'QIljtB book ioas prceenteb hg

MILTON M. LEONARD, D.V.M.

THIS BOOK IS DUE ON THE DATE
INDICATED BELOW AND IS SUB-
JECT TO AN OVERDUE FINE AS
POSTED AT THE CIRCULATION
DESK.

ESiCEPTION

e^rher if this

150M/01 -92— 920179

Date due will be
item is RECALLED

. Wft\v

SURGICAL AND OBSTETRICAL
OPERATIONS

W. L. WILLIAMS

Professor of Surgery and Obstetrics In the New York State
Veterinary College, Cornell University

Embodying portions of the OPERATIONSCURSUS of Dr. Pfeiffer,

Professor of Veterinary Science in the

University of G lessen

THIRD EDITION, REVISED AND ENLARGED

1912

CARPENTER & COMPANY

ITHACA. N. Y.

Copyright, 1912

BY

CARPENTER & CO.

Press of

Andrus & Church

Ithaca, N. Y.

PREFACE TO THE THIRD EDITION.

The author caused to be published in 1900 a booklet
entitled : " A Course in Surgical Operations by W. Pfeiffer
and W. L. Williams," consisting of an authorized transla-
tion of Dr. Pfeiffer's Operating-Cursus with such changes,
additions and omissions as were deemed desirable. Three
years of constant use, with such criticisms as came to the
author from others, served to point out desirable changes
of so sweeping a character as to demand a practically new
treatise specially adapted to American conditions, and to
render the continuance of a formal joint authorship inex-
pedient and in 1903 the author published a more extended
volume under the present title, followed by a large second
edition in 1906. In this third edition the author has con-
tinued to draw freely upon Dr. Pfeiffer's Operations-Cursus
in the preparation of the text which in many chapters is
practically copied therefrom, including the illustrations with
grateful acknowledgement of his profound obligations. On
the other hand nothing has been copied or extracted except
it could be freely adopted as the author's own view, releas-
ing Dr. Pleiffer from all responsibility for the character
of .any of the contents.

The volume is primarily designed for the use of the au-
thor's classes in laboratory surgery and embryotomy in which
the student performs the surgical operations described, on
animals procured for the express purpose, under chloroform
anaesthesia whenever possible, after which the subject is
destroyed while still anaesthetized ; at the same time it has
been aimed to render the volume of the greatest possible
value to the practitioner consistent with this plan. The
operations included under this scheme are necessarily limited
to those which can be reasonably well performed on com-
paratively sound animals of little value and regularly pro-
curable for laboratory purpo.ses. The list covers a wide

iv PREFACE TO THE THIRD EDITION.

range and is designed to give to the student as thorough
training as is practicable in a laboratory course and includes
well nigh all the more important varieties of confinement,
anaesthesia, disinfection, sutures, bandaging, dressing and
other adjuncts to operative work. The chapter on trephin-
ing of the facial sinuses has been dealt with at much greater
length in the present edition in order to fully and clearly
describe the author's method of operating.

The operation for the surgical relief of roaring in horses
has undergone a complete revolution since the publication
of our second edition in 1906 and the technic therefor which
we had begun to develop in 1905 and tentatively inserted
in the second edition has undergone phenomenally rapid
changes until now it would appear that the technic had
acquired a certain degree of permanency, though still too
new to expect it to remain unchanged. The introduction
of the ventricular burr by Dr. J. H. Blattenberg and various
suggestions in the details of technic by Prof. Hobday of
England and others has materially aided in bringing the
operation to its present state of reliability and caused the
operation introduced by us in 1905 to become accepted
throughout America and Europe to the exclusion of other
methods. We have accordingly omitted the chapter on
arytenectomy from this edition, as an obsolete operation
and have inserted an entirely new chapter upon the opera-
rion for roaring in which we have endeavored to bring the
technic thoroughly up to date.

Generally but one method of operating is described, the
one chosen being that which in the author's experience has
proven the most valuable in actual practice, and no opera-
tion has been introduced purely for practice but each one
has been tested and known to have practical value.

When two methods of operating are given, they are
inserted because each has definite points of superiority over
the other and one method may be specially applicable in a

PREFACE TO THE THIRD EDITION. v

given case, another in a different patient where the same
operation is to be performed as for example, a milk cow is
best spayed through the vagina while a heifer must be
operated upon by an incision through the abdominal walls.

Considerable stress has'been laid upon the surgical anato-
my of the parts involved in each operation ; some uses of
the various operations are mentioned ; some of the chief
dangers of each are pointed out and in some cases references
to literature upon the operation or the diseases for which
the operation is designed, are cited.

Figures i, 2, 6, 7, 9, 10, 11, 15, 16 and 17 and Plates Nos.
XII, XIV, XVI, XXIII, XXIV, XXVII, XXVIII,
XXIX, XXXI, XXXIV, XXXV, are from Dr. Pfeiffer's
Operations-Cursus ; and the remaining Plates and figures
were either drawn under the direction of the author by
Mr. C. W. Furlong, formerly instructor in Industrial Draw-
ing and Art in Sibley College, Cornell University, or were
made from original photographs.

W. Iv. Williams.

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

Ligation 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 GENITAL ORGANS :

Puncture of the Chest 100

Puncture of the Intestine _. loi

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 Ovariotomj'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 1 74

Ulnar Neurotomy 179

Sciatic Neurotomy 1S5

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 L,imb 215

Amputation at the Humero-radial Articulation 21S

Detruncation 21S

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 ma}^ 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 au}' 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 afiatomy deals with the structure of the dead
body while surgical operations are performed upon the
living structures : they are not alike.

xii INTRODICTION.

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 ot 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 recoverN", by the
removal of the effects of the disease of the tooth.

The removal of molars may therefore involve extraction
with forceps, trephining the dental alveolus and repulsion
of the tooth and trephining of the sinuses because of em-
pyema or other pathologic conditions referable to the dental
affection ; consequently all of these should be studied as
related topics.

1. EXTRACTION OF TEETH.
Plates I and II.

Instruments. Extracting forceps, fulcra of various
sizes, mouth speculum with abundant lateral working room,
exporteur forceps, toothpick, splinter forceps, reflecting
lamp.

Technic. In simple cases with a quiet animal the pa-
tient may be sufficiently confined by being backed into a
corner or very much better by securing in stocks. In com-
plicated cases or very resistant animals it is best to place
the patient upon the operating table or in default of this,
cast and secure in lateral recumbence on the sound side.

Apply the speculum and identify the diseased tooth by
manual exploration ; determine if the tooth is of unnatural
size or form, if it is loose, if the gums are separated from the
neck at 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 partiall)- masticated food
by means of the toothpick or fingers.

In applying the forceps, have an assistant draw the
tongue out at the commissure of the lips on the side oppo-

EXTRACTION OF TEETH. 3

site to the affected member and introducing one hand into
the mouth, place the index finger on the posterior border
of the diseased tooth and with the other hand, push the
opened forceps backward upon the dental row until they
reach the diseased member, then firmly grasp it with the
instrument, pressing the jaws down as deeply as possible
against the alveolus.

In many cases the diseased tooth can be clearly seen,
especially with the aid of the reflecting lamp, and the
forceps may be readily applied by sight, which is frequently
preferable to the sense of touch.

Withdraw the free hand from the mouth, grasp the
forceps handles firmly and loosen the tooth in its alveolus
by establishing and maintaining as long as necessary a gentle
to and fro lateral movement. The tooth is thus loosened in
its alveolus by causing it to revolve very slightly back and
forth on its long axis, thereby spreading the alveolar cavity.
When the tooth has become well loosened, the fact is indi-
cated by its revolving with the forceps and by an audible
crepitant sound caused by the passage of air bubbles to and
fro through the blood and lymph in the alveolus. Maintain
the forceps in position with one hand and with the other
introduce the fulcrum to a point where the depression on its
superior surface will receive the projecting rivet-head of the
instrument or in an otherwise secure position affording a
safe support, while the inferior surface rests evenly upon
the crown of a tooth anterior to that which it is desired to
extract, as is shown in Plate I. The fulcrum needs be held
firmly in place in order to prevent it from gliding away
under pressure.

In extracting the first premolars there is no opportunity
for resting the fulcrum on teeth anterior thereto and con-
sequently forceps have been made with fulcra beyond the
forceps jaws resting upon teeth more posteriorly situated.
This is not essential. If the tooth is thoroughly loosened.

Plate J.
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.

EXTRACIION 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 efficientlj' 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 im
order to complete its removal it may be necessary to take
a deeper hold with the extracting forceps or withdrawing
these complete the operation with the aid of exporteur
forceps, or still better frequently with the hand. In young
horses where the teeth are very long we have found it im-
possible to complete the extraction until the tooth had been
divided transversely by means of the tooth cutting forceps.

The dangers in the extraction of teeth are chiefly :

I. The transverse fracture of the tooth, leaving the fang
still fixed in the alveolus, a danger not infrequently un-

8 REPULSION OF TEETH.

avoidable when the crown has become greatly- weakened by
disease so that it lacks the necessar)^ power of resistance ;
under most other conditions transverse fracture may be
largely guarded against by the careful securing of the
patient in a manner to effectively prevent sudden throwing
of the head while the forceps are applied, and by using good
judgment in the amount of force exerted while loosening
the tooth in its alveolus. As stated above we should not
expect to be able to extract with forceps the teeth of very
young horses which have not become partly detached by
disease or in which the fangs are the seat of odontomes.

2. Fracture of the alveolar walls is an accident which
may generally be prevented by proper care in the application
of force and the avoidance of any attempt to extract a tooth
when the existence of an enlargement of the fang is apparent
or suspected.

3. The tooth may slip from the forceps into the pharynx
and be swallowed, an accident avoidable by inserting the
hand into the mouth as the tooth begins to emerge from its
alveolus, and if need be, grasp it with the fingers.

2. REPULSION OF TEETH.
Plate II.

Uses. The removal of molars, pre-molars, tooth fangs
from which the crowns have been broken away, alveolar
odontomes, etc., which can not be removed safely by means
of the forceps.

Instruments. Mouth speculum, razor, 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. 9

Technic. Secure the animal in the lateral recumbent
position with the affected side up. The operating table
affords hy 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

o o

REPULSION OF TEETH. 13

best to detach the soft parts from the zygoma onl}' at first
and then remove the alveolar plate of the ridge with the
bone forceps or chisel,, after which the line into the mouth
is direct and the instrument can then be readily pushed be-
tween the soft and osseous tissues for the remainder of the
distance and the separation completed.

In operating upon the inferior molars covered by the
masseter an opening through the muscle may be made near
its lower border large enough to admit the trephine or the
muscle may be detached at its point of insertion to the
inferior maxillary bone and two parallel incisions carried
upwards a short distance, permitting the raising of a flap,
or what is generally best for the second and third molars, a
curved incision is made at the antero-inferior border of the
masseter muscle parallel to the parotid duct and satellite
vessels and just posterior to them and the muscle lifted up
and drawn backwards sufficiently to expose the bone im-
mediatel}^ over the tooth fang.

With a light, narrow bone chisel cut away and remove
the external alveolar plate over the entire extent of the
tooth, from the oral margin of the trephine opening into-
the mouth cavity. Hold the chisel so that the outer edge is
inclined from the affected tooth toward the adjoining one,
thus making a bevelled channel through the alveolar plate
tending to loosen the isolated section of bone by driving it
outwards. Drive the chisel for a short distance on one
side, then upon the other, and thus break the alveolar plate
away in small sections and avoid an extension of the
fracture to neighboring alveoli and damage to adjacent
teeth. Care should be taken that the bone chisel is sharp
otherwise extensive fractures of the bone may occur. With
gouge and chisel remove all remnants of bone over the
lateral side of the tooth lajdng it completely bare as shown
in Plate II.

The soft tissues of the part should not be disturbed
beyond the excision of the circular piece, corresponding to-

14

REPULSION OF TEETH.

the disk of bone removed by the trephine and the detaching
of them from the portion of bone to be chiseled away.

When the tooth has been bared so that every part of its
lateral surface can be seen or felt, the punch may be placed
against the end of the fang, a few firm, quick blows given
with the mallet, so directed that the force is in a line with
the long axis of the tooth, and the organ driven into the
mouth where it is seized by the forceps or the hand and-
removed. If it is not readily and safely dislodged in this
way, place the heavy bone chisel against it and with the aid
of the mallet comminute the tooth by breaking it trans-
versely and splitting it longitudinally, in which process the
fragments are generally loosened from the alveolar walls and
can then be readily removed wath the aid of the gouge, or
heavy dressing or splinter forceps. Remove carefully all
fragments of tooth or of loosened bone, cleanse and disinfect
the wound, pack with iodoform gauze and dress daily.

In cases where a fistulous opening remains after repulsion
of molars without the removal of the alveolar wall, or if a
tooth has been drawn by means of the forceps and the
alveolus fails to heal, the bony plate should be removed in
the above manner.

Dangers. Wounding of the adjoining tooth is to be
avoided chiefly by carefully locating the fang of the affected
one and placing the instrument as exactly as possible over
its centre, by using a trephine not exceeding 2 to 2.5 cm. in
diameter and cautiously sawing through the compact layer
of the external plate only, removing the cancellated tissue
with the gouge and extending the opening in the desired
■direction after the outlines of the tooth fang have been
clearly determined. If an adjoining fang is wounded, the
tooth should be removed as it will not heal but will result
in a permanent tooth fistula.

Fracture of the alveolar walls of the inferior maxilla
may occur during the removal of the external alveolar plate
-with the chisel or of the repulsion of the tooth with the

REPULSION OF TEETH. 15

punch. The first is to be averted by care in having the
chisel sharp, by observing the precaution of making a
bevelled cut through the bone, by using only moderate
blows and driving the instrument alternately for a short
distance on each side. The second danger of extensive
fracture may be averted by being cautious to see after each
stroke on the punch that it has not slipped inward along
the median side of the tooth, pressing the internal plate
away from the tooth and tending to produce a longitudinal
fracture nearly or quite as long as the dental arcade.
Careful digital exploration in the mouth may 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. I^. 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 ifi/erior in the sense that it is nearer to the nasal
opening so that with the head in a vertical position or in a
longitudinal section the inferior sinus is below the superior,
while if the head be placed horizontally or a cross section
made, a small portion of the superior sinus may show below
the inferior.

The uses of trephining are in a measure common to all
the sinuses and are chiefly for the relief of empyema of the
cavities involved, necrosis of the bony or cartilaginous walls,,
tumors of various kinds, especially dental in the young and

TREPHINING OF THE FACIAL SINUSES.

17

malignant growths in the old, foreign bodies in the sinuses,
differential diagnosis of diseases of this region, etc.

Veterinarians trephine the sinuses by two fundamentally
different plans ; with, and without excision of the cutaneous
disk corresponding to the piece of the bone removed. The
first is generally used in Great Britain and North America,
while the last is the prevailing method in continental
Europe and other parts of the world. The reason assigned
for these variations in method are conflicting. To us there
seem to be adequate reasons for preferring the excision of
the cutaneous disk. We regard as the chief considerations
in an operation the following : the avoidance of infection ;
the prevention of pain during the operation or the after-
treatment ; the reduction of the scar to a minimum ; rapidity
and certainty of recovery ; convenience in operating and
dressing. Inevitably a septic operation, the degree of
infection is largely dependent upon the area of the wound,
the 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 greatly. If we compare the usual European technic
with that given below we would find the wound area ap-
proximately 2.2 sq. in. in the European method, while in
the latter we have only about .44 sq. in. or proportionately
the wound area in the soft tissues in the two operations
would be as 5 : I .

It is very evident that the technic given below affords
immeasureably better facility for maintaining cleanliness in
the wound and with a minimum amount of insult to the
tissues in the process of dressing.

