. One great advantage which objec- tive cauterization can claim over ordinary firing is, that when prop- erly performed, it leaves no blemish whatsoever. Deep Cauterization. The cauterization which is carried beyond the thickness of the skin and penetrates the subcutaneous structures, receives this designation. The manner in which the cautery is inserted into the tissues, and the length of time it is allowed to remain in contact with them, have justified the division of this kind of cauterization into rapid deep J and inherent, or disorganizing cauterization. Rapid Deep Cautekization. This is the comj)aratively recent mode known as needle firing, inasmuch as it consists in the insertion of elongated sharp, needle shaped cauteries, heated to a hght red. Urbain Leblanc is credited with the introduction of this species of instrument and is the Fic. 806.— Abadie Cautery. 176 OPERATIONS ON THE SKIN AND CELLULAK TISSUE. author of the first report of its results. The first cautery used by Abadie resembled the one shown in Fig. 206. In using it, the animal is generally secured in the standing position. It is applied at a Hght red heat and made to penetrate through all the tissues down to the subcutaneous cellular structure, and even through the synovial sheaths. Leblanc's advice is to make the puncture by passing the iron three or four times in succession in the same spot, but Abadie completes it at a single stroke. This firing is followed by severe inflammation of the jDarts, great pain, swelling, abimdant serous secretion, and the escape of synovial fluid. It has, therefore, powerful revulsive effects, which, how- ever, leave scarcely any marks, provided only the finest parts of the cautery have penetrated the tissues. Otherwise extensive and fatal suppirrative arthritis may be looked for. This cauterization is indicated in cases of exostosis, tendinous swellings, articular and tendinous synovial dilatations, splints, ringbones, spavin, side- bones, thick tendons, articular and tendinous windgalls, thorough pins, blood spavins, etc. In the true needle cauterization or ignipunctvire, the form of the cautery is changed, but in aU other respects there is no difference. The forms of the needle instruments are numerous, and of course each one claims some special merit. The cautery of Bianchi and that of Foucher were first used, and these were fol- lowed by the instruments in which the point or needle of platinum could be changed. There were others of more comphcated make, as those of Bom-guet, Salles, Lagarrigue, Vasselia and others, or Fig. 207.— Bianchi Cautery, RAPID DEEP CAUTERIZATION. 177 Fig. 208.— Foucher Cautery. of more recent invention the autothermic cautery of Mr. Ehret (Fig. 211). In using these instruments, whatever may be the position of the animal, the perforation is made with a single stroke only, the poiats being from three-fourths of an inch to an inch apart. When operating on a sjTio^dal bursa, the needle is apphed but once ; but if the skin is thick and indurated, two or even three times may be necessary. The subsequent application of a stiff blister is recom- mended by some, immediately after the operation, but by others after an interval of a few days. This firing is always accompanied by severe inflammation and its usual phenomena, but it generally subsides after a few days. 178 OPERATIONS ON THE SKIN AND CELLULAR TISSUE. Fig. 209.— Cautery with Changing Points. No severe accidents are likely to accompany needle firing. Small hemorrhages may occur, but they usually cease spontane- ously, though it must be admitted that fatal cases of arthritis have been recorded, which, however, are avoidable by the use of proper precautions. The attention required by the patient after these operations do not vary from those required in ordinary cau- terization, although the duration of the period of rest, always necessary, may be less prolonged. Inherent Firing. This differs from other kinds, in beiug performed with the cautery heated to a white heat, with a view to produce more or less deep disorganization, according to the needs of the case. Sometimes the aj)j)hcation is made upon the surface only, but at others at a required depth upon the deejDer tissues. INHERENT FIRING. 179 Fig. 210.— Bourguet Cautery. Fig. 211.— Autothermic Cautery. 180 OPERATIONS ON THE SKIN AND CELLULAR TISSUE. In the first instance, it is indicated in superficial cutaneous ulcers, in wounds indisposed to cicatrize ; in those following warts, in fun- goid growths, in cancerous, melanotic or fibrous tumors, in gan- grenous wounds and those following the opening of a cold abscess ; in fistula due to caries or necrosis of bones, tendons or Ugaments, etc. The instruments used are of various shapes : round, oUvary, annular or cultellar. They are applied firmly upon the tissues, and held in place for a few seconds, according to the density of the parts If the surface is wider than the instruments, the firing must be done by sections, applying the iron in detail upon spots, untn the entire siu-face has been touched. This is a better method than that of rubbing the instrument over the surface, and renders the effect more regular and uniform. In the second degree, or the cauterization into the depth of the tissues, a conical instrument is used and held in its place of insertion until it has lost most of its heat, thus reaching whatever depth may be neces- sary. This cauterization is indicated against anthracoid, gangrenous, farcinous and cancerous tumors ; in wounds of a virulent or veno- mous nature; in purulent infiltrations of the skin or of the cellular tissue ; in caries of bones, tendons, cartilages and liga^ ments, in dental caries, in indurated tumors, in fimgoid growths, poh'poid granulations, etc. Renault has recommended them in the treatment of the large sores so often occurring in granular dermatitis. Subcutaneous Cauterization, Otherwise known as Neapolitan cauterization, or " a la Nan- zio," consists in the apphcation of the cautery in points directly upon the muscular structure, exjDOsed by an incision made through the skin. The method was known and had been mentioned by Ruini, Solleysel, Bourgelat, RejTial and others in more or less modified and varying terms, before Mr. de Nanzio called the at- tention of the profession to the good results he had obtained by it. Its application is principally efficacious in the treatment of chronic lameness of the shoulder or of the coxo-femoral joint. The instruments requu-ed are two bistouries, one curved and one straio-ht, two flat tenaculums, a bull-dog forceps, scissors and an ordinary olivary cautery. De Nanzio thus describes the opera- SUBCUTANEOUS CAUTEKIZATIOX. 181 Fig. 212. — Cauteries of Nancio. tion : " My method consists in making an incision from above downward to the skin covering the articulation, the location of which has been first carefully determined. The skin is then dis- sected from the cellular tissue, and the flaps enveloped with folds of wet cloth. The flat tenaculum placed on each border of the incision keeps it open, and with a blunt cautery, not too red, three Fig. 213.— Firing k la Nanclo. 182 OPERATIONS ON THE SKIN AND CELLULAR TISSUE. or four points are applied upon the seat of tlie articulation, carefully ascertaining with the finger the point which the cau- terization has reached, and carefully avoiding the opening of the jomt." The subsequent treatment is simple, and consists in cleanli- ness, lotions of clear or slightly astringent water, and the protec- tion of the woirud by small threads of oakum. The suppui'ation is abundant and the wound ugly, but these effects are soon modi- fied, and healing is followed by only a simple linear cicatrix. Se- vere comphcations have been recorded as sequelae of this operation, but, on the other hand, several authors have spoken of it ia very favorable terms. Our own experience with it has not been suffi- cient to warrant the expression of a confident opinion. Cauterization with the Thermo-Cautery. This valuable iastrument, the invention of Doctor Paquelin, has only within a comparatively recent period been added defi- nitely to the armament of the veterinarian. The original instru- ment, as used in human surgery, has been modified by the inven- tor, and as now sold by our instrument makers, is fully adapted Fig. 214.— Paquelin Cautery. CAUTERIZATION WITH THE THERMO CAUTERY. 183 Fig. 215.— Paquelin and de Place Cautery. to veterinary practice, and possesses points of superiority over all the rest. It is used in the same manner and under the same rules as other modes of firing already considered, but while its application is followed by similar results, it possesses also many other attendant advantages, which render it a valuable addition to our operative means. The veterinary cautery of Paquelin and de Place is a modifica- tion which has recently been introduced, and which is considered superior to the original instrument by those who have used it, principally on account of the facility with which an even degree of temperature is kept during the entire length of the operation. The low price of the instrument is also an important item for vet- erinary practice. Cauterization in Other Aniivials. Firing in Large Ruminants. — If firing is not as commonly used with these animals as with solipeds, it is not because its ne- cessities are less frequent, but rather from economic considera- 184 OPERATIONS ON THE SKIN AND CELLULAE TISSUE. tions, and because when tliey become seriously disabled, instead of subjecting them to expensive surgical treatment, a wise pecu- niary policy consigns tliem to the shambles where they may still claim an unimpaired market value ; while a dead horse is (in popidar estimation, at least) held to be of no particular worth in theory, that is, whatever may be the unconscious practice of un- inquiring eaters of " beef." It has been apphed, however, in very numerous instances, by Cruzel, Roche, Lubin, Festal, and especially by Lafosse, who rec- ommended its appHcation in articular, muscular and tendinous lameness ; for synovial dilatations, bony growths, anchylosis and luxations, and also in nervous affections, epilepsy, paraplegia, va^ rious i^aralytic cases and amaurosis. The modus operandi is the same as that already described for solipeds, although allowance must be made for the thickness of the skin, which requires a deeper application, and necessitates the repetition of the firing from twelve to fifteen times in the same line, in order to obtain an ordinary effect. The scabs of the firing generally separate in from fifteen to twenty days, and leave pale rose wounds, followed by cicatrizations with a smooth sur- face. The swelliag of the parts, and the reactive fever following the operation, is more severe, but subsides quite readily. The animal must be prevented from rubbing or hcking himself in order to obviate the danger of secondary wounds with their trou- blesome complications, as with soHpeds. In smaller animals cauterization is seldom resorted to. In dogs, however, its appHcation is sometimes indicated in lameness of the elbow, the stifle, and even the hip joints. Superficial firing by points has been advantageously apphed, and is recommended by Peuch and Toussaint. Accidents of Actual Cauterization. To a great extent, the accidents and failures following the use of the cautery result from the non-observance of the rules estab- lished for the regulation of the operation, and subsequent care- less and incompetent nursing. The remedy for these is too obvi- ous to need mention. {a) Section of the Skin. — This is a very common accident, usu- ally chargeable to the carelessness or incompetence of the sur- ACCIDENTS OF ACTUAL CAUTERIZATION. 1S5 geon, or it may be caused by tlie use of too heavy or too sharp an instrument, or to an excess of heat or of pressure. It is recog- nized by the separation of the edges of the wound, and the ap- pearance at the bottom of the lines of a white nacreous stria, shown by the subcutaneous tissue. There is no remedy for this accident, and though it is not a very severe lesion, it is likely to be followed by rough and irregular cicatrices. (b) Honorrhage. — We have said that firing is an essentially bloodless operation if properly performed. The apjjearance, there- fore, of drops, or j)erhaps of a small stream of blood, at the bot- tom of the lines or points, and perhaps running over the surface of the skin, though unattended with danger and not likely to be injurious, is, at the least, evidence of some miscarriage of skill. If it arises from the use of a rough or too sharp an instrument, it can be readily suppressed by sewing the part, or applying upon bleeding vessels another cautery, heated a little in excess of the first. Sometimes the burning of a small quantity of pulverized resin, or of a small lock of hair in the bleeding cavity, will have a sufficient hemostatic effect, and simple pressure will seldom, if ever, fail. (c) Tearing off Scabs. — This is the result of careless and in- secure dressing, and in omitting to provide effective safeguards for preventing the patient from reaching the wound with his own teeth, or rubbing it against some hard object. Suppurating wounds of various dimensions are often the result of this inad- vertency, requiring careful treatment, and sometimes leaving bad blemishes to be regretted. {(1) Sloughing of the Skin and Subcutaneous Tissues. — This accident is not uncommon, and like that just mentioned, is the effect of the improper application of the cautery, though less the effect of the firing than of burning the parts, and it is character- ized by all the conditions of ordinary burn wounds. Among specific causes, however, may be mentioned too strong a firing, or firing with lines too near together, or touching each other at some angle, or in crossing, or when too large an iron is used, or one brought to a radiating heat, or too high a temperature; or when greasy substances have been applied in the lines, or the skin submitted to long frictions. All these causes tend to the disorgan- ization of the skin, with mortification and sloughing, and its sei^ara- tion in large patches, leaving after heahng, broad, ugly blemishes. 186 OPERATIONS ON THE SKIN AND CELLULAR TISSUE. {e) Bad cicatrices. — Though firing, however carefully applied, will always be followed by legible marks, there are cases in which bad, callous cicatrices form a positive and repulsive life-long dis- figurement of the animal. In the most aggravated forms of the ac- cidents enumerated, there are circumstances which particularly favor their occurrence. Among these may be regarded the thin- ness and sensitiveness of the skin, the interference of the animal himself, by rubbing and biting, and an excessive suppurative action accompanying the falling off of the scabs. No treatment is known that can be made effective against these lesions, but it is satisfactory to know that they do not inhere in the operation, and are preventable in the exercise of proper skill by the operator, and attention by the nurse. EXUTOKEES. An executory is any therapeutic agency or means the effect of which is to promote the formation of purulent matter, and to sustain the suppurative process after it has been established. Some exutories have no si^ecial intrinsic quahties, and simply take effect in the manner characteristic of foreign bodies when lodged in any portion of the system ; while, on the other hand, some of them possess specific properties by which a special irrita- tion is produced in the tissues with which they come in contact. The various forms of seton are included in the first class; the trochiscus, blisters, however composed, the moxa, and the actual cautery belong to the second. But while the fact of the utilization of the operation is as old as the practice of medicine itself, the modes of application and the materials used have varied considerably during various epochs. The use of the root of black hellebore was recommended for diseases of the ears in large ruminants, and also in the treatment of diseases of the chest, or iu cedematous swellings of the abdomen. At a later period, the actual cautery found its advocates iu the treatment of tetanus. The introduction of feathers, or long quills under the skin, in the treatment of old shoulder lameness, followed, and in some parts of the world this practice has not yet been wholly abandoned. Sometimes the feathers were used alone, and in other cases air was blown into the cellular tissue under the skia, in the parts where they were to be placed. The EXUT0RIE8. 187 first description of the seton and its effects was given by Markam, in 1556. But even after that date we read of the use of irri- tating soft pencils, or candles composed of various ointments, melted or mixed together, and introduced under the skin, incised for the purpose, and more or less massed or bruised with some hard substance. But the accidents which were apt to accompany some of these energetic forms of treatment were of so serious a nature that they gradually fell into disuse, and to-day this class of principal exutories includes only the seton in its various forms, the trochiscus and the vesicating preparations. Exutories act as counter irritants, resolvents, and alteratives. The irritation which follows their contact with the living tissues excites the purulent secretions, and the activity in the process of interstitial resorption, which they stimulate, render their adoption and frequent use a source of much benefit and great satisfaction to the veterinary practitioner. The list of ailments in which their value is manifest and unquestioned is a long one, and com- prehends affections of the chest, catarrhal inflammation of the air passages, and affections of the abdominal organs, with those of the eye, and in dogs of the ear. They stimulate the resolution of local affections having a tendency to chronicity, for example, oedematous swellings of the extremities, and they are frequently indicated in diseases of the locomotory apparatus, in certain af- fections of joints, and in rheumatic lameness, and also to excite the resolution of soft tumors, especially those of the synovial structures. The most ehgible of the forms in which exutories are prepared, especially when they are designed to act as a means of drainage, or to prevent the accumulation of pus in anfractuous cavities, is the seton. It is recommended in nervous affections and in paralysis, and also for the relief of atrophied regions, and, according to Bouley, it may often become a means of diagnosis, as well as of prognosis. In an acute disease having a tendency towards recovery, a seton will have an irritating effect, and give rise to a phlegmons swelling about its tract, while in the same disease, if the tendency be toward a fatal termination, the artificial suppuration which it causes will soon cease to flow, and the tract will remain compara- tively dry. There have been those who have made the seton a prophylac- tic agent, or insurance institution, to be made use of at certain 188 OPERATIONS ON THE SKIN AND CELLULAR TISSUE. special periods or seasons of the year, and have thus invented the seton of prevention, or of precaxition^ but without satisfactorily demonstrating what is to be prevented, or what anticipated. The theory, if any, in which such an assumption originates cannot be certified, and honest veterinarians cannot themselves identify it with such a practice or pretext. If exutories are a frequent resort, and are highly appreciated in veterinary surgery, and their general use is commonly unat- tended with danger, yet they are not always so absolutely harm- less that they may be trifled with, and prescribed without due consideration of the peculiar conditions under which their use is contra-indicated. It cannot be rationally supposed that the potency to which they owe then* beneficial effect when rightly directed is to vanish when it is erroneously applied, and that it can be made innocuous by misdii-ecting it. Animals debilitated by heavy work or by disease ; those affected with chronic organic ailments; those threatened with eruptive diseases, or suffering with septic complaints; none of these are fit subjects for the application of exutories. SETONS. A seton is a form of exutory which consists in the introduction of a foreign substance under the skin, ordinarily a band of linen tape, or a leather ring. The former is known as the tape seton, while the second is more approj)riately termed a rowel. Tape Seton. This is usually merely a piece of clean, white tape, of suitable width and length as requii'ed by the case. In some cu'cumstances, however, cords or braids of lint or horse-hair are substituted. The seton may either be introduced under the skin alone and dry, or it may be saturated with some irritating fluid, or covered with a stimulating ointment, to increase its effect and promote the purulent secretion. The operator must not fail to allow a suffi- cient length to securely tie the ends which pass out at the two openings of the tract through which it is drawn. Yet they are not always secured by an ordinary knot, but are quite generally united by a species of twist upon their extremities, which can be readily loosened when it becomes necessary. This knot must be sufficiently wide and strong to prevent it from sHpping through SETON NEEDLES. 189 Fig. S16.— Seton Knots. the incision. In some cases, instead of makiag a knot on the tape, small wooden pins are secured at the extremities, and answer the same purpose. The essential instrument required to apply a seton is the peculiar needle known as the seton needle. It is, of course, made various lengths, some consisting of but a single piece (Fig. 218); D Fig. 217. Fig. 218. Fig. 219. Fig. 220. SETON NEEDLES. Fig. 221. 190 OPERATIONS ON THE SKIN AND CELLULAE TISSUE. while others are in two or three sections, connected by screw joints (Figs. 219, 220, 221), and in some few instances fitted to handles (Fig. 217). But however they may otherwise vary, they are in the general form of a stiff, ii'on rod, with one lanceolated extrem- ity, both edges sharp, and a large eye at the blunt end to receive the tape. The lanceolated portion is sKghtly curved on the flat side. There are also other forms designed for special objects, among which may be mentioned one which is used for passing a seton through the frog of the foot, and is therefore knovim as the froer seton-needle. Fig. 282.— Frog Seton Needle. For small animals, such as the dog, the smaller sized straight needles are often suitable, and the one which is used for making the quill-suture is very convenient. Besides the seton needle proper, in its authorized and usual patterns, occasions sometimes occur when to meet special require- ments, a straight, pointed bistoury and a pair of scissors are re- quu-ed as adjimcts. Fig. 223.— Quill Suture Needle. The operation of setoning is comparatively a bloodless one, and the division of the cellular tissues through which the needle passes is very often made without any hemorrhage. Yet there are regions where more or less blood may subsequently escape. A region, therefore, where the ceUular tissue is abundant and loose, is that which is most favorable for the introduction of setons. The modus operandi is simple. The hair must be closely chpped from about the points selected for the two preHminary punctures, one for the entrance and one for the exit of the needle, SETON NEEDLES. 191 and the patient must be properly secured. Certain nervous ani- mals may oblige the surgeon to place them in the recumbent posi- tion, but our experience has taught us that the cases in which this is necessary are very exceptional, and that in the great majority of operations, the simplest means of restraint, a twitch, with the raising and securing of one or two of the extremities, is all that is requii'ed. The appHcation of local anesthesia, so far as it may be practi- cable, is also a measure which is in all respects judicious and com- mendable. With the spraying aj)paratus, any part of the body can be reached with great facility. In introducing the needle, many veterinarians pass it directly through the skin, which is raised in a fold, and drawn away as far as possible from the deeper tissues. This maybe readily practica- ble in regions where the cellular tissue is very loose and abundant, as under the chest ; but it is much less so, and more dangerous where the skin is thick, and the subjacent connective tissue is de- ficient or scant, and especially if the edges and point of the needle are not perfectly sharp. For this reason the method preferred by many is more judi- cious, of making an incision with the straight bistoury through the skin at each of the two extremities of the proposed tract through which it is intended to pass the seton. The manipulation is sufficiently easy and simple, the operator holding the skin in a fold with one hand, while with the other he guides the needle under the skin and parallel with it, through the cellular tissue, entering through one of the punctures made with the bistoury, and emerging through the other. The point most important to observe here is that of so guiding the needle in its motion that it shall neither plunge into the deeper tissues nor emerge outwardly at the wrong place. At this point the scissors may be utilized by lajong blades flatwise over the place of exit, and pressing down the svu'face. Du-ections are sometimes given, as the next step, to insert the tape into the eye of the needle, but it woidd seem that the safer plan would be to have the tape already in place when the needle is introduced. After the tape has been drawn through, and the needle disengaged, the next and final step is either to unite the ends of the seton by a knot, or, without t}Tng, to secure them separately by the twisting or plaiting already described, and leave them free. 192 OPERATIONS ON THE SKIN AND CELLULAR TISSUE. The first effects following tlie application of a seton are those met with in a majority of ordinary wounds ; more or less swelling and inflammation, followed by an access of the suppurative pro- cess. At the points of insertion and -exit of the needle, a certain amount of hemorrhage takes place, generally of no importance, and subsiding without interference, and this is succeeded by a swelling along the braid of the seton, at first more or less difiusi- ble, with a tendency to increase during the first forty-eight hours but then becoming more defined. In the beginning, and for the first two days, there is a flow of a thin serosity from the opening of the seton, which gradually assumes the character of suppura- tion of good quahty in the shape of creamy, laudable pus. Up to this period the seton needs no attention, and should be left with- out interference, to exhibit the natural traumatic effect of its presence. Although it is desirable to have the suppuration well estabhshed and flowing freely, it must not be permitted to accumu- late in the tract, and should be subjected once or twice a day to gentle pressure along the entire length of the seton, to expel the least portion of purulent matter present. At the same time, such a pressure as would be Hkely to crush the granulations of the wound and thus excite small hemorrhages, must be avoided. The cleaning and washing of the openings of the seton, and of the tape itself, must be carefully and strictly performed as often as the abundance of the discharge requires it. It should be sys- tematically attended to, not less than once or twice daily, at the least. Precautions must be taken to prevent the animal from biting and pulling off the seton, and yet this accident is very possible, and it may frequently become necessary to replace it. In that case the needle shotdd be introduced by its blunt end, with the new tape previously inserted in the eye. At times it becomes necessary for other reasons to renew the seton. A feasible way to effect this will be to attach the old tape to the new, and draw out the former by means of the latter. The length of time a seton ought to be allowed to remain in place varies according to circumstances, extending to a period of from three to four weeks, or even longer. "When the time has arrived for the discontinuance of a seton, if more than one have accomplished their purpose and had the desired effect, they ought not to be all i-emoved at the same time, but singly, and with an interval between them. Nor must the APPLICATION OF TAPE SETONS. 193 wound be neglected because the seton has been removed, but it must receive needed attention for several days. The openings of the tract will still require cleaning, and the residue of the pus will stiU requii'e the aid of jDressure to effect the final emj^tying of the wound. Tape setons are ajDplied upon all parts of the body, but more frequently, of course, in regions where their theraj)eutic effects are most needed, for which reason they will be most commonly found on the breast, the ribs, the shoulder, the hip, the thigh, the stifle, the abdomen, the neck, the cheeks and the foot. (a) The Hreast. — This is a very common location for the setons. In inserting it the animal is secured in the usual way, but to pre- vent his striking the operator with his fore feet it will be necessary to have one of his hind legs raised and firmly held. If there is but one seton it must be introduced on the median line ; if two, one on each side of it. The position assumed by the operator varies, according to the abihty he possesses, and the hand with which he operates. If ambidexter, and but a single seton is to be introduced, he can operate from either side of the animal, and if two are to be insert- ed, he can change the needle from one hand to the other, to suit his convenience, without change of position. This seton is to extend from the anterior extremity , of the sternum downward and backward, under the chest, or between the fore legs, backward beyond the elbow. When the incision of exit has been made, and the tape introduced into the eye of the needle, the instrument must be drawn away in the direction op- posite to that in which it was introduced, to avoid the possibiUty of doing injury with the point or the edges. {b) 0)1 the Ribs or the Chest. — Setons are used in these regions for the treatment of diseases of the thoracic organs. Sometimes as many as three are applied, either on one or both sides of the chest. They should be placed in a slightly oblique direction from before backward and from above downward, beginning about the middle of the side of the thorax, and ex- tending as far as the lower border of the chest, occupying, there- fore, the lower half of the thoracic cavity. The manner of insert- ing the seton in the tract made by an incision with a bistoury through a fold of the skin has been already described, and a repetition in minute detail becomes unnecessary. 194 OPEBATIONS ON THE SKIN AND CELLULAR TISSUE. Care must be taken while ojDerating in this region to avoid wounding the spur vein, which can be done by raising the skin well from it when the point of the instrument has reached its course, by which movement the needle passes outside of the vein and can be brought outside on the inferior border of the thorax. The tape is then placed in the eye of either the needle or the blade as already frequently described. Our own practice is to secure the tape through the eye of the blade, and draw the tape into position by removing the needle from below upward, considering this plan to be both more convenient and less dan- gerous. (c) At the Shoulder. — Setons are often applied in this region against lameness of old standing; at times only one, at others two, or even more, according to the extent and location of the dis- eased region. When applying more than one, they are commonly placed parallel with each other. Many practitioners place them crossing each other, meeting in the middle of their length, with their point of meeting on a level with the center of the scapulo- humeral joint. In placing them, the compound, or three-jointed needle, somewhat flexible (already described), will be necessary, as being capable of adapting itself as much as possible to the convexity of the joint. Some care is required in the selection of a proper place for the puncture, and the animal must be kept in the standing position as much under restraint as possible. There is probably no special rule for the location and direction in which setons should be applied, the discretion of the operator, in many cases, furnishing the only guide. This is well illustrated in the application of the monstrous " seton a la Gaulet,'''' so called from its inventor, and which consisted in surrounding the entii'e scapular surface with one immense seton, beginning at the cervical angle of the scapula, running along its anterior border to a point below the shoulder, passing in front of the breast to the axilla, through that region, horizontally back on a level with the elbow, to return outward and then upward to the dorsal angle of the scapula, where it ended. This form of exutory is no longer toler- ated, the dangers attending it, from the severe and exhausting di-ainage of the organism having brought it into discredit, with the result of its dismissal from general practice. A seton at the shoulder requires special protection from the animal, by means of the cradle or the side bars, its location APPLICATION OF TAPE SETONS. 195 makiag it too easily accessible to his teeth to be suffered to re- main long in place without such a defence. (d) Seton at the Hip-Joint. — Lameness of this region is fre- quently treated by the tape seton, the conditions of their apphca- tion being nearly identical with those required when the shoulder is the region involved. They are placed, whether single or dou- ble, directly over the artictdation, or crossing each other in the X form, and also over the center of the joint ; and care must be taken that they are not inserted so obliquely as to interfere with the free flow of the pus. A needle similar to that used with the shoulder will be found convenient, and for a similar reason, the thickness of the skin, and the closeness of its connection with the sub-tissues, will render necessary the preHminary incisions with the bistoury to faciUtate the entrance of the needle ; and the con- trol of the animal, as he is to be treated on his feet, should be secured by supplementing the restraint of the twitch with that of the side lines, and raising one of the hind legs. {€) Setons at the Thigh. — These are prescribed in chronic swelling of the hind legs. The region they shovdd cover extends from a level with a point a little below the inside of the ischial tuberosity to the superior third of the shank, and they should be placed in a slightly oblique direction from without inward. It is necessary while operating here, as in the hip-joint, to have the animal well secured, and not only the twitch and the side-lines, but sometimes the raising of one of the fore foot will be required ; as of all setons, this is probably the most painful to insert, in con- sequence of the division of branches of the sciatic nerves, which lie in the course of the needle. The stejDS of the operation do not in any way vary from those in other regions, and therefore do not call for a redescription excepting perhaps to sj^ecify that in placing the tape the convexity of the blade must be turned in- wardly, and an assistant wiU be needed to hold the tail aside. The tying of the tail to the surcingle on the opposite side of the body will prevent its becoming soiled with the discharge of the seton, and render the subsequent care of the patient easier. {f) Setons at the Stijie. — This seton is recommended by Peuch and Toussaint in lameness of that region which has resisted vesi- cating liniments and blistering applications. They recommend the recumbent position for the safety of the operator. A convex bistoury and the ordinary seton-needle are reqiiired. The animal 196 OPERATIONS ON THE SKIN AND CELLULAK TISSUE. while lying down has his hiad leg extended by the traction made upon it by assistants with a rope. An incision is made above with the bistoury, and the needle introduced through it, it is pushed downward in front of the joint, carefully raising the skin as it progresses, to avoid injury of the femoro-patellar articulation. {g) Seton on the Abdometi. — This seton is both difficult and dangerous to apply in the standing position, and, therefore, unless the animal is very carefully secured, and the ojDerator unusually dexterous, it is better to have the animal cast. The seton placed on the median line, ur^der the abdomen, extends from about the xyphoid cartUage back to near the sheath or other mammae. In applying it, care must be taken to avoid injury to the tunica abdom- inahs and the abdominal muscles, or making a deep wound of the abdomen. Caution must also be exercised against the possi- bility of the animal kicking against the needle at the moment of its passage through the skin at the opening of exit. The tape when introduced in the eye of the instx'ument is to be drawn into the tract by pulling the needle away from behind forward. (h) Setons to the Neck. — These are recommended against im- mobihty and periodic ophthalmia. They are jDlaced in an obHque direction, one or two, on one or both sides of the neck. The hori- zontal direction sometimes recommended is certainly quite un- likely to facilitate the free escape of pus. In introduciag the needle it is better to direct it from below upward, starting at about the level of the convexity of the mastoido-humeralis muscle. (i) Setons on the Cheeks. — These have been more or less ad- vised in the treatment of diseases of the eyes, and principally of periodic ophthalmia. They are placed a little below the zygomat- ic spiae, below and in front of the temporo-maxillary articulation, and extend downward some distance in front of the zygomatic crest. The blood vessels of that region, and principally the large nerves which cover the masseter muscles, must be carefully avoid- ed, to guard against paralysis of the lij). {j) Setons in the Foot. — The insertion of a seton in the foot, or the /?'og-seton, as it is also called, has been principally recom- mended in the treatment of navicular disease, though it is con- sidered by many as of very doubtful utihty. A sj)ecial curved needle (see Fig. 222) is used for the purjjose. The horse is in some instances kept in the standing jDOsition, while in some special cases it is better to have him thrown. KOWEL SETON. 197 The shoe being removed, and the sole and frog pared down and made as thin as possible, either an incision may be made in the hollow of the heels, or the needle inserted without it through the skin, in such a dii*ection as to have its point emerge at about the front part of the middle commissure of the frog. The tape is drawn into position by pulling the instrument straight away through the opening of exit. The seton is to be secured by tying ends together. When the operation is performed while the animal is standing, a strong assistant must hold the foot, and the needle pushed and passed through the frog rapidly, as by possible struggles, severe injuries of the tissues of the posterior part of the foot might result. Rowel Seton. This form of exutory is of earlier origin than the ordinary taj^e seton, and consists in a round piece of leather, felt or pasteboard, sometimes perforated in its center, which is deposited in a pouch Fig. 224,— Rowel Seton. made under the skin, either simple, or sometimes surrounded with a band of tape to prolong its continuance. It is principally used when the disposition of the parts renders the introduction of a tape seton difficult, or when it is for any reason contra-indicated, and especially when the exutory being indispensable to the well being of the patient, it is at the same time imperatively required that the animal shall be preserved free from any blemish or dis- figurement. It is also to be preferred with animals which cannot be prevented from tearing out the ordinary tape seton with their teeth. A pair of scissors and a straight bistoury are required for its insertion. A simple incision is made with the bistoury, long enough 198 OPEKATIONS ON THE SKIN AND CELLULAR TISSUE. to allow tlie introduction of the rowel, rolled or doubled on itself ; then, with the scissors passed flatwise under the skin, a pouch is made, by dividing the cellular tissues, of sufficient dimensions to secure the rowel, which is to be opened or unrolled and flattened in the pouch in such a manner as to bring its central opening in correspondence with the incision in the skin. This form of seton can remain for a period of from fifteen to twenty days, and there are cases where it has been kept in place as long as six weeks. It can easily be removed with the forceps or a pointed tenaculum. Teochiscus. This is an exutory formed of some mineral or vegetable sub- stance, sometimes termed an issue pea, possessed of irritating or even caustic properties, which are introduced under the skin in the same manner as the rowel. They differ from the other exutories by causing a greater amount of irritation, a higher degree of in- flammation, and for that reason are left in place for a shorter period, and are removed as soon as inflammatory symptoms are well estabhshed. They ai-e less frequently used in sohpeds, but are of more common employment in cattle. In the former, how- ever, lameness of long standing in the upper segments of the legs has been successfully relieved by them. In cattle they are often inserted in the dewlap. They can be introduced directly under the skin, either through an incision made alone, or attached to a seton, which may continue longer in place after the removal of the trochiscus. Accidents, Sequels of Setons. The accidents which sometimes follow the application of setons are: hemorrhage, gangrenous swellings, abscesses, excessive granulations or fungosities, and indurations. (a) Hemorrhage. — In ordinary circumstances, their introduc- tion is accompanied by the escape of only a few drops of blood, but there are cases where abundant hemorrhages occiu', either resulting from an injury to some blood vessels, or because of a special hemorrhagic predisposition in the animal, as when it is in a debilitated or anaemic state. When there is hemorrhage, it usually shows itself at the con- clusion of the operation, the blood oozing in drops from the open- ACCIDENTS, SEQUELJi OF SETONS. 199 ings of the seton, or causing a swelling, if it accumulates in the tract. The ordinaiy means of hemostasis must be employed, as cold douches, iced lotions, etc., and if these fail, the seton must be removed, and the openings plugged with oakum, moistened with hemostatic liquids, or with absorbent cotton ; or it may even be necessary to close the openings with sutures, or resort to the the application of pressiu'e. Bouley recommended the introduc- tion of a thick tent of oakum through the entire length of the tract. (b) Gangrenous Sicellings. — These are among the most common and dangerous of accidents accompanying setons, and occur prin- cipally during warm weather, in debilitated animals, or such as are exposed to bad hygienic conditions or affected with some special diseases. The gangrene manifests itself by the appearance of a warm and painfiil swelling, oedematous and diffused, spreading rapidly, but in the central portion cold and painless, and a general reaction soon becomes manifest. The animal becomes diill ; the pulse is accelerated and small, and the temperature heightened, the dis- charge of the setons has changed its character to that of a thin, sanious, and very foetid suppuration. All these symptoms become rajDidly exaggerated, and soon threaten the Hfe of the patient, unless heroic measures are at once resorted to. When the tract assumes this gangrenous aspect the tape must be immediately removed, and the tract thoroughly emptied and cleansed, by injections of antiseptic liquids such as solutions of phenic or saHcyUc acid, followed by cauterization with the red iron in the tract, and through the oedematous swelling, accom- panied by the free administration of tonics and antiseptics inter- nally. No means should be neglected likely to overcome the threatening septicaemia, which, if not controlled, will certainly have a fatal termination. (c) Abscesses. — When the seton has been left in place too long, or there has been neglect in respect to the care and cleanliness of the tract, or when the tape has been removed, numerous abscesses will sometimes be fotmd along the course of the seton. They have the character of phlegmonous swellings, and soon become fluctuating. "WTiile they i-emain superficial, no serious results need be appre- hended, and all they require is to be opened to allow the escape 200 OPERATIONS ON THE SKIN AND CELLULAR TISSUE. of the pus, and to be treated generally after the manner of similar tumors in other parts of the body. But occasionally a filtration of the pus takes place between the diiferent layers of tissues, and the abscesses become troublesome. To avoid their formation there must be a complete and regular evacuation of the tract by pressing out the contents once a day or oftener, according as the discharge requires it. To avoid the possibility of the migra- tion of the pus and the formation of a deep abscess, the operator must be careful not to make a false tract with the needle during its passage under the skin. {d) JExcessive Granulations or Fungosities. — These often occur at the openings of the tract, when the tape has been left in place a long time. They are not of a serious character, and can be re- moved by excision or cauterization. (e) Indurations. — These are also among the sequelae of setons left in position too long, or when, after the removal of the tape, care has not been taken to press out and thoroughly empty the tract of any remaining portion of the discharge. These indurations aj^pear in the form of long, hardened cords, extending more or less in the original length of the setons. They often disappear spontaneously, by a slow process of resorption, but in many cases it becomes necessary to have recourse to friction with alterative ointments composed of preparations of mercury or iodine. Deep pointed cauterization, or their entire removal by dissection are also recommended. ABLATION OF TUMOES. Under this heading are included the various modes of the divi- sion of tissues involved in the removal of tumors — a tumor being, as technically defined, a non-inflammatory mass, constituted by tissues of new formation, and having a tendency to persistency and possible growth. The term ablation, of which the common definition is simply taking away, is in surgery employed to denote the excision or re- moval of tumors — a tumor being, in a surgical sense, any morbid, circumscribed enlargement affecting any of the structures or organs of the body, sometimes harmless, and sometimes maHgnant and fatal in their character and termination. The sui'gical means at the disposal of the veterinarian, by which this operation is accomplished, are not so numerous as ABLATION OF TUMOKS. 201 those employed in human surgery, and can be comprehended in the four principal processes of excision, ligature, tearing and punctiu'e. They are about equally employed, according to the circumstances and nature of the case, and the discretion of the operator. 1st. — Excision. This mode of ablation can be performed in four ways, with the scissors, the bistoury, the ecraseur or the thermo-cautery. (a) With the jScissors. — This is the simplest process, but is apphcable only to tumors of diminutive size, such as warts, con- dyloma, and in general, to growths having a small and narrow peduncle. Curved scissors are generally used. The tumor is raised from the skin and secured with a pair of bull-dog forceps before the scissors are applied. The hemorrhage which may follow is not usually serious, and ordinarily requires no interfer- ence, and when necessary, can be readily controlled by means of cooling appHcations, pressure or cauterization. {b) With the Bistoury. — When the tumor is cor,\j)aratively small, with a narrow peduncle, its removal is effected in the same manner as with the scissors, the only change being in the stroke of the instrument. Usually a single stroke of the bistoury is suf- ficient. But if the tumor is of large dimensions and covered by the skin, the operation becomes more complicated and requires more time and care. It is ordinarily divided into three steps, viz. : the incision of the skin, the dissection of the tumor, and its extir- pation. The form and size of the incision must of course correspond to those of the tumor, which must be considered in reference to its basis, connections, adhesions and surrounding tissues, as well as the healthy or morbid condition of the teguments. The straight incision is applicable to subcutaneous tumors, free from adhesions or comparatively loose and susceptible of enucleation, while that made through a fold of the skin is better adapted to encysted growths, which it would be dangerous to open. The eUiptic incision is used when a portion of the skin is to be removed, because of its being diseased or too thin, and its closing up would be too difficult; or when the extent of the skin exceeds that of the wound it covers. Crucial incisions, or those of the T or Y shape, are indicated when a tumor of large size is to be exposed, 202 OPERATIONS ON THE SKIN AND CELLULAR TISSUE. while it is necessary to preserve tlie skin which covers it. What- ever form of incision may be used, it must always extend beyond the base of the tumor to allow a free dissection and an easy removal of all the diseased tissues. The convex bistoury is preferred in this step of an operation and must be appKed with light pressure, and a very guarded motion, to avoid any subcutaneous blood ves- sels that may run over the surface of the growth, and which may be of large size. The incision is followed by the dissection, which is done with the scalpel or the bistoury, by separating the tumor from the teg- uments, carefully avoiding surrounding structures, which should be held aside with the forceps or tenaculum, in order to keep the wound open and accessible. Instead of the scalpel or bis- toury, the blunt end of the scissors sometimes becomes the in- strument by which the adhesions of the cellular tissue covering the tumor are most easily destroyed. In the third step, or the extii'pation of the tumor, either the bistoury, the scalpel or the sage knife may be the most eligible in- strument, according to the consistency of the tumor, whether hard, cartilaginous or bony If it is of sufficiently small size, by steady- ing it with the forceps or tenaculum, it may be excised with a single stroke of the instrument. If too large for this, it may be controlled by passing a loop of ribbon or tape through it, by which its position can be changed at pleasure, to facilitate its complete dissection. The hemorrhage following may be arrested by any of the usual hemostatic measures. TVTien the tumor is of large di- mensions this last step of the operation wiU require great care in the execution, and the blood vessels which may run through its base must be seciu:ely ligated before the tumor is entirely excised. Fig. 225. — Ecraseur of Chassaignac. ABLATIOX OF TUMORS. 203 (c) With the Ecraseur. — The instrument used in this method has received its name from the fact of its crushing action upon the tissues upon which it is appHed and for which it was invented by Chassaignac. The origrnal form of the instrument of Chassaig- nac has been subjected to various modifications, some being made to use with a chain alone, others to carry a wii'e, and others again to carry a chain or a wire alternately. Others like that of Keynal, of INIiles, of Smith, and many others, vary also in shape or in size, but without differing in their general princijjles, and whether employed for the removal of tumors, or in special operations, as Fig. 337.— Ecraseur with Wire. Fig. 238.— Ecraseur with Chain or Wire. those oi castrations in males, or spaying in females, the modus operandi remains the same. This consists in enclosing the base or pedvmcle of the tumor with the chain or wire of the instru- ment, and tightening it more or less rapidly at the discretion of the operator, by means of the screw in the handle until it is com- pressed, strangulated and crushed, and at last entirely separated. The action should be more or less gradual, according to the size of the parts and the consistency and vascularity of the tissues. A 204: OPERATIONS OX THE SKIN AND CELLULAR TISSUE. Fig. 229.— Ecraseur of Reynal. Fig. 229a,— Haussman Ecraseur. slow movement of the ecraseur is essential to avoid hemorrhage, but although this rule is recommended by European authors, it does not seem to be as important as it is reported to be, if we may judge by the results obtained by American practitioners, in view of the manner in which they use this instrument in the operations of castration. Our experience, however, justifies a slow and careful application of the crushing process, especially in the removal of tumors where blood vessels of large size or in a state of disease may be known to ramify, and particularly in the ablations of the champignon of castration. ABLATION OF TUMORS. 205 (d) With the Thermo- C autery . — The ablation of tumors can also be performed with the flat platinum cautery of Paquelin, well heated, by following the same rules as with the bistoury, both when either the growths are small, or the incision of the skin and dissections of the tumor have been previously performed. The advantages gained by the use of the red-heated cautery in controlling the hemorrhage while the incision goes on, is too ob- vious and important to be ignored or depreciated. 2d. LiGATUKE. The Hgature operates on the tumor in its own pecuHar and effective way, by circumscribing the base and depriving it of its nutriment by occludijig the circulation and leaving it to undergo the process of gangrenous dissolution and sloughing, with the ad- vantage of obviating any apprehended danger of subsequent hem- orrhage. The kind of ligatiu-es used for this purpose will vary with the choice of the practitioner. In veterinary siirgery, the material is variously flax, hemp, silk, catgut, india rubber cords, or metallic wire. Whipcord or fishing hne is often used, when a powerful constriction is to be appHed, and their efficiency is in- creased by being waxed or soaped. There are various ways of applying a ligature, but they are all subject to the following rules: the size of the hgatiu-e must be proportioned to that of the parts to be ligated, and to their resistance ; it ought to be aj^phed only upon a hmited portion of the tissues, and the skin ought never to be included, except when the peduncle is very narrow, or the skin already ulcerated. First Method, Simple Ligature. — A cord or band is affixed around the base of the tumor, and tightly tied by a single knot. Sometimes the bleeding knot or double clove-hitch is preferred, drawn tightly and secured by a simple knot. The mortification of the growth may be accelerated, if thought proper, by covering the ligature with some caustic preparation, such as an ointment of sulphide of arsenic, or also by adding to the effect of the Hgatiu*e that of the actual cautery. Second Method, Double Ligature. — This is brought into requisition when the peduncle of the tumor is too large to be easily embraced by a sin- gle Hgature. It is made by piercmg the base of the pj^_ 230.-Tape8try growth through the centre, by means of a straight Ligature. 206 OPERATIONS ON THE SKIN AND CELLULAR TISSUE. needle with a double thread or cord, thus dividing the growth into separate halves, each having its own distinct hgature, tied on opposite sides of the peduncle. Third Method^ Multix)le Ligature. — At times, the tumor may have a sufficiently wide base to require the addition of a third ligature in order to secvire a sufficient amount of constriction to slough the entire mass, in which case special needles become necessary. These are longer than the ordinary ones, though more or less flexible, and with an eye in the centre, additional to that at the extremity, according to indications. When the tumor is to be divided into three portions two needles are necessary, and a correspondingly long thread. The needles being passed together through the base of the tumor, with sufficient intervals between to divide it into three nearly equal Fig. 231.— Treble Ligature. parts, leave, when drawn through, three Ugatures with which to enclose separately the central and two lateral portions of the peduncle. If it becomes necessary to apply four ligatures, two different needles are necessary, one (female) long, having an eye in the Fig. 232.— Female Needle. Fig. 233.— Male Needle. centre, and another (male) of the ordinary form, with the eye at its extremity, but of a size which will permit its passage with a double thread through the central eye of the other. This male needle is to carry a long, double thread. The manipulation is very obvious. The first needle is inserted far enough to bring the central eye half way through the growth, and the second needle is passed through it, and out at the other side ; then, draw- ing out the first, two double ligatures are left, or one for each quarter of the tumor. All that then remains is the tying of the four knots. To describe it more in detail, the female needle is inserted in ABLATION OF TUMOKS. 207 Fig. 234. -1st Step of the Ligature by Four. Fig. 235.— 2d Step of the Ligature by Four. the growth until the eye reaches the centre, when the male needle is introduced at a right angle with it, and passed through the eye, as in Fig. 234, to be drawn out on the opposite side of the tumor caiTying the Ugatures with it (Fig. 235). In the second step of the operation, the passage of the male needle through the tumor with the double ligatxu*e is completed, and by the sej^aration of the needle from one of the threads, two threads are left loose. The female needle is then pushed through the tvunor, when one of the threads is cut off (Fig. 236) ; the fourth step being completed by having the female needle drawn back Fig. 236.— 3d Step of the Ligature by Four. Fig. 237.^th Step of the Ligature by Four. through its original tract with the last threads or loop (Fig. 237), and when the needle is finally separated, it leaves the tumor divided into four segments by fomr threads, whose extremities are drawn and tightly seciu-ed by a single knot (Figs. 238, 239). 208 OPERATIONS ON THE SKIN AND CELLULAR TISSUE. Fig. 239.— The Liga- tures Secured. Fig. 338.— The Tumor divided In Four. Fourth Method, Subcutaneous Ligature. — This method is sel- dom practiced, as there are always objections to leaving under the skin the mortified structures divided by the constriction of the cord. But as there may be circumstances under which the growth cannot be immediately uncovered, its appHcation becomes a ques- tion of necessity. Three needles are required: one. A, straight and sharp; the second, B, straight and pointed; the third, C, curved and also pointed. These are placed upon a single long thread. T'^"^'"'^ II a Fig. 240.— Thread and Needles for Subcutaneous Ligatures. FiG. 241.— 1st Step. The growth A being subcutaneous, and spherical in shape, a vertical cutaneous fold is raised above its superior thii'd, through the base of which the needle A is introduced. Leaving the fold loose, and the skin resuming its position, a first portion of liga- ture is foimd in place, under the teguments, surrounding one- third of the cii'cumference at C (Fig. 241). The curved needle, C, is then passed through the tumor, entering at C, and coming out at B, with the loop D, and at B the needle is removed (Fig. 242). By these first steps of the operation, the superior thii-d of the growth is surrounded by the loop of thread B, C, D, both of whose ABLATION OF TUMORS. 209 Fig. 242.— 3d Step. Fig. 243.— 3d Step. extremities come out by the same opening (Fig. 243), while a sec- ond thread, f f, is free between the superior and the two lower thirds of the tumor (Fig. 244). The manipulations for the superior thii'd of the growth ai'e repeated for the lower third, with another thread, and the middle third is then surrounded by two parallel threads A, B and C, D (Fig. 245). Fig. 244.-^th Step. Fig. 245.— 5th Step. Both of these two threads are joassed into the curved needle, and it then becomes easy to carry under the skin the extremity of the thread B to the opening D, and the thread A to the opening C, where it will be tied to thread B. All the threads A, B, C, D will thus form a loop embracing the middle third of the growth, as the other threads will surround the upper and the lower thirds. All the ligatures can be then tied to the required degree and the operation is completed (Figs. 246, 247). Fig. 2J6.— The Ligatures in Position. Fig. 247.— The Ligature Secured. When the ligature that is to apply the necessary constriction upon the base of the tumor is in place, it must be tied more or 210 OPEKATIONS ON THE SKIN AND CELLULAR TISSUE. less suddenly and firmly, but never with sufficient force to pro- duce an immediate section, an operation which could have been more easily performed, and with less pain, with the bistoury. To avoid this section, apply the constriction slowly, and in accordance with the effects produced, and the resistance encountered by the ligature. If the tissues are soft and frangible, it would be unsafe to complete the constriction at once, and it should be deferred to a later period ; if, on the contrary, it is hard and resisting, the ligature may be drawn tightly, and firmly tied at once. Ordinary traction on the ligature may be made with the hands only, but when extra strong and steady traction is required, wooden holders will prove of great assistance. These means of securing the hga- ture on the tumor are successful so long as it is comparatively superficial, but if it is situated at a certain depth, special instru- ments are requu'ed. Among these is one particularly adapted to the removal of growths from the natural cavities, such as the nasal, rectal, vaginal or inguinal regions. It consists of a wooden or metallic tube, of variable length, through which the loop of a double, strong, waxed Hgature can be introduced into the cavity Fig. 248.— Ligature Carrier, and adjusted around the base of the tumor, and when in position, tightened by traction on the thread at the mouth of the tube, and so secured that the constriction can be maintained at any degree of tightness, and increased or relaxed at pleasure. 3d. — Elastic Ligature. This is but a variation from the ordinary ligature, in which an india-rubber cord or tubing of suitable diameter is substi- tuted for the other means of constriction. It is applied like the others at the base of the^tumor, and secured in the same manner. The peculiarity of its action arises, of course, from its elasticity, the result of which is a constant unrelaxing, self-regulating con- striction, which continues automatically until the ablation is effected. The growth upon which the elastic ligature is appHed soon begins to undergo changes, which may be at first unnoticeable. ABLATION OF TUMORS. 211 But presently it becomes cooler, the skin becomes soft, flabby, and of a dark brownish color ; the mass becomes dry and con- tracted, and in from fifteen to twenty days it drops off, leaving a wound which heals in the usual manner. The use of this Hgature is, we believe, principally advantage- ous for small growths, and we have obtained good results from it in the castration of medium or small-sized animals, as well as in the treatment of small and superficial tumors, as warts, and the like. But in respect to large growths, such as the fibromas of the elbow joint, from the enormous size of the wovmd which follows, and the excessive length of time this requires to heal, we cannot feel justified in recommending it in similar cases. 4th. — Removal by Tearing. This is a method of extirpating tumors by mere force, grasp- ing them with one hand or with the forceps, and with the other they are simply — with a twisting motion — torn from their connec- tion. Of course it can only be practiced on small growths, but it has the advantage of preventing hemorrhage, and can be jserf ormed with the hands alone, or with the assistance of special forceps or nippers. The principal objection is that it sometimes fails to remove the fundamental element of the growth, and a renewal of the trouble may be looked for. 5th. — Puncture. This subject has already been partially considered. It is per- formed with either the bistoury, the lancet, or the trocar, but it is principally appHcable to soft tumors only, and as by its un- aided action it is ordinarily insufiicient to effect their complete disappearance, it becomes necessary to resort to instrumental help, in which cauterization with the pointed red iron, bhstering apphca- tions, or the injection of irritating or modifying compounds, as solution of tincture of iodine, become the efficient adjuncts, if not in truth the actual curatives. CHAPTEK VI. OPERATIONS ON BONES. FRACTURES. In technical language a fracture is a " solution of continuity in the structure or substance of a bone," and it ranks among the most serious of the lesions to which the horse — or any animal — can be subject. It is a subject of special interest to veterinarians, and to horse owners as well, in view of the variety of forms in which it may occur, as weU as of the loss of time to which it sub- jects the patient, and the consequent suspension of his earning capacity. Though of less serious consequence in the horse than in man, it is always a matter of grave imj)ort. It is always slow and tedious in healing, and is fre- quently of doubtful and unsatisfactory result. This solution of continuity may take place in two principal ways. In the most numerous in- stances it includes the total thickness of the bone and is a complete fracture. In other cases it in volves a portion only of the thickness of the bone, and for that reason is described as incomplete (Fig. 250). If the bone is divided into two separate portions, and the soft parts have received no injury, the fracture is a simple one ; or it becomes compound if the soft parts have suffered laceration, and comminuted if the bones have been crvished or ground into fragments, many or few. The direction of the break also determines its further classification. Broken at a right an- gfle, it is transverse (Fig. 251) ; at a FIG. 249.-Complete ^ ' i -^ i \t Fracture. different angle it becomes oblique FRACTURES. 213 (Fig. 252), and it may be longitudinal or lengthwise. In a com- plete fracture, especially of the obhque kind, there is a condition of great importance in resjject to its effect upon the ultimate re- sult of the treatment, in the fact that from various causes, such as muscular contractions or excessive motion, the bony fragments do not maintain their mutual coaptation, but become separated at the ends, and this fact has made it necessary to add another descrip- tive term in the words — with displacement. And this term again suggests its negative, and introduces the fracture without displace- FlG. 251.— Transverse Fracture of the Radius. Fig. 252.— Oblique Frac- ture of the Femur. 214 OPERATIONS ON BONES. ment, when the facts justify this description. Again, a fracture may be intra-artlcular or extra^articidar, as it extends within a joint or otherwise, and once more, intra-periosteal, when the peri- osteum remains intact. Axid, finally, there is no absolute limit to the use of descriptive terminology in the case. The condition of displacement is largely influential in deter- mining the question of treatment, and as affecting the final result of a case of fracture. This, however, is dependent njDon its loca- tion or whether its seat be in one or more of the axes of the bone, in its length, its breadth, its thicknsss, or its circumference. An incomj)lete fractiire may also be either simple or comminuted, the periosteum, in the latter case when it is intact, keeping the frag- ments together, the fracture in that case belonging to the inti'a- periosteal class. At times there is only a simple fissure or split in the bone, making a condition of much difficulty of diagnosis. Two varieties of originating cause may be recognized in cases of fracture. They are the 2>f'&(iisposing and the occasional. As to the first, different species of animals differ in the degree of their liabHity. That of the dog is greater than that of the horse, and, in horses, the various questions of age, the mode of labor, the season of the year, the portion of the body most exposed, and the existence of ailments, local and general, are aU to be taken into account. Among horses, those employed in hea\y draught work or that are driven over bad roads, are more exposed than Hght-draught or saddle horses, and animals of different ages are not equally liable. Dogs and young horses, with those which have become sufficiently aged for their bones to have acquired an enhanced degree of frangibility, are more hable than those which have not exceeded the time of their adult prime. The season of the year is undoubtedly, though in an incidental way, an important factor in the problem of the etiology of these accidents, for though they may be observed at all times, it is during the mouths when the shppery condition of the icy roads renders it difficult for both men and beasts to keep their feet, that they occur most frequently. The long bones, those especially which belong to the extremities, are most frequently the seat of fractures, from the circumstance of their superficial position ; their exposure to contact and collision, and the violent muscular efforts involved both in their constant rapid movement and then- labor in the shafts or at the pole of heavy and heavily laden carriages. FRACTURES. 215 The relation between sundiy idiosjnicrasies and diatheses and a liability to fractures is too constant and well established a path- ological fact to need more than a passing reference. The history of rachitis, of melanosis, and of osteo-porosis, as related to an abnormal frangibihty of the bones, is a 25art of oiir common medi- cal knowledge. There are few persons who have not known of cases among their friends of frequent and almost spontaneous fractiu'es, or at least of such as seem to be produced by the slightest and most inadequate violence, and there is no tangible reason for doubting an analogous condition in individuals of the equine constitution. Among local predisposing affections, mention must not be omitted of such bony diseases as caries, tuberculosis, and others of the same class. Occasional or "efficient" causes of fracture are in most instances external traumatisms, as violent contacts, coUisions, falls, etc., or sudden muscular contractions. These external acci- dents are various in their character, and are usually associated with quick muscular exertion. A \'iolent, ineffectual effort to move too heavy a load ; semi-spasmodic bracing of the frame to avoid a fall or resist a pressure; a quick jump to escape a blow; stoi:)ping too suddenly after speeding ; struggling to Hberate a foot from a rail — perhaps to be thrown in the effort — aU these are familiar and easy examples of accidents hapj)ening hourly, by which our equine servants become sufferers. We may add to these the fractiu*e of the bones of the vertebrae, occui'ring when a patient is cast for the pvu-pose of undergoing a surgical opera- tion, quite as much the result of muscular contraction as of a jDre- existing diseased condition of the bones. A fracture occuiTing under these circumstances may be called with propriety indirect^ while one which has resulted from a blow or a fall differently caused is of the direct kind. The symptoms belonging to the existence of fracture vary ac- cording to the site of the lesion. In case of its being on a bone of the extremity there is irregularity in the performance of the functions of the apparatus to which the fractured bone belongs, and as a necessary consequence of the existing lesion, lameness more or less marked. If the broken bone belongs to one of the extremities, the impossibility of the performance of its natural function, in sustaining the weight of the body and contributino- to the act of locomotion, is usually comj)lete, though the degree of 216 OPERATIONS OX BONES. poweiiessness ^yi\l vary according- to the kind of fracture and the bone which is injured. For example, a fractui-e of the cannon bone without displacement, or of one of the phalanges which are siuTOunded and sustained by a complex fibrous structvire, is, in a certain degree, not incompatible with some amount of resting of the foot. But, on the contrary, if the shank bone, or that of the forearm be the impHcated member, it would be very difficidt for the leg to exercise any agency whatever in the support of the body. And in a fractiu-e of the lower jaw, it would be obviously futile to expect it to contribute materially to the mastication of food. A fractui'e seldom occurs which is not accompanied with a degree of deformity, greater or less, of the region or the leg affected. This is due to the exudation of the blood into the meshes of the surrounding tissues and to the displacement which occui's between the fragments of the bones, with subsequently the sweUing which follows the inflammation of the surrounding tissues. The character of the deformity will mainly depend uj)on the manner in which the displacement occiu's. In a normal state of things the legs perform their movements with the joints as their only centres or bases of action, with no participation of intermediate points, while with a fractiu-e the flexibility and motion which will be observed at unnatural points are among the most strongly characteristic signs of the lesion. No one need be told that when the shaft of a Umb is seen to bend midway between the joints, with the lower portion swinging freely, that the leg is broken. But there are still some conditions where the excessive mobility is not easy to detect with certainty. Such are the cases where the fracture exists in a short bone, near a movable joint, or in a bone of a region where several short and small bones are united in a group, or even in a long bone where its situation is such that the muscular covering prevents the visible manifestation of the symptom. If the situation of a fracture precludes its discovery by means of this abnormal flexibility, other detective methods remain. And after all there is one decisive sign which, though it may not avail in every case, as it does not, is in cases where its testimony can be secvired absolute and positive beyond question. This is crej)- itatioti, or the peculiar effect which is produced by the friction of the fractured surfaces one aver part of the leg as in an inflexible case. Fracture of the first Phalanx. — The hinder extremity is more liable than the fore to this injury. It is usually the result of a Fig. 2S0 — Splint and Dressing on Lower Part of Foro Leg. Fig. 291.— Bourgelafs Splint for Frac- ture of the Cannon and Phalanges. FRACTURES. 257 Fig. 28-2 Longitudinal Fractures of the 09 Suffraginis. Fig. s»83. Comminuted Fracture of the 03 Suffraginis. violent effort, or of a sudden misstep or twisting of the leg, and may be transverse, or, as has usually been the case in our experi- ence, longitudinal (Fig. 282), extending from the upper articular surface down to the centre of the bone and generally oblique and often comminuted (Fig. 283). The symptoms are the swelling and tenderness of the region, possibly crepitation ; a certain ab- normal mobility; an excessive degree of lameness, and in some instances a dropping back of the fetlock, with perhaps a straight- ened or upright condition of the pastern. The difficulty of reduction and coaptation in this accident, and the probability of bony deposits, as of ringbones, resulting in lameness, are circumstances which tend to discourage a favorable prognosis. The treatment is that which has been recommended for aU fractui'es, as far as it can be apj)lied. The iron splint of figure 281 gives excellent results in many instances, but if the fracture is incomplete and without displacement a form of treatment less energetic and severe should be attempted. One case is within our knowledge in which the owner of an injured horse lost his property by his refusal to subject the animal to treatment, the post mortem revealing only a simple fracture with very slight dis- placement. 258 OJtilAlIONS ON E05'£S. Fractxires of the Coronet. — Though these are generally of the comminuted kind, there are often conditions associated with them which justify the surgeon in attempting their treatment. Though crepitation is not always easy to detect, the excessive lameness, the soreness on j)ressure, the inability to carry weight, the difficulty experienced in raising the foot, all these suggest, as the solution of the question of diagnosis, the fracture of the coronet, with the accompanying realization of the fact that there is yet, by reason of the situation of the member, immobilized as it is by its structure and its surroundings, room left for a not iin- favorable prognosis. Only a slight manipulation will be needed ia the treatment of this lesion. To render the immobility of the Fig. 284.— Animal with Fracture below the knee with Spints 4nd Support KoBting in Slings. FRACTURES. 259 region more fixed, to support the bones in their position by band- aging, and to establish forced immobility of the entire body with the slings is usually all that is required. Ringbone, being a common sequela of the reparative process, must receive due at- tention subsequently. One of the severest complications likely to be encovmtered is anchylosis. Fractures of the Os 2)edls. — Though these lesions are not of very rare occiu'rence their recognition is not easy, and there is more of speculation than of certainty pertaining to theu' diagnosis. The animal is very lame, and, as much as possible, spares the in- jured foot, sometimes resting it upon the toe alone and sometimes not at all. The foot is very tender, and the exploring pincers of the examining surgeon causes much pain. There is nothing to encoiu'age a favorable prognosis, and a not unusual termination is an anchylosis with either the navicular bone or the coronet. No method of treatment needs to be suggested here, the hoof performing the office of retention unaided. Local treatment by baths and fomentations will do the rest. It may be months before there is any mitigation of the lameness. Fracture of the Sesamoid JBones. — This lesion has been con- sidered by veterinarians, erroneously, we think, one of rare oc- currence. We believe it to be more frequent than has been sup- posed. Many observations and careful dissections have convinced us that fractures of these little bones have often been mistaken for specific lesions of the numerous ligaments that are implanted upon their superior and inferior parts, and which have been de- scribed as a "giving way" or "breaking down" of these liga- ments. In our 2^ost mortem examinations we have always noted the fact that when the attachments of the Hgaments were torn from their bony connections minute fragments of bony structure were also separated, though we have failed to detect any diseased process of the fibrous tissue composing the ligamentous substance. From whatever cause this lesion may arise, it can hardly be considered as of a traumatic nature, no external violence having any apparent agency in jDroducing it, and it is our belief that it is due to a pecuUar degeneration or softening of the bones them- selves, a theory which acquires plausibility from the consideration of the spongy consistency of the sesamoids. The disease is a peculiar one, and the suddenness with which different feet are successively attacked, at short intervals and without any obvious 2G0 OPERATIONS ON BONES. cause, seems to prove the existence of some latent morbid cause which has been vmsuspectedly incubating. It is not peculiar to any particular class of horses, nor to any special season of the year, ha%ing fallen under oui' observation in each of the four seasons. The general fact is reported in the history of a majority of cases that it makes its appearance without premonition in animals which, after enjoying a considerable period of rest, are first exercised or put to work, though in point of fact it may manifest itself while the horse is still idle in his stable. A hypothetical case, in illustration, will explain our theory. An animal which has been at rest in his stable is taken out to work and it will be presently noticed that there is something un- Fig. 285.— Fracture of Os Sesamoids. usual in his movement. His gait is changed, and he travels with short, mincing steps, without any of his accustomed ease and free- dom. This may continue until his return to the stable, and then, after being placed in his stall, he will be noticed shifting his weight from side to side and from one leg to another, continuing the movement until rupture of the bony structiu-e takes place. But it may happen that the lameness in one or more of the ex- tremities, anterior or posterior, suddenly increases, and it be- comes evident that the rupturv has taken place in consequence of a misstep or a stumble while the horse was at work. Then, upon coming to a standstill, he will be found with one or more of his FRACTURES. 261 toes turned up — he is unable to place the affected foot flat on the^ ground. The fetlock has dropped and the leg rests upon this part, the skin of which may have remained intact or may have been more or less extensively lacerated. It seldom happens that more than one toe at a time will turn up, yet still the lesion in one wiU be followed by its occui'rence in another. Commonly twa feet of a biped, the anterior or posterior, are affected, and we re- call one case in which the two fore and one of the hind legs were included at the same time. The accident, however, is quite as likely to happen while the horse is at rest in his staU, and he may be found in the morning standing on his fetlocks. One of the earliest of the cases occurring in our own experience had been under our care for several weeks for suspected disease of the fet- locks, the natvire of which had not been made out, when, appar- ently improved by the treatment which he had undergone, the patient was taken out of the stable to be walked a short distance into the country, but had little more than started when he was called to a halt by the fracture of the sesamoids of both fore legs. While there are no positive premonitory symptoms known of these fractvires we believe that there are signs and symptoms which come but little short of being so, and the appearance of which will always justify a strong suspicion of the truth of the case. These have been indicated when referring to the soreness in standing, the short "mincing" gait, and the tenderness be- trayed when pressure is made over the sesamoids on the sides of the fetlock, with others less tangible and definable. These injuries can never be accounted less than serious, and in our judgment will never be other than fatal. If our theory of their pathology is the correct one, and the cause of the lesions is tnily the softening of the sesamoidal bony structure and inde- pendent of any changes in the ligamentous fibers, the possibihty of a soUd osseous union can hardly be considered admissible. In respect to the treatment to be recommended and instituted it can only be employed with any rational hope of benefit during- the incubation, and with the anticipatory piu'pose of prevention. It must be suggested by a suspicion of the verities of the case^ and apphed before any ruptm-e has taken place. To prevent this and to antagonize the causes which might precipitate the final catastrophe — the elevation of the toes — resort must be had to the shngs and to the application of firm bandages or splints, perhaps 2G2 OPERATIONS OX EONES. of plaster of Paris, with a high shoe, as about the only indications which science and nature are able to offer. When the fracture is an occun-ed event, and the toes, one or more, are turned up, anv f urther resort to treatment will be futile. DISLOCATIONS. Strength and solidity are so combined in the formation of the joints of our large animals that dislocations or luxations are inju- rios which are but rarely encountered. They are met with but seldom in cattle and less so in horses, while dogs and smaller animals are more often the sufferers. The accident of a luxation or (its synonym) dislocation {dis- jylacement) is less often encountered in the animal races than in man. This is not because the former are less subject to oc- casional violence involving powerful muscular contractions, or are less often exposed to casualties similar to those which result in luxations in the human skeleton, but because it reqviires the co- operation of conditions, anatomical, physiological, and perhaps mechanical, present in one of the races and lacking in the other, but which can not in every case be clearly defined. Perhaps the greater relative length of the bony levers in the human formation may constitute a cause of the difference. Among the predisposing causes in animals, caries of articular surfaces, articiilar abscesses, excessive dropsical conditions, de generative softening of the ligaments, and any excessive laxity of the soft structures, may be enumerated. The symptoms of fractures and of dislocations are not always so variant as to preclude the possibility of error in determining a case without a thorough examination, but the essential difference, as it must always exist, must always be discoverable. In a dislocation there is one very pecuhar and characteristic feature in the impossibility of motion associated with an excessive liberty of movement — the impossibility of active or controlled motion, and a facility of passive movement (or movableness) at either the affected joint or at another of the same leg near to it. In a dislocation of the scapulo-humeral (or shoulder) joint the animal possesses no power of motion over the limb — no muscular contraction can avail to cause it to perform its various functions — but in the hands of the surgeon it may be made to describe a DISLOCATIONS. 263 series of movements which would be simpy.r -yapo&t;iiol« with the joint in a state of integrity. Both fractnrf/S and luxations are marked by deformity, but while in a fracture with displacement there will usually be a shortening of the leg, a dislocation may be accompanied by either a shortening oi' a lengthening. SweUino- of the parts is usually a well-denned feature of these injuries. "With all this similarity in the symptomatology of luxations and fractures, there is one sign which either by its presence or its absence will greatly assist in Kcttling a case of differential diag- nosis, and this is the existence or lack of crejntatlon. It has no place or cause in a mere dislocation ; it belongs to a fracture, if it is a complete one. If there is crepitation with a dislocation then it proves that there is a fracture also. The prognosis of a luxation is comparatively less serious than that of a fracture, though at times the indications of treatment may prove to be so difficult to apply that complications may arise of a very severe character. The treatment of luxations must of course be similar to that of fractures. Reduction, naturally, will be the first indication in both cases, and the retention of the replaced parts must follow. The reduction involves the same steps of extension and counter- extension performed in the same manner, with the patient subdued by anesthetics. The difference between the reduction of a dislocation and that of a fracture consists in the fact that in the former the object is simply to restore the bones to their true normal position, with each articular surface in exact contact with its companion surface, the apparatus necessary afterwards to keep them in situ being similar to that which is employed in fracture cases, and which will usually require to be retainei for a period of from forty to fifty days, if not longer, before the ruptured retaining hgaments are suffi- ciently firm to be trusted to perform theu* office unassisted. A vari- ety of manipulations are to be employed by the surgeon, consisting in pushing, pulling, pressing, rotating, and indeed whatever move- ment may be necessary, until the bones are forced into such rela- tive positions that the muscular contraction, operating in just the right directions, pulls the opposite matched ends together in true coaptation, a head into a cavity, an articular eminence into a trochlea, as the case may be. The '' setting" is accompanied by a 264 OPEBATIONS ON BONES. peculiar snapping sound, audible and significant, as well as a visible return of the surface to its normal symmetry. /Special JJislocatlons. — "Wliile all the articulations of the body are liable to this form of injury, there are three in the large animals which may claim a special consideration, viz: 2^he Shoulder Joint. — We mention this displacement without intending to imply the practicability of any ordinary attempt at treatment, which is usually unsuccessful, the animal whose mishap it has been to become a victim to it being disabled for Hfe. The superior head of the arm bone, as it is received into the lower cavity of the shoulder blade, is so situated as to be liable to be forced out of place in foiu' directions. It may escape from its socket, according to the manner in which the violence affects it, outward, inward, backward, or forward, and the deformity which results and the effects which foUow will correspondingly differ. We have said that treatment is generally unsuccessful. It may be added that the difficulties which interpose in the way of reduction are nearly insurmountable, and that the apj)lication of means for the retention of the parts after reduction woidd be next to impossible. The prognosis is svifficiently grave from any point of view for the luckless animal with a dislocated shoulder. The Hi}) Joint. — This joint pai'takes very much of the char- acteristics of the scapiilo-humeral articulation, but is more strongly built. The head of the thigh bone is more separated, or promi- nent and rovmder in form, and the cup-like cavity or socket into which it fits is much deeper, forming together a deep, trae ball- and-socket joint, which is, moreover, re-enforced by two strong cords of funicular ligaments, which unite them together. It will be easily comprehended, from this hint of the anatomy of the re- gion, that a luxation of the hip joint must be an accident of com- l^aratively rare occurrence. And yet cases are recorded in which the head of the bone has been affirmed to slip out of its cavity and assume various positions, inward, outward, forward, and back- ward. The indications of treatment are those of all cases of dislocation. When the reduction is accomplished the surgeon will be apprised of the fact by the peculiar snajDping sound usually heard on such occasions. Pseudo luxations of the Patella. — This is not a true disloca- tion. The stifle bone is so peculiarly articulated with the thigh DISLOCATIONS. 265 bone that the means of union are of sufficient strength to resist the causes which usually give rise to luxations. Yet there is some- times discovered a peculiar pathological state in the hind legs of animals, the effect of which is closely to simulate the manifestation of many of the general symptoms of dislocations. The peculiar pathological condition originates in muscular cramps, the action of which is seen in a certain change in the coaptation of the artic- ular surfaces of the stifle and thigh bone, resulting in the exhibi- tion of a sudden and alarming series of symj)toms which have suggested the phrase of "stifle out" as a descriptive term. The animal so affected stands quietly and flrmly in his stall, or per- haps with one of his hind legs extended backward, and resists every attempt to move him backward, and if urged to move for- ward he will either refuse, or comply with a jump, with the toe of the disabled leg di-agging on the ground and brought forward by a second effort. There is no flexion at the hock and no motion at the stifle, while the circular motion of the hip is quite free. The leg appears to be much longer than the other, OAving to the straight- ened position of the thigh bone, which forms almost a straight line with the tibia from the hip joint down. The stifle joint is motionless, and the motions of all the joints below it are more or less interfered with. External examination of the muscles of the hip and thigh discovers a certain amount of rigidity, with perhaps some soreness, and the stifle bone may be seen projecting more or less on the outside and upper part of the joint. This state of things may continue for some length of time and until treatment is appHed, or it may spontaneously and suddenly terminate, leaving everything in its normal condition, but perhaps to return again. Pseudo-dislocation of the patella is likely to occur under many of the conditions which cause actual dislocation, and yet it mav often occur in animals which have not been exposed to the or- dinary causes, but which have remained at rest in their stables. Sometimes these cases are referred to falls in a slippery stall, or perhaps shpping when endeavoring to rise ; sometimes to weakness in convalescing patients ; sometimes to lack of tonicity of structure and general debility; sometimes to relaxation of tissues from want of exercise or use The reduction of these displacements of the patella is not usually attended with difficulty. A sudden jerk or spasmodic 266 OPERATIONS ON BONES. action will often be all that is required to spring the patella into place, when the flexion of the leg at the hock ends the trouble for the time. But this is not always sufficient, and a true reduction may still be indicated. To eflect this the leg must be drawn well forward by a rope attached to the lower end, and the patella, grasped with the hand, forcibly pushed forward and inward and made to sUp over the outside border of the trochlea of the femur. The bone suddenly shps into position, the excessive rigor of the leg ceases with a spasmodic jerk, and the animal may walk or trot away without suspicion of lameness. But though this may end the trouble for the time, and the restoration seem to be perfect and permanent, a repetition of the entire transaction may subse- quently take place, and perhaps from the loss of some portion of tensile power which would natm-ally follow the original attack in the muscles involved, the lesion might become a habitual weakness- Warm fomentations and douches with cold water will often promote permanent recovei-y, and liberty in a box-stall or in the field will in many cases insure constant relief. The use of a high- hepled shoe is recommended by European veterinarians. The use of stimulating liniments, with frictions, charges or even severe blisters, may be resorted to in order to prevent the repetition of the difficulty by strengthening and toning up the parts. AMPUTATIONS. To amputate is simply to cut off. In veterinary surgery it comprehends the removal from the body of an animal of one or more of its projecting parts, as a portion of a leg, or an entu'e ex- tremity; the horns, the ears, the penis, the tail, etc. From the nature of the case it involves a degree of deformity, greater or less, with a loss of the function of the severed member. The difference between amputation and extirpation has respect only to the organs or members which become subject to the opera- tion. The parts already referred to are amputated ; the organs or members liable to extii'pation have their seat in the interior regions, as the testicles, the ovaries, and even the uterus, in females, and any other non-vital organs or morbid growths, including some of the glandular structures, more particularly the lymphatic. Amputations in domestic animals are of two classes : In one case they are performed at the dictate of a capricious fashion, for A:MPnTATIONS. 267 tlic alleged purpose of imi^rovinj the appearance of the animal, and are performed upon parts of only secondary and accessory functional importance, and vrhich may be removed almost with im- punity, as the ears, the tail or the horns. In the second class, the subject is brought under the general laws governing diseases and remedies, and they are practiced only as it becomes necessary by the existence of diseased conditions in important organs, such as the penis, the tongue and the locomotory organs. In this class the serious nature of the operation must be measured by the importance of the function fulfilled by the organ implicated. The instruments necessary for the operation are amputating knives, similar to those used in human surgery, or more commonly those belonging to our veterinary work, a strong, convex bistoury. Figs. 286, 28~.— Amputating Knives. Fig. 28S.— Amputating Saw. which is generally sufficient, an amputating saw, means of tem- 2iorary hemostasis, cord, an elastic band or ligature, needles, sutures and artery and dissecting forceps. For dressings, balls and pads of oakum of various sizes, com- presses and antiseptic washes are needed. In the present chapter we shall limit our consideration to the amputation of the legs, the horns and the ears. 268 operations on bones. Amputation of Members or Limbs. The amputation of the Hmbs of animals is a matter of much less importance than a similar mutilation would be in human sur- gery, and its occurrence is relatively much less frequent, being necessarily limited by the exclusion of that large class of subjects whose usefulness would necessarily be lost by the total impaii'ment of theu' organs of locomotion, thus rendered unfit for their work, and even when it is indicated for animals designed for food con- sumption, the question becoming pertinent whether it would not be wiser and more profitable, in a large majority of cases, as it would unquestionably be more humane, to deUver them at once to the butcher, before subjecting them to a painful mutilation which must necessarily more or less impair their condition, and therefore materially diminish theu- market value. As a matter of fact, it is principally upon dogs that, in ordinary cu'cumstances, the veterinarian is called to operate in this manner, as even in his mutilated condition, he may continue to be able to fulfil many of his duties as one of the domestic animals. But still there are circumstances in respect to animals other than the dog, under which the operation may be indicated and rationally prac- ticed, as when the life of a valuable animal is to be saved on account of his desii'able qualities as a breeder, and which may not be dis- abled from his special function by the lack of a hmb. A valuable ram or bull, a high-bred ewe or cow, or perhaps also a mare or a stalHon, may, for such a reason, become proper subjects for an amputation. But even under these conditions, other considerations of impor- tance must not be overlooked, and whether it is a fore or a hind leg which must be sacrificed, will be a point of great weight to be considered in deciding for or against the operation. A female with only three legs may yet carry a foetus to term, and be fat- tened and put in good condition before being sold for meat, or may possibly be covered by a male ; but it would be impossible for the stallion or the bull, deprived of one of his hind quarters, to mount and keep the raised position a sufficient time to complete the act of copulation. Animals of small size and weight, being more supple and active in their movements, suffer least from the loss of one of their Umbs. The distance from the mass of the body to the seat of the ampu- AMPUTATIONS. 269 tation is also a consideration of moment. A reference to all the reasons will necessarily prove that of all domesticated animals, the horse is probably the one upon which the operation is least justifiable. If ever to be performed upon him, it can only be upon the lower regions of the leg close to the grv>und, inasmuch as the shortened leg can still be made useful as an apparatus of support, either dii'ectly or indirectly, by artificial means. The sum of the matter seems to be embodied in the following general considerations pertaining to the question of the amputa- tion of the limbs of our domestic animals : 1st. In Dogs it is indicated in diseases of both bones and soft parts, as in comminuted fractures, complicated with contused wounds of the skin or other soft strictures ; in old caries, com- plicated with suppurative arthritis ; in osteo-sarcoma ; in the crushing of muscular tissues around bones and their complete sej)aration ; in extensive gangrene, as that resulting from the ap- plication of too tight a bandage ; in chronic suppurative articular disease ; in sloughs of soft tissues surrounding the exposed bones ; and in deep cancerous affections. 2d. I71 Ovines. — Indications are offered, as in dogs, in com- minuted fractures, with lacerations of soft tissues, and more com- monly in complicated phalangeal arthritis. 3d. In ^ovines. — The same conditions exist as in the smaller ruminants. 