Copight'N?. 9/Z COPYRIGHT DEPOSm SURGICAL AND OBSTETRICAL OPERATIONS W. L. WILLIAMS Professor of Surgery and Obstetrics in the New York State Veterinary College, Cornell University Embodying portions of the QPERATIONSCURSUS of Dr. Pfeiffer, Professor of Veterinary Science in the University of Giessen THIRD EDITION, REVISED AND ENLARGED 1912 . CARPENTER & COMPANY ITHACA. N. Y. sv \^ .^^ Copyright, 1912 BV CARPENTER & CO. Press of Andrus & Church Ithaca, N. Y. /0 >.J^-o €CI.;J314825 PREFACE TO THE THIRD EDITION. The author caused to be published in 1900 a booklet entitled : " A Course in Surgical Operations by \V. Pfeiffer and W. L. Williams," consisting of an authorized transla- tion of Dr. Pfeiffer' s Operating-Cursus with such changes. additions and omissions as were deemed desirable. Three years of constant use. with such criticisms as came to the author from others, served to point out desirable changes of so sweeping a character as to demand a practical!}' new treatise specially adapted to American conditions, and to render the continuance of a formal joint authorship inex- pedient and in 1903 the author published a more extended volume under the present title, followed by a large second edition in 1906. In this third edition the author has con- tinued to draw freely upon Dr. Pfeiffer' s Operations-Cursus in the preparation of the text which in many chapters is practicalh' copied therefrom, including the illustrations with grateful acknowledgement of his profound obligations. On the other hand nothing has been copied or extracted except it could be freely adopted as the author's own view, releas- ing Dr. Pleiffer from all responsibility for the character of any of the contents. The volume is primarily designed for the use of the au- thor's classes in laboratory surgery and embryotomy in which the student performs the surgical operations described, on animals procured for the express purpose, under chloroform anaesthesia whenever possible, after which the subject is destroyed while still anaesthetized ; at the same time it has been aimed to render the volume of the greatest possible value to the practitioner consistent with this plan. The operations included under this scheme are necessarily limited to those which can be reasonably well performed on com- paratively sound animals of little value and regularly pro- curable for laboratory purposes. The list covers a wide IV PREFACE TO THE THIRD EDITION, range and is designed to give to the student as thorough training as is practicable in a laboratory course and includes well nigh all the more important varieties of confinement, anaesthesia, disinfection, sutures, bandaging, dressing and other adjuncts to operative work. The chapter on trephin- ing of the facial sinuses has been dealt with at much greater length in the present edition in order to fully and clearly describe the author's method of operating. The operation for the surgical relief of roaring in horses has undergone a complete revolution since the publication of our second edition in 1906 and the technic therefor which we had begun to develop in 1905 and tentatively inserted in the second edition has undergone phenomenally rapid changes until now it would appear that the technic had acquired a certain degree of permanency, though still too new to expect it to remain unchanged. The introduction of the ventricular burr by Dr. J. H. Blattenberg and various suggestions in the details of technic by Prof. Hobday of England and others has materially aided in bringing the operation to its present state of reliability and caused the operation introduced by us in 1905 to become accepted throughout America and Europe to the exclusion of other methods. We have accordingly omitted the chapter on arytenectomy from this edition, as an obsolete operation and have inserted an entirely new chapter upon the opera- rion for roaring in which we have endeavored to bring the technic thoroughly up to date. Generally but one method of operating is described, the one chosen being that which in the author's experience has proven the most valuable in actual practice, and no opera- tion has been introduced purely for practice but each one has been tested and known to have practical value. When two methods of operating are given, they are inserted because each has definite points of superiority over the other and one method may be specially applicable in a PREFACE TO THE THIRD EDITION. y given case, another in a different patient where the same operation is to be performed as for example, a milk cow is best spayed through the vagina while a heifer must be operated upon by an incision through the abdominal walls. Considerable stress has been laid upon the surgical anato- my of the parts involved in each operation ; some uses of the various operations are mentioned ; some of the chief dangers of each are pointed out and in some cases references to literature upon the operation or the diseases for which the operation is designed, are cited. Figures i, 2, 6, 7, 9, 10, 11, 15, 16 and 17 and Plates Nos. XII, XIV, XVI, XXIII, XXIV, XXVII, XXVIII, XXIX, XXXI, XXXIV, XXXV, are from Dr. Pfeiffer's Operations-Cursus ; and the remaining Plates and figures were either drawn under the direction of the author by Mr. C. W. Furlong, formerly instructor in Industrial Draw- ing and Art in Sibley College, Cornell University, or were made from original photographs. W. ly. WiLIwIAMS. Cornell University, March, igi2. CONTENTS. I. I. OPERATIONS ON THE HEAD : Page. Extraction of Teeth i Repulsion of Teeth 8 Trephining the Facial Sinuses 16 Trephining of the Frontal Sinuses 19 Trephining the Superior Maxillary Sinuses 32 Trephining the Inferior Maxillary Sinuses 41 Trephining the Nasal Fossae 45 Poll Evil Operation 53 Ivigation of the Parotid Duct 61 Entropium Operation 62 Staphylotomy 63 Trifacial Neurotomy 64 II. OPERATIONS ON THE NECK : Opening the Guttural Pouches 70 Tracheotomy 76 The Operation for Roaring 78 Intra-tracheal Irrigation 87 Intravenous Injection 88 a. Phlebotomy with Fleams 91 b. Phlebotomy with Lancet 92 c. Phlebotomy with Trocar 93 Ligation of the Carotid Artery 93 CEsophagotomy 98 III OPERATIONS ON THE TRUNK AND ON THE GENITAI, ORGANS : Puncture of the Chest 100 Puncture of the Intestine 10 1 Subcutaneous Caudal Myotomy 103 Caudal Myectomy for Gripping of the Reins 105 Amputation of the Tail 109 Urethrotomy 114 Amputation of the Penis 117 Vaginal Ovariotomy in the Mare 123 Vaginal Ovariotomy in the Cow 130 Ovariotomy in the Cow by the Flank 133 CONTENTS vii Ovariotomy in the Bitch by the Flank 134 Ovariotomy in the Bitch by the Linea Alba 141 Ovariotomy in the Cat 142 Castration of Cryptorchid Horses 143 IV. OPERATIONS ON THE EXTREMITIES : Tenotomy of the Flexor Tendons of the Foot 154 Tenotomy of the Peroneal Tendon (Stringhalt Operation) 157 Tenotomy of the Cunean Tendon (Spavin Operation) 159 Neurotomy 161 Digital Neurotomy 167 Plantar Neurotomy 169 Median Neurotomy 174 Ulnar Neurotomy 179 Sciatic Neurotomy 185 Anterior Tibial Neurotomy 191 Resection of the Lateral Cartilages 196 Resection of the Flexor Pedis Tendon 202 Amputation of the Claws of Ruminants 204 Bayer's Sutures 209 II. EMBRYOTOMY OPERATIONS : Cephalotomy 212 Decapitation 214 Subcutaneous Amputation of Ant^irior Limb 215 Amputation at the Humero-radial Articulation 218 Detruncation 218 Destruction of the Pelvic Girdle, Anterior Presentation 222 Amputation of the Limbs at the Tarsus 226 Intra-pelvic Amputation of the Posterior Limbs, Breech Pre- sentation 230 Evisceration of the Fetus 239 INTRODUCTION. Man}^ details must be omitted in the succeeding text which are of importance in each operation, but which, if inserted, would render the volume unwieldy in size for the purpose designed. These details are in a measure alike in each case, and it is assumed that the student has already familiarized himself with them. The more important of these may be summa- rized as follows : 1. The subject should be securely confined in each case as directed, because the method designated has been found effective in the operation under description, and serves to fix the relations of the parts in such a way as to conform to the surgical anatomy of the region as outlined in the text. It is to be constantly borne in mind that a change in the atti- tude of the animal may cause profound alterations in the relations of parts which displacement may greatly embarass the operator, or even prevent his carrying out the operation according to the technic given. In securing an animal for operation the whole body should be confined in a way that will sufficiently control movements and will insure safety to the patient and operator ; the part to be operated upon must be so fixed as to properly limit its motion and in a position to afford the greatest facility for the carrying out of the operation according to the technic given. 2. Anaesthesia should be carefully carried out everywhere possible, because in addition to the humane sentiments in- volved, the resulting perfect control of the animal is an essential in aseptic or antiseptic surgery. The student should make a careful study of anaesthesia in these exercises and acquire invaluable experience and confidence for their use in actual practice. X INTRODUCTION. 3. Disinfection must be scrupulously applied in every de- tail since upon its effectiveness must rest the verdict of success or failure as measured by modern surgical thought. The operator's finger nails should be well trimmed, smoothed and cleansed, and his hands and arms thoroughly scrubbed with a stiff brush in hot water and soap for a period of fifteen minutes, and all dirt and old epidermal scales removed. The parts should then be disinfected. This may be accom- plished by immersing the hands in a hot concentrated solu- tion of permanganate of potassium for ten minutes and then decolorizing them in a strong solution of oxalic acid in boiled water. Or the hands may be disinfected after the washing with soap and water by immersing and scrubbing them for ten minutes in a i to 1000 solution of corrosive sublimate, but in order to make this thoroughly effective the solution needs be alcoholic, or the hands should first be immersed in alcohol, ether, or other substance capable of dissolving fats and permitting the disinfectant to penetrate to every part without being obstructed by sebum or fat. Great care should be exercised by the student not to touch any object with his hands after they have been disinfected for the operation, unless such object has also been disinfected or sterilized, or in case it becomes necessary to touch objects not sterile, the disinfecting process should be repeated before proceeding further with the operation. This constitutes one of the most difficult of all details for the beginner to acquire, and each failure should be remedied by repeating the process over and over until the habit of maintaining effectual asepsis is acquired and fixed. The operative field should always be carefully shaved be- fore beginning the operation, and the shaved area should always be ample, so as to insure against contamination from adjacent hairs, as well as to give a clear view of the field. The area should then be disinfected in a reliable INTRODUCTION. xi manner, that advised for the operator's hands serving as a type. Whenever circumstances will permit the operative field should be kept in an antiseptic bath or pack for twenty- four hours prior to the operation in order that the deeper parts of the skin, especially the hair follicles and sebaceous glands, shall become thoroughly disinfected, a process well nigh impossible in a short period. The suturing, dressing and bandaging of the wound should be carried out carefully in every case and no opera- tion left without completing it in the best manner possible. The student should make each operation as real as possible and not omit any detail even if he thinks he already knows it sufficiently well, as the repetition of a supposedly familiar detail serves an important purpose in the fixing of a habit which is inestimably more valuable to the surgeon than any theoretical knowledge of technic. The safe surgeon is he who has so accustomed himself to the technique of asepsis and antisepsis that he carries it out rigidly in an automatic manner and is thus free to concen- trate his entire attention on the surgical problems before him. The student who consults his interests will go yet farther and prior to undertaking any operation on the living subject will study the regional anatomy of the part on the cadaver and learn therefrom all that he can of the structure of the part which he must finally complete upon the living animal. No dissection of the cadaver can ever teach true surgical structure as the dead tissues can not be like the living, but such dissection can and does give great aid and should be pursued as far as it can lead and enough will still remain to be learned on the living subject. It is to be constantly re- membered that anatomy deals with the structure of the dead body while surgical operations are performed upon the livhig structures : they are not alike. xii INTRODUCTION. The student should further take occasion to study in con- nection with each operation the object or objects for which it is performed in practice, its effect on the diseased or other parts, the untoward results to be anticipated, etc. Suggestions occur from time to time in the text designed to aid the student in these lines and help weave connecting bonds between the operation, its objects and results. Surgical operations may in themselves be valueless or worse and acquire value only when properly correlated to disease and skillfully performed. Surgical and Obstetrical Operations. I. SURGICAL OPERATIONS. I. OPERATIONS ON THE HEAD. TOOTH OPERATIONS. Prefatory remarks. The grinding teeth of the horse consisting of three premolars and three molars in each row are of such dimensions and attachments that their removal in case of disease or defect often presents difficulties of no small degree. These teeth attain their greatest size at the time of erup- tion and most of each tooth remains firmly imbedded in its alveolus while a very shallow crown projects into the buccal cavity. The teeth are gradually pushed out of their alveoli as their crowns are worn away by attrition as age advances and the proportion of the intra- to the extra-alveolar part gradually decreases until in very old animals the alveoli be- come obliterated and the last vestige of what was once the apex of the fang rests insecurely in the buccal mucosa. The facility with which teeth may be extracted increases as the age of the animal, being as a rule easily drawn with forceps in old, while in case of freshly erupted teeth in young horses it may be almost or quite impossible to extract them with forceps of any kind, except in those cases where they have become somewhat loosened as the result of disease or accident. When aberrations in development occur, lead- ing to the formation of dental tumors or odontomes the possibility of extraction by means of forceps is frequently wholly excluded. In cases where dental disorder has led to empyema of the facial sinuses, even if the tooth may be drawn by means of forceps, further operation is generally 2 EXTRACTION OF TEETH. necessary, in order to assure a prompt recovery, by the removal of the effects of the disease of the tooth. The removal of molars may therefore involve extraction with forceps, trephining the dental alveolus and repulsion of the tooth and trephining of the sinuses because of em- pyema or other pathologic conditions referable to the dental affection ; consequently all of these should be studied as related topics. 1. EXTRACTION OF TEETH. Plates I and IL Instruments. Extracting forceps, fulcra of various sizes, mouth speculum with abundant lateral working room, exporteur forceps, toothpick, splinter forceps, reflecting lamp. Technic. In simple cases wdth a quiet animal the pa- tient may be sufficiently confined by being backed into a corner or very much better by securing in stocks. In com- plicated cases or very resistant animals it is best to place the patient upon the operating table or in default of this, cast and secure in lateral recumbence on the sound side. Apply the speculum and identify the diseased tooth by manual exploration ; determine if the tooth is of unnatural size or form, if it is loose, if the gums are separated from the neck at any point, if it is out of line with the other teeth in the row, if it is painful to the touch, if it be split, etc. An external tooth fistula or a tumefaction over the affected member may aid in distinguishing it. Aid may also be had by illuminating the mouth with a reflecting electric or other lamp. Remove any accumulations of partially masticated food by means of the toothpick or fingers. In applying the forceps, have an assistant draw the tongue out at the commissure of the lips on the side oppo- \' EXTRACTION OF TEETH. 3 site to the aifected member and introducing one hand into the mouth, place the index finger on the posterior border of the diseased tooth and with the other hand, push the opened forceps backward upon the dental row until they reach the diseased member, then firml}^ grasp it with the instrument, pressing the jaws down as deeply as possible against the alveolus. In many cases the diseased tooth can be clearly seen, especially with the aid of the reflecting lamp, and the forceps may be readily applied by sight, which is frequently preferable to the sense of touch. Withdraw the free hand from the mouth, grasp the forceps handles firmly and loosen the tooth in its alveolus by establishing and maintaining as long as necessary a gentle to and fro lateral movement. The tooth is thus loosened in its alveolus by causing it to revolve very slightly back and forth on its long axis, thereby spreading the alveolar cavity. When the tooth has become well loosened, the fact is indi- cated by its revolving with the forceps and by an audible crepitant sound caused by the passage of air bubbles to and fro through the blood and lymph in the alveolus. Maintain the forceps in position with one hand and with the other introduce the fulcrum to a point where the depression on its superior surface will receive the projecting rivet-head of the instrument or in an otherwise secure position affording a safe support, while the inferior surface rests evenly upon the crown of a tooth anterior to that which it is desired to extract, as is shown in Plate I. The fulcrum needs be held firmly in place in order to prevent it from gliding away under pressure. In extracting the first premolars there is no opportunity for resting the fulcrum on teeth anterior thereto and con- sequently forceps have been made with fulcra beyond the forceps jaws resting upon teeth more posteriorly situated. This is not essential. If the tooth is thoroughly loosened, Plate I. Extraction of Teeth. Sagittal section through the oral cavity, show- ing plan for extracting the third inferior pre- molar, viewed from within the mouth. A Forceps jaws applied to third premolar. B Fulcrum resting upon first premolar. CC, Plates of mouth speculum resting upon incisor teeth. \ % EXTRACTION OF TEETH. 7 as it should be, one hand placed in the interdental space with the dorsal surface against the jaw and the volar grasp- ing the instrument, will serve as an effective fulcrum. In other cases an iron or steel fulcrum is not essential, but a stick of hard wood of proper size and form acts quite as efficientl}^ and may even keep its position better because the teeth upon which it rests sink into it somewhat. On the whole the fulcrum is not so important as some have considered it, since, after a tooth is loose enough to be drawn with its aid, a very trifling additional loosening will permit it to be easily lifted from its alveolus without it. The tooth fang is extracted by forcing the handles of the forceps toward the jaw in which it is located, so that as it is gradually drawn out the forceps tend to pivot on the fulcrum in a way to permit the tooth to emerge from its alveolus in the direction of its long axis. By referring tO' Plate II it will be seen that the long axes of the different teeth vary, that of the molars being obliquely forwards from, fang to crown towards the incisors, while the crowns of the premolars are directed obliquely backwards toward the molars. The slant of the teeth is most marked at the ends- of each arcade while at the middle they acquire an almost- perpendicular position. In drawing the last molar the back of the forceps will, generally strike against the opposite dental arcade before the tooth has completely emerged from its alveolus and ini order to complete its removal it may be necessary to take- a deeper hold with the extracting forceps or withdrawing; these complete the operation with the aid of exporteur forceps, or stMl better frequently with the hand. In young horses where the teeth are very long we have found it im- possible to complete the extraction until the tooth had been divided transversely by means of the tooth cutting forceps. The dangers in the extraction of teeth are chiefly : I. The transverse fracture of the tooth, leaving the fang still fixed in the alveolus, a danger not infrequently un- B REPULSION OF TEETH. avoidable when the crown has become greatly weakened by disease so that it lacks the necessary power of resistance ; under most other conditions transverse fracture maj' be largel}^ guarded against by the careful securing of the patient in a manner to effectively prevent sudden throwing of the head while the forceps are applied, and by using good judgment in the amount of force exerted while loosening the tooth in its alveolus. As stated above we should not expect to be able to extract with forceps the teeth of very young horses which have not become partly detached by disease or in which the fangs are the seat of odontomes. 