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SURGICAL AND OBSTETRICAL
()PERATIONS

BY

W. L. WILLIAMS

Professor of Surgery and Obstetrics in the New York State Veterinary

College, Cornell University.

Embodying portions of the OPERATIONSCURSUS of Dr. W. Pfeiffer,

Professor of Veterinary Science in the University of Giessen.

SECOND EDITION, REVISED

PUBLISHED By THE AUTHOR
ITHACA, N. Y.
1907

LIBRARY of CONGRESS

Two Copies Recelved

DEC 8 1906
Copyright Entry

SG

cLass AA XXc,, No.

eager ao i
COPY B.

COHYRIGHT, 1906,
BY

Ww. L. WILLIAMS.
ak

PRESS OF
ANDRUS & CHURCH,
ITHACA, N. ¥.

PREFACE.

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 Operations-Cursus with such changes,
omissions and additions as were deemed desirable. Three
years of constant use, with such criticisms as have come to
the author from others, have served to point out desirable
changes of so sweeping a character as to demand a practi-
cally new treatise and to render the continuance of a formal
joint authorship inexpedient. The author has drawn freely
upon Dr. Pfeiffer’s Operations-Cursus in the preparation of
the text which in many chapters is practically copied there-
from, including the illustrations, and gratefully acknowl-
edges his profound obligations thereto. On the other hand
nothing has been copied or extracted except it could be freely
adopted as the author’s own view, releasing Dr. Pfeiffer
from all responsibility for the character of any of the con-
Eents.

The volume is primarily designed for the use of the auth-
or’s classes 1n 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
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 varietes of confinement,
anaesthesia, disinfection, sutures, bandaging, dressing and
other adjuncts to operative work. The chapter of trephin-

iv PREEPACE:

ing of the facial sinuses had been dealt with at length in
order to fully and clearly describe the author’s method of
operating ; a new operation for poll evil has been inserted
and there has been included a description of some of the
most important embryotomy operations as they are carried
out in the laboratory by means of freshly killed, new born
calves which are placed in the position described, in the arti-
ficial uterus of a specially prepared skeleton.

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.

Where 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
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 on by an incision through the abdominal walls.

Considerable stress has been laid upon the surgical an-
atomy 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.

The figures in the text except Nos. 5, ro and 11, and the
Plates Nos. 1,11, VII, xX, KH oly, XV Saaee
XT XM, XX RXV, XXV i Land X XTX aire
Dr. Pfeiffer’s Operations-Cursus; Plate No. III was drawn
by Dr. C. F. Flocken, Bureau of Animal Industry, Wash-
ington, D. C., and the remaining Plates were drawn under
the direction of the author by Mr. C. W. Furlong, in-
structor in Industrial Drawing and Art in Sibley College,

Cornell University.
W. L. WILLIAMS.

Cornell University October, 1903. \

PREFACE: TO SECOND EDITION.

The rapid exhaustion of our first edition has been highly
gratifying to the author by indicating the appreciation of
students and practitioners.

We now submit a second edition which has been revised
and somewhat extended. In our revision we acknowledge
with thanks numerous valued suggestions from Drs. Liau-
tard, Adams, Udall and others to which we have given
careful consideration.

As before it has been aimed to continue the volume as a
brief, concise handbook of the technic of a number of the
most important surgical proceedures, omitting the details
common to all or most operations, and assumed that the
student or practitioner has learned these otherwise.

Our illustrations have been materially changed from the
menicoition. Plates IX; XI, XIV, XxX; MMI, XXIV,
mee KVL XXVIII XXXII, XXXII, and. Figures
1 to 8 and 12 to 14 are from Pffeiffer’s Operations-Cursus,
while the other plates and figures have been made especially
for this work under our personal supervision.

The present edition is submitted with a full conscious-
ness of its many defects.

We dG. WEL EAMS:

Cornell University, Ithaca, N. Y.
DECEMBER, 1906.

CONTENTS.

I, OPERATIONS ON THE HEAD:

Page
i.) doetraction or Mecthe. ox wh oe lies oY I
2. Mine piteonor beer see ee tel 8
Trephituing the Hacial Sinuses V5 <= 88 2. 16
S: drephining of the Hrontal Sinuses: 622. so ee 19
4. Trephining the Maxillary Sinuses-\) =) > 2 2 ee
57, brephining tle Nasal, Fossae 37k. oy ee 2. 37
6. Poller Operation. o eere. 5 sek re AI
7 yioeeion: ot the Parotid (Ducts. > J a 45
o. Hntrepiam Operation eo i) ee 2 ee 50
OF. Staphy olonmiy. = 22) 2) ee ne Boe ee 5I
TO. ME Earial NeuroOtontys - me a oTkY oo Nok! ee 55
Il. OPERATIONS ON THE NECK:
i, Opening the Guttural Pouches! 2. 9622" pe 23> Se ee 57
2 eel PACHEOLOLhy. eee a a oe ae ee 63
PA AEVPCMCCLOM y? < 28552 poe ae 8 Se 3s 65
14. Roaring Operation by Excision of the Vocal Cords and Ven-
icicle of. the Laryix 226 5 a ee 70
15. latra-tracheal Irrigation 220 ooo 8 Oh 75
16... Intravenous. Injection — 212" oath ow oy 75
17. @ Phlebotomy with Fleams 222... 225. 2223-4 a7.
6: Phiebotomy with Lancet..." > so ee 78
c.- Phlebotomy with: ‘Trocar: =.=. 3029 2 79
HS, Ligation of the Carotid Artery 3 42 eee 79
19. Chsophagotomy o2. Aer a ee 84
III. OPERATIONS ON THE TRUNK AND ON THE GENITAL ORGANS:
20; Puncture-of the Chest! =. 0 ee 86
21. Puncture of ‘the intestines). = 2 ee eee 87
22, Subcutaneous Caudal Myotomy 2.2. =. =. 0) +) eee 89
23. Caudal Myectomy for Gripping of the Reins --— __ eee gI
24. Amputation of ‘the Pailes2.¢. 2220 3s eee 95
on, Unethrotonty 2%. 2-9) eo ed ee a ee 100
26, Amputation of the Pets 222). 322 ge ee
27: NVaginal.Ovariotomy insthe Mare)-. =) = a eee _ 108

CONTENTS. vil

ao. Vaginal Ovariotenty inthe Cows. 06 “re 11g
29, ‘Ovariotomy.in the Cow by the Plank 0 0 a
30. Ovariotomy in the Bitch by the Flank________ 122
31. Ovariotomy in the Bitch by the Linea Alba______ 129
Pee vanGrotipstn the Cats cm SN ee Ste a 1St
apo atrationyvol Cryptorehid Horses: 3 28?) 2 132
IV. OPERATIONS ON THE EXTREMITIES :

34. Tenotomy of the Flexor Tendons of the Foot__.......______ 142
35. Tenotomy of the Peroneal Tendon (Stringhalt Operation)___ 144
36. Tenotomy of the Cunean Tendon (Spavin Operation). to. 146

BGM GLarimyS Sane erate To Thee yo Ds She eae es 148
cial Nou nOGtiny. 2 5 ho... woe gan ie dg) I51
eer ita eur OVO TIL on a a eon a 159
permed Neurotomiy cS. eS Se ee 160
Pere ae NeTILOFO Ty. Us neat. CN era ee er ie 167
Reemoialie Meuroloniy of! yo oo pin AN oe 5 ted £73
meowanenor bibiak Neurotomiy 2.00 ea eS 183
Poeenection of the Ijateral Cartilagés se 185
age esection of the: Flexor Pedis: Tendon 2252.8. 192
fe uputation'of the.Claws of Ruminants_.. 22006420 5. 194
SPE See eatstss CLERICS, S09 000 Fa By SI he 5 SAS tio Nagel 199

EY;
EMBRYOTOMY OPERATIONS:

mE RECOVERY 15 G42 Joatiets og 2. ec SF cr oN et a 3 Ra 203
MEME API ERTLO TIN «Mi kia we LS 8 SEO FS a kD a pete 205
49. Subcutaneous Amputation of Anterior Limb____________ 206
50. Amputation at the Humero-radial Articulation___________ 208
oeIC RUGS tO (02 iste See Pt oy et ee Wi thd et ee nS 208
52. Destruction of the Pelvic Girdle, Anterior Presentation______ 212
5g. amputation of the Limbs at the Tarsus__..2 2. 216
54. Intra-pelvic Amputation of the Posterior Limbs, Breech Pre-

OELUNSN g 2 5 DSR ee SU a AL a, eve a 220
femme ecenieoiual the: Petus.i 90s ~ oS es er ee 229

INTRODUCTION.

Many details must be omitted in the succeeding text which
are of importance in each operation, but which, if inserted,
would render the volume unwieldy in size for the purposes
designed.

These details are in a measure alike in each case, and it is
assumed that the student has already familiarized himself
with them. ‘The more important of these may be summa-
rized as follows :

1. The subject should be securely confined in each case
as directed, because the method designated has been found
effective in the operation under description, and serves to fix
the relations of the parts in such a way as to conform to the
surgical anatomy of the region as outlined in the text. It
is to be constantly borne in mind that a change in the atti-
tude of the animal is capable of causing profound alterations
in the relations of parts which may greatly embarass the
operator, or even prevent his carrying out the operation
according to the technic given. In securing an animal for
operation we must confine the whole body in a way that will
sufficiently control its movements and will insure safety to
the patient and operator and the part to be operated upon
must be so fixed as to properly limit its motion and in the
position which affords the greatest facility for the carrying
out of the operation according to the best technic known.

2. Anaesthesia should be carefully carried out everywhere
possible, because in addition to the humane sentiments in-
volved, the resulting most perfect control of the animal is
an essential in aseptic or antiseptic surgery. ‘The student
should make a careful study of anaesthesia in these exercises
and acquire invaluable experience and confidence for use in
actual practice.

3. Disinfection must be scrupulously applied in every de-
tail since upon its effectiveness must hang the verdict of

INTRODUCTION. 1

success or failure as measured by modern surgical knowl-
edge. The operator’s hands and, if need be, his arms
should be thoroughly scrubbed with a stiff brush in hot
water with soap for a period of fifteen minutes, the finger
nails well trimmed and cleansed, and all dirt and old epider-
mal scales removed. ‘The parts may then be disinfected by
immersing in a hot concentrated solution of permanganate
of potassium for ten minutes and then decolorized ina strong
solution of oxalic acid in sterile water. Or the hands may
be disinfected after the washing with soap and water by im-
mersing and scrubbing them for ten minutes in a I to 1000
solution of corrosive sublimate, but in order to make this
thoroughly effective the solution needs be alcoholic, or the
hands should first be immersed in alcohol, ether, or other
substance capable of dissolving fats and permitting the dis-
infectant to penetrate the sebaceous glands. Great care
should be exercised by the student to not touch any object
after the hands have been disinfected for the operation unless
it also has been disinfected or sterilized, or in case it becomes
necessary to touch objects not sterile, the disinfecting process
should be repeated before proceeding further with the oper-
ation. ‘This constitutes one of the most difficult of all de-
tails for the beginner to acquire, and each failure should be
remedied by repeating the disinfection over and over until
the habit of maintaining effectual sterilization is acquired
and fixed.

The operation field should always be carefully shaved be-
fore beginning the operation, and the shaved area should
always be very ample, so as to insure against contamination
from adjacent hairs, as well as to give a clear view of the
field. The area should then be disinfected in a reliable
manner, that advised for the operator’s hands serving as a
type. Whenever circumstances will permit the operation
field should be kept in an antiseptic bath or pack for twenty-
four hours prior to the operation in order that the deeper
parts of the skin, especially the hair follicles and sebaceous

x INTRODUCTION.

glands, shall become thoroughly disinfected, a process well
nigh impossible in a short period.

The suturing, dressing and bandaging of the wound
should be carried out carefully in every case and no opera-
tion left without completing it in the best manner possible.

The student should make each operation as real as possible
and not omit any detail, even if he thinks he already knows
it sufficiently well, as the repetition of a supposedly familiar
detail serves an important purpose in the fixing of a habit
which is inestimably more valuable to the surgeon than any
theoretical knowledge of technic.

The safe surgeon is he who has so accustomed himself to
the technic of asepsis and antisepsis that he carries them
out rigidly in an automatic manner and can leave his atten-
tion riveted on the surgical problems before him.

The student who consults his interests will go yet farther
and prior to undertaking any operation on the living subject
will study the regional anatomy of the part on the cadaver
and learn therefrom all that he can of the structure of the
part which he must finally complete upon the living animal.
No dissection of the cadaver can ever teach true surgical
structure as the dead tissues can not be like the living, but
such dissection can and does give great aid and should be
pursued as far as it can lead and enough will still remain to
be learned on the living subject.

He should further take occasion to study in connection
with each operation the object or objects for which it is
performed in practice, its effect on the diseased or other
parts, the untoward results to be anticipated, etc.

Suggestions occur from time to time in the text designed
to aid the student in these lines and help weave connecting
bands between the operation, its objects and results.

Surgical operations are in themselves valueless or worse
and acquire value only when properly correlated to disease
and skillfully performed.

Surgical and Obstetrical Operations.

1 oURGICAL OPERATIONS.

OPERATIONS ON THE HEAD.

LuB x ERACTION OF TEETH
PEATE I:

Prefatory remarks. ‘The grinding teeth of the horse,
consisting of three molars and three premolars in each row,
are of such dimensions and attachments that their removal
in case of disease or defect often presents difficulties of no
small degree.

These teeth attain their greatest size at the time of erup-
tion and most of each remains firmly imbedded in its
alveolus while a very shallow crown projects into the buccal
cavity. The teeth are gradually pushed out of their alveoli
as their crowns are worn away with age and the proportion
of the intra to the extra-alveolar part gradually decreases
until in very old animals the alveolar cavities become obliter-
ated and the last vestige of what was once the apex of the
fang rests insecurely in the buccal mucous membrane.

The facility with which teeth may be extracted increases
as the age of the animal, being easily drawn with forceps
in the old, while in case of freshly erupted teeth in the
young horse we have usually been unable to extract them
with forceps of any kind, except in those where they have
become somewhat loosened as a result of disease or accident.
When aberrations in development occur, leading to the for-
mation of dental tumors or odontomes the possibility of ex-
traction by means of forceps is frequently wholly excluded
and in cases where dental disorder has led to empyema of
the facial sinuses, even if the tooth may be drawn by means
of forceps, further operation is generally necessary, in order

2 EXTRACTION OF TEETH.

to assure a prompt recovery, by the removal of the effects
of the disease of the tooth.

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

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

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

Apply the speculum and identify the diseased tooth by
manual exploration ; determine if the tooth is of unnatural
size or form, if itis loose, if the gums are separated from the
neck at any point, if it is out of line with the other teeth in
the row, if it 1s painful to the touch, if it be split, ete. Am
external tooth fistula or a tumefaction over the affected
member may aid in distinguishing it. Aid may also be had
by illuminating the mouth with a reflecting electric or other
lamp. |

Remove any accumulations of partially masticated food
by means of the toothpick or with the fingers.

In applying the forceps, have an assistant draw the
tongue out at the commissure of the lips on the side oppo-
site to the affected member and introducing one hand into
the mouth, place the index finger on the posterior border
of the diseased tooth and with the other, push the opened
forceps backward upon the dental row until they reach it,

then firmly grasp the diseased tooth with the instrument,
\

EXTRACTION OF TEETH. 3

pressing the jaws down as deeply as possible against the
alveolus. In many cases the diseased tooth can be clearly
seen, especially with the aid of the reflecting lamp, and the
forceps may be readily applied by visual aid and this is
frequently preferable to the sense of touch. Withdraw the
free hand from the mouth, grasp the handles firmly and
loosen the tooth in itsalveolus by establishing and maintain-
ing as long as necessary a gentle to and fro lateral move-
ment. ‘The tooth is thus loosened in its alveolus by caus-
ing it to revolve very slightly back and forth on its long
axis, thereby spreading the cavity. When the tooth has
become well loosened, as indicated by its revolving with
the forceps and by the audible crepitant sound caused by
the passage of air bubbles to and fro through the blood
and lymph in the alveolus, maintain the forceps in position
with one hand and with the other introduce the fulcrum to
a point where the depression on its superior surface will
receive the projecting rivet-head of the instrument or in an
otherwise secure position and give it a safe support, while
the inferior surface rests evenly upon the crown of a tooth
anterior to that which it is desired to extract, as is shown
in Plate I. The fulcrum needs be held firmly in place in
order to prevent it from gliding forward under pressure.
In extracting the first premolars there is no opportunity
for resting a fulcrum on teeth anterior thereto and con-
sequently forceps have been made with fulcra beyond the
forceps jaws resting upon teeth more posteriorly situated.
This is not essential. If the tooth is thoroughly loosened,
as it should be, one hand placed in the interdental space
with the dorsal surface against the jaw and the volar grasp-
ing the instrument, will serve as an effective fulcrum. In
other cases an iron or steel fulcrum is not essential, but a
stick of hard wood of proper size and form acts quite as
efficiently and may even keep its position better because
the teeth upon which it rests sink into it somewhat. On

PEATE 4.
EXTRACTION OF TEETH.

Sagittal section through the oral cavity, show-
ing plan for extracting the third inferior pre-
molar, viewed from within the mouth.

A Forceps jaws applied to third premolar.

B Fulcrum resting upon first premolar.

CC, Plates of mouth speculum resting up-
on incisor teeth.

