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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 Giessen THIRD EDITION, REVISED AND ENLARGED 1912 » CARPENTER & COMPANY PHACA, N.Y. CoPYRIGHT, IgI2 BY CARPENTER & CO. Press of _ Andrus & Church Ithaca, N. Y. saa. y € CLA314825 JLo f/f 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’sclasses in laboratory surgery and embryotomy in which the student performs the surgical operations described, on animals procured for the express purpose, under chloroform anaesthesia whenever possible, after which the subject is destroyed while still anaesthetized ; at the same time it has been aimed to render the volume of the greatest possible value to the practitioner consistent with this plan. The operations included under this scheme are necessarily limited to those which can be reasonably well performed on com- paratively sound animals of little value and regularly pro- curable for laboratory purposes. The list covers a wide iv PREFACE TO THE THIRD EDITION. range and is designed to give to the student as thorough training as is practicable in a laboratory course and includes well nigh all the more important varieties of confinement, anaesthesia, disinfection, sutures, bandaging, dressing and other adjuncts to operative work. The chapter on trephin- ing of the facial sinuses has been dealt with at much greater length in the present edition in order to fully and clearly describe the author’s method of operating. The operation for the surgical relief of roaring in horses has undergone a complete revolution since the publication of our second edition in 1906 and the technic therefor which we had begun to develop in 1905 and tentatively inserted in the second edition has undergone phenomenally rapid changes until now it would appear that the technic had acquired a certain degree of permanency, though still too new to expect it to remain unchanged. The introduction of the ventricular burr by Dr. J. H. Blattenberg and various suggestions in the details of technic by Prof. Hobday of England and others has materially aided in bringing the operation to its present state of reliability and caused the operation introduced by us in 1905 to become accepted throughout America and Europe to the exclusion of other methods. We have accordingly omitted the chapter on arytenectomy from this edition, as an obsolete operation and have inserted an entirely new chapter upon the opera- rion for roaring in which we have endeavored to bring the technic thoroughly up to date. Generally but one method of operating is described, the one chosen being that which in the author’s experience has proven the most valuable in actual practice, and no opera- tion has been introduced purely for practice but each one has been tested and known to have practical value. When two methods of operating are given, they are inserted because each has definite points of superiority over the other and one method may be specially applicable in a PRET AOE ALO PME THIRD EDITION. Vv 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. Pieiuies. 1,2; 6,7, 9, 10,;,11,.15; 16 and 17. and Plates Nos. eee TY UX VE XXII XXIV, XXVIT, XXVIII, Poo XX XT 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. LL. WILLIAMS. Cornell University, March, 1972. CONTENTS. I; I. OPERATIONS ON THE HEAD: Bxtracton or “Teeth 2 is oh One ela 2 Repulsion of Lecthr. os. 2. so) AU ee ee eee Prephinine-the-Macig) Situses.. 8 2. Trephining of the Frontal: Sittuses 2 =! 222 5a ee Trephining the Superior Maxillary Sinuses_.+_2. 22.2 eee ‘frephining the Inferter Maxillary Sinuses: 3.) eee ‘Trepainine: the: Nasal: Mossae@s ) sx sts ae ee es Poll Byal' Operation. oe 5 2. bs ok ee Livation er the Parotid. Duct... ai utcopium:. Operation._.: 2 222 20 staplylopomy 22-258 8) <2 hd RS SS tritactal Nevrotemiy. 2.2% Seer Se Uae ae II. OPERATIONS ON THE NECK: Opening the Guttural Pouches hracheotomly 2b U2 ito. 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 1% to 2 inches laterally therefrom. With a heavy convex scalpel make a circular incision at the desired point as large as the area of the trephine, directly through the skin, subcutem and periosteum down to the bone and remove in one piece the entire mass of encircled soft tissues by seizing the skin with a tenaculum and forcibly separating the periosteum from the bone with the scalpel or bone chisel. Control the hemorrhage. With the center-bit of the trephine extended place it accu-. rately upon the denuded area perpendicular to the surface: of the bone and grasping the handle firmly turn it to and fro until the bit has penetrated the bony plate and the saw has cut a distinct groove to serve as a guide when the center- bit should be retracted and the operation continued until the disc of bone is detached, being careful to maintain the trephine perpendicular to the surface. The operation is facilitated by grasping the shaft of the trephine between Plate IV. Trephining of Facial Sinuses. Right side of face, viewed laterally, showing extent and relations of the sinuses. 0, orbital cavity; SM, superior maxillary sinus; IM’, median portion of inferior maxillary sinus; NC, nerve conduit of superior maxillary trunk of the trifacial ; IM, lateral portion of inferior maxillary sinus; F, frontal sinus ; ST, opening through superior turbinated bone for the establishment of drainage from the frontal and superior maxillary sinuses into the nasal passage ; IT, opening through inferior turbinated bone for the establishment of drainage from the median portion of the inferior maxillary sinus into the nasal cavity. TREPHINING OF THE FRONTAL SINUSES. a7 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 itasarasp. 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 front within. In order to prevent the aspiration by the patient of the contents of the sinuses, whether pus, blood or irrigating fluids, and to facilitate their escape from the nostril, any irrigation on the recumbent animal should be carried out with the poll elevated and the head flexed. Plate V. Trephining of Facial Sinuses. Oblique lateral view of the face with the sinuses exposed. SM, superior maxillary sinus; IM’, median portion of in- ferior maxillary sinus; NC, nerve conduit of superior maxil- lary division of trifacial nerve ; IM, lateral portion of inferior maxillary sinus; F, frontal sinus; FE, fenestrum of com- munication between the frontal and superior maxillary sinuses; ST, artificial opening through the superior turbi- nated bone at the lowest part of the frontal sinus establishing a free communication with the nasal passage; IT, artificial opening through the inferior turbinated bone at the bottom of the median portion of the inferior maxillary sinus, affording drainage into the nasal passage. 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, Vand 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 TLREPHINING SUPERIOR MAXILLIARY SINUSES. insure the permanency of the opening through the turbi- nated bone. In case of severe hemorrhage the nasal and sinusal cavities may be tamponed for twenty-four hours with a long strip of gauze which may be secured if necessary by suturing to the lips of the trephine wound. In practice the operation can be best carried out generally with the animal in the standing position the operative area being first anaesthetized by the use of cocaine or by inducing artificial oedema. In the standing position we largely avoid the danger of aspiration of fluids and the hemorrhage is greatly lessened. . 4. TREPHINING THE SUPERIOR MAXILLARY SINUSES. Plates III-X. Uses. Empyema, diseased teeth, odontomes or other tumors. Instruments. Same as for the frontal sinuses. Anatomically there are two maxillary sinuses, superior, SM, and inferior, IM, Plates III-X, having a thin im- perforate bony partition between them. This partition shifts somewhat in position with age and in case of disease undergoes profound changes in location and is frequently totally obliterated in cases of empyema, dental cysts and other affections. If the sinusal partition be present, good drainage of the superior sinus may demand the surgical destruction of the partition so that some authors advise trephining directly upon the partition in order to open the two cavities simultaneously. In extensive disease of either sinus the partition between the two frequently becomes obliterated so that there remains but one sinus to open ; in limited disease the opening of both cavities is ill advised. In extensive disease the existence of a partition may generally be ignored in operating and TREPHINING SUPERIOR MAXILLARY SINUSES. a3 the trephine opening be aimed at the probable focus of the malady and, should this fail to reach the desired locality, the proper location for the opening may now be determined by digital or other examination through the first opening. A second operation should then be made to directly reach the seat of the affection and if need be, yet a third to secure proper drainage. Shave and disinfect as much of the area as may be re- quired bounded above by the inferior border of the orbital cavity, laterally by the zygomatic ridge, inferiorly by the lower end of the zygoma and medianwards by the middle line of the face. Determine the proper point for operation by percussion or otherwise. If it be desired to enter the superior maxillary sinus only, SM, Plates III-X, locate the opening beneath the orbital cavity and in front of the zygo- matic ridge, SM, Plate