2. Fracture of the alveolar walls is an accident which may generally be prevented by proper care in the application of force and the avoidance of any attempt to extract a tooth when the existence of an enlargement of the fang is apparent or suspected. 3. The tooth may slip from the forceps into the pharynx and be swallowed, an accident avoidable by inserting the hand into the mouth as the tooth begins to emerge from its alveolus, and if need be, grasp it with the fingers. 2. REPULSION OF TEETH. Plate II. Uses. The removal of molars, pre-molars, tooth fangs from which the crowns have been broken away, alveolar odontomes, etc., which can not be removed safely by means of the forceps. Instruments. Mouth speculum, razor, convex scalpels, trephine, bone gouge, Luer's sharp bone forceps, (rongeur forceps) light and heavy bone chisels, mallet, tooth punch, curette, compression artery forceps, scissors, needles, thread, absorbent cotton, antiseptic gauze, extracting forceps, splinter forceps, tenacula, metal probe. \ REPULSION OF TEETH. g Technic. Secure the animal in the lateral recumbent position with the affected side up. The operating table affords by far the best means for securing for the conven- ience and safety of operator and patient. If the sinuses are so involved as to make possible the inhalation of pus, blood or other injurious matter, perform tracheotomy in ample time to avert danger. Anaesthetize locally or generally as required. Shave and disinfect the operative area and trephine according to the method described in the following chapter, down through the alveolar plate immediately over the fang of the affected tooth. Avoid dulling the trephine by striking it against the tooth fang. If an external fistula exists the identity of the affected tooth is best determined by passing a metallic probe through it against the diseased fang while one hand is passed into the mouth and the location of the probe more fully ascer- tained. Care should be exercised in trephining to not injure the adjoining teeth. After removing the disc of bone isolated by the trephine, control all hemorrhage and then enlarge the opening and remove the bony tissues till the tooth fang is bared its entire width. Insert a scalpel or bone chisel between the external face of the bone and the soft tissues at the oral margin of the trephine opening and with one hand in the oral cavity with the fingers resting upon the alveolar border on the lateral side of the tooth to serve as a guide, push the scalpel or chisel along between the bone and soft tissues until it emerges from the gums alongside the affected tooth and extend this separation backwards and forwards until the soft tissues are completely detached from the alveolar wall over the entire area of the diseased member. When operating upon the superior molars, the fangs of which are covered by the zygomatic ridge, the chisel or scapel cannot be pushed directly from the trephine opening into the mouth between the soft tissues and the bone because the line is concave instead of direct. In these cases it is s § a I a, Oh ^ Oi >% ^ ^ ^ a; J^ c :: -"« 2 O o 03 03 w '§ 'H "B C2 5 a -/ )/ en %»• REPULSION OF TEETH. 13 best to detach the soft parts from the zygoma only at first and then remove the alveolar plate of the ridge with the bone forceps or chisel, after which the line into the mouth is direct and the instrument can then be readily pushed be- tween the soft and osseous tissues for the remainder of the distance and the separation completed. In operating upon the inferior molars covered by the masseter an opening through the muscle may be made near its lower border large enough to admit the trephine or the muscle may be detached at its point of insertion to the inferior maxillary bone and two parallel incisions carried upwards a short distance, permitting the raising of a flap, or what is generally best for the second and third molars, a curved incision is made at the antero-inferior border of the masseter muscle parallel to the parotid duct and satellite vessels and just posterior to them and the muscle lifted up and drawn backwards sufficiently to expose the bone im- mediatel}^ over the tooth fang. With a light, narrow bone chisel cut away and remove the external alveolar plate over the entire extent of the tooth, from the oral margin of the trephine opening inta the mouth cavit}^ Hold the chisel so that the outer edge is inclined from the affected tooth toward the adjoining one, thus making a bevelled channel through the alveolar plate tending to loosen the isolated section of bone by driving it outwards. Drive the chisel for a short distance on one side, then upon the other, and thus break the alveolar plate away in small sections and avoid an extension of the fracture to neighboring alveoli and damage to adjacent teeth. Care should be taken that the bone chisel is sharp otherwise extensive fractures of the bone may occur. With gouge and chisel remove all remnants of bone over the lateral side of the tooth laying it completely bare as shown in Plate II. The soft tfssues of the part should not be disturbed beyond the excision of the circular piece, corresponding to- 14 REPULSION OF TEETH. the disk of bone removed by the trephine and the detaching of them from the portion of bone to be chiseled away. When the tooth has been bared so that every part of its lateral surface can be seen or felt, the punch may be placed against the end of the fang, a few firm, quick blows given with the mallet, so directed that the force is in a line with the long axis of the tooth, and the organ driven into the mouth where it is seized by the forceps or the hand and removed. If it is not readily and safely dislodged in this waj' , place the heavy bone chisel against it and wath the aid of the mallet comminute the tooth b}^ breaking it trans- versely and splitting it longitudinally, in which process the fragments are generally loosened from the alveolar walls and can then be readily removed with the aid of the gouge, or heavy dressing or splinter forceps. Remove carefully all fragments of tooth or of loosened bone, cleanse and disinfect the wound, pack with iodoform gauze and dress daily. In cases where a fistulous opening remains after repulsion of molars without the removal of the alveolar wall, or if a tooth has been drawn by means of the forceps and the alveolus fails to heal, the bon}' plate should be removed in the above manner. Dangers. Wounding of the adjoining tooth is to be avoided chiefly by carefully locating the fang of the affected one and placing the instrument as exactly as possible over its centre, b}^ using a trephine not exceeding 2 to 2.5 cm. in diameter and cautiously sawing through the compact layer of the external plate only, removing the cancellated tissue with the gouge and extending the opening in the desired •direction after the outlines of the tooth fang have been clearly determined. If an adjoining fang is wounded, the tooth should be removed as it will not heal but will result in a permanent tooth fistula. Fracture of the alveolar walls of the inferior maxilla may occur during the removal of the external alveolar plate with the chisel or of the repulsion of the tooth with the \ REPULSION OF TEETH. 1 5 punch. The first is to be averted by care in having the chisel sharp, b}^ observing the precaution of making a bevelled cut through the bone, by using only moderate blows and driving the instrument alternately for a short distance on each side. The second danger of extensive fracture may be averted by being cautious to see after each stroke on the punch that it has not slipped inward along the median side of the tooth, pressing the internal plate away from the tooth and tending to produce a longitudinal fracture nearly or quite as long as the dental arcade. Careful digital exploration in the mouth may discover this fracture while still "simple" but a stroke or two more will convert it into the very much more serious ' ' compound ' ' fracture opening into the oral cavity. Keeping one hand constantly in the mouth at the point of impact is always desirable as a precautionary measure. Transverse fracture of the tooth while yet in situ by means of the bone chisel, as above described, is a great safe- guard against this injury by lessening the force required in repulsion and by the removal of the tapering fang, which then leaves a more secure base for the punch to act upon. It should never be forgotten that the impact from the punch must always be as nearly parallel to the long axis of the tooth as is possible. The fracture of the superior maxilla and bony palate is not so probable as the preceding and is preventable by mod- erate care in the denuding of the tooth before punching, by comminution of the tooth in proper cases, by the careful ad- justment of the punch and applying the force in the proper direction. Literature. Odontomes, Sir Bland Sutton, Jour. Comp. Med. and Vet. Arch, Vol. XII. p. i ; A Clinical Study of Odontomes, W. ly. Williams, Am. Vet. Review, Vol. XV, p. I ; Notes on Odontomes, do ; Am. Vet. Rev. Vol. XXIII, p. 82 and Oest. Mon. Thierheilkunde, Bd. XXIV, s. 122. 1 6 TREPHINING OF THE FACIAL SINUSES. TREPHINING OF THE FACIAL SINUSES. Plates III- XL Prefatory Note. The facial sinuses of the horse consti- tute an exceedingly intricate and extensive group of cavities, communicating more or less freely with each other or with the exterior through the medium of the upper air passages, of which they are to be regarded as a part. Their arrangement and relations permit them to frequently become the seat of, or central figure in many forms of disease which require for their differential diagnosis, amelioration or cure, the operation known as trephining. Their extent and relations to each other and to surrounding parts varies greatly with age and may be profoundly changed as a result of disease, amounting not infrequently in the frontal, superior and inferior maxillary sinuses ceasing to exist as separate cavities and becoming merged into one vast diverti- culum. The general position, extent and relations of these are indicated by Plates III-XI. It is to be noted that in cross sections the superior and inferior maxillary sinuses appear to be reversed in relation, to their nomenclature. It is difficult to make a cross sec- tion of these sinuses in such a manner that the antero- inferior extremity of the superior sinus does not show below and external to the inferior one. The inferior maxillary sinus is inferior in the sense that it is nearer to the nasal opening so that with the head in a vertical position or in a longitudinal section the inferior sinus is below the superior, while if the head be placed horizontally or a cross section made, a small portion of the superior sinus may show below the inferior. The uses of trephining are in a measure common to all the sinuses and are chiefly for the relief of empyema of the cavities involved, necrosis of the bony or cartilaginous walls, tumors of various kinds, especially dental in the young and \ % TREPHINING OF THE FACIAL SINUSES. ly malignant growths in the old, foreign bodies in the sinuses, differential diagnosis of diseases of this region, etc. Veterinarians trephine the sinuses b}^ two fundamentally different plans ; with, and without excision of the cutaneous disk corresponding to the piece of the bone removed. The first is generally' used in Great Britain and North America, while the last is the prevailing method in continental Europe and other parts of the world. The reason assigned for these variations in method are conflicting. To us there seem to be adequate reasons for preferring the excision of the cutaneous disk. We regard as the chief considerations in an operation the following : the avoidance of infection ; the prevention of pain during the operation or the after- treatment ; the reduction of the scar to a minimum ; rapidity and certainty of recovery ; convenience in operating and dressing. Inevitably a septic operation, the degree of infection is largely dependent upon the area of the wound, the facility for maintaining cleaniness and the degree of disturbance to the tissues while being dressed. The wound area in the bone is alike in all cases but that in the skin varies greath\ If we compare the usual European technic with that given below we would find the wound area ap- proximately 2.2 sq. in. in the European method, while in the latter we have only about .44 sq. in. or proportionately the wound area in the soft tissues in the two operations would be as 5 : I . It is very evident that the technic given below affords immeasureably better facility for maintaining cleanliness in the wound and with a minimum amount of insult to the tissues in the process of dressing. The amount of pain caused in the operation which should be eliminated by local anaethesia depends chiefly upon the extent of the skin incision which is essentially equal in the two plans so that the only difference would be in the 1 8 TREPHINING OF THE FACIAL SINUSES. dissection of the skin from the bone in the European operation. The pain caused in dressing must be greater in the European method because the detached, overhanging skin must be moved and disturbed each time causing pain and inviting infection. The question of pain in dressing must alwa3^s be seriously considered as it not only affects the time required for dressing and its efhcacy, but has an important relation to the docihty of the animal after re- covery, some horses having their dispositions permanently ruined by the irritation due to the oft repeated painful dressing of wounds. The cicatricial contraction of the tissues of the horse is so great that the removal of a circular disk of skin y%\.o i^z in. in diameter on the face does not leave a visible scar so that the question of blemish falls back upon that of infection, which, as we have asserted above is far more probable by the continental European method. The rapidity and certainty of recovery are dependent upon the considerations above discussed. The removal of the cutaneous disk is certainly easier and quicker than the other method. The convenience for dressing is evidently superior by the English and American method. The opening of the sinuses into the nostrils is based upon the surgical principle that suppurating cavities should be provided with ample drainage from the most dependent part. The direction to leave the external wound open, at first thought seems antagonistic to general surgical princi- ples but it should be remembered that the wound consists only of the incision through the skin, connective tissue and bone penetrating a suppurating cavity, and that any object which we can place in this opening can only serve to dam back the secretions of the cavity and can not prevent them from coming in contact with the wounded surface. It must further be regarded that the respiratory mucosa of the upper air passages are not irritated or injured in any \ % TREPHINING OF THE FRONTAL SINUSES. 19 manner so far as we can observe clinically by the direct ad- mission of air into them through a trephine, or other artificial opening, but on the contrary the suppuration in a sinus is constantly aggravated by the retention of the pus and ex- clusion of air and recovery facilitated by thorough drainage and aeration. 3. TREPHINING OF THE FRONTAL SINUSES. Plates Ill-XL Uses. Fracture of the bony walls, necrosis, tumors. The ample communication below with the superior maxillary sinus (See FE, Plates V and VI) prevents the accumulation of pus or fluids in the frontal sinuses even if formed therein unless the former becomes filled and the contents back up into the latter. In empyema of the frontal sinuses, trephining can not give relief, but calls for a repetition of the operation on the maxillary sinuses. Instruments. Razor, scissors, convex scalpels, artery forceps, tenacula, probe, trephine, curette, gouge, Luer's sharp bone forceps (rongeur forceps), hammer, chisel, probe-pointed bistoury, dressing forceps, disinfecting and dressing materials. Technic. The operation may be performed upon the standing animal with the aid of local anaesthesia of the skin, the bone having virtually no sensation. Restless animals may be further secured with the twitch, in the stocks, upon th,e operating table or b}^ casting on the sound side. Clip and shave the hair from the region of the frontal bone at that point which the operator has reason to beheve is nearest the center of disease. The highest point at which the sinus may be trephined is indicated by F in Plate III. The most central portion of the cavity is reached by trephin- Plate III. Trephining the Facial Sinuses. F, highest point at which an opening may be made into the frontal sinus without wounding the cranium and brain ; N. opening into naj^al sinus ; SM, opening into superior maxillary sinus ; IM, opening into external portion of in- ferior maxillary sinus ; IM^ opening into the median portion of the inferior maxillary sinus. \ 5M IM ^ IM TREPHINING OF THE FRONTAL SINUSES. 23 in^ on a level with the inferior border of the orbital cavity on the lines FE, Plates V and VI. Trephining at this point gives the operator access to the superior maxillary sinus, SM, Plates IV-VI, through the fenestrum, FE, Plates V and VI. The lowest and generally most essential point for trephining is at ST, Plates IV and V, where the opening affords free drainage externally from the most de- pendent part of the cavity and at the same time offers ample opportunity for securing dependent nasal drainage by breaking through the superior turbinated bone at ST, Plates IV, V and XI. By consulting Plates VII-IX, it will be seen that after reaching the level of the nasal septum, a trephine opening immediately against the median line like that at F, Plate III would wound the septum and superior turbinated bone and penetrate the nasal cavit3\ Consequently the operator must avoid making the trephine opening in this region near the median line, but must keep 1 34 to 2 inches laterally therefrom. With a heavy convex scalpel make a circular incision at the desired point as large as the area of the trephine, directly through the skin, subcutem and periosteum down to the bone and remove in one piece the entire mass of encircled soft tissues by seizing the skin with a tenaculum and forcibly separating the periosteum from the bone with the scalpel or bone chisel. Control the hemorrhage. With the center-bit of the trephine extended place it accu- rately upon the denuded area perpendicular to the surface of the bone and grasping the handle firmly turn it to and fro until the bit has penetrated the bony plate and the saw has cut a distinct groove to serve as a guide when the center- bit should be retracted and the operation continued until the disc of bone is detached, being careful to maintain the trephine perpendicular to the surface. The operation is facilitated by. grasping the shaft of the trephine between Plate IV. Trephining of Facial Sinuses. Right side of face, viewed laterally, showing extent and relations of the sinuses. O, orbital cavity ; SM, superior maxillary sinus ; IM^, median portion of inferior maxillary sinus ; NC, nerve conduit of superior maxillary trunk of the trifacial ; IM, lateral portion of inferior maxillary sinus ; F, frontal sinus ; vST, opening through superior turbinated bone for the establishment of drainage from the frontal and superior maxillar}' sinuses into the nasal passage ; IT, opening through inferior turbinated bone for the establishment of drainage from the median portion of the inferior maxillary sinus into the nasal cavitv. \ % TREPHINING OF THE FRONTAL SINUSES. 