4th. In JEquines. — Amputation is indicated as a means of saving an animal for breeding purposes ; in compHcated fractures of the cannon bone, or of the phalanges ; in gangrene of the digital organs; extensive abscesses of the same region, with softening of tendons, and in suppurative arthritis. It is also sometimes per- formed for the removal of a supplementary limb. 5th. In Birds. — The amputation of a wing or even of a leg can be performed, either to prevent flight, or to relieve a diseased process of the limb. But in all cases it should be performed upon healthy tissues, above the seat of the disease, and at the greatest, possible distance from the trunk. The number of cases on record is not largo, and they are prin- cipally reported in European veterinary journals. In these we find a case of amputation at the hock in a ewe, by Chabert ; in a cow at the knee, by Chaumontel; in an ox of one of the toes, by 27J OPERATIONS ON BONES. Durant ; in a dog at the arm, by Fromage de Feugre ; in a sheep^ in a case of foot rot, by Lecoq; in a mare at the fetlock, by Maurette ; in a stalHon, on the third phalanx, by Bouley ; and in English journals: in a cow in the metacarj)al region, by Laing; a cow on the hind cannon, by Shield ; and on a mare La this country, by Huidekoper. Others are reported, which were attended by vari- ous degrees of success, many of them, however, terminating fatally. The proper mode of performing the operation is to secure the animal in the decubital position, and to place him under the influ- ence of general anesthesia, securing temporary hemostasis, by the application of the circular Hgatm-e, or a bandage tightly placed above the point of amputation, or, preferably, by using the process of Esmarch, which secures a more perfect removal of the blood, and enables the operator to perform a thoroughly bloodless opera- tion. Digital pressure, sometimes recommended for the smaller animals, will not, however, secure as good a result as that obtained by the circular hgature. The operation is made in two ways : first, in the continuity of the bones, or by the division of the substance of the bone itself ; and second, in their contiguity, or at the nearest sound articula- tion. This last is also called disarticulation. All amputations consist of three steps : The division of the soft tissues, that of the bones, and the arrest or prevention of hemorrhage. TJte First Step, the Division of the Soft Tissues, may be prac- ticed several ways, among which the principal are the circular, eUiptic and the ovalar methods, and that by flaps ; all of which have the common object in view, of lea\dng a flap of proper form and sufficient dimensions to cover the stump of the bone, and prevent its projection beyond the surface of the wound. The circular method, which is the oldest, consists in incising the skin in a circular manner, stretched over the surface of the region with the left hand of the operator, or with that of an assist- ant. This must be done with rapidity, made by one stroke of the knife, appUed as perpendicularly over the skin as possible. If the amputation is to be made in the continuity of the bones, the skin being divided while stretched by the assistant, is sepa- rated from its adhesions underneath, and reversed upward ; when close to the line where it is yet adherent, the muscles are divided circularly, by one stroke of the knife, drawn to the bone. These AMPUTATIONS 271 muscles spontaneously retreat, and the superior stump is drawn upward beyond the cutaneous incision. This action may be facil- itated by separating from the bone whatever attachments may exist between them. The periosteum is thus divided, on a level with the retracted muscles. The amputation in the contiguity of the bones, differs from that in the continuity only in the fact that when the section of the muscles is made, there is no division of the periosteum necessary, and the disarticulation is completed with either the bistoury or amputating knife, or, in preference, with the sage knife. The method hy flaps consists in making on one or both sides of the bones, one or two flaps of skin which ai'e afterwards united to cover the stump, and form the new surface. In amputation by the contiguity of the bone, the method to be preferred, and which may be practiced both fi*om within, out- ward and contrarywise, is this : In the first instance, the knife is passed through the soft tissues at the point where the bone is to be separated, and the entire mass divided by drawing the instru- ment toward the operator in a somewhat obhque dii'ection. In the second way, or from without inward, the flap is first drawn with the jDoint of the knife, and then dissected from without, or, otherwise, made at once in the same direction, by one stroke of the instrument. The flaps must be rounded, not angular, at their line of meeting, and in such a way that the amputated wound wOl represent an elliptic infundibulum, whose center is occupied by the stump of the bone, surrounded by whatever projecting fleshy structures may be brought over it to form a protective cushion. The second step of the operation is that of the section of the bone, or of the articular attachments. In sawing the bone in its continuity, the periosteum being divided, and the soft tissues protected by compresses, some httle art is necessary. The saw applied perpendicvdarly to the axis of the bone, should be worked slowly at first, imtil a track is formed, after which the movement may be more rapid. Pressure upon the instrument is unnecessary, if it has been properly set. Special caution should be observed in finishing, in order to avoid leaving rough edges to be cut off with the bone forceps. The saw must be propelled wholly by the action of the arm of the surgeon, his body remaining completely motionless. When the amputation is made upon the segment of a leg 272 OPERATIONS ON BONES. which has two bones, though they may be divided separately, it will be preferable, if they can be held together with sufficient firmness, to act upon them jointly, but finishing the smaller bone first. The actual disarticulation, or second step of the amputation, is performed by dividing the ligaments or other structures which surround the joint, from without inward. Beginning with the strongest and most external ligament by giving a movement of semi-flexion to the articulation, not necessarily cutting them in theu' middle, the joint is penetrated by inserting the knife be tween the articular surfaces. The double sage knife, according to Bouley, is the most convenient. In articulations composed of ir- regvilar surfaces, united by inter-articular hgaments, care must be taken to avoid injui'ing the bones, and to divide the fibrous cords only, as most of the synovial capsules must be removed, in order to avoid fistulous compHcations. In some disarticulations, according to Bouley, it is necessary to use the saw to remove diarthodiul projections on the surface of the amputated bone, which if left in place would prove a serious obstruction to the cicatrization of the stump The last step of the operation is the arrest, or, what is better, the 2)fevention of the hemorrhage. It consists simply in twisting or ligating the arterial vessels which have been divided. If the means used for the temporary hemostasis prevent the operator from discovering its source, the ligatures can be slightly relaxed until it is betrayed by the oozing of the blood. The various methods of permanent hemostasis have already been considered, and need no further description. In the application of a dressing to the wound of amputation, the requu-ements are few, but they are imperative, and they are sufficient, assuring the best results by their simplicity and soHd- ity. The soft tissues and the skin must be brought together, over the extremity of the bone, and kept together by the appLca- tion of a continued suture, lea\dng a place of drainage for the suppuration and the sloughing of the Hgatures which occlude the blood vessels, and the extremities of these must be gathered to- gether at the most dependent part of the wound. This is com- pleted and protected by the application of an antiseptic dressing consisting of pads of oakum, absorbent cotton, or threads of tourbe, kept in place by rollers, and supported by an outside AMPUTATIONS. envelope of coarse cloth. The "wound may cicatrize by first or by second intention, according to the severity of the original injury, as well as to the amovmt of attention bestowed upon the antisep- tic appHcations which may have been employed. Fig. 289.— Wooden Leg after Amputation. CompHcations are not uncommon after amputations, though they do not materially dififer from those which are encountered in other serious operations. Among those which may be mentioned are: 1st. Secondary hemorrhage, as the result of carelessness in the application of the hgatvu:es, which can be overcome, however, by immediate or lateral compression, or by the renewal of the lig- ature. 2d. Abscesses, of various dimensions, resulting from the presence of the ligatures into the woiind, or possibly of necrosis of the bone. These collections are to be treated in the usual way, as are also underrnining of the shin by suppiarative collections, phlebitis, purulent infection and gangrene, all of these being con- ditions having the same indications as in other forms of traumatic lesions. There are, however, some complications which belong specially to the sequelae of this operation, such as may result from an im- proper section of the bone, which might end in the formation of a conical stump, a condition which, like that of strangulation of the stump, can only be reheved by a new amputation, with a bet- 27J: OPERATIONS ON BONES. ter section of the bone, and more careful attention to the subse- quent dressing. JVecrosis of the amputated bone may also com- plicate the pi'ocess of cicatrization, accompanied by more or less pain and difl'used suppuration, which cannot be relieved until the necrotic bone has sloughed away. Amputations in the contiguity of the bones are, besides, likely to be complicated with synovial Jistidas, which may be of an ar- ticular or tendinous nature. The ordinary forms of treatment in similar cases will be sufficient for these. These general rules regulate amputations of every kind, though the various steps of the operation may have somewhat varied, ac- cording to cu'cumstances. But whether it be in the continuity or contiguity of a bone, or whatever may be the bone involved ; whether the scapulo-humeral joint, the fetlock or the digital re- gion ; or even to remove supplementary digits ; they are of equal applicability, and the general modus operandi remains the same. Even in the operation of amputation of the %oings we find but little room for modification or change. In operating upon the wings of birds, with the principal object of destrojdng their power of flight, it may frequently be accom- plished by simply cutting off the extremity of the wing, at the carpal articulation, with the scissors, and cauterizing the wound with perchloride of iron or nitrate of silver. Another method is to pull out the feathers from the inner side of the wing, as far as the elbow joint, the skin being then incised with a bistoury somewhat below the joint, and dissected and reversed upward, the bones being then divided with the bone forceps. The wound should be carefully washed or sj^onged with cold water, to check the bleeding, and the skin drawn over the stump, secui-ed by interrupted sutures. The. bird requires no special attention, and the wound heals in a few days. Amputation of Horns. The amputation of horns is an operation the description of which dates back to 1790. It is indicated in cases of fractui-es, or of vicious growths which might embarrass the motions and prevent the usefulness of the animal, and also to provide against the mu- tual injuries which cattle are Hable to inflict upon one another. It is also indicated in cases of suppurative collections in the si- nuses, and for the removal of parasites from those cavities. It has AMPUTATIONS. 275 of late not only assumed a place among the operations of fashion, but has found favor from its alleged tendency to improve the quantity and quality of milk, and of the flesh yielded by animals subjected to it. It is in relation to this hj^pothesis that Goxu'don considers it as " a great j^rogress in the raising of horned cattle, and which, on account of the benefits that may be derived from it, is perfectly justifiable." The operation is comparatively a sim- ])\e one, but nevertheless involves special considerations, varying according to the species of the animal. 1st. In Jjovines. — If only the free extremity of the organ is to be cut off, it is done -s^-ith the saw carried rapidly through the horny structure, the animal, of course, being properly secured. But occasionally, especially in cases of fractui'e, the section is to be made near the base, or the middle of the horn, and soft and sensitive tissues are also involved. The amputation must then be made below the fracture with a sharp saw, apphed perpendicularly to the long axis of the horn, and comj)leted as rapidly as possible. The oj)eration will be accomj)anied by some hemorrhage, but not sufficient, usually, to require the ai^pHcation of severe hemo- statics. The wound is dressed with pads of absorbent cotton, or of carbohzed or antiseptic oakum, retained by compresses or the Maltese cross bandage. Possible collections of pus must be watched for, and the sinuses should be carefully cleaned by injec- tions. The dressings are renewed as often as the indications require, and continued until the granulations have closed the cavities of the sinuses, and the suppiu-ation has almost entii'ely subsided. The application of a permanent dressing in the form of a pitch j)laster is recommended by Gourdon. It need not be removed, like the ordinary di'essing, and under some circumstances is of great advantage. Among the probable accidents attendant upon this operation, there are four which require mention : (a) Hemorrhages, more or less serious, always occur after the section of the horn, and of its bony support. Usually, it is sufficiently arrested by the dressing alone, but there are times when the appHcation of the actual cautery becomes necessary to subdue it. (b) Inflammation of the mucous membrane of the sinuses may also follow. In its ordinary manifestation it is not serious, and is 276 OPERATIONS ON BONES. likely to terminate either by resolution or even suppuration, though in a few cases it may be followed by gangrene. (c) Gangrene, which generally manifests itself toward the eighth or tenth day, ordinarily ends in death, and is often accom- panied by an attack of ophthalmia more or less violent. (d) Incomplete cicatrization of the stump, occurring principally in cases in which .the wound has been neglected, and suft'ei'ed to remain too long unprotected by a dressing, and when the mucous membrane of the horn has become the seat of chronic inflamma- tion. A central fistula usually results, accompanied by an abiin- dant suppuration, which is apt to prove exceedingly intractable to treatment. 2d. In 7nany young ruminants this operation is performed on calves two or three months old, and consists in removing the rudi- mentary horns. For this Charlier has invented a peculiar tre- phine kind of circular gouge, which is used as follows : The ani- FiG. 290. — Charlier'B Method of Amputation of ITornB in a Calf, let Step. mal being thrown and held by two assistants, the hair is cut short around the base of the horns, and the trephine applied over the horns in such a manner as to divide the skin and subjacent tissues down to the frontal bone where they ai'e isolated by a circular in- cision. Then by a downward and horizontal twist of the trej^hine the divided structures are gouged out and the secreting matrix of AMPUTATIONS. 277 Fig. 291.— Charlier's Method of Amputation of Horns in a Calf. 2d Step. the horn removed. The hemorrhage is controlled with a com- pressive bandage or other hemostatic, and antiseptic di-essing appHed. The wound generally heals rapidly and without compH- cations. Amputation of the Tail. For some unexplainable reason the term " docking " has been appHed to this operation, which is simjply the removal of some of the vertebrae composing the caudal appendix. It is one of the most peculiar among the operations of fashion, althourrh, of course, under some special conditions incident to all animals, it is also sometimes performed as an operation of genuine beneficent surgery. This may be the case, for example, when the tail is abnor- mally so long and heavy as to interfere with the usefulness and comfort of the animal, or when it becomes the seat of disease and becomes affected with caries or necrosis, or fistulous tracts, or af- fections of the skin. In some instances, also, this curtailing oper- ation does constitute a true surgico-therapeutical means of obtain- ing a local bleeding. Docking, which is of EngUsh origin, is now performed all over the world, and has given rise to a great deal of controversy ujDon the question of its propriety. Whether it is an act of inexcusable cruelty or not, it is not at j^resent our province to decide, but from a surgical point of view we feel that it is due to truth to say that we are satisfied that a gi-eat deal of what has been said in oj)position to the operation results, from the various and, too often, bungling 278 OPERATIONS ON BONES. and cruel methods wliich have characterized the details of the amputation. We beheve that some of these methods may be so modified as to reHeve the operation of its apparent character of cruelty. We refer now especially to the means which have been and are employed for the arrest of the hemorrhage which is likely to follow the section of the blood vessels of the region. The tail has for its bony support a series of the caudal verte- bra — from fifteen to eighteen — varying in number and diminish- ing in size from the sacrum to the end of the organ, and united by a thick inter-vertebral ligament, and attached to them are the caudal muscles in pairs, three on each side, the superiors or ele- vators, the inferiors or dej^ressors, and the laterals or inclinato?'s. Beside these, there is also the ischlo-caudal muscle, which extends from the ischiatic ligament upward and backward to terminate on the sides of the first caudal vertebrae. Between each of the lateral and inferior caudal muscles runs the lateral caudal, and on the median line between the inferior muscles the inedian caudal ar- tery, all running to the end of the tail, and likely, when divided, to cause a more or less troublesome hemorrhage. All these or- gans are surrounded by the caudal aponeurosis, from the deep surface of which proceed bands which form a special sheath for each muscle, and is ultimately united by its external face to the thick skin which surrounds the region. This skin on the upper and on each lateral face of the tail is covered with long, thick, coarse hair, while the inferior face is hairless, smooth and com- paratively thin. Fig. 292.— Tail Cutters. AMPUTATIONS. 279 Docking projaeiiy includes three steps : 1st, the preparation of the tail ; 2cl, the amj)utation ; and 3d, the arrest of the hemor- rhage. (There is, however, a mode of operation in which the last two steps can be merged into one.) The animal is kept in the upright position, and weU secured. 1st Ste2). Preparation of the Tail. — This is first well washed and combed, and ought to be cleaned with an antiseptic solution. The place where the amputation is to be perfonned should be marked by clipping the haii' from it in a circle, and above this the hair should be secured either by being braided, or simply tied tightly in a mass with a string around the tail. Some practition- ers apply a cord Hgature or an elastic bandage above the place to prevent the hemorrhage. 2d Step. The Amputation. — This is accomplished by several methods. The oldest mode was by using a simple hatchet as the instrument with which the tail, properly prepared and laid over a wooden block, was severed by a heavy blow on the "instrument." (Fig. 292). Fig. ;.'93. Tail Cutters. Fig. 294. 280 OPERATIONS ON BONES. At a later period, special knives called tall cutters, were in- troduced. These were peculiar large sliears, differing more or less in general form and in that of their cutting edges, but which were used in the same manner, and are still in common use by many practitioners. The manner of using them is very simple. The tail, prepared as before mentioned, and held horizontally by an assist- ant, is so placed in a hollow formed in the edge of the shears as to insure a perpendicular stroke, and the division is made by closing the blades with a single quick and forcible motion. Other instru- ments were invented to work by springs. Fig. 296.— Spring Tail Cutter. Some practitioners, instead of dividing the entire thickness of the organ, prefer to do so by disarticulating the vertebrae with a bistoury, first making flaps on each side of the skin in order to find the joint. 3d Ste}"). — To stojy the Ilemorrhage. — The moment the tail is amputated three streams of blood spring from the stumj), with more or less force, according to the position of the member, unless a ligature or an elastic bandage has been previously applied. In Fig. 297.— Tail Cautery. AMPUTATIONS. 281 either case attempts may be made to ligate or to employ torsion of the arteries, but the hemostatic generally employed is the actual cautery. The tail-cautery, heated to nearly a white heat, is firmly held upon the truncated tail for a few seconds until it has stopped the hemorrhage. To assist this process and obtain the formation of a thicker scab, certain com- bustible substances are some- times placed u-poii the wound before the cautery is apphed, to increase the heat by their igni- tion. A ring of hair or a Httle pulverized resin may be employed for this purpose. ^ We have before noted that in this measure of hemostasia there is much that is reprdsive and coarse, and that it is not at all in har- mony ^ith the spirit of modern scientific surgery, and we have long felt a conviction that a great improvement is possible in the manipulation of such a case. We have, therefore, made the matter one of careful experimentation, and the conclusion we have reached is that the following course of procedure will meet all the indica- tions and fulfil all the pur^^oses contemplated, and at the same time avoid the compHcations hkely to occur, and ob'vdate the objections of the sensitive and the timid, besides seciuing results entirely satisfactory to all the parties concerned. First, to render the ojoeration painless, we inject cocaiae at two or three points in the cii'cumf erence of the tail skin. Then, around the tail, and above the ring made by cHiDping the haii-, as before mentioned, to mark the place of amputation, we place a narrow elastic band at a tension merely sufficient to stop the hemorrhage. Having waited for the full effect of the anesthetic, and accurately identified the center of the articulation between two of the vertebrae through which we intend to amputate, with a strong and sharp bistoury we make rapidly a circular incision of the skin entirely around the tail, and, if possible, di\ide the .aiuscle with a single stroke through the intervertebral ligament. With a httle care and practice the amputation may be completed in a few seconds, and there remains at the end of the tail but a smooth, perfectly blood- less stump. We cover the fresh surface vdth a dressing powder, antiseptic, caustic or astringent as indicated, and leave the patient eating his oats as he had been doing during the operation, unaware 282 OPERATIONS ON BONES. of the mutilation to which he has been subjected. We leave the elastic band m. j)lace for from twenty-four to thirty-six hours, pos- sibly loosening it once during that time, or tightening it, if any oozing of blood is discovered, and removing it entirely as soon as it becomes safe to do so. The stump generally needs no special care, except in cases of possible complications which may follow the ojDeration. The am- putation of the tail by fla^js is also performed by some veterinarians with great success, this mode leaving a wound which generally heals very rapidly and without the ordinary possibility of compHcation. Among these are, first, hemorrhage. The occurrence of this is an evidence that the hemostasia has been imperfect, proba- bly the cauterization has not been sufficiently thorough; or the torsion of the arteries has been insufficient; or the hgature has been loosely tied. This accident requu-es a repetition of the man- ipiilation, and perhaps another cauterization or torsion or ligature. With the appHcation of our elastic band this can scarcely ever oc- cur. If it does, another turn of the band will complete the work. Bad asi^ect of the Stump. — The amputation of the tail by sec- tion through the continuity of the bone, as commonly happens when the tail-cutters have been used, leaves in the center of the wound a projecting portion of a vertebrae, which is usually biUTit by the cautery, when this has been used. As the result of this, and surrounding the mortified bone, large granulations rapidly appear, overlapping the circtdar edges of the wound, and char- acterized by an abundant discharge. The necrotic bone must then be amputated and the granulations hea\Tly cauterized with caustics of the potential kind; the saturated solution of chloride of zinc making an excellent prescription for the piu'pose required. To obviate this complication the operator will do well, when any portions of vertebrae have been left in the stump, to remove the fragments with the bone forceps rather than to wait for their re- moval by the natural process of necrosis. We have never encoun- tered these complications when using the elastic band, being- careful to amputate at the articulation of the vertabrae. The l^owdered dressings we have used have always kept the granulations under control. Multiple Abscesses. — ^We have met these once, as the result of the presence of a very thick scab, which prevented the escape of the underlying suppuration. TREPHINING. 283 Gangrene and Tetanies have also been recorded as sequelse of this operation. The rules we have given apply without change to the amputa- tion of the tail in smaller animals, as sheep, dogs and cats. TKEPHINING. The operation of trephining or trepanning consists in boring into or through a bony or other hard structure, in order to form an aperture for surgical purposes. Although the cranium is usually the seat of the opening, it may be made in any part of the body where the indications demand it. The application of the trephine or of terebration, as it is called when it is performed at the base of the horns of cattle, dates back to antiquity, having a record antedating the time of Hippocrates, and yet it was not until toward the year 1749 that it in fact entered the domain of veterinary surgery. About that time Lafosse, Sr., performed it to open the frontal and maxillary sinuses in the treatment of glanders and other diseases mistaken for it. It was afterwards recommended by Greave and Haubner as the proper treatment for the relief of purulent collections in the sinuses of the head, and it has been recommended by many others for parasitic affections of the cranial cavity, as cases of ccenurus cerebralis. Trephining is undoubtedly indicated in many j)athological conditions, and in fact ought to be more frequently practiced by the veterinarian of to-day. Much has been lost, no doubt, by its neglect and disuse. Its value is most fully demonstrated in cases where it becomes necessary to remedy the effects of mechan- ical lesions taking the form of bloody or purulent gatherings within the craniiim, like those which may result from the pressure of fragments of fractured bones upon the brain. Fractures of the cranial bones resulting in this manner are not common with our domestic animals, but when they do occur they are always of a serious nature, and too often are beyond remedy. In a case of remediable character the removal of the pressure upon the men- inges by trephining and cleansing the wound from the matters which produce and continue it, whether bony fragments or bloody extravasations, is the treatment indicated before any other. Yet as experience has many timss i:)roved that the brain is able to sus- tain a very considerable amount of j^ressure without betraying 284 OPEEATIONS ON BONES. any signs of inconvenience, the indication of trephining only becomes absolute when serious nervous manifestations are ex- hibited. In simple contusions, or even with complete fradtxu'e of the bone, trephining is not indicated unless brain lesions are unmistakably present. It is indicated in soHpeds in cases of chronic discharges -pro- ceeding from supjDiu-ative collection in the sinuses, characterized by a yellowish, grumous, and often offensive, running at the nose, usually from but one side, and not uncommonly accompanied by a deformity of the face, caused by a bulging of the bones, and associated with it a dullness on percussion over their surface. Jessen & Unterburger have also recommended it in cases of suppuration in the cavities of the nasal turbinated bones. In the treatment of chronic catarrhal inflammation of the horns or of the portions of the frontal sinuses which extend into the appendix of the head, in ruminants, it has given excellent results. It is also indicated for the removal of foreign bodies, either of a pathological nature or the product of wounds, entering the cranium from the outside. It is available for the removal of polypi or any kind of neoplasm, of migrating dental cysts, of odontomse, or as one of the first steps in the operation for the removal of diseased teeth from their alveolar ca\dty; in all these cases it is the first indication. It is also of common application in exti'acting parasites, the coenurus especially, from the cranial cav- ity of small ruminants, when their location has been first j)Ositively ascertained. In some severe cases of diseased withers accom- panied vnth abundant suppuration, which may filtrate under the internal surface of the scapulae, and accumulate between that bone and the thorax, it has been claimed that, performed upon the scapula, it would furnish an eligible means of reaching the bottom of the collection, and providing suitable drainage and consequent relief. Trephining the wall of the foot in special cases of laminitis, to assist the escape of the effused blood from between the laminoe has also been tried, but with what results we are not informed. It has even been performed in the treatment of immo- bility, but so far as we have learned, has never been followed by satisfactory results. It is also referred to in connection with the cranial inoculation of rabies, as performed by Pasteur. The special instrument employed in the operation is the TREPHINING. 285 trephine, or trepan, in various modified forms. There are also others which may be considered as accessory, viz., scissors, bis- touries, forcejDS, bone-scrapers and elevators. The brace and bit trephine is the original instrument which has been more or less modified, and which, while it is capable of more rapid execution, is probably less controllable than the ordin- FiG. 2i is engaged to form the hernial sac, s; the intestine, ii it ii, is shown entering the hernial sac gradually. Fig. 375. In the ventral kind tlie ajierture is wide and of varying dimen- sions, and it may, moreover, be quite wanting, or again, it may be long and cylindrical, as in inguiaal rupture; while in the um- bilical variety it is very short, and represented merely by the thickness of the edges of the hernial ring. The bodt/ or middle portion of the intestines, or that which becomes lodged in the cavity of the sac, also varies in size, direction and form, and may be considered under the four principal heads of the cylindrical. HERNIA. 389 Fig, 376.— Cylindrical Hernial Sac. Fig. 377.— Spheroidal Hernial Sac. Fig. 378.— Conical Hernial Sac. Fig. .379.— Pyriform Fig. 380.— Hernial Sac Hernial Sac. in Clusters, or having three contractions — f,d,b. Figs. 381, 38S Multilobular Hernial Sacs. 390 OPERATIONS ON THE DIGESTIVE APPARATUS. the spheroidal, the convex, the 23yriforni, to which Zundel adds the clustered and the midtilohular. The relation as to dimensions between the body of the hernia and the measurement of the ring is a point of importance in re- lation to estimating the more or less serious nature of a case. It will readily be inferred that with a narrow and contracted open- ing, an obstruction may easily take place, and at an early date, and that in due time the result will be manifested in the legitimate form of a strangidation, an accident which will be accompanied with various phenomena, according to the degree of pressure and the dm^ation of the period of formation, and all of them attended with trouble and danger. At first, as the capillary circulation becomes retarded and diffi- cult, the intestines assume a red color, which passes successively thi'ough many shades, from deep red to brown or a blue-black, indicating the arrest of the blood, of which the dreaded sequel may be looked for in the apjDearance, a httle later, of signs of mor- tification of the parts involved. The blood then transudes through the walls of its vessels, and filtrates into the sub-serous and sub-mucous cellular tissue, thus increasing the bulk of the contents of the sac. At the same time the external svu'f ace of the j^i'otmding intestines becomes the seat of what is at first a yellowish exudation, but which becomes a bloody deposit, ready for organization if the patient fives long enough to survive the pains of the strangulation. By the eight- eenth or towards the twenty-fovu'th houi', however, signs of total gangrene make theu" appearance and the hernial portion becomes flabby, cool, and insensible; the odor becomes very oflensive, and the tissues easily lacerated or torn. The fatal end is then near, being rarely deferred beyond the twenty-fourth houi-, unless im- mediate relief has been interposed. But, of course, every case does not observe this regular succes- sion of symptoms, nor reach the same final termination, and in the instances in which the interference with the cu'culation is less pronounced and the degree of pressure upon the protruding organ is lighter, probably not more than sufficient to interfere moderately with the movement of the intestinal contents, we have a modified evil to contend with in the obstruction or €ngorgeme')it of the hernia, with consequences in view less discouraging to con_ template The exudation upon the surface of the contents of the HEENIA. 391 // r / /;' \ Fig. 383.— Strangrulated Inguinal Hernia. A, intestinal circumvolution. B, herniated portion of the intestine. D P, neck of the vaginal sac compressing the intestines. E, inierual wall of tlie vaginal sac. T, tes- ticle in the fundus of tlie vaginal sac. sac has resulted in an adhesion with the internal sm-face, and the hernia has taken its place in the class of the irreducible. Hernias of long standing, which have, at intervals, shown indications of obstructions, are, in the greater number of mstances, m fact, ir- reducible. There are still, however, cases of simpler condition in which the \iscera continue to be movable in the sac, in which fact they are due to the lubricating effect of a free serous exudation. 392 OPERATIONS OX THE DIGESTIVE APPARATUS. Aside from other distinguishing characteristics, all hernias are di\'isible into two classes — internal and external. Of the latter, some, as the eventration, have no containing sac, while the others, which have a serous covering, are in reality alone entitled to be considered as the true hernias. These, usually occurring through one of the natiu'al ojDenings, are called natural, in opposition to the accidental, which, like the ventral hernias and the eventration, occur through accidental and artificial openings. Any of the ab- dominal \dscera, wdth the exception of the pancreas and the kid- neys, may enter into the formation of a hernia, and as each is known by the name of the displaced organ, we are given the designations of enterocele for a hernia of the small intestines ; ep/- jilocele, for that of the omentum, and entero-epiplocele of both the intestines and omentum. The name of gastro-ventral is given to the ventral hernia which involves with it the stomach ; cystocele, when it is the bladder which is affected, and liysterocele when the uterus is concerned. Hernias can be, moreover, congenital or oc- casional — that is, they may exist at birth or previous to it, and also when making their appearance under special causes after birth. They may be also considered as acute when recent, or chronic, when of long standing. Their originating causes are numerous, and may be said to comprehend any which may predispose an animal to such a lesion by contributing to an increase of the pressure which the organs contained in the abdominal cavity bring to bear upon its walls, or any weakness in the walls, which may diminish their power of re- sistance to the pressure, as, for example, a condition of leanness arising from a sudden or recent change from a state of obesity ; blows upon the abdomen ; wounds and cicatrices of the abdomi- nal walls ; violent, jerking efforts, such as those required in com- pulsory jumping or hauling, or in any other of the struggles to Avhich they are too often forced, and even when under the sur- geon's hands, when, as a patient, the animal is cast and secured for an operation; the rapid relaxation after contraction of the natural openings, repeated pressure, or excessive dilatation, as with stalhons used for covering mares, may be placed among the predisposing causes. They have also been observed in mares, after violent efforts during parturition ; also during colics and other tympanitis. To recapitulate and partly to repeat The general symptoms characteristic of hernias, are compar- HERNIA. 393 atively easy to recognize, and can be reduced to two principal f>oints, to wit — tlie discovery of a tumor, and appearance of an opening coexisting in tlie abdominal walls. These tumors and openings offer many varieties of form and character. The tamor located opposite to a natural opening, or under a breach or separ- ration in the structure of the abdominal walls, or under a cicatrix, forms a mass, indolent, elastic, remittent, of varying size, but di- minishing or increasing iinder peculiar conditions, such as rest or pressure, and the standing, or the lateral or recumbent position, etc., andha-s-ing different forms, being located in various j^laces. It has also, in many instances, the quality of being reducible, that is, it may be made to disappear by means of certain manipu- lations and appropriate treatment, and arrangements of position, to return to their previous status when these agencies are sus- pended; or again, they will become j)ermanently irreducible under special j)athological changes already alluded to. The presence of borborygmus is also an important item among the means of form- ing a physical diagnosis of these tumors. This is detected more or less readily when the displaced organ is a portion of the in- testines. They are, however, missing when the hernia is formed by other organs, as, for instance, in case of ejjiplocele. Other points connected with this subject remain to be mentioned. Among these are the final symptoms, and more or less remote re- sults, which may foUow the presence and working of the lesion upon the general economy and the physiological functions at large, when the acute action has passed away. The constitutional symptoms, or what may be so denominated, will vary, in their nature and their intensity, correspondingly with the condition of the hernia and the comiohcations which may ac- company each case. Among these compUcations, four principal ones may be mentioned as taking precedence : 1st. Irreducibility. — This is more frequent in old cases than in new, and is probably due to the increase in size of the dis- placed organ to the degeneration of the tissues, or to old adhe- sions between the organ and its covering, the sac. These cases, which may be considered rather permanent than merely chronic, maintain their status, either completely or partially, unchanged. Yet they cannot, natiu'ally or rationally, be held to be compatible with a sound constitution or unimpau'ed stamina in the animals HO conditioned, and their Habihty to contract indispositions easily 31)4 OPERATIONS ON THE DIGESTIVE APPARATUS. lias frequently been remarked. Difficulty ia tlie performance of movements requiring effort has also been noticed, with conse- quently a liability to suffer traumatic injuries from external vio- lence. To this must be added a facility in contracting: 2d. Injiamtnation. — Generally this occurs as the result of external injuries, but it may also occur vfithout any apparent cause. Its seat is the sac or its contents, and it affects the serous structures alone, or assumes a phlegmonous aspect. The inflam- mation of the serous tissue is often overlooked, vrhile that of the phlegmonous cannot pass unobserved. It may sometimes assume a very serious character, and become even more dangerous than the true strangulation. 3d. Obstructions or engorgements, common in intestinal her- nias, are due to the accumulation of alimentary or stercoraceous masses in the displaced intestines, or to gases which interfere with the reduction of the hernia. This is often comi^licated with strangulation, but is not in itself of a very dangerous natui^e. 4th. Strangulation. — This condition has been already consid- ered. It is the result of excessive pressure upon the blood vessels of the disj)laced organ, and while under its three periods or degrees of congestion, inflammation, and gangrene, has usually a fatal termination. The general treatment of hernia has the two objects in view of the destruction or obliteration of the sac, and the reduction or closino- of the ring. If the first is not always easy to accomj)hsh the reduction of the diameter of the ring often is so. Each form of hernia demands some special directions for the reahzation of these two objects, and these wiU each receive its own share of attention as they may in turn come under our notice in further treating the various forms of hernia. Inguinal Hernia. Ino-uinal hernia results from the passage or presence of a portion of the intestines, or of the omentum, or of both together, in the testicular or vaginal cavity whose opening of communica- tion with the peritoneum or inguinal i-ing continues in its normal condition, having never closed. A brief survey of the general anatomy of the region involved will be a necessary prehminary to our discussion of the subject, which is one of interest and im- portance. HERNIA. 395 a^ Fig. 384.— Anatomical Disposition of the Inferior Inguinal Ring and Testicular Sac. Explanation of Fig. 384.— A C, testicular sac, in which are shown— Ist, the neck situated above the letter A, and concealed in the inguinal canal ; 2d, a middle portion extending from A to E ; 3d, a fundus, B C, where the testicle is. D D, division of the scrotal artery. P G, inferior iugulnal ring, whoso internal commissure is rounded and formed of white fibres crossing each other and attached to the prepubic tendon. H H, fleshy portion, from the small oblio.ue, and forming the anterior and internal lip of the inguinal ring. K K, postero internal edge of the inguinal ring, formed princi- pally by an aponeurotic portion of the great oblique. L, scrotal artery. M, veins of the scrotum and of the penis. N, paitof the penis thrown backward, o o o, tunica abdominalis. P, muscles of the flat of th3 thigh, short adductor of the thigh. The inguinal canal is an infundibuliforin canity, flattened from one side to tlie other. It is situated in tlie groin, and 39G OPEKATIONS ON THE DIGESTITE APPARATUS. through it pass the testicular cord and the testicular blood ves- sels, in the male, and the blood vessels of the mammae in the female, as they emerge from the abdominal ca\ity. Situated on one side of the prepubic region, it observes an oblique dii-ection, downward, backward, and from without inward, being formed posteriorly by the crui-al arch, and anteriorly by the fleshy portion of the small oblique muscle of the abdomen. Inferiorly it has an opening called the inferior inguinal riny, which is made through the aponeiurosis of the great obhque, oval in shape, and 2)ossessing two H2)s, edges or pillars, united together by two commissures. The li2)s, divided into anterior and 2^osterior, are formed by the fibres of the aponeurosis of the great oblique muscle of the abdomen, and a few of the muscular fibres of the small obUque, reinforced by some bands of the tunica abdominalis. The commissures, divided into external and internal, result from the union of the extremities of the two pillars. The superior opening of the inguinal canal is known also as the peritoneal or superior inguinal ring, and is situated in front of and directly opposite the crural ring. It represents a single slit, subject to dilatation, placed also between the crural arch and the small oblique of the abdomen, and allowing on its inner border the pas- sage of the anterior pudic or posterior abdominal artery, it sur- rounds the neck, and forms the entrance of the vaginal sheath. It is open in horses, and often in bo\anes also, and it allows a direct communication between the cavity of the vaginal sac and that of the peritoneum — undoubtedly a predisposing condition to hernias, not to be overlooked. The testicular sac offers to our attention, from the point of view from which we now consider it, an entrance, or true infundibulum, overlapping the internal opening of the inguinal ring or canal ; a yieck situated just below that ring, a continuation of the infundibulum or entrance, and which at a short distance from its origin offers a well marked contraction in its diameter — this being the point where strangulation takes i^lace — a middle part, containing the spermatic cord; and a bottom, or true cul-de-sac, where the testicles and the epididj^mis are lodged. The special signification of the terms which have been else- where and already employed to designate and classify the varie- ties of form and manifestation characterizing different varieties of hernia are of interest, and should not be lost sight of. They are HEENIA. 397 divided pnucij)ally into recent or acute, and old or chronic, and we find them considered as enterocele, epiplocele, and entero- epiplocele, according to their contents. The name of vaginal hernia has been used to denote a case in which the intestine is du'ectly engaged in the inguinal canal; and hernia of the ring, or hernia i)i the canal, describes that ia which the viscera have en- tered but a short distance into the sheath. Bubonocele signifies that the intestine has entered but a veiy slight distance into the inguinal sheath, in opposition to the oscheocele or scrotal hernia, when, the intestine falls quite down into the sac, and with the testicles themselves, occupies the bottom of the scrotum. Inguinal hernias are generally accidental, but, as some authors hold, are also sometimes congenital, having been found existing at birth ; and iu many instances they become perynanent, the in- testines occupying the vaginal sac without change, as a fixity. Then, again, they may be intermittent, disappearing more or less completely, under peculiar conditions, only to reappear under the stress of new influential causes. Of course the classification of re- ducible and irreducible, always holds. The classification of the hernia of castration, which takes place during or after that opera- tion, is considered by some to be properly one of the forms of eventration. A consideration of the anatomical disposition of the vaginal canal, and especially of its upper ring, which prssents an opening communicating with the peritoneal cavity, wUl explain the reason why inguinal hernias of the horse are more common in the stallion than in the gelding. It is rare in bovines, but Laf osse has seen it in sheep and in rams and although the anatomical disposition of the canal in the dog render its occurrence difficult, Wolstein has observed it in that animal. Cases are rare in females, but Girard, Jr., has seen it in mares, Rychner in cows, and Heriag, Hertwig and Goubaux in bitches. Recent Inguinal Hernia. When the hernia appears suddenly, in a subject not predis- posed to it, the first symptoms are those of abdominal pain, ap- pearing suddenly and without warniug, and quite inconsistent with the general perfect health of the animal. These symptoms are at first vague in their significance, and definable merely as ex- hibitions of simple pain in the abdomen. 398 OPERATIONS ON THE DIGESTIVE APPARATUS. If ill the stable, the animal becomes restless, paws with his fore feet, gazes earnestly toward his flanks, and flexes his legs, as if to He doA^-n, and perhaps accomphshes that movement, but only to resume the standing position. The skin is moist, the per- spii-ation appearing on the face, around the ears, behind the shoulders and in the groins. If he is in harne is, his action is changed, he shortens his steps, stops pulling, wants to stand still, and becomes covered with abundant perspiration running over him and di'ipping from his belly. These first symptoms excite suspicion as to the real cause of the trouble, but they soon assume a character which changes the susjoicion into certainty. They rap- idly assume greater severity, increasing in the ratio of the suffer- ings of the animal, which then has no more rest or intermission, and gives evidence of the most intense abdominal pain. He paws and stamps upon the floor more and more violently, sometimes kicking his abdomen; gazes anxiously toward his flanks; lies carefully down and rolls to and fro on his back, sometimes keeping the dorsal position for a few moments, as if he could only thus find relief; then suddenly rises to his feet and repeats the movements, which give evidence of the torture he suffers, but more forcibly and rapidly than before. The expression of his face soon becomes characteristic. The lips are contracted, the nostrDs are retracted and dilated, and the -svidely ojDened eyes ap- pear unnaturally large and prominent, rendering then* agonized expression more and more striking. The respiration becomes ac- celerated and the pulse more rapid; the jDerspiration streams more copiously from his body and the poor animal groans under the weight of his trouble. After a lapse of some hoiu's, the time arrives for the occurrence of strangulation, which may be pronounced the crisis or fatal event of inguinal hernia. It is characterized by a iDeculiar mo- tion of the head, which is thrown up and down repeatedly (and which the French have designated by the word " encensd.'") This motion, Avhich is sometimes habitual with horses while in harness, has a pecuHar meaning when it becomes the expression of the colic of hernia. It is then performed slowly, the head being ele- vated gradually and extended upon the neck, to be suddenly dropped again as if from weakness, to be again raised and dropped during the few and brief intervals of remission of the pains, while the animal possesses the ability to keep on his feet. HEKXIA. 399 In fact, wlieu the hernia is completed, the cohcs are so violent that the animal no longer lies down, but literally throws himself with violence upon the ground, ha-sing become forgetful of the natural instinct of conservation, and now rendered indifferent to all other pain by the overpowering force of the hernial torture. With his body covered with bruises, and bleeding from numerous superfi- cial wounds, he now becomes a pitiable object. There are animals of particularly sensitive temperament which will even, hke those in a rabid furor, bite themselves on then- flanks and forearms in their delii'ious desperation. During these excessive sufferings there seem to be just two positions in which the animal can experience a comparative de- gree of comfort. They are, lying on his back, or maintaining the dog-sitting postiu*e, on his haunches. But these movements of reprieve are of but short duration, and the pains may continue to be manifested without cessation, by tumultuous, \dolent, imequal struggles, which may continue twelve or fifteen houi's, or even more. At last, toward from the fifteenth to the twentieth hour, all the signs of pain subside, and a great calm succeeds to the pre^aous violent agitation. This, however, is far from being a good sign, or an indication of the termination of the disease. It is, on the contrary, a sure token that a fatal termination is close at hand, and if the patient has ceased to suffer, it is because the anesthesia of death has fallen upon the organ in which his pains originated. The parts which were so recently altogether too much alive, have died. Gangrene has attacked the imprisoned intestine, and with its appearance, loss of feeling has also come — and death — for death is the loss of feeling. The animal is now in a con- dition of extreme prostration. The temperature is diminished ; the perspiration is cold, the pulse is imperceptible, his face is without expression, the poor brute can scarcely maintain a stand- ing posture or move his legs when urged to stir, and when the last remnant of his strength is exhausted, after a few hours, he drops upon the earth and dies withovit a struggle. Death rarely delays beyond twenty-foui* hours following the strangulation. This is the extreme limit, and in the greatest number of cases it takes place within a shorter period. These manifestations (the description of which we borrow from H. Bouley), constitute the series of general symptoms of hernia, but, at the same time, they do not belong exclusively to that kind 400 OPEEATIONS ON THE DIGESTn'E APPARATUS. of injury. They are those of any violent abdominal pain spring- ing from any cause, and may be met with iu invaginations, volvulus, intestinal obstruction, etc. But if not possessing any positive and intrinsic significance in themselves, they assume great value in the diagnosis, when added to the series of local, ox pathogno'mic symp- toms which have their origin and limit in the inguinal region. Two methods are available for the location of the seat of the lesion, one being the external exploration of the inguino- scrotal parts, the other consisting in the internal rectal examin- ation of the pubic region. In a horse, and especially a stallion, suffering from cohcs, the indication to a general and immediate examination of the inguinal region, for abnormal appearances, is always present, and it will not be safe to be too easily satisfied with visual examination exclusively, to become certain that no part of the intestines is engaged in the vaginal sac. The eye may be deceived; it is the touch alone which Avill prevent all possibility of error. The sensation imparted to the touch at the beginning of a recent inguinal hernia is that of a thickened testi- cular cord which has lost its usual suppleness, and whose con- stituents can no longer be determined under the pressure of the fingers. Thus thickened, the cord gives a sensation of resistency, increasing as the exploration is carried further up in the groin, while toward the bottom of the sac, the scrotal mass feels fuller than usual, the testicle becoming less movable, giving the sensa- tion of a slightly puffy tumor. After several hours duration of the disease, the characters become better marked, in consequence of the increase in the size of the intestine, and the amount of exu- dation, and there is also a formation of gases above the neck of the sac, which also contributes to its increase in size. The hernial tumor has thus become changed from its oi'iginal appearance, by its enlarged size, and is easily detected by the great general tension caused by the presence of the accumulatiug gases ; the cord is found to be tumefied in its whole length, while its renitentcy increases as it extends upward into the canal. Direct pressure with the fingers upon the tumor does not seem to cause great pain, jDrobably because this local sensation is dulled by the extension of the excessive pains which radiate from the hernia throughout the entire abdominal system. The external characters of the inguinal tumor become more noticeable when both sides of the testicular regions are compared, the difference between the HEENIA. 401 healthy and the diseased regions being then easily ascertained. Continued spasmodic movements of the healthy testicles have been observed. In the rectal examination of the horse, the hand may be easily carried beyond the anterior border of the pubis, and the condition of the superior opening of the inguinal canal, and the state of the organs engaged in it thus ascertained. In the normal condition, the anterior pillar of the superior opening of the canal is easy of identification. It is in front and on each side of the pubic region, and by reason of the extensi- bihty of its muscular stnicture, requires no greater force for its separation from the posterior pillar than the introduction of two fingers into the ring. When the intestine is in the vaginal canal, after having passed through the superior opening, it can be felt with the hand through the walls of the rectum, its situation being generally on the inner side; and being thus recognized, it can be raised, pvdled upon, and sometimes even extracted from the open- ing through which it had passed. But to be able to judge accu- rately the nature of the object which has been felt, requires in the surgeon an amount of exj)erience in the taxis not always pos- sessed, while its absence may at times betray the explorer into serious error. Moreover, the sensations transmitted through the rectiun cannot in every case be truly interpreted, and it sometimes becomes necessary to combine the two modes of examination em- ployed simultaneously — the rectal investigation and the external, manual, testicular exjDloration. Thus, when with one hand in the rectum, pressing on the in- ternal ring, and the other pushed well into the depths of the in- guinal region, both are brought in contact, and it is discovered by the actual touch that the inguinal canal is clear, the hypothesis of strangulated hernia is at once negatived. On the other hand, if there is hernia, and the imprisoned intes- tine is encountered, the fingers of the two hands cannot possibly come in contact, and the next question will be one of indication, if not of prognosis. As a rule, the prognosis of recent inguinal hernia is always seri- ous. If developed without organic predisposition it is necessarily a serious lesion by reason of its tendency to spontaneous strangu- lation, which when unreHeved means death by torture, unless the fatal event should be humanely anticipated and prevented by the 402 OPERATIONS ON THE DIGESTIVE APPARATUS. fiat of a compassionate master. But a fatal prognosis need not be unnecessarily volunteered. Timely and vigorous measures, es- pecially emphasizing the " timely,'' may still prevent the strangu- lation and defer the sentence of mortality, and the sooner, there- fore, the means of rehef are applied, the more certain vpill be their effect. Every minute's delay increases the force of the disease and lessens the chances of success. It is rarely the case that the lapse of fifteen hours leaves any room for confidence, though it is not yet time to abandon hope. Within that period there are many chances for saving the patient, but after the earlier periods of the attack a single hour's neglect may be fatal — that hour may prove to be the turning-point of the conflict. The treatment of recent inguinal hernia assumes two forms, consisting of the taxis, and the operation of herjiiotomy, or the en- largement of the neck of the vaginal sheath with a cutting instru- ment. The first mode is indicated at once, or as soon as the her- nia is recognized. The reduction must be accompHshed in the shortest time possible, the danger of strangulation becoming more imminent and threatening with the lapse of every moment. The taxis may give immediate relief, and may be materially assisted by douches of cold water. In this case the taxis consists in the manipulation of the part with the hands, by pressure and otherwise, for the purpose of re- placing the protruding intestine in its proper cavity ; technically, the reduction of the hernia. This manipulation is apjjhed either by simple pressure over the external surface of the diseased part, or, if practicable and necessary, by supplementing it with a proper traction apphed upon the intestine from within thi'ough the rectal walls. This manipulation may be apphed by two processes, first the subcutwieous, medial or indirect; and second, the direct taxis. 1st. The Indirect Taxis. — In the first or indii-ect method, the animal is placed in a standing position, with the hind legs secured. Then the hand and arm of the operator, well oiled, are introduced into the rectum, using the right, if he is to operate on the left side, and vice versa. When iu the rectal cavity, the hand is carried to the anterior border of the pubis, while with the other, passed iu front of the patella, pressure is apphed upon the scrotal sac, and the iatestine pushed toward the superior opening. The hand in the rectum then gras^JS the loops of the hernia, tkrough the rectal walls, and at the same time pulls them upward. Through these HERNIA. 403 manipulatious the surgeon may succeed in removing the difficulty, if by that time the testicular sheath continues to be free from con- gestion. But if this akeady exists, and the coHcs are increasing in severity, the taxis in the standing position becomes impossible and it will be necessary to throw the animal. This done, he must be placed in the dorsal position, with his hind legs kept apart and his haunches raised as much as possible by bunches of straw. In this position, the operator must proceed to practice what must be described as an exceedingly deHcate massage or taxis upon the scrotal sac, both hands being used, in such a manner as to crowd or press the intestinal mass toward the superior opening of the canal. The design of this is to stimulate the circulation thi'ough the capillaries, and also to free the cavity of the intestine from the semi-fluid and gaseous contents which may be present, by this means diminishing its volume and facilitating its reduction. That this must be done with the utmost caution and patience, needs hardly to be urged. And it should be persevered in for at least a period of thii'ty seconds before advancing to the other step, which consists in gradually pushing the intestine toward the opening. If the protruding loop is not too long, and the massage has succeeded in its design, and the bidk of the tumor has been sufficiently diminished, and, above all, if the hernia has had but a short existence, it may be within the probabilities that this external taxis alone will be sufficient to reduce it. But such a result cannot be counted on with any degree of certainty, and it is then the simple dictate of wisdom to make assurance sure, if possible, by having recourse to double taxis, and attacking the danger at both its internal and external accessible points. For a single operator to undertake the performance of both branches of this compound manipulation can hardly be advised. Few men possess the necessary powers of endurance, and an acci- dent might easily compromise the very life of both surgeon and patient. At the least, it involves quite an unnecessary amount of effort and fatigue. All the reasons are in favor of a division of the work, by which a competent assistant will be put in charge of the rectal taxis portion of the labor, while the practitioner in chief will direct and execute all the other stej^s of the treatment. The successful result of the operation will be known at once by the diminution of the tumor, the disappearance of its l)uffy and tense condition, by the sudden sensation of yielding, felt by 404 OPERATIONS ON THE DIGESTIVE APPARATUS. the hand working in the rectum, and also by the facility Avith "which the fingers of that hand can be introduced into the now liberated superior ring. Anesthetics have been recommended as powerful adjuncts in the api^Ucation of the taxis, in this class of cases. Bouley recommended their use, and Baggr, a Russian veterinarian, agrees with Bouley, in advising their administration. His pro- ceeding is thus described: The rectum being emptied, a solution of two to four grammes of chloral and sixty or seventy centi- grammes of acetate of morphia are thrown into it, while at the same time compresses of chloroform are laid on the diseased side of the inguinal region. In the course of ten minutes there is such a relaxation of all the tissues that the reduction by rectal taxis is quite easy. The spermatic cords are then sm-rounded by rolls of bandages moderately tight, in order to prevent the retui-n of the hernia. These bandages are left on for eight or ten hours. The danger of strangulation upon the testicular cords is an im- portant objection to the adoption of this process. Severe appli- cations of douches of cold water applied for one or two hours previous to the taxis have been successfully employed by Steff and Lacassin. A process known as that of Patey, fi'om its discoverer, con- sists in the injection of oil of belladonna into the hernial sac, the action of the oil, it is claimed, producing the dilation of the pseudo-sphincter, which prevents the reduction. It causes a cer- tain flaccidity of the parts, renders the taxis much easier, and con ■ siderably facihtates the reduction. 2d. The Direct Taxis. — This procedure is of too dangerous a character to maintain a place in the domain of veterinary sm-gery, except under very exceptional conditions. It consists in apply- ing the manipulations of the taxis directly upon the intestine, previously exposed by the dissection of the testicular envelopes. These manipulations, which are dangerous when the intestine is distended by gases or fluids, may, however, be rendered easier by relieving the intestinal loop, through the use of a fine needle- trocar or aspu-ator, of the cause of its abnormal dilatation. The method of Renault, mentioned by Zundel, is also a form of direct taxis which, though it may be employed in cattle, involves a subsequent fatal peritonitis in the horse. The operation con- sists in the opening of the flank and the performance of the re- HERNIA. 405 duction by direct traction with the hand thus introduced into the abdomen. The operation of herniotomy is that which consists in the section of the neck of the vaginal cavity. It is the proper opera- tion iox strangulated hernia. Bouley has said: "This operation is not, as one may be inclined to think, a last resource, which is not to be used except after the taxis, under its various forms, has been appHed and failed. Far from it. We believe, on the con- trary, that in the horse, the taxis is a means of treatment which is truly indicated only in the first five or six hours of the descent of the intestine ; that even, in this first period of time, one must not use it too much nor too long, from fear of the complications which might arise through the rectal manipulations, and that after this limit of a few hours has elapsed, it is better to have re- course immediately to the operation, without trusting to vain hojDCS from the use of the taxis." The operation is comparative- ly a simple one, the dangers which were formerly apprehended having been greatly reduced by a better knowledge of the seat of the strangulation, and of the parts to be di^ided, and the ratio of mortahty is now so smaU — forty-two recoveries out of fifty-two operations — that hesitation is no longer justifiable. The instruments required for this operation are straight and cvirved bistouries, scissors, an ordinary director, a herniotome (Figs. 384a, 385), or blunt, straight bistouiy, and a jDair of curved clamps with strong cords to secure their branches. The hernia- tome is a histoury-cache, which, however, since the use of general anesthesia, has been replaced by the blunt, straight bistou.ry, en- ables the operator to divide the neck of the vaginal sheat*h in the right place with more certainty than heretofore, and to regulate more accurately the dimensions necessary to relieve the strangu- lation. The director which is best adapted for use in herniotomy is one which has a flat, lanceolated, grooved surface at one end, and which, while it guides the blade of the bistoury, contributes hkewise to the protection of the intestine against the possibihty of injury by the sharp edges of the bistoury. The patient to be operated on is laid upon a soft bed, anes- thised as completely as possible, and placed upon his back. The hind leg coiTesponding to the side where the hernia is located is freed from the hobble, secured with a rope, and carried outward in abduction, with the rope made fast to a fixed point near by — 406 OPERATIONS ON THE DIGESTIVE APPARATUS. Fig. 385. Herniotomes of Colin, as a ring in the wall, a post, a tree, or other immovable object. If the opera- tion is to be performed at night, which is too often necessarily the case, the presence of additional assistants will probably be required, in order to insure an abundant amount and proper man- agement of light, which is indispensable in so delicate a dissection. In operating, the surgeon kneels be- hind the patient and with a curved bis- toury begins by making a long incision uj)on the tumor, parallel with the long axis of the testicle. This incision is similar to that which is made in castration with covered testi- cles, and must involve only the scrotum, the dartos, and the first layers of the lamellated cellular tissue which unite this last to the tunica erythroidea. The remaining portion of this lamellae is then carefully incised, until the fibrous coat is exposed, and the tumor is entirely enuclea- ted from its envelope of cellular tissue. This done, the fibres of the tvmica erythroidea are scraped apart with the point of the straight bistouiy, until the vaginal sac has been open- ed, which the operator dis- covers by the appearance of a stream of liquid pass- ing through. The canula- ted director is then intro- duced into the opening and HERNIA. 407 guides the bistoury, with which the hernial sac is now freely opened, in front and behind. This free cutting allows the escape of aU the serous or sero-sanguineous fluid contained in the sac, varying in quantity according to the duration of the hernia. The contents of the hernial sac are now exposed. They consist of the testicle, pushed outward, against the commissure of the ring ; the loop of the intestine, placed on the inner side of the spermatic cord, rarely extending as far down as the testicle, but usually reaching to the level of epididymis, and again, not un- commonly remaining in the condition of a hubonoale. But what- ever may be the dimensions of the protruding loop, the intestine is always easily recognized by the roundness of its form, the smooth- ness of its surface and its color, which may range from various shades of red to bluish black. It is also recognized by the changes which have taken place in its consistency, resulting from the bloody and serous infiltration which has taken place in its structixre. The intestine should now be carefully wiped off with a soft, fine sponge, or washed with lukewarm water, in order to free it from any de- posits or adhesions of serous or bloody matter that may be present. The opening of the hernial sac should be immediately followed by the exploration of the neck with the index finger, with a view to the determination of the exact point where the strangulation exists, and to judge of its degree of tightness. This will not be found upon the superior opening of the inguinal canal, as thought by Girard, D'Arboval, Hertwig, Hering, Laf osse, Rey, Verrier and others, but should be looked for two or three centimetres below that opening, as demonstrated by Bouley ; that is, where the neck of the vaginal sac is situated. This point made out, if the hernia is very recent, and the intestine has not yet become the seat of thick- ening, a few tactical manipulations can be apphed, the internal face of the vaginal sac having first been lubricated with sweet oil, or some mucilaginous substance, or even oil of belladonna ; and even cool irrigation has been of service. In the performance of this taxis the first step is committed to the assistant, who stretches both borders of the sheath in order to separate them in the form of a funnel, the testicle being drawn outward, in order to stretch the cord also. The operator then apjDlies both hands upon the loop of the intestine, and with moderate and gradual pressure endeavors to push it through the neck of the vaginal sac. Rectal taxis applied at the same moment may also be of great assistance. But these 408 OPERATIONS ON THE DIGESTIVE APPARATUS. efforts must not be i^ersevei-ed in too long. If not successful al- most immediately, it is better to have recourse at once to the in- cision of the neck of the sac than to expose the intestine to the subsequent eflect of pressures or tractions of which the termina- tion may be a fatal gangrene. The following steps are recom- mended by Boiiley in making this incision. Says this author : '" One assistant takes hold, with both hands, of the edges of the incision made through the vaginal sac, stretching them into a funnel shape ; another draws the testicle outward and backward, to stretch the cord. Then the operator having explored with his finger the con- dition of the neck, introduces the blunt bistoury or the herniotome (Fig. 386) as far as the neck of the sac, taking for his guide the index finger of his right hand (Fig. 388), introduced into the neck or canulated du'ector, and holding the instrument in such a manner that its iplomphalus. UmbiUcal hernia is quite com- mon in horses and dogs, not less so in bovines, and has been no- ticed in swine and sheep. It is most common in young animals, especially soon after bu'th, is at times congenital, and may be long continued, even to adult age, or for eight, ten or twelve years. Umbilical hernias are either congenital or accidental. The former are formed during foetal hfe and continue at birth, al- though, according to some authors, they are, strictly, not so much congenital as accidental, and are, in fact, the result of the pulling and stretching of the umbihcal cord diuing the act of de- livery. However this may be, they do usually, in fact, make their appearance during the second and third months following birth, when through the persistency of the opening, and the imperfec- tion of the umbilical cicatrix, the intestines are enabled to pro- trude through the ring, and subsequently to prevent its closing by their presence. But again, while the cicatrix is weak, the ac- tive exercise and forcible movements of the young animal while at play may cause the rupture ; and still, again, the protrusion may be caused by intestinal derangements. Indeed, all traumatic causes, such as contusions, blows, and any violent efforts taking place during the period of consolidation of the closing cicatricial tissue, may become an originating cause of this lesion. Animals of low and lymphatic constitution are much predisposed to this trouble, especially such as feeble colts, born of mares badly cared for and insufficiently fed during gestation. Heredity fills a large place among the predisposing causes in low-conditioned mares with feeble organizations, and suffering with similar trouble when young, dams of this class naturally bringing forth foals of defective stam- ina, liable to perpetuate the same constitutional tendencies. The symptoms of umbilical hernia are generally exclusively local. It is characterized by a semi-globular or pyriform tumor situated on the median Hue of the abdomen at the umbihcal ring, 426 OPERATIONS ON THE DIGESTIVE APPARATUS. and varying in dimensions from the size of a hen's egg to that of a child's head — dimensions which may vary according to the con- dition of vacuity or fullness of the intestine ; the position of the animal, vsrhether standing or lying, or according to the length of time it may have existed. The consistency of the tumor is very variable. It may be soft, easily depressed by the finger ; elastic, when distended with gases ; or soft and puffy when containing alimentary matter — these changes being accounted for by the na- ture of the organ. An enteromphalus will give the sensation of an elastic mass, while the ej)iplomphalus will form a puffy swell- ing. This species of hernia is almost always painless, and exhib- its as one of its peculiar and constant symptoms the character of being reducible. In the generality of cases, it can be made to disajDpear temporarily by the taxis and by forcing the protruding portion back into the abdomen, but only to reappear at once as soon as the pressure is withdrawn, especially if the animal is on his feet. On being thus reduced, the opening of the ring can readily be detected, and the fingers may be freely introduced thi'ough its diameter and its form and dimensions ascertained shewing it to be sometimes elliptic, sometimes cu'cular, and some- times irregular, the originating cause of the hernia itself deter- mining the difference. Besides these more common symptoms of umbilical hernia, there are others which can be detected by more careful examina- tion. For instance, on applying the hand over the tumor, the ver- micular motions of the intestines may be recognized, and by feel- ing in the hernial sac, the presence of f pecal masses may be discov- ered ; and it may be possible by auscultation even to detect the presence of borborygmus through the displaced intestines, and even to observe its true nature, by reason of the transparency of the sac and its envelopes. These are the most ordinary symp- toms of an exomphalus, although it is subject to complications, and the sj'^mptomology will vary accordingl3^ There are cases, but they are rare, in which the hernia be- comes irreducible. The most serious of these are such as are found to have become so in consequence of the formation of ad- hesions between the protruding organ and the hernial sac — a very infrequent occurrence. The most common cause will be the pres- ence of undigested masses of food accumulated in the intestines, such as hard balls of faeces or sand. HEEXIA. 427 Inflammation of umbilical hernia may follow blows or bruises, though such a result from these accidents is not a common one, and its occurrence will naturally be accompanied with changes in the appearance of the tumor, such as the usual phenomena attending inflammatory action, as increase of temperatiu'e, ten- derness or pain, oedema, etc., which may even at times so com- bine theu' effects as to render the hernia irreducible. Engorge- ments and strangulations, however, are very rare complications of this form of hernia, a fact easily understood when it is con- sidered that the neck of the hernial sac is formed by the umbihcal ring itself. An exomphalus is usually an affection of httle gravity, and often disappears spontaneously, or if it persists after the period of weaning, is easily radically ciired when the animal grows and develops. Yet even if undisturbed and unchanged, they persist in remaining, their existence is not incompatible with perfect health and full ability to labor, however they may reduce the com- mercial value of the animal. They are less injurious to young animals than to adults, and less dangerous when small than when assuming large dimensions. When simple, they are easily amen- able to treatment, but if compHcated they become dangerous, es- pecially so when the capacity of the ring is so disproportioned to the dimensions of the protruding intestines that strangulation be- comes an accident of easy occurrence. Reducible hernia is at- tended with but little hazard, while the danger arising from the possible formation of adhesions in cases which have passed into the irreducible class becomes a matter of very serious import. If it is an admitted fact that animals suffering with umbUical hernia do often recover spontaneously, the recovery being a normal incident of the natural develojDment of the animal, due to changes of position in the abdominal contents, not to specify other effi- cient causes ; then the question of immediate or early interfer- ence undoubtedly receives and justifies a negative answer. Our own testimony is that we know of cases where patient waiting, even for a period of twelve months, has been rewarded by the radical disappearance of the hernia. But the objections to such long waiting are of a tangible and serious natm-e, and sui'gical interference becomes imperative and indispensable. The jjersons are few who are able or willing to nurse an idle horse for a year for the sake of saving him from the pain of an operation. 428 OPERATIONS ON THE DIGESTIVE APPABATUS. The object of all treatment is, of course, the reduction and re- tention of the hernia, but the means of doing so are various. They are mainly included under four heads. The first method is by bandages ; the second, by external or topical applications ; the third, by surgical operations for the constriction of the tumor ; and the fourth, such special treatment as may be required to meet compilicatiojis. 1st. Bandages. — The bandage of retention is essentially a belt buckled around the body, by which a pad is kept over the open- ing of the umbilicus to prevent the escape of the abdominal con- tents, and temporarily perform their office in the subcutaneous hernial sac. It is designed to aid in the mechanical closing of the umbilical opening until that takes place by the process of physio- logical change in the sac and its borders. The forms of bandage in use are many and various, among which Peuch and Toussaint name four principal kinds. A most import- ant requisite in all of them is that while they possess the solidity and fixity necessary to retain the reduced hernia in place, they shall cause the minimum amount of discomfort to thie patient. The bandage of Marlot, according to Zundel, is the one which best fulfills the three conditions of solidity, fixity and elasticity. It consists of a kind of padded saddle, with straps at its four corners, buckling on two belts, the anterior or pectoral, which sur- rounds the chest like a gii'th, and the posterior or ventral, which presses the retaining pad against the umbilicy. This pad is a wide hair cushion of a moderate thickness, kept in jDlace and pre- vented from slipping back by a longitudinal girth connecting the pectoral and the ventral belts. The bandage of Massicra is much recommended in Italy. This also is a small saddle with two wide girths passing under the thorax, and pressing against the sternum and the epigastric re- gion, with a steel band corresponding at its posterior extremity with the umbilical ring, forming a plate padded with a hair cushion. The apparatus of Strauss, used in Germany, is made somewhat on the same principle, but is reinforced by a kind of breeches which prevents it from slipping backward. The length of time necessary for a patient to wear a bandage will vary with the dimensions of the hernia — from one to three months, according to Lafosse, being required to obtain a radical cui'e. Marlot claims that an average of thirty-two days is all that HERNIA. 429 is necessary. The bandages must be applied only after the perfect reduction of the hernia, and the most accurate adaptation of the pad to the umbilical opening. These appliances are of difficult adjustment and are unavoidably uncomfortable to the animal from their liability to chafe and excoriate the skin. They, therefore, constitute a mode of treatment which must necessarily be attended with uncertainty, and, therefore, as justifying only a careful and modified recommendation. Still, it has in the hands of many prac- titioners given very satisfactory results. 2d. Local Applications. — The treatment by irritating local med- ication aims to produce in the tissues surrounding the hernial sac an inflammation which will end in a serous infiltration which will crowd away the protruding organ, prevent its return into the open- ing, and subsequently facilitate the obhteration of both the sac and the ring. This result is obtained by the use of certain chem- ical agents, which applied on the hernial tumor tend to produce various degrees of inflammation, from simple rubefaction to com- plete escharification of tissues. In former times sulphuric acid was recommended, and as late as 1833, Hertwig employed it in appU- cations made during two or three days. Blisters and their con- geners have had their day. Astringents have also been recom- mended, as also caustics, principally in the form of ointnients, as that of chromate of potash, in the proportion of one part in eight, as recommended by Foelen — these also have had their advocates. But of all these, nitric acid, applied externally, is the one which has proved most satisfactory and least dangerous. The treatment consists in applying acid upon the tumor of the exomphalus, in sufficient quantity to produce an escharotic effect, and afterwards promote the sloughing of the cutaneous sac. The mode is thus described : After positive diagnosis of the nature and character of the tumor, the animal being kept in the standing posture, the hairs cut short, the acid is applied over the entire sur- face of the sac, by rubbing it in with a brush, or a small ball of oakum secured at the end of a stick, and dipped into the acid — which should register 34"^ to 36° Baume — first passing it circularly over the base of the examphalus to define the place where its action is required, and then including the entire surface. A sufficient quantity of the caustic must be appHed, and with enough energy to produce the disorganization of the skin in its entire thickness, and positively produce its mortification. Experience has proved 430 OPERATIONS ON THE DIGESTIVE APPARATUS. that the deeper the action of the caustic, the more successful the operation is likely to be. It is said that nearly one ounce of the acid is required for a tumor as large as a man's fist, and that the friction should be continued from three to five minutes. The dui'ation of the friction and the quantity of the acid to be used must, however, be guaged by the dimensions of the tumor, and also with carefrd consideration of the thickness of the skin. Dayot, to whom is due the positive and practical introduction of this mode of treatment, proposes to apply the acid in instalments, and recom- mends that the appHcation be repeated once or twice an hour, according to the thickness of the skin, until the desired effect is assured. The result of our own experience is a conviction that as a rule only a single appHcation is necessary. Nitric cauterization praduces a yellow eschar, which ordinarily remains for a long time, soft, supple, and unctuous to the touch, but the epidermis of which is easily lacerated. In some cases the formation of the eschar is followed by a large swelling of the cauterized parts and the sur- rounding tissues. Sometimes it makes its appearance immediately following the operation, but more commonly it appears at a later period, gradually increasing during the first hours following the cautery, although again, in other cases, this swelling is altogether absent. The oedema is the direct effect of the action of the caustic upon the subcutaneous cellular tissue, which becomes infiltrated ; and in this condition applies a uniform pressure in all directions upon the peritoneal hernial sac, crowding back into the abdominal cavity the displaced intestines and preventing their return by the kind of retentive bandage which is formed by the engorgement which takes place around the sac. In the days follovring, after reaching the maximum develop- ment, the oedema gradually diminishes by resorption, becoming at the same time somewhat harder, the portions of cauterized skin which is in its center meanwhile gradually drying, and becoming transformed into a dry, hard plate. In place of the hernia there now remains a fibrous mass of new formation, which gradually diminishes and is soon more or less resorbed. In the meantime, while these phenomena are taking place, the process of the separation of the eschar has begun and progressed, and on the eighth day, on the boundary between the dead and the li\dng structures, a fissiu'e shows itself, and minute granulations appear. The separation goes on slowly, from the HEKNIA. 431 circumference to the center, leaving, when complete, a rose surface, granulating evenly, small fibrous formations sometimes appearing in its center. This wound heals rapicll}^, lea\'ing a contracted cicatrix, which assists in keeping the hernia in its place, while the indurated skin, which for some time remains adherent to the still fibrous, abdominal, subcutaneous tissue, contributes to the com- plete obhteration of the ring. After a month the cure is radical, and in place of the hernia, there remains only a hairless cicatrix, often without pigment. Though this treatment is simple, and has, by the results it has shown, justified the credit it enjoys among those who have had experience and knowledge of its working, it must not be at once accej)ted as infaUible, or unattended with danger. Cases are on record which negative such a claim. For instance, too severe a cauterization may be followed by the entire sloughing of some portion of the abdominal walls, followed by a large eventration ; and peritonitis, tetanus and intestinal fistulse are complications which have sometimes disappointed hopes which seemed to be well fovmded. Animals to which this treatment has been appHed must be carefully watched for some time during the period following the cauterization. They must be especially prevented from indulging the tendency they often betray — to bite, or scratch with their feet or legs, the irritated, cauterized surface. A cradle or aprons hanging in front of then- hind legs, or even bandages may prove effectual to prevent this suicidal habit. The topical remedies we have mentioned before, might in strictness be considered as coming under the head of external treatment, since they have all been applied to the siu'face of the skin. There is, howevor another mode of application which is subcutaneous, and which is represented by the method of Dr. Luton, and employed in the treatment of the same ailment in childi'en. It consists in injecting subcutaneously, at each cardinal jDoints of the hernial sac, a few drops of a saturated solution of chlorides of sodium (kitchen salt). We have had but one oppor- tunity to try the value of this treatment, which we improved by injecting ten drops of this solution at each point of a hernial tumor. "We produced an enormous swelling, followed after several weeks by resorjDtion and complete disappearance of the hernia. According to Peuch and Toussaint, our friend M. Cagny has 432 OPERATIONS ON THE DIGESTIVE APPARATUS. made the same experiment, but failed to obtain a successful result. 3d. Surgical Operations for the Constriction of the Tumor. — Modes of surgical treatment are numerous, usually having in view the destruction of the hernial sac, by the process of mortification, so controlled and directed as to bring about the necessary work of adhesion between the walls of the sac, above the hne where the mortification begins, with the formation of a secondary cicatriza- tion between the edges of the skin, where the mortified sac has dropped off. Before casting the animal, without which the operation cannot be performed, the surgeon must satisfy himself that the hei'nia is reducible, and that there is no adhesion, and shoidd carefully measure the dimensions of the sac in order to know accurately where the constriction must be applied. The animal must be placed weU on his back, with his hind quarters elevated — a posi- tion which is sometimes sufficient alone to enable the hernia to reduce itself. If that fails to occur, the sac can be evacuated by the taxis. It is then to be well stretched, and the appHcation of the means of constriction proceeded with. These means are many, but may be considered under the three heads of the ligature, the clamp and the suture — all of which are occasionally combined in use, as the ligature with the suture, or the suture with the clamp. (a) The Ligature. — This old mode of operation consists in the appUcation — the hernia having been reduced — of a strong cord, firmly tied at the base of the hernial pouch. The modus operandi is very simple. The hernia being already reduced, either by the taxis or by the power of gravitation, as before mentioned, and the horse in the right position, on his back, the sac is raised from the abdomen, and a strong Ugature, firmly tightened, is appHed at its base, a strong fishing line forming the best of hgature for this purpose. The degree of tightness of the ligature must be such that the mortification of the sac will be a gradual process, and that it does not slip from the waUs of the sac, on account of the progress of the inflammatory swelling. Stm this constriction must not be permitted to become so ex- treme as to produce too rapid a sloughing of the skin, with the possible result of a calamitous eventration. In order to prevent the displacement of the ligature, some HERNIA. 433 practitioners recommend the introduction of two small wooden pins just under it, either parallel or crossing each other, through the base of the sac. If the hernia is very large, instead of employing this mode of simple ligature, en masse, the operator may use two Ugatures. By pushing through the middle of the sac, close to the abdomen, a dog seton-needle, carrying a doubled cord, and converting it into two parts in cutting it from the needle, each length will serve to embrace half of the tumor, in the manner practiced in the -pvo- cess of removing large, hard tumors by ligature. Legoff has rec- ommended the use of several ligatures dipped into ammonia, placed one above the other upon the whole length of the sac, from its bottom to its base, tightening them more and more as they ap- proach the abdomen. By this process he combined constriction with cauterization. This mode of treating umbihcal hernia is a simple and easy one, but yet it is not very frequently practiced. The uncertainty of its results, the possibility of the sloughing of the skin at too early a period, with the danger of eventration, as well as that of injuring the intestines with the wooden pins or the needle, have all combined to impair its credit and discourage its use among care- ful operators. (b) Clamp. — In this process, which dispenses with the caustic, after the reduction of the hernia, the skin is stretched and pressed between the branches of a wooden clamp or of a specially adapted forceps. The clamp is a simple implement, and may be made with a curve, in which case its convexity is made to adapt itself to that of the abdomen. When applied, it is pressed close to the abdom- inal walls, and its branches brought together with nippers adhoc, and secured with a strong cord, as in the process of castration. The clamp is left on from nine to fifteen days. In many cases, the displacement of the instrument is prevented by using the wooden or metallic pins passed through the skin below it, the ends of the latter being bent over to keep them in place. This operation possesses some great advantages, but offers also some special dangers, among which is the instinctive tendency of the patient to get rid of the irritating appliance by tearing it off. Another objection to the clamp is found in the danger of caus- ing troublesome excoriations of the sheath by the friction which it necessarily occasions. Benkert and Brogniez have advocated 434 OPERATIONS ON THE DIGESTIVE APPARATUS. the use of metallic clamps, but an important objection is found in theii' weight. Borhauer had the branches of the wooden clamp perforated in several places for the introduction of the pins which held it in place. Bordonnat has invented a sj^ecial form of me- talhc clamp or rather forceps, with sharp points on the inner bor- FiG. 391.— Clamp of Bordonnat. der of one of its branches about one-half or three-quarters of an inch apart, and in the other a corresj)onding number of holes into which the points are designed to fit when the instrument is closed. Each branch has a prolongation at each end, which on one carries a vertical projection cut with a screw-thread, while in the other there are holes corresponding with the projections, and there are nuts to fit the screws. ^Vhen the instrument is appHed, and the projections passed through the holes, the nuts not only hold it in place, but are adapted to fix the pressure at any desired point, or change it at pleasure. The umbihcal forceps of Maiiot is made of two small wooden plates, slightly curved lengthwise, and brought together by means of gooves in their dove-tailed extremi- ties, through which screws are fastened. This instrument, like the metallic clamps, is objectionable principally on account of its weight, and is generally less practical than the ordinary clamp. (c) Sutures. — These are of various kinds, all agreeing, how- ever, that the stitches upon which they rely shall be so close and tight that the circulation will be so efi'ectually cut off in every part of the hernial sac that mortification cannot fail to follow. The Quilled Suture. — This consists in placing the sac between two small rods of hard wood or metal, and tjang them before and behind with strong cord twisted and rolled around their extremi- ties, and also by jjassing here and there in then* length sutures of double the strength of those which are appHed in cases of ordi- nary quilled suture. Acting somewhat by pressure, this mode much resembles the treatment by the clamp, but is Httle used at present, notwithstanding some small advantages which it may be thought to possess. HERXIA. 435 Txoisted Sutures. — This consists in applying upon the hernial sac several stitches of strong cord in order to keep the reduced hernia in statu quo. It is sometimes used in dogs, but is luicer- tain and dangerous. Suture of Delavigne. — This is another dangerous mode of operation, no longer in practice because of the hazard of injury to the intestines. It consists in applying a strong double sutui'e at the base of the sac in the following manner : With a small needle, like that used by harness makers in sewing leather, a thread is passed through and through on both sides of the flat, cutaneous surface from right to left, or vice versa, then carried back the re- verse way at a small distance from the first puncture, and the sutiu'es firmly tied. This is repeated until the entii'e sac is in- cluded and the sutures have gone beyond the umbilicus. From fifteen to twenty days are said to be sufficient to eflfect a radical cure. Method of Mangot. — To make a closing suture on the hernial sac, without danger to the intestine, Mangot has recommended the use of a perforated plate of lead, by which to aid in the reten- tion of the intestines in place and acciirately define the Hne upon which the sutures are to be applied. The plate is made to cor- respond in dimensions with the opening of the umbilical ring, but somewhat longer and wider. Besides the longitudinal slit in its center, it also has an eye at each corner for the attachment of stiings to secure it in place by t}dng them over the back. The hernia being reduced, and the plate put in place by pushing the skin of the sac through its longitudinal opening, the operator ap- phes a continued suture over and on the outside of the plate to keep it in position, wdth the flap of sewed skin hanging below it, the entu'e apparatus being securely attached to the abdominal walls by two pins running through the sac at the extremities of the suture. During the first days there is much inflammation. About the third or fifth day the pins are removed and the skin below the su- ture excised, leaving the plate to be retained only by the strings which pass over the back. These are sufficient, however, to keep it in place, and its removal will not be necessary until inflamma- tion is well estabHshed all around them. A simple dressing, held in place by a bandage, will help the cicatrization, which is said to take place in from seven to eight days. 43G OPEKATIONS ON 'I'HE DIGESTIVE ArPAllATUS. Method of Ilannon. — The modus operandi here indicated does not vary from that of Mangot, except in being modified by the use of the quilled su- ture, as before described, instead of employing the transversal pins of Man- got. Method of Mignon. — This is a com- plex mode, consisting of a combination of the ligature, the clamp and the suture. Like Mangot, he passes the skin through a plate of lead, attaches perforated clam j)s on the protruding sac below it, and pass- es the stitches or sutures through the perforations in the clamps. Method of JBenard. — This is strictly speaking, the application of the crossed suture, a stitch exactly resembling that of harness and shoemakers in their re- spective trades. In making it, a peculiar forceps is used, which is apphed like a clamp, and serves not only to keep the sac closed and secured, but also to pre- vent the return of the intestines into its cavity, and to assist in guiding the two needles with which the suture is made. Its branches are at one end articulated together, and also at the other in order to fit into handles. It is twenty-two cen- timeters in length, without including the handles ; two centimeters in height, and one and a half in thickness. The branch- es are brought together tightly by a spe- cial screw arrangement near the handles, and each has a number of holes, placed regularly, one centimeter apart, and uni- ted by a groove. Two strong straight needles and strong waxed thread are re- quired. In operating, the hernia being first reduced, the skin is weU stretched fig. 392— Nippers of Benard HEKNIA. 437 between the branches of the forceps, then these are tightened by the screw management of the handles, and next the instrument is committed to the care of an assistant. The crossed suture is then made by the simultaneous passage of the needles through the holes in the branches of the instrument. The directions to insert the needles simultaneously must not be overlooked. If disregarded, the penalty liable to follow will be the tearing of the waxed thread with the points of the instrument, and also a tang- ling of the thread. This method gives a stronger ligature than Mangot's, but it lacks the support furnished by the metaUic plate. Method of Marlot. — The methods of Benard and Mangot are here combined. A pecuhar thin forceps is used having dotted grooves on its outer surface to indicate where the stitches are to Fig. 393.— Plate and Nippers of Marlow. be placed. When the suture is finished and the forceps removed a plate of zinc like that of Mangot is applied, as a means of reten- tion, the zinc plate being thought to be an improvement upon that of lead, on account of its adaj^ting itself better to the parts. Method of Chedhomme. — The animal in this method is kept on his feet, properly secured, and a plate of lead applied, as in the l^rocess of Mangot. The hernial sac, folded in two on its longitu- dinal axis is then passed through the opening of the plate, the operator making the least possible traction until the remaining j)or- tion of the umbihcal cord, which is still quite large, is firmly held between the thumb and the index finger of the right hand. Then a stronger traction is made upon the sac, at the same time moving it in various dii-ections, while with the left hand the plate is strongly pressed towards the abdominal walls. Then with the intestines entirely replaced, the operator grasps the sac with the 438 OPERATIONS ON THE DIGESTIVE APPARATUS. left hand, and with the right, introduces a strong needle which is pushed through and through at each extremity of the sac, and an elastic hgature passed three or four times around its base. Towards the tenth day the slough is completed, and only a small wound remains, which cicatrizes rapidly. Direct Suture of the urnhilical ring. — Director Degive recom- mends for the treatment of umbilical hernia in young dogs, the direct inteiTupted sutures of the ring, the number of stitches varying with its dimensions. After bringing the threads together the wound is left open until they have safely eliminated themselves. We have employed this mode of operation for many years in the hospital of the American Veterinary College, using antiseptic pre- cautions, and with the best results. Making a longitudinal hne on the median line of the sac, and having carefully pushed back the intestines, the edges of the ring are sewed together with two or three stitches of cat gut Hgature. The parts were then thor- oughly washed with a solution of bichloride of merciuy, and the edges of the skin brought together with sUk sutures and a com- pressing bandage appHed for the protection of the wovmd from the patient's own teeth. Complete cicatrization follows in a few days. "Whatever may be the original mode of treatment the secondary effects are about the same in each case. They consist of irritation of the parts, more or less marked, and betrayed by the patients by varying degrees of restlessness, and possibly, in some cases, by abdominal joain or cohcs. After a few hours the swelling of the part begins. A diffused oedema takes place above the point of compression, and the hernial sac is sHghtly swollen and warm and becomes covered with little phlyctenoids, indicating a commencing necrosis. Perhaps a Uttle fever is manifested and there is great thirst. By the third day the swelHngis quite large, and in males it may involve the sheath. The sac then becomes cooler, the fever subsides, the appetite re- turns, and the animal which has instinctively kept his feet, rests himself by lying down. On the foiu-th or fifth day the skin of the sac is insensible, cold and flabby, and the sloughing process between the Hving and the dead skin has begun. Little by Uttle this pro- cess becomes more active, and the separation becomes more and more marked, the secretion around its opening a purulent character, and from the sixth to the tenth day the complete sloughing vsdll have taken place. The wound that remains is now granulating. HEKNIA. 