re y isd fa Ya Siti tt fe Phe, 4 Ok o "ies a nn hala yt ae ake ‘ : = : ye ceabae race Reaviech hth " ry mt sent eke rbtier ie i MeKCh a ret in tte pita fi ean eee ars Spee Pie ee PP ep ge IIT a y es Shee a Fae e eee CNP incerta cela te, s oem mt Reena Seater reece Rees a Sai = ee, seat Sean : as a ee ees za me Rene ‘ ne a a Cetera Senate Rate tT Shah etn tate Fé, tne ar Aner ee Cay ARSE RES Pht CORNELL UNIVERSITY. 3 THE Roswell P. Flower Library THE GIFT OF ROSWELL P. FLOWER FOR THE USE OF THE N. Y. STATE VETERINARY COLLEGE 1897 8394-1 ‘ornell University Library Tani SURGICAL DISEASES OF THE DOG AND CAT LC iyo fn ge Pace PN tae eek dani. wae ee eee A SURGICAL DISEASES THE DOG AND CAT WITH CHAPTERS ON ANAESTHETICS AND OBSTETRICS (SECOND EDITION OF ‘CANINE AND FELINE SURGERY’) BY FREDERICK T. G. HOBDAY, F.E.C.V.S,, F.RS.E. MEMBER OF THE BOARD OF EXAMINERS OF THE ROYAL COLLEGE OF VETERINARY SURGEONS LATE PROFESSOR IN THE ROYAL VETERINARY COLLEGE, LONDON ; CONSULTING VETERINARY SURGEON TO THE BRITISH BULLDOG AND THE GRIFFON BRUXELLOIS CLUBS } HONORARY VETERINARY SURGEON TO THE LADIES’ KENNEL ASSOCIATION, THE FOX-TERRIER \ 7 > CLUB, ETC., ETC. SECOND EDITION, REVISED AND ENLARGED CHICAGO CHICAGO MEDICAL BOOK COMPANY Ciqera + TO DARCY POWER, Eso. M.A., M.B. (Oxon.), F.R.C.S., F.S.A., SURGEON TO ST. BarTHOLowWEW's HospiraL, AND LATE LecrureR ON HisToLoGy aT THE Rovat VETERINARY COLLEGE, LoNnbDoN, THIS BOOK IS DEDICATED AS A SLIGHT TOKEN OF THE AUTHOR’S DEEPEST GRATITUDE PREFACE TO THE SECOND EDITION THE reception accorded to the first edition has proved that a small text-book of the kind was distinctly wanted, and in presenting a second and enlarged edition the author regrets that illness and other causes have allowed the first to remain so long out of print. By the request of numerous friends, the work has been enlarged to include symptoms and general details of treat- ment other than that which may be described as purely surgical, although the original idea of the author to keep the book as a handy manual for the final-year student has still been adhered to. The introduction of antiseptics has revolutionized all the old-fashioned ideas, and has benefited the animal world to almost as great an extent as that of man. It is true that we have not quite the same advantages as our confrércs in human surgical practice, but it is astonishing what can be done by strict attention to the principles intro- duced by the discoveries of Pasteur, and applied to surgery by the teachings of Lister. Operations which only a few years ago were looked upon beforehand with dread are now done every day, and owners of pet animals have learned to appreciate the value of modern antiseptic methods almost as much as the members of the profession themselves. For much help and advice in the revision of the proofs I IX x PREFACE TO THE SECOND EDITION am indebted to Mr. D’Arcy Power, M.A., M.B., F.R.C.S5., and to Professor MacFadyean, M.B., B.Sc., M.R.C.V.S. To Mr. Reginald Waud, artist, and to Mr. R. E. Holding, veterinary draughtsman, for sketches too numerous to specify individually, and to Messrs. Hooper and Berry, of Kensington, for much patience in photographing the many and often refractory patients, 1 owe much thanks. To Messrs. D. Crole, T. Angwin, and T. Duncan, all M.R.C.V.S., to Messrs. Arnold and Sons, and to others whose names are mentioned in the text, I am also indebted for many specimens or fresh sketches, without which it would have been impossible to illustrate the work to any- thing like its present extent. If the publication of this volurne will only advance in the slightest degree the application of modern surgical principles for the benefit of the suffering animal world, the wishes of the author will be more than gratified. F. H. 10, SILVER STREET, KENSINGTON, W. November, 1905. PREFACE TO THE FIRST EDITION DuRING my experience in the Free Out-patients’ Department of the Royal Veterinary College I have often thought that a small text-book containing directions with regard to surgical operations upon canine and feline patients would be appre- ciated by the students engaged in the daily work of the Clinique for small animals, and perhaps also by the busy practitioner. It is with the idea of supplying these directions in as concise a manner as possible that this little manual has been written. The major portion of the work has already appeared as a series of articles in the Journal of Comparative Pathology and Therapeutics, to the editor of which, Professor MacFadyean, I am particularly indebted for much help in revising the proofs, and for many suggestions. To Messrs. Arnold and Sons, Messrs. Kréhne and Sese- mann, and Mr. B. Kihn, I am obliged for the loan of draw- ings of instruments and appliances. Almost all the operations herein described have been per- formed in the Clinique during the past seven years, and the ultimate results have been carefully noted as far as possible and summarized. References are given to where the in- dividual cases may be found in detail. BE. Hs ROYAL VETERINARY COLLEGE, LoNnpDon, N.W., Lay, 1900. x1 CON TEN Ts CHAPTER I PAGES GENERAL RULES FOR TREATMENT OF THE PATIENT BEFORE AND AFTER A SURGICAL OPERATION I—6 CHAPTER II ANTISEPTIC PREPARATION OF INSTRUMENTS, DRAINAGE-TUBES, SUTURE MATERIAL, SPONGES, ETC. 7—13 CHAPTER III METHODS OF SECURING 14—22 CHAPTER IV THE ADMINISTRATION OF AN4&STHETICS (LOCAL AND GENERAL) 23—46 Local Aneesthetics 24 General Anesthetics 29 Morphia and Chloral 45 CHAPTER V ACCIDENTAL AND OPERATION WOUNDS; CONTUSIONS 47—58 CHAPTER VI ABSCESS, CYST, SINUS, FISTULA, AND POLYPUS 59—65 CHAPTER VII TUMOUR, INFLAMMATORY NEW GROWTH, GRANULOMA 66—76 CHAPTER VIII THE Ear 77—87 Examination of the Interior before, and Application of Dress- ings after, an Operation 77 Polypi, Tumours, and Enlarged Ceruminous Glands 78 Hzematoma or Tumefied Flap 79 XH XIV CONTENTS Amputation of the Ear-flap or a Portion of it 83 Cropping 83 Operations to Cause the Ears to Droop 85 Tumours 87 CHAPTER IX OPERATIONS ON THE SKULL, Face, Lips, AND NOSTRILS 88— 100 Trephining 88 Tumours on the Nose 89 Tumours and Polypi in the Nostrils go Other Foreign Bodies in the Nostrils 2 Hare-lip and Cleft Palate 2 Rodent Ulcer of the Lip 96 Pus in the Antrum 97 Tumours 99 CHAPTER X THE EYE AND EYELIDS IOI—I22 Examination for, and removal of, Foreign Bodies 102 Pterygium or Dermoid Growths on the Cornea 102 Dropsy of the Eyeball (Hydrops Ocult) - 104 Wounds and Ulcers of the Cornea 105 Staphyloma 106 Strabismus, or Squint 107 Cataract 109 Excision of the Eyeball Ill Protrusion or Paralysis of the Membrana Nictitans IIg Displacement or Tumefaction of the Orbital Gland 116 Entropion and Trichiasis 117 Ectropion 120 Tumours 121 CHAPTER XI OPERATIONS ON THE MOUTH, PHARYNX, TONGUE, AND TEETH 123—139 Examination 133 Removal of Foreign Bodies 124 Ranula 126 Scarification of the Tongue 127 Amputation of the Tongue or a Portion of it 128 Hare-lip and Cleft Palate 130 Tumours 130 Papilloma or Wart 130 Sarcoma or Carcinoma 133 Epulis 135 CONTENTS xv PAGES Scaling and Cleaning the Teeth 135 Extraction of Teeth 136 Insertion of False Teeth 137 us in the Antrum 139 CHAPTER XII THE THROAT AND NECK I40—I50 Choking 140 Passing the Probang 142 Csophagotomy 143 Tracheotomy 145 Foreign Bodies around the Neck 147 Tumours 148 Dislocation of the Neck 150 CHAPTER XIII THE THORACIC AND ABDOMINAL WALLS I51—165 Accidental Injuries involving the Thorax 151 Violent Contusions ISI Punctured Wounds ISI Fractured Ribs 152 Paracentesis Thoracis (Tapping the Chest) 153 Tumours of the Chest Wall 155 Paracentesis Abdominis (Tapping the Abdomen) 156 Laparotomy 158 Accidental Injuries involving the Abdomen 160 Gunshot Wounds 161 External Violence and Contusions 162 Acute Suppurative Peritonitis 163 Tumours of the Abdominal Wall and Mammary Glands 165 CHAPTER XIV THE STOMACH AND INTESTINES 166—202 Aids to Diagnosis 166 Colic 168 Puncture of the Stomach or Bowel 171 Foreign Bodies in the Stomach 17I Gastrotomy 177 Gastric Ulcer 178 Foreign Bodies in the Lower Part of the G:sophagus 178 Gastrectomy or Gastrostomy 179 Intussusception of the Intestine 180 Fecal Impaction of the Intestine 183 Foreign Bodies in the Intestine 186 Enterotomy 188 xvi CONTENTS PAGES. Enterectomy and Anastomosis of the Intestine 190 Volvulus 198 Stricture of the Bowel 198 Strangulation of the Intestine 199 Meckel’s Diverticulum 199 Peritoneal Bands 199 Tumours of the Stomach and Intestine 199 Appendicitis and Typhlitis 208 CHAPTER XV DISEASES OF THE RECTUM AND ANAL REGION 203—217 Prolapse of the Anus and Bowel 203 Reduction and Minor Operative Interference 207 Gersuny’s Wax Operation 209 Proctopexia, or Ventrifixation of the Bowel 210 Amputatien of the Prolapsed Portion 211 Imperforate Anus 213 Cloaca 213 Hemorrhoids or Piles 214 Fistula of the Anus 215 Obstruction of the Anal Glands 216 Rectal and Anal Tumours 217 CHAPTER XVI OPERATIONS ON THE OMENTUM, LIVER, SPLEEN, AND PAN- CREAS 218—22 The Omentum 218 The Liver 218 The Spleen 220 Removal of Tumours from the Abdominal Organs 222 CHAPTER XNVII HERNIA 224—238 The Main Principles of Surgical Treatment 224 Umbilical Hernia 225 Abdominal (or Ventral) Hernia 227 Inguinal Hernia 228 Scrotal Hernia 232 Perineal Hernia 234 Femoral Hernia 237 CHAPTER XVIII THE URINARY ORGANS 239—265 Examination of the Urethra and Bladder; Passing the Catheter 239 Imperforate Urethra or Vagina 240 CONTENTS xvii VAGES Calculi in the Urethra - 241 Stricture of the Urethra 247 Prolapse of the Urethra 248 Renal Calculus - 248 Hernia, Prolapse, and Rupture of the Bladder agi Tumours 253 Calculus of the Bladder 255 The Prostate Gland - - 263 CHAPTER NIX THE MALE GENERATIVE ORGANS 266—287 Tumours on the Penis and Prepuce 266 Wounds of the Prepuce 270 Foreign Bodies around, or Fracture of , the Penis 271 Phimosis 273 Paraphimosis 274 Tumours of the Testis 275 Castration 276 Cryptorchids 280 Hermaphrodites 283 Torsion of the Cord 286 CHAPTER XX THE FEMALE GENERATIVE ORGANS 288— 305 Examination 288 Prolapsed Vagina 289 Malignant Tumours 291 Benign Tumours 292 Nymphomania 293 Hysteria, Odphorectomy, and Ovariotomy 204 ' Purulent Metritis 298 Hysterectomy 299 Hysterotomy 304 Stricture 305 CHAPTER XNI DIFFICULT PARTURITION 306—323 Maternal Dystokia 306 Foetal Dystokia 310 Accidents, etc. 315 Treatment of the Mother and Puppies or Kitten 318 Malformations 323 xvill CONTENTS CHAPTER XNII TAGS THE Limbs AND TAIL 324-356 Dislocations 324 Fractures 332 Amputations 341 Overgrown Nails - 349 Tenotomy and Suture of Tendon 351 Foreign Bodies 352 CHAPTER XNNIII VALUE OF THE ROENTGEN RAYS IN DIAGNOSIS 357-—362 INDEX 363 —366 LIST OF ILLUSTRATIONS Frontispiece : A Canine Operating-room. = 1. Animals’ Thermometer (Author’s Pattern) 5 2. Canine Thermometer, showing Fever Markings (Author’s Pattern) 5 3. Instrument Sterilizer 8 4. Instrument Cabinet 9 5. Glass Ligature Bottle (Clarke’s) II 6. Photograph of Dog held for safe Examination 15 7. A Clove Hitch applied 16 8. A Piece of Tape applied asa Muzzle 16 g. A Clove Hitch ready for Application 17 1o. The Author’s Pattern of Hobble 17 11. Improvised Hobble 18 12. The Author’s Pattern of Operating Table 18 13. Key Hobble looped ready for Application 19 14. A Dog fixed with Hobbles on an Ordinary Table in the ‘Abdominal’ Position 19 15. A Dog fixed on the Operating Table in the ‘Dorsal’ Position - 20 16. Gray’s Operating Rack attached to an Ordinary Table, with a Cat fixed in the ‘Abdominal * Position 21 17. Ether Spray Apparatus 24 18. Glass Tube containing Ethyl Chloride ready for Application 25 19. Drop-bottle for the Administration of a General Ancesthetic 31 20. Wire Muzzle Mask 32 21. The Author’s Anzesthetic Inhaler (First Pattern) 33 22. Junker’s Inhaler (Kréhne and Sesemann’s Pattern) 34 23. The Author’s Second Design of Inhaler ‘a 24. Lhe Author’s Third Pattern of Inhaler showing another Form of Mask 36 25. An Electrical Motor Pump for the Administration of Anzs- thetic Vapour (Author’s Pattern) 37 26. Antidote Drop-tube and Bottle for Hydrocyanic Acid - 42 27. Elizabethan Collar 48 28. Insufflator for the Application of Dry Dressings 50 29. Artery Forceps of Different Patterns 51 XIX 62 FIG. . A ‘Surgical’ Knot . A ‘Granny’ Knot . Aluminium Suture Button (Pugh’s) . Different Patterns of Sutures . Needle-holder (Macphail’s) . Wire Suture Needles (Reeks’) . Abscess Knife (Syme’s and Paget’s Blades) . Exploring Trocar and Cannula . Dalmatian with Cyst in the Submaxillary Space . Director and Blunt Needle combined . Curette or Volkmann’s Spoon . Photomicrograph of Carcinoma . Inoperable Sarcoma of the Neck . Photomicrograph of a Round-celled Sarcoma . A Lipoma with Distinct Pedicle . Blunt Tumour Hook or Retractor . Ecraseur (Farmer Miles’ Pattern) . A Large Lipoma, Inoperable, owing to its Extent and LIST OF ILLUSTRATIONS Large Size . Microphotograph of a Granuloma . Kramer’s Speculum - . Avery’s Speculum . Papillomatous Growths in Dog’s Ear . Hzematoma of the Ear-flap before and after Operation . A Simple Many-tailed Bandage for the Ears, cut out of a Piece of Calico . Natural Carriage of Ears . Dog of same Breed which has been cropped . Ugly Ears, one being pricked up and the other carried properly . The same Dog after Operation . Boarhound with Malformed Ear (Congenital) . The same after Operation . Trephine . Granuloma of the Nose . Cat with Polypus of the Right Nostril . Polypus Snare (Blake’s) . An Inoperable Case of Single Hare-lip in a Griffon . A Bulldog, Three Years old, with Single Median Hare-lip, but no Cleft Palate . A Bulldog Puppy, Five Months old, with Unilateral Hare-lip and Cleft Palate, before Operation . The same Puppy after Operation . Malformed Bull-puppy with Double Hare-lip and Cleft Palate . The Usual Situation of the Discharge . Left Upper Fourth Premolar, showing Result of Fracture and Inflammation of the Fangs 1. Photograph showing Eye-shade in Position . Mongrel with Dermoid Growth on Cornea of the Eye PAGE 53 53 54 55 57 60 61 62 62 64 68 70 71 73 74 75 76 77 79 80 81 84 86 86 86 88 89 go gt 93 94 94 95 98 99 lor 103 95+ 96. 97. 98. 99- 100. Iol. 102. 103. 104, 105. 106. 107. 108. 109. TIO. III. LIST OF ILLUSTRATIONS . Eye (from Fig. 72) magnified to show Dermoid Growth on the Cornea . Fox-terrier with Dropsy of the Eyeball and Glaucoma - - Bowman’s Eye Speculum . Colhe with Internal Squint of Each Eye - Strabismus Hook (Walton’s) . Graefe’s Cataract Knife . Graefe’s Cystotome and Curette . Pug-dog with a False Eye (Left One) of Vulcanite . A Cat fitted with a Glass Eye (Left One) . Patterns of Glass Eyes for Dogs and Cats . Japanese Spaniel before a Glass Eye was inserted . The same with Glass Eye 27 situ . Cat with Paralysis of the Membrane . A Displaced and Tumefied Orbital Gland . Entropion and Trichiasis of the Left Eyelid . Sketch showing Elliptical Piece removed from each Eyelid affected with Entropion . Sketch showing V-shaped Incision for the Relief of Ectropion . Photograph of Carcinoma of the Orbit of a Dog . Photograph of Carcinoma of the Orbit of a Cat - Mouth Speculum (Author’s Pattern) - Mouth Speculum (Gray’s Pattern) . Portion of Sheep’s Femur which had been longitudinally fixed for Two Days on the Molar Teeth of a Collie Half a Sheep’s Pelvic Bone which had become fixed on Fox-terrier’s Lower Jaw Cat with Ranula Throat Forceps Squamous-cell Carcinoma of the Tongue of a Cat Apparatus by which a Dog which had lost Half its Tongue could drink Water Mouth of Terrier, smothered with Warts (Papillomata) on the Tongue and Buccal Mucous Membrane Head of Pug showing Warty Growths at Seat of Inoculation on Right Upper Lip Carcinoma of the Pharynx and Cervical Glands of a Terrier Endothelioma, perforating the Palate, of a Great Dane Deformity of the Face due to Carcinoma of the Lips Scaling Instruments of Different Patterns Different Patterns of Tooth Forceps Set of False Teeth made for an Aged Collie Set of False Teeth made for an Aged Schipperke An Aged Schipperke Dog with Set of False Teeth ¢ sz¢e An Aged Collie whose Loss of Incisors was satisfactorily replaced with Gold by American Bridge Work A Kitten’s Larynx transfixed by a Needle . - 131 133 133 134 136 137 138 138 138 138 140 Xxil FIG. 112. 1133 1T4. 115. 116. 117. 118. I19. . Trocars and Gannule } Various Sizes (nested) . Tumour (weighing 25 pounds) attached to the Sternum He aH iS td IS hos WW WB a HHH WE we Pov G2 G2 Gs too 140. T4I. 142. 1213 Td. 145. LIST OF ILLUSTRATIONS Carcinoma of the (Esophagus in a Cat Two Patterns of Probang A Lacerated Wound in the Csophagus caused by the Continued Presence of a Foreign Body Two Patterns of Tracheotomy-tube Collie Pup with Tracheotomy-tube /7 sé¢eu Yorkshire Terrier from the Subcutaneous Tissue of whose Neck an Indiarubber Ring was removed Pointer Bitch with Myxoma of the Neck Bull-terrier with Dislocated Neck . Cross-bred Mastiff with Dropsy of the Abdomen (Ascites) a. Sites of Incision for Various Operations To fuce p. Adenoma-carcinoma of the Mammary Gland . A Bitch with Large Mammary Tumours . Skiagraph of a Lady’s Hatpin in the Gsophagus and Stomach of a Kitten 26. Photograph of a Sheepdog Ten Days after Operation, from whose Stomach a Rubber Ball was removed by Gastrotomy . Site of Incision in the Abdominal Wall, Ten Days after Operation, through which a Rubber Ball was removed from the Stomach . Intussusception of the Intestine . A Cat’s Intestine with a Piece of Sewing Tape passing from Stomach to Rectum . Bowel Clamp (Makins) . Murphy’s Button and Mayo Robson’s Bobbin . Two Hairpins clamped on the Intestine in Position for Operation . The Hairpins tied in Apposition, with some of the Sutures i Sttit . Cones with Sutures and Needles attached . Mode of Insertion of Cone . Operation half completed (Dog’s Bowel) 37. Post-mortem Specimen of a Cat showing Enormously En- larged Kidneys 38. A Case of Perityphlitis and Ulceration of the Bowel 39. Caecum of a Bull Bitch distended from Inflammation of the Interior Prolapse of the Bowel Suture of the Bowel to the Abdominal Wall Anal Adenomata Inoperable Sarcomata of the Liver in the Abdomen of an Irish Terrier Dog Tumours (Sarcomata) of the Spleen Umbilical Hernia (Front and Lateral Views) ‘ : PAGE 141 142 44 145 177 181 IQI FIG. 146. rehy: 148. 149. 150. TST. 152 153. 154. 155. 156. 157. 155. 159. 160. 161. . Bladder Calculi 2 sztz . Shapes of Bladder Calculi . Site of Incision for Suprapubic Lithotomy . Perineal or Posterior Pubic Lithotrity 166. . Urethral Dilator 168. 169. 170. 171. 172. 173. 174. 175. 176. 177. 178. 179. 180. 181. 182. 183. 184. 185. 186. 187. 188. 189. LIST OF ILLUSTRATIONS Tumours in Inguinal Region (for comparison with next figure) Inguinal Hernia A Double Inguinal Hernia fixed in a Suitable Position for Operation Hernia LBistoury A Pug-dog with Scrotal Hernia An Aged Yorkshire Terrier with Scrotal Hernia An Aged Dachshund with Perineal Hernia (Omentum) Perineal Hernia in a Collie Catheter inserted ‘into the Bladder, illustrating a Perineal Hernia which had been opened and found a Fistula Curved Hernia Needles (MacEwen’s) for suturing the Inguinal Ring Flexible Metal Sound Usual Position of Incision in Urethrotomy Urethral Forceps Kidney Calculi 27 situ Small Renal Calcul Pedunculated Tumour of the Bladder Lithotrite Thompson’s Evacuator Suppurating Prostate Gland Carcinoma of the Prepuce Contagious Venereal Growths on the Penis Wound in the Prepuce Malformation of the Prepuce and Penis Sarcoma of the Testicle Method of holding Cat for Castration Fox-terrier with Ectopic Testicle Wire-haired Terrier with Ectopic Testicle Dissection of a Cryptorchid Hermaphrodite Puppy Dissection of Hermaphrodite Tumour of Undescended Testicle Vaginal Speculum Prolapse of the Vagina Contagious Venereal Tumours of the Vagina Fibromas of the Vagina Diseased Uterus and Ovary Prolapse of the Uterus Bull Bitch after Ovaro-hysterectomy Myoma of the Uterus Gs Go pb WW hb Go G2 WG Go DAM wun WoW 291 293 295 300 301 302 XXIV FIG. 190. Ol. 192. 193. 194. 