27 the thumb and fingers of one hand, constituting a support in which it may turn back and forth. The pressure under which the trephining is carried out must not be too great or the instrument may become wedged and broken. When the bony plate which has been isolated begins to loosen, remove the trephine and break, or pry out the piece of bone with the bone gouge or chisel. Smooth an}^ uneven edges of bone with a heavy scalpel or by re-inserting the trephine and using it as a rasp. The abnormal contents of the sinus may now escape through the opening or be re- moved with the curette, forceps or scissors, and the cavity irrigated with an antiseptic fluid. Leave the trephine wound entirely open and irrigate the sinuses dail}^ with antiseptics. The frontal, being in free communication below wnth the superior maxillary sinus, the irrigating fluids may fall directly into the latter until it becomes filled. The superior turbinated bone of the same side forming the median wall of the frontal sinus, it is commonly perforated by necrosis, in cases of serious disease establishing a communication be- tween the frontal and nasal cavities, through which pus and irrigating fluids readily escape into the nostril. It has been assumed that pus or other contents in con- siderable quantity might pass from the superior maxillary sinus into the nasal cavity through the normal communi- cating slit between the two cavities but a careful study of anatomical arrangement of these parts, opposite N, Plates VII-X, shows very clearly that it is impossible as the margins of the slit acts as a valve and closes it when pressure is applied from within. In order to prevent the aspiration by the patient of the contents of the sinuses, whether pus, blood or irrigating fluids, and to facilitate their escape from the nostril, any irrigation on the recumbent animal should be carried out with the poll elevated and the head flexed. Plate V. Trephining of Facial Sinuses. Oblique lateral view of the face with the sinuses exposed. SM, superior maxillary sinus ; IM^, median portion of in- ferior maxillary sinus ; NC, nerve conduit of superior maxil- lary division of trifacial nerve ; IM, lateral portion of inferior maxillary sinus ; F, frontal sinus ; FE, fenestrum of com- munication between the frontal and superior maxillar}' sinuses ; ST, artificial opening through the superior turbi- nated bone at the lowest part of the frontal sinus establishing a free communication with the nasal passage ; IT, artificial opening through the inferior turbinated bone at the bottom of the median portion of the inferior maxillary sinus, affording drainage into the nasal passage. \ % TREPHINING OF THE FRONTAL SINUSES. 31 By studying Plates IV-X it will be seen that any collec- tion of pus or other pathologic contents in the frontal sinus at F would result in poor drainage so far as may be obtained by trephining through the external wall only. The drainage, whether the contents have formed within the frontal sinus itself, or have entered it through the fenestrum, FE, Plates V and VI, from the superior maxillary sinuses should be completed by making an artificial communication through the turbinated bone between the frontal sinus and the nasal fossa at ST, Plates IV, V and XI. This is to be accomplished by breaking through the thin walls of the turbinated bone by means of a probe or other suitable instru- ment and enlarging the opening sufficiently with the probe- pointed bistoury or with the finger. In locating the exact point for making this opening in the turbinated bone it is advisable to pass a slightly curved heavy probe, a pair of long curved uterine dressing forceps or some other slightly curved and somewhat rigid instrument up the nostril to the operative region and having an index finger in the sinus against the median wall, the movements of the sound can easily be felt and the wall be broken down either by pushing the sound up into the sinus or thrusting the finger downwards into the nasal passage. In order to prevent aspiration of pus, blood or other fluids after the perforation of the highly vascular turbinated bone, the animal must be allowed to get up immediately or if under general anaesthesia a trachea tube should be inserted sufiiciently early to avoid danger. Thread a long probe with a heavy suture about 75 cm. long and inserting it through the trephine opening into the nasal passage draw it out through the nostril and removing the probe, attach a strip of gauze 75 cm. long to one end of the suture, draw it out through the nostril and tie the ends together on the side of the face to prevent dislodgement. Retain the gauze in position for about forty-eight hours to 32 TREPHINING SI 'PER 10 R MAXILLIAR Y SINUSES. insure the permanency of the opening through the turbi- nated bone. In case of severe hemorrhage the nasal and sinusal cavities may be tamponed for twenty-four hours with a long strip of gauze which may be secured if necessary by suturing to the lips of the trephine wound. In practice the operation can be best carried out generally with the animal in the standing position the operative area being first anaesthetized by the use of cocaine or by inducing artificial oedema. In the standing position we largely avoid the danger of aspiration of fluids and the hemorrhage is greatly- lessened. 4. TREPHINING THE SUPERIOR MAXILLARY SINUSES. Plates lll-X. Uses. Empyema, diseased teeth, odontomes or other tumors. Instruments. Same as for the frontal sinuses. x\natomically there are two maxillary sinuses, superior, SM, and inferior, IM, Plates III-X, having a thin im- perforate bony partition between them. This partition, shifts somewhat in position with age and in case of disease undergoes profound changes in location and is frequently totally obliterated in cases of empyema, dental cysts and other affections. If the sinusal partition be present, good drainage of the superior sinus may demand the surgical destruction of the partition so that some authors advise trephining directly upon the partition in ordei to open the two cavities simultaneously. In extensive disease of either sinus the partition between the two frequently becomes obliterated so that there remains but one sinus to open ; in limited disease the opening of both cavities is ill advised. In extensive disease the existence of a partition may generally be ignored in operating and TREPHINING SUPERIOR ^[AXILLARY SINUSES. 33 the trephine opening be aimed at the probable focus of the malady and, should this fail to reach the desired locality, the proper location for the opening may now be determined by digital or other examination through the first opening. A second operation should then be made to directly reach the seat of the affection and if need be, yet a third to secure proper drainage. Shave and disinfect as much of the area as may be re- quired bounded above by the inferior border of the orbital cavity, laterally by the zygomatic ridge, inferiorly by the lower end of the zygoma and medianwards by the middle line of the face. Determine the proper point for operation by percussion or otherwise. If it be desired to enter the superior maxillary sinus only, SM, Plates III-X, locate the opening beneath the orbital cavity and in front of the zygo- matic ridge, SM, Plate III, or at any point directly beneath this to midway between SM and IM, Plate III, at about the level of the dotted line IM'. The trephining is carried out as described for the frontal sinuses on page 19. After the trephining has been com- pleted remove any purulent collection or tumors or carry out an}' other necessary operation in the affected sinuses and after cleansing, if the trephine opening does not insure perfect drainage of the lateral sac, either lower it by cutting away its inferior border with the bone forceps or make a second trephine opening at the necessary point. Since empyema of the superior maxillary sinuses is due in the vast majority of cases to infection derived from diseased teeth or dental alveoli it is essential after the sinus has been opened that the operator search carefully and minutely over the alveoli of the molars for naked, eroded tooth fangs or for fistulae leading down into the dental alveoli. If dental disease is recognized the trephining of the sinus is to be supplemented by repulsion of the offending tooth as described on page 8. 3 Plate VI. Trephining of Facial Sinuses. Frontal view of right side of face with sinuses exposed. SM, superior maxillary sinus ; IM', median portion of inferior maxillary sinus ; IM, lateral portion of inferior maxillary sinus ; F, frontal sinus ; FE, communication between the frontal and superior maxillary sinuses. SH TREPHINING SUPERIOR MAXILLAR Y SINUSES. 37 Under the influence of disease the sinuses ma}^ extend far beyond their normal location or ma}- contract or become largely obliterated by being filled with new bone or soft tissue. The median portion of the superior maxillary sinus on the inner side of the bony conduit of the trifacial nerve, NF, Plates IV-X, can not always be completel}^ drained through the opening SM, Plate III, and provision for this must then be made by trephining into the lower part of the frontal sinus and thence breaking through the superior turbinated bone, ST, Plates IV-V, into the nasal passage or at times it may be feasible to break through the inner wall of the superior maxillary sinus on the median side of the nerve conduit into the nasal cavity. If the inferior maxillary sinus is also involved good nasal drainage may be had by breaking down the inter-sinusal partition and then penetrating the inferior turbinated bone at IT, Plates IV-V, and inserting through this opening a long and thick strip of gauze which is brought out through the nostril and the ends tied together on the side of the face to prevent displacement. Retain this in position, renewing daily until the permanency of the opening is assured. It generally occurs in extensive empyema of the sinuses that an opening in the turbinated bone takes place b}^ necrosis and in some cases affords the desired drainage while in the majority the pathologic opening is so placed that it is incomplete. Leave all wounds entirel}' open and irrigate daily with antiseptic solutions. Dangers. Care must be exercised to not injure the superior maxillary division of the trifacial nerve, NF, Plates IV-X, either in trephining or after the sinuses have been opened. The bony conduit of this nerve is in rare cases entirely resorbed by pressure from dental cysts or other causes, leaving it stretched across the cavity as a white nacrous cord, intensely sensitive. Any injury to this nerve Plate VII. Trephining of Facial Sinuses. Cross section of the right half of the head of a horse at the posterior border of the last molar. F, frontal sinus ; IM, lateral portion of inferior maxillary sinus at extreme posterior or superior part ; IM^, median portion do.; N, nasal cham- ber opposite the communication between it and the superior maxillary sinus ; NF, conduit of superior maxillary branch of the trifacial nerve ; SM, superior maxillary sinus ; M^, fragment of last molar. V-__^ TREPHINING INFERIOR MAXILLAR Y SINUS. 41 causes intense pain and renders the animal very resistant to the necessary manipulations in the after care of the wound and may leave the patient pernamently nervous about the handling of its face. Hemorrhage is generally not severe and may occur from the skin, where it may be readily controlled by compression or ligation ; from the intra-osseous vessels, where it may be checked by pressure with absorbent cotton, by pushing a small portion of cotton into the channel of the vessel with a needle or tenaculum or by plugging the vessel with a conical piece of wood ; from the wounded turbinated bones where it may be stopped by packing with gauze. These tampons should be removed after twenty- four hours. 5. TREPHINING THE INFERIOR MAXILLARY SINUS. Plates Ill-XL Uses and Instruments. Same as in the preceding. Anatomical Outline. The inferior maxillary sinus is an exceedingly irregular cavity, differing in details of form and extent in individuals and at various ages. As shown in the illustrations its disposition might be compared to a pair of saddle bags hanging over the nerve conduit, the lateral and median chambers not very unlike in extent. As suggested in Plates IV-V, the floor of the lateral cavity is broken up by irregular bony septa, which in some cases cut the sinus up into quite separate cavities. Sometimes it extends downwards barely below the end of the zygoma, at other times- it reached down below the infra-orbital foramen. There is hence no rule by which the operator may at all times make his opening precisely at the lower extremity of the sinus. Technic. The general technic is the same as for the frontal and superior maxillary sinuses, but two trephine Plate VIII. Trephining the Facial Sinuses. Cross section of the left side of the head of an aged horse at the second molar, seen from the front. F, frontal sinus ; N, nasal sinus, oppo- site the communication between the nasal and inferior maxillary sinuses ; IM, lateral portion of inferior maxillary sinus ; IM^, median portion of inferior maxillary sinus ; SM, superior max- illary sinus ; NF, superior maxillary division of trifacial nerve in its bony conduit ; SZ, subzygo- matic artery ; P, palatine artery ; M2, second molar. \ % TREPHINIFG THE NASAL FOSSAE. 45 opeuings should always be made. The first opening should be made close against the median side of the zygoma near its lower or nasal extremity, Plate III, IM, and the inferior border lowered sufficiently with the bone forceps to provide thorough drainage for the lateral compartment of the sinus. The second opening is to be made on the median side of the nerve conduit, NC, Plates IV-V as indicated at IM' in Plate III. The location may he accurately determined by palpating with the index finger through the first opening at IM, Plate III. This compartment can not be well drained upon the face through either of the trephine openings and a third opening, penetrating the inferior turbinated bone at IT, Plates IV-V, is essential to ideal results by affording free drainage into the nasal chamber. The opening through the inferior turbine is made in the same manner as described for the opening through the superior turbine from the frontal. Thorough search should be made throughout the sinus for the causes of disease, teeth, etc., these removed and followed by after treatment the same as advised for the two preceding operations. 6. TREPHINING THE NASAL FOSSAE. Plates Vll-X. Uses. Operations upon the septum nasi, or the tur- binated bones, or the removal of tumors or foreign bodies from the nasal passages. Instruments. Same as for the frontal sinuses (page 19). Technic. The trephining, N, Plate III, is carried out by the method described above, in the nasal bone, close by the median line of the face and according to indications at any point from a level of the dotted line, SM, Plate III, to the juncture between the nasal and pre-maxillary bones near the upper extremity of the false nostril. Plate IX. Trephining the Facial Sinuses. Cross section obliquely downwards and back- wards through the right half of the head of a two-year old colt at the first molar. F, frontal sinus ; N, nasal passage at point of communica- tion with the inferior maxillary sinus, IM ; IM^, median portion of inferior maxillary sinus ; SM, extreme lower end of superior maxillary sinus opened; Mi, first molar; M2, second molar; P, palatine artery ; SZ, sub-zygomatic artery. — r--Ml ' Ma TREPHINING THE NASAL FOSSAE. 49 A study of Plates VII-X will show that the trephining of these cavities requires great care in order to avoid wound- ing either the highly vascular septum nasi or even more vascular turbinated bones. The operation should be im- mediately against the septum since otherwise the superior turbinated bone may be wounded or an important intra- osseous artery in the nasal bone, just above its union with the superior turbinated, as shown in Plate IX, may be severed. If the turbinated bone is penetrated the frontal, and through it, the superior maxillary sinus is opened and ex- posed to infection with all its consequences. Special care is accordingly necessary that the trephining should not be carried too deeply, that the bone be barely penetrated, and that the osseous disc be carefully removed in order to avoid the wounding of the turbinated bone, which lies in close proximity to the nasal bone. The operative area is narrow and the trephine used should not exceed 2 cm. in diameter. Whenever possible the operation should be carried out on the standing animal which decreases the hemorrhage and the danger from aspiration of fluids. The hemorrhage may be further controlled in operations upon the septum nasi and turbinated bones by spraying the parts with adrenaline chloride and cocaine. Even in the standing animal, if extensive operations are to be carried out on the very vascular .septum nasi or on the turbine, it is advisable to preform trachetomy before trephining, and retain the trachea tube in position until all danger has pa.ssed. When the animal is confined in the recumbent position the patient's safety'demands that tracheotomy be performed in almost all cases before any operation is begun upon the septum nasi or turbinated bones. After tracheotomy, anaesthesia ma}^ be maintained by means of an ordinary funnel with its tube bent at right angles and inserted into Plate X, Trephining of Facial Sinuses. Cross section of the left side of the head anterior to the last molar, and through the widest part of the inferior maxillary sinus. M', last superior molar ; SM, superior maxillary sinus at its antero-inferior extremity ; IM, in- ferior maxillary sinus, lateral portion ; IM^, do. median portion ; N, nasal fossa ; S, sound lodged in lachrymal duct ; NF, trifacial nerve ; F, frontal sinus. ^_.__SM r — M POLL EVLL OPERATION. 53 the trachea tube while the chloroform is dropped on a towel spread over its mouth. After completing any required operation upon the septum, turbinated bones or other parts, hemorrhage may be controlled by packing one or both nasal fossae with single strips of gauze of sufficient size and carefully securing them by sutures to the sides of the trephine wound or otherwise. 7. POLL EVIL OPERATION. Plate XI. Instruments . Clipping shears, razor, sharp scalpels, one dozen compression artery forceps, probe-pointed bistoury, probe, IvUer's bone forceps, bone gouge, curette, suture and dressing material. Technic. Clip the foretop and mane and shave the forehead and the top of the neck back to a distance of 8 or 10 cm. or as much farther as may be required to pass beyond and behind the supposed extension of disease, and disinfect the area. Confine the animal in lateral decubitis preferably upon the operating table, place under complete anaesthesia and remove the halter or other headgear. With sharp scalpel make a longitudinal incision on the median line of the head and neck beginning at a point presumably posterior to the diseased area and carrying it over the poll down onto the forehead for a distance of 4 or 5 cm. below the foretop. Continue this incision through the skin, the subcutem, the adipose tissue, AT, Plate XI, and either through, or passing around alongside the neck ligament, LN, into the diseased area beneath the latter. Dissect the ligamentum nuchse away from the adjoining tissues as far back as diseased, divide it obliquely upward and backward as indicated at AA, and detach anteriorly from the base of the occiput. Be careful to remove every a .1 O 03 OJ „ H '^ <: c •2 < < CO <«tf A Q o •^ k ^ ;3 1 1 1 13 'd a ■<«tf Cu Co <3 (U bjO a. ^ OJ ^' t+H h4 o ^ ,__, _o > d) tj ,_! OJ X o Ph 1 1 '^ c J} ^o u a ^ o ■*-> u u M-H ,o -> O rt «0 « 'vh Ot •«u ?3 (U ,_, Q _S M-( cS •Z u '35 • f-l Oj a 1 a I— bjO O ** o Vh O ^ bo p 4J .s .5 [5 , 1 bJO tn a; a S 1 o (J5 )h o a „ ^ o ^ »-j )-l >— ( biO . o o o •-^ 05 o goo ij ... o oj S <^ ^'^ o S tn biC ^ t/5 S o .^ I m ^ I ;3 -• a; o ^ 5 s (V u 15 ^ u bJO Si -s Id .2 - Oh h4 O Si g P o bo AMPUTATION OF THE PENIS. 