439 Its length exceeds its width, and it is somewhat depressed in its center It progresses rapidly towards cicatrization, only a small scar remaining, and this is readily concealed by the growth of the surrounding hair. (d) Operation i7i Cases of Complications. — If the hernia is irreducible and there is strangulation, the enlargement of the ling must be carefully made with a curved, blunt bistoury, having a short, guarded shai'p edge. "When the reduction is prevented by adhesions, the operation necessary for their division will demand the exercise of the utmost sldll and caution to avoid injuiy of the peritoneum, and there should especially be no neglect or parsi- mony in respect to the employment of antiseptic precautions. In fact, it would in many instances be wiser to leave the animal to the resources of natiu*e than to undertake an operation of so much deUcacy and importance, and which involves so many serious con- sequences, without amply providing every resource of skill and knowledge, and anticipating every contingency of accident or dan- ger. In some cases, when the strangulation has been due to the formation of gases in the protruding intestine, we have used the aspirator for their removal, and then have met with no difficulty in reducing them by the taxis. This is a means, however, which is also recommended in the treatment of strangulated inguinal hernia, and is discussed in the chapter appropriated to operations in that region. Diaphragmatic Heenia . A diaphragmatic hernia, or diaphragmatoeele, is formed by the displacement of one of the abdominal organs, and its intrusion into the pleural cavities, through a laceration of the diaphragm. It is necessarily an accidental opening, through which such a dis- placement takes place. One case is on record, and only one, where the hernia passed through a normal opening, viz., the oeso- phageal. The causes which give rise to ruptures of this kind may be classified under thi*ee heads : first, external violence ; second, pow- erful contraction of the expiratory muscles while making a violent efi'ort ; and third, the exertion of force and pressure upon the dia- phi'agm by the organs, situated on its posterior face. (a) External Violence. — Foremost in this category are blows or contusions on the posterior costal region, such as may be made 440 OPERATIONS ON THE DIGESTIVE APPAEATUS. by the shafts of vehicles with either the blunt or broken ends. The laceration of the diaphragm may occur either with or without involving the fracture of the ribs. Several cases of this kind have been seen and recorded by Professor Barrier. (b) The Poxoerful Contractions of the Expiratory Muscles during Violent Mtiscidar Efforts. — It may result from the vio- lent and concentrated action of the abdominal muscles, compress- ing powerfully the intestinal mass, and crowding it against the diaphragm, until it destroys its continuity at one or more points, sufficiently to admit of the passage of the abdominal organ into the thoracic cavity. Durand has seen it in a six-months-old colt ; Didry and Fabey have reported cases where the hernia took place during violent efforts in hauling a load, and Franconi met with a case of a similar character to the one referred to in which the rup- ture opened into the oesophagus. Schild has seen it associated with the efforts of parturition. (c) Violent Action and Pressure upon the Diaphragm by the Orgajis /Situated on its Posterior Face. — The obhquity, forward and downward, of the inferior plane of the abdomen, is shared forward upon the posterior face of the diaphragm by the organs related to it, as the liver, the stomach and the anterior curvatures of the large colon. These are bulky organs, and their united weight being very considerable, the pressure it exerts upon the diaphragm, under any extra impulse would tend directly and nat- urally to the disruption of the weaker muscular fibres of the midriff, and these yielding, the hernia would immediately become developed, and thus we have the generation of this kind of hernia. A sudden fall might easily bring this to pass, in a second or two of time. Bouley has recorded a case in which this accident oc- cured in an animal cast for a surgical operation. Pilton has seen it take place in an animal falling down while butting against a slope of ground. Diaphragmatic hernias, like others, are either acute or chronic ; or convertible', recent and free, or of old standing, with adhesions. The distinctions of hepatocele, splenocele, stomachocele and entero- cele are of but Httle importance, none of these differences being discoverable in the li\Tng animal. The symptoms of acute hernia of the diaphragm differ, accord- ing to the extent of the laceration of the muscle, and the size of the displaced abdominal mass. There are cases in which the in- HERNIA. 441 jury is of so aggravated a character from the first, that a fatal result immediately follows the formation of the hernia, the only characteristic symptoms present being those of rapid asphyxia. In other cases, though death must ine^itably follow, the life of the animal may be prolonged for several hours, or even several days. And again, there are recent hernias which have been formed under such conditions that they are still compatible with the sur- vival of the animal. These assume the chronic character, and not infrequently escape discovery. The horse affected with diaphragmatic hernia becomes dull, anxious and uneasy, avoiding his manger and avoiding his food. He j)aws in the stall, giving evidence of suffering from abdominal pains, but which betray no peculiar characteristics, and possess no special or positive significance. Very often coUcs precede the hernia, and its formation compHcating the case, the coHcs be- come more violent. During these colics the animal hesitatingly and carefvilly lies down, rolls much, and assumes various attitudes of no special significance, though the dog-sitting posture is some- times held to be characteristic. During these colics, which are more persistent than those due to intestinal indigestion, the pulse remain strong and quite regular, and respiration is not only ac- celerated, but difficult — the physiognomy is anxious, with an ex- pression of apprehended suffocation, the nostrils are tetanically dilated, inspiratory movements are performed with effort, and expiration is of twice or three times its normal frequency. The coexistence of this condition of the respiration with the colics is a sign of great importance as an element of the diagnosis. At times auscultation furnishes valuable data. Borborygmus may be detected in the thorax, where the respiratory miu-miu* ought to be heard, and dullness on percussion takes the place of the nor- mal resonance, where the respiratory murmur has disappeared. Bouley, though he recommends this means of diagnosticating, considers it to be apphcable only for hernias of large size, in which, according to Lafosse, an increase in. the size of the thorax, a well marked projection of the cartilaginous circle of the ribs, and to- gether with these, a reduction in the size of the abdomen would be noticed. When the hernia is small, the respiratory function is unaltered. Acute diaphragmatic hernias, not necessarily of fatal tendency, are more difficult to detect. Probably from their rareness they 442 OPERATIONS ON THE DIGESTIVE APPARATUS. often escape discovery, notwithstanding a somewhat positive exhi- bition of abdominal and thoi*acic symptoms. And if this is so with the acute form, it must necessarily more frequently occur with chronic cases, which not only do not jeopardise life, but even fail to interfere with the usefulness of the animal. The horse thus affected not only has the double expiration of his emphysematous lungs, but he continues to be subject to intermittent coUcs, and especially if the hernia is formed by the intestines, and they con- tinue to suffer from occasional obstructions. To this complication of occasional actual obstruction must be added a perpetual Hability to become strangulated, with a certainty of speedy death following that accident. The lesions found at the post-mortem examinations of ani- mals which have died with this description of hernia varies. The accidental diaphragmatic openings may exist in different parts of the central aponeurotic portion or in the peripherical muscular zone, and may assume various forms, being at one time round, at another eliptic or triangular, or indefinite and irregular, at times very narrow, at others so extensive that the abdominal and thoracic cavities are no longer distinct. Between these two extremes there are many degrees and ample scope for the formation of chronic hernias of a non-mahgnant character. When the hernia is recent and has existed before death, the borders of the laceration whether muscular or aponeurotic, are irregular, thready, infiltrated and bloody, with small blackish clots adhering to the extremities of the red muscular fibres. But when the rupture is of post-mortem formation, resulting from excessive meteorism, there is no trace of capillary hemorrhage upon the lacerated edges of the aperture. "With a chronic hernia these edges have various aspects; at times thin, at others in thick cords ; now torn in scallops, and again with a regular edge, they are always smooth, hard, of fibrous consistency, and even presenting a cartilaginous aspect. There is never any formation of a special serous sac for these hernias, even for those which take place through the normal openings. The organs most commonly met in these diaphragmatoceles are the omentum, the small intestines, the anterior curvature of the large colon, and more rarely, the spleen and the stomach. If not con- gested by pressure in passing through the opening, they continue to perform their functions. In these injuries the prognosis can never be confidently favor- HEKNIA. 443 able. It is always serious. Some kill immediately, while with others there may be a respite of several hours or days, and with those which are chronic, there may be no apparent impairment of life or health. But whatever may be the character or the aspect of a given case, and however the prognosis may vary, it must never be forgotten that diaphragmatic hernia has this invariable character, that its effect is always to interfere with the respiration ; that the horse is at the best permanently affected with heaves, is unable to j)erform any active or laborious service where strong lungs are needed, and is always more or less liable to engorgement and strangulation. Diaphragmatic hernias are incurable, their sit- uation, in the deepest interior of the anatomy, rendering it impos- sible to apply any means of direct therapeutic treatment. They cannot be reduced, and even if that were practicable, they could not be secured and retained in situ. Attempts have been recom- mended by Bouley to reduce them by making an incision through the flank and replacing the protruding organ in its proper posi- tion by the taxis with the hand in the abdominal cavity. Whether in our days of perfect antiseptics such an operation could be suc- cessfully performed on the horse is a question not yet solved. The experiment might be attempted with better chances of success in cattle. In any case the operation will be justifiable only as a last resource, and when the life of the suffering animal is abso- lutely in jeopardy, in fact, as a final alternative, a dernier resort. Ventral Hernia. This term includes all hernial tumors produced by the pro- trusion of one or several of the abdominal organs through an ac- cidental opening in the muscular and fibrous walls of the abdomen, under the skin, which remains intact. The opening through which this kind of rupture takes j)lace is always accidental, unlike those which pass through the natural channels, as the umbilical or in- guinal, but still, in common with them, has a peritoneal lining. Ventral hernias are of quite common occurrence, principally however, in large animals, while in small quadrupeds they occur less frequently, and they may take place in any part of the abdo- men. They are known by distinctive names, corresponding with those of the protruding organ, as gastrocele, hepatocele., enterocele and epiploocele, etc. They usually originate as direct causes in blows or contusion 444 OPERATIONS ON THE DIGESTIVE APPABATUS. Fig 394 —Ventral ilerma upon the abdominal walls, made by blunt bodies, wbicb, lacking force to pierce through the elastic skin, are yet sufficient to lace- rate the interior abdominal walls. An example of this occurs in a thrust from the shaft of a vehicle, or its broken end, in case of a fall, or of kicks or horning among cattle in the field. In colts they are more commonly found in the lower wall of the abdomen, the animal frequently inflicting them upon itself by attempting too high a jump over a picket fence, and failing to clear it properly. Serres says that in cattle they may follow a severe distension of the abdomen under the influence of tympanitis, abdominal dropsy, or gestation. The character of a case of ventral hernia will vary in respect to its being acute and recent, or chronic and old. Indeed, the lapse of but a few hours will materially change its character from one to the other. If seen immediately after the infliction of the HERNIA. 445 injury, it is in tlie form of a round, soft, elastic tumor, well- defined in its outlines, and easily reducible. But if not examined until after a season of delay, the definite configuration disappears, and it is changed into an inflammatory swelling, cedematous, warm and painful to pressure — in fact having the aspect of a warm ab- scess. In the recent cases, the edges of the torn abdominal walls may be identified through the thickness of the skin, but the sur- geon will vainly try to make out this condition if the inflamma- tory process following the lesion has become established, and the serosity and the blood have become sufiiciently infiltrated into the cellidar tissue to make the change described. After a few days, if the hernia is not situated too low in the abdomen, the swelling moves downward toward a more dependent spot, and gradually abating disappears in about two weeks. Upon reaching this point, the hernial tumor is once more recognized, constituting, as it does, the exclusive manifestation of the displacement of the in- testinal mass, and its presence outside of its natural cavity. It is recognized by its changing conditions — elastic when the intestine is empty ; soft and puffy during digestion ; by its state of tension, increasing with effort, and by being painless, depressible and re- ducible. TMien reduced, the edges of the opening are easily made out, but it is not uncommonly found, upon the subsidence of the inflammatory process, that, during the continuance of that state, adhesions of the protruding organ with the walls of the sac have formed, and the hernia has become irreducible. In their dimensions, ventral hernias vary considerably. They may measure from the size of a large nut to that of a man's head, or even exceed that. Zundel reports a case where the rumen had penetrated into the sac, which hung almost to the ground, and had produced a dis- placement of the mammae, crowding them in a mass toward the right side of the abdomen. Although the diagnosis of ventral hernia is not difficult, it is still not impossible to mistake a recent case for certain other affec- tions of the abdominal walls, such as tumors of bacterian anthrax, or those of a bloody nature, or with phlegmonous or cedematous growths. The reducibility and elasticity of the tumor, the bor- borygmus, and the presence of the opening through the abdomi- nal walls, are intelligible signs by which to recognize the ventral hernia. Aspiration of the tumor may sometimes be performed, and rectal examination will also be of great assistance provided 446 OPERATIONS ON THE DIGESTIVE APPARATUS. the injury is not beyond the reach of exploration with the hand. Certain comphcations are not uncommon in ventral hernia. Besides irreducihil'ity ah'eady mentioned, excessive inflammation has sometimes been followed by traumatic peritonitis. Lacera- tions of the displaced organs have proved fatal. Internal hemor- rhages, fistulas and consecutive eventration have also been record- ed. Strangulation is not unknown, though it is comparatively rare. But with all these possibilities, it is not a rare circumstance to meet with animals affected with ventral hernia, even of large di- mensions, which have reached a good age with all the appearance of perfect health. From data like these upon which to found a judgment, it ought not to be difficult to deduce a prognosis which should never be far wrong. But, although compatible with the life, health and utilization of the animal, such a lesion must neces- sarily detract more or less from its commercial value. Under any cii'cumstances, it is a blemish. The least dangerous of this class of ruptures are those which are situated on an elevated point of the abdomen. Recent and uncomplicated, they are amenable to treatment more or less, according to their extent ; if old or chronic, the chances of success are reduced ; if strangulated, they are generally fatal. Usually, a ventral hernia, to be curable, must be treated when it is recent, and before sufficient time has elapsed for the intestines to become, as it were, accommodated to their new position, and especially before the cicatrization of the borders of the lacerated openings has taken place. Recent and free from complications, all that is required is their reduction and retention in their proper j)lace. When reduced, whether by rectal taxis or by external pres- sure, the parts are covered with a mixture of pitch and Venice turpentine melted together, upon which is spread oakum cut in small, short threads, which is to be covered with a second appli- cation of the pitch, after which a sheet of pasteboard, itself also impregnated with the pitch mixture, is placed over the opening. The whole is then covered and held in place by a broad bandage carefvdly rolled around the abdomen. Leather is sometimes used in heu of the pasteboard. This bandage, when appHed upon male bovines, requires to be carefully adapted in order to avoid any possible interference with the penis, and its freedom of motion in the act of micturition. The complications of swelling or bloody HEKNIA. 447 extravasations must not prevent the immediate application of the bandage. In cases of chronic hernia, compression is no longer sufficient. Jannet recommends the use of clamps as in umbilical hernia, and reports having reheved a case where the tumor was as large as a child's head. Leblanc advises the quilled suture, and Schwane- feld cured by this mode a hernia twice as large as the head of a man. Hertwig speaks favorably of the application of Delavigne's method in exomphalus. Going, Lafosse and Hertwig have ob- tained success with nitric acid injections, and Krantz and Schutt with bHsters. Peyon, Dandrieu, Terrien and Obich have had good results with the dii*ect suture of the ventral waUs in bovines, and even solipeds. Bouley objects to the suture of the edges of the opening, and also to injections into the evacuated sac of irri- tating substances, to excite inflammation and produce the adhe- sion of its waUs. We have oiirselves experimented several times with the subcutaneous injections, but every attempt has resvdted in failure. According to Peuch & Toussaint, if old ventral her- nias are to be treated, the best jolan is to have recourse to bandag- ing, as employed in the treatment of exomphalus. EVENTRATIONS. An eventration may be defined as a compound hernia, and it constitutes an accident of the first degree of severity, consisting in the formation of a hernia, of indefinite dimensions, taking place through an opening invohing the entire thickness of the abdomi- nal walls, the skin included, in such a manner that some portion of the abdominal viscera, but most commonly the intestines or the omentum, become directly exjaosed. Ordinaiily they are due to some traumatic lesion, such as a thrust from or a fall upon a sharp body, or they may be produced by stab wounds, or punctures with a fork or a knife ; or again, by kicks infiicted by other animals, or horn-blows, when cattle are crowded into too contracted a space and struggle for more room, or quarrel when herded in pastures. And they quite commonly end the career of the wretched \ictims of barbarity which are compelled to assist in the bloody and cruel sjwrt of the Spanish bull fight. They are also observed at times following severe surgical manipulations, as in castration, during the operation for strangulated inguinal hernia, after the efforts of 448 OPERATIONS ON THE DIGESTIVE APPARATUS. distokia. They may also form one of tlie complications of some of the forms of the treatment of umbihcal hernia. In the smaller animals, such as dogs, they may be produced by a severe bite by a larger animal. The pathognomonic symptom of an eventration may be con- sidered the protrusion of a portion of the abdominal contents through its lacerated walls. If the opening through which this takes place is small, the viscera will appear as a small round tumor, which 25resently becomes transformed into a large mass of intes- tinal circumvolution, which itself varies in dimensions, according to the extent of the laceration. As the exposed intestines begin to jDrotrude, they for a period retain their physiological appear- ance and normal color, but they undergo rapid changes, becoming progressively darker, blueish and then black, and grow cool to the touch. The viscera as they protrude from the abdomen may be quite intact, but they often are injui-ed, bruised or torn, the con- ditions varying according to the peculiar circumstances attending the accident. And not only is this so, but the sequel of the case must be especially considered, since an eventration which possibly might be susceptible of cure, if carefully tended from the first, may become so aggravated and exaggerated as to preclude aU possibility of remedy, as when the wounded creature, frantic with pain, from cohcs and otherwise, in rearing and struggling, forces his entrails more and more out of their place, and tears and tram- ples them upon the earth until they become a mere mass of crushed and bruised viscera, ground into the earth. And yet, colics are not always present in eventrations, even in horses whose irritable temper, combined with the condition of the injured parts, would naturally tend to render their occurrence quite inevitable. The prognosis of their injuries varies according to the species of the animal, and also under the special condition and circum- stances of each case, as judged by itself. In horses, it is, in the majority of cases, a fatal accident. The sensitiveness of the animal to impressions upon the nerves, and the delicate susceptibility of the peritoneum account for this. In ruminants they are less serious, and certainly still less so in carnivorous animals, where sometimes the whole intestinal mass may be seen hanging through the laceration, and with extensive co-existing inflammation, with- out the occurrence of a fatal termination. Swine are also very sensitive to this kind of injury, though the EVENTBATI0N8. iid prognosis may vary witli them, according to the condition of the lesion, being more or less favorable according as the bulk of the protruding viscera is less or greater. The chances of recovery will also vary in the ratio of the degree of the exposure of the vis- ceral organs to the atmospheric air, or to the severity of any traumatic accidents they may have encountered. The indications of treatment suggested in these cases is obvious. The first is always, when practicable, reduction. To return the intestine to the situation designed by nature for its occupancy is the first step to take. If it has not been seriously wounded, and is in a state of cleanliness, and has escaped contact with the earth and other soils and stains, simple washing may be attended to at once. But if, on the contrary, it is bruised, soiled and inflamed, it must be carefully cleansed with warm water, before being re- turned to its position. This reduction must be carefully per- formed by the taxis, and if the opening of the abdomen is too smaU to allow this to be accomplished with facility, it will be good prac- tice to enlarge the opening with the knife, rather than to hazard the too free manipulation of the tender parts which will form the dangerous alternative which may become the exciting causes of consecutive inflammatory, and perhaps gangrenous sequelae. K instead of the intestines the eventration allows the exit of the omentum, this also must be cleaned and washed, if necessary, and returned, though in some instances it may be torn or cut off after ligating its large blood vessels, or better yet, ligating the whole mass with animal Hgature. The second step of the operation con- sists in applying means of restraint to retain the returned organ and prevent a second exit. The quilled suture is at this juncture the means which always first suggests itself to the surgeon's mind. The clamps have their advocates, but Zundel prefers the metallic interrupted sutures. The entire application is to be supported, reenforced and protected by a wide bandage, similar to some of those recommended in umbilical hernia. LAPABOTOMY. This operation, which consists in the opening of the abdominal cavity through the loins or flanks, is one which, considering the general indication for which it is performed in human surgery, has found but little application and occupies but a small place in 450 OPERATIONS ON THE DIGESTIVE APPARATUS. veterinary practice. According to Director Degives, who furnishes the only description of the operation to vrhich we have been able to obtain access, the indication for laparotomy occurs in cases of intestinal invagination, internal hernia and intestinal strangulation and for the removal of foreign bodies from the abdominal cavity or the intestinal tract. Once a celebrated surgeon of New York had decided to prac- tice it upon one of his valuable dogs, which was suffering with impaction caused by the lodgement of a mass of hair in the intes- tines, which we fortunately succeeded in softening and removing by internal treatment. The indications for the operation are im- perative as soon as a fatal result becomes imminent and certain. The instruments necessary are a convex bistoury and suture needles. Dr. Degives briefly describes the operation as follows: '■' I^osi- tion and Hestraint of the animal standing up, or in stocks, or resting against a wall or its equivalent. If the animal is restless let him be thrown down on the side opposite to that of the opera- tion, which is divided into three steps. First Stepy opening of the Jla7ik. — The abdominal opening must be in the upper part of the flank, upon a line between the hip and the last rib. This opening may be made in two ways : 1st, or /Simple 3Iethod. — It consists in making an incision through the various anatomical layers, in the same direction, in order to form a simj^le vertical wound, large enough to admit the hand. The parts having been shaved, the division of the skin, the abdominal muscles and the peritoneum is made successively with the convex bistoury. The incision of the deep layers alone pre- sents any difnculty, and this requires some attention, the hemor- rhage being sometimes troublesome ; but when the peritoneum is exposed, the incision is increased, from without inward, with either a blunt bistoury or the straight bistoury controlled by a grooved director, an assistant protecting the intestines from the contact of the instrument. 2d, or J^ew 3fethod, by. Complex Incision. — In this each mus- cle is divided in the direction of its own proper fibres. Thus, the first is a transverse, cutaneous incision ; second, three muscu- lar divisions, running in directions more or less opposed to each other ; the first, obliquely downward and backward ; the second, obliquely forward and downward, and the third transversal and parallel to that of the skin. These incisions are very easily made. LAPAEOTOMT. 4:51 little more being necessary than a simple laceration of the intesti- nal tissue with the fingers — there is httle or no hemorrhage. The opening thus made admits the hand into the abdomen, and when it is removed the fibres of each muscle having a tendency to come together spontaneously, the opening is more or less efi'ectuaUy closed. Second step. — This varies, to correspond with the object of the operation ; 1st, whether the extraction of a foreign body in the abdomen or intestines, or 2d, the reduction of an invagination or of an internal hernia (diaj^hragmatic, mesentoric, epiploic, or pan- creatic), and, 3d, the displacement or removal of a tumor involving the intestines. In the reduction of an internal hernia, it may be necessary either to pull or to push upon the displaced organ. In some cases the hernial ring must be enlarged, and if that cannot be done with the fingers, the bistoury must be used. The reduction of an intes- tinal invagination is obtained by the combined action of a slight traction on the invaginated part and a steady external pressure upon the enlargement formed by it in the portion of the intestines in which it is enfolded. When the swelling of the organs or the presence of abnormal adhesions prevent the reduction, the traction must be increased and in opposite directions — the invaginated por- tion in one, the enfolded portion in the opposite. If a stone, a calculus, or any foreign body is to be extracted, the intestine is to be incised at some distance from the insertion of the mesentery, on its lateral face, between the two curvatiu'es. On the i-emoval of the body the intestinal suture is to be appHed. Third stejy, Closing the Parietal Wound. — ^AMien the complex incision has been made, a strong cutaneous suture is all that is re- quired. When the division has been a simple one, the edges of the muscvdar wound are brought together by ordinary interrupted sutures, and the skin is afterward sewed up. The drainage at the lower part of the wound is always advantageous." As enteritis and peritonitis are common sequelae of this opera- tion much care and watchfulness devolve on the surgeon in direct- ing the regimen and nursing of the patient in order to prevent the possibility of their access from becoming a certainty. CHAPTER IX. OPERATIONS ON THE RESPIRATORY APPARATUS. ON THE GUTTURAL POUCHES— HYOVERTEBROTOMY. This term fails to meet the approval of Zundel, who has pro- posed that of Hyosi^ondylotomy as a substitute, in order the better to indicate the puncture of the sac of the guttural pouches which it signifies. The former name, however, has been generally ac- cepted, and while its etymology would point to the operation by which the punctui'e referred to is made between the hyoid bone and the atlas, it is still used to mean generally, the punctui'e of the pouches, at whatever point it may be made. These guttural pouches, which exist exclusively in the sohpeds, and are two in number, are situated between the cranium, the pharynx and the atlas, resting upon each other on the median line, each one, by an expansion of the mucous membrane of the Eustachian tubes, forming a sac and filling the triangular space situated j)osterior to the pharynx and extending to the larynx. The mucous membrane which forms them is easily stretched, and the. cavity may thus become greatly distended by the accumulation of pus, and when this is the case, the pouch extends below the larynx and the lower extremity of that organ. Thus situated in the parotid region, these two sacs sustain important relations to other points, varying according to the position, whether of extension or flexion, of the head upon the neck, and are covered by seven separate tissues, as represented in theii* order from without inward, by 1st, the skin ; 2d, a layer of subcutaneous connective tissue, more or less abundant ; 3d, a thin expansion of cutaneous muscle with the parotido-auricularis muscle ; 4th, the parotid gland, whose internal face is moulded upon the muscles and blood vessels un- derneath ; 5th, the following muscles in the order as named from above downward, viz., the small oblique of the head — the stylo- hyoideus, which fills the space left between the anterior border of HYOVERTEBROTOMY. 453 Fig. 395.— Antero-PoBterior Section of the Head, showing the Mouth, Fances, and Nasal Cavities. 1, genio-glossuB muscle; 2, genio-hyoideus muscle; 3, the velum palati; 4, pharyn- geal cavity; 5, oesophagus; 6, guttural pouches; 7, pharyngeal opening of the Eustach- ian tube; 8, laryngeal cavity; 9, lateral ventricle of the larynx; 10, trachea; 11, ethmoi- dal turbinated; 12, maxillary turbinated; 13, ethmoidal volutes; 14, cerebral compart- ment of the cranian cavity; 15, cerebellar compartment of the same; 16, falx cerebri; 17, tentorium cerebelli; 18, superior lip; 19, inferior lip. the styloid process of the occipital bone and the superior border of the long branch of the hyoid, through which the puncture is made in order to enter the guttui'al pouches, and back of this the stylo-hyoideus and the superior border of the digastricus ; then, 6th, on the deepest layer, the guttural pouches are found supe- riorly, resting intimately on the internal face of the stylo-hyoideus muscle, inferiorly closely cemented with the posterior face of the pharynx and posteriorly with the superior extremity of the long muscle of the neck ; and 7th, the numerous and important blood vessels and nerves belonging to the parotid region. 454 OPERATIONS ON THE KESPIUATOKY APPARATUS. Fig. 397.— Parotid Region— Superficial Layer. PP, parotid gland; ^Ipa, parotldo-auriciilar muscle; 3, transveral artery of the face; 4, maxillo-muscular vein ; 7, jugular vein; 8, glosso-facial vein; 9, transversal vein of tbe face; 10, maxillo-muscular vein; 12, posterior auricular vein; 13, facial nerve; 15, auricular branch of the ad cervical pair. The arteries are the three divisions of the primitive carotid ; 1st, the occif»ital, which, by its mastoid branch, runs over the ex- ternal surface of the styloid process of the occipital bone ; 2d, the internal carotid, which runs upward through the thickness of the fold of the mucous membrane which forms the guttviral sacs ; 3d, the external carotid, with its parotid branches, the maxillo-mus- cujlar, the posterior auricular, the superficial temj^oral trunk and the internal maxillary The veins, which are numerous, empty HYOVEnTEBKOTOMY. 455 Fig. 397.— Parotid Region— Middle Layer, P, parotid gland; D, digastricua muscle; Sh, oooiioito, or stylo-hyoideus, muscle; Sm, sterno-maxillaris muscle; P, thyroid gland; n, posterior border of the great branch of the hyoid bone; 1, primitive carotid artory; 2, external carotid artery; 3, transversal artery of the face; 4, maxillo-muscular artery; 5, posterior auricular artery; 6, thyro-laryngoal artery; 7, jugular vein; 8, glosso-facial vein; 9, transversal vein of the face; 10, maxillo-muscular vein; 11, anterior auricular vein ; 12, posterior auricular vein; 13, facial nerves ; 14, anterior auricular nerve. into tlie jugular or its clijBferent branches. The principal nerves of the parotid region are the facial, the pneumogastric, the sj)inal, the superior cervical ganglion of the sympathetic, the great hypo- glossus and the glosso-pharyngeal. These nerves, with the exception of the facial, are situated on the external face of the pouches below the long branch of the hyoid bone and the stylo-hyoideus. 456 OPERATION'S ON THE RESPIRATORY APPARATUS. This rapid summary of the anatomy of the parotid region -^tII sufficiently indicate the dangers which the surgeon is likely to encounter at successive steps of the operation, and especially if he duly considers the location of the occipito-hyoideus, which must be reached before the puncture can be made, and again, the pecu- liar course followed by the posterior auricular artery as it emerges from the parotid to reach its destination. Hyovertebrotomy is indicated in all cases of repletion of the guttural pouches resulting from a purulent collection and main- tained by a process of chronic inflammation. It is i^rincijiaily when horses have become liable to be attacked with strangles that these purulent collections are formed. They are marked by an increase of size in the pouches, gradually augmenting with the continued formation of the pus, and interfering more and more with deglutition and respiration, sometimes assuming such pro- portions as even to threaten suffocation. Attacks of phar^Tigitis or lar^Tigitis, or catarrh of the anterior chambers of the respira- tory apparatus and nasal cavities, or sinuses, are at times noticed in connection with this affection. To revert to the anatomical arrangement of the parts : The guttural pouches, opening into the cavity of the pharynx by a narrow slit, are situated on the lateral surface, and thus allow any collection of pus they may contain to flow without interruption into the pharynx, and hence into the other nasal cavities. We have here an explanation of the fact that a discharge from the nose in any one of a variety of affections, such as suppuration of the o-uttural pouches, pharjaigitis, laryngitis, catarrh, and also the dis- charge of glanders, may all possess different characteristics, and each exhibit a different aspect, and therefore demand a different diagnosis and reqmre different treatment. The discharge from the guttural pouches is whitish, glaiiy, more or less mixed with mucosities, inodorous, non-adhesive to the wing of the nose, and intermittent, being marked during mastication or deo-lutition, and especially while swallowing liquids — in all form- ing an assemblage of characteristics which should be sufficient to distinguish the affection from all others. There is, besides this, a neo-ative point, in the absence of chancres, which with the distinct nature and peculiarity of the discharge, and the characters so t;y'pical of the maxillary lymphatic glands in that disease, will laro-elyaid in determining the difference between the two affections. HYOVEETEBROTOMY. 457 In respect to glanders, moreover, the bad odor, the thick, gru- mous nasal discharge, and the soreness and dullness on percussion of certain parts of the face, will in many cases serve to identify and distinguish a pathological condition of the sinuses very dif- ferent from that of the disease we are considering. Gohier and Vatel also refer to guttural tympanitis, or dilatation of the pouches by air, as a featiu'e of theii- disordered condition. The amount of pus collected in the pouches varies in different cases to such an extent that from only a trifling degree of dilatation it may be suf- ficiently extensive to produce a sensible projection of the sac below the parotid. This dilation furnishes a guide for the determination of the proper point at which to make the puncture, whether in the upper, in the middle, or in the lower part of the pouches. The upper operation is hyovertebrotomy proper. Besides these three modes of operation, Gimther has proposed a fourth method which consists in penetrating the pouches through the nasal cavities. Tipper operation — Hyovertebrotomy propjer. — As described by Chabert and Fromage de Feugre, this is one of the finest and most delicate operations of veterinary siu^gery. Extremely so when per- formed on horses whose pouches are healthy and normal in size, it loses a great deal of its apj)arent difficulty when these are full of pus with prominent and well developed walls. The nerves and blood vessels which surround them are then easily pushed aside from theii' position, and the lobules of the parotid are more or less separated. The instruments reqiiired for this operation are: a pair of scissors, a convex and a straight bistoury, a dissecting forceps, an Fig. 398.— Curved Trocar, or Hyovertebrotome. S probe, or preferably, the curved trocar, the hyovertebrotome (Fig. 398), and a piece of tape. Artery forceps and ligatures ought to be always within reach. Bouley, Zundel and others recommend that the animal should be kept in the standing position with simply a twitch on the lip, 458 OPERATIONS ON THE RESPIRATORY APPARATUS. but our experience has taught us that the recumbent position is the safest, especially if there are plenty of assistants at hand, with instructions to keep the head of the animal steady, and in a mode- rate state of extension on the neck. The operation is divided into three steps ; 1st, The incision of the shin and dissectio7i of the 2yarotid ; 2d, The puncture of the pouch through the occip)ito-hyoideus muscle ; and 3d, The estab- lishment of the counter-opening. Before considering these three steps, it will be well to answer sundiy important questions jDut by Lecoq in the first good de- scription of the operation, made in 1841. Where shall the jruncture be made? The anatomical disposition, which we have already examined, suggests as an answer to this query, that the occi2nto-hyoideus imiscle is the proper place for the puncture. Its inner side is lined with the mucous membrane of the pouches, and as has al- ready been remarked, when this is distended by fluid and becomes tense and resisting, it is in a much better condition for the pass- age of the knife through its thickness than when flabby and soft, and therefore movable and shifting, as if endeavoring to evade the knife. At any other point the pouches are so surrounded by im- portant blood vessels and nerves that the operation is precluded by the danger which would be incurred by attempting it. IVhere inust the first incision be made to reach the occipito- hyoideus muscle ? It would be easy to reach the muscle by a division of the paro- tid gland, but this would involve the formation of a fistula, and a wound difficult to heal, to avoid which the gland must be raised out of the way. This should be done by raising the posterior bor- der, where it is loose and free from blood vessels or nerves of importance, in preference to doing so by distvu'biug the anterior border or superior extremity, where the posterior aiu-icular arteiy, the facial nerve and the sub-zygomatic artery are situated. The superior extremity of the incision must begin near the inferior border of the tendon common to the splenius and small com- plexus muscles, a little in front of the transverse border of the atlas, and extend downward for a space of two or three inches. TJpfon vihat point of the muscle must the puncture be made? The answer to this is — upon the central portion of the muscle. The introduction of the bistoury into the superior part of the HYOVEETEBROTOMY. 459 muscle will involve possible danger to the posterior auricular ar- tery, and the risk of the di\ision of the facial nerve. In what direction must the sharp edge of the bistoury be turned? The reply to this is the poitit of minimum danger from irregu- lar motions of the instrument, caused by the struggling of the patient ; and this result is most likely to be accompKshed by carry- ing the bistoury towards the tuberosity of the hyoid bone, and consequently in the direction of the patient's nose. With the instrument turned towards the ear, there woiild be possible dan- ger of dividing the posterior auricular artery, the facial nerve or, perhaps, the internal carotid. In carrying it toward the atlas, the internal carotid, and the nerves surrounding it, would be the endangered j)arts, if any. If directed downward, toward the larjnix, a division of the great hy- poglossus, and possibly of the external carotid, might be possible. What must be the direction of the instrument? If the bistoury is pushed through the occipito-hyoideus muscle, and in a direction perpendicular to it, there will be great danger, at a certain depth, of reaching and penetrating through the in- ternal carotid artery ; but if an obHque direction be given to the instrument, not only is this danger avoided, but no accident be- yond some slight muscular injm-y, of no importance, need be ap- prehended. Where is the counter-opening to be made? The right place will be the most dependent part of the pouches, and the instrument used must be either the S probe or the trocar, as will be hereafter described. These preliminary points being understood, we shall the more intelligently follow the description of the three steps of the opera- tion, which we now proceed to give. 1st. The Incision of the Skin and Dissection of the Posterior Border of the Parotid. — This incision is made a Uttle in front of the transverse process of the atlas. It includes the skin and some subcutaneous aponeurotic fibres, and extends to the posterior bor- der of the parotid, which is at this point exposed. With the straight bistoiuy and dissecting forceps, the parotid border is dissected, and under it the aponeurosis of the levator-humeri is divided. The finger is then pushed between the aponeurosis and the small obUque muscle of the head, in order to reach the occipito- 460 OPERATIONS ON THE RESPIRATORY APPARATUS. hyoideus, which is readily identified by feeling for the styloid pro- cess of the occipital bone and the superior border of the long branch of the hyoid. Some little hemorrhage and some strug- gling of the patient may follow this incision, caused by the divis- ion of the auricular vein and nerve, but the consequences will not be serious. 2d. Puncture of the Pouch through the Muscle. — The central point of the muscle being identified, the operator, with a straight bistoury held in the manner of a writing-pen, introduces it under the parotid, obliquely, from above downward, and from behind forward, and thus divides the muscle through and through, and penetrates the pouch. If the puncture proves to be sufficiently large, the index finger is introduced into the opening for explora- tion, and, if necessary, for its further dilatation. If the collection of pus is not very abundant, and the mucous membrane lining the sac not greatly distended, it will be important to have a very sharp-pointed instrument, which will make its work of incision sure, instead of merely pushing the membrane avray from the internal face of the muscle — an accident which might lead to serious results. But again, when the collection is abundant and the pouches much distended, the use of the bistoury may prove unnecessary, the puncture being then readily made by pushing the index finger through both the muscle and the mucous membrane of the pouch. 3d. Making a Goitnter-Opening. — The S probe, or curved tro- car (Fig. 398), is introduced through the opening made, and is pushed down to the bottom of the pouch, where the mucous mem- brane is easily torn ; it is then carefully directed toward a point a little below the glosso-facial branch of the jugular, back of the thick border of the maxillary bone, and pushing against it with sufficient force, the instrument forms a prominent point under the skin. If the S probe is used, an incision is made with the bistoury through the skin, and the instrument is exposed. If the curved trocar, it is by a strong pushing movement passed through the skin and brought outside. Whatever instrument may be used, a piece of tape or kind of seton is introduced from the lower through the upper opening, and the continued escape of pus thus facilitated and ensured. The extremities of this piece of tape are secured together by tying them with the knot used with the or- dinary seton. HYOVERTEBROTOMT. 4G1 The attention required by the patients after the operation is of the simplest kind, consisting in keeping the wounded surface thoroughly clean and keeping up the flow of the pus. This wiU. at first make its escape through the upper opening, but will soon find its way through the lower one, and so long as it is discharg- ing the opening must not be allowed to close, nor must the seton be moved. Puncture in the Middle and the Lower Regions of the Parotid. — These modes of operation are so nearly identical that, with H. Bouley, we think they may with propriety be jointly con- sidered. In these cases but httle attention to the anatomy of the part is required. The growth of the j^urulent collection distends the pouches, displaces the blood vessels and nerves, separates them more or less from the parotid, and becomes more superficial, and, in fact, may ulcerate through the skin and empty itself spontane- ously. But this process is a very slow, tedious and painful one, and subjects the patient to such a degree of suffering, that it be- comes a duty imperative to interpose the resources of surgery for its relief. The puncture in this case should be made as early as possible, and at the fluctuating poiat, as with an ordinary abscess. It is made with the bistoui-y, or, what would be better, with the olivary actual cautery, by which the prevention of hemorrhage will be as- sured. The opening thus made and cauterized, will, moreover, have less tendency to close too rapidly, besides which the modify- ing effects of the cauterization will have a highly advantageous in- fluence upon the healing process. The opening of the pouch at its lower extremity has been recommended when the purulent collection is small, or when con- cretions of inspissated pus are supposed to exist in the canities. It is done by first dissecting the wide and thin lower portion of the parotido-aiii'icularis, then of the base of the parotid, under which the distended pouch is seen and punctiu-ed. We remember a case where the collection in both cavities was such that we had no difficulty in opening them on each side of the neck, about on a level with the thyroid glands, the lower operation with emphasis ! Puncture Through the Eustachian Tubes. — Gunther has in- vented a tube, rounded at one extremity, a sort of hollow bougie, 462 OPERATIONS ON THE RESPIRATORY APPARATUS. which he introduces into the guttui-al pouches by passing it through the nasal canities and the Eustachian tubes. Although in performing this operation the animal is thrown down, it is very difficult to accomplish, and requires to be preceded by the operation of tracheotomy. It also requires to be repeated several times, by reason of the Hability of the collection to return. The mode of operation is a matter of no importance, since the solutions of continuity resulting from it seldom assumes a form more serious than that of an ordinary simple wound, and requir- ing no special directions as to treatment. Even ordinary de- tergent washes are scarcely necessary. LAKYNGOTOMY— AEYTENECTOMY. ^ The history of surgical interference at the larjTix, to relieve the peculiar difficulty of respiration known as roaring, depending upon paralysis of the larjTigeal muscles, dates as far back as 1845, when Professor Gimther, of Hanover, attempted, in succession, the resection of the vocal cords, the removal of the vocal cord of the paralyzed side of the larynx, the partial excision of the arytenoid cartilage, the entire extirpation of that cartilage, the removal of the vocal cord and of the corresponding laryngeal ventricide, and finally the fixation of the arytenoid, by an anchylosis at its artic- ulation loith the thyroid cartilage. The results obtained by Gun- ther were more or less successful. These experiments were repeated by Gerlach, H. Bouley, Stockfelth and Bassi, but subsequently repudiated and ignored. But in later years Professor Moller, of Berlin, and George Flem- ing, of London, have turned then- attention to the subject, with the suggestion of various new modes of operating, which have yielded results more or less encouraging. The matter has been followed up by other veterinarians in various parts of the world, and re- cently especially by Professor Cadiot, and the successes which have been recorded, though not always perfect, seem to justify the prosecution of further inquiries and new trials for the relief of a disease which has thus far baffled the skill of veterinarians, and consigned many a valuable animal to the hands of the knacker. ^'' The operation of Professor Moller, also recommended by Pro- fessor Cadiot, as at present jaracticed, is the excision of the pai'a- lyzed cartilage. That of George Fleming is the removal of the LAKYNGOTOMY ARYTENECTOMY. 463 cartilage and the vocal cord. We shall describe the Fleming and Cadiot modes as we find them recorded in their own works. '* Roaring in Horses," by the former, and " The Surgical Treat- ment of Chronic Roaring," by the latter. -' The Fleming Method. — The special instruments necessary are small ordinary forceps; scalpels; bull-dog forceps; tracheal Fig. 399 —Tracheal Tampon Canula. tampon ; a canula, f oi^med of a long tracheotomy tube, with an india rubber bag surrounding its middle. This bag is inflated by means of an india-rubber air-pump, after the insertion of the tube into the trachea, and is useful in preventing the flow of blood into the bronchii during the horse's getting up after the operation, and for half an hour subsequently. Other instruments required are a razor-shaped knife, with which to excise the cartilage ; a bent knife with which to remove the muscles from the outside of the arytenoid cartilage ; a hook to seize and raise the lower end of Fig. 400.— Razor-shaped Knife. Fig. 401.— Bent Knife. Fig. 402.— Hook to Secure the Cartilage. 464 OPEBATIONS OX THE KESPIKATORY APPAKATUS. yiG. 404.— Curved Scissora. Fig. 406.— Electric Lamp. tte cartilage ; a special forceps with toothed ends, to seize the body of the cartilage ; curved scissors to cut through the mucous membrane ; tAvo retractors to keep the trachea opened during the operation ; and an electric lamp to illuminate the interior of the laxjnx. Fleming describes the operation as follows: "The horse should be well fed for a day or two preceding the operation, but have little or no food or di'ink for some hours before its actual performance. In the case of thoroughbred horses, a dose of foui- ounces of tincture of opium in a pint of watei', half an hour be- fore operating, is ad^dsable. The hair must be removed closely from around the upper part of the trachea and larynx, before the LAEYNGOTOMY ARYTENECTOMY. 465 animal is cast, and he is thrown in the usual manner, on a good bed of straw or moss or litter. The chloroform bag is put on, and when the required state of narcosis is induced, the animal is placed on his back, and maintained there by sacks filled with straw, placed close under each side of the body. The neck and head are ex tended in a hne with the body, the head placed on the vertex and kept steady by an assistant. The operator places himself in a kneeling position, on the off, or right side of the body, if right handed, beside the neck, with his back to the shoulder and face toward the head." The operation is divided into three stages : First Stage. — " With a scalpel, an incision of from four to six inches in length is made through the skin, the middle liae of the larynx and trachea, opposite the posterior border of the lower jaw, extending from the body of the thyroid cartilage to the second or third tracheal ring. This exposes the subscapulo-hyoid, sterno- hyoid and sterno-thyroid muscles, which are incised to the same extent, and as close as possible to their line of junction ij'aphe) in the middle, the section being then carried through to the laiynx and trachea. There is a variable amount of hemorrhage now to contend with, which, if only oozing, may be checked by sponging it dry until the blood has ceased to flow ; and if it comes from twigs of arteries or veias, they may be seized, and twisted, or ligated.'' Second Stage. — "The middle crico-thyroid ligament, cricoid car- tilage, and one, two or three tracheal rings are cut through, in a straight line, exposing the interior of the larynx and trachea. If blood vessels are cut, they should be taken up. A retractor is applied to the sides, and these being pulled gently apart by an assistant, there is ample space ia which to manipulate. The con- vex lower border of the arytenoid on each side can now be seen, and if the respiration is deep, that which is next the operator (the right), will be observed to move actively from the side toward the middle ; while if the roaring is due to paralysis of the left dilator muscle, there is no movement in the opposite cartilage. "SMien the breathing is very tranquil, which is often the case, the right carti- lage moves almost imperceptibly, and it becomes necessary to as- certain whether the left one is really immovable. This can be done by passing the finger, or a long probe, up toward the epi- glottis, when the act of swallowing will be excited, during which 466 OPERATIONS ON THE RESPIRATORY APPARATUS. the 1-igbt arytenoid cartilage is energetically jerked into the mid- dle of the cavity ; but the left one is either motionless or only feebly stirs, depending upon the degree of the wasting of the con- strictor muscles on that side. " If any blood lodges in the trachea, it can be removed by large or small (handled) sponges, which may be passed to the operator by an assistant who receives and washes them. As the horse is now breathing through the wound, the chloroform bag may be removed. "It is always advisable to examine the interior of the larynx carefully, in order to ascertain its exact condition, as there may be something more in the case than an immovable cartilage. For this purpose the electric lamp is invaluable. Fig. 407.— Left Side Section of Larynx, showing the Parte excised In the Operation for Roaring. " The left arytenoid cartilage may be excised by commencing at the lower convex border, or at the upper part, where it meets the right cartilage (Fig. 407), If the latter method is selected, then a cut with a razor-shaped knife is made through the mucous LAEYNGOTOMY ARYTENECTOMT. 467 membrane, into the arytenoid ligament and arytenoid muscle, as close to the margin of the cartilage as possible, beginning between the cartilage of Santorini, downward and then upward and the vocal process at the insertion of the vocal cord (Fig. 407). The hook is inserted in the vocal process, which is raised, and the vocal cord is separated from the cartilage by the scissors ; then the muscles on the outside of the cartilage are cut with the bent knife, or, what is better, pushed from its surface as close as possi- ble. The hook is removed, and the body of the cartilage seized with the rachet forceps. The mucous membrane connecting the"* cartilage with the vocal pouch is divided, with the curved scissors, cutting as close to the cartilage as possible, to save the membrane. "The arytenoid cartilage is now free, except at its articula- tion with the cricoid, and it may either be disarticulated or cut through with the scalpel at this point, care being taken to leave no loose portions or shreds. The cartilage being now only retained by the soft parts at the upper portion (or base of the arytenoid cartilage), these are cut through, close to it, with the scissors, when it is altogether detached. " Care must be taken to avoid wounding the other cartilages, or the pharyngeal mucous membrane, and to spare that membrane in proximity to the arytenoid cartilage as much as possible, remov- ing only that which covers its surface and the cartilage of Santorini. " The vocal cord is now removed close to its attachment to the thyroid cartilage, in front and at its fixed border (Fig. 407). This can be done with the scissors, a finger being passed to the bottom of the ventricle to faciUtate the excision ; or the cord may be drawn from the side by inserting a hook in it, to allow plenty of room for the scissors. " If the hemorrhage is troublesome, which it seldom is, the blood can be mopped out of the trachea with the sponges. It cannot pass down that tube, owing to the position of the neck. If necessary, the electric lamp may be employed to ascertain how the operation has been performed, or even during it performance ; but after a little experience this is unnecessary." Third Stage. — "The trachea being completely freed from blood, and the tampon canula introduced, the bag being inflated after it has been properly placed into the trachea by means of the air-pump, the canula is secured in position by a tape around the 468 OPERATIONS ON THE RESPIRATORY APPARATUS. neck. It is only requii'ed for about half an hour, until the hemor- rhage has ceased, as it will prevent the entrance of blood into the lungs while the horse is getting up, and for a short time after- ward respiration being carried on through the tube. It ought not to be left any longer, being liable to injure the interior of the trachea. The blood being again removed from the larynx, one or two syringe-fulls of the common salt or borax solution are inject- ed into it and the pharynx. This washes out these cavities and the sinuses of the head, a necessary precaution, as putrefying blood in them sometimes gives rise to troublesome consequences. Swallowing should be induced by touching the epiglottis, and then the horse may be turned on his side, the lower margin of the wound being depressed, to allow the remaining blood and water to flow out. This completes the operation. " The horse is no*r allowed to recover from the chloroform? and when ready he may be assisted to get upon his feet, care being taken that the canula is not displaced while doing so. The wound is kept open with the finger for a short time, to allow any remaining blood to escape, and it is afterward cleansed away from around the wound, the face and nostrils sponged to refresh the patient, and if the weather is cold, the body clothed and the legs bandaged." Method of Cadiot. — The special instruments required are a Fig. 408.— Blunt Bistoury. Pig. 409.— Curved SclsBorfl. Fig. 410.— Spring Tenaculum, or Dilator, blunt bistoury, curved scissors, whose blades are nearly perpen- dicular to the branches, a spring tenaculum, a hooked or long bull-dog forceps, a canula tampon, like that used by Fleming, a LARYNGOTOMY ARYTEKECTOMY. 469 Fig. 411.— Hooked Forceps. peculiar curved needle, shown in Figure 418, straight, long and ordinary curved scissors, bistouries, dissecting forceps, artery nip- pers, loose and fixed sponges, thi'ead, cotton, pheniated or iodo- formed gauze, and antiseptic solutions. The preparation of the animal is similar to that in Fleming's- method. First Stage. — Incision of the Skin and Muscles covering the Larynx. — The incision must be made on the median Hne, and ex- tend from the body of the thp'oid to the second or thu-d tracheal ring. This is done with the convex bistoury, first dividing the skin in its whole length, when the edges separating show the raphe of the stern o-hyoid and omoplat-hyoideus muscles. The muscular layer can then be divided exactly upon the median line. The division of the prelaryngeal connective tissue closes the first stage. The hemorrhage is always Hght and easily controlled. Second Stage. — Incision of the Larnyx and of the First Tioo Rings of the Trachea, Introduction and Fixation of the Can- ida. — The incision may be made by a single stroke of the knife, di\dding the crico-thyroid, and with it, successively, the cricoid and the crico-tracheal ligaments, and the first rings of the trachea. But by this mode of operation, the vocal cords may be injured, and to avoid this, the bistomy held perfectly vertical, with the edge turned backward, is inserted through the crico-thy- roid ligament, immediately in front of the cricoid cartUage, and this is divided with the crico-tracheal ligament, as well as the first ring of the trachea. The edges of the laryngo-tracheal incision are then opened with the spreaders, or the spring tenaculum, and the division of the thyro-cricoid ligament is completed, from be- hind forward, and from within outward. As by the act of inspi- ration the vocal cords move more or less outward, this movement should be carefully watched while making the incision of the crico-thyroid membranes to save them from injury. The canula- tampon is then introduced, and when in place, is moderately in- flated by an assistant, the operator measviring the degree of dila- 470 OPERATIONS ON THE RESPIRATORY APPARATUS. tation with his fingers in the superior part of the trachea. T\Tien it is sufficiently expanded, a hgature is applied upon the India rubber tube, and this is cut ofi'. Though the tampon is inflated, Fig. 412.— Arytenectomy. The second step ia over. The crico-thyroid ligament, cri- coid cartilage, crico-tracheal ligament and the two first tracheal rings are divided. The canula and the tenaculum are in place— rc. Cricoid Cartilage. IR, First King of the Trachea. the canula has a tendency to slip in the larynx, and for the pre- vention of this accident should be secured by bands or strings tied backward over the neck. Third Stage. — Ablation of the Arytenoid Cartilage. — The ablation of the cartilage is effected by several steps : (a) Incision of the Mucoits 3femhrane along the Superior and Posterior Borders of the Cartilage. — With a blunt bistoury and a shght pressure, an incision is made in the mucous mem- brane along the side of the superior and posterior borders of the LABYNGOTOMY AKYTEKECTOMY. 471 arytenoid (see Fig. 413), the instrument being then carried into the larynx on the median line, from before backward to the cri- coid, and thence from within outward and from below upward, as far as the insertion of the vocal cord. To save the mucous mem- PlG. 413.— Sd Step, a, Incision of the Mucous Membrane along the Superior and Pos- terior Borders of the Arytenoid. brane, the incision may be made at some distance from the bor- ders of the cartilage, but the division of the membrane must be complete. (b) /Section of the Vocal Cord ; Dissection of the Cartilage on its Inferior and Anterior Borders and External Face. — With long, shai-p, straight scissors, the vocal cord is excised at its in- sertion upon the arytenoid (see Fig. 414). The cartilage is then, by small nips of the scissors, made from behind forward, dis- sected in dividing the mucous membrane along its inferior bor- der, and the muscular fibres of the crico-arytenoid and thj-ro-ary- tenoid, inserted on its external face (Fig. 415); the mucous mem- brane, which covers the anterior border, being divided from above 472 OPERATIONS ON THE RE8PIBAT0EY APPARATUS. Fig. 414.— 3d Step, b, Section of the Vocal Cord. downward with the scissors. To facilitate this part of the oper- ation, the cartilage must be firmly held with either the hooked or the bull-dog forceps, and carried toward the median line, when the inferior border and the external face are dissected, and drawn backward and upward when the dissection goes on, on the ante- rior border. The only important or particular caution needed here, is to hold the point of the scissors always in contact with the cartilage, to keep close to it, to save the mucous membrane, and to avoid the larjTigeal ventricle as well as the tissues loosened from the external face of the cartilage. Toward the end of this third step, when the cartilage is separated from the fibres of the thyro-arytenoid muscle, a hemorrhage takes place from the divid- ed laryngeal branch of the thyroid artery (Fig. 416). This must be controlled by torsion or artery nippers. (c) Section of the Cartilage near its Articulation with the LABYNGOTOMY — ABYTENECTOMY. 473 PlO. 415.— 3d Step, b. Dissection of the Arytenoid at its Inferior Border and its External Face. Cricoid. — Raised and immobilized with a strong forceps, or the hook forceps, held with the left hand, the arytenoid is separated from without inward near its postero-superior angle, the articu- lar, with the blimt bistoury. Held in a vertical direction, or some- what obliquely downward and forward, the bistoury is moved to- ward the external part of the arytenoid, immediately in front of the cricoid, and the section is made by a limited and careful saw- ing motion. When the arytenoid is partially ossified, which is a condition encountered in nearly one half of the patients, some force may be used. A feeling of cessation of resistance, and an increased mobility of the cartilage, indicates the completion of the section. (d) Dissection of the Cartilage hy its Superior Face (Fig. 417). — This is done with the curved scissors. The cartilage being well 474 OPERATIONS ON THE BESPIKATOKY APPARATUS. !f- . Fig. 416.— 3d Step, c, Section of the Arytenoid near its Articular Angle. ^1, Laryngeal Branch of the Thyro-Laryngeal Ai-tery. raised with the forceps, the scissors are introduced under its poste- rior portion, with the branches held almost vertically, and close to the cartilage, from behind forward, and the fibres of the arytenoid muscle are nipped off. "With careful attention, the perfect dissec- tion of the entire cartilage, including its beak, may be effected. During this part of the operation, blood and pharjoigeal mucosi- ties may interfere with the manipulations, and must be removed with pieces of soft cloth, wadding or sponges. When these various manipulations have been well executed as described, the surface left by the loss of substance presents a neat and smooth appearance, not only on its borders, but over its en- tire extent. Professor Cadiot, in this step of the operation, omits the excision of the vocal cord, which he considei'S unnecessary. Fourth Stage. Suture. — The borders of the wound are brought LARYNGOTOMY — ARYTENECTOMY. 475 PiG. 417.— Sc? Step, d. Excision of the Cartilage with the Curved Scissors. together with two or three interrupted catgut sutures, made with a special needle (Fig. 418). Three of these are generally re- quired (Fig. 419). After cleansing the larynx of the blood, it is dressed with wad- ding or iodoformed gauze. The edges of the external wound are brought together by two interrupted sutures, one upon the mus- cular coat, the other on the skui, the latter being so placed as to prevent the displacement of the canula. The care of the wound, aside from the matters of cleanliness and the appKcation of antiseptic measures, varies according to the two modes of operation. But they agree in advising the* early removal of the canula at a period not later than the day following that of the operation. Careful diet is indicated, but Fleming advises strict fasting from both food and water for two or three days, while Cadiot per- mits the animal to have his ordinary diet without interruption. 476 OPERATIONS ON THE KESPIKATORY APPARATUS. Fif. 41h — i?/i >sr< J* ITow to Apply tbe Sutures. There is no serious febrile reaction, and after three or four weeks tlie cicatrization is complete. ( The result of the operation cannot be fuUy ascertained until about three months after the operation, when the animal can be tested. The application of the sutures constitutes an improvement, we beheve, on Fleming's operations for assisting the cicatrization of the laryngeal wound, which, however, can be more easily watched if the external sutures recommended by Cadiot are dispensed with. Excessive granulations, when detected, must be cauterized with chloride of zinc or nitrate of silver. Among the accidents and compUcations that may follow ary- tenectomy, and which are mentioned by Fleming and Cadiot, are wounds of the mucous membrane and of the arytenoid left in the larynx, incomplete deglution of the dressing, pneumonia from TRACHEOTOMY. 477 FIG. 419. — The Sutures are in Place; three are necessary. foreign bodies, excessive granulations of the cicatrix, pyemia, tetanus, besides those which result from the division of the carti- laginous structure, such as deformity of the tracheal rings, and the contraction of the tracheal diameter. TRACHEOTOMY. This term represents an oj)eration consisting in making a methodic opening of varying dimensions, in the cervical position of the trachea, in order to provide a free channel for the atmos- pheric air into the respiratory tract. Its ultimate object is either the removal of foreign bodies, or of the abnormal growth from the larynx, or to facilitate the passage of the air necessary to respira- tion. Its subjects are principally the large domestic animals, more especially the horse, and it has also been employed with advantage on ruminants, and often successfully on dogs. 478 OPERATIONS ON THE RESPmATOBY APPARATUS. The importance of the operation, with its utility, is readily demonstrated by 8tud;jdng the effect of its performance, and esti- mating the reUef which immediately follows, in some special cases of ailment or accidents, complicated with the danger of immi- nently impending suffocation. It is performed in the middle of the inferior border of the neck, in that portion where the trachea Fig. 520.— Tracheal Region. T, Trachea; A A, Sterno-nyoideus and Thyroideus Mus- cles; S H, Sub-Scapulo-HyoideuB ; S M, Sterno-Maxillaris ; J, Jugular Vein. being most subcutaneous, can be readily felt, in the lozenge formed by the diverging branches of the stemo-maxillary muscles below, and the two converging sub-scapulo-hyoideus above. The trachea is here merely covered by the subcutaneous band of the sterno-hyoiaeus and sterno-thyroideus, and the whole is wrapped TRACHEOTOMY. 479 by the thin expansion of the cutaneous colli. In this middle third of the neck, the cartilaginous rings of the trachea, with the liga- ments between which unite them, are readily identified. The indications of tracheotomy, which are quite numerous, are enumerated by Zundel, under five principal heads : 1st, when an obstacle exists which interferes with the free access of air to the lung, as in case of contraction or obstruction of any portion of the air passages, including all the diseases of the upper part of the respiratory tract, and acting directly, such as acute laryngitis, oedema of the glottis, and polypi or paralysis of the laiynx ; or to- gether with those which act indu'ectly, as strangles, purulent col- lections in the guttural pouches, anasarca and purpura hemorrha- gica ; 2d, when foreign bodies have become lodged in the fauces or the larynx, in order to facilitate their extraction, either directly, by means of special forceps, or indirectly, by pushing them back into the mouth to enable the surgeon to grasp them with his hand ; 3d, to remove tumors, polj'pi, cysts or cancerous growths ; 4th, in cases of fractures of the bones of the face, of the cartilages of the larjoix, or of the trachea ; and 5th, again, when the trachea has become the seat of any specific lesions, such as tracheocele ; caries of the tracheal cartilages, or of deformities, such as may resiilt from frac- tures, ossifications and contractions. The operation is, however, contra-indicated when the cause or object which impedes respiration occupies a point so low in the passage as to be beyond reach by the tracheotomy tube ; or when the difficulty in breathing and the danger of suffocation are due to a diseased condition, either of the lungs or of the heart. The instruments required for the operation are : a pair of curved scissors, a convex and a pointed bistoury, a sharp-pointed tenacvdum, a bull-dog forceps, two blunt tenaculums and a trach eotomy tube. Some special instruments for the division and am- putation of the trachea have been invented, but the tracheotomes as they are called, do not generally serve as good a purpose as the ordinary instruments already named. Tracheotomy tubes are of various forms and devices. Some are of very simple construction, and others are more or less com. pUcated. The ordinary tube consists of a bent and curved can- ula, made of various diameters, more or less cylindrical, and secured on a square plate, nearly flat, or with a curve in order to adapt it to the convexity of the neck, and with an eyelet or 480 OPERATIONS ON THE RESPIRATORY APPARATUS. Fig. 421.— Ordinary Tracheotomy Tube, front and back view. slit at each corner, for the attachment of bands or straps. These tubes are generally made of silver or nickel-plated metal, though gutta percha is the material sometimes used, its lack of solidity, however, rendering the instruments composed of it uncertain and dangerous. Besides this ordinary tube, there is a long catalogue of others, among which we have those invented by Dieterichs, Gowing, Spooner, Vachette, Pradat, Brogniez, Leblanc, Renault, Peuch, Imlin, Trasbot, and these do not exhaust the list. But among all this host of instruments of this class there is probably none which fulfils its pui-pose better than that of Du'ector Degives, somewhat modified by Professor Peuch (Fig. 430), which, by its simplicity, and especially from the fact of its being a self-holder, has proved itself to be the most convenient of all for general prac- tice. When once inserted and adjusted, this tube may be left in place without danger of removal or droj)ping of itself, while the or- dinary tube, which requires to be secured by strings tied over the neck, can never be as safe as the self-retaining instruments, which hold themselves. There are two methods of performing the operation, one of which may be called the classical, and the other the immediate method. In the former, two adjoining tracheal rings are di^dded, and re- moved, in part or totally ; in the latter, a longitudinal incision is made through the rings without loss of substance (Fig. 433). In TRACHEOTOMY. 481 Fig. 428.— Tube of Dleterichs ; posterior view. Fig. 423.— Qowing's Tracheotomy Tube. Fig. 424.— Spooner's Traclieotomy Tube. either case the animal is, if possible, kept on his feet, with the head elevated by a twitch appHed on the lower lip. It may sometimes be necessary to place him in stocks ; to hobble his fore legs, or perhaps only to raise one of the fore feet. In some instances the patient is unable to stand, and, in fact, is already down when the surgeon is called, and this is probably one of the only conditions when the longitudinal incision is fully justified. Classical Jlethod. — This includes three steps, the object of 4:82 OPERATIONS ON THE RESPIRATORY APPARATUS. Fig. 425.— Vachette's Tube. Fig. 426.— Tube of Pradat, Fig. 427.— Tube of Brogniez. the first being the the exjoosure of the trachea ; of the second, to open it by removing a cu'cular portion of the organ ; and the third by the introduction of the tube into the apertui-e prepared for it. TRACHEOTOMY. 483 Fig. 438.— Tube of Leblanc, mounted Fig. 429.— Tube of Renault. Fig. 430.— Tube of Peuch. The operator stands facing the animal, slightly on the right. Orasping the trachea (the hair having been closely cHpped), he fixes and stretches the skin with the left thumb and fore finger, at about the middle of the tracheal region, and incises it with a sin- gle stroke of the convex bistoury, cutting through the skin and the cutaneous muscle. The incision is about three inches in length, and exposes the stemo-hyoideus and thp'oideus muscles. These must be carefully isolated from the face of the trachea by 484 OPERATIONS ON THE RESPIRATORY APPARATUS. Fig. 432.— Tube of TrasboL i6 Tig. 433.— Trachea, open for the introduction of the Tube. TBACHEOTOMY. 485 the dissection of the cellular tissue which confines them, and drawn apart by means of two blunt tenaculums, leaving a gaping wound through which to reach the trachea, which is thus exposed, and in readiness for the second step of the process. Second Step. — In the second step portions of the two cartilages which have been selected, are held by the pointed tenaculum, passed through the connecting ligament, are excised, and a circvdar open- ing established by the removal of a semilunar segment from each ring. It is necessary at this point to be certain that the isolated valve is secujrely held, to guard against the force of suction, by which it may be hable to be drawn into the trachea as the new breathing place is suddenly opened. Third Step. — This consists in the insertion of the tube into the aperture prepared for it, and is the simplest and easiest part of the procediu'e. The only difficulty likely to occur is from the neglect or error of the operator in measuring the dimensions of the opening, and securing a perfect coaptation between that and the tube. If the opening proves to be too narrow, it must, of course, be enlarged, with the caution before mentioned against losing any detached portions by the suction of the trachea. The bull-dog forceps is of value here. If the tube is of the self-hold- ing kind, its introduction completes the operation ; but if the or- dinary tube before described is used, the t}^g over the neck of the tapes attached to the flat plate becomes the final manipulation. If no tube is at hand, the wound must be held apart with tapes apphed upon its edges, and tied over the neck. Immediate Operation by Longitudinal Incision. — This is done with the sharp straight bistoury, passiug it at once through all the tissues, penetrating the trachea between two cartilages, and making a vertical incision of two or three rings. This mode, as we have said, is principally justifiable in case of emergency when suffocation is imminent, and no time can be lost in procur- ing the instruments necessary for the classical operation. There is still another mode of operating, credited to Kris- haber, which, from the location where it is performed, is better known as sub-cricoidean tracheotomy^ and which consists in mak- ing the opening through the crico-tracheal ligament, which unites the cricoid cartilage to the first tracheal ring. It includes three steps, comprising the incision of the skin and dissection of the underlying muscles, the incision of the Ugament, and the inser 486 OPERATIONS ON THE RESPIRATORY APPARATUS. tion of the tube. This mode of operating is simple and of easy performance, especially in the absence of any swelling of the re- gion. It i^revents perichondritis, aud is not followed by changes in the diameter of the trachea. It has, besides, the advantage of allowing the tube to be, to a great extent, concealed, and thus removes one of the princij)al objections urged against the operation in cases of chronic roaring, for which it might well be recommended. The subsequent measures vary somewhat, depending upon whether the operation has been performed as only a temporary expedient, or as a permanent means of rehef for the difficulty in breathing. In the first case, it is not necessary to remove the tube before the acute symptoms, which have required its intro- duction, have subsided, which is a condition which generally does not continue more than two or three days. If, however, during- that time the canula of the tube should become closed by the dis- charge or other pathological secretions, it must be removed, cleansed and rej)laced, to be left until its use becomes unneces- sary, which will be readily discovered by the restored regularity of the respiration when the tube is removed or its canula becomes occluded. If the tube is to be worn permanently, careful attention should be paid to its j)i"oper fit and adjustment, and its daily removal and thorough cleansing should never be overlooked. It should be ascertained that the instrument fits properly, being held with sufficient firmness in the opening, and making a safe and moder- ate pressure on the soft tissues around. When the instrument has been worn for a (variable) time, the opening of the trachea has a tendency to contract, and becomes smaller by reason of the development of the granulation of the edges of the wound. In this case it may become necessary to enlarge the opening, by the excision of the granulations, sufficiently to allow of the ready re- introduction of the tube. When it becomes desirable to close the wound, the removal of the tube, and the apjDlication of an ordi- nary dressing, protecting it only by a pad of antiseptic oakum, kept in place by a few turns of bandage around the neck, is all that is necessary. Usually, after two or three weeks the cicatrix is complete. The operation of tracheotomy may be accompanied or followed by various accidents : TEACHEOTOMY. 487 Hemorrhage is rare, the small amount of bleeding which occurs proceeding from the di\ision of some of the arterioles, branches of the carotid, passing between the cartilages over the surface of the inter-cartilaginous Hgament. It ceases spontane- ously, and never requires any special attention. Emphysema of the neck may take place when the cellular tis- sue is very loose and the edges of the skin overlap the tracheal in- cision. It generally subsides without interference, or by moder- ate, regulated pressure. Tracheocele. — Renavdt so denominates certain growths which appear on the tracheal mucous membrane, as the result of the ir- ritation produced by the friction of the branches of the tube which come in contact with it. He claims to have noticed their appear- ance six weeks after the removal of the instrument. The nature of the tumor varies much. They may be purulent, but they are more commonly fibrous and of slow growth ; and may sometimes take the character of ossification of the cartilages. If these ob- structions appear above the seat of the operation, the trouble is easily remedied by the reintroduction of the tube, but if, how- ever, they are found below that point, it is a more serious com- plication, since it requires a second operation at a point below that of the first. The obstruction of the trachea by plastic exudation above and below the seat of the operation, or its contraction, caused by the overlapping of the divided ends of the rings which may have been incised, may also be met with, and can only, as in the former case, be overcome by a second operation. "We personally remember a case in which the formation of a post-tracheal abscess, which had produced extensive contraction in the calibre of the trachea, proved fatal through the impossibihty of the introduction of a tube after a second operation. The patient had been treated sev- eral weeks previously for an attack of strangles, which had re- quired an operation, and some six weeks after his recovery was brought back sufi'ering with a severe attack of roaring. As he entered our hospital he fell to the ground, and the second opera- tion was rapidly performed by a longitudinal incision, but the tubes we had at hand were all too large, and in a few moments the animal died. At the post-mortem a large abscess was found behind the trachea, just opposite the seat of the first operation, and the pus in collecting had so compressed and deformed the 488 OPERATIONS ON THE RESPIRATORY APPARATUS. trachea that the index finger could scarcely be inserted into the passage. THOKACENTESIS. The usual intention of this oj^eration is the removal from the thoracic cavity of suppurative matter {empyema) or blood or se- rous fluid, by puncturing the walls of the chest. It is indicated in hydrothorax and in some traumatisms of the chest, and when- ever there is a large collection of bloody or other fluid in the thorax ; in all cases, in fact, where the ordinary forms of treatment have failed to relieve the patient thus affected. Although extensively performed in human surgery, where the advantages and facilities of operating are so many and so manifest, it has naturally proved less beneficial to veterinary patients. And still, though probably in the majority of the cases in which it has been employed the rehef which has followed it has been of only a temporary charac- ter, and served only to prolong briefly the life of the animal sub- jected to it, some few cases are on record in which it has given very excellent results. The researches of St. Cyr have, moreover, demonstrated that the operation is perfectly harmless, contrary to the opinion formerly held, and that a large proportion of its fail- ures to effect recovery are due to the fact that its appHcation had been too long postponed to justify a reasonable expectation of success ; when, in fact, it had been deferred until the accumula- tion of fluid had already become too abundant, and the pleural membranes had ah'eady assumed the condition of a tendency to pyogeny. On this point, Peuch and Toussaint remark that if the punc- ture is made when only the lower thii'd of the cavity is full, and if after the evacuation of the Uquid a diluted solution of tincture of iodine is injected into the pleural sac, as is done in human surgery, perhaps more satisfactory results might be realized. Our own view, however, is that the disposition of the pleura and of the cavities, which they form, would scarcely justify the in- jection. The instruments required are a straight or convex bistoury, and a small trocar, straight or sUghtly curved. Reul has invented a paracentO'injector trocar (Fig. 434), which is used for both the i:»uncture and the subsequent injection of the medical compounds. The use of the aspirator (Dieulafoy) is also recommended. THORACEISTESIS. 489 Fig. 434. — Trocar paracento-injecteur de Keul. According to St. Cyr, the j)roper place for the puncture is between the seventh and eighth sternal ribs, a little above the spur vein, this point permitting the removal of a larger quantity of fluid than any other, with the advantage also of offering a wider space between the ribs, and a dimin- ished thickness in the muscular sub- stance. Unless there are special rea- sons to the contrary, the puncture is made on the right side ; if operating on the left is indicated, care must be taken to avoid injuring the heart. For this reason the puncture is made between the eighth and ninth ribs, with the point of the in- strument turned backward. The puncture is made with the patient on his feet, and he rarely needs any apparatus of restraint, though it will always be judicious to apply a twitch on his lip. St. Cjr describes the operation as follows : " The operator makes an incision ^vith the bistoury, about one inch long, near the anferior border of the eighth rib or of the ninth, if he is on the left side, dividing the skin and superficial muscular layers until he reaches the internal intercostal muscle, which he leaves intact. In piercing the cavity, he holds the trocar with the right hand, guarding against its entering the chest too deeply by keep- ing his fingers sufficiently near the point to gauge and control its depth through the remaining undivided muscle. What remains then is to withdraw the rod from the trocar, and keep the latter in place while the fluid esca^^es. Any albumi no-fibroid clots, which may enter the caniJa and obstinict the flow of the liquid, may be dislodged by introducing a blunt stylet into the tube. "WTien the canula is withdrawn after the escape of a sufficient amount of fluid, the wound is closed with a single pin suture. The trocar of Mr. Keul is inserted (Figure 434) in the usual manner, with the nut E closed, and after removing the desired 490 OPERATIONS ON THE RESPIRATORY APPARATUS. quantity of fluid, the uut F is closed and E is opened. In the funnel D, the diluted tincture of iodine is poiu'ed and carried into the chest as slowly as the operator thinks proper, where it mixes with the remaining portion of the fluid. A^Tien the injection re- turns in the instrument to a level with the little piece of glass C, the nut E is closed, and the instrument removed, thus guai'ding entirely against the introduction of ail' into the chest. In respect to the quantity of fluid that can be safely removed at once, there are varying opinions. Some practitioners hold that the cavity ought to be entirely emptied, or, at least, so far as the location of the puncture allows, while others favor the method of discharging the contents by installments. According to St. C}t, who has experimented very extensively in this matter, the removal of a small quantity is followed by a negative result, the fluid forming again in a very short time ; while, on the other hand, if the entire accumulation is taken away at one time, amounting, perhajDs, to forty or fifty quarts, it must be at the hazard of encountering, as supervening disorders, syncope, rupture of the pulmonary vesicles, congestions, or splenic or hep- atic hemorrhages, with an ultimate fatal termination. The question thus remains unsolved, and if recoveries have been recorded by Lafosse, Jr., Strauss, Massot, Bar and others, failures have followed the operation in the hands of Gohier, Pilger, Bassi, Dieterichs, Prudhomme, St. Cyr, etc. Pelle and Sewell have obtained recoveries when removing all the fluid at once. Our own experience has been negative in the cases in which we have observed both conditions — that of partial, and, as well, that of the entire removal of the fluid. Supplementing the operation with medicinal injections of some sort has been recommended. Hertwig has used astringent solutions ; Leblanc, Bouley and Prudhomme have favored the use of tinctui'e of iodine, and the following prescriptions, used in human siu'gery, are recommended by Peuch and Toussaint : Weak Solutio7i — ^ — Tinct. of iodine, 10 parts; iodide of potass., 1 part ; distilled water, 100 parts. This is first used, but, if it fails, the following is injected : Strong Solution — B — Tinct. of iodine, 30 parts; iodide of potass., 4 parts; distilled water, 100 parts. The general treatment recommended for those forms of dis- eases in which these hqaid accumulations originate, must be per- THOKACENTESIS. 491 severed in after the thoracentesis, including the counter-irrita- tions, diui'etics, tonics, stimulants, alteratives, etc. The operation is performed on the dog also in the same man- ner as on the horse, but either with smaller trocars, or, what is better, with some one of the aspirators recently invented. With this animal the results are more satisfactory on account of the simplicity and unilateral development of the pleuritic effusion. CHAPTER X. OPERATIONS ON THE CIRCULATORY SYSTEM. BLEEDING— VENESECTION. The term bleeding, or venesection, signifies the opening of certain veias for the escape of a portion of the blood, for a ther- apeutical, or experimental purpose. If it is designed to reduce the volume of the circulation, it is known as general^ and is per- formed upon some one of the larger blood vessels ; if practiced to remove blood only from a given region, it becomes local,, and in that case the smaller vessels are divided. A better division is that which is based on the nature of the vessel which is opened, and thus it is phlebotomy,, if a vein is opened; arteriototny, if an artery; and capillary, or arterio-phleboto'my , when the opera- tion is practiced upon the capillary system. There has been much discussion upon the question of the utility of blood-letting, and strong advocates and earnest oppo- nents, who have argued its benefits and denied its usefulness, and, in fact, ascribed evil results to its practice, whether the depletion affects the general circulation or a limited region. But upon this we shall not enter. Those who maintain its practice consider it to be indicated when it is desirable to reduce the activity of the circulation, or, on the contrary, to stimulate it in parts where, from different causes, it has been temporarily susj)ended, and to stimulate absorption, or to reUeve the organism of foreign ele- ments. It is, however, contra-indicated in aU eruptive fevers, in anaemic patients, and in those suffering with typhoid diseases. The old fashion of " taking blood " as a prophylactic measure, or at a certain season of the year, is simply the result of an ignor- ant delusion. The quantity of blood that can be removed must vary, of course, with the size, the nature and the condition of the animal. PHLEBOTOMY. 493 Gourdon recommends the following scale as representing the aver- age bleeding, j)i'oper, for the animals named : The horse, between 4 and 5 pounds ; large ruminants, 5 to 6 pounds ; pig, 1 to 1^ pounds ; sheep, 6 to 9 ounces ; dog, 3 to 6 ounces. PHLEBOTOIklT. J^hlebotomy, or the opening of veins, is the mode universally adopted for general bleeding, and is generally performed upon superficial veins. The instruments necessary are fleams, lancets, scissors, bleed- ing-sticks, pins, pin-holders, graduated jars or vases, and a piece of silk, and, for small animals, bandages. The fleam, made in various forms, resembles a small lancet, and is secured on a steel suj)port received into a metallic, horn or gutta-percha handle. Ordinarily, two or three lancets of different Fig. 435.— Ordinary Fleam, with three blades. sizes have one common handle, upon which they are so mounted as to be used singly with facility. Some of them, of German make, or of EngUsh invention, or of a Belgian pattern, act with a spring, like the phlebotome of Brogniez. The bleeding-stick is simply a stick of hard and heavy wood, a foot or more in length, with which to drive the fleam into the vein. 494 OPEBATIONS OK THE CIRCULATORY SYSTEM. Fig. 439.— Fleam of Brognlez. Fig. 440.— Bleeding Stick. PHLEBOTOMY. 495 The graduated vase is to receive the blood, and at the same time measure its flow. In ordinary practice a pail is substituted. The^>ms must be long and strong. The jn^i-holder is used to assist in the introduction of the pin when the suture is made and the bleeding terminated. Sponges and cold water should be accessible. Modus Opekandi. I*osition of the Animal. — The standing position is the one generally preserved. The animal is held well in hand by an as- sistant, and if he appears to be excited and unwilHng to stand quietly, and soothing treatment has no effect, a twitch is placed on his nose, or a cap on his head. The operation consists of three steps: 1st. Preparation of the Blood Vessel: This consists in appl jdng sufficient pres- sure upon it to temporarily interrupt the circulation and cause it to become more prominent under the skin. This is done with the fingers, and some- times with a ligature, when the loca- tion of the vessel permits it. In some blooded and thin-skinned animals, a httle brisk exercise is sufficient to stim- ulate the circulation and render the veins prominent. 2d. Opening of the Vessel. — This is done with the fleam, the lancet or the bistoury. The fleam is more com- monly used for large animals. Held as in figure 441, it is brought opposite the vessel, parallel to its course, and per- fectly perpendicular to it, and at such a distance from the skin as to approx- imate very nearl}-, but without forming an actual contact with it. When in this position the fleam is made to pen- etrate the vessel by a smart blow with ,„ ,. the bleeding-stick on the back of the -Manner of Holding the , , , Fleam. blade; some practitioners, instead of Fig. 441. 496 OPERATIONS ON THE CIRCULATOEY SYSTEM. striking with the stick, apply the blow with then- hands, but with cattle, the stick is indispensable. The moment the blow has been applied properly, the stream of blood escapes freely; when the blow has been too Hght, and the skin only di\ided, with but a scanty or no escape of the blood, it is called a xohite hleed- 1710 ; and slahhery when the opening is not large enough for the escape of a full stream, or when the openings of the vein and of the skin are not in apposition, which will be the case if the fleam, instead of being held perfectly perpendicidar to the skin, has been held obliquely. The opening of the blood vessel with the spring fleam is performed in the same manner, except that the lancet receives its impulse from the spring instead of the stick. The puncture with the lancet or bistoury should be made with a single stroke of the instrument. In large and superficial veins, the spring lancet is as easily and safely managed as the fleam. 3d. Closing the Stood Vessels and Stopping the Floio. — "When a sufficient quantity of blood has been drawn, and the j)res- sure upon the vein, which has been continued during the flow, is gradually relaxed, the stream ceases, more or less completely. To terminate it entirely, a simple stitch of pin sutm-e is ax)j)hed. It is to be preferred to all other means, such as pressure, bandaging or adhesive plasters. The suture is made by grasping the two edges of the skin with the thumb and index finger of one hand, and sho"htly raising them, then transfixing them with a long pin through their middle, with either the hand or the pin-holder, in- cluding a fair amount of skin, and completing it by a special knot, made with silk or a loop of the long hair of the mane or tail of the animal. In ajjpljing this suture, the skin must not be pulled away from the body too far, nor the knot tied excessively tight. To keep the wound clean and prevent Fig. 442.— Suture after the animal from rubbing off the dressings is all ing. 'CcisX is necessary, for a few hours, after the operation. The wound heals by first intention, and the suture and the pin can be safely removed after twenty-four hours. Phlebotomy in Solipeds.. Four of the principal superficial veins are selected for this operation in sohpeds ; the jugular, the cephaHc, the subcutaneous thoracic and the internal saphena. PHLEBOTOMY. 497 Phlebotomy at the Jugulae. This vein is usually selected on account of its size, its situation, and the facility with which it can be opened, and the wound of the skin closed. It is, however, contra-indicated when the vessel is in any degree diseased, or when the animal is suffering with itching skin diseases. Formed by the superficial temporal trunk and the iuternal maxillary vein, the jugular descends through the parotid gland to- ward its inferior extremity, receiving several collateral veins, and reaches the groove of the lower part of the neck, which from its presence is called the jugular groove, until it reaches the lower extremity of the neck, when it enters the chest. In its course in the groove it accompanies more or less closely the carotid artery. Fig. 443.— Anatomy of the Jugular Vein and CEscphagus in the Horae. J J, Jugular vein; C, carotid artery; O H, omo-hyoideus muscle; D, cEsophagus; S, sterno-maxillaris muscle; M, mastoido-humeralis muscle. 