The amount of pain caused in the operation which should
be eliminated by local anaethesia depends chiefly upon the
extent of the skin incision which is essentially equal in the
two plans .so that the only difference would be in the

1 8 TREPHINING OF THE FACIAL SINUSES.

dissection of the skin from the bone in the European
operation. The pain caused in dressing must be greater in
the European method because the detached, overhanging
skin must be moved and disturbed each time causing pain
and inviting infection. The question of pain in dressing
must always be seriously considered as it not only affects
the time required for dressing and its efficacy, but has an
important relation to the docility of the animal after re-
covery, some horses having their dispositions permanently
ruined by the irritation due to the oft repeated painful
dressing of wounds.

The cicatricial contraction of the tissues of the horse is
so great that the removal of a circular disk of skin J^ to 1)4
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 III-XI.

Uses. Fracture of the bonj' walls, necrosis, tumors.

The ample communication below with the superior
maxillary sinus (See FE, Plates V and VI ) prevents the
accumulation of pus or fluids in the frontal sinuses even if
formed therein unless the former becomes filled and the
contents back up into the latter. In empyema of the
frontal sinuses, trephining can not give relief, but calls for a
repetition of the operation on the maxillary sinuses.

Instruments. Razor, scissors, convex scalpels, artery
forceps, tenacula, probe, trephine, curette, gouge, Luer's
sharp bone forceps (rongeur forceps), hammer, chisel,
probe-pointed bistoury, dressing forceps, disinfecting and
dressing materials.

Technic. The operation may be performed upon the
standing animal with the aid of local anaesthesia of the
skin, the bone having virtually no sensation. Restless
animals may be further secured with the twitch, in the
stocks, upon the operating table or bj' casting on the sound
side.

Clip and shave the hair from the region of the frontal
bone at that point which the operator has reason to believe
is nearest the center of disease. The highest point at which
the sinus may be trephined is indicated by F in Plate III.
The most central portion of the cavity is reached by trephin-

Plate III.
Trephining the Facial Sinuses.

F, highest point at which an opening may be
made into the frontal sinus without wounding
the cranium and brain ; N, opening into nasal
sinus ; SM, opening into superior maxillary
sinus ; IM, opening into external portion of in-
ferior maxillary sinus ; IM', opening into the
median portion of the inferior maxillary sinus.

TREPHINING OF THE FRONTAL SINUSES.

23

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 cavity. Consequently the operator
must avoid making the trephine opening in this region near
the median line, but must keep i^A 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 laterall}-, showing extent and
relations of the sinuses. O, orbital cavity ; SM, superior
maxillary sinus ; IM', median portion of inferior maxillary
sinus ; NC, nerve conduit of superior maxillary trunk of the
trifacial ; IM, lateral portion of inferior maxillary sinus ; F,
frontal sinus ; ST, opening through superior turbinated bone
for the establishment of drainage from the frontal and superior
maxillary sinuses into the nasal passage ; IT, opening through
iuferior turljinated 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 any uneven
edges of bone with a heavy scalpel or by re-inserting
the trephine and using it as a rasp. The abnormal contents
of the sinus may now escape through the opening or be re-
moved with the curette, forceps or scissors, and the cavity
irrigated with an antiseptic fluid.

Leave the trephine wound entirely open and irrigate the
sinuses daily with antiseptics.

The frontal, being in free communication below with the
superior maxillary sinus, the irrigating fluids may fall
directly into the latter until it becomes filled. The superior
turbinated bone of the same side forming the median wall
of the frontal sinus, it is commonly perforated by necrosis,
in cases of serious disease establishing a communication be-
tween the frontal and nasal cavities, through which pus
and irrigating fluids readily escape into the nostril.

It has been assumed that pus or other contents in con-
siderable quantity might pass from the superior maxillary
sinus into the nasal cavity through the normal communi-
cating slit between the two cavities but a careful study of
anatomical arrangement of these parts, opposite N, Plates
VII-X, shows very clearly that it is impossible as the
margins of the slit acts as a valve and closes it when pressure
is applied from within.

In order to prevent the aspiration by the patient of the
contents of the sinuses, whether pus, blood or irrigating
fluids, and to facilitate their escape from the nostril, any
irrigation on the recumbent animal should be carried out
with the poll elevated and the head flexed.

Plate V.

Trephining of Facial Sinuses.

Oblique lateral view of the face with the sinuses exposed.
SM, superior maxillary sinus ; IM^, median portion of in-
ferior maxillary sinus ; NC, nerve conduit of superior maxil-
lar}' division of trifacial nerve ; IM, lateral portion of inferior
maxillary sinus ; F, frontal sinus ; FE, fenestrum of com-
munication between the frontal and superior maxillary
sinuses ; ST, artificial opening through the superior turbi-
nated bone at the lowest part of the frontal sinus establishing
a free communication with the nasal passage ; IT, artificial
opening through the inferior turbinated bone at the bottom
of the median portion of the inferior maxillary sinus, affording
drainage into the nasal passage.

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
sufficiently early to avoid danger.

Thread a long probe with a heavy suture about 75 cm.
long and inserting it through the trephine opening into the
nasal passage draw it out through the nostril and removing
the probe, attach a strip of gauze 75 cm. long to one end of
the suture, draw it out through the nostril and tie the ends
together on the side of the face to prevent dislodgement.
Retain the gauze in position for about forty-eight hours to

32

TREPHININa S( PERIOR MAXILLIARY SINUSES.

insure the permaneucy 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 IIl-X.

Uses. Empyema, diseased teeth, odontomes or other
tumors.

Instruments. Same as for the frontal sinuses.

x\natoniically there are two maxillarj^ sinuses, superior,
SM, and inferior, IM, Plates III-X, having a thin im-
perforate bony partition between them. This partition
shifts somewhat in position with age and in case of disease
undergoes profound changes in location and is frequently
totally obliterated in cases of empyema, dental cysts and
other affections. If the sinusal partition be present, good
drainage of the superior sinus may demand the surgical
destruction of the partition so that some authors advise
trephining directly upon the partition in ordei to open the
two cavities simultaneously.

In extensive disease of either sinus the partition between
the two frequently becomes obliterated so that there remains
but one sinus to open ; in limited disease the opening of both
cavities is ill advised. In extensive disease the existence
of a partition may generally be ignored in operating and

TREPHINING SUPERIOR MAXILLARY SINCSES.

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 tlie 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. ilfter the trephining has been com-
pleted remove any purulent collection or tumors or carry
out any 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 ca.ses to infection derived from diseased
teeth or dental alveoli it is es.sential 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 fastulae leading down into the dental alveoli. If dental
disease is recognized the trephining of the sinus is to be
supplemented by repulsion of the offending tooth as
described on page 8.
3

Plate VI

Trephining of Facial Sinuses.

Frontal view of right side of face with sinuses
exposed. SM, superior maxillary sinus ; IM^,
median portion of inferior maxillary sinus ; IM,
lateral portion of inferior maxillary sinus ; F,
frontal sinus ; FE, communication between the
frontal and superior maxillary sinuses.

SM

TREPHINING SUPERIOR MA NIL LARY SINUSES.

37

Under the influence of disease the sinuses may extend far
beyond their normal location or may contract or become
largely obliterated by being filled with new bone or soft
tissue. The median portion of the superior maxillary sinus
on the inner side of the bony conduit of the trifacial nerve,
NF, Plates IV-X, can not always be completely drained
through the opening SM, Plate III, and provision for this
must then be made by trephining into the lower part of the
frontal sinus and thence breaking through the superior
turbinated bone, ST, Plates IV-V, into the nasal passage
or at times it may be feasible to break through the inner
wall of the superior maxillary sinus on the median side of
the nerve conduit into the nasal cavity. If the inferior
maxillary sinus is also involved good nasal drainage
may be had by breaking down the 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 by
necrosis and in some cases affords the desired drainage
while in the majority the pathologic opening is so placed
that it is incomplete.

Leave all wounds entirely open and irrigate daily with
antiseptic solutions.

Dangers. Care must be exercised to not injure the
superior maxillary division of the trifacial nerve, NF,
Plates IV-X, either in trephining or after the sinuses have
been opened. The bony conduit of this nerve is in rare
cases entirely resorbed by pressure from dental cysts or
other causes, leaving it stretched across the cavity as a white
nacrous cord, intensely sensitive. Any injurj^ 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 ;
vSM, superior maxillary sinus ; M', fragment of
last molar.

IM-

TREPHINING INFERIOR MAXILLAR Y SINUS. 4 1

causes intense pain and renders the animal very resistant to
the necessary manipulations in the after care of the wound
and may leave the patient pernamently nervous about the
handling of its face.

Hemorrhage is generally not severe and may occur from
the skin, where it may be readily controlled by compression
or ligation ; from the intra-osseous vessels, where it may
be checked by pressure with absorbent cotton, by pushing
a small portion of cotton into the channel of the vessel
with a needle or tenaculum or by plugging the vessel with
a conical piece of wood ; from the wounded turbinated
bones where it may be stopped by packing with gauze.
These tampons should be removed after twenty-four hours.

5. TREPHINING THE INFERIOR MAXILLARY SINUS.
Plates III XI.

Uses and Instruments. Same as in the preceding.

Anatomical Outline. The inferior maxillary sinus is
an exceedingly irregular cavity, differing in details of form
and extent in individuals and at various ages. As shown
in the illustrations its disposition might be compared to a
pair of saddle bags hanging over the nerve conduit, the
lateral and median chambers not very unlike in extent.
As suggested in Plates IV-V, the floor of the lateral cavity
is broken up by irregular bony septa, which in some cases
cut the sinus up into quite separate cavities. Sometimes it
extends downwards barely below the end of the zygoma,
at other times it reached down below the infra-orbital
foramen. There is hence no rule by which the operator
may at all times make his opening precisely at the lower
extremity of the sinus.

Technic. The general technic is the same as for the
frontal and superior maxillary sinuses, but two trephine

Plate VIII.

Trephining the Facial Sinuses.

Cross section of the left side of the head of an
aged horse at the second molar, seen from the
front. F, frontal sinus ; N, nasal sinus, oppo-
site the communication between the nasal and
inferior maxillary sinuses ; IM, lateral portion
of inferior maxillary sinus ; IM^, median portion
of inferior maxillary sinus ; SM, superior max-
illary sinus ; NF, superior maxillary division of
trifacial nerve in its bony conduit ; SZ, subzygo-
matic artery ; P, palatine artery ; M2, second
molar.

TREPHINING THE NASAE FOSSAE.

45

openings should always be made. The first opening should
be made close against the median side of the zygoma near
its lower or nasal extremity, Plate III, IM, and the inferior
border lowered sufficiently with the bone forceps to provide
thorough drainage for the lateral compartment of the sinus.
The second opening is to be made on the median side of
the nerve conduit, NC, Plates IV-V as indicated at IM' in
Plate III. The location may be accurately determined by
palpating with the index finger through the first opening
at IM, Plate III. This compartment can not be well drained
upon the face through either of the trephine openings and
a third opening, penetrating the inferior turbinated bone at
IT, Plates IV-V, is essential to ideal results by affording
free drainage into the nasal chamber. The opening through
the inferior turbine is made in the same manner as described
for the opening through the superior turbine from the
frontal. Thorough search should be made throughout the
sinus for the causes of disease, teeth, etc., these removed and
followed by after treatment the same as advised for the two
preceding operations.

6. TREPHINING THE NASAL FOSSAE.
Plates VII-X.

Uses. Operations upon the septum nasi, or the tur-
binated bones, or the removal of tumors or foreign bodies
from the nasal passages.

Instruments. Same as for the frontal sinuses (page
19).

Technic. The trephining, N, Plate III, is carried out
by the method described above, in the nasal bone, close by
the median line of the face and according to indications at
any point from a level of the dotted line, SM, Plate III, to
the juncture between the na.sal 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.

-Ma

TREPHINING THE NASAL EOSSAE.

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 Hes in close
proximity to the nasal bone. The operative area is narrow
and the trephine used should not exceed 2 cm. in diameter.

Whenever possible the operation should be carried out
on the standing animal which decreases the hemorrhage
and the danger from aspiration of fluids. The hemorrhage
may be further controlled in operations upon the septum
nasi and turbinated bones by spraying the parts with
adrenaline chloride and cocaine. Even in the standing
animal, if extensive operations are to be carried out on the
very vascular septum nasi or on the turbine, it is advisable
to preform trachetomy before trephining, and retain the
trachea tube in position until all danger has passed. When
the animal is confined in the recumbent position the
patient's safety demands that tracheotomy be performed in
almost all cases before any operation is begun upon the
septum nasi or turbinated bones. After tracheotomy,
anaesthesia may be maintained by means of an ordinary
funnel with its tube bent at right angles and inserted into

4

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 maxillar\' sinus. M^,
last superior molar ; SINI, superior maxillary
sinus at its antero-iuferior extremity ; IM, in-
ferior maxillary sinus, lateral portion ; IM^, do.
median portion ; N, nasal fossa ; S, sound
lodged in lachrymal duct ; NF, trifacial nerve ;
F, frontal sinus.

IM-

— F

-NF
- - 1 M

u.

— SM

— M

POLL E]'IL 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 XL

Instruments. Clipping shears, razor, sharp scalpels, one
dozen compression artery forceps, probe-pointed bistoury,
probe, Luer's bone forceps, bone gouge, curette, suture and
dressing material.

Technic. Clip the foretop and mane and shave the
forehead and the top of the neck back to a distance of 8 or
lo 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

< o

cs n 3
■S -S -5

O 4J tn

-l->

lU

o

lU

'^

X

o

Ph

1

o

■&

5

tc

_o

'S o

s" 1^ 3

POLL EVIL OPERATION. 57

portion of the ligament in the area indicated and all calca-
reous deposits or other diseased tissues.

With lyuer's forceps groove a channel about 2 cm. wide
from behind to before directly upon the median line, through
the occipital protuberance to the depth of about 2 cm. mak-
ing the bottom as near as possible on a level with the wound
in the soft tissues as indicated by the dotted line, AA.
Using Luer's forceps as a curette detach all vestiges of the
neck ligament from the base of the occiput and leave the
bone bare and smooth. If the Luer or ronguer forceps are
not available the grooving of the occiput may be accom-
plished with a strong curved bone gouge. Or the grooving
of the occiput and curetting away of the attachments of the
neck ligament to the base of the occiput may be very
effectually accomplished with a hoof knife. Be careful to
avoid penetrating the cranial cavity or the occipito-atloid
articidation . If the operator is not perfectly clear regarding
the anatomy of the parts he would do well to have before
him a sagittal section of the head of a horse which may
serve as a guide. In curetting the ligamentous attachments
from the occiput the operator should keep the index finger
of the left hand at the bottom of the wound, against the
occipito-atloid ligament in order to protect it from injury.
The operation is rendered safer also by rigid control of the
hemorrhage to which end he needs an ample number of
compression artery forceps.

Control the hemorrhage, cleanse and disinfect the wound,
pack with iodoform gauze and suture for its entire length
except the anterior part, where the tampon should slightly
protrude, and dust the margin of the wound with iodoform
and tannin. Remove the tampon after foity-eight hours
and dress antiseptically daily. The sutures may or may
not be removed according to conditions. In carrying out
this operation our chief aim should be to remove all diseased
parts, to afford perfect drainage anteriorly, to secure and
maintain antisepsis, and to keep the wound directly on the
median line from which no visible scar will result.

Plate XII.
Ligation of the Parotid Duct.

Fig. I. Segment of the left ramus of the in-
ferior maxiHa of the horse seen from the right
and beneath, sp, usual operative field ; a, ex-
ternal maxillary artery ; z>, external maxillary
vein ; st, si, parotid duct.

Fig. 2. Life size of operation field on external
side of maxilla ; a, external maxillary artery ; z\
external maxillary vein ; .s7, parotid duct ; ;;/.
masseter muscle.

Fig.

LIGATION OF THE PAROTID DUCT. 6 1

8. LIGATION OF THE PAROTID DUCT.
Plate XII.

Objects. The destruction of the parotid gland in case of
fistula from wounds or abscesses.

Instruments. Razor, convex scalpel, straight probe-
pointed scalpel, tenaculum forceps, ligation forceps, tenacula,
needle holder, probe, suture and dressing material.