121 After the penis has been drawn out, and the preputial region carefully cleansed and disinfected, an assistant grasps the organ just behind the preputial ring and holds it firmly. A catheter is then introduced into the urethra and pushed upwards beyond the point where it is designed to amputate the organ and a temporary elastic ligature, T, is then applied Fig. 12. Amputation of the penis, showing needle inserted for a suture. V, Dorsal vessels of penis ; A, Fibrous tunic of the corpus cavernosum ; S, Skin ; CC, Corpus cavernosum ; CS, Corpus spongiosuuKof urethra ; U, Urethra. above the assistant's hand around the penis, or a piece of tape is looped around it above the hand and is made to serve both as a tourniquet and as a means for holding the penis. Or the penis may be grasped in front of the ligature with double tenaculum forceps and held. 122 AMPUTATION OF THE PENIS. Apply a small cord just behind the glaiis penis, L, Fig. I, P ate XIX, and then make a triangular incision on the ventral surface of the organ about 4 cm. long by 3 cm. wide, the base of the triangle being forward as shown in Fig. I ; carry this incision through the skin, S, the corpus spongiosum, CS, and along the corpus cavernosum, CC, down to the urethra, U. Dissect away the tissues in the triangular area without opening or wounding the urethra and when this has been completed make a longitudinal incision from near the apex of the triangle to its base through the urethral walls to the catheter. Beginning at the apex of the triangular wound insert a series of inter- rupted sutures as shown in Fig. 2, Plate XIX in such a manner that they pass through the urethral wall and the skin so that when tied the wounded surfaces are completely hidden and the urethral mucous membrane is brought into apposition with the integument. Continue these sutures down to the base of the triangle after which remove the catheter and excise the organ by a cut extending in a slightly oblique direction from below upwards and forwards. Take a straight needle armed with the silk suture and passing it through the margin of the urethral wound, the adjacent fibrous capsule of the corpus cavernosum and across but not through the erectile tissue, insert it again into the superior portion of the fibrous capsule and carry it out through the adjacent dorsal vessels and the skin as shown in Fig. 12, and, bringing the ends of the sutures together, tie in such a way that the urethral mucous membrane and the margin of the skin are brought into immediate contact and the blood vessels securely closed in such a manner as to guard against hemorrhage. By this plan when the sutures are tied, the cut borders of the fibrous envelope are brought together over the erectile tissue, thus preventing hemor- rhage from that tissue also. Insert as many sutures as may be required to completely and securely close the wound VA GINAL O I A RIO TOM Y IN THE MARE. j 2 3 and finally leave every part wholly covered with epithelium. By this plan it is hoped to avoid stricture of the urethra in the process of healing. Remove the tourniquet and release the patient. 26. VAGINAL OVARIOTOMY IN THE MARE. Figs. 13-14. Objects. The alleviation of vice when related to ovarian irritation or disease. Instruments. Colin's scalpel, ratchet ecrasure, 55 cm. long, vaginal tensor. Preparation of patient. It is highly important that the animal should be kept on a scant laxative diet for at least 24 hours and preferably longer prior to the operation, so that the alimentary canal shall be somewhat empty and thus decrease the intra-abdominal tension and relieve the operator from much annoyance due to the pressure of the viscera. Technic. The vagina of the mare is unique in its physiological behavior. Under venereal excitement or the introduction of the operator's hand or of tepid water the organ has the power of ' ' ballooning ' ' or dilating to a degree not so marked in other animals ; the vaginal walls become erected, hard, and stand apart from each other, filling the pelvic cavity, resting firmly against the pelvic bones and ligaments at every part except at the points where the bladder and rectum intervene and these organs are pressed out flat and occupy a minimum amount of space. In the quiescent state the vaginal walls are in contact and from the perinaeum forward to within about 10 cm. of the uterine os, the vulva and vagina are connected above with the rectum by the pelvic connective tissue, while anterior to this point the vagina is covered by peritoneum, and it is 124 VAGINAL OVARIOTOMY IN THE MARE. in this area that the incision needs be made in the operation. The ballooning of the vagina profoundly alters the relation of this operative area, and changes it from the horizontal in the quiescent organ to the perpendicular in the ballooned condition. These variations permit of two methods of operating : I. On the ballooned organ without anaesthesia and with the animal confined in the standing position. II. On the quiescent organ in the recumbent position under anaesthesia : I. Without anaesthesia. Secure in the stocks with the head elevated, a rope over the back to prevent rearing. Fig. 13. Special spraying ecraser, 55 cm. long. Fig. 14. CoUn's scalpel. straps beneath the body to prevent lying down, straps or ropes before and behind the animal to prevent backward and forward movements, all four feet pinioned to the floor, and the tail firmly secured and stretched to a beam above. Apply a bandage to the tail extending for a distance of 12 to 15 inches from the base of the tail in order to secure the tail hairs out of the way of the operator. With soap, water and brush cleanse the tail, perineum and vulva thoroughly, being especially careful to remove all VAGINAL OVARIOTOMY IN THE MARE. 125 detachable masses of sebum ; 50 per cent, alcohol may be used sparingly to aid in removing this. Too free a use of alcohol excoriates the delicate skin. Cleanse the clitoris carefully. Follow the washing with a free application of i: 1000 aqueous sublimate solution to the external parts and for a short distance inside the vulvar lips and to the clitoris. Do not introduce irritant disinfectants into the healthy vagina nor deeply into the vulva as it may cause severe straining during and subsequent to the operation and by in- juring the vulvo-vaginal mucosa favor subsequent infection of the vaginal wound. Wash away the sublimate solution with a tepid 0.6 per cent, soda bicarbonate solution, and fill the vulvo-vaginal canal with the same. After thorough disinfection of the hands and arms remove the disinfectants by washing in sterile soda solution, which at the same time renders the hand unctuous and readily introduced through the vulva. x\rmed with the guarded sterilized scalpel, Fig. 14, intro- duce the right hand into the vagina promptly and when it is well " ballooned " unsheath the knife and placing it just above the os uteri parallel to the long axis of the uterus and a few mm. to the right or left of the median line in order to avoid a loose fold of mucous membrane generally existing there, the blade being held vertical, that is the cutting sur- face parallel to the longitudinal muscular fibers of the vagina, and guarding the possible extent of its introduction with the thumb and fingers, push it directly forward in a straight line with a quick thrust through vaginal mucosa, the muscular walls and the peritoneum, until the disap- pearance of resistance indicates that the latter has been penetrated. This is the most critical step in the operation. If the hand is introduced into the vagina immediately after the injection of the sterile saHne solution the vagina will generally be found '' ballooned " or will quickly become inflated under manual movements. If the solution is thrown 126 J'AGINAL OVARIOTOMY IN THE MARE. out the vagina may collapse and closely invest the hand, in which case more of the liquid should be injected when it will again dilate. If the hand is introduced without the knife, withdrawn and then introduced with it, it will be frequently found that the vagina has collapsed and needs a second filling with the fluid. Patience until dilation is accomplished and promptness to act when attained are prime requisites to success. The knife should be pushed through the vagina quickly making a clean wound the width of the blade, when the latter is to be withdrawn and laid aside. It should be re- membered that in this "ballooned" state, the anterior wall of the vagina is but 2 or 3 mm. thick and easily pene- trated. Introduce the hand again, push one finger into the incision, then a second and third, and eventually holding all the fingers in the form of a cone push the entire hand into the peritoneal cavity. Immediately below the incision and continuous with the tissues involved in the wound lies the uterus with a transverse diameter of 4 to 6 cm. With the palm of the hand downward, trace the uterus forward a distance of 15 to 18 cm., where it ends abruptly in two cornua of about the same size as the body, which are given off horizontally at almost right angles. Trace these to the right and left for a distance of 14 or 15 cm., where they end obtusely, and 3 or 4 cm. beyond this in a direct line, resting upon the anterior border of the broad ligament is the dense oval ovary varying in size from 2.5 to 7 cm. in diameter. Prepare the ecraseur for use by withdrawing the chain until the loop is of barely sufficient size to admit of its being readily slipped over the ovary. Grasp this loop and the end of the ecraseur tube in the hand, carry the instrument to the ovary and drop the loop over it from above. Pass some of the fingers beneath the ovary and push it up through the chain loop and grasp it there with the thumb VA GINAL O I A RIO TOM} ' IN THE MARE. 1 2 7 and index finger. Holding the ovary with one hand tighten the chain quickly with the other, examine to make sure that a loop of intestine is not caught, draw the ovary well through and get a large portion of the oviduct, and crush off promptly, holding to the gland until carried out through the vulva. Remove the other ovary in the same way. Generally it is most convenient to remove the left ovary with the right hand and vice- versa but each may be re- moved with either hand. Wash away any blood from the external parts, apply sublimate solution freely to the vulva, perineum and tail. Keep the patient quiet for five or six daj'S, and feed lightly on a laxative diet. II. In operating under anaesthesia the animal should be cast or confined upon the operating table in lateral re- cumbency preferably with the posterior part of the body somewhat higher than the anterior so as to avoid visceral pressure in the pelvic cavity. Place the animal under com- plete anaesthesia. Prepare the parts in the same manner as already described. Carry the knife into the vagina in the manner previousl}^ described and render the roof of that organ tense by pushing the os uteri downward and forward with the hand or by means of a vaginal tensor or speculum. It is important that the vagina be held well down toward the floor of the pelvis so as to carry it away from the rectum, posterior aorta and iliac arteries while the incision is being made. The incision is now to be made just above and be- hind and a trifle to one side of the os uteri in essentially the same manner as under I, except that when the vaginal tensor is used Jthe cut is made upward and backward instead of directly forward. The remainder of the operation is identical with what we have described under I. Under anaesthesia the vagina is flaccid and can not be made to " balloon." 128 VAGINAL OVARIOTOMY IN THE MARE. DANGERS. Wounding of the rectum is scarcely possible under the first method if care is taken not to attempt the incision until the vagina is well "ballooned," and then making the stab wound directly forward. If made upwards when the organ is so erected the accident is highly probable, and with the undilated vagina where it is necessary to cut upwards the danger is ever present. Its prevention demands that in the first method, the operator await the complete " ballooning "^ and then make his incision as directed. In the second method, the accident is to be prevented by being careful to- push the vagina down away from the rectum and hold it away while the incision is being made. If the wound in the rectum passes through the pelvic connective tissue behind the peritoneum it is of little consequence, but the operation should be abandoned ; if the bowel is opened into the peritoneal cavity the accident is generally fatal. Wounding of the iliac arteries, which generally pro- duces prompt death from hemorrhage, results from the in- cision being made upwards instead of forwards when the vagina is " ballooned " or from a failure to hold the roof of the vagina down and away from the part while making the incision in the flaccid organ as is the case with the recumbent animal under anaesthesia. It is most likely to occur with timid operators who become nervous, especially when the vagina does not " balloon " promptly or the mare is not well secured. The accident is wholly unnecessary if the operator will await the " ballooning " in the first operation while by the second method it is prevented by proper care in holding the vagina downward and forward during the incision. When it has occurred it is generally beyond remedy though in some cases the prompt intravenous injection of adrenaline chloride may stay the hemorrhage and save life of the patient. \ % VAGINAL OVARIOTOMY IN THE MARE. 129 ^A^ounding of the uterus ma}^ occur when the incision is directed downward and may greatly embarrass the operator and confuse him by passing the hand through the incision into the uterine cavity. It is to be avoided in the first operation (without anaesthesia) by carefully directing the incision straight forwards. When the accident occurs it is of little consequence beyond the embarrassment and may be overcome by again dilating the vagina with fresh injections of the soda solution and making a new incision, or if pre- ferred the first cut may be corrected by placing an index finger against the peritoneum at the upper part of the wound, and with a sudden and vigorous thrust break through into the peritoneal cavity, or the error may be corrected by again using the scalpel and directing the in- cision properly. If it is attempted to rupture the peritoneum with the finger it must be done by a sharp thrust since otherwise a large section of the membrane will be pushed away from the subjacent tissues. Incomplete penetration of the vaginal wall is liable to occur if the scalpel is dull or the vagina imperfectly " bal- looned " and flaccid, or if the operator is unduly timid. It is best prevented by avoiding the causes as related, and once it has occurred it is generally best to again "balloon " the organ in the operation without anaesthesia and make a new incision either to the right or left of the first. It may be overcome also by thrusting the index finger through the peritoneum as described in the preceding paragraph or completing the cut with the scalpel. The mistaking of a ball of feces for the ovary has oc- curred to inexperienced operators and the fatal error of re- moving the portion of the rectum surrounding the fecal pellet committed. The blunder is uncalled for ; the fecal ball is movable in the bowel, the intestine is far more massive than the broad ligament, and the ovary is to be definitely identified by its being lodged in the broad ligament just 9 1 30 r.-^ GIN A L O I 'A RIO TOM J ' IN THE CO W. beyond the end of the cornua, which is continuous with the uterus. If, therefore, one traces the uterus forward to the cornua, thence along each of these to their extremities and along the borders of the broad ligament to the ovary, as above directed, the error will not occur. The incision may be made too low and pass beneath the broad ligament. It is to be avoided by being careful to keep close to the median line and above the os uteri. If it occurs the operation may be completed from beneath with- out very great difficulty only that the ovary now lies above the hand and must be drawn down from on top the broad ligament in order to fix the ecraseur upon it. Infection constitutes always the most serious danger and is to be avoided by properly securing the animal, by the avoidance of irritant antiseptics in the vagina, by rigid anti- sepsis at every stage, and by carrying out the mechanical parts of the operation deliberately, vigorously and neatly. If infection should occur it will generally take the form of pelvic cellulitis with abscesses and rectal stricture. Enemas of a normal salt or soda solution affords the surest relief of the stricture and impaction in front of it. The abscesses must be watched and opened early into the vagina or rec- tum, and the case treated internalh' and locally according to general surgical principles. 27. VAGINAL OVARIOTOMY IN THE COW. Objects. Increasing the fat- or milk-producing qualities and the cure of nymphomania or other ovarian disease. Instruments. Colin's scalpel, vaginal dilator. Miles' spaying shears, spaying ecraseur. Technic. Confine the cow in the standing position in the stocks, secure the head firmly and pass two boards be- neath the abdomen and sternum to prevent lying down, and a rope over the middle of the back to prevent arching of the spinal column and straining. VAGINAL OVARIOTOMY IN THE COW. 131 Wash and disinfect the tail and the perineum and flush out the vagina with a 0.5 per cent, sohition of carbolic acid or lysol at a temperature of about 100° F. Insert the vaginal dilator with one hand and push the prolongation at the anterior end into the os uteri. With the other hand elevate the handle of the dilator and depress and push for- ward the uterus, thus rendering the roof of the vagina tense and pushing it downward away from the rectum Carry the scalpel into the vagina with the right hand and resting it in the oval of the dilator make an incision through the roof of the vagina, beginning at a point 8 to 10 cm. posterior to the OS uteri and extending backward on the median line for a distance of 2 or 3 cm. Be careful to make the incision entirely through the mucosa, muscle and peritoneum at the first cut, since any failure to complete it tends to cause the peritoneum to separate from the muscular coat and form a pocket between them, while the serous membrane being very elastic renders it difficult to complete the incision. Introduce two fingers through the incision, and reaching over the side of the vagina to the right or the left, the right or left ovary respectively is recognized lying immediately against the lower part of the vagina, just at the anterior border of the pubis, in a mass consisting of the cord-like Fallopian tube and the fimbriae of its pavilion. The ovary may be distinguished as a firm oval mass 2 to 4 cm. in length and I to 2 cm. in its lesser diameter attached to the broad ligament. If not promptly recognized by the sense of touch, trace the vagina and uterus forwards with the fingers from the vaginal incision to the cornua and follow them as they bend forward^ and downward, and then backward and up- ward to the oviducts, until the ovary is reached where it is attached to the broad ligament, just beyond the fimbriated end. Grasp the ovary between the fingers and draw it through the incision into the vagina. Introduce the scissors or emasculator with the other hand, and when the ovary is 132 VAGINAL OlARIOTOMY IN THE COW. reached open them barely sufficient to admit the ovarian attachments between the blades and cut the gland away along with a portion of the broad ligament. Or introduce the ecraseur and drawing the ovary through the loop of the chain and holding it securely until the instrument is tightened, crush it off in this way. It is essential that plenty of the broad ligament and ovi- duct be excised with the ovary to insure the entire removal of the latter, because the accidental leaving of the smallest particle of ovarian tissue will cause a development of this into abnormally large cystic ovisacs, and will tend to in- crease instead of decrease nymphomania. Should the animal be pregnant the ovary on the gravid side is dragged downward and forward out of reach of the operator's fingers, and if it is desired to complete the operation it may be necessary to enlarge the vaginal wound and introduce the entire hand, when the ovary can be reached and re- moved. Generally no after care is necessary. The Dangers are similar to those of the mare. The iliac arteries may be wounded in the same manner as in the mare and is preventable by being careful to push the vaginal roof well downwards awa}^ from the rectum and sacrum. In rare instances fatal hemorrhage follows the cutting off of the ovaries with the scissors especially in cows sterile be- cause of diseased ovaries accompanied by a want of tone. For this reason it is safer in cows sterile from diseased ovaries to use the ecraseur but even this instrument is not wholly proof against hemorrhage and fatalities have been rarely recorded after its use so that some veterinarians have advised ligation of the arteries instead, but this is a complex process which requires much time for its accomplishment. Another danger appears in the presence of the rumen, the supero-posterior portion of which when filled with food projects into the pelvic cavity and if the cut is directed for- wards a stab wound readily penetrates its walls with fatal results. Make the cut upwards and backwards. OVARIOTOMY IN THE COW BY THE FLANK. 