UEZD

EXTRACTION OF TEETH. |

the whole the fulcrum is not so important as some have
considered it, since, atter a tooth is loose enough to be
drawn with its aid, a very trifling additional loosening will
permit it to be easily lifted from its alveolus without it.

The tooth fang is extracted by forcing the handles of the
forceps toward the jaw in which it is located, so that as it
is gradually drawn out the forceps tend to pivot on the
fulcrum in a way to permit it to emerge from the alveolus
in the direction of its long axis. By referring to Plate II
it will be seen that the axes of the different teeth vary,
that of the molars being obliquely forwards towards the
incisors while the crowns of the premolars are directed
obliquely backwards toward the molars. The slant of the
teeth is most marked at the ends of each arcade while at
the middle they acquire a practically perpendicular position.
In drawing the last molar the forceps will generally strike
against the opposite dental arcade before the tooth has
completely emerged from its alveolus andin order to com-
plete its removal it may be necessary to take a deeper hold
with the extracting forceps or withdrawing these complete
the operation with the aid of exporteur forceps, or still
better frequently with the hand. In young horses where
the teeth are very long we have found it impossible to
complete the extraction until the tooth had been divided
transversely by means of the tooth cutting forceps.

The dangers in the extraction of teeth are chiefly :

1. The fracture of the tooth, leaving the fang still
fixed in the alveolus, a danger not infrequently unavoidable
when the crown has become greatly weakened by disease so
that it lacks the power of resistance necessary to its extrac-
tion ; under most other conditions it may be largely guarded
against by the careful securing of the patient in a manner
to effectively prevent sudden throwing of the head while the
forceps are applied, and by using good judgment in the
amount of force exerted while loosening the tooth in its

8 REPULSION OF TEETA.

alveolus. As stated above we should not expect to be able
to extract with forceps the teeth of very young horses
which have not become partly detached by disease or in
which the fangs are the seat of adontomes.

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

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

2. REPULSION OF TEETH.

Pee IO

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

Instruments. Razor, convex scalpels, trephine, bone
gouge, Luer’s sharp bone forceps, (rongeur forceps) light
and heavy bone chisels, mallet, tooth punch, curette, com-
pression artery forceps, scissors, needles, thread, absorbent
cotton, antiseptic gauze, extracting forceps, splinter forceps,
tenacula, metal probe, mouth speculum.

Technic. Secure the animal in the lateral recumbent
position with the affected side up. The operating table
affords by far the best means for securing for the conven-
ience and safety of operator and patient. If the sinuses are
so involved as to make possible the inhalation of pus, blood
or other injurious matter, perform tracheotomy in ample
time to avert danger. Anzesthetize locally or generally as
required. Shave and disinfect the operative area and

\

REPULSION OF TEETH. 9

trephine according to the method described in the following
chapter down through the alveolar plate immediately over
the fang of the affected tooth. Avoid dulling the trephine
by striking it against the tooth fang itself. If an external
fistula exists the identity of the affected tooth is best
determined by passing a metallic probe through it against
the diseased fang while one hand is passed into the mouth
and the location of the probe more fully ascertained. Care
should be exercised in trephining to not injure the adjoining
teeth. After removing the disc of bone isolated by the
trephine, control all hemorrhage and then enlarge the open-
ing and remove the bony tissues till the tooth fang is bared
its entire width. Insert a scalpel or bone chisel between the
bone and soft tissues at the margin of the trephine opening
nearest the mouth and with one hand in the oral cavity
with the fingers resting upon the alveolar border on the
lateral side of the tooth to serve as a guide; push the
scalpel or chisel along between the bone and soft tissues
until it emerges from the gums alongside the affected tooth
and extend this separation backwards and forwards until
the soft tissues are completely detached from the alveolar
wall over the entire area of the diseased member. When
operating upon the superior molars the fangs of which are
covered by the zygomatic ridge, the chiselor scapel cannot
be pushed directly from the trephine opening into the mouth
between the soft tissues and the bone because the line is
concave instead of direct. In these cases it is best to
detach the soft parts only from the zygoma at first and then
remove the alveolar plate of the ridge, after which the line
into the mouth is direct and the instrument can then be
readily pushed between the soft and osseous tissues for the
remainder of the distance and the separation completed.

In operating upon the inferior molars covered by the
masseter an opening may be made near its lower border
large enough to admit the trephine or the muscle may be

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detached at its point of insertion and two parallel incisions
carried upwards a short distance, permitting the raising of
a flap or what is generally best, a curved incision is made
along its antero-inferior border parallel to the parotid duct
and satellite vessels and just anterior to them (or posteri-
or if preferred ) and the muscle lifted up and drawn back-
wards sufficiently exposing the parts.

With a light, narrow bone chisel cut away and remove
the external alveolar plate over the entire extent of the
tooth, from the oral margin of the trephine opening into
the mouth cavity. Hold the chisel so that the outer edge is
inclined from the affected tooth toward the adjoining one,
thus making a bevelled channel through the alveolar plate
tending to loosen the isolated section of bone by driving it
outwards. Drive the chisel for a short distance on one
side, then upon the other, and thus break the alveolar plate
away in small sections and avoid an extension of the
fracture to neighboring alveoli and damage to adjacent
teeth. Care should be taken that the bone chisel is sharp
otherwise extensive fractures of the bone may occur. With
gouge and chisel remove all remnants of bone over the
lateral side of the tooth laying it completely bare as shown
in Plate II. ‘The soft tissues of the part should not be dis-
turbed beyond the excision of the circular piece, correspond-
ing to the disk of bone removed by the trephine and the
detaching of them from the portion of bone to be chiseled
away. When the tooth has been bared so that every part
of its lateral surface can be seen or felt, the punch may be
placed against the end of the fang, a few firm, quick blows
given with the mallet, so directed that the force is in a line
with the long axis of the tooth, and the organ driven into
the mouth where it is seized by the forceps or the hand
and removed. If it is not readily and safely dislodged in
this way, place the heavy bone chisel against it and with
the aid of the mallet comminute the tooth by breaking it

14 REPOLSION ‘OF TEETH.

transversely and splitting it longitudinally, in which pro-
cess the fragments are generally loosened and can then be
readily removed with the aid of the gouge or heavy dress-
ing or splinter forceps. Remove carefully all fragments of
tooth or of loosened bone, cleanse and disinfect the wound,
pack with iodoform gauze and dress daily.

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

Dangers. Wounding of the adjoining tooth is to be
avoided chiefly by carefully locating the fang of the affected
one and placing the instrument as exactly as possible over
its centre, by using a trephine not exceeding 2 to 5 cm. in
diameter and cautiously sawing through the compact layer
of the external plate only. removing the cancellated tissue
with the gouge and extending the opening in the desired
direction after the outlines of the tooh fang have been
clearly determined. If an adjoining fang is wounded, the
tooth should be removed as it will not heal but will result
in a permanent tooth fistula.

Fracture of the alveolar walls of the inferior maxilla
may occur during the removal of the external alveolar plate
with the chisel or of the repulsion of the tooth with the
punch and mallet. The first is to be averted by care in
having the chisel sharp, by observing the precaution of
making a bevelled cut through the bone, by using only
moderate blows and driving the instrument alternately for
a short distance on each side. The second danger of ex-
tensive fracture may be averted by being cautious to see
after each stroke on the punch that it has not slipped in-
ward along the median side of the tooth, pressing the in-
ternal plate away from the tooth row and tending to pro-
duce a longitudinal fracture nearly or quite as long as the

\

REPOL SION OF TEETH. BS

dental arcade. Careful digital exploration in the mouth
may discover this fracture while still ‘‘simple’’ but a
stroke or two more will convert it into the very much
more serious “‘compound ’’ fracture opening into the oral
cavity. Keeping one hand constantly in the mouth at the
point of impact is always desirable as a precautionary

measure. ‘Transverse fracture of the tooth while yet in
situ by means of the bone chisel, as above described, is a

great safeguard against this injury by lessening the force
required in repulsion and by the removal of the tapering
fang, which then leavesa more secure base for the punch to
act upon. Itshould never be forgotten that the impact from
the punch must always be as nearly parallel to the long axis
of the tooth as is possible.

The fracture of the superior maxilla and bony palate is
not so probable as the preceding and is preventable by mod-
erate care in the denuding of the tooth before punching, by
comminution of the tooth in bad cases, by the careful ad-
justment of the punch and applying the force in the proper
direction.

Literature. Odontomes, Sir Bland Sutton, Jour. Comp.
Dieo..and Vet, Arch;-Vol. XII:-p. 1; A Clinical Study of
Odontomes, W. L. Williams, Am. Vet. Review, Vol. XV,
p.1 ; Notes on Odontomes, do ; Am. Vet. Rev. Vol. XXIII,
p. 82 and Oest. Mon. Thierheilkunde, Bd. XXIV, s. 122.

16 TRE PHINING OF THE FACIAL SINUSES.

TREPHINING OF THE FACIAL SINUSES.
PLATES; LIL, LV; Vy Vig Vill anpe VIEL

Prefatory Note. ‘The facial sinuses of the horse consti-
tute an exceedingly intricate and extensive group of cavities,
communicating more or less freely with each other and with
the exterior through the medium of the upper air passages,
of which they are to be regarded as a part.

Their arrangement and relations permit them to frequently
become the seat of, or central figure in many forms of disease
which require for their differential diagnosis, amelioration or
cure, the operation known astrephining. Their extent and
relations to each other and to surrounding parts varies
greatly with age and may be profoundly changed as a result
of disease, amounting not infrequently in the frontal,
superior and inferior maxillary sinuses ceasing to exist as
separate cavities and becoming merged into one vast diverti-
culum. Similar changes may occur in the nasal and tur-
binated cavities. The general position, extent and relations
of these are indicated by Plates IV, V, VI, VII and VIII.

It is to be noted that in cross sections the superior and
inferior maxillary sinuses appear to be reversed in relation
to their nomenclature. It is difficult to make a cross sec-
tion of these sinuses in such a manner that the superior
sinus does not show between the inferior one and the oral
cavity. The inferior maxillary sinus is zz/evzor in the
sense that it is nearer to the nasal opening so that with the
head in a vertical position or in a longitudinal section the
inferior sinus is below the superior, while if the head be
placed horizontally or a cross section made the superior
sinus is below the inferior.

The uses of trephining are in a measure common to all
the sinuses and are chiefly for the relief of empyema of the
cavities involved, necrosis of the bony or cartilaginous walls,
tumors of various kinds, especially dental in the young and
malignant growths in the old, foreign bodies in the sinuses,
differential diagnosis of diseases of this region, ete.

TRECPHINING OF THE PACTAL ‘SINUSES. 1

Veterinarians trephine the sinuses by two fundamentally
different plans ; with, and without excision of the cutaneous
disk corresponding to the piece of the bone removed. The
first is gererally used in Great Britain and North America,
while the last is the prevailing method in continental
Europe and other parts of the world. The reason assigned
for these variations in method are conflicting. To us there
seem to be adequate reasons for preferring the excision of
the cutaneous disk. We regard as the chief considerations
in an operation the following : the avoidance of infection ;
the prevention of pain during the operation or the after-
treatment ; the reduction of the scar toa minimum ; rapidity
and certainty of recovery ; convenience in operating and
dressing. Infection is largely dependent, aside from
aseptic operation and protective dressing, upon the area of
the wound, the facility for maintaining cleanliness and the
degree of disturbance to the tissues while being dressed.
The wound area in the bone is alike in all cases but that in
the skin varies greatly. If we take as a type the usual
European technic and compare it with that given below we
would find the wound areas approximately as follows: in
the European method 2.2 sq. in. while in the operation as
given below we have only about .44 sq. in. or proportion-
ately the wound area in the soft tissues in the European
operation to that given below would be as 5:1.

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

The amount of pain caused in the operation would depend
chiefly upon the extent of the skin incision which is equal
in the two plans so that the only difference would be in the
dissection of the skin from the bone in the. European
operation. The pain caused in dressing must be greater in
the European method because the detached, overhanging

2

18 TREPHINING OF THE FACIAL SINUSES.

skin must be moved and disturbed each time causing pain
and inviting infection. The question of pain must always
be seriously considered as it not only affects the time re-
quired for dressing and its efhcacy, but has an important
relation to the docility of the animal after recovery, some
horses having their dispositions permanently ruined by the
irritation due to the oft repeated painful dressing of wounds.

The cicatricial contraction of the tissues of the horse is
so great that the removal of a circular disk of skin 7% to 1%
in. in diameter on the face does not leave a visible scar
so that the question of blemish falls back upon that of in-
fection, which, as we have asserted above is far more
probable by the European method.

The rapidity and certanity of recovery are dependent
upon the considerations above discussed. The removal of
the cutaneous disk is certainly easier and quicker than the
other method. ‘The convenience for dressing is evidently
superior by the English and American method.

The opening of the maxillary sinuses into the nostrils is
based upon the surgical principle that suppurating cavities
should be provided with ample drainage from the most
dependent part. The direction to leave the external wound
open, at first thought seems antagonistic to general surgical
principles but it should be remembered that the wound
consists only of the incision through the skin, connective
tissue and bone, and that any plug which we can put in
this opening can only serve to dam back the secretions of
the cavity and can not prevent it from coming in contact
with the wounded surface. It must further be regarded
that the respiratory mucosa of the upper air passages are
not irritated or injured in any manner so far as we can ob-
serve clinically by the direct admission of air into them
through a trephine, or other artificial opening, but on the
contrary the suppuration in asinus is constantly aggravated
by the retention of the pus and exclusion of air and re-
covery facilitated by thorough drainage and. aeration.

TREPHINING OF THE FRONTAL SINUSES. 19

3. TREPHINING OF THE FRONTAL SINUSES.
PLATES TH VITE.

Uses. Fracture of the bony walls, necrosis, tumors.
The ample communication below with the superior
maxillary sinuses prevents the accumulation of pus or fluids
in the frontal cavities even if formed therein unless the
former become filled and the contents back up into the
latter. In the case of empyema of the frontal sinus, trephin-
ing does not generally give full relief but calls for a re-
petition of the operation on the maxillary sinuses also.
Instruments. Razor, scissors, convex scalpels, artery
forceps, tenacula, probe, trephine, curette, gouge, Luer’s
sharp bone forceps (rongeur forceps), hammer, chisel, bone
screw, lens-shaped bone knife, probe-pointed bistoury,
dressing forceps, disinfecting and dressing materials.
Technic. The operation may be performed upon the
standing animal with the aid of local anaesthesia of the
skin, the bone having virtually no sensation. Restless
animals may be further secured with the twitch, in the
stocks, upon the operating table or by casting on the sound
side. Clip and shave the hair from the region of the front-
al bone on a level with the superior border of the orbital
cavity as indicated in Plate III or at any point below on a
line extending from F toward a point midway between N
and I M down to a level with the dotted line, S M, and dis-
infect the area carefully. F represents the highest point
at which the frontal sinus can be penetrated without injury
to the cranium. ~ Within the shaved and disinfected area
locate the point for trephining, F, Plate III so that the in-
ferior border of the opening on a medium sized horse will
be not higher than on a level with the superior border of
the orbital cavity at the dotted line below F and the inner
margin about 1 em. from the median line of the face. With
a heavy convex scalpel make a circular incision as large as
the area of the trephine, directly through the skin, subcutem

PEATE Lu:
TREPHINING THE FACTAL SINUSES.

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

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TREPHINING OF THE FRONTAL SINUSES. 23

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 a scalpel or bone scraper. Control the
hemorrhage. With the centre extended place the trephine
accurately 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 should be retracted and the operation con-
tinued until the disc of bone is detached, being careful to
maintain the trephine prependicular to the surface. ‘The
operation is facilitated by grasping the shaft of the trephine
between the thumb and fingers of one hand, constituting a
support in which it can glide back and forth. The pressure
under which the sawing is carried out must not be too great.
When the bony plate which has been isolated begins
to loosen, remove the trephine and insert the bone screw
into the centerbit opening and break out the piece of bone
or pry it out with the bone gouge or chisel. Smooth any
uneven edges of bone with the lens-shaped knife. The ab-
normal contents of the frontal sinus can now escape through
the opening or be removed with the curette, forceps or scis-
sors, and the cavity irrigated with an antiseptic fluid. Leave
the trephine wound entirely open and dress daily with anti-
septics. The frontal sinuses being in free communication
with the superior maxillary, and the superior turbinated
bone of the same side forming its median wall, indirectly
the irrigating fluid can escape through the nasal opening
by way of the former or by a perforation through the
latter.

In order to prevent the aspiration of the contents, which
are generally purulent, or may consist of blood or irri-
gating fluids, and to facilitate their escape, irrigation should
be carried out with the poll elevated and the head flexed.

PLATE LV.
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
chamber opposite the communication between
it and the superior maxillary sinus ; NF, con-
duit of superior maxillary branch of the trifacial
nerve; S M, superior maxillary sinus; M?,
fragment of last molar.

TREPHINING OF THE FRONTAL SINUSES. Py |

By studying Plates [V—VII it will be seen that any collec-
tion of pus or other disease products at F would result in poor
drainage so far as may be obtained by trephining through
the external wall only, and consequently in order to com-
plete it aside from that through the superior maxillary sinus
an artificial communication between it and the nasal fossa
may be made at ST, Plate VIII by a second opening oppo-
site that point near the median line midway between F and
N, Plate III, and then breaking through the thin walls of
the turbinated bone by means of a probe or other suitable
instrument and enlarging it 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 passa 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 fluids, the animal must
be allowed to get up immediately or if under 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 dis-
lodgement. Retain the gauze in position for about forty-
eight hours to insure the permanency of the opening through
the turbinated bone. In case of severe hemorrhage the
cavity can be tamponed for twenty-four hours with a long
strip of gauze which may be secured if necessary by sutur-

PLATE V.
TREPHINING THE FACIAL SINUSES.