498 OPERATIONS ON THE CIRCULATORY SYSTEM. but in the middle tbii'd of its length becomes separated from it by the flat ribbon-like structm'e of the sub-scapulo or omo-hyoideus, whose fibres pass obliquely between the two blood vessels, from below upward. It is, therefore, in the middle third of the neck that the bleeding at the jugular must be made, in order to avoid wounding the carotid artery. Besides the general rules already stated, this special bleeding requires peculiar measures. (a) Position of the Animal. — He must be kept well in hand, with the head somewhat elevated, and must be prevented from seeing the various movements of the operator, by covering his head with the cap or mask, or by having the eye, on the side of the operator, covered with the hand of an assistant. {b) The fleam is generally employed, the size of the blade vary- ing according to the thickness of the skin and the condition of the blood vessels. The left jugular is generally selected, unless contra- indicated for some special reasons. (c) Preparation of the J^ein. — The application of artificial pressure for the dilatation of the vein is not only unnecessary in solipeds, but has in some cases proved dangerous. In this step of the operation the hand is to be preferred as safer and more reh- able than any ligature or bandage can jDossibly be. The compression is made with the fingers of the hand which holds the fleam, applying it in the jugular groove, below the point where the incision is to be made. The projection of the vein may be made more distinct by moistening the hair over the spot to be punctured, with a wet sponge. The improper habit to which some practitioners are addicted, of doing this with their sahva, by spitting upon the neck is to be severely condemned. If the bleed- ing takes place on the left side, the pressure mvist be made with the left hand, the operator turning his back toward the hind parts of the animal. If it takes place on the right side, the pressure is made with the fingers of the right hand. (d) 02)ening of the Vein. — Placed as we have described, at the side of the neck of the patient, his back turned toward his hind parts, and pressing with the fingers of his left hand which holds the fleam, as before stated, the operator grasps the bleeding- stick, and striking upon the fleam, opens the vein, and the blood escapes in a good, full stream. Maintaining the pressure on the vein throughout the flowing of the blood, he lays aside the stick PHXEBOTOMY. 499 and the fleam, and attends to the flow of the blood into the grad- uated jar, or the jDail provided to receive it. (e) Keeping the Stream. — As we have said, the pressure upon the blood vessel must be sustained from the beginning to the end of the operation. Rehe-ving it but for a moment is an error, likely to be followed by the introduction of air through the wound into the vein. Not only must it be kept up continuously, but it must be steady. The habit which largely prevails of moving the fingers or the vase up and down along the vein while the pressure is apjolied, and with the idea of stimulating the flow of the blood, is most dangerous. If the blood does not escape freely, though the operation has been properly performed, an increased circvilation may be stimulated by making the animal move his jaws, or shak- ing the bit in his mouth, or placing the bleeding-stick or a finger of the assistant, into the mouth over the bars, and quietly moving them. {/) When the bleeding is to be stopped, the operator applies one of his fingers over the wound of the skin and gradually re- moves the pressure made below it. When this has been done, he proceeds to the appHcation of the suture, always introducing the pin with the head turned upward, irrespective of the side on which the operation has been performed. {g) Subsequent Care. — This is the same as in other cases, but we may add that an animal that has been bled at the jugular is unfit to work for three days, in order to give time for the wound to heal completely. Phlebotomy at the Cephalic Vein. The cephalic is one of the terminal branches of the median subcutaneous vein, and runs upward and forward to pass toward the low^er extremity of the coraco-radialis, where it crosses the tendinous band which this muscle sends to the anterior extensor of the metacarpus, running in the sjDace which separates the sterno- humerahs muscle from the levator-humeri, and emj^t^ing into the jugular, a little in front of the confluent of those two veins. In this course, the most accessible portion is that which rests on the inferior extremity of the levator-humeri. The fibrous band of the coraco-radialis is the guide indicating its position, viz., a little in- side the forearm, on a level with the anterior and obHque fold which separates the arm from the forearm. 600 OPEKATIOXS ON THE CIBCULATOKY SYSTEM. Fig. 444. — Anatomy of the Cephalic Vein, m, Median subcutaneous vein; 6, basilic vein; c, cephalic vein; d, inferior extremity of the coraco-radialis; i, aponeurotic band extending from the coraco-radialis to the anterior extensor of the metacarpus; s, ster- no-humeralis; h, mastoido-humeralis; «, space between these two muscles; /, humeral vein. On accoiint of the presence of the other terminal branches of the main vein, from which the cephalic rises, viz., the' basilic, pres- sure upon the cephaHc does not allow of its dilatation. To obtain this, the animal must be exercised for some time, and when brought to stand still, to raise the opposite leg, or to carry the leg to be bled forward. As the vein is easily displaced from its position, it is hardly PHLEBOTOMY. 501 «afe to attempt to oi^en it with tlie lancet. The fleam is always preferable. If the bleeding is from the left vein, the instrument is held with the right hand, the operator is placed against the shoulder, fleam having its blade turned downward, the fingers resting against the chest, and with a blow of the stick the vein is opened. This bleeding is often accompanied by the formation of a hematoma over the course of the vessel, due to the fact that very often the fleam has opened the vein through and through. This, however, is not a matter of any serious consequence. Phlebotomy on the Subcutaneous Thokacic. This vein runs on the side of the thorax, on a level with the sterno-trochineus muscle, and is readily discovered toward the sixth or seventh rib. To render it more conspicuous, a bandage can be appHed around the chest, as suggested by Chabert, or by carrying the leg of the side to be bled forward, and by rubbing hard the tract of the vein, or even by simple pressure with the fingers. The operation can be performed either by a simple puncture with a lancet, or with a fleam, held parallel with the course of the ves- sel, andl)etween two ribs, to avoid breaking the instrument against one of the bones. The bleeding is stopped in the usual way. It is not unfrequently followed by the formation of a thrombus, which generally disappears by pressure, or astringent local appli- cations, and often by spontaneous absorption. Phlebotomy at the Inteknal Saphena. The comparatively large size of this vein, and its superficial position, both explain and justify the fact that next to the jugular, it is the one most commonly selected for the operation. For this reason phlebotomy is indicated here, when it is contra-indicated upon the vein of the neck. The saphena is formed by two branches, and in its course crosses sHghtly the dii-ection of the tibia in running upward on the siu'face of the tibial aponeurosis, arriving at the flat of the thigh, formed by the short adductor of the leg, and then dips in the space left between this muscle and the long adductor, where it empties into the femoral. In this course the vein is superficial, covered only by a thin skin, from which it is separated by a thin aponeurotic layer. It is at a point where the vein passes over the 602 OPERATIONS ON THE CIKCULATOUY SYSTEM. Fig. 445.— Anatomy of the Internal Sai-hena Vein, s, internal saphena vein; e. Its anterior root; t, its posterior root; /, femoral vein; g, deep inguinal lymphatic glands; c, short adductor of the leg; I, long adductor of the leg; a, subcutaneous aponeurotic layer; r, fascia lata. flat of the thigh that it must be opened. If the operation is per- formed with the fleam, the higher the better ; if with the lancet, it can be done as the veia passes over the tibia, where it is more accessible. In operating, the leg opposite the one to be bled is held up and backward by a strong assistant, in the posture of the black- smith about putting on a shoe. PHLEBOTOMY. 503 If the lancet is used, the operator, placing himself on that side also, bends down, and, looking from under the abdomen of the horse, brings the instiniment close to the vein, opening it by a rapid stroke, and enlarging the orifice by a shght incising motion of the instrument. If the fleam is used, the operator assumes the same position, and applies it precisely as has been described in the cases akeady considered. Operating on the right side he holds the fleam with the right hand and strikes with the bleeding-stick in the left, and vice versa. This position of the operator is awkward, and not without danger, exjjosing him to the chances of a blow with the stifle of the leg which is held by the assistant. To avoid this, Peuch and Toussaint suggest that the assistant, instead of holding the leg backward, should carry it forward, and that the operator should place himself behind the animal. It is also claimed that in that position the vein is more easily exposed. The operation is per- formed ia the same way, except that the instrument is held with the right hand if one operates on the left leg, and with the left hand if the bleeding is done on the right leg. The flow of the blood in this bleeding is generally slabbery, and the introduction of the pin of the suture quite painful, and means of restraint are, therefore, often necessary before the ani- mal will submit to the application of the suture. Phlebotomy on Other Supeeeicial Veins. Others, besides the veins which have been described, are also subject to phlebotomy, but its performance is more with some local object in view than that of a general bleeding. All are performed with the lancet, the region (Fig. 446) where they occiu' being at the transversal of the face, a ; the angular of the eye (b) ; the facial or glossofacial, d ; the superficial nasal, (c) ; the posterior auricular (e) ; the deep lingual; the inferior caudal, and the median subcutaneotcs of the forearm. If required by their size and position a pinned suture is applied after the bleeding, but in several instances pressiu-e alone is sufiicient. Phlebotomy in Large Ruminants. The operation is confined to two principal veins of the large ruminants. These are the jugular and subcutaneous abdominal. 604 OPERATIONS ON THE CIRCULATORY SYSTEM. C Fig. 446. Phlebotomy on the Jugular. It is performed in tlie same manner essentially as in the soli- peds, and with the same instruments. But as cattle are less sub- missive to the preparations which precede the operation, means of restraint must be used with them, and they must be tied to a tree or a post. The jugular of cattle has thicker walls than that of sohpeds, its diameter is much greater, and it is separated from the carotid in its whole length by a thicker layer of muscle. For these reasons a larger fleam becomes necessary. To dilate the vein a strong ligature is applied tightly on the neck, the pres- sure of the fingers never being sufficient to furnish the necessary force. To open the vein the blow of the stick must be heavier, and when properly given is followed, as in sohpeds, by a strong stream of blood, which rapidly ceases when the ligature is loosened or removed. It is not always necessary to apply a pinned suture, but it is always safer and more prudent to do so, though the in- troduction of the pin is rendered difficult by the toughness and thickness of the skin. The value of the pin-holder is demon- strated in this case. The thrombus which so often follows this operation is not serious, and, in fact, its formation is stimulated by some practi- tioners. Phlebotomy at the Subcutaneous Abdominal. This vein is of enormous volume, extending from the udder to the xyphoid cartilage of the sternum, at the side of the abdomen, PHLEBOTOMY. 505 to terminate in the internal thoracic vein. It is, therefore, easily recognized, and particularly so in milch cows, and it is, therefore, unnecessary to use the Hgature or any other means to swell its dimensions, the pressure of the fingers being more than sufficient. A fleam of medium dimension is preferable to the lancet in this case. The animal is firmly held by the head, and to prevent his kicking, is pulled forward by its tail passed between its hind legs. In opening the vein the operator places himself forward of the shoulder, his back tiuTied toward the head of the animal, holding the fleam with the hand corresponding to the side of the animal against which he is placed. The bleeding is stopped with a pin, or, what is better, a bandage, to prevent the formation of a thrombus. Phlebotomy on Small Aihimals. Bleeding is seldom performed on sheep. When it is indicated it is performed on ih.e facial, the Jugular, the ce^y/ialic, or the ex- ternal saphena. The vessel is opened with the lancet, the wool, Fig. 447.— Position of the Facial Vein in Sheep. if necessaiy, having been clipped off from the place of puncture, and the wound is closed with a pin sutui*e. In svyine two sets of veins are eUgible for the operation, the posterior auricular, as it runs at the internal face of the ears, and the external saphena, where it passes along the tendo Achilles. The lancet is used upon both. The first stops bleeding without help ; the second is closed with the j^in suture. In dogs, the jugular is sometimes opened. This vein, from its position, requires the appHcation of a string around the neck to swell the vessel. The puncture is made with a small fleam or a lancet, and the wound closed with a pin. The external saphena 50G OPEKATIONS ON THE CIRCULATORY SYSTEM. being qiaite large is cliosen in preference to the hiternal, which is very small. The place of selection is the superior part of the vcxn, when it nearly reaches the posterior border of the leg. A bandage is applied to stop the hemorrhage. The cephalic might be opened as it passes toward the interior third of the humerus, the wound being closed by a stitch of twisted suture. ACCIDENTS OF BLOOD-LETTING. The operation of blood-letting may be followed by several complications, some being of little importance, while others may be sufficiently serious to compromise the life of the patient. Among them may be named : The white and the slabbery bleed- ing ; wounds of surrounding non- vascular organs ; the thrombus ; inflammation of the vein, or phlebitis ; wound of the carotid, and the introduction of air into the veins. Others, such as the lesions of nerves, syncope, etc., are seldom, if ever, encountered in veter- inary practice. 1st — White and Slabbery Bleeding. It is a question whether these, properly speaking, should be classed among the true sequelae of blood-letting. "We already alluded to them when describing the various methods of perform- ing phlebotomy. They are often the result of the disposition of the parts, the vein being deficient in size, or more deeply situated than natural, and thus imbedded in the loose surrounding cellular tissue ; or, perhaps, the cause is an unguarded movement of the animal ; and it is often known to be the imperfect manipulation of the surgeon in stiiking the fleam too lightly, or not vertically, and so failing to bring the openings of the skin and the vein into exact coaptation. These accidents are, however, of an unimportant character, and are easily obviated by exercising more care and dehberation. 2d — Wounds of Surrounding Nox- vascular Organs. (a) Wounds of the Trachea. — The improper action of the surgeon is generally chargeable with this accident. He may have erred in using too large an instrument, or the error may have con- sisted in making excessive pressure when ligating the neck with the cord used to effect the distension of the jugular. It is a rare ACCIDENTS OF BLOOD-LETTING. 507 accident, but may be easily recognized by the flow of blood which escapes through the nostrils, and possibly by the changes which may affect the respiration by threateuings of strangHng, suffoca- tion, etc. In this serious case the ligation of the blood vessel is the only means of stopping the hemoiThage. {b) Wozinds of the Caudal Muscles. — This is comparatively a common accident with cattle, but is seldom attended with symp- toms of a serious character. The principal danger consists in the possibility of the formation of fistulous tracts, more or less re- beUious to treatment, as besides the muscles, the tendons, and even the bones may have been injured by the instrument. 3d — Theombus. This is understood to be a bloody tumor, or hematoma, which is formed around the opening of the vein by the accumulation of the blood in the surrounding cellular tissue. It appears when the opening of the vein does not accurately correspond with that of the skin, or when the incision of the tegument is too small to allow a free flow of the blood through it. It often appears when the animal is allowed to rub himself after the operation, or when the opening of the vein has involved a section of one of the valves. Some veins, as the saphena, the cubital, and the subcutaneous thoracic, are more exposed to thrombus than others, even when the operation has been well performed and completed. At these veins, they are generally not serious, and are readily subdued by simple treatment, if they do not spontaneously disapjoear. But the thrombus, which is sometimes encountered at the jug- ular, is of a more serious character, and is not unfrequently com- plicated with phlebitis. The symptoms of this lesion are essentially local, and the symptoms and the disease are, in effect, one, consisting of a tumor of uncertain dimensions, according to the quantity of blood col- lected under the skin. In the beginning it is roimd, well circum- scribed, soft, and slightly elastic to the touch, but the swelling soon becomes hard, perhaps oedematous, or somewhat diffused, when it has been caused by rubbing on the part of the animal. The simplest cases gradually disappear after two or three days. But at other times they are not so tractable, and serious trouble may ensue, the tumor becoming stationary, or perhaps increas- ing in size, and then changing its character. It becomes warm 508 OPERATIONS ON THE CIECULATOEY SYSTEM. and painful, assumes aspects of a phlegmonous nature, and per- hajis becomes complicated with hemoiThages. It is not yet too late to look foi' resolution, hnt if it does not soon take place, and if the symptoms increase, and the swelling extends, the vein is changed into a hard, large cord, and a case of phlebitis is estab- lished. Ahsorjytion and resolution are now the two most favorable ter- minations of thrombus, but they are of unusual occurrence, except when the tumor is of small size, and promptly attended to. Supiyuration is the more common event, and if this continues to be superficial, recovery may be looked for without obhteration of the vein. PMebitls, which commonly accompanies a deep suppurative thrombus, is always a serious termination. Abscess of the throm- bus, however, may assume various modifications, and may pass to a chronic condition, or that of induration, or one of still more serious nature, that of gangrene. When it has become developed, the animal must be immedi- ately secured to prevent him from rubbing the parts, and as early as possible the treatment should be directed to the Hmitation of its development and the promotion of its absorption. Local ap- pHcations of cold water ; astringent compresses, moistened with vinegar or lead solutions ; poultices of clay, of soot, or of chalk, mixed with vinegar, will very often be sufficient to control or re- move the growth. Sometimes, however, the absorption will be more effectually stimulated by frictions with cantharidis oint- ment, and in a week or ten days the thrombus will have entu-ely disappeared. The Girard ointment, of Venice turpentine and bichloride of mercury, is sometimes also very effective. If the tumor assumes the nature of an abcess, and this re- mains superficial, it may be opened with the bistoury, or the actual cautery, and should hemorrhages occur they must be principally controlled by pressiu-e. 4th — Phlebitis. The first effect of the inflammation of veins is the coagulation of the blood and the formation of a clot in a given length of the vascular canal, adherent more or less to the walls of the vessel, the resiilt being the partial or perhaps complete obliteration of the vein, and hence a certain disarrangement of the circulation, which ACCIDENTS OF BLOOD-LETTING. 509 may be supplemented by the anastomotic action of collateral ves- sels above and below the occluded portion. Or, again, the circula- tion may be entirely obstructed, and, as a consequence of the in- flammatory changes, adhesions follow, between the clot and the venous wall, the clot being resorbed, and the obhterated vein transformed into a fibrous cord. So long as the inflammation is limited to the internal wall of the vessel, phlebitis is known as adhesive ; but if it extends to the external or even to the middle structure, and becomes suppurative, it is so distinguished. Either of these forms of the disease may be changed by a third modifica- tion to that of hemorrhagic phlebitis. These three forms or diver- sities of the disease have been established by Peuch and Tous- saint, whose views touching the treatment of the aflection we also reproduce, referring our readers for the pathological history of the lesion to the various works relating to it. 1st. Adhesive Phlebitis. — At the beginning of the disease, the animal must be placed under such conditions as will tend most favorably to influence the process of organization between the clot and the venous waUs, and to prevent the estabhshment of suppuration. To effect this object, the enforcement of a state of immobility in the patient is most essential. His head must be firmly secured on both sides, and his mastication made as easy as possible, by suitably regulating the consistency of his diet, in order to diminish the force of the circulation, and so far obviate the danger of the displacement of the clot and possible resulting hemorrhage. The diseased parts should be treated by local ap- plications, among which lotions of lead water, with continued cold water irrigations, will give excellent results. But ointments of any kind should be avoided, especially in warm weather, from their liabihty to become rancid and irritant, and to stimulate the patient to rub himself. The use of cooling apphcations must be perse- vered in, in preference to the frictions with vesicatories, which, especially in nervous animals with tender skin, might be liable to encoiu'age the suppurative process. In tougher-skinned animals, and those of a lymphatic temperament, in which the inflammation has a tendency to become chronic, resolvents, blistering, liquid liniments, and alteratives are indicated, and of these, and first in order, must be named cauterization with the red ii'on. The conical cautery is applied on closed, fine points, and arranged qviintuply, every second point being deep, while the others are 510 OPERATIONS ON THE CIRCULATORY SYSTEM. only superficial. By this peciiliar mode of firing the absorption becomes greatly stimulated, and the resorption of the tumor very rapid. Cauterization, however, if beneficial in chronic, is not so in acute cases, having in the latter a tendency to be followed by sup- puration, 2d. tSuppioritive I^hlehitis. — For this form of this serious af- fection several modes of treatment are proj^osed. {a) Expectant Treatment. — This is the plan by which the phy- sician or surgeon, administering palliatives onl}-, trusts to the vis conservatrix for cure, watching meanwhile the development of the disease, and waiting for and expecting the guidance of nature in respect to his own interference. {b) tSimple Incision. — This is the simplest of surgical inter- ferences, and means nothing more than the opening of the abscess, the enlargement of the fistulous tract, and the formation of an exit for the pus and coagulated blood which it contains. This is done with an ordinary bistoury, guided by a probe or grooved director. (c) Injections. — The fistulous tract which exists on the phle- bitic tumor is washed with a detersive injection of solutions of tincture of iodine, or perchloride of iron; or of corrosive subli- mate, from sits to TTjVtf. These are intended not only to remove any remaining clots softened by the suppuration, but also to stimulate the granulations and the cicatrization. {d) Enlargement of the Fistula and Introduction of a Seton. — ^An S probe is introduced into the fistula, and when it has reached the upper part of the swelling formed by the vein, close to the obturating clot (which must not be disturbed), an incision is made over its blunt end to enable it to pass out through the skin. The fistulous tract is then enlarged with the straight bis- toury from below upward to a small extent, and between the two openings a small seton is passed by means of the .probe, and se- cured in place by knotting the ends. The movement of the seton by di-awing it to and fro, effects the removal of such portions of the clot as may remain in the wound. (e) Enlargement of the Intra Venous Fistula in its Whole length. — This consists in opening the ti'act from its commence- ment to its suj)erior cul de sac, as far as the adhesion between the clot and the veia extends, the incision sometimes reaching below the opening made by the fleam. Thus exposed, the tract ACCIDENTS OF BLOOD-LETTING. 511 is washed out with the tiBcture of iodine or perchloride of iron solution, or even destroyed with the actual cautery. The last two forms of treatment, however, are dangerous, from their Hability to occasion consecutive hemorrhages. 3d Hemorrhagic Phlebitis. — The most serious incident of phlebitis, proceeding, as it does, from both the adhesive and the supj)iu'ative forms, is the more or less abundant hemorrhage, which, residting from any of the various causes which have been mentioned, may interfere with the cicatrization or obHteration of the venous wound. Three modes of treatment are practiced for their suj^pression. These are the twisted and the quilled suture, and the ligation of the vein. (a) The Ticisted Suture. — This consists in the combination of several (two or three) long pin sutures, placed upon the wound made by the fleam, and including a larger portion of the skin at the sides than the single pin suture of an ordinary bleeding. Sometimes wooden pins are substituted for those formed of me- tallic material, and when the sutures are completed, the wound is strengthened by a coating of some strong, adhesive mixture. Some practitioners, however, prefer to this the ajaplication of a severe blistering friction, which, by the pressure of the swelling which it produces upon the internal circumjacent parts, secures practically all the effects to be obtained by a compressive bandage. (b) Quilled Sutures. — These are applied on each side of the wound, securing a good hold by placing them at some distance from the edges, and embracing tightly between them a thick por- tion of the skin. This point is important, for the reason that this portion of skin is destined to be sacrificed by being left to slough off, and this must not take place until the obUteration of the wound is entirely completed. (c) Ligature of the Vein. — The success of this operation, to be assured, requires the selection of a healthy portion of the vein on which to place the ligature, even if it become necessary to look for it among the original roots of the jugular, viz., the facial and the glosso-f acial. In performing it, the animal must be secured in the recumbent position. A single incision is made through the skin, the whole extent of the obliterated vein, parallel to its axis, and the vessel exposed and separated from the surrounding tissues. The separation, which reqviires sldllful and cautious manipulations, can be effected by means of either a director or a long probe. It 512 OPERATIONS ON THE CIRCULATOKY SYSTEM. ■will be no more than a wise precaution to apply a second ligature below the clot, to prevent the possibility of the escape of suppura- tive matter into the general cu'culation. The material of the ligature may be either ordinary linen cord or silk. Our own pref- erence is for sterilized catgut. The resulting wound is treated in the manner proper for aU similar wounds, and in from twenty to twenty-five days complete recovery may generally be looked for 4th. Wotmd of the Carotid. — This comphcation of phlebotomy at the jugular is not of common occurrence, but is easily possible. It may become one of the consequences of using a fleam unneces- sarily large, and out of proportion ^vith the dimensions of the vein and the thickness of this skin ; or it may be caused by the exhibi- tion of needless violence, in striking too heavy a blow with the bleeding- stick. Nor are these the only causes to which wounds of the carotid may be referred. An abnormal anatomical disj)Osition of the artery^, either permanent or temporary, may cause it to re- ceive the wound designed for its neighbor the jugular. The symptoms pertaining to this accident are very character- istic. The color and volume of the blood, and the rapidity of the per saltum flow of the stream are sufficient evidences of the arterial and non-venous source of the hemorrhage. ConcuiT-'ently with this, a swelling takes place around the edges of the wound, increasing with greater or less rapidity, and nearly resembling the ordinary thi-ombus of venous extravasation, though differing from it by the rapidity of its formation. This false aneurism is now subcutaneous, and has a tendency to extend itself downward toward the lower part of the neck, and has, indeed, been found extending as far as the entrance to the chest. This accident is generally one of a serious nature, not alone in itself, but often because of the specific manij^ulations which it necessitates in order to overcome it. There are, however, several fatal cases on record. The indications of treatment may be either quite simple, or, at times, of serious import. If the puncture of the artery is but a small one, and the flow not abundant, one or two strong pin sutures may be sufiScient to control it, especially if associated with it steady and firm pressure is estabhshed directly upon the coiu'se of the vessel, either by compressive bandages, or, what is better, with the fingers firmly pressing in the jugular groove. If, however, the wound is large, and accompanied by a ACCIDENTS OF BLOOD-LETTING. 513 correspondingiy jirofuse liemorrhage, it becomes necessary to have recourse to the direct applications of a ligature. A description of this operation will be made the subject of our chapter on hemostasia. 5th. Introduction of Air into the Veins. — This is one of the most remarkable of the accidents attending the operation of phle- botomy. The phenomenon has been observed as early as the seven- teenth century, but it was not until 1806 that it was observed and recorded as belonging to the category of casualties connected with the famihar act of blood-letting in an animal. The first author to put the occurrence on record in this connection was Verrier, who reported a case in 1806, and he was soon followed by others with accounts of their experience with the same lesion and operation in human practice. There are two principal causes to which this accident can be attributed. One of these may be an unnecessarily large aperture in the vein, but more commonly it follows improper manipulations on the part of the surgeon, particularly the ii-regular pressure made upon the vein dming the flow, by many practitioners, who have formed the habit of rubbing the vessel along its length, under the erroneous idea that by this movement they accelerate the bleeding. Again, and perhaps principally, the casualty may be the result of neglecting to close the wound of the skin with the finger below the point from which the current proceeds, before the pressure iipon the vessel is stopped. The occurrence is made known by a peculiar gurgling sound, which is made more evident by auscultation of the heart. In the meantime, the animal is attacked by shiverings; the respiration becomes accelerated ; there is a rapid heaving of the flanks ; the body becomes covered with perspiration ; the action of the heart is quickened; the countenance becomes anxious; the animal is seized with convulsions ; falls down and dies, unless by the con- tinuance of the flow through the open vein the air may be carried out through the same channel by which it entered, or unless the quantity has been very minute. As the result of our own study, tested by many experiments, we have become strongly inclined to believe that the quantity of air necessary to produce death must be very large, more, in fact, than a careful operator would allow to enter without attempting to prevent it. The possibUity of the occurrence of this accident may easily 514 OPERATIONS ON THE CIRCULATORY SYSTEM. be obviated, seeing that it merely requires careful attention to the execution of the few details which constitute the act of vene- section. But when it has taken place, the simplest and most ob- vious thing to do is, if possible, to remove the air from the vessel in which it has intruded. The means of effecting this consists ia reopening the closed vem, and permitting the blood to resume its flow. The loss of thi'ee or four pounds of blood additional is usually sufficient to insure the escape of all the air. Gourdon recommends, in addition, showering with cold water, stimulating frictions, and even, if the case seems to require it, artificial respiration. AKTEEIOTOMY. Bleeding from an artery is so termed to distinguish it from phlebotomy. It is not commonly used in practice, being princi- pally resorted to as a means of local dej^letion, and is performed only on some of the most superficial of the vessels. In fact, there are but three of these eligible by their position to the operation. These are the transveral of the face, the posterior auricular, and the middle caudal. The modus operandi differs but Uttle from that of phlebot- omy, except that there is usually no need of the apphcation of ar- tificial means to swell their bulk or increase then- rotundity, their position, and theu' distinct and characteristic pulsation, so readily detected, sufficiently revealing their location and course. In open- ing arteries the fleam is seldom used, the lancet or a pointed bis- toury being a much more eligible instrument. The incision of the vessel is made across its course instead of longitudinally, as in phlebotomy, and the flow of blood must be arrested by means of pressui'e with compresses or bandages. (a) Bleeding at the Transversal of the Face. — Though the position of this artery is nearly correspondent in all animals, it is principally with solipeds that it is chosen for blood-letting. It is situated below the temporo-maxillary articulation, and crossing the direction of the fibres of the masseter muscle, where it is cov- ered only by a fine skin, it is opened at the same level with the place where phlebotomy is usually performed. Some operators prefer casting the animal, others the standing position. The appearance of the vessel is that of a small, round pulsa- ting cord, and, as before stated, it is incised, not as the veins and ARTEEIOTOMY. 515 opened, but in the direction of its axis. The stream differs from that which flows from a vein, and instead of issuing with a regu- lar flow, escajDCs per salttim, or by alternating leaps, synchronous with the action of the heart. It also differs from that of the veins in color, being of a lighter and brighter red. As the apphcation of a pin suture will scarcely be suflicient to perfectly suj^press the flow, pressure must be resorted to, either by direct apphcation over the posterior border of the maxillary bone, or over the place where the artery passes, or by covering the incision with a pad of oakum, retained by means of a circular bandage passing by sev- eral turns over the upjDcr part of the head. The animal should be tied up for several days after the bleeding, or until the closing of the artery is fully assured. {b) Bleeding at the Posterior Auricular. — Though the trans- versal of the face can be opened in large ruminants, as well as in horses, arteriotomy in those animals is more commonly performed upon the posterior auricular, where it is attended by all the con- ditions of size and position required to serve the convenience of the surgeon. In cattle^ uj^on which it has been practiced for both its general and local effects, it has been recommended in diseases of the brain, and for affections of the eyes and other parts of the head. The posterior auricular runs under the parotid gland from the base of the concha upward on its external face, near its supe- FlG. 448.— Anatomy of the Posterior Auricular Artery in Cattle. 516 OPERATIONS ON THE CIKCULATORY SYSTEM. rior border, where it loses itself. It is most superficial toward the base of the cartilage as it issues from imder the posterior cer- vico-avu'icular muscle. The operation is comparatively simple. The animal being firmly- held or tied to a post or a tree, hard friction is applied to the ear to stimulate the cu-culation and render the artery more promi- nent. The concha is held by the left hand, vnth. the index finger ia front and the thumb behind the artery, the incision is made by piercing the vessel with the lancet held perpendiciilarly to the concha, the artery being cut directly across, and the incision en- larged by a downward movement of the instrument. This is fol- lowed by the appearance of a few drops of artei-ial blood, but which soon stops unless the flow is assisted, which is done by the operator, without releasing the ear, by striking light blows or taps with a small stick along the course of the artery between the in- cision and the animal's head. This last step is indispensable to obtain a good, free flow, ^^er saltum, of course. This whipping process is continued until the stream becomes abundant, but may be suspended when it reaches that point, to be renewed again, however, if the hemori-hage diminishes. Artificial means to close the incision are not usually requii'ed, the flow generally ceasing spontaneously, but when that fails to occur a pin suture or a bandage at the base of the concha, or finally the ligation of the artery, if necessary, will effect the object. The animal must be kept confined for some time, to prevent him from rubbing the wound or shaking his head too violently. In swine, this artery is so easily reached that it is often se- lected in j)reference to other blood vessels which may be more or less imbedded in the fat of the animal. The knowledge of its position is very important, as it is very small and difiicult to find. Running vertically between the temporo-maxillary joint, it reaches the base of the concha, and passes by the side of its convex sui-- face towards its point. It must be opened at the lower third of the cartilage, where it presents its largest dimensions. The artery must be cut transversely with the lancet. The bleeding ceases spontaneously, or, if necessary, may be treated in the manner in- dicated for cattle. (Fig. 449.) (c) JjleecUng at the Median Gaxidal. — In cattle this artery is quite large and very superficial. It rims along the inferior face of the tail, being covered at the base of that organ by the inferior CAPILLARY BLEEDING. 517 Fig. 449.— Anatomy of the Posterior Auricular Artery in Swine. caudal muscles, then becoming superficial and readily accessible to the end of the member. In opening it, it is pierced by the lancet in the longitudinal axis of the vessel, the tail being kept elevated. Ordinarily, however, not only is the artery cut directly across, but the skin or surrounding muscular fibres are included. The incision must be made on a level with the suj)erior third of the tail ; higher up the operation may be compHcated with abscess, disease of the vertebrae, sloughing of the tail, etc. If it becomes necessai-y to stimulate the flow of blood the same "whipiDing" process may be employed that was recommended in bleeding from the posterior auricular. A bandage may be applied round the tail to stop the hemorrhage, though it is not commonly needed. A few practitioners prefer to operate with the fleam. CAPILLARY BLEEDING. The consideration of the operation which consists in the de- pletion of the minute extreme vessels naturally and logically fol- lows that which treats of a kindred procedure with the veins and arteries. The intention of the treatment instituted for all is the same, and their curative efi"ects are adapted to similar ailments. These are principally local, and may be divided into two classes, to wit : those which have been in a great measure discarded from general practice, and those which stiU retain their place in the domain of veterinary surgery. The former includes bleeding at the palate, the coronet, and the foot, and the latter comprehends 518 OPERATIONS ON THE CIIICULATOUY SYSTEM. the punctures, the scarifications, the ventouses, or cupping, and the leeching, of regular current practice. (a) I^unctures and Scarijicatioris. — These are methods of producing small superficial wounds through the skin and the sub- cutaneous cellular tissue, to obtain the efiect of a local bleeding, or the escajDe of any other fluid contained in the subcutaneous substance. They are indicated against local sweUings and serious efi'usions, or oedema of the cellular tissue. They can be appUed upon any part of the body, and though they take efiect in the escape of but small quantities of fluid, their action may be stimu- lated by additional local apphcations, such as warm poultices, warm water fomentations, or dry, stimulating frictions. Punctures, however, are principally effective when employed to overcome cedematous swellings of the extremities, and of the genital organs, while scarifications are prescribed with better ad- vantage to obtain the resolution of cold or chronic swellings, or to control the inflammatory process in cases in which the tissues are largely swollen and threatened with gangrene. Both the bistoury and the lancet, and, in rare instances, the fleam, are used in fulfilling these indications. In making punctiu-es the skin and cellular tissue are pricked or pierced to the depth required, with the bistoury or lancet, by rapid thrusts distributed over the entire sturface of the swelling, and when the fleam is used it is manipulated precisely as when used in bleeding, though, of course, with quick repetitions. {b) Scarifications may be defined as rather small incisions, made with a convex bistoury, with which the skin is cut from without inward, in parallel series, but which, in some instances, when an increased effect is desired, are doubled by a second series crossing the first at an angle. (c) Cupping. — This mode of obtaining cajDillary bleeding is very seldom employed in veterinary practice. The cups are, how- ever, indicated in subcutaneous infiammations, accompanied with swellings, and res\ilting from blows, contusions, kicks, and other and similar traumatic causes, and are often preferable to bhsters. They are recommended in arthritis, ostitis, and even in internal phlegmasia. They render valuable aid in emptying some forms of abscesses, and are credited with the possession of power to arrest or prevent the absolution of virus introduced into wounds or deposited on their surface. CAPILLARY BLEEDING. 519 There are two modes of cupping, the dry and the scarified, or wet. The dry cup consists in the simple application of the in- strument upon the skin to produce a swelling, accompanied with more or less injection of the capillary vessels, and a local irrita- tion, which generally rapidly subsides. The operation of scarified cupping consists, first, in applying the instrument to produce the swelling, and when the tumefac- tion is sufficient following it with the scarificator. In completing the first step, which is the same as for the dry cuppings, several means are used. The skin being prepared by clipi:)iug or shaving off the hail", a small glass globe, filled with heated air, is placed over the spot selected for the operation. A small ball of wadding or oakum, either dry or moistened with an inflammable liquid, is placed in the glass and lighted, and as it begins to burn the glass is pressed upon the skin. To avoid burning the skin, pmnphuj, or vacuum-cuj)s, have been devised, some of which are provided with scarificating blades. These are, however, too complicated for our general practice. When the effect of the cupping is com- pleted, the red and tumefied skin, which is exposed as the glass is removed, is scarified with instruments ad hoc, as the lancet or the bistoury, and the cup is immediately reapplied over the same spot. The blood then escapes freely from the incisions, and con- tinues to flow untn the cup is filled and removed. {d) Leeches are not as frequently used in veterinary surgery as they might be with profit. They are well adapted to small animals, such as dogs, whose fine and vascular skin yields readily to theh* appHcation. For applying them the skin is first smeared with a little milk, sugar, or blood, and the leech, placed ia a small glass, or cup, or clean pill-box, is brought in contact with the skin by reversing the cup or box upon the chosen place. Usually it attaches itself at once, and remains until it becomes gorged with blood, when it voluntarily releases its hold. Sometimes, however, it is better to place them upon a thiqk compress, moistened with tepid water, and to apply this over the skin. In applying them on the leg it is a good plan to cover them with a cloth, secured with a string tied about the leg above and below, forming a sort of bag. When the animal fails to drop off, after being thoroughly gorged, a sprinkle of salt speedily causes him to release his hold. The succeeding hemorrhage will ordinarily cease after a short 520 OPERATIONS ON THE CIRCULATORY SYSTEM. time without aid, but if it is desirable to continue it, the parts may be fomented with warm water, or covered with a warm poviltice. (e) lileeding at the Folate. — Bleeding in this region of the mouth is done by a division of the capillary network which rests between the mucous membrane and the fibrous coat which lines the bones forming the palate. The bones rejiresented by the inferior face of the palatine pro- cess of the great maxillary bone, and the posterior face of the short jDrocess of the anterior maxillary, are covered -^-ith a fibrous coat, which extends over theii* whole sui'face and the cartilage that fills up the incisive slit. On each side of the palate run the palato-labial arteries, which, forward, form an arch, and anastomose together, and give rise to a single branch, which enters the in- 8 cisive canal formed by the internal face of the two small maxillaries. The veins, which are very numerous, fonn a large network which fills the space left between these two large arteries. The whole is covered by the mucous membrane, which is white, rosy, thick, adherent to the fibrous coat, and showing a number of rugae, about twenty, curved forward and diminishing posteriorly in size and prominence. Anteriorly they are very large, by reason of the presence of a certain amount of cellular tissue, which di- minishes by degrees, from before backward. The anastomosis of the arteries takes place about on a level with the thu'd rugse of the palatine surface, and it is, therefore, posterior to this that the bleeding must be per- formed to avoid wounding the artery. The instrument required is the simj^le bistoury, or the one rep- resented in figure 451. The operator, facing the animal, and hold- ing the tongue with the left hand, draws it out of the mouth on the right side, and with the edge of the knife turned backward, makes a small incision from before backward, in the middle of the palate between the fourth and fifth rugae. There is no danger of wounding the arteries if the incision is made at the proper j)lace and on the median line. When that is the case, the hemorrhage, continuing for a variable length of time, subsides by degrees. Fig. 450.— Circulation of the Palate. ■»(, Pala- tine mucous membrane «, grooves of the palate; «, palato-labial artery. CAPILLAKY BLEEDING. 521 Fig. 451.— Lancet to Bleed at tlie Palate. If, on the contrary, an artery has been divided and the flow of blood becomes sufficiently abundant and continuous to become alarming, it becomes necessary to employ hemostatic means. These may be a small sponge compressed or moistened with cold water or an astringent solution ; or, if necessary, a pad of oakum can be applied and secured with a bandage passed through the mouth and around the maxillary bone, and tied on the face. It can also be accomphshed by means of a peculiar bit, represented in Fig. 452. This bit has a small board in its middle, and on each side of the bar two straps, one to act as the check-piece of a bridle, the other being passed over the nose where they are buckled to- gether more or less tightly. The board of the bar is padded, and pi^ 452. -Apparatus to Apply Pressure is appHed directly over the place *» stop the Bleeding at the Palate. of the incision. The pressure should be continued for several hours. This operation was first recommended ia cases of stomatitis, in the pecuhar form known by the unmeaning name of lampas, but is resorted to for a much better purpose in apoplectic conges- tion of the head. (/) Bleeding at the Coronet. — In the " Dictionary of Veterin- ary Mediciae and Surgery," Bouley says: "There exists on each side of the coronet, a rich superficial venous plexus resting on the cartilaginous plates of tha foot, formed at this point by the union of numerous veins of the digital region. These veins are united by large communicating vessels, running on the anterior and posterior faces of the second phalanx. Nothing is easier than to open one of these vessels by plunging the point of a bistoury through the skin ; the puncture being followed by an abundant flow of blood, and, if it is repeated, a large bleeding, quite as abundant as that obtained by the opening of another large vein, 522 OPERATIONS ON THE CIRCULATORY SYSTEM. can be gained. But it is not a mattei' of indifference whether the puncture is made in front or behind, or upon the sides of the re- gion. It must never be made on the sides, because of the danger of injuring the cartilage, several cases of cartilaginous quittor having been kncmi which were attributable to no other cause than bleeding on the side of the coronet. In front the operation is less dangerous, although a wound of the tendon of the anterior exten- sion of the phalanges is possible. It is safer to bleed on the pos- terior part of the coronet, where no danger can be looked for. This bleeding has been principally recommended as a local operation in cases of acute laminitis. {g) Bleeding on the Foot. — The toe is the part selected when bleeding is performed on the foot. It is an operation which has been known for many years, and under various forms, and with different applications has been described by Vu-gilius, Columelle, AbsjTtus and Vegetius. It consists in the incision and removal of a portion of the sole of the foot. It is indicated in all cases where local bleeding is justified, and has, therefore, been recom- mended in all congestions and inflammations of the foot, such as bruises, burned soles and acute laminitis, though in this last case its execution is rendered difficult by the unwilhngness of the ani- mal to sujDport its weight on one leg during the operation. There are several ways of bleeding at the toe. 1st. The Chabert Method. — A special shoe must first be pre- pared; it may be simply an ordinary shoe notched on its inner border, which, without being removed, permits both the opera- tion of bleeding and the subsequent application of a dressing. In operating, the sole is pared out and a groove made between the point of the frog and the toe of the wall, with a drawing-knife, until the soft tis- sues are reached. An incision is then made with the curved bistoury at the bottom of the groove, between the wall and the inferior border of the os fig. 453— Shoe for pedis, and an incision made dividing all the ves- the Bleeding at the sels that come in contact with the instrument. t.^abrrt'rMrthod* "V\Tien the flow of blood has been stifficient, the hemorrhage is suppressed by a compressing dressing of oakum kept in place by bandages, or with plates, according to the condi- tion of the foot, and whether it had been shod with the notched shoe, or had remained entu'ely shoeless. SURGICAL HEMOSTASIA. 523 2d. The Valet Method. — After the preparation of the foot, as with the other method, a groove is made. It is posterior and parallel to the line which marks the separation of the wall and the sole, and the incision is made transversely, with a bistoury or a sage-knife. It is usually followed by a good flow of blood. An ordinary shoe is then jDlaced on the foot, and a compressing dress- ing of oakum put on and kej^t in place by plates. 3d. Crejnn^s Method. — The difference between this and the other processes consists in making the incision with a narrow draw- ing-knife, which provides a larger opening for the escape of the blood. A wide-webbed shoe, with a padding of oakum over the wound, suffices to control the hemorrhage. All of these methods have the same object in view, but many veterinarians prefer to make the incision a little back of the line separating the sole from the wall, and right at the toe, and they sometimes remove a small portion of the sole with the sage-knife or the bistoury. The dressing which is required in these cases must be care- fully applied, as protruding granulations may sometimes make their appearance, and interfere with the cicatrizing process. If the hemorrhage which accompanies the operation should be con- sidered insufficient, it can be stimulated by placing the animal in a foot-bath of blood-warm water. SUKGICAL HEMOSTASIA. The extraneous hemorrhage, whether it be avoidable or un- avoidable, which may occur during an operation, forms one of the most embarrassing of the interferences to which the sur- geon is liable, not only from the difficulties it interposes in the way of the success of the operation, by disturbing his manipula- tions, but as well, sometimes, by the effect of the loss of blood upon the patient. It may happen, indeed, that instead of ceasing spontaneously, or yielding to the effects of the ordinary dressings, the hemorrhage becomes so obstinately persistent as in itself to constitute a serious, and, if unsubdued, a fatal accident. It be- comes necessary therefore for the operator, as one of the jjractical elementary incidents of his calling, to be always prepared in an emergent case to arrest the rebellious circulation by prompt and efficient measures. Hemorrhage being an essential danger in all 52'4 OPERATIONS ON THK CIECDLATOBY SYSTEM. operations of considerable magnitude, the means of subduing it should always, especially in cases of that class, be included among the customary instruments and apphances of the working surgeon. The flow may proceed from any of the blood vessels, the arteries, however, from the nature of their fimctions and the force of their action, requii-ing more frequently and more particularly the appli- cation of precautionary and remedial measures. Tempoeaey ok Preventive Hemostasia. This becomes necessary as an occasional expedient, when the presence of the blood is likely to become an obstacle to the opera- tion, and the preventive means may be applied either before or during its performance. Included under this general head is the circular compression, or ligation en masse, when the situation and the form of the region render it practicable. The effect of this being the flattening or collapse of the vessels, and the temporary closure of their calibre, one of the necessary conditions of its suc- cessful application, especially with the superficial vessels, is that they shoiild be situated near enough to some structure sufficiently hard and solid to fui-nish an unyielding 2yoint a2y2nd to the com- pressing agent. If, from the position of the artery, no such point of resistance can be made available among the surrounding parts, resistance can be estabHshed by a double pressure made in op- posite du-ections, in such a manner that the compressing powers can furnish mutual support, each to the other. By this plan com- pression can be effected in four different ways. 1st. By Digital Pressure. — AVhen this can be apj^lied and proves sufficient, it is the simplest and the best mode. While it serves to obstruct the circulation, its action is limited to the ves- sel which alone needs it, and the tissues are not contused by the pressure; it can, moreover, be suspended or renewed at will, and can be managed by an assistant who may be placed in a position in which interference with the operator can be entirely obviated, and, indeed, can sometimes be joerformed by the surgeon himself. It is obtained by pressing the vessel with the tips of the fingers placed either vertically upon the vessel itself, or along its course ; and only such a moderate degree of force need be employed as will prove sufficient to close the calibre of the vessel, without fatiguing the hand by unnecessary pressure. SURGICAL HEMOSTASIA. 525 2d. Compression xoith the Circular J^lgature. — Either a band- age or a circular string of sufficient strength may be employed in this method. If needed upon the leg, it should be placed upon the lower part of the limb, either dry and moderately tight, or moistened with cold water. If kept in place for a certain length of time previous to an operation, the effect will be to so reduce the force of the circulation in that part as to render the perform- ance comj)aratively a bloodless one. This proceeding is often associated in veterinary practice with the operation of neurotomy. In operations upon the foot, comparatively perfect hemostasia may be obtained by circumscribing the coronet with a hgature Fig. 454. — The Adstrictor of Brogniez. formed of a strong circular string, tightly drawn, but as a substi- tute for this, a special instrument has been invented by Brogniez, which he calls the adstrictor, which secures the same results. 3d. Compression by the Toxirniquet. — The adstrictor of Brog- niez is but a j)eculiar form of tourniquet, which is composed of two oval cushions or pads supported by metallic plates, and se- cured on the inner face of a circular band adjustable as to its Fig. 455.— Tourniquet. length, and secured by a common buckle. This band is buckled around the leg, and the pressure is made by the pads, which are laid directly over the course of the vessel. 4th. Compression hy Esmarclc's Method. — Another mode of compression, borrowed from human surgery, that of Professor Es- marck, is designed to wholly prevent the loss of blood, and enable the surgeon to i^erfonn a j^erfectly dry or bloodless operation. It 52G OPERATIONS ON THE CIKCULATOKY SYSTEM. consists of a roller of India rubber, to be so api)lied around the seat of the operation as to cause the blood to recede toward the center of the body, its return being prevented by firmly placing a ligatui-e just above the point of incision. The pressure pro- duced by this band can be regulated by means of a tourniquet, or a piece of elastic tubing, or an ordinary string that may be twisted with a stick. This mode of compression is adapted to cases of amputation of the limbs and of the tail, or the removal of tumors. Pekmanent, ok Definite Hemostasia. The arrest of hemorrhage may become necessary at any step of an operation, but it is ordinaiily when it has been completed that the indication must be fulfilled. It is true that in many in- stances, even after extensive lesions, the hemorrhage will cease spontaneously, but it is equally true that at other times special interference becomes a necessity. If the hemorrhage is capillary, the surgeon may safely overlook it, and leave it to subside under the influence of the retractihty of the tissues ; but if it is of ve- nous origin, it cannot be safely left to spontaneous action. Still, usually it is only when one of the larger veins is the seat of the bleeding that danger becomes imminent, as with those situated near the center of the cnculatory system ; but serious accidents are seldom to be feared. If the vein is cut across, moderate pres- siu'e upon the orifice will generally insure the formation of a clot which will constitute a sufficient plug, or if the vein is opened longitudinally by a lateral incision, pressure at the point of the woimd, though not strong enough wholly to stoj) the circulation within the vessel, may still be sufficient to assure the rapid obHter- ation of the wound. But when large veins or arteries are opened, or even when the cajDillary hemorrhage is usually abundant, more compUcated means of hemostasia must be resorted to, and not only applied carefully and securely, but also with celerity. The means of obtaining permanent hemostasia are of two kinds — one taking effect through ihej'tJtysico-ehe'mical action of special agents, the other including those which are known as surgical means proper. Physico-Chemical Hemostatics. Among these must be considered the refrigerants, absorbents, astringents or styptics, and 2)otential and actual cauterization. SUEGICAIi HEMOSTASIA. 527 1st. Refrigerants. — The agents included in this class act almost exclusively by depriving the parts upon which they are applied of their heat, and in producing a certain excitation upon the vaso-motor nerves, followed by a toxic contraction of the mus- cular fibres of the vessels, and the diminution, or sometimes the complete arrest, of the bloody flow. Their action is priacipally efficacious on vessels of small calibre, such as the capillaries. Cold water, snow, cracked ice, and the very volatile Hquids, as ether, chloroform, and freezing mixtures, fiU an important place ia this category. In veterinary surgery, cold water, beiag the sim- plest, the most accessible and abundant, and the easiest to apply, heads the list. It is used in the form of douches, baths, lotions and injections, or by means of compresses, pads, or cushions of oakum laid upon the seat of hemorrhage. The saline mixtures, and the snow or cracked ice, are placed in cloths, bags or blad- ders, but their action must be watched in order to obviate the possibiHty of congelation and mortification of the tissues, quite a possible result of excessive refrigeration. Refrigerants are generally considered as forming the least ef- fective of hemostatics, but their facility of application has brought them into common use. They are principally indicated against external capillary bleeding, or that which escapes from a small vessel, but would generally prove insufficient against a hemor- rhage from a large vessel. They may, however, prove advanta- geous against some internal hemori'hages, which, though they may be controllable by other dkect means, yet can be reached by the water without difficulty or danger, and act dh-ectly or by con- tinuity in producing the necessary contraction. In this manner, injections into the nasal cavities, or the uterus, or rectum are often efficacious in arresting a hemorrhagic flow suddenly occur- ring. But in any case, refrigerants should be aj)plied with care, and their effect watched. If they are allowed to remain too long in place, or the temperature be too low, they may induce an in- flammatory reaction and local gangrene, or produce other dan- gerous general effects upon the internal economy. On the other hand, if imperfectly applied, and without a sufficient degree of cold, theu' action, ah'eady weak, wiU become a mere useless nega- tion, if not worse. Between these two extremes there is a middle course, which the competent surgeon wUl be able to observe by exercising his discretion, and an appeal to his own experience. 528 OPERATIONS ON THE CIRCULATORY SYSTEM. 2d. Absorbents. — Hemostatic absorbents i^roper are agents which by their capillary action suck up or soak in the sanguineous element from traumatic surfaces, and having their structure thickened and condensed by the presence of this contained liquid, coagulated in their mass, oppose thereby an invincible obstacle to the escape of the blood. Oakum, charpie, j)^^^^? spider-webs, flour, fuller's earth, sj)onge, and various vegetable powders be- long to this catalogue of medicaments. Oakum, which is the substance which meets with general favor and is most commonly used, is applied in the form of balls, drj^, or soaked in cold water, and packed over or into the depth of a wound, and kept in place with bandages or compresses. Compressed sponge has proved, in our hands, an excellent hemostat, not only in capillary bleediag, but in that also of me- dium-sized vessels. There is, however, an objection to its use in the fact of its liabihty to become adherent to the tissues with which it is in contact, and the consequent danger of renewing the hemorrhage when removing it. 3d, Astringents, or Styj^tics. — These agents produce the co- agulation of the blood, by a chemical action, resulting from the combination of the astringent's substance with the Uving tissues. Then- action differs essentially from that of the refrigerants in the fact that they possess the special property of producing, by their power of fibrillar astriction, the occlusion of the vessels through the coagulation of the blood in their interior. Astringents are used in both the solid and the liquid fonn. Burnt alum in powder, and certain vegetable powders, belong to the first class. The solution of sulphate of iron, sulphate of copper, alum, acetate of lead, alcohohzed water, solution of tannic acid, etc., are included in the second. They must be judiciously used, however, because of then* liability sometimes to excite local inflammations, more or less active. The action of the liquid as- tringents is deeper, more energetic, more lasting, and more dur- able than that of the sohd, and they are for that reason sometimes more rehable for the control of hemorrhages from large vessels. Their consistency renders them, of course, alone available for moistening compresses, balls, the tampon, or pads of any descrip- tion. The most powerful of this class is the perchloride of ii'on, which is remarkable for its power of coagulating the blood almost instantaneously. "When applied with oakum upon a bleeding sur- SURGICAL HEMOSTASIA. 529 face it forms, with the blood, a blackish magma, and a resisting, sti'ongly-adherent clot in the cavity of the vessel. 4th. Potential Caustics. — The chemical astringents have gen- erally the same mode of action. Upon being placed in contact with the tissues they enter into combination with their elements and form a coagnlum, and it is the presence of this clot which produces the hemostatic effect. They are but little used, hbw- ever, in veterinary practice. The nitrate of silver, some of the mineral acids, as sulphuric, nitric, or arsenious, or bichloride of mercury, are the potential caustics which are occasionally used, though it should always be with great caution, in view of the possible danger of producing an excessive effect. 5th. Actual Cauterization. — Cauterization with the hot iron is the oldest and principal hemostatic in use in the surgical treat- ment of the domestic animals, and in many instances may be made to supersede all the chemical agents we have considered, more especially in cases of capillary hemorrhage. It is appHed with the iron heated to a white heat, and laid upon the bleeding sur- face, where it immediately creates a thick, impermeable eschar, adherent to the wound, and offering an insurmountable barrier to the escape of the blood. To obtain all the effect desired the wound must be thoroughly free from all extraneous substances, liquid or soHd, that nothing may interfere with the rapid formation of the eschar. The blood should be well soaked out, a plug of oakum firmly pressed upon the wound, and the iron pressed perpendicularly upon the tissues ; this rapidly forms the eschar. The application of the cautery must be continued for a few seconds only, on account of its Ha- bility, while coohng off, to adhere to the tissues and to the eschar, with the consequent risk of reoj^ening the wound and renewing the hemorrhage upon attempting its removal. It is better if the eschar is not sufficiently thick, after a first application, to renew it a second, or even a third time, always taking the same precau- tions, and being careful to avoid contact with sound tissues. In this operation it is essential that the temperature of the cautery should be at its maximum. Half-heated, or cooled off by the blood, not only is the application more painful, but the effects are incomplete and the hemorrhage is likely to return. If the blood escapes too freely, or coagulates too slowly, the eschar not forming, it may sometimes become necessary to carbonize the 530 OPERATIONS ON THE CIRCULATORY SYSTEM. bleeding siu'face by means of some combustible substance which will furnish more solid materials for the protective scar. A loop of hair, or some pulverized rosia, placed upon the wound, and bui-nt with the cautery, often fulfills the requirements. For hem- orrhage from parts below the surface, the edges of the wound must be separated before the cautery is introduced, to prevent its cooling before reaching the proper point of apphcation. When the eschar is well formed and estabhshed it should be left without interference to complete the process of sloughing. The thermo-cautery, with which the required heat can be re- tained at a uniform degree, is one of the best instruments for the apj)lication of this mode of hemostasia, there being no need of removing it until an eschar of sufficient thickness has been ob- tained. Surgical Hemostatics. Among the numerous surgical means of obtaining both per- manent and definitive hemostasis, there are three which principally merit our attention : conij^ressioti, ligature and torsion. (A) Compression. — "We have already referred to this method while considering the subject of temporary hemostasia. There are cases in which it acts as an excellent mode of permanently controlling hemorrhage, whether proceeding from arterial, venous or caj)illary sources, and equally whether from a large surface or from a deep cavity, where the origin of the hemorrhage cannot be distinctly located. Still, for arterial hemorrhages it is only effica- cious for vessels of small or medium size, or when the wounds are of small dimensions. There are secondary circumstances which determine the designations of certain variations of pressure. One is the situation of the vessel, relatively to that of the bleeding orifice, when the pressure, to be effective, must therefore be direct or lateral, and with the latter, either mediate or immediate. Some- times, again, it is apphed at a distance from the bleeding point, and in an indirect manner, and involves an alternative between 2ylugging and direct comj)ression. It is apphed to the wound itself when the vessel has been cut du-ectly across. It is usually effected by covering or filling the wound with a dressing of balls of oakum applied du*ectly upon the bleeding orifice, and covering these with pads, increasing in dimensions as they become more superficial. The whole apparatus is submitted to pressure SURGICAL HEMOSTASIA. 531 by approximating the edges of the wound, as mucli as possible, by means of interrupted, pin, or a quill suture ; or sometimes a circular bandage of dry or compressed sponge, cut into small pieces, may be used in the same manner as the oakum with ex- cellent effect, especially when the hemorrhage is abundant, or ligation become impracticable. The objection to the mode of compression, generally speaking, is its liability to become loosened in consequence of the softened and yielding condition of the surrounding tissues. For this rea- son the mode of applying the force directly is not often practiced, or, at least, is adopted only when the hemorrhages are small and controllable by slight pressure, or in case of the section of an in- compressible artery, like that of a bone. In order to increase the effect of direct pressure the surgeon sometimes has recourse to the joint use of some of the physico- chemical hemostatics before mentioned. ( « ) InimecUate Lateral Compression. — This is practiced against hemorrhages due to lateral wounds of blood vessels, and is appHed directly upon the opening in the vessel. The method of its application does not differ from that of direct compression, and it is Hable to the same objections in its irritating effect upon the surface of the wound and consequent interference with cica- trization, and the danger of a renewal of the bleeding. More- over, if the vessel is without a solid resting-place, and there is no sufficient resisting point, hemorrhage is not arrested. But again, in a contrary condition, it may be followed by gangrene or the obHteration of the vessel, and if the wound is of such a form that this last accident cannot be avoided it is better to have immediate recourse to the ligature. It remains, then, that this mode of hem- ostasia is only advisable when the wound is small and the artery small and superficial, or in such a position that it cannot be ligated. Immediate lateral compression, however, can be made with great benefit with the finger ujDon the wound, pressing with the necessary force to prevent the escape of the blood, without clos- ing the caHbre of the vessel. The finger is kept in position for one or two hours, with an occasional inspection to discover whether the hemorrhage has ceased, and when it is removed there remains but a simple wound, easy to dress. This mode of compression has the advantage of obviating the accidents that may occur from excessive external pressure main- 532 OPEUATIONS ON THE CIRCULATORY SYSTEM. tained by ligatures and dressings, sucli as the division of tlie skin and the possibility of gangrene. The value of this measure of digital compression may be estimated by the fact of its successful appHcation to a vessel of the dimensions of the carotid artery in a case of a wound by pricking. {b) Mediate Lateral Compression. — The compression here is applied outside of the solution of continuity, in such a manner as to leave a certain thickness of the tissues between the injiu'ed ves- sel and the compressing apparatus. It may take effect either directly upon the wound itself, or elsewhere along the course of the vessel. It can be effectively made only upon superficial ves- sels, principally arteries which, like those of the extremities, lie upon or near enough to resisting surfaces to furnish a means of support to the pressiu-e. The manner in which temporary and permanent hemostasia can be obtained is the same, excepting that the cords, bandages and tourniquet are replaced by graded com- presses, supported by rollers or appropriate bandages, wliich are contiuued only dui'ing the existing necessity. The objection to this hemostatic method, and which it shares with all the other processes of compression, is, that when a large vessel is to be compressed, and a certain amovmt of force becomes necessary, other tissues, with other vessels, veins and nerves ahke, must participate in the same pressure, and, as a consequence, dis- turbances of varying degrees of severity will occur in parts situ- ated beyond the compressed surface, proportioned to the duration of their exposure to the acting cause. Hence the indication, in applying the apparatus, to begin at the peripheric portion of the region, to carry it toward the center, in passing over the wound ah-eady protected and covered by the balls, pads or compresses, which constitute the true means of compression. The principal objections to this process of hemostasia can be obviated by leaving on the apparatus only for the minimum time necessary to obtain the cicatrization of the wound of the vessel, which will, of course, vary according to circumstances, and will be especially influenced by the consideration whether the caUbre of the vessel is to be preserved or obliterated. If the vessel be a small one, the wound of small dimensions, and the continuity of the channel is to be preserved, a few hours will be sufficient ; or, if otherwise, it is to be obliterated, one or two days will be required, or even at times one or two weeks. SUEGICAIi HEMOSTASIA. 633 (c) Plugging. — Tliis mode of compression is chosen as a per- manent hemostatic to arrest hemorrhages which occur upon the surface of natiu'al cavities, or upon wounds where the injured vessel cannot be reached. This is done with balls, or pledgets of oakum or sponge, carried with a forceps to the bottom of the cavities, or with sachets, arranged in the manner of the tampon, impregnated with an astiiagent solution or a cold mixture, the whole being kept in place by the dressing which closes the cavity. It is used in cases of epistaxis and hemorrhages from the uterus, or those following castration. But with all its advantages it is an uncertain mode, and opposes but a sHght obstacle to the hemor- rhage ; besides which it irritates, by the pressure of the plugging material on the pai'ts with which it is in contact, where it acts in the manner of a foreign body, which in fact it is, giving rise to some pain, and perhaps stimulating muscular contractions, and thus exciting the hemorrhage anew. However, these objections are not of sufficient weight to contra-indicate its employment as a ready and efficacious means of hemostasia, or to prevent it from being wisely appreciated and largely employed by the siu'geon. (B) — Ligature. — The ligature is the typical and obvious means of hemostasia — the hemostat par excellence — ^perfect in its sim- phcity, though consisting simply in tying a circular thread or cord around the wounded vessel with sufficient tension to close its channel, suppress the cii'culation, and convert the tube into a cord. It can be applied either on the cut extremity of an artery, or upon its continuity. It is seldom applied upon veins, however, from its liability to induce phlebitis, but still, it is resorted to in wounds of large veins, or when the hemorrhage cannot be con- trolled by other means. As with compression, ligature may be imnnediate or mediate^ and may also be divided into temporary and permanent — tem^ porary, when its continuance depends upon some contingency — permanent^ when it is to remain until it is eliminated by suppura- tion, or becomes organized and absorbed, as when the ligating thread is composed of some special animal fibre — which is the kind most commonly used. The instruments required for this operation are : tenaculum, aneiu'ism needle, Hgature materials, ordinary dissecting or bull- dog forceps, scalpel or bistoury, and the grooved director. 534 OPERATIONS ON THE CIKCULATOKY SYSTEM. The kind of forceps used are known as artery forceps, and are of numerous varieties. Tig. 457.— Cooper Needles, or Tenaculum. The tenaculum, or aneurism needle, is a kind of blunt tenacu- lum with an eye at its end, and is used to seize or secui-e the vessels. The suture materials are linen thread, silk, animal hgatures, such as catgut or tendinous fibrilla, and sometimes very fine me- tallic wire. Ordinary linen thread and silk, well waxed, are most commonly used in veterinary practice. (a) Jmmediate Ligature. — This is the surest of hemostatic means. It is applied principally upon large arteries surrounded only by their cellular sheaths, and a difference is made in applying SUEGICAL HEMOSTASIA. 535 it between vessels wliich are perfectly intact and those which have been partially cut through or otherwise injured. The immediate ligating of an artery entirely divided mcludieB but two steps: the prehension of the artery and the adjustment of the hgature. "VVTien drawn out of its position with the proper forceps the artery must be carefiilly examined for possible adhesions, and especially any nervous threads which may be attached to its sur- face — all of w^hich must be dissected. In placing the Hgature many operators carry the thread, form- ing a loop, with the forceps, and on seizing the artery and seeing that it is clear from the surrounding tissues, they shp the loop down over the instrument upon the vessel, to be tied by an assist- ant. The apparent simplicity of this movement is deceptive ; too often the loop of the Hgature adheres to the wound, the ends roll over themselves and one another, the Hgature cannot be properly placed over the vessel, and the knot is tied over the forceps before the thread has reached the artery. To avoid this it is better, when the vessel has been weU secured and isolated, to have the assistant apply the Hgature by its middle upon the jaws of the forceps, be- hind the hand of the siu'geon holding them, in order to be free in his movements. Then making first a simple knot, without twist- ing the thread, and tying it close to the forceps, he then, with the Fig. 458.— Applying tbe Ligature. thumbs, pushes the thread fxu-ther along the artery, and ties it by pressing the thumbs together with sufficient firmness to rupture the internal membrane of the vessel. If the wound be deep, in- stead of the thumbs both indexes are used to cany the thread along the artei-y and tie it. The forceps is then removed and 53G OPERATIOKS ON THE CIRCULATORY SYSTEM. Fig. 460.— Improperly-made Knot. a second straight knot is made (Fig. 459). The knot represented in Fig. 460 is improperly made and liable to become loosened. The extremities of the thread are left of a sufficient length to allow their being turned toward the most dependent part of the wound. If they are cut too short they are Hable to become loose in the tissues, and be covered or concealed by the granulations and become the center of a suppurative gathering. Ligatures intended to remain in the tissues, must be made of animal material. The wound of an artery always involves the appUcation of a ligature on both extremities of the course, the central and the peripheric. "Where the artery cannot easily be raised or dissected from the tissues into which it is retracted, the pointed tenaciilum can be used to draw it out of its position ; this instrument is more suita- ble for small than large vessels, the coat of which it is liable to tear. In the immediate ligating of an intact artery, aiid without a solution of continuity, the vessel is exposed by means of an in- cision, either parallel or sometimes oblique, and at others perpen- dicular to the artery, according to its situation and the natui'e of the subjacent tissues, carefully noting any projections of the bones, muscles, or tendons which can be made available as points de repere; observing, indeed, all the anatomical connections exist- ing between the different structiires. When the artery has been nearly reached, in order to avoid injuring it, it should be separated by dissection with the forceps and the bistoury from the tissues covering it, or by introducing a blunt, grooved dii'ector under them, as a guide, and dividing them with the knife. The sheath of the vessel is also carefully divided and sejjarated from the ves- sel itself, which is then carefully isolated from its vein or surround- ing adhesion, and the blunt-eyed tenaculum, or the aneurism SUKGICAIi HEMOSTASIA. 537 needle passed under it. Sometimes this is easily done, but in other cases the density of the connective tissue svu'rounding the artery is too great to allow the needle to j)ass readily under it, in which case the obstacle can be removed by scraping it away with the finger-nail, which will obviate the application of extra trac- tion upon the vessel. The ligature can then be adjusted around the vessel by means of the tenaciilum, and the operation completed as usual. (b) Mediate Ligature. — This operation comprises including in the ligature of the vessel a certain portion of the surrounding tissue — a portion which should be as small as possible. It is done with a curved needle and a ligature of single or double waxed thread or silk. The needle is introduced into the thickness of the tissues, at a small distance from the artery, and passed aroiind it with the Ugature, which should be firmly tied in the usual way. The ligature is quite painful in consequence of the pressure it makes upon the nervous fibres which accompany the artery, and it is less safe than the immediate operation, exposing the vessel dur- ing its performance to the risk of wounds from the needle, and requii-ing, besides, a stronger traction upon the ligature and the knot, from the increased bulk of tissues involved ; and there is, again, great uncertainty as to securing a sufficient division of the internal and middle coats of the artery. For these reasons it is less adapted to large than to small arteries. The effects produced by the application of a ligature are not wholly mechanical. It is also followed by certain pecuHar changes in the condition of the vessel, and by specific inflammatory phe- nomena which resvilt in the permanent obliteration of the tubular character of the artery. AATien an artery is tied with the ligature the internal and mid- dle coats of the vessel are also divided by the compressing thread, and by their retraction above and below it they form a double cone, the apices of which rest on the ligated spot, the external coat resisting and arresting the flow of the blood. A clot is then formed, and the irritation produced by the pressure of the ligature stimulating the proliferation of the cellular elements of the walla of the vessel, adhesions are soon estabhshed between them and the coagulated blood, and the termination is the solidification of the former tube. 538 OPERATIONS ON THE CIECULATORY SYSTEM. The presence of the ligature and its effect on the suiTOundings of the blood vessel give rise to a process of elimination, by which, after a certain time, the Hgating thread is exj)eUed, carrying vpith it the vascular stump situated beyond the ligature. At the same time, and while these phenomena are taking place outwardly, the clot, adhering more and more to the vascular surfaces, soon be- comes the seat of peciiliar absorbent changes, and gradually dimin- ishing in size, at length disappears. As the resorption of the clot takes place the walls of the ves- sel contract until at length the cahber of the artery becomes en- tirely obliterated, and the former tubular canal is transformed into a fibi'ous cord, extending from the point of the ligatiire to the nearest collateral vessel. This obHterating process of the arterial canal may, however, be defeated by the interference of too active an inflammation, pro- ducing the premature sloughing of the ligature, or by the exist- ence in too close jiroximity to the point of Hgation of a collateral arterial branch. In both cases hemorrhages may follow ; in the first, because the adhesion of the clot is imperfect, and in the second, because no clot has been formed. (C) ToKsioN. — This hemostatic process has been known from an early date, but was not methodically described until about forty or fifty years ago, by Amussat, who recommended it in preference to the method of hgation. But daily experience has demonstrated its inferiority, and j)roved it to be a less powerful hemostatic meas- ure than that of the hgatirre, and, moreover, that it is only avail- able for hemorrhages occurring in small vessels. There are several ways of applying torsion. Among the principal is that recognized by Amussat. It requires four forceps, two ordinary anatomical, another whose branches are terminated by smooth cylindrical jaws, and the fourth the artery-ttolsting forceps. The artery is held with one of the ordinary forceps ; with the other the tissues surrounding it are separated from it ; then the twisting forceps grasp the artery at its extremity in place of the one first used, keeping it out of the wound, and when thus secured the instrument with the smooth transverse jaws is applied above it, close to the tissues, and firmly pressed upon the coats of the artery. In this position, the twisting forceps is given a rotary motion upon its axis, as if the vessel were to be rolled over its extremities, and is twisted xxyioxi itself by seven or eight Fig. 461.— Artery Forceps for Torsion. turns. The smootli-jaw forceps is then removed, and the stump of the artery is released and pushed into the tissues, unless the torsion has been sufficiently severe to jDroduce the laceration and retraction of the vessel. As the result of these manipulations the two internal coats of the torn artery retract upon themselves and the external coat is elongated and rolled upon itself — all in such a manner that the clot is arrested by the retracted internal mem- 540 OPEKATIOKS ON THE CIRCULATORY SYSTEM. branes, as well as by the support contributed by the pseudo-plug- ging, which results from the twisting of the external coat. This process is a compHcated one, but it has been modified in. several ways. In one process only two ordinary artery forceps are used ; one ajjplied at some distance from the end of the artery, transversely to its axis, and the other holding the vessel by its end in continuity to its length. Keeping the first tight on the vessel, the torsion is made by ten or twelve complete rotations of the second. Another still simpler mode consists in graspiag the mouth of the bleeding vessel, and giving it a number of rotations with a strong artery forceps, the artery being thus twisted without tear- ing or entirely dividing it. Nothwithstanding all these modifica- tions, torsion is not applicable to large arteries, and cannot super- sede the ligature. It is slower in performance ; it is more painful ; it requires a greater isolation of the vessel ; and the possibility of untwisting, and with it, secondary hemorrhage, is always to ba feared. CHAPTEE XI. OPERATIONS ON THE NERVOUS SYSTEM. PLANTAE NEUEOTOMY. Although the word oietirotomy, when correctly defined, means, in a general sense, the dissection of nerves, it has in surgery an- other signification, and is appUed indifferently to describe the di- vision, the resection or the amputation of a nerve, according to the sjjecial manipulations of a given case. In veterinary surgery, it is held to be strictly apphcable to the oj)ei-ation which consists in the dissection and removal of a portion of a nerve, and as the present chapter proj^oses to treat principally of affections of the foot, it is simply correct to emjiloy the term plantar as a prefix to the title, as we have done. The design of the operation is the destruction of the susceptibihty of the region or organ imphcated in the treatment, and to subdue the pain, if not permanently, at least for a j^eriod of time sufficient to restore a working animal to his abihty to labor, which, without such a reheving operation, would have been lost to usefulness and comfort. This curious and important operation has a comparatively recent history. It is of English origin, two British sui'geons claiming priority in its performance. These rival contestants are Moorcrof t and Sewell, who put it in practice, the former in India, and the latter in England, at about the same time. After its in- troduction, it was frequently performed by Enghsh veterinarians, among whose names occur those of Goodwyn, Coleman, PercivaU, Spooner and others. Its introduction on the continent was in France, and is credi- ted to Gii'ard, Jr., who described it in 1824, and from that date it continued to be a subject of experiment at the hands of many veterinarians. We say experiment, because it was only after a 542 OPERATIONS ON THE NERVOUS SYSTEM. long series of trials, and as the result of much discussion of its merit and value, that it secured an afifirmative verdict from the magnates of veterinary practice, and became an estabhshed posi- tion in our science. Yet the objections which it encountered in Eui'ope have not to this day been wholly eradicated, and on this side of the Atlantic there are few practitioners who still decline to give it their confidence and adoj^t it in their practice. The opposition which it has encountered is founded principally upon the failures, the accidents and the unfortunate sequelae, which were not rarely met with during the period immediately following its original introduction. These objections we now proceed to consider. Stumbling has been mentioned as one of the first effects of the loss of the tactile function of the foot, by the destruction of its sensibility. The animal which has lost the soHdity and the certainty of his gait, will only after a long time become accus- tomed to the proper use of the comparatively inert mass repre- sented by so indispensable a part of his organization as his foot, so complicated in its arrangements and adaptations, and so per- fect a portion of his anatomical structure before the extirpation of its nervous sense. And yet, while this condition of stumb- ling must be fully appreciated by those whose anatomical knowl- edge enables them to take into fvill and careful consideration the physiology of the part, and who have verified the objection from their own observation, there are also veterinarians of large practice and long experience who have operated in numerous cases, even upon animals used for fast work, where the muscular efi'ort is of a comparatively violent character, who have met with the accident only in very rare and strictly exceptional cases. It must rationally be inferred that an unskilled operation of such a character would leave the patient in a condition of which an awk- ward and stumbHng gait would be but a natural and inevitable sign. But it would also be in the course of a natui'al and healthy reaction for a horse to educate himself rapidly to the situation, and acquire a new certainty of movement and confidence in the use of his feet, which would soon restore him to his former abil- ity to labor. The casting off of the hoof, as a compHcation or termination of the operation in neurotomized horses, is one necessarily of a fatal character. This fatality has, in some instances, followed the PLANTAR NEUROTOMY. 543 operation within a period of from one to two months, but on the other hand its occurrence has been deferred in other animals for 3'ears. Evidently, these varying restdts must be considered as the effect of different and quite disconnected causes. The truth is, indeed, that in the first instance it is due to a gangrenous dis- organization of the tissues within the foot, and in the second, in- stead of being the residt of insufficient vitality, or arising from lack of nutrition of the parts, it is more probably the consequence of the unregulated force of the concussion when the foot strikes the earth — unregulated because of the loss of the discriminating instinct formerly exercised, but now lost with the missing nerve- consciousness which once controlled all the movements of the limb. It could scarcely happen that such a condition of things shoiild fail, after years of continuance, to encounter some susceptible temper in which to exhibit its baleful influence. A reason which must not be overlooked in relation to the cast- ing off of the hoof is the fact that in the neurotomized animal the essential s^nnptoms of the first development of any lesions which might give rise to it, are missing. The first of these symp- toms is the pain which is normally manifested by the lameness, and for that reason it is that the care and attention required by the foot of a neui*otomized horse are at once so important and so commonly overlooked and omitted. But without ignoring the possibihty of this accident, the question is presented, whether it is of such common occurrence that its frequency constitutes a cogent reason for aboUshing the operation. Our answer to this, founded on the shovring of the record, must be given in the negative. To quote but one among many authorities — Professor Nocard says that out of more than one thousand operations, he has never met with that accident. For ourselves, in a practice of many years, with a number of neurot- omy cases which we can count by the hundreds, we also have never encountered it. In the only case we have seen, other causes existed in the form of suppurative corns, which were overlooked, and which were, moreover, compHcated with gangrene of the vel- vety and podophyllous tissues. The Softening of the JPerforans Tendon and its subsequent rupture, is also a very severe sequelae of neurotomy. This may take place almost immediately after the operation, or it may be postponed until after a few months, when the animal has resumed 544 OPEKATIONS ON THE NERVOUS SYSTEM. liis work. It has, indeed, been charged to undue liaste, in com- pelling tlie animal to labor without allowing sufficient time for the healing j)rocess to be completed, and it is also alleged that it is a consequence of the performance of the operation on both sides of the leg at once. It is both a possible theory and a plausible argu- ment that the failure of the tendon is the result of the shocks in- flicted upon it while in a condition of disease and unconsciousness, and this may explain the possibility of the accident without any reference to the circumstance of putting the animal to work. But this falls far short of proving that the neiu'otomy exercised any jjotent agency in bringing on the softening and ruptiu*e. And as to the effect of performing the double simultaneous operation, our opinion will be readily uiferred from the fact which we here state, that out of the large number of nexu'otomy cases which have passed through our hands, we have seen but a single case of softening and ruptiu'e of the perf orans tendon, and that was associated with a fracture at the os pedis. The horse had been operated on upon both feet, and on both sides at once, for navicular disease of old standing, and on the thu"d day following he was found in his box standing on both fetlocks. He was destroyed and it was found that the tendons of the perf orans had given away in both feet, with a fracture of the navicular bone and os pedis on one foot, and of the OS pedis alone at the semi-lunar crest on the other. It is oui* constant habit to operate on both sides, and with this sole excep- tion, we have never met with softening of the tendons. Sprinfjhalt. — Beugnot and Renner report cases in which the performance of the operation on the lund feet was followed by the apj)earance of springhalt. In addition to the points we have been discussing, other alleged objections exist, which may claim superior force and value, but there are none among them of sufficient weight, in view of the many benefits realized from the operation, to justify its repu- diation and abandonment. Among these may be mentioned the theory that the foot de- prived of its sensibility by neurotomy is more exposed to the se- quelae of pricks, contused wounds, corns, etc., from the circum- stance that there is no betrayal or visible manifestation of the lameness which is usually indicative of lesions of that organ. It is further objected that in many instances the lameness shows, sooner or later, a tendency to relapse. But there is httle PLANTAK NEUROTOMY. 'A5 validity in this allegation, from the known fact that in a majority of cases its early recurrence is mainly due to imperfect methods or an unskillful performance of the operation, and cannot, for that reason, be considered a proper incident of the case, but simply an accident, which may be obviated by care and precaution, and ia judging the transaction, must be eliminated from the argu- ment. Probably the most important and most nearly vaHd objection is that the suppression of the nervous influence has more or less effect upon the nutrition of the digital region. Notwithstanding the observations of Braael, the question of the direct influence of the digital nerves upon the nutrition of that region is a point which has not yet been thoroughly comprehended by our physiol- ogists. For this region this objection, and the points involved in it, call for further study, and it is nearly certain that when it has received this the end will be the removal of the reproach brought against neurotomy of interfering with the vegetative hfe of the digital region. Having thus examined the objections which have been urged against neurotomy, a consideration of the advantages claimed for it will come next in order of mention. Lea^dng out of view the few failures to which the operation, in common with every human act or endeavor, whether in great matters or small, is from the constitution of things, hable, we proceed to the facts which demon- strate the usefulness and value of the treatment, with a desciip- tion of the various modes of procedure practiced by different sur- geons. The facts of the direct and successful results which be- yond question have been secured, are so numerous and so patent, and they so far counter-balance all j)Ossible accidents, that no conceivable array of abortive cases, if reported truly and with- out prejudice, can impaii' theii" force and significance. It would be impossible to reach even a proximate estimate of the value saved and the loss prevented by the restoration of unnumbered • useless and suffering animals to comfort and usefulness. And these are what might be called the positive or direct ad- vantages of neurotomy. But besides these, there are other advan- tages in the secondary effects of the operation, of which the im- portance cannot be ignored, especially when they are commended to our attention by such authority as that of Professor Nocard, of Alfort, when he says : " In several cases I have noticed a great 546 OPERATIONS ON THE NERVOUS SYSTEM. diminution in the size of exostoses (ringbones), which we treated by neurotomy ; . . . " and again, " Neurotomy, by remo\dng the pain existing in the posterior parts of the foot, removes the cause for knuckling, and prevents the retraction of the tendons ;" and further, " It ju'events also the serious accidents, so frequent after firing of the coronet, sloughing of the skin, cartilaginous quittor, necrosis of tendons or hgaments, opening of joints, etc., all being accidents likely to follow the severe cauterization which, to be suc- cessful, is required in the treatment of those exostoses." Speaking of these advantages, Zundel says : " In rare cases, besides the removal of the lameness, the recovery of the disease which gave rise to it, may also be observed. Thus, after neuro- tomy, contracted feet have, after a few months, regained their nor- mal form, and exostoses have stopped their growth and even di- minished in size." Ha\ing thus considered this matter, both "pro and con, giving on one side the objections urged against it, with the alleged facts and inferences with which its opponents seek to maintain their ar- gument, and on the other hand, shown the reasons which influence the friends of the operation in advocating and putting it in prac- tice, with their statement of its utility and the important bene- fits it is capable of conferring, we are prepared to examine into the conditions which indicate or counter-indicate this particular method of surgical interference. Bouley, speaking of its indications, said: "When the digital region is the seat of a chronic disease, manifested by pain and continued lameness, provided the alterations of structiu-e are not of such a nature as to interfere mechanically with the execution of the function of the region, neurotomy is indicated." And speaking of lameness, the seat of which is not located, Messrs. Hardy and Hugues go farther, for with them "neurotomy can and ought to be performed when a lameness from an unknown cause, 'and whose nature is not recognized, has for a period of more than three months resisted ordinary therapeutical and surgical means." Taking these as axiomatic rules, laid down by such authorities, and substantiated by the results obtained by their observance, it becomes evident that in all cases of lameness of the nature de- scribed by these writers, or, to repeat, lameness and pain from an unknown cause, neurotomy is the indication, and if it fails to cure PLANTAR NEUROTOMY. 