III, or at any point directly beneath this to midway between SM and IM, Plate III, at about the level of the dotted line IM’. The trephining is carried out as described for the frontal sinuses on page 1g. After 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 cases to infection derived from diseased teeth or dental alveoli it is essential after the sinus has been opened that the ‘operator search carefully and minutely over the alveoli of the molars for naked, eroded tooth fangs or for fistulze 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. oO 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. Ni TREPAINING SOPERIOR MAXILLARY SINUSES. ay 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 wail 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 [V-—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, iftensely sensitive. Any injury to this nerve Plate VII. Trephining of Facial Sinuses. Cross section of the right half of the head of a horse at the posterior border of the last molar. F, frontal sinus; IM, lateral portion of inferior maxillary sinus at extreme posterior or superior part ; IM’, median portion do.; N, nasal cham- ber opposite the communication between it and the superior maxillary sinus; NF, conduit of superior maxillary branch of the trifacial nerve ; SM, superior maxillary sinus; M’, fragment of last molar. ipa ee i ‘oa Lee eh, < 1 - M , ey Aue oat ine | a SADA ae Ore ee PIP, MA obeys da eae Pee A 2 7 3 ah ‘. 4 i es P Lee: i ; i OP ; Pile: E o' ch AMPOULATION OF TAIL. cere) ligature as close as possible to the root of the tail. Have an assistant hold the tail upwards, 7. e., dorsalwards, and tightly stretched. Make an incision 15 to 20cm. 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 11-1000 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. 1.—Tail amputated showing flaps un- sutured; B, Bandage securing hairs turned upward out of operator's way. Fig. 2.—Operation completed showing su- tures ; B, Bandage applied to secure hairs of tail upwards out of operator’s way. Fig. 2 “ yea “f MMP OTATION OF THE TATE. ee ke Technic. The animal may generally be operated upon in a standing position secured in the stocks or with the aid of the side line. Local anaesthesia may be applied by in- jecting cocaine or other drug deeply upon the nerve trunks as well as just beneath the skin. The animals’ attention may be attracted by means of the twitch if found necessary. The point of amputation is determined by the location of the disease. Over the area of operation clip the hair, shave and thoroughly disinfect. Apply the tourniquet or elastic bandage at the base of the tail so as to render the operation bloodless. Above the seat of operation turn the hair upward toward the root of the tail and secure it there by means of the bandage, B, Fig. 1, 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 1 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. 1, 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 8 114 ORETHROTOMY., LATHOTQM Y. sutures should be begun at the apex of the two flaps and comparatively deep. Disinfect the stump thoroughly and if the hair is suffici- ently long it 1s 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 ina 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. 10. 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 a5cm. 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 CRETAKROTOMY.. LITHOTOMY. II5 down to the catheter, Fig. 11, k. In order to prevent infil- tration of urine after the operation, special care is to be taken to make the lower end of the wound slanting in such a manner that the deeper margin is higher than the superficial. After the catheter has been drawn back away from the ischial arch, introduce the lithotomy forceps into the urethra or bladder, grasp the stone and draw it outward in its natural direction. The grasping of the stone with the forceps is Urethrotomy at the ischial notch. materially aided by means of the left hand introduced into the rectum. One must avoid grasping, along with the stone, the mucous membrane of the bladder. Partial filling of the bladder with a tepid aseptic solution will aid in grasp- ing the calculus and in avoiding the implication of the bladder walls. By careful rotary movement and pushing the forceps backward and forward the operator can deter- mine before traction is exerted if the forceps can be with- 116 ORETHROTOMY. 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- Urethrotomy (life size). 4, skin; a, retractor penis muscle ; 6, bulbo-cavernous muscle; c, spongy urethra; #, urethra; k, catheter. sequently must be gradually brokeu 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. \ AMPUTATION OF THE PENTS. Ery, 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 1 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 obstruet 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. “erqyern “A ‘sammjns Surmoys uoryesodo pazatduroy— “% “SIT ‘rayoyyeO ‘OD ‘ ornqzesvy “7 +: erqyes ‘qQ * wnsou -I9ABD SHdIOD ‘DO ‘ UIyAS ‘S - eIq}eIn jo wmsol -Suods snd1o9 ‘Sp ‘yenbrusmo0} se posn ainyzesty] SSP ‘uoryetodo jo oases }SIT{—'l ‘SI ‘sluag jo uoljDjnduy “XIX ?7°ld Agee AMPUTATION OF THE PENIS. I21 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 designea to amputate the organ and a temporary elastic ligature, T, is then applied Fig. 12. Amputation of the penis, showing needle inserted for a suture. V, Dorsal vessels of penis ; A, Fibrous tunic of the corpus cavernosum ; S, Skin ; CC, Corpus cavernosum ; CS, Corpus spongiosuin.of urethra ; U, Urethra. above the assistant’s hand around the penis, or a piece of tape is looped around it above the hand and is made to serve both as a tourniquet and as a means for holding the penis. Or the penis may be grasped in front of the ligature with double tenaculum forceps and held. 122 AMPOTALTON OF DE TE IVES. Apply a small cord just behind the glans penis, L, Fig. 1, P ate XIX, andthen makea 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. 1; 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 XI Xin such a manner that they pass through the urethral wall and the skin so that when tied the wounded surfaces are completely hidden and the urethral mucous membrane is brought into apposition with the integument. Continue these sutures down to the base of the triangle after which remove the catheter and excise the organ by a cut extending ina slightly oblique direction from below upwards and forwards. Take a straight needle armed with the silk suture and passing it through the margin of the urethral wound, the adjacent fibrous capsule of the corpus cavernosum and across but not through the erectile tissue, insert it again into the superior portion of the fibrous capsule and carry it out through the adjacent dorsal vessels and the skin as shown in Fig. 12, and, bringing the ends of the sutures together, tie in such a way that the urethral mucous membrane and the margin of the skin are brought into immediate contact and the blood vessels securely closed in such a manner as to guard against hemorrhage. By this plan when the sutures are tied, the cut borders of the fibrous envelope are brought together over the erectile tissue, thus preventing hemor- rhage from that tissue also. Insert as many sutures as may be required to completely and securely close the wound VAGINAL OVARIOTOMY IN THE MARE. 123 and finally leave every part wholly covered with epithelium. By this plan it is hoped to avoid stricture of the urethra in the process of healing. Remove the tourniquet and release the patient. 26. VAGINAL OVARIOTOMY IN THE MARE. Figs. 13-14. Objects. The alleviation of vice when related to ovarian irritation or disease. Instruments. Colin’s scalpel, ratchet ecrasure, 55 cm. long, vaginal tensor. Preparation of patient. It is highly important that the animal should be kept on a scant laxative diet for at least 24 hours and preferably longer prior to the operation, so that the alimentary canal shall be somewhat empty and thus decrease the intra-abdominal tension and relieve the operator from much annoyance due to the pressure of the viscera. Technic. The vagina of the mare is unique in its physiological behavior. Under venereal excitement or the introduction of the operator’s hand or of tepid water the organ hasthe power of ‘‘ ballooning’’ or dilating to adegree not so marked in other animals ; the vaginal walls become erected, hard, and stand apart from each other, filling the pelvic cavity, resting firmly against the pelvic bones and ligaments at every part except at the points where the bladder and rectum intervene and these organs are pressed out flat and occupy a minimum amount of space. In the quiescent state the vaginal walls are in contact and from the perinaeum forward to within about 10 cm. of the uterine os, the vulva and vagina are connected above with the rectum by the pelvic connective tissue, while anterior to this point the vagina is covered by peritoneum, and it is 124 VAGINAL OVARIOTOMY IN THE MARE. in this area that the incision needs be made in the operation. The ballooning of the vagina profoundly alters the relation of this operative area, and changes it from the horizontal in the quiescent organ to the perpendicular in the ballooned condition. ‘These variations permit of two methods of operating: I. On the ballooned organ without anaesthesia and with the animal confined in the standing position. IIT. 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. 