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

TREPHINING THE MAXILLARY SINUSES. 31

ing to the lips of the 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 aspira-
tion of fluids and the hemorrhage is greatly lessened.

4. TREPHINING THE MAXILLARY SINUSES.

PLATES III-VIII.

Uses. Empyema, diseased teeth, odontomes, tumors.

Instruments. Same as for the frontal sinuses.

Anatomically there are two maxillary sinuses, superior,
SM, and inferior, IM, Plates III-VII, 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 present, good drainage of the superior
sinus may demand its surgical destruction so that some
authors advise trephining directly over it in order to open
the two cavities simultaneously. In extensive disease the
prior destruction of the partition renders such an aim super-
fluous ; in limited disease the opening of both cavities is ill
advised. The partition may be ignored in operating for
extensive disease and the trephine opening be aimed at the
probable focus of the malady and, if missed, it should be
located through the primary, or what now becomes an ex-
ploratory opening, and a second operation 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 required 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

32 TREPHINING THE MAXILLARY SINUSES.

the proper point for operation by percussion or otherwise.
If it is desired to enter only the superior maxillary sinus,
SM, Plates III-VII locate the opening immediately beneath
the orbital cavity and in front of the zygomatic 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’. ~Inorder to penetrate the inferior maxillary
sinus at its lowest part, the trephine opening needs be
located just in front of the lower end of the zygomatic
ridge at IM, Plate III, or on a line obliquely upwards there-
from as far as the furrow marking the suture between the
maxillary and nasal bones at IM’. The trephining is
carried out as described for the frontal sinuses. After the
trephining has been completed remove any purulent collect-
ion 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 one at the necessary point.
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 sinuses on the inner
side of the bony conduit of the trifacial nerve, NF, Plates
IV-VII, can not be drained properly through the openings
SM and IM Plate III, and provision for this must generally
be made by trephining into the inferior maxillary sinus at
IM’, Plate III, and then making an opening 3 to 5 cm. in
diameter through the inferior turbinated bone at IT, Plate
VIII, either with the finger, probe-pointed bistoury, or
other suitable instrument, and inserting through this open-
ing 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 as-
sured. \

TREPHINING THE MAXILLARY SINUSES. 33

If the partition between the two sinuses is intact it may
be necessary to destroy it immediately above IM’, Plate III,
in order to drain the median portion of the superior maxil-
lary sinus if that is required. If a molar has been removed
and in so doing the bony wall leading down from the nerve
conduit, NF, Plates IV—VII, destroyed in the operation,
sufficient drainage may be afforded into the mouth and the
opening through the turbinated bone rendered unnecessary.
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-VII, either in trephining or after the sinuses
have been opened. The bony conduit of this nerve is in
rare cases entirely resorbed by pressure from dental cysts or
other causes, leaving it stretched across the cavity as a white
nacrous cord, intensely sensitive. Any injury to this nerve
causes intense pain and renders the animal very resistant
to the necessary manipulations in the after care of the
wound and may leave it pernamently nervous about the
handling of its face.

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

3

PEATE VE
TREPHINING THE FACIAI, SINUSES.

Cross section downwards and _ backwards
oblique through the half of the head at the first
molar in a two year colt. F, frontal sinus ; N,
nasal passage at point of communication with
the inferior maxillary sinus, 1M ; IM', median
portion of inferior maxillary sinus; SM, ex-
treme lower end of superior maxillary sinus
opened ; M1, first molar; M2 second molar;
P, palatine artery ; SZ, sub-zygomatic artery.

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TREPHINING THE NASAL FOSSAEL. 37
5. TREPHINING THE NASAL, FOSSAE.

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

Instruments. Same as for the frontal sinuses.

Technic. ‘The trephining is carried out by the method
described above, in the region of the nasal bone, close by
the median line of the face and according to indications at
any point from a level of the dotted line, SM, Plate III, to
the upper extremity of the false nostril. The operation
should be immediately against the median line since other-
wise the frontal or superior turbinated sinuses may be
opened, the highly vascular superior turbinated bone
wounded or an important inter-osseous artery in the nasal,
just above its union with the superior turbinated, bone as
shown in Plate VI, may be served. Special care is also
necessary that the trephining should not be carried too
deeply and that the osseous disc be carefully removed in
order to avoid wounding the highly vascular turbinated
bone, which lies in close proximity to it. The operative
area is narrow and the trephine used should not exceed 2
cm. in diameter. Whenever possible the operation should
be carried out on the standing animal which decreases the
hemorrhage and the danger from aspiration of fluids. The
hemorrhage may be further controlled in operations upon
the septum nasi and turbinated bones by spraying the parts
with adrenaline chloride and cocaine. Hven in the standing
animal, if extensive operations are to be carried out on the
very vascular septum nasi or on the turbine it is generally
advisable to preform trachetomy before trephining, and re-
tain the trachea tube in position until all danger has passed.
When the animal is confined in the recumbent position the
patient’s safety demands that tracheotomy be performed
before the operation is begun in almost all cases. Anaes-
thesia may be maintained in such cases by means of an
ordinary funnel with its tube bent at right angles and in-

PrAre VLE
TREPHINING OF FACIAL SINUSES.

Cross section of the left side of the head
anterior to the last molar, and through the
widest part of the inferior maxillary sinus. M_’,
last superior molar ; SM, superior maxillary
sinus at its antero-inferior extremity ; IM, in-
ferior maxillary sinus, lateral portion ; IM’, do.
median portion ; N, nasal fossa ; S, sound Jodged
in lachrymal duct; NF, trifacial nerve; F,
frontal sinus.

POLL FVILsOPERATION. 4I

serted into the trachea tube while the chloroform is dropped
on a towel spread over its mouth. After completing any
required operation on the septum, turbinated bones or other
parts, hemorrhage may be controlled by plugging one or
both nasal fossae with single strips of gauze of sufficient
size and carefully securing them by sutures to the sides of
the trephine wound or otherwise.

6. POLL EVIL OPERATION.

PEATE VIET:

Instruments. Clipping shears, razor, sharp scalpels,
probe-pointed bistoury, probe, Luer’s bone forceps, bone
gouge, curette, suture and dressing material.

Technic. Confine the animal in lateral decubitis prefer-
ably upon the operating table, place under complete anaes-
thesia and remove the halter or other headgear.

Clip the foretop and mane and shave the forehead and
the top of the neck back to a distance of 8 or 10 cm. or as
much farther as may be required to pass beyond and be-
hind the supposed extension of disease, and disinfect the
area. With sharp scalpel make a longitudinal incision
on the median line of the head and neck beginning at a
point presumably posterior to the diseased area and carry-
ing it over the poll down onto the forehead for a distance
of 4 or 5 cm. below the foretop. Continue this incision
through the skin, the subcutem, the adipose tissue, AT,
Plate VIII and either through or passing around alongside
the neck ligament, LN, into the diseased area beneath the
latter. Dissect the ligamentum nuchz away from the ad-
joining tissuesvas far back as diseased and divide obliquely
upward and backward as indicated at AA, and detach
anteriorly from the base of the occiput. Be careful to re-

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LIGATION OF THE PAROTID DUCT. 45

move every portion of the ligament in the area indicated
and all calcareous deposits or diseased tissues. With Luer’s
forceps groove a channel about 2 cm. wide from behind to
before directly upon the median line through the occipital
protuberance to the depth of about 2 cm. making the bottom
as near as possible on a level with the wound in the soft
tissues as indicated by the dotted line, AA. Using Luer’s
forceps as a curette detach all vestiges of the neck ligament
from the base of the occiput and leave the bone bare and
smooth. If the Luer or ronguer forceps are not available
the grooving of the occiput may be accomplished with a
strong curved bone gouge. Be careful to avoid penetrating
the cranial cavity or the occipito-atloid articulation. Con-
trol the hemorrhage, cleanse and disinfect the wound, pack
with iodoform gauze and suture for its entire length except
the anterior part, where the tampon should slightly pro-
trude, and dust the margin of the wound with iodoform
and tannin. Remove the tampon after forty-eight hours
and dress antiseptically daily. The sutures may or may
not be removed according to conditions. Incarrying out
this operation our chief aim should be to remove all diseased
parts, to afford perfect drainage anteriorly, to secure and
maintain antisepsis, and to keep the wound directly on the
median line from which no visible scar will result.

7. LIGATION OF THE .PAROTID: DUCT.
PLATE IX:

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

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

Technic. In case of salivary fistula insert a probe
through it into the duct toward the gland and with

PLATE Exe:
LIGATION OF THE PAROTID DUCT.

Pig, 1. Segment of the left ramus of the in-
ferior maxilla of the horse seen from the right
and beneath. sf, usuai operative field; a, ex-
ternal maxillary artery ; v, external ne
vein ; s/, st, parotid duct

Fig. 2. Life size of operation field at sf, fig. 1;
a, external maxillary artery ; v, external eee
lary vein ; s¢, parotid duct ; 777, masseter muscle.

SL ik
rt at

tre

LIGATION OF THE PAROTID DUCT. 49

a sharp scalpel lay it free for a distanc2 of from 1 to 2 cm.
on the glandular side of the fistulous opening. If the
fistula has its location on the side of the cheek, cast the
horse and shave and disinfect the region on the inferior
maxilla where the artery, vein and parotid duct turn around
its inferior border. When the operator glides his finger
over the vascular region from before backward there is felt
a resistant cord, the external maxillary artery about 3 mm,
in diameter, pulsating in the living animal. Between this
and the oral border of the masseter muscle make an incision
about 4 cm. long parallel with the artery through the skin
and skin muscle. This incision is more readily made by
gathering up a fold of skin about 2 cm. high and cutting
through it. Pick up the loose connective tissue with a pair
of forceps and excise it. Immediately behind the external
maxillary artery, 2, Figs, I and II, Plate IX, is the ex-
ternal maxillary vein, v, and behind this and immediately
on the border of the masseter muscle lies the parotid duct,
st. Incase of salivary calculi which cannot be removed
through the mouth and cystic dilation of the parotid duct,
make the cutaneous incision at the affected point, open the
canal, and after the removal of the calculus, etc., close the
duct wound by means of intestinal sutures in such a way
that the external surfaces of the lips of the wound in the
wall of the duct are brought in contact, or ligate the duct
on the proximal side of the point of operation. Ligation is
accomplished by passing a strong silk thread behind the
duct by means,of a curved aneurism needle carrying the
ligature around it and tying with a surgeon’s knot. ‘The
parotid duct can also be previously split and an internal
wound made at the point of ligation. Close the skin
wound by means of a continuous suture and cover the
operative surface with iodoform collodion or with wound
gelatine.

4

50 ENTROPIUM OPERATION.

8. ENTROPIUM OPERATION.

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

Technic. Quiet adult horses may be operated upon in
the standing position with the aid of local anaesthesia, other
horses and small animals should be secured in lateral re-
cumbency preferably upon the operating table. Shave and
disinfect the skin of the inverted eyelid. Grasp the skin of
the eyelid midway between the inner and outer canthi
either with the fingers or the forceps and elevate a skin fold
parallel with the border of the eyelid to such a height that
the inverted member assumes its normal position. Pass

Fie. I.
Entropium operation on the superior and inferior eyelids of the dog.

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

STAPH YLOTOMY. 51

9. STAPHYLOTOMY.

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

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

Technic. Cast the patient or secure on the operating
table in lateral recumbency and turn the nose upward.
Adjust the mouth speculum and open the mouth as wide as
possible ; draw the tongue well out with the left hand while
the right carrying the knife on the middle finger is passed
carefully through the fauces until it hooks over the posterior
border of the soft palate. The knife is then gently drawn
forward making an incision along the median line of the
soft palate from its posterior, free border to its attachment
on the palatine bone. The hand is then withdrawn and the
speculum removed for a few minutes to permit the patient to
rid its pharynx of any blood clots or mucus that may have
accumulated. Readjusting the speculum as before, the
right hand is again passed through the fauces and now that
the palate is divided a digital exploration may perfectly re-
veal the presence of any abnormality in the region.

BEATE X,
TRIFACIAL NEUROTOMY.
LL, Levator labii superioris proprii muscle ;

IOF, infra-orbital foramen ; NF, superior max-
illary division of the trifacial nerve.

_TRIFACIAL. NEUROTOMY. 55

lo. -TRIFACIAL “NEUROTOMY.
PATE xX.

Object. The relief of involuntary shaking of the head.

Instruments. Razor, scissors, convex scalpel, tenacula,
aneurism needle, compression artery forceps, needles, thread,
absorbent cotton, a strong piece of muslin 12 cm. square.

Technic. Secure in lateral recumbency, preferably upon
the operating table, and produce complete anaesthesia. Re-
move the halter, bridle, or other head gear. Shave and
disinfect an area 8 to 10 cm. square over the infra-orbital
foramen. Locate by touch the infra-orbital foramen, IOF,
Plate X, below the levator labi1 superioris proprius muscle
and displace this slightly upward toward the median line of
the nose until the foramen can be clearly felt below the
muscle. With the scalpel begin an incision somewhat
superior to the foramen and near its nasal border and make
a wound downward and forward in the direction of the
comimisure of the lips about 5 cm. long through the skin,
muscle and connective tissue down to the nerve and control
hemorrhage with the greatest care. If the larger branches
of the glosso-facial vessels are severed they should be ligated
or twisted. Some times it may be well to ligate these
vessels prior to making the incision.

Hold the lips of the wound apart with two tenacula, disect
away the connective tissue from the nerve until every part
of it is clearly in view. Pass an aneurism needle beneath
the nerve trunk and lifting it from the bone make a search
for a small artery which usually passes along beneath it
through the foramen and if this can be found either ligate
it immediately at its point of emergence and again 5 cm.
lower down and divide between the two ligatures or sepa-
rating it from the nerve protect carefully against injury.
With a probe-pointed bistoury or scissors sever the nerve at
the foramen and grasping the distal end disect away about
5 cm. of the trunk and excise. Be very careful to include
all branches and especially one or two superior or dorsal

56 TRIFACIAL NEUROTOMY.

twigs which are directed upward near the foramen. After
the hemorrhage has been brought under complete control
and all blood clots have been removed cleanse the wound
carefully and dust over with iodoform and close with con-
tinuous sutures. Owing to the great difficulty of securing
complete asepsis, it may be better in some cases to not suture
but to insert instead an antiseptic tampon retained by sut-
ures for 24 hrs. after which remove and dress the wound
antiseptically 2 or 3 times daily. In order to protect this
first wound during the operation upon the other side take
the piece of muslin mentioned among the needs for the
operation, and folding it several times in a square, place it
over the wound and suture it firmly at each corner. Turn
the animal to the opposite side and repeat the operation on
the other nerve except the application of the square piece
of muslin which is here unnecessary. As soon as the animal
stands, remove the protective piece of muslin from the first
wound, disinfect both, dust them over with iodoform and
tannin or cover with wound gelatine and leave undisturbed
to heal by primary union. Avoid halter, bridle or other
fixtures which might injure the wounds after the operation.

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

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

Il; OPERATIONS ON ‘THE NECK.

11. OPENING OF THE GUTTURAL POUCHES.

PLATE XI.

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

Technic. I. Vzborg’s method. ‘The operation is possible
on the standing animal, but generally the patient must be
cast or placed on the operating table and secured in lateral
decubitis with the head extended. By extending the head
and compressing the jugular vein there is brought out the
triangle immediately behind the posterior border of the in-
ferior maxilla and below the parotid gland comprised be-
tween the posterior angle of the inferior maxilla, the terminal
tendon of the sterno-maxillaris muscle and the external
maxillary vein. In this so-called Viborg’s triangle after the
removal of the hair and the disinfection of the skin which
is maintained stretched, make a 5 cm. long incision through
the skin andskin muscle immediately beneath the afore-
mentioned tendon and parallel to it. In case of pronounced
swelling in Viborg’s triangle the operator must determine
the location for the incision by the position of the sterno-
maxillaris muscle. The skin and subcutem having been
incised to a sufficient extent, force a passage with the finger
or with probe pointed scissors closed or other blunt instru-
ment through the loose connective tissue on the median side
of the parotid gland, to the guttural pouch and penetrate it
at its lowest point with the finger or trocar. In order to
open the empty guttural pouch it is desirable to grasp a
portion of its wall by means of forceps. Through the
operative wound a drainage tube can be introduced into the
pouch, and fixed in its position by sutures. The opening

PLATE XT.

OPENING OF THE GUTTURAL POUCHES (Hyo-
YVERTEBROTOMY ) ACCORDING TO VIBORG
AND CHABERT.

Head and neck of recumbent horse viewed
from the side. 57, Stylo maxillaris muscle ; A,
parotid gland; /, guttural pouch; &, larynx ;
st, sterno-maxillaris muscle; 7, rectus capitus
anticus major muscle ; c. external carotid artery ;
é, external maxillary artery ; 2, internal maxil-
lary artery; v, external maxillary vein; s,
probe; a, wing of atlas.

—
aa

OPENING OF THE GUTTURAL POUCHES. 61

can be enlarged in an anter-posterior direction to the extent
of 5 to 8 cm. or large enough to admit the operator’s hand.