195. hb Ww N WR HW NN tv & +H DW W ED HW WW LN DON ANEW Dr w * ow LIST OF ILLUSTRATIONS Sarcomas of the Pelvis and Ovaries Spaniel Bitch after Hysterectomy Group of Puppies saved by Hysterectomy A Monstrosity A Monstrosity Parturition Forceps . Puppy sucking from a Feeding-bottle . Ward’s Foster-mother . Tee’s Foster-mother . A Bulldog saved by Ovaro-hysterectomy . Collie Dog with Dislocated Wrists . Collie Dog with Leather Splints applied and 203. Dislocation of the Elbow and 205. Dislocation of the Patella and 207. Malformed Patella Joints . Dislocation of the Pollux (Skiagraph) - A Cyst in the Spinal Cord . Dislocation of the Tail-bones (Skiagraph) and 212. Fracture of Both Fore-legs . Fracture of the Wrist . A Badly-set Wrist . A Swollen Foot . Comparison between Two Femurs . Cat with Fractured Leg . Fractured Shoulder . Fracture of Each Humerus . Comminuted Fracture of a Digit (Skiagraph) . Amputation Saw 2. Fractured Leg . Artificial Limbs . Amputation of Both Fore-legs to 230. False Legs applied . Pug with Overgrown Nails . Nail Forceps . Severed Gastrocnemius Tendon . Skiagraph of Cat’s Leg with Foreign Body . Serous Cysts . An Inflammatory New Growth and 238. Skiagraphs of Fractures . Skiagraph of Comminuted Fracture Skiagraph of Pelvis Skiagraph of a Dog’s Normal Stifle Joint PAGE 393 307 310 311 312 eid Ww ~o N BW OO ON ANF Ww NH OW ONWUP WH DOD Gs G2 Fa W WD LI WH W Go Gs W W Ud Gd Od Wd WH UW Ls G2 Gs OW) Od WW Gon Oe Se ae Rae Ss Wn RWW NN 344-347 wo wm ° 350 352 353 = 9355 - 356 358 359 361 362 CANINE AND FELINE SURGERY CHAPTER I GENERAL RULES FOR TREATMENT OF THE PATIENT BEFORE AND AFTER A SURGICAL OPERATION WHEREVER possible, it is better, though not absolutely necessary, that the patient should be prepared some time before passing through the ordeals of anesthetization and operation. If the animal has been recently removed from its owner and placed amongst fresh surroundings, such as the infirmary of the operator, it is always wise, when possible, to allow it to get accustomed to the strange place and attendants, and to make sure that the dog or cat has a good appetite and is feeding well. If there is fever, catarrh, or other sign of ill-health, the operation, unless the case is an urgent one, should be postponed. The action of the bowels and kidneys should be watched, and if the former are at all constipated, a dose of laxative medicine about twenty-four hours, or an enema about two hours, before operating is a wise precaution. The laxative chosen, however, should not be one which will cause nausea, griping, or loss of appetite. Castor-oil or liquorice are suitable, and for the enema either warm water and soap, or glycerine and water, answer the purpose well. Where an abdominal operation involving the stomach or intestine is anticipated, and the condition of the patient will I I 2 CANINE AND FELINE SURGERY allow it, some intestinal antiseptic (such as chinosol, izal, calomel, carbolic acid, 8-naphthol, etc.) should be adminis- tered every four or six hours for three or four consecutive days previously. Immediately before some operations it is necessary to repeat the enema and to withdraw the urine by the aid of a catheter. A light meal of finely-divided solid food or a quantity of beef-tea or milk is advisable about seven or eight hours before anesthetization. Vomiting during, or when recovering from, the application of chloroform, so frequently met with in human patients under similar conditions, is very rare in the dog and cat. The author has only met with it in eight or ten instances out of more than a thousand closely recorded administrations of chloroform (see Chapter IV.). It is generally due to the presence of solid food in the stomach. After an operation under anesthesia the patient should be put in a quiet place where there is plenty of fresh air, and allowed to recover. The eyes, nostrils, and mouth should be sponged with cold water, care being taken that none of it gets into the back of the mouth. On no account should stimulants or other fluids be administered in any quantity down the throat until recovery has taken place, as some of it is likely to find its way into the trachea and lungs. When the animai is able to lap voluntarily, a little cold water may be allowed, but solid food should not be given for at least an hour. A clean place, attention to hygiene and diet, together with antiseptic dressings as often as necessary, will complete the directions to bring about restoration to health. Preparatory Treatment of the Site of Incision. The antiseptic treatment is the only one which is admissible in modern surgery. All instruments, the patient, the operator, the operating-table, and all surroundings, must be considered as dirty until they have been treated antiseptically and TREATMENT BEFORE AND AFTER OPERATION is} rendered surgically clean. It is only by this method that one can hope to get an uninterrupted series of successful results. All hair from the site of operation and the contiguous parts should be removed a short time before operating, by the aid of scissors or clipping machines and a razor, the skin being thoroughly scrubbed for fully two minutes with soap and hot water containing some disinfectant, then again for two minutes with ether, spirit, or ether soap to remove all grease and sebaceous material, and afterwards swabbed with an antiseptic of reliable strength. Turpentine, which is some- times used in human surgery, is not permissible, as it acts as a violent irritant to the skin of the dog and cat. A pad of wadding soaked in some antiseptic, and carefully kept in position over the site for an hour before the operation com- mences, completes the process by which the parts are rendered surgically clean. If a preliminary dressing cannot be applied, owing to the situation of the wound, the temper of the animal, or some other cause, the antiseptic chosen and the cleansing process must be applied with extra thoroughness and care at the time of operating. The use of the razor is absolutely essential to bring about a continuous series of primary wound unions without pus formation. This primary union can, however, be assured in more than go per cent. of cases if only the operator will take the care to be surgically clean. This statement is based upon the results of careful records taken upon more than a thousand wounds in veterinary patients.! The choice of an antiseptic must rest with the operator. Probably those which are in most common and general use for surgical purposes are solutions of carbolic acid, lysol, creolin (each of which is used in from 1 to 2 per cent. solutions with water), corrosive sublimate (I in 1,000 parts), 1 Veterinary Record, vol. xv. p. 685. (Proceedings of the Central Veterinary Medical Society.) I—2 4 CANINE AND FELINE SURGERY chinosol (r in 1,000 to r in 500), boracic acid (5 to Io grains to the ounce), and biniodide of mercury (1 in 1,000 solution, being aided by the addition of a little more than an equal amount of potassium iodide). Of these, boracic acid is particularly selected for wounds on the cornea of the eye; solutions of carbolic acid, lysol, creolin, and perchloride of mercury, must be used with the greatest care when operating on small dogs or cats, as toxic symptoms sometimes ensue even when these drugs are applied only to a small area.! As an illustration of this the following case is worth remark. The patient, a female cat in an emaciated condition, was placed on the operating-table for laparotomy, the obiect being to remove a cork which could be distinctly felt to be present in the intestine. A 5 per cent. solution of carbolic acid was used to disinfect the site of operation after the hair had been shaved off, and also for the instruments. A little was also used to wipe the edges of the bowel wound and to disinfect the peritoneum in one place where it became soiled. The solution was, how- ever, used sparingly, but before the operation was completed symptoms of carbolic acid poisoning had commenced, the voluntary muscular system was twitching violently, and the temperature became subnormal. Antidotal measures were adopted, but within two hours after the comple- tion of the operation the patient was dead. Solution of biniodide of mercury has advantages over that of the perchloride, in that no precipitate is formed when it becomes mixed with blood, and it does not combine with albumin. Many of these antiseptics can now be purchased in the convenient form of tabloids, tablets, or soloids, one of which dissolved in a certain quantity (usually a pint or a quart) makes a lotion of the requisite strength in a few moments. After trials of various antiseptics, those usually chosen by the author have been ether soap and creolin for the operator’s hands and the preliminary washing of the patient, and chinosol for the final cleansing. 1 Journal of Comparative Pathology and Therapeutics, vol. x., p- 361; zdem, vol. 1X., p. I. TREATMENT BEFORE AND AFTER OPERATION 5 Value of the Thermometer after Operations. Indications that a septic infection is already present or that one has taken place after an operation are suspected by the general dulness of the patient, loss of appetite, haggard facial expression, a thready or almost imperceptible pulse, and a rise of temperature. The thermometer is one of the most valuable aids to a diagnosis of septic infection, although it must not be forgotten that a very little excitement will in a few moments cause the temperature of a healthy dog or cat to become raised even as much as one or two degrees. In order to test this point, the author made a large number of observa- tions on dogs, cats, and other animals.!’ From a series made upon over 200 dogs, the normal average rectal temperature worked out at tor'5° F., and from a series made upon forty-one cats the average - = Sa fe LL Teh yt pits tye WE te —S pe ET thy) ARNOLD & SONS PATENT, LONDON Fig. 1.—Animals’ Thermometer (Author’s Pattern). HEA! 3 a HIGH ARNOLD & SONS MAN Sees FEVER FEVER

Tbid., vol. »., p. 362+ 10—2 148 CANINE AND FELINE SURGERY each respiration produced a whistling sound, and the dog fell over from semi-asphyxia when excited in the slightest degree. After removal of the ring the patient ultimately recovered. Fig. 117.—Yorkshire Terrier from the Subcutaneous Tissue of whose Neck an Indiarubber Ring (actual size shown here) was removed.! 1, Dog's head ; 2, wound in neck caused by the ring ; 3, dog's back. Tumours. The chief varieties of tumour met with in this region are sarcoma, carcinoma, fibroma, myxoma. For particulars regarding their removal, see p. 74. t Journal of Comparative Pathology and Therapeutics, vol. xv., p. 268 (Broad and Hobday). THE THROAT AND NECK 149 Fig. 118.—Pointer Bitch with Myxoma of the Neck. Fig. 119.-—Bull-terrier with Dislocated Neck.t 1 For this photograph I am indebted to Mr. F. Moreton-Wallis M.R.C.VAS, 150 CANINE AND FELINE SURGERY Dislocation of the Neck. This accident is, fortunately, not commonly met with. It is usually the result of a sudden wrench or of direct violence, and may cause instant death. The patient carries its head on one side, and expresses pain when an attempt is made to straighten it. Reduction under chloroform by careful manual manipulation is the only remedy which can be advised if it is the owner’s wish to have the attempt made. Warning should, however, be given that there is considerable danger attached to the pro- cedure, especially if the dislocation has existed for some time. The sooner the attempt is made after the accident has occurred, the better the chances of success. A skiagraph is of great assistance in determining the exact extent of the lesion. The patient whose photograph appears above was injured whilst ‘ratting, and was quite lively and well in health afterwards, and could walk all right, but when running would fall over. Reduction was attempted under chloroform, but terminated fatally. CHAPTER NIII THE THORACIC AND ABDOMINAL WALLS Accidental Injuries involving the Thorax. ConTusions and punctured wounds of the thoracic wall are frequently met with in the dog and cat, being caused by direct violence from such things as the toe of a boot, sticks, stones, wheels of vehicles, bites of other animals, or contact with spiked railings. Fractures are not as frequent as one might expect, owing to the wonderful elasticity of the ribs in these animals. Violent contusions cause stiffness and pain, and may give rise to a pleurisy. They are treated by hot fomentations and sedative or absorbent lotions, complications (such as abscesses, etc.) being treated as they arise. Punctured wounds should be treated antiseptically and sutured as soon as possible, the patient being kept in a clean place and perfectly quiet. The prognosis given must always be guarded, although the result need by no means of necessity be fatal. Lacerations from vicious bites in this direction are sometimes of a terrible nature, leaving only one course open, viz., the destruction of the patient; but punctured wounds from palings may be so small as to be missed unless the skin is carefully denuded of hair before giving an opinion. Air enters the thorax (this condition being termed pneumothorax), and the lung on that side collapses to a more or less extent, 51 152 CANINE AND FELINE SURGERY but the animal may live for some time after a very extensive injury, and may even ultimately recover. A lurcher dog brought for treatment, suffering from injuries the result of a fight rather more than a quarter of an hour before, had the left shoulder almost completely torn away, the thoracic muscles being frightfully lacerated, and the heart and lungs exposed to view. The patient was perfectly conscious, but successful remedial measures were impossible, and a dose of hydrocyanic acid terminated its sufferings. A fox-terrier dog,! two or three years old, had a punctured wound of the lower part of the thorax, between the fifth and sixth (or six and seventh) ribs on the right side, the result of contact with spiked palings. The lung was not collapsed, and with each inspiration came into view. The wound was cleansed thoroughly, sutured, and treated antiseptically, the patient making an excellent recovery. The skin wound measured 3 inches in length, and the wound through the thoracic muscles into the chest cavity was rather more than half an inch in length. When pus forms in the pleural cavity the condition is termed empyema. Its treatment in canine and feline patients, unless localized to a slight area, is practically hopeless. Fractured ribs are often not easily diagnosed, and that the last rib is a ‘floating’ rib is a point which must not be lost sight of, as its unattached extremity has frequently been mistaken for a fracture. The fracture can only be detected by the pain exhibited upon manual examination, or by sounds of crepitus, and is suspected by the history given and the intense disinclination to move exhibited by the patient. Respiration, too, may be hurried and painful. Treatment consists in the tight application of a sheet of cotton-wool and a rolled bandage around the ribs, in order to afford them as much rest as possible, and to keep them in position. This should be allowed to stay on for a fortnight or three weeks, the patient being kept quiet and dieted sparingly and frequently on food which does not distend the stomach, which is laxative in character. ! Journal of Couparative Pathology and Therapeutics, vol. ix., p. 153+ THE THORACIC AND ABDOMINAL WALLS 153 Paracentesis Thoracis (Tapping the Chest). The accumulation of fluid in the chest can usually be traced as a sequel to an attack of pleurisy, although in many cases no acute symptoms of the disease have been observed by the owner. It is equally commonly met with in the dog and cat. Symptoms.—The patient is noticed to be dull, capricious in appetite, and to have lately become very much emaciated ; exercise or other exertion causes distress and great lassitude, the respiration being distinctly laboured, and a Jine from the last rib diagonally along the tucked-up flank (the so-called ‘pleuritic ridge’) is well seen in short-haired dogs. The temperature is not usually high, and may even be normal or sub-normal. Occasionally the appetite will remain ravenous even until a very late stage in the disease, and death may occur suddenly without any. preliminary warning. The operation of ex- ploring the chest is done to verify the diagnosis of fluid, and effect its removal when found to be present. Operation.—Unless absolutely necessary, it is not advisable to fix the patient before performing this operation, but merely to have the animal quietly held in the standing position. Any pressure on the throat or chest is dangerous, and death is very apt to ensue suddenly from asphyxia if the patient struggles or falls heavily to the ground. Carefully shave the hair from and disinfect (see p. 2) a spot about an inch above and behind the point of the elbow on the right side; a fine trocar and cannula, which have been boiled, are introduced subcutaneously. for a short distance, and the point tarned in between two of the ribs (usually the sixth and seventh or seventh and eighth; see Fig. 122). The trocar is then with- drawn and the cannula inserted as far as necessary, the fluid contents of the chest being allowed to escape slowly. Any material blocking the end of the cannula and retarding the 154 CANINE AND FELINE SURGERY flow must be removed by the careful reintroduction of the trocar or a sterilized blunt probe. The left side may or may not, at the discretion of the operator, be punctured in the same way. On this side, when choosing the site of puncture, the portion of chest wall immediately over the heart-beat must be avoided, the trocar being inserted very cautiously just through the pleura in a slanting direction, and then withdrawn, the rest of the puncture being made with the blunt cannula. The author has seen one of the heart ventricles accidentally punctured, the blood spurting out with each heart-beat. The patient was kept under close observation afterwards for a week, and appeared to suffer no inconvenience. 1a Fig. 120.—Trocars and Cannulz : Various Sizes (nested). Symptoms of collapse must be watched for, and the amount of fluid withdrawn left entirely to the discretion of the operator. The author’s opinion is that as much as possible should be withdrawn unless signs of syncope appear, as it is practically impossible to entirely empty the dog’s chest, on account of its shape. Solution of iodine, chinosol, adrenalin chloride, or some antiseptic may, or may not, be injected, after which the cannula is carefully and slowly withdrawn. The seat of puncture is dried with aseptic cotton-wool, and covered with iodoform (or orthoform) and collodion. Of these, adrenalin chloride is the one with which the most favourable results have been recorded. It was first advocated in the treatment of erous effusions by Dr. Barr, of Liverpool, in 1903, and Drs. Plant and THE THORACIC AND ABDOMINAL WALLS 155 Steele have confirmed its value in human patients (Br7tish Medical Journal, July 15, 1905). Reading of the recoveries obtained in human practice, the author was induced to try it in veterinary patients, the result being to confirm its beneficial effects. The method of using is to with- draw as much of the fluid as possible, and inject from half a drachm to a drachm of adrenalin chloride (1 in 1.000), diluted with from two drachms to two ounces of sterilized water, before the cannula is withdrawn. The wound is' sealed with collodion, and the exterior of the chest or abdominal wall is massaged to spread the fluid about as much as possible. It is supposed that the beneficial results attained are due to the property which adrenalin chloride possesses, when added to the serous exudation, of causing rapid coagulation, with immediate formation of flakes or bands of lymph. Prognosis.—If done with antiseptic precautions, exploration of the chest with a fine trocar and cannula may be resorted to again and again without fear. Although cases do occasionally receive permanent benefit,’ the prognosis must always be guarded, as the relief given may only be temporary, and very often more fluid is formed and has to be removed within a few weeks. Potassium iodide administered internally is said to have a beneficial effect in preventing the re-formation of fluid, and in aiding the absorp- tion of any that may be left, quinine and strychnine being also recommended to give tone to the system; but cases of complete recovery are few and far between. Life may certainly be prolonged for some months by repeated tapping, and if recovery does take place, the patient should be care- fully looked after for a long time. Tumours of the Chest Wall. The chest wall, in common with other parts of the body surfaces, is apt to be the site of tumour growths, and at times these grow to enormous size, as shown in Figs. 47 and 122. The patient (Fig. 121) was an adult fox-terrier, male, with a huge tumour hanging from a little to the right of the middle line in the pectoral region. The surface was bosselated and almost warty in appearance ; contact with the ground had caused a few suppurating sores, but other- 1 Veterinary Journal, November, 1905 (k. Lewis Green, M.R.C.V.S.). 156 CANINE AND FELINE SURGERY wise the external surface was intact, and the dog did not seem in pain. Chloroform was administered, and the growth, when excised, weighed about two and a half pounds.! Treatment is as already described (p. 74). Paracentesis Abdominis (Tapping the Abdomen). The operation is performed to remove fluid from the abdominal cavity. This condition is most commonly met Fig. 121.