547 the iindiscovered disease, it will, at least, relieve the lameness, if not in all, yet still in a large majority of the cases. In contraction of the heels, or in feet subject to chronic corns, as result of their conformation, and in some cases of chronic laminitis, where there is either no alteration of structure, or very little, as well as in keraphylocele, here also neurotomy is bene- ficial. But it is principally in navicular disease that its advan- tages are best illustrated. And next to these, as best adapted to prove and exempHfy its benefits, must be classed ringbones and sidebones, the characteristic exostoses of the digital region. Excellent results have followed it when performed for the relief of the lameness which often supervenes upon severe injuries, or operations about the foot, such as fractures of the phalanges, crush- ing of hoof, or any of the sometimes violent acts of surgical intei'- ference necessitated by the diseases of that region. The question has even been discussed of the probability of obtaining beneficial results in tetanus, following traumatic lesions of the foot ; especially in punctui'ed wounds. A glance at the counter-indications of neurotomy will furnish a plausible exj)lanation of the objections alleged against it in its earlier history. In the fact that the complications now recognized as thus related to it were then unknown, and consequently un- recognized, and the operation performed notwithstanding, we at once discovered a sufficient reason for the failures and bad results of the treatment, and the consequent odium into which it naturally feU. It was not yet adequately comprehended — it was misapplied — it was, perhaps, unskilfully performed — it failed. A very logical formula; but it ought not to have been denounced. Neurotomy is indicated in navicular disease, and for some in the very iacipiency of the attack, all other modes of treatment being only palliative and temporary, and when it has advanced to its chronic stage an operation will be of little advantage, or wholly unsuccessful, if at this period the bone has become extensively diseased, and the tendon reduced to the condition of a mere mem- braneous pellicle. It is also contra^indicated in all forms of acute inflammation of the foot ; in badly formed feet, such as the flat or pumiced of chronic laminitis ; and, again, when the lameness origi- nates in a very large exostosis or other bony disease likely to be- come a mechanical obstruction to the movements of the articula- tion, or to the play of tendons, or to produce anchylosis. To 548 OPERATIONS ON THE NEKVOUS SYSTEM. resume, it may be said with Boviley, " one must not ask from neu- rotomy more than it can grant, by applying it to cases where the lameness must necessarily persist, even after the removal of pain in the diseased parts." One important practical point in the performance of the opera- tion is the determination of the place where it is to be performed. A reference to the anatomical disposition of these plantar nerves will aid us here. In the forelegs both the external and inter- nal plantar nerves form branches about equal in size, running on each side of the leg, with an identical disposition. Each of these nervous branches is situated along the tendon of the perforans Fig. 462.— Plantar Nerves in Digital Region. P, plantar nerve ; A, original of the digital nerves ; B B B, cartilaginous branch; CC C, cutaneous branch; D, digital artery, with the nerve back of it; E E, ramifications of the cartilaginous and cutaneous branch ; F F, bulbous branches ; G, Transverse branches back of the fetlock joint: V, digital vein. PLANTAR NEUROTOMY. 549 muscles, then, at a xDoint a little above the fetlock, they ramify and divide into three branches, or digital nerves proper ; one prin- cipal, posterior or continuation of the main tnuik, running toward Fig. 463.— Plantar Nerve on the Posterior Face of the Phalanges. P. plantar nerve; A, origin of the plantar nerve above the sesamoids; B, cartilagi- nous branch; C, cutaneous branch : D, digital artery; H, branch to the cartilaginous bulbs— sometimes absent; I, branch of the plantar cushion; K, transversal coronary- branch; j\l, podophyllous ramification; O, pre-plantar nerve; Q, branch to the patilobe eminence: R, arterial branches; V, vein which is sometimes found running back of the plantar nerve. the middle part of the lateral cartilage of the foot, under which it passes ; a second, anterior, smaller than the posterior, which is divided toward the middle of the first phalanx, into several branches, ramifjdng in the tendon and other parts of the anterior reoion of the foot ; and a thii-d, or middle branch, which goes to the coronary band and podophyllous tissue. The consideration of the relation held by these plantar and digital branches to the blood vessels constitutes an important practical point in the opera- tion. Artery, vein and nerve descend on both sides of the fet- lock, in such a manner that the vein is situated in front, the artery 550 (JPKKATIONS ON THE NERVOUS SYSTEM. in the middle, and the nerve behind — the veia being on a plane somewhat more suj)erficial than the artery, which is a Httle deeper. Consequently the operation may be performed at any one of four points, and on either side of the leg. These are, first, above the fetlock, on the plantar nerve proper ; second, below the fetlock, on the posterior bi'anch ; third, below the fetlock, also on the anterior branch ; and fourth, according to Nocard, above the fetlock, on the anterior branch. The first or second of these locations is more often selected for the operation, and forms either the high or low process. For each of these operations there is a point of selection. In the high process this is immediately above the fetlock, where the nerve is most superficial and most easily exposed, on the outside border, and a little in front of the perforans tendon. In the low method it is below the fetlock, in the middle of that part of the coronet region where a depression is felt between the tendon and the first j^halanx. The question of preference between the high and low opera- tions has been made the subject of much discussion, and it re- mains stni unsolved. With many the high operation is that which yields the best results ; others hold that the object especially con- templated in any given case must determine the point as the oc- casion presents itself. It is only just to say, however, that the ma- jority of practitioners prefer the high operation ; not only because it is easier to perform, but also because it is more likely to be successful. Personally, we believe that the high operation, with some few exceptional cases, is that which will prove almost generally beneficial. The instruments necessary are, a pair of scissors, a convex bistoury or scalpel (we prefer the latter), a narrow, straight bis- toury, two dissecting forceps, a pair of blunt tenacvdums, with an elastic band (Fig. 464), an aneurism tenaculum (Fig. 465), needles, thread and sponges. Those who are familiar with the oj)eration highly commend a new instrument, the neurotome (Fig. 466), which has been invented to take the place of the straight bistoury. Neurotomy is a simple operation, but a very paiaful one, and it is necessary, therefore, to have the animal well secured from the commencement of his struggles, which may endanger both himself PLANTAB NEUROTOMY. 551 Fig. 464.— Blunt Tenaculum, witb Elastic Band. Fig. 465.— Blunt Tenaculum, Fig. 466.— Right and Left Neurotomes. and the surgeon and his attendants. "We fully agree with the admitted rule that animals undergoing surgical operations should be thrown and properly secured. We, with other practitioners, however, have succeeded so well in obtaining complete local an- esthesia by the use of cocaine, that it has enabled us to perform the operation in the standing position. We, nevertheless, can scarcely see the necessity for genei-al anesthesia when, as we be- heve, the intense pain which occurs the moment of the division of the nerve can be mitigated by careful local anesthesia after the nerve is exposed, shovdd the operator think it necessary. A careful consideration of the various methods recommended for securing an animal, when cast for operation, has induced us to adopt the following as the simplest, the safest and the easiest to apply and control : The animal is thrown upon the side of the leg which is to be opei'ated upon, and, both legs being bound together above the knee with a few twists of a flat rope in the form of a figure 8, the leg to be treated is removed from the hobble and di-awn 552 OPERATIONS ON THE NERVOUS SYSTEM. forward with a rope attached to the foot. In this manner the inside of the leg is first treated, after which the animal is tm-ned over and the process repeated on the outside. If the operation is to be performed on both legs, the patient may be thrown on either side indiflerently, and his legs secured as before described. The vmder leg is then first released and dealt with on the inside ; then rebound to the hobble and the upper leg liberated, and the process repeated on the outside. The horse is then turned over, and the inside of the second leg operated upon is neurotomized and returned to its hobble ; and finally, the upper leg, which was on the under side at the beginning, is operated on upon the outside. Our mode of operating may differ somewhat from those prac- ticed by others, but the general plan is the same. The patient, having always been prepared by local treatment of his fetlocks, which have been soaked and firmly bandaged for twenty-four hours, is cast and seciu-ed, as before stated, the hair is closely clij)ped with the scissors, and the parts thoroughly washed with an antiseptic solution (bichloride of mercury). Having carefully felt for the location of the nerve, which, in many cases, can be discovered by feeling the pulsations of the artery, an incision is made through the skin with, if possible, one stroke of the convex bistoury, measuring from an inch to an inch and a half in length. It is an advantage to have the incision slightly oblique to the direction of the nerve. Then, with a forceps in one hand, and the handle of a bistoury or scalpel in the other, the cellidar tissue is lacerated from the edges of the incision, in order to allow the application of the two blunt rubbered tenaculmns, which, when in position, hold open the wound; or sometimes threads are used instead, being passed through the edges of the wound and tied on the opposite side of the leg. If the incision has been made in the proper place, after sponging away the trifling hemorrhage which obscures the wound, the nerve may be seen at the bottom, or it may be found surrounded with more or less condensed cellular tissue, and the next move is its dissection. With a dissecting forceps in each hand, we firmly grasj) the con- nective tissue with one, while with the other we tear it away immediately over the nerve, removing it by two or three small portions at a time until the nerve is exposed, lying more or less closely to the artery. Then, with a gentle two-and-fro movement, we isolate the nerve from its attachments with the cellular PLANTAR NEUEOTOMY. 553 structure, and -when it is loosened, a fact easily recognized by an apparent shrinking in its length, it is ready for the division. At times we pass under it the blunt aneurism tenaculum, carry- ing a thread with which to secure it, and when secured, passing the pointed bistoury under it, we divide it with a single upward stroke of the instrument. In other instances, instead of the ten- aculum and thread, we use the neurotome, which, having a curved, blunt end, enables us at once to isolate the nerve, and with a simple motion of the sharp edge to divide it from below upward. Upon making the section the lower end of the nerve is secured with forceps, drawn out of the wound, separated from its adhe- sions by scraping it with the bistovuy, and when a portion about an inch or an inch and a half in length has been dissected, and" the resection is completed, either with the neurotomy knife or the bistoiiry, the wound is to be cleansed with antiseptic washes. The edges are in. a very few instances secured by a stitch of suture, but we often prefer a simple antiseptic dressing and a bandage. There is, of course, no doubt that animals will often struggle during the operation, and especially at the moment when the liga- ture is tightened upon the nerve, or when the nerve is divided, but the pain in either case is so transient that while we appreciate the value of anesthesia, we cannot recommend, in ordinary prac- tice, general etherization or chloroformization. If it is necessary to have recourse, as some do, to the tourniquet, or of any other means, to control a possible hemorrhage, a large experience in the practice of this operation has failed to show us a single case where such practice would have been of advantage. The various details of the operation are substantially the same, both for the high and the low process. It must be borne in mind, however, when operating below the fetlock, that the nerve is often concealed by a little fibrous band, which a careless operator might mistake for the nerve itself. There is probably no special attention required as supple- mental to the operation. The wound heals more or less I'apidly by first or second intention, and, as a rule, after two or three weeks there are no signs of the occurrence excepting a simple linear cicatrix remaining. Of the accidents which may be en- countered during the operation, hemorrhage is the most import- ant. Generally this is referrible to an error on the part of the 554 OPERATIONS ON THE NERVOUS SYSTEM. operator in dividing the artery or the vein, and usually it is not dangerous, though it may still prove very troublesome. If the artery is divided the ligature must be apphed on the truncated ends ; if the vein, pressui'e vpill be sufficient. The last important point involved in a case of neurotomy is the length of time required by a neurotomized animal to recuper- ate before he can safely return to his work. It is undeniable that to a too hasty return of the patient to his accustomed labor most of the objections and alleged complications of the operation may be traced, and for this reason the answer to the question how long a rest shall follow the operation must be as long as circum- stances will penult. Zundel, Gourdon, Fleming, and others, make a month the minimum period within which no considerable exertion should be undergone ; we would sometimes be still more liberal in allotting the length of the vacation. CHAPTER Xn. OPERATIONS ON THE GENITO-URINARY APPARATUS. CATHETERISM OF THE URETHRA. The object of this operation is the exploration of the interior of the bladder, and consists in the introduction of a catheter, species of canula, or through the urethral canal into that organ, for the purpose of ascertaining and removing its contents. Al- though the urethra of the male has great length, with an acute curve at the ischial arch, the operation is not a difficult one. It is described as the partial and the complete, according to the dis- tance to which the instrument is inserted into the canal, being partial when the catheter is pushed in the urethra only as far as the pelvic portion of the passage, but complete when it is carried completely into the bladder. The operation is employed in animals of both sexes, and is indicated in cases of retention of urine, due either to the pressure of calculi, or to the spasmodic contractions of the bladder, which accompany some cases of colic ; or, again, when in attacks of paraplegia the animal is unable to micturate naturally. It also constitutes one of the first steps of the operation in urethrotomy, in cystotomy, and in lithotrity. We shall consider the operations separately as performed in males and in females. In Males. — The catheter used in veterinary practice for male solipeds is composed of a tube of wire, twisted in close spirals, and covered with a species of thin oil-cloth, making the outer sur- face perfectly smooth, and forming a perfect canula. It is fur- nished with a stylet made of flexible rush broom, or whalebone, which can be readily withdrawn from the cavity of the instru- ment. Metallic catheters, invented first by Brogniez, and improved on the plan of those used in human medicine, may also be ob- 556 OPERATIONS ON THE GENITO-UEINARY APPARATUS. tained, but tliey are not in as general use as the simpler and cheaper kind above described. India-rubber instruments, more or less pliable, constructed on the same general plan, are also made. In solipeds, urethral catheterism can be performed either when the animal is standing or in the recumbent position. In the first case he is kept quiet by the application of a twitch on one hp and of the hobbles on his hind legs. This done, the first step is to secure control of the penis by drawing it out of the sheath, which must first have been thoroughly cleaned and washed to remove all the sebaceous secretion which by its greasy consistency renders this step of the operation quite a difficult one, many animals resisting the attempt to accomplish this with all their force. But by obtaining and retaining a firm hold of the penis above the glans, and drawing upon it slowly, firmly and steadily, the resist- ance of the animal may be at length overcome, and the organ brought into full view. The operator then, guided by the little protrusion of the urethral canal, in the middle and a little toward the lower border of the glans, carefully introduces the instru- ment, which should be freely lubricated with oil or vaseline, pushes it slowly toward the ischial arch. When the instrument CATHETERISM OF THE URETHRA. 557 reaches the ischial space the stylet must be withdrawn in order to avoid the difficulty of bending the catheter over the curve formed at that point in the urethra. At this moment a gentle but firm and steady pressure upon the end of the instrument (easily felt at the ischial arch), made by an assistant bending it forward, will, with a little careful pushing, effect its entrance into the bladder. This will, of course, become known at once by the cessation of the resistance, and by the escape of the urine which may be con- tained in the bladder. The removal of the instrument is effected by simj)ly drawing it carefully from the passage. Sometimes simple pressure over the ischial arch is insufficient, and the bending of the instrument into the proper direction is to be made through the rectum, and hence the indication of having that organ well emptied before proceeding to the ojDeration. The indication of great caution in this operation is suggested by a consideration of the fact that (if the canal should chance to be of unusually naiTow diameter or its walls softened by disease) there is sometimes danger of forming false passages, by punctm'- ing the mucous membrane, and forcing the catheter into the erectile tissue which surrounds the ui-ethra. This is an incident which, however, can be avoided by removing the stylet from the canula before its introduction into the urethra, the canula itself being terminated by a perforated oval bulb, jDerfectly smooth, and thus incapable of inflicting injury. In Catheterizmg Females, a small catheter may be and is sometimes used, but as a rule, the metaUic instrument is prefer- able, the conditions of the method, the shortness of the passage Fig. 468.— Female Catheter. and its comparatively large diameter, with the facility with which it can be entered; rendering the metallic on all accoiints more eligible than the composition or the rubber tube. The instrument, being lubricated with oil or vaseline, the oper- ator, opening the vulva with the left hand, introduces his right, holding the instrument, into the vagina, and carries it foi-ward to the meatus urinarius, which he can feel at about six or seven 558 OPERATIONS ON THE GENITO-UEINAEY APPARATUS. inches iu front of tlie \ailya. "WTiile thus holding the instrument, he feels, with the middle finger of his right hand, for the mucous valvidar fold which covers the meatus, pushes the finger under it, and then, bringing the bulb end of the catheter to the opening of the urethra, inserts it into the bladder. The accidents that may arise from carelessness, or otherwise, in the catheterism of males, are not met with when treating females. URETHROTOI^IY. Incisions of the urethral canal are made for various purposes. The removal of foreign bodies, usually calcuh ; the restoration of the suspended power of micturition when is has been caused by the closure of the passage ; the estabhshment of an artificial ui-ethral opening ; and the penetration of the ca^aty of the bladder when necessary for surgical purposes — these are among the reasons for which this imj)ortant canal is incised by the surgeon. It is principally performed on males, the dimensions, aside from its shortness, of the urethra in females being, as a rule, ample, and the organ sufficiently dilatable for the removal of calcuh, or other objects, without invohdng the necessity of an operation. Among the males, the ox is the animal which most frequently re- quires it, by reason of the peculiar hability of this animal to suffer from a constitutional tendency to the formation of calcuh and the fact that these accretions are often arrested in the urethra, in consequence of a peculiar double curvature, or S formation, in the penis. "With horses, it is in some districts quite a common operation. In these animals, however, the calculi, though of rare formation, are larger and are more generally retained, either in the bladder or in the first portion of the urethra. In smaller animals, calculi are also quite common and troublesome, especially in dogs, on account of the presence of the bony formation in the structure of the penis. In the horse, the principal operation is performed in the peri- neal region, or the part extending on the median hne from the anus to the scrotum, boxinded above and on each side by the ischial tuberosities, and below by the flat of the thighs. The skin of the perineum is very fine and thin, and is hairless URETHKOTOMY. 559 JS-v Fig. 469.— Anatomy of the Perineal, Anal and Caudal Regions. 1 1.— The skiu. 2. — Portion of the aponeurotic sheath of the coccygeal muscles. 8 3. — Inferior sacro-coccygeal muscles. 4 4. — Lateral sacro-coceygeal muscles. 5 5. — Is- chio-coccygeal muscles. 6. — Suspensory ligament of the anus. 7 7.— Lateral caudal arteries. 8.— Deep caudal vein, satellite of the median artery. 9.— Median caudal artery. 10 10.— luferior caudal nerves. H.— Lymphatic glands. 1313. — Superficial caudal veins. 13'.— One of the superficial caudal veins. 13.— Portion of the perineal aponeurosis. 14 14.— Semi-merabranosus muscle. 15.— Sphincter ani. 16 16.— Ischio cavernous muscle. 1717.— Bulbo cavernous muscle. 18 18. — Suspensory ligaments of the penis. 19 111.— Bulbous or interm.1 pubic arteries. 20.— Incision of the urethral canal for urethrotomy. 21.— Anus. 560 OPEKATIONS ON THE GENITO-UEINARY APPABATUS. below the anus, but downward and on the sides, is is covered with short hah*. Below the skin are found the two principal layers of aponeurotic covering, di\aded into the superficial and the deep. The former, of fibro-elastic texture, is the continuation of the dar- tos, and covers the perineal region, thinning down as it nears the anus, to disappear at the sphincter ani. Its most superficial fibres give attachment to a subcutaneous muscular* fasiculus, which from the sj)Hneter ani runs downward to lose itself about three inches beloAv. The latter jDlane, or deep aponeurosis is formed of white inextensible fibrous tissues. Intimately adherent by its external face to the superficial layer, it covers and unites with the accelerator urinse, and the ischio-cavemous muscles, as well as with the suspensor and retractor Hgaments of the penis. It then passes between the ischio-cavernous and the semi-membranosus, to attach itself above on the ischial tuberosity and become lost downward on the thighs. Some of its fibres directly siUTOund the fixed portion of penis, «,nd join the aponeurosis common to all the muscles of the flat of the thigh. The suspensor and retractor of the penis form, in the upper perineal region, that is, from the anus to the ischial arch, an ex- pansion of siifficient width to form a true anatomical layer. Below this they represent bands about half an inch wide, situated on the median line, and covering the accelerator muscle. They are formed of white muscular fibres. The blood-vessels and nerves of this region, with the other parts pertaining to the anatomy of the urethra, have already been considered. The pecuharity that belongs to the penis of ruminants must not be overlooked, when the question of urethrotomy in these animals is under discussion. Their penis is very long and thin, and is surrounded in the perineal region by a complete aponeurotic sheath, and on a level with the pubis it has two curvatures, which give to the organ the form of an S. On a level with the second curvature it gives attachment to the suspensory ligaments. The free portion of the organ is elongated, strongly filiform, and covered by a fine, rosy mucous membrane. The pecuharities possessed by the penis of the horse do not exist in cattle. The operation of urethrotomy is classified and designated with reference to the part of the urethra, which is to be divided, and this is of course determined by the location of the body to be re- moved, making the designations principally regional; and it is URETHROTOMY. 561 therefore said that the operation can be performed in three ways, though three places woukl be the more accurate phrase. Thus we have first, the incision at the point of the penis, or preputial urethrotomy y second, the division in the scrotal region, or scrotal urethrotomy ; and third, the incision below the anus, or ischial urethrotomy. Preputial ITeethrotomy. In horses and dogs the urethra becomes more or less con- tracted toward the full extremity of the penis, and calculi are therefore apt to become arrested in that locality ; in other cases, masses of sebaceous matter will collect in the navicular fossa. In. sheep, saline concretions are found, either in the prepuce or in the urethra. All these conditions involve a contingency of sui'gical interference. To remove them in the horse and in dogs, a trans- verse incision is made with a bistoiu-y over the sj)ot where the presence of the foreign body is detected, and it is readily disposed of. If the erratic substance is in the urethra, an incision is made through its membranes and it is removed in entirety, or sometimes after having been reduced to fragments by means of a probe or of a curator. In sheep, the simple amputation is recommended by some. The wound made in these cases heals without trouble. ScROTAI, UflETHROTO^rr. Scrotal urethrotomy ean be performed either on the front or behind the testicles. In cattle it is ordinarily jDosteriorly that the calculus is lodged, more commonly in the second than in the first curvature, and hence the indication for selecting this place for the operation. Yet there are practitioners who prefer the anterior sec- tion, because the penis being more superficial at that place, there is less cellular and adipose tissue to be divided before exposing it. In either case, the animal is thrown, with the hind leg carried forward and secm-ed as for castration. If the operation is to be performed "behind the testicular mass, an incision is made on the median line, measuring about three inches in length, the cellular tissue divided with the knife or the finger and the penis drawn out through the incision. The calculus is extracted through a longitudinal incision. The canal should then be examined with a probe or bougie, to ascertain whether any more ofi'ending bodies are present, and if so, they are of course also removed. The 5G2 OPERATIONS ON THE GENITO-URINAKY APPARATUS. wound may be either closed by sutures, or, preferably, left without interference, to obviate the possible danger of the formation of future scrotal abscesses. In the pre-scrotal operation, the hair is first clij:)ped short, and an incision made through a transverse fold of the skin, to expose the penis. The concluding steps are the same as those in the former case. It is, however, always advisable, when the animal is secured, and before dividing the tissues, to insert the hand into the pre- puce to draw out the organ. By thus straightening it and remov- ing the S curvature, it is possible, and sometimes occurs, that calculi are displaced and extracted without the necessity of resort- ing to the knife. The urinary fistiJas which are among the sequelae of scrotal urethrotomy, are of two or three weeks' duration, seldom continu- ing longer. Care must be taken to protect the skin from the irritation produced by the dripping of the urine through the wound. Ischial Urethrotomy. This is the most common of the three operations, and is aj^pli- cable to all males. It is performed without casting, with the animal hobbled on both hind legs and a twitch on his lip. (Fig. 470.) The decubi- tal position is seldom required. The free use of cocaine has enabled us to operate without any means of restraint, not only in horses, but in camels, which are very awkward and uneasy animals at the best, and especially when in the hands and under the knife of the surgeon. The insertion of a catheter has been recom- mended by many, to serve as a guide to the dissection of the urethra, while others prefer the artificial dilatation of the canal by the injection of water. In some cases, however, neither of these expedients is necessary. The presence of the calculus and the dilatation of the urethra above it, by the confined urine, greatly assists in the location and puncture of the canal. The incision must be made on the main line, on a level with the ischiatic arch. The structures to be divided are first, the skin, then the subcutaneous cellular tissue, the aponeurotic layers, and the accelator urinse; which being completed, a straight puncture can be made in the urethra between the two suspen- sory ligaments. The incision is then extended upward or down- URETHKOTOMT. 563 Fig. 470.— Secure for Ischial Uretlirotomy. ward, as may be required, with the bistoury, guided by the grooved director, a blunt bistoury being sometimes chosen from the motive of prudence, in order to avoid possible injiu'y to the svuTOunding blood vessels. In our experience we have secured very satisfactory results by adopting the method recommended by Bouley, of making one comprehensive puncture, which penetrates the canal without any preliminary dissection of the incumbent parts, especially when a catheter has been placed in the urethra for the guidance of the knife. The hemorrhage, which generally accompanies this mode of operation is of no great importance, often subsiding of itself, and seldom requiring external hemostatic appUcations. We believe it to be the better course, when the object in view has been realized, to leave the wound to itself, without interfering with the healing process by seeking to facilitate it by the applica- tion of sutures. It gradually granulates and closes without any special care beyond the observance of cleanliness and the neces- sary measures to prevent irritation of the skin from the contact of the urine as it "leaks " through the wound. When the urethra has been opened, in whatever region of the penis the offending foreign body may be lodged, it is readily 56i OPEKATIUNS ON THE GENITO-UKINAKY APPAKATUS. ©\ Straight. Curved. Figs. 471, 472.— Forceps to remove Foreign Bodies from the Bladder. extracted witli straight or curve forceps. These can also be em- ployed to secure those of comparatively small size that may be found in the bladder, and answer very well hkewise for those masses of a sedimentary nature that are commonly seen in mares. There may sometime be some peculiar pathological conditions which render it necessary to prevent the closing of the wound in cases of ischial urethrotomy, and when the formation of a perma- nent artifical opening should, perhap, be attemjDted. The entire closing of the urethra, in its anterior portion, re- UKETHKOTOMY. 565 suiting from some special trauma- tism would be such a case ; or again, when the formation of calcuh has become an established constitutional habit, and the results of this perver- sion of the nutritive and assimilative function are always present and con- tinually renewed. In view of this unfortunate state of things, and to prevent the closing of the wound, Troeber recommends the use of a peculiar tube, which, when intro- duced into the urethra can be per- manently retained in place for an indefinite length of time (Fig. 473). We have attempted the formation of an artificial urethral opening, by tsevidng together the mucous mem- brane of the canal and the skin, but the results of the experiment were of the most transient character. Fig. 473.— Tube of Troeber, for IscWal Urethrotomy in Bovines. CYSTOTOMY. Improperly known also as lithotomy, is an operation which consists in the incision of the neck of the bladder to remove cal- culi of dimensions too great for removal intact through the urethra. This operation has no longer a place in our surgery, and, in fact, there is no existing reason for its performance. If a calculus is of small or of medium size the neck of the bladder can always be sufficiently dilated to permit its passage, and if it should be of greater dimensions, and rendered impossible of ex- traction by its size, the operation of Hthotrity is always available, and in experienced hands as nearly certain and safe as can reason- ably be expected. LITHOTKITY. This term designates the operation of crushing, or piercing, or drilling stones in the bladder, in order to reduce them to frag- ments, preparatory to their removal by means of forcej)s or cur- ates, or by washing them out of the bladder with water. It mostly corresponds with, or rather, includes the lithotomy of 566 OPERATIONS ON THE GENITO-URINARY APPARATUS. Fig. 474.— Lithotritor of Guillon. human surgery. It was per- formed for the first time by H. Bouley in 1858, with the assistance of a practitioner of human sui'gery, Dr. Guil- lon. Horses are more specially the subjects of this opera- tion in cases when the cal- culi are too bulky and too hard to be broken and re- moved with the forceps alone. In ruminants, on the contrary, vesical calculi, though more common, and more numerous in single animals, are generally of sufficiently small size to permit the relief of the pa- tient by the simj)le opera- tion of lu-ethrotomy. The instruments neces- sary for this operation are the lithotritor, or lithoii- triptor, with also the crush- ing forceps. The lithotri- tor of Guillon (I'ig. 474), or the crushing forceps of Bouley (Fig, 475), are those generally used. We are con- vinced by our experience of these instruments that the -. principal, and probably the only objection that applies to them lies against their mechanical construction. We consider them to be too clumsy, too large and too heavy; objections, however, which are very easily obvi- LITHOTRITY. 567 ated by any competent instru- ment-maker. While tliey must necessa- rily possess sufficient power to crush the calculi, we fail to see that a proper attention to the features of symmetry, finish, and convenience of manipula^ tion can involve any sacrifice of efficiency. The instrument can be made to possess ample strength, while still more easy to handle when introduced in- to the bladder through the com- paratively small opening of is- chial urethrotomy. A bivalve speculum (Fig. 476) to dilate the wound of the Tirethra is sometimes of great value. A large syringe, and plenty of water, or what is better, an irrigator for douches to wash out the bladder, will complete the series of neces- sary instruments. The opera- tion is performed Avith the ani- mal in the standing position, secured as for urethrotomy, or cast if the operator so prefer it, and placed under the influ- ence of general anesthesia. "We borrow from H. Bou- ^^^- 475.— Crushing Forceps of Bouley. ley, the father of the operation, his own description of the modus operandi : Access to the bladder having been obtained by the process akeady described, the essential operation is divided into three principal steps : 1st. The introduction of the Hthotritor, and searching for and grasping the stone ; 2d, crushing of the calculus ; 3d, removal of the fragments. 568 OPERATIONS ON THE GENITO-UEINARY APPARATUS. FIG 476.— Bivalve Speculum. 1st. Introduction of the instrument for searching and grasp- ing the stone. — This step varies with the instrument, as to whether the lithotritor or the crushing forceps is used. If the first, the instrument, well greased and kept closed, is inserted through the urethral incision, with its concavity resting on the convexity of the ischial arch, and is pushed obliquely forward and downward through the pelvic portion of the urethra and the neck of the bladder. When in this ca^aty the branches of the instrument axe opened, and by a sHght and slow movement made to traverse the cystic space until it comes in contact with the calculus, which then drops into the hollow of the branch adopted by its shallow form to receive it. The jaws of the instrument are then brought to- gether and the stone firmly secured. The same description, in every particular, applies to the ma- nipulation of the crushing forcejDS. In some cases, however, it is necessary to disarticulate the in- struments, and to introduce the branches separately, uniting them when both have been inserted. It is important, in every case, to leave a small portion of urine in the bladder to facilitate the movement of the stone and aid in its seizure without grasping and pinching the lining membrane of the organ. If the bladder is empty a portion of water might be injected. 2d. Crushing of the Stone. — This is done by slowly approxi- mating the jaws of the instrument. It is not necessary to reduce the stone to very minute particles. It will be sufficient if their dimensions are not too great to permit their free escape through the urethral passage. In removing the instrument after accomplishing the crushing, a great deal of the comminixted calculus is extracted between its jaws. 3d. Removal of the Fragments. — Dilating the urethral wound LITHOTKITY. 5G9 with the bivalve siDeculum, a stream of water is then thrown into the bhidder, either with the syringe or the tube of the irrigator. The water ought to be tepid and antiseptic ; and a hand intro- duced into the rectum and manipulating the bladder, will facili- tate the repulsion of the larger fragments, and the washing out of the smaller. The general attention requh'ed in all cases of serious operations will be necessary after the performance of lithotrity. In respect to any special dressing, they are the same as those in- dicated in simple urethi-otomy. Serious, however, as this operation is, it is comparatively free from dangerous sequelse. Hemorrhages of easy control have been met, urinary abscesses, with infiltration, have occiuTed, serious woimds of the ui'ethra, of the rectum and of the bladder may also happen, but they are of rare occurrence, and can be avoided by careful manipulation through all the steps of the operation. AMPUTATION OF THE PENIS. This oj^eration is indicated in the horse when the penis becomes the seat of warty growths; of epithelial, papillomatous, or can- cerous degenerations ; of fracture ; of paraphymosis, or of paraly- sis. Warty growths are usually found covering more or less the free part of the penis; or its free extremity; or the glans penis; and are also sometimes met with on the inside of the sheath, their presence being accompanied with an offensive and very irritating sebaceous discharge, becoming at times so painful as to interfere with mictiu-ition. They resist the severest forms of treatment, and it is not unusual for them to develop into forms of a more alarming nature, notably those of chancroid degeneration, of which, in fact, these epithihal growths are but the seminal origin. In other cases the erectile tissue of the glans penis becomes the seat of ulceration, extending in depth, spreading in such a manner over the penis that the free portion of the organ becomes a mere mass of bleeding surface, of u-regular aspect, macerating in the pus which abiuidantly forms, and which escapes with its pecuharity of bloody saniousity, with the most repulsive odor and irritating effect, rendering the act of micturition most painful and difficult. In many instances the animal so dreads to bring his penis out of the sheath that he urinates within the cavity formed by the folds of the skin, adding another soiu'ce of u'ritation to that already 570 OPERATIONS ON THE GENITOURINARY APPARATUS. existing. And if the penis is still allowed to pass out of the sheath, the micturition is made with a crooked stream, which in- stead of escaping forward is, on the contrary, discharged back- ward. In such a case no treatment will reheve the difficulty but the removal of the entire diseased structure. In fractures of the penis ; in many conditions of paraphymosis ; or in those of paralysis, the organ hangs suspended outside of the sheath, and cannot be restored to its cavity. If pushed back it soon returns to its abnormal condition, and even if retained by artificial means, will continue in place only while the means are continued to enforce it, becoming displaced again whenever the restraining agency ceases to operate. This serves to render the animal useless, in consequence of its appearance being so repul- sive as to preclude his employment in pubHc view. Of course the only radical cure for such an ailment is the knife or its equivalent. The operation usually consists in the removal of the free por- tion of the penis, the necessity for going beyond this seldom occurring, yet in order to reach the diseased part it is sometimes necessary to divide the sheath along the median line. The general anatomy of the organ, as far as it relates to the operation, is very simple. The penis it formed by the corpus Fig. 477.— Penis in Normal Condition. cavernosum, a long, erectile structure, flattened from side to side, and grooved on its inferior border for the reception of the corpus spongiosum urethrse. Terminated inferiorly by a blunt point, this corpus cavernosum dips into the erectile tissue of the lu-ethi'a. After passing out of the pelvic cavity, by the ischial arch, the spongious portion of this canal, is received into the groove of the corpus cavernosum, at the anterior part, and also extends beyond it. The mucous membrane is covered externally by the tissue AMPUTATION OF THE PENIS. 571 which gives to this part of the urethra its name, and this erectile tissue terminates anteriorly in an enlargement, more or less developed, forming the head of the penis, or the glans penis. The urethra proper protrudes a Httle below the center of the head of the penis, and shows in a cavity underneath, the urethral fossa, more or less filled with a sebaceous secretion. The blood vessels which ramify in these erectile structures are the two dor- sal arteries of the penis, anterior and posterior, and the veins, which form large branches, running also upon the dorsal border of the organ. Zundel very wisely insists upon two principal conditions (to which we shall again refer) to reaUze in the operation, y^rs^ to manage to leave a free means of exit for the urine, by cutting away less of the urethra than that of the cavernous body, and second, to avoid the hemorrhage, which is especially liable to take place in horses, on account of the abundant circulation in the erectile tissues. The animal if to be placed in the recvunbent position, as in the operation for castration, that is, on the left side ; or it may prove advantageous to place him on his back. Five modes of operation are described by different writers on the subject — 1st, the ligature; 2d, cauterization; 3d, excision; 4th, by scraping; and 5th, by crushing. As an adjunct to the various instruments which these different operations may require, metalHc catheters are also necessary. 7V?e Ligatwe. — The catheter being introduced into the urethra, beyond the point where the amputation is to be made, a strong ligatiu'e is appUed at that point and tightened sufficiently, if pos- sible, to strangulate the portion of the penis which is to be removed. After from twenty-four to forty-eight hours, the external layers of the tissues will have become mortified, even to a certain depth in the penis, and a new ligatui-e is then appUed, and strongly tied like the first one. The deeper layers of the penis are also, after a day or two longer, so mortified that they continue attached to the tissues above the Hgature only by a small particle, which can be divided with the knife. The catheter may then be removed or it may be allowed to remain in place a few days longer. No special subsequent treatment is requii'ed. If, after a few days, micturation seems to become difficult, the urethral opening may be enlarged by the introduction of a bougie 672 OPERATIONS ON THE GENITO-URINARY APPARATUS. or a catheter, or again enlarged by an incision with the bistoury. Instead of the ordinary string, an elastic ligature may be sub- stituted with the advantage of maintaining an uninteiTupted pres- sure upon the tissues up to the moment when mortification is established in the part to be amputated. Cauterization. — No catheter is required with this plan. Two ligatures are applied, one anterior, by which the penis is kept out of its sheath, and one posterior, acting as a hemostatic, placed above the point where the division is to be made. The operator then with a flat and sharp cautery, heated to white heat, makes a complete section of the penis. But, says Zundel, " as the urethra is especially dehcate and sensitive, it is better, in order to avoid its retraction, to separate it from the cavernous body about half an inch in front of the place where the section is made." A hollow bougie of india rubber inserted into the urethra will also j^revent its contraction. Professor Nocard has recommended the use of the galvano- cautery, to obtain an easier division of the tissues, a more perfect hemostatis and to shorten the duration of the operation. Excision. — After introducing a metallic catheter, a rapid sec- tion of the organ is made by a single stroke of the knife. Again, says Zundel, " when the urethra is reached, it must be dissected a little forward, toward the glans penis, and caused to protrude about half an inch beyond the point cauterized." Scraping of the penis. — This method, which was put in prac- tice in 1829 by Moiroud and Delafond, consists in scraping the penis with a bistoury, in such a way that the remaining portion of the organ forms a cone, with its apex formed by the urethra. A catheter may be introduced into the canal previous to the opera- tion and left in place for awhile ; or again, it may, if thought proper, be entirely dispensed with. This mode precludes the danger of hemorrhage. Crushing. — By operating with the ecraseur, the amputation is perfected without danger of hemorrhage. The chain of the instrument is applied at the point of amputation, and by slow and gradual action, cuts through the tissues until the diseased part drops off. The danger attending this method is that the chain may break during the process, in consequence of the resistance of the cavernous tissue. This accident has certainly been encoun- tered by many practitioners, and we have ourselves witnessed it AMPUTATION OF THE PENIS.. 573 in two instances. On one occasion it was found necessary to re- place the chain twice, and to complete the amputation with the knife. Reynal has modified the crushing operation by making the action of the ecraseur slower. He has invented a small instru- ment (ecraseur) which is left in place for two or three days, being tightened every day, or several times a day, until the mortification is complete, and the diseased penis sloughs off. In this method, a metallic catheter is placed in the urethra ; in the other the catheter is not required. In reflecting upon the various modes of operation we have thus described, and noting especially the two very important, and indeed, essential requirements referred to by Zundel, in respect to the matters of micturition and hemorrhage, we are struck with the fact that in none of those methods are these obvious require- ments complied with, or if they are, it is in a manner so faintly impHed, and so indefinite and unsatisfactory as to be scarcely intelhgible, and certainly to leave no distinct impression on the mind, of the importance of the points referred to. In every case the danger of possible subsequent interference with micturition is threatened, whether the catheter is used during or after the operation, or even, we fear, if left in the passage " at least two months," as recommended by Peuch and Toussaint. We can remember cases of our own which, with even a longer retention of the catheter, were followed by failure. We have attempted the formation of an artificial urethral opening below the ischial arch, and with no better result. We are tempted to believe that the hemorrhage is less danger- ous than many think, and we believe it could be controlled by ordinary pressure, or by plugging the sheath afterward, or by stUl other means of hemostasia. Taking all this into consideration, we cannot but think strange of it, that the process used in human surgery, which we find merely mentioned in some European works, but which we beheve has been performed by Gerlach, and which we ourselves adopted more than fifteen years ago, should be practically ignored or rejected by writers as well as practitioners. We have practiced it during the pei'iod mentioned without having encountered the shghtest compHcation or troublesome sequelae. We refer to it as the only safe, and as, therefore, the best mode 574 OPERATIONS ON THE GENITO-URINARY APPARATUS. of operation for the amputation of the penis. It differs from any that have been previously recommended, and is as follows : The animal being prepared for the operation in the ordinary way, the penis is secured with a ligature at its end and drawn out of the sheath, and another ligature tightly applied on the upper part of the organ. An incision of the skin covering the penis is made entirely around the organ and down to the cavern- ous body, with the j)recaution of drawing the skin slightly back- ward, so that when the amj^utation is completed, and the skin allowed to retm'n to its position, it will sHghtly overlap the stump of the penis. We divide the cavernous body, carefully avoiding injury to the urethra, and when this organ is reached it is dissected from its groove forward into the cavernous body (Figure 477a) for a PlO. 477l(intar cushion, chronic podoparenchyderm,itis (Mercier), and epithelioma of the frog (Fuchs). None of these has ever been accepted, and the old hippiatric name has been retained. History. — It is conceded that the old veterinarians were ac- quainted with canker, and Vegetius evidently speaks of it, but not untn the time of Solleysel do we find a description somewhat complete of the disease and its treatment ; Garsault, La Gueri- niere, Weyrother and others spoke of it, and have expressed various opinions as to its etiology, and especially as to its treat- ment. So little progress was discernible in the writings of Bour- gelat, Chabert, Huzard and Girard, on that very question, and so many false ideas were admitted, that Chabert in despair has called canker the opprohrium of veterinary medicine. It is but recently that serious research as to the nature of the disease have thrown some Hght on the question, and estab- lished the important fact that its seat is not in the disorganized horn, but in the secreting organs, and that there is an alteration va. the products of this secretion ; that it is consequently to these that remedies must be appHed. We might refer to the writings of Jeannie, Crepia, Hurtrel d'Arboval, Prevost, Mercier, Plasse, Percivall, Dietrichs, Eichbaum, Wells, H. Boidey, Rejoial, Haubner, Fuchs, Bey, Megnin, etc., each of whom has furnished his contingent, whUe still the inti- mate nature of the disease remains but imperfectly known, and there is but little certainty either in the treatment or its results. Let us observe, however, that in our day canker has become comparatively a rare disease, especially in cities, which, doubtless, is because of the cleanliness of the streets. In the beginning of this century, canker and grease — closely related diseases — were frequent in Paris; then horses were obhged to travel through deep gutters of mud, while to-day these affections are exceptional occurrences (H. Bouley). The same thing has been observed by Percival in England. When hygienic precautions were not as well understood as they are to-day, in establishments employ- DISEASES. 593 iBg large numbers of horses, wlien the stables of mail and stage coaches, and even those of military garrisons, were small, ill-venti- lated and dirty, among horses standing in filth and soiled manure, these afi"ections were relatively common ; with hygienic improve- ments, they have almost disapjieared. In the army, canker was the cause of considerable annual loss, almost as serious as those from glanders ; to-day it is rare and almost rmknown. Improvements in the different breeds of horses, either by bet- ter choice of reproducers, or by changes in the mode of feeding, resulting from the progress of agricultural processes, the suppres- sion of common pastures, etc., have contributed to render the disease less common. Symjytoms. — It is seldom that the symptoms of canker can be observed from the start ; slow in its progress, and not surexciting the sensibility of the parts, the disease may progress without manifesting any ill effects, and consequently escape notice by the owner or groom, nothing appearing to call his attention to the affected foot. Thus, in a majority of cases canker is only dis- covered after it has been in existence for a considerable period, and when serious alterations have already taken place. It is often at the shoeing shop, when the shoes are changed, that in the laminae is observed a moisture more or less abundant, giving rise to softening and raising of the hoof. The disease sometimes attacks only one foot, often several feet at a time ; at times when one foot is cured, another becomes affected, and the disease thus appears traveling alternately from one foot to another. Usually the disease begins with the inflamation of the kerato- genous membrane which covers the median lacunae of the plantar cushion ; the hoof covering this is softened, raised by a serous moisture, and once loose, is not renewed, the tissue producing it ha\Tng lost its function of secreting the horny substance, and now secreting a serous element, which becomes the caseous matter of which we shall speak hereafter. Sometimes the disease begins by moisture in the hollow of the coronet, by a kind of grease, a disease which we shall see to be of the same nature as canker. The is an oedematous swelling, warm, somewhat painful, of the phalangeal region, first serous, then be- coming opalescent, which seems to filtrate through the softened, but not yet raised, epidermis. This inflammation, spreading little by little toward the hoof, extends to the plantar keratogenous 594 OPEKATIONS ON THE FOOT. membrane, and gives rise to an exhalation of the same nature as that of the skin which produces the separation of the hoof, and the first marks of canker. Sometimes one may observe at once, a fungoid growth of ficus, formed by an hypertrophy of the tissues underneatli ; this growth is more or less moist and offensive, bleeding easily, having the aspect of cauliflowers, and protruding through a break of the softened hoof, and forming a thready detritus to be subsequently studied. Commonly, the hoof is more or less loose, and under it is a caseous matter, greasy, ordinarily of a foetid odor, easily re- moved by scraping, being non-adherent to the tissue which secretes it. If the parts are well cleaned from this, the velvety tissue of the pyramidal body of the frog, appears to be covered with a smooth membrane of a slight whitish color ; the external layer then appears formed by a pellucid epidermic covering, show- ing through its transparency the purplish color of the capillaries underneath. The velvety tissue is diseased, but still retains its functions, which, on the contrary, are increased but pervei-ted, and instead of secreting a horny substance which adheres to the surface of tbe keratogenous membrane, produces the caseous mat- ter already referred to. The break in the hoof frequently seems small in size. Nevertheless, the altei-ation of the keratogenous tissues, viz : the substitution for its normal, of a pathological se- cretion, whose product is this loose caseous matter, is far ad- vanced. There is then an extensive, though a concealed separa^ tion of the hoof. One then must not allow himself to be deceived into supposing it to be a limited diseased process, by the apparent external integrity of the horny box. The characteristic of canker is its tendency to spread, like can- cerous affections. Once manifested in any part of the sub-horny tissues, the special changes which characterize the disease seldom remain circumscribed; on the contrary, they generally extend from that part as a centre, throughout the whole circumference, and little by little, attack slowly but continuously the whole ex- tent of the secreting apparsitus, and thus loosen the entire horny l30x — starting from the median lacunae, or the glomes of the frog, it extends to the branches and the body of the plantar cushion ; then spreads at the side, in the lateral laminse, from there all round on the velvety tissue, then by degrees reaches the inferior ex- tremity of the podophyllous laminee and going upward, reaches DISEASES. 595 the coronary band, the last point, where, in extreme cases, the hoof i^reserves its adhesions with the tissues which form it. In this condition the disease process progresses more slowly than be- tween the sole and the velvety tissue, and then it seems to remain stationary ; otherwise the di'opping of the hoof would be possible. We have seen that often at the beginning, but especially as the disease progresses, there are growths called fici, found principally round the laminae, the frog and the sole. These are of whitish color, opal, varying in size and in shape ; they constitute an irregular mass, formed of those fici pressed together ; some of these growths have a wide basis, others are somewhat peduncu- lated ; sometimes they are single, tubercular, slightly elevated ; at other times elongated bodies, true fibrous bundles. The fici are nothing more than the normal villosities of the keratogenous tissue which have become tumefied and hyj)ertrophied, and are found principally where, in the normal state, the villosities of the velvety tissue are themselves more numerous and more developed. Where these vegetations are confluent, as upon the sharp edge of the bone, they are separated from each other by a kind of deej) sinu- ous grooves, filled with the caseous matter secreted by the diseased keratogenous structure. These growths bleed easily and grow rapidly again when excised. Those most developed, and which seemed to form a homogeneous mass, constitute, however, an aggregate of smaller vegetations united in a certain part of their extent, and continued at their bases. Besides the vegetation of the living tissues, the plantar sur- face of the foot presents, in old cankers, isolated fasciculi of soHd homy substance, of thready appearance, soft, analogous in their form to coarse brushes whose hairs are glued together. These isolated, still adherent, brushes are seen spreading toward the sole ; they correspond with parts of the velvety tissue which have maintained their soundness in the midst of the diseased surface, and there continue to secrete healthy hoof. These homy growths are ordinarily mvJtiple, and are of various shapes, often twisted, and give to the plantar surface a pecuHar aspect, so much so, that their brushy masses sometimes retain the mud of the streets and are filled at their bases with a black and fcetid substance of an ugly appearance. When canker has amved at a very advanced period, it is char- acterized by the deformity of the whole horny box, whose length 596 OPERATIONS ON THE FOOT. and -width is considerably increased. The last of these conditions is a sure sign that the disease has spread under the wall of the quarters and of the heels, and has produced the complete separa- tion of the bars from above and below. "\Mien percussed, the hoof at the heels gives a dull sound. The excessive length is only an indirect consequence of the disease, and is due to the fact that, so as to keep the animal at work, the walls are spared as much as possible by the blacksmith, so as to avoid the contact of the protrudmg parts with the ground. Physiological signs are almost entirely absent in canker. It is a ciuious fact that the sensibihty which is generally highly in- creased in all affections of the foot, even in chronic diseases, re- mains always so obscure in canker that animals may be used for a long time without lameness, though the sub-homy tissues have become quite unprotected over a large surface. ComjMcations. — Very frequently, canker is complicated by a disease of the skin, analogous to it, known as grease / a disease which, if not entirely of the same nature, as admitted by Plasse, Megnin, etc., is closely related to it. It is often through this that canker begins, and very often the two diseases exist together in the same animal, one sometimes following the other, just as canker of one foot follows that of another. Among the complications of canker, as generally admitted, are some injiu'ies of the plantar cushion : inflammation and necrosis of cartileges, ligaments or tendons, and even caries of the os pedis and anchylosis, which are sometimes observed ; however, a close examination of the facts allows us to say that these accidents do not arise under the simple influence of the disease alone, but that they are due to the improj^er use of sharp instruments, of the actual cautery, and especially of potential caustics. As La Gueri- niere said, the deep lesions of tendons and of the os pedis, which are observed in severe cankers, have no other cause than the action of too powerful dessicatives. Duration, marcJi, termination. — Canker is an essentially chronic disease, and may be of long continuance, even lasting for years. Stni, under this heading there are many variations, whose cause it is difficult to find. There are horses whose disorganization of the hoof is complete after two or three months. There are others where the disease remains stationary for more than a year. We have seen it remaining limited to one lacuna for months, and all DISEASES. 597 at once assume a rapid evolution of disorganization. We have noticed this principally after the use of sharp instrviments. Generally, animals affected with canker feed well, and for a long time retain a good condition ; toward the end, however, they lose flesh and exhibit symptoms of septicohemia, especially if affected with grease. We do not admit that, as advanced by some, canker can give rise to such virulent diseases as glanders and farcy. Diagnosis. — At the beginning, canker may be confounded with thrushes, and many veterinarians have considered this as the first stage of canker. There is, however, a great difference be- tween the two : first, as to the anatomo-pathological point of view, inasmuch as the pultaceous, foetid secretion is less abiind- ant ; that the loosening of the hoof is less, and that there are no fici ; and again, especially in the point of view of the treatment, where single cases of cleansing, with or without dessicatives, easily control it, while canker remains rebeUious to them. I^rognosis. — The prognosis varies. Where the animal is young, well fed, and the disease is not too old, it is favorable. Yet it remains uncertain, as often the most benign form may last long and remain rebellious to all treatment. The severity and the extent of the internal lesions cannot be estimated by the altera- tions or deformities of the hoof, as these appearances are often decejDtive. Canker, though considered incurable for a long time, is not absolutely so — far from it ; with rational treatment, prop- erly carried on, it is curable in the majority of cases. There are cases, however, not very rare, where relapses and useless attempts have discouraged the owner as well as the veterinarian, and where it has been more advantageous to destroy the animal rather than to submit him to a long, tiresome, and always exj)ensive treat- ment. Pathological Anatomy and Nature of the Disease. — It has always been considered that a morbid condition susceptible of producing disorders so severe as those produced by canker, must necessarily be a deep affection, essential and important to the organic structure, and depending on a complete transformation in its texture. And, indeed, it is the impression which predominated from the time of Solleysel down to the foundation of veterinary schools and which still exists with Girard, who considers canker as a gnawing ulcer which changes and alters the tissues it invades, 598 • OPERATIONS ON THE FOOT. and even with Yatel and Hurtrel d'Arboval, who looks upon canter as the carcinoma of the reticular structure of the foot. It is but recently that these ideas have been abandoned. Du- puy, in 1827, considered canker as a hypertrophy of the fibres of the hoof, admitting at the same time the disintegrations and softening of those same fibres occasioned by an ammoniacal sap- oni^ation produced by an altered secretion. In 1841, Mercier expressed the opinion that canker is nothing more than a chronic inflammation of the reticular tissue of the foot, characterized by diseased secretions of this apparatus. It is now known that there is in canker no essential alterations of the sub-horny tissues ; no radical change of theii* substance, and no deposit of heteromorphous molecules in their structure. This last mentioned fact was well observed by Robin, who in his microscopical remarks constantly observed the absence of the characterizing elements of canker. Hertwig and Haubner, who have made researches in the same direction, arrived at the same resiilt and have noticed the absence of any cancerous cells in canker. This opinion is, however, doubted by GHsberg and Fuchs, who look upon canker as an epithelioma, though they bring no sufficient evidence to establish it. Except vegetal parasitism, of which we wiU speak hereafter, and which makes of canker a true dartre, an herpetic disease, as demonstrated by Megnin, there is only in canker a chronic in- flammatory condition of the sub-horny tissues which is mani- fested by a perversion in their secretion, and is complicated by a morbid hj^DertroiDhy of the villous processes by which theu' sur- face is normally covered. Robin has seen in the fici, papillse made thicker and more brittle by the plastic infiltration which moistens them ; he has observed besides, that at the points where the secre- tion is good, it is so active, that instead of drying in sheaths, to scale off afterward in transverse pieces, as normally occurs in the frog and sole, the epithelial cells grow lengthwise, as those which form the walls of the foot. Hence these long, horned, twisted threads (epithelioma t) which are seen rising from the sole of long affected cankerous feet. It has sometimes been admitted that fici had deep roots in the tissues, and even in the plantar aj^oneurosis, which is an error ; injections and macerations having shown that there are no essen- tial changes in the anatomical structiu'es of these parts, and that DISEASES. 599 what have been considered as the roots of fici were only celhilar tissues, which has become indurated under chronic inflammation (Bouley). Fici are only fasciculi of villosities whose vascular net- work is no longer retained by the thick horny box which encloses them and which is infiltrated with plastic material. Bouley has already admitted that canker could not be better classified than among skin diseases, with and after dartroid aifec- tions, and thus gave reason to Huzard senior ; Plass also found that canker had the greatest analogy with grease, and that in it the nutrition of the horn underwent the same alteration with nu- trition of hairs in the second affection. Megnin, in 1864, observed, in operating upon fresh pieces taken from the living animal, and from one which had not received any treatment, that in canker there is constantly a cryptogam, as in favus, and that canker is a parasitic affection. Examining the caseous product of the abnormal secretion which charactei-izes canker, Megnin found in it a large quantity of very animated vibrios, swimming in a Hquid having in suspension nu- merous epidermic cells more or less advanced in dissolution ; he found besides rounded corpuscles, which he recognized as the spores of the cryptogam, and from which the vibrios escaped at the maturity of the granulations there contained. In examining the fici, he has recognized them to be an aggregate of hypertrophied villosites, at the base of which were found in the mass obtained by a shght scraping epidermic cells or parts of cells enclosed in a net-work of inter-crossed, ramified threads, appearing to rise from certain centers marked by an agglomeration of spores, forming in their whole a yellow spot. In the water of the microscopic prep- arations, one finds also several of these isolated threads, epithelial cells, globules of lymph, of blood and finally spores ; very rarely vibrios ; oftener micrococci. These threads are nothing more than the parasites, the myceUum product of the vegetation of the spores ; those contained in the serosity, swell, break up, and the granulations which escape from them become for some time the vibrios, or as we prefer to call them, pseudo- vibrios ; as soon as the brownian motion, which for some time animates the granula- tions, ceases, the cells which have proceeded from them (the micro- cooci) gather together in chains and form the characteristic threads of the mycehum. This parasite of canker has been named by Megnin the Tcera- GOO OPEEATIONS ON THE FOOT. phyton or parasitic plant of the horn, by analogy with the tricho- jjhyton, the parasite of the hair. We consider this name very apjDropriate and j^refer it to the name of odium batracosis, parasite of the canker, which Mr. Megnin has also proposed. Etiology. — The causes of canker are yet but little known; there is one, however, which cannot be ignored, and which, if it does not produce the disease, assists materially in its develop- ment and is indisjjensable to its existence. We refer to the con- dition of dampness. It is that influence of dampness which explains why the disease is so very common in the marshy lands of Poitou ; in the pastures of Holland, and in general in low grounds ; and why it is more frequent in northern than in southern coun- tries. Canker is incomparably more frequent in rainy seasons than in those where dryness predominates. We have already seen in the history of the disease that it is since the streets and the stables of administration are kept more free from dampness that canker has become less common. Sometimes the action of direct irritating causes has been admitted, and then the canker has been attributed to irritating muds and the excrementitial liquids of stables ; their contact often giving rise upon the skin, upon the glomes of the frog, to an ery- thematous inflammation, soon followed by a serous flow, which ex- tends to the sub-horny structures and gives rise to an exudation in the laminae of the frog. This cause produces the rotten frog (thrushes) but not canker. We believe that this cause has princi- pally been admitted by veterinarians who look upon thrushes as the first stages of canker, but this is not so, and for canker to develop itself under similar conditions, others are necessary, which are as yet unknown. Canker has also been attributed to narrow and contracted feet, so common in horses of meridional climates, and in which the sole is very concave, with the frog and pyramidal body shrunk in. Often in the laminae of these feet a sero-purulent moisture is dis- covered, more or less ofi'ensive, which is a rotten frog, but not canker, and but seldom followed by it. To produce canker a simple irritation of the sub-horny struct- ure is not sufficient. There must be a special cause, proper to canker, stimulating alone the characteristic changes of the cause. This cause we find in the crj'ptogam which characterizes canker, propagates it, and which has no power of spontaneous existence. DISEASES. 601 As with other j)arasitic diseases, canker is communicable by contagion ; although the examples are quite rare they cannot be doubted. Hutrel, d'Arboval, Plass, Blind and Megnin have ob- served them, and in all the cases dampness has contributed to the propogation of the cryptogam. The lymphatic constitution in an animal is eminently propi- tious to the development of canker, as it is observed to be, in fact, for all parasitic diseases. It is known by daily observation of facts that horses whose skin is thick, with the hairy system well developed, the feet flat, with thick frogs, are more often affected with canker than animals of a nervous constitution. It is more particularly observed in horses with much white at their extremities, with stockings and white feet, and in those where there is a tendency to albinism. An unknown diathesis has also been considered as causing a predisposing constitutional organic condition, but this has not been justified by observation. It may happen that canker cured or dried on one foot, may attack another foot, perhaps a third, and then a fourth, to re-appear in the first ; this character of the disease has often been mentioned as proof of this diathesic condi- tion ; but it may also be explained by its contagious character. The disease remains too much localized to be constitutional, as generally in diathesic diseases we have critical eruptions upon different organs or different tissues. Treatment. — From the preceding remarks, it is evident that in feet affected with canker, the keratogenous apparatus of the foot has undergone no essential alteration in its structure, that its thickness and density have only increased by consequence of the infiltration and organization in its net- work of the plastic products of inflammation. And, again, the secreting function of this appa- ratus, far from being arrested, is on the contrary, more active ; but the products it gives instead of being concrescible, remain difflu- ent ; hence the impossibility for the hoof to be restored in the regions where this alteration of secretion exists and remains. These important facts, says M. Bouley, must take the lead in the chapter of the therapeutics of canker, because they teach the i:)ractitioner that the object to effect, in the treatment of this dis- ease, is not to radically destroy the diseased tissues, as has been too often done and recommended, but to return to them their physical and physiological properties by the application on their 602 OPERATIONS ON THE FOOT. surface, of modifying agents which influence the nutritive and secreting functions of their tissues without interfering with their structure. To reach this point, the most varied pharmaceutical agents have been recommended, the most successful being those which at the same time had parasiticide properties. We, however, find it difficult to give the preference to any of them ; and we have now more faith in the mochis faciendl, to the skill of the operator, to the continued use of dressings properly applied, than to such or such agent ; all of those which have been recommended if methodically apphed, can cure canker, and it will be wise to em- ploy them alternatively ; when one fails at first it is prudent to try another ; canker is a disease so often rebellious to treatment, especially when confined to the lacunse of the frog, that too many remedies cannot be used. The first indication is to remove the excess of the horn of the wall, the length of which, we have said, is often very great ; then prepare a convenient shoe for the dressings. This shoe nec- essarily varies, as canker is exclusively localized to the plantar surface of the foot or extends to the podophyllous laminae. Gen- erally an ordinary shoe is used, more or less covered (wide) and so hoUowed as to allow the free application of plates by which the dressing is kept in place. When the condition of the disease requires the removal of large pieces of horn, a truncated shpper is used, proportioned in cutting to the extent of the parts of the wall upon which it is to be applied. There are cu-cumstances even when shoes cannot be used, so much does the disease extend under the wall. It is then necessary to use a shoe without naUs, or boots, secured to the coronet by means of straps. In all cases the rule is to take care that the dressings remain fixed in the most exact manner, and that through them a methodic, steady, but not excessive pressiu'e is constantly apj)Hed over the diseased parts. The first step of the operation passed, the next consists in the removal with proper instruments of all the loose portions of the horn, either at the plantar surface, at the quarter, or at the heels. One must avoid, in this operation, the excision of soft parts ; but the important indication is to follow the disease where- ever it exists, and to leave no part of the horn which may have been detached by morbid exudations. Better cut the healthy structures, and have them bleed, than to neglect to completely expose a diseased part. This done, the horn is to be thinned as DISEASES. 603 much as possible, upon the cu*cumference of the diseased spots, in order to give a suppleness which would ease the sweUing of the uncovered parts. Upon the exposure of the disease where it exists, the fici exist- ing on the surface and edges of the velvety tissues are to be removed with the scissors or sharp sage knife ; at the same time the parts of horn which may have remained are to be cut off, avoiding, however, the healthy tissue beneath, which still retains its normal character. "WTien the canker is very extensive, so that the wall is loose on each quarter, or on all its circumference, it is of advantage to pro- ceed in the required operations at different times. This done, the shoe can be put on ; after which the diseased surface and surrounding horn are to be covered with a thick layer of the medicamentous preparation. If this is in form of a paste, as is often the case, it is spread over with a spatula. If in powder, it is thrown over it carefully. If Hquid, balls of oakum are soaked with it and placed on, the whole being then kept in place by pads and plates. The important point is that the dressing should be so appUed as to be easily changed, that an exact, regular and sufficiently strong pressure be kept on. No better means can be used for this than the divided plates already referred to. In canker the dressing must be renewed every day, and even twice daily at the beginning of the treatment. This is an essential condition of success, whatever may be the therapeutical agent employed ; and this is not a simple difficulty in practice where the patient is not always of easy access. Moreover, this dressing is somewhat compHcated, and can only be skillfully made by the vet- erinarian himseK. It often occiu's that upon the removal of the first dressing, (the second day) one finds the tissues already covered by a layer of hardened horn, adherent to the surfaces. One must then, with the finger, a spatula, or a dry pad of oakum, rub it off where it is found loose and movable and, if necessary, renew the appHcation of the dressing. The same must be done at the other dressings, carefully watching if this new horn thus formed by the influence of the medication, is not separable from the parts vmderneath by the different morbid secretions of the disease. One must then carefully scrape off all that is not adherent, and thin the edges, and the projections of all the horn which retains its soundness ; 604 OPEKATIONS ON THE FOOT. the caseous substance being also removed ; the same compressive dressing to be put on again. The modification in the horny secretion, and the formation of a layer of hardened and adherent horn, are especially great in the parts where podophyllous and velvety tissues exist ; but are very slow, and surrounded with difficulties in the median and lateral lacunae of the frog. After ten days of treatment, one may have brought about a normal secretion on the whole cu'cumference of the sole, on the inferior face of the os pedis, and on the prominent parts of the pyramidal body. But in the lacunae the alteration remains isolated, and resists treatment ; and it often happens that, if neglected, it may again spread and the disease reach its former extent. It is then the case, when the disease is Umited to the lacunae, to add to the ingredient already in use and which is kept applied upon the restored parts, another stronger and more active agent, sometimes simply absorbent; here again it becomes diffi- cult for us to advise the practitioner, the number of recommended drugs being very large and the result depending less on their nature than in the inteUigent and persisting manner with which it is appHed. "When caustics are used, it must be done with great care, to Umit their action only to the thickness of the keratogen- ous tissue, and not to carry it to the destruction of the bone, or still worse, of the plantar aponeurosis. Let us glance at the drugs which have proved most successful in the treatment of canker : First we have the different pyrogen- ous preparations, especially wood tar, recommended by Bracy, Clark, Eeynal and Bouley, and which give astonishing results. Gas tar, oil of cade, petroleum and soot have also been used, but with less advantage ; creosote and phenic acid have often shown them- selves very useful, by penetrating easier to the base of the villosities where the parasite resides and thus acting more regularly ; phenic acid proved very useful with Krause, Gerlach and Zundel. After these the best recommended preparations are the salts of iron. Hertwig seems to be well pleased with the powder of sul- phate, and Ai-nold recommends the pyi'olignite of the same metal ; Megnin advises specially the perchloride, which, like phenic acid, is rather a powerfvd astringent than a true caustic. The prepar- ations of copper have also had their time, and especially the aceta- tes, such as the cegyptiacum ointment (Girard, Schaack, Eainard and Rey) ; the baths of sulj)hate of cojjper were employed by DISEASES. 605 Verrier, Jr., of Rouen; a solution of sulphate of copper and of zinc in water or \inegar were recommended by Delaval and Haub- ner ; Solleysel employed the prej^arations of copper, but added to them arsenic and other drugs ; Eichbaum preferred the powder of chloride of lime, and Rauch ordinary lime, while Aubry employed a mixture of lime and caustic potash. Caustics were well recommended by other practitioners, but their prescriptions seem to be contraiy to the rule we have laid down in the beginning. However, one must not forget that the tissues of the foot, especially when diseased, offer an extraordinary resistance to the action of caustics ; they are, so to speak, impene- trable, and the irritation they produce remains superficial, while where those tissues are healthy such agents produce a deej) cau- terization. Again, this resisting force of the indurated tissues against the actions of caustics is limited, and it is possible that one, two or three applications may apparently remain inefficacious, where a f oiu'th or a fifth will give rise to extensive cauterization. The result is explained by the repeated ii-ritating influence of the caustic agent, which, by gradually increasing the vascularity of the parts it touches, increases also the means of their absorption and imbibition. These facts must also be present to the practitioners mind, and it is by them that he will be guided in their use, rendering them at will, simply modifying, catheretic, or deep caustics. Nitric acid was used by Percivall and Delorme, the latter con- sidering it the best means in use. Sulphuric acid has also been employed, seldom alone, but mixed with agents likely to reduce its effects and render its applications more convenient. CoUignon and Renault recommend its reduction with alcohol; Mercier mixed it with four parts of oil of turpentine ; Prang6 with equal parts of tar, and Plass made a paste of it "odth btu'nt alum. This last remedy, very simple in its formula, was applied without any dressing ; it has proved most excellent in a great number of cases, but may give rise to too deep cauterization (Bouley, Mendel). Arsenious acid was much used by old horsemen, combined with oegyptiacum, turpentine and other ingredients. Hoffmann prefers the arsenite of soda in solution ; he sold his secret to the Austrian government for a high price. Butter of antimony was recom- mended by Huzard Sr., Prevost, and especially Huzard ; chloride of zinc was preferred at the Lyons school. The treatnxent of canker by actual cauterization was indicated GOG OPERATIONS ON THE FOOT. by Solleysel, but soon abandoned by him. In applying the cau- tery upon the uncovered tissues of the hoof, we encounter the chance of producing a very severe inflammation, which spreads by degrees and gives rise to extensive slough of the hoof, as a con- sequence of the serious exudation which takes place ; the action of the cautery may then become either too mild or too vigorous. Stni, it has been recommended by Prevost, of Geneva. Hiirtrel d'Arboval, who also employed it, used it in the following manner: the parts being covered with a mixture of gunpowder and sulphur, a red-hot iron was applied to the sj^ot, the powder bui-ning sud- denly and the svdphur slowly. If the combustion was too slow, he increased it and kept it up by the same means. ^Tien the ojDeration is concluded the 23art8 are transformed into a black scar, which can be easily removed by scraping, and the application and cauterization may be repeated, and so on until it appears that a sufl&cient amount of heat has penetrated the tissues to destroy the material by which canker may be regenerated. The cauterization being once properly effected, then in order to sustain irritation, the foot is covered with Burgundy pitch, or resin, melted and warm, which is allowed to cool off on the foot, when a dressing of oakum and the shoe are put on. The dressing is changed as soon as suppuration shows itself and renewed with the same ingredients in the same manner until the wound becomes healthy and granu- lating. It is only for the sake of the record that we refer to the ex- clusively surgical treatment, based upon the erroneous idea that the fici of canker are abnormal products, deejily implanted in the tissues beneath, and where it was ad\ised to look for the imagin- ary roots of these fici at their extreme Umits. In this treatment, not only the diseased horn was removed, but the entire sole, the plantar cushion and often the plantar aponeurosis was excised. This practice, advised by Lafosse junior, was also recommended in the veterinary schools by Chabert in France, and Dieterichs in Germany. It prevailed for a long time, though experience showed that the wound resulting fi-om such an operation was of very slow recovery, that the frog especially could not be regenerated, that there remained a central ulcer, and that it gave rise to such a mal- formation of the foot that the animal remained lame for a long time, sometimes for life. Notwithstanding these objections, ob- served by Jeaune, Girard and Eichbaum, this treatment is still DISEASES. 607 followed by a few who prefer it to the simple operations of Solley- sel, which consists in the division of the loose pieces of horn and the excision of the fungoid projections. We have thus far only spoken of the local, without refeiTing to the internal or constitutional treatment of canker, recommended by those who look upon the disease as constitutional. Without beheving that it can have any real curative effect, we, however, admit its usefvdness, when the disease is of old standing, and that the animal has suffered much by it. Ferruginous preparations are specially advisable, and we prefer the carbonates that are used by Delwart to the suI^Dhates recommended by Prevost, Delaval and Hertwig, and it is well to unite them with bitters and tonic powders. Ai'senious acid is prescribed internally by Delaval, Feviillette, Niederberger, Obich ; and other alteratives, such as mercury, which we would not advise. Nor can we understand how any benefit is to be dei-ived from diuretics and purgatives, and especially from the use of external emunctories, such as setons. COKNS. Under this name is understood an alteration of the tissues iinderneath the hoof ; of the heels of the horse's foot by lesions of the h\dng parts in the movements of expansion of the hoof ; by bruises, compressions or contusions. There is then a capillary hemorrhage which extends in ecchymosis in the hoof. A com, then, is a bruise of the Hving horn at the extreme end of the branches of the sole, and especially in the laminated tissue of the folds of the bars. It is a very common disease, and one to which all horses are exposed. Some have them constantly. Corns are seen mostly on the fore feet, and on the inside more commonly than on the external side. They are rare on the hind feet, because in the various gaits the weight of the body is carried more on the front legs and on the posterior part of the foot, while in the hind legs it is the front part which principally receives it. I. Divisions. — Lafosse Sr., has distinguished them into natural and accidental, while Girard considers them all as accidental. H. Bouley designates as essential those which come from other than external causes. We believe that it would be better to estabUsh the divisions on pathological and anatomical bases, and admit a 608 OPERATIONS ON THE FOOT. cor?i of the wall, or laminated, that which has its seat in the laminae which unites the wall to the tissues underneath, viz., in the keraphyllous and podophyllous tissues of the heels and bars, and a corn of the sole, or velvety, that which has its seat in the velvety tissue which unites the sole to the fleshy parts. The laminated corn corresponds exactly to the " natural " of Lafosse and to the " essential " of Bouley. It is due to lacerations in the movements of expansion of a badly-made foot. The other is due to contusions. "WTiatever may be the ado^Dted divisions, we, with Girard, and as admitted in practice, recognize in each category, the dry, the moist and the suppurated corn. II. Etiology. — All feet are exposed, but not all predisposed to corns. They are more frequent in heavy feet, with those where the heels are high or contracted in which there is a motion of re- traction of the hoof which interferes with the displacement back- ward of the third phalanx at the time of rest, and hence the lacera- tions are easy ; besides, there is a continual pressure upon the living parts of the posterior region of the nail. Corns are fre- quently observed in excessively long feet where the hoof does not receive the moisture necessary to its elasticity ; it then losses its suppleness and fails to assist the internal motions of the parts contained within. It is seen whenever the hoof is too dry, the posterior diameter of the feet being then diminished. Corns are seen on weak feet, on which the hoof is too thin to resist the dilating effect of the internal structure, and spreads excessively. Wide and flat feet, with low heels, in which the interior surface of the branches of the sole is on a level with the plantar border of the quarters and bars, are very often affected with corns. The pres- sure of the shoe or the roughness of the ground produce these bruises through the sole. Here the conditions are unfavorable to the normal dilatations of the hoof ; the ungeal phalanx, being unsupported by the convexity of the sole, has a tendency to drop down lower, the tissues are easily lacerated and bruised in its dis- placement at the time the foot rests on the ground. The most senous causes of corns arise from the shoeing, which not only sometimes gives to the hoof a shape predisposing to that disease, but also very often is a determining cause itself of these injuries. " As long," says Hartmann, " as horses will have corns, horse-shoeing cannot pass as an art, and their too frequent pres- ence is an evident proof of our imj)erfect means of protection to DISEASES. 609 the hoof." Without shoeing there would be no corns, and it is in its irrational methods that the true causes of these accidents originate. It is by the greater or less frequency of corns that ojie may judge of the state of that art in a country. The faults are found, 1st, in the manner in which the foot is pared, or in the shape which it receives ; 2d, hi the fitting of the shoe ; 3d, in its appHcation. In paring the foot, the sole is often weakened and thinned too much ; it does not resist the pressure, and, at the time of resting the foot, all the weight of the body is thi'o^^Ti upon the point of union of the sole with the wall. Ordi- narily too much has been cut away from the frog, and this not resting any more on the gi'ound, no longer resists the pressure, and the lowering of the branches of the sole is then extreme, as proved by the expeiiments of Leisering. The custom of cutting the corns, and of cutting the hoof at the heels, acts in a similar manner; the posterior half of the foot is weakened, and that is the part which must carry the greatest part of the weight. One needs only to compare a foot from which the shoer has removed much horn at the sole, frog and bars, with one in which the hoof has been left alone for a long time. In making a vertical and tranverse section of the two in the middle of the frog, a little in front of the angles of the sole, he will see at once how weak the point of reunion of the sole with the waU has become, the means of resistance to the pressure of the weight of the body through the third phalanx being thus diminished, and consequently a pre- disposition to bruises created. The shape of the shoe also contributes to corns ; an excess of concavity ; a shoe which from the last nail-hole is not flat to the heels, whose branches are too much inclined, contributes to the lateral contraction of the foot and gives rise to corns. In this case the shoe resists the play of the horny box, and by itself, through the sole, exercises a great pressure upon the tissues underneath. Too high caulks, in preventing the resting on the frog, cause an excessive pressiu-e on the inside of the foot, and compel it to rest on the heels and the branches of the sole, which are too much lowered. The opposite excess, when the shoe is thin at the heels, as in the Coleman shoe — which is thick at the toe and thin at the heels — produces a similar result, because m increasing the jjres- sure on the heels, it gives rise to bruises of the tissues through the retrossal processes, which comes down too heavily. A very 610 OPEKATIONS ON THE FOOT. wide shoe, too thin, may also contribute to the genesis of corns, because, then, the shoe helping, with the intensity of the reactions on the pavement or on too hard and stony roads, the shoe soon gives under the foot, and compresses the sole and tissues beneath. The manner in which the shoe is j)ut on may also be a cause of corns ; the shoe ought to rest exclusively on the inferior border of the wall, and not touch the sole ; when it is too narrow it may be a cause of contusion or of contraction ; if too wide it prevents the natural expansion. It is upon horses long shod that the wrong apjolication of the shoe as a cause of corns is observed. As a con- sequence of the growth of the hoof, the shoe no longer sufficiently protects the plantar border of the foot, the heels of the shoe being inward and pressing on the bi-anches of the sole ; this is especially the case when the shoe is thinned by wearing ; it yields, and easily bruises the j)arts of the sole on which it rests ; high caulks, on a branch already too short, or too thin, act the more injuriously be- cause, not being concentrated on the projection of the caulk, the branch gives away sooner, and presses still more on the heels. The shoe becomes an indirect cause of corns, when hard sub- stances, as stones or dry earth, are found between its superior and inferior face on the sole, or between the frog and the internal bor- der of the branches of the shoe ; this is a secondary cause, which was formerly considered of great importance. The work of horses has a great influence, corns being very fre- quent in horses which work on pavements and stony and hard roads. They are rare in country horses, but common in those of great cities ; a rapid gait contributes to their development on account of the great pressure on the ground. The seasons have also an influence, dry and warm weather depriving the hoof of its moisture, and by preventing its elasticity of motion, increasing the effect of pressure upon the tissues. Emigration has been considered a cause of corns. Horses coming from the north of Germany are mentioned as having been rapidly affected by them after being in large cities. But if the change too suddenly made from soft to dry bedding is an effective cause, the mode of shoeing can also be considered as a stimulating cause. The same is true with respect to the African horses, which are generally free from the disease in their native country, but frequently suffer with them when brought to France, and submitted to a mode of shoeing so different from that of the Arabs. DISEASES. 611 III. Symptoms. — The ordinary symptoms of corns are noticed in the abnormal position of the leg at rest, in the lameness and the sensibility of the region. When lame with a corn the horse carries the leg forward of the plumb line, and keeps it semi-flexed at the fetlock; he tries to relieve the painful region by resting ; sometimes he manifests his pain by pawing and moving his feet from forward backward, pushing his bed Tinder him. The lameness is not characteristic ; it varies greatly in intensity, from a slight soreness to lameness on three legs. It is generally proportioned to the intensity of the disease. However, there are horses so accustomed to then' corns that they do not go lame, while others are very much so for a trifling injury. Sometimes it is intermittent, and diminishes when the suppuration has made its way between hair and hoof. The sensibility of the heel — seat of a corn — is discovered by an explo- ration with the blacksmith's nippers. Sometimes it is made known by pressure of the fingers, the cases varying, of course, according to the severity of the disease. There is often heat, especially at the coronet, which may be tumified, particularly so when the corn is of a compHcated suppurative character. To obtain an accurate view of the disease the foot should be well pared, and this opera- tion may be greatly facilitated by the application of poultices for twenty-four or forty-eight hours previously. It is only by the objective examination and the j)athological anatomy, so to speak, of the corn that the moist or suppurative variety can be distinguished from the dry, and we shall find either a simple ecchymotic spot, or a complete disintegration of tissues. IV. Pathological Anatomy. — The lesions vary according to the severity of the disease. In dry corn, we find an infiltration of blood in the homy structure. This is blood which has transu- dated through the laminated or irritated velvety tissue from the injured blood vessels. This blood gives to the hoof various tints, more or less pronounced, not unfrequently yellowish, according to the intensity and duration of the disease. The hoof sometimes loses consistency and becomes brittle ; at others, it is hard and dry, and then resembles healthy hoof minus its coloration. If the ecchymotic spot involves the whole thickness of the horn, from its surface to its depth, it is an evidence of the continued activity of the cause. A deep mark indicates a recent injury ; a superficial one is an evidence of an older corn, which disappears, 612 OPERATIONS ON THE FOOT. and then it seldom produces lameness. Sometimes the marks are arranged in layers, the healthy horn being alternated with others which are infiltrated with blood. This is a proof of the intermit- tent character of the acting cause which has originally produced the com. The ecchymosis, however, is not the actual seat of the corn, which is more in the velvety and especially in the laminated tissues, which are torn or bruised, the blood escaping through the sole simply by the action of the laws of gravitation. It is rarely that this lesion is looked for in the case of dry corn, and it is usually ignored ; but in the confirmed com, a true alteration of the lamhise of the keraphyllous tissue is observed. This is re- placed by a homy tumor, a kind of keraphyllocele, analogous to that of chronic laminitis, due to a union of the laminae under the influence of the fibro-plastic exudation resulting from the inflam- mation, which is of varying size, and presses more or less on the sub-horny tissues. In some cases, this horn breaks up little by little, and gives rise to quarter crack. The ecchymotic spots of the dry corn may vary in size ; they may range from the size of a pea to that of a ten-cent coin. At other times they may occupy the entire space between the bars and the walls of the foot. In moist corn, there is not only hemori'hage, but also inflam- mation proj^er, with serous exudation. The hoof is colored, as in dry com, of a brownish tiat, due to the infiltration of blood which occui-ed at the start ; on searching deeper, one will discover be- tween the hoof and the Hving tissues beneath a separation of varying dimensions, filled by citrine serosity. Most frequently this separation takes place at the line of the sole with the wall, and extends under both. The horny substance is then more or less impregnated with this serosity, and then has a charcteristic yellow appearance and a waxy consistency. In suppurative corn, or more properly, suppurating, the in- flammation ends in sujDpuration. The pus is secreted by the vel- vety and laminated tissues. It makes room for itself by gradually separating the hoof as its formation progresses. Before long it passes between the i^odophyllous grooves of the bars and of the quarters, the horny are lossened from the fleshy laminse, and in its ascending progress the pus soon makes its appearance between hau'S and hoof at the quarter, at the heels, or at the glomes of the frog. It is not common for the pus to make its way through a hoof of too thick or resisting a nature, unless it has first been DISEASES. 