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. £25 detachable masses of sebum; 50 per cent. alcohol may be used sparingly to aid in removing this. Too free a use of alcohol excoriates the delicate skin. Cleanse the clitoris carefully. Follow the washing with a free application of I: 1000 aqueous sublimate solution to the external parts and for a short distance inside the vulvar lips and to the clitoris. Do not introduce irritant disinfectants into the healthy vagina nor deeply into the vulva as it may cause severe straining during and subsequent to the operation and by in- juring the vulvo-vaginal mucosa favor subsequent infection of the vaginal wound. Wash away the sublimate solution with a tepid 0.6 per cent. soda bicarbonate solution, and fill the vulvo-vaginal canal with the same. After thorough disinfection of the hands and arms remove the disinfectants by washing in sterile soda solution, which at the same time renders the hand unctuous and readily introduced through the vulva. Armed with the guarded sterilized scalpel, Fig. 14, intro- duce the right hand into the vagina promptly and when it is well ‘‘ ballooned’’ unsheath the knife and placing it just above the os uteri parallel to the long axis of the uterus and a few mm. to the right or left of the median line in order to avoid a loose fold of mucous membrane generally existing there, the blade being held vertical, that is the cutting sur- face parallel to the longitudinal muscular fibers of the vagina, and guarding the possible extent of its introduction with the thumb and fingers, push it directly forward in a straight line with a quick thrust through vaginal mucosa, the muscular walls and the peritoneum, until the disap- pearance of resistance indicates that the latter has been penetrated. This is the most critical step in the operation. If the hand is introduced into the vagina immediately after the injection of the sterile saline solution the vagina will generally be found ‘‘ ballooned ”’ or will quickly become inflated under manual movements. If the solution is thrown 126 VAGINAL OVARIOTOMY IN THE MARE. out the vagina may collapse and closely invest the hand, in which case more of the liquid should be injected when it will again dilate. If the hand is introduced without the knife, withdrawn and then introduced with it, it will be frequently found that the vagina has collapsed and needs a second filling with the fluid. Patience until dilation is accomplished and promptness to act when attained are prime requisites to success. The knife should be pushed through the vagina quickly making a clean wound the width of the blade, when the latter is to be withdrawn and laid aside. It should be re- membered that in this ‘‘ballooned’’ state, the anterior wall of the vagina is but 2 or 3 mm. thick and easily pene- trated. Introduce the hand again, push one finger into the incision, then a second and third, and eventually holding all the fingers in the form of a cone push the entire hand into the peritoneal cavity. Immediately below the incision and continuous with the tissues involved in the wound lies the uterus with a transverse diameter of 4 to 6 cm. With the palm of the hand downward, trace the uterus forward a distance of 15 to 18 cm., where it ends abruptly in two cornua of about the same size as the body, which are given off horizontally at almost right angles. Trace these to the right and left for a distance of 14 or 15 cm., where they end obtusely, and 3 or 4 cm. 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 VAGINAL OVARIOTONY IN THE MARE. 127 and index finger. Holding the ovary with one hand tighten the chain quickly with the other, examine to make sure that a loop of intestine is not caught, draw the ovary well through and get a large portion of the oviduct, and crush off promptly, holding to the gland until carried out through the vulva. Remove the other ovary in the same way. Generally it is most convenient to remove the left ovary with the right hand and vice-versa but each may be re- moved with either hand. Wash away any blood from the external parts, apply sublimate solution freely to the vulva, perineum and tail. Keep the patient quiet for five or six days, and feed lightly on a laxative diet. II. In operating under anaesthesia the animal should be cast or confined upon the operating table in lateral re- cumbency preferably with the posterior part of the body somewhat higher than the anterior so as to avoid visceral pressure in the pelvic cavity. Place the animal under com- plete anaesthesia. Prepare the parts in the same manner as already described. Carry the knife into the vagina in the manner previously described and render the roof of that organ tense by pushing the os uteri downward and forward with the hand or by means of a vaginal tensor or speculum. It is important that the vagina be held well down toward the floor of the peivis 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 samme 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 OVARIOTOMNY IN-THE MARE. DANGERS. W ounding of the rectum is scarcely possible under the first method if care is taken not to attempt the incision until the vagina is well ‘‘ ballooned,’’ and then making the stab wound directly forward. If made upwards when the organ is so erected the accident is 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. W ounding 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 membrane will be pushed away from the subjacent tissues. Incomplete penetration of the vaginal wall is liable to occur if the scalpel is du// or the vagina imperfectly ‘‘ bal- looned’’ and flaccid, or if the operator is unduly timid. It is best prevented by avoiding the causes as related, and once it has occurred it is generally best to again ‘‘ balloon’’ the organ in the operation without anaesthesia and make a new incision either to the right or left of the first. It may be overcome also by thrusting the index finger through the peritoneum as described in the preceding paragraph or completing the cut with the scalpel. The mistaking of a ball of feces for the ovary has oc- curred to inexperienced operators and the fatal error of re- ‘moving the portion of the rectum surrounding the fecal pellet committed. The blunder is uncalled for; the fecal ball is movable in the bowel, the intestine is far more massive than the broad ligament, and the ovary is to be definitely identified by its being lodged in the broad ligament just 9 130 VAGINAL OVARIOTOMY 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 very great difficulty only that the ovary now lies above the hand and must be drawn down from on top the broad ligament in order to fix the ecraseur upon it. Infection constitutes always the most serious danger and is to be avoided by properly securing the animal, by the avoidance of irritant antiseptics in the vagina, by rigid antt- sepsis at every stage, and by carrying out the mechanical parts of the operation deliberately, vigorously and neatly. If infection should occur it will generally take the form of pelvic cellulitis with abscesses and rectal stricture. Enemas of a normal salt or soda solution affords the surest relief of the stricture and impaction in front of it. The abscesses must be watched and opened early into the vagina or rec- tum, and the case treated internally and locally according to general surgical principles. 27. VAGINAL OVARIOTOMY IN THE COW. Objects. Increasing the fat- or milk-producing qualities and the cure of nymphomania or other ovarian disease. Instruments. Colin’s scalpel, vaginal dilator, Miles’ spaying shears, spaying ecraseur. Technic. Confine the cow in the standing position in the stocks, secure the head firmly and pass two boards be- neath the abdomen and sternum to prevent lying down, and a rope over the middle of the back to prevent arching of the spinal column and straining. \ VAGINAL OVARIOTOMY IN THE COW. EZ 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. Becareful 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 fimbriz of its pavilion. The ovary may be distinguished as a firm oval mass 2 to 4 cm. in length and 1 to 2 cm. in its lesser diameter attached to the broad ligament. If not promptly recognized by the sense of touch, trace the vagina and uterus forwards with the fingers from the vaginal incision to the cornua and follow them as they bend forward and downward, and then backward and up- ward to the oviducts, until the ovary is reached where it is attached to the broad ligament, just beyond the fimbriated end. Grasp the ovary between the fingers and draw it through the incision into the vagina. Introduce the scissors or emasculator with the other hand, and when the ovary is 132 VAGINAL OVARIOTOMY 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. \ OVARIOTOUY IN THE COW BY THE FLANK. 133 28. OVARIOTOMY IN THE COW BY THE FLANK. Instruments. Clipping shears, convex scalpel, spaying shears, or ecraseur, heavy needle and thread. Uses. Same as the preceding, applicable to heifers or to cows in which the vulva is too small to admit the operator’s hand or in case of diseased vagina or uterus. The animal may be secured as in the preceding or con- fined in lateral recumbency with the hind legs extended backward and the anterior limbs forward. To accomplish this loop a rope about the two fore feet, another about the two hind feet, and drawing upon these, cast the animal and secure it in recumbency with the legs extended and body stretched by fastening the ropes to two strong posts about 8 to 10m. 