—Tumour (weighing 25 pounds) attached to the Sternum. with in old dogs (although this is by no means a constant rule), and is generally associated with some disease of the peritoneum or, more frequently, cirrhosis of the liver and kidneys. Sarcoma and other tumours of the liver are some- times seen in dropsical patients. Operation.—The best situation to choose for this operation is the linea alba, or as close to it as possible, an inch or so ' Veterinary Journal, March, 1905 (R. G. Haskell, M.R.C.V.S.). THE THORACIC AND ABDOMINAL WALLS 157 behind the umbilicus. The patient is fixed on its side, and after the removal of the hair and thorough disinfection of the part a small trocar and cannula are introduced subcutaneously for about half an inch, and turned cautiously into the abdomen; the stilette is then immediately withdrawn. Care must be taken with the abdominal wall, so as not to injure any of the abdominal organs. The method of procedure Fig. 122.—Cross-bred Mastiff with Dropsy of the Abdomen (Ascites). 1, Site of paracentesis thoracis operation ; 2, site of paracentesis abdominis operation. afterwards is the same as already described in the preceding paragraph (paracentesis thoracis), the maximum amount of adrenalin being injected; very large quantities are sometimes removed. The subject of the illustration (Fig. 122) was a mongrel mastiff, five and a half years old, with a history that the owner had observed a gradual increase in the size of the abdomen during the past four months. On June 2, 1899, paracentesis abdominis was performed, and 54 gallons of fluid were removed, some warm chinosol lotion being injected up the cannula afterwards. The relief afforded to the patient was imme- diately obvious, and no further operation was necessary for some four months, although at this period (October) there was some evidence which appeared to point to the fact that the abdomen was slowly refilling. 1 Journal of Comparative Pathology and Therapeutics, vol. Xit., p- 262. 158 CANINE AND FELINE SURGERY Prognosis must be guarded, but the prospects are much better than in the case of removal of fluid from the chest. The life of the patient may be saved for a much longer time, and occasionally permanent benefit results, as the following cases show: In consultation with Mr. Charles Taylor, M.R.C.V.S.,a French poodle bitch, four years old, which had recently developed ascites shortly after reariny a litter of puppies, was operated upon. A large quantity of fluid was withdrawn, and the bitch was put on iodide of potassium twice a day. The fluid showed no signs of recurrence, and the patient made an excellent and permanent recovery, remaining in the same owner’s possession for some time afterwards.! Mr. R. Gillard,? M.R.C.V.S., records a case of permanent recovery in a wire-haired fox-terrier, male, aged four years, from whose abdomen 13 pints was removed on the first occasion, and a further quantity on a second occasion. ‘F.R.C.V.S/ also reports in the Veterinary Record (November 12, 1904) a case of permanent recovery after withdrawal of fluid from a six-year-old fox-terrier dog. Laparotomy. This consists in opening the abdominal cavity either with a view to exploring® or operating upon some of its internal organs, the removal of foreign bodies, for dystokia, or as a treatment for ascites and tubercular peritonitis.“ On the day preceding any major abdominal operation, the patient should be bathed and the site of incision (together with some distance around it) shaved and disinfected as directed on p. 50. No solid food should be given for about twelve hours before, although a little milk or beef-tea may be taken. Operation.—Administer a general anzesthetic (see p. 23), with the patient in the abdominal position, and then turn the animal over on to its back, fixing it there with hobbles, the limbs being well extended. Rigidly disinfect again and incise the skin in the median line, the actual situation 1 Veterinary Journal, vol. \x., p. 125. 2 [bid. feterinury Record, September, 1900. 4 Watson Cheyne, Lritish JWedical Journal, December 23, 1899. Fig. 122¢.—Sites of Incision for Various Operations. A, tracheotomy; B, cesophagotomy ; C, gastrotomy; D, umbilical hernia; E, ex- ploratory laparotomy, odphorectomy, and ovariotomy; F, ovaro-hysterectomy and hysterotomy (Czesarean section); G, suprapubic lithotomy (female); H, inguinal hernia. [To face p. 158. THE THORACIC AND ABDOMINAL WALLS 159 chosen depending upon which organ is to be operated upon. Carefully arrest all hemorrhage either with artery forceps or tampons of aseptic wadding, puncture the peritoneum, insert a director, and with the aid of a scalpel or scissors make an incision of the required length. After doing whatever is necessary to the internal organs, remove all blood from the neighbourhood of the wound, suture the peritoneum with fine silk, and the muscles with silk, and the skin with silkworm gut. The peritoneum and muscles may be taken together, and some practitioners suture all three layers (peritoneum, muscles, and skin) at once, but this method cannot be as safe as if they are taken separately. A continuous suture may be used for the peritoneum, but interrupted sutures are unquestionably the best for the muscles and skin, as, if septic infection takes place, it is necessary to remove one or two for the cleansing and dressing of the wound. The sutures should be placed close; if far apart a piece of omentum is apt to protrude, and the bowel may follow it. About a third of an inch is a fair distance. In order to complete the operation, the exterior is carefully dried with ether and aseptic wadding and covered with iodoform (or orthoform) and collodion, as already directed on p. 50. Occasionally in large dogs, where a long incision has been made, a bandage is useful over this to give support to the edges of the wound; but in the majority of cases this is not necessary, and only forms a source of annoyance and irrita- tion to the patient. Care must be taken to keep the animal perfectly quiet and on low diet for about ten days, and on no account to allow it to go up and down steps or to jump from a height. Neglect of these precautions is liable to lead to the reopening of the wound and escape of the intestines. Water should also be allowed sparingly, and care should be taken, above all, to avoid any food or ad- mixture of foods which might produce vomiting. Such a 160 CANINE AND FELINE SURGERY misfortune would be very likely to cause tension upon the sutures, and even rupture, protrusion of intestine, and death. In two instances which came under the author’s personal observation this accident occurred. A retriever dog, upon which laparotomy had been successfully performed five days before, was surreptitiously given a hearty meal by its owner, with the result that the abdominal sutures burst open and the intestines escaped ; and in a second case a very valuable bull bitch lost her life a week after laparotomy, when all danger seemed past, by vomiting violently after an injudicious meal. Prognosis is excellent, provided rigid attention is paid to antisepsis; and as a general rule, beyond the removal of the cutaneous sutures four or five days later, the wound requires no further attention. Hernia may result in about 4 or 5 per cent. of cases, but is generally traceable to some neglect of detail, and now and then a buried silkworm gut suture gives rise to irritation, and requires to be removed. The median line is preferable wherever it can be con- veniently used, because (1) there is less tissue to cut through ; (2) less hemorrhage, the bloodvessels here being few and small; (3) if infection takes place and pus collects in the abdomen, it has a better chance of draining away ; and (4) healing is very rapid, provided that septic infection does not take place. In fact, union by first intention can generally be assured.! Accidental Injuries involving the Abdomen. Small animals are continually receiving injuries to the abdomen, especially from being kicked or struck violently, from the wheels of motor-cars and other vehicles, gun accidents, and from contact with spiked palings. The last- named is apt to inflict an ugly wound, through which the omentum and intestines may make their exit. The prognosis ' The conclusions arrived at in this chapter are the result of an experience of more than 380 carefully recorded abdominal sections in dogs or cats, in the majority of which union of the abdominal wound was obtained by first intention. THE THORACIC AND ABDOMINAL WALLS 161 of such cases must always be grave on account of septic dangers ; but numerous instances of recovery are on record, and the owner should certainly be encouraged to make some attempt to save the patient’s life. The prolapsed organ should be returned and held in place by the hand covered with a clean handkerchief or other cloth, until an assistant can adjust something to act as a temporary retention bandage. The sooner skilled professional aid is obtained, the better the chance of success. The patient should be put on the operating- table and chloroformed, the parts thoroughly washed with warm antiseptic and returned, the external orifice being sutured as described for laparotomy (see p. 159). If the gut is, or has, been exposed, a careful search should first be made for perforations, and these closed by Lembert’s sutures (see p- 54). In the case of omentum, the protruding portion had better be removed altogether, as this lessens the chance of infection, and the absence of even a large piece of it will not be of vital consequence to the patient (see p. 218). A greyhound, four years old, attempted to clear some spiked railings near Hyde Park, and became impaled on the top, staying there until released by friendly hands. When lifted down, it was seen that a bunch of intestine as large as a cocoanut had escaped. The owner, a lady, holding a handkerchief over the wound and the protruding bowel, had the patient carefully lifted into a cab, and arrived at the infirmary within ten minutes after the accident. The dog was placed on the operating- table in the dorsal position and chloroformed ; the intestines, visibly soiled, were carefully washed with warm chinosol solution (1 grain to the ounce), and returned to the abdomen ; the edges of the wound being similarly treated and then sutured in separate layers with silkworm gut. The patient gave very little further trouble, and made an excellent recovery. With gunshot wounds of the abdomen, if extensive but not yet fatal, the patient is usually in such agony that it is better to destroy the animal as speedily as possible. If slight, it is questionable whether it is wise to interfere surgically beyond the application of antiseptic external dressings (see p- 50), rest, and the dietary prescribed on p. 160, It must be II 162 CANINE AND FELINE SURGERY left to the discretion of the surgeon as to whether the gut is sufficiently injured to necessitate laparotomy (see p. 158), repair of the bowel injuries (see p. 189), and surgical or anti- septic treatment of the interior. In cases of external violence and contusions, without the presence of a visible wound, such immediate contingencies as the rupture of some internal organ or internal vessel must be thought of, especially when the patient appears in a state of collapse, and peritonitis is apt to ensue as a sequel. The stomach and liver are commonly ruptured. In either case it is quite a forlorn hope, especially if a lot of food has escaped into the abdomen. Laparotomy (see p. 158) should be performed without delay, and an examination made; the rupture being sought for, and if possible repaired, by sutures, all food being carefully removed and the peritoneum thoroughly irrigated with antiseptic solution. Ruptured vessels must be sought for in the same way and ligatured, all blood in the peritoneum being carefully removed with anti- septic irrigation. This is a very troublesome procedure, on account of the small space and cramped conditions in which the operator has to work ; but it is possible, and occasionally will be the means of saving a valuable life. Contusions alone cause great pain and stiffness, and may even lead to peritonitis. An animal which has been injured by being run over, even although at the time it may not seem very much hurt, should be dieted carefully and receive a little gentle laxative medicine, being kept quiet and under observation for at least three or four days. In cases in which there is great pain, laxative and cooling medicine (such as calomel or magnesium sulphate) should be given internally, and the parts treated externally with refrigerant and sedative lotions (such as lead and opium, or arnica and spirit, etc. If an abscess or hematoma forms, it must be treated as already directed (see p. 59), being lanced with particular care THE THORACIC AND ABDOMINAL WALLS 163 to examine first for hernia, and to see that the knife does not open the abdomen. Acute Suppurative Peritonitis. Pus in the abdomen, when floating about freely and not encapsuled, of necessity sets up a peritonitis, and if not removed is fatal. This condition may cause death within three or four days, or the patient may live for several weeks after the operation or injury which has been its source of origin. Symptoms.—In acute suppurative peritonitis the temperature rises three or four degrees, respiration is accelerated, the pulse is quick and wiry, the abdomen is tender on pressure, the eye is abnormally bright, the mucous membranes are very hot and feverish, and the animal vomits, refuses food, and is dull. Death may take place within forty-eight hours, being preceded by coldness of the surface and extremities and coma. In the chronic form the disease may progress unsuspected until near the finish, the patient eating food a little capriciously, but appearing normal in other ways. The thermometer is the best guide, but even that is uncertain in the dog and cat, as the least excitement and exertion will cause variations (see p. 5). In either condition the previous history is always worth the most careful consideration. Operation.—The only chance of escape from death lies in the removal of the purulent fluid, and the only prospect of doing this effectually lies in surgery. When the peri- toneum is invaded, laparotomy should be done without delay (see p. 158), and the sooner it is done the better for the chance of success, the abdomen being carefully irrigated (not swabbed, as this removes the lining cells) with warm non-irritating antiseptic solution (such as chinosol, a grain to the ounce). Sterilized saline solution (a teaspoonful to a pint of distilled water) employed at a slightly higher temperature than that ITI--2 164 CANINE AND FELINE SURGERY of the body (about 105°) is also employed for the purpose, on account of its restorative effect. Before completing the sutures, a large sized rubber drainage-tube is left in position between the last two, the whole being covered with an antiseptic pad and bandage. Any pus collecting in this tube must be carefully sucked out with a syringe two or three times a day. This tube is removed as soon as the collection of pus has ceased, being replaced by an antiseptic ‘tent’ or ‘ plug.’ After-treatment—Day and night attention by a_ skilled canine nurse, if one can be obtained. Small doses of stimu- Fig. 123.—Adeno-carcinoma of the Mammary Gland.! lants in beef-tea, milk, Benger’s Food, or other nutrients at intervals, varying from every half-hour to every four hours at discretion. Subcutaneous injections of brandy or ether, and nutrient rectal suppositories or enemas, are also valuable. Prognosis—This must always be very grave. As a rule with acute suppurative peritonitis death takes place before the surgical measures which have been adopted can take effect, and it is only when the purulent area is a small one at the time of its discovery that experience teaches the operator to hope for a successful issue. With a localized peritonitis 1 For this photograph I am indebted to the Cancer Research Association. THE THORACIC AND ABDOMINAL WALLS 165 confined to the pelvic region, or within a few inches of an Operation or accidental wound, there is always more hope than with the diffused variety. Tumours of the Abdominal Wall and Mammary Glands. Tumours of the exterior of the abdomen are very common, especially in the region of the mammary gland, and frequently they attain an enormous size. The chief varieties are those of sarcoma or adenoma, but osteoma, chondroma, fibroma, and carcinoma are also seen; and one must not forget that in a bitch whose milk has been allowed to accumulate and Fig. 124.—A Bitch with large Mammary Tumours.! remain in the mamma, indurated portions of gland, which feel very like tumour tissue, are met with. The Treatment is the same as for tumours in other parts of the body (see p. 74), and one must not forget that, as a rule, mammary tumours are very muscular, so that particular attention must be paid to avoid hemorrhage by taking up the vessels as they appear. In making a diagnosis one must bear in mind the similarity in appearance in some cases (Figs. 146 and 147) of mammary tumours and inguinal hernia, so that an operation should not be undertaken until after a very careful examination. 1 For this photograph I am indebted to Mr. A. S. Hodgkins. CHAPTER NIV THE STOMACH AND INTESTINES Aids to Diagnosis. IN veterinary patients there is often an especial difficulty in making an cxact diagnosis as to the cause, etc., of stomach and bowel trouble; unfortunately, our patients cannot so definitely reply to our queries as can the human patient to the surgeon. At the same time, there are many symptoms and signs which are unmistakable, and in animals, such as the dog and cat, which have comparatively small, thin bodies, we are frequently able to definitely locate and diagnose the nature of the offending obstruction. A thorough and searching manual or digital examination should always be made, and the patient’s symptoms and general condition taken carefully into consideration, before an operation is decided upon, together with the history prior to and during the attack, as related by the owner. The history cannot always be accurately relied upon, and one should always be prepared to discount points upon which the owner is not absolutely certain, or which are related only upon conjecture. The habits of the dog, especially in relation to a propensity for picking up stones, etc., and any previous attacks in consequence, should be especially inquired into; and in the case of a kitten the tendency to play with cords, and to swallow bits of cotton, hair, etc., must not be forgotten. Any previous attacks of a like character, the 166 THE STOMACH AND INTESTINES 107 suddenness or otherwise of the symptoms (indicating acute or chronic trouble), and the passing of intestinal parasites (especially of the round worm, Ascaris marginata, in puppies), all materially assist one in making a diagnosis. The general condition must always be carefully considered, more especially from the point of view of the operator and the success of the operation. If the patient is already moribund, it is not fair to blame the operation for an un- successful result. In bowel obstruction, especially impaction from feecal matter, toxic absorption may already have taken place and gained such headway that its effect cannot be overtaken. In obstruction from any cause, the general prostration and weakness which, of necessity, takes place from pain, and inability to take or retain food, are im- portant factors, and the earlier surgical aid ts called in (if medicinal means seem likely to be ineffectual), the better the chance of the patient. In these days, too, thanks to Lister and Pasteur and the antiseptic methods they have introduced, the surgery of the abdomen has taken its proper place with all other major operations, and abdominal section a com- paratively common operation. The symptoms have particularly to be watched. Colic is more commonly present in the earlier stages and before obstruction is complete, whilst vomiting, haggard counte- nance, and continual straining, with no result, may indicate complete stoppage. For the examination of a dog or cat suffering from obstruc- tion of the bowels, the patient should be placed on a table or chair at a height convenient for manipulation. After the general appearance has been noted, the pulse and temperature should be taken; if possible, before excitement has changed their character (see p. 5). Clammy mucous membranes, a quick, almost imperceptible pulse, and a temperature which is over 104°5” F. or below g9° F. are exceedingly bad signs. The patient is then muzzled or securely held by the head, 168 CANINE AND FELINE SURGERY and the abdomen palpated between the hands or fingers. This is best done in small animals by placing the left hand firmly on the spine, whilst the right one, with outstretched fingers turned upwards on one side and the thumb on the other, passes carefully along the under surface of the abdomen from before to behind in an endeavour accurately to locate and diagnose the cause of the pain and obstruction. In the larger breeds both hands must be used, one being passed along each side. In small patients with some kinds of swallowed foreign body, the aid of the Rontgen Rays may be satisfactorily invoked (see pp. 173 and 357). Preparation of the Patient.