613 siifficiently softened by poultices and thinned down with the knife. This suj)puration, in the generahty of cases, brings on serious compHcation, by the excessive pressure to which the sub-horny tissues are then subjected. Gangrene of the velvety tissue near the branches of the sole and of the podophyllous grooves which have been lacerated in the suppuration, are very common compli- cations. If the pus remains long in the hoof its gangrenous re- sults may extend to the os pedis, the laternal cartilage, the plantar cushion, and even to the plantar aponeurosis, and give rise to necrosis or caries of the bones, or to quittor, to a more or less variable extent. This sub-horny suppuration, which may some- times be considerable, as well as the compHcations accomj^anying it, are detected with the probe. V. Termination and Prognosis. — Resolution is a common termination of corns. But their relapse is common also, especially in feet predisposed to them by bad conformation. A kind of chronic condition of the disease, and one which is more liable to become serious than the accidental variety, is the ordinary ter- mination in this case. The mere extent of the disease is of less importance in the diagnosis than the predisposing conditions. Generally the dry corn is less serious than the moist one, and especially less than the suppurative. Comphcated corns, princi- pally in flat, wide feet, with low heels, by reason of uncertain, protracted and expensive treatment, are in general fatal, and necessitate the destruction of the patient. YI. Treatment. — The largeness of the sjjace we have consumed in considering the etiology of corns will comjDcl us to be brief in our remarks upon the pre^^entive treatment. Shoeing, which is so often the cause of corns, may also be made a means of preventing them, even upon predisposed feet, if performed with intelligence and proper observation, based vc^oxl the anatomy and physiology of the foot. Generally speaking, one must not proceed rashly by changing too suddenly the mode of shoeing. We do not think that any one specified system of shoeing will with certainty pre- vent corns, but we do believe that each case demands its sijecial study and care. Usually, a flat shoe, and which has the heels rather thin but resisting, and which rests on the waU proper, even of the diseased one, if not too painful, is to be preferred. If the shoe is for a low-heeled foot, the heels of the shoe should be thicker in order to supply then* insufficient height and to offer 614 OPERATIONS ON THE FOOT. more resistance to the weight of the body. Sometimes the pro- tecting effect of the shoe must be completed by the use of a plate of gutta percha or leather between the foot and the shoe ; india rub- ber does not answer, as by its elasticity it interferes with the re- sistance of the shoe. It is absolutely necessary to preserve the hoof in a sufficiently supple condition, to effect which tar, hoof ointments and other greasy substances are used. Flaxseed meal, poultices of cow manure and salt water, a damp bedding, tallow in the hollows of the heels, all are very good preventives and even cirrative means, which a careful hostler will not neglect. Paring the feet thin, as practiced by some, is very objectionable, and is a serious obstacle to the extirpation of corns. The feet should be pared as little as possible, especially at the heels or in the lacunae. As for the curative treatment, there are, according to H. Bou- ley, four indications to follow : First, remove the acting cause ; second, treat the injury it has produced; third, reheve the pres- sure upon the diseased region, until it has returned to its healthy condition; fourth, prevent the return of the injury. The first indication is easy to fulfill with the accidental corn, but often nearly impossible in that due to a bad conformation of the feet. The second indication varies according to the extent of the disease. Generally it is advised to thin down the hoof at the bruised part and its surroundings, so as to relieve the pressure on congested or inflammed parts. Still, we are not in favor of too much thinning of the hoof, and except under pecuhar conditions, would practice it very slightly. Even in the moist corn, we be- lieve in leaving to the hoof a certain protective thickness. The pressure can be sensibly diminished by the appHcation of chloro- formed oil, or of tincture of creosote ; they very readily penetrate the hoof, and act directly upon the inflamed parts. We believe that excessive paring, the "cutting out of the corns," to use the shoer's expression, is injurious, and predisposes to new corns, by weakening the region and promoting a more rapid desiccation and contraction of the hoof. In all cases of dry and moist corn, one must avoid making the parts bleed, the exposure of the soft tis- sues, and all vmnecessary cutting. Thinning is necessary in sup- purative corn, and has to be done over the whole extent of the separation of the horn, and a wide channel of exit made for the pus on the side of the sole. It is a wise plan not to remove the DISEASES. 615 entire mass of the loosened hoof, as by this the dressing will be much facilitated. Cold baths are useful in all cases of corns ; at other times poultices of bran or other material are preferred. Sometimes sulphate of ii'on or of copper are added to the bath, especially in the moist corn. In the suppurative kind, when the suppuration is irregular, and when complications are likely to foDow, warm and sHghtly aromatic baths are better, and after this, a dressing with tincture of creosote, renewed the same day or the next. Later, cold iron or copper baths may be used again ; if the suppuration has broken out between hairs and hoofs, injections of Yillates' solution, after free escape of the pus by the plantar surface, are indicated. In the complicated suppurative corn these means are insuffi- cient. We must cut deeper, and for this the animal must be thrown. Then, when the diseased tissues are exposed by the removal of the loosened hoof, the nature of the lesion must indi- cate the requirements of the treatment. The velvety and podo- phyllous tissues, if gangrenous, must be excised as far as their diseased condition extends; carious bone is to be scraped, the fibrous and fibro-cartilaginous structures, if necrosed, are to be excised or cauterized, or sometimes left alone and watched, ac- cording to the peculiar character and extent of their lesions and the extent to which they exist. Once operated on, a dressing with plates and bands is applied, and the animal allowed to rise. It is by a pecuhar shoeing that, for some time, the painful heel must be reheved from supporting its part of the weight of the body, and protected from outside pressure. This is the "bar shoe." By the transverse bar, which unites both branches, it pre- sents a support to the frog and protects the heels. The resting of the shoe takes place equally upon the wall of the toe and of the quarters, especially the external, and it does not rest on the diseased heels which may have been first cut away. Some veter- inarians prefer the truncated, or the obhque bar shoe, or that with a bar forming an acute re-entering angle. Hartmann recommends the first ; Mayer prefers the bar shoe in which the bar heels have been thinned down, and even hollowed, to avoid as much as possi- ble the pressure on the diseased part ; this shoe has sometimes given us good results in horses with a weak frog. In many cases ordinary shoeing answers ; then the diseased hoof is pared down. 616 OPERATIONS ON THE FOOT. The branch of the shoe in. this case reqviires a greater thickness. "Whatever may be the mode of shoeing used much advantage can be obtained by the application of a sole of leather or of gutta percha. Sandceacks. Seime of the French ; Hornspalt of the Germans ; Flssura of the Italians — are fissures or solutions of continuity observed on the walls of the foot, ordinarily very narrow, which follow the direction of the horn. PrinciiDally observed on the hoof of soU- peds, it has been seen also in ruminants, but rarely, and of httle importance. I. Division. — They may exist on every part of the wall. On the median line of the nail they are called toe-crack, and then are more frequent on the hind feet. They are rarely found on the outside or inside toe (the tnaiiielles of the French), but commonly met with on the quarter {quarter-cracks), then situated on the lateral parts of the wall, toward the heels, and more frequently on the fore feet, especially on the inside. They are sometimes obhque, relatively to the thickness of the wall. Cracks are superficial or deep, according to the thickness of the wall involved. They are complete when they extend from the coronary band down to the jjlantar border ; incomplete when more Hmited. In this last case, those which do not extend up to the skin are the more disposed to recovery, and will grow down with the growth of the wall, while those which extend to the coronary band are more serious, being continually aggravated as the growth of the hoof progresses. According to the date of their formation, they are called recent and old. Simple cracks are those which only involve the wall ; they are complicated where there is more or less serious lesion of the tissues beneath, such as inflammation of the laminae, hemor- rhage, or caries of the bone. A serious complication is that of keraphylocele. II. Symptoms. — Often the solution of continuity is the only one observed, and it is the special characteristic of the disease. But the fissure may be masked, either accidentally or by design. It may be concealed by the haii's, by the mud, or covered by hoof- ointment, tar, wax, or even a putty of gutta-percha. Concealed internal cracks have sometimes been discovered, such as fissures involving the internal face of the wall, which, consequently, were DISEASES. 617 not noticed from the outside, or showing but a sHght depression on the surface of the wall. These cracks are only discoverable when the foot has been well pared down. As slight as the solu- tion of continuity may be, it participates in the motion of dilata- tion of the foot, and it is better detected when the foot is raised than when it rests on the ground. This is the case when it is a toe- crack, but on the contrary, the quarter-crack is more open when the animal rests its weight on the leg, in which case, the sepa- ration of the borders of the cracks may be from two to four milli- metres, and may expose the bottom of the fissure. Ordinarily, cracks appear first at the coronet, and there is then but a slight opening, but as they become older, and grow down, they have a tendency to become deeper and more complete. When of old standing, their borders are rough and scaly, having between them an ulcerated tissue and sometimes a fungus growth, from which escapes a sanious fluid. In other cases, as of quarter-crack, the edges have a tendency to cover each other. Superficial cracks are not always attended with lameness ; it is, on the contrary, often very severe when they are deep. The pain is generally in proportion to the depth and degree of opening of the fissure, and also especially to any compUcations which may exist in the tissues beneath. The lameness seems at times to be due to the injviry of the deep, soft tissues, and to be caused by the motions of the horny box when they become pinched, irritated and brviised. The afiected animals are especially lame when the foot rests on the ground, and the lameness is greater on a hard than on a soft surface. If an animal suffering with toe-cracks is moved on descending ground, the lameness is greater than on ascending a hill, the weight of the toe in the latter case producing less opening of the edges of the solution of continuity. In quarter- cracks, the severity of the lameness is always in proportion to the rapidity of the gait; many horses which are but slightly lame on a jog, become much more so when the gait is accelerated, the dila- tion of the heels being greater, and the separation of the b rders of the crack increasing in proportion to the speed. When there is lameness, there is naturally an increase of heat and sensibility of the foot, especially at the seat of the crack. This is often dis- covered by feeling with the hand ; old cracks are generally accom- panied by a thickening existing at a corresponding point of the hoof. A deep, but recent crack, is ajjt to be accompanied with 618 OPERATIONS ON THE FOOT. hemorrhage ; there is blood which sometimes exudes between the borders of the crack, and flows in abundance when the movement is rapid ; and old crack, in similar circumstances, may show pus, sometimes mixed with blood. A misstep, a sprain, may give rise to hemorrhage in cracks which are ordinarily dry. In toe-crack, the solution generally involves the thickness of the wall, through which it runs in a line almost parallel to the median plane of the body, while in quarter-crack it is often oblique and irregular, not exactly following the direction of the fibres, but following the thickness of the wall obliquely in such a way that the external solution of continuity is more posterior than the external. If the crack is rather old, and the foot where it exists is contracted, it is generally incurvated, one border covering the other, and some- times they seem to be moidded on each other, so as to cover and conceal the true crack. III. Complications. — Among these we may first mention the inflammation of the recticular tissue, which is first pinched and injiored. This may be followed by suppuration and local gangrene. Very often the disease is followed by necrosis of the os pedis, and caries of varying depth. In toe-crack cases have been seen of caries of the tendon of the anterior extensor of the phalanges, and even arthritis, though rarely occuring, have been observed. In quarter-crack, one may have cartilaginous quittor and suppurative corns. As before stated, these lesions are indicated by the severity of the lameness, the presence of the blood or pus through the crack, and the extreme sensibihty of the part. It is especially when, in the coxu-se of treatment, a part of the hoof has been removed, that the keratogenous apparatus has been exposed, that the abnorma- coloration of the podophyllous tissue is seen, in its swollen condi- tion and its sensibility to pressure, accompanied with the presence of the pus or sanious discharge, and at times the necrosis of the bone. Sometimes, also, foreign substances, as dirt or gravel, may be found introduced in the cracks, and acting as causes of irrita- tion to the sensitive tissues below. A complication, not so freqvient, however, according to some authors, is that known as Keraphylocele, and which consists in an hypersecretion of horn, from the coi^onary band on the inside of the crack. Sometimes the horny growth remains separate from the borders of the crack, and is adherent to the wall only by its base, towards the coronary band ; this is especially the case when DISEASES. 619 the wall has been thinned down or partly removed. In other cases it is adherent to the two borders of the crack, and this forms a natural cicatrix. This horny column, of varying length and strength, according to its age, presses vipon the tissues beneath, and gives rise to severe lameness. With time there is correspond- ing atrophy of the podophyllous tissue, or even of the os pedis. This is often followed by a marked deformity of the hoof, and especially a deep fissure, parallel to the dii'ection of the crack. The soft tissues under the keraphyllocele often in time become harder, in consequence of the disappearance of the papUlse ; the hoof then is no longer adherent to the tissues beneath, and so incurable cracks are the result. A double wall or false quittor have often also been observed. Thus deformed, the foot is always subject to lameness, even if the crack is cured. Contraction or atrophy of the frog have been observed with quarter-crack. IV. Progress, duration, termination. — Ordinarily, cracks once existing become worse. From being superficial and imperfect they become deep and complete as a natural result of the ordinary motions of the foot. If rest and some hygienic attention can be given, they may recover spontaneously, and disappear by the nat- ural downward growth of the hoof. This fortunate termination, however, is principally obtained when the crack is due to acci- dental causes, without deformity of the foot. V. Prognosis. — Simple cracks, superficial and incomplete, especially arising from the j)lantar border, almost always recover under rational treatment, which has for its princij)al aim the pre- vention of increase in the size of the fissure. Cracks starting from the coronary band are alwaj^s of a more serious nature, with a ten- dency to increase easily. Still they are no longer to be consid- ered incurable. Cracks in which the borders are much separated by the motion of walking ; those which are obhque ; those whose edges are incurvated inward ; those where a portion of the wall is loose ; those which bleed, and those where there is a continued irritation of the sub-horny tissues, are the most serious ; and so much so, that they may require quite serious sui'gical interference, and after all baffle the best skill of the operator. VI. Etiology. — The causes of cracks vary greatly, and are often multiple in a single case. Seldom the result of accident, they are most commonly the combined effect of both a predispos- ing and an extraneous cause. A frequent one among others is 620 OPEKATIONS ON THE FOOT. the relative dryness of the hoof, which then becomes excessively brittle. We have seen the conditions in which the hoof loses its natural flexibility, and shall here only state that alternate changes from dampness to dryness have as much influence as the drjTiess alone. Cracks are more frequent in animals working along damp than in those pvdhng in dry and stony roads. They are common in animals which after being kept in pastures are placed in good j^aved stables, with dry bedding. It is principally in these condi- tions we find the quarter-crack. During some seasons, while a term of dryness follows continued wet weather, the conditions are favorable to then* formation, and they often assume an epizootic form. Emigration to dry cUmates is a frequent cause, by produc- ing the contraction of the ungueal structure. This last circum- stance explains why cracks are more common in army horses, which are called to go on long journeys during the warm days of summer But if the European horse taken to Africa suffers less from the disease, a similar result occurs to the African horse when brought to our climate. The Arabian horse readily contracts quarter-cracks in our stables, and with our shoeing. Animals with small feet, or with hard and thick hoofs, have a natural predispo- sition, which is also found in Hungarian, Russian or Tartar ani- mals. Feet excessively large are also easily affected with the disease, especially those which have canker or grease. Unskilful shoeing may predisj)Ose to cracks, and this is princi- pally the case if the wall is thinned or rasped down too much ; the same result is obtained from shoes which are too wide or too heavy, or which are kept on by too heavy nails. Feet with toes turned outward are predisposed to it, as in these the weight of the body rests more on the internal quarter, which being thinner than the external, give way the easiest. Con- tracted feet are subject to it. Quittor, suppurative corns, and some other diseases, are also predisposing causes. Among occa- sional or accidental causes may be mentioned traumatism, contu- sions of the foot and blows during work. The service of heavy trucking for heavy horses exposes the hind feet to toe-crack, especially if the pulling is done in going up hill or on slippery pavements; mules' feet are very subject to it, and heavy falls in jumping and external blows are occasional causes. Heredity in cracks has been mentioned. We do not admit this, except so far as it belongs among the predisposing causes DISEASES. 621 which may be transmitted, and we should object to an animal for breeding purposes though otherwise well-formed, if he were afifected with cracked feet. VII. Treatment — Prophylaxy ought to be the princijDal treat- ment of cracks. It is not always easy, however, to prevent them, and it becomes important therefore, to treat them as soon as they api^ear. One ought at least to try to prevent them from becoming comj^lete and deep. This form of treatment may be called the hygienic, as it is not properly curative, and so long as the crack is not yet completely formed, the animal may be kept at work as if everything was normal. Cui-ative treatment is that which is apj)lied to the deep or complete disease, more or less complicated, and it most commonly consists in removing that portion of the wall which bruises and irritates the tissues beneath, and in equal- izing the wound. In general, there is no necessity for haste in operating, the hygienic treatment being often sufficient to obviate the need of serious operations. The distinction between the hygienic and curative treatment is not, however, always definitely marked, and quite often the two modes of treatment must be combined, both the hygienic and the curative being necessary. The prophylactic treatment consists specially in the applica- tion of tonics, with the object of preventing the hoof from drying. Its normal hyrogoscopic condition must be preserved, and it must be prevented from taking up too much of the dampness of the ground upon which it travels, as well as from losing that which keeps up its flexibility. At times it must be rendered more moist and, according to the requii-ements of the case, recourse must be had to hoof ointments and other greasy substances, glycerine and astringent poultices. At the same time the shoeing must be care- fully attended to ; the shoe must not be too heavy nor too wide, and should be secured by nails of a proper size. The hygienic treatment has for its first and principal indica- tions to prevent the solution of continuity from increasing, from extending through healthy structure, and especially to new hoof, as this is secreted by the coronary band. The borders of the cracks must be prevented from separating in the movements of dilatation of the foot. The normal suture of the wall not being produced by the natural process, or at least producing it only in keraphyllocele, which is Ukely to be as injurious as the crack it- self, the borders of the crack must be brought together artificially. G22 OPERATIONS ON THE FOOT. It lias been supposed that this could be done with the putty of Defay's, a mixture of gutta-percha (2 parts) and gum ammoniac (1 part), introduced into the well-cleaned fissure, and pushed in as deejily as possible by a warm iron plate or a spatula. This putty is excellent for superficial cracks, but is insufficient to bring the bordei's together when the fissure is somewhat deep, or especially if it is irregular and sinuous. A better way, at least for toe crack, is that which consists in suturing the edges of the solution of continuity by metallic clasps, which immobilize the hoof. This mode is always preferable to circvdar ligatures of wire or cord, which have the effect of interfer- ing with the natural elasticity of the hoof. Clasps only fix the hoof locally, and are an old means of treatment, having been used by Solleysel and Garsault. It was advised to j^erforate the horn through and through with a small punch, and pass a wire, which was bent over the crack, or twisted together at the ends. The same authority recommends the driving of a nail through both edges, and securing it tightly, as in the application of the nails of the shoe. This treatment was recently recommended by Haupt, Lafosse and Rey. The first of these professors takes an ordinary nail, with a small head, drives it through one edge of the crack, so as to come through the other at an equal distance from the point of entrance ; the nail being thus driven to the head the borders of the crack are then brought together, and the nail secured in the ordinary way. Two or three of these clasps are employed, according to the extent of the crack. Lafosse makes a groove on each side of the fissure about one centi- meter from the border, in a direction transverse to that of the fibres of the wall, which limits the passage of the nail. The nail is then introduced and secured as in the first instance. Rey makes a track for the nail first, by drilling a hole through the borders of the crack. The animal must be cast during these operations. The best kind of clasps or hooks are undoubtedly those of Vachette, which require special instruments for theu' apphcation, but give a real solidity to the means of fixing the position of the parts. The clasps are all prei:)ared, made of strong wire, bent at both extremities, and slightly sharj) inwardly (Fig. 469). These are secured on the foot by a special nipper or forceps (Fig. 490) in the notches made on the wall with a special cautery (Fig. 491) ; DISEASES. 623 this cautery has its extremities flattened, the width of the clasp, apart from each other. The forceps used to secure these is strong ; its branches are flattened from side to side, and grooved inward, and sufficient!}' apart from each other, while it is open, to receive the clasps between its border ; these branches, with the clasp, are exactly fitted to the notches made in the wall with the cautery. (?" - ^■— ^ FIG. 489.— Clasps. !!!l|!ffll|lll!lllll!!t Fig. 492.— Clasps applied in the Thickness of the Wall. Fig. 491— Cautery of Vachette. Fig. 490.— Forceps of Vachette. It is sufficient to press the branches of the forceps to close the teeth or extremities of the clasps, and bring firmly together the borders of the ©racks. The number of clasps varies according to the case under treatment. A very simple mode of effecting reunion of the borders of the Fig. 493.— Toe Crack secured with Clasps. Fifi '.^....i„Lr Crack secured ■with Clasps. 62-4 OPERATIONS ON THE FOOT. crack is that of Hartmann. It consists in applying upon the wall a sheet of ia-on, adapted to its outside, and secured on the foot by two small screws. Clasjis are of a certain utility for toe cracks, but they often fail in quarter cracks, on account of the thin condition of the wall, which is particularly well marked in some feet. If the living tis- sues are encroached uj)on, the clasp may give rise to complica- tions, and still it is in that region that the effect of the motion of the hoof must be prevented, and where immobility is essential, to prevent the separation and spread of the edges of the crack. Castandet has indicated a mode of treatment which has proved very successful, and which may be applied to both toe and quarter crack, where the fi ssure of the wall extends from the coronary band to the lower border of the foot. It consists in making a groove at about one centimeter on each side of the crack, which in depth extends to its bottom, which, when reached, is white. If the solution does not go to the lower border of the foot, these grooves are made obliquely, and so as to meet together at then* lower termination, and form a V-shape. Thus the crack cannot increase, and it grows down without injury to the soft tissues. Castandet, after this operation, cauterizes the coronary band. The transversal groove, recommended by Levrat, which cuts the tissues in two and extends beyond the crack on each side about three centimeters, which goes down to the soft tissues of the foot and not beyond them, has for its object to diminish the effect of percussion produced by the contact of the foot with the ground. It, however, does not prevent the edges of the lissure from sepa- rating, as the groove of Castandet does. It is chiefly useful when there is a separation of the wall, or false quarter. At times a transverse groove has been made to prevent an incomplete fissure, starting from the plantar border, from spreading to the coronary band. According to Hartmann, a single hole drilled through the wall is, in most cases, sufficient. Shoeing is of much assistance in the hygienic treatment of cracks. In toe cracks, the toe should be spared as much as pos- sible while the heels are lowered by paring, or by the appHcation of a shoe thicker at the toe, or by the removal of the calks at the heels. While Defays holds that the shoe ought to lie close and tight to the plantar regions of the crack, Hartmann, on the con- trary, advises the paring of that surface at the toe, so that the shoe DISEASES. 625 cannot rest on the crack, and recommends the application of two clips on each side of the toe. In quarter cracks, it is recommended to lower the toe, to save the bars and the frog ; and when the crack is incomplete, and not accompanied with lameness, Defays recommends not to lower the diseased quarter, and to have the heels resting w^ell on that branch of the shoe which shall be thick and straight. Schrebe advises a calk on that side. If the crack is deep, with excessive lameness and deep lesions, the quarters and heels must be pared down as much as possible, and a bar to be then put on, resting on the frog, if need be. An ordinary shoe, with a thick branch, may be sometimes employed. As part of the hygienic treatment, we may consider the means recommended to increase the secretion of the coronary band. It is known that a sHght irritation at that part of the foot is accom- panied with an increased secretion of hoof, which is sometimes siifficient to give rise to a new growth of healthy horn. One of the most common methods is to sHghtly cauterize the coronary band with the iron. This was already known by old practitioners, who employed an S cautery ; but they committed the en-or of burning the hoof too deeply instead of simply cauterizing the cor- onary band. SoUeysel speaks of the cauterization of the band. Garsault mentions only the burning with three S's across the crack. Such cauterization could have no useful effect, and the deep appUcation of the cautery might be followed by serious com- plications. For these reasons Lafosse objected to them. In our days it is abandoned, and the coronary band only is touched by the cautery ; Castandet and Rey also employ it. Chemical cauteries have also been recommended, nitric acid by Laguerriniere, and more recently by Lafosse. Putty of corrosive sublimate and ointment of oxide of mercury are also in use, but have no marked advantages. Blisters j^rove very beneficial, and also turpentine, as recommended by Lafosse and Rey, and the oil of Cade by Maui-y. Defays ad\dses the putty of gutta percha, which is also used to conceal the clasj^s. The curative treatment is necessary whenever any complication attends the crack. If it is recent, antiphlogistics and rest should be first tried ; cold bathing, blisters combined with hygienic treat- ment may then be sufficient. A single groove at the upper part of the crack, near the coronary band, is often sufficient, or a re- 626 OPEEATIONS ON THE FOOT. Fig. 495.— Operation of simple Too Cracli by the process of thin- ning down the wall in V-shape. moval of a Y-sliaped portion of the lioof, extending more or less deeply, accord- ing to the condition of the crack, care being observed to avoid the growth of vascular granulations between the edges of the crack. There are cases where it is not necessary to remove the segments of the hoof entii'ely down to the soft tis- sues, bvit only to thin tbem down and to apply over it a dressing of oakum, se- cured by several turns of roller band- ages. In aU cases a bar shoe must be applied to relieve the joressure on the quarter where the crack exists. This is principally recommended by Prevost, Girard and others. If there are deep lesions of the sub-horny tissues, a piece of the wall must be removed, and the operation for radical ciu*e be performed. It is an old operation, by which all diseased tissues are exposed. As little of hoof as possible is removed. In operating, two grooves will be made alongside and at some distance from the solution of continuity. The wall between is removed so as to expose the podophyllous tissues from the coronary band down to the sole, care being taken to avoid the tearing of the structure of the coronary band, and the diseased tissues are then removed. If the podoj)hyllous tissue, it is excised with the sage knife ; if the bone is carious, it is scraped with the drawing knife. The whole Fig. 496.— Operation for Com- plicated Toe Crack B, by removal of a piece of the toe of the wall. A A. — Oblique grooves limiting the size of the piece to remove. Fig. 497.- Dressing for Complicated Toe Crack. DISEASES. 627 is tlien dressed up with a shoe having the toe thinned down, and extending somewhat beyond the border of the foot. The cicatrization does not take place from the coronary band alone, but also from the horny secretions of the podophyllous tis- sues. The repau* is then quite rapid. The first dressing is re- moved after eight or ten days, and if everything goes on well need not be changed more than once a week. The animal is not to be put to work until the hoof has obtained a certain consistency. The operation for quarter crack is similar, except that only one groove is required in front of the crack, the tissues being exj)Osed as in the operation for the removal of the lateral cartilages of the foot. Calk. Synonyms. — Kronentritt (Ger.) — Atteinte (Fr.) — Thus is called a contusion, with or without wound, that the animal receives on the coronet, from the shoe of another foot, or from a foreign body, or by another animal walking behind or alongside him. The skin of that region is very thick, slightly extensible, not easily yielding to the imflammatoiy swelling ; there is commonly sloughing and mortification of tissues, accompanied with violent pain. It is frequent in animals that forge, also in very young horses or those which are weak in the lumbar region, and which interfere and cut themselves in walking. This lesion is also very common in the districts where horses are shod with high calked shoes, when the wound resulting from it is made by the internal branch of the shoe, which lacerates the skin of the coronet. Horses shod to travel on ice are commonly affected with it ; the injury being more or less serious according to the size and sharp condition of the calk. Horses ridden in ridding schools are often affected with it dur- ing the various evolutions of the haute ^cole. It is called single when the wound is slight ; concealed when the pain is great and continued, as in the case where it takes place on the tendon, near the heels or the quarters ; horny when the contusion has taken place on the wall or at the coronary band ; complicated, when it is very serious and accompanied with other more severe lesions. It is always a horizontal wound or a tumor by contusion. 628 OPERATIOXS ON THE FOOT. I. Symptoms. — It is ordinarily recognized by the wound or swelling which exists upon the parts. Often the horse is lame, and the affected part warm and painful ; sometimes the hairs are cut, the skin scratched or torn. There may be a slight bleeding at the seat of the wound. When the wall has received the con- tusion, the vascular network underneath may become inflammed, and then pus is formed between the teguments and the hoof, which then become separated. Sometimes even the lateral fibro- cartilage of the foot becomes irritated and swollen, and ulcerates, especially when the contusion has taken place on that part where the cartilage is ; in this case the injury may be complicated with cartilaginous quittor. In severe cases, one may recognize a furuncular calk, charac- terized by the mortification and sloughing of a portion of skin at the place where the contusion took place ; it is the cutaneous quittor of old hippiatry, with formation of a core ; this is always very painful, and the inflammation generally spreads underneath the wall. Bouley calls it gangrenous when there is unlimited similar mortification of the tissues ; in this case the slough in- volves large portions of the skin. At times it may be called phleg- monoxis, when an abscess forms itself under the skin, then the coronet is warm, thick and inflamed, and the pain is extreme. Then if an incision be made through the dermis in its entire thick- ness, an abundant bleeding takes place, generally followed by the resolution of the disease ; if there is already suppuration, it is at the same time immediately allowed to escape. IT. Treatment. — If the injiuy is slight or recent, whether with or without wound, very cold water and the removal of the cause by taking off the shoe, are sufficient to bring on a cure. But if the contusion has been great and deep, recovery is more difficult to obtain on account of the suj)puration which will follow. Then the application of poultices is indicated ; if there is formation of a core, and mortification of tissues, poultices of honey are espec- ially indicated ; in case of phlegmon, the poultice must be warm, and then incisions and counter opening must be made for the escape of pus ; afterward dressings are made with oakum saturated with tepid wine or tincture of aloes. "When the caulking is horny, the use of emolhent topics is in- sufficient ; an excellent way then is to obtain the required slough- ing of the tissues by actual cauterization — the ii-on heated to white DISEASES. 629 heat ; by thus destroying a portion of the hoof and the soft tissues one wUl avoid the excessive pressure at the coronary band ; this may also be prevented by the thinning down of the wall with the sage knife ; but one must be careful not to remove too soon the portions of horn which may be detached. When the calking takes place at the heel, it is good — so as to prevent other complications — to pare the foot down, especially at the heel, to remove the divided hoof and transform the wound to a simjjle one which can be dressed, as already stated, or with digestive ointment secured by several turns of a roller. AATien there are wounds of the teguments, it sometimes hap- pens, if the immediate union has not been obtained, that the por- tion of skin forming the inferior edge of the wound turns down and that the granulations protrude, tending to form a kind of fungoid growth. Chabert says that these must be cut off and di'essed with oakum soaked in alcohol. Calking at the hind feet being the most severe, and those which are followed by the most serious complications, on account of the urine and droppings of the animal, which impregnate the wound, one can never be too particular in keeping them clean and dressing them well. When they end in cartilagious quittor, they must be treated as that disease usually is. As to the means of prevention, they consist in not placing the horses too close to each other in stables, fairs, etc., in not forcing them too much in their gait, in shoeing properly those which forge or interfere, and in placing or riding them in such a way as to avoid the possibility of their wounding each other. Punctured Wound of the Foot. Synonyms. — Naglebritt (German) — Nail in the foot (EngHsh) — Clou de rue (French). — In veterinary science this designation has been given to a punctured wound, often with laceration, some- times with contusions, either at the sole or frog of the foot of the monodactyles, and produced by sharp or cutting bodies, most commonly nails, upon which the animal steps. The form of these bodies, the direction they take, the force with which they pene- trate, and the part of the sole they enter, give rise to various lesions of varying gravity as they are older or as the injured part enjoys a greater sensibility. Etiology. — Nails, stumps of nails, are most often those which 630 OPERATIONS OX TIIK FOOT. are picked up in the streets ; at other times it is a metallic sub- stance elongated and sharpened ; again, there are pieces of glass, or other substances, such as bones or sharp stones, which are picked up and produce the wound. It is j)rincij)ally in the streets of populous cities, in the yards of builders, or on the grounds where buildings are pulled down, that horses are liable to receive these injuries. In riu'al districts they are rare, comparatively, to what they are in cities. It is evident that horses with wide, flat, thin, softened hoofs are more exposed than those which are of different structiu^e. I. Divisions. — Punctured wounds of the foot may be simjile or sujjerficial, deep ox penetratinfj. One of these bodies piercing into the frog requires to go in deep to be serious, as above the frog (which is itself quite thick, though formed by a soft and flexible horn) is the plantar cushion, a fibrous, soft and elastic mass, which off'ers a great resistance. If, however, the injiu-ing body is a very long nail, which runs per- pendicularly in through the frog at the plantar cushion, it may reach the terminal extremity of the perforans tendon, situated immediately under the plantar cushion, and penetrate the sesa- moid slieath. It is known that this sheath forms a sac of some dimensions, that it extends above and below from the inferior half of the coronary to the semi-lunar crest, and in its transverse axis extends from one retrosal process to the other ; the inferior portion of this synovial bursa covers the plantar aponeurosis in its whole extent. Sometimes, again, the puncturing body pene- trates as far as the bone ; sometimes the navicular ; at others the OS pedis, and sometimes even penetrates into the articulation. II. Symptoms. — They vary according to the seat of the lesion, its depth, the mode of action of the penetrating body, length of time it has remained in the wOund, and the nature of the lesions it has made ; all conditions which may change the chai'acter of the disease from a first degree, when the animal shows no evi- dence of pain, to the extreme point, where its Hfe is in danger, and evens ends in death, by the excessive local alterations and the sufferings accompanying it. Often the first point which assists in the diagnosis of the case is the history. The driver has seen the horse become suddenly lame, has examined the foot, and found a nail more or less deeply imbedded ; or it is the surgeon who finds the nail in its hiding- DISEASES. 631 place. The exploration of the pai't shows with certainty the nature of the lesion, the direction and depth of the wound, as well as the physical condition of the body which has made it, and all cii'cum- stances which allow a positive diagnosis to be made. Quite often the nail is no longer in the foot ; sometimes it has left its mark — an opening which can be explored ; often this is not visible at first sight, though the wound may be even deep ; this is when the injury to the hoof has been very slight, and when the hoof has retracted on itself by its elasticity or when the open- ing is concealed by the dirt of the streets. It must be remem- bered that sometimes the penetrating body remains broken in the soft tissues after its entrance through the hoof. If the accident is recent, only a little blood may be faund — Hquid or coagulated — over the wound ; later, some serosit}', more or less purulent, is observed ; the pus is white or black, sometimes mixed with syno- vial fluid ; sometimes there are granulations on the bodies of the wound which protrude over the edges, commonly called proud flesh. Such are the first objective symptoms obtained by the exploration of the parts. Ordinarily they are insufiicieut, for it is not always easy to probe the wound. It then becomes neces- sary at the beginning to pare off the hoof all around the wound, and sometimes to hollow it at the point of injury, without going to the sensitive structure, however. In this way the exploration and the probing of the wound are rendered much easier. The pain, expressed by the lameness, is almost always mani- fested ; it varies according to the seat of the lesion and its depth. At first the intensity of the lameness does not give the exact measure of the disease, and often one may be led into error by it ; but it gives an exact value of the lesion when a few days have elapsed since the injury was received; if the pains are slight or absent, they indicate that the reparative process is going on well ; it is, on the contrary, interfered with by complications when, as time goes on, the lameness increases instead of becoming dimin- ished. Generally one can say that the injury will amount to nothing when the lameness is slight, while, on the contrary, seri- ous complications must be always looked for when it is great and remains on long, even when the first lesion has been slight and supei-ficial. The wound, which has penetrated through the hoof only, has no symptoms, no sequelae ; the animal is not lame from it, or if he be the lameness is very shght, the foot resting entirely 632 OPERATIONS ON THE FOOT. on the inferior surface ; when the resting takes place only on the toe, ordinarily the tendon is injured, possibly the synovial sheath ; in cases where high inflammation exists the pain is very great, the animal walking on three legs only. The anatomical examination of the injured part teaches that the most serious punctured wound of the foot is that of the cen- tre of the foot, where the tendon, synovial sac, and where the articulations may have been injured. Forward of this the wound is less serious, even if it involves the bone. Posterior to it, it can only injure the plantar cushion. Under this condition the plantar region of the foot is divided into thi'ee zones ; one, ante- rior, from the toe to the point of the frog ; one, middle, extending from the first to the median lacunae of the frog ; and the third, anterior, covering the space left back of this to the heels. The most serious of the injimes to which the foot is liable are those caused by foreign bodies which penetrate the middle zone, that being the most complicated portion of the structure. The symptoms will vary, according as the wound extends to the plan- tar ajDoneurosis, or only as far as this membrane ; or lacerates the soft surrounding tissues without touching it ; or it goes beyond this and injuries the small sesamoid sheath, or even going deeper, severs the na\icular bone, or its ligamentous attachment to the os pedis ; or reaches the last phalangeal articulation. A wound of the plantar aponeurosis is always very painful, especially when complicated with necrosis, in which case there is no weight put on the diseased leg, and continual lancinating pains and reacting fever are soon observed. The wound is then fistulous in character, and the suppuration then flowing from it meets with difficulties in its escape, w^hich gives rise to a state of general i nflammation, and the foot becomes hot and very painful If the necrosed scar becomes loose and sloughs off, being de- tached by suppuration, improvement soon ensues, but as the ne- crosis of the tendon has generally a tendency to spread, there is an increase in the character of the symptoms. If the wound extends to the sesamoid sheath from the start, the syno-vial fluid is observed escaping, first pure, but soon becoming milky and purulent in aspect, if the sheath has become inflamed, and easily coagulated in yellowish clots. The pain is then very great, much more so than when the aponeurosis alone is diseased. At times, by rapid closing of the plantar wound or obstruction of the fis- DISEASES. 633 tula, a warm swelling forms itself in the back of the coronet, which raises the skin by degrees and becomes elevated, prominent at one point, and giving a feeling of fluctuation. This swelling ends in ulceration, and allows the escape sometimes of an abundant s}Tio\T.al, purulent discharge. The wound of the small sesamoid and of its hgament adds nothing to these series of symptoms. The probing of the tract will only determine it by the sensation of roughness which it will give ; but generally one must be careful in using the probe, es- pecially when the flow of synovia is absent. If the foreign body has pierced through the ligament, or has penetrated in the coffin joint, phalangeal arthritis is the consequence. The same result is likely to follow excessive inflammation of the foot and the macer- ating effect of the suppuration, in which case the tendon may soften down and give w^ay. It may then also happen that this tendon retracts by the contraction of the musciilar fibres, and can then be traced upward to the back of the coronet, or of the fet- lock, according as the giving way has taken place higher or lower. With arthritis there is a hot, painful swelling of the whole cor- onet, with diffused oedema above the fetlock and the cannon, and extending upward to the whole leg, comj^licatiug the lesion by lym- phangitis, and painful swelhng of the lymphatic glands. Then sub- cutaneous abscesses are found round the coronet, with gangrene of the tissues ; while, again there may be only an extensive fibro- plastic exudation, which ends in calcarious organization and anchy- losis. In the anterior zone the only serious lesion met with is caries of the OS pedis, characterized by great pain, continual lancination, loss of the use of the leg, and high reacting fever. There is abundant bloody and foetid suj)puration, and the probe gives the sensation of the soft resistance of the bone, of its rough condition, and its partial fragility. The caries having most generally a pro- gressive march, complications of separation of the hoof, to a vary- ing extent, are often seen ; the pus arrives at the surface between bail's and hoof ; and diffused gangrenes are also often seen, which extend as well to the podophyllous as to the velvety tissues. In the posterior zone, the only serious wounds are the lateral ones, which may injure the fibro-cartilage and become comphcated with their caries or quittor and fistula down to the lacimse of the frog, as we have seen in suppurating corn. 634 OPERATIONS ON THE FOOT. Nails may penetrate the posterior zone through and through, coming out behind the coronet, without danger. The sub-horny suppuration may detach the frog and be the only serious compli- cation to be met with. As terminations of all these injuries we may see resolution, sujv puration, gangrene, softening of the tendons and phalangeal arth- ritis, and as sequelae, bony tumors of the coronet, and anchylosis. The most serious complications are the dropping of the entire hoof, the rupture of the tendons, tendinous and cartilaginous quit- tors, for the injured hoof, and chronic laminitis for the opj^osite one. IV. Prognosis. — This varies according to the seat of the wound. Less serious in the postei'ior than in the anterior zone, it is less in the last than in the middle, where the region is so complicated and the nature of the tissues so different. The depth of the wound has also some influence on the prognosis. "Wounds of the plantar aponeurosis are more dangerous than those of the plantar cushion ; those of the sesamoid sheath are more so than those of the aponeuj-osis ; they are still more serious if the bones are affected ; the worst of all is that of the joint. The direction of the foreign body and its simple or compHcated action, will also influence the prognosis. This, we have already said, can be established by the severity of the lameness. The nature of the foreign body must also be taken into consideration ; if blunt, which crushes the tissues, it is more dangerous than if sharp and pointed. In a flat or convex foot, punctured wounds are more serious than in a well-made foot. They are less serious in heavy than in light draught horses, as the former, though they may remain lame, are still useful. The excitable condition of a patient will also alter the prognosis. Wounds of the anterior feet are more serious than those of the posterior. V. Treatment. — In aU cases, the first indication is to obtain a natural cicatrization and natiu-al repair, always more rapid and jDerfect than that which is gained by sm-gical interference. This is generally easily secured, and for this reason it is important to avoid too severe manipulation upon the injured foot. One must watch the progress of the disease, give the foot as much rest as possible, remove the shoe, thin down in its whole extent the plan- tar hoof, so as to avoid any pressure, and keep the foot in a cool- DISEASES. 635 ing batli — ordinary cold water, to which often is added acetate of lead, sulphate of iron, or common salt, very beneficially. Poultices, cold preferable to hot, give excellent results. By this treatment, the progress of the inflammation is checked, and very often deep and serious wounds, even those where the tendinous sheath has been injured, are easily cured. If the lameness gradually diminishes, the case rapidly gets well ; at any rate, by this treatment, the inflam- matory process is diminished, and the painful pressure of the hard- ened and thick hoof is avoided. In the winter, when cold baths are of difficult application, chloroformed or carbolized compresses may be applied round the foot. The hoof is thus softened and the pain reduced. At other times a bhster is applied round the coronet. If the lameness remains, or seems to increase, it is due to ten- dinous necrosis or caries, and it becomes necessary to operate. Must the surgeon then have recoiu^se to an operation, and make a simple wound with his sharp instrument ? Or, is it still better to merely depend on natural resources, and assist them ? It is difficult to lay down any special rules. If the disease is old, if the necrosis has progressed and is still increasing, a serious operation becomes necessary. If the necrosis is recent, one must be guided by external indications. Notwithstanding (Renault remarks) one should not be too hasty, as the animal must neces- sarily be laid up for several months afterward. It is often suffi- cient, in a recently punctured wound, in order to avoid complica- tions, to modify the conditions of the fibrous tissues in the whole extent of the lesion, by appljong substances simply antiseptic, or still better, sUghtly caustic. Rey employs the cold bath, in which he dissolves a pound of sulphate of copper for ten or fifteen quarts of water ; by this means he has secured the speedy recovery of severe punctiu'ed wounds. For a long time, and with the same object, we have been using a mixture of equal parts of sulphate of coj^per and sulphate of iron, having first hollowed the foot downward around the source of the puncture, and the sole being pared down as thin as could be borne. H. Bouley prefers the application of pulverized corrosive sub- limate ; after tracing the wound to its bottom, he fills it well with the powder. This remedy was already recommended by Solleysel, who used it in caries of the os pedis. Other practitioners prefer phenic acid, and claim for it great advantages. By the action of 63G OPERATIONS ON THE FOOT. the caustics upon the fibrous tissues exposed to necrosis, or already in tliat condition, a double salutary result is obtained ; first, the transformation of the part, which is the seat of a pro- gressive gangrene, into a chemical eschar ; and, again, promoting the more active vascularization of the surrounding parts, and con- sequently their increased power of healthy reaction ; conditions twice favorable to the sloughing of the eschai*, and the process of repair following it. "When the wound has reached the os pedis, and this has become carious, a portion of the sole is removed, so that the suppuration can escape, the bone is scraped ofi", and a dressing of carboHzed alcohol applied, kept on by a thin shoe or slipper, with tin plates. When there is a fistulous wound, through which syno%ia escapes, yet not purulent, caustics are recommended. Solleysel preferred these, but blacksmiths used them so carelessly that they soon were discarded. Since, however, they have been employed again, not in powder, but as trochiscus. Key recommends the corrosive sublimate in conic pencils, introduced to the bottom of the fis- tula ; by them he obtains an eschar, a solid clot, from the synovia, which closes up the wound and prevents the synovial flow, at the same time stimulating the granulations which close up the fistiila. We have already said that these measures must be used only when the synovia is not purulent, as then the escape of morbid liquids may be prevented. It is not then uncommon to see abscesses forming at the back of the coronet ; generally not so serious as is usually beheved ; not as much as those which take place in front and which are due to suppuration of the articula- tion. After the running out of those abscesses, sometimes the wound of the foot assumes a better aspect, the symptoms im- prove, and the animal recovers rapidly. Injections of a very weak solution of tincture of iodine, as weU as the baths of copper or iron, are then very advantageous. Hertwig advises the introduc- tion of a seton through the sesamoid sheath. This treatment is not always sufficient, especially where the lesions are deep. All the diseased structures must be then ex- posed, and they must be removed and the wound changed into a simple one, which, well dressed, wiU heal without difficulty. The operation is required in proportion to the extent and nature of the lesion, and if this is recent and comparatively superficial, if a piece of the foreign body yet remains in the wound, or if its re- DISEASES. 637 moval has resulted in the sloughing of a small piece of dead tis- sue, it may be sufficient, the foot being pared thin, as already ad- vised, to simply make an infundibuliform opening, various in size, so as to exjoose the bottom of the VFOund. For that purpose, the di'awing knife or the sage knife is used, a light shoe is put on, and a dressing of digestive ointment, oegyptiacum, or simply alcoholic mixtiu'es, are kept on by plates. At times it is advantageous to assist the process of sloughing by the use of caustics, sulphate of copper, Villate's solution, tincture of iodine, etc. If the wound is near or at the heels, the branches of the shoe are shortened and an appropriate dressing is put on. Subsequent dressings requii*e the same care. Cicatrization goes on and the hoof soon returns to its normal condition. Sometimes the surgeon is called only when the inflammation is far advanced and suppuration already estabHshed. This peculiar condition is manifested by the swell- ing and heat of the parts, the acute pains, and often the high fever. The wound then must be at once enlarged and the pus allowed to escape, and this is the true operation for deep punctured wounds. The operation becomes more serious if there is separation, partial or total, of the sole or frog, with a more or less advanced disorganization of the tissues underneath. If there is escape of purulent synovia, extensive cuttings are to be made. In olden times, to perform the operation of the deejJ punc- tured wound, the entire removal of the sole was performed, with- out distinction or exception and notwithstanding the severe pain following it. In our day, a portion of separated sole or frog only is taken off. This is done by sUces, and only so far as neces- sary for the other steps of the operation. This operation is indicated when there is great pain, continu- ing without regard to what treatment has been followed. It is also when the plantar aponeurosis has assumed a greenish tint, diffused in its extent, without indication of a repaii'ing process, with the mai'ks of sloughing of the dead structure. The instru- ments needed are various : sage knives, single and double ; draw- ing knives of various sizes : a directory, bistoury and forceps. The animal, properly secured, and placed under anaesthetics, if too irritable (Bouley), the horny structures are removed where- ever the suppuration has separated them from the soft tissues be- neath, or the sole is only pared down thin, as well as the horny frog in its whole extent. G38 OPERATIONS ON THE FOOT. Tliis first step of the oj^eration completed, the operator intro- duces a du-ector into the whole tract of the fistula, and with a sharp sage knife a longitudinal incision is made, following the canula of the directory as a guide, above and below the fistulous opening, and in the direction of the antero-posterior axis of the foot. This done, with the sage knife held in full hand, with one cut the surgeon, by a deep incision, removes the greatest thick- ness of the tissues all around the longitudinal cut he has just made, transforming the fistulous tract into a conical iBfundibu- lum, whose apex is at the bottom of the wound. If then the apo- neurosis is not yet exposed, the operator removes with the for- ceps and bistoury whatever tissues still cover it. Then follows the excision of the aj)oneurosis. This is meas- ured by the extent of the necrosis. As a rule, it must reach a little beyond the diseased jDart, and by that operation the puru- lent synovia finds a free chance to escape. If the sesamoid is sound, it must be left alone, but if the diathrodial surface is roughened, ulcerated and on the way to desquammation, it must be scraped ofi" with the narrow and long drawing knife. The complications of arthritis cannot be interfered with by the surgeon. It is by general antiphlogistic treatment, and by local and external ajiplications that they must be treated. The operation ended, the dressing follows, and becomes one of the most important parts of the means of recovery. As light a shoe as possible is placed on the foot, a coat of hoof ointment, Venice turpentine, or tar, is applied upon the thinned sole ; pads of oakum, wet with alcohol, carbolized or not, are then carefully laid on the soft j^arts. Some practitioners cover them with cegyptiacum (Mandel) ; others simply with Venice turpentine (Lafosse). The pads or balls of oakum must not be too thick or hard, as no pressure is needed. The whole dressing is retained by plates, and several cii'cular straps of tajie above the coronary band. Cold water baths are always good afterward. In the subsequent dressings one must bear in mind that the work of repair, the granulating, is more rapid in the tissues of the plantar cushion and fleshy sole than upon the bone and tendinous tissue ; and that in this case it is longer than uj)on bone if this has been scraped. The result of this is a wound which presents DISEASES. 639 ■various aspects iu its progress of cicatrization. It often has a Iiaudsome granulating appearance over its entire surface, while at tlie bottom there may be a clot of coagulated synovia covering the surface of the sesamoid and the edges of the wound of the plantar aj^oneurosis. A free escaj^e of synovia must always be facilitated, and often the development of the granulations has to be con- trolled. If the cicatrization proceeds well and regularly, dress- ings need be changed but seldom, being satisfied with the cold bath, with copper solutions. Dressings can be made with tincture of myrrh or aloes ; some- times in the centre vnth tincture of iodine. At times caustics are again used, while at others, fragments of bone or of tendon have to be excised. The entire closing of such a wound may sometimes take place in a month ; but often, even without complications, two or three are required. Comphcations may easily make their appearance and interfere with the cicatrization. Sometimes pieces of necrosed tis- sues which remain at the bottom of the wound give rise to fistulous tracts, until they are entirely removed. In this case, twice as long a time may be necessary to a cure. The pain and intensity of the lameness after the operation do not accurately indicate the nature of the disease ; the general phlogosis, especially the synovial in- flammation, always causes a special acute pain, which for from three to six weeks may prevent the animal from resting his foot on the ground. This pain is entirely independent of the process of repair, and must not alarm the veterinarian. While the react- ing fever is absent, and there is a good appetite and no swelling in the region of the coronet, the progress may be considered sat- isfactory. After the cicatrization of the plantar wound made during the operation, the parts may return to their physiological condition, or nearly so ; or, on the contrary, remain in an entirely abnormal condition. Often, indeed, the sesamoid sheath may become obht- erated, the diarthrodial surface has lost its smoothness and there is no more sliding upon it, the tendon having become united to it. The animal then remains lame, and cannot be utilized except in walk- ing ; if coronary anchylosis, ringbones are detected, and the appli- cation of firing is indicated. Sometimes neurotomy gives excellent results. 640 OPEEATIONS ON THE FOOT. CONTBACTED HeELS HoOF BoUND. Synonym: Zwanghuff, German; Encasleture, French; Incas- tellatura, Italian; Encatenadura, Spanish. This name has been given to a defect of the horse's foot, by which it becomes characterized by its general narrowness, more marked, however, in the posterior than the anterior part. It is especially marked by the diminution of the lateral diameter of the horny box, the deformity consisting in a greater or less contrac- tion of the heels and of the quarters. It is principally observed in the fore feet, and it is there only that it presents the characters we are about to describe. This is due to tbe fact that in the fore legs there is need of a certain ex- pansibility in the posterior part of the foot, which, especially during the action of locomotion, receives the weight of the body ; while the contraction of the hind feet gives rise only to an ordinary form of lameness. Sometimes one of the anterior legs only is affected; sometimes both, and in this latter case the alteration is usually greater in one foot than in the other. Some horses are also seen whose feet are contracted only on one, usually the inner side, while the other preserves its normal form and du-ections. Sometimes "hoof -bound" is only a simple deformity, without lameness and without serious result. But in most cases, it consti- tutes a very serious affection, which renders many horses useless and almost without value. It is of more common occurrence than is generally admitted, and gives rise to many other affections of the foot. Cases of lameness treated as located in the shoulder, or as naviciilar disease, are very often nothing but the result of com- mencing contraction of the heels. True navicular arthiitis and hoof-bound are closely related. Whether the disease of the sesa- moid sheath, arising primitively, brings on the subsequent con- traction ; whether the contraction already existing gives rise to the alteration of structiu'e which constitutes the disease so named, cannot always be determined. Hoof -bound was known in old times, and the oldest hippiatrics have proposed means to cure it. Riders especially have studied it, because the disease is most com- mon in fine saddle horses, whose feet are small. It is frequent in Turkish and Spanish horses, and animals from the PjTenean dis- tricts, but common horses are not exempt from it. DISEASES. 641 H. Bouley describes two forms of the disease, the true and the pretended or false contraction. In the first, the hoof is veiy nar- row, sometimes even concave on its lateral face, to such an extent that its antero-posterior considerably exceeds its tranverse diame- ter; while at the same time its wall is more vertical, and the heels considerably higher than normal, and the foot looks like that of a mule, of which this is recognized as the normal appearance. In the false contraction, there is merely a diminution of the transver- sal diameter of the horny box in its posterior parts, the foot being narrow and contracted at the heels only. We prefer to recognize a total contraction where the whole foot is contracted, and is smaller than its fellow, atrophied, so to speak, consisting in a contraction of the quarter — when it is principally narrow in those quarters, the condition extending back to the heels — and a contraction of the heels when this is well marked from the quarters to the heels only. A coronary and a plantar contraction have also been designated, depending upon whether it occurs at the superior or inferior part of the foot, and there are cases where the contraction is intermediate, that is, in the middle of the foot only, while it has its normal size, both at the coronary band and at the plantar border. Single and complicated contrac- tions have also been named. It is admitted that it may be co')%- genital, though rare ; more often, however, it is developed by it- self, as a result of special causes. I. Symptom,s. — The physiognominal aspect of the hoof-bound foot is characteristic, and it is by this that we shall begin the symp- tomatology of the disease. When the disease is total, the com- plete general dimensions of the foot are observed to be smaller than would be required by the size of the animal affected ; most frequently the hoof has an oval form, consequent upon the antero- 230sterior diameter exceeding the lateral, which is generally dimin- ished. In the contraction of the quarters, the narrow condition of the foot is specially marked from the centre of the quarters back to the heel. In contraction of the heels, the diminution is ver}' marked from the centre of the quarters to the end of the heels, so that the two sides of the wall converge toward each other posteriorly in following nearly a straight line, instead of the cir- cular appearance of the normal state, and the heels have princi- jDaUy lost their round appearance, and are elongated, and even pointed in ajDpearance. The wall, in the regions where the con- 642 OPEBATIONS ON THE FOOT. traction is more marked, that is, behind, is either perpendicular to the ground, or even oblique downward and inward, in such a way that the coronary circumference is greater than the plantar, and consequently it represents an inverted trvmcated cone. The opposite form of contraction, that of the coronary, is seldom seen, and we may ignore it. The waU is iiTegularly rough and ramy, and without its shining appearance. The heels are gener- ally high, nearly as high as the toe, though it is not so severely altered in cases where the heels only are contracted. As a con- sequence of the contraction of the plantar border of the wall, the sole seems to become folded in the direction of its antero-posterior axis, and it shows a much greater concavity on its internal face than in the normal state. This cavity is then filled by the frog, considerably reduced in size, thus presenting an idea of the sever- ity of the contraction. Most frequently it is a thin, thready body, flattened on its sides by the closing of the bars ; its branches, thin and narrow, resembling two bands so closely resting on each other that the lacunae which separates them is no more than a narrow fissure, which will scarcely admit the introduction of the thin blade of a knife, and from the bottom of which escapes a sero- purulent, gray or blackish liquid ; the lateral lacunae being also transformed into two narrow and deep fissures, fiUed with the same fluid. The bars, generally high, assume a direction perpen- dicular to the ground, instead of being obhque, as in the normal state, from the centre of the foot toward its circumference. In all the regions of the foot, but especially at the wall, the horn is so dry and hard that sharp instruments cannot cut its cor- tical covering, while it is at the same time brittle, and hence nu- merous superficial fissures appear at the quarters, and the outside and inside toes, the frog itself being hollowed by fissures upon its body and branches. Sometimes it happens that the bars show deep fissures, running from above downward, to the extremity of the lateral lacunae, which are thus continued by a crack of the heel up to the skin of the coronary band. There is often a sepa- ration of the wall and the sole, the formation of what has been called a double wall, or false quarter. Quarter cracks are com- monly met with it. Corns are frequently seen in connection with it. "Whatever may be the form of the contraction, it is generally accompanied by pain, manifested by change of position while at rest and by lameness when in action. DISEASES. 643 If only on one side, the affected leg is carried forward, and thus relieved from the too painful pressure which would take place if it remained in a vertical direction Tinder the center of gravity. When both feet are diseased, the horse is constantly moving and balancing himself, pointing the legs alternately, and sometimes stretching both legs forward, as in laminitis, but always moving, so as to push his bedding under him and away from his- fore feet. If the pain is slight, there is only a stiff gait, and the aniroaX hesitates and stumbles easily. But if the disease is advanced the lameness is great and the animal is very groggy in his gait. He fears to rest on his heels, which, without being a peculiar charac- teristic, is a symptom which present, however, a particularly notice- able condition. While there is hesitation in the action of resting, there is difficulty in that of the shoulder. This is principally observable when the disease affects both feet. The shoulders then seem to be fixed to the trunk, and their motion forward is very limited. The sjinptoms are mostly more marked when the animal leaves the stable. It may then happen that the pain tem- jDorarily losing somewhat of its intensity as the horse is moved, the shoulders become more free, the hberty of action returns, and once warmed up, the animal may offer a totally different ap- pearance from that when first leaving the stable. But as soon as they become rested, the pain returns as severely as before, if not more so, and with it the same exhibitions of symptoms. The examination of the unshod foot while it is warm, shows the extreme sensiblity of the heels. The foot being pared, gen- erally one may observe, in the region where the contraction is most marked, yellowish or reddish discolorations, evidences of the bruises in the living parts, as well as of the serous or bloody exudations which have taken place on their surfaces. These indi- cations are especially abundant on the level of the sole and wall. If the contraction is old, there is at that point a purulent mass which, when removed, leaves a ea\dty which sometimes extends upward under the quarters. It is a separation of the waU, of two or three centimeters in depth. An important observation for hoof-bound, and which assists in its recognition, is the increased wear upon the shoes at the toe, which takes place not only when animals are working, but also while idle in the stable, as the result of pointing and scraping the 644 OPERATION'S OX THE FOOT. stable floor. The horse which has both feet diseased in constantly in motion, to such an extent that his shoes are entirely worn in a few days. At times the pain is so great that it gives rise to general symp- toms ; the animal becomes anxious, loses his appetite, refu^ses his food, lies down most of the time, and rises only with difficulty. II. Coinplicatiofis. — We have already seen that quarter cracks and drt/ corns are common affections of contracted feet. Exos- tosis of the phalangeal region is also commonly met in such feet, especially side-bones. Knuckling, and diseases of the tendons and of their sheaths are also often caused by contractions of the feet. The rest of the foot on its whole surface is thus perverted and the tendons become retracted, painful and swollen. Navicular disease is so often met with in com|)any with con- tracted feet, that one disease is frequently mistaken for the other. Laminitis has been said to be also one of the complications ; if so, it is at least quite rare in its occurrence. Tetanus has sometimes been observed among its associations, and Hartmann attributes the development of* so-called idiopathic cases of that disease to this condition of the feet. The emaciation of the affected leg is a complication seen also, with other forms of lameness. III. Patholofjlcal Anatomy. — We have indicated the external changes of the hoof. The tissues that have been long enclosed in the contracted foot become atrophied ; molecular changes do not take place as in the normal state ; they become changed in aspect, composition and properties ; they become denser and more com- pact, and are no more able to fulfill, to the same extent, their physiological functions. The plantar cushion is so completely pressed upon itself that the stratified structure of its fibrous layers can scarcely be dis- tinguished, and the presence in the interstices of the yellow fibrous substance is with difficulty observed. It forms only a homogene- ous mass, whitish in color, resisting in consistency, and lardac- eous in aspect The dilated bulbs which are above the cushion are also considerably diminished in size, and present, when cut through, a uniform white color, its composing substance being reduced to a single inelastic mass. The ungueal phalanx becomes deformed by degrees, loses its circular shape and becomes of an elongated oval form. Its lateral DISEASES. 645 faces assume a perpendicular direction ; its structure is modified ; its substance becomes more compact, and the small vascular open- ings are obliterated, while the largest are increased in size. The work of obhteration is specially observable at the patilobe emi- nences, which appear to be crushed. The lateral cartilages are also much compressed, condensed and modified in their struc- tiu'e. The navicular bone is also compressed, the sheath and its sup- port not allowing the easy play of the tendons, and it is in this way that navicular disease may follow hoof-bound. But there is a specially noticeable modification in the keratogenous appara- tus, which, as a consequence of the arterial obliterations, fails to receive freely and actively the necessary amount of blood. The horny secretion proper to the podophyllous tissue, the white or soft horn, is reduced; the podophyllous tissue itself is atro- phied ; its lamellae are less prominent and their separations are diminished in depth ; the adherence of the podophyllous or kera- phyllous tissues still exists where the circulation of the blood is not interrupted, but beyond, they are easily separated and often present deep excavations toward the sole. If hoof-bound advances slowly, the same atrophy of the sub- horny tissues takes place. Then, howevei% it proceeds by degrees, the tissues accommodating themselves in size to the gradually diminishing dimensions of the cavity where they are contained, and there is an equal proportion between the size of the hoof and the volume of the tissues enclosed in it. These being less com- pressed, there is less pain. In this manner an excessive contrac- tion of the heels may sometimes exist without marked lameness. IV. JProgywsis. — This is the more serious as the disease is more developed. Total hoof-bound if excessively tenacious, and resists the best curative measures, though if there is only a slight contraction at the heels, it is generally amenable to judicious treatment. The duration of the disease is an important factor in the question of the success of the treatment, as the condition of the OS coronse, os pedis, navicular bone, sesamoid sheath, plantar cushion and the atrophy of the keratogenous membranes have all to be taken into consideration. The age of the diseased animal and any existing compUcations are, of course, circumstances which influence the prognosis in an important degree. 646 OPEKATIONS ON THE FOOT. V. Etiology. — Hoof-bound, says H. Bouley, is not a simple fact, produced by a unique cause acting always in the same man- ner : it is, on the contrary, a very complex one, to the production of which a great number of causes of various character and inten- sity contribute with simultaneous or successive effects. The hygrometic condition of the horny substance is a principal feature in the etiology of the disease. It is when the hoof loses by evaporation the moisture which it should contain that it con- tracts as all organic substances do, and its flexibility returns when by sufficiently long immersion in a Hquid, the moisture it has lost is recovered. Observation proves that this disease often finds the conditions of its presence in circumstances which induce dryness in the part. In such cases the foot has the property of retracting, to an extreme degree, especially toward its posterior extremit}^ where the frog is situated, constituted as it is of a softer and more depressible substance than that of the wall. The same phe- nomena takes place in the living structure that is observed upon the hoofs of dead feet ; a phenomenon which cannot even be pre- vented by filling their cavity with plaster. During life the hoof is constantly permeated by a current of fluids which penetrate it from its depth to the surface. It is the serous food that the hoof is continually absorbing by the hygroscopic properties common in living tissues, which covmterbalance the tendency of the foot to retract upon itself and keep it in the dimensions required for the perfect recej^tion of the parts it covers. So long as the equilib- rium is preserved between the loss of this fluid by evaporation and its renewal through the perspiration of the keratogenous apparatus, the hoof preserves its physiological form ; but if this equilibrium is destroyed by an excess of thie loss, then the condi- tion occurs for the retraction of the hoof and the infliction upon the parts underneath of an excessive and painful pressure. This explains why, as proved by observation, lameness in general and that of contracted heels especially, is more frequent in warm than in moist seasons. Long standing in the stable is also an efficient producing cause. The feet become dry upon a constantly dry bedding, and here also the influence of inaction must be taken into account. The disease is commonly found in stabulation, but seldom when the animal is in pasture ; and when it has existed it often disappears in the latter circumstances. The alternation of dampness and dryness also influences per- DISEASES. 647 baps more the genesis of the disease than dryness alone. A foot too much impregnated with dampness, which is afterward left to the air, becomes harder than a normal one placed in the same con- ditions. It retracts easier, also. It is probable that the water, in softening the superficial layers of the wall, also renders the evap- oration of the Hquids of its deep parts more active. In the ordi- nary condition of the foot, the evaporation is d imini shed by the impermeability of the external hoof, which it owes to its density ; but where this hoof is softened by maceration, its fibres, partly disintegrated by the dissolution of the glutinous substance which ieeps them as a compact mass, allow the air to penetrate in their interspaces ; air which diies them to a certain depth ; hence a groportionate movement of retraction of the entire hoof upon itself. This evil effect of an excess of moisture explains how it is that poultices or other moist applications which horse attendants abuse so frequently, may give rise to results entirely opposite to the one in view, and why the hoof becomes dry and brittle, if not contracted. These topical apphcations take off from the cortical layer of the foot its protecting varnish, and expose it to lose its water of growth. Some of the practices in shoeing contribute also to the dessi- cation of the hoof ; such is principally that which consists in rasp- ing the wall from the coronary band to the plantar border ; as also the too long continued contact of a hot shoe with the foot. Shoeing itself promotes the same result, as, protected by a shoe, the foot no longer wears normally and grows beyond nor- mal limits. The mass of hoof which, in the process of growth, has gone beyond the inferior limits of the podophyUous fissures, is no longer in contact with the liring parts beneath, and they cease to be impregnated by the fluids which are thus constantly allowed to evaporate. It then dries up by evaporation and become hard, and retracts upon itself in such a manner that the circumference of the foot ia the lateral diameter diminishes more or less, espec- ally posteriorly, and thus forces the incurvations of the sole and of the bars (H. Bouley). If a horse remains shod for several months without having his feet trimmed and pared by the black- smith, these are seen contracting by degrees, as they increase in length, and soon assume the aspect of hoof-bound. But these are not the only effects of shoeing in the etiology of contraction. On the contrary, this practice is the most common 648 OPERATIONS ON THE FOOT. cause of this lesion of the hoof if not practiced with the intelli- gence it requires. We have said, in speaking of corns, that they were proofs of bad shoeing. The same might be said of the con- traction. Moreover, corns generally indicate great errors in shoe- ing, while hoof-bound demonstrates the ignorance of the physiology of the hoof, which in action must enjoy the necessary elasticity to relieve the contact with the weight of the body upon the ground. No doubt the theory of Bracy Clark exaggerates the degree of elasticity in admitting a great power of dilatation of the hoof, but it is an opposite excess to deny it entirely. The dilatation of the hoof, though limited, is evident at the heels; especially on feet which have never been shod (Merche). There is especially in the inside of the foot, in the soft and supple parts, a cei'tain compres- sibility of the hoof, which is often overlooked, and which is inter- fered with by a too narrow or vmmethodical shoeing. The external dilatation of the hoof is comparatively limited, but on the inside of the hoof there is, in the posterior part of the foot (especially in the fore feet) a movement do'unward and out- ward of the OS pedis, for whether the normal elasticity of the hoof is necessary, either by the physical and physiological constitution or the arrangement of the constituent parts of the hoof. Quite often, then, shoeing, especially if too tight, resists the internal pressure. Even admitting that the dilatation of the heel is nor- mal, shoeing which would prevent it, would always produce, at the time of rest, a pressure upon the hoof which would limit the comj)ressibility of the deep, soft tissues. The frog, especially, formed of a softer horn, and placed under the plantar cushion, must receive this gradual pressure, which diminishes by degrees as the hoof becomes harder, and is reduced considerably as it reaches the external horny layers. The errors committed in shoeing, and which predispose to hoof-bound, vary. The first is in the manner in which the foot is pared ; too often the heels are lowered to excess, whUe the toe is allowed to remain too long ; too often, again, the bars are hollowed too deeply, thinned too mdch, as well as the frog. The wall then tends to retreat, as it is no longer protected behind. In reducing the height of the heels, in opening them, the tendency to contrac- tion is increased ; the thinned hoof dries up, the lowered heels lose their strength, and the bars are unable to perform their functions. DISEASES. 649 A vicious adjustment also contributes to contraction. Wlien the shoe is so prepared that its upper face is concave, and its branches form a plane incUned from without inward, and when this face extends back to the heels, there is a circidar pressure produced upon the inferior border of the wall. This is a case in which the foot has a tendency to drop, pressed in as it also is by the weight of the body as the foot rests on the ground. Another wrong practice is to place the nails too near the heels. The fixing of the shoe on tha foot tends always to produce con- traction, as Bracy Clark observed ; it especially prevents the wide- ening of the hoof, as remarked by Rodet and Coleman. But this effect of the nails is well marked at the heels, where they prevent the dilatation of that part of the foot. These effects of shoeing are to be observed so much the more rapidly and seriously when the hoof is thicker, denser, and of a finer stmcture, as it is observed in small feet. In these feet, the hoof grows more rapidly, and is on this account more ready to contract. Let us now consider that this effect of shoeing is per- manent, and that to the effect of a first shoeing comes to be added that of a second, of a third, and so on, and we can i*eadily under- stand how truly the great number of contracted heels one may meet with can be attributed to erroneous shoeing. Inaction is also an important cause, as, says Turner, the horse is by nature destined to be always in motion; it is a condition of its health, and it is on account of this condition that in the state of nature he is free from contracted heels. It is, on the contrary, because the domesticated horse is confined within a stall for hours and days, that his feet become contracted. We have seen colts raised without exercise, whose feet were contracted before they were shod. Contraction of the heels is often the result of other diseases of the hoof, and of other lameness. It is commonly associated with corns, navicular disease, punctured wounds of the plantar region, accompanied with long sensitiveness of the posterior parts of the foot, after-diseases of the frog, thrushes, side bones, phalangeal articular diseases; in fact, after all affections of long standing, even if they have their seat in the uj)per segment of the frog. Finally, heredity has been named as one of the causes. This cannot be denied as to some breeds, princij)ally of meridional climates, as a consequence of the organization of their feet, which 650 OPERATIONS ON THE FOOT. ai'e usually small. The proposition lias, however, we believe, been exaggerated. This is proved by the Arabian horse, which, though accused of the vicious confirmation from heredity, has, according to Vallon, Crompton, and others, the most admirable comf ormation of his feet, when it has not been shod. It is broad, with good heels, neither too high nor too low, well open, well prominent, wide frog, the external wall being strong and well developed. In the horses of Caramania, Anatoha, Sjoia, and those of the Arabs, which are constantly in the desert, from Bagdad and Bassaro to the Gulf of Persi4 the foot is handsomely made, and free from all contractions when it has been exempted from shoeing. VI. Treatment. — Prophylaxy plays an important part in the treatment of this disease. It is easier and especially more rational, to prevent than to cure it when once estabhshed. One of the first indications is to prevent the drying of the hoof, to effect which baths and poultices have been commonly used — the latter formed of cow manure, of clay, etc. — or by the appHca- tion of greasy substances, in order to diminish the evaporation of the water of the hoof. Some practitioners are accustomed to use tar and various hoof ointments. The number of preparations brought into use is considerable, and in respect to some of these, the secret of which has been kept by the inventors, the effects have been entirely different, and the hoof, instead of preserving its natural good condition, has been altered in its qualities. "It is not with ointment," says Hartman, "that the hoof injured by the blacksmith can be repaired. It is by good shoeing, and never otherwise. The workman, to excuse himself, attributes to the quality of the hoof the origin of the mischief he has done." Hoof ointment never gives to the hoof its natural polish, but many oint- ments, by becoming rancid, take off that which the blacksmith has left. The irritating ingredients which compose them sometimes produce the same results. This does not mean that a reasonable application of ointment is not necessary ; but to act favorably it is essential that one coat should be cai'efully removed before the apphcation of another. Otherwise, the new will fail of its proper effect, and, on the contrary, the old coat, by its alteration, will give rise to a deterioration of the hoof, especially in affecting the substance which unites the homy elements, and would reduce it to fine powder. And, again, ordinarily it is only the wall which DISEASES. 651 is greased, the hoof of the sole and of the frog being left without, though they may be in equal need of it. The best hoof ointment is made of lard, a small quantity of wax or turpentine, sometimes mixed with tar. Glycerine is very useful, to give the hoof supple- ness when it has become hard ; it is applied by friction, after the foot has been well washed and dried. In the majority of cases poultices are preferable to mucilaginous baths. Greasing is necessary for horses which are much exposed to dampness, and is as good for the sole and frog, as for the wall. It is appHcable, also, to feet which have to stand on diy bedding. Feet, which, on account of diseased conditions, require to be fre- quently soaked or poulticed, ought also to be greased. Bedding of fine sand and of sawdust has been recommended. It is well, also, to place horses upon marshy lands. All these measures may be advantageous if the feet are properly shod. Good shoeing is the essential prophylaxy of hoof-bound ; we must avoid all imj^roper practices likely to promote desiccation and contraction of the foot, such as abuse of the rasp ; too long api^lication of the heated shoe when fitting it to the foot ; the lowering of the heels ; the excessive paring of the frog or of the bars ; the bad fitting of the shoe ; useless calks ; too many nails in the quarter or near the heels — all these errors must be carefully avoided. The foot, moreover, must not be allowed to grow too long. The shoeing should be renewed at least monthly, even if the shoe is not woi-n. And lastly, the horse must not be allowed too long periods of inactivity. It has been proposed to abohsh the custom of shoeing, but in the present conditions and modes of using the horse this is im- possible. The feet, deprived of their accustomed j)i'otection, would soon become painful, and only by keeping the animal in the coun- try could the feet be siiffered to remain unshod. Several modes of shoeing have been invented to pi'event con- tractions in feet which are predisposed to them. Some are vm- doubtedly beneficial, but they must be used as an ordinary shoe- ing, and not reserved until the access of the disease. Good ordinary shoeing is often all that is requu-ed, but no doubt better and quicker results will be obtained by the shoe with short branches, with the flat shoe, or with the Charlier shoe. The half shoe, the shoe with sho7't branches {fer a croissant), originally recommended by Cesar Fiaschi, then by Solleysel, La- 652 OPERATIONS ON THE FOOT. Fig. 498.— Short-branched Shoe. fosse, Sr., and Crompton, is an ordinary shoe, made light, with very short branches (Figure 498), which when put on protects the toe, the mammae (outside or inside toe), and the anterior parts of the quarter in such a man- ner that the parts posterior to these remain uncovered, and rest directly on the ground. Thus shod, the shoe is almost in its natural condition; it rests on the ground by its posterier part, and the heels are made to contribute to the movement of expansion of the elastic parts of the foot. This shoe, then, has real advantages, if the posterior part of the foot is yet normal, but if the heels are low and the frog atrophied, it ceases to be of service. The flat shoe, or the shoe with base {fer a siege), first recom- mended by Osmer, Morcroft, and more recently by Miles, Ein- siedel and Hartmann, is the style generally adopted at the pre- sent time in Saxony, and in various parts of Germany, as well as in England. In France it has found its way through the benefits observed by a few veterinarians. It is a shoe almost equal in thickness to its width, square, so to speak, but as light as possi- ble ; the internal border of the foot surface being hollowed or dished in order not to come in contact with the sole, while the part which rests on the plantar border of the wall is perfectly flat and horizontal. The heel portion is rounded, and covers mostly the heels of the foot where the borders of the shoe become per- fectly adapted to the borders of the wall, to the remotest part of the heels, and preserves the same contour until it reaches the frog. The shoe nowhere projects beyond the border of the wall ; it is only toward the toe that it is slightly raised and has a small cHp. The groove of the English shoe renders its application better than the peculiar nail holes of the French. Five or six nails are usually sufficient. This shoe allows the dilatation of the foot in DISEASES. Gr,3 all its limits, and while protecting the heels, does not predispose to their contraction. For its appUcation, the plantar border only- needs paring. That of the sole, the frog and the bars must be carefully avoided. For the shoeing of Charlier, or peri-plantar (Figs. 499 and 500) the part of the hoof which is most exposed is protected. It Fig. 499.— Foot prepared for Charlier Shoe. FiG. 500.— Foot Shod; Charlier's Method, preserves entirely all the other f>arts of the plantar surface in such a way that, as in the conditions of nature, it is only by the fact of the wearing of the shoe that the excess of hoof is gradually re- moTcd. The foot shod by this process is provided at its inferior border with a metallic bar, often greater in thickness than in width, lodged in a groove made exclusively in the wall. This bar adapts itself in its internal circumference to the contour of the sole, which projects beyond the border of the groove, because aU its thickness has been preserved as well as that of the frog and of the bars. In this way the rest of the foot receives its adjustment from the shoe itself, and by the regions of the plantar surface which it surrounds. This result does not, however, take place immediately, or when the foot is recently shod ; but by degrees, and as the shoe wears out, the time arrives when the horse walks both on his shoe and the sole of his foot. Owing to the general equalization of the friction any partial wear is thus diminished. 654: OPERATIONS ON THE FOOT. and the important result is secured of reducing the weight of the shoe without the necessity of too frequent renewals, experience having proved that for the fore-feet it is quite as durable as the ordinary shoe of twice its weight, but which from the manner in which it is appHed suffers, unaided, the effects of the pressure and friction (H. Bouley). As in the action of paring the foot only the projecting portions of the wall at the inferior border are re- moved, the preserved parts of the plantar region resist the move- ment of retraction, and thus prevent its occurrence in a transverse direction. Again, as the thickness of the Charher shoe is greater than its width, it possesses a certain elasticity and adapts itself to^ the successive movements of the dilatation and contraction of the horny box, however limited they may be. We may now refer to some special modes of shoeing, recom^ mended as preventive of contracted heels, but which seem to us to possess inferior advantage to the preceding. We first find the unilateral shoe of Tiu'ner, which, according to that veterinarian, relieves the foot from pressure upon the heels by placing the nail holes on the toe and the external branch only. Tui-ner recom- mends also the conservation of the frog and that of the bars, and it is probably to this that the success he has obtained by that mode of shoeing is due. Coleman recommended a shoe very thick at the toe and thin at the heels, the toe being three times as thick as the heels. This veterinarian thought that by this shoe the animal was obliged to rest on his frog ; at the same time the nails were driven in the toe principally, so as to allow the dilatation of the heels. This shoe has no real advantages, and predisj)oses to corns. The bar shoe is of some utility when the frog is well developed, by placing on that part the pressure of the foot, and leaving the heels free. But it often fails in contracted heels, because in apply- ing it these parts require to be pared down, in order to increase the prominence of the frog, and a condition is thus produced which does not exist in contracted feet. The same may be said of the Charlier bar shoe. The objections stated and the reasons suggested are true of all the various shoes designed to adjust the frog pressure. The hinge-shoe or articulated (Figs. 501 and 502) of Bracy Clark and Vatel, and the half-shoe of Sempastous, of Peillard, also possess but a doubtful utility. Practice has not confirmed DISEASES. 655 Fig. 502.— Hinged Shoe. FiG. 502.— Articulated Shoe. the hopes of their inventors. They are difficult to make, easily injui'ed, and of small soHdity, and their advantages are wholly of the problematic order. Mayer has recommended a shoe whose internal border is thicker than the external, in such a way that the plane of the plantar surface of the shoe shaU be inclined outward, and instead of the concavity of the ordinary shoe, where the foot is pressed when in position of rest, there is a convexity which promotes and even increases the dilatation of the foot. This mode of shoeing has for its inconvenience the exposure of the sole to contusions. It supposes an extensive expansion of the foot which is not natu- ral ; the horizontal plane is amply sufficient in ordinary circum- stances. We have, however, used it advantageously in preventing the pressure of the sole against the shoe by means of a sheet of gutta-percha. We have used it in almost complete contraction, and we think we have noticed, with Hartmann, that the dilatation once started by a mechanical means, not too severely appHed, nature continues it, ynth. the assistance of that style of shoe. In- stead of giving that special shape of the shoe in its entu*e length, it has been proposed to have it only at the branches ; each heel presenting at its internal border a thickness double, or even treble, that of the external, by which the shoe is inclined outward by its plantar and becomes horizontal by the grovmd face. It is flat at the toe and the quarters, and is the shoe with slipjiers of de la Broue (Fig. 503), of SoUeysel, and that Vatrin has used in pro- posing to have the internal half of the width of the shoe inclined (Fig. 504). It thus resembles the shoe genete or with ears, of 65G OPERATIONS ON THE FOOT. FlO. 503. Fig. 504.