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 OVARIOTONY IN DHE LI FCH.- 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 OVARTOIONUY IN THE BITCH. B25 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 2to5 mm. ‘The most remarkable feature of the apparatus from a surgical standpoint is the great development of the broad Jigament 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 non-pregnant bitch lying on the back with the abdominal floor removed and the omentum pushed away. TT, the two pos- terior teats; B, bladder; V, vagina; U, uterus; LUC, LUC, left uterine cornua with a portion of its broad ligament, BL, lying across it; RUC, right uterine cornua with its broad ligament, BI/, 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. O,O, ovaries; R, rectum; K, left kidney ; AA, a line indicating the level of the external tuberosities of the ilia. OVARIOTOMY IN THE BITCH. 139 The ovary being indistinct and hidden is difficult to iden- tify directly, and the cornua being covered over by the duplicature of the broad ligament is not readily reached, so that the finger generally comes in contact first with the broad ligament of the uppermost cornu hanging loose in the peritoneal cavity : engage this between the end of the finger and the abdominal wall and draw it out through the wound, grasp it and continue drawing upon the folds of the ligament, especially upon the median or under-most portion until the naked cornu appears through the opening, seize it and draw out the anterior portion until the ovary follows, then grasp the latter with the thumb and index finger of one hand and the ovarian ligament with the same members of the other and tear the ligament through between them by linear tension. Extend the tear through the broad liga- ment as high toward its lumbar attachment as is convenient and backward to the neighborhood of the uterine bifurca- tion. Draw upon the exposed cornu until the point of bi- furcation appears, when the other branch is to be grasped and drawn out through the opening. In young puppies the securing of the second cornu is very difficult and requires great care to prevent the rupture of the first. The object may be facilitated by pressing the upper flank of the bitch downward, thereby greatly diminishing the transverse diameter of the abdomen. The succeeding operation (30) avoids this difficulty ina 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 uutil 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 140 OVARIOTOM VIN 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 ex 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. I4t 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 QVARIGTOMY IN THE CAT. in the same manner as by the flank method. By passing an index finger forward to reach the lower surface of the rec- tum in front of the uterus and then drawing it backwards the finger passes between the former and the cornua and the latter are picked up. It has a distinct advantage over the flank method in that in puppies there is not so much difficulty in bringing out the ovaries, nor the danger of the rupture of the cornua and the ovary being retained. By the use of retractors in the abdominal incision the operator is enabled to see the uterus in position and grasp it by means of forceps, obviating the necessity for introducing the finger into the peritoneal cavity. The sutures must extend entirely through the abdominal wall and be carefully placed in order to prevent hernia. Interrupted sutures are preferable. If the operation has been properly performed no bandage is necessary and the patient will not disturb the sutures. If asepsis has not been strictly followed infection may occur and the consequent irritation cause the patient to tear the sutures out, which may lead to protrusion of the intestines or other abdominal ‘viscera. If the sutures do not include the deeper layers of the abdominal wall hernia is liable to occur and require a second operation. 31. OVARIOTOMY IN THE CAT. Instruments. Same as for the bitch. Technic. The cat:may be spayed by either the flank method or through the linea alba. The point of incision in either case is the same as in the bitch but owing to the smaller size of the animal it is necessary to make the wound quite small. The abundance of fur renders it essential that an ample area be shaved and the surrounding hair be saturated with a disinfectant and carefully brushed away CASTRATION OF CRYPTORCHID FAORSES. 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 lavers 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 makea clean incision directly into the peritoneal cavity and to avoid separating the peritoneum from the muscles or the muscular layers from each other... The uterus and ovaries of the cat are naked and far more easily distinguished than in the bitch, there being no extra deposit of fat in the broad ligament. The sutures are to be applied to the wound in the same manner as in the bitch. 32. CASTRATION OF CRYPTORCHID HORSES. Plates XXI and XXII. Instruments. Scalpel, emasculator. Technic. Confine the animal by casting in the dorsal position with the hocks well flexed and both posterior limbs completely abducted so as to fully expose the inguinal region. Or secure upon the operating table on the side opposite to the retained gland and abduct the upper pos- terior limb by drawing it upward by means of a pulley: Cleanse and disinfect the inguinal region. Anaesthize. Make an incision about 10 to 12 cm. long through the skin and dartos directly over the normal position of the scrotum; parallel to the median raphe about 4 or 5 cm. distant from it. Insert the two index fingers in the wound, press them into the areolar tissue toward the external inguinal 144 CASTRATION OF (GCRYPTORCHID 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 testicle is 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 ina 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 X XI, 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. Inthe 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 X XII, where the testicle is completely withdrawn into the peritoneal cavity and spread out over the right flank. The processus CHSTRALION 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 X XII 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 IO Plate XXII. 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 CRY PTORCHID 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 KE, in Plate XXII. Having reached the vas deferens the operation is proceeded with as above. Thus far the operator has not concerned himself with the location of the testicle but relies wholly upon the vas deferens or gubernaculum, since when either of these is recognized the testicle is virtually within his power. He thus proceeds upon the basis that he is not to fd the testicle for the reason that it is not Jost but that it has de- finite relations and attachments which permit of certain displacements of the organ itself but not of its attachments. Having drawn the vas deferens out through the wound tension is exerted upon it which tends to cause the testicle to follow but sometimes the gland is too large to pass the internal ring and the latter needs be dilated by inserting an index finger in it or the testicle needs be guided through the opening. We have described herein one method of castrating a cryptorchid horse where the cryptorchidy is due to an arrest in the development of the gland and of its descent. There are other methods employed which introduce variations at each step, many operators making the incision over the external ring* instead of near the median line. Other Plate XXII. Castration of Cryptorchid Horse. Right inguinal region and testicle of 24 hrs. colt. P, processus vaginalis surrounded by a dotted line and containing a curved sound, S; G, first portion of gubernaculum testis ; G’, second portion of gub- ernaculum testis extending to the epididymis, E; E, epididymis ; G’, gubernaculum extending from epididymis (globus minor) to the testicle ; T, testicle; A, testicular artery; V, V, vasa deferentia; B, urinary bladder ; UA, umbilical arteries. nate ae y Pars as a aa he - by ; Megicl 1 a a Cie Si) aes ¥ cay er pte | CASTRATION OF CRYPTORCHID HORSES. 153 operators avoid opening the internal ring and penetrate the peritoneal cavity somewhat in front of and above the ring through the small oblique muscle. When one plan has been learned the variations are easily applied. There are other causes of cryptorchidy which in rare cases require a different procedure in order to extract the gland varying with individual cases but the essentials for the tracing and recognition of the testicle are the same. Prior to attempting the operation it is well to make a rectal exploration and determine as far as may be the loca- tion of the testicle, whether it be on the right or left side, and its character, should it be in any way pathologic. After the testicle is brought to the surface it may be re- moved with the emasculator or by such means as the opera- tor may prefer. Cryptorchid testicles when due to arrest in development are not vascular and there is little tendency to hemorrhage after excision. Place an antiseptic tampon in the wound, pushing it well up against the internal ring and retain it in position by means of sutures for a period of 24 to 48 hours when it is removed and the wound dressed antiseptically. The operation for cryptorchidy in the smaller animals is essentially the same as in the horse except that the incision is to be made ordinarily through the flank as in spaying. The same attachments are to be our guide and the operation is to proceed upon almost parallel lines. IV. OPERATIONS ON THE EXTREMITIES. 