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

Il. Chabert’s method. Secure the horse in the lateral re-
cumbent position, remove the hair and disinfect the skin
beneath the wing of the atlas. Make an incision about I
em. in front of the lower half of the wing of the atlas and
parallel to it, about 6 cm. long extending through the skin
and skin muscle down to the parotid gland. ‘The incision
is facilitated by rendering the skin tense with the left hand
and care is to be taken not to wound the auricular nerve
which passes directly along the atlas. Then draw backward
the posterior lip of the wound and separate with blunt in-
struments the posterior border of the parotid gland from
the atlas, to which it is bound by loose connective tissue,
and draw it forward with tenacula. At the bottom of the
opening thus formed there is seen the stylo-maxillaris
muscle, sm, Plate XI, lying against the median side of
the parotid gland covered only by the aponeurosis of the
mastoido-humeralis muscle, With the handle of the scalpel
inclined toward the wing of the atlas penetrate in the

62 OPENING OF THE GUTTURAL POUCHES.

direction of their fibers the aponeurotic expansion ofthe
mastoido-humeralis, and the stylo-maxillaris muscle. The
puncture is thus located between the ninth and tenth
nerves on one side and the internal carotid on the other.
Since the wall of the guttural pouch rests against the median
side of the digastricus muscle it is opened by this incision.
The operator inserts an index finger along the blade of the
knife at first and then withdrawing the instrument passes
the other index finger also in the penetrant wound and by
forcibly parting these, dilates it. The abnormal contents are
then removed by means of forceps, curetting and irrigation.
In order to prevent adhesion of the wound lips in the firmly
stretched stylo-maxillaris muscle, introduce a strong drain-
age tube into the pouch and fix it to the external borders of
the wound by a suture.

Ill. Dieterich’s method. ‘This combines the operations
under I and II, with the difference that the superior opening
of the pouch is made immediately behind the stylo-maxillaris.
In order to accomplish this the cutaneous wound over the
wing of the atlas must be prolonged belowit. After detach-
ing the posterior border of the parotid gland the operator
searches in the loose areolar tissue with the index finger of
the left hand for the vascular angle which is formed by the
occipital, internal carotid and external carotid arteries which
may be detected by pulsation—the same is located at a depth
of somewhere from 8 to 10cm. Place the volar surface of
the finger in the vascular angle and push a sharp scalpel
along its dorsal side to the pouch which here becomes
opened on its posterior lateral surface.

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

FRACHEOTOMY. 63

12, TRACHEOTOMY.
Ee 2s

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

Technic. Inthe superior third of the cervical region,
in the neighborhood of the fourth to the sixth tracheal ring,
shave and disinfect the skin on the anterior surface of the
neck to the extent of 10 cm. long by 5 cm. wide. The
operation is best performed upon the standing animal with
ie fiedad extended. In lateral. decubitis of the horse the
operation is carried out with some difficulty, and generally
the operator fails to get the incision on the median line.

ies 52:

TRACHEOTOMY. s, sterno-thyro-hyoideus muscle ; #7, trachea ;
sch, mucous membrane of the posterior wall of the trachea ;
Z, interannular ligament.
The operator stands before the right shoulder of the horse
with an assistant opposite him.

Make the incision by rendering the skin tense along the
median line of the trachea with the left hand and then mak-
ing a drawing cut from above to below with the scalpel.
After the skin muscle is cut through, in order to avoid hem-

—

64. TRACHEOTOMY.

orrhage, separate the two sterno-thyro-hyoideus muscles by
means of tenacula along the median line in the white strip
of connective tissue. ‘The opening into the trachea may be
made in a variety of ways. The quickest and most crude
method is to slit it from above downwards through three or
four tracheal rings, and pressing the severed ends apart
insert the tube through the opening. Since the tracheal
rings are incomplete, being open on their dorsal surfaces,
cutting through the ventral portion divides each ring into
two separate parts and their being pushed apart, distorts
them and tends to the causation of chondritis and collapse
of the trachea, a danger which increases with the duration
of time that the tube is maintained in position. It is there-
fore most suitable for hurried operation in impending
suffocation where the tube will probably be needed for a
short time only.

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

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

ARYTENECTONOMY. 65

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

13. ARYTENECTOMY.
PEATH 2411;

Object. Therelief of roaring or larynigismus paralyticus.

Instrumenst. Razor, scissors, scalpel, razor shaped
knife with long handle, long curved scissors, long curved
uterine dressing forceps, double tenaculum forceps, trachea
tube, retractors, reflecting lamp, absorbent cotton and dress-
ing material.

Technic. Perform tracheotomy as advised in preced-
ing chapter. Secure the animal in lateral recumbency
preferably upon the operating table and induce complete
anaesthesia closing the trachea tube in the meantime or
administering the chloroform through this by means of a
bent funnel while the nostrils are occluded by tampons.
Shave and disinfect the skin over the laryngeal region.
Place the animal upon its back with the head extended and
remove the halter or other head gear. If necessary continue
the adminstration of chloroform through the trachea tube
by means of a funnel the small end of which is inserted in
it while the chloroform is dropped on a towel spread over
the larger end. The operator takes his place on the right
side of the animal and the assistant on the left. Make a
longitudinal incision through the skin and subcutem be-
ginning at the anterior part of the thyroid cartilage and ex-
tending backward on the median line of the 3rd. or 4th.
tracheal ring. Control the cutaneous hemorrhage. Con-
tinue the incision through the subjacent muscular tissue
being careful to follow the median line exactly until the
crico-thyroidean ligament, CTL, Plate XII, the cricoid
cartilage C, and the first tracheal ring TRI, are laid bare.

5

PLATE XXII.
ARYTENECTOMY.

EH, epiglottis; TT, thyroid cartilage; CC,
cricoid cartilage ; TRI, first tracheal ring; V.
left vocal cord ; A, left arytenoid cartilage sur-
rounded by dotted line of incision ; CTC, crico-
thyroideau ligament.

ARYTENECTOMY. 69

Again control any hemorrhage. Plunge the scalpel with
its cutting edge directed backward through the crico-
thyroidean ligament on a level with the dotted line T and
extend this backward along the median line severing the
ewcoid cartilage, C, and the first tracheal ring,’ VRI.. In-
sert the retractors and have the larynx held well open by as-
sistants. Illuminate the larynx by means of a reflecting
lamp as may be required. After controlling any hemor-
rhage caused by the foregoing make an incision through
the mucosa and the intervening connective tissue between
the two arytenoid cartilages, A, beginning at the anterior
part and extending backward to the cricoid, thence turn-
ing upward and laterally, incise the mucosa across the
posterior end of the arytenoid thence forward .along its
lateral border through the vocal cord, V, and turning down-
ward as the animal hes, that is toward the dorsal part of
the larynx, continue the incision to the point of beginning.
In making this incision cut as closely as possible to the
margin of the cartilage so that a minimum amount of the
mucous membrane will be removed. Grasp the lateral
border of the cartilage with the long tenaculum forceps and
with a razor-shaped knife or the scissors separate the lateral
and anterior portions of it from the adjacent tissues keep-
ing always immediately against it in order to produce as
clean a wound as possible and to avoid injuring adjacent
vessels from which hemorrhage would occur.

When the cartilage has been detached over the greater part
of its surface locate the crico-arytenoid articulation and dis-
articulate or cut through the arytenoid as close to the articu-
lation as possible with the razor-shaped knife or the scissors.
Remove all blood by means of pledgets of absorbent cotton
securely held in the long dressing forceps, or the clots may
be pushed into,the pharynx when they will generally be
swallowed. Carefully remove any cartilaginous remnants
or tissue shreds and control the hemorrhage from any

70 ROARING OPERATION.

visible vessels. Dust the wounds thoroughly with iodoform
and tannin and if the capillary hemorrhage is great pack
the larynx with a single strip of iodoform gauze and secure
it by sutures through the margin of the skin wound. Re-
move this tampon after twelve to twenty.four hours. Wash
and disinfect the wounds daily.

Remove the trachea tube daily and cleanse, and retain it
in position for 6 to 10 days or until the animal breathes
freely without it. After about 8 days insert the retractors
in the laryngeal wound, dilate it, examine the interior
with the aid of a lamp and give any needed attention to
unhealthy granulations or other untoward conditions.

14. ROARING OPERATION BY EXCISION OF THE VOCAL
CORDS AND VENTRICLE OF THE LARYNX.

PRATE: XTi

Objects. The same as in the preceding operation except
that we attempt to relieve roaring by causing the arytenoid
cartilage to become fixed against the side of the glottis by
cicatricial adhesion.

Instruments. Same as in the preceding.

Technic. The technic of this operation is identical with
the preceding until the larynx has been been opened.
Grasp the left vocal cord with the double tenaculum for-
ceps, one jaw of which rests in the ventricle and lift it up-
wards until the parts are rendered tense. With the razor
shaped scalpel make an incision parallel with the long axis
of the vocal cord on the tracheal side of it through the mu-
cous membrane and cord and continue this incision forward
internally along the immediate border of the arytenoid car-
tilage barely through the mucous membrane and laterally
make a similar cut directed forwards approximately 1 to
1% cm. distant from the preceding as indicated by the
dotted line in Fig. 1, Plate XIII. Keeping the parts in-

ROARING OPERATION. 7%

cluded in the tenaculum forceps tense, dissect the vocal
cord and mucous ‘membrane from the underlying parts
from behind forward toward the apex of the arytenoid car-
tilage and continue the two incisions forward until the ven-
tricle has been passed when they are made to converge and
finally meet, thus isolating completely the mucous mem-
brane of that depression. Should the tension upon the
vocal cord and mucous membrane by means of the tenac-
ulum forceps be too great they may tear asunder in which
case the remnants must be grasped by means of the tenac-
ulum forceps or better with the long dressing forceps and
the operation continued. The mucous membrane should
be carefully trimmed around the margin of the wound and
care should be taken to not remove entirely the remnants
of the wasted thyro-arytenoideus muscle because that tends
to permit the cartilage to drop down too low in the larynx
nor. should the incision in the ventricle be carried deeper
than the mucous membrane lest we wound important ves-
sels and produce annoying hemorrhages. Remove all blood
clots and disinfect the parts. Apply no sutures to the
wound in the vocal cords, mucosa or larynx. After the
animal has recovered from the anaesthesia, cleanse the ex-
ternal wound carefully and wash it daily with an antiseptic
and if thought best apply this also to the wound in the vo-
cal cord by means of saturated absorbent cotton grasped
with the long dressing forceps and pushed up to the area
through the laryngeal incision. Cleanse the trachea tube
daily and keep in position from six to ten days or longer,
should the animal show difficulty in breathing when it is
removed.

PLATE XIII.

OPERATION FOR RELIEF OF ROARING.

Fic. 1. Longitudinal section through the
ventricle of the larynx ; A, Arytenoid cartilage;
TA, Anterior fasiculus of thyro-arytenoideus
muscle ; TA’, Posterior bundle thyro-arytenoid-
eus; VC, vocal cords; V, Laryngeal ventri-
cle ; T, Thyroid cartilage ; E, Epiglottis.

Fic. 2. Sagittal section of the larynx. C,
cricoid cartilage ; C-T, crico-thyroidean liga-
ment. Other lettering same as Fig. I.

MR Aon: Ree 6 tia:
Ss

Pre, 33

INTRA-TRACHEAL IRRIGATION. 75

15. INTRA-TRACHEAL IRRIGATION.

Objects. The washing of irritant or septic substances
from, and the disinfection of, the trachea and bronchi.

Instruments. Same as for tracheotomy, and a gravity
irrigating apparatus fitted with 3 m. of rubber tubing about
I cm. in diameter, 5 liters of .6 per cent. soda chloride solu-
tion at a temperature of 37 to 39° C.

Technic. Operate on the standing animal. Perform
tracheotomy. Elevate the gravity apparatus containing the
irrigating fluid 1 to 2 m. above the patient, have the
animal’s head slightly elevated, insert the free end of the
rubber hose in the trachea tube and let the fluid flow into
the trachea in a moderate stream until it is filled and the
animal makes expulsive efforts, when the inflow is stopped
and the animal permitted to lower his head and expel the
fluid, then raise the head again and repeat until the fluid is
expelled clear. Repeat the operation according to require-
ment. In cases of suppurative bronchitis, peroxide of
hydrogen may be added to the solution.

16. INTRAVENOUS INJECTION.
BIG 3:

Instruments. Scissors, hypodermic syringe.

Technic. ‘The operation is performed on the standing
animal on either jugular vein at about the juncture of the
upper and middle thirds of the neck ; to most operators the
right jugular is the more convenient. At the place desig-
nated the subscapulo-hyoideus muscle lies between the
jugular vein and the carotid artery. After clipping the hair,
the skin should be carefully disinfected. The vein lies in
the jugular groove between the mastoido-humeralis and the
sterno-maxillaris muscles covered only by the skin and skin
muscle. Stand by the shoulder of the horse and compress
the jugular with the thumb as shown in Figure 3 or with the

76 INTRAVENOUS INJECTION.

second to the fourth fingers, in which case the ball of the
thumb rests on the mastoido-humeralis muscle, in a way that
the vein becomes filied above the point of compression in the
shorn area and stands out asa swollen cord. In the case
of fleshy necked horses this compression is more readily
attained if the head is somewhat eievated and extended by an
assistant. If the vein can not be made prominent in this

Fic 3. Intravenous Injection.

way the compression should be alternately applied and with-
drawn suddenly, the course of the vein then reveals itself by
a wave-like movement along the jugular groove. Just
above the point of compression the vein is the most fully
distended and firmly fixed. After testing the hypodermic
needle to see that it is open hold it between the second and
third fingers while the thumb covers its basal opening and
thrust it through the skin, cutaneous muscle and jugular
wall, in the direction of the vein obliquely forwards and up-
wards 1 to 2cm. deep, so that the point of the needle enters
the vessel at its most distended part. In this way it is easy
to prevent injury to the median wall of the vein. If the

PHLEBOTOMY. 77

vein has been properly punctured blood will flow from the
needle upon the removal of the thumb. If the vein is not
entered at the first attempt the needle should be partly with-
drawn and then pushed in again in a slightly different direc-
tion. The compression is then removed and the hypo-
dermic syringe in which no air is contained is connected
and the contents slowly discharged into the vein. In with-
drawing the needle be careful to press the skin firmly against
the underlying part. ‘The omission of this precaution fre-
quently results in the formation of a subcutaneous hema-
tome.

17, PHLEBOTOMY.
FIG, 3.

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

Technic. a. Phlebotomy with fleams may be performed
on either jugular vein. The operation is preferably carried
out on the standing animal, but is not difficult when the
patient is recumbent. The point of operation is at about
the boundary line between the upper and middle cervical
regions, because it is here that the subscapulo-hyoideus
muscle which separates the jugular vein from the carotid
artery is most voluminous and consequently affords the
greatest protection to the latter. At this point clip or shave
and disinfect the skin. Grasp the extended blade of the
fleam at the joint with the thumb and index finger of one
hand, while the third and fourth fingers compress the
jugular vein at a point far enough below the shaved part
that the fleam blade rests upon it. In fleshy-necked
animals the course of the vein may be clearly made out by
causing its repeated distension and relaxation. It is well
to be careful that the point of the fleam blade is not allowed
to prick the skin prematurely and render the animal rest-

78 PHLEBOTOMY.

less, and that it is held perpendicular to the surface and
parallel to the long axis of the vein. The most elevated
point of the vessel should be struck by the blade in sucha
way that the skin, subcutaneous muscle and jugular wall
are penetrated parallel to the long axisof the vessel. Drive
the fleam blade into the vein by a short, sharp blow with a
small stick of heavy wood. ‘The extension on the fleam
blade prevents its beiug driven too deeply. The size of
the blade to be used depends upon the thickness of the skin
and other tissues covering the vein. If the vein is opened,
dark red blood escapes from the wound in a large stream.
If the operation does not succeed at the first effort, one
should select an undamaged portion of the skin for a second
attempt so that the opening into the vein may be direct and
clean. When the vein is opened lay the instrument aside,
the compression of the vessel being continued in order to
prevent aspiration of air into it and also that the lips of the
skin wound shall not become displaced in relation to that
of the vein by which the escape of blood would be impeded
or stopped. ‘The flow of blood may be favored by inducing
masticatory movements by the animal. The amount of
blood withdrawn varies between 3 and 8 liters, according
to size of the animal and the object to be attained. The
wound may be closed by an interrupted or a pinned suture.
For the latter, relieve the compression on the vein and
grasp the lips of the skin wound between the finger and
thumb and stick the pin perpendicularly through the middle
of ita few mm. from its borders. Apply a noose of silk
ligature previously prepared over the pin and close and tie
the loop. In applying the pin and loop, take care not to
élevate the skin from the underlying part, which tends to
the production of a hematome.

b. With the lancet the operation is preferably performed
on the right side of the neck. Compress the vein as illus-
trated in Fig. 3, and hold the lancet between the thumb and

LIGATION OF TALACAROTID ARTERY. 79

index finger in such a manner that it can only penetrate as
far as into the vein, and then push it in quickly just in
front of the compressing thumb through the skin, subcutem
and venous wall as deep as the fingers holding the lancet
will permit.

Hold the blade perpendicular to the long axis of the
vein, and avoid directing the point dorsalwards, which would
endanger the superior wall of the vessel or cause the
lancet to glide over the wall and not enter the vein. When
the lancet has entered the vein, extend the wound somewhat
toward the head by flexing the hand dorsally. In cattle it
is necessary to compress the vein by means of a cord tightly
drawn around the neck, the operator taking the same posi-
tion as in the horse while an assistant holds the animal by
the horns or nose. Close the wound as in a.