— Vatrin'3 Shoe. which we shall speak hereafter. This shoe is only indicated when the heels are already contracted ; they have no indication as pro- pjylastic shoeing. The shoe with slippers is indeed a shoe which in some cases may cure contraction. " If the results obtained have not been very satisfactory," says Defays, " this depends not uj)on the shoe, but arises from the defective manner in which the foot was pared. To be efficacious in that shoeing the heels must be left alone, and the sole and the bars must be well thinned. It is true that in this way the foot is in the most favorable condition for contraction, but the circulation is rendered easier in the tissues underneath, and the effects of the thinning of the hoof are diminished by the resistance opposed to contraction by the incHned planes of the bi'anches of the slipper. The same may be said of the shoe of de Belleville, also recommended by Solleysel, and for whose appH- cations the foot has to be carefully pared. We feel assured of the propriety of recommending the use of the inclined plane of the branches of the shoe with the presence of a small clip on the inner borders of the heels, such as proposed by Vatrin. Attempts have been made to dUate the contracted foot and to cause its return to its normal dimensions by mechanical means. The shoe with ears (Fig. 505) has been devised for this pur^^ose. This is a shoe provided on the inner border of each heel with DISEASES. 657 an oblique, blunt, sometimes perpendicular clij), resting upon the bars, which have been previously hollowed out for its reception, the design of which is to resist the return of the hoof which has been dilated, to its former contracted condition. Ruinien had spoken of this shoe as early as 1618. It was put on, after the dilatation of the hoof with the farrier's nippers, applied on each FiG. 505.— Shoe with Ears. Fig. 506.— Jarrier Spreader. side of the quarter, the sole being entirely removed. In our days this operation of removing the sole is considered useless, and in- stead of the nippers of the farrier, dilators are used, under the name of spreaders (desencasteleur). The oldest known form is that of Jarrier (Fig. 506). This is composed of two curved branches, 11 centimetres in length, articulated at one of their ex- tremities like the ordinary compass, at which point there is a screw of peculiar form by which the branches are closed or opened at will, the other extremity having a strong claw projecting out- ward. These claws are applied inside of the bars, toward the heels, which are previously thinned out, and by manipulating the screw the hoof is dilated to the extent desu'ed. The shoe is then used like an ordinary one, both heels being armed with a clip on the internal border, the clips resting on the heels of the foot, which have been first opened with the drawing knife. This mode of treatment proved successful with Lafosse and others who ex- perimented with it at the Saumur school. Under various experi- ments, the desencasteleur has changed its form. Thus, Lafosse has arranged the two branches to run separately upon a transversal G58 OPERATIONS ON THE FOOT. Fig. 507— Lafosse Desencasteleur. rod like an ordinary vice, in wliich form the brandies are shorter, and more power is obtained (Fig. 507). There are many other imiDrovements which we cannot mention for lack of space. Instead of applying the dilatation upon the hoof, and after- ward using a shoe which is closely adapted to the dilatation thus obtained, spreading shoes have been used. In the method of Jarrier, the shoe has to maintain the hoof in the condition of dilatation which has been accomplished by the instruments of ex- pansion. It is a very dehcate and difficult operation, so far as the proper dilatation of the foot is concerned, requiring the closest adaj)tation between the chps of the shoe and the parts of the wall upon which they rest. An error of a few millimetres only is. suffi- cient to defeat the desired result ; and the shoe, moreover, must be taken off at each operation. To avoid this, special shoes, which would act also as dilators, were invented. It w^as not, however, a new idea; La Gueriniere had as earl}^ as 1733 prepared a shoe composed of three pieces — one median, corresponding to the toe, and two laterals, in connection with the quarters ; these latter are respectively articulated with the first, and have each three nail- holes. "When this shoe was fixed upon a foot, whether uusoled or not, its branches were spread apart by a plate left in place, and by increasing by degrees the length of the plate, a gradual and increasing dilatation of the hoof was obtained. Gaspard Saunier improved upon this shoe by placing on the internal border of the branches, cranks, with a plate placed crosswise and resting upon them (Figs. 508 and 508«). The objection to this shoe is that it cannot remain on the foot except when the animal is at rest, as when he is at work it soon becomes loosened ; besides which it is difficult to make properly. DISEASES. 659 Fig. 508.— Spreading Shoe. Fig. 508a.— a Better Form. Rolland has contrived an articulated shoe in three pieces, the two lateral pieces being kept apart by double steel springs, which press upon them from the toe on their internal border, and thus effect the desired dilatation. Hatin has a simpler shoe (Fig. 509). It is a light shoe, with nail-holes dis- tant from the heels, and provided on ^^^ *^ '^ the internal border with a small cHp, upon which I'ests a V spring, fixed by its point upon the toe of the shoe. The branches of the spring lodge in the hoUows of the sole and of the frog, and press upon the shoe, and thus pro- duce a slow dilatation. Steinhoff has also invented a shoe with springs. It has recently been proposed to obtain the dilatation by means of a strong sole of cautchouc, placed between the shoe and the foot, leaving the frog full ; very thin where it rests upon the shoe and the foot, and becoming thicker toward the inner border of the shoe, which it overlaps. First it rests in the groove of the bars, and then portrudes upon the flat of the shoe, and bears on the ground at the time of rest. This elastic mass, compressed at the moment of contact, shghtly dilates the shoe, which is articulated, or, what is better, very nar- row at the toe, and square ; the heels, also, are thus slowl}"^ and gradually dilated. Fig 509.— Hatin's Shoe. 660 OPERATIONS ON THE FOOT. Goodwin also has invented a very ingenious, but too compli- cated shoe, composed of three articulated pieces. From the center of the median piece a prolongation of iron extends to the back of the frog, and is of sufficient thickness to be perforated, the hole ha\ing a thread through which a screw is introduced, running on each side. The branches of the shoe have three nail-holes, and from the inner border of the heel rises a clip so turned as to rest on the origin of the bar. The mechanism of the shoe is easy to understand, each branch being opened by the play of the screw which passes through the prolongation of the median piece, one extremity of which rests upon this prolongation, while the other presses upon the inner border of the movable branch. The Goodwin shoe has been es- sentially improved by Foures (Fig. 510). It is a bar shoe, the bar being thicker than the rest of the shoe, and wider than the ordinary bar shoe. The bar is notched on each side, and through each notch runs a thread or vise which holds a mov- able clip, which is made to rest on the inside of the bars, and which are first properly thinned out. By a motion of the clip through the thread, the heels are slowly dilated Fig. 510.— Foures' Shoe. by degree. This shoe, however, is very expensive, difficult to make, and easily put out of order. In all these methods of dilatation the shoe has to be made of several pieces, and in this condition is found a constant cause of weakness and of rapid deterioration, for which reason they are not very practicable. It is not so with the system used by De- fays, Sr., by which the shoe, besides containing the essential ele- ments of the desired mechanical dilatation, is left entu-e to fulfill the functions of the ordinary shoe, as well. That which charac- terizes Defays' method, who had used it in 1829, but which was made known only in later years, is that the shoe itself, which, by its ductihty in action, becomes the agent of the dilatation of the hoof, becomes also, by its natviral tenacity, the obstacle to the return of the foot to its former contracted condition, when once it has yielded to the outward motion which it has acquired. De- DISEASES. 6G1 fays uses an ordinary shoe, tliick and narrow, and then further narrowed at the toe, if it is to be used on a foot regularly con- tracted. "When it is thus affected, at five or six centimetres of the heels if the contraction exists at the quarters, at the end of each branch. This shoe carries on the inside border a strong, resisting clip, made at right angles, to rest on the internal border of the wall of the heels. The shoe is flat, grooved, like an English shoe, with nail-holes slightly turned inward ; the last nail-hole made as far as possible from the heels. It is made of the best quality of iron, in order to resist, when cold, the greatest amount of forced spreading by the dilator ; it is the expansive slipper of Defay's {pantoufle ex2)ansive). The foot upon which this slipper is to be fixed must have both heels pared evenly, the sole and the bars pared down to a spring, and the hoof round the frog, on each side, thinned down as much as can be borne. Then, the shoe, flattened and without curvature on its faces — resting, therefore, on a strictly horizontal plane — is put on the foot in such a manner that the cHp of the heels rests against the internal face of the quarters. This done, the space between the two heels is measured with a compass, and then the dilator is applied (Fig. 511). This instrument represents a true vice, with jaws reversed, moving from, instead of approaching each other. It is formed of two jaws which can be made to ap- proach or separate by a transverse screw put in motion by a mov- able lever. The degree of separation is regulated by a graduated rule placed horizontally, which serves also to maintain the jaws at the same point when separated. The two jaws being introduced between the heels of the shoe, the vice being held j)erpendicularly to the plantar face, the screw is slowly turned until the branches are opened, say, eight or nine millimetres; then at the point or points of the shoe which have yielded to the pressure of the in- strument, one or more blows are struck with a hammer on the outside of the branch of the shoe, to loosen the instrument, until it drops down, without disturbing the screw, a record being made of the degree of dilatation secured, upon the graduated r.egister. After three or four days the same operation is repeated, the spread- ing being then not more than four or five millimetres. It must be less than at the first, because at the beginning the less perfect contact between the projection of the heels of the shoe and the wall has allowed a considerable amount of dilatation without pro- G62 OPERATIONS ON THE J'GOT. Fig. 511.— Defays' Contrary Vise. ducing much result. These repeated dilatations once in four days for a month, are assisted by the apphcation of soft j)oultices in horses which, on account of the pain and consequent lameness, are kept in the stable. Others may be put to work, and receive poultices only when at rest, or may be turned into damp fields. The shoe rarely needs changing during the treatment, which lasts about a month. This mode of opening the heels is especially practicable and of easy application, and has the advantage of allowing the use of the horse, whose foot is as well jjrotected as with the ordinary shoe. It becomes indispensable when the dis- DISEASES. G63 ease has been of long continuance, and is accompanied with much lameness. It is liable to but one contra-indication, and that is when the foot is not sufficiently strong to hold it, by reason of the heels having been pared down excessively. It has been tested for a long time, not only by the Defays, Senior and Junior, but by many others. H. Bouley, in France, with Hartmann and Mayer in Germany, recommend it as an excellent curative treatment. These instruments have been modified and perfected, such as those shown in Figs. 512 and 513. Fig. 512.— Defays' Improved VIbb. Fig. 513.— Mericant's Desencasteleur. We must again mention the simple and hght desencasteleur of Jovard (Fig. 514), which is as powerful as that of Defays. It is composed exclusively of a double vice, with opposite threads, opening or closing two strong claws, which are applied upon the Fig. 514. — Jovard Desencasteleur. internal borders of the branches of the shoe ; a rod of iron is in- troduced in the holes of the head of the vice and puts the instru- ment in motion. It may be said that on general princijjles it is preferable to treat hoof-bound by the use of dilating shoes than to resort to the bloody operations recommended in earher times. It is these 6G4: OPERATIONS ON THE FOOT. that Brognie^ recommended liigbly for the removal of one or two quarters of the wall, with an appropriate dressing. H. Bouley, however, believes that it would be wrong to discard these 02)era- tions entii'ely ; he believes that there are conditions where they become necessary, and where they furnish better and quicker results than the others referred to. AYe cannot overlook the treatment recommended by Barthelemy, which consists in the thinning first with the rasp, then with the drawing knife, of the bars, in their whole length, depth and thick- ness; thinning them down to a spring under the j^ressure of the finger. This done, a layer of blister is applied on the skin of the cuti dura and upon it, in the parts corresponding where the hoof has been thinned down; the appHcation to be renewed several times, until the lameness has subsided. This operation is followed by an excess of the horny secretion and a marked enlargement of the hoof, and gives good but slow results. Gross has often oper- ated in the same manner, alternating the bHster with poultices. A modus operandi which has also been very satisfactory, is the one that was recently made known by Weber, and which consists in the division of the wall at several points, by grooves extending down to the kerajjhyllous horn, in the du-ection of the fibres of the hoof. Two or three are made, on each side, between the quarters and the heels, the heels at the same time being pared down, when a bar shoe is put on which rests on the frog, or if that organ is atrophied, pressure upon it is simulated by the ad- dition of pieces of leather. Frequently, instead of paring the heels down excessively, and when the frog is atrophied, we prefer a slipper after having pared the sole and bars to a spring. The method of AVeber is not new. It was previously known by La- gueriniere, and is mentioned by Brogniez and Hurtrel d'Arboval. With it we may slowly but surely achieve success, and there are but few feet which are not reheved or cui-ed ; but the grooves must be renewed from above at each shoeing. Solleysel made lines of cauterization on each side of the heels, extending from the hair to the shoe, which, running through the hoof, softens it and renders it more tractable. We cannot at present consider the comphcations likely to be encountered, but must satisfy ourselves by I'emai'king that in cases of false quarters, to avoid the painful pinching of the soft parts between the two walls, there is nothing better than to clean the DISEASES. GGo place of separation thoroughly with the drawing knife, and to fill the space with a putty of gutta percha. Diseases of the Fkog. This part of the horse's foot is exposed to many pathological lesions. Some are merely accidental, and result from the intro- duction into its structure of nails, and other various foreign "bodies, more or less sharp, which the animal jDicks up in walking or performing his work. We have already considered these forms of lesion in the article upon punctured wounds. The frog is often bruised, a lesion which may be followed by a complication which we may be allowed to consider under the name of furuncle of the frog. But besides this, some special diseases are also ob- served, among them one already known to us under the name of canker^ and another which is more commonly known under that of thrushes. (A) Thrushes. — This affection is often, but wrongly, considered as the beginning of canker, being characterized by the presence of a puriform secretion, blackened and very foetid, which collects and accumulates in the lacunae and excavations of the frog, whether in its middle or upon its sides. There is often an in- creased sensibihty of the parts, which in some cases may give rise to very serious lameness, preventing the animal from stand- ing, and rendering the movement of walking very painful. The horn of the frog often becomes soft and thready, when the frog is called rottcii, and the softness increases until it drops off by piece- meal. The causes of this affection are, first, excessive work on stony roads ; changes from excessive drjTiess to moisture ; the strong muds of streets, and standing in damp and dirty places, esj)ecially in ui'ine and manure, as is often the case in badly kept stables. But there are horses whose feet are also affected with thrushes even when standing on a dry bedding ; those whose feet are con- tracted ; and again, well-bred horses with good frogs, and in which there is a constitutional tendency to that condition of the horny structiu'es. The treatment consists in avoiding aU known causes likely to give rise to this morbid condition of the frog. Sometimes the foot must be pared, and all the parts where the puriform secretion GGG OPERATIONS ON THE FOOT collects exposed and thoroughly cleansed. The lacunas of the frog are then to be dressed with Villate's solution, ^gyptiacum oint- ment and sometimes only with simple drying powders, a mixture of subacetate of copper, burnt alum and tannin. When the pain is excessive, glycerine, with a little Goulard's extract or per-chloride of iron, is very beneficial. Dusting with calomel powder gives also excellent results. In some cases again, excellent results are obtained by poulticing. It is certain that proper shoeing must, in many instances, be of great advantage. (B) Furuncle of the Fkog. — Under this name is understood the partial necrosis of that portion of the jDlantar cushion which is situated above the frog proper, from a bruise of that part of the hoof. Loiset describes it under the name of plantar fihro-chon- dritis, connecting it with quittor, which he named, lateral Jihro- chondritis. Symptoms. — There is nearly always, and especially at the out- set, a severe lameness, the greater in degree as the mortification is more extended and more deeply situated. While standing, the affected leg is carried forward, resting on the toe ; the heels are raised, and the fetlock is half flexed. In action, the rest is very shght, sometimes quite absent, and occurs on the toe only. As the disease progresses, and the necrosed spot develops itself, the animal rests his foot better, and the lameness diminishes. Upon examination of the foot early in the history of the case, a small oj^ening may ordinarily be discovered, either on the body of the frog, or in its branches, while at other times there is merely a discharge of a yellowish serous pus of a strong odor, and more abundant in quantity than would be expected from the size of the wound, while surrounding it the hoof is loose and sometimes ready to drop off. If the disease is several days old a mass of dead tissues is ordinarily found partly loose, projecting through the opening of the frog, which has the aspect of a whitish body, slightly green, soft, loose and detached among the surrounding tissues. When this core (bourbillon) is not visible it may some- times be felt with the finger introduced through the wound in the frog. If there is no lesion of the frog the purulent fluid accumulates under the hoof, raising and loosening it from the velvety tissues to a varying extent. Fluctuations may be sometimes even felt under the hoof. Some- DISEASES. G67 time tlie pus oozes through the lacunae of the frog, while again it may then apjjear at the heels, after making its way under the en- tire sole. Pathological Anatomy. — As we said at the beginning, the characteristic lesion of the frog is the gangrene of a portion of the fibrous structure of the plantar cushion, when it changes its general appearance and becomes of livid yellow-gi'eenish color, while at the same time a process of elimination takes jjlace in the surrounding parts, and pas forms, separating the dead tissues from the healthy structure siuTOunding. This process of elimina- tion is more active on the surface than in the deeper parts of the plantar cushion, to which very often this core remains attached. In some serious cases the disease becomes complicated with ne- crosis of the plantar aponeurosis, or of the os pedis, and some- times of caries of the lateral cartilages, or cartilaginous quittor. Causes. — Furuncle of the frog always proceeds from some vio- lent injury through the horny envelope of the tissues it covers, either when the hoof has been cut through and through by a sharp instrument, or as the result of some simple bruise with- out solution of continuity, contusion, or even crushing. Any for- eign body likely to produce a punctured wound of the foot may produce it. But in such cases as are accompanied by furuncle it is necessary that the wound should be more of a contused or bruised than of the punctured variety. Rough', angular stones are the most common agents of injury, being often picked up be- tween the shoe and the frog, and then, pressing more or less upon the tissues underneath, they produce the same result when they are located in laminae of the frog. A thick, voluminous frog in a foot with low heels is very much exposed to the class of injuries under discussion, equally with the frog whose horny covering has been pared too closely. Treatment. — The first indication, says H. Bouley, when one has to treat a furuncle of the frog, is to thin down as much as possible the horn of the plantar region, and especially that of the frog, of the bars and the branches of the sole, in order to avoid the painful pressure it would produce if its thickness should in- terfere with the expansion of the parts. This done, if the frog is already punctured, and there is an opening communicating with the cavity where the core (or bourbillon) exists, a free incision or opening must be made through the hoof and the fibrous covering 6G8 OPEKATIONS ON THE FOOT. of the plantar cushion, and thus the escape of the pus facilitated. If the horny frog has remained intact, a longitudinal incision must also be made in order to allow the frog to discharge, and avoid further burrowing or undermining of the hoof. It is bad practice to attempt to j)ull the core out with a sharp instrument. It is better to leave it undisturbed and wait for the natm-al process of elimination, which may, however, be hastened by the application of a poultice. The time required for the entire separation of the necrosed spot varies, and as it approaches, the animal begins to improve in the matter of resting his foot. "When it becomes en- tirely detached, the cavity which it occuj)ied in the plantar cushion is treated as a simple wound, with turpentine or tincture of aloes. However, a dressing supported by the shoe with plates is always advantageous, and must be frequently repeated. No great length of time is usually required for the entire healing of the parts, and the animal is soon returned to his work. In a few cases, nevertheless, the furuncle becomes complicated with necrosis of the plantar cushion, disease of the os pedis, or of the lateral cartilages, the treatment of which must vary according to the natiire and severity of the lesions. In these instances operations similar to those required in cases of deep punctured wounds of the foot or in cartilaginous quittor are indicated. Keeaphtllocele. This name was given by Yatel to a tumor which forms on the internal surface of the wall of the horse's foot, at the expense of the keraphyllous tissue, which becomes hypertrophied. These tumors are sometimes iiTegularly rounded, at other elongated, but usually rounded and again flattened from side to side. They vary in size from that of a goose quill to that of the finger, and while in some cases they occuj)y the whole length of the wall from the coronary baud to the plantar border, in others they only begin at one-third or one-half of the height of the wall. The difference in size allows a di^ision of keraphyllocele into complete and incomplete. At different points the columns are roughened by frequent enlargements. Sometimes full and formed by a very- compact and hard tissue, they are, however, sometimes of a fis- tulous character and accompanied by a blackish discharge of an offensive odor. The lamellae of the reticular tissue which are nearest to them are generally wider and thicker than in the nor- DISEASES. G69 mal state. As the tumor increases it compresses the lamellated tissue and the corresponding surface of the os jjedis, injuring the soft parts, and resting in a groove they thus form for their development. The causes which give rise to their development are more especially cracks of the walls ; though they often follow laminitis or supervene upon severe operations on the wall. Vatel claims to have observed them after injuries on the hoof resulting from the hammering of the foot while being shod. The symptoms are very obscure. At first the animal is but slightly sore in travehng, but the lameness increases as the tumor enlarges in size. The region su.rrounding the tumor is always warmer and more sensitive than is natural. In many horses the coronet presents a swelling, well marked. In some cases the dis- eased quarter is depressed, and the toe seems elongated. "When a toe or quarter crack is accomj)anied with severe lameness kera- phyllocele may generally be suspected. But when none of these external signs exists it is exceedingly difficult to make a positive diagnosis of their presence, for though the swelling of the coro- net, the heat and the pain of the hoof may be present, those symj)toms may belong also to other diseases of the foot. Then the only means at our disposal is to pare the foot well down, when, at the surface of the sole, the extremity of a portion of hoof ordinarily harder than the normal consistency may be detected. The treatment consists in removing the portion of the hoof corresponding to the horny tumor, as in a case of toe cracks, and treating the wound thus made in the same manner, according to the indications presented. Laminitis. Synonyms : Behe, Verschlag, Hufentzundxmg , German ; Foiir- bure, Fourhature, French; Rifondhnento, Italian; Agiiadura, Spanish. By this name is understood the bloody congestions of the keratogenous apparatus of ungulated animals. The increase of the circulating fluid produces a swelling of the Hving tissues of the foot ; but these being enclosed in a box of so hard, resisting a material, a painful pressure results, which becomes especially common and serious in horses and other solipeds. It has also been observed in bovines, though it is then less frequent and G70 OPERATIONS OX THE FOOT. serious. It has also been seen in sheep, in goats and in swine. It may, in fact, occur in all ungulated animals. Dogs, even, are not exempt from its attacks. The simple bloody congestion, more or less inflammatory, of the keratogenous apparatus of the horse, is sometimes called acute laminitis and acute founder. The disease ma^' pass off by reso- lution, leaving no traces of its occurrence, but more commonly it becomes complicated with some lesion of more important and serious a character, as hemori'hage, suppuration, inflammatory exudation, and especially of a hypersecretion of the horny sub- stances, in which case it becomes chronic laminitis or founder; an affection which gives rise to alterations of a peculiar nature, and leads to certain changes in the form and character of the hoof. We do not agree to the divisions admitted by several authors, into traumatic laminitis, rheumatismal laminitis, and metastatic kwiinitis. I. /Symptotns. — Laminitis, in most instances, is preceded by certain general symptoms, such as are premonitory of the inva- sions of ordinary inflammatory diseases, but of an uncertain sig- nificance. There is dullness, general insensibility, muscular tremblings, and stiffness of the loins. The resj^iration is accel- erated, the pulse febrile, the mucous membranes injected, the mouth dry, the foecal discharges dry and coated, the urine scanty; and perhaps anorexia is present. Rodet, who held that laminitis is more a secondary than primitive affection, and that it is simply an inflammatory angeiothenical fever which had localized itself, was obliged to acknowledge that this fever has nothing character- istic, and that it is always followed by laminitis. It is certain, however, that but a short time elaj^ses — from several hours to one or two days — after the originating cause has become active, before the bloody congestion of the reticular tissues and the peculiar phenomena belonging to the disease become manifest. It is only when the capillary circulation of the foot has considerably increased, and when the rigidity of the structure prevents the sv\^elling of the podophyllous tissue, that laminitis truly exists. Laminitis in the horse has the following principal symptoms : Considerable heat of the entire foot, extreme sensibility with intense pain, increasing rapidly, and obliging the animal to rest upon the sound legs, in order to relieve the affected ones; difiS- DISEASES. 671 culty and uncertainty in walking ; and sometimes a peculiar trem- bling of the muscles of the patellar face of the femur, and of those of the extensors of the fore arm, which fill the triangular sj)ace formed by the scapula and the humerus. The physiognomy always indicates intense suffering. The pulse is hard, the respi- ration increased, and the skin hot, and in places moistened by a copious perspu-ation. These symptoms vary with the legs which are affected, whether the disease is located in the fore or hind feet exclusively, or in all four together. As M. Bouley says, it is a peculiarity of this affection that it may remain localized in the feet of one patient, either forward or behind, or may at once attack the four extremities, and that it seldom attacks the limbs on one side only, to the exclusion of the feet of the opposite side, i. e., it may be laterally biped, affecting either both the fore or both the hind feet, but not often occurring otherwise. Some- times, however, the disease is more marked in one leg than in the other of one biped. It is generally only after some traumatic lesion, or other local influence, that laminitis occurs in one foot only. "WTien laminitis affects the two anterior feet, the animal carries its extremities forward, and the hind feet are brought well vmder the centre of gravity. The standing of the animal is altered, the walking difficult and painful, and the resting of the feet on the ground is done with hesitation and fear. The feet are carried forward, because the pressure takes place on the frog and on the heels ; if it should occur as in the healthy and normal condition, upon the entire inferior cii'cumf erence of the foot, there would be pressure upon all the li\dng tissues, which are gorged with blood, tumefied and painful, and this pressure would greatly increase the suffering of the patient. It is, then, to reUeve himself, and to avoid the intensity of the pain, that the animal instinctively changes its mode of resting on the ground. In placing the heels down, the weight is borne only upon a follicular, fatty tissue ; from there it spreads along the side of the coronet to the fetlock, and thus upon all the other portions of the leg, and in this way the foot becomes greatly relieved during the action of resting. If, however, the fore legs only were carried forward, the effect would be equivalent to lengthening the body of the animal, and he would be unable to carry on the action of walking. To allow the fore feet to be moved, it is necessary that the body be carried 672 OPERATIONS ON THE FOOT. forward by the hind legs and brought closer under the centre of gravity, a position which contributes also to the relief of the animal "while at rest. The more painful and diseased the feet become, the more the animal fears the impingement of the ground. Thus, so to speak, he sounds the ground before putting the foot down, and for this reason the walking becomes slow, stiff and difficult, and the noise of the contact of the foot louder than that of the healthy legs. Sometimes the animal proceeds only by a series of jumps, or a kind of rearing, while backing is especially difficult. The hoofs of the foundered feet give to the hand, when feeling them, a sensation of heat greater than that in the physiological condition; a sensation which can be more readily detected by a comparison of the fore and hind feet simultaneously examined. The pains in the diseased feet are rendered more manifest, also,, by percussion upon the hoof with the hammer, when each blow» however light, is followed by a motion of the animal in suddenly withdrawing his foot on account of the painr experienced. The lateral arteries of the fetlock, in the foundered legs, beat stronger than in health, and can be readily felt by the fingers. The feet cannot be raised without great effort, and when raised, the animal stands only with great difficulty, and makes struggling attempts to relieve himself and resume its natural mode of standing on. four legs. When laminitis affects only the fore feet, the animal will sometimes remain standing for a length of time together; he may retain this attitude for several days, without any displacement of his body ; still he is observed moving surplace, from side to side, especially on his fore legs, relieving one foot for a moment to give the same comfort immediately afterward to the other. But when» exhausted by fatigue and pain, the foundered horse lies down, it is very difficult to get him on his feet again. He continues in the decubital position, lying mostly flat upon his side, the fore legs in constant motion, and soon complicates his diseased condition by the addition of bed sores upon the prominent parts of his body. The attitude of the animal is very different when the hind feet are affected; then both the anterior and posterior bij^eds are brought to each other, the feet of the hind legs being carried for- ward under the abdomen, so that the rest may take place upon the heels ; and the anterior ones are carried backward, and nearer DISEASES. B73 to the centre of gravity, to assist the function of the hinder ex- tremities in sustaining the weight of the body. In this case, the animal is constantly in side motion, on account of the pain he en- diu'es Walking is still more difficult, and seems to take place as if the animal was treading on sharp needles, as, the more the an- terior biped is engaged under the body, the more also those legs are loaded with the animal's weight, and the more difficult is their movement. But the anterior legs, contrary to their ordinary func- tion (not being adapted to the supj)ort of an overshare of the body) sustaining now a great part of its mass, and moreover, compelled to assist in the act of propvdsion, necessarily and in- evitably become easily fatigued, and too often in theu' turn be- come likewise affected. Animals suffering with posterior laminitis are found occupjang the standing position less frequently than those whose fore feet are affected. Their unsteady equilibrium, consequent on their mode of standing, tires them more quickly, and compels them to lie down, and once on the ground, it is again more difficult to make them rise. They may do so readily with the fore legs, but the posterior extremities do not always resj)ond to the caU. The attitude of animals suffering with laminitis of all the four feet, is the same as of those which are affected in the fore feet only. All four feet are carried in advance of their plumb line, the anterior forward, the posterior well under the centre of gravity. Sometimes the horse has all his feet somewhat apart, in order to carry the principal j)art of the weight on the inner side of the foot. The standing posture being painful to either foot, the animal lies down most of the time. Locomotion is very difficult and staggering, and the animal can only be induced to move by severe punishment, and even that cruel resort sometimes fails to effect it. If the animal is made to walk, he does it with the great- est difficulty, by reason of the increase of his sufferings, brought on by the displacement. His legs, stiff and trembling, are raised in a convulsive manner, and brought b^ck to the ground with the greatest hesitation, and upon the heels ; the constant motion of the lips of the animal being well characteristic of his sufferings. In the ox, laminitis is more frequent in the hind than in the fore feet. It is, however, more serious in the latter, the inner being more affected than the outer toe. The foundered ox walks with hesitation, and takes advantage of every opportunity to lie 674 OPERATIONS ON THE FOOT. dowB. "\Mieu standing, his back is arched, the feet closed to- gether, the hind feet resting on the heels, the fore legs on the l^oints of the toes. The fever is severe, sometimes attended with loss of appetite and of rumination. If the disease continues long, the cattle will die. The abdomen is stuck up and the animal loses flesh very rapidly, indicating a serious condition, as the dis- ease is principally found in fat animals, which are obliged to make forced marches to be delivered at their markets. II. — Terinination and Complications. — Well treated, laminitis is generally of short duration, and ends in three or four days by resolution. Sometimes, however, this is not accomplished until a later period, even toward the tenth day, though cases of this charac- ter are rare ; and even when resolution proceeds slowly, some lesions in the foot may be looked for, and chronic laminitis will probably result. Resolution in acute founder is marked by the gradual disappearance of the local and general symptoms. In some sub- jects, the imj^rovement is quite rapid from day to day, and the form of termination is known as delitescency. Laminitis ending in resolution is not usually followed by alterations in the horny box or the tissues which it covers. When the congestion which constitutes the disease terminates otherwise than by resolution, it is always followed by accidents of varying character. Some of these may have a happy termination, but, in the end, are more or less likely to be followed by a de- formity of the homy box, to which the name of chronic laminitis is given. Before entering upon this, however, let us examine the various complications which may follow acute founder, and study in succession: the hemorrhage, inflammation with exudation, stq^2^u7'ation, gangrene, consecutive arthritis, metastasis, and, lastly, chronic laminitis. Resolution is most commonly met with in the ox. Sometimes the separation of the hoof by suppuration occurs, and chronic founder is not observed in that animal. It is seldom that seedy toe is observed. a. — Hetnorrhage, or ap6x)lexy of the reticular tissue, is due to the rupture of the excessively distended capillaries, when the ex- travasated blood either infiltrates into the meshes of congested tissue, or spreads around it, and penetrates between the podophyl- lous and keraj)hyllous lamellae, filling up the spaces at the toe, the mammae and the anterior parts of the quarters, the os pedis being pushed back by the pressure of the incompressible fluid. The DISEASES. 675 pain is then very great ; the blood, continuing to separate the tis- sues, often oozes at the coronary band. If this last sign is absent, a groove may be made with a draw- ing-knife in the region of the toe, behind the commissure of the sole and of the wall. If we meet with a cavity, resiilting from the extravasation of the blood in the podophyllous and keraphyl- lous space, or if blood flows out from it, the true nature of the compHcation becomes at once ajDparent. This mode of explora- tion is generally difficult, as the animal in pain does not readily allow his feet to be raised, and as the other foot cannot sustain the entire weight of the body, the horse easily falls down. It is sometimes necessary to throw the animal in order to make this exploration, which very often becomes necessary if we would know accurately the progress of the disease. h. — Inflammation, with fibrinous exudation, or pse ado-mem- branous formation on the surface of the podophyllous tissue. The transudated fibrine mixes with the hoof, secreted by the podo- phyllous tissue, and this matter separates that structure from the kerajDhyllous laminse, especially at the anterior part of the region. Again, in chronic laminitis we find this abnormal secre- tion pushing the os pedis forcibly backward and separating the toe of the bone from that of the hoof, and thus producing a pain still greater and more violent than that produced by the laminitis and the hemorrhage. These j)ains are often so intense that they give rise to an access of furious Vertigo. But pains, even when of an exaggerated degree, indicate simply the presence of the exudative form of laminitis. It is not a positive sign; the foot must be exjjlored at the toe, where, in the vacuum which exists between the horny lamellae is found, more or less abundantly, a citrine serosity of a slightly reddish color. Sometimes this ser- osity oozes between the hair and the hoof, in consequence of the separation of the tissues at the coronary band, and appears in the form of a thin, reddish foam, about the band itself. c. — Suppuration between the wall and the podophyllous tis- sue is a complication more rare than the others, but which, how- ever, has been observed, especially when laminitis is traumatic. We have seen it appear under the sole and separate it entirely from the tissues underneath. In these cases, the pain is always very great, and the living structures are pressed beyond measure. Standing is impossible, and the animal continues lying down, or, G76 OPERATIONS ON THE FOOT. under tlie influence of the 2>ains, constantly moving from one leg to another, balancing himself, so to speak. There is no relief for him until the suppuration has shown itself between hair and hoof, when it oozes outward at the coronet. Belief, however, may also be obtained by making an opening at the toe with the drawing-knife. This complication often results in the entire separation and drop- ping oft' of the hoof. Cases have been observed when this acci- dent has taken place as early as the third day (Lafosse, Stanley). Gillmeyer has seen a new foot grow out entirely, but this requires a long time. (l_ — Gangrene of the sub-horny tissues sometimes takes place, though seldom, under the influence of the excessive pressure, especially when there is sub-horny exudation. The violent pains then cease suddenly ; the resting becomes more solid ; the move- ments take place without difficulty. But at the same time, the physiognomy of the patient becomes anxious and contracted; the pulse becomes small and difficult to count ; the temperature of the body diminishes ; the animal has a trembling gait ; is indifferent to any excitement ; he is prostrated, and soon he ends by sep- ticaemia. The hoof then often drops off, and the sub-horny tis- sues are seen to be of a bluish-brown color, without consistency, but with a very foetid odor. Volpi thought that laminitis was the inflammation of the articu- lation of the foot ; but this arthritis, if it exists (a fact which is rare), is not a consecutive phenomenon, but a complication. The inflammation does not remain limited to the recticular tissue; it extends also, and consecutively, to the contiguous structure, spreads to the tendons and articular ligaments, even penetrates to the synovial capsules of the articulation of the third with the second phalanges, and may also react upon other parts of the organism. The anchylosis of the articulation of the foot with that of the coronary joint are complications somewhat frequent, as well as that of the ossification of the cartilages of the foot. e. — Jletastasis has been often observed, and when accom- panied by intense fever have been noticed as complicated with serious diseases of the chest, especially of pleuro-pneumonia. At other times, it has been the intestines to which the metastasis has transferred the disease, in which case there is, in most instances, constipation of the bowels. Enteritis, however, is seldom ob- served, notwithstanding what has been said on the subject. This DISEASES. 677 metastasis has also been seen toward the lumbar region, and this is much more commonly believed from the fact that there is more motion at the hip than at any other joint during locomotion, and also because the back and the loins are more or less arched. In fact, laminitis has been, by some, designated as an affection of the loins ; some have looked upon it as a rheumatism of that region. All these errors have originated in the peculiar motion of the ani- mal while walking, or of its jDecidiar mode of resting when stand- ing still. "We have also observed an attack af complete myehtis as a complication of laminitis. f. — The most common complication met with in chro7iic lam- initis is an affection which we might have treated as a special sub- ject had we not, upon principle, considered it as a sub-inflamma- tory state of acute founder of the foot. An attack of laminitis which has not ended by resolution in five, ten, or fifteen days at most, takes a character of persistency which, in most cases, ends in absolute incurability. To j^i'operly study chronic laminitis we must observe it when the alterations which characterize it are ac- comphshed. When we have comj^leted the consideration of the pathological changes, we will examine the intermediate period, and discuss the mechanism by which these alterations take place in relation to the pathological anatomy. The first thing observed is the change of form in the hoof (Fig. 515). The nan of a horse's foot easily recalls the form of a Chinese shoe (Knollhuf, of Germany). The hoof seems to have also lost its varnish and its suppleness in the • , T J- i.1 T Fig. 515.— Chrome Laminitis. points correspondmg to the dis- eased parts. It is, besides, brittle, and seems to have lost part of its connection with the remaining parts of the foot, and there is a change in the direction of the wall, the fibres of which, instead of being oblique to the ground, assume an almost hori- zontal direction. The foot seems as if flattened from above down- ward, and the lines which bound its surface form a well-marked obtuse angle with that of the coronary region. The anterior wall of the foot also forms a well-marked projection forward, from which results a great exaggeration of the antero-posterior diame- ter of the nail with the transverse diameter and the oval form of 078 Ol'Elt.VTIoNS ON THE I'OOT. the horny box. The external surface of the wall, instead of be- ing smooth, as in physiological conditions, presents, on the con- trary, a roughened appearance, which results from the presence of cu'cles of ridges and cu'cular grooves, placed one above the other and extending from one heel to the other. A remarkable peculiarity is here observed in the fact that in the anterior part of the nail the circles are quite near each other, while, on the con- trary, upon the lateral parts they are separated by much wider grooves. "When, then, at the toe, the wall has some difficulty in growing downward, on account, probably, of the internal adhes- ions between the podophyllous and keraphyllous tissues; the heels, on the contrary, grow without difficulty, and thus obtain a relative height superior, and sometimes even equal, to that of the toe. Often at the mammae and quarters of the foot contractions are seen, and longitudinal grooves running from the coronary band to the plantar surface, reminding one of the lesions usually met with in encastelure. Considered on the side of the inferior face, the old f ound- dered hoof offers four remark- able lesions (Fig. 516). Besides its oval form, a disj)Osition al- together different from that of the normal state, the sole is convex in all the anterior part of the plantar region, especially at the point of the frog. There exists at that point a transversal tumor or enlargement, projecting sufficiently to "exceed in height the inferior border of the wall. The solar sheet has been pushed outward by the pressure against the suj)erior face from the contents of the horny box, and the foot is convex. This convexity never equals the entire extent of the foot, the deformity ending at the boundary of the inferior border of the bars, beyond which and backward are foiuid the cavities of the lateral lacunse of the frog, so much more elevated as the heels ai*e also higher (Fig. 517). The center of this tumor or enlargement of the sole is often flexible under the pressure of the finger, and generally bleeds easily on the application of the sharp tools of the blacksmith. It is not rare to see the sole perforated through and through and showing the inferior border of the os pedis project- ing through the border of the bone, which then soon becomes Fig. 516.— Chronic Laminitis, last stage, DISEASES. 679 f u -k Fig. 517.— Foot affected with Chronic Lamlnitis. a.— Anterior extensor of the phalanges, b.— Ordinary wall, o.— Coronary band. d.—PodophyUouB tissue modified, e.— Morbid horny waU. /.—Seedy toe. f/.— Displaced and deformed OS pedis, A.— Velvety tissue. i.—Perforans tendon, j.— Navicular bone. fc.— Perforatus tendon. I —Plantar cushion. necrosed. This is the result of the excessive displacement of the OS pedis and of the strong pressiu-e upon the velvety tissue against the sole-tissue, which is atrophied or even destroyed (Fig. 518). This is an ulcerating wound, somewhat semi-lunai', secreting a Fig. 518.— Chronic Laminitis, with Keraphylocele (ISO OPERATIONS ON THE FOOT. veiy ofieiisive pus, witli granulation and proud flesh, or even sepa- ration of the sole. Between tbe sole and wall the line of demarcation is no longer so well defined as in the normal state. At the toe, the mammse and the anterior part of the quarter, there is an excavation formed of softer horn of bad natui'e, and less identified with the true horn of the wall and of the sole. A complete vacuity is often found, a cavity around the internal face of the wall at the toe and at the mammae of varying depth and size, but always larger at the inferior than at the superior end of the foot, where it gradually diminishes, and often contains a dry, granular mass, resulting from the dr^dng of the blood, and the dried plastic lymph, mixed with small, horny, pulverized masses. This cavity is formed in front by the healthy wall and posteriorly by a new wall due to the secreted hoof thrown upon the podophyllous tissue ; this is called seedy toe. This double wall is observed especially after laminitis of the hind feet ; it is more common in the donkey and the mule ; it is also noticed in horses with small feet, as in those of Oriental breeds. The deformities of the horny box due to chronic laminitis are not in all cases identical in their character; there are degrees in them, and consequently they vary in their features, which varia- tions are due to the duration of the disease and its intensity, and also, according to H. Bouley, to the primitive form of the diseased foot. In a case of chronic founder of the fore feet, one may often notice a difference between the deformity of the left and that of the right foot. The deformities may take place at various times, and one may find a well-marked case of seedy toe while as yet the wall has preserved its normal oblique direction and shown rudimentary ramy appearances. Again, the wall may have under- gone changes in its direction only at the new hoof, which grows from the coronary band ; there is then formed between the old wall and the coronet a circular groove, sometimes called the digi- tal cavity, the deformities of the wall taking place only as it grows down. At times, also, instead of the groove, there is a ridge of horn at the coronary band, originating in the hyper-secretion of the horn, which grows also downward. And, again, there are cases where there is seedy toe and still no well-marked alteration of the shape of the wall of the sole. Chronic laminitis is alwa^-s accompanied with more or less DISEASES. G81 lameuess. There are cases, however, where it is missing ; for ex- ample, in seedy toe. Ordinarily, the foot is raised from the ground with a convulsive motion, as may be well observed in donkeys and mules, which animals rest their feet on the heels. This soreness diminishes with time, as the foot, assuming its new form, offers a wider space to the sub-ungulated tissues and presses less upon them, these tissues having, at the same time, become somewhat atrophied. In cases of hernia of the os pedis, the resting of the foot on the ground is almost impossible, the animal being afraid to bear his weight on the sole. The heat and the pain of the feet are less marked. The percussion is louder in case of seedy toe, whUe it is duller when the space between the wall and the recticu- lar structure is filled with hoof of new formation. This percus- sion is very painful in case of keraphylocela Unless there are serious lesions, chronic laminitis is not accompanied with fever, III. Jr*athological Anatomy. — At the initial period of lamini- tis, when there is only simple congestion of the keratogenous ap- paratus, and especially of the podophjilous tissue, the sub-horny tissues are in a condition of sanguineous derangement, characterized by objective signs. "WTien the hoof covering them during life is removed, they are found of a dark red color, in a kind of eythema. When pressed between the fingers, their thickness is noted to be increased, and they are found to be gorged with blood, an incision made through them allowing the escape of a lai'ge quantity of that fluid. If the laminitis exists for several days, the podophyllous tissue is found to be infiltrated with plastic exudations, and if there has been hemorrhage or apoplexy, blood is found between both the sensitive and insensitive laminae. In other cases there is pus, and in case of gangrene, the tissues are found of a livid color. The alterations are still more serious in cases of chronic founder. "WTien a foot, foundered for some time, is divided by the saw in its antero-posterior axis by a section of all the parts, the thing first noticed is a change in the connection of the os pedis with the wall. These changes, however, exist principally at the toe, and extend as far as the half of the quarters, on a level with the lateral cartilages of the foot, while further backward they are not to be observed. On the side, some laminse are always found in their normal condition, as can be seen by a section of the foot made transversely. Generally, a yellowish substance, of 682 OPERATIONS ON THE FOOT. liorny appearance, but softer, fills up the space situated between the walls and the keratogenous structure. This is the product of the exudation of the inflamed i^odophyllous laminae, mixed with the horny substance which they secrete normally. These laminae are themselves hypertrophied, being sometimes one and two cen- timeters in length and exceeding by four or five times their nor- mal size. The keraphyllous laminae are also hypertrophied, a condition which is evidently due, as respects the podophj'llous tissue, to the increase of vital activity, resulting from the inflam- matory condition of the tissue and to the infiltration by fibro- plastic exudation, resulting from the inflammation. As to the keraphyllous laminae, they repeat on the internal face of the wall, in an inverse manner, the disposition of the secreting laminae of the hoof between which they are formed and lodged. These, however, as they increase in extent, unite at their base in the whole of that portion which does not co-operate to their union with the podophyllous bands, and then forms a compact mass uniting most frequently wdth the internal face of the wall. Some- times this mass of yellowish hoof occupies the whole space be- tween the OS pedis and the wall, but, in some cases, it adheres only to the wall, when it forms around the keratogenous tissue, a new wall, also provided with keraphyllous laminae, and there is formed between it and the normal wall that porous, brittle mass, without homogeneity, which fills up the space, which constitutes the seedy toe. The mass thrown between the wall and the os pedis presses upon it ; the anterior face of the bone assumes a vertical direction, and the os pedis j)i'esses toward the solar arch on its anterior border at a point situated posterior to that where, in normal feet, this border rests. Notwithstanding its resting power, the wall gives to the effort of the mass interposed in front, the form of the foot changes, and then results the change to the oval in the contour of the foot. Under the influence of the dis- placement of the phalanx, not only the flattening and afterward the convexity of the sole and even its perforation results, but the plantar cushion is itself pressed down and crushed between the bone and the frog, which is then generally atrophied. A hoof of new formation is often developed between the sole and the infe- rior face of the phalanx, in order to prevent it from necessarily sinking. This increases the j^ressure upon the bone and contrib- utes to its atrophy and sometimes to its complete disintegration. DISEASES. 683 But, between the surface of the coronary band and the origin ol the roof, whose formation is anterior to the laminitis, there may also be a new layer of hoof, more resisting than that which occupies the space between the wall and the podophyllous tissue. which is no more hoof mixed with the fibrinous exudation, but a pseudo-hoof secreted by the coronary band. The fibres of this hoof, however, instead of being rectilinear and growing down in the direction of the old wall, with the fibres of which they are continuous, are, on the contrai*y, sinuous and nodulated, and dis- posed to take a somewhat horizontal direction. There is often, besides the old wall, a deep horny tumor, a keraphyllocele which grows inside, attempts to replace the soft horn secreted by the podojDhyllous tissue, and adds to the pressure of the os pedis, by forming a new wedge, more solid and resisting, which produces a displacement of the j)halanx, Avhose anterior face then often be- comes more than vertical. This horny secretion from the coronary band is made evident by a section of a foundered foot, when the cutigeral cavity will be found much enlarged. Guy on, Jr., Hert- wig, and Gourdon remark that the displacement of the os pedis is counterbalanced by the more rapid development of the heels and the projection of the foot forward ; and that thus the phalanx does not support the weight of the body except by its inferior border only, but preserving nevertheless, its primitive position. It is especially observed that when the foot is completely de- formed, the projection of the wall does not prevent the os pedis from remaining in its normal position. The growth of the hoof from the podophyllous tissue and the coronary band is not easily stopped. The horny masses w^hich are formed continue to increase, and even soon end in uniting. There then remains a thick mass of deformed shape, four or five times thicker than the normal wall, but where the kei^ajjhyllous leaves are still noticed, corresponding to the podophj'llous laminae, largely. develojDed, and above all, running deeply into the wall of the hoof. The space between the wall and the anterior face of the os pedis is filled with pus besides the secreted hoof ; the seedy toe, if it existed, disappears. Though the hoof becomes thus much more voluminous than before, the deep parts are not any more in their normal condition, but are lodged in a smaller and smaller space, and are thus in such a state of compression that they become atrophied. The bone is altered in its texture, as 684 OPERATIONS ON THK FOOT. Fig. 519.— Changes of Structure of the Os Pedis in old cases of Chronic Laminitifl. well as in its form, and becomes denser and more brittle. (Fig. 519). One might suppose that as the disease progresses, the os pedis would become pressed backward more and more toward the sole, in consequence of its giving way under the pressure. This, however, is not so. As the old normal walls disappear, the new horn yields to the pressure from forward, the heels rise, the os pedis resumes its horizontal direction, and the danger of hernia of the bone diminishes, and a hypersecretion of the hoof is even noticed toward the point where the hernia would have taken place, in the middle of the pumiced sole. We have, so far, supposed that chronic laminitis is always manifested by the presence, between the internal face of the wall and the podophyllous surface, of a mass of abnormal hoof. But there are cases, after hemorrhage, and especially after serous exudation, where, instead of it, a cavity is found — a seedy toe. There is also an entire separation between the os pedis and the wall. But the horny prdduction, that of the podophyllous tissue especially, is not sufficient in amount to fill up the whole space, there being hoof only upon the podophyllous tissue. There is then a sound wall formed, separated from the old one by a vac- uum, which is often filled by a dry mass derived from the blood and serosity, mixed with the horny cells. But more frequently DISEASES. 685 the separation is limited to the height of the podophyllous tissue, and the wall yet remains adherent to the coronary band, by its cutigeral cavity. The band then continues to produce the ex- ternal wall of the hoof, while the podophyllous produces the abnoimal wall, and the seedy toe remains between the two walls. There are cases where the separation, produced by the con- gestion of laminitis, takes place to such an extent, in circumfer- ence or in height, that the hoof loses all its adhesion, except toward the heels ; and then one may see the curious fact of the new generation of an entire new nail within the old one, the for- mer being, so to speak, sequestered in the latter. IV. Differential Diagnosis. — It is possible that, notwith- standing its distinctly characterized physiognomy, laminitis, of the hind feet especially, may be mistaken for a disease of the sj)inal region. Often, when the founder is light, the hinder parts wag, as in sprains of the loins, but the resting of the feet on the heels, their heat and their sensibility, will soon point out the dis- tinction. In more severe cases, the hinder founder may stimu- late paralysis, especially if the animals cannot or will not raise themselves. Here the history of the case is very useful, and the explorations of the feet will assist in making the diagnosis. We have seen cases of laminitis behind, where the raising of the foot has been such that it might be taken for springhalt, or even for locomotor ataxy. It may be also taken for tetanus when in mild form, or yet incompletely characterized. V. Drognosis. — Laminitis is so much more alarming and re- bellious as to treatment, as it is more extensive, more serious, and of longer existence. The most serious cases are those which are due to a constitutional predisposition, and those which follow a general alteration, or are complicated with other diseases. Chronic laminitis is especially serious from the production without separation, and in an excessive measiu'e, of the horny substance. Seedy toe is then less serious, and that which does not extend to the coronary band is sometimes curable by the gradual growth of the hoof; the tumor of the os pedis is the most rebellious to treatment. The destruction of patients is often necessary, from then- inabihty to walk or to do any work, and that notwithstanding all treatment they are entirely useless. VI. Etiology. — Laminitis has been attributed to many and the most varied causes, and, among others, has now been ascribed 686 OPERATIONS ON THE FOOT. to a traumatic origin, consisting of injuries of the foot ; and again, to internal lesions, resulting in the inflammatory process which is characteristic of the affection. The external traumatic injuries, which it is claimed are those chiefly instrumental, are, on the contrary, of very rare occurrence as causes of the disease. Our observations agree with those of H. Bouley, and if there is a traumatic causation for this disease, or, at least, one identical with it in respect to symptoms and primitive lesions, it is, nevertheless, certain that its progress is very different ; there is found with it an evident tendency to sup- puration instead of exudation, and there is no such formation as the chronic process which is found when laminitis is due to an internal phlegmasia. It has been said in reference to the action of the heated shoe ujDon the hoof, the percussion of the blacksmith's hammer and the pressure of the shoe and of the nails upon the Hving tissues, that all these causes together must, as their sure effect, make the foot tender, and stimulate in its constituting structure, the con- gestion which is the initial phenomenon of founder itself. But this assumption may be successfully contested. But shoeing may produce many forms of lameness ; never laminitis. It has been said that feet of defective conformation are more commonly af- fected with founder that those which are well formed. This, however, is not so ; feet with contracted heels are no more predis- posed to it than flat feet, as claimed by Girard. Traumatic acci- dents, as blows, injuries and pressure, produced by stones, crush- ing of the feet under heavy weights or imder the wheels of a truck, etc., may produce a violent congestion of the reticular tis- sue of the foot, and consequently laminitis. But this founder Itself is of too active a character and more complex, perhaps with a natural tendency to suppuration, as we have already said. It must then be considered as varying from laminitis proper, or that form in which the congestion is of a more passive character, or at least internal and somewhat analagous to that which is sometimes observed in the lungs or in the intestines. It might be better described as an "astonishment" {donyiement) of the foot, as it is sometimes called. Laminitis proper is rarely due to a unique cause, but more properly to a number of cii'cumstances or to an assemblage of various causes by which the horse is at first somewhat indisposed DISEASES. 687 — sick in fact ; and it is only after various general symptoms that the disease localizes itself in the feet, or, as the old phraseology has it, falls in the feet. The most effective cause is too abundant and especially too substantial feeding, which produces plethora by rich blood. It is the use of other grains than oats, as wheat, barley or rye, which especially predisposes to the disease. Latin authors called it hordeatio (from hordemn, barley), and it is mentioned by Sol- ley sel, Garsault, Gaspard de Saunier, and various hippiatrics. Eodet has observed its bad effects in Egypt and in Spain, where animals were fed not only with those grains, but where they received wheat in spike. Miltenberger had observed the same effects dur- ing the war of 1812, in Poland, where the horses were fed with rye. Even in our days laminitis is seen breaking out in the years when feed is scarce and when oats have to be replaced by other grains, as is proved by the observations of Bouley, Verrier, Key, etc. Artificial varieties of fodder also predispose to founder, though less often ; even oats, when given in excess, may produce it (Solleysel, Blind), and esjjecially if new oats (Hertwig). The influence of seasons cannot be denied, and it is during the summer months that laminitis is more frequent, while it is rare in winter, as well as in the spring and fall. It is to the warm climates of Spain and Egypt that Rodet attributed, in great part, the frequency of the founder observed in the army horses en- gaged in campaigning in those countries. It has been also attrib- uted to the sudden checking of the perspiration, and cutaneous chills when the animals are sweating ; a cold bath or the drink- ing of cold water at that moment having also often been consid- ered as occasional causes. The work of the horse greatly influences the development of laminitis. It is more frequent in those which are driven at great speed than in those which work while walking, and especially in whose frame an excess of strength is required, and particularly those which labor on rough and stony ground. It is almost in- evitable if the animal is well fed, and if he is unaccustomed to that kind of work and not trained for it, and most especially if it is during warm weather. This explains why the disease was so frequent among post, diligence and coach horses, especially dvir- ing the period preceding the establishment of railroads, when the expenditure of strength exacted from these unfortunate animals 688 OPERATIONS ON THE FOOT. reached the last limits of possibility. More recently, again, dur- ing the war of 1870-71, when railroad traveling was more or less impeded, laminitis became more common among horses from which an excess of muscular eifort was requu'ed. It is a frequent and very serious accident among English race horses (Hering). Laminitis in oxen is due almost exclusively to the fatigue of long journeys and to repeated frictions of the unshod feet upon the ground. It was very common before the era of railroads in animals brought to market. But prolonged rest and inaction also predispose to founder. The disease is frequent in horses making sea voyages. It is not rare to see horses become foundered when they are obhged to stand up during several days in consequence of injuiies to the ex- tremities, or other pathological conditions, requiring them to be kept in slings. In diseases of the feet which have required pain- ful operations (toe or quarter cracks, punctured wounds of the feet, quittor, etc.) it is quite common to see an animal persevere in maintaining the standing position, and too often has the leg corresi^onding to one first attacked become also affected, leaving both of the anterior or both of the posterior ultimately affected in a serious manner. It is common for laminitis to follow intestinal congestions, especially if these result from the administration of a drastic purge, as aloes for example, and this is a very serious form of the disease. Tisserand has seen laminitis of the anterior extremities following parturition in mares, and particularly after abortion. Gloag and Smith have observed similar facts. Hertwig says that it sometimes foUows rheumatismal affections, especially the acute form. A metastatic laminitis has been seen following diseases of the chest. H. Bouley does not believe in these cases, and thinks the laminitis is the effect of the quadrupedal standing position, or also the feeding with farinaceous substances in too great quantity. At times, founder accompanies malignant fevers, such as anthrax and typhoid attacks, which are always accompanied with a certain alteration of the blood VII. Treatment. — In acute laminitis all attempts must tend to remove the congestion of the keratogenous apparatus, or at least to abate its intensity, so as to prevent or diminish the seri- ous sequelse that may too often foUow. To effect this, general or DISEASES. 689 local bleedings have been specially recommended, with antiphlo- gistic appUcations upon the congested regions. General bleeding at the jugular is especially indicated; a large bleeding of from five to ten litres, repeated if the pulse or the condition of the dis ease indicates it. Local bleeding, often recommended, seems to us, generally speaking, to be useless ; that of the toe is of difiicult performance in founder, as the feet are usually raised from the ground with difficulty, and the operation is quite painful, and may give rise to more or less serious complications. However, in serious cases it can be done while the animal is thrown down, not so much on account of the blood depletion as to prevent the pos- sibility of gangrene supervening. It is more useful in the ox, according to Lafosse, who recommends to pare the foot down to the quick and to put on the shoe again if the animal has to con- tinue its journey. The topical applications employed are varied and numerous ; the simplest and most practical is cold water, cold baths at half the leg (Fig. 520) ; take in running water, if it can be done, and if the animal stands up; walking in the water is then recom- mended, if practicable, walking increasing the venous circulation of the part. Instead of running water, ponds, marshy grounds, pools of stagnant water, or even liquid manure may serve the same purpose. In establishments where horses are numerous, there are special tubs where the water is constantly changed. The animal may be placed in some of these, uj) to his fetlock, in an astringent solution. Mathew has in- vented an apparatus for continued irriga- Figs. 520.— Local Cow Douch ,. . ,. a • £ 2. t Application. tion, consisting or a reservou' 01 water ele- vated above the body of the animal ; around each coronet is placed, in shape of a bracket, a tube of india rubber, perforated with holes opening on the hoof ; from the reservoir runs a tube which bifur- cates and furnishes to each leg a descending division connected with the bracket (Fig. 521). The water is then allowed to run around the coronet and drip over the foot. Instead of simple water, the use of snow or broken ice has been recommended, wrapped in cloth round the hoof ; pads of oakum dipped in solu- 690 OPERATIONS ON THE FOOT. IFiG. 521.— Apparatus of Mathew for Cold Water Application. tion of salt, suljibate of iron, or alum ; clay poultices mixed with vinegar liave also been used. As the heat of the foot has a ten- ' dency to rise, the temj^erature of the liquid or of the topic used must be often changed in order to keep up its antiphlogistic ef- ifect. Baths of sulphate of iron are especially indicated in cases of traumatism. Irritating frictions, used as derivatives, are also recommended, but their efficacy in this case is at least problematical. Irritation, when the congestion is somewhat passive, is not easy to produce. However, frictions of the hock with oil of turpentine, by the pain they produce stimulating the animal to move and not allowing him to remain in a state of almost complete immobility, may be advantageous. Blisters around the coronet are useful toward the third or fourth day, when plastic exudation or hypersecretion of the hoof are to be feared. Frog seton is recommended by English practitioners ; Gabriel says it is a sure means to prevent the separation of the nail. This seems to us unwarranted. Internally, the administration of ni- tre, cream of tartar, amraoniacal salts, sulphate of soda, are given ; drugs which are indicated by the febril state ; alkaline remedies, and principally of nitrate of potash in large doses, are administered to render the blood more fluid and increase the venous circulation. Aloes, recommended in England by Hertwig, are contra-indicated, as increasing the disease and facilitating the dropping of the foot. DISEASES. 691 It has been advised to take the shoes ofif. This is not only a difficult operation, on account of the sufferings of the animal, ob- liged to stand uj^ou one leg, but it seems to us useless. Shoeing has not the effect suj^posed of it in the etiology. If it is well ' fitted it is not uncomfortable to the foot, while its removal from the foot, hy the hammering it requires, is always painful, and had better be avoided. It has been recommended to pare the foot, to shorten it, to thin the sole down ; but this operation seems to us in many cases superfluous. It is true that the topics will act more readily upon the living tissues underneath, but the advantages thus obtained do not compensate for the difficulty of the operation ; at any rate, it cannot be done except when the animal lies down. We shall pass silently the effect, so to speak homeopathic, that English veterinarians pretend to obtain with very warm poultices around the foot, and which have their reasons only when suppuration or gangrene is threatening. Neither shall we refer to the compression of the foot, recommended by Nanzio — a treat- ment which is much nicer in theory than in practice. In a great number of cases, the patient is considerably relieved by resting on a good bed, and this is especially necessary for severe laminitis when locomotion is very painful. However, in less serious cases, walking on soft ground, especially on grass, is an excellent treat- ment. It stimulates the circulation in parts where the blood has a tendency to accumulate, and controls the venous engorgement of the keratogenous tissue. It has been sometimes recommended to support the animal in slings to relieve him ; but as with this one would expose his patient to pulmonary complication, it is bet- ter to cast him and keep him in that forced position, being careful to turn him over from time to time. A dietetic regime, light feeding, during the first days at least, cooling drinks, rectal injections and comfortable blankets are all indicated. One must particiilarly watch what takes place in the foot, and for this purpose grooves made at the surface of the foot have also been recommended; but they cannot be made deep enough, as the wall is always there resisting more or less to the eccentric forces of the deep parts. If toward the third or fourth day there is no marked improve- ment, especially in traumatic founder, if even the patient becomes 692 OPERATIONS ON THE FOOT. worse, if the pulsation at the digital arteries is stronger, harder and more frequent, it becomes necessary at once to thin the sole down, and make a puncture upon the line of demarcation of the sole and wall with the drawing knife. Often then a flow of pus or blood, more or less altered, takes place, the nature of which in- dicates the progress of the disease. If it is of a grey blackish color, it is evidence that the horny tissue only is affected ; while if white, it indicates a greater change. Hertwig advises this opera- tion always, when laminitis is of long duration. He thus pro- duces an artificial seedy toe, which is considered the mildest form of the disease. He recommends to make a deep groove upon this white line so far as there is separation of the wall from the podo- phyllous tissue, and then combines the treatment with the use of astringent baths of sulphate of copper. We have, on several oc- casions, been pleased with this treatment, combining it with the application of a blister around the coronet. It is preferable to the longitudinal grooves, or to trephining, which is sometimes recommended. There are numerous cases, however, when, notwithstanding aU these rational means, the disease cannot be arrested, and when a fatally chronic laminitis ensues. This must be considered inciu'- able in the majority of cases. It is almost impossible to bring the foot back to its physiological condition, and, above all, to pre- vent the hypersecretion of the hoof which characterizes it. However, in case of simple seedy toe, if it is the result of hemorrhage, or even of suppuration, a cure may sometime be ob- tained. Generally, by thinning it down, the entire portion of the wall which, at the toe, the mammae and the anterior part of the quarters is superposed, to the keraphyllous hoof, without adhering to it, is removed. The keraphyllous hoof, also, is thinned down in its whole extent ; then a dressing of hoof ointment or tar is ap- plied so as to protect it from drying and to keep it supple. In these cases, the hoof coming down from the coronary band has sometimes united with that flowing over the podophyllous laminae. At other times the seedy toe is only cleaned of its contents, and is filled with medicated oakum, if there is a wound of the podo- phyllous tissue, or with hoof ointment and Venice turpentine, the whole being kept in place by a wide web shoe. The last treat- ment seems to us the best, only instead of hoof ointment we em- ploy gutta percha, melted with gum ammoniac, as recommended DISEASES. 693 by Defaj^s. For this there must be uo wound, and the cavit)^ must be well cleaned of all substances, or even washed with ether to remove all greasy substances which would prevent the gutta percha from adhesion with the hoof. This course has enabled us to see deep seedy toes recover by the gradual growth of the foot. Hence, the indication to try to obtain an artificial seedy toe as early as possible, as recommended by Hertwig. When there is thickening of the keraphyllous horn and adhes- ion with the wall; when, also, the toe is formed entirely by a de- formed horny mass, the case is more serious and the treatment more uncertain. It has been recommended, wrongly, we believe, to perform the operation which consists in cutting off all the pro- truding hoof — to even cut off all the accidental production. To do this the rasp and drawing-knife are used, the keraphyllous mass being thrown down as much as possible. D'Arboval has also ad- vised to make with the drawing-knife an artificial seedy toe be- tween the internal face of the wall proper, which is preserved, and the anterior face of the podophyllous apparatus, upon which a thin layer is left. This treatment has an advantage over the other of keeping the wall intact, to render easier and more solid the application of the shoe which is to protect the foot and allow the animal to resume his work. This operation, however, is only pal- liative. It, however, gives great reUef, especially in the first steps of chronic laminitis. Gross has been satisfied with thinning down with the rasp the superior part of the wall, below the coronet, in a width of about foui" centimeters, in such a way that from one heel to the other there was only a very thin coat, which he protected with basilicon ointment. The coronet was then stimulated with a little oil of cantharides. Under this treatment, a new growth of hoof is started, not so protruding, and by paring down by degrees the hoof, a new foot was grown in a few months, less deformed and more regidar. Meyer and Gunther say that they have obtained good success with this treatment, which nearly resembles that of Gohier and Dehan, except that with those the entire wall was pared down to a thin pellicle, flexible under the pressure of the finger. Silber- man advised to place around the hoof, below the coronai'y band, after paring it down thin, a band of steel, two fingers wide, which could be tightened by a screw j)laced at the heels. In this way 694 OPERATIONS ON THE FOOT. the secretion of the coronary band was kept under control, but not that of the podophyllous tissue. Generally in these cases the supj^leness of the hoof must be kept v;p by apjjropriate topics. It must be cut off when too thick, and a shoe must be applied sufficiently wide in the w^b to protect the anterior part of the sole as far as the point of the frog. This shoe must be quite hollow on the foot surface, so as to avoid any pressure upon the sole. It must be nailed on principally at the heels, as nails at the toe would not hold sufficiently. Betw^eeu the shoe and the foot a piece of gutta percha, or felt or leather may be put on. Thus shod, a horse will still do long service, even in cities, and much more in the country. When there is a wound at the sole, with separation of the part, suppuration, caries of the os pedis, which protrudes through the sole, it is advised to have recourse to a surgical oj)eration. The contents of the abscess under the sole must be evacuated, and the sole thinned down in the entire plantar region. If the bone is carious it is scraped, the necrosed parts are removed, and a proper dressing, kept up by plates under the shoe, is put on. There are a few cases where, by this treatment, horses have been enabled to resume their work. Often in chronic laminitis when, notwithstanding the opera- tion and the shoeing, the horse is unable to resume his work, ac- cording to H. Bouley, the operation of neurotomy will then be beneficial. Grad is not of the same opinion. He claims that the relief is then uncertain and only temporary. Jessen and Hering say that this operation is followed very often by the sloughing of the hoof, and the animals stumble very easily. According to BrauU this operation is followed by a greater growth of the hoof. If the lameness is reduced after the operation the deformity of the foot continues to increase. Navicular Disease. Synontms. — Chronische HufgenMahme, German; 3Ialadle N'aviculaire, French. This disease, called by Loisel and H. Bou- ley, podosesmnoideal synovitis (synovite podosesamoidienne) ; by Braull, chronic podotrochlitis, is an inflammation of the sesamoid sheath of the horse, that Turner and some other English veterin- arians were the first to describe, and which is mostly observed in thoroughbreds. DISEASES. 695 The disease is ^jrincipally seen in the fore feet, and more com- monly in one foot alone ; sometimes, however, both legs are affected, one first, and the other following. Navicular disease of the hind feet is seldom observed. It is accompanied with lameness and deformity of the foot*, and often proves rebellious to treatment. It is followed by con- traction of the heels {encastelure) which is itself often mistaken for navicular disease. At any rate, the affections are nearly re- lated, whether the disease of the sesamoid sheath, first occuiTing, is followed by the contraction, or that the hoof, originally con- tracted, gives rise to the subsequent alterations of structure which constitute navicularthritis. At present we shall only con- sider the deep inflammation of the podosesamoideal articulation^ occurring without primitive alteration in the form of the foot. I. Symptoms.- — These are at first obscui'e. The lesion is deeply situated, and is, so to speak, concealed in the hoof, which itself, is generally at first of very limited extent. The first symp- tom which attracts attention is the lameness, which sometimes, indeed, seems to be merely a certain weakness of the affected leg. This lameness is at first intermittent and slight, but gradually in- creases. "WTien in the stable, the animal " points," that is, the dis- eased foot is carried forward of a vertical Une, and assumes a state of general relaxation of the muscles, with the coronet straightened and the foot mostly resting on the toe. This in- complete rest of the leg, which is sometimes kept in motion for- ward and backward, becomes especially aj^parent if the animal is moved backward in his stall. He then sets down his foot with much hesitation, and for a short time ; the same thing also occurs when, in order to relieve the opposite leg, the animal puts all his weight on the diseased one. Still, a close examination of the foot fails to reveal any marked lesion ; no change of form appearing, no wain at the coronary band ; merely a little heat toward the heels, or on the frog, where there can also be found a certain amount of low and deep sensibility, made apparent only by per- cussion of the hammer upon the foot, or by the jDressure with the blacksmith's nippers, principally toward the heels and the frog. According to Laf osse, the frog is often found indurated, atrophied and thrush^^ If exercised, the horse frequently stumbles, and sometimes falls on his knees ; he fears the pain of resting the heels on the ground, and is limited in the movements of his knee G96 OPERATIONS OX THE FOOT. and fetlock. If the heels are pared oflf, in such a manner that the frog is well prominent, and the horse becomes much heated, the lameness is increased, although at first it may have been very slight. Blacksmiths may frequently obtain the same result by placing under the foot a bar shoe, which, then resting on the frog, and not the heels, greatly aggravates the lameness until it be- comes excessive. This mode of diagnosis was originally indicated by Brauell : When, after more or less exercise, the animal is left to cool off, he at once points, straightens his fetlock, and slightly flexes the knee; the leg has a trembhng motion, and no rest is taken upon the heels. There are, however, according to Hertmg, cases where navicu- lar disease suddenly reaches a period where, in the stable, the animal avoids all resting on the heel ; j)oints constantly, and hes- itates to put his foot on the ground when made to walk. It al- ways seems that there must be some traumatic lesion in the foot, as a punctured wound or a suppurating corn ; and still there is no increased heat in the hoof, and no extraordinary pulsation of the arteries of the foot. The disease has a tendency to increase, and the animal soon becomes very lame upon being put to work, especially on a hard road or rough ground. The heat of the foot is increased princi- pally after work, though not in proportion to the lameness. The sensibility of the foot is also more manifest under the exploring pressure of the nippers. In the stable the pointing is well marked, and the trembhng of the leg gives signs of deep and per- sistent pain. It is only after se v^eral months of this suffering that the foot begins gradually to show a change of shape. It then be- comes visibly narrowed and elongated, in a manner which can readily be detected both by sight and management. There is a general atrophy of the hoof; the periople has disappeared, or scales off; the foot becomes covered with ridges, more or less marked, but better develojoed toward the heels ; the frog has be- become sunken and atrophied; the sole is ecchymosed, present- ing e%idences of corns; and the leg is atrophied, especially about the muscles of the shoulder. In cases where both fore feet are affected, the animal points with either foot alternately, while seeking the desii-ed relief for each, but the rest on either is very short. The hiad legs are brought under the centre of gravity, the back is arched, and the DISEASES. 697 decubitus prolonged. In stepping out of the stable, both fore feet are held stiffly, and kept close to the ground, the animal stumbles on his fetlocks, and often falls, and one might suspect him of being weak. In walking, his shoulders seem to be ligidly attached to his body, but as he warms up the legs move more freely and his actions become less limited ; but immediately on cooling o£f, and especially the day following one of hard work, all the sj'mptoms reappear, with even aggravated intensity. The disease increases steadily with the lapse of time. When one, or what is more rarely the case, both hind feet are affected (Loiset has seen it occur), the animal is stiff behind; he is lame on one or both feet; he puts his foot on the toe only; knuckles at the fet- lock; and presently an atrophy of the muscles of the superior regions takes place. II. Progress, Duration, Teryniiiation. — The disease gener- ally' maintains a steady progress ; nevertheless it very often un- dergoes a remission, due to the hygienic conditions in which the animal is placed; to the seasons; to the state of the atmosphere, and to other causes. It may diminish in severity, and its symp- toms disappear, while in its first period, if the animals are left at rest — without shoes if possible — loose in a box, with damp bed- ding, or in a marshy field ; or in winter, during the rainy season, while the atmosphere continues in a moist condition for a long period. It is, under these cu'cumstances, not uncommon to see feet which had become contracted quite recover their natural di- mensions. Aside from these exceptional cases of recovery, the lesion keejDS on slowly destroying the tissues where it exists ; the lameness remains constant, or becomes intermittent for years, sometimes after the animals have become entirely unfit for work. There are frequent complications involving the surrounding parts ; sometimes a true arthritis, and besides the complete atro- phy of the muscles of the shoulder, the carpal Hgament becomes thickened, the tendon of the j)erforans undergoes the same alter- ation, and ring-bones and side-bones may follow. Again, how- ever, the animal may become knuckled to such a degree that he can scarcely rest his foot on the ground at all. III. Pathological Anatomy. — As we have said, the disease has its seat in the synovial caj)sule, fonned by the small sesamoid sheath between the navicular bone and the perforans tendon, slid- ing upon it. At first may be observed a certain injection of the 698 OPERATIONS ON THE FOOT. synovia, and a darker hue in tlie coloration of the trochlear carti- lage with the corresponding face of the tendon, the sjTiovia be- coming reddish and thick, the surrounding cellular tissue becom- ing, also, inflamed and infiltrated. At a later period, when the disease has somewhat progressed, there is a thickening of the ■walls of the capsule, which is then filled with a clear citrine ser- osity. There is then, a kind of hygroma, a chronic dropsical con- dition of the sheath. In the interior of this are also to be found fibrous bands, running fi*om the tendon to the bone. If the dis- ease is older, erosions are found upon the diarthrodial surface of the navicular varying in number and in size, and the tendon is roughened on its anterior face with longitudinal fissures. At times, it becomes atrophied and thin, dry and brittle; and has been found, it is said, ruptiu'ed transversely. In many cases, the cartilage covering the bone has disappeared and the bone is ex- posed, hollowed and afi"ected with osteoporosis. The union of the bone with the tendon has also been found among the varieties of determination. IV. Diagnosis. — This disease is at first easily mistaken. for some form of rheumatic affection. "Where pain is the main symp- tom it is easily detected, but where there are no other signs of in- flammation, it is just the lack of proportion between the intensity of the lameness and the serious symptoms, such as the absence of heat ; of special sensibility ; of pulsations in the digits, which distinguishes naviciilar disease from other affections of the feet. The error with contracted heels is easier, as here the change of form of the foot being primitive, at once attracts the attention of the practitioner; while this alteration in the foot is absent in navicularthritis at the outset of the disease. V. I^rognosis. — Generally, it is unfavorable, as most com- monly the veterinarian is called only when the disease has already made serious progress and j)assed into the chronic stage ; and again, because of the difficulty of reaching the disease by reason of its peculiar location. VI. Etiology. — To proj^erly understand the etiology of this disease, one must bear in mind the part played by the anterior legs in the action of locomotion. Columns of sup^Dort more than of impulsion, it is their office to sustain the weight of the body when it is thrown forward by the extension of the hind legs. The reaction of the ground is first felt at the shoulders, through the DISEASES. 699 muscular sliugs which attach them to the trunk, but it is partlj' dimiuished in the scajDulo-humeral joint, which closes, notwith- standing the resistance of the muscles implanted on its apex. The remaining force is transmitted to the vertical column, represented by the union of the radius, the carpus and the metacarpus. Reach- ing the digital region, this force is there decomposed. Part of it, passing on the phalanx, loses itself and disappears in front of the horny box of the foot, the other being thrown ujDon the flexor tendons, and finally upon the perforans, which distributes it to the posterior parts of the foot, and to the navicular bone. It must be observed that in this comj^lex action of decomposition of the shock, the os sesamoid, though pushed from before backward by the OS coronse is, however, supported by the resistance of the per- forans tendon. Consequently, both the bone and the tendon are pressing upon each other, when the feet are placed on the ground, throwing the body forward by the impulse of the hinder paiiis, and thus press powerfully against each other. When this pressure takes place in an animal going full speed, and a good and high stepper, it may commence by becoming merely a slight confusion, but, if often repeated, the result may be some lesion upon the corresponding surface of the bone and of the tendon, or of the synovial which facihtates their move- ments. But the energy of action in the animal cannot be con- sidered the only producing cause of these lesions, as a vice of conformation in the foot, a want of elasticity in its posterior parts where the resisting power is diminished, may also produce it. The disease, then, is observed in animals whose plantar cushion, covered by a smaU, dry and atrophied frog, is itself badly devel- oped, from being compressed between the bars, which are more vertical, or the heels, which are more contracted; all these be- ing conditions which diminish the flexibiUty of the back of the foot. Two principal causes, then, co-operate in the genesis of navi- cular disease, and are almost always present in animals thus affected. On the one hand, it will appear among well-bred ani- mals, especially those of English breeds, those from Hanover, Mecklenbiirg and Normandy, which will be more affected. Loiset and Lafosse, however, have seen it in common breeds, in animals with flat feet and soft horns. Lafosse says he has seen it in mules. But besides this influence of the breed, there is the effect of what 700 OPERATIONS ON THE FOOT. we may denominate the hygiene of the foot ; the too dry bedding, certain wrong modes of shoeing and all the predisposing causes of contracted heels. Let us add also, as a cause, the effect of changing the animals from marshy fields, where they were walk- ing on soft, damp ground, to stables with dry bedding — a cause commonly present in horses transported from northern Germany to the south. Hard work and excessive exercise are also causes of this affection — for example, jumping fences with a heavy rider, slipping in steeple-chases, racing, a sudden stop on the fore feet, especially on stony, hard, frozen or rough ground. All these are fruitful cases of navicular disease. Traumatic causes, such as punctured wounds, involving the sesamoideal sheath, are also j)roductive causes which may origin- ate navicular disease. We do not believe in internal causes, nor admit, with Loiset, that visceral inflammation, sudden arrest of jDerspiration, especially of the lower part of the legs, can produce the disease. We shoiild rather anticipate that these metastases would affect more the more important serous structure. Neither can we admit, with Lafosse, that this affection can also follow a sudden arrest of the milky secretion. VII. Treatment. — We have seen, in speaking of the termina- tions of these lesion, that in certain peculiar circumstances which may be accounted favorable to the return of the elasticity of the foot, a spontaneous recovery is possible. This leads us to the measure of the prophylactic means proper to be used; and it seems evident that by a better hygiene of the feet, by rational shoeing, sometimes educating young horses only gradually to fast work, one may in many cases avoid navicular disease. While it is in its first stages, one may, with care and patience, sometimes reheve the patient. In this case, absolute rest is coun- ter-indicated, but on the contrary, moderate exercise, upon even and not too hard ground; or, if the lameness is great, walking exercise onl}^, at a moderate gait. The absorption of the serosity present is made easier by a little exercise than by absolute rest. Bleeding from the toe, or the veins of the affected legs, is also, at least, superfluous, the disease becoming chronic almost at the outset. It is also a good practice to shoe the horse, and above all, to remove the shoe frequently. The best shoeing is that which allows for the natural expansion of the hoof. The Charlier shoe has proved useful, while the bar shoe, which is heavier, and DISEASES. 701 presses upon the frog, is couuter-inclicated. It is important to en- courage the suppleness of the hoof by proper ointment, especially the ajiplication of glycerine, and to have under the feet a bed- ding always shghtly damp and soft. The bedding of moist saw- dust is very convenient ; we prefer it to poultices, and even to the tepid alkaline baths mentioned by Hertwig. At times, at inter- vals of about eight days, and then during two consecutive days, a good friction with blister ointment above the coronet is advan- tageous, as well as one with Lebas' ointment. English practi- tioners prefer salines ; the better treatment would be to tui-n the animal to grass. Brauell advises iodine internally, and says he has found it work well. Others recommend diuretics. Setons in the shoulder or chest seems to us inexpedient. We prefer the ad- ministration of a purgative ball every eight days. Sewell and Brauell advise a seton, running from the hollow of the coronet through the plantar cushion, a little behind the tendon of the perforans, and within a short distance, therefore, of the diseased capsule, making its exit at the anterior third of the frog. This drain is to be maintained for two, three, and even four weeks ; SeweU, BraueU, Hertwig, and several other veterinarians, English especially, claiming much benefit from it. This seton is intro- duced by means of a curved frog seton-needle ; it has been used but little in France. Bruner has recently proposed the puncture of the sesamoideal capsule with a trochar, introduced into the hollow of the coronet, an operation only practicable if the serous collection can be felt outward. After the punctiu'e, he recommends an injection of iodine. Lafosse proposes after the removal of the sole, the transversal incision of the plantar cushion, with removal of a part of it, down to the tendon, following the axis of the sesamoid; then the cau- terization of the bone and its cartilage, in imitation of what is sometimes done in punctured wounds of the foot. BraueU recom- mended as a useful surgical operation, the section of the perforans tendon in the metacai-pal region, in order to prevent friction against the sesamoid groove, and to aUow an easier adhesion be- tween the tendon and the bone. But it is to be feared that this section, suj)posing that it proves successful, might so weaken the tendon as to render the animal unfit for fast work. If navicular disease should be accompanied with deviation of the wall, and contraction, true or false, the treatment will be that 702 OPEBATIONS ON THE FOOT. of this affection in its simple form. An oj)eration, often recom- mended, has been that of neurotomy, upon the posterior branches of the plantar nerves, repeated at intervals of at least fifteen days, in order to remove the lameness wholly, without entirely depriv- ing the foot of the sensibility of feeling. Berger, Brauell, Bou- ley, Gross, Mandel, and others, have obtained real success by it ; but it is attended with serious dangers ; at any rate the benefit is not of long duration, or about one year. The animal then stumbles more readily, and is more exposed to traumatic lesions, etc., and it is probable from this cause that double neurotomy is seen to be followed by softening of the deep parts of the foot, suppuration, sloughing of the foot, while the animal has previously shown no signs of pain. Consequently, neurotomy is an operation which finds its apphcation only in peculiar and exceptional cases, and animals thus operated upon remain fit for light work only. QUITTOR. Synonyms. — Fesselgeschwur, German ; giarda, Italian ; gialarrs, Spanish ; javart, French. A name of unknown etymology, by which old hippiatrics desig- nate various affections of the inferior regions of the legs of the horse, donkey and mule, and even of bovines. These possess the common character of a degeneration of a portion of the tissues, that is expelled by the efforts of nature under the form of a slough {hourbillon). There is a softening of the mortified structures, and an elimination by suppuration. In several old works, these sloughs are called quittors {Javars), and this name has been ex- tended to the disease itself. This name having been preserved by use, notwithstanding the efforts of Vatel in opposition, we shall also employ it, and with Girard, recognize: 1st. The simple or cutmieous c[aittor, which is only the furuncle which occurs in the thickness of the dermoid structure nearest to the coronary band. 2d. The tendinous quit- tor, which greatly resembles the felon of man, where a portion of the sub-cutaneous cellular tissue, and of a tendon sloughs out. 3d. The sub-homy quittor, the furuncle of the cutidura of the coronary band itself, the slough involving the superior portion of laminated tissue. 