33. TENOTOMY OF THE FLEXORS OF THE PHALANGES, Plate XXIII. Objects. The relief of contraction of the flexor tendons of the foot. Instruments. Razor, scissors, sharp tenotome, bandage material. Technic. ‘Tenotomy is generally performed on the flexor of the third phalanx, seldom on the superficial flexor or flexor of the second phalanx. Confine upon the operating table with the affected member undermost and the foot fully extended. In default of a table confine in lateral recumbency and apply an exten- sion splint to the foot as shown in Plate X XIII. 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 les between the lower extremity of the great carpal or tarsal sheath above and the superior extremity of the tendonous sheath of the fetlock below, so that neither of these is wounded during the operation, but the tendon is severed at a point where it is invested by loose connective tissue which retains the divided ends in their normal line of direction, somewhat fixed, and favors their ultimate reunion. Grasp the metacarpus or metatarsus in this area from above and behind in such a manner that the thumb rests upon the median or upper surface, and the index and second fingers on the lateral or under side of the flexor pedis tendon. While the left thumb pushes the skin toward the bone, that is, forward, a sharp pointed tenotome held perpen- dicularly in the right hand is introduced with the cutting edge toward the hoof through the skin, subcutem and anti- brachial fascia down to the flexor pedis tendon. Immedi- ‘moOpta} Ioxoy daap ‘7 | ajosnut 1Oxey [eloysedns oy} Jo uopuay, ‘s ‘yurjds WoIstia}x9 sy} UOdN punog ss1OY JO JOO} d10F JYSTY *‘suopuaT] SIPId 40X2) 7 2Y} jo? fwuoj,ouaT THXX = ?7?Ild 156 TENOTOMY OF FEXORS OF PHALANGES. ately on the anterior border of the tendon insert the teno- tome so far that the point of it can be felt on the lateral or outer side through the skin with the left hand. Care is to be exercised in making this invading incision to not include the metacarpal, or metatarsal, arteries, veins and nerves. The vascular bundle lying immediately against the anterior border of the flexor of the third phalanx, it is easy to err by inserting the tenotome in front of the vessels, that is between the suspensory ligament and vessels instead of between the flexor of the third phalanx and vessels. It is safer to make the skin incision far enough posteriorly to insure safety to the vessels, cut down upon the tendon, then incline the handle of the tenotome backwards, push the point of the tenotome obliquely forward and downward behind and beneath the vascular bundle and then carrying the handle forward bring the instrument to a perpendicular position while it is forced down along the anterior surface of the tendon until it nears the inferior border when the tenotome handle should be carried yet further forward so that the point is directed obliquely backward, to facilitate its passing between the vessel bundle and the tendon out to the skin. The invading incision thus describes the segment of a circle, with its concavity backward toward the tendon. The cutting edge of the instrument is then turned against the tendon, that is, it is directed backward, the foot is ex- tended by an assistant with the aid of a rope bound around the pastern and looped over the hoof, and the tendon is cut through under light pressure, the operator pressing the handle of the knife forward and downward, using the meta- carpus or suspensory ligament as a fulcrum upon which the back of the tenotome rests as a lever. A loud cracking, as well as the disappearance of resistance to extension shows that the tendon has been severed. After the removal of the knife and seeing that there is a wide space between the ends of the tendon, the foot is un- PERONEAL TENOTOMY. 157 bound from the splint and a bandage applied to the meta- carpus, which rests upon the fetlock joint and remains in position for eight days. Healing of the cutaneous wound by primary union. 34. PERONEAL TENOTOMY. Plate XXIV. Object. The relief of Stringhalt. Instruments. Razor, scissors, sharp tenotome. Technic. On the lateral side of the metatarsus a triangle, d, opening toward the tarsus is formed by the tendons of the extensor pedis longus muscle, /, and the lateral extensor of the foot, e, which unite on the anterior surface of the middle of the metatarsus. ‘The synovial sheath of the extensor pedis longus muscle extends inferiorly to near the point of juncture of the two tendons; the sheath of the lateral ex- tensor ends below 3 to 4. cm. above the point of union. In the middle of this space without a sheath, which is 3 to 4 cm. long, and below the aunular 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. [he tendon of the lateral extensor is easily felt under the skin as a hard cord about 0.7 to 1 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. ¢, Peroneal tendon; / crural fascia ; 7, 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 asa fulcrum. If the tendon has been completely severed its retracted ends may be felt under the skin 1 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 6cm. 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 Os lameness. The dotted line crosses the 10 For the relief of spav cunean tendon. ergot. NEUROTOMY. 163 a stab wound, merely sufficient to afford passage for the blade of the instrument, about I cm. below its inferior border at a point midway between the anterior and posterior borders of the hock, or slightly anterior thereto. Push the tenotome flatwise between the skin and tendon, as shown in the plate, force it upwards to the superior border of the tendon, then turn the cutting edge toward it and elevating the handle, using the superior border of the skin wound as a fulcrum, cut the tendon through from without inwards. By firm pressure upon the skin over the tenotome peri- osteotomy is simultaneously accomplished. The completion of the operation is evidenced by the separation of the cut ends of the tendon leaving a well-marked depression at the point of division. Disinfect the wound, apply an antiseptic tarred bandage resting upon the fetlock and including the hock and allow to remain undisturbed for six days. Healing by primary union. After the incision through the skin has been made, the Peters’ knife may be used instead of the straight scalpel, and the tendon and periosteum cut through at two or three different points, the cuts diverging upwards from the cutaneous wound, V-shaped. NEUROTOMY. General Remarks, Neurotomy is performed for a vari- ety of objects, such as the relief of pain in a sensitive nerve itself, as in trifacial neurotomy, p. 64, the relief of pain or lameness in a part supplied by a sensory nerve, or the inhibition of motor power, as in the ‘‘cribbing’’ opera- tion by severing the spinal accessory where it passes into the sterno-maxillaris muscle. The following neurotomies are designed to relieve pain and the consequent lameness dependent upon a pathologic condition of some part or tissue on the distal side of the 1 tb 162 NEUROTOMY. point of operation and to which the divided sensory nerve is destined. Neurotomy of a sensory nerve is always a painful opera- tion, and its performance without anaesthesia is unjustifiable from a humane standpoint, and cannot be so well done either from the view of mechanical correctness or the carrying out of antiseptic standards. Some neurotomies can be well per- formed on the standing animal if it is quiet and the operator is experienced, the parts being rendered insensitive by means of cocaine or other local anaesthetic ; in the greater neurotomies general anaesthesia may be desirable or neces- sary from the humane or operative standpoint. The confinement of animals for neurotomy on the sensory nerves of the extremities for the relief of lameness is always to be viewed as a critical procedure for the reason that the operation is generally made because of the local manifesta- tion of a more or less general disease which may be accom- panied by general fragility of the skeleton, and as a result most casting accidents occur in cases of confining for neurotomy or firing in cases of lameness belonging to the great group of dry arthritis or spavin family. Casting must, therefore, be done with the greatest possible care, and the operating table is to be constantly and greatly preferred. Neurotomy is properly a last resort in lameness and should not otherwise be performed. It has two great and ever present dangers. If the part deprived of sensation is too badly diseased to bear the weight and resist the insult result- ant upon the part being called to do its normal or even an extra amount of work, it must ultimately give way, the bones become fractured, the tendons separate from the bone, the intra-ungular tissues lose their integrity and the hoofs become detached (exungulation) or other degenerative changes take place asa result of causing a part to do a work for which its condition unfits it. The second great danger occurs from wounds or other traumatisms to the tissues distal to the operation when the \ NEUROTOMY. 