133 28. OVARIOTOMY IN THE COW BY THE FLANK. Instruments. Clipping shears, convex scalpel, spaying shears, or ecraseur, heavy needle and thread. Uses. Same as the preceding, applicable to heifers or to cows in which the vulva is too small to admit the operator's hand or in case of diseased vagina or uterus. The animal may be secured as in the preceding or con- fined in lateral recumbency with the hind legs extended backward and the anterior limbs forward. To accomplish this loop a rope about the two fore feet, another about the two hind feet, and drawing upon these, cast the animal and secure it in recumbency with the legs extended and body stretched by fastening the ropes to two strong posts about 8 to 10 m. apart. The operation may be performed in either flank. Clip the hair from the upper part of the flank, disinfect an area 15 to 25 cm. square and make an incision about 12 cm. long beginning at a point equi-distant from the anterior tuberosity of the ilium, the ends of the transverse processes of the lumbar vertebrae and the last rib and extend it down- wards perpendicularly severing the skin and subcutaneous muscle. Divide the external oblique muscle in the direction of its fibres by means of the scalpel handle or the fingers and repeat the process upon the internal oblique after which puncture the peritoneum with the scalpel. Some operators cut directly through the entire abdominal wall at a single stroke, but this comes to the operator only by experience. Force one hand through the opening into the peritoneal cavity and search for the ovaries at the same point and by the same method as in the preceding operation, that is, locate the uterus within the pelvic cavity, between the rectum and bladder and trace it, the cornu, and broad ligament to the ovary. The uppermost ovary can be drawn out through the wound and cut off with the scissors or ecraseur ; the lower one must be held with one hand and 1 34 O VARIO T03f} ' IN THE BITCH. the instrument introduced along the arm and when the ovary is reached, apply the scissors or ecraseur and cut or crush it off. The beginner must always remember that the positive means for identifying the ovaries is by tracing the uterus from the vagina along its cornua to the oviduct and thence to the organ in the broad ligament. Cleanse the wound and close the skin incision with continuous sutures. 29. OVARIOTOMY IN THE BITCH BY THE FLANK. Plate XX. Instruments. Spaying knife, suture material. Techic. Confine the animal in lateral recumbency, preferably upon the right side for a right handed operator, the head somewhat depressed, the limbs extended and the body well stretched. Clip, shave and disinfect a sufficient area in the exposed flank at a point just anterior to and be- neath the external angle of the ilium. With one hand grasp the skin fold of the flank and render the skin of the region tense, while with the other holding the spaying knife like a pen make at first a drawing incision from below upward about 2 to 3 cm. long, ending above at a point slightly be- low the external angle of the ilium, the incision extending through the skin and subcutaneous tissues ; without remov- ing the knife from the wound elevate the handle and with a quick thrust make a stab wound extending through the external and internal oblique muscles and peritoneum at a single cut. The operator can determine when the peritoneal cavit}^ has been entered by the disappearance of resistance. Introduce an index finger into the peritoneal cavity, and as soon as this has been entered follow directly along the peritoneum upward and backward toward the angle of the ilium where the uterine cornua lie covered over by the broad ligament. The internal generative organs of the \ % OVARIOTOMY IN THE BITCH. 135 bitch are unique among our domesticated animals. The uterus, U, Plate XX, is small and physiologically unim- portant, the cornua, RUC and LUC, are ample in size and constitute physiologically the uterus. The distance from the cornual extremity, LUC, to the ovary, O, which is occupied by the Fallopian tube is very brief so that the cornua and ovary are well nigh in contact. The ovary, O, O, is very small, smooth and completely hidden in the pavilion which here constitutes a sac having a very small longitudinal opening of 2 to 5 mm. The most remarkable feature of the apparatus from a surgical standpoint is the great development of the broad ligament which is broader than the distance from the lumbar region to the abdominal floor, while the uterus and uterine cornua are stretched between the vagina, V, and the ovary, O, so that they are suspended in the sub-lumbar region resulting in a double fold of the broad ligament hanging down like a curtain be- tween the parietal peritoneum and the uterus and cornua on either side. The broad ligament of the bitch is conse- quently suspended at one point from the sub-lumbar region, at the other from the uterus, so that instead of that organ being suspended by the ligament the relation is reversed and the ligament is suspended from the uterus, or rather uterine cornua. In Plate XX the right broad ligament, BL', is laid out upon the side exposing the right uterine cornu, RUC, while on the left side the ligament is divided at about its center and the posterior portion, BL', is laid out on the flank,, while the anterior, BL, is left in its normal position con- cealing a portion of the cornu, LUC. Unlike our other domesticated animals, the broad ligament is heavily loaded with fat which gives it an appearance very similar to the omentum, but the net-work is far less conspicuous or want- ing, the omentum also extends back into this region so that the two are in contact. Plate XX. Ovariotomy in the Bitch. Abdomen of a nou-pregnant bitch lying on the back with the abdominal floor removed and the omentum pushed away. TT, the two pos- terior teats ; B, bladder ; V, vagina ; U, uterus ; LUC, LUC, left uterine cornua with a portion of its broad ligament, BL. lying across it ; RUC, right uterine cornua with its broad ligament, BL^, turned outwards exposing the full length of the cornua. On the left side the ligament is divided so that the anterior half rests in its nor- mal position while the posterior half, BL'', is turned back. 0,0, ovaries ; R, rectum ; K, left kidney ; AA, a line indicating the level of the external tuberosities of the ilia. --Ab.^.. 1^ I ^rji ::iL^_^ OVARIOTOMY IN THE BITCH. 139 The ovary being indistinct and hidden is difficult to iden- tify directly, and the cornua being covered over by the duplicature of the broad ligament is not readily reached, so that the finger generally comes in contact first with the broad ligament of the uppermost cornu hanging loose in the peritoneal cavity : engage this between the end of the finger and the abdominal wall and draw it out through the wound, grasp it and continue drawing upon the folds of the ligament, especially upon the median or under-most portion until the naked cornu appears through the opening, seize it and draw out the anterior portion until the ovary follows, then grasp the latter with the thumb and index finger of one hand and the ovarian ligament with the same members of the other and tear the ligament through between them by linear tension. Extend the tear through the broad liga- ment as high toward its lumbar attachment as is convenient and backward to the neighborhood of the uterine bifurca- tion. Draw upon the exposed cornu until the point of bi- furcation appears, when the other branch is to be grasped and drawn out through the opening. In young puppies the securing of the second cornu is very difficult and requires great care to prevent the rupture of the first. The object may be facilitated by pressing the upper flank of the bitch downward, thereby greatly diminishing the transverse diameter of the abdomen. The succeeding operation (30) avoids this difficulty in a large measure. Should the distal cornu be ruptured and with its ovary drop away from the operator, it becomes nec- essary to turn the animal over and make a second incision on the opposite side, somewhat further forward. When the second cornua has been secured draw it out as far as prac- ticable and holding it tense insert an index finger along it until the ovary is reached, which is recognized by its slightly greater size and density succeeding the brief neck represent- ing the Fallopian tube between the end of the cornu and I40 OVARIOTOMY IN THE BITCH. ovary, while beyond it can be felt the ovarian ligament. Engage the ligament between the end of the index finger and the abdominal wall, and with a firm and vigorous move- ment, using the finger end and nail as a curette, rupture the ovarian ligament by drawing the finger toward the in- cision, and with the aid of tension upon the cornu draw the ovary out through the abdominal incision and divide the broad ligament as before. Remove the cornua with the attached ovaries by rupturing them transversely near the bifurcation by means of linear tension. If the bitch be pregnant and especially if far advanced the uterine cornua will lie upon the abdominal floor, much enlarged and very much more flaccid than the nongravid uterus and feeling very much like intestines. The change in the position of the uterus has caused the unfolding of the duplicature of the broad ligament so that it no longer covers the cornu. In such cases the operation is performed in the same way except that rupturing the blood vessels by linear tension does not insure against hemorrhage and it is neces- sary to ligate the ovarian and uterine arteries with catgut or silk. In cases of pregnancy the entire cornua should be drawn out and a strong ligature placed around the uterus or vagina, and the ovaries, uterine cornua and their con- tents be removed en masse. Release the upper posterior limb and close the cutaneous wound by a continuous suture. Dangers. Rupture of the uterine cornu alluded to above. It is always to be remembered that the leaving of one ovary in position even though the other gland with the two cornua and uterus are removed, induces intense oestrum and renders the animal if anything more disagreeable than before the operation. The ureter may be mistaken for the cornu but is smaller, is closely attached to the abdominal walls, and does not have the broad ligament with its large deposit of fat. The kidney is far larger than the ovary, more exposed, and located more anteriorly. OVARIOTOMY IN THE BITCH. 141 The iliac arteries are at times caught and ruptured by the finger but the blunder is uncalled for except through nervousness of the operator. Instances of puncturing the bladder in making the in- cision have been reported. If the bitch has been led out and caused to urinate prior to operating, the accident is made practically impossible. 30. OVARIOTOMY IN THE BITCH BY THE LINEA ALBA. Plate XX. Instruments. Same as in the preceding. Technic. Confine in the dorsal position with the head sharply declined. Shave and disinfect an area on the median line about 6 cm. square extending forward from the pubic brim. Make an incision on the median line about 4 cm. long beginning just in front of the pubic brim and extend- ing forward cutting entirely through the skin, the linea alba and peritoneum. Insert an index finger and identify the uterus or broad ligament by its location and form. The finger usually comes in contact first with the urinary bladder which may more or less obstruct the passage to the uterus according to its degree of distension. When empty as shown at B, it offers practically no obstruction. When very much distended it may be evacuated by gentle pressure with the fingers. The operator should be careful not to draw the bladder out through the incision as its replace- ment may prove difficult and its puncture with a hypo- dermic needle or an enlargement of the abdominal incision may be necessary in order to bring about its return. Push the bladder aside if necessary and just above it and below the rectum the uterus should be readily distinguished and either it or the broad ligament caught by the finger and brought out through the incision after which the operation proceeds 142 OVARIOTOMY IN THE CAT. in the same manner as by the flank method. By passing an index finger forward to reach the lower surface of the rec- tum in front of the uterus and then drawing it backwards the finger passes between the former and the cornua and the latter are picked up. It has a distinct advantage over the flank method in that in puppies there is not so much difficulty in bringing out the ovaries, nor the danger of the rupture of the cornua and the ovary being retained. By the use of retractors in the abdominal incision the operator is enabled to see the uterus in position and grasp it by means of forceps, obviating the necessity for introducing the finger into the peritoneal cavity. The sutures must extend entirely through the abdominal wall and be carefully placed in order to prevent hernia. Interrupted sutures are preferable. If the operation has been properly performed no bandage is necessary and the patient will not disturb the sutures. If asepsis has not been strictly followed infection may occur and the consequent irritation cause the patient to tear the sutures out, which may lead to protrusion of the intestines or other abdominal 'viscera. If the sutures do not include the deeper layers of the abdominal wall hernia is liable to occur and require a second operation. 31. OVARIOTOMY IN THE CAT. Instruments. Same as for the bitch. Technic. The cat may be spayed by either the flank method or through the linea alba. The point of incision in either case is the same as in the bitch but owing to the smaller size of the animal it is necessary to make the wound quite small. The abundance of fur renders it essential that an ample area be shaved and the surrounding hair be saturated with a disinfectant and carefully brushed away CASTRATION OF CRYPTORCHID HORSES. ^43 from the operative area. The cat being more subject to infection than the bitch the aseptic precautions must be of the strictest possible character. The operative area must be thoroughly disinfected and cleansed and equal care must be taken not to introduce irritant disinfectants into the wound. A great danger also exists in the tendency of the muscle layers of the abdomen to readily become separated by pressure from the finger and form a pocket in which wound discharges accumulate and constitute a dangerous seat for infection. Great care must therefore be taken to make a clean incision directly into the peritoneal cavity and to avoid separating the peritoneum from the muscles or the muscular layers from each other. The uterus and ovaries of the cat are naked and far more easily distinguished than in the bitch, there being no extra deposit of fat in the broad ligament. The sutures are to be applied to the wound in the same manner as in the bitch. 32. CASTRATION OF CRYPTORCHID HORSES. Plates XXI and XXIL Instruments. Scalpel, emasculator. Technic. Confine the animal by casting in the dorsal position with the hocks well flexed and both posterior limbs completely abducted so as to fully expose the inguinal region. Or secure upon the operating table on the side opposite to the retained gland and abduct the upper pos- terior limb by drawing it upward by means of a pulley. Cleanse and disinfect the inguinal region. Anaesthize. Make an incision about lo to 12 cm. long through the skin and dartos directly over the normal position of the scrotum, parallel to the median raphe about 4 or 5 cm. distant from it. Insert the two index fingers in the wound, press them into the areolar tissue toward the external inguinal 144 C ASTRA riON OF CR J PTORCHID HORSES. ring and drawing them apart separate the tissues sufficiently to permit the entrance of the hand. With the fingers held in the shape of a cone bore a passage in the areolar tissue through the external abdominal ring and con- tinue in a direction approximately toward the external angle of the ilium until the aponerosis of the small oblique muscle near the crural arch is reached. Unless rectal ex- ploration has shown that the testicleis within the abdomen, take care in traversing the inguinal space between the ex- ternal and internal rings that the gland is not passed hj unrecognized (inguinal cryptorchidy) lying in this region- covered by peritoneum and the cremasteric fascia. Some- times the epididymis has descended to the scrotal regioni while the testicle remains within the abdomen, thus result- ing in a long, narrow inguinal canal. Pass the hand upwards, outwards and forwards along the aponeurosis of the small oblique until the crural arch is- reached slightly anterior to the crural ring in which the pulsating femoral artery can be felt, and palpate at this point in the muscular wall for the internal inguinal ring which varies greatly in different individuals but usually reveals- itself to the fingers as an oblong slit or ring about one inch in length covered only by peritoneum. Through this usually extends a portion of the gubernaculum testis or of the vas- deferens. Examing Plate XXI, the peritoneal view of the internali ring is shown crossed by the dotted line, V, of the upper or right testicle, into w^hich extends a short distance the tail of the epididymis. In the lower or left testicle the ring has been opened and the gland lies in a position correspond- ing to the right and showing the epididymis and vas defer- ens lying in the processus vaginalis, P. The surgical rela- tion of the parts is further illustrated in Plate XXII, where the testicle is completely withdrawn into the peritoneal cavity and spread out over the right flank. The processus CASTRATION OF CRYPTORCHID HORSES. 145 vaginalis, P, is outlined by a dotted line into which is in- troduced a curved sound, S, along side of which lies the gubernaculum, G. The gubernaculum, it will be observed is divisible into three sections, a slender one, G, which by passing along behind the peritoneum escapes from the abdominal cavity at the postero-external commissure of the ring to extend to the scrotum. The second portion of this organ, G', is much thicker and extends from G to the epididymis at E, while the third division, G", extends from the epididymis to the testicle. In Plate XXII it is shown that the testicle under all ordi- nary conditions is inevitably attached through its guber- naculum testis to the postero-external commissure of the ring and that it has a second definite attachment to the seminal bladder through the medium of the vas deferens, V, and a third by means of the testicular artery, A. The gubernaculum and the vas deferens constitute the essential guides in locating and recognizing the testicle. By forming a hollow cone with the fingers about the in- ternal ring, the vas deferens, epididymis and gubernaculum tend to drop out into the processus vaginalis where they may be grasped with the fingers without the peritoneum having been ruptured. The vas deferens and epididymis present characteristics which are unmistakable to the trained touch consisting of a small firm cord (vas deferens) or a small mass of fine threads (tail of epididymis) which roll freely between the thumb and finger and give a sensa- tion which is unlike that produced by any other tissue in. the body. Grasp the part firmly and tearing through the peritoneum seize the vas deferens and carefully draw it out through the external wound. (In teaching cryptorchid castration to the beginner we make our opening down to the internal ring and grasp the vas deferens between the thumb and finger without penetrating the peritioneal cavity and then 10 Plate XXL Castration of Cryptorchid Horse. Urino genital apparatus of 24 hr. colt. T, T, testicle ; A, testicular artery ; G, gubernaculum testis ; V, V, vas deferens ; B, urinary bladder ; UA, umbilical arteries retracted within abdomen ; P, processus vaginalis ; UV, umbilical vein. CASTRATION OF CRYPTORCHID HORSES. 