Technic. In case of salivar}' fistula insert a probe
toward the gland through the fistula into the duct and with
a sharp scalpel lay the duct free for a distance of from i to
2 cm. on the glandular side of the fistulous opening. If the
fistula has its location on the side of the cheek, cast the
horse and shave and disinfect the region on the inferior
maxilla where the artery, vein and parotid duct turn around
its inferior border. When the operator glides his finger
over the vascular region forward and backward there is felt
a resistant cord, the pulsating external maxillary artery
about 3 mm. in diameter. Between this and the oral border
of the masseter muscle make an incision about 4 cm. long
parallel to the artery through the skin and skin muscle.
Pick up the loose connective tissue with a pair of forceps
and excise it. Immediately behind the external maxillary
artery, a, Figs, i and 2, Plate XII, is the external maxil-
lary vein, V, and behind this and immediately at the border
of the masseter muscle lies the parotid duct, si.

In case of salivary calculi which cannot be removed
through the mouth or of cystic dilation of the parotid duct,
make the cutaneous incision at the affected point, open the
canal, and after the removal of the calculus, etc., close the
duct wound by means of intestinal sutures in such a way
that the external surfaces of the lips of the wound in the
wall of the duct are brought in contact, or ligate the duct
on the proximal side of the point of operation and destroy
the gland.

62 ENTROPIUM OPERATION.

Ligation of the duct is accomplished by passing a strong
silk thread beneath the duct by means of a curved aneurism
needle, carrying the ligature around the duct and tying
with a surgeon's knot. The parotid duct \wa.y also be
previously split and an internal wound made at the point of
ligation. Close the skin wound by means of a continuous
suture and cover the operative surface with iodoform
collodion or with wound gelatine.

9. ENTROPIUM OPERATION.

Instruments. Razor, scissors, convex scalpel, tenaculum
and ligation forceps, tenacula, needle holder, needles, thread,
absorbent cotton.

Technic. Quiet adult horses may be operated upon in
the standing position with the aid of local anaesthesia, other
horses and small animals should be secured in lateral re-

FlG. I.
Eutropium operation on the superior and inferior eyelids of the dog.

cumbency preferably upon the operating table. Shave and
disinfect the skin of the inverted eyelid. Grasp the skin of
the eyelid midway between the inner and outer canthi
with the forceps and elevate a skin fold parallel with the
border of the eyelid to such a height that the inverted
member assumes its normal position. Pass a finger into the

STAPHYLOrOMY.

63

<:onjiinctival sac to make sure that the conjunctiva is not
drawn into the skin fold. Clip the fold off with the scissors
immediately below the forceps, removing an oblong piece.
Between the border of the eyelid and that of the wound
the skin should be left intact for at least .5 cm. Ligate or
compress any bleeding vessels and close the wound by means
of interrupted sutures. The wound may be covered with
iodoform collodion or wound gelatine or dusted over with
iodoform-tannin. It is usually unnecessary and inadvisable
to cover the parts with hood or other appliance since so long
as the wound is healing properly the animal will not disturb
it.

10. STAPHYLOTOMY.

Object. An operation devised by Dr. M. H. McKillip
for making a manual exploration of the Eustachian tubes,
guttural pouches, larynx, pharynx and posterior nares ; and
for operations upon the.se structures. The form and extent
of the soft palate of the horse is such as to render it ex-
tremely difficult to make a manual exploration of the parts
above and behind it, and impossible to make a visual ex-
amination except with the aid of the expensive and compli-
cated rhino-laryngoscope, which only aids in diagnosis while
staphylotomy combines with this operative advantages, per-
mitting the free introduction of the hand into the laryngo-
pharyngeal region.

Instruments. Mouth speculum, short curved probe-
pointed bistoury with a ring to fit the middle finger.

Technic. Cast the patient or secure on the operating
table in lateral recumbency and turn the nose upward.
Adjust the mouth speculum and open the mouth as wide as
possible ; draw the tongue well out with the left hand while
the right carrying the knife on the middle finger is passed

64

TRIFACIAL NEUROTOMY.

carefully through the fauces until it hooks over the posterior
border of the soft palate. The knife is then gently drawn
forward making an incision along the median line of the
soft palate from its posterior, free border to its attachment
on the palatine bone. The hand is then withdrawn and the
speculum removed for a few minutes to permit the patient to
rid its pharynx of any blood clots or mucus that may have
accumulated. Readjusting the speculum as before, the
right hand is again passed through the fauces and now that
the palate is divided a manual exploration may perfectly^
reveal the presence of any abnormality in the region.

11. TRIFACIAL NEUROTOMY.

Plate XIII.

Object. The relief of involuntary shaking of the head-
Instruments. Razor, scissors, convex scalpel, tenacula,
aneurism needle, compression artery forceps, needles, thread,
absorbent cotton, a strong piece of muslin 12 cm. square.

Technic. Secure in lateral recumbency, preferably upon
the operating table, and produce complete anaesthesia. Re-
move the halter, bridle, or other headgear. Shave and
disinfect an area 8 to 10 cm. square over the infra- orbital,
foramen. Locate by touch the infra-orbital foramen, lOF,
Plate XIII, below the levator labii superiorisproprius muscle
and displace this slightly upward toward the median line of
the uo.se until the foramen can be clearly felt below the
muscle. With the scalpel begin an incision somewhat
superior to the foramen and near its nasal border and make
a wound downward and forward in the direction of the
commisure of the lips about 5 cm. long through the skin,
muscle and connective tissue down to the nerve and control
hemorrhage with the greatest care. If the larger branches-
of the glosso-facial vessels are severed they should be ligated

TRIFACIAL NEUROTOMY

65

or twisted. It is even better to ligate or compress these
vessels prior to severing them.

Hold the lips of the wound apart with two tenaciila or by
placing a strong suture through each wound margin and
through the skin at a point 6 to 8 cm. distant and tying the
sutures tightly, dilate the wound thoroughly and dissect
away the connective tissue from the nerve until every part
of it is clearly in view. Pass an aneurism needle beneath
the nerve trunk and Hfting it from the bone make a search
for a small artery which usually passes along beneath it
through the foramen and if this can be found either ligate it
immediately at its point of emergence and again 5 cm.
lower down and divide between the two ligatures or
separating it from the nerve protect carefully against injury.
With a probe-pointed bistoury or scissors sever the nerve at
the foramen and grasping the distal end dissect away about
5 cm. of the trunk and excise. Be very careful to include
all branches and especially one or two superior or dorsal
twigs which are directed upward just as they emerge from
the foramen. After the hemorrhage has been brought under
complete control and all blood clots have been removed
cleanse the wound carefully, dust over with iodoform and
close with continuous sutures.

In order to protect this first wound during the operation
upon the other side take the piece of muslin mentioned
among the needs for the operation, and folding it several
times in a square, place it over the wound and suture it
firmly at each corner to the skin. Turn the animal to the
opposite side and repeat the operation on the other nerve
except the application of the square piece of muslin which
is here unnecessary. If circumstances will at all permit it
is far safer to operate upon only one side first, allowing this
to heal and then operate upon the other side.

As soon as the animal stands, remove the protective piece
of muslin from thp first wound, disinfect both wounds, dust
5

Plate XIII.

Trifacial Neurotomy.

LL, levator labii superioris proprii muscle ;
lOF, infra-orbital foramen ; NF, superior max-
illary division of the trifacial nerve.

LL-
lOF-
NF—

TRIFACIAL NEUROTOMY. 69

them over with iodoform and tannin or cover with wound
gelatine and leave undisturbed to heal by primary union.
Avoid halter, bridle or other fixtures which might injure
the wounds after the operation.

In some cases the operation may be performed upon the
standing animal under local anaesthesia and whenever this
is possible it is greatly to be preferred since the hemorrhage
is far lessened and the danger from sepsis reduced, but with
most affected animals the standing operation is impractic-
able.

Dangers. The chief danger in the operation is from in-
fection, which sets up a severe neuritis in the proximal end
of the nerve, aggravates the symptoms and causes much
suffering. In order to prevent infection the aseptic precau-
tions need be unusually strict in every detail and the anaes-
thesia profound. Carefully avoid wounding the neighbor-
ing vessels and control completely any hemorrhage that
occurs in order to avoid a hematom in the wound, which
always invites infection.

Literature. Involuntary twitching of the head relieved
by trifacial neurectomy. W. L. Williams, Jour. Comp.
Med. and V. A., vol. XVIII, p. 426. Involuntary shaking
of the head and its treatment by trifacial neurectomy, do.
Am. Vet. Rev., vol. XXIII, p. 321 and CEst. Monatsch.
Thierheilkunde, Bd. XXIV, s. 211.

II. OPERATIONS ON THE NECK.

12. OPENING OF THE GUTTURAL POUCHES.

Plate XIV.

Instruments. Razor, Scissors, convex sharp-pointed
and straight probe-pointed scalpels, artery forceps, tenacula,
probe, trocar, curette, drainage tubing, suture and dressing
material.

Technic. I. Viborg^ s method. The operation is possible
on the standing animal, but generally the patient must be
cast or placed on the operating table and secured in lateral
decubitis with the head extended. B}^ extending the head
and compressing the jugular vein there is brought out the
triangle immediately behind the posterior border of the in-
ferior maxilla and below the parotid gland comprised be-
tween the posterior angle of the inferior maxilla, the
terminal tendon of the sterno-maxillaris muscle and the
external maxillary vein.

In this so-called Viborg's triangle after the removal of
the hair and the disinfection of the skin which is maintained
stretched, make a 5 cm. long incision through the skin and
skin muscle immediately beneath the aforementioned tendon
and parallel to it. In case of pronounced swelling in
Viborg's triangle the operator must determine the location
for the incision by the position of the sterno-maxillaris
muscle. The skin, subcutem and cervical fascia having
been incised to a sufficient extent, force a passage with the
finger or with closed probe pointed scissors or other blunt
instrument through the loose connective tissue on the
median side of the parotid gland, to the guttural pouch and
penetrate it at its lowest point with the finger or trocar.
In order to open the empty guttural pouch as an exercise
operation it is desirable to grasp a portion of its wall by
means of forceps. Through the operative wound a drainage

OPENING OF THE GUTTCRAL POUCHES.

71

tube can be introduced into the pouch, and fixed in position
by sutures. The opening can be enlarged in an antero-
posterior direction to the extent of 5 to 8 cm. or large
enough to admit the operator's hand. Through this
enlarged wound, the operator may palpate the Eustachian
tube and other portions of the interior of the pouch and
perform desired operations.

A far more common operation in veterinary practice
than the opening of the guttural pouches, is the opening of
strangles abscesses of the sub-parotid lymph glands, lying
between the inner face of the parotid gland and the external
face of the guttural pouch. The operation here used is the
same as Viborg's for the guttural pouch but does not
penetrate that cavity because the inner wall of the abscess
has pushed the external wall of the pouch inward so that
the former largely occupies the usual location of the latter.
The dyspnoea generally prohibits casting the animal and
necessitates operating in the standing position. In some
cases the dyspnoea is so severe as to demand tracheotomy
before the opening of the abscess can be undertaken because
the excitement aggravates the difficult respiration to the
point of suffocation.

II. ChaberV s metJiod. Secure the horse in the lateral re-
cumbent position, remove the hair and disinfect the skin
beneath the wing of the atlas. Make an incision about i;
cm. in front of the lower half of the wing of the atlas audi
parallel to it, about 6 cm. long extending through the skin:
and skin muscle down to the parotid gland. The incisioni
is facilitated by rendering the skin tense with the left hand!
and care is to be taken not to wound the auricular nerve-
which passes directly along the atlas. Then draw backward
the posterior lip of the wound and separate with blunt in-
struments the posterior border of the parotid gland from
the alias, to which it is bound by loose connective tissue,
and draw it forward with tenacula. At the bottom of the

Plate XIV.

Opening of the Guttural Pouches { Hyoyertebrotomy)
According to Viborg and Chabert.

Head and neck of recumbent horse viewed
from the side, sm, stylo maxillaris^niuscle ; />,
parotid gland ; /, guttural pouch ; k, larynx ;
st, sterno-maxillaris muscle ; r, rectus capitus
anticus major muscle ; c, external carotid artery ;
e, external maxillary artery ; /', internal maxil-
lary artery ; v, external maxillar}- vein ; s,
probe ; a, wing of atlas.

OPENING OF THE UrTTCRAL POUCHES. 75

opening thus formed there is seen the stylo-maxillaris
muscle, sm, Plate XIV, lying against the median side of
the parotid gland covered only by the aponeurosis of the
mastoido-humeralis muscle. With the handle of the scalpel
inclined toward the wing of the atlas penetrate in the
direction parallel to the long axis of their fibers the aponeu-
rotic expansion of the mastoido-humeralis, and the stylo-
maxillaris muscle. The puncture is thus located between
the ninth and tenth nerves on one side and the internal
carotid artery on the other. Since the wall of the guttural
pouch rests against the median side of the digastricus
or sterno-maxillaris muscle it is opened by this incision.
The operator inserts an index finger along the blade of the
knife at first and then withdrawing the instrument passes
the other index finger also into the penetrant wound and
by forcibly parting these, dilates it. The abnormal contents
are then removed by means of forceps, curetting and irriga-
tion. In order to prevent adhesion of the wound lips in
the firmly stretched stylo-maxillaris muscle, introduce a
strong drainage tube into the pouch and fix it to the external
borders of the wound by a suture.

III. Dieterich' s method. This operation is effected at a
point between I and II, the opening of the pouch being
made immediately behind the stylo-maxillaris muscle. In
order to accomplish this the cutaneous wound over the wing
of the atlas must be prolonged below it. After detaching
the posterior border of the parotid gland the operator
searches in the loose areolar tissue with the index finger of
the left hand for the vascular angle which is formed by the
occipital, internal carotid and external carotid arteries which
may be detected by pulsation— the same is located at a depth
of from 8 to 10 cm. Place the volar surface of the finger
in the vascular angle and push a sharp scalpel along its
dorsal side to the pouch which here becomes opened on its
posterior lateral surface.

76

TA'ACHEOTOMY

This method has the advantage over Chabert's that for
the removal of hard contents (chondroids) the opening can
be readily dilated, even to such an extent that the entire
hand may be passed into the air sac and the opening of the
Eustachian tube be explored as in Yiborg's operation.

12. TRACHEOTOMY.
Fig. 2.

Instruments. Razor, scissors, convex scalpel, tenacula,
tenaculum and ligation forceps, trachea tube, and suture
material.

Technic. In the superior third of the cervical region,
in the neighborhood of the fourth to the sixth tracheal ring,
shave and disinfect the skin on the anterior surface of the
neck to the extent of lo cm. long by 5 cm. wide. The
operation is best performed upon the standing animal with
the head extended. In lateral decubitis the operation is
carried out with some difficulty, and generally the operator
fails to get the incision on the median line. The operator
stands before the right shoulder of the horse with an
assistant opposite him.

Render the skin tense along the median line of the
trachea with the left hand and then make a drawing cut 5
to 8 cm. long from above to below with the scalpel. The
incision should be made carefully upon the median raphe of
the skin which is virtually destitute of sensation and requires
no anaesthesia. After the skin muscle is cut through, in
order to avoid hemorrhage, separate the two sterno-thyro-
hyoideus muscles by means of tenacula along the median
raphe in the white strip of connective tissue. The opening
into the trachea may be made in a variety of ways. The
quickest and most crude method is to slit it from above
downwards through two or three tracheal rings, and press-

TRACHEOTOMY.

77

ing the several ends apart insert the tube through the open-
ing. Since the tracheal rings are incomplete, being open
on their dorsal surfaces, cutting through the ventral portion
divides each ring into two separate parts and their being
pushed apart, distorts them and tends to the causation of
chondritis and collapse of the trachea, a danger which in-
creases with the duration of time that the tube is maintained
in position. It is therefore most suitable for hurried opera-
tion in impending suffocation where the tube will probably
be needed for a short time only.