163 unnerved parts are not rested as they would be in natural conditions when injured, and as a result reparative changes are prevented and supplanted by retrograde processes with ultimate death of the part and of the animal. In other words sensory neurotomy robs an organ or tissue of the enormously conservative force of pain. Pain causes the animal to rest the affected part, protects the painful tissues against disintegrating and destructive insults and favors restorative processes ; robbed of this protective in- fluence of pain by the severance of the sensory nerves, the diseased tissues are without their natural protection. Nerves are generally accompanied by satellite arteries and veins which are always liable to be wounded during the neurotomy and are inore embarassing because of the hemor- rhage clouding the operation field and inviting error than dangerous because of the loss of the blood itself. It is essential to a good operation that the hemorrhage be kept under control throughout so that each tissue will stand out in relief and the nerve reveal its identity in addition to its location, size and relations, by its intensely white, nacrous, striated character. ‘The test of compressing the nerve in order to identify it by the resultant pain is unsurgical and unnecessarily cruel. Sepsis holds an important place in considering the dangers of neurotomy because the infection of a sensitive nerve causes very great pain and if considerable, tends to cause a false neuroma or fibroma in the connective tissue of the nerve trunk, calling for a second operation in order to re- move the tumor, and resultant lameness. Neurotomies should consequently be performed only in properly selected cases, the smallest possible trunk that will sufficiently relieve the pain should be selected for the opera- tion, it should be performed with due regard for suffering and for asepsis, should be performed quickly and neatly, the incisions being free, laying the nerve trunk bare without tearing up the tissues and clouding them and at every point aim at celerity, accuracy and neatness. Plate XXVI. Digital Neurotomy. V, Digital vein; A, digital artery; N, principal digital nerve; L, ligament. DIGITAL NEUROTOMY. 167 36. DIGITAL NEUROTOMY. Plate XXVI. Objects. The relief of navicular lameness in cases where plantar neurotomy is not deemed necessary or advisable. Instruments. Razor, scissors, scalpel, probe pointed bistoury, tenacula, aneurism needles, bandages. Technic, Digital neurotomy may generally be perform- ed on the standing animal, the operative area having first been anaesthetized by means of cocaine or otherwise, a twitch applied to the upper lip and the affected foot held up by an assistant. If necessary because of restlessness of the animal or inexperience of the operator, confine on the oper- ating table or cast the animal and apply the extension splint to the foot to be operated on as shown in Plate XXIII, ex- cept that the lower binding cords rest on the metacarpus instead of the pastern. Extending downwards from the fetlock joint toward the coronet, between the posterior border of the first phalanx and the anterior border of the flexor tendons there is a slight furrow, at the posterior part of which, close to the external margin of the tendon, lies the median or principal digital nerve accompanied in front by the digital artery, A, anterior to which hes the digital vein, V. Immediately behind the nerve and generally lying a trifle deeper, is quite commonly found a second venous trunk of considerable size. Near the middle of the first phalanx the nerve is crossed externally in an oblique direction from above to below and from behind to before by a white ligamentous band, L, slightly broader than the nerve extending from the base of the ergot of the fetlock to the retrossal process of the pedal bone. This must not be mistaken for the nerve, N, and need not be if it is re- membered that the latter is accompanied on the same plane and ina 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 X XVI 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 aud over the groove between the flexor pedis tendon and the phalanges shave and disinfect an area 4 to 5 cm. square. In the center of this area at the anterior border of the flexor tendon, with the scalpel held perpendicular to the skin, make an incision from above downwards a distance of from 2 to 3 cm. cutting cleanly through the skin and subcutaneous fascia down upon the nerve. The incision is favored by tensing the skin between the thumb and index finger of the left hand, but care should be taken not to dis- place it backwards or forwards. Dilate the wound by pressure upon the skin with the thumb and index finger or otherwise and carefully incise longitudinally the fibrous sheath enveloping the nerve and artery. Pass an aneurism needle beneath the nerve, and forcing it upward and down- ward, separate thereby the nerve from the surrounding tissues. Insert a probe pointed bistoury, or scissors beneath the nerve, and divide it at the upper angle of the wound and excise a section 3 cm. long. Disinfect and bandage with or without suturing the wounds. Leave the bandage in place 6 to 8 days. PLANTAR NEUROTOMY. 169 37. PLANTAR NEUROTOMY. Plate XX VII. 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 artery 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 downward over it. Just at the anterior margin of the flexor pedis tendon and at the posterior part of the groove lies the threadlike cord of the nerve, z, 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 XX VII. Plantar Neurotomy. a, lateral digital artery ; v, lateral digital vein ; mn, common lateral digital nerve; d, anterior branch ; 0, posterior branch ; s, superficial flexor tendon; /, perforans tendon; 7, suspensory ligament of fetlock ; 7, 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 strize 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 isremoved. 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. Plate 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, inclined somewhat forward. ‘The operator places himself between the neck and the forearm of the patient and, after the median region of the elbow joint has been washed with soap and water, searches for the median nerve where it glides over the posterior part of the joint to disappear behind the radius. Shave the skin at and below this point, disinfect it with sublimate or creolin solution and 50% alcohol. ‘The nerve, nm, 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 NEUEOTOMY OF THE MEDIAN NERVE. 3 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. Zhe operator needs be careful not to prick this vein weth the tenacula, as the hemorrhage therefrom ts exceedingly annoy- ing’ during the operation. Avoid the use of tenacula after pene- trating the fascia and retract the wound lips cautiously with aneurism needles instead. Still further forward and deeper may be felt the pulsating brachial artery. Incise the nerve sheath carefully and divide it upward and downward with the scalpel or scissors, whereupon the yellowish and dis- tinctly fibrous nerve comes into plain view. Pass an aneurism needle beneath the nerve pushing it so far through that the distal end is readily grasped and drawing it up and down with the two hands, separate the nerve from the adjacent tissues throughout the length of the wound. Be careful to not cut the nerve too high and erroneously include the motor nerve of the flexor of the metacarpus and the flexors of the foot, which ts generally given off postert- orly just below the humero radial articulation. ft 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 anglé of the wound, and excise at least 3 cm. of it. Plate XXVIII. Median Neurectomy. Median surface of the right humero radial articulation. a@, brachial artery; , median nerve; v, brachial vein; 4, antibrachial fascia ; p, sterno-aponeuroticus muscle. Lf Be 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 1 cm. farther out- ward than the lower. Beneath the fascia between the aforesaid muscles is seen the ulnar nerve, Plate XXIX, x Plate XXX, NU, on the median or inner side of it the collateral ulnar vein, Plate X XIX 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; 7, oblique (middle) flexor of the carpus; a, collateral ulnar artery; 3, antibrachial fascia ; ~, ulnar nerve. Mhiph if U, VANS GE 4 Plate XXX. Ulnar Neurotomy. Cross section through the forearm, about Io 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. etal’ Ip SCJATIC NEUROTOMY. 185 40. SCIATIC NEUROTOMY. Plates XXXILXXXII. 