Phlebotomy with the spring lancet is carried out in a sim-
ilar manner, the jugular being compressed in the same way,
and the lancet, with the spring set, placed over the vein in
such a way that the opening will be made in the same direc-
tion and manner as with the fleams. The lancet blade is
then released and penetrates the vein. The compression be-
low is continued as in other cases.

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

18. LIGATION OF THE CAROTID ARTERY.

PLATE, XLV:

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

Instruments. Scissors, scalpel, tenacula, aneurism

PEATE X1V.

Fic. 1.—a, Ligation of the common
carotid artery ; 6, CGisophagotomy.

Fic. 2.—Ligation of the common
carotidartery. c,common carotid artery ;
Jj, juguiar vein; v, vagus nerve; S,
sympathetic nerve ; 7, recurrent nerve;
p, cervical panniculous carnosus muscle;
m, sternomaxillaris muscle; sz, levator
humeri muscle.

Fic. 3.—Csophagotomy. ¢, com-
mon carotid artery ; 7, jugular vein ;
0, 0’, cesophagus; s, sympathetic
nerve ; 7, trachea; s¢, mastoido hum-
eralis (lavator humeri) muscle.

LIGATION OF THE CAROTID ARTERY, 83

needle, mouse-toothed forceps, lgation forceps, suture
material.

Technic. The operation is possible on the standing
animal with the aid of cocaine or other local anaesthetic but
it is preferable to confine the patient in lateral recumbency
and anaesthetize.

The operation is made at the same point as for phlebotomy
and the same cutaneous wound, a, Plate XIV, may be used
for this purpose. ‘The incision should be at least 10 cm.
long extending through the skin, fleshy panniculus and
subscapulo-hyoideus muscles and then a passage forced with
the fingers, to the trachea. At the region of the neck
indicated, the carotid passes along the border between the
lateral and dorsal surfaces of the trachea, accompanied
dorsally by the vagus and sympathetic nerves and ventrally
Merde tecutrent. <(In; Figure 2, Plate: XIV;. the vagus
and sympathetic nerves, v and s, are pushed out of their
normal position and appear ventrally to the carotid.) Pass
the index finger over and behind the carotid until the
trachea is reached, and encircling the inner and lower sides
of the artery, force a way through the surrounding areolar
tissue and draw the vessel out through the wound. Asa
rule the carotid is still loosely surrounded by connective
tissue, which comes from the deep fascia of the neck and in
which also the three above mentioned nerves are found.
These nerves must be carefully separated from the carotid
and must on no account be included in the ligature. Ligate
the carotid twice with an intervai of about 2 cm. between
the two ligatures and divide the artery midway between
them. ‘The second ligature is necessary in order to prevent
hemorrhage from the distal end through collateral anasto-
moses and it is essential to sever the artery in order to avoid
its rupture by the stretching of the undivided carotid dur-
ing movements of the neck where the nutrition has been cut
off at the point of ligation. Provide drainage for the wound
and suture the muscle and skin.

~—

84 GSOPHAGOTOMY.

I9. CGASOPHAGOTOMY.
PLATE XIV.

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

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

The operation is performed at any point between the
pharynx and chest where the lodgment of a foreign body
or other condition may demand it. When the cesophagus
is empty the operation is best performed in the lower third
of the neck at 6, Figure 1, Plate XIV.

Anincision 10cm. long through the skin and skin muscle
is made on the left side between the anterior border of the
mastoido-humeralis muscle and the jugular vein. With the
two index fingers divide the loose connective tissue down to
the cesophagus, which lies between the left scalenus muscle,
trachea and jugular vein. Along the supero-external
border of the trachea rnns the carotid, accompanied dorsally
by the vagus and sympathetic and ventrally by the re-
current nerves. The cesophagus feels like a round muscle
within which one can distinguish a firmer cord, the mucous
membrane. When brought into view the organ has a pale
red color, and it, with the trachea is surrounded by the
deep fascia of the neck. Pass one finger around the
cesophagus from behind, draw it away from the trachea,
force a passage through the deep fascia of the neck and
draw it out through the external wound. After making an
incision through the muscle and mucous membrane intro-

(ESOPHAGOTOM Y. 85

duce a probe pointed bistoury or a scissors blade into the
lumen of the cesophagus and split its wall. The mucous
membrane is white and lies in thick longitudinal folds.
When there is a foreign body in the cesophagus the opera-
tion is performed at the point where it is lodged in the
manner described and the incision should be made only
large enough to permit its removal. In diverticuli of the
cesophagus an elliptical piece of the mucous membrane
which has been overstretched is cut out. The cesophageal
wound is closed by a laminated suture, that is, the mucous
membrane is united by means of an intestinal suture and
the muscular wall closed over this. The skin and muscular
wound may either be left open or closed with the Bayer
suture and bandaged with a drainage tube in the lower
angle.

III. OPERATIONS ON THE TRUNK AND GENITAL
ORGANS.

20; PUNCIURE OF THE CHEST:
FIG. 4.

Objects. ‘The relief of hydrothorax or pyothorax.

Instruments. , Razor, scissors, trocar, 1° m. OL eiieen
tubing of the same size as the trocar, vessel for receiving
the escaping fluid, dressing material.

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

FIG. 4.
Puncture of the chest ; puncture of the intestine.

the table. ‘The anterior ribs are so covered by the shoulder
that they cannot be counted from before backwards and
must be enumerated from behind forwards. In the horse
we estimate eighteen ribs and in the dog fourteen. Count-
ing II or 12 intercostal spaces from behind we reach the

PUNCTURE: OF FHE INTESTINES. 87

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

21. PUNCTURE OF THE INTESTINES.

a

FIGS. 4, 5.

Object. The relief of intestinal tympany.

Instruments. Razor, scissors, trocar.

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

88 PUNCTORE (‘OF THE INTESTINES.

flank about equi-distant from the last rib, the extremities of
the transverse processes of the lumbar vertebrae and the ex-
ternal angle of the ilium in the standing horse ; at the upper-
most point of the abdomen in the recumbent animal, that is,
at the most prominent part of the distension. After the
skin at this place has been clipped or shaved and disinfected
grasp the trocar with the index finger and the thumb of the
left hand and holding the instrument perpendicular to the
body surface, give it a firm, quick blow with the palm of
the right hand and drive it through the abdominal wall into
the intestine. With a properly constructed trocar of the
dimensions suggested in Figure 5 no preliminary puncture
with the lancet is required or advisable. The cutting end
of the stilette should be very long, tapering and sharp so
that it will cut as freely as the lancet. By performing the
operation as directed the trocar ordinarily punctures the

FIG. 5.

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

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

replace the stilette and press the skin against the abdomen
\

SUBCUTANEOUS CAUDAL MYOTOMY. 89

with the thumb and finger of one hand while the trocar is
drawn out with the other. This tends to prevent particles
of ingesta from following the canula out of the intestine and
becoming lodged at some point in the track of the wound to
set up inflammatory processes there. Before introduction,
the trocar should always be rendered sterile but should not
bear irritant antiseptics, which becoming lodged in the
wound tend to irritate the tissues and produce abscesses.
Puncture of the intestine is so often extremely urgent that
deliberate aseptic precautions are not always practicable and
trocarization only too frequently results in abscesses in the
abdominal wall. Its prevention must depend chiefly upon
the disinfection of the skin and instrument. It becomes
important to use an instrument which is clean in advance.
If the one shown in fig. 5 is well disinfected after using and
the sheath is filled with alcohol before it is screwed on, the
instrument will remain sterile until it is again unsheathed
and then the alcohol will quickly evaporate and leave it
aseptic.

22. SUBCUTANEOUS CAUDAL MYOTOMY.
FIGs 6;

Object. The correction of curved tail.

Instruments. Sharp straight tenotome, bandage.

Technic. The point or points of curvature and their
extent are to be carefully noted by having the animal trotted
away from the operator. The curvature is generally due to
unequal development of the two levator or extensor muscles,
Fig. 6.-ec, though quite rarely the depressors, 7, may be
implicated. Confine the animal in stocks, or in default of
these, control by means of a twitch and sideline. Cleanse and
disinfect the tail and have it sharply bent by an assistant in
the opposite direction to the curvature. Locate the longi-
tudinal furrow between the levator and depressor muscles on

go SUBCUTANEOUS CAUDAL MYOTOMY.

what has now become the convex side and at the lower margin
of the levator and just above v, Fig. 6, insert the tenotome at
the most prominent part of curvation, the incision being paral-
lel with the muscular fibers, and push the instrument entirely
through the muscle to the vertebra, then turning the cutting
edge upwards, at the same time advancing the point toward
the median line, sever the entire muscle. The superior
lateral caudal artery, s, Fig. 6, bleeds profusely if severed,
and wounding of it may usually be avoided by withdrawing
the tenotome a trifle in passing that point. Wounding the

Fic 6.

Transverse section of the tail. 2, caudal vertebra ; c, sacro-
coccygeus lateralis muscle ; @, sacro coccygeus superior ; /,
depressor longus and brevis muscles (sacro-coccygeus infer-
ior) ; 2, intertransversales muscles ; a, coccygeal artery ; s, su-
pero-lateral coccygeal artery; /, infero-lateral coccygeal ar-
tery ; v, caudal veins (dorsal, ventral, lateral) ; sch, caudal
fascia ; 2, skin.

skin over the muscular incision 1s avoided by placing
the thumb of the left hand over the line of incision so
the knife will be recognized as soon as the muscle and cau-
dal fascia are cut through. Remove the knife in the same
manner as introduced. Release the horse and have him
trotted again. //the operation ts sufficient, the tail should curve
in about the same degree as before, but in the opposite dtrec-

CAUDAL MYECTOMY. gI

fon. If this has not been attained examine carefully and
sever any remaining bundles of muscle, and this not suffic-
ing repeat the operation as before at another point 5 or 6
cm. above or below the first, severing the muscle again.
Or if the depressor appears implicated, sever it in a similar
manner. In extreme cases the entire lateral half of the
caudal muscles, tendons and aponeurosis may be severed.
Apply an antiseptic pad to the wound and retain it by a
moderately firm bandage, which serves at once as an occlu-
sive dressing and effective hemostatic. Remove the band-
age after 24 hours. By this plan of operation it is not
intended to tie the tail to the side of the animal during the
time of healing but when bandaging it immediately after
the operation, it should be held away from the side toward
which it formerly curved so that the bandage would tend to
prevent the return of the organ to its former position.

23. CAUDAL MYECTOMY.
FIG 6 AND PLATE XV

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

Instruments. Elastic ligature, straight bistoury,
tenacula, absorbent cotton, bandages.

Technic. Confine the animal in lateral decubitis or in
stocks, cleanse and disinfect the parts and apply the elastic
ligature as close as possible to the root of the tail. Have
an assistant hold the tail upwards, z. e., dorsalwards, and
tightly stretched. Make an incision 15 to 20 cm. long, over
the middle of the inferior surface of each depressor longus
muscle, beginning close against the elastic ligature and ex-
tending toward the apex, severing at once the skin and
caudal fascia down to the muscle. Let an assistant retract
the lips of the incision with tenacula while the operator
dissects the depressor longus muscle, DC, Plate OV. trom

PEATE ZV;

CAUDAL MvkEcToMy To PREVENT GRIPPING
OF THE REINS.

DC, Depressor coccygeus longus muscle ; T,
tourniquet.

Rory coos Set gest
ES cote OO

eb

ase

AMPUTATION. OF THE TAIL. 95

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 1I-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 higature. Remove the ligature, when hemor-
rhage may ensue, which is to be controlled by the applica-
tion 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 asan 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.

24. AMPUTATION OF THE TAIL.
PEATE XVE:

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

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

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 trunk
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

PLATE OVI.

AMPUTATION OF 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 hair of tail
upwards out of operator’s way.

AMPUTATION OF THE TAIL. 99

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 asto 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. Locate as accurately as possible the
position of a joint at the point where it is desired to oper-
ate 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 con-
tinue it downward, backward and inward along the side and
inferior surface until directly opposite to the place of begin-
ning. Make a similar incision upon the opposite side of the
tail, cut through ail 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. 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 sutures should
be begun at the apex of the two flaps and comparatively
deep.

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

L. OF C,

I0O URETHROTOMY. LITHOTOMY.

25. URETHROTOMY. “LITHOTOMY.
Fic, 7, 8.

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, lthotome, lithotomy
forceps, lithotrite, absorbent cotton, drainage tube, suture
material.

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

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

The point of operation will depend upon the location of
the calculus or other obstacle. If it is found in the pelvic
portion of the urethra or in the bladder, the operation is
made at the ischial notch, Fig. 8. First the penis is drawn
out from the prepuce and the catheter introduced into the
urethra and pushed upward until it has passed the ischial
notch. After disinfection of the skin, render it tense and
make a 5 cm. long incision on the median line at the ischial
arch through the skin, bulbo-cavernosus muscle, spongy
portion of the urethra, and the urethral mucous membrane
down to the catheter, Fig. 8, k. In order to prevent infiltra-
tion 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 inner margin is higher than the outer.

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 by the forceps is
materially aided by means\of the left hand introduced into

URETHROTOMY. LITHOTOMY. IOI

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 grasping the
calculus and in avoiding the implication of the bladder walls.
By careful rotary movement and pushing the forceps back-
ward and forward the operator can determine before the ex-
traction of the stone if the forceps can be withdrawn easily
and without much resistance through the neck of the

A 7 ie 2
Fic. 7. Urethrotomy at the ischial notch.

ara ae ak

bladder. If the stone is so large that it can not pass the
neck of the bladder lithotripsy may be performed. ‘This
operation requires time and patience, since as arule itis 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-
sequently must be gradually broken off at its periphery and
the individual pieces of calculus removed. ‘The character
of the surface of the stone has an evident bearing upon the
practicability of lithotripsy.

When this operation is impossible, the surgical dilation

102 URETHROTOMY. LITHOTOMY.

of the pelvic urethra with the lithotome can be undertaken
as a last resort. Introduce the instrument and divide the
urethra upward and laterally as the instrument is withdrawn.
In order to prevent injury to the rectum it should be emptied
before the operation is undertaken. After the removal of
the stone, push the catheter again over the ischial arch and
unite the lips of the wound in the urethral mucous mem-
brane by means of intestinal sutures. Flush the bladder

”

oe

Fic. 8. Urethrotomy (life size). 4, skin; a, retractor penis muscle;
6, bulbo-cavernous muscle; c, spongy urethra; #, urethra; &,
catheter.

and urethra by means of a warm, 3 per cent. boric acid solu-
tion 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. 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. )

AMPUTATION OF THE PENIS. 103

26. AMPUTATION OF THE PENIS.
PLATE SOV IT AND PIG. 9;

Instruments. Scalpel, elastic ligature, strong silk
thread, strong piece of tape 1 m. long, artery and compres-
Siem forceps. _

Technic. ‘The operation is carried out on the recumbent
animal under complete anaesthesia, the upper hind foot
being drawn backward or upward or otherwise so fixed as
to not obstruct the field of operation. The point of opera-
tion 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 cavernosum
to the ischium. If possible amputate in front of the pre-
putial ring. After the penis is drawn out, and the pre-
putial region is carefully cleansed with warm water, soap
and brush and disinfected, an assistant grasps the organ just
behind the preputial ring and holds it firmly. A temporary
elastic ligature, T, is then applied 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 it can he grasped
in front of the ligature with double tenaculum forceps and
held. Insert a catheter into the urethra and push it beyond
the elastic ligature or tourniquet. Apply a small cord just
behind the glans penis, L, Fig. 1, Plate XVII, and then
make a triangular incision on the ventral surface of the
organ about 4 cm. long by 3 cm. wide, the base of the
triangle being forward as shown in Fig. 1; carry this
incision thrbugh the skin, S, the corpus spongiosum, CS,
and along the corpus cavernosum, CC, down to the urethra,
U. Disect 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 commissure insert a series of

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AMPUTATION OF THE PENIS. 107

interrupted sutures as shown in Fig. II, Plate X VII in such
a manner that they pass through the urethral wall and the
skin so that when tied the wounded surfaces are completely
hidden and the urethral mucous membrane is brought into
apposition with the integument. Continue these sutures
down to the base of the triangle after which remove the

FIG. 9.

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
spongiosum of urethra; U, Urethra.

catheter and excise the organ by a cut extending in a slightly
oblique direction from below upwards and forwards. Take
a straight needle armed with the silk suture and passing
it through the margin of the utheral wound, the adjacent
fibrous capsule of the corpus cavernosum and across but

108 VAGINAL OVARIOTOMY IN THE MARE.

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. 9, and bringing the ends of the sutures together,
tie in such a way that it brings the uretheral mucous mem-
brane and the margin of the skin in immediate contact and
closes the blood vessels securely 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.
Finally leave every part wholly covered with epithelium.
By this plan we hope to avoid stricture of the urethra in
the process of healing. Remove the tourniquet and release
the patient.

27. VAGINAL OVARIOTOMY IN THE MARE.
FIGS. 10, Ir AND PLatH X VILL.

Objects. The alleviation of vice when related to ovarian
irritation or disease.

Instruments. .Colin’s scalpel, ratchet ecrasure, 55 cm.
long.

Preparation of patient. It is highly important that
the animal should be kept ona 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 tension within that cavity and relieve
the operator from much annoyance due to the pressure of
the viscera.