149 passing a pair of long uterine dressing forceps along the hand, fasten them upon the vas deferens. The student then completes the operation, using the forceps as a guide. He thus learns the relations and character of the parts and recognizes the internal ring with the peritoneum still stretched across it, intact.) In case the vas deferens can not be felt before rupturing the peritoneum, it may be broken through with the index finger and inserting the finger into the cavity, the gubernaculum is found attached to the postero-external border of the ring, and but a short distance therefrom the finger comes in con- tact with the vas deferens or with the tail of the epididymis where the gubernaculum crosses it at E, in Plate XXII. Having reached the vas deferens the operation is proceeded with as above. Thus far the operator has not concerned himself with the location of the testicle but relies wholly upon the vas deferens or gubernaculum, since when either of these is recognized the testicle is virtually within his power. He thus proceeds upon the basis that he is not toyf^z^the testicle for the reason that it is not lost but that it has de- finite relations and attachments which permit of certain displacements of the organ itself but not of its attachments. Having drawn the vas deferens out through the wound tension is exerted upon it which tends to cause the testicle to follow but sometimes the gland is too large to pass the internal ring and the latter needs be dilated by inserting an index finger in it or the testicle needs be guided through the opening. We have described herein one method of castrating a cryptorchid horse where the cryptorchidy is due to an arrest in the development of the gland and of its descent. There are other methods employed which introduce variations at each step, many operators making the incision over the external ring instead of near the median line. Other Plate XXII. Castration of Cryptorchid Horse. Right inguinal region and testicle of 24 hrs. colt. P, processus vaginalis surrounded by a dotted line and containing a curved sound, vS ; G, first portion of gubernaculum testis ; G^ second portion of gub- ernaculum testis extending to the epididymis, E ; E, epididymis ; G^^ gubernaculum extending from epididymis (globus minor) to the testicle ; T, testicle ; A, testicular artery ; V, V, vasa deferentia ; B, urinary bladder ; UA, umbilical arteries. CASTRATION OF CRYPTORCHID HORSES. 153 Operators avoid opening the internal ring and penetrate the peritoneal cavity somewhat in front of and above the ring through the small oblique muscle. When one plan has been learned the variations are easily applied. There are other causes of cryptorchidy which in rare cases require a different procedure in order to extract the gland varying with individual cases but the essentials for the tracing and recognition of the testicle are the same. Prior to attempting the operation it is well to make a rectal exploration and determine as far as may be the loca- tion of the testicle, whether it be on the right or left side, and its character, should it be in any way pathologic. After the testicle is brought to the surface it may be re- moved with the emasculator or by such means as the opera- tor may prefer. Cryptorchid testicles when due to arrest in development are not vascular and there is little tendency to hemorrhage after excision. Place an antiseptic tampon in the wound, pushing it well up against the internal ring and retain it in position by means of sutures for a period of 24 to 48 hours when it is removed and the wound dressed antiseptically. The operation for cryptorchidy in the smaller animals is essentially the same as in the horse except that the incision is to be made ordinarily through the flank as in spaying. The same attachments are to be our guide and the operation is to proceed upon almost parallel lines. IV. OPERATIONS ON THE EXTREMITIES. 33. TENOTOMY OF THE FLEXORS OF THE PHALANGES. Plate XXIII. Objects. The relief of contraction of the flexor tendons of the foot. Instruments. Razor, scissors, sharp tenotome, bandage material. Technic. Tenotomy is generally performed on the flexor of the third phalanx, seldom on the superficial flexor or flexor of the second phalanx. Confine upon the operating table with the affected member undermost and the foot fully extended. In default of a table confine in lateral recumbency and apply an exten- sion splint to the foot as shown in Plate XXIII. On the median side at the middle of the metacarpus or metatarsus the skin is shaved and disinfected over the tendon of the flexor pedis muscle. The location named lies between the lower extremity of the great carpal or tarsal sheath above and the superior extremity of the tendonous sheath of the fetlock below, so that neither of these is wounded during the operation, but the tendon is severed at a point where it is invested by loose connective tissue which retains the divided ends in their normal line of direction, somewhat fixed, and favors their ultimate leunion. Grasp the metacarpus or metatarsus in this area from above and behind in such a manner that the thumb rests upon the median or upper surface, and the index and second fingers on the lateral or under side of the flexor pedis tendon. While the left thumb pushes the skin toward the bone, that is, forward, a sharp pointed tenotome held perpen- dicularly in the right hand is introduced with the cutting edge toward the hoof through the skin, subcutem and anti- brachial fascia down to the flexor pedis tendon. Immedi- o t: d -«-i (U a •■"1 u 2h O ■Ji X ^ OJ CO o qH s '7. a, S 2i (2 < CO a; ^ •< tj; o ^ u Dh ^ ;3 a J n; o 2: O X a; 5; < ^ 3 c/) Vk, *o O (J^ ^ Vi g. 'o a; Oh 3 tn •te o o 0) K ti: ^ s: u o ■1-1 t+H a 5 o biO ^ ■f5 ^ 156 TENOTOMY OF FEXORS OF PHALANGES. ately on the anterior border of the tendon insert the teno- tome so far that the point of it can be felt on the lateral or outer side through the skin with the left hand. Care is to be exercised in making this invading incision to not include the metacarpal, or metatarsal, arteries, veins and nerves. The vascular bundle lying immediately against the anterior border of the flexor of the third phalanx, it is easy to err by inserting the tenotome in front of the vessels, that is between the suspensory ligament and vessels instead of between the flexor of the third phalanx and vessels. It is safer to make the skin incision far enough posteriorly to insure safety to the vessels, cut down upon the tendon, then incline the handle of the tenotome backwards, push the point of the tenotome obliquely forward and downward behind and beneath the vascular bundle and then carrying the handle forward bring the instrument to a perpendicular position while it is forced down along the anterior surface of the tendon until it nears the inferior border when the tenotome handle should be carried yet further forward so that the point is directed obliquely backward, to facilitate its passing between the vessel bundle and the tendon out to the skin. The invading incision thus describes the segment of a circle, with its concavity backward toward the tendon. The cutting edge of the instrument is then turned against the tendon, that is, it is directed backward, the foot is ex- tended by an assistant with the aid of a rope bound around the pastern and looped over the hoof, and the tendon is cut through under light pressure, the operator pressing the handle of the knife forward and downward, using the meta- carpus or suspensory ligament as a fulcrum upon which the back of the tenotome rests as a lever. A loud cracking, as well as the disappearance of resistance to extension shows that the tendon has been severed. After the removal of the knife and seeing that there is a wide space between the ends of the tendon, the foot is un- PERONEAL TENOTOMY. 157 bound from the splint and a bandage applied to the meta- carpus, which rests upon the fetlock joint and remains in position for eight days. Healing of the cutaneous wound by primary union. 34. PERONEAL TENOTOMY. Plate^ XXIV. Object. The relief of Stringhalt. Instruments. Razor, scissors, sharp tenotome. Technic. On the lateral side of the metatarsus a triangle, d, opening toward the tarsus is formed by the tendons of the extensor pedis longus muscle, /, and the lateral extensor of the foot, e, which unite on the anterior surface of the middle of the metatarsus. The synovial sheath of the extensor pedis longus muscle extends inferiorly to near the point of juncture of the two tendons ; the sheath of the lateral ex- tensor ends below 3 to 4 cm. above the point of union. In the middle of this space without a sheath, which is 3 to 4 cm. long, and below the annular ligament of the hock the operation is carried out. After the skin has been shaved and disinfected, confine in the stocks or operate upon the standing horse, with the aid of local anaesthesia, a twitch being applied to the nose and the opposite hind foot held up with the side-line. The tendon of the lateral extensor is easily felt under the skin as a hard cord about 0.7 to i cm. in diameter. Stretch the skin and with the back of the hand toward the hock grasp and compress the tendon with the thumb and-index finger of one hand, insert the tenotome with the cutting edge toward the foot perpendicularly upon the tendon through the skin, subcutem and aponeurosis derived from the crural fascia ; push it from before back- ward under the tendon, turn the cutting edge against it, and with the hock extended sever the tendon as well as the Plate XXIV. Peroneal Tenotomy for Stringhalt. Right hind foot seen from the external side. The skin covering the lateral extensor of the foot is laid back in the form of a flap, the crural fascia divided. e, Peroneal tendon ; f, crural fascia ; /, tendon of the anterior extensor pedis muscle ; d, the triangle formed by / and e. CUNEAN TENOTOMY 159 fascia through to the skin. In accomplishiug the section of the tendon the knife is to be used as a lever of the first class with the anterior border of the metatarsus acting as a fulcrum. If the tendon has been completely severed its retracted ends may be felt under the skin i to 2 cm. above and below the wound. After the operation an antiseptic bandage is applied, resting upon the fetlock. The bandage should remain eight days and the cutaneous wound heal by first intention. Care should be taken to not wound the tendon of the extenson pedis longus muscle. Recently it has been proposed to permanently obliterate the function of the peroneus muscle by severing its tendon within its tarsal sheath above and below the tarsus and withdraw the isolated section. The same object ma}^ be attained by merely severing the tendon within its sheath below the tarsus, if the operation is carried out under aseptic precautions because when thus performed the epithelium advances over the retracted cut ends and leaves them free in the sheath. 35. CUNEAN TENOTOMY. Plate XXV. Object. The relief of spavin lameness. Instruments. Razor, scissors, straight scalpel, Peters' spavin knife. Technic. Most horses can be operated on standing, with the aid of cocaine, otherwise cast, or secure on the operat- ing table, on the affected side and extend the tarsus. Shave and disinfect an area 5 to 6 cm. square on the inferior median surface of the hock over the course of the cunean tendon of the chief flexor of the metatarsus, as indicated in Plate XXV. Locate the tendon, CT, by palpation as it passes obliquely downward and backward and make a transverse incision with a straight scalpel or tenotome, in the form of Plate XXV. Cunean Tenotomy. For the relief of spavin lameness. CT, cunean tendon. The dotted line crosses the ergot. NEUROTOMY. i6i a stab wound, merely sufficient lo afford passage for the blade of the instrument, about i cm. below its inferior border at a point midway between the anterior and posterior borders of the hock, or slightly anterior thereto. Push the tenotome flatwise between the skin and tendon, as shown in the plate, force it upwards to the superior border of the tendon, then turn the cutting edge toward it and elevating the handle, using the superior border of the skin wound as a fulcrum, cut the tendon through from without inwards. By firm pressure upon the skin over the tenotome peri- osteotomy is simultaneously accomplished. The completion of the operation is evidenced by the separation of the cut ends of the tendon leaving a well-marked depression at the point of division. Disinfect the wound, apply an antiseptic tarred bandage resting upon the fetlock and including the hock and allow to remain undisturbed for six days. Healing by primary union. After the incision through the skin has been made, the Peters' knife may be used instead of the straight scalpel, and the tendon and periosteum cut through at two or three different points, the cuts diverging upwards from the cutaneous wound, V-shaped. NEUROTOMY. General Remarks. Neurotomy is performed for a vari- ety of objects, such as the relief of pain in a sensitive nerve itself, as in trifacial neurotomy, p. 64, the relief of pain or lameness in a part supplied by a sensory nerve, or the inhibition of motor power, as in the "cribbing" opera- tion by severing the spinal accessory where it passes into- the sterno-maxillaris muscle. The following neurotomies are designed to relieve pain and the consequent lameness dependent upon a pathologic condition of some part or tissue on the distal side of the II l62 NEUROTOMY. point of operation and to which the divided sensory nerve is destined. Neurotomy of a sensory nerve is always a painful opera- tion, and its performance without anaesthesia is unjustifiable from a humane standpoint, and cannot be so well done either from the view of mechanical correctness or the carrying out of antiseptic standards. Some neurotomies can be well per- formed on the standing animal if it is quiet and the operator is experienced, the parts being rendered insensitive by means of cocaine or other local anaesthetic ; in the greater neurotomies general anaesthesia may be desirable or neces- sary from the humane or operative standpoint. The confinement of animals for neurotomy on the sensory nerves of the extremities for the relief of lameness is always to be viewed as a critical procedure for the reason that the operation is generally made because of the local manifesta- tion of a more or less general disease which may be accom- panied by general fragility of the skeleton, and as a result most casting accidents occur in cases of confining for neurotomy or firing in cases of lameness belonging to the great group of dry arthritis or spavin family. Casting must, therefore, be done with the greatest possible care, and the operating table is to be constantly and greatly preferred. Neurotomy is properly a last resort in lameness and should not otherwise be performed. It has two great and ever present dangers. If the part deprived of sensation is too badly diseased to bear the weight and resist the insult result- ant upon the part being called to do its normal or even an extra amount of work, it must ultimately give way, the bones become fractured, the tendons separate from the bone, the intra-ungular tissues lose their integrity and the hoofs become detached (exungulation) or other degenerative changes take place as a result of causing a part to do a work for which its condition unfits it. The second great danger occurs from wounds or other traumatisms to the tissues distal to the operation when the NEUROTOMY. 163 unnerved parts are not rested as they would be in natural conditions when injured, and as a result reparative changes are prevented and supplanted by retrograde processes with ultimate death of the part and of the animal. In other words sensory neurotomy robs an organ or tissue of the enormously conservative force of pain. Pain causes the animal to rest the affected part, protects the painful tissues against disintegrating and destructive insults and favors restorative processes ; robbed of this protective in- fluence of pain by the severance of the sensory nerves, the diseased tissues are without their natural protection. Nerves are generally accompanied by satellite arteries and veins which are always liable to be wounded during the neurotomy and are more embarassing because of the hemor- rhage clouding the operation field and inviting error than dangerous because of the loss of the blood itself. It is essential to a good operation that the hemorrhage be kept under control throughout so that each tissue will stand out in relief and the nerve reveal its identity in addition to its location, size and relations, by its intensely white, nacrous, striated character. The test of compressing the nerve in order to identify it by the resultant pain is unsurgical and unnecessarily cruel. Sepsis holds an important place in considering the dangers of neurotomy because the infection of a sensitive nerve causes very great pain and if considerable, tends to cause a false neuroma or fibroma in the connective tissue of the nerve trunk, calling for a second operation in order to re- move the tumor, and resultant lameness. Neurotomies should consequently be performed only in properly selected cases, the smallest possible trunk that will sufficiently relieve the pain should be selected for the opera- tion, it should be performed with due regard for suffering and for asepsis, should be performed quickly and neatly, the incisions being free, laying the nerve trunk bare without tearing up the' tissues and clouding them and at every point aim at celerity, accuracy and neatness. Plate XXVI. Digital Neurotomy. V, Digital vein ; A, digital artery ; N, principal digital nerve ; L, ligament. \ DIGITAL NEUROTOMY. 167 36. DIGITAL NEUROTOMY. Plate XXVI. Objects. The relief of navicular lameness in cases where plantar neurotomy is not deemed necessary or advisable. Instruments. Razor, scissors, scalpel, probe pointed bistoury, tenacula, aneurism needles, bandages. Technic. Digital neurotomy may generally be perform- ed on the standing animal, the operative area having first been anaesthetized by means of cocaine or otherwise, a twitch applied to the upper lip and the affected foot held up by an assistant. If necessary because of restlessness of the animal or inexperience of the operator, confine on the oper- ating table or cast the animal and apply the extension splint to the foot to be operated on as shown in Plate XXIII, ex- cept that the lower binding cords rest on the metacarpus instead of the pastern. Extending downwards from the fetlock joint toward the coronet, between the posterior border of the first phalanx and the anterior border of the flexor tendons there is a slight furrow, at the posterior part of which, close to the external margin of the tendon, lies the median or principal digital nerve accompanied in front by the digital artery. A, anterior to which Hes the digital vein, V. Immediately behind the nerve and generally lying a trifle deeper, is quite commonly found a second venous trunk of considerable size. Near the middle of the first phalanx the nerve is crossed externally in an oblique direction from above to below and from behind to before by a white ligamentous band, L, slightly broader than the nerve extending from the base of the ergot of the fetlock to the retrossal process of the pedal bone. This must not be mistaken for the nerve, N, and need not be if it is re- membered that the latter is accompanied on the same plane and in a like direction by the satellite artery, A, and vein, V, enclosed with it in a fibrous sheath. At the uppermost part of the first phalanx the nerve lies in front of this ligament, -168 DIGITAL NEUROTOMY. a short distance inferiorly it passes beneath it, while from the middle of the pastern downwards the nerve lies behind the ligament. The operation is practicable at any point over the line of the nerve from the top to the bottom of the shaved area in Plate XXVI or from the superior end of the first phalanx down to a level with the superior border of the lateral carti- lage, but preferably at about the point shown in Plate XXVI , near the superior end of the first phalanx. At the desired point and over the groove between the flexor pedis tendon and the phalanges shave and disinfect an area 4 to 5 cm. square. In the center of this area at the anterior border of the flexor tendon, with the scalpel held perpendicular to the skin, make an incision from above downwards a distance of from 2 to 3 cm. cutting cleanly through the skin and subcutaneous fascia down upon the nerve. The incision is favored by tensing the skin between the thumb and index finger of the left hand, but care should be taken not to dis- place it backwards or forwards. Dilate the wound by pressure upon the skin with the thumb and index finger or otherwise and carefully incise longitudinally the fibrous sheath enveloping the nerve and artery. Pass an aneurism needle beneath the nerve, and forcing it upward and down- ward, separate