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 coniplete general or local anaesthesia. The posterior tibial or sciatic nerve, 2, Plate XXXII 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 1 cm. in diameter, glides away forward from _be- tween the fingers with a distinct recoil. If the nerve can not be recognized in this manner the hock should be more strongly extended, by which means the nerve may be caused to recede from the perforans muscle, so that it can more readily be felt near the middle of the groove extending be- tween it and the tendo- Achilles. At this point on the median side of the leg the skin is shaved, disinfected and an incision made through it 5 cm. long, parallel to the tendo-Achilles. The white rigidly- stretched crural fascia is now divided in the same direction after which it should be determined by palpation that the nerve lies in the middle of the wound. Excise with the scissors an elliptic or oval piece of the fascia or hold it apart along with the lips of the cutaneous wound by means Plate XXXII. Sciatic Neurotomy. Right hind leg viewed from the median side,. f, crural fascia; #, sciatic (tibial) nerve; vz, plantar vein. Plate XXXII. Tibio-Feroneal Neurotomy. Cross section through the tibia at about Io c.m. above the tibio- astragaloid articulation. SA, recurrent tibial artery; NS, sciatic nerve ; NMC, musculo-cutaneous branch of anterior tibial nerve ; NP, deep or sensory branch of anterior tibial or peroneal nerve; EP, ex- tensor pedis muscle; MP, peroneus muscle; FM, flexor metatarsi muscle. ANTERIOR TIBIAL NEUROTOMY. IQI of the tenacula. In poor horses the contour of the nerve, covered only by loose connective tissue, stands out promi- nently, in fat horses it is surrounded by a large amount of adipose tissue. Cut through this fat and connective tissue and expose the tibial nerve, z, Plate XX XI 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 dchind instead of zz front of it, asis 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 XXXIL-XXXIII. Object. An adjunct operation to the preceding since this ‘nerve supplies sensation to the tarsus in common with the ‘sciatic. Thétwo 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 XX XII-X XXIII, and the peroneus muscles, P, Plate X X XIII, 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 rocm. 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 XX XIII, is separated from the extensor pedis longus, EP, Piates XX XII and X XXIII, 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 4cm., there appears the thin margin of the flexor metatarsi magnus, FM, Plates XXXII and X XXIII, which lies im- mediately against the extensor pedis without a visible con- nective tissue partition but revealing itself by a markedly lighter shade of color and its ready separation from the ex- tensor with the scalpel. The deep branch of the peroneal nerve, NP, Plates XXXII and XXXIII, lies loosely im- bedded on the anterior side of the margin of the flexor meta- tarsi facing the extensor pedis, at times visible at the margin, at others placed more deeply reaching in some cases a distance from the margin of 4 or 5 mm. Within this range is seen the slender nerve trunk almost devoid of surrounding con- nective tissue and measuring about 2 mm. in diameter. Pass the aneurism needle beneath it and remove a piece 3 to 4cm.long. Close the cutaneous wound with interrupted sutures and dress antisptically without a bandage. 196 RESECTION OF THE LATERAL CARTILAGE 42. RESECTiON OF THE LATERAL CARTILAGE. The Bayer Quittor Operation. Plate XXXIV. Object. The cure of quittor or necrosis of the lateral cartilage. Instruments. Elastic ligature, drawing knife, scissors, razor, hoof rasp, hoof plane, craniotomy or other heavy for- ceps for the removal of the horn, artery forceps, elevator or long bone chisel, right and left sage knives, curette, needle holder, thread, needles, iodoform ether, iodoform gauze, tampons, absorbent cotton, bandages. Technic. For a few hours before the operation place the affected foot in a bath of creolin or other antiseptic solution after having first rasped the diseased quarter lightly and make a semicircular groove in the horn of the lateral wall and quarter down to the horny lamina, as shown at s in Fig. 1, 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 1 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 papille 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 1 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 laminz and cutaneous flap held upwards. Posterior half of the cartilage excised. | sensitive lam- ine; w, coronary band; &, anterior half of cartilage; #, cavity caused by the removal of the posterior half of the cartilage ; 7, necrotic cartilage ; #, parachondral surface of the skin and sensitive lamine ; S, perpendicular, crescent-shaped incision in the horny wall; g, fistula, XXXIV. Fig. 2. Resection of the Lateral Cartilages of the os Pedis. Completed operation showing the sutures in place and the’ parts ready for the application of dressings. » 200 RESECTION OF THE LATERAL CARTILAGE. Above the cartilage toward the fetlock the operator must keep the fingers of one hand against the external skin in order to avoid cutting through it or thinning it too much at this point. The flap is held turned upwards by an assist- ant or a strong suture is passed through it and turning it upwards the suture ends are carried around the pastern and tied. As a rule there is now seen a prominent, greenish colored necrotic piece of cartilage surrounded by brownish red masses of granulations. By means of an incision through the cartilage parallel to the long axis of the foot, divide it into anterior and posterior halves and extirpate the latter first by dissecting it out on the inner side from the para- chondral tissue with the sage knife. Begin the excision of the cartilage by engaging the supero-anterior angle of the posterior half with the tenaculum and exerting moderate traction dissect it away from the underlying tissues first along the line of the dividing incision down to the base and then cut backward toward the heel cutting the cartilage away from its continuous bone. Zhe point of the knife must be constantly directed against the cartilage. Since the inner surface of the anterior half of the cartilage lies immediately against the capsular ligament of the corono- pedal articulation the latter should be sharply extended by an assistant seizing the toe and forcing it forward. By this means the capsular ligament is drawn away from the cartilage during its extirpation. The anterior half of the cartilage, £, 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 zmmedzately against the cartilage, material danger of penetrating the RESECTION OF THE LATERAL CARTILAGE. 46% 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, 4, 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 1-1000 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 14days. 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, tenacule, 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 hoursif 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. % cm. outward from the lateral groove of the frog and uniting at its apex. This triangular piece of frog which has been isolated by the incision is now grasped with the tenaculum and dissected away. The remnants of the fatty frog should be removed with the sage knife or scalpel by means of a horizontal incision, and there is then revealed. the flexor pedis tendon which may be greenish or yellowish colored and necrotic, or may be covered with reddish colored granulations. RESECTION OF THE FLEXOR PEDIS TENDON. 203 Should there be present also suppurative pododermatitis the bars on the affected side must be excised along with the other portions. The position and extent of the navicular bone can be determined by palpating the flexor tendon. A transverse incision is then made over the middle of the navicular bone Fig. 15; Resection of the Flexor Pedis Tendon. Solar surface of the foot. c, Semi-lunar crest of os pedis; uw, os pedis ; 7, navicular-pedal ligament ; s, navicular bone; 6, flexor pedis tendon; ¢, sensitive Jaminze of the bars; s¢, fatty frog; /, sensitive frog; 4, horny frog. through the flexor pedis tendon into the navicular bursa, the distal end of the tendon grasped with the tenaculum forceps and lifted up from the navicular bone with the aid of two lateral curved incisions. Between the inferior or anterior border of the navicular bone and the semi-lunar crest of the os pedis stretches the capsular ligament of the inferior articulation reinforced by dense fibrous bands. The flexor 204 AMPUTATION OF THE CLAWS OF RUMINANTS. pedis tendon is united to this by a few bundles of fibres. Dissect the tendon carefully away from the capsular liga- ment, avoiding opening the articulation, and then cut it away from the semi-lunar crest of the os pedis. If necrotic or discolored pieces of the fatty cushion or the tendon still remain, remove these with scissors, scalpel or curette. Curette the roughened cartilage of the navicular bone and remove any necrotic or inflamed, softened portions of the bone. In extensive necrosis of the suspensory ligaments of the heel and of the ligaments extending from the fetlock joint to the lateral cartilages, the necrotic portions as well as the neighboring fatty cushion with its numer- ous elastic fibres, must be resected. In case of purulent areas extending along the tendon and opening above in the heel, draw through the tract a large strip of gauze thoroughly saturated with tincture of iodine and allow it to remain. If the suppurating area extends well up into the heel without an opening, incise from above and handle as preceding. Disinfect the operation wound, irrigate with iodoform ether and tamponade it with dry iodoform gauze. Over this apply a firm pad of oakum saturated with 1-1000 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. Fic. 1. d, horny wall, rasped thin; g, artic- ular condyle of 2nd phalanx; a, 6, c, course of incision. Fic. 2. Median claw preserved. Viewed from the solar surface outward. a, external corono-pedal ligament; 7, internal do; &, ten- don of the flexor pedis muscle; g, distal artic- ular surface of the 2nd digit; g’ articular sur- face of 3rd digit ; 2”, navicular bone; /, lateral claw ; 7, median claw; 0, bulb of the heel. iil aed a Ty ee RHE 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 Retention, and Continuous Approximation Sutures. d, d’, a”, drainage tubes ; ¢, retention suture (closed end); e’, open end; 4, 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 14 210 THE BAVER SUTCORE: 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 to6cm. 