Technic. The vulvo-vaginal canal of the mare is unique
in its physiological behavior. Under venereal excitement
or the introduction of the operator’s hand or of tepid water
the organ has the power of ‘‘ballooning’’ or dilating to a
degree not seen so far as we know in other animals; the

VAGINAL OVARIOTOMY IN THE MARE. 109

walls become erected, hard, and stand apart from each
other, filling the pelvic cavity, the vaginal walls resting
firmly against the pelvic bones at every part except at the
points where the bladder and rectum intervene and these
organs are pressed out flat and occupy a minimum 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
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, OA, Plate XVIII, and changes it from
the horizontal in the quiescent organ to the perpendicular

FIG. 10 Special spraying ecraser, 55 cm. long.

Fic. 11. Colin’s scalpel.
in the ballooned condition. These variations permit of
two methods of operating: I. On the ballooned organ with-
out anaesthesia and with the animal confined in a standing
position. II. In the quiescent organ in the recumbent posi-
tion under anaesthesia :

I. Without anaesthesia. Secure in the stocks with the
head elevated, a rope over the back to prevent rearing,
straps beneath the body to prevent lying down, straps or
ropes before and behind the animal to prevent backward

PLATE XVIII.

VAGINAL OVARIOTOMY IN THE MARE.

Diagrammatic sagittal section through the
‘‘ballooned’’ vagina. V, vagina; OA, opera
tive area; I, point of incision; U, uterus; R,
rectum ; A, aorta with dotted lines posteriorly
to indicate location of the iliacs.

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VAGINAL OVARIOTOMY IN THE MARE. LZ

and forward movements, all four feet pinioned to the floor,
and the tail firmly secured and stretched to a beam above.

With soap, water and brush cleanse the tail, perineuin and
vulva thoroughly, being especially careful to remove all
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 with a
tepid .6 per cent. soda bicarbonate solution, and fill the
vulvo-vaginal canal with the same. After thorough dis-
infection 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.
II, introduce the right hand into the vagina promptly and
when it is well ‘‘ ballooned ’’ unsheath the knife and plac-
ing it just above the os uteri at I, Plate XVIII, 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 be-
ing held vertical, that is the cutting surface 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 disappearance of resistance
indicates that the latter has been penetrated. ‘This is the
most critical step in the operation.

8

ig YF VAGINAL OVARIOTOMY IN THE MARE.

If the hand is introduced 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 out the va-
gina 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, with-
drawn and then introduced with it, it will be frequently
found that the vagina has collapsed and needs a second fill-
ing 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 va-
gina quickly making a clean wound the width of the blade,
when the latter is to be withdrawn and laid aside. It should
be remembered 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 hold-
ing all the fingers in the form of a cone push thevemtmee
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

)

em. With the palm of the hand downwards, trace the uterus,
U, Plate XVIII, 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 dircct line, resting upon the anterior border of the
broad ligament is the dense oval ovary varying in size from
2.5 to 7 em. in diameter. Prepare the ecraseur for Gseiay
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 which is to be used in the operation and carry the in-

VAGINAL OVARIOTOMY IN THE MARE. [15

strument 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
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 cut 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.

If. In operating under anaesthesia the animal should
be cast or confined upon the operating table in lateral re-
cumbency preferably with the posterior part of the body
somewhat higher than the anterior so as to avoid visceral
pressure in the pelvic cavity. Place the animal under com-
plete anaesthesia. Prepare the parts in the same manner
as already described. Carry the knife into the vagina in
the manner previously described and render the roof of that
organ tense by pushing the os uteri downward and forward
with the hand or by means of a vaginal tensor or speculum.
It is important that the vagina be held well down toward
the floor of the pelvis so as to carry it away from the rectum
and posterior aorta and its branches while the incision is
being made. ‘The incision is now to be made just above
and behind and a trifle to one side of the os uteri in essential-
ly the same manner as under I, except that the cut is now
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.’’

jul VAGINAL OVARIOTOMY IN THE MARE.

DANGERS.

W ounding of the rectum is scarcely possible under the
first method if care is taken not to attempt the incision until
the vagina is well ‘‘ballooned,’’ and then making the stab
wound directly forward. If made upwards when the organ
is so erected the accident is highly probable, and with the
undilated vagina where it is necessary to cut upwards the
danger is ever present. Its prevention demands that in:
I, the operator await the complete ‘‘ ballooning ’’ and then
make his incision as directed. In II, 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 fatal.

W ounding of the iliac arteries, which produces prompt
death from hemorrhage, results from the incision 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.

W ounding 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. M is to be avoided in the first

VAGINAL OVARIOTOMY IN THE MARE. 07

operation by carefully directing the incision straight for-
wards; 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 preferred the first cut may
be corrected by placing an index finger against the perito-
neum 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 incision properly. If it is at-
tempted to rupture the peritoneum with the finger it must
be done by a sharp thrust since otherwise a large section of
it 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 organin 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 forthe 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
beyond the end of the cornua, which is continuous with the
uterus. If, therefore, one traces the uterus forward to the
coruna, thence along these to their extremities and along
the border of the broad ligament to the ovary, as above
directed, the error will not occur.

118 VAGINAL OVARIOTOMY IN THE MARE.

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 proper securing of the animal, by the
avoidance of irritant antiseptics in the vagina, by rigid anti-
sepsis at every stage, and by carrying out the mechanical
parts of the operation deliberately, vigorously and neatly.
If infection should occur it will generally take the form of
pelvic cellulitis with abscesses and rectal stricture. Enemas
of a normal salt or soda solution affords the surest relief of
the stricture and impaction in front of it. The abscesses
must be watched and opened early into the vagina or rec-
tum, and the case treated internally and locally according
to general surgical principles.

VAGINAL OVARIOTOMY IN THE COW. L19Q

28. VAGINAL OVARIOTOMY IN THE COW.

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

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.

Wash and disinfect the tail and the perineum and flush
out the vagina with a .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 10cm. posterior
to the os uteri and extending backward on the median line
for a distance of 2 or 3cm. 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 thé vagina somewhat below it, 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

20 VAGINAL OVARIOTOMY IN THE COW.

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 with the other hand, and when the ovary is reached
open them barely sufficient to admit its attachments between
the blades and cut it 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 oviduct
be excised with the ovary to insure the entire 1emoval of
the latter, because the accidental leaving of the smallest
particle of ovarian tissue will cause a development of this
into abnormally large Graafian follicles, and will tend to
increase 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 1s 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 which are

very fat and lack tone as a result of close confinement. For
\

OVARIOTOMY IN THE COW BY THE FLANK. 121

this reason it is apparently safer in confined cows 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 re-
quires much time for its accomplishment. A new danger
appears in the presence of the rumen, the supero-posterior
portion of which projects into the pelvic cavity when filled
with food and if the cut is directed forwards a stab wound
readily penetrates its walls with fatal results. Make the
cut upwards and backwards.

29. OVARIOTOMY IN THE COW BY THE FLANK.

Instruments. Clipping shears, convex scalpel, spaying
shears, or ecraseur, heavy needle and thread.

Uses. Same as the preceding, applicable to heifers or to
cows in which the vulva is too small to admit the operator’s
hand or in case of diseased vagina or uterus.

The animal may be secured as in the preceding or con-
fined in lateral recumbency with the hind legs extended
backward and the anterior limbs forward. ‘To accomplish
this loop a rope about the two fore feet, another about the
two hind feet, and drawing upon these, cast the animal and
secure it in recumbency with the legs extended and body
stretched by fastening the ropes to two strong posts about
8 to 10 mapart. ‘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
em. 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-
ward perpendicularly severing the skin and subcutaneous
muscle. Divide the external oblique muscle in the direction

122 QOVARTOLOUMY IN-THE-BIT Cy.

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. Foree fene
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 and then 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 the instru-
ment 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 posi-
tive means for identifying the ovaries is by tracing the
uterus from the vagina along its cornua to the Fallopian
tube and thence to the organ in the broad ligament.
Cleanse the wound and close the skin incision with con-
tinuous sutures.

30. OVARIOTOMY IN THE BITCH BY THE FLANK.
PRATE XX.

Instruments. Spaying knife, suture material.

Technic. Confine the antmal in lateral recumbeneys
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 likea
pen make at first a drawing incision from below upward about
2 to 3 cm. long, ending above at a point slightly below the
external angle of the ilium, the incision extending through

OVARIOTOMY IN THE BITCH. n23

the skin and subcutaneous tissues ; without removing 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 peritonenm
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 bitch are unique among
our domesticated animals. The uterus, U, Plate XIX, is
small and physiologically unimportant, the cornua, RUC
and 1,UC, are ample in size and constitute physiologically
the uterus. ‘The distance from the cornual extremity, LUC,
to the ovary, O, which is occupied by the Fallopian tube is
very brief so that the cornua and ovary are well nigh in
contact. The ovary, O, O, is very small, smooth and com-
pletely hidden in the pavilion which here constitutes a sac
having a very small longitudinal opening of 2 to 5 mm.
The most remarkable feature of the apparatus from a surg1-
cal standpoint is the great development of the broad ligament
which is broader than the distance from the lumbar region
to the abdominal floor, while the uterus and uterine cornua
are stretched between the vagina, V, and the ovary, O, so
that they are suspended in the sub-lumbar region resulting
in a double fold of the broad ligament hanging down like a
curtain between the parietal peritoneum and the uterus and
cornua on either side. The broad ligament of the bitch is
consequently 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 re-
versed and the ligament is suspended from the uterus, or
rather uterine cornua.

In Plate XIX the right broad ligament, BL/, is laid out

PLATE XIX.

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, vayina; U, uterus ;
LUC, LUG, left uterine cornua with a portion
of its broad ligament, BL, lying acrossit ; RUC,
right uterine cornua with its broad ligament,
BL/, turned outwards exposing the full length
of the cornua. On the left side the ligament is
divided so that the anterior half rests in its nor-
mal position while the posterior half, BL/, is
turned back. O, O, ovaries ; R, rectum ; K, left
kidney; AA, a line indicating the level of the
external tuberosities of the ilia.

~ rnc Fs, ;

OVARTOTOMY INOLAE BIT CE L277

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. The ovary being indistinct and
hidden is difficult to identify 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 con-
tact 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 open-
ing, 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 be-
tween them by linear tension. Extend the tear through the
broad ligament as high toward its lumbar attachment as
is convenient and backward to the neighborhood of the uter-
ine bifurcation. Draw upon the exposed cornu until the 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 cornua is very difficult and requires
great care to prevent its rupture. The object may be facili-
tated by pressing the upper flank of the bitch downward,
thereby greatly diminishing the transverse diameter of the
abdomen. —

The succeeding operation (31) avoids this difficulty in a

128 OVARIOTOMY IN THE -BITCH.

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 practica-
ble and holding it tense insert an index finger along it until
the ovary is reached, which is recognized by its slightly
greater size and density succeeding the brief neck represent-
ing the Fallopian tube between the end of the cornu and
ovary, while beyond it can be felt the ovarian ligament.
Kngage 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 ligainent 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 coronua will le upon the abdominal floor, much en-
larged 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 dupli-
cature 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 ten-
sion does not insure against hemorrhage and it is necessary
to ligate the ovarian and uterine arteries with catgut or silk.
In cases of pregnancy the entire cornua should be drawn
out and astrong ligature placed around the uterus or vagina;
and the ovaries, uterine cornua and their contents be re-
moved ev masse. Release the upper posterior limb and close
the cutaneous wound by a continuous suture.

Dangers. Ruptureofthe uterine cornu alluded to above.

OVARIOTOMY IN THE BITCH. 129

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 be-
fore 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.

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.

31. OVARIOTOMY IN THE BITCH BY THE LINEA ALBA.
PLATE XIX.

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

9

130 QVARIOTOMY IN THE BITCH.

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 the 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 preceeds 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 is 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 infec-
tion 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.

OVARIOTOMY IN THE CAT. ie Wi

32. 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 tomake 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
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
abdominal muscle layers to readily become separated by
pressure from the finger and form a pocket in which wound
discharges accumulate and constitute a dangerous seat for
infection. Great care must therefore be taken to make a
clean incision directly into the peritoneal cavity and to
avoid separating the peritoneum from the muscles or the
muscular layers from each other. The uterus and ovaries
of the cat are naked and far more easily distinguished than
in the bitch, there being no extra deposit of fat in the broad
ligament. The sutures are to be applied to the wound in
the same manner as in the bitch.

132 CASTRATION. OF CRYPTORCHID: HORSES:

33. CASTRATION OF CRYPTORCHID HORSES.
PLATES XX 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. Orsecure upon the operating table on the side
opposite to the retained gland and abduct the upper posteri-
or limb by drawing it upward by means ofapulley. Cleanse
and disinfect the inguinal region. Anaesthetize. Make
an incision about 1o to 12 cm. long through the skin and
subcutaneous tissue 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
and press them into the areoler tissue toward the external
inguinal ring and then 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 continue in a direction approximately toward the ex-
ternal angle of the ilium. Unless rectal exploration shows
that the testicle is within the abdomen, take care in travers-
ing the inguinal space between the external and internal
rings that the gland is not passed by unrecognized (inguinal
cryptorchidy) lying in this region covered by peritoneum
and the cremasteric fascia. Search 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 covered only by peritoneum.
Through this may extend a portion of the gubernaculum
testis or of the vas deferens or epididymus which latter may
have descended into the scrotum while the testicle remains

in the abdomen. ‘

CASTRATION OF CRYPTORCHID HORSES. 133

Examining Plate XX, 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 epididymus. In the lower or left testicle the ring
has been opened and the gland lies in a position correspond-
ing to the right and showing the epididymus and vas defer-
ens lying in the processus vaginalis, P. ‘The surgical rela-
tion of the parts is further illustrated in Plate X XI, where
the testicle is completely withdrawn into the peritoneal cavity
and spread out over the right flank. The processus
vaginalis, P, is outlined by a dotted line into which is in-
troduced a curved sound, S, along side 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
epididymus at E; while the third division, G’”’, extends from
the epididymus to the testicle.

In Plate X XI it is shown that the testicle under all ordinary
conditions is inevitably attached through its gubernaculum
testis to the posterio-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 mears of the testicular artery, A. The guber-
naculum 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, epididymus 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 epididymus
present characteristics which are unmistakable to the
trained touch consisting of a small firm cord (vas deferens)

PLATE XX.

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.

'tetanen ree

CASTRATION OF CRYPTORCHID HORSES. 137

or a small mass of fine threads (tail of epididymus) which
roll freely betweeu 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 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 direction 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 this 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 epididymus
where the gubernaculum crosses it at H, in Plate X XI. Hav-
ing 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
are recognized the testicle is virtually within his power.
He thus preceeds upon the basis that he is not to jd 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 to be dilated some by

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CASTRATION OF CRYPTORCHID HORSES. I41

means of inserting an index finger in it or the testicle
needs to 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
at each step, many operators making the incision over the
external ring instead of near the median line and it is even
more common for the operator to avoid opening the internal
ring and penetrating the peritoneal cavity somewhat in front
of and above it through the small oblique muscles. When
one plan has been learned the variations are easily applied.
There are other causes of cryptorchidy in rare cases which
require a different procedure in order to extract the gland
which varies with particular cases but the essentials for the
discovery 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 removed
with the emasculator or by such means as the operator may
prefer. Cryptorchid testicles when due to arrest in develop-
ment are not vascular and there is little tendency to hemor-
rhage after excision. Place an antiseptic tampon in the
wound, pushing it well up against the internal ring and re-
tain it in position by means of sutures for a period of 24 to
48 hours when it is removed and the wound dressed anti-
septically.

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 EXTREMITIBS:

34. TENOTOMY OF THE FLEXOR PEDIS TENDONS.
PLATE XXII. |

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 deep,
or flexor pedis tendon, seldom on the superficial, or flexor
of the os coronae.

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 XXII.

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

Grasp the metacarpus or metatarsus in this area from
above and behind in such a manner that the thumb rests
upon the median or upper surface, and the index and second
fingers on the lateral or under side of the flexor pedis
tendon. While the left thumb pushes the skin toward the
bone, that is, forward, a sharp pointed tenotome held per-
pendicularly 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-
142

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144 PERONEAL TENOTOMY.

ately on the anterior bordor 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. The cut-
ting edge of the knife is then turned against the tendon of
the flexor pedis, that is, it is directed backward, the foot is
extended by an assistant with the aid of a rope bound
around the pastern and looped over the hoof, and the ex-
tensor pedis tendon is cut through under light pressure, the
operator pressing the handle of the knife downward and
forward, using the metacarpus 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. By keeping as close to the anterior border of the
tendon as possible we can avoid injury to the plantar nerve,
the common digital artery, the internal cutaneous, and the
internal and external interosseous veins which run between
the flexor pedis and the suspensory hgament.

After the removal of the knife and seeing that there is a
wide space between the ends of the tendon, the foot is un-
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.

35. PERONEAL TENOTOMY.
PLATE XXIII.

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

PEATE XI

PERONEAL TENOTOMY FOR STRINGHALT.

Right hind foot seen from the external side.
The skin covering the lateral extensor of the
foot is laid back in the form of a flap, the crural
fascia divided. e¢, Peroneal tendon ; /, crural
fascia ; /, tendon of the anterior extensor pedis
miusele ; d, the triangle formed by / and e.

IG 145

146 CUNEAN TENOTOMY.

pedis longus muscle extends inferiorly to near the point of
juncture of the two tendons ; the sheath of the lateral ex-
tensor ends below 3 to 4 cm. above the point of union. In
the middle of this space without a sheath, which is 3 to 4
cm. long, and below the annular ligament of the hock the
operation is carried out. After the skin has been shaved
and disinfected, confine in the stocks or operate upon the
standing horse, with the aid of locz] anaesthesia, a twitch
being applied to the nose and the opposite hind foot held up
with the side-line. The tendon of the lateral extensor is
easily felt: under the’ skin as a hard cord abouts, 7.sto oe
cm. in diameter... Stretch the skin and with the back of
the hand toward the hock grasp 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 theskin, subcutem and aponeurosis derived from the
crural fascia ; pushit from before backward under the tendon,
turn the cutting edge against it, and with the hock extended
sever the tendon as well as the fascia through to the skin.
In accomplishing the section of the tendon the knife is to be
used asa lever of the first class with the anterior border of the
metatarsus acting as a fulcrum. If the tendon has been
completely severed its retracted ends may be felt under the
skin I to 2 cm. above and below the wound. After the op-
eration 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.