—Where circumstances will allow it, the patient, in addition to the usual preparation for an operation (see p. 1), should three or four times a day receive doses of some internal antiseptic. Of these, chinosol, carbolic acid, izal, salol, calomel, or 8-naphthol are amongst those most commonly selected. Colic. Patients, especially canine, are frequent sufferers from abdominal pain. Cases are met with most commonly, perhaps, in puppies, but adults are by no means exempt. The causes are various, the commonest being flatulent dis- tension of the stomach or bowel, the presence of round worms (Ascaris marginata) and foreign bodies, violent and irritant poisons, hernia, intussusception ; and a strangulation of the gut by fibrous bands, Meckel’s diverticulum, or volvulus. Symptoms.—Sudden seizure, continual yelping which cannot be quietened, raised temperature, quickened pulse, and dis- tended abdomen, the animal crawling away to hide itself, and laying flat on its belly on a cold surface between the spasms, but changing about from place to place to try to get relief during the seizures. Vomiting, especially if the dog takes food (which it will THE STOMACH AND INTESTINES 169 sometimes do between the fits of pain), may occur, the presence of food decidedly aggravating the pain. Eventually, if no relief is given, excessive prostration ensues, and the patient dies. Treatment.— Medicinal agents should be resorted to first, unless a certain diagnosis has been made which makes this course to be considered useless. If worms or some foreign body be suspected in the stomach, a dose of apomorphine should be given to cause vomition and an attempt to get rid of the cause of the irritation. Otherwise hot flannels or compresses covered with mackiritosh cloths should be applied externally, and an enema, together with medicinal agents (ether, ammonia, turpentine, opium, chlorodyne, bismuth, or castor-oil, etc., depending upon what the diagnosis has been) given by the mouth. Should relief not be afforded by these within three or four hours, and the abdomen is still much distended, the stomach or intestine may be punctured (see p. 171); failing ease from this, an exploratory laparotomy (see p. 158) should certainly be done without further delay. Even if no possible cause for the colic is found, the operator need not despair of a successful issue; for in a number of cases the opening of the abdomen alone has caused relief from vomiting and violent pain,! and, so far as the operation itself is concerned, no great alarm need be felt if strict attention has been paid to antiseptic precautions. Peritonitis, that bugbear of old-fashioned surgery, is, comparatively speaking, a rare sequel to laparotomy performed under antiseptic precautions, even when dogs and cats are the patients.” Five consecutive cases upon the result of which the above assertion was first made are worth briefly recording. In each patient there was more or less acute abdominal pain, the history obtainable being either none at all or else of a swallowed foreign body. 1 Journal of Comparative Pathology, vol. Xii., p. 259. ’ Veterinary Record, vol. xiii., p. 142. 170 CANINE AND FELINE SURGERY CASE 1.—October, 1898. Dalmatian dog, two years old, the subject of persistent vomiting for the past three weeks. The dog was very thin, and could neither retain fluids nor solids. As no drugs gave permanent relief, it was thought that there must be some foreign body present, and an exploratory laparotomy was done under chloroform. By some mis- fortune the animal escaped from hospital, and was ultimately found three days later at the Dogs’ Home; it then ate yreedily and retained any food. The wound healed by first intention, and the patient was sent home, remaining quite well until January of 1899. Between January and April several similar attacks occurred, these being temporarily relieved by doses of orthoform. In April, after an especially severe attack, the owner had the dog destroyed. Posf-mortent examination revealed nothing to account for the symptoms. CASE 2.—December 1, 1898. A cat, fifteen months old, had for about ten weeks suffered from occasional fits of abdominal pain and great prostration. An exploratory laporotomy revealed no visible cause, but the patient recovered well, and afterwards had no return of the symptoms. CASE 3.—December 1, 1899. Fox-terrier, male, six years old. The owner said the animal had swallowed a meat-skewer. Being a little sceptical at the time, we treated the dog with medicines for a week, but at the end of that time, as there was great debility and partial paralysis of the hind-legs, we thought that probably the owner was right in saying that a meat-skewer had been swallowed. An exploratory laparotomy was made, but no foreign body was found. The wound healed by first intention, the sutures being removed on the third day, and the patient was sent home on December 6. Reinspection was made at intervals during the next three months, but there was no return of the symptoms. CASE 4.—May 19, 1899. Retriever, male, nine years old, supposed to have swallowed a solid rubber ball. There was excessive abdominal pain, vomiting, no feeces had been passed for three days, and the dog seemed very weak and ill. An exploratory laparotomy revealed nothing. Until the 22nd the dog appeared very dull, but on this date suddenly brightened up and began to feed. Diet was given sparingly, and it was arranged for the owner to remove the animal home on the 29th. Unfortunately, on the 28th the owner came to see how things were progressing, and, with mistaken kindness, gave the dog a heavy meal of a food of which he was especially fond. The result was that violent peristalsis was caused, the abdominal wound was torn open, and the intestines escaped. A dose of poison was at once given, as veterinary help was not accessible at the time. CASE 5.—July 13, 19Q90. Fox-terrier, male, four years old, in acute abdominal pain for several days. Various drugs were unsuccessfully tried, and, feeling sure that some foreign body must be present, an exploratory laparotomy was performed. Nothing was discovered, but the pain ceased at once ; recovery was uneventful, and the patient was THE STOMACH AND INTESTINES 171 discharged from hospital on the 20th. With the exception of a buried suture abscess some months afterwards, the patient had no return of the colicky pain. Puncture of the stomach or bowel must be done with all attention to antiseptic precautions, as already described (see pp- 2 and 158), the site of operation being shaved and dis- infected, whilst the trocar and cannula is boiled. This instru- ment (see Fig. 120) should be of small size, an ordinary exploring needle (see Fig. 36) answering very well, and is inserted under local anesthesia (ethyl chloride or anestile answer splendidly) through the skin over the most distended spot, and directly into the stomach or bowel. For the stomach, the instrument is inserted on the right side, about an inch behind the last rib, and pointed forwards very cautiously so as to avoid the liver or diaphragm. The safest plan is, as soon as the skin has been penetrated, to withdraw the point of the trocar within the cannula, and explore with the blunt end of this for the distended organ. This will yield on pressure, whereas the liver and diaphragm each offer a solid resistance. Puncture of the stomach is followed by a rush of gas when the stilette is withdrawn. The usual place chosen for bowel puncture is either high up in the flank, about midway between the last rib, the sacrum, and the lumbar vertebrz, or about an inch on one side or other of the median line. When the gas present has escaped the instrument is removed, the operator carefully pushing the skin away from him towards the abdomen as the stilette is pulled out. Foreign Bodies in the Stomach. Meat-skewers, hatpins, sticks, pins, needles, nails, tacks, beads, stones, corks, coins, rubber or wooden balls, etc., are swallowed by both dogs and cats, especially the former, and at times give rise to a good deal of trouble, which neces- sitates surgical interference. Gastrotomy, too, is occasionally necessary for the removal 172 CANINE AND FELINE SURGERY of a foreign body firmly impacted in the lower portion of the cesophagus, when it cannot be removed from above (see p. 178), and for the excision of ulcers from the stomach wall. Skewers are not at all infrequently met with by the canine practitioner in London and large towns where the horse-Hlesh used for dog and cat food is sold in thin slices held together by a wooden skewer. A greedy animal will sometimes bolt the lot intact, especially if there is another dog near; and the author has removed the offending article from the region of the flank close under the thigh (showing that it must have found its way down the intestine), as well as from between the posterior ribs over the stomach. Broken pieces of stick have frequently been removed from the stomach or cesophagus. The author has in his possession the end of a candle-rod, 54 inches long, removed from the cesophageal region of a St. Bernard dog, by Mr. J. Blakeway, F.R.C.V.S.1 Sticks are usually swallowed by puppies or as the result of an accident. Stones are often involuntarily swallowed by dogs as a result of the habit which some people have of throwing a stone for a dog to fetch. Sometimes a very large number will be taken, and the author knew of one instance in which an Aberdeen terrier had swallowed no less than 114, mostly sharp flint-stones. ‘The animal showed an arched back, and was, as might be expected, very dull and depressed, but eventually passed them all and made an excellent recovery. In another instance a dog was seen to swallow a peculiar shaped stone on December 13, and the same stone was vomited back in the owner’s presence on February 12 following. Hatpins have been most commonly met with in kittens. P. J. Simpson recorded one 44 inches long (Veterinary Record, vol. xv., p. 409), and J. McCall also recorded one of 74 inches long (l‘eterinury Record),? each of which was ! Veterinary Journal, vol. \x1., p. 26. * Vol. aiv., p. 766. SATOWVW ‘oom “L AW 0} pelqepul we J sty} Joy _ (UML & Jo yOeUOS pue snsvydosap ayy wi uldjyey s,Apey ev jo yduiserjgs— Scr “By 74 CANINE AND FELINE SURGERY successfully removed ; whilst Fig. 125 shows the skiagraph of a kitten which had swallowed a lady’s hatpin 6 inches long. Coins and such small articles are readily swallowed. Copper coins undergo corrosion in the stomach or intestine, and in time cause serious illness and death if not removed. Silver coins merely tarnish, and, unless they cause mechanical obstruction, need give rise to no alarm. The author on one occasion found, on fost-mortem (made for the purpose by the owner’s request), a two-shilling piece which the dog had been seen to swallow five years previously. It had made a sac for itself in a portion of the stomach wall, and, beyond being tarnished, was quite undamaged ; nor had it given the patient any inconvenience, the animal being fat and well when destroyed by a dose of hydrocyanic acid. Of other foreign bodies the variety may be legion. Mr. S. Bennett (letertnary Journal, vol. 1x., p. 318) has recorded a case in which a fish-hook was found in the rectum of a cat. Mr. F. Spencer has recorded an instance of the greater portion of a lamb’s foot passed per anu, with the hair still on it (Veterinary Record, vol. xv., p- 409) ; and the author on one occasion discovered a valuable diamond collar stud which the owner had missed and suspected his dog of swallowing. The patient depicted in the photographs (Figs. 126 and 127) was operated upon by Mr. W. H. Chase, the dog having swallowed a hard composition cricket-ball when playing with some children.t Professor Udrischi, of Bucharest, successfully removed a lady’s hairpin from the stomach of a kitten, the article having accidentally slipped down the patient’s throat whilst it was being used as an improvised tongue depressor.2,. Mr. A. S. Hodgkins has recorded a piece of lead pipe # inch thick, 2 inches long, and 1$ ounces in weight, vomited from the stomach of a toy Yorkshire, only 7 pounds weight herself.? Symptoms.—In many instances the patient has shown no illness whatever until, in the case of a hatpin or skewer, an abscess swelling has been observed under the skin. The most common situation in which this is met with is the right or left side, between some of the last ribs, the cesophageal region, and the flank (from an inch to 2 inches above the linea alba). 1 Journal of Comparative Pathology and Therapeutics, September, 1902. ’ Veterinary News, July, 1905 (translated from Archiva l’eterinaria). 3 » Vetertnury Record, vol., xiv. p. 147. THE STOMACH AND INTESTINES 17 5 As a rule some history can be obtained, either that the patient has been seen to swallow the suspected foreign body, or that the animal is in the habit of swallowing such things; but this is not to be too definitely relied upon unless accom- panied by certain symptoms, as on more than one occasion a dog has been operated upon in a vain endeavour to recover some object which has been discovered on the owner’s premises a few days later. The chief signs exhibited are: attempts at vomiting, dis- Fig. 126.—Photograph of a Sheep Dog, Ten Days after Operation, from whose Stomach a Rubber Ball was removed by Gastrotomy.! inclination to feed, general dulness and depression ; in a later stage, unthriftiness of the coat, irregularity of the bowels, blood in the motions, and progressive emaciation. Treatment.—For small bodies, such as nails or fish-hooks, some dietary of the ‘stodgy’ variety, which will surround the foreign body and gradually pass it along the intestine, is required. Suet pudding, if the animal will take it, is 1 For Figs. 126 and 127 I am indebted to Mr. C. S. Simpson, veterinary student. — 176 CANINE AND FELINE SURGERY very effectual ; the cat will generally take this if mixed with a little fish, and to the ordinary house-dog it is not un- acceptable when hungry. For a foreign body which is not sharp, some emetic (apomorphine is the quickest and best) will often cause its reappearance, and if this is ineffectual a dose of castor-oil should be administered. With skewers, hatpins, or needles, if the patient is not suffering any apparent inconvenience, the wiser plan is to await develop- ments, as the point will in a few days make its way to the surface, causing an abscess. When this is lanced, the foreign body is grasped and withdrawn. The head of such a sub- stance as a lady’s hatpin may either be cut off close and allowed to fall back into the stomach or intestine (where it will soon be got rid of), or the orifice carefully enlarged and the head withdrawn. The former is preferable. As a rule adhesion has already taken place between the internal organ and the peritoneum, and, if the abscess cavity is carefully cleansed, the patient makes a rapid and permanent recovery. One must not forget that there is an element of risk of death from peritonitis, and the alternative to put before the owner is that of an immediate operation; but it is really wonderful how little inconvenience is sometimes shown to the presence of wounds caused by meat-skewers and _hat- pins in the stomach, even when no antiseptic or surgical measures are taken. During the past few years quite a number of practitioners (\Wolsterholme, Perryman, Brooks- banks, Tutt, R. Gillard,’ Woodruff,? Mayall, and others)’ have recorded cases in which foreign bodies have been carried for a length of time in the stomach of the dog or cat, with- out causing any more alarming symptom than the formation of an abscess in the side. At the same time, the practitioner 1 Veterinary Record, vol. vii, pp. 187, 295 ; vol. x., p. 206; vol. xi, PP. 376, 434. * The Veterinary Student, vol. i., No. 2, p- 2. 3 Journal of Comparative Pathology and Therapeutics, vol. viii. p. 2545 vol. x., p. 360. THE STOMACH AND INTESTINES 177 not infrequently discovers one of these bodies, on post- mortem, to have been the cause of death. One must not necessarily expect to see needles which have been swallowed come out in any one particular spot, as their wandering habits are, when once inside the body of a dog or a cat, as great as they are in that of the human individual. The Operation, technically known as gastrotomy, is per- Fig. 127.—Site of Incision in the Abdominal Wall, Ten Days after Operation, through which a Rubber Ball was removed from the Stomach. formed as follows: The patient is prepared and laparotomy performed as already described (see p. 158), the site of in- cision being the median line, from 2 to 3 inches below the cartilage of the sternum. The stomach is drawn up outside the abdominal wall as far as possible, resting on a piece of sterilized mackintosh or jaconet (which has been slit to receive and protect it), and carefully packed and surrounded with lint or boiled Iz 178 CANINE AND FELINE SURGERY cloths, the foreign body being sought for and brought close up against a portion of the wall where the bloodvessels are small or absent, and an incision made directly over it. Usually, as soon as the stomach is punctured, a certain amount of gas rushes out, and, as it may carry fluid contents with it, this should be guarded against by making a pre- liminary puncture with a fine trocarand cannula. Should any fluid escape, it must immediately be caught before it can reach the peritoneum. The foreign body is extracted, the internal edges of the wound carefully cleansed with antiseptic solution, and a close row of silk Czerny-Lembert or Lembert (see p. 55) sutures inserted with a small, round, milliner’s needle. The first row passes through all three coats, the second row being of Lembert’s pattern and inserted through the serous and muscular coats only, about a sixth or a fourth of an inch from the edges of the wound, so that they act as a double protection against the exit of fluid. Particular care must be taken to close the small ‘ pucker’ which is left at either end of the wound. With a gastric ulcer the chief trouble lies in the difficulty of making an accurate diagnosis; the operative procedure consists in making an elliptical incision so as to remove all the necrosed edge, and drawing the sound portions of the wall together as already described. The abdominal cavity must be carefully examined for any material which may have escaped, this being thoroughly removed with antiseptic swabs. Foreign bodies in the lower part of the esophagus usually consist of large pieces of bone, gristle, etc., which have been greedily swallowed, and which cannot enter the cardiac orifice of the stomach, and cannot be pushed down with the probang or brought up by an emetic (see p. 142). In one case we were successful in removing a very large piece of gristle by means of a strong slender pair of dressing THE STOMACH AND INTESTINES 179 forceps passed up the cesophagus through the stomach wall when all attempts to move it with the probang had failed! The removal of any foreign body from here must always be done as gently as possible, otherwise the pneumogastric nerves, which pass through this opening in the diaphragm, may be seriously injured, and the result may even be fatal. The method of opening the stomach and closing the wound is as already described. After-treatment consists in keeping the patient as quiet as possible, allowing nothing but a little water, or milk and water, containing boric acid, during the first forty-eight hours, nutrient enemas of beef-tea or mutton broth, or suppositories, being given per rectum every four or six hours at discretion. On the third day a little milk, Plasmon, Benger’s Food, or beef-extract by the mouth may be allowed in addition, and at the end of the fifth or sixth day some finely minced raw meat or cooked fish. Care must be taken during the first fortnight that the stomach never becomes distended, on account of the risk of tearing out the sutures. Prognosis—The prognosis must always be guarded, as the operation is a major one; but if the diagnosis is certain, and the patient not too debilitated, it ought certainly to be adopted if medicinal treatment has failed and the animal's life is per- ceptibly in danger. The operations of removal of the stomach or a portion of it (gastrectomy), or gastrostomy, the making of a per- manent fistula in it, are hardly likely to be performed in every-day veterinary surgery, it being by far the most humane plan painlessly to destroy a patient needing either. That each is now possible has been demonstrated repeatedly in human surgery (chiefly for cancer), the patients’ lives being prolonged thereby, but the author is not aware of any record of this dreaded disease in the stomach of the dog or cat. 1 Journal of Comparative Pathology and Therapeutics, vol. xii. p- 262. r2—2 180 CANINE AND FELINE SURGERY Gastrectomy is done in the case of a malignant growth affecting the stomach, the diseased part being excised and the healthy portions united by Lembert’s or Czerny-Lembert’s sutures. In gastrostomy the stomach is opened and a fistula, through which food is passed, permanently established. Intussusception of the Intestine. This condition, a ‘telescoping’ or ‘invagination’ of one portion of intestine into another, is most commonly met with in young animals, although adults are by no means exempt. It is produced as a sequel to the violent peristalsis set up by some irritant, such as indigestible food or the presence of worms. As regards situation, the commonest varieties are the ileo-czcal and the enteric. In the former the ileum is invaginated into the colon, the intussusception extending as far as.the tleo-ceecal valve, and it may even go so far as to protrude through the anus to the extent of 5 or 6 inches (see p. 106). Fig. 140 is an illustration of this. The patient, a valuable bull puppy, aged three months, was supposed to be suffering from prolapse of the rectum, but upon closer examination this was found to be the small intestine, as when returned the intussusception could still be distinctly felt at the end of the finger. Laparotomy was performed, an intussuscep- tion of the ileum 8 inches long was reduced, and the patient made an excellent recovery.! With the enteric variety the small intestine is protruded into a portion of itself. Sometimes a number of puppies in the same kennel will suffer about the same time, and unless a post-mortem is made the cause will be inexplicable. The specimen shown in Fig. 128 was a portion of the small intestine of a Chow-chow puppy, eight weeks old, and in the kennel from which it 1 Veterinary Record, vol. xvii., p. 493- THE STOMACH AND INTESTINES 181 came the owner had lost no less fiat four within a week, the fost mortem revealing an intussusception in each case, the puppies being from four different litters.) Symptoms.