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, a’, passed Fig. 17. Splint Bandage. d, da’, d”, drainage tubes; e, retention suture (closed ends); @’, do, open end; 7, iodoform gauze; s, 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 BAYER SOTUORE. 211 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, @”’, 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. Il. EMBRYOTOMY OPERATIONS. Fig. 18. General Considerations. The following exercises in embryotomy 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 with 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. 18: 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 1 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; EH, 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. 214 DECAPITATION, of 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 separation. 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 AMPUTATION. 215 Some obstetrists have found difficulty in applying traction to the inferior maxilla by means of a cord. First makea 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 cesophagus 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 216 SUBCOLANEOGS AMPULATION: 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 fron 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 SUBCOLTANZLOUS AMPUTATION. 2T9 only come into action when the shoulder is nearly severed. It is only necessary then to separate the 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 er: -repelling force to’ the sternum oi -the fetus. Ii 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. 218 DETRUNCATION. 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, asin 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 Se — ‘umn [oo eulds pue sajosnur 9y} SMLIIAs 10} yUI0d gazed “IPUL CLL [BJF JSP] 94} OF Jayered pue puryaq aur payop ayy, ‘“urys 9} YSnosy} uorstour Jo yurod ‘G ‘stajad oy} ur paseSud yaayz pury omy oq} ‘uortsod [erovs-os1op ‘ uorjeyasaid JoLazUY UL AUIOJOAIQUIT “U01}DIUNAIIG IAXXX ?7°Ild 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 XXX VII. 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, I’, becoming locked with the shaft of the maternal \ ‘HOTL[NIYAS [BIOUIDJ-OX09 [eUtoyeur Jo out]jno ‘y + UINzOsI “Y ‘qjeys sz ysnory} Surssed jastyo SUIMOYS ‘HINI[L [BF VT -UINYL [eUTeyeur ‘J Ssaajad omy 94} 90M} -9q yorduit Jo yutod yaiyo ‘5 ‘PeAIO] 1931 saajad eursjem pur [ey] 94} ‘uormtsod [e1ovs-os1op : uorjeyasaid Jorieyue ul AmojoAIqUIyT ‘apyp4In 910]9d au} fo? uo]jInNAWSIq HAXXX ?7?ld 15 226. AMPUTATION OF THE LIMES AT THE TASES 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 XXX VIII. 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 acord around the leg above the tarsus as indicated in Plate XX XVIII 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- \ ‘[PSTYD 9q} JO suvau Aq uorjeyndme jo ssaoo1d ur snsiel “LI, ‘squiy 1or1a3sod any yo mor} “HSPOT S[GONpst YIM worezueseid s01103sod ay} ut AmojoArqmiyq “SMS4D[ 24} JD squirT 4011a}3s0q ay} Jo uoljDjnduy THAXXX ?3°]1q 220) INTRA-PELVIC AMPUTATION. 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 1s severed along with the bone, then loosen the chisel by rotation and lateral motion and drive somewhat deeper into the tarsus until it is com- pletely severed. Withdraw the severed metatarsus and re- move any dangerous spicules of bone remaining on the stump and see that the latter is safely secured by a cord passing around the leg above the os calcis. Repeat the operation on the other hock in a similar manner using the right hand to guide the chisel. Extend the two limbs into the passages by traction and effect a posterior delivery. 53. INTRA-PELVIC AMPUTATION OF THE POSTERIOR LIMBS, BREECH PRESENTATION. Plates XXXIX-XL. Uses. The overcoming of dystocia due to a posterior presentation with the hind limbs completely retained in the uterus, the so-called breech presentation, in cases where the deviation can not be readily corrected. Technic. Introduce one hand armed with the embry- otomy knife through the maternal passages until the peri- \ ‘ant yost pure siqnd ‘wniyt jo suosod Surpnyout UOHB[NI IV [VIOMIII “OXO9 P9zL[OSI 9Y} J9AO podoo] st ador ay, ‘siqnd jejay ay} Vg » INUWOJ IPJoF ON JO JojUBYIOI, “ “MoeUesoid Yyoossig pauteyer Ayayaqd “UL0D SBT PUTTY 9} YIM uOojeHAsSeId JOLI19}s0d 91} ur AtmojosIquIy “SOIPNUBAIXY 10142}SOq ay} JO uo1ZDjnduy a1ajad -pajuy ‘XIXXX 97°ld 234 INTRA-PELVIC AMPUTATION: 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 XI.” Dheggemics 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 PA TRS ¥ TUNEL [BJF 9} JO WJVYS oy} YSnory} Suissed uMoys STJPStyo OY, “ANU; [eJOJ “WS siqnd ‘q ‘ umnost eusozyem ‘7 | want Tey “T/T wan [eusazem ‘J ‘wornezuasaid yoooig ‘pouteyar Ayozayd “M109 sso] PUIY 94} YM MONLUaSeId r0TI0}s0d 94} Ul AmojoAIqUIT “SOIPIWIBAIXY 140119}80q ay} Jo uoljDjnduy diajad DAJUT “IX 23°ld 238 INTRA-PELVICAMPGTATION. of aponeurosis and anteriorly, chiefly on the median line, the prepubic tendon ; these are to be cut, if necessary, with the chisel or knife. Vigorous traction may now be applied by means of the cord, the operator in the meantime guard- ing the most advanced end of the detached piece of pelvis with the palm of his hand in order to prevent injury to the maternal organs. Sometimes this detached piece of the pelvis tears away from the femur when traction is applied and comes away alone. In such a case the cord is to be applied over the head and trochanter of the femur and traction again applied drawing the limb away in a reversed position, the skin being turned back or everted as it ad- vances until the region of the hock is reached where the integument does not so readily separate and only requires to be cut loose and the member allowed to come away. During the removal of the limb the operator is to con- stantly note the progress with his hand and sever by tearing or cutting any tendons or muscles which offer special obstruction to the operation. Repeat the operation upon the opposite limb in the same manner except that but one incision need be made through the bone, that is, through the shaft of the ilium. During the entire work the opera- tion is carried out subcutaneously or rather intra-fetally and the maternal parts are amply guarded against injury. The size of the fetal trunk may be further reduced if de- sirable, by evisceration, (54), and followed still further by the introduction of the chisel guided by the hand and the ribs, on one or both sides, severed one after another until the chest can completely collapse. Or the ribs may be yet more conveniently severed by introducing the sector in the body cavity, pushing it forward until the first rib is reached catching the spherical end over the rib and drawing back- wards, sever each rib in turn. If need be some of these may be removed and one of the anterior limbs caught by a cord around the scapula and extracted intra-fetally. The remnant of the fetus is to be extracted by means of a cord fastened about the lumbar region of the spine. \ LVISCE RATION. 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. ‘lhe ribs are generally best reached by the removal of the shoulder, as already described under subcutaneous ampntation 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 EVISCERATTION. tion is then to be repeated if required, upon the second and third ribs in the same manner until an opening into the chest is secured ample in size for the introduction of the operator’s hand. Force one hand through the opening and tear the medi- astium above and below from the thoracic walls, and then grasp either the trachea at its bifurcation or the heart and tear them away. ‘The heart, which constitutes the greater bulk of the thoracic viscera, is best grasped in the palm of the hand, with the fingers engaging the aorta and pulmo- nary arteries. When the thoracic viscera have been with- drawn, thrust the fingers through the diaphragm and locat- ing the liver, isolate the diaphragmatic area to which it is attached, and engaging both with the fingers remove the two together. The liver constitutes, in a normal fetus, the chief intra-abdominal mass, occupying more space than all other organs combined. After the liver has been removed the intestinal tube, with its contents, is withdrawn without difficulty, as its attachments are feeble. The kidneys may also be removed. Evisceration in the posterior presentation is preferably performed through the pelvis, generally in connection with intra-pelvic amputation of the posterior limbs, (53). It may be performed without destruction of the pelvic girdle by making an incision through the perineal region and then severing the sacro-sciatic ligament as directed under 53. When admission has been gained to the abdominal cavity introduce the hand and withdraw the alimentary tube, then rupture the diaphragm about the liver and tear away the latter organ in the same manner as in the anterior presentation. ‘The liver is so friable that it cannot well be removed by grasping the organ itself, but comes away entire with the central part of the diaphragm. Remove the heart and lungs as above directed. ios ~ tome - yet be 7 : rg om witligs WANN WATT 0 020 948 660 4