36. CUNEAN TENOTOMY.
PLATE XXIV.
Objects. ‘The relief of spavin lameness.
Instruments. Razor, scissors, straight scalpel, Peters’
spavin knife.
Technic. Most horsescan be operated on standing, with

PEATE X XTV,

: CUNEAN TENOTOMY.

For the relief of spavin lameness. CT,

cunean tendon. The dotted line crosses the
ergot.

148 NEUROTOMY.

the aid of cocaine, otherwise cast, or secure on the operating
table, on the affected side and extend the tarsus. Shave
and disinfect an area 5 to6 cm. square on the inferior median
surface of the hock over the course of the cunean tendon of
the chief flexor of the metatarsus, as indicated in Plate
XXIV. Locate the tendon, CT, by palpation as it passes
obliquely downward and backward and make a transverse
incision about 1 cm. below its inferior border at a point
midway between the anterior and posterior borders of the
hock, or slightly anterior thereto, the width of the scalpel
blade. 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 wound as a fulcrum, cut the tendon through from
without inwards. By firm pressure upon the tenotome in
the latter method periosteotomy is simultaneously accom-
plished. ‘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 bandage resting upon the fetlock
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, 10, pp. 55-6, 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. :

NEUROTOMY. 149

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
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 necessa-
ry 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 is accompanied
by fragility of the skeleton, and asa result most casting acci-
dents 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 otherwisé 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

150 NEUROTOMY.

changes take place as a result of causing a part to doa 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
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.

Nerves are generally accompanied by satellite arteries and
veins which are always hable to be wounded during the
operation and are more embarassing because of the hemor-
rhage clouding the operation field and inviting error than
dangerous because of the loss of the blood itself. It is essen-
tial to a good operation that the hemorrhage be kept under
control throughout so that each tissue will stand out in good
relief and the nerve reveal its identity in addition to its loca-
tion, 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.
\

DIGITAL NEUROTOMY. I51

37. DIGITAL NEUROTOMY.
PLATE XXV.

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 the 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 X XII, except
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 phalanges and deep flexor tendon there isa slight furrow,
at the posterior part of which, close to the external margin
of the tendon, lies the median or principal digital nerve ac-
companied in front by the digital artery, A, anterior to
which lies the digital vein, V. Immediately behind the
nerve and generally lying a trifle deeper, is quite commonly
found a second venous trunk of considerable size. Near the
middle of the first phalanx the nerve is crossed externally
in an oblique direction from above to below and from behind
to before by 2 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,

—

PLATE XXV.
DIGITAL NEUROTOMY.

V, Digital vein ; A, digital artery ; N, digital
nerve ; L, ligament.

DIGITAL NEUROTOMY. 155

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 XV or from the superior end of the first phalanx
down to a level with the superior border of the lateral carti-
lage, but perhaps preferably at about the middle of the
pastern. At the desired point and over the groove between
the flexor pedis tendon and the phalanges shave and disin-
fect 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 displace it backwards or forwards. Dilate
the wound by pressure 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 follow with a second one
immediately beside the first. Draw the two apart, one
toward the toe, the other toward the fetlock, and separate
thereby the nerve from the surrounding tissues. Remove
one aneurism needle, insert a probe pointed bistoury, or scis-
sors 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.

PLATE X2Vi5
PLANTAR NEUROTOMY.

a, lateral digital artery ; v, lateral digital vein;
m, common lateral digital nerve; d, anterior
branch ; 0, posterior branch ; s, superficial flexor
tendon; /, perforans tendon; 7, suspensory
ligament of fetlock ; #, metacarpus.

<i DI Ss
Sa A. Qe

PLANTAR NEUROTOMY. 159

38. PLANTAR NEUROTOMY.
PLATE XXVI.

Objects. 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 apply a bandage saturated with
sublimate or creolin solution to the fetlock joint 24 hrs. be-
fore 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,
shave the site of operation and thoroughly disinfect the
region of the metacarpus and fetlock with soap, brush, and
sublimate or creolin solution and 50% alcohol. Passing
the fingers from before to behind with light pressure over
the region just above the fetlock joint, there is felt immedi-
ately in front of the flexor pedis tendon a channel-like de-
pression 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, 2, 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 incision

160 NEUROTOMY OF THE MEDIAN NERVE.

3 to 5 cm. long, the lower angle of which is 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 liesin the middle of the wound.
If necessary continue the dissection with the scalpel until
the nerve is clearly revealed ; it is distinguished by its faint-
ly yellowish color, its fine longitudinal strize and its location
behind the metacarpal artery. Immediately above the fet-
lock joint the median metacarpal or metatarsal nerve divides
into an anterior smaller, d, and posterior larger branch, oa.
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, then a second instrument is inserted beside it
and the two pulled apart separating the nerve from the ad-
jacent tissues, the scissors or a small probe-pointed bistoury
is passed beneath and itis cut through quickly at the superior
angle of the wound. ‘The distal end of the nerve is then
dissected free downward and both branches excised at the
lower angle of the wound so that a section 3 to § cm. long
is removed. The cutaneous wound is united by a continuous
suture and a temporary bandage applied. If the horse has
been secured by casting, the extension splint, if it has been
used, is then removed, the foot replaced in the hobble and
the horse turned to the other side. ‘The operation on the
opposite metacarpal nerve is carried out in the same way
after which a sterile bandage is apphed and allowed to re-
main eight days. Healing by primary union.

39. NEUROTOMY OF THE MEDIAN NERVE.
PLATE x VIE.
Objects. ‘The relief of lameness due to disease so located

in the anterior limb that it cannot be overcome by plantar
neurotomy.

NEUROTOMY OF THE MEDIAN NERVE. 161

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 XXII. Anaesthetize.
The foot is drawn out firmly from the shoulder, inclined
somewhat forward. ‘The operator places himself between
the neck and the forearm 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 pos-
terior 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% aclohol. The
nerve, 2, 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, lyingsomewhatdeeply. ‘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 sterno-aponeuroticus
muscle. Any hemorrhage from the skin, subcutis, or mus-
cle, is checked. ‘The tenacula are inserted cautiously in the
lips of the wound, and these being drawn apart the white
anti-brachial fasciais brought into view and a search is
made with the index finger to determine the exact location

II

PLATE SV.
MEDIAN NEURECTOMY.

Median surface of the right humero.radial
articulation. a, brachial artery; ~, median
nerve ; v, brachial vein ; 7, antibrachial fascia ;
p, sterno-aponeuroticus muscle.

NEUROTOMY OF THE MEDIAN NERVE. 165

of the nerve, and the fascia is divided with the scalpel and
an oval piece excised with the scissors immediately over it.
If much fatty tissue is found beneath the fascia it may be
dissected away carefully with the scalpel or cut away with
the scissors. There now comes into view a delicate reddish
colored fascia-like membrane, the nerve sheath, behind
which a blue 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 pro-
ject out from beneath the border of the same. ‘The opera-
tor needs be careful not to prick this vein with the tenacula,
as the hemorrhage therefrom is exceedingly annoying dur-
ing the operation. It is best to avoid the use of tenacula
after penetrating 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 up-
ward and downward with the scalpel or scissors, whereupon
the yellowish and distinctly fibrous nerve comes into plain
view. Pass an aneurism needle beneath the nerve then pass
another alongside the first and drawing the two apart sepa-
rate the nerve from the adjacent tissues throughout the
length of the wound. Se careful to not cut the nerve too
high and erroneously tnclude the motor nerve of the flexor of
the metacarpus and the flexors of the foot, which ts generally
given off posteriorly just below the humero radial articulation.
Lift the nerve up and cut it through at the superior angle
of the wound: by a sudden clip with the scissors or with the
probe pointed bistoury. Lay the peripheral end of the
nerve bare to the lower angle of the wound, and excise at
least 3 cm. of it. Tamponade the wound with dry iodoform
gauze and approximate the skin with a continuous suture.
The tampon dnd sutures remain from 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

166 NEUROTOMY OF THE MEDIAN NERVE.

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 completely effect the desired
end. In order to produce complete anaesthesia of the foot,
therefore, it isnecessary at the same time to perform ulnar

neurotomy.

NEUROTOMY OF THE ULNAR NERVE. 167

40. NEUROTOMY OF THE ULNAR NERVE

PLATES XXVIII AND XXIX.

Objects. An adjunct operation to 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 XXIX. 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 XXVIII,
n, Plate XXIX, NU, on the median or inner side of it
the collateral ulnar vein, Plate X XVIII 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 XXVIII.

ULNAR NEUROTOMY.

Right forearm seen from behind. ¢, external
flexor of the carpus ; /, oblique (middle) flexor
of the carpus; a, collateral ulmar artery; 4,
antibrachial fascia ; 7, ulnar nerve.

“UMOYS JOU SI WOT
JO UloA oyT[o}es ay} ‘ArazyIV wun any SI opts
UvIpstt $}I UO Sutd’y ‘aarau Uevipem ‘WN ‘ dArou
Teun “ON ‘sndieo aq} jo toxay anbriqo “7O
‘sndievo 04} Jo 10xay [euss}xa ‘AH ‘Morleq mor
PeMaIA ‘au0q wuosIsId ayy 2A0q® ‘UID OI jnoqe
‘qUIIT 94} Jo snipez aq} YSno1y} WoT}Ias sso1D

“AWOLOWNAN YVNI

“XIXX ALV Ig

SCIATIC NEUROTOMY. ss

4t. SCIATIC NEUROTOMY.
PLATES XXX AND, X XT,

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 and secure it out of
the way. Produce complete anaesthesia. The posterior
tibial or sciatic nerve z, Plate XXX 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. Immediate-
ly behind the perforans muscle and between this and the
tendo-Achilles the nerve, nearly 1 cm. in diameter, glides
away forward from between the fingers with a distinct re-
coil. If the nerve can not be found in this manner the
hock should be stongly extended, by which means it is
caused to recede from the perforans muscle, so that it can
more readily be felt near the middle of the groove extend-
ing between it and the tendo-Achilles. At this point 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 of the tenacula. In poor horses the contour of
the nerve, covered only by loose connective tissue, stands

PLATE XXX.

ScIaTIC NEUROTOMY.

Right hind leg viewed from the median side.
Jf, crural fascia; 2, sciatic (tibial) nerve; 2,
plantar vein.

s: -,
/ =

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ms

a)

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-xo ‘qq {aAJou [eauosad Jo [eIql} 1Ol19}Ue jo YouURIq Axzosuas 10 daap
‘AN { dAdau [VIG JOTa}Ue Jo YOURIG SNOIsUeNI-O|Nosnur SINN | dAseu
oeros ‘SN { Asaqze jeIqh, Wornser “VS “wore[nonle plojeseijse
-OIq!} oY} BAOqeR ‘MID OI jnoge je BIGH eq} Y[SNO1Y} UOT}IIS SsOIy

"AWOLOUNAN IVHNOUAG-O1MLL

‘IXXX ALVWId

PAE) SOXexXclt.

ANTERIOR TIBIAIL NEUROTOMY.

EP, extensor pedis muscle; P, peroneus
muscle; NP, deep branch of the peroneal or
anterior tibial nerve; FM, flexor metatarsi
muscle.

ANTERIOR TIBIAL NEUROTOMY. 183

out prominently, in fat horses it is surrounded by a large
amount of adipose tissue. Cut through this fat and con-
nective tissue and expose the tibial nerve, 2, Plate XXX
and NS, Plate XX XI, to view ; immediately before it lies
the plantar vein and on the lateral side is situated the re-
current tibial artery, SA, Plate XX XI. The cross section
in Plate XX XI is located somewhat below the point for
operation and the vein has crossed obliquely over the nerve
so that it appears Jehznd instead of zz front of it, as is the
case generally at the point where the operation is performed.
Separate the vessels completely from the nerve with the
handle of the scalpel, pass two aneurism needles from be-
fore backward beneath it and drawing these apart separate
the nerve trunk from the adjacent tissues and cut it 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 by
first intention.

42. ANTERIOR TIBIAL NEUROTOMY.
NEUROTOMY OF THE DEEP BRANCH OF THE PERONEAL NERVE.
PRATES XEXOSL AWD XO:

Object. An adjunct operation to the preceding as it sup-
plies sensation to the tarsus in common with the sciatic.
The two constitute what is known as Bossi’s double neuro-
tomy 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 ex-
tensor pedis longus, EP, Plates XX XI and XXXII, and
tHe perotieus muscles, P, Plate XX XI, MP, Plate XX XTI,
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-astragoloid articulation.

184 ANTERIOR TIBIAL NEUROTOMY.

Ata 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 XI, is separated from the extensor pedis longus, EP,
Plates XX XI and XXXII, by a strong sponeurotic sheath
continuous with the tibial aponeurosis. Penetrate the latter
anterior to the aponeurotic partition directly against the ex-
tensor pedis, EP, and passing along the posterior border of
this muscle to a depth of 2 to 4 cm., there appears the thin
margin of the flexor metatarsi magnus, FM, Plates XX XI
and XXXII, which lies immediately against the extensor
pedis without a visible connective tissue partition but reveal-
ing itself by a markedly lighter shade of color and its ready
separation with the scalpel from the extensor. The deep
branch of the peroneal nerve, NP, Plates XX XI and XXXII,
lies loosely imbedded on the anterior side of the margin of
the flexor metatarsi 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 connective tissue and measuring
about 2mm. in diameter. Pass the aneurism needle beneath
it and remove a piece 3 to 4 cm. long. Close the cutaneous
wound with interrupted sutures and dress antiseptically
without a bandage.

RESECTION OF THE LATERAL CARTILAGE. 185

43. RESECTION OF THE LATERAL CARTILAGE.
THE BAYER QUITTOR OPERATION
PLATE XXXIII.

Object. The cure of quittor or necrosis of the lateral
cartilage.

Instruments. Elastic ligature, drawing knife, scissors,
tazor, hoot rasp, hoof plane, craniotomy or other heavy for-
ceps for the removal of the horn, artery forceps, elevator or
long bone chisel, double-edged sage knife, curette, needle
holder, thread, needles, iodoform ether, iodoform gauze,
tampons, absorbent cotton, bandages.

Technic. Fora few hours before the operation place
the affected foot in a bath of creolin solution after having
first rasped the diseased quarter ghf/y and made a semicir-
cular groove in the horn of the lateral wall and quarter
down to the horny lamina, as shown at s in Fig. 1, Plate
XXXII. It is essential to not materially thin the horn on
the quarter with the rasp since by weakening it, it yields
and breaks and can not be properly detached from the
sensitive laminae.

The operation is performed 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 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 ap-
proximately 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 entire foot up to the fetlock joint thoroughly
cleansed with brush, soap, creolin or sublimate solution and

186 RESECTION OF THE LATERAL CARTILAGE.

50 per cent. alcohol. The fetlock and pastern are carefully
wrapped in a towel saturated with sublimate solution or
other disinfectant. 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 forceps and carefully loosened from the sensitive parts
by drawing upward parallel to the laminae and then back-
ward from the coronary papillz and keraphyllous tissue.
After the coronary band has been smoothed with the scissors,
make two perpendicular incisions through the skin and
coronory band, one behind the anterior and the other in
front of the posterior border of the groove in the horn and
connect the two by means of a semi-circular incision in the
sensitive laminae. ‘This U-shaped incision should be so
made that between it and the horny wall there is left an
area of sensitive laminae I to 2 cm. wide, in order that there
may be sufficient room in the soft tissues for the application
of the sutures, as shown in Fig. 2. The lines of incision
through the coronary band should be so located as to in-
clude between them the entire lateral cartilage.

The isolated flap is now dissected closely against the os
pedis and its ala and from the lateral surface of the
cartilage, the operator first lifting the flap with forceps,
later with the hand. 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 assistant 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

PLATE

Pie i:

RESECTION OF THE LATERAL CARTILAGES OF THE OS PEDIS.

Horny wall removed, sensitive laminze and cutaneous flap held
upwards. Posterior half of the cartilage excised. /, sensitive lam-
ine ; w, coronary band: &, anterior half of cartilage; 4, cavity
caused by the removal of the posterior half of the cartilage ; 7, necrotic
cartilage; #, parachondral surface of the skin and sensitive lamine ;

5, perpendicular, crescent-shaped incision in the horny wall ; g, fistula.
\

MOCKTIT.

pa

aes
SS
ah

\

BIGs. 23
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,

RESECTION OF THE LATERAL CARTILAGE. IQI

granulations. By means of an incision through the carti-
lage 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 parachondrial
tissue with the double-edged sage knife. The point of the
knife must be constantly directed against the cartilage.
Since the inner surface of the anterior half of the cartilage
lies immediately against the capsular ligament of the corono-
pedal articulation the latter should be sharply extended by
which 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. Remnants of cartilage at its juncture
with the retrossal process of the os pedis, and granula-
tions are to be removed with the curette. Cut away with
the scissors and knife any remnants of cartilage adherent
to the flap, A, 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 bandage is left in position from 12 to 14days. Healing
by first intention.