Tracheotomy, s, sterno-thyro-hyoideus muscle ; /, trachea ;
sch, mucous membrane of the posterior wall of the trachea ;
/, interannular ligament.

A second method of operation, illustrated in Fig. 2, con-
sists in making a transverse incision through the inter-annu-
lar ligament between the two last exposed tracheal rings the
length of the diameter of the tube to be inserted. Make
a perpendicular incision upward from each end of this at a
point I to 1.5 cm. from the median line through one or two
tracheal rings, according to the size of the tube. With
forceps or tenaculum grasp the segments of partially de-

78

THE OPERA riON FOR ROARING.

tached cartilage and remove them by cutting through the
inter-annular ligament.

A third and to us preferable method is to insert a narrow
bladed scalpel transversely at about the lower third of the
lowermost bared tracheal ring and cutting outwards and
upwards in a curved line, pass through the first inter-annu-
lar ligament and continue into the succeeding segment until
near its superior border, when the incision is curved down-
ward to eventually reach the starting point, the isolated
section of the trachea being securely grasped with a pair of
forceps before its excision is completed. By this method
no tracheal ring is severed.

The trachea tube is to be removed and cleansed daily as
long as its use is necessary, and when discontinued the
wound should be left open and dressed antiseptically.

13. THE OPERATION FOR ROARING.
Plate XV. Figs. 3-5.

Instruments. Razor, hypodermic syringe, scalpels,
tenaculum, artery forceps, laryngeal speculum, two long
curved dressing forceps, hard rubber syringe with long pipe,
ventricular burr, reflecting lamp, razor-shaped scalpel, long
curved scissors.

The following technic has for its aim two fundamental
objects which are to be kept constantly in mind :

I. It is aimed to bring about a prompt, firm, complete
and permanent adhesion of the arytenoid cartilage and vocal
cord against the inner face of the thyroid cartilage in the
normal position of forced iu.spiration, so that no air can
become impacted into the ventricle to force the vocal cords
and arytenoid cartilage downwards and inwards to obstruct
the free ingress of air.

THE OPERATION FOR ROARING. 79

2. It is aimed to complete the operation without wound-
ing a cartilage either in the essential operation when re-
moving the ventricular mucosa, during the invading incision
through the crico-thyroidean membrane, and later, should
dyspnoea occur, by inserting the laryngeal tube through
the existing incision instead of performing tracheotomy.

Technic. Docile animals are readily operated upon in
the standing position. The animal should be confined in
stocks, or otherwise, in such a manner that his^head may
be securely held in an elevated and extended position. The
safety of the operator further demands that the patient
shall be so secured that he can neither rear nor strike.

Resistant animals need be cast or confined upon the
operating table. General anaesthesia upon the recumbent
animal is usually unnecessary, and is only demanded in those
cases of unusual resistance to confinement, where the patient
may injure itself by its violent struggles.

Ordinarily ample anaesthesia, whether from the stand-
point of surgical efficiency or of sentiment, is obtainable by
the use of local anaesthetics, preferably of cocaine and
adrenaline.

Shave and disinfect the operative area, and inject sub-
cutaneously a sufficient amount of the local anaesthetic.

Make a longitudinal incision over the larynx through the
skin and fascia as accurately as possible on the median
raphe, commencing opposite to the anterior extremity of
the thyroid cartilage and extending downward and back-
ward to the region of the first tracheal ring. Separate the
sterno-thyro-hyoideus muscle on the median line with the
scalpel blade or handle as preferred. Control the hem-
orrhage. If the operation is performed upon the standing
animal with the aid of cocaine and adrenaline, the incision
is virtually bloodless.

Locate the crico-thyroidean ligament, triangular in form,
bounded anteriorly and on both sides by the thyroid cartilage

Plate XV.
Operation for Relief of Roaring.

Fig. I. Longitudinal section through the
ventricle of the larynx ; A, arytenoid cartilage ;
TA, anterior fasiculus of thyro-arytenoideus
muscle ; TA^, posterior bundle thyroarytenoid-
eus ; VC, vocal cords ; V, laryngeal ventricle ;
T, thyroid cartilage ; E, epiglottis.

Fig. 2. Sagittal section of the larynx. C,
cricoid cartilage. Other lettering same as Fig. i.

TA y tX .VC

Fig. 2.

THE OPERA TION FOR ROARING.

83

and posteriorly by the cricoid ring. Error may occur here
and the space between the cricoid and first tracheal rings be
mistaken for the crico-thyroidean ligament. This is readily
obviated by careful digital palpation, which reveals the
triangular crico-thyroidean ligament with its rounded apex
directed forward and its lateral borders sharply defined by
the hard borders of the alse of the thyroid cartilage, while
the base of the triangle rests upon the more elastic anterior
border of the cricoid cartilage.

Fig. 3.

Laryngeal dilator in position.

Having carefully identified the crico-thyroidean ligament,
place the back of the scalpel against the anterior border of
the cricoid cartilage, accurately upon the median line, the
point directed obliquely backwards toward the cavity of the
trachea. Push the scalpel through the ligament into the

84

THE OPERATION FOR ROARING.

laryngeal cavity, and carry the incision forwards on the
median line to the body of the thyroid cartilage.

Detach the slotted piece from the laryngeal retractor (Fig.
4) and insert the closed retractor into the incision through
the ligament, the ratchet end of the speculum being directed
toward the trachea, the curved spurs on the jaws of the
retractor resting within the cricoid ring. Open the dilator
to the full extent of the crico-thyroidean space. Insert the
hook of the slotted piece into the cavity of the thyroid
cartilage and secure in position by means of the thumb screw.

Illuminate the cavity of the larynx. In the standing
animal, when facing good light, the natural illumination
suffices. The illumination may be improved with the aid
of a hand mirror.

Excellent illumination is always available by means of a
reflecting electric lamp. With a good lamp the illumination
may be perfectly controlled in a dark room or in the dark-
ness of night. When the animal is cast and turned upon
his back, the light rays should enter the larynx from above
obliquely downward and forward. If the operation is being
done in the open field by sunlight, the patient's head should
be directed away from the sun, or good illumination fails.

Observe the motion of the arytenoid cartilages, and
determine, if not previously done, whether the unilateral or
bilateral operation is to be performed. Inject into the
larynx and laryngeal ventricle or ventricles a sufficient
quantity of a solution of cocaine and adrenaline to blanch
and anaesthetize the mucosa. The ventricles are more con-
veniently injected if the syringe nozzle is bent near the tip.

The ventricles commonly contain some mucus, which
interferes with the securing of the mucosa and should be
taken up and removed by means of a small piece of absorbent
cotton pressed into the ventricle with the long curved dres.s-
ing forceps.

When the ventricular mucosa has been effectively anaes-
thetized introduce the burr into the ventricle and draw the

THE OPERATION FOR ROARING.

8 s

sheath on the burr shaft away from the burr for the distance
of about I cm. Press the burr gently against the bottom of
the ventricle, hold the canula to prevent its revolving, and
give the burr one or two turns to the right until the re-
sistance indicates that the mucosa is securely engaged.
The canula is now pushed against the burr and gentle
traction applied to the handle, revolving the burr and canula

1

Fig. 4. Fig. 5.

Laryngeal dilator. Ventricular burr, modified

after Blattenberg.

now and then a trifle, until the everted mucosa from the
bottom of the ventricle appears beyond the mouth of the
ventricle. Grasp the everted portion of the muco.sa securely
with the long curved dressing forceps and then continue
traction with these until the ventricular mucosas has been
completely everted. Then cut away the everted mucosa by
excising it with the razor-shaped scalpel or by means of

86 THE OPERATION FOR ROARING.

long scissors at approximately the point indicated by the
dotted line in Plate XV.

If the right side of the larynx appears to be affected also,
or if for other reasons it seems desirable, repeat the operation
upon the right ventricle.

(The operation may also be performed without the use of
the ventricular burr, but it is more difficult, especially upon
the standing animal. The technic is the same until the
removal of the ventricular mucosa is reached, when, instead
of the burr, the mucosa of the ventricle at its arytenoid
border is grasped with the forceps, tension is applied, and
the mucosa is incised along the arytenoid border and thence
along the summit of the vocal cord. The incision is con-
tinued at the point indicated by the dotted line in Plate XV
until the ventricular mucosa has been isolated from that of
the larynx in general. Cautiously exerting tension with
the forceps upon the incised border of the ventricular
mucosa, dissect it away from the loose underlying areolar
connective tissue either with the Moeller razor-shaped
scalpel or with a scalpel handle.)

However the mucosa is removed the operator should take
care that the removal is complete, since any remnant
incautiously left behind in the ventricle may prevent the
desired adhesion of the arytenoid to the thyroid cartilage or
a small patch of mucosa being left deep in the ventricle
might permit adhesion of other parts, imprisoning the
mucous islet and ending in a mucous cyst.

When the mucosa has been removed from one or both
ventricles, all blood coagula should be wiped away, any
shreds of tissue removed and the denuded tissues painted
over with tincture of iodine. The application of the tincture
of iodine is best made with the long curved dressing forceps
carrying a small pledget of cotton saturated with the drug.
The operator needs have care in this application lest the
horse in forcible expiration blow some of the iodine in his
face and eyes.

THE OPERATION EOR ROARING. 87

If the patient has been cast, anaesthetized and turned
upon his back, turn him upon his side, remove the confining
apparatus, and, while he is recovering from the anaesthesia,
keep the laryngeal incision open and the larynx free from
blood. The hemorrhage from the operation is the greatest
when it has been performed under general anaesthesia, less
if cast and the operation performed under local anaesthesia
and by far least of all when it is performed upon the stand-
ing animal with the aid of cocaine-adrenaline anaesthesia.

As soon as the operation has been completed upon the
standing animal, the head may be released and the patient
returned to the stall. It may be allowed to eat or drink at
convenience. The same is true of the patient cast for the
operation, and only local anaesthesia applied. Patients
cast and chloroformed should be prevented from eating or
drinking for some hours and should be fed sparingly for
three or four days.

During the first 48 hours after operating, especiall}^ after
the bilateral operation, the patient should be closely watched
in reference to dyspnoea either from hematoma in the
ventricles or from edema or emphysema of the parts. If
dyspnoea becomes at all apparent, tracheotomy should be
promptly performed, or what we greatly prefer, a laryngeal
tube should be inserted and fixed securely to the margins
of the external wound by means of stout sutures, and further
security given by passing strong tapes about the neck and.
tying firmly.

Ordinarily the ventricular wounds should not be disturbed,
after the operation. The external wound should be dressed
antiseptically daily till healed ; a period of about three
weeks. Horses used for ordinary work purposes may
usually be returned to their work after five to six weeks.

S8 INTKA I 'ENO US IXJECTIOX.

14. INTRA-TRACHEAL IRRIGATION.

Objects. The washing out of oils or other insoluble or
irritant substances accidentally introduced into the trachea
and bronchi while drenching or otherwise, and the disin-
fection of the trachea and bronchi.

Instruments. Same as for tracheotomy, and a gravity
irrigating apparatus fitted with 3 m. of rubber tubing about
I cm. in diameter, 5 liters of .6 per cent, sodium chloride
solution at a temperature of 37 to 39° C. In cases of
suppurative bronchitis, peroxide of hydrogen may be added
to the solution.

Technic. Operate on the standing animal. Perform
tracheotomy (page 76). Elevate the gravity apparatus
containing the irrigating fluid i to 2 m. above the patient,
have the animal's head slightly elevated, insert the free end
of the rubber hose in the trachea tube and let the fluid flow
into the trachea in a moderate stream until it is filled and
the animal makes expulsive efforts, when the inflow is
stopped and the animal permitted to lower his head and
expel the fluid, then raise the head again and repeat until
the fluid is expelled clear. Repeat the operation according
to requirement.

15. INTRAVENOUS INJECTION.

Fig. 6.

Instruments. Scissors, hypodermic syringe.

Technic. The operation is performed on the standing
animal on either jugular vein at about the juncture of the
upper and middle thirds of the neck ; to most operators the
right jugular is the more convenient. At the place desig-
nated the subscapulo-hyoideus muscle lies between the
jugular vein and the carotid artery and affords some pro-
tection against injury of the latter. After clipping the hair,

INTRAVENOUS INJECTION. 89

the skin should be carefully disinfected preferably with
tincture of iodine. The vein lies in the jugular groove
between the mastoido-humeralis and the sterno-maxillaris
muscles covered only by the skin and skin muscle.

Stand by the shoulder of the horse and compress the
jugular with the thumb as shown in Figure 6 or with the
second to the fourth fingers, in which case the ball of the
thumb rests on the mastoido-humeralis muscle, in a way that
the vein becomes filled above the point of compression in the

Fig. 6.

Intravenous Injection.

shorn area and stands out as a swollen cord. In the case
of fleshy necked horses efficient compression is more readily
attained if the head is somewhat elevated and extended by
an assistant. If the vein cannot be made prominent in this
way the compression should be alternately applied for a
time and then withdrawn suddenly, when the course of the
vein reveals itself by a wave-like movement along the
jugular groove.

go INTRA I UNO US INJECTION.

In cattle digital compression of the jugular is not usually
efficient in causing distension. It is more practical to dis-
tend the jugular by passing a looped cord around the base
of the neck and drawing it tightly. The very conical neck
of the cow tends to cause the cord to slip forward and loosen,
which may be obviated by having an assistant grasp the
cord at the top of the neck and hold it in place. A very
efficient method for distending the jugular of the cow is to
stretch a strong cord tightly between two posts at the
heighth of the base of the neck, lead the animal against it
and secure the head firmly to a post in front of the animal
sufficiently tight to cause the lower part of the neck to
press firmly against the cord.

Just above the point of compression the vein is the most
fully distended and firmly fixed. After testing the hypo-
dermic needle to see that it is open hold it between the
second and third fingers while the thumb covers its basal
opening and thrust it through the skin, cutaneous muscle
and jugular wall, in the direction of the vein obliquely for-
wards and upwards i to 2 cm. deep, so that the point of the
needle enters the vessel at its most distended part. In this
way it is easy to prevent injury to the median wall of the
vein. If the vein has been properly punctured blood will
flow from the needle upon the removal of the thumb. If
the vein is not entered at the first attempt the needle should
be partly withdrawn and then pushed in again in a slightly
different direction.

Be careful that the hypodermic syringe contains no
air. The material to be injected should be zvarmed to approxi-
mately the body temperature. The syringe is then connected
with the needle and the contents slowly discharged into the
vein. In withdrawing the needle be careful to press the
skin firmly against the underlying part. The omission of
this precaution frequently results in the formation of a
subcutaneous hematome.

PHLEBOTOMY. gi

16. PHLEBOTOMY.
Fig. 6.

Instruments. Razor or scissors, fleams, lancet, phle-
botomy trocar, spring lancet, pins, suture material.

Technic. a. Phlebotomy zvith fleams may be performed
on either jugular vein. The operation is preferably carried
out on the standing animal, but is not difficult when the
patient is recumbent. The point of operation is at about
the boundary line between the upper and middle cervical
regions, because it is here that the subscapulo-hyoideus
muscle which separates the jugular vein from the carotid
artery is most voluminous and consequently affords the
greatest protection to the latter. At this point cHp or shave
and disinfect the skin. Grasp the extended blade of the
fleam at the hinge with the thumb and index finger of one
hand, while the third and fourth fingers compress the
jugular vein at a point far enough below that the fleam
blade rests upon the shaved part. In fleshy-necked animals
the course of the vein may be clearly made out by causing
its repeated distension and relaxation. In some very heavy
necked horses, or in very restless animals, efficient distension
of the jugular is best obtained by cording the neck as
described under " Intravenous Injection."

It is well to be careful that the point of the fleam blade is
not allowed to prick the skin prematurely and render the
animal restless. The instrument should be held perpen-
dicular to the surface and parallel to the long axis of the
vein. The most elevated point of the vessel should be
struck by the blade in such a way that the skin, subcutan-
eous muscle and jugular wall are penetrated parallel to the
long axis of the vessel.