thereby the nerve from the surrounding tissues. Insert a probe pointed bistoury, or scissors beneath the nerve, and divide it at the upper angle of the wound and excise a section 3 cm. long. Disinfect and bandage with or without suturing the wounds. Leave the bandage in place 6 to 8 days. PLANTAR NEUROTOMY. l6g 37. PLANTAR NEUROTOMY. Plate XXVII. Object. The relief of navicular, or ringbone lameness or other painful, non-suppurating disease of any parts below the fetlock joint. Instruments. Razor, scissors, convex scalpel, compres- sion arter}^ forceps, tenacula, aneurism needles, suture ma- terial, elastic ligature. Technic. It is well to shave the site of operation and thoroughl}^ disinfect the region of the metacarpus and fet- lock with soap, brush, and sublimate or creolin solution and 50% alcohol, and apply a bandage saturated with sublimate or creolin solution to the fetlock joint 24 hrs. before the operation in order to secure thorough disinfection. Confine the animal and fix the limb as in the preceding operation. After the removal of the disinfecting bandage, and producing local anaesthesia pass the fingers from before to behind with light pressure over the region just above the fetlock joint, where there is felt immediateh^ in front of the flexor pedis tendon a channel-like depression extending from above the fetlock downward over it. Just at the anterior margin of the flexor pedis tendon and at the posterior part of the groove lies the threadlike cord of the nerve, 71, 3 mm. thick, which glides away from underneath the fingers with a distinct recoil. The site of operation lies immediately above the fetlock in the posterior third of the metacarpus or one may operate at any point higher up as far as beyond the middle of the metacarpus or metatarsus s"o long as care is taken to include the anasto- mosing branch given off by the median plantar nerve at about the middle of the metacarpus and bending obliquely around behind the tendons to join the lateral nerve some- what lower down. At this point stretch the skin between the thumb and index finger of one hand and make an in- Plate XXVII. Plantar Neurotomy. a, lateral digital artery ; v, lateral digital vein ; n, common lateral digital nerve ; d, anterior branch ; o, posterior branch ; s, superficial flexor tendon ; p, perforans tendon ; i, suspensory ligament of fetlock ; in, metacarpus. PLANTAR NEUROTOMY. jy^ cision 3 to 5 cm. long, the lower angle of which is usually just above the fetlock joint, cutting directly through the skin, subcutera and connective tissue sheath down onto the nerve, laying it bare. The borders of the cutaneous wound are held apart with tenacula and by palpation with the fingers or by vision it is determined if the nerve lies in the middle of the wound. If necessary continue the dissection with the scalpel until the nerve is clearly revealed ; it is distinguished by its faintly yellowish color, its fine longi- tudinal striae and its location behind the metacarpal artery. Immediately above the fetlock joint the median metacar- pal or metatarsal nerve divides into an anterior smaller, d, and posterior larger branch, o. This division should be laid bare in order that the operator may not erroneously cut one branch only. Immediately above this point of division the aneurism needle is passed under the nerve, pushed well through and forced up and down,, separating the nerve from the adjacent tissues, the scissors or a small probe-pointed bistoury is passed beneath and it is cut through quickly at the superior angle of the wound. The distal end of the nerve is then dissected free downward and excised at the lower angle of the wound so that a section 3 to 5 cm. long is removed. The cutaneous wound is united by a continuous suture and a temporary bandage applied. If the horse has been secured by casting, the extension splint, if it has been used, is then removed, the foot replaced in the hobble and the horse turned to the other side. The operation on the opposite metacarpal nerve is carried out in the same way after which a sterile bandage is applied and allowed to remain eight days. Healing by primary union. 1 7 4 NE URO TO MY OF THE MEDIAN NER VE. 38. NEUROTOMY OF THE MEDIAN NERVE. Plate XXVllL Objects. The relief of lameness due to disease so located in the anterior limb that it cannot be so well overcome by plantar neurotomy. Instruments. Razor, scissors, convex scalpel, artery and compression forceps, tenacula, aneurism needles, suture material. Technic. The operation is performed on the median surface of the anterior limb immediately below the humero- radial articulation on the recumbent horse after the affected foot has been fully extended on the operating table or in de- fault of this removed from the hobbles and bound upon the extension splint as shown in Plate XXIII. Anaesthetize. The foot is drawn out firmly from the shoulder, inclined somewhat forward. The operator places himself between the neck and the forearm of the patient and, after the median region of the elbow joint has been washed with soap and water, searches for the median nerve where it glides over the posterior part of the joint to disappear behind the radius. Shave the skin at and below this point, disinfect it with sublimate or creolin solution and 50% alcohol. The nerve, n, lies as a rule somewhat in front of the middle of the median side of the forearm against the postero-internal margin of the radius and can be felt, about 5 to 6 mm. in diameter, lying somewhat deeply. The position of the nerve varies with the different attitudes of the forearm. In fat and fleshy horses the identification of the nerve is more difficult. It may be felt upon the standing animal. With the nerve lying between the thumb and index finger of the left hand, at the point where it begins to disappear behind the radius after having passed over the humero- radial articulation, stretch the superposed skin and immediatel}^ upon and parallel to it make an incision 5 cm. long, first through the skin, then through the aponeurotic expansion NEUROTOMY OF THE MEDIAN NERVE. 175 of the sterno-aponeuroticus muscle. Check any hemorrhage from the skin, subcutis, or muscle. The tenacula are in- serted cautiously in the lips of the wound, and these being drawn apart the white anti-brachial fascia is brought into view and a search is made with the index finger to determine the exact location of the nerve, the fascia is divided with the scalpel and an oval piece excised with the scissors im- mediately over the nerve. If much fatty tissue is found be- neath the fascia it may be dissected away carefully with the scalpel or cut away with the scissors. There now comes in- to view a delicate reddish colored fascia-like membrane, the nerve sheath, behind which a dark cord, the brachial vein, V, is visible, the latter being intimately connected with the nerve sheath. The vein lies mostly behind and beneath the nerve and may project out from beneath the border of the same. The operator fteeds be careful not to prick this vein with the tejiacula, as the hemorrhage therefrom is exceedingly annoy - hig during the operation. Avoid the use of tenacula after pene- trating the fascia and retract the woimd lips cautiously ivith aneurism needles instead. Still further forward and deeper may be felt the pulsating brachial artery. Incise the nerve sheath carefully and divide it upward and downward with the scalpel or scissors, whereupon the yellowish and dis- tinctly fibrous nerve comes into plain view. Pass an aneurism needle beneath the nerve pushing it so far through that the distal end is readily grasped and drawing it up and down with the two hands, separate the nerve from the adjacent tissues throughout the length of the wound. Be careful to 7iot cut the nerve too high ajid erroneously include the motor nerve of the flexor of the metacarpus a7id the flexors of the foot, which is generally give^i off posteri- orly just below the hiunero radial articulation. Lift the nerve up and cut it through at the superior angle of the wound by a sudden clip with the scissors or with the probe pointed bistoury. Lay the peripheral end of the nerve bare to the lower angle of the wound, and excise at least 3 cm. of it. Plate XXVIII. Median Neurectomy. Median surface of the right humero radial articulation. a, brachial artery ; ;/, median nerve ; z\ brachial vein ; f, antibrachial fascia ; p, sterno-aponeuroticus muscle. 12 NEUROTOMY OF THE ULNAR NERVE. lyg Tamponade the wound with dry iodoform gauze and ap- proximate the skin with a continuous suture. The tampon and sutures remain i to 2 days. Since sensation of the lower part of the limb is partly maintained by the deep branch of the ulnar nerve which at the lower part of the carpus, covered by the tendon of the oblique flexor becomes the lateral plantar nerve, neurotomy of the median nerve does not always completely effect the desired end. In order to produce complete anaesthesia of the foot, therefore, it is necessary to perform ulnar neurotomy. 39. NEUROTOMY OF THE ULNAR NERVE. Plates XXIX-XXX. Object. An adjunct operation of the preceding b}" which the enervation of the carpus and foot is completed. Instruments. Same as in the preceding. Technic. Above and behind the carpus there may be felt a groove between its external and middle flexors, KF and OF, Plate XXX. At this point 10 cm. above the pisiform bone the skin is shaved and disinfected and an in- cision 6 cm. long made through the skin and antibrachial fascia. This incision extends just outside the median line of the posterior surface of the radius in such a way that the superior angle of the wound is about i cm. farther out- ward than the lower. Beneath the fascia between the aforesaid muscles is seen the ulnar nerve, Plate XXIX, n Plate XXX, NU, on the median or inner side of it the collateral ulnar vein, Plate XXIX v, and between the two and somewhat deeper the collateral ulnar artery, a. The nerve, about 3 mm. in diameter is picked up with the aneurism needle, severed at the upper and lower angles of the wound, the lips of the wound united by a continuous suture and a bandage applied. Healing by first intention. Plate XXIX. Ulnar Neurotomy. Right forearm seen from behind, e, external flexor of the carpus ; f, oblique (middle) flexor of the carpus ; a, collateral ulnar artery ; b, antibrachial fascia ; «, ulnar nerve. Plate XXX. Ulnar Neurotomy. Cross section through the forearm, about lo cm. above the pisiform bone, viewed from below. EF, external flexor of the carpus ; OF, oblique flexor of the carpus ; NU, ulnar nerve ; NM, median nerve. Lying on its median side is the ulnar artery, the satellite vein of which is not shown. \ SCI A TIC NEURO TOMV. 1 85 40. SCIATIC NEUROTOMY. Plates XXXl-XXXll. Objects. The destruction of sensation in the tarsus and parts beyond for the relief of otherwise incurable spavin lameness, diseases of the tendons, etc. Instruments. Same as in the preceding. Technic. Expert surgeons may operate on the standing animal under local anaesthesia. Place the animal on the operating table on the diseased side, extend the affected limb and draw the upper leg forward or backward and secure it out of the way. Produce complete general or local anaesthesia. The posterior tibial or sciatic nerve, ;z, Plate XXXI and NS, Plate XXXII, is then sought by grasping the leg with the left hand from behind in such a manner that the thumb rests above and the fingertips below it. Reaching forward with the fingers to the deep flexor of the foot grasp the leg with moderate firmness and draw the band slowly backward. Immediately behind the perforans muscle and between this and the tendo- Achilles the nerve, nearly i cm. in diameter, glides away forward from be- tween the fingers with a distinct recoil. If the nerve can not be recognized in this manner the hock should be more strongly extended, by which means the nerve may be caused to recede from the perforans muscle, so that it can more readily be felt near the middle of the groove extending be- tween it and the tendo-Achilles. At this point on the median side of the leg the skin is shaved, disinfected and an incision made through it 5 cm. long, parallel to the tendo-Achilles. The white rigidly- stretched crural fascia is now divided in the same direction after which it should be determined by palpation that the nerve lies in the middle of the wound. Excise with the scissors an elliptic or oval piece of the fascia or hold it apart along with the lips of the cutaneous wound by means Plate XXXI. Sciatic Neurotomy. Right hind leg viewed from the median side, y, crural fascia; n, sciatic (tibial) nerve; v, plantar vein. Plate XXXII. Tibio- Peroneal Neurotomy. Cross section through the tibia at about lo cm. above the tibio- astragaloid articulation. SA, recurrent tibial artery; NS, sciatic nerve ; NMC, musculo-cutaneous branch of anterior tibial nerve ; NP, deep or sensory branch of anterior tibial or peroneal nerve ; EP, ex- tensor pedis muscle ; MP, peroneus muscle ; FM, flexor metatarsi muscle. ANTERIOR TIBIAL NEUROTOMY. 191 of the tenacula. In poor horses the contour of the nerve, covered only by loose connective tissue, stands out promi- nently, in fat horses it is surrounded by a large amount of adipose tissue. Cut through this fat and connective tissue and expose the tibial nerve, /z, Plate XXXI and NS, Plate XXXII, to view ; immediately before it lies the plantar vein and on the lateral side is situated the recurrent tibial -artery, SA, Plate XXXII. The cross section in Plate XXXII is located somewhat below the point for operation and the vein has crossed obliquely over the nerve so that it appears behind instead of m front of it, as is the case generally at the point where the operation is performed. Separate the vessels completely from the nerve with the handle of the scalpel, pass an aneurism needle from before backward beneath it through to the handle and grasping both ends force the instrument upwards and downwards in •order to separate the nerve trunk from the adjacent tissues. Cut the nerve off at the upper and lower angles of the wound removing a section at least 5 cm. long. Suture the cutaneous wound and apply a bandage allowing it to remain •eight days. Healing should occur by first intention. 41. ANTERIOR TIBIAL NEUROTOMY. Neurotomy of the Deep Branch of the Peroneal Nerve. Plates XXXII-XXXIII. Object. An adjunct operation to the preceding since this nerve supplies sensation to the tarsus in common with the sciatic. The two constitute what is known as Bossi's double neurotomy for spavin. Instruments. Same as in the preceding. Technic. Confine as in the preceding but with the -affected leg uppermost. Locate the furrow dividing the Plate XXXIII. Anterior Tibial Neurotomy. EP, extensor pedis muscle ; P, peroneus- muscle ; NP, deep branch of the peroneal or anterior tibial nerve ; FM, flexor metatarsi muscle. 13 ANTERIOR TIBIAL NEUROTOMY. 195 extensor pedis longus, EP, Plates XXXII-XXXIII, and the peroneus muscles, P, Plate XXXIII, MP, Plate XXXII, and shave and disinfect an area 6 cm. long by 3 cm. wide directly over this depression and extending upward from a point 6 to 7 cm. above the tibio-astragaloid articulation. At a point 8 to 10 cm. above the flexure of the hock make an incision through the skin and subcutis 5 or 6 cm. long over the line of division between the two extensors of the foot. Superficially the operator passes near by the musculo- cutaneous division of the anterior tibial nerve, NMC, Plate XXXII, which must not be mistaken for the deep branch. The peroneus muscle, MP, Plate XXXII, and P, Plate XXXIII, is separated from the extensor pedis longus, EP, Plates XXXII and XXXIII, by a strong aponeurotic sheath continuous with the tibial aponeurosis. Penetrate the tibial aponeurosis a7iterior to the aponeurotic partition directly against the extensor pedis, EP, and passing along the posterior border of this muscle to a depth of 2 to 4 cm., there appears the thin margin of the flexor metatarsi magnus, FM, Plates XXXII and XXXIII, which lies im- mediately against the extensor pedis without a visible con- nective tissue partition but revealing itself by a markedly lighter shade of color and its ready separation from the ex- tensor with the scalpel. The deep branch of the peroneal nerve, NP, Plates XXXII and XXXIII, lies loosely im- bedded on the anterior side of the margin of the flexor meta- tarsi facing the extensor pedis, at times visible at the margin, at others placed more deeply reaching in some cases a distance from the margin of 4 or 5 mm. Within this range is seen the slender nerve trunk almost devoid of surrounding con- nective tissue and measuring about 2 mm. in diameter. Pass the aneurism needle beneath it and remove a piece 3 to 4 cm. long. Close the cutaneous wound with interrupted sutures and dress antisptically without a bandage. 196 RESECTION OF THE LATERAL CARTILAGE. 42. RESECTION OF THE LATERAL CARTILAGE. The Bayer Quittor Operation. Plate XXXIV. Object. The cure of quittor or necrosis of the lateral cartilage. Instruments. Elastic ligature, drawing knife, scissors, razor, hoof rasp, hoof plane, craniotomy or other heavy for- ceps for the removal of the horn, artery forceps, elevator or long bone chisel, right and left sage knives, curette, needle holder, thread, needles, iodoform ether, iodoform gauze, tampons, absorbent cotton, bandages. Technic. For a few hours before the operation place the affected foot in a bath of creolin or other antiseptic solution after having first rasped the diseased quarter lightly and make a semicircular groove in the horn of the lateral wall and quarter down to the horny lamina, as shown at s in Fig. I, Plate XXXIV. It is essential to not materially thin the horn on the quarter with the rasp since by weaken- ing it, it yields and breaks and cannot be properly detached from the senitive laminae. The operation is peformed upon the recumbent, anaes- thetized animal, in such a position that the diseased cartilage of the affected foot lies upward. The operating table consti- tutes incomparably the best means of confinement in every respect. After the application of the elastic ligature in the metacarpal or metatarsal region the groove in the horn is deepened with the drawing knife down to the sensitive laminae without injuring them. The groove must be so located that it extends beyond the anterior and posterior borders of the lateral cartilage, and downwards to within i or 2 cm. of the margin of the os pedis and approximately perpendicular to the surface of the horn wall so that it will form a secure support for the dressing to be later applied. The hair on the coronary band is clipped or shaved and the RESECTION OF THE LATERAL CARTILAGE. 197 entire foot up to the fetlock joint thoroughly cleansed with brush, soap, creolin or sublimate solution and 50 per cent, alcohol. The fetlock and pastern are carefully wrapped in a towel saturated with sublimate solution or other disin- fectant. The hoof should be similarly wrapped except the operative area and every precaution taken against the transfer of infecting material from neighboring parts into the wound. The elevator or long bone chisel is then inserted beneath the lowest part of the semi-circular piece of horn which has been isolated, the horn is elevated from the sensitive structures somewhat, grasped with the heavy for- ceps and carefully loosened from the sensitive parts by drawing upward parallel to the laminae until the coronary band is reached and the traction is then directed backwards toward the heel, separating the wall from the coronary papillae and keraphyllous tissue. Care is to be taken here to avoid lacerating the underlying tissues, especially when the traction is first directed backwards. If the soft tissues threaten to tear this should be arrested by the timely use of the scalpel or sage knife as conditions may suggest. After the coronary band has been smoothed with the scissors, make two perpendicular incisions through the skin and coronar}^ band, one behind the anterior and the other in front of the posterior border of the groove in the horn and connect the two by means of a semi-circular incision in the sensitive laminae. This U-shaped incision should be so made that between it and the horny wall there is left an area of sensitive laminae i to 2 cm. wide, in order that there may be sufiicient room in the soft tissues for the application of the sutures, as shown in Fig. 2. The lines of incision through the coronary band should be so located as to in- clude between them the entire lateral cartilage. The isolated flap is now dissected closel}- against the os pedis and its ala and from the lateral surface of the carti- lage, the operator lifting the flap with forceps or tenaculum. Plate Fig. 1, Resection of the Lateral Cartilages of the os Pedis. Horny wall removed, sensitive laminae and cutaneous flap held upwards. Posterior half of the cartilage excised. /, sensitive lam- inae ; w, coronary band ; k, anterior half of cartilage ; h, cavity caused by the removal of the posterior half of the cartilage ; n, necrotic cartilage ; p, parachondral surface of the skin and sensitive laminae ; s, perpendicular, crescent-shaped incision in the horny wall ; g, fistula. XXXIV. Fig. 2. Resection of the Lateral Cartilages of the os Pedis, Completed operation showing the sutures in place and the^parts ready for the application of dressings. 