192 RESECTION OF THE FLEXOR PEDIS TENDON.

44. RESECTION OF THE FLEXOR PEDIS TENDON.

Ere: 12;

Object. ‘The removal of necrotic tissues and disinfection
in cases of infected wounds, chiefly of nail pricks of the
navicular bursa.

Instruments. Elastic ligature, drawing knife, double-
edged. sage knife, scissors, tenaculum forceps, cunetee:
scalpels, tenaculz, bandage material. ?

Technic. Before the operation thin the horn of the sole,
frog and bars until the soft parts can be seen through them
and apply an antiseptic bandage saturated in creolin solution
for 24 hours if time will warrant. Secure the patient on the
operating table or by casting in lateral recumbency with the
affected foot extended. Anaesthetize. Cleanse and disinfect
the entire foot with soap, brush, creolin or sublimate solution
and 50% alcohol and apply the elastic tourniquet in the
metacarpal or metatarsal region. Apply towels saturated
with antiseptics as in preceding operation. Make a trans-
verse incision through the base of the frog 2 to 3 cm. from the
balls through the horny and sensitive portions and the fatty
cushion down to the flexor pedis tendon. Follow this by two
converging incisions extending forward and inward in an
oblique direction corresponding to the semi-lunar crest of the
os pedis, the line of incision being in the bars about % 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. Asa general rule the operator finds
that he has not yet reached the flexor pedis tendon but only
the fatty cushion which covers the latter. The remnants
of the fatty frog should be removed with the double-edged
sage knife or scalpel by means of a horizontal incision, and
there is then seen the greenish or yellowish colored necrotic
flexor pedis tendon, which may at times be covered with

RESECTION OF THE FLEXOR PEDIS TENDON. 193

reddish colored granulations. Should the operation be in-
dicated on account of a suppurative pododermatitis the bars
onthe affected side must be excised along with the other
portions. The position and extent of the navicular bone
can be determined by feeling through the flexortendon. A
transverse incision is then made over the middle of the
navicular bone through the flexor pedis tendon into the
navicular bursa, the distal end of the tendon grasped with

PIG 12

RESECTION OF THE FLEXOR PEDIS TENDON.

Solar surface of the foot. c, Semilunar crest of os pedis ;

“, OS pedis; 7, navicular pedal ligament ; 5s, navicular bone ;

6, flexor pedis tendon ; ¢, sensitive laminze of the bars; st#,

fatty frog ; /, sensitive frog ; 4, horny frog.
the tenaculum forceps and lifted up from the navicular bone
with the aid of two lateral curved incisions. Between the
inferior border of the navicular bone and the semi-lunar crest
of the os pedis stretches the capsular ligament of the in-
ferior articulation between these two bones reinforced by

TS

194 AMPUTATION OF THE CLAWS OF RUMINANTS.

dense fibrous bands. ‘The flexor pedis tendon is united to
this by a few bundles of fibres. Dissect the tendon carefully
away from the capsular ligament, avoiding opening the
articulation, and beyond 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
orcurette. With the latter, currette the roughened cartilage
of the navicular bone and remove any necrotic or inflamed,
softened portions. 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 por-
tions as well as the neighboring fatty cushion with its
numerous elastic fibres, must be resected. In case of fistula
extending along the tendon and opening above in the heel,
draw through it a large strip of gauze thoroughly saturated
with tincture of iodine and allow it to remain. Disinfect
the operation wound, irrigate with 1odoform ether and tam-
ponade it with dry iodoform gauze. Over this apply a
firm pad of oakum saturated with r-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.

45. AMPUTATION OF THE CLAWS OF RUMINANTS.
PLATE XX RMIY.,

Uses. The cure of ‘‘ foul in the foot’’ or panaritium
when complicated with suppurative arthritis or osteitis.

Instruments. Half round rasp, double-edged sage knife,
scissors, convex scalpel, artery forceps, drawing knife,
elastic ligature.

Technic. Cast the animal and secure the foot, tone
operated upon in an extended position, apply the elastic
ligature after disinfecting the claws with soap, water, brush

AMPUTATION OF THE CLAWS OF RUMINANTS. 195

and creolin solution, rasp away the horn on the lateral side
of the diseased claw, especially at the posterior 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 man-
ner 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 double-
edged sage knife into the joint, the concavity of the knife
being directed toward the fetlock, and make a curved incis-
ion 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, however, ex-
tends only to the navicular bone. By this incision the oper-
ator divides the horn, the sensitive lamina, the external
corono-pedai ligament and the capsular ligament of the
corono-pedal articulation. Pass the knife between the na-
vicular and pedal bones and extend the incision downwards
perpendicular to the solar surface through it, separating the
navicular bone from the os pedis. In this manner the na-
vicular 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 protection. The band-
age 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 XXXIV.
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 ; z, internal do; &, ten-
don of the flexor pedis muscle ; 2, distal artic-
ular surface of the 2nd digit ; g’ articular sur-
face of 3rd digit ; ¢’’, navicular bone ; /, lateral
claw ; 7, median claw ; 0, bulb of the heel.

THE BAYER SUTURE. 199

46. THE BAYER SUTURE.

FIG. 13 AND 14

Uses. The closure of large or penetrant wounds with
convenient and secure means for applying and retaining
antiseptic dressings.

Instruments, Large curved suture needle armed with
strong silk thread, about 20 cm. long, which is doubled and

FIG. 13

RETENTION, AND CONTINUOUS APPROXIMATION SUTURES.

d, d’, d’’, drainage tubes; ¢, retention suture (closed end); e¢’, open
end ; 0, fixation suture for the drainage tube ; f, continuous approxi-
mation suture.

passed through the eye in such a manner that the loop ex-
tends considerably beyond the cut ends ; small needles and
thread ; needle forceps; drainage tubing preferably two
very large and one small with lateral openings ; thin wooden

200 THE BAYVER SOTORE.

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

Technic. After the skin has been shaved over an area
having a radius of 5 to6 cm. from the wound, the suture
needle is inserted 2 to 3 cm. from the lips through the skin
and subjacent tissues, a strong drainage tube, a’, passed

FIG; 14.

SPLINT BANDAGE.

d, d’, a’’, drainage tubes; e, retention suture (closed ends) ; e’, 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
and enter the soft tissues and thus prevent to some degree,
the pressure necrosis otherwise taking place, due to the tense

THE BAYER SOUTORE. 201

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 drainage 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 to-
gether in such a manner as to form a ridge 3 or 4 cm. high,
the suture needle can 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 united by contin-
tous approximation sutures like an overcasted seam. This
suture ends at least 2 cm. above the lower angle of the
wound. The third drainage tube is introduced into the
latter 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 shoved under
the tubing. The upper- and lowermost splints should be se-
cured 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.

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: a hooked ring knife; a Colin’s
scalpel like Fig. 11; an embryotomy chisel : m. in length,
the handle 1.5 cm. in diameter with a ring end, the blade
about 10 cm. long by 4 cm. wide and 2 to 3 mm. thick, the
cutting edge concave from side to side and “the corners dull
and rounded; mallet; several cotton ropes I cm. in diame-
ter with a small spliced loop at one end.

; 47. 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 will 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. After thoroughly cleansing and disinfecting the parts

204 CEPHALOTOMNY:

inject a copious amount of tepid lysol solution into the va-
gina, 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) operatioamm
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 of the chisel firmly against the part with
one hand in such a manner as to effectively guard the in-
strument from slipping 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 stopping and forcibly revolving it upon
its long axis and breaking the fcetal 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 face and head in order that it may protect the ma-
ternal parts from the jagged bones during the passage of the
remains of the head. The removal of the partially detached
pieces of bone may in many cases be greatly facilitated by
looping one of the cords 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.

DECAPITATION. 205

48. 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.

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

Make a circular incision through the integument encir-
cling the head at a convenient point and separate the skin
backward toward the occiput by forcing the hand between
it and the bones or by using the chisel as a spatula
or dissecting it away with the Colin’s scalpel, continuing
the separation over the occiput to the atloid region. Make
a transverse incision below across the trachea and 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.

206 SUBCUTANEOUS AMPUTATION.
49. 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, dorso-sacral
position, 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 be corrected or is not so readily over-
come as is the amputation of the limb.

Technic. Our larger, 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 acord to the pastern of the
limb, the shoulder of which hes 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

SUBCUTANEOUS AMPUTATION. 207

away from the body. ‘The next most important obstacle is
the pectoral muscles which should be torn asunder by sep-
arating them into small bundles and tearing them through
with the fingers between the sternum and limb, or the pro-
cess nay be aided by incision with a knife or with the chisel.
When these are well divided the remaining impediments to
tearing the shoulder away consists largely of ‘the trapezius
and rhomboideus muscles at the top, the latissimus dorsi be-
hind and the great serratus and the angularis scapula which
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. The impact
upon the maternal organs due to the traction may be re-
duced to almost any desired degree by applying a repelling
force to the sternum of the fetus so that the impact upon
the maternal organs equals the difference between the trac-
tion applied upon the cord and the repulsion applied to the
fetal sternum. 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 moder-
ate 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 pas-
sages or we may reduce the size of the trunk by evisceration
as described under 55.

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, rendering it easy of repulsion and simplifies the
correction of deviations of any parts.

.

208 DETRUNCATION.

50. 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 imb when it is impossible, on account of the
position to reach the shoulder.

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

St. DETRUNCA TION.
PLATE XXXV.

Object. In case a fetus in the anterior presentation and
dorso-sacral positon has one or both posterior limbs devi-
ated forward and the feet engaged in or against the pelvis,
it is 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

MA
Pg
oo”
Lie 4

‘uumnyoo [euids pue sajosnut ay) Suisaaas 40j Jutod sajzeo
TPUL GH [e}aF ASP] 9q} OF Jajjesed puv puryaq oury peop ay] ‘urys
21} 4Ysno1y} Uotstout Jo yuIod ‘cg ‘stAjad ay) Ul paxeSuea yaoy pury omy
eq) ‘Woiztsod [esdes-o1qazsaA $ uoIe}Uasaid JOlajue ul AozoAaquiy

‘NOLLVONOULAG

“AXXX ALVIg

222 DESPRUCTION. 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, (49), and fol-
low with evisceration, (55), 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 it from the fetal body backward until the
last rib is passed, as shown at the curved line in Plate
XXXV. 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 eviscerated, 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 passages, thus converting it into
a posterior presentation. Ordinarily this would result in a
lumbo-pubic, which should be converted into the lumbo-
sacral position, when its extraction can be readily brought
about.

52. DESTRUCTION OF THE PELVIC GIRDLE IN THE
ANTERIOR PRESENTATION.

PEATE XXXVAG
Object. In somewhat rare instances perhaps more fre-
quently in the cow the pelves of the mother and fetus be-

come interlocked, the antero-external angle of the fetal
ilium I’, becomimg locked with the shaft of the maternal

“UO}PE[NITPAV [VIOUS] -OX0D
[etayeut jo auTpno “y + mnyer “Y + eys s}t Ysno1y} Surssed jasiyo
SULMOYS ‘WINI[L [elaF YT $ uINYL [earayem ‘7 :Sadtad OM} 94} Uday
aq yordumt jo yutod sary ‘DQ "‘paxoozssjzur soared jeurajem pue [e323
aq} ‘uor}sod [erses-o1qay1aA ‘ UOTe}MaseId 10j19} 08 UT Amojodiquy

‘WIGUID SIATHA AHL AO NomonuLsaq

“IAXXX 41IVIg

216. AMPUTATION OF THE LIMBS AT THE TARSGS

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,
(49), and eviscerate, (55), 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, placing 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 foramen
ovale, 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 pel-
vis thus loses its rigidity and undergoes great diminution in
size so that it can readily be withdrawn.

53. AMPUTATION OF THE LIMBS AT THE TARSUS.
PLATE XXXVII

Object. It occasionally happens in the mare, far more
rarely in the cow in the posterior presentation with the hind
limbs retained at the hock that 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 uanecessary amount of labor.
In these cases it is frequently easier for the obstetrist and
safer for the mother to amputate the limb at the tarsus.

Technic. .Pass’a cord around the leg above themtansms
as indicated in Plate XX XVII 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 perpendicular as pos-

‘LOSIYD ay} JO suvsU
Aq uoneyndure jo ssadoid ut snsivy ‘Ey, ‘squirt s011aysod any jo uoly
‘Udjat B[QIONpaUt WIM wonvyztesaid s0113\sod ay} ur dojo Kaqmiyq

SOSaYV, HHL LV SAWI’T XOIMHLSOd HHL AO NOILVLOINY

‘ITIAXXX H1WId

220 INTRA-PELVIC AMPUTATION.

sible 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 leg thus forcing
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 lumbo-sacral position and it is
desired to amputate the left limb, the chisel should be held
in the palm of the left hand with its dorsal surface against
the vaginal walls and the instrument carefully guarded and
guided during the entire operation. ‘The amputation should
preferably be through the lower section of the tarsus but
may be made through the head of the metatarsus. Do not
drive the chisel entirely through the hock without removal
as it may become caught and clamped between the divided
bones, but drive for a few inches along the lateral side being
sure that the skin at that point is severed along with the
bone, then loosen the chisel by rotation and lateral motion
and drive somewhat deeper into the tarsus until it is com-
pletely severed. Withdraw the severed metatarsus and re-
move any dangerous spicules of bone remaining on the
stump and see that the latter is safely secured by a cord
passing around the leg above the os calcis. Repeat the
operation on the other hock in a similar manner using the
right hand to guide the chisel, Extend the two limbs into
the passages by traction and effect a posterior delivery.

54. INTRA-PELVIC AMPUTATION OF THE POSTERIOR
LIMBS, BREECH PRESENTATION.

PLATES KX X VILE AND! SCROLL

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
eviation can not be readily corrected.

Technic. Introduce one hand armed with the etinbry-
otomy knife through the maternal passages until the peri-

hw

we

arr me

ot

\ ; Se
ie Bee eS :
y Wee BAe: Pete
4 ee eas) ee

: = ee

“UII [B}JOF 94} JO Yeys 94} Ysnoiyy Suissed umoys
SI [OSIYO oY, “AnUtay [Bjajz “YS siqnd ‘q ! wniyost jeusajeu ©] S wntyI
[Pej T/T + Wn[L eussyem ‘J ‘uorjezaaseid ydaeig = ‘paurejas Apaqard
“109 sda PUIY 24} YUM UoTeUasaid s0;19}sod ayy ur Ktmojohaqus‘yq

“SHILINAULXY YOIMALSOd AHL AO NOILVLOMWY OIA’IHd VULNI

‘INIAXXX SIVTd

224 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 insert-
ing the knife at the shaft of the ilium divide the former
backward to the perineum, 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 accom-
plished 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 one hand and place it against the shaft of the
ilium as shown between I’ I’ in Plate XX XVIII 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 peri-
osteum are completely severed. Disengage the chisel and
then place it against the symphysis pubis or against the
ischium opposite the foramen ovale 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 com-
pletely 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 isolated portion
of the pelvis and have one or more assistants exert traction
as indicated in Plate XX XIX. ‘The chief obstacle to the
withdrawal of the limb is the great gluteus muscle which
should be sought for, identified and torn through with the
fingers at a distance of 5 or 6 cm. from its attachment to the
great trochanter. Other important points of resistance are
the attachment posteriorly of the skin, vulva and anus to

fend

ure oa “fi .
," rin

‘anys! pue siqnd ‘unit Jo suorjsod Surpnyjout uoyepnoiyae jesromiay
-OX09 p9}P[OSI oY} 19A0 padooy st ador ayy, ‘siqnd [ejay oy} ‘,q Sanmoy
Tejaf 94} JO JoJUBYD0I} “YF ‘uOT}EJUaSe1d YOoo1g ‘pauteyas A[aja[d
“M09 S82] PUIY 24} WIM UOT}eYUasaad 10119j3Ss0d 9y} ut AMojosIQqQuq

‘SHILINAALXY WOIMHLSOd AHL AO NOMLVLOdWY OIA'THd-VULNI

“XIXXX ALWId

228 INTRA PELVIC AMPUTATION.

the ischium through the medium of aponeurosis and anter-
iorly, chiefly on the median line, the prepubic tendon ; these
are to be cut, if necessary, with the chisel or knife. Vigor-
ous traction may now be applied by means of the cord, the
operator in the meantime guarding 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 lmb
away in a reversed position, the skin being turned back or
everted as it advances 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
constantly 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, (55), 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 and if need be some of
these may be removed and one of the anterior limbs caught
by a cord around the scapula and extracted intra-fetally.
The remnant of the fetus is to be extracted by means of a
cord fastened about the lumbar region of the spine.

EVISCERATION. 229

55. EVISCERATION.

The evisceration of the fetus is frequently desirable in
obstetric 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 sup-
porting the body walls and permits the body remnant to be
bent or moved more readily for the correction of any mal-
presentations; 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.

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

In the anterior presentation, unless the fetus is far ad-
vanced through the vulva, evisceration is best performed by
the removal of one or more of the anterior ribs. The ribs
are generally best reached by the removal of the shoulder,
as already described under subcutaneous amputation of the
anterior limbs, (49). When these 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-
tion is thén to be repeated if required, upon the second and
third ribs in the same manner until an opening into the

230 EVISCE RATION.

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 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, are withdrawn without difficulty,
as its attachments are feeble. ‘The kidneys may also be re-
moved.

Evisceration in the posterior presentation is preferably
performed through the pelvis, generally in connection with
(54). 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 (54). When admission has been gained to the abdom-
inal 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 en-
tire with the central part of the diaphragm.

Remove the heart and lungs as above directed.

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