—The patient may or may not show signs of colic, but is continually straining when at exercise and endeavouring to pass a motion, but only a little fluid or dark, blood-stained mucus comes away even after the most violent efforts. Food will not be refused at the commence- ment, and will be retained for a while, but after the existence of the lesion for a few hours vomiting occurs if it is taken. The eyes are bright, and the patient withdraws out of sight Fig. 128.—Intussusception of the Intestine. as much as possible, and away from its companions, remain- ing abnormally quiet except when straining. Sometimes the membranes are icteric and jaundice is a complication. Examination of the exterior of the abdomen between the fingers and thumb, or the fingers of both hands, readily reveals a sausage-shaped swelling in thin patients; but in fat animals this is not so readily detected, although after the lapse of some hours the abdominal wall will become less tense ; it is alwaysa good plan to make frequent examinations. 1 Miss Aleen Cust, Veterznary Record, 1904. 182 CANINE AND FELINE SURGERY The swelling is not tender on pressure in the early stages, nor is the abdominal wall sore. When the diagnosis is made, the sooner an operation is performed the better the chance of success. Purgatives and other medicines are generally returned as soon as administered. The inflation of the bowel with warm enemas may be tried, a long tube, passing as far up the gut as possible, being used; but undoubtedly the surest and safest method of reduction lies in the application of modern surgery. It is true that now and again sloughing of the intussus- cepted gut will occur, firm adhesion of the serous edges having taken place, and the ‘ cast ’ of bowel will be passed per anu ; but the process is a comparatively slow one, the animal is in pain until it has happened, there is great risk of stricture as a sequel, and there is also great risk that the gangrene and peritonitis which must accompany the process may extend and cause the death of the patient. Ulceration, too, may occur, and then a fatal termination would be certain. Operation.—The surgical method of affording relief consists in the performance of laparotomy (see p. 158) and the replace- ment of the gut into its natural situation by means of the fingers.! If the intussusception is of recent origin, this can be done without any difficulty, but if it has existed for some time adhesions will have formed, and the outlook is much more serious. If these adhesions can be broken down with- out materially injuring the bowel wall, this should be done ; if not, the whole piece must be excised (see Enterectomy, p- Igo). Prognosis—The prognosis of an uncomplicated case is excellent if the operation has not been delayed too long. It is, of course, serious if enterectomy has become necessary. After-treatinent—It is very important that the bowels 1 Journal of Comparative Pathology and Therapeutics, vol. xii., p. 261 ; Veterinary Record, vol. xvil., p. 493. THE STOMACH AND INTESTINES 183 should be kept as quiet as possible for some days, and to insure this the patient should receive doses of opium either by the mouth or in the form of suppository. The dietary and other treatment should be as described on p. 179, exercise and excitement of any kind being forbidden. Fecal Impaction of the Intestine. Obstinate constipation and impaction of the intestine by hardened fzeces are very common troubles in the dog and cat, especially those of unclean habits and belonging to inatten- tive owners. The administration of laxative or purgative medicine and the use of the enema syringe are usually sufficient to put matters right, but occasionally surgical aid has to be invoked. A very obstinate impaction of the intestine is particularly met with in the shooting breeds of dogs, although by no means solely confined to these varieties, being caused by over-indulgence in game and rabbit bones. These, matted together with hair or fur, form a hard, bony mass which it is extremely difficult to dislodge. In two cases met with by the author, the animals (retrievers) had passed no feces for at least three weeks.! The obstruction usually occurs in the colon, and it may extend upwards for a considerable distance into the small intestine. In one of the retrievers above mentioned, fully a foot of intestine was involved by a mass as hard as a stone, the small intestine in front being enormously dilated and full of semi-fluid faeculent material. Symptoms.—The patient becomes dull, refuses food, vomits occasionally, and is observed to strain continually in an attempt to pass faces, the effort being utterly ineffectual and accompanied by pain. After an attempt the poor beast will look around at its flanks and stand rigidly still, looking 1 Journal of Comparative Pathology and Therapeutics, vol. xii., p. 261 (Dunstan and Hobday). 184 CANINE AND FELINE SURGERY up when spoken to with a most appealing glance in its eyes, and showing the greatest disinclination to move. The coat is unthrifty, and after a week or ten days the dog becomes emaciated and perceptibly weak. Palpation reveals great tenderness of the abdominal walls, especially on pressure, and the presence of a hard, swollen mass can be detected. On examination per rectum the mass can generally be felt, and the surgeon must guard against being scratched by the spicules of bone, which are sometimes as sharp as needles. Operation.—Surgical aid is rendered after all efforts to remove the impaction by medicines given by mouth or rectum have failed. The simplest plan consists in the injection of melted lard or warm oil per rectum, and the removal of as much as possible, bit by bit, with the fingers or a blunt spoon or curette. This can generally be done to a certain extent, but often the lump is out of reach and matters become more serious. Laparotomy (see p. 158) must be performed, and the obstructed bowel massaged and kneaded gently but firmly, until its contents break up into fragments of suff- ciently small size to be passed on into the rectum; they are then removed by an assistant. The process of kneading must be done very patiently with the ends of the fingers and thumb, great care being taken to avoid injury from the nails; it is a good plan to try first at one end and then at the other, gradually working towards the centre, or any place that feels softer than its surroundings. A second plan consists in opening the bowel and removing the obstruction in that way (see Enterotomy, p. 188), the operation being rendered more risky than in an ordinary case on account of the large accumulation of fluid feculent matter and the lax, debilitated condition of the serous and muscular coats of the intestine, the latter in particular rendering the insertion of sutures without tearing a matter of very careful and delicate manipulation. Enterectomy and subsequent anastomosis (see p. Igo) offer THE STOMACH AND INTESTINES 185 another solution to be adopted at the discretion of the surgeon. Prognosis—The prognosis when the hardened feces can be removed by the spoon alone is good, the only after-treat- ment necessary being the injection for a few days of some emollient antiseptics, such as chinosol and oil, or chinosol, glycerine, and water. When the case has progressed so far that laparotomy, enterotomy, or enterectomy have become necessary, the prognosis is grave, because, as a rule, the patient is debilitated from inability to take proper nourish- ment and from absorption of septic materials. Death from collapse may occur within a few hours afterwards, and in one case met with death occurred suddenly four days after- wards from invagination and strangulation of the bowel, a large piece of the healthy portion having pushed its way into the dilated portion where the obstruction had existed before the latter had had time to contract and recover its tone and normal size. At the same time, the operation is the one which gives the patient the best chance of recovery, and the author has known it to be successful in two very typical instances, in each of which the dogs had enormous masses of concretion which had been accumulating for many days.' The bowel of one patient (an Aberdeen terrier) was per- severingly massaged for fully three-quarters of an hour before the whole mass could be broken down and removed. After-treatment.—It is sometimes most difficult to get the bowel to recover its normal tone. The case above mentioned, in which invagination occurred four days after operation, is an instance of this. For the first twenty-four hours the patient, when the bowel has not been opened, should receive a little dilute brandy and some preparation of strychnine in milk, Benger’s Food, Plasmon, or some farinaceous food, every four hours, and the 1 Journal of Comparative Pathology and Therapeutics, vol. xii, p. 261 ; Veterinary Record, vol. xvil., p. 492. 186 CANINE AND FELINE SURGERY quantity should be small, whether taken voluntarily or administered. On the third day the dose of strychnine can be increased, and this should be continued until convalescence is well established. Rectal feeding by suppository or enema may be added at discretion, and an enema administered if there is no action of the bowels. When convalescence has perceptibly commenced, recovery is usually rapid. For instructions as to after-treatment when the bowel has been opened, see p. 179. Foreign Bodies in the Intestine. Sticks, pieces of wood, stones, corks, balls, coins, nails, sponge, hair (especially in Persian cats), cotton (particularly in kittens), tape, and other foreign bodies, are frequently met with in the intestines of the dog and cat, and sometimes give rise to irritation, inflammation, and even perforation, peri- tonitis, and death, without of necessity causing complete ob- struction of the bowels. Sometimes they are in very large quantities, and the author knew of one instance in which II4 stones were passed, at intervals extending over two days, by an Aberdeen terrier. Corks are very commonly met with in cats, and are a frequent source of death from obstruction of the gut, the offending body usually being half a wine-bottle cork or a portion of one of a large medicine-bottle size. Pieces of sponge, too, are not uncommon, being soaked in fat and generally given with malicious intention. Both these sub- stances swell when they have been soaking in the intestinal juices for a few hours. Probably one of the most extraordinary cases ever met with is illus- trated in Fig. 129, and was recorded by Mr. T. G. Heatley, M.R.C.V.S., in the Veterinary Journal for May, 1905. ‘he patient, a Persian cat, aged two years, swallowed a long piece of ordinary sewing tape, and, as might be expected, became very ill in consequence. Four days before THE STOMACH AND INTESTINES 187 death it was noticed by the owner to be dull and out of sorts, refusing all food, attempting to vomit, and occasionally lapping a little cold water. When brought to Mr. Heatley saliva was hanging from the mouth, the cat could scarcely stand, and was rapidly becoming comatose ; death took place the same evening, and a Zost-morfem examination revealed the bowels to be slightly congested externally, and with a curious puckered appearance. About 3 inches of the tape projected into the stomach through the pyloric orifice, and the remainder had worked its wav to within 5 inches of the anus. Fig. 129.—A Cat’s Intestine with a Piece of Sewing Tape passing from Stomach to Rectum. Syimptoms.—In some cases where a sharp body has been swallowed, no signs of illness are exhibited until the foreign body appears on the surface; but where a blunt article is the cause we get dulness, capricious appetite (the patient will look for food, but refuse to eat when it is brought, or only take a little and leave the remainder), occasional colic of a more or less violent character, and a tendency to hide in a quiet place; efforts to pass faeces result in diarrhcea or a 188 CANINE AND FELINE SURGERY small quantity of blood-stained mucus. In the early stages the temperature may be raised; in the later stages it becomes subnormal. The eyes and face have a curious, anxious expression. After some days the body becomes emaciated, fits of vomiting occur, and the patient is greatly prostrated. In cats this stage is often reached before the patient is brought to the practitioner, and it is usually too late to save the animal's life. Palpation of the abdomen between the hands will in many cases enable the foreign body to be located, and its removal by medicinal or surgical means must then be decided upon. If it has only recently been swallowed, and from its size, ctc., the practitioner considers that purgatives, external manipulation, or enemas, will effect its removal, and the patient seems in no immediate danger, medicinal means may be tried; other- wise the earlier the abdomen is opened the better. Operation—The patient 1s prepared, secured, and anes- thetized, in the same way as for laparotomy (see p. 158). Having opened the abdomen, a search is made along the intestine until the foreign body is reached, and an attempt is then made to pass it along the gut towards the rectum, where it may be seized with forceps by an assistant. This must be done very carefully, as, if the agent has been in one place for long, the bowel wall will be very much weakened and is easily torn. If this can be accomplished, the abdominal wall is sutured, anda prognosis of success is almost assured. If this is not possible, the gut must be opened, this operation being technically known as enterotomy. Or it may be even necessary to excise a portion, this being termed enterectomy, the cut ends being united afterwards. Enterotomy. The portion of intestine containing the foreign body is brought into view through a slit or hole in a piece of macintosh or jaconet cloth, which has been boiled and soaked in anti- THE STOMACH AND INTESTINES 189 septic, and an attempt made to move it into a spot where the wall is still healthy. The site of incision having been decided upon, the material within the gut is gently but firmly squeezed above and below for about half an inch or an inch, and the bowel clamped to prevent its return, and so prevent exit of infective matter when the incision is made. l‘or this purpose clamps (see Fig. 130) can be used, although pieces of rubber tubing held tightly around the bowel with artery forceps improvise very well, or (Maunsell’s suggestion) safety-pins padded with sponge or wadding. The bowel is then carefully packed around with boiled aseptic lint or wadding, an incision made in the longi- tudinal direction in the least congested part, as far away Fig. 130.—Bowel Clamp (Makins). from the mesenteric attachment as possible, and the obstructing substance extracted. The edges of the wound and the intestine above and below as far as the clamped portion are thoroughly cleansed and disinfected, Lembert’s or Czerny-Lembert’s sutures (see p. 55) are inserted, and the wound in the abdominal wall treated as after an ordinary laparotomy (see p. 158). Prognosis and After-treatment.—Careful dieting, as already described after gastrotomy (see p. 179). If the patient has not already become exhausted, the prognosis, although alway’s grave, may be considered hopeful. Interesting cases of recovery after operation have been reported by Vennerholm! and Pauer.?. In Vennerholm’s case the foreign body was 1 Veterinary Record, vol. x., p. 327 (Mayall’s translation). 2 Jbrd., vol. xii., p. 110. 190 CANINE AND FELINE SURGERY situated in the rectum, whilst Pauer removed a stone from the upper part of the bowel near the stomach. To add to the interest of the latter case, a careful fost-mortem examination was made when the dog died (from another ailment) five years later, and the scar could distinctly be seen, although otherwise the bowel was quite normal. Enterectomy and Anastomosis of the Intestine (Enterorrhaphy). In certain cases in which the bowel has become gangrenous or injured, owing usually to the presence of a foreign body or some other cause, the only chance of saving the patient’s life depends upon the excision of the diseased portion and the union of the cut ends. The former is technically termed enterectomy, and the reunion of the cut ends enterorrhaphy. These operations, although, of course, very serious ones, have now regularly taken their places in human surgery, and that it can be successfully performed in healthy dogs and cats has been demonstrated many times.t The chief difficulty in veterinary practice seems to be to make a sufficiently accurate diagnosis early enough—v.c., before gangrene and septic peri- tonitis have set in or the patient has become exhausted. In the author's experience” the results, although not altogether with- out success, have not been good, but in most cases the patient was very much exhausted when brought for treatment. For an enterectomy the preliminary preparations are the same as for laparotomy and enterotomy (see pp. 158 and 188); for the intestinal anastomosis careful suturing alone may be donc, or resort may be had to certain mechanical aids, such as those afforded by cones, discs, buttons, bobbins, etc., made of metal, decalcified bone, carrot, turnip, potato, ete. The abdomen is opened in the usual way in the median line or flank, according to the position of the obstruction, and the offending portion of intestine sought for and withdrawn, 1 Journal of Comparative Medicine and Veterinary Archives (Cecil French), 1902, p. 102. Lancet, October, 1897 (Martyn Jordan). 2 Veterinary Record (Ridler and Hobday). THE STOMACH AND INTESTINES 1g! being pulled through a hole in a mackintosh or jaconet cloth (which has been carefully boiled), soaked in warm antiseptic, and packed around with antiseptic lint or wadding. The contents of the bowel are forced back by pressure with the fingers and thumb for about 2 inches above and below the diseased part and clamped. Special instruments are designed for the purpose; they can be improvised by fixing pieces of rubber tubing around the gut, or (Maunsell’s suggestion) by safety-pins padded with sponge or wadding. The mesentery is incised in the shape of an inverted V, and the branches of the mesenteric artery actually supplying Fig. 131.