200 RESECTION OF THE LATERAL CARTILAGE. Above the cartilage toward the fetlock the operator must keep the fingers of one hand against the external skin in order to avoid cutting through it or thinning it too much at this point. The flap is held turned upwards by an assist- ant or a strong suture is passed through it and turning it upwards the suture ends are carried around the pastern and tied. As a rule there is now seen a prominent, greenish colored necrotic piece of cartilage surrounded by brownish red masses of granulations. By means of an incision through the cartilage parallel to the long axis of the foot, divide it into anterior and posterior halves and extirpate the latter first by dissecting it out on the inner side from the para- chondral tissue with the sage knife. Begin the excision of the cartilage by engaging the supero-anterior angle of the posterior half with the tenaculum and exerting moderate traction dissect it away from the underlying tissues first along the line of the dividing incision down to the base and then cut backward toward the heel cutting the cartilage away from its continuous bone. The point of the knife must be constantly directed against the cartilage. Since the inner surface of the anterior half of the cartilage lies immediately against the capsular ligament of the corono- pedal articulation the latter should be sharply extended by an assistant seizing the toe and forcing it forward. By this means the capsular ligament is drawn away from the cartilage during its extirpation. The anterior half of the cartilage, k, is then removed in the same way, except with the greatest possible care to avoid puncturing the corono-pedal articulation-. The chief precaution is to dissect only with the point of the sage knife, using at all times that knife, right or left, which will result in the concave surface being presented toward the cartilage ; then by carefully keeping the line of excision immediately .agai7ist the cartilage, material danger of penetrating the RESECTION OF THE LATERAL CARTILAGE. 201 joint is avoided. Remnants of cartilage at its juncture Tvith the retrossal process of the os pedis, and granulations are to be removed with the curette. Cut away with the scissors and knife any remnants of cartilage adherent to the flap, p, thin if necessary the entire flap and excise the fistulous openings, g. After thorough disinfection of the entire field of operation sprinkle it over thickly with powdered iodoform and return the flap to its former position and retain it there by a sufiicient number of interrupted sutures as shown in Fig. 2. The first sutures to be applied should be at the border line between the skin and coronary band so as to insure accurate apposition at this point. Sprinkle the wound surface with iodoform and cover the parts over with iodoform gauze and tampons which rest firmly upon the perpendicular wall of horn. Finally invest the hoof and pastern up to the fetlock joint with an abund- ance of oakum saturated with i-iooo sublimate solution and lay a heavy tar bandage over it, the turns of which must completely invest it at every point and render the dressing impermeable to moisture. Remove the elastic liga- ture. If the animal is free from fever, feels and eats well, the bandege is left in position from 12 to 14 days. Healing by first intention. The two chief dangers in the operation are the opening of the corona-pedal articulation and the persistence of a scar in the coronary band resulting in a quarter crack. If the operation has been kept thoroughly antiseptic, the opening of the articulation is not necessarily serious. The question of preventing a weakening scar at the coronary incision is one of strict antisepsis and accurate suturing. The operation frequently fails under indifferent technic. It is an operation for the careful surgeon only. 202 RESECTION OF THE FLEXOR PEDIS TENDON. 43. RESECTION OF THE FLEXOR PEDIS TENDON. Fig. 15. Object. The removal of necrotic tissues and disinfection in cases of infected wounds, chiefly of nail wounds of the navicular bursa. Instruments. Elastic ligature, drawing knife, sage knives, scissors, tenaculum forceps, curette, scalpels,, tenaculse, bandage material. Technic. Before the operation thin the horn of the sole,, frog and bars until the soft parts can be seen through them and apply an antiseptic bandage saturated in creolin solution for 24 hours if time will warrant. Secure the patient on the operating table or by casting in lateral recumbency with the affected foot extended. Anaesthetize. Cleanse and disinfect the entire foot with :5oap, brush, creolin or sublimate solution and 50% alcohol and apply the elastic tourniquet in the metacarpal or metatarsal region. Apply towels saturated with antiseptics as in preceding operation. Make a trans- verse incision through the base of the frog 2 to 3 cm. from the balls through the horny and sensitive portions and the fatty cushion down to the flexor pedis tendon. Follow this- by two converging incisions extending forward and inward in an oblique direction corresponding to the semi-lunar crest of the OS pedis, the line of incision being in the bars about y2 cm. outward from the lateral groove of the frog and uniting at its apex. This triangular piece of frog which has been isolated by the incision is now grasped with the tenaculum and dissected away. The remnants of the fatty frog should be removed with the sage knife or scalpel by means of a horizontal incision, and there is then revealed the flexor pedis tendon which may be greenish or yellowish colored and necrotic, or may be covered with reddish colored granulations. RESECTION OF THE FLEXOR PEDIS TENDON. 203 Should there be present also suppurative pododermatitis the bars on the affected side must be excised along with the other portions. The position and extent of the navicular bone can be determined by palpating the flexor tendon. A transverse incision is then made over the middle of the navicular bone Fig. 15. Resection of the Flexor Pedis Tendon. Solar surface of the foot, c, Semi-lunar crest of os pedis ; u, OS pedis ; r, navicular-pedal ligament ; s, navicular bone ; b, flexor pedis tendon ; e, sensitive laminae of the bars ; st, fatty frog ; f, sensitive frog ; /z, horny frog. through the flexor pedis tendon into the navicular bursa, the distal end of the tendon grasped with the tenaculum forceps and lifted up from the navicular bone with the aid of two lateral curved incisions. Between the inferior or anterior border of the navicular bone and the semi-lunar crest of the OS pedis stretches the capsular ligament of the inferior articulation reinforced by dense fibrous bands. The flexor 204 AMPUTATION OF THE CLAWS OF RUMINANTS. pedis tendon is united to this by a few bundles of fibres. Dissect the tendon carefully away from the capsular liga- ment, avoiding opening the articulation, and then cut it away from the semi-lunar crest of the os pedis. If necrotic or discolored pieces of the fatty cushion or the tendon still remain, remove these with scissors, scalpel or curette. Curette the roughened cartilage of the navicular bone and remove any necrotic or inflamed, softened portions of the bone. In extensive necrosis of the suspensory ligaments of the heel and of the ligaments extending from the fetlock joint to the lateral cartilages, the necrotic portions as well as the neighboring fatty cushion with its numer- ous elastic fibres, must be resected. In case of purulent areas extending along the tendon and opening above in the heel, draw through the tract a large strip of gauze thoroughly saturated with tincture of iodine and allow it to remain. If the suppurating area extends well up into the heel without an opening, incise from above and handle as preceding. Disinfect the operation wound, irrigate with iodoform ether and tamponade it with dry iodoform gauze. Over this apply a firm pad of oakum saturated with i-iooo sublimate, enclose the entire hoof up to the fetlock in oakum and apply over this a bandage. Over this apply a tar bandage and remove the elastic ligature. In the absence of fever the bandage remains in position for 8 to 12 days. 44. AMPUTATION OF THE CLAWS OF RUMINANTS. Plate XXXV. Uses. The cure of "foul in the foot" or panaritium when complicated with suppurative arthritis or osteitis. Instruments. Half round rasp, sage knives, scissors, convex scalpel, artery forceps, drawing knife, elastic liga- ture, dressing materials. \ AMPUTATION OF THE CLAWS OF RUMINANTS. 205 Technic. Cast the animal and secure the foot to be operated upon in an extended position, apply the elastic ligature and after disinfecting the claws rasp away the horn on the lateral side of the diseased claw, especially at the pos- terior part of it, until the horny wall becomes so thin that it can readily be pressed in with the fingers. Anaesthetize. The corono-pedal articulation can be felt, about 3 cm. below the coronary band, by grasping the claw with the left hand in such a manner that the thumb rests upon the thinly rasped horn while with the other hand the claw is moved from side to side. At the lowest point of the articulation push the sage knife into the joint, the concavity of the knife being directed toward the leg, and make a curved in- cision at first forward and upward to the neighborhood of the coronary band, then with strong flexion of the foot a second curved incision backward and upward which, how- ever, extends only to the navicular bone. By this incision the operator divides the horn, the sensitive lamina, the ex- ternal corono-pedal ligament and the capsular ligament of the corono-pedal articulation. Pass the knife between the navicular and pedal bones and extend the incision down- wards perpendicular to the solar surface through it, sepa- rating the navicular bone from the os pedis. In this manner the navicular bone is preserved as well as the ball of the heel, the latter of which is of special significance in healing. The inner wall of the claw with the powerfully developed corono-pedal ligament is divided from before backward. After the vessels which can be seen are ligated, the articular surfaces of the navicular and coronary bones curetted and the necrotic remnants of tendon removed an antiseptic bandage is applied and a tar bandage placed over it for pro- tection. The bandage remains for 12 or 14 days. If the structures above this point of amputation are irremediably involved the digit should be amputated higher up, at the articulation of the first and second phalanges or through the first phalanx. In these higher amputations a flap operation is generally practicable. Plate XXXV. Amputation of the Claws of Ruminants. Fig. I. d, horny wall, rasped thin ; g, artic- ular condyle of 2nd phalanx ; a, b, c, course of incision. Fig. 2. Median claw preserved. Viewed from the solar surface outward. a, external corono- pedal ligament ; ?', internal do ; /^, ten- don of the flexor pedis muscle ; g, distal artic- ular surface of the 2nd digit ; g^ articular sur- face of 3rd digit ; g^^, navicular bone ; /, lateral claw : in, median claw ; b, bulb of the heel. Fig. 2, THE BAYER SUTURE. 209 45. THE BAYER SUTURE. Figs. 16 and 17. Uses. The closure of large or penetrant wounds with convenient and secure means for applying and retaining antiseptic dressings. Instruments. Large curved suture needle armed with strong silk thread, about 20 cm. long, which is doubled and Fig. 16. Retention, and Continuous Approximation Sutures. d, d^, d'\ drainage tubes ; G ;-, X c/5 r: ^ 'S ^ H rso-s of il the 1 col O -M o rt n3 C ^ C 'o -r 'H. 1 .2 c/:^" 2 'g ^ ntat is. 1 pa es a V 5 ^ ^ S o •^ •w (D IV -^ ii •;: -; bf y in a engage tted lir ■ severi S ^-1 5 n OJ ^ t^ ryot id fe The oint '^ -5 ^ 5 "^ ^ en W o .5 ii 222 DESTRUCTION OF THE PELVIC GIRDLE. against the maternal vulva by making an incision through the skin and skin muscle. If practicable it is best at this point to remove one shoulder subcutaneously, (48), and fol- low by evisceration, (54), in order to give greater opera- tive room and increased mobility of the fetus. Insinuate the hand between the skin and the deeper structures and forcibly separate the integument from the fetal body back- ward until the last rib is passed, as shown at the curved line in Plate XXXVI. Force the finger tips through the abdominal wall behind the last rib and passing along the entire border of each posterior rib, separate the abdominal walls from the ribs and sternum. After the abdominal muscles have been detached, and the fetus has been evis- cerated, rotate the thorax upon its long axis which will cause a division of the vertebral column near the dorso- lumbar articulation and the anterior portion of the fetus falls away. Secure the two posterior feet with cords, unless this has already been done, spread the detached skin, which has been pushed back from the thorax, carefully over the amputation stump of the lumbar vertebrae, repel these by means of the hand while an assistant draws upon the cords attached to the feet, push the remnant of the fetal trunk into the uterus and advance the feet along the genital pass- ages, thus converting it into a posterior presentation. Ordinarily this would result in a dorso-pubic — which should be converted into the dorso-sacral position, when its extraction can be readily brought about. 51. DESTRUCTION OF THE PELVIC GIRDLE IN THE ANTERIOR PRESENTATION. Plate XXXVII. Object, [n somewhat rare instances perhaps most fre- quently in the cow the pelves of the mother and fetus be- come interlocked, the antero-external angle of the fetal ilium, r, becoming locked with the shaft of the maternal "tl o Q cd n nj •^ Dh en g !■- s-s ^ O -^ Oj o I -" *^ -^ -S •' :.' .. - c S a u B B .2 '-^ ^ Vl X. ^ ^ 'U '^ Hi .2 ^- '^ cs ^ > bC^ .2 13 U 2 .§ m a ^ z: ^ "V a ^ 7\ V X 15 2 26 A MPUTA TION OF THE L I MBS A T THE TA RSUS ilium I at C in such a manner that any safe degree of trac- tion fails to dislodge it. Technic. Remove one anterior limb subcutaneously, (48), and eviscerate, (54), through an opening made by the removal of two or three of the exposed ribs. Introduce the chisel through this opening and carry it back with the hand, place it against the shaft of the fetal ilium, I', have an assistant drive it through the shaft from before to behind and then withdrawing the chisel replace it against the pubic brim either at the symphysis pubis or opposite the obturator foramen, and drive it through the pubis and ischium at either of these points. The coxo-femoral articulation is thus detached and isolated so that the entire limb may drop backward beyond its fellow, the remnant of the severed ilium, I', can drop downward or move in any direction and the entire pelvis thus loses its rigidity and undergoes great diminution in size so that it can readily be withdrawn. 52. AMPUTATION OF THE LIMBS AT THE TARSUS. Plate XXXVIII. Object. It sometimes happens in the mare, far more rarely in the cow that in the posterior presentation with the hind limbs retained at the hock owing to the unusual size of the fetus or its having been dead for some time, dry and emphysematous, that the deviation can not be overcome or its correction would entail an unnecessary amount of labor. In these cases it is frequently easier for the obstetrist and safer for the mother to amputate the limb at the tarsus. Technic. Pass a cord around the leg above the tarsus as indicated in Plate XXXVIII and have an assistant hold the leg steady by gentle traction. Introduce the chisel carefully guarded in the palm of the hand, and place it against the lower part of the tarsus as shown between T, T. The chisel should be placed as nearly as possible perpen- s^ al ^ 03 i b l§ (2 U '-I-' Q) ,u o < C/D ^ ^ Q *1 2 V) - a i.s 1 1 s 1 e n 5 «0 c£ .OH 5; Hal S J •s e •o t, . 1 H«l 1 1 ^^ '^ Embryo tion of the means of t 2 30 IN TEA- PEL VIC AM PUT A TION. dicular to the long axis of the metatarsus. The proper direc- tion of the chisel may at times be greatly favored by placing the cord upon the metatarsus instead of the tibia thus forc- ing the tarsus toward the sacrum of the mother and tending to throw the metatarsus straight across the pelvic cavity. When the fetus is in the dorso-sacral position and it is desired to amputate the left limb, the chisel should be held in the palm of the left hand with its dorsal surface against the vaginal walls and the instrument carefully guarded and guided during the entire operation. The amputation should preferably be through the lower section of the tarsus but may be made through the head of the metatarsus. Do not drive the chisel entirely through the hock without removal as it may become caught and clamped between the divided bones, but drive for a few inches along the lateral side being sure that the skin at that point is severed along with the bone, then loosen the chisel by rotation and lateral motion and drive somewhat deeper into the tarsus until it is com- pletely severed. Withdraw the severed metatarsus and re- move any dangerous spicules of bone remaining on the stump and see that the latter is safely secured by a cord passing around the leg above the os calcis. Repeat the operation on the other hock in a similar manner using the right hand to guide the chisel. Extend the two limbs into the passages by traction and effect a posterior delivery. 53. INTRA-PELVIC AMPUTATION OF THE POSTERIOR LIMBS, BREECH PRESENTATION. Plates XXXIX-XL. Uses. The overcoming of dystocia due to a posterior presentation with the hind limbs completely retained in the uterus, the so-called breech presentation, in cases where the deviation can not be readily corrected. Technic. Introduce one hand armed with the embry- otomy knife through the maternal passages until the peri- \ a ft. 5 .0 ft. I p: <^ o a '^ g O ^ (J ^3 o o 55 ^ G O t; o o j_r re B o OJ O O ex a; O be 03 o O a; v' 1-3 G (u a o 234 INTRA-PEL VIC AMPUTA TION. neum of the fetus is reached and make a free incision through that region involving the anus in the male fetus and the anus and vulva in the female and enlarge the incision sufficiently to admit the operator's hand into the fetal pelvis. Locate the great sciatic ligament and with the knife divide the ligament from end to end, thus enlarging the pelvic cavity and giving ample operating room. If the pelvis of the fetus is too small to admit the hand of the operator at all before severing the sciatic ligament, this may be accomplished by cautiously cutting from behind forward with Colin's scalpel or with the chisel. When this has been severed and sufficient operating room attained, carry the chisel with the hand and place it against the shaft of the ilium as shown between I' I' in Plate XXXIX as nearly perpendicular to the long axis of the iliac shaft as possible and keeping the hand in touch with the chisel blade, have an assistant drive it through the bone until it and its periosteum are completely severed. Revolve the chisel on its long axis and force the cut ends of the bone apart. Dis- engage the chisel and place it against the symphysis pubis or against the ischium opposite the obturator foramen and drive it through the ischium and pubis at this point. Using the chisel as a lever, separate the isolated portion of the pelvis as completely as practicable from the surrounding tissues, and with the fingers separate the muscles from the detached pelvic bone for a short distance from the severed ends on either side. Carry a cord in, pass the loop over the ends of the severed section and tightening it secure the iso- lated portion of the pelvis and have one or more assistants exert traction as indicated in Plate XL. The chief obstacle to the withdrawal of the limb is the great gluteus muscle which should be sought for, identified and torn through with the fingers at a distance of 5 or 6 cm. from its attachment to the great trochanter. Other important points of resistance are the attachment posteriorly of the skin, vulva and anus to the ischium through the medium / B 5-:: CJ "^ ^ en >? S (0 biO ^ o V i> ^ > ^ )-l OJ •w _^ .^ M s .1 s^ Q> hi ,a .5 H«( -^ )h ,H