Drive the fleam blade into the vein by a short, sharp blow
with a small stick of heavy wood. The extension on the
fleam blade prevents its being driven too deeply. The size

g2 PHLEBOTOMY.

of the blade to be used depends upon the thickness of the
skin and other tissues covering the vein. If the vein is
opened, dark red blood escapes from the wound in a large
stream. If the operation does not succeed at the first effort,
one should select an undamaged portion of the skin for a
second attempt so that the opening into the vein may be
direct and clean.

When the vein is opened lay the instrument aside. The
compression of the vessel must be continued in order to
insure the flow of blood, to prevent aspiration of air and
also to provide that the lips of the skin wound shall not be-
come displaced in relation to that of the vein by which the
escape of blood would be impeded or stopped. The flow of
blood may be favored by inducing masticatory movements
by the animal. The amount of blood withdrawn varies
between 3 and 8 liters, according to the size of the animal and
the object to be attained.

The wound may be closed by an interrupted or a pinned
suture. For the latter, relieve the compression on the vein
and grasp the lips of the skin wound between the finger and
thumb and stick the pin perpendicularly through the middle
of them a few mm. from their borders. Apply a noose of
silk ligature, previously prepared, over the pin and close and
tie the loop. In applying the pin and loop, take care not
to elevate the skin from the underlying part, which tends
to the production of a hematome.

b. With the lancet the operation is preferably performed
on the right side of the neck. Compress the vein as illus-
trated in Fig. 6, and hold the lancet between the thumb
and index finger in such a manner that it can only penetrate
as far as into the vein, and then push it in quickly just in
front of the compressing thumb through the skin, subcutem
and venous wall as deep as the fingers holding the lancet
will permit.

Hold the blade perpendicular to the long axis of the vein,
and avoid directing the point dorsalwards, which would

LIGATION OF THE CAROTID ARTERY.

93

endanger the superior wall of the vessel or cause the lancet
to glide over the wall and not enter the vein. When the
lancet has entered the vein, extend the wound somewhat
toward the head by flexing the hand dorsally. In cattle it
is necessary to compress the vein by means of a cord tightly
drawn around the neck, the operator taking the same posi-
tion as in the horse while an assistant holds the animal by
the horns or nose, or the vein may be still more effectively
distended by causing the patient to press against a tightly
stretched cord with the base of the neck as advised for
intravenous injection on page 88. Close the wound as in a.

Phlebotomy with the spring lancet is carried out in a
similar manner, the jugular being compressed in the same
way, and the lancet, with the spring set, placed over the
vein in such a way that the opening will be made in the
same direction and manner as with the fleams. The lancet
blade is then released and penetrates the vein. The com-
pression below is continued as in other cases.

c. Phlebotomy with the trocar is performed in the same
manner as has been described for intravenous injection. So
long as the flow of blood continues the compression of the
vein must not be intermitted. The phlebotomy trocar
should be about 5 mm. in diameter.

17. LIGATION OF THE CAROTID ARTERY.
Plate XVI.

Objects. The control of hemorrhage from wounds or
the prevention of hemorrhage during the removal of tumors
or other operations in the parotid region.

Instruments. Scissors, scalpel, tenacula, aneurism
needle, mouse-toothed forceps, ligation forceps, suture
material.

Technic. The operation is possible on the standing
animal with the aid of cocaine or other local anaesthetic but

Plate XVI.

Fig. I. — a, Ligation'of the common
carotid artery ; b, O^sophagotomy.

Fig. 2. — Ligation of the common
carotid artery ; c, common carotid
artery; 7, jugular vein ; v, vagus nerve;
s, sympathetic nerve ; r, recurrent
nerve ; p, cervical panniculous carno-
sus muscle ; ;//, sternomaxillaris mus-
cle ; .sV, levator humeri musclf.

Fig. 3. — ajsophagotomy. c, com-
mon carotid artery ; j\ jugular vein ;
o, o\ oesophagus ; s, sympathetic
nerve ; f, trachea ; st, masto'ido-hum-
eralis (lavator humeri) muscle.

Fig. 1.

LIGATION OF THE CAROTID ARTERY.

97

it is preferable to confine the patient in laternal recumbency
and anaesthetize.

The operation is made at the same point as for phlebotomy
and the same cutaneous wound, a, Plate XVI, may be used
for this purpose. The incision should be at least lo cm.
long extending through the skin, fleshy panniculus and
subscapulo-hyoideus muscles and then a passage forced with
the fingers to the trachea. At the region of the neck indi-
cated, the carotid passes along the border between the
lateral and dorsal surfaces of the trachea, accompanied
dorsally by the vagus and sympathetic nerves and ventrally
by the recurrent. (In Fig. 2, Plate XVI, the vagus and
sympathetic nerves, v and s, are pushed out of their normal
position and appear ventrally to the carotid.) Pass the
index finger over and behind the carotid until the trachea
is reached, and encircling the inner and lower sides of the
artery, force a way through the surrounding areolar tissue
and draw the vessel out through the wound. As a rule
the carotid is still loosely surrounded by connective tissue,
which comes from the deep fascia of the neck and in which
also the three above mentioned nerves are found. These
nerves must be carefully separated from the carotid and
must on no account be included in the ligature. Ligate
the carotid twice with an interval of about 2 cm. between
the two ligatures and divide the artery midway between
them. The second ligature is necessary in order to prevent
hemorrhage from the distal end through collateral anasto-
moses and it is essential to sever the artery in order to avoid
its rupture by the stretching of the undivided carotid dur-
ing movements of the neck where the nutrition has been
cut off at the point of ligation. Provide drainage for the
wound and suture the muscle and skin.

g8 OESOPHA GO TO MY.

18. OESOPHAGOTOMY.
Plate XVI.

Instruments. Razor, scissors, convex scalpel, straight
probe-pointed bistoury, tenacula, artery forceps, absorbent
cotton, suture material.

Technic. The operation can be carried out on the
standing or the recumbent animal. At its origin the
oesophagus lies above the trachea somewhat to the left of
the median line and as it decends it gradually deviates
farther until in the lower cervical region it lies down Slong
the left side of the trachea.

The operation is performed at any point between the
pharynx and chest where the lodgment of a foreign body
or other condition may demand it. When the oesophagus
is empty the operation is best performed in the lower third
of the neck at d, Fig. i, Plate XVI.

An incision lo cm. long through the skin and skin muscle
is made on the left side between the anterior border of the
mastoido-humeralis muscle and the jugular vein. With the
two index fingers divide the loose connective tissue down to
the oesophagus, which lies between the left scalenus muscle,
trachea and jugular vein. Along the supero-external
border of the trachea runs the carotid artery, accompanied
dorsally by the vagus and sympathetic and ventrally by the
recurrent nerves. The oesophagus feels like a round muscle
within which one can distinguish a firmer cord, the mucous
membrane. When brought into view the organ has a pale
red color, and it, with the trachea is surrounded by the
deep fascia of the neck. Pass one finger around the
oesophagus from behind, draw it away from the trachea,
force a passage through the deep fascia of the neck and
draw it out through the external wound. After making an
incision through the oesophageal muscle and mucous mem-
brane introduce a probe pointed bistoury or a scissors blade

OESOPHA GO TOM } '

99

into the lumen of the oesophagus and split its wall. The
mucous membrane is white and lies in thick longitudinal
folds.

When there is a foreign body in the oesophagus the
operation is performed at the point where it is lodged, in
the maimer described and the incision should be made only
large enough to permit its removal. In diverticuli of the
oesophagus an ellipical piece of the mucous membrane
which has been overstretched is cut out. The oesophageal
wound is closed by a laminated suture, that is, tlie mucous
membrane is united by means of an intestinal suture and
the muscular wall closed over this. The skin and muscular
wound may either be left open or closed with the Bayer
suture and bandaged, with a drainage tube in the lower
angle.

III. OPERATIONS ON THE TRUNK AND
GENITAL ORGANS.

19. PUNCTURE OF THE CHEST.

Fig. 7.

Objects. The relief of hydrothorax or pyothorax.

Instruments. Razor, scissors, trocar, i m. of rubber
tubing of the same size as the trocar, vessel for receiving
the escaping fluid, dressing material.

Technic. Operate upon the standing animal, the point
of operation in the horse being the seventh intercostal space
on the left side, and the sixth on the right. Dogs may be

Fig. 7.

Puncture of the chest ; puncture of the intestine.

laid upon the table. The anterior ribs are so covered by
the shoulder that they cannot be counted from before back-
wards and must be enumerated from behind forwards. In
the horse there are usually eighteen ribs and in the dog
fourteen. Counting ii or 12 intercostal spaces from behind

PUNCTURE OF THE INTESTINES. loi

we reach in the horse the point of operation on the left and
right sides respectively. Clip or shave the designated inter-
costal area immediately above the thoracic vein. Grasp the
trocar firmly with the thumb and index finger of one hand
at such a distance from the point as will permit the canula
to enter the chest. After the skin over the seat of operation
has been drawn aside by the hand, place the trocar at the
anterior border of the rib with the point inclined slightly
forward and with a sharp blow with the palm of the other
hand drive the instrument through the skin, cutaneous and
intercostal muscles, internal thoracic fascia and pleura into
the pleural sac. When the resistance ceases, the thoracic
cavity has been entered. Remove the stilette and permit
the pus, lymph, or other fluid to escape. This flow is at first
continuous, but later becomes rythmic, synchronous with
respiration. The intermission of the flow during inspiration
permits air to enter the pleural cavity unless precautions
are taken against it ; this is most readily obviated by slipping
one end of the rubber tubing over the exposed part of the
canula and placing the other extremity in the receptacle for
the fluid where it will be submerged. This will not only
prevent aspiration of air into the chest but will act as a
siphon to aid in the withdrawal of the fluid from the pleu-
ral cavity. In the absence of the tubing the entrance of
air may be avoided by closing the canula with the finger
after each expiration.

20. PUNCTURE OF THE INTESTINES.

Figs. 7-8.

Object. The relief of intestinal tympany.

Instruments. Razor, scissors, trocar.

Technic. Puncture of the intestine is preferably per-
formed on the standing horse but may be carried out on the
recumbent animal. The point of operation is in the right

I02 PUNCTURE OF THE INTESTINES.

flank about equi-distant from the last rib, the extremities
of the transverse processes of the lumbar vertebrae and the
external angle of the ilium in the standing horse ; at the
uppermost point of the abdomen in the recumbent animal,
that is, at the most prominent part of the distension. After
the skin at this place has been clipped or shaved and disin-
fected gasp the trocar with the index finger and the thumb
of the left hand and holding the instrument perpendicular
to the body surface, give it a firm, quick blow with the
palm of the right hand and drive it through the abdominal
wall into the intestine.

With a properly constructed trocar of the dimensions
suggested in Figure 8 no preliminary puncture with the
lancet is required or advisable. The cutting end of the
stilette should be very long, tapering and sharp so that it
will cut as freely as a lancet. By performing the opera-
tion as directed the trocar ordinarily punctures the caecum.

Fig. 8.

Intestine trocar with sheath. Outside diameter of canida 3 mm.,
length of canula, 16 cm.

Withdraw the stilette and permit the gas to escape
through the canula. The canula may become occluded by
particles of ingesta entering it and these should be removed
by reinserting the stilette. The intestine first punctured
may collapse and the flow of gas cease while the tympany
continues in other parts ; this may be overcome by reintro-
ducing the stilette and pushing the trocar through the
distal wall of the bowel and into the intestine beyond. If
this does not succeed, the trocar may be withdrawn and
reinserted in a neighboring area or if need be on the
opposite side of the animal.

SUBCUTANEOUS CAUDAL MYOTOMY.

103

In withdrawing the canula replace the stilette and press
the skin against the abdomen with the thumb and finger of
one hand while the trocar is drawn out with the other.
This tends to prevent particles of ingesta from following
the canula out of the intestine and becoming lodged at
some point in the track of the wound to set up inflammatory
processes there.

Before introduction, the trocar should always be rendered
sterile but should not bear irritant antiseptics, which be-
coming lodged in the wound tend to irritate the tissues and
produce abscesses. Puncture of the intestine is so often
extremely urgent that deliberate aseptic precautions are not
always practicable and trocarization only too frequently
results in abscesses in the abdominal wall. Its prevention
must depend chiefly upon the disinfection of the skin and
instrument. It becomes important to use an instrument
which is clean in advance. If the one one shown in Fig. 8
is well disinfected after using and the sheath is filled with
alcohol before it is screwed on, the instrument will remain
sterile until it is again unsheathed when the alcohol will
quickly evaporate and leave the trocar aseptic.

21. SUBCUTANEOUS CAUDAL MYOTOMY.
Fig. 9.

Object. The correction of curved tail.

Instruments. Sharp straight tenotome, bandage.

Technic. The point or points of curvature and their
extent are to be carefully noted by having the animal trotted
away from the operator. The curvature is generally due to
unequal development of the two levator or extensor muscles,
Fig. 9.-<?, though quite rarely the depressors,/, may be
implicated.

J04 SUBCCTAXEOrS CAUDAL MVOTOMV.

Confine the animal in stocks, or in default of these, con-
■:trol by means of a twitch and sideline. Cleanse and disin-
fect the tail and have it sharply bent by an assistant in the
opposite direction to the curvature. Locate the longitudi-
nal furrow between the levator and depressor muscles on
what has now become the convex side and at the lower
margin of the levator and just above v. Fig. 9, insert the
tenotome at the most prominent part of curvation, the
incision being parallel with the muscular fibers, and push

Fig. 9.

Transverse section of the tail. «, caudal vertebra ; c, sacro-
coccygeus lateralis muscle ; e, sacro coccygeus superior ; f,
depressor longus and brevis muscles ( saero-coccygeus infer-
ior); 7, intertransversales muscles ; a, coccygeal artery ; 5, su-
pero-lateral coccygeal artery ; /, infero-lateral coccygeal ar-
tery ; -v, caudal veins (dorsal, ventral, lateral) ; sch, caudal
fascia ; h, skin.

the instrument entirely through the muscle to the vertebra,
then turning the cutting edge upwards, at the same time
advancing the point toward the median line, .sever the
entire muscle.

The superior lateral catidal artery, s, Fig. 9, bleeds pro-
fusely if severed, and wounding of it may usually be
avoided by withdrawing the tenotome a trifle in passing
that point.

CAUDAL MYECTOMY.

105

Wounding the skin over the muscular incision is avoided
by placing the thumb of the left hand over the line of in-
cision so the knife will be recognized as soon as the muscle
and caudal fascia are cut through. Remove the knife in the
same manner as introduced. Release the horse and have
him trotted again. If the operatio7i is stifficient, the tail
should acrve in about the same degree as before, but in the
opposite direction. If this has not been attained examine
carefully and sever any remaining bundles of muscle, and
this not sufficing repeat the operation as before at another
point 5 or 6 cm. above or below the first, severing the muscle
again. Or if the depressor appears imphcated, sever it in
a similar manner. In extreme cases the entire lateral half
of the caudal muscles, tendons and aponeurosis may be
severed.

Apply an antiseptic pad to the wound and retain it by a
moderately firm bandage, which serves at once as an occlu-
sive dressing and effective hemostatic. Remove the band-
age after 24 hours. By this plan of operation it is not
intended to tie the tail to the side of the animal during the
time of healing but when bandaging immediately after the
operation, the tail should be held away from the side toward
which it formerly curved so that the bandage may tend to
prevent the return of the organ to its former position.

22. CAUDAL MYECTOMY.
Fig. 9 and Plate XVII.

Objects. For the prevention of the gripping of the reins
by the tail.

Instruments. Elastic ligature, straight bistoury, ten-
acula, absorbent cotton, bandages.

Technic. Confine the animal in lateral decubitis or in
stocks, cleanse and disinfect the parts and apply the elastic

Plate XVII.

Caudal Myectomy To Prevent Gripping
of the Reins.

DC, Depressor coccygeus loiigus muscle ; T,
tourniquet.