—A, Murphy’s Button; B, Mayo Robson’s Bobbin. the region to be excised are taken up with pressure forceps and ligatured, it being recollected that the collateral branches of these are few in number, and that therefore as few as possible of the main branches must be interfered with. The bowel is cut through with scissors held at right angles to its lumen, and the latter is swabbed out as far as the clamps with wadding soaked in some fluid antiseptic. The two serous surfaces are brought into contact by interrupted sutures of Lembert’s pattern (see p. 55), inserted about a tenth of an inch from the edge and an eighth or a tenth of an inch apart, particular care being taken not to penetrate the 192 CANINE AND FELINE SURGERY mucous coat of the bowel, and to tuck the edges in neatly. A very fine round needle and silk No. o or oo should be used. Mr. Cecil French, D.V.S., of Washington, has originated a very ingenious and practical scheme by which two hairpins are utilized to facilitate anastomosis. By this method two hairpins are taken and bent to the shape shown in Fig. 132, Fig. 132.—Two Hairpins clamped on the Intestine in Position for Operation. three or four pairs of pressure forceps being necessary to act as clamps. French recommends! a No. 8 or No. g size of milliners’ needle, and No. 2 size of black sewing silk. Great care is taken that no mesenteric vessels are obliterated other than those supplying the area of intestine it is intended to remove. The area to be resected is carefully mapped out, the mesen- 1 Journal of Comparative Medicine and Veterinary Archives, 1902, p- 162. THE STOMACH AND INTESTINES 193 teric vessels secured by ligature by means of a curved needle and fine silk, and the anastomosing loops running near the mesenteric attachment are secured at a point level with the proposed line of resection. One prong of the hairpin is passed through the mesentery at the upper point of resection, and, together with its fellow, is brought tranversely across the gut. The two are clamped together, as in Fig. 133. The intervening portion of intestine is severed with a scalpel quite close to the clamped prongs of the pin, and a wedge-shaped portion of mesentery also removed. The two Fig. 133.—The Hairpins tied in Apposition, with some of the Sutures 27 s7¢i. hairpins are then tied or clamped tightly together, and sutures placed on one side, starting at the mesenteric attach- ment. The bowel is turned over, and the sutures applied in the same manner on the other side. The pins are then untied or unclamped, and severed at their bent ends with bone or wire cutting forceps and withdrawn, one prong at a time. The remaining openings are closed with one stitch each, particular care being exercised that the margin is properly turned in at the mesenteric attachment. Finally the incision in the mesentery is closed by a continuous suture. French records that he operated experimentally upon six different animals with five completely successful results. In 13 194 CANINE AND FELINE SURGERY the sixth case the patient was only five weeks old, and succumbed to obstruction of the gut from formation of adhesions between the line of coalescence and a portion of the bowel wall immediately beyond, this giving rise to an acute curvature of the gut. Of the various mechanical devices for facilitating the anastomosis of the divided ends of the intestine after enterec- tomy, the metallic button invented by Murphy of Chicago (see Fig. 131) is probably the one which has attracted the most notice amongst surgeons during the past few years. The advantages claimed by Dr. Murphy are that—‘ (1) the button dispenses with the need of sutures; (2) the possibility of non-apposition is prevented ; (3) the danger of sloughing is avoided ; (4) the too rapid digestion of the catgut sutures is prevented ; (5) the operation being more rapid, prolonged anesthesia is avoided; (6) the great ease of the operation renders the instrument as safe in the hands of the everyday practitioner as in that of the most dexterous specialist.’ All who have used it have not found these advantages. After a course of experimental work on dogs, Jordan speaks of ‘the danger arising from the presence of the large metallic button, and the risk of gangrene spreading further than is necessary, in Murphy's operation.’ Harrison Cripps! speaks very strongly against its use in human surgery, his experience leading him to directly opposite conclusions to those of Murphy, whereas others speak very highly in its favour. It is placed and fixed in position as follows: A continuous running thread is passed in and out completely around each end of the intestine in a manner similar to the * puckering string’ or ‘draw string’ of a bag; the male half of the button is placed in the distal end of the bowel, and the female half in the proximal end, being held there by an assistant ; the silk is then drawn up around each stem of the button and tied securely. The two halves are steadily and firmly 1 ¢Ovariotomy and Abdominal Surgery,’ p. 281. THE STOMACH AND INTESTINES 195 pressed together, so that the two serous surfaces of the intestine come in direct contact. In from a week to a fortnight sloughing occurs of the parts included within the button, and the latter is passed through the bowel, union of the two serous surfaces having occurred in the meantime. Jordan,’ in India, performed enterectomy experimentally upon fifty-nine pariah dogs by various methods, the one which gave the greatest percentage of success being as follows: Two hollow cylinders, each three-quarters of an inch long, were made either from the decalcified femora of geese or turkeys, or from fresh carrots, turnips, or potatoes, Fig. 134.—Cones with Sutures and Needles attached.” and bevelled off at one end so as to form a hollow truncated cone, the apex being less than, and the base the diameter of, the lumen of the bowel. Each cone was furnished with two sutures, which were passed through its wall from the apex to the base, one on each side, a big knot at the apical end pre- venting the suture from being pulled through the cone. The apex was then inserted, and the ‘ cone sutures ’ passed through all the layers of the bowel an eighth of an inch from the cut margin, one at the mesenteric attachment, and the other at the opposite side of the gut. The other cone being similarly passed, an assistant approximated the ends of the bowel, and the corresponding pairs of sutures were tied moderately 1 Lancet, October, 1897, p. 1098. + For this and the following two figures I am indebted to the Lavcev. 13—2 196 CANINE AND FELINE SURGERY tightly. The ends of the sutures were cut as short as possible. The cut ends of the gut were thus fixed in contact, slight inversion of the ends occurring at the sutures. A continuous ‘double turned’ suture (see Fig. 134) was now commenced on the under surface of the bowel about one- third of an inch from the mesenteric attachment ; especial care was paid to the first four stitches to insure that the knot of the ‘cone sutures’ was buried beneath the line of the continuous suture, the needles here being inserted a little farther from the cut margins. The assistant, holding the bowel at the apex of each ‘cone’ between the thumb and fingers, kept the cut ends of the gut in view (other- Fig. 135.—Mode of Insertion of Cone. wise excessive inversion occurred during the suturing), and gradually rotated the bowel back to its original position as the suturing proceeded. Especial care must be taken to bury the ‘cone suture’ knots, or peritonitis is apt to ensue. As each ‘ double turn’ (see Fig. 134) of the continuous suture was in process of being tightened, the assistant, with the closed blades of a pair of scissors applied on the flat, or other instrument, inverted the margins of the bowel, and kept them so until the double turn was drawn sufficiently tight to invert them permanently. When the gut had been sutured all round, the two ends of the suture were tied with a reef-knot ; the bowel was carefully cleansed and the line of resection inspected, to insure that the edges were everywhere THE STOMACH AND INTESTINES 197 inverted. The mesentery was drawn together with a con- tinuous suture. The gut was then bathed in hot antiseptic water and returned, the abdominal wall being treated as already described for an ordinary laparotomy. Thirty-two dogs were operated upon by this method, pieces of from 4 to 13 inches being excised. Only two deaths occurred, and one of these might reasonably be attri- buted to other causes than the enterectomy. It must not, Fig. 136.—Operation half completed (Dog’s Bowel). AA, Arteries ligatured; BB, arterial loops ; C, gap in mesentery; D, double turn; E, cut margins of gut; GG, gut. however, be forgotten that these were comparatively healthy animals, none of them suffering at the time from disease of the intestine. The sequelz as reported were excellent, the animals after- wards rapidly putting on flesh; but Mr. Jordan does not appear to have kept them under observation for more than about six months to see whether or not stricture resulted. The after-treatment consisted in the above cases in dieting 198 CANINE AND FELINE SURGERY with milk for the first two days, the dogs being allowed as much as they would drink. For the next four days minced meat and boiled rice were substituted, and they were then allowed to eat anything. Prognosis and A fter-treatinent.—This i$ already described on p. 179. Volvulus. Torsion of the intestine upon itself, so commonly met with in the horse, is comparatively rare in the dog or cat. The Symptoms come on suddenly, and are those of violent pain, occasional vomiting, the patient being distressed, and the abdomen distended. If not operated upon, strangulation of the bloodvessels and gangrene of the intestine will precede death, the animal being out of pain when this has taken place. It may be surmised to exist by the history given by the owner, and by the negative evidence of the existence of direct obstruction, intussusception, etc., whilst its certainty can only be demonstrated by an exploratory laparotomy (see p. 158), which should be done without delay if medicinal agents (such as ether, ammonia, opium, chlorodyne, etc.) fail to give relief within a reasonable time. If volvulus is found, an attempt should be made to untwist it. If this is impossible, an enterectomy may be done (see p. 190), or the patient may be painlessly destroyed by a dose of Scheele’s hydrocyanic acid administered intra-thoracically before con- ‘sciousness returns. Stricture of the Bowel. Occurring most frequently in the rectum, the only remedy for this condition lies in enterectomy (see p. 190), but, as it is usually associated with other conditions, it is generally the most humane course to put the patient painlessly away. ' Journal of Comparative Pathology and Therapeutics, vol. x., p. 173- THE STOMACH AND INTESTINES 199 Strangulation of the Intestine. This condition may be caused by volvulus, hernia, or through the presence of peritoneal bands or of a Meckel’s diverticulum. The two former are described elsewhere (pp. 198 and 224) in detail; the latter are rarely recorded, although possibly they are sometimes overlooked. The author has met with two distinct instances. Meckel’s diverticulum is a congenital abnormality oc- curring as a fibrous cord with one end attached to the lower end of the mesentery of the ileum, and the other end floating loose in the abdomen for about an inch or more. It is really an abnormal condition of the omphalo-mesenteric duct, which, instead of lying close to the peritoneal wall and becoming entirely obliterated, has become detached. The free end becomes adherent to the abdominal wall, or even the gut itself, and if there is a portion of intestine enclosed within the loop, as the gut grows it becomes impinged upon and strangulated. Peritoneal bands may be caused by detached pieces of omentum, the constant drag upon them during peristalsis causing them to become cord-like, or as a sequel to an old peritonitis. The Symptoms and Treatment are as already described above (see Volvulus), and it is only by an exploratory laparotomy that their presence can be discovered. Tumours of the Stomach and Intestines. Tumours of the stomach and intestine of the dog and cat are not common. Carcinomata and sarcomata! (Fig. 41) are occasionally met with, but even these malignant growths, so frequently seen in the stomach or lower bowel of man, are very rare in this situation in the dog and cat, although occasionally the testicles and ovaries are affected (see pp. 276 1 Journal of Comparative Pathology and Therapeutics, vol. x., p. 173. 200 CANINE AND FELINE SURGERY and 295). Knowing the tendency of dogs towards obesity, one might have expected that lipomata, such as have been recorded in the [ horse, would have been | found, but even these are only noteworthy by their absence. In the cat the extreme mobility of the kidneys must not be forgotten, and these organs (especially if enlarged, as in Fig. 137) have on more than one occasion been diagnosed as tumours, and laparotomy has been performed with the object of removing them. Their situation and shape, together with a few Fig. 137.—Post-mortem Specimen of a Cat showing Enormously Enlarged : : : Kidneys. patient, are the chief aids to diagnosis, but that the shape may become distorted and misleading is well illustrated days’ observation of the in the photograph. Appendicitis and Typhlitis. Appendicitis, to which so much attention has recently been drawn in human surgery, is an impossible disease in the dog or cat, on account of the absence of the appendix from these animals, and eolotomy, the operation by which an artificial communication is made between the lower bowel and the outside of the body, needs but a passing remark here, as (except experimentally) it would not be performed 1 For this photograph I am indebted to Mr. H. G. Simpson, F.R.C.V.S. THE STOMACH AND INTESTINES 201 on either a canine or feline patient. The lethal chamber would be a more humane and preferable termination. The case illustrated in Fig. 138 was that of a mastiff, aged about twelve years, whose history was that the appetite and general health had been variable and the bowels irregular for about two months. When brought under treatment the temperature was 103° F., pulse 146, the extremities Omentum Abscess Heum Colon Broken- down adhesions Czeceum Ulcer Ulcer Pancreas Fig. 138.—A Case of Perityphlitis and Ulceration of the Bowel.? The upper specimen is the ileo-czecal region, the lower specimen is a portion of duodenum. cold, and all the symptoms of general collapse. Vomition had occurred several times, but no tenderness of the abdomen was discoverable by external manipulation. Coma set in, and death occurred about thirty-six hours afterwards, a fos/-sortem examination revealing extensive peri- typhlitis with ulcers in the duodenum and ileum, in the latter of which one had perforated, thus allowing the intestinal contents to escape into the abdominal cavity.t Typhlitis is, however, tolerably frequently met with, the Symptoms shown being those of acute abdominal pain, 1 Journal of Comparative Patholozy and Therapeutics, vol. xviii, p. 75 (G. H. Livesey). 202 CANINE AND FELINE SURGERY the patient being unable to get rest and ease for long in any position. Colicky pain will be especially shown after food has been taken, and may be so severe as to cause continual yelping, moaning, or screaming. Pressure on the posterior part of the abdomen between the fingers and thumb causes evidence of soreness, and in some cases the swollen caecum can distinctly be detected. Treatment may be medicinal or surgical. The former consists in the administration of the usual sedatives, together with a dose of castor oil to clear out all irritants from the gut, and a dose of morphia subcutaneously may be requisite. If the pain is not eased within twelve hours, laparotomy (see Fig. 139.—Czecum of a Bull Bitch distended from Inflammation of the Interior. p- 158) should be performed, and the cecum and surrounding bowel carefully massaged between the finger and thumb, in order to macerate the contents, which are often in a semi- solid, thick condition. Collection of gas (the caecum is usually much distended) can also be got rid of by this means. After-treatment is as already described on p. 179, and for several weeks afterwards no bones or very indigestible food should be given. Torsion of the Stomach has been recorded twice. It is rare, and is not a condition which can be diagnosed except by exploratory laparotomy.' It causes acute pain and col- lapse, with death in a very short time. ! Veterinary Record, vol. ix., p. 449 (Wallmann and Kitt, Mayall’s translation). CHAPTER XV DISEASES OF THE RECTUM AND ANAL REGION Prolapse of the Anus and Bowel. THIS condition is most commonly met with in young dogs and cats, although adults are by no means exempt. The protrusion usually consists of everted rectum, but occasionally of ileum or colon; the latter is much more serious to replace, and necessitates an abdominal operation to put matters right, as it generally accompanies an intussusception. In such a case the sooner this is done, before adhesions take place, the better for the chances of success (see p. 180). Prolapsus Ani. Syiptoms.—In slight cases the mucous membrane of the anus alone is visible, appearing after defecation as a small red protrusion. It is most common in old, fat dogs, and usually accompanies a visibly relaxed condition of the exterior of the anus. Medicinal Treatment consists in an attempt to get the patient into good general condition. In a fat dog a diet of lean meat (raw for preference), given regularly and restricted in amount, together with medicinal doses of iodide of potas- sium and plenty of exercise, is the best ; and, after the super- fluous flesh has been reduced, a course of tonic medicine. Astringent lotion (alum, tannic acid or lead) should also be 203 204 CANINE AND FELINE SURGERY applied to the anus, and cold astringent injections administered twice or three times a dav fer rectum. For a dog merely debilitated, this condition must be over- come by a course of hematinic or general tonic medicine and local astringents. Should these measures fail, operative measures must be resorted to. Operations.— Knowing, from observations made upon the healing of wounds, that the cicatrix which eventually forms occupies less space than did the original tissue, the surgeon makes use of this knowledge in regions where such a course is possible. The stricture which frequently forms after certain operations upon the cesophagus, bowel, or urethra is an illustration of this. The operations for entropion (see p- 119) and this operation upon the relaxed anus are in- stances in which the cicatricial tissue can be satisfactorily made use of. The patient should be fed only on milk or sloppy diet for two or three days, getting nothing whatever (if of a hardy breed) for twenty-four hours previous to the ordeal; in the case of tov dogs, cats and delicate animals, however, a small saucerful of milk or beef-tea may be given about six or eight hours beforehand. A warm boric acid (grs. x to 31.) or chinosol (gr. ss. to 51.) enema is ad- ministered, a cocaine suppository 1s inserted, and about an hour later the patient placed in the abdominal position (see p- Ig) on the operating-table. The parts round the anus, hind-quarters and tail are carefully shaved and prepared anti- septically (see p. 2); a finger is passed into the rectum, and the relaxed mucous membrane withdrawn. The anal orifice is painted outside and inside with a 5 per cent. solution of cocaine, and, with a pair of sharp scissors, two or three superficial elliptical wounds, from a third of an inch to an inch long, in the longitudinal axis, are made just where the skin and mucous membrane join. These are afterwards DISEASES OF THE RECTUM AND ANAL REGION 205 treated antiseptically by iodoform or other suppositories and lotions, the dog or cat receiving opium for two or three days, and restricted milk or beef-tea diet for a week, in order to give the anus as little work as possible. Gersuny’s Wax Operation (sec p. 209) 1s also of value in these cases, the sterilized paraffin melting at 105° being injected subcutaneously, and in the submucous tissue, near the anus, in such a way that pillars are formed which mechanically obstruct and tighten this orifice. Prolapsus Recti. Sometimes the prolapse is met with in a puppy in apparently good health, but, as a rule, it occurs after (or during) some debilitating illness and suddenly; the animal, apparently all right a few moments beforehand, now having an inch or more in view. Constipation, diarrhcea, hemor- rhoids, any rectal irritation and the consequent straining, are prevailing causes. Symptoms.