4th. The cartilaginous quittor, or the limited caries of the lateral fibro-cartilage of the os pedis, and which old writers compounded with the horny quittor. We might join to DISEASES. 703 those the furuncle of the frog. We believe it useless, at present, to enter upon a general consideration of quittor, and wiU pro- ceed to examine the pathological phenomena presented by each variety. A. Cutaneous Quittok. — This is a simj^le furuncle of the coronary region of the foot, in that part of the dermis nearest to the coronary band, ha^dng, however, a special character on account of the extraordinary thickness and inelasticity of the dermis of the region it occupies, the resiilt being a kind of strangulation of the inflamed tissue beneath, and a very painful compression It is through error that some authors have designated by the same name, the furuncle of the canon, of the fetlock, and of the co- ronet. The hind feet are more subject to it than the fore, and it is more frequent at the heels, at the fiexiu'e of the fetlock, though it is also observed on the sides and front of the coronet, in which case it is much more painful. Cutaneous quittor has also been observed in bovines, where, however, as we shall see as we pro- ceed, it is generally comphcated with the tendinous variety, and becomes a true felon. I. Symptoms. — Cutaneous quittor is characterized by an in- flammatory tumor or swelling, warm, painful, and tense, of the coronary region of the foot, the color of the skin being but little changed, if it is dark, but if the skin is light then the redness is well marked. This swelling is accompanied with a diffused sedema, extending to the fetlock, or even to the hock. We often find angeioleucites, or rather what we call leucophlegmasise. The lameness is generally extreme, and the animal frequently can scarcely rest on the diseased leg. The pain is sometimes so great as to induce general fever and loss of appetite, and the animal becomes dull and depressed. After acquiring certain dimensions, the tumor shows a tendency to soften at its summit, its base, however, remaining hard for a considerable time. Rising more and more, it soon ulcerates at a point from which flows a small quantity of bloody pus, followed by the appearance of the slough, {bourbillon). An abscess is now formed in the tumor, which, as it opens, carries with it a portion of the skin, sometimes limited, at others measuring from four to ten centimeters, and there is a slough formed of the subcutaneous cellular tissue which separates by the suppuration with the portion of dead skin. This comes 704 OPERATIONS ON THE FOOT. out by degrees. It is still adherent by its base and cannot be pulled out with the forceps unless by tearing and with acute pain, and this is often followed by slight hemorrhage. A few days later it will, however, become entii'ely loose, and in its place there \vill remain a cyHndroid open ca\ity extending through the tu- mor, from its summit to its bottom, and from this a deep wound results, followed by a sero-bloody secretion, mingled with pus. As soon as the slough has taken place, or when it begins, the lameness subsides, as well as all the other phenomena of the j)ain. The wound heals up rapidly if there is no complication. Cutaneous may easily be comj^licated with tendinous qmttor if the disease or process of sloughing of the mortified tissues ex- tends to the tendons or ligaments of the region involved. This complication is specially common in bovines, where cutaneous quittor generally gives rise to more swelling and greater suflering than in the horse. The quittor has quite a rapid progress, and may last from eight to fifteen days ; very seldom longer. At times, it seems to be a single furuncle ; at other times, there are several existing to- gether. Often again, they come in succession, the first one treated being soon followed by others. This is said to take place princi- pally when the diseased part remains exposed to the action of ir- ritating substances, and relapses are prevented by protecting the part from the effects of these occasional causes. II. Pathological Anatomy. — It is an inflammation of the very abundant sub-cutaneous cellular tissue of the region, spread- ing from a starting point ; the inflamed tissues are mortified and becomes gangrenous, and b}^ a process of suppuration, the econ- omy attempts to eliminate them. The slough represents more particularly the inflamed cellular tissue, which is thickened, and which has become filamentous and hard and much impregnated with purulent serosity. HI. Etiology. — Contusions of the region, bruises and punc- tured wounds are quite frequent causes of cutaneous quittor, but it may also take place without evidence of determining causes. Mud, manure, urine, all filth in which animals have to walk or re- main, are also considered as causes. For this reason the disease is more common in the fall and winter, on account of the action of cold at times, and frozen mud. It is also more frequent in cities than in the country. Ray observes that the mud of cities is al- DISEASES. 705 ways more irritating and contains mineral substances, especially lime, alkalines, and salts, and other substances. The gutters of some industrial establishments have also a direct irritating action. D'Ai'boval has observed that the mud of places where mineral spiings exist, is more u'ritating, as also are calcareous soils, where cutaneous quittor is more frequent than in any other. Common, lai'ge horses, notwithstanding then- thick skins — or, rather on that account and on account of the hair which covers it — are more commonly affected than private horses. Towing horses are much more exposed to the disease than those otherwise employed. IV. Treatment. — As a first direction, during the course of the treatment it is always a prudent rule not to work the animal and to keep it in the stable, the feet being kept dry on a good bedding. An internal treatment is seldom necessary to control the general symptoms ; if any is required, ordinary salines will generally be sufficient. It is necessary to assist the process of suppuration of the abscess by emolients, warm baths, j)oultices of flaxseed or of marshmallows, with melted lard, applied quite warm, or by the application of a mixture of honey and bran or flour. We have applied a coating of blister ointment to the tu- mor, covered with a warm poultice ; the matui'ing effect is then very rajDid. It is often necessary to lance the tumor to reduce the pain and prevent the mortification of » large piece of skin. This oj)eration is recommended by D'Ai'boval and H. Bouley, and is specially indicated when the tumor is much developed. It is then important to incise in the entire thickness of the dermis and to a sufficient length, and if necessary to make severel parallel in- cisions which will give rise to a copious flow of blood. In this mode, the parts are reheved, the pressure of the tumefaction is reduced and the gangrene diminished, if not entirely prevented. It is necessary — and we insist on this point — to incise so deeply that the tumefied skin is divided in its entire thickness. We have seen blacksmiths thus operate by the introduction of points of cauterization in the summit of the abscess ; but this mode, though facilitating the sloughing of the strangulated part and reducing the compression, ought not to be preferred to the incision with a sharp instrument — cauterization is more painful. "UTien gangrene exists and the abscess is open, the incision is certainly less efficacious than at the outset, but it is not for that reason useless, as it relieves the pain and prevents excessive com- 706 OPERATIONS ON THE FOOT. pression. We do not by it attempt to loosen the slough, which it is advantageous to have detaching loose itself when it holds only by its base. If the abscess, once formed, is slow to vilcerate, making a point of cauterization is a good way to stimulate the escape of the matter of the slough. This mode of opening pro- duces in the part an increase of vital action and forms a sore of benign character, which falls off by the effect of the suppuration formed underneath, and which is nearly always followed by a comparatively speedy recovery. To obtain this radical cui-e, it remains to continue the use of the ordinary means to facihtate suppuration and bring on resolution. If the wound is pale and covered at the bottom with large granulations, it must be dressed first with basiHcon ointment and afterward with alcohohc liqviids, as spirits of camphor, tincture of aloes, or simply an aromatic in- fusion; at times, baths of sulphate of iron, with a little sulphate of copper, are indicated ; or, when the wound has become red, the granulations vascular and of healthy character, a simple dressing of oegyptiacum ointment, diluted in vinegar, is enough. If proud flesh develops itself, it must be cut off. It is important to have the wound covered with a protecting dressing, which must be re- newed daily if the suppuration is very abundant, or it may some- times be left on for two days. B. Tendinous Quittor. — Synonym: Horniourne (Germ.) — It is the nervous quittor of hijppiatres, and the analogue of the felon of man. It is again a furuncle, different from the preceding, only because instead of being limited to the skin and subcutane- ous cellular tissue, there is caries of a portion of the tendons (especially the flexors), or of the ligaments of the region, and also, at times, necrosis of the bone with sjmovitis and arthritis. By extension, though we think, improperly, the name has also been given to the felon of the region of the cannon, while the applica- tion ought to be confined to that of the digital region, situated in the fold of the fetlock. The quittor may be superficial or deep-seated when it affects only the subcutaneous cellular tissue, uniting the skin to the ten- dons, or where the inflammation extends to the phalangeal sheath, and the pus accumulates into it. Differing from cutaneous quit- tor, this form, generally less common, is more frequently seen in the anterior than the posterior extremities. It may also be seen ^ cattle. DISEASES. 707 I. Symptoms. — The first symptom is an excessive lameness, manifesting itself even where no visible change exists in the af- fected leg. The animal evidently suffers great pain, while his actions do not aid us in localizing it accurately, though the foot is always examined as being the probable seat of it, the animal raising it more rapidly than the other from the ground, and rest- on it with much caution and hesitation. After from two to five days, a phlegmonous tumor appears at the coronet, above the heel. It is extremely warm, and much more painful than that in cutaneous quittor, the hoof and the skin preventing the free de- velopment of the inflammation by strangulating it. The foot almost ceases to rest on the ground, but is flexed and raised from it, feeling in the parts being very painful. The swelling of the leg extends to the fetlock, or to the cannons, and even to the knee. The animal has more or less fever, and when there is a deep quittor, he loses aU his appetite, and ordinarily lies down and continues in the recumbent position. Generally, much time is required for the phlegmon to assume the character of an abscess, as the slough, being in this case no longer formed by the cellular tissue, is slower to define itself. This process of suppuration is not so well localized ; there is, on the contrary, a kind of deep abscess, which probably becomes complicated by the resistance opposed to the ulcerative inflamma- tion by the aponeurosis of the sheath and the thickness of the skin. However this may be, it is always very difficult to recog- nize the presence of one or several of these abscesses, even when they form in the subcutaneous cellular tissue, and so much the more if the purulent gathering is deeply seated. After the opening of the abscess and exfoliation of the slough, either with or without the dropping of a portion of the skin, there does not remain the simple wound of the cutaneous quittor, but on the contrary, a persistent fistula, running down a necrosed point of the tendons or of the fibrous sheaths. At times, almost from the outset, we may observe in the fold of the coronet numer- ous little pimples, which terminate in as many deep fistulse, from which ooze a more or less thick humor, foetid, puriform and bloody. In frequent cases, the disease in unaccompanied with suppuration, and there is a swelling, more or less hard, with a gradual diminution of the pain and other inflammatory symptoms. A more frequent complication is the suppiirative inflammation of 708 OPERATIONS ON THE FOOT. the tendinous sheaths, or even of the digital articulations. There may also be a diffused gangrene with separation of the hoof and purulent infiltration under the horny box — periostitis, and caries of the cartilage. This is the deep tendinous quittor in the most severe form. In this last case, especially if there is an accumula- tion of pus in the tendinous sheath, the tumor is very painful, the slightest touch giving rise to the manifestation of extremely acute suffering, the hoof being constantly raised from the ground. The fever is violent, there is a complete anorexia, and the exercise of all fiinctions is more or less disturbed. The compulsory resting upon the healthy legs may give rise to swelling of the hocks, and even to laminitis. In cattle, tendinous quittor becomes more painful than in the horse, and is always accompanied by a swelling which may extend to the knee. Rumination stops, and the animal endures great an- guish. The slough is followed by a wound of varying depth, which often exposes the diseased articular surfaces of the phalanges. If this remains too long, the pus may affect the interdigital ligament, complicate the disease, and even make it incurable. In this case, the amputation of one of the digits may sometimes be performed. II. Progress, Duration and Termination. — The duration is generally protracted ; the disease often gives rise to chronic lesions diificult to remove. This will be easily tmderstood, if we remem- ber that the region affected is composed, between the skin and the bones, of synovial capsules, ligaments, tendons and aponeu- roses, more or less cellular tissue, and of very strong nervous ramifications. If the disease is not very deej)ly seated or unilat- eral, complete recovery may be looked for; but if there are chronic lesions, if the articular surfaces become affected; espe- cially if particles of bones are sloughing, if the animal recovers it will be but imperfectly, and it will usually be accompanied by anchylosis of the joint, and diffused gangrene is also a complica- tion to be looked for. III. Diagnosis. — We said at the beginning that tendinous quittor is a very obscure disease ; the lameness is very great, but not characteristic ; in proceeding, we referred to the acute local pains at the side of the tendinous cord of the cannon, the inflam- matory swelling, the increase of local paias, and the general reac- tive fever. IV. Prognosis. — It is a very serious disease, on account of DISEASES. 709 the possible complications and bequelae. Tlie loss, or the deform- ity of a phalanx, -which are sometimes arf.ong the sequelae of the felon of man, are in him accidents which never give rise to serious comphcations, or are quickly forgotten, while in the horse such comphcations ai^e equivalent to the death of the animal. V. Etiology. — The causes are the same as those of a simple quittor, which is complicated with the tendinous kind ; this is also observed after the subcutaneous abscesses, frequently resulting from bruises, or even from punctered wounds. It is most com- monly met with in low-bred horses, and Fisher says that it is more frequent, and less maHgnant, in young than in adult ani- mals ; according to this writer, it is a common manifestation of distemjjer. Irritating muds favor its development in the same manner in active as in simple quittor. It often appears without appreciable causes. VI. Treatment. — When tendinous quittor is superficial, it re- quires about the same treatment as the simple kind, except that, in this case, the counter openings must be made earl}- to prevent the sloughs, migrations of the pus and the gangrene. The siu'- geon must not forget that the inflammation in this affection must ordinarily terminate by suppuration, and he must bear in mind that there is a possibility of the modification of the inflamed cell- ular tissue, and that the mortified portion of that tissue must slough out, as their presence, too long continued, may be very dangerous. The general indication is to prevent, as much as pos- sible, the accumulation of the pus, an indication which will be best fulfilled by making openings for its escape, even before the formation of the abscess. As the tissues which surround the pus are very resisting, nature will not be able, or if so, only with great difiiculty, to effect the expulsion of these matters. It is for this reason that it is necessary to assist her operations by making an opening for the escape of the pus and of the slough. The oj)era- tion is A\ithout danger ; but if it is not performed in good time, lesions will be likely to spread, the disease cease to remain a local trouble, and the Hfe of the animal become compromised. It is also more necessary to make an opening when the puru- lent secretion is established, for in this case it is important to avoid delay and to facilitate its escape. A simple longitudinal in- cision, four or five centimeters long, is sufficient, when the collec- tion hes immediately under the cutaneous organ. This incision 710 OPERATIONS ON THE FOOT. must involve the whole thickness of the skin, as far as the ten- dons, and should be made in the middle of the coronet region, as near the foot as possible. It gives rise to an abvmdant hemor- rhage, which reheves the part, and warm poultices and baths, to accelerate the suppuration, are then indicated. When the product of suppuration has passed in the tendinous sheath, a longitudinal opening of this part towards the most de- pendent points, is indicated. To do this, a canulated directory is introduced to guide the bistoury ; when the incision is made, the pus flows freely, and by this mode the large blood vessels and the various ligaments of the region are avoided in the operation. Notwithstanding the incision, or if the suppuration had ah-eady accumulated before it was made, the pus may also accumulate in the pouch formed by the tendinous sheath behind the tendons. It is then very difficult to prevent its collection in those deep parts, and it may extend to the small sesamoid. It is because the pus cannot run toward the skin that it filtrates along the tendon. It is only by pressure and by injections that the indications presented can be fulfilled. After making free incisions, one may try by j)res- sure to remove the pus accumulated between the tendons and their sheaths, following it by cleansing injections, which must be re- peated as often as possible. The wounds which remain after the slough, in the superficial tendinous quittor, and that which follows the opening of the simple or multiple abscesses when it is deeper, are always charac- terized by the presence of fistulas running down to some necrotic spot of the tendons or of their sheaths. For these, an injection is recommended of tincture of aloes, tincture of iodine, and some- times of Villate's solution; lately, dressings with petroleum or phenic acid have been used. Phenicated baths, those of sulphate of iron and lotions of permanganate of potash have also proved useful. At times, when the fistulas are persistent, it is necessary, after enlarging them, to have recourse to actual cauterization with a pointed cautery introduced, while at a white heat, down to the bottom of the tract. A general dressing of the wound follows, with tincture of aloes, sometimes with egyptiacum. The dress- ings shovdd be more or less frequent, according to the quantity of the pus discharged. We must dress it until the wound is entirely healed, and it must, moreover, be carefully watched for fear of another infiltration of pus, or the formation of other fistulas. DISEASES. 711 Superficial cauterization is necessary in order to remove the induration and swellings likely to follow, and to stimulate the resolution. The action of the firing may be stimulated by blister- ing, or by an alterative ointment of iodide of mercury, of siilphur, etc. C. Sub-Horny Quittor. — This is the inflammation of the su- perior part of the keratogenous apparatus of the cutidiu'a; or even of the superior parts of the sensitive laminae. This quittor is, therefore, located under the horny box, and is more like the cartilaginous kind, which old hippiatrics, and especially Solleysel and Garsault, describe with it. It generally takes place on the quarter, and more seldom at the toe, or at the mammae. Some ■ times it is observed at the heels, but it is then of small conse- quence. I. Sym2)tonis. — The lameness is very great. The animal walks on three legs, and there is strong reactive fever, due to the excessive pain — this form of the disease being more painful than the others, in consequence of the pressure of the horny structm-e upon the inflamed tissues. At the origin of the nail a warm and very painfxil tumor is found; the foot is hot and the hairs staring on the site of the injury. If the disease has existed for some time, there is a separation of the hoof at its origin, due to a sero- purulent exudation, and under the hoof suppui-ation and mortifi- cation of a more or less extensive portion of the coronary band, or of the laminae will be found. The suppxiration which there exudes varies, being in rare instances blackish, as it is usually found in traumatic injuries of the hoof; or, again, it is white and unctuous, with the odor of decaying cheese; while more commonly it consists of a bloody or greyish matter, mixed with pus. If the mortified portion is not deeply seated, so that the slough can take place readily, the quittor is quite simple, since as soon as it has dropped off there is a well marked improvement. The pain then ceases almost instantaneously, and the wound at once progresses toward cicatrization. But it is not rare, even when the mortification is somewhat superficial, to find the sub-ungueal suppiiration extending so that the matter runs under the hoof, producing at times more or less serious fistula, or a separation of the sensitive and insensitive laminae. Gii'ard says it has been seen to extend downward to the sole, and to separate it from the vel- vety tissue. The deep, sub-horny quittor may be complicated, 712 OPERATIONS ON THE FOOT. forward, with necrosis of the tendon of the extensor muscle; with the inflammation of the joint; with caries of the os pedis, and even to assume the cartilaginous form of the disease by its exten- sion to the cartilages of the foot. After the recovery of the sub-horny quitfcor, if the coronary band has been mortified in its entire depth, the foot may present permanent longitudinal fissures, or seams, or transversal grooves, presenting evidences of the existence of a cicatricial tissue when the quittor was in progress. II. I^rognosis. — The gravity of this quittor depends upon the depth of the disease. "VAHien superficial and affecting only the surface of the tissue, it is easy to cui-e, but if deeply seated it is more serious, on account of the possibility of complications. III. Etiology. — Bruises and violent blows are the ordinary causes of sub-horny quittor. It is commonly due to overreach- ing, or to the wounds occurring when animals are 'wearing long caulks, as in winter. The irritating effect of frozen mud has also been admitted as a cause. IV. Treatment. — The superficial quittor requires a simple treatment. Emollient baths and maturating poultices are then indicated. It is a good plan to thin the wall with the rasp or the sage knife over the whole extent of the furuncular tumor to a height of about two fingers, A compress of chloroformed oil, W'hile it alleviates the pain, is also indicated to soften the wall. It frequently becomes necessary to puncture the tumor, but we prefer to cauterize it with a pointed iron, following the cauteriza- tion with a poultice of honey with Venice turpentine or camjihor. Some authors recommend astringent baths, as oak bark, or of sulphate of iron. It is often the case that after some interval fol- lowing sloughing of the bourhillon, the wound continues to dis- charge a liquid secretion, which is an evidence that there is a ten- dency to accumulation of matter toward the lateral cartilage, or under the wall, in the laminae ; or that there is some carious spot existing. In the first, if probing horizontally, a cavity is de- tected, it is convincing e-^ddence that a cartilaginous quittor is in course of development ; in the second case, the pressure and col- lection of the matter increases the inflammation of the laminae, separates the w^all, and complicates the disease, necessitating the operation of the sub-horny quittor. The removal of the portion of the hoof which covers the lesion, DISEASES. 713 must, however, mclucle more tliau the purulent center, so tnat the diseased tissues may be well exposed and the suppurative process detach them readily. This removal, always proportioned to the internal lesions, is made either lengthwise, following the direction of the horny fibres, or crosswise. In that case, it will attack only a portion of the wall toward its point of union with the skin. This latter method, it is true, requires less cutting, but it has sev- eral quite serious objections and often necessitates a second oper- ation. Even in cases where the growth of the granulations can be controlled, and where a good return of the horse is obtained, the horse only recuperates its perfect integrity by the slow growth dowTiward of the wall. In some cu'cumstances the operation is completed by the removal of a portion, or even of the entire mass of the sole, when it is separated from the velvety tissue. The removal of a portion of the wall must be accomplished in the manner which will be indicated for cartilaginous quittor, in carefully avoiding the injury of the coronary band and of the podophyllous tissue. The diseased tissue being exposed, all that is of bad appearance is removed, the carious portion being freely taken off. An ordinary dressing of oakum with diluted alcohol, or any other drug, kept in place with a light shoe or slipper, en- tire or truncated, as the case requires, is then aj^plied. As for all wounds of the foot, the dressing needs only to be changed when the pus accumulated under the oakum, or other pecuhar conditions indicate it. It is true that changing the dress- ing is an effective means of cleansing the wound, but it has the inconvenience of also irritating it, and especially at the begin- ning may tend to interrupt the natural process of repair. It is of advantage, after the first dressings, to change them as infrequently as possible. In this way hemorrhages, which may always be looked for, are avoided. This is a point of the first importance. It has been proved that even in operations where a portion of the wall has been removed, a dressing left on for from fifteen to twenty days without removal, was followed by rapid recovery, the new hoof growing under the oakum without suppuration. It is useless to probe or wipe out the surface of the wound. On the second dressing, that is, after a few days, the parts begin to be covered with numerous white points, which are so many rudi- ments of hoof. These, which at first are soft, white, and isolated, gather together by degrees, and first unite into a thin layer, soft 714 OPERATIONS ON THE FOOT. and yellowish, which becomes hard and thick ; it is the hoof secret- ed by the laminse, which, Uttle by little, unites with that coming from the coronary band. Excessive granulations or proud flesh are removed in the ordinary way. D. Cartilaginous Quittor. — Hufknorjyelfister (German) — {improperly called suh-horny quittor, by Lafosse, Jr., coronary quittor of 'Wiiei; Jibro chrondrltis of the third f»halanx, by Vatel; sub-horny cartilaginous quittor of Girard ; quittor proper of Del- wart). This form of quittor is peculiar to solipeds, they being the only animals which have fibro-cartilage on the os pedis. Fig. 533.— Cartilaginous Apparatus of the Hrrse's Foot, a.— Lateral flbro cartilage. 6.— The superior border, c— Its posterior border, d.— Anterior lateral ligament, e.— Flexor tendons. /.—Extensor tendon. ^.— Os pedis. A.— Ketrorsal process. These fibro-cartilages (Fig. 523) are two pieces, which, with the plantar cushion, complete the os pedis and form the base of the heels, each representing a piece flattened sidewise, a pai*allelo- gram in shape, and extending posteriorly to the cofiin bone. Their external face is convex and pierced with foramina for the passage of veins, and sHghtly overlies the surface of the bone of the foot. It is separated from the skin by a very rich vascular plexus. The internal face, concave, is hollowed by vascular grooves, and covers (forward) the articulation of the foot and the cul-de-sac of the synovial sac which protrudes between the two lateral hgaments of that joint. Downward and backward it is united to the plantar cushion, either by continuity of tissue, as DISEASES. 715 near the inferior border, or by fibrous bands running from one to the other. The superior border, either convex or straight, is thru and separated from the posterior by an obtuse angle in front of which it i^resents a deep notch for the passage of the blood ves- sels and nerves. The inferior border is attached, forward, to the basilar and retrosal processes of the os pedis. Behind this it re- flects inward, to continue to the inferior face of the plantai* cush- ion. The posterior border, obHque, backward and downward, is slightly convex and unites with the preceding. The anterior border, oblique in the same direction, is more intimately united to the anterior lateral ligament of the articulation and can be sepa- rated from it only by artificial dissection. It sends upon this ligament and upon the anterior extensor of the phalanx, a fibrous extension, which unites with that of the opposite side. In their structure, the fibro-cartilages comprehend a mixture of fibrous and cartilaginous tissue, a mixture which is far from being homogeneous and even in the various parts. The more it is examined forward and near the base, the more its substance is seen to resemble that of cartilages proper, being white, flexible, brittle, and homogeneous. Toward its posterior part it loses its character of homogenity, becomes less brittle and presents in its thickness a greater amount of fibrous textui'e. More posteriorly again, the fibro-cartilaginous structure is more marked. By close attention it seems to show cartilaginous nuclei, isolated, and sur- rounded with an entirely fibrous substance ; and again, at its pos- terior extremity it becomes fibro-greasy with much cellular tissue and unites with the plantar cushion. The vitality of the cartilage is in inverse ratio with its density and consequently is greater in its posterior part than toward the base and its anterior extremity. This fibro-cartilage may easily and more or less completely be- come ossified ; old horses are those which most commonly present this condition, and draught horses are more subject to it than those used to the saddle. It assumes various forms. At times it occupies the entire extent of the cartilage, and at others only at its base ; sometimes the external surface is ossified, while the internal remains in its normal structure ; then again, the ossification exists only anteriorly while the posterior is cartilaginous, and it more rarely happens that the process consists in bony lamellae, which, starting from the base, spread toward various points of its cir- cumference. 716 OPERATIONS ON TUE FOOT. These fibro- cartilages are generally more developed iu the an- terior than the posterior extremities. They also present, in one foot, this slight difference, that the internal stands a little higher than the external. Cartilaginous quittor is a serious affection, characterized by the partial caries of one of the fibro-cartilages ; it is a partial gan- grene whose character is to slowly sj)read into the cartilaginous structiire upon which it starts. To be treated with success, it re- quires a very regular attendance, and often an operation, which consists in the removal of the cartilage. Sometimes this opera- tion is indispensable, and its study is interesting, especially be- cause, though not as commonly performed as at the beginning of this century, it is one which requires a high degree of surgical skill for its success. I. Symjytoms. — A division has been made of an acute and chronic form of this disease. Under the first name, is considered the earlier period of the affection, that in which there is inflam- mation of the cartilage and painful swelling of the part, and when the caries or necrosis of the fibro-cartilage is not yet established ; or if there is a wound, when it does not yet granulate, and the suppuration, if it exists, is very slight. Chronic javart would be that in which the partial and progressive mortification of the fibro-cartHage exists; for, as Renault has said, it is the ordinary termination of fibro-chondritis. When free from serious complication, the disease is generally accompanied with but little lameness ; sometimes there is almost none, and animals can be kept at work, esjDecially at a slow gait; but if made to trot, the horse will show lameness. It is especially when the quittor exists in the posterior parts, that the inflamma- tion and the pain are not excessive, because there is then an abundance of soft, fatty tissue. But when the caries is more for- ward, and is situated more deeply, in a point nearer the articular surface, the lesion then affects the fibrous tissues and the pain is greater. It is sometimes excessively acute. Upon the lateral part of the coronet, toward the heels or the quarters, more or less tumefaction appears, more or less painful, according to the duration of the disease, and in this case more or less indurated. In the centre there exists a granulating fistu- lous wound. There are one or several fistulse (Figs. 524, 525, 526) whose openings show granulations, bleeding easily, their course DISEASES. 717 Figs 524, 525, 5S6. -Cartilaginous Quittor. Various Spots of Necrosis. 718 OPEKATIONS ON THE FOOT. always forward, running at times in straight lines, at others ir- regularly. The tracts frequently communicate and discharge a granular, serous and thin pus, of pale greyish color, generally odorless, or slightly sanious, containing greenish particles, which are but pieces of diseased fibro-cartilage. The pus dries up on the surface and adheres to the hoof and to the hair, and some- times irritates the surface of the skin. If one of these fistula be- come cicatrized, a fluctuating tumor soon appears, close to it, which rapidly ulcerates, and then gives rise to another fistula. If the disease is quite old, the hoof of the quarter corresponding to the necrosed cartilage, loses its perioplic band, becoming rough, ramy and cracked, and the wall is thickened, because the irritation of the coronary band has stimulated its growth. This change in the condition of the wall varies with the length of time the dis- ease has existed, and consequently, it indicates its duration quite accurately, when one remembers that the hoof grows downward about one centimeter in each month. When cartilaginous quittor is the sequelae or complication of the suppurative com, of a punctured wound by a nail of the shoe, or any other affection of the foot, the symptoms proper to these diseases are first observed, though the lameness is greater, and the fistulse of the quittor is e\ident. Often, however, this, instead of being external and on the coronet, is situated at the in- ferior part of the foot, at the internal face of the inferior border of the wall, upon the sole, and sometimes connected with the wound of some of those affections of the foot. II. Pathological A7iatomy. — When one examines the cartil- age affected with the necrosis proper of quittor, he always finds lesions in proportion to the intensity and the age of the disease. It is seldom, however, that the portions of the cartilage which have undergone the green degeneration, constituting the caries, reaches more than one centimeter in extent ; they have the form of a small plate, of a green color, ordinarily elongated, and adhe- rent to the healthy parts of the cartilage by one of its extremities, that which is more forward and the deepest. Others have com- pared it to the green growth of a seed in germination. The points of the fibro-cartilage which are in immediate contact with the carious portion, have also a slightly pale greenish hue. These are already diseased ; there is already a beginning of necrosis ; in the remainder of its extent the exfoliation is separated from the DISEA8E8. 719 cartilage by a reddish, soft tissue, which also lines the inside of the fistulous tract. This fistula, which extends from the necrosed spot to the skin, is but the hoUow tract left by the diseased proc- ess upon the cartilage, while gradually destroying its substance. Always lined with a pseudo-mucous membrane, by a true pyro- genic apparatus, the fistula is often narrow, sinuous, irregular in its course and extent, especially if the disease is of some standing. Renault, and after him Lafosse, have mentioned a special al- teration of the fibro-cartilage which is sometimes met, and which Lafosse looks upon as a step toward recovery. It is a softening of the tissue, anatomically characterized by a loss of the consist- ency of the cartilage, resembling the case of the cellular tissue becoming indurated, or that of bones deprived of their earthly salts after soaking in weak acids ; its yeUoAvish color is then char- acteristic. It may be noticed during life, and is recognized by a softening in the region of the cartilage, which then yields, giving easily to the pressure of the finger; besides this, ^ a probe intro- duced into the fistulous tract readily penetrates into the softened substance. But the true way to diagnosticate this change con- sists in raising the coronary band or after thinning the wall ; then one wiU see and may feel the true nature of the transformation. Lafosse adds that, in presence of this alteration, the removal of the cartilage is no more necessary, for then the cicatrization is readily obtained by stimulating the sloughing of the necrosed tis- sue or by removing it. With cartilaginous quittor there is always plastic infiltration of the cellular tissue surrounding the cartilage. Very often the wall of the synovial capsule of the articulation of the foot is some- what thickened, and in that case there is less risk of injuring it during the operation. — (Rey.) III. Progress, Duration and Termination. — Left to itself, the caries of the fibro-cartilage may last for a long time, through difficulty in determining its true nature. Si)ontaneous cure, how- ever, is not impossible, as Renault proved it, and as many practi- tioners have seen it, especially in young and healthy subjects, when the disease is mild at its outset and effects parts of the or- gans where the fibrous element predominates, as in the posterior portion of the cartilage. This fortunate result follows the slough- ing of the " bourbillon " which makes its appearance under the shape of a greenish particle. 720 OPERATIONS ON THE FOOT. But, ordinarily, the disease progresses slowly, destroying the cartilage by degrees, and the diseased process ceases only when the caries has reached the ligament of the joint, which it some- times also attacks. The tissue of the fibro-cartilages has not the force of reaction possessed by other inflamed structures, and which is so well marked in cellular tissue. A process of suppura- tion, such as rapidly eliminates the mortified structure, cannot very readily take place in it, and when by natural forces the cari- ous sj)ot is ehminated and jDushed outward, the surrounding tis- sues are most commonly already affected. These undergo the same alterations, and are eliminated in the same manner until the entire cartilage is destroyed. This process of caries by repe- tition may last a year. In its progressive stage, the disease may spread to surround- ing parts, such as the os pedis, the plantar aponeurosis, the liga- ment of the joint, or the sesamoid sheath, all of which may be- come the seat of inflammation. They are diagnosticated by the greater pain and more marked lameness, symptoms which are comparatively light in the simple necrosis of the cartilage. Finally, as a possible complication of cartilaginous quittor, one may observe an entire emaciation of the animal, an alteration of the fluids due to a putrid or purulent infection; some authors claim to have even seen glanders and farcy follow it ; this is inad- missible. IV. Diagnosis. — Cartilaginous quittor is recognized only when there is a wound from which escapes the product of the supjDuration and of the necrosis. This pus has nothing charac- teristic, notwithstanding what has been said. If it is thinner than that of a simple solution of continuity of the region, or that of simple quittor ; if it is less foetid than that of bony caries, it has, however, of itself some special characters, varying according to the subject and the degree of the disease, and especially resem- bling much that of sub-horny quittor. If the escape of the pus is slow, and it is desired to carefully examine it, a simple pad of oakum, kept by a few turns of bandages on the fistulous opening, will, when removed, give a sufficient opportunity to recognize its nature. The probing will often assist in distinguishing the cartilagin- ous from the simple or sub-horny quittor. In these last, the fis- tula is less profound, and does not reach the thickness of the DISEASES. 721 cartilage ; but, as in cartilaginous disease, the fistula is often sin- uous, it is better to use a soft, flexible instrument, such as a fine probe made of lead. The injection of liquid may take the place of the probing ; injected in a superficial tract, it retiu-ns outward directly, while in deeper and irregular fistuloe, it will penetrate more readily. The indiu-ation of the coronet, the rough and ramy appearance of the hoof of the quarter corresponding to the fis- tula, indicate generally a necrosis of the fibro-cartilage ; these characters are missing in the furuncle. V. J^rognosls. — In consequence of the tenacity of the disease, this form of quittor is always serious ; though this gravity has, in our days, greatly diminished, on account of the means of treat- ment now in use, which were unknown some thii-ty years ago. Now, this affection, which was considered by aU hippiatrics as al- most incurable and which more recently was treated by an opera- tion which rendered the animal unfit for work for several months, can in the majority of cases be cured in about fifteen days. The prognosis, however, varies and depends on the compHca- tion. "WTien there is caries of the ligaments, inflammation of the articulation of the foot, or of the sesamoid sheath, the extirpation of the cartilage itself, done with the greatest dexterity, is not even a warranty of recovery. It remedies only the necrosis of the cartilage, but leaves the other diseased processes to progress in such a manner that the animal remains worthless if he has not to succumb to them. The pain is, besides the other signs, one of the most important points to consider : very acute, it is generally a discoiu'aging omen, and points to the existence of serious com- j)lications. W. Etiology. — Heavy draught horses are more frequently af- fected, on account of their pecuhar work. The most common cause is a bruise, a blow, a burn, a prick, any wound exposing the cartilage; it is most common in horses drawing trucks loaded with stones, which may drop on their feet and crush the fibro- cartilage. The same cause exists for horses working in extensive works of buildings, in the construction of raih'oads, and in the shops of mechanic construction. Owing to these conditions, it is also more common in large cities than in the country, and more frequent in stony and tem- porary roads than in those which are smooth and flat. Flat feet, with low heels, are more exposed than others, as well as those 722 OPERATIONS ON THE FOOT. whose hoofs are soft. Quittor is more frequent in the fore than the hind feet, the fibro-cartilages of the fore feet being more de- velojjed and more flexible, and because their heels are generally lower than in the hind legs. In some, it is more common on the internal than the external quarters, while with us, it has been the contrary. It is often a compUcation of suppurative corn ; of punctured wounds of the foot, of canker, of simple and sub-horny quittor, of grease, etc., which are then the determining causes of the disease. VII. Treatment. — "VMien the disease is recent and the quittor acute, and antij)hlogistic treatment may be attempted and resolu- tion looked for, baths and emollients are generally beneficial. A good blister has sometimes joroved advantageous, and when it is used, hmited suppuration, with the formation of a simple slough, may take place. If necrosis is well estabhshed, it is an indication of the neces- sity of a recourse to more energetic treatment, in which case sev- eral measures are recommended, including the actual and poten- tial cautery and the removal of the cartilage. In actual cauterization, the necrosed spot is destroyed by a cautery brought to a white heat, applied directly upon it, after it has been exposed by a free incision. It is a simple treatment, and one that has been successful in cases of posterior necrosis where much fibrous tissue was diseased, and principally in young and well-conditioned animals (Lafosse, Sr., Girard, Vatel, Mangin, Renault). Still, this treatment not only often fails, but may even become a means of irritation of the fibro-cartilage, and cause an extension of the necrosis. (Hurtral, D'Arboval, Lafosse). In our day, this treatment is almost entirely ignored by good practition- ers, and the potential cautery more generally adopted. This had already been employed by hippiatrics. Solleysel piincipally recommended the use of corrosive sublimate mixed with aloes ; Girard, Barreyre and Bernard also mentioning it. English veterinarians recommended their use very strongly. (AVhite, Blaine, Riding, etc.). These practitioners all used the soHd caustic, either in the form of trochiscus or in powder, and if they obtained good results, it required a much longer time than that required in our day by the use of the liquid forms of caustics which are at our command. With the solid form, the action was of limited extent, and scarcely more effective than that obtained DISEASES. 723 by the actual cautery; moreover, they frequently injured the healthy structures by irritating them and increasing the inflam- mation, and thus resulting in serious complications. As we have said, hquid caustics are largely used to arrest the spread of the caries; they modify the process of decomposition, dry up the suppuration and stimulate the tissues without injuring the healthy structures. This mode of treatment must be ci'edited to Mariage, who in 1847 established the unfailing efficacy of re- peated injections of Villate's solution; one of sulphate of copper and sulphate of zinc, 64 grammes of each in 1 Hter of vinegar, and decomposed by 125 grammes of Goulard's extract. It is reaUy simply a solution in vinegar of acetate of copper and zinc, holding sulphate of lead in suspension. Villate himself had al- ready used his solution with success by injecting it in cartilagin- ous quittor as early as 1829, since which time Burgniet, Verrier, Sr., Collignon and others have recognized the benefit of hquid escharotics in the treatment of the same disease. Villate's solu- tion is not a specific, and cartilaginous quittor has been cured by the injection of tincture of su.blimate with solution of nitrate of silver (Bernard), with the perchloride of iron, chloride of copper, sulphate of copper and zinc, nitrate of lead, more or less concen- trated mineral acids, and especially the Rabel water (Collignon). It is difficult to say which is the more useful of these drugs and which has been more successful. Success has also been ob- tained with injections of tincture of iodine, phenic acid and even petroleum. It is less the nature of the drug that insures the ef- fect than the mode of using it. We ought also to say that, ad- vantageous as this mode of treatment is, it is not infallible, though Mariage and others so consider it. It is not to be preferred to the extirpation of the cartilage, an operation which proves suc- cessful when all other means have failed. To obtain a cure by the use of liquid applications it is essen- tial to make injections every day, and even several times daily. These are made with a syringe, carefully adapted in respect to size, with a small canula. The injection must be pushed well in, but must be allowed to escape freely after coming in contact with all the diseased surfaces which it is designed to modify. To effect this, it becomes necessary, as the fistulse are sometimes very nar- row, and even irregular, to enlarge them, or to make counter openings. Mariage had originally insisted that these precautions 724 OPERATIONS ON THE FOOT. were essential to the success of the treatment. H. Bouley and Viseur also strongly insisted upon the same point, viz., that of en- larging the listiila in order that the liquid should not be allowed to remain at the bottom of the fistulous tracts, by which all possi- bility of the extension of the disease from that cause might be avoided. These enlargements of the fistulas, or counter openings, close, however, very rapidly; as a remedy to which, Hivernat has suggested the introduction into the tracts of little wedges of wood pomted like pencils, for the purpose of lacerating the walls of the fistula, followed by the insertion in them of small setons, moist- ened with Villate's solution. Guerrapain introduced a fine meche of oakum, a seton in the tract, by means of a curved needle. If the fistula runs dovraward its bottom is under the wall, and he thins this down and makes a counter opening through the hoof thus thinned. This seton prevents the closing of the counter opening, and enables the oj)erator to push thi'ough the injection regularly. Other precautions are also necessary. One, especially, is rest. The animal must not be put to work. Lafosse says that these liquid caustics act with regularity and cru'e with certainty. A bar shoe, not pressing on the diseased quarter, is also useful. Emol- lient poultices are sometimes necessary after the injection, to diminish the irritation. Mariage also recommends them. If the fistula extends under the coronary band, or the j)odophyllous tis- sue, it becomes necessary to thin, or to remove altogether, the hoof of the diseased quarter. After fifteen days of this treatment, the exfoUation often takes place, and recovery follows. Often, however, twice this length of time is necessary. After the first eight days the pus becomes more abundant, white and laudable; the tumor softens and dimin- ishes, as the pain subsides. Later, the injections penetrate with greater difficulty, which is a good sign. The injections constantly attack the germ of the disease and leave it without chance to re- form or to spread; the gangrenous structure which develops in the cartilage is changed into an inert substance; the pyogenic membrane of the fistulous tract is stimulated; the process of granulation becomes more rapid ; the wound becomes more and more healthy, and the diseased process ceases. If, however, it continues, the wound changes its character, large granulations develop themselves, and in theu' center the openings of the fistu- DISEASES. 725 lous tracts, which open on the cartilage, make their appearance. At times the wound closes ; but, after a short interval, opens again, or another forms at another point. There is then a repetition of the same course of treatment by caustic appHcations — but gener- ally this indicates a complication, and suggests the proj)riety of an operation. The injections are generally successful, however, and most certainly so if the caries occupies the posterior parts of the cartilage. They may even succeed in the anterior parts, when the animal is young and of good constitution. But if the cartil- age has already become partly ossified, the caustic is irregular in its action, and the result becomes doubtful. If the caries is deep and extensive, and especially if the necrosis extends through and through to a point corresponding to the synovial capsule of the articulation of the last phalanx; or if the necrosis exists on the internal face of the cartilage, where it covers that structure, then the repeated injections of Villate's, gr of any other caustic, may be followed by serious complications. An old or complicated caries will offer an increased resistance to the treatment by liquid caus- tics, in proportion as there is more or less difficulty in bringing them in direct contact with the necrotic points. The thii'd method of treatment is that of the removal of the cartilage. This operation, first recommended by Lafosse, Sr., in 1754, was often performed by his son, and may be considered one of the most valuable residts of the application of anatomical knowledge to the practice of veterinary surgery. This operation was also performed by Bourgelat and his students, by Girard, Hurtrel, D'Arboval, and was principally studied and described by Renault. In Germany, notwithstanding the writings of Langen- bacher, Dieterichs and Hertwig, it did not meet with approval, and Enghsh veterinarians seldom, if ever, resorted to it. At pres- ent, even in France, it is seldom performed, excej)t in case of fail- lu'e by the caustic injection treatment, and this is often the case where the disease is situated in the anterior part of the fibro- cartilage, where the cartilaginous tissue predominates, or where the vitality is diminished, and above all, where ossification has taken place. It is an operation of the greatest delicacy, and ac- companied with great risks on account of the proximity of the joint of the foot, and it requ^ires an experienced oj)erator and thorough practitioner to justify a hope of successful results. It consists in the excision, by layers, of the diseased cartilage, and 720 OPEKATXONS ON THE FOOT. in avoiding injury to the coronary Ixaul, and to the podophyllous tissue, wliich are essential elements of the organization of the foot. It is also essential to avoid injury of the lateral ligament of the foot joint, which is close to the cartilage, and above all, of the synovial capsule of the joint, which is directly covered by the cartilage. The partial or entire extirpation of the cartilage can be performed. In the first case, only a portion of the necrosed fibro-cartilage is removed. Vatel, Sanstas, Renault, Bell and La- fosse have reported many cases of recovery by this mode of oper- ation, but it is not likely to be thoroughly successful, unless in circumstances as favorable as those accompanying the treatment by liquid caustics. It is generally much better when the operation is decided upon to perform it by excising the entire structure, and removing all the carious elements. The partial removal is to-day entirely abandoned, and entire extirpation accepted as the true and only operative procedure. The best method of performing it is that recommended by Renault and adopted in our colleges. We shall make it the subject of description with all necessary details, and with various modifications as performed by other practitioners; we shaU also offer some observations upon various other modes of pei'forming the operation in question. The operation includes two principal steps : first the removal of the part, or the whole of the wall corresponding to the diseased cartilage ; and second, the extu^pation of the cartilage itself. The opinions of surgeons vary as to the amount of hoof w^hich should be removed, and the extent of homy tissue to be taken off. In respect to the length of the superior border of the portion requir- ing removal, it is generally agreed that it must extend from the anterior extremity of the cartilage backward, that is, the two pos- terior thirds of the space reaching from the toe to the heels, or one-third of the circumference at the coronary band. But opinion continues divided as to the lower border (Fig. 527). Lafosse, Sr., left it longer than the superior, and made the direction of the division of the groove correspond to that of the fibres of the hoof. Lafosse, Jr., accepting the idea of Solleysel and of Dieterichs, did not reach the sole with its groove, and removed only a portion of hoof parallel to the coronary band. Renault jorefers crossing the fibres of the hoof with the groove, and brings the lower end of it to one-half the dimensions of the upper border, its groove running backward. Rey considers this to be running too far back and DISEASES. 727 C if Fig. 527.— Direction the Groove should take to remove the Quarter in the Operation for Cartilaginous Quittor. .1 B. — According to Lafosse. A C— According to Rey. A D. —According to Renault. A i'.— According to Lafosse and Dietei-icths. too near the heel, and recommends the groove to be so made that the lower border will have the same length as the uj)per, and for that reason advises that it be as nearly parallel as possible with the line of the heels. Lafosse, Sr., removes too large a portion of the hoof. Lafosse, Jr., leaves a portion of hoof which not only is useless, but which interferes with certain steps of the operation, when with the double sage knife, the skin is separated from the external surface of the cartilage, and also, when this is removed ; and again, there is a separation between the severed portions of the quarters much greater than occurs in the process of Eenault, which, like that of Rey, exposes the entire cartilage, and greatly facilitates the operation. It is to be understood that the foot has been prepared ; that the hair has been clipped over the skin covering the cartilage; that the sole has been pared thin, down to the blood, as well as the bar corresponding to the diseased cartilage, so that the quarter has been allowed to project below the sole, to facilitate its ever- sion. The foot has been, moreover, well prepared by two or three days of poulticing, to render the hoof easier to be cut by the in- strument, and the operation easier to perform, and therefore shorter in its various steps, beside placing the patient in the best condition for the endurance of so serious an operation. After casting the animal upon a good bed, and fixing the feet, placing a temporary hemostasis, by the use of a strong cord, simi- lar to a tourniquet, around the coronet, a groove is made, using various-sized drawing-knives, running from the anterior angle of the lower border of the cartilage downward to the sole, following 728 OPERATIONS ON THE FOOT. the direction recommended by Lafosse, Sr., Rey, or Renault. This groove, made first with the widest, and finished with the narrow- est of the drawing knives, must not touch the podophyllous tissue, and still must run through the entire thickness of the wall, with- out producing hemorrhage. In this step of the operation, as Girard correctly observes, short cuts of the knife are always bet- ter and quicker than those made by scraping or dragging with the instrument. It is also important to come down to the soft tissue at the coronary band first, and successively downward to the inferior border of the wall, as otherwise, as the instrument is moved from above downward, with a certain amount of force, it might slip and cause a serious division or laceration of the podo- phyllous tissue. The separation is then made of the wall from the sole by another groove, extending from the end of the groove already made, on the quarter, back to the heels. This is done without difficulty, with a small drawing-knife, when the foot has been properly prepared. There is, however, one point which usually offers more or less resistance when the quarter is removed. It is that where the wall is continued to the bars. This resistance is sometimes so considerable that if much traction is made, the wall will break more or less in front of the heels, where it is com- paratively thin, and it may consequently become necessary to re. move, by itself, the portion which has remained attached. This little accident, however, can be avoided by ascertaining certainly before the extraction of the wall is effected, that the continuity of the wall and bars has been cut off. This being the case, the com- plete separation of the wall from the sole is made by runnipg the sharp edges of the double sage knife through the structure of the living tissue underneath. The resection of the quarter can then be proceeded with. For this purpose, a properly constructed lever is carefully in- troduced into the groove before mentioned, at the wall and sole of the foot. The mferior and anterior angle of the hoof at this point being then carefully raised, an assistant grasps it with the nippers, turns it back and tears it slowly, while the surgeon, with such a motion of the lever as may be necessary, assists in the tearing off of the portion of the quarter requiring removal. If adhesions remain, interfering with this manipulation, they are removed by cutting with a sharp instrument. As this separation of the wall reaches about to the coronary band, the separation is very easy, DISEASES. 729 and uo fear of lacerating the soft structiu'es need be entertained. Care is necessary at this step, however, to avoid injuring the cor- onary band, and the podophyllous tissue ; to prevent which it will be prudent on the part of the assistant to press upon the band as the separation takes place. This being accomplished, the edges of the wound are carefully examined; any projections remaining are removed, and the blood is sponged off. The double sage knife is then carefully plunged, with the convexity tiu^ned upward (that is, towai'd the skin), be- tween the external surface of the cartilage and the internal face of the skin, below the border of the coronary band, and then carried forward and backward, or as requked, until the separation of the skin and the cartilage is completed and the external surface of the cartilage is exposed. In moving the instrument backward, it is necessary to be very cautious, especially while carrying the sharp edges downward and inward, in order to avoid injury to the cor- onary band and the skin, of which, however, there can be but little danger, when the knife is carefully held and properly directed. The succeeding step is to separate the skin from the cartilage ; it is to be carefully raised and separated from its attachments under- neath, which is sometimes a process quite difificult to accomplish, as the skin has always become more or less tumefied, and there- fore has lost much of its natural flexibility and suppleness. Some operators, in order to avoid these difficulties, and overlooking the functions of the coronary band, cut it, and remove it, with those portions of the skin which cover the cartilage. Others, more con- servative (Herting, for example) cut it only through the middle, until they reach the superior border of the cartilage, and then, raising the two flaps of the skin, accomplish the same result with less cutting. The destruction of the principal organ of the secretions of the hoof having been involved in the first method, and having now taken place, it can never be restored to a healthy condition, and the animal continues to be exposed to the frequently serious com- plications of "false quarter." By the second method, the produc- tion of a new wall is nearly always accompanied with the forma- tion of a "quarter crack." The recovery is slow in either case, and more or less deformity is likely to follow. It is, then, the better and wiser plan to separate the skin from below, and to avoid the division of the coronary bands or of the teguments. 730 OPERATIONS ON THE FOOT. The next step is the removal of the cartilage altogether. This is done with the single sage knife, held firmly in the hand, either the left or the right, always, however, that corresponding to the side of the heel to be operated upon. Taking a point of rest with the flat of the thumb upon the plantar surface of the foot, the in- strument is jDushed between the skin and the cartilage, and the sharp edge turned backward, with a firm rotary motion, down- ward and forward. The detached portion of cartilage is then seized with a pair of bull-dog forceps, and brought outward, and the sage knife is brought forward, downward and outward, from under the cartilage. It is a good plan, in order to make more room for working, to raise the skin and coronary band with a blunt tenacvJum. The operation should always be commenced at the posterior part, in order to avoid the articular synovial cap- sule, which might be opened if the removal of the cartilage was begun forward. As the operator reaches the anterior part of the cartilage, which is situated almost over this capsule, it is prudent to hold the foot in excessive extension, and thus avoid injury to the capsule. This is an important point to consider in the oper- ation. The sharj) instrument being carefully handled, every por- tion of the cartilage is taken oif, either at once, or better by layers successively, until the whole is removed. It is thus accomplished in three or four j)ieces. In some instances the anterior portion is^ cut off by a longitudinal incision, made with a straight bistovu-y,. following the direction of the posterior face of the coronet, the object, in this case, being simply to render the operation easier. The cartilage is thus removed, great care being taken to avoid opening the capsular articular bursse. It is essentially necessary to remove the whole of the diseased tissues, in order to bring the parts into the condition of a simple wound. Still, there need be no alarm if some small portions remain, more fibrous than cartilag- inous, which, deep as they are, may protect the synovial capsules or the ligament ; and moreover, they often slough off by them- selves, with the abundant suppuration which follows. To operate with the greater facility, it is well to have two forms of sage knife, one right and one left-handed, and some of extra strength, with which to remove the larger particles of cartilage, the others being small, thin and light, being adapted to the more careful dissection necessary toward the lateral ligament, and about the synovial bursae of the joint. DISEASES. 731 Toward the end of the operation, the surgeon will, with the finger, carefully explore the condition of the parts, to insure him- self that the cartilage is entirely removed ; that the articular syn- ovial sac has been preserved intact; that the ligament of the joint remains perfect, and that the parts are well washed, and ready for the dressings. Although in the absence of possible complications, the operation is now finished, it may yet be followed by some serious sequelae, which we will next consider. The operation may become complicated by a variety of atten- dant and accessory circumstances. Among these are, the opening of the articular capsules; the wounding of the anterior lateral ligament of the articulation ; the ossification of the fibro-cartilage ; caries of the os pedis ; and the alteration of the coronary band and of the reticular tissue. The opening of the articular capsule, either during the oj^er- ation, or by ulcerative process, is not so serious an accident as it was originally thought to be. Still, however, it requires some at- tention. It only becomes dangerous when the ulceration is ac- companied by serious disorganization, and especially when it is associated with purulent arthritis. (Renault, Hurtrel, D'Ai'boval, Bernard). It is treated by simple pressure, camphorated paste, a little corrosive sublimate mixed with starch, or better, with Egyptiacum ointment. The wound of the ligaments has also been considered a very serious accident, which, according to Girard, cripples an animal permanently. But Lafosse thinks this an exaggerated notion, and claims to have witnessed the radical recovery of animals after the necrosis and sloughing of the ligament. If ossification of the cartilage is discovered during the opera- tion, the removal of all the unossified portion is first proceeded with, in order to prevent a recui'rence of the disease. The extir- pation of the osteo-cartilaginous portion is then effected, either with a small drawing-knife, or the gouge, or the bone forceps. The removal is made as far as the ossification is found to be com- plete, the operator making sure that every portion of cartilage is thoroughly destroyed. If the ossification is but partial or irregu- lar, the surgeon must be guided by the condition of the parts. When the entire cartilage has undergone ossification, its suscepti- bility to caries has ceased. When caries of the os pedis exists, the part must be destroyed 732 OPERATIONS ON THE FOOT. with the sage knife, the gouge, or the chisel, according to the existing conditions. But in this case, portions of the reticular structure require removal, of which, however, as little as possible shoiild be destroyed. It may happen that the portion of the coronary hand covering the cartilage may be destroyed, either wholly or in part, either as an effect of the disease, or by accident diu'iug the operation. In the first case, if the entire band has been destroyed, there is noth- ing to be done. But in the other case, if any portions of it re- main, care must be taken to insure then- preservation, as they may supply the necessary elements for a new, healthy secretion of hoof, and the quarter may grow again, more soHd and less de- formed. If the wound of the coronary band consists mei'ely in a simple division of limited extent, the wisest course will be to at- tempt to obtain union by immediate adhesion, or first intention, by bringing the edges of the incision together and maintaining the contact by careful dressing. "When the alteration of the re- ticular tissue alone, is present, it is very essential to avoid the ex- cision of the injiu'ed laminae. It is, in fact, the better course to avoid wholly the use of sharp instruments, and to leave to the natural process of suppuration the removal of the disorganized parts. Renault having observed how their removal interfered with the reparative process, has often left them undisturbed, even when their dark color and softened condition indicated the small- ness of their chance of conservation. The success of the opera- tion after a first dressing, has shown the wisdom of the plan of non-interference ; they were found covered with a new layer of yellowish hoof; and D'Arboval has on several occasions observed the same result. The dressing must be methodically and carefully applied. Done weU, a dressing greatly assists in the recovery, while many, when badly performed, have been the cause of serious complica- tions, which have greatly hindered the repau-ing process, and of- ten, indeed, rendered a disease incurable, which need not have been beyond remedy. In the application of the dressing, two points are important to consider : first, we must di-ess the subcu- taneous wound, resulting from the separation of the skin and the extraction of the fibro-cartilage ; the other, that of the sub-horny wound, produced by the removal of the portion of the quarter. Both are important, but the second requires the greater care, and DISEASES. 733 is more difficult and more important tlian the former ; any excess in the sanguiaeous circulation must be prevented, and excessive granulations must be kept under control. The dressing, then, must be somewhat compressive, without being excessively rigid, in order to ob\'iate possible danger of excessive inflammation ; not too loose or so soft as to allow hemorrhage, or the undue pro- liferation of granvdations. It must be both supple and firm, and of an even and uniform pressure. The proper material is balls of oakum for the subcutaneous wound, and pads of the same mate- rial for the sub-horny, the first being moistened with alcohol, while the others are made dry. It is in question whether we should aim to obtain immediate adhesive union of the wound resulting from the removal of the cartilage, or in other words, whether it is good treatment to in- troduce some material of dressing between the skin and the bot- tom of the wound. Here opinions vary. Our belief is, that this union is by no means easy to secure ; and that the removal of the cartilage, more or less altered, prevents it at various points. StUl, we must not raise the skin too much, and choosing a middle course between, only a small, soft ball of oakum is now placed in the deepest part of the wound, or a thin pad is placed between the two parts, sufficient to represent about the natural form of the part, being enough, however, to prevent the immediate reunion from taking place. A hght, thin shoe having been prepared (Figure 528), adapted to assist the application of the dressing and its holding prop- erly, it is put on with one of its branches cut off short on the side where the operation has been j)erformed, while the other branch projects backward beyond the heel, to support the rollers of the bandage of the dressing. Des- plas had thought to turn up that long branch of the shoe (Fig. 529) in the shape of a hook to assist in . ^'"- SSJ.-Truncated Shoe for Dressing i in case of Cartilagmous Quittor or Coui- holding the dressings. This is plicated com. 734 OPERATIONS ON THE FOOT. Fig. 529.— Desplas' Shoe for Dressing after Operation of Cartilaginous Quitter and Complicated Corns. useless. Some veterinariaus leave the animal unshod, but the bandage is more lilcely to slip off. The shoe must be put on while the animal is down, and before the application of the dressing. "With some practitioners, that is the moment for the removal of the tourniquet or cord, which had been applied at the beginning of the operation in order to prevent the bleeding. This is an un- necessary precaution, and only renders the application of the dressing more difficult. First, balls of oakum are placed over the coronary band, then, upon the points of union of the preserved wall and of the podophyllous tissue, and then all over the wound. We must endeavor, as Renault says, to give the dressing a cylin- drical form, or rather, according to E,ey, hemispherical, after which the whole is covered with pads and rollers. These must be put on in abundance, the rollers passing over the branch of the shoe on the sound side, and running successively from above down- ward, and generally from before backward (Figs. 530, 531, 532, 533). Flat feet require special care in dressing, and the fore feet are generally more difficult to dress than the hinder. ^Tien all is finished, the animal has to be watched for several days. Ordi- narily, after the operation, there is abundant hemorrhage, occur- ring within some fifteen minutes, and oozing through the dress- ings. This requires no special attention, and generally ceases sj)ontaneously, or by the pressure of the dressing, or by the use of the cold bath. If the dressing seems to be too tight, and the animal shows signs of acute pain, with strong reactive fever, it is not therefore necessary to remove the dressing, but may be suffi- cient simply to loosen the bandage. The animal should be placed in a wide stall, or box, if possible, where he may move freely, and DISEASES. 735 WARIOUS STEPS IN THE APPLICATION OP THE DRESSING AFTER OPERA- TION FOR CARTILAGINOUS QUITTOR. Fig. 532— 3d Step. Fig. 533.— Dressing Completed. lie down easily ; and lie must be prevented from tearing off the dressing by the application of a neck cradle. A low diet is neces- sary for several days, in some instances mashes being the only food allowed. Still, a good appetite and lively condition are always good signs. The interval of time which should be allowed to elapse be- tween the operation and the removal of the first dressing, should be judged by the amount of paia which the animal seems to suf- fer ; by the temperature of the atmosphere ; and by the amount of liquid discharge found ooziag from the wound and moistening the dressing which covers and protects it. Generally, the dress- ings should be disturbed as late and as seldom as possible. Cir- cumstances will sometimes occur, however, which necessitate their removal earlier, as for example, the extreme heat of the weather; 736 OPERATIONS ON THE FOOT. the extremely offensive odoi* proceeding from the diseased parts; and a sudden and evident increase of pain in the wound, without any known cause. Under these circumstances, which, however, are of rather infrequent occurrence, it is sometimes necessaiy to remove the dressing as early as the third day, although at this time, as suppuration is not yet well established, the operation is qiiite painful, and may be accompanied by free hemorrhage. But if the weather is not excessive; or the dressing remains dry on the outside, and matters seem to be generally in good condition, the better course is to wait from eight to ten days, before the dressing is renewed. Indeed, numerous cases are on record when a still longer period has been allowed to elapse, and the re-dress- ing has been deferred to the extent of three weeks, or longer. In any event, great caution must be exercised in the removal of the dressings, and the surgeon should be careftd to have all his ap- pliances ready in advance, in order that the wound may be ex- posed to the air for the shortest possible space of time. "SMien exposed, the wound should be of a red color, with commencing granulations, and a temporary hoof, soft and whitish in apjjear- ance, should be visible on the podophyllous tissue. A di'essing is then applied of tincture of aloes, or a weak solution of iodine. At a later period the dressings are changed at intervals of about eight days, and an apphcation is made of pulverized stdphate of coj^per, in order to facilitate the drying and hardening of the soft hoof. Baths of sulphate of iron, with a small portion of sulj^hate of copper are of service in promoting and hastening the cicatriza- tion. About the thh'tieth or fortieth day after the extirpation of the cartilage, the animal may be put to Hght work. But three or foui- months, if not a longer period, must elapse, before it will be safe to task him with heavy labor. Toward the end of the assigned term he shotdd be fitted with a bar shoe, shortened on the side where the quittor has existed. If the dressing is skillfully applied and proper care is exercised, the diseased foot may be sufficiently protected, and the animal made to resume his work with safety. In time, the portion of hoof secreted by the coronary band unites with that of the podophyllous tissue, and after a few months, no remains of the operation are visible. But if the cor- onary band has ulcerated; if the skin has been divided; if by contact of the firing iron, or api)lication of caustics, it has been DISEASES. TST destroyed; the quarter then presents irregularities, and some- times divisions, which may be of long continuance, and give rise to a lameness which may, perhaps, become permanent. This danger indicates the necessity of exercising the utmost skill and caution in operating, iii order to avoid possible injuries to the coronary band. Several modifications of the ordinary mode of operation have been proposed. Some have had for then- principal object, the prevention of the extraction of the hoof, with a view of thus re- turning the animals to their work at the earliest period practic- able. It is thus that Hazard, Jr., proposed to make a crucial incision ujDon the skin covering the fibro-cartilage ; the four flaps being so dissected as to expose it, and then removing it with the sage knife. In this process, the extirjjation of the entire cartilage becomes extremely difficult without inflicting injury upon the lat- eral ligaments and the synovial cajDsules. Pagnier has proposed to merely thin down the quarter, to make an incision in the skin along the suj)erior border of the car- tilage, and through this to remove the organ. But in this opera- tion, however thin the hoof may be, it always interferes with the entire extirpation of the cartilage. Bernard, following the idea of Lafosse junior, who only re- moved the superior border of the wall, proposed a mode of pro- ceeding which is principally useful in cases of separation of the hoof. Instead of removing the band of hoof parallel with the coronary bourrelet, Bernard pared it down with the drawing- knife, the sage-knife, or the rasj), in order to make it as thin as possible, while avoiding the injury to the sensitive laminse. This done, an incision is made along the coronary band, below it, de- stroying its union with the laminse. At this step of the operation, the indications are the same as in the ordinary modus operandi^ except that the coronary band being covered with a certain thick- ness of hoof, is less flexible. This, however, is easily removed, as soon as it becomes softened. The remaining steps of the opera- tion are the same as in the ordinary, old way. That is to say, the posterior part of the cartilage being well defined, the sage-knife is used in the same manner. In this method, however, as the sage-knife works more flat-wise, there is less danger of wounding the ligaments or the synovial capsules. If any part of the car- tilage remains near these organs, some care must be used in "^38 OPERATIONS ON THE FOOT. removing it, and it must be done by degrees, and in very small portions. The advantages of this process are: 1st, the avoidance of ex- tensive wounds, and of the extreme pain produced by the extirpa ■ tion of the quarter. 2d, to keep the foot shod, and to allow the animal to resume his work as soon as the first pain has subsided, which may occiu' at quite a considerable interval in advance of the perfect cicatrization of the wound. 3d, to avoid long and fre- quently-repeated dressings. In this method, however, the quarter left intact sometimes in- terferes with the operation, and the excision of the cartilage is more diflficult, being only practicable, indeed, in cases where there is a separation of the wall. Maillet has modified the method of Bernard, so that, instead of thinning down the band of hoof, he only apphes the rasp upon the quarter, and thins down with it all that portion which is ex- tirpated in the process of Renault, and avaihng himself also, of the drawing and sage-knives. The remaining details of the oper- ation are like those of the ordinary processes. An objection to this mode is that it can be put in practice only in cases where there is already a separation of the wall. It is objectionable from its tendency to weaken the foot too much, by interfering with the firm and solid adjustment of the shoe, as well as retarding its application to the hoof. CHAPTEK XIV. OPERATIONS UPON THE EYE AND EAR. ON THE EYE. Ophthalmology, though it has made appreciable progress in vet- erinary practice within a few years, has not yet reached a position corresponding with that which it occupies in human surgery, and probably avlU not for years to come, if ever. The difference in value and importance between the functions of the organ of sight in the man and in the horse is too measureless to induce or re- quii'e an equal amount of interest and study in the optical path- ology of the two animals, the human and the equine. It is in- deed, a fact that many of the forms of disease which affect the eye of the horse have not yet been recognized and investigated by students of veterinary medicine. For these reasons the contents of the present chapter will be limited to those affections in which, strictly speaking, special sur- gical interference has been so imperatively needed as to compel the attention of scientific veterinarians, by considerations of both duty and interest. We shall consider the subject under two principal divisions, or heads, viz., operations, performed on the accessory, and those pertaining to the essential organs of the ocular apparatus. 1. — Operations Peefokmed on the Accessoey Oculae Oegans. On the Eyelids. — These constitute the two cutaneo or mu- cous veils, which are situated in front of the organ, and are divided into superior and inferior, uniting at their extremities to form the angles or commissures of the eye. Besides these, there is a pecu- Har apparatus situated on the internal or nasal angle, known as a third eyelid, or menhrana nictitans. This is a small cartilage, thinned out on its free border, continued on its posterior portion with the adipose cushion of the eye, and covering it in front, wiping, as it were, its corneal surface, whenever the ocular globe 740 OPERATIONS UPON THE EYE AXD EAK. is drawn back into the orbital caAaty. On the intei'nal commis- sure are found the earuncula lachrymalis, showing on the upper and lower lids the lachrymal 2>uncta, both of which empty into the lachrymal sac, which is itself continuous with the lachrymal canal, and through the lachrym,al duct empties at the lower com- missure of the nostril by the lachrymal opening. Among the surgical diseases of the eyelids must be mentioned traumatic lesions, pathological growths, defective congenital con- formations, and specific diseases of theu' elements. A. — Traumatic Lesions. Bruises of the eyelids are specially common in horses after kicks and blows in that region, and may also be the result of fric- tion and chafing from the harness. If the cause has been severe, oedema of the lid is the result, as well as more or less flow of tears, and, possibly, irritation of the cornea. These accidents are generally of no great severity so long as the globe of the eye re- mains intact, but if this is injured serious comijlications ensue. The indications of treatment are those of all similar injuiies of a local character, consisting of cooling astringents, with local bleeding, which generally bring rapid relief. B. — Solutions of Continuity. These are very common with all our animals. They are sel- dom simple, but are more commonly complicated with lacerations of the tissues, by nails, hooks, etc., or even the teeth of other animals Clean wounds by sharp instruments are rare, and ai'e easier to treat than those having torn and irregular edges. They may be superficial, and may involve the thickness of the lid alone, but they may also be deep and complicated with wounds of the globe of the eye itself. The condition of the wound in this re- spect is important to know, and should be ascertained as early as possible. The raising of the eye with the elevator palpcebrum (Fig. 534) greatly facilitates this examination, and the animal sel- dom offers any serious resistance to it. Fig. 534.— Eyelids Elevator. SOLUTIONS OF CONTINUITY. 741 Simple lacerations of tlie lids commonly heal without any treat- ment beyond mere cleanliness — a soft sjDonge and a little clean water. But the application of the pin or twisted suture, in con- nection with antiseptic measures will greatly promote cicatrization by the first intention. Cai'e must be taken to confine the animal's head in such a manner as to prevent him from rubbing the wound until cicatrization is weU established. C. — Defective Congenital Conformations. Under this head we shall consider the deviation of the Uds, either outwardly or inwardly, from the convex lines of the cornea, with which they should be parallel. A deviation in the growth of the eyelashes, or cihse, is another annoying irregularity of the same region. The outward deviation of the eyelid is called eetro- 2) ion; the inward, entropion. The deviation of the eyelash is known as trichiasis. 1. Ectropion. — The two principal causes of this abnormal condition are an excess of mucous membrane or deficiency of skin. Again, the ectropion depending upon paralysis of the orbic- ularis palpoebrum, is of a different natiu'e. Ectropion occurs more frequently in the lower than in the upper lid When depending on a want of skin, it is generally the result of a wound or a burn, or possibly of an abscess, and is a cicatricial ectropion, in which the retraction of the cicatricial tissue has carried the lid with it. Paralytic ectropion is the result of age, and is more or less peculiar to old animals. It may also result from a diseased condi- tion of the conjunctiva, or of some of the organs of the orbital cavity. \ The treatment of a case of this affection should be modified by the nature of its cause. If it is due to excess in the mucous membrane, the redundancy must be reduced. If caused by want of cutaneous sui-face, the remedy must be apphed to that surface. If a hyphertrophied, mucous membrane is the trouble, astrin- gents, caustics, and scarifications must be employed ; or even the removal of portions of the conjunctival mucous membrane, with the scissors or the bistoury. If, on the contraiy, the deformity results from the condition of the skin, blepharoplasty or hlepha- rortapy must be resorted to. The simplest manner of operating consists in amputating a V-shape portion of the eyehd and uniting the edges with stitches. 742 OPERATIONS UPON THE EYE AND EAR. 2. Entropion. — This is a malformation in whicli tlie border of the lid is turned inward. "WTiile in an ectropion the skin is in excess, the reverse condition is discovered here, where it is defi- cient. It is often the result of ophthalmic attacks, and it may also follow a loss of substance in the conjiinctiva, after ulceration, or the removal of foreign growths. According to Leblanc and D'Ai'boval it may follow some eruptive fevers, or parasitic dis- eases. In entropion there is an increased flow of tears, abundant muco-purulent secretion, keratitis, which may become ulcerative, and loss of sight. The treatment consists in the excision of all the inverted por- tion of the deformed lid, which is accomplished by raising it from the globe with a forceps, and separating it with a single cut of the curved scissors, the protruding portion being then amputated. The hemorrhage is stopped with cooling lotions. Another mode of operating consists in cutting off only a por- tion of the skin of the lid, and unfolding it by passing the finger under the inverted border. Then a fold of skin is amputated near the free border of the lid, and the edges brought together by twisted pin suture. 3d. The deformity of trichiasis, or abnormal growth of the lashes has been observed by Leblanc in sheep, but in our domestic animals is a rare disease. Amputation of a portion of the skin ; pulling out the eyelashes, followed by cauterization, and extirpation of the free border of the lids, have all been recommended against this abnormality of cutaneous secretion. D. — Pathological Growth and Caries of the Membrana NiCTITANS. Acute inflammation of the third eyelid, either as a symptom of ophthalmia, or resulting from direct traumatism, such as blows, or the presence of foreign bodies, terminating in caries of the constituent cartilage of this dehcate organ, or the formation and development of epithelioma of the mucous membrane, are condi- tions often seen in our domestic animals, principally in horses and dogs. We have often noticed this peculiar affection, so easily recognized by the presence at the nasal angle of the eye, of granu- lating masses of various sizes, protruding at their internal commis- sure of the lids, and over the surface of the cornea, accompanied DISEASES OF THE MEMBRANA NICTITANS. 743 with more or less suppuration, lacrymation and ectropion of the lower lid. The epithelial growths, when small, will sometimes disappear under the application of caustics, or can be removed with the ligature, or by direct amputation with fine scissors. In some cases they assume very large dimensions, the mucous membrane becoming more or less ulcerated, and the cartilage itself diseased, and amputation of the entire cartilage becoming necessary. This operation is not of recent origin, having been per- formed, within our knowledge, some years ago, though entirely upon empirical grounds, in tetanic cases, from the fact that the protrusion of the membrana nictitans over the inner side of the external surface of the ocular globe, quite out of its nor- mal position, had often been noticed among the symptoms of lock-jaw. The removal of the " hawcJc,''^ as the operation was then called, has never, however, for the reasons which were them ac- cepted, become legitimized among the therapeutics of the scien- tific veterinarian. The removal of part, or what is more effectual, of the whole of the membrana nictitans requires three instru- ments, a speculum ocuH, a special forceps, like that of Snellen, and a pair of curved blunt scissors. The animal must be thrown, and the eye being anestheticised with cocaine, and the Hds kept well apart with the speculum, the organ, with the mucous membrane which covers it, is drawn out with the Snellen forceps, and by degrees severed in its continuity. "VMien it is loosened sufficiently to be brought entirely out of the orbital cavity, it is separated with the scissors from all its attach- ments. The adipose mass which was then slightly protruding re- turns to its position and the operation is concluded. There is always a little hemorrhage accompanying the dissec- tion, which, however, is readily subdued by means of a simple compress of cold water. No special subsequent attention is neces- sary. H. — Operations on the Lachrymal Apparatus. A. — On the Caruncula Apparatus. The caruncula lachrymalis is sometimes the seat of hypertro- phy, as commonly seen in cattle, the vague designation of Encan- this being given to all such lesions of the caruncvda lachrymalis, whatever may be their origin or nature. 744 OPERATIONS UPON THE EYE AND EAR. It is an affection which is quite frequent in dogs, as the result of localized chronic conjunctivitis. It is characterized by a tume- faction of the organ, more or less developed, pedunculated, pro- truding in the inner commissure of the lids, and accompanied by lachrymation, caused by the obstruction of the lachrymal punctee. "While at the outset anodynes and astringent coUyria may some- times control its development, there are many cases in which its removal by ligature or excision is indicated. Silk is recommended by Leblanc as the best material for a ligature, but elastic thread is in our judgement much to be preferred. Excision is far preferable. The operation is a simple one, con- sisting in merely severing the peduncle with a curved scissors or Fig. 535.— Bistoury for the Excision of the Encanthis. a bistoury (Fig. 535), ad hoc. The comparative abundant hemor- rhage that follows is controlled by cold water applications. The wound which remains is treated on general principles. 13. — On the Lachrymal Ducts. The occlusion or obliteration of these little canals by foreign bodies, or as the result of inflammation of their mucous membrane, sometimes occurs in horses. Its characteristic symptom is an abundant and continual lachrymation, and it is only by careful examination of the condition of the orifices of the lachrymal punc- tse, that a correct diagnosis can be assured; a thick, muco-puru- lent discharge sometimes oozing from them. Though this diffi- culty often subsides by resolution of the inflammation, or the use of washes and coUyria, there are cases where surgical interfer- ence, of the nature of a true catheterism of the duct, with possi- bly an enlargement of its canal with the bistoury, cannot be dis- pensed with. The probe of Bowmann (Fig. 536), and the knife of Weber (Fig. 537), answer the purpose very well. The animal is placed in the decubital position, the grooved probe introduced into the duct, and its wall divided with the knife, guided by the groove of the probe. ON THE LACHBYMAL APPABATUS. 745 Fig. 536.— Probe of Bowmann. FiG. 537.— Knife of Weber. G. — On the Lachrymal Canal. The obliteration of the lachrjTual canal may become necessary in consequence of changes in the structure of its walls, or the pressure made upon it by the surrounding parts. In the first case, it occurs as the result of traumatic lesions, or of inflamma- tion of the mucous membrane, the exudates accompanying it, and the accumulation of thick secretions in the channel of the canal. In the second case, it is due to severe rhinitis, sweUing of the in- flamed mucous membrane of the nasal cavities, polypi, bony growth of any kind, or in cases of dental caries. The symptoms are : Lachrymation, filling up of the canal, its inflammation, and arrest of the flow of the tears through the lachrymal opening at the nose. According to Professor Leclainche, there are foiu* modes of treatment for the relief of this trouble. 1st. Opening of the natural tract and removing the cause of the obstruction. — This is done by the catheterism of the canal by means of fine probes, or by detersive injections forced through the inferior opening in the nostrils; or, again, as jjracticed by Director Trasbot, by insufflation. 2d. Making an Artificial Tract. — If the point of obliteration is situated near the lower opening of the canal, an artificial open- ing can be made above it. To do this, Leblanc recommends the in- troduction of a whalebone probe through the superior lachrymal opening into the canal until the place of obstruction is reached when a counter opening is made with a fine bistoviry through the walls of the canal. Two or three silk threads are then introduced into the new passage between the two openings and left in place for about twenty days. If the obHteration is in the bony portion of the canal, and cannot be overcome with the silver probe, the perforation of the lachrymal bone and an artificial fistula must be made. 746 OPERATIONS UPON THE EYE AND EAR. Neither of these ojDerations is often followed by successful re- sults, although the perforation of the bone enables the tears still to escape in the nasal cavities. The formation of a fistula fur- nishes a channel for the flow of the tears over the lachrymal sur- face of the face. 3d. Obliteration of the Natural Tract. — The intention of this operation is to effect the entire obUteration of the duct from the lachrymal puncta and the lachrymal duct down. It is obtained by the cauterization of these parts, either alone or inclusive of the obUteration of the lachrymal sac. Tinctiu*e of iodine often pro- duces the same effect. As the result of this treatment, the flow of the tears takes place over the face. 4th. Extirpation of the Lachrymal Gland. — This is not re- ferred to as a practicable measure, but only because it is some- times mentioned in the way of theorizing. The situation of the gland in our domestic animals renders the operation an impossi- bUity. m. — Operations on the Essential Organs or Sight. On the Globe. — The essential organ of vision, or ocular globe, is a membranous ball, completely closed, and filled with transpar- ent fluids of different densities, and popularly known as the humors (or media) of the eye. This ball, nearly spherical, flattened from backwards in front, has its greater convexity in front, where it is closed by the cornea, a transparent expansion, thick and resisting ; the glass of the eye. Posteriorly, it is composed of three capsular, concentrical sheaths, proceeding from without inward. These are the fibrous sclerotic, the choroid and the retina (Fig. 538). In the cavity of the globe one of these membranes — the cho- roid — throws out, perpendicularly to the great axis of the organ, a septum, the iris, a kind of contractile diaphragm, perforated in its center by the pupil. The retina is a membrane of special nature, being an expan- sion of the optic nerve, and performs the function of receiving the impressions of Hght, and transmitting its impressions and images to the brain. The humors of the eye are three, considered from before back- ward, the most anterior being the aqueous, the most posterior the vitreous, with the crystalline lens in the intermediate position. ON THE ESSENTIAL ORGANS OF SIGHT. 1^7 Fig. 538.— Theoretical Section of the Horse's Eye. a.— Optic nerve. &.— Sclerotic, c— Choroid.— rf.—Eetina. «— Cornea. /.— Iris.— ^ ft. —Ciliary circle (or ligament) and processes given off by the choroid, though repre- sented as isolated from it, in order to indicate their limits more clearly, i.- Insertior of the ciliary processes on the crystalline lens, y.— Crystalline lens. A:.— Crystalline capsule. /. — Vitreous body, ww.— Anterior and posterior chambers, o.— Theoretical indication of the membrane of the aqueous humor, pp.— Tarsi.