AMPUTATION OF TAIL. 109

ligature as close as possible to the root of the tail. Have
an assistant hold the tail upwards, i. e., dorsalwards, and
tightly stretched. Make an incision 15 to 20 cm. long, over
the middle of the inferior surface of each depressor longus
muscle, beginning close against the elastic ligature and ex-
tending toward the apex, severing at once the skin and
caudal fascia down to the muscle. Let an assistant retract
the lips of the incision with tenacula while the operator
dissects the depressor longus muscle, DC, Plate XVII, from
the adjacent tissues at either side, sever it by a transverse
incision close against the ligature and dissect away the en-
tire muscle down to the lower end of the wound and there
excise it. Repeat the operation on the opposite side.

Make two elongated tampons of absorbent cotton, of the
size and form of the muscles removed, saturate these with
i-iooo sublimate solution, insert neatly in the wounds and
over this to aid in securing antisepsis and to equalize the
pressure apply a pad of absorbent cotton, saturated with
sublimate solution, covering the wounds and encircling the
tail and secure by a moderately firm bandage as closely as
possible to the elastic ligature. Remove the ligature, when
hemorrhage may ensue, which is to be controlled by the ap-
plication of a second bandage extending higher up on the
tail. Remove the bandage in 24 hours and dress as before
for a second day after which treat as an open wound. Care
should be taken to not apply the bandage too tightly or
leave it in place for more than 24 hours, since otherwise
necrosis of the tail is liable to occur and necessitate
amputation.

23. AMPUTATION OF THE TAIL.
Plate XVIII.

Objects. The treatment of malignant, or incurable dis-
eases of the tail.

Instruments. Elastic bandage, scalpel, razor, artery
forceps, bone cutting forceps, suture material.

Plate XVIII.
Amputation of the Tail.

Fig. I. — Tail amputated showing flaps un-
sutured ; B, Bandage securing hairs turned
upward out of operator's way.

Fig. 2. — ^Operation completed showmg su-
tures ; B, Bandage applied to secure hairs of tail
upwards out of operator's way.

Fig. 1.

Fig. 2.

AMPUTATION OF THE TAIL.

113

Technic. The animal may generally be operated upon
in a standing position secured in the stocks or with the aid
of the side line. lyocal anaesthesia may be applied by in-
jecting cocaine or other drug deeply upon the nerve trunks
as well as just beneath the skin. The animals' attention
may be attracted by means of the twitch if found necessary.
The point of amputation is determined by the location of
the disease. Over the area of operation clip the hair, shave
and thoroughly disinfect. Apply the tourniquet or elastic
bandage at the base of the tail so as to render the operation
bloodless.

Above the seat of operation turn the hair upward toward
the root of the tail and secure it there by means of the
bandage, B, Fig. i, Plate XVIII. Locate as accurately as
possible the position of a joint at the point where it is desired
to operate and with the scalpel begin an incision on the
median line on the upper side of the organ about i cm.
above the articulation and carry this obliquely outward for
a distance of 4 to 6 cm. according to the size of the tail and
then continue it downward, backward and inward along the
side and inferior surface until directly opposite to the place
of beginning. Make a similar incision upon the opposite
side of the tail, cut through all the connective tissue and
muscles down to the bone and then disarticulate with the
aid of the scalpel. Search for the arteries and control the
hemorrhage by torsion or ligation. The vessels will be
more readily found by loosening the tourniquet so as to
permit the blood to flow.

Some operators prefer to begin the incision at the side of
the tail instead of upon the dorsal surface and in that way
have a dorsal and ventral flap instead of right and left as
indicated in Fig. i, Plate XVIII. The excision having been
completed the flaps are brought together by means of strong
silk or silk worm gut sutures as shown in Fig. 2. The

114

URETHROTOMY. LITHOTOMY.

sutures should be begun at the apex of the two flaps and
comparative!}' deep.

Disinfect the stump thoroughly and if the hair is suffici-
ently long it is well to draw it down over the wound,
to which an antiseptic covering has been applied, and retain
the dressing in position by tying a cord around the hair just
beyond the point of amputation.

24. URETHROTOMY. LITHOTOMY.
Figs. 10-11.

Objects. For the removal of calculi from the bladder
or urethra or performing other operations on these parts.

Instruments. Catheter, convex scalpel, scissors, artery
and compression forceps, tenacula, lithotome, lithotomy
forceps, lithotrite, absorbent cotton, drainage tube, suture
material.

Technic. Urethrotomy may be performed on horses in a
standing position, the hind feet being secured with hobbles.

It is best, however, to operate under anaesthesia with the
patient in lateral or dorsal recumbency, either on the operat-
ing table or cast, being careful to .secure as gently as possi-
ble, having first emptied the bladder if practicable, since
rupture of an overdistended viscus may readily occur during
violent struggles by the animal.

The point of operation will depend upon the location of
the calculus or other obstacle. If it is found in the pelvic
portion of the urethra or in the bladder, the operation is
made at the ischial notch. Fig. lo. First the penis is drawn
out from the prepuce and the catheter introduced into the
urethra and pushed upward until it has passed the ischial
notch. After disinfection of the skin, render it tense and
make a ,5 cm. long incision on the median line at the ischial
arch through the skin, bulbo-cavernosus muscle, spongy
portion of the urethra, and the urethral mucous membrane

URETHROTOMY. LITHOTOMY. ^^

down to the catheter, Fig. 1 1 , k. In order to prevent infil-
tration of urine after the operation, special care is to be
taken to make the lower end of the wound slanting in such
a manner that the deeper margin is higher than the
superficial.

After the catheter has been drawn back away from the
ischial arch, introduce the lithotomy forceps into the urethra
or bladder, grasp the stone and draw it outward in its natural
direction. The grasping of the stone with the forceps is

Fig. 10.

Urethrotomy at the ischial notch.

materially aided by means of the left hand introduced into
the rectum. One must avoid grasping, along with the
stone, the mucous membrane of the bladder. Partial filling
of the bladder with a tepid aseptic solution will aid in grasp-
ing the calculus and in avoiding the implication of the
bladder walls. Bj^ careful rotary movement and pushing
the forceps backward and forward the operator can deter-
mine before traction is exerted if the forceps can be with-

Ii6

URETHROTOMY. LITHOTOMY.

drawn easily and without much resistance through the neck
of the bladder.

If the stone is so large that it cannot pass the neck of the
bladder lithotripsy may be performed. This operation re-
quires time and patience, since as a rule it is not possible to
encompass the entire calculus with the forceps. That is,
the narrowness of the neck of the bladder prevents the
sufficiently wide opening of the forceps. The stone con-

Fig. 11.

Urethrotomy (life size), /r, skin; a, retractor penis muscle;
/), bulbo- cavernous muscle ; r, spongy urethra ; //, urethra ;
k, catheter.

sequently must be gradually broken off at its periphery and
the individual pieces of calculus removed. The character
of the surface of the stone has an evident bearing upon the
practicability of lithotripsy.

The surgical dilation of the pelvic urethra with the
lithotome is usually far more practical than the crushing of
the stone. Introduce the instrument and divide the urethra
upward on the median line as the instrument is withdrawn.

AM PUT A 7 ION OF THE PENIS. 1 1 7

In order to prevent injury to the rectum it should be emptied
of feces before the operation is undertaken. After the re-
moval of the stone, the operator may push the catheter
again over the ischial arch and unite the lips of the wound
in the urethral mucous membrane by means of intestinal
sutures. Flush the bladder and urethra by means of a
warm, 3 per cent, boric acid solution injected through the
catheter and then withdraw the latter. Finally, suture
the skin wound and insert a drainage tube or iodoform gauze
in the lower angle.

Or the whole wound may be left entirely open and dressed
daily with antiseptics. In case the pelvic urethra has been
divided the suturing of the external wound is of questionable
utility.

(For student practice on an anaesthetized horse, intro-
duce a stone into the bladder through the urethral wound
and practice grasping and removing it with the lithotomy
forceps. )

25. AMPUTATION OF THE PENIS.
Plate XIX and Fig. 12.

Instruments. Scalpel, elastic ligature, strong silk
suture, strong piece of tape i m. long, artery and compres-
sion forceps.

Technic. The operation is carried out on the recumbent
animal under local or general anaesthesia, the upper hind
foot being drawn backward or upward or otherwise so fixed
as to not obstruct the field of operation. The point of
operation is determined by the character of the disease and
the object to be attained. It may be made at any point
from the glans penis to the attachment of the corpus caver-
nosum to the ischium. If possible amputate in front of the
preputial ring.

•^ i^i u t

t" 5 > u 1-1

rt o j5 -M 3

H-||S«

LT iH - -S

. o o O ^

s a ^ o

i"" ll

g""l.i

of op
liquet

Skin;
L, Lig
operat

& § «:' »• "S

^2»-||

jn v< +j CX

■^ ^ :S Ji g

-Fi:
used
ure
U, U
—Co

rt

u

W a; O .- Ci

,a

ti)S g 1 bi)

sai|-=-

D

t 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

Amputation of the penis, showing needle inserted for a snture.
V, Dorsal vessels of penis ; A, Fibrous tunic of the corpus
cavernosum ; S, Skin ; CC, Corpus cavernosum ; CS, Corpus
spongiosum of urethra ; U, Urethra.

above the assistant's liaiid 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 AMPUTATIOX OF THE PENIS.

Apply a small cord just behind the glans 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 raucous 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 OVA RIO TOM Y IN THE MARE. 1 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 fiat and occupy a minimum amount of space.
In the quiescent state the vaginal walls are in contact and
from the perinaeum forward to within about 10 cm. of the
uterine os, the vulva and vagina are connected above with
the rectum by the pelvic connective tissue, while anterior
to this point the vagina is covered by peritoneum, and it is

124

VAGINAL OVARIOTOMY IN THE MARE.

in this area that the incision needs 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.

Colin's scalpel.

straps beneath the body to prevent lying down, straps or
ropes before and behind the animal to prevent backward
and forward movements, all four feet pinioned to the floor,
and the tail firmly secured and stretched to a beam above.
Apply a bandage to the tail extending for a distance of 12
to 15 inches from the base of the tail in order to secure the
tail hairs out of the way of the operator.

With soap, water and brush cleanse the tail, perineum and
vulva thoroughly, being especially careful to remove all

VAGINAL OVARIOTOMY IN THE MARE.

125

detachable masses of sebum ; 50 per cent, alcohol may be
used sparingly to aid in removing this. Too free a use of
alcohol excoriates the delicate skin. Cleanse the clitoris
carefully. Follow the washing with a free application of
i: 1000 aqueous sublimate solution to the external parts and
for a short distance inside the vulvar lips and to the clitoris.
Do not introduce irritant disinfectants into the healthy
vagina nor deeply into the vulva as it may cause severe
straining during and subsequent to the operation and b}' in-
juring the vulvo- vaginal mucosa favor subsequent infection
of the vaginal wound.

Wash awaj' the sublimate solution with a tepid 0.6 per
cent, soda bicarbonate solution, and fill the vulvo-vaginal
canal with the same. After thorough disinfection of the
hands and arms remove the disinfectants by washing in
sterile soda solution, which at the same time renders the
hand unctuous and readily introduced through the vulva.
Armed with the guarded sterilized scalpel, Fig. 14, intro-
duce the right hand into the vagina promptly and when it
is well " ballooned " unsheath the knife and placing it just
above the os uteri parallel to the long axis of the uterus and
a few mm. to the right or left of the median line in order to
avoid a loose fold of mucous membrane generally existing
there, the blade being held vertical, that is the cutting sur-
face parallel to the longitudinal muscular fibers of the
vagina, and guarding the possible extent of its introduction
with the thumb and fingers, push it directly forward in a
straight line with a quick thrust through vaginal mucosa,
the muscular walls and the peritoneum, until the disap-
pearance of resistance indicates that the latter has been
penetrated. This is the most critical step in the operation.

If the hand is introduced into the vagina immediately
after the injection of the sterile saline solution the vagina
will generall}' be found " ballooned '' or will quickly become
inflated under manual movements. If the solution is thrown

126 VAGINAL OJ'ARIOTOMY 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 J A RIO TOM \ ' IN THE MA RE. 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
days, and feed lightly on a laxative diet.

II. In operating under anae.sthesia the animal should be
cast or confined upon the operating table in lateral re-
cumbency preferably with the posterior part of the body
somewhat higher than the anterior so as to avoid visceral
pressure in the pelvic cavity. Place the animal under com-
plete anaesthesia. Prepare the parts in the same manner
as already described. Carry the knife into the vagina in the
manner previously described and render the roof of that
organ tense by pushing the os uteri downward and forward
with the hand or by means of a vaginal tensor or speculum.
It is important that the vagina be held well down toward
the floor of the pelvis so as to carry it away from the rectum,
posterior aorta and iliac arteries while the incision is being
made. The incision is now to be made just above and be-
hind and a trifle to one side of the os uteri in essentially the
same manner as under I, except that when the vaginal
tensor is used the cut is made upward and backward instead
of directly forward. The remainder of the operation is
identical with what we have described under I. Under
anaesthesia the vagina is flaccid and can not be made to
" balloon."

128 VAGINAL OVARIOTOMY IN THE MARE.

DANGERS.

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

Wounding of the uterus may occur when the incision is
directed downward and may greatly embarrass the operator
and confuse him by passing the hand through the incision
into the uterine cavity. It is to be avoided in the first
operation (without anaesthesia) by carefully directing the
incision straight forwards. When the accident occurs it is
of little consequence beyond the 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 men)brane will be pushed
away from the subjacent tissues.

Incomplete penetration of the vaginal wall is liable to
occur if the scalpel is dull ox the vagina imperfectly "bal-
looned " and flaccid, or if the operator is unduly timid. It
is best prevented by avoiding the causes as related, and
once it has occurred it is generally best to again "balloon"
the organ in the operation without anaesthesia and make a
new incision either to the right or left of the first. It may
be overcome also by thrusting the index finger through the
peritoneum as described in the preceding paragraph or
completing the cut with the scalpel.

The mistaking of a ball of feces for the ovary has oc-
curred to inexperienced operators and the fatal error of re-
moving the portion of the rectum surrounding the fecal pellet
committed. The blunder is uncalled for ; the fecal ball is
movable in the bowel, the intestine is far more massive
than the broad ligament, and the ovary is to be definitely
identified by its being lodged in the broad ligament just
9

I30

I'AGINAL OVARIOTOM)- IN THE COW.

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 verj^ 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 internally and locally according
to general surgical principles.

27. VAGINAL OVARIOTOMY IN THE COW.

Objects. Increasing the fat- or milk-producing qualities
and the cure of nymphomania or other ovarian disease.

Instruments. Colin's scalpel, vaginal dilator. Miles'
spaying shears, spaying ecraseur.

Technic. Confine the cow in the standing position in
the stocks, secure the head firmly and pass two boards be-
neath the abdomen and sternum to prevent lying down, and
a rope over the middle of the back to prevent arching of
the spinal column and straining.

VA GINAL O VARIO TOM \ ' IN THE CO W. 131

Wash and disinfect the tail and the perineum and flush
out the vagina with a 0.5 per cent, solution 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 fimbrise 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

\AGINAL OJARIOrOMY 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 away 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 the.se, cast the animal and
secure it in recumbency with the legs extended and body
stretched by fastening the ropes to two strong posts about
8 to 10 m. apart. The operation may be performed in either
flank.

Clip the hair from the upper part of the flank, disinfect
an area 15 to 25 cm. square and make an incision about 12
cm. long beginning at a point equi-distant from the anterior
tuberosity of the ilium, the ends of the transverse processes
of the lumbar vertebrae and the last rib and extend it down-
wards perpendicularly severing the skin and subcutaneous
muscle. Divide the external oblique muscle in the direction
of its fibres by means of the scalpel handle or the fingers
and repeat the process upon the internal oblique after which
puncture the peritoneum with the scalpel. Some operators
cut directly through the entire abdominal wall at a single
stroke, but this comes to the operator only by experience.