—The patient withdraws from the society of its companions, and is quieter than normal; the floor where it has lain down is blood-stained, the hind-quarters also, and it resents interference with the region of the tail. Examination of the region reveals the prolapsed gut in a more or less congested, and perhaps lacerated, condition. If not attended to, it becomes in a few hours intensely swollen, livid, and acutely painful. If neglected altogether, death is apt to take place either from shock, collapse, or septic absorption; or adhesion may take place at the anal ring, the part below being constricted and ultimately sloughing away. If the patient is seen in the act of defecation or attempted defe- cation, the gut will be protruded and retracted as straining takes place and ceases again. After these efforts the animal looks round at the affected part. If observed within an hour or so, the bowel is readily 206 CANINE AND FELINE SURGERY returned by a little manipulation, and now is the time to differentiate between rectum and small intestine. When it is the former, a digital examination reveals the interior to be perfectly smooth, the walls being relaxed and in their normal place again. When one has to deal with an intussusception and prolapse of the bowel above the rectum, the rounded edges of the intussuscepted portion will be felt at the finger- tip, just out of reach, and the end of the finger can be Fig. 140.-- Prolapse of the Bowel. distinctly passed into a pouch between the interior of the rectal wall and this piece of gut. As a rule, too, in the case of a prolapsed rectum, when returned, the bowel will remain i situ for some hours, and often permanently, whereas in the case of an intussusception and prolapse of the small intestine, the gut will be protruded immediately the patient moves a few yards—i.c., of course. if no mechanical means are taken to prevent it. DISEASES OF THE RECTUM AND ANAL REGION 207 Reduction and Minor Operative Interference——H seen soon after the trouble has occurred, the patient should be muzzled and put on a table of convenient height, the protruding parts carefully washed with soap and water and warm antiseptic (the hair around the anus being removed with the scissors or razor), anesthetized with a 5 per cent. solution of cocaine (see p. 26), and gradually kneaded and manipulated with the ends of the fingers until it is returned. Care must be taken that the mucous membrane, which becomes very friable if prolonged exposure has taken place, is not damaged by the finger-nails; carbolic oil or vaseline are useful adjuncts, and a thin cloth soaked in antiseptic forms a useful protective, besides distributing the pressure over a larger surface. When the parts are very swollen and hard to the touch, either hot fomentations to relax the parts, or cold applications (such as ice) to the gut to act as an astringent, are advisable. The former are preferable when the case is seen early and the parts have not become lacerated. When they have become friable, cold water or ice should be used, as after their application the mucous surface becomes stronger and better able to bear the pressure which must, of necessity, be put upon it. It is astonishing how readily, after continuous fomentation for half an hour or even less, the tissues of the anus and bowel will relax, and enable the operator, by careful manipulation, to return an apparently hopeless prolapse. It is always wise, too, before finally resorting to the use of the scalpel, to chloroform the patient ; as this effectually overcomes the resistance offered both by the voluntary movements of the animal itself and the spasm of the anus. The kneading is done with the ends of the fingers and thumbs of both hands, com- mencing with the extremity of the prolapse, gradually turning the edges into the lumen until only about an inch remains outside, when the anus itself is also manipulated, and with a final push the whole will disappear from view. 208 CANTNE AND FELINE SURGERY The middle finger is then inserted as far as possible, and the interior of the rectum adjusted, a morphia suppository inserted, and one or more stitches put across the anus. If preferred, the draw-string or tobacco-pouch suture (as recom- mended by Miiller),1made by passing tape or stout silk suture material in an * in-and-out’ manner through the skin around the anal orifice, may be inserted (see p. 56). These are left an situ for a week or so. Stockfleth* advises a similar pro- cedure for constricting the rectum, by placing pins at in- tervals around the anus and uniting them with threads. Pessaries introduced into the rectum usually do more harm than good, and act as a continual source of irritation. The chief trouble to be dealt with is the straining which takes place afterwards and causes a return of the prolapse. This is to be guarded against by keeping the animal as quiet as possible, resort being had to the medicinal use of opium by the mouth or rectum, the latter in the form of suppository. Diet should consist of milk or beef-tea for about a week, and the patient must be kept under observation for some time, as it is a trouble which is very apt to occur again even after two or three months. The author had one case in which the rectum was prolapsed and returned fourteen times before the owner consented to further operative measures. A course of nerve tonics such as strychnine or arsenic, together with attention to the state of the bowels to prevent constipation and the administration of regular meals and exercise, should be commenced after the active symptoms have subsided. Major Operations.—In cases of recurrent prolapse the animal becomes a continual care and nuisance, and one or other of the following operations may be done: I. Gersuny’s operation, made popular in this country in human surgery by Mr. Stephen Paget,? which consists in 1 “Diseases of the Dog’ (Glass’s translation), p. 73. ” [dem. > Lancet. DISEASES OF THE RECTUM AND ANAL REGION 209 narrowing the lumen of the lower bowel and anal orifice by the subcutaneous injection of sterilized wax. 2. Proctopenia, or ventrifixation of the bowel—ie., lapar- otomy and the fixation of the bowel to the abdominal wall by sutures. 3. Amputation. In each case the most careful attention to antiseptic pre- cautions (see p. 21) must be observed to insure success, and provided this is done a tolerably satisfactory prognosis may be given. Amputation is the most serious of the three, but even with this the result is good if the patient has not become too weak to stand the operation. Gersuny’s Wax Operation.—The patient is placed on the operating-table in the abdominal position and chloroformed, the lower bowel having been washed out by an antiseptic enema (warm boric acid or chinosol solution). The operator then allows the rectum to be prolapsed as far as it will come down (even assisting in the process with the finger) on toa sterilized mackintosh cloth or piece of jaconet, where it is carefully cleansed. The wax to be used (a special variety of white paraffin wax melting at 105°, properly sterilized, and put up in convenient-sized, wide-mouthed bottles) has pre- viously been melted by placing it in a bow] of hot water, and is now drawn up into a sterilized syringe. A thermometer is placed in the water to guard against scalding, as the heat at which it should actually be injected is just above that at which the wax melts. A fold of the mucous membrane of the bowel is picked up between the finger and thumb in a longitudinal direction, the needle is inserted, and the wax slowly injected. During the process, to prevent clogging in the needle, an assistant covers this with a hot swab; as soon as the injection is completed, this is changed to ice-cold water, which is poured over the pillar of wax thus formed in order to make it ‘set. The process is repeated two, three, or perhaps four times, pillars of wax being formed on opposite 4 210 CANINE AND FELINE SURGERY sides of the bowel in such a way that (when returned), if straining takes place, these approach one another and mechanically prevent eversion. After as much has been inserted as is deemed sufficient to effect the required purpose, the still prolapsed and everted gut is carefully manipulated between the fingers and gradually returned, the middle finger being inserted to adjust the mucous membrane. In doing this operation, care must be taken to puncture the mucous membrane in as few places as possible, the wax having an unpleasant habit of escaping freely through the tiniest hole. The operator, too, must always be prepared to guide the fluid wax in the proper direction, and to mould it into the required shape.! The author has had the opportunity of testing Gersuny’s method on five most troublesome cases of prolapse, all the patients being bull-dogs. In one case the bowel had been prolapsed no less than fourteen times, in a second eight or nine times, and in a third the owner had periodically had to have it returned during a period of three months. In each instance pessaries and sutures of various patterns (interrupted and tobacco-pouch) had temporarily kept the bowel up, but eventually it always protruded again. In every case a successful and permanent result was attained. Proctopexia, or Ventrifixation of the Bowel.—\When a prolapse takes place again and again, and no adhesions have formed, laparotomy is performed in the median line (see p- 158), and the bowel drawn inwards and fixed to the abdominal wall. Several catgut or kangaroo tendon sutures are used, being passed through the mesentery and abdominal muscles whilst the bowel is held away from the direction of the pelvis. Catgut and kangaroo tendon are better than fine silk as suture material, because they take longer to become absorbed, and so allow more time for firm adhesion to take place; silkworm gut would soon tear its way out. After the sutures have been inserted, the abdominal wound 1 Veterinary Record, 1904. (Proceedings of the Liverpool University Veterinary Medical Society.) DISEASES OF THE RECTUM AND ANAL REGION 211 is closed and the patient carefully dieted, as already described, opium being given for the first forty-eight hours. Mr. H. Gray! and Professor Liénaux? (Ammales de JAféd. Vet.) have each reported a successful case treated in this way, and the subject of the illustration (Fig. 141) was a bull puppy, operated upon by the author in conjunction with Mr. F. H. Ridler, M.R.C.V.S., for persistent prolapse of the ileum through the anus. When laparotomy was performed an ex- tensive intussusception was discovered. This was reduced ; the bowel was sutured to the abdominal wall as already described, the patient making a satisfactory and permanent recovery. Fig. 141.—Suture of the Bowel to the Abdominal Wall. AA, Skin; B, abdominal muscles ; C, mesentery; D, rectum ; F, bladder. Amputation of the Prolapsed Portion.— When the rectum has been out for some days, and adhesions have taken place, it is often impossible to return it, and amputa- tion must be practised. The patient is placed on the operating-table in the abdominal position (see p. 19), the anal region is carefully shaved and disinfected, and anti- septics are thoroughly applied to the exterior and interior of 1 Veterinary Journal. 2 bad. I4—2 a12 CANINE AND FELINE SURGERY the rectum, the prolapsed portion resting on a piece of sterilized mackintosh. Cocaine or general anesthesia (see p- 23) may be used. A round metal sound or probe (an ordinary clinical thermometer case answers very well) is inserted into the lumen of the rectum, and half a dozen inter- rupted silk sutures are passed through the bowel downwards on to this and back again with a curved needle close to the skin of the anal orifice, in order to prevent the intestine from completely disappearing into the abdomen when the inverted portion is cut off. A circular incision is then made with a sharp scalpel halfway round below the sutures; more sutures are then inserted close to the sphincter to unite the cut edges firmly, and the other half is then excised and treated in the same way. A fter-treatiment.—The patient should be kept quiet for ten days, on a milk diet only for the first week, the bowels being kept as still as possible. Doses of opium are useful for the first two days, but suppositories should be avoided at first in the majority of cases, as the rectum should be kept as empty as possible. The anus should be kept clean by the use of antiseptics. Sawdust, broken cork, peat moss, or any dusty bedding, should be avoided in the kennel, as, indeed, in any case where a wound is under treatment. A stricture may follow, but this is not usual, and as a rule a good result follows. In one case which came under the author’s observation, a bul! terrier, about eighteen months old, was brought in for treatment, with an everted rectum which had been in that condition for two days. It had been re- placed and kept in position by sutures which eventually gave way. It was excised under chloroform, about 2 inches being removed. Opium was administered internally, and the patient kept as quiet as possible. This was February 25, 1897. On March 9 a further portion, about an inch in extent, became prolapsed, and was excised under cocaine, and on March 23 a still further portion of about half an inch under a mixture of cocaine and eucaine. About ten minutes afterwards the dog strained and put out quite 5 inches of intestine through the anal opening. This was returned, the anus sutured across, and 30 grains of cannabis indica extract DISEASES OF THE RECTUM AND ANAL REGION 213 administered. On the next day a further 10 grains of cannabis extract was given, the animal straining occasionally, but not sufficient to expel the gut. After this date matters progressed favourably and the dog made a good recovery.! Imperforate Anus. This condition is congenital, and is occasionally met with in the newly-born puppy or kitten, there being no visible anal opening. It may not be observed at once, the author having had one case in which the animal was three days old before the owner noticed anything wrong. In this instance there was a distinct subcutaneous bulging of the perineum, indicating the presence of a rectum full of material which could not escape. Symptoms.— Beyond not seeming to thrive, there is nothing to indicate this condition on the part of the patient. An examination is the only method of detection. Operation.—This is easy if a rectum is present, and consists simply in making an incision through the skin in the position where the anus ought to be, cutting a small circular piece out so as to separate the two edges of the wound, opening the rectum, drawing it into the wound, and suturing it there. If the intestine is otherwise normal, a satisfactory termination may be looked for. In the case alluded to above, all that was necessary was to incise the skin and cauterize the edges in order to prevent union until normal defeeca- tion was established. The patient progressed quite satisfactorily. Cloaca. Ry this is indicated a congenital (or accidental) malforma- tion of females by which the anus and vagina have a common external orifice. If there is enough material present, plastic surgery may be tried; and in cases where it is the result of an accident, the sooner sutures are inserted and the part 1 Journal of Comparative Pathology and Therapeutics, vol »., p. 1743 Vetertnary Record, vol. »., Pp. 213. 204 CANINE AND FELINE SURGERY treated antiseptically, the better. In the newly-born puppy or kitten, it is better in most cases to leave the animal until the tissues become larger and stronger before attempting operative interference. Hezemorrhoids or Piles. A dilated and very troublesome varicose condition of the veins around and just within the anus is not infrequent in fat old dogs, especially pugs, and gives rise to a good deal of pain and irritation, especially when faeces are passed, and when the animal is at all constipated. Symptoms.—The patient is continually licking the parts and rubbing along the ground. The anal surface frequently appears moist and swollen, and the faces may be streaked with blood. Treatment.—Attention should be paid to the state of the bowels, mild doses of cascara, sulphur or other laxatives being given regularly, whilst locally the parts must be kept clean and dressed with hazeline lotion (1 to 8 or 10), or with extract of hamamelis made into an ointment. The B.P. ointment of galls and opium is also a valuable remedy. If the piles are ‘internal ’—72.c., inside the rectum—these medicaments must be so inserted that they come into direct contact with the dilated veins, and their administration must be carried out frequently during the day. Should medicinal treatment prove ineffectual, operative measures must be adopted. Operation.—The piles should be picked up one at a time with forceps, and either ligatured by passing a curved needle and silk around them, the intervening portion being excised, or clamped and removed with the actual cautery at dull red heat. If they are to be higatured, it is best to form a groove at the base of each by cutting around it with a pair of blunt- pointed scissors, the incision being deeper on the cutaneous DISEASES OF THE RECTUM AND ANAL REGION 215 than on the mucous aspect. The ligature should be of floss silk, which has been thoroughly well boiled to make it sterile. In every case the anus should be thoroughly stretched by the introduction of the forefingers of the two hands of the surgeon until the contraction of the sphincter is entirely overcome. After-treatment.—After the operation the patient should be kept without food for twenty-four hours, and during the next three or four days should only receive milk, beef-tea or other sloppy diet in sparing quantities. Doses of opium should be given two or three times daily, the object being to keep the bowels at rest. On the third or fourth day a dose of oil and a warm enema can be given if the patient has had no action of the bowels and seems uncomfortable. Locally the parts must be kept clean and dressed with some anti- septic. Fistula of the Anus. True fistula of the anus is comparatively rare in the dog or cat; enlarged anal glands and other discharging sinuses in this region are not uncommonly confounded with it. Foreign bodies, such as needles and sharp pieces of bone, are the usual cause, and even fish-hooks have been discovered in the rectum. Careful examination should always be made by passing a blunt-pointed probe up the suspected fistula, and at the same time feeling for the internal orifice with one finger in the rectum. The probe must be passed very care- fully, and not in any way forced, as there may be several sinuses, some of them being blind ones. A rectal speculum (Fig. 182) and electric lamp are of value for thorough ex- amination, and in many cases when anesthesia is complete a considerable portion of rectum may be everted. Symptons.—The patient is continually attempting to reach the anal region with the tongue, or drags its hind-quarters along the ground, exhibiting signs of great irritation and 216 CANINE AND FELINE SURGERY pain. The parts are very painful on manipulation and during defecation, especially if constipation is present. Operation.—Treatment consists in opening up each sinus freely with a director and bistoury. and carefully curetting the walls (or treating them cautiously with some caustic to destroy their indurated lining), and afterwards applying anti- septics in the same way as to a sinuous wound. Prognosis.—In cases where ulceration of the bowel has not taken place, the wound generally heals up and brings about a satisfactory termination, although progress may be slow. Either a local or general anesthetic should always be used. Obstruction of the Anal Glands. The anal glands are two sac-like pouches, lined with mucous membrane, situated one on either side of the rectum, and opening into the latter by orifices which are to be found just inside the anus. They frequently become filled with purulent or semi-solid sebaceous material which cannot escape, and give rise to symptoms of irritation and annoyance on the part of the animal. Symptonts—The patient will be continually licking the anal region or rubbing it along the ground. Examination reveals that the parts are sore, perhaps visibly swollen, and often ulcerated. Defzecation, too, especially if constipation is present, is painful. Operation.