Force one hand through the opening into the peritoneal
cavity and search for the ovaries at the same point and by
the same method as in the preceding operation, that is,
locate the uterus within the pelvic cavity, between the
rectum and bladder and trace it, the cornu, and broad
ligament to the ovary. The uppermost ovary can be drawn
out through the wound and cut off with the scissors or
ecraseur ; the lower one must be held with one hand and

134

OVARIOTOMY IN THE BITCH.

the instrument introduced along the arm and when the
ovary is reached, apply the scissors or ecraseur and cut or
crush it off. The beginner must always remember that the
positive means for identifying the ovaries is by tracing the
uterus from the vagina along its cornua to the oviduct and
thence to the organ in the broad ligament. Cleanse the
wound and close the skin incision with continuous sutures.

29. OVARIOTOMY IN THE BITCH BY THE FLANK.
Plate XX.

Instruments. Spaying knife, suture material.

Techic. Confine the animal in lateral recumbency,
preferably upon the right side for a right handed operator,
the head somewhat depressed, the limbs extended and the
body well stretched. Clip, shave and disinfect a sufficient
area in the exposed flank at a point just anterior to and be-
neath the external angle of the ilium. With one hand grasp
the skin fold of the flank and render the skin of the region
tense, while with the other holding the spaying knife like a
pen make at first a drawing incision from below upward
about 2 to 3 cm. long, ending above at a point slightly be-
low the external angle of the ilium, the incision extending
through the skin and subcutaneous tissues ; without remov-
ing the knife from the wound elevate the handle and with
a quick thrust make a stab wound extending through the
external and internal oblique muscles and peritoneum at a
single cut. The operator can determine when the peritoneal
cavity 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-preguant bitch Ij'ing on
the back with the abdominal floor removed and
the onventiim 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.

RUC-

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 coruu 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

CASTRA TION OF CRYPTORCHID HORSES. 143

from the operative area. The cat being more subject to
infection than the bitch the aseptic precautions must be of
the strictest possible character. The operative area must
be thoroughly disinfected and cleansed and equal care must
be taken not to introduce irritant disinfectants into the
wound. A great danger also exists in the tendency of the
muscle layers of the abdomen to readily become separated by
pressure from the finger and form a pocket in which wound
discharges accumulate and constitute a dangerous seat for
infection. Great care must therefore be taken to make a
clean incision directly into the peritoneal cavity and to
avoid separating the peritoneum from the muscles or the
muscular layers from each other. The uterus and ovaries
of the cat are naked and far more easily distinguished than
in the bitch, there being no extra deposit of fat in the broad
ligament. The sutures are to be applied to the wound in
the same manner as in the bitch.

32. CASTRATION OF CRYPTORCHID HORSES.
Plates XXI and XXII.

Instruments. Scalpel, emasculator.

Technic. Confine the animal by casting in the dorsal
position with the hocks well flexed and both posterior
limbs completely abducted so as to fully expose the inguinal
region. Or secure upon the operating table on the side
oppo.site to the retained gland and abduct the upper pos-
terior limb by drawing it upward by means of a pulley.
Cleanse and disinfect the inguinal region. Anaesthize.
Make an incision about 10 to 12 cm. long through the skin
and dartos directly over the normal position of the scrotum,
parallel to the median raphe about 4 or 5 cm. distant from
it. Insert the two index fingers in the wound, press
them into the areolar tissue toward the external inguinal

144

CAS7 /NATION OF CRYPTORCHID 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 by
unrecognized (inguinal cryptorchidy) lying in this region
covered by peritoneum and the cremasteric fascia. Some-
times the epididymis has descended to the scrotal region
while the testicle remains within the abdomen, thus result-
ing in a long, narrow inguinal canal.

Pass the hand upwards, outwards and forwards along the
aponeurosis of the small oblique until the crural arch is
reached slightly anterior to the crural ring in which the
pulsating femoral artery can be felt, and palpate at this point
in the muscular wall for the internal inguinal ring which
varies greatly in different individuals but usually reveals
itself to the fingers as an oblong slit or ring about one inch
in length covered only by peritoneum. Through this usually
extends a portion of the gubernaculum testis or of the vas
deferens.

Examing Plate XXI, the peritoneal view of the internal
ring is shown crossed by the dotted line, V, of the upper or
right testicle, into which extends a short distance the tail
of the epididymis. In the lower or left testicle the ring
has been opened and the gland lies in a position correspond-
ing to the right and showing the epididymis and vas defer-
ens lying in the processus vaginalis, P. The surgical rela-
tion of the parts is further illustrated in Plate XXII, where
the testicle is completel}^ 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 XXI.

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 \.o find \.\\^
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 lirs. colt. P, processus
vaginalis surrounded by a dotted line and containing a curved sound,
vS ; G, first portion of gubernaculuin testis ; G', second portion of gul)-
ernaculum testis extending to the epididymis, E ; E, epididymis ;
Q'\ gubernaculum extending from epididymis (globus minor) to the
testicle ; T, testicle ; A, testicular artery ; V, V, vasa deferentia ; B,
uriuarv bladder ; UA, um1)ilical arteries.

m

^

to

/'■

QQ

\ /
V

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 easil}' applied.

There are other causes of cryptorchidy which in rare cases
require a different procedure in order to extract the gland
varying with individual cases but the essentials for the
tracing and recognition of the testicle are the same.

Prior to attempting the operation it is well to make a
rectal exploration and determine as far as may be the loca-
tion of the testicle, whether it be on the right or left side,
and its character, should it be in any way pathologic.

After the testicle is brought to the surface it may be re-
moved with the emasculator or by such means as the opera-
tor may prefer. Cryptorchid testicles when due to arrest
in development are not vascular and there is little tendency
to hemorrhage after exci.sion. Place an antiseptic tampon
in the wound, pushing it well up against the internal ring
and retain it in position by means of sutures for a period of
24 to 48 hours when it is removed and the wound dressed
antiseptically.

The operation for cryptorchidy in the smaller animals is
essentially the same as in the horse except that the incision
is to be made ordinarily through the flank as in spaying.
The same attachments are to be our guide and the operation
is to proceed upon almost parallel lines.

IV. OPERATIONS ON THE EXTREMITIES.

33. TENOTOMY OF THE FLEXORS OF THE PHALANGES.
Plate XXIII.

Objects. The relief of contraction of the flexor tendons
of the foot.

Instruments. Razor, scissors, sharp tenotome, bandage
material.

Technic. Tenotomy is generally performed on the
flexor of the third phalanx, seldom on the superficial flexor
or flexor of the .second phalanx.

Confine upon the operating table with the affected
member undermost and the foot fully extended. In default
of a table confine in lateral recumbency and apply an exten-
sion splint to the foot as shown in Plate XXIII.

On the median side at the middle of the metacarpus or
metatarsus the skin is shaved and disinfected over the
tendon of the flexor pedis muscle. The location named lies
between the lower extremity of the great carpal or tarsal
sheath above and the superior extremity of the tendonous
sheath of the fetlock below, .so that neither of these is
wounded during the operation, but the tendon is severed at
a point where it is invested by loose connective tissue which
retains the divided ends in their normal line of direction,
somewhat fixed, and favors their ultimate 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-

4 - -

1 5 ^

U .2

o o
5 P

156 TENOTOMY OF FEXORS OF PHALANGES.

ateh' 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 concavit}^ 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 w^hich 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 ; /, 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 accomplishing 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 may 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
cunean tendon.
ergot.

of spavin lameness. CT,
The dotted line crosses the

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 theretp. 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

J 62 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 b)'^
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
neurotomj^ 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. 1 67

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 lies 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, ly, 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 betw^een 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. 169

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 arterj' forceps, tenacula, aneurism needles, suture ma-
terial, elastic ligature.

Technic. It is well to shave the site of operation and
thoroughly 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 immediately in
front of the flexor pedis tendon a channel- like depression
extending from above the fetlock dow^nward 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, «, 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 so 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 ; z, suspensory
ligament of fetlock ; ;;/, metacarpus.

PLANTAR NEUROTOMY.

173

cision 3 to 5 cm. long, the lower angle of which is usually
just above the fetlock joint, cutting directly through the
skin, subcutem 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, 0. 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.

174 NEUROTOMY OF THE MEDIAN NERVE.

38. NEUROTOMY OF THE MEDIAN NERVE.
PlatB XXVIII.

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, incHned
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 immediately
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 needs be careful not to prick this vein with
the tenacula, as the hemorrhage therefro?n is exceedi^igly annoy-
ing'during the operation. Avoid the use of tenacula after pene-
trating the fascia and retract the tvound lips cautiously with
aneurisr7i Jieedlcs 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 not cut the nerve too high ajid erroneously
include the motor nerve of the flexor of the metacarpus and
the flexors of the foot, which is generally giveyi off posteri-
■orly just below the htcmero 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 ; n, median
nerve ; v, brachial vein ; f, antibrachial fascia ;
p, Fterno-aponeuroticus muscle.

NEUROTOMY OF THE ULNAR NERVE.

179

Tamponade the wound with dry iodoform gauze and ap-
proximate the skin with a continuous suture. The tampon
and sutures remain 1 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 by
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, EF
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;/, oblique (middle) flexor
of the carpus ; a, collateral ulnar artery ; d,
antibrachial fascia ; n, 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.

i85

SCIATIC NEUROTOMY.

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, n, 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
hand 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. Exci.se 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,
/, crural fascia; «, 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 arter}- ; 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.

f«

'^

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, n, 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 in fro7it 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-XXXI/I.

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, aud
the peronens 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 anterior 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 ram. 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.

ig6 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 ra.sp. 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 /z^^/*/}/
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 coronary 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 sufficient 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 closely 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 ; zv, coronary band ; k, anterior half of cartilage ; A, cavity
caused by the removal of the posterior half of the cartilage ; n, necrotic
cartilage ; />, parachondral surface of the skin and sensitive laminae ;
s, perpendicular, crescent-shaped incision in the horny wall ; £\ 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 ca?'tilage.

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
.against the cartilage, material danger of penetrating the

RESECTION OF THE LATERAL CARTILAGE. 201

joint is avoided. Remnants of cartilage at its juncture
with 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 sufficient 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 soap, 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
^2 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

Resection of the Flexor Pedis Tendon.

fl
Solar surface of the foot, r, Semi-lunar crest of os pedis ;
u, OS pedis ; r, navicular-pedal ligament ; s, navicular bone ;
d, flexor pedis tendon ; e, sensitive laminae of the bars ; si,
fatty frog ; /, sensitive frog ; //, 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

AMPITATION OF THE CLAWS OF RUMINANTS.

pedis tendon is united to this b}- 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 ; k, 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 ; ;;/, 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 ; t\ retention suture (closed end); e' , open
end ; b, fixation suture for the drainage tube ; f, continuous approxi-
mation suture.

passed through the needle eye in such a manner that the loop
extends considerably beyond the cut ends ; small needles
and thread ; needle forceps ; rubber tubing preferably two
large pieces and one small with lateral openings ; thin wooden

14

2IO THE BAYER SUTURE.

splints 15 cm. long, 2 to 4 cm. wide, with rounded ends ;
iodoform gauze ; iodoform ether 1:10.

Technic. After the skin has been shaved over an area
having a radius of 5 to 6 cm. from the wound, the suture
needle is inserted 2 to 3 cm. from the lips through the skin
and subjacent tissues, a piece of the rubber tubing, d' , passed

Fig. 17.

Splint Bandage.

d, d\ d" , drainage tubes ; t% retention siiture (closed ends); e' , do,
open end ; j, iodoform gauze ; ^, splints.

through the closed end of the suture and the thread drawn
tight. If before threading the needle a clove hitch is made
at the middle of the thread, or if threaded as above directed
and the thread is thrown about the tube in a double noose,
the two threads will be kept in contact as they leave the tube
to enter the soft tissues and thus prevent to some degree,
the pressure necrosis otherwise taking place, due to the tense

THE BA YER SUTURE. 21 1

threads of the suture separating from each other. The
needle is then passed through the opposite lip of the wound
from within to without at the same distance from the lips,
the needle removed, the free ends drawn taut and a single
knot tied against the skin to prevent the separation of the
two threads for the reasons just stated above. The second
large tube, d" , is laid between the open ends of the double
silk thread and these are tied upon it with a triple knot,
after they have been drawn sufficiently tight that the
approximated wound lips form a crest. If the lips of the
wound can be grasped with the hand and held together in
such a manner as to form a ridge 3 or 4 cm. long, the
suture needle may be passed through both simultaneously.
The first suture should be located about 3 cm. beneath the
upper angle of the wound, the other retention sutures follow
at distances of about 5 cm. from each other and applied in
the same way.

The lips of the wound are then united by continuous
approximation sutures like an overcasted seam. This
suture ends at least 2 cm. above the lower angle of the
wound. The third tube, for drainage, is introduced be-
neath the latter sutures and fixed by a special suture.

The entire cutaneous surface lying between the drainage
tubes is covered with iodoform gauze, and between each two
retention sutures there is laid over this gauze the wooden
splints previously cut to the proper size, the ends of which
are pushed under the tubing. The upper- and lowermost
splints should be secured to the drainage tubing by means
of sutures passed through them. The entire bandage is
finally saturated with iodoform ether. The bandage and
retention sutures remain eight days, the approximation
sutures fourteen.

II. EMBRYOTOMY OPERATIONS.

Fig. 18.

General Considerations. The following exercises in
embryotomj' operations are designed to give to the student
a general view of the subject by a simple plan as carried
out through the aid of a skeleton provided wnth an artificial
uterus into which are placed freshly killed, newly born
calves in such a position as may be desired and the opera-
tions carried out by the student as described. At the same
time it is hoped to offer through these descriptions to the
veterinary obstetrist a simple and effective plan for perform-
ing embryotomy which has been fully tested by the author
in an extensive obstetrical practice. In describing these
operations we purposely limit the instruments to be used to
the fewest number and simplest kinds, yet using all that are
essential in the performance of any of the following obstet-
rical operations. We designate the same instruments for
each operation. They are, see Fig. i8 : a hooked ring knife;
a Colin's scalpel ; an embryotomy chisel ; long blunt hook ;
short blunt hook ; repeller ; probe pointed sector ; injection
pump ; mallet ; several cotton ropes i cm. in diameter with
a small spliced loop at one end.

46. CEPHALOTOMY.

Object. The diminution of the size of the head on ac-
count of its oversize or of the smallness of the maternal
pelvis, so that it may pass through the pelvic canal.

Technic, In these cases the head is usually engaged in
the canal sufficiently tight that no further fixation is neces-
sary. Should further fixation be desired, fix the long blunt
hook deeply in one orbit. After thoroughly cleansing and
disinfecting the parts inject a copious amount of tepid lysol

CEPHALOTOMY.

213

or bacterol solution into the vagina, then carry the chisel
carefully guarded by one hand into the passage and place
it accurately upon that part of the head of the fetus where
it is desired to begin the operation ; generally on the median
line of the nose with the blade of the chisel standing
parallel to the septum nasi of the fetus. Holding the blade

Fig. 18.

Aseptible Embryotomy Outfit.

A, embryotomy chisel ; B, repeller ; C, sector ; D, long blunt
hook ; E, short blunt hook ; F, ring knife ; G, hook knife ; H,
Colin's scalpel. The lower figure represents the entire set with
injection pump arranged in aseptible metal case.

2 1 4 DE CAPITA TION.

ot the chisel firmly against the part with one hand in such
a manner as to effectively guard the instrument from slip-
ping aside and wounding the maternal organs, steady and
direct the handle with the other hand and have an assistant
drive the chisel by means of blows of proper vigor with the
mallet into the bones of the face and head. Do not drive
the chisel deeper than the length of the blade without stop-
ping and forcibly revolving it upon its long axis and break-
ing the foetal bones apart. The partially detached pieces of
bone may be torn away with the fingers or in case the skin
is quite adherent to them the bone may be held with the
fingers of one hand, the chisel introduced with the other
and using it as a spatula complete the separatioi;. Repeat
the use of the chisel as often as may be necessary in order
to bring about the required diminution of the head, care
being taken at all times not to wound the maternal parts
and to conserve as far as practicable the skin of the fetal
face and head in order that it may protect the maternal
parts from the jagged bones during the passage of the re-
mains of the head. The removal of the partially detached
pieces of bone may in many cases be greatly facilitated by
looping a cord over them and having an assistant apply
traction sufficient to pull them away, the operator guarding
the maternal organs by holding the piece of bone during its
detachment and extraction, in the palm of his hand.

47. DECAPITATION.

Objects. The facilitation of repulsion and correction of
the deviation of fetal parts. The operation is generally car-
ried out when the fetal head is far advanced in the pelvic
canal or has passed beyond the vulva.

Technic. Attach a cord to the inferior maxilla or around
the neck of the fetus and have one or more assistants draw
the head out as far as possible.

SUBCUTANEOUS A MFC 'TA TION. 2 1 5

Some obstetrists have found difficulty in applying traction
to the inferior maxilla by means of a cord. First make a
perforating wound with the knife between the rami of the
lower jaw, then carry the looped cord over the jaw and push
it beyond the perforating incision with the loop resting
within the mouth and finally pass the free end of the cord
through the perforation from the buccal cavity outwards,
and drawing upon this the inferior maxilla is so engaged
that it will permit the application of powerful traction.

Make a circular incision through the integument encir-
cling the head at a convenient point and separate the skin
backward toward the occiput by forcing the hand between
it and the bones or by using the chisel as a spatula or
dissecting it away with the Colin's scalpel, continuing the
separation over the occiput to the atloid region. Make a
transverse incision below across the trachea and oesophagus
and surrounding muscles and above through the ligamentum
nuchae. Grasp the head firmly with both hands and twist
it forcibly on its long axis rupturing the articular ligaments
and the remaining muscles and other soft tissues, detaching
the head at the occipito-atloid articulation. The removal
of the head greatly diminishes the bulk of the fetus and it
may now be repelled, or deviated parts brought into the
desired position or other operations performed.

48. SUBCUTANEOUS AMPUTATION OF ANTERIOR LIMBS.

Objects. Amputation of the anterior limbs is very
frequently called for in obstetric practice especially in the
mare, chiefly in cases of transverse presentation with all
four feet presenting and the head retained where it may be
impossible to safely correct the deviation ; in cases of wry
neck in the foal in the anterior presentation, when it is
impossible to correct the deviation of the head, or in any
case in the mare or cow where deviation of the head cannot

2 1 6 SUBCL TANEOUS AMPUTA TION.

be corrected or is not so readily overcome as is the amputa-
tion of the limb.

Technic. Our herbivorous animals being devoid
of a clavicle, the anterior limb is attached to the thorax by
means of the skin and muscles only and is therefore compar-
atively easily amputated. Attach a cord to the pastern of
the limb, the shoulder of which lies most exposed or is most
readily reached and have one or two assistants exert traction
on it and draw it out as far as possible with safety to the
mother. Insert one hand armed with the hooked embry-
otomy knife up to the top of the scapula or as nearly thereto
as can be reached, the knife being well guarded in the palm
of the hand which rests against the limb of the fetus ; press
the knife into the skin and subcutaneous tissues and drawing
the hand downward slit them freely and deeply from the top
of the scapula down to the pastern. Lay aside the knife and
force the fingers between the skin and subjacent tissues of
the limb and while the assistant maintains gentle traction,
separate the skin upward by forcing the hand or the ball of
the thumb through the loose connective tissue until the
upper region of the scapula is reached. The separation of
the skin from the subjacent parts may require at certain
points, like the olecranon or carpus, the aid of the chisel
or knife to divide firm bands of connective tissue. This
separation of the skin from the subjacent parts has removed
the chief source of resistance to the tearing of the limb
away from the body. The next most important obstacle is
the pectoral muscles which should be torn asunder by sep-
arating them into small bundles and tearing them through
with the fingers between the sternum and limb, or the pro-
cess may be aided by incision with a knife or the chisel.
When these are well divided the remaining impediment to
tearing the shoulder away consists largely of the trapezius
and rhomboideus muscles at the top, the latissimus dorsi be-
hind, the great serratus and the angularis scapula which

SUBCUTANEOUS AMPUTATION.

217

only come into action when the shoulder is nearly severed.
It is only necessary then to separate ttie skin from the limb
and divide the pectoral muscles in order to readily draw the
limb away by traction. Divide the skin now around the
pastern and have two or three assistants exert traction upon
the limb while the operator places his hand against the
sternum and pushes in the opposite direction. Or the op-
erator may increase his repulsion by using the repeller and
pushing upon the crutch with his hand while an assistant
pushes upon the repeller handle. The impact upon the
maternal organs due to the traction may be reduced to al-
most any desired degree by applying a corresponding degree
of repelling force to the sternum of the fetus. If the re-
pelling force applied to the fetal sternum equals the traction
upon the limb the impact of the fetus against the maternal
organs becomes nil.

If traction does not bring the limb away promptly the
operator should attempt to extend the division of the
muscles attaching the limb to the thorax while moderate
traction upon the limb is continued.

Further diminution of the size of the fetus may now be
had by removal of the other limb in the same way which is
especially desirable in the transverse presentation with all
four limbs in the passages or we may reduce the size of the
trunk by evisceration as described under 54.

This diminution suffices to permit the remnant of the
fetus to be withdrawn with the head deviated to the side,
the total resistance being no greater than had the head and
neck presented normally. It also renders the fetal body
very flaccid, and easy of repulsion and simplifies the cor-
rection of any deviations of parts.

2 1 8 DETR UNCA TION.

49. AMPUTATION AT HUMERO-RADIAL ARTICULATION.

Object. Amputation at this point is rarely desirable, but
may at times be necessary in the mare in order to remove
an anterior limb when it is impossible, on account of the
position to reach the shoulder.

Technic. Attach a cord to the pastern and have an
assistant render the leg tense by exerting moderate traction,
as in the preceding. Introduce the hand armed with the
embryotomy knife, carefully concealed in the palm, and
girdle the skin around the articulation. Passing above the
head of the olecranon on the posterior side, divide the
attachment of the anconean group of muscles with the
knife by cutting from behind forward. Then divide
transversely, as far as possible, the muscles and ligaments
passing over the articulation. Rotate the limb forcibly on
its long axis while strong traction is maintained, and rup-
ture the principal ligaments until the limb is completely
detached and comes away. In cases of limited room it may
sometimes be easier to detach the skin of the limb from the
pastern up to the articulation, as in the preceding chapter,
rather than to girdle it.

50. DETRUNCATION.
Plate XXXVI.

Object. In case a fetus in the anterior presentation and
dorso-sacral position has one or both posterior limbs devi-
ated forward and the feet engaged in or against the pelvis, it
may be necessary, or at least advisable in the mare, that the
trunk of the fetus be divided in order to bring about delivery
without serious or fatal injury to the mother.

Technic. Secure the two hind feet by means of cords,
if possible, prior to other manipulations. Apply cords to
the two anterior limbs and the head, have one or two assist-
ants draw the anterior part of the fetus as far out as is prac-
ticable and safe, and then girdle the fetal body immediately

c bo

o ^

•5 2

o -^

a

--; O

03 -^

i^ 'Tl

^ 'S

S '"

£ o

o *-■

TJ n

'o

■1 ^'''

•2

^

2

«

g

^i:

■kl

(U OJ

0

V

-?•

a;

Q

•^ P <u

H o

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

_o

a'

2

§.

"o

"cfl

'o

:-5

if

"2

^^

■^

u

cS

'o

cfl

3

6

^

5

O

2
o

."^

^'

<

s

i

n

o

5

a
3

Q,

_o

'rS

2i

^

«

"c3

•^

"5

n

"3
a

&{

w

*?

8

J

OJ

2

'"3

0,

,0

S

i i^

a

-M

&

tuO

CS

o

2

a

'ci

1

a

aj

i

o

a
W

a
5

■a

1

a
o

5

^

13

o

■M

o

o

15

2 26 AMPUTA TION OF THE LIMBS A T THE TARSUS.

ilium I at C in such a manner that any safe degree of trac-
tion fails to dislodge it.

Technic. Remove one anterior limb subcutaneously,
(48), and eviscerate, (54), through an opening made by
the removal of two or three of the exposed ribs. Introduce
the chisel through this opening and carry it back with the
hand, place it against the shaft of the fetal ilium, I', have
an assistant drive it through the shaft from before to behind
and then withdrawing the chisel replace it against the pubic
brim either at the symphysis pubis or opposite the obturator
foramen, and drive it through the pubis and ischium at
either of these points. The coxo- femoral articulation is thus
detached and isolated so that the entire limb may drop
backward beyond its fellow, the remnant of the severed
ilium, I', can drop downward or move in any direction and
the entire pelvis thus loses its rigidity and undergoes great
diminution in size so that it can readily be withdrawn.

52. AMPUTATION OF THE LIMBS AT THE TARSUS.
Plate XXXVIII.

Object. It sometimes happens in the mare, far more
rarely in the cow that in the posterior presentation with the
hind limbs retained at the hock owing to the unusual size
of the fetus or its having been dead for some time, dry and
emphysematous, that the deviation can not be overcome or
its correction would entail an unnecessary amount of labor.
In these cases it is frequently easier for the obstetrist and
safer for the mother to amputate the limb at the tarsus.

Technic. Pass a cord around the leg above the tarsus
as indicated in Plate XXXVIII and have an assistant hold
the leg steady by gentle traction. Introduce the chisel
carefully guarded in the palm of the hand, and place it
against the lower part of the tarsus as shown between T, T.
The chisel should be placed as nearly as possible perpen-

u ,0

^1

I- o

.2 -H
I I

.2 H

o ^

230

INTRA-rEL VIC AMPUTA 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 wnth the embry-
otomy knife through the maternal passages until the peri-

8

<s

o

5

41

o

TS

s

»)

6iC .G

in

•2

^

CJ

1

^

_t«

n

0

c
2

u
O

'2

"5

£

„-

>

■*-'

r^

~

■fci

H

^

^o

'^

o"

•S

s?

o^

"o

n

1

-2

1

OJ

n
o

V

1

§

1

(U

a-

2

1

I

a:

TJ

•i

n

5

n

»s

OJ

^

5

S
o

n
'3

jfl

V.

Hw

p

c

;;

PM

03

234

INTRA-PEL J 'IC 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

,H

<u

^

^

1.

atern
tal fe
ilium

ts

2

S <ii '-

0

_s

a.

^' '^'' <S

03

u

s^-

<

4J

_■ ,r, 1^

5 -J 3

^

■^ 3 <*H

0

)-<

presenta
m ; P, p
e shaft o

1

1

tu

^

o

^ -H -^

5

^

■^

jd

2i.2 2P

•a

3

«g 0

^

• 5 -^

V

>i

13 (u "*^

0.

o

Ji -j^ be
■5 ^ •-

J;

03 " !/3

o

^

>1

^ ^' 1

etely
ium ;
lown

238 INTRA- PEL VIC AM PL 'TA TION.

of aponeurosis and anteriorlj', chiefly on the median line,
the prepubic tendon ; these are to be cut, if necessary, with
the chisel or knife. Vigorous traction may now be applied
by means of the cord, the operator in the meantime guard-
ing the most advanced end of the detached piece of pelvis
with the palm of his hand in order to prevent injury to the
maternal organs. Sometimes this detached piece of the
pelvis tears away from the femur when traction is applied
and comes away alone. In such a case the cord is to be
applied over the head and trochanter of the femur and
traction again applied drawing the limb away in a reversed
position, the skin being turned back or everted as it ad-
vances until the region of the hock is reached where the
integument does not so readily separate and only requires
to be cut loose and the member allowed to come away.
During the removal of the limb the operator is to con-
stantly note the progress with his hand and sever by tearing
of cutting any tendons or muscles which offer special
obstruction to the operation. Repeat the operation upon
the opposite limb in the same manner except that but one
incision need be made through the bone, that is, through
the shaft of the ilium. During the entire work the opera-
tion is carried out subcutaneously or rather intra-fetally
and the maternal parts are amplj^ guarded against injury.
The size of the fetal trunk may be further reduced if de-
sirable, by evisceration, (54), and followed still further by
the introduction of the chisel guided by the hand and the
ribs, on one or both sides, severed one after another until
the chest can completely collapse. Or the ribs may be yet
more conveniently severed by introducing the sector in the
body cavity, pushing it forward until the first rib is reached
catching the spherical end over the rib and drawing back-
wards, sever each rib in turn. If need be some of these
may be removed and one of the anterior limbs caught by a
cord around the scapula and extracted intra-fetally. The
remnant of the fetus is to be extracted by means of a cord
fastened about the lumbar region of the spine.

E J 'ISCERA TION. 239

54. EVISCERATION.

Evisceration of the fetus is frequently desirable in ob-
stetric practice and has a variety of uses. It decreases the
size of the fetal trunk considerably and permits its more
ready passage through the genital canal, as in the anterior
presentation ; with lateral deviation of the head it renders
the fetal trunk flaccid through the removal of the viscera
supporting the body walls and permits the body remnant to
be bent or moved more readily for the correction of any mal-
presentation ; it permits freedom of intra-fetal operations
•directed against other parts, as for detruncation, or for the
•destruction of the pelvic girdle in the anterior presentation,
and when a fetus is emphysematous, evisceration permits
the gases of decomposition to pass into the fetal body cavity
and thence externally. The escape of gases is very greatly
favored further by the cutting of the ribs.

Technic. Evisceration may be variously performed, but
is generally demanded in either the anterior or posterior
presentation and a description of these will suffice.

In the anterior presentation, unless the fetus is far ad-
vanced through the vulva, evisceration is best performed by
the removal of one or more of the anterior ribs. The ribs
are generally best reached by the removal of the shoulder,
as already described under subcutaneous amputation of the
anterior limbs, (48). When the ribs have been laid bare in
the manner described the operator can thrust the finger tips
through the intercostal muscles in the first space and enlarge
the opening thus made by tearing through the muscles up-
wards to the spinal column and downwards to the sternum ;
then grasping the posterior border of the rib near its middle,
fracture it by means of a sudden and vigorous pull. The
fractured ends may then be grasped and pulled, broken or
twisted off. The chisel may be brought into use if required
in order to divide the rib, the hand of the operator con-
stantly guiding and guarding the chisel blade. The opera-

240

EVISCERATION.

tion is then to be repeated if required, upon the second and
third ribs in the same manner until an opening into the
chest is secured ample in size for the introduction of the
operator's hand.

Force one hand through the opening and tear the medi-
astium above and below from the thoracic walls, and then
grasp either the trachea at its bifurcation or the heart and
tear them awaj'. The heart, which constitutes the greater
bulk of the thoracic viscera, is best grasped in the palm of
the hand, with the fingers engaging the aorta and pulmo-
nary arteries. When the thoracic viscera have been with-
drawn, thrust the fingers through the diaphragm and locat-
ing the liver, isolate the diaphragmatic area to which it is
attached, and engaging both with the fingers remove the two
together. The liver constitutes, in a normal fetus, the chief
intra-abdominal mass, occupying more space than all other
organs combined. After the liver has been removed the
intestinal tube, with its contents, is withdrawn without
difficulty, as its attachments are feeble. The kidneys may
also be removed.

Evisceration in the posterior presentation is preferably
performed through the pelvis, generally in connection with
intra-pelvic amputation of the posterior limbs, (53). It
may be performed without destruction of the pelvic girdle
by making an incision through the perineal region and
then severing the sacro-sciatic ligament as directed under
53. When admission has been gained to the abdominal
cavity introduce the hand and withdraw the alimentary
tube, then rupture the diaphragm about the liver and
tear away the latter organ in the same manner as in the
anterior presentation. The liver is so friable that it cannot
well be removed by grasping the organ itself, but c'omes
away entire with the central part of the diaphragm.

Remove the heart and lungs as above directed.