—Temporary relief can be given by the applica- tion of pressure, the finger being introduced into the rectum and the contents of the glands evacuated, but as a rule they refill in a very short time. An hour before operating the rectum should be emptied by a warm glycerine and boric acid enema. The parts should be painted with a 5 per cent. cocaine solution or a general anesthetic administered (see p. 23), and the glands freely opened from the outside about a third or DISEASES OF THE RECTUM AND ANAL REGION 217 half an inch from the sphincter of the anus, with a Symes’ knife or fine scalpel. The interior is then scraped with a small sharp curette (see Fig. 40), and the whole of the secreting lining destroyed. The parts are then treated anti- septically like an ordinary wound. Prognosis.—If the operator has shaved around the part and otherwise practised antiseptic precautions, he may safely promise a complete and rapid recovery. The author has Fig. 142.—Anal Adenomata.! never seen or heard of a bad result in consequence of the complete obliteration of one or both anal glands. Rectal and Anal Tumours. These are treated, where possible, as already described (see p. 66). Unfortunately, they are often of a malignant nature, the chief varieties being anal adenomata in connection with the anal glands, fibromata in very fat, unhealthy dogs, and.carcinomata of the rectum. 1 For this photograph I am indebted to Professors Mettam and Wooldridge. CHAPTER XVI OPERATIONS ON THE OMENTUM, LIVER, SPLEEN, AND PANCREAS The Omentum. THE omentum is frequently involved in cases of hernia, and may even be the only organ found in the sac. In wounds of the lower portion of the abdominal wall it is very apt to be the first to protrude. In appearance it looks like a white fatty mass. If there is any difficulty about returning it, or if it is at all in the way or soiled, the protruding portion may be excised without the slightest fear. In fact, if it is at all soiled, this is by far the safer plan, as it is a structure which does not readily lend itself to antiseptic cleansing. In one case which came under the author’s observation the whole of the omentum was removed, and the patient did not seem in any way to suffer from its disappearance. Operation.—Under the usual antiseptic precautions (see p- 158) any vessels in the line of excision are secured by ligature, the parts below are removed either by scissors or scalpel, and the remainder returned into the abdomen. The abdominal wall is then treated as already described under laparotomy. The Liver. Practically, the surgery of the liver in the dog and cat is confined to the occasional removal of a tumour which has 218 OPERATIONS ON THE OMENTUM, LIVER, ETC. 219 sufficient pedicle to permit of this procedure.’ Even this had better be done with a clamp and the actual cautery (a heated scalpel does well), as the liver tissue is so vascular and friable that it does not lend itself well to the application of sutures. If a rupture is only suspected and the symptoms are not Fig. 143.—Inoperable Sarcomata of the Liver in the Abdomen of an Irish Terrier Dog. A, C, Liver tissue; B, gall-bladder ; D, stomach ; EEE, sarcomata ; F, intestine. urgent, rest and hemostatic medicine internally is the best course to adopt. Some of the tumours attached to the liver are of enormous size, and in time almost fill up the abdomen, giving to the bitch or female cat the appear- ance of pregnancy, and to the male that of ascites, from 1 Journal of Comparative Pathology and Therapeutics, Vol. Xi., Pp. 251 (Nelder and Hobday). 220 CANINE AND FELINE SURGERY each of which a careful distinction must be made. Sarcoma is the commonest variety, and, on account of its malignancy, it is questionable whether the most humane plan when this tumour is discovered, even if no others are in sight, is not to destroy the patient painlessly before consciousness returns. Sometimes the liver will be almost entirely destroyed by tumour tissue, as shown in the illustration (Fig. 143). The Spleen. Occasionally large tumours are met with in the spleen, and during external violence it may be badly ruptured, and fatal hemorrhage ensue if it is left. A certain diagnosis can only be made by laparotomy and internal observation. Removal of the whole of the organ is always a serious operation, both at the time and as regards its sequel, death from marasmus often following within twelve months. Mr. Martyn Jordan has, however, shown by an _ experi- mental research into the effects of partial excision upon healthy dogs that excellent results can be obtained. The chief untoward results to be looked for at the time of operating are those of death from hemorrhage or shock ; the former must be guarded against by careful clamping and ligaturing of every vessel along the splenic omentum or those which supply the portion to be excised, and to avoid the latter the operation should be performed as rapidly as possible, hypodermic injections of stimulants being at hand for immediate use if required. Operation — Splenectomy.— For extirpation of the whole organ, the patient is prepared, secured, and operated upon as in an ordinary laparotomy (see p. 158), the incision being made on or near to the median line, about an inch behind the sternum. The spleen is then sought for and brought as much out of the orifice as necessary, each vessel, however small, being clamped or ligatured in two places before being cut through, after which the organ is removed. OPERATIONS ON THE OMENTUM, LIVER, ETC. aor In six cases in which Mr. Jordan removed the whole spleen, ‘all the dogs suffered greatly from shock, and there were three deaths,’ one being from marasmus and two from shock. For partial excision Jordan recommends the following method of continuous ligature, by which he obtained a practically bloodless section: ‘A long needle threaded with fairly coarse silk twist 1} feet long is inserted on the inner Fig. 144.—Tumours (Sarcomata) of the Spleen.! or under surface about half an inch from the edge or border, and passed through the thickness of the spleen, emerging on the outer or upper surface about the same distance from the edge; the ligature is drawn through until the ends are equal; the free end is brought up round the border of the spleen, and a double turn made with the two ends and drawn as tightly as possible, this turn being kept over the exit of the needle. The needle is then passed back through the ! This spleen was removed on Jost morteni from the pug-dog illustrated in Fig. 42, and the case was quite a hopeless one. 222 CANINE AND FELINE SURGERY spleen on the occluded side of the organ, as close to the line of ligature as possible, and an eighth of an inch from the edge or border side of the turn: this being done in order that the next loop shall include the spleen where the needle has previously passed through, so that any oozing along this track shall be stopped when the loop was drawn tight. The needle is then repassed through the spleen from the under to the upper surface half an inch further on, and a double turn again taken and drawn tight. Continuing in this way, the spleen is traversed. A reef-knot is then tied and the ends cut short. The occluded end of the spleen is then cut through close to the line of the ligature.’ Interrupted, instead of continuous, interlaced ligatures are sometimes used. Prognosis. Following out his method of continuous ligature, Jordan had twenty-one successes out of twenty- two cases, the animals being Indian pariah dogs varying in ages from a month upwards. In nineteen of them the lower half of the spleen was excised without a single fatality or noticeable disturbance afterwards; in the remaining three, in which the upper half was excised, all the animals showed great constitutional disturbance, and one death occurred from shock. This authority concludes that it is the removal of the upper half of the spleen which is full of danger, on account of the risk of shock and after-hemorrhage, and that it is much more difficult to operate upon than the lower half. Removal of Tumours from the Abdominal Organs. Diagnosis of tumours of the abdominal organs can usually be made with certainty in thin emaciated patients, but in fat animals it is often a matter of difficulty. The liver and spleen, and the uterus and ovaries in the case of the bitch, are the organs most commonly affected (see pp. 218 and 295), OPERATIONS ON THE OMENTUM, LIVER, ETC. 223 and of these the uterine and ovarian are the most successfully dealt with. Tumours of the liver are especially vascular, and their removal is accompanied by hemorrhage. In all cases the principles of operation are the same. Rigid antiseptic precautions must be adopted, and lapar- otomy performed under anesthesia; the tumour is then sought for, and removed by ligature and the knife, or what- ever way is deemed advisable by the operator, in order to get as little hemorrhage as possible, the abdominal wound being sutured and treated in the usual way. Sarcomata have been the most common variety met with in the author’s experience. CHAPTER AVII HERNIA A hernia (or rupture, as it is more commonly termed) consists of the protrusion of an organ, or portion of an organ, out of its normal situation, through an opening in the surrounding tissues. As a general rule, when speaking of hernia, it is understood that the organs of the abdomen are referred to, although a hernia of brain substance or other parts of the body sub- stance may occur, and quite correctly be described under this heading. General Remarks.—The varieties most commonly seen in the dog and cat are umbilical, abdominal (or ventral), and inguinal. Scrotal, perineal, and femoral are met with, but are comparatively rare. Care must be taken to differentiate between tumours and abscesses, occurring in these regions, and hernia. In some cases this is by no means an easy matter, even to those who have had considerable experience. In hernial sacs one must endeavour to trace the form of the herniated organs by careful manipulation between the finger and thumb, and if there is any doubt about the matter, the patient should be again examined after a course of purgative medicine and fasting. The main principles of surgical treatment are the same in all cases, and consist in the return of the organs to their normal situation and the adoption of the steps necessary to retain them there. In all cases the patient 22h HERNIA 225 should be carefully prepared as already described (p. 2). If a general anesthetic is used (see p. 29), the patient is placed on the operating-table in the abdominal posture (Fig. 14), and afterwards turned on its back or side as the operator may consider the most convenient. If a local anzsthetic (see p- 24) is sufficient, the animal is at once placed in the most convenient position for the performance of the operation, and the anesthetic applied. Rigid antiseptic precautions (see p- 7) are always necessary with regard to instruments, the parts to be incised, and the operator’s fingers. If the internal organs are at all adherent, the greatest care must be taken to prevent injuring them with the scalpel. The author had one case of ventral hernia in a cat in which this accident occurred, the small intestine being cut transversely for fully seven-eighths of its circumference. A numberof worms (Ascards mystax) were removed from the interior of the bowel, the gut was carefully cleansed with chinosol solution and sutured with silk (Lembert’s pattern), and the patient made an excellent recovery.! Lustruments required —These consist of two sharp scalpels, a director, probe, blunt-pointed scissors, two pairs of dis- secting forceps, two or three pairs of Spencer Wells’ artery forceps, two curved and two half-curved needles, silk and silkworm gut. In addition, a hernia bistoury, a pair of MacEwen’s needles (Fig. 155), and for perineal hernia, if the distended bladder is suspected to be present, a small exploring trocar and cannula, are useful adjuncts. Umbilical Hernia. This condition consists of a swelling at the umbilicus: it may be soft and fluctuating, in which case it is generally reducible, the umbilical ring being plainly defined; or it may be irreducible from adhesions or because the umbilical ring has contracted since the mass was extruded. In the latter 1 Ridler and Hobday, Veterinary Record, 1got. 15 226 CANINE AND FELINE SURGERY case it usually feels hard to the touch, and the contents consist of omentum alone. When the bowel is present there is danger of strangulation. The hernia may vary in size from that of a pea to half an orange, and is frequently congenital; severance of the um- bilical cord, either by the bitch or the canine accoucheur, too close to the umbilicus will also cause this trouble. It is Fig. 145.—Umbilical Hernia (Front and Lateral Views). commonly met with in all breeds, particularly pure-bred bulldogs, Japanese and St. Bernards. Coughing or struggling will cause the hernial sac to become suddenly very tense and distended. In the bitch intended for breeding purposes, the presence of an umbilical hernia is more serious than in the dog, and there is no doubt that the tendency is hereditary. In both sexes, if the hernia is of any size, steps should be taken HERNIA 227 to reduce the abnormality, especially in the more active breeds, as the skin over the rupture is always very thin, and it has only to become lacerated in order to expose the abdominal organs, and possibly give rise to a fatal peritonitis. Continual lying on the skin of the abdomen is apt to cause alceration of the skin and subsequent adhesions of the con- tents to the sac. Occasionally, as the patient reaches one or two years of age and the tissues become stronger, the hernia will disappear, or will become so reduced in size as to give no cause for anxiety. Treatment.—A small hernia may be reduced by the aid of a rounded strip of cork affixed over the swelling by strips of plaster. In a quiet puppy this is well worth a trial. If that fails, the radical operation will usually bring about a complete and permanent cure. The skin is shaved, scrubbed, and carefully incised directly over the centre of the swelling by the aid of a scalpel and director. The contents of the sac are returned into the abdomen, all adhesions to the edges of the ring being broken down. The edges of the dilated umbilical ring are refreshed so as to give a raw surface and drawn together with silk or gut sutures, the skin sutured with silkworm gut, and the wound coated with collodion and iodoform (or orthoform). Sometimes a simple solution of the difficulty consists in excising a portion of the omentum and returning the re- mainder into the abdomen before suturing the ring as mentioned above. Abdominal (or Ventral) Hernia. The term ‘ventral (or abdominal) hernia’ is applied to a protrusion of some of the internal organs through a hole in the abdominal wall in some situation other than the umbilical, inguinal, perineal, scrotal or femoral regions. It may be of large size, and can generally be traced to some injury, such as 15—2 228 CANINE AND FELINE SURGERY a kick or violent blow. Sometimes it occurs as a sequel to an operation on the belly wall. The contents of the sac may consist of any of the abdominal organs, especially the intestine, which is apt to become strangulated if the neck of the sac is at all constricted. It consists of a soft, fluctuating swelling which is readily dis- tinguished from tumour tissue by the impression given to the finger-tips. Treatment——A general anesthetic is much the safest and most convenient for this, as any struggling on the part of the patient is apt to cause protrusion, and consequent risk of soiling, of the contained organs. Under strict antiseptic precautions (see p. 2), the skin and sac wall are incised with scalpel and director, the contents returned into the abdomen (care being taken to see that all adhesions are broken down), the edges of the muscles are lightly scraped and freshened up, and the edges of the rupture are drawn together. If it is possible to secure the peritoneum, three layers of sutures are inserted: the first, of fine silk, through the peritoneal coat; the second, of silk or catgut, through the muscle; and the skin with silkworm gut. If the peritoneum cannot be sutured separately, care must be taken to pass the silk or gut sutures through it when suturing the muscular layer. The resulting cicatrix is stronger. A layer of collodion and iodoform or orthoform (see Laparotomy, p. 158) hermetically seals the wound, and, if the rent has been a large one, it may become necessary to affix a bandage to give support for a time. The silk sutures become buried and absorbed in time, whilst the silkworm gut is removed in about a week or ten days. Inguinal Hernia. Inguinal hernia is common in bitches which have already borne young, and is not infrequent in maiden animals. Between the years 1896 and 1900 alone, the author met with HERNIA 229 nine cases in females which had never been mated by the dog; in one puppy, a Pekinese only three weeks old, there was a double inguinal hernia, each side being quite as large as a walnut and easily reducible. It is most frequently met with on the left side. Asa rule, in these cases, the contents of the sac consist of one or both horns of the uterus; frequently in addition one finds intestine and omentum. In one case met with in April, 1896,! a small Manchester terrier bitch, with a double inguinal hernia, had in the right sac a portion of the small intestine, the pancreas, omentum, bladder, right horn of the uterus, the czecum, and even a portion of the rectum. Sometimes a single horn of the uterus is found to be herniated in each inguinal region, and occasionally one or two foetuses are present. In another instance met with by the author, a fox-terrier bitch was operated upon for an inguinal hernia containing a pregnant horn. The foetus was removed, and the horn afterwards excised, the animal suffering so little disturbance that she gave birth to a puppy in the ordinary way seventeen days latcr.? ‘ It is diagnosed by palpation with the finger-tips, the patient being turned on her back and held loosely by the hind-legs whilst the diagnosis is made. Care must be taken not to mistake cystic adenomata or other tumours in the inguinal region for a hernia (see Figs. 146 and 147). Treatinent——Chloroform is by far the best anzesthetic to employ, as it is so essential that the patient shall be perfectly still. An attempt should always be made to reduce the hernia by gentle pressure under a general anesthetic when the parts are thoroughly relaxed. Whether this can be effected or not, the skin is prepared antiseptically (see p. 2), and an incision is made through the skin directly over the hernial sac, care being taken not to penetrate this, and, if possible, to avoid 1 Journal of Comparative Pathology and Therapeutics, vol. x., p. 171. 2 Jbid., vol. vill., p. 153. 230 CANINE AND FELINE SURGERY making an opening into the peritoneum. If the organs have not been returned, another attempt may now be successful, Fig. 146.—Tumours in Inguinal Region (for comparison with next figure). particularly if the exterior of the sac be carefully separated from the surrounding skin by means of a scalpel handle or Fig. 147.-—Inguinal Hernia. some blunt instrument. The extremity of the sac is seized with a pair of pressure forceps—Spencer Wells’ or Pean’s pattern of artery forceps (see Fig. 29) answer admirably—and HERNIA 231 the sac itself twisted slowly until it forms a kindof pedicle, around which a ligature of aseptic silk or gut can be placed. The lower portion of the sac is then cut off, and the external wound sutured and treated on aseptic lines. If very much dilated, the inguinal ring should also have several sutures drawn across it. In some cases of inguinal hernia, however, the sac has to Fig. 148.—A Double Inguinal Hernia fixed in a Suitable Position for Operation. be opened and its contents exposed before reduction can be effected. The greatest care must now be used to avoid septic infection. After the organs have been returned, the inguinal canal must be sutured with silk or catgut, a pressure pad of aseptic wadding being applied or not according to discretion, Fig. 149.—Hernia Bistoury. and the external wound sutured with silkworm gut and covered with iodoform collodion. At times it is found necessary to incise the inguinal ring before the organs can be returned, and for this purpose a special bistoury with only a very small portion of its edge sharpened is cautiously used. At other times some portion of the herniated organs, particularly in the case of omentum 232 CANINE AND FELINE SURGERY or uterus, has to be excised; this is best done with the scalpel after applying a ligature, the stump being sutured to the inguinal ring or returned into the abdominal cavity. The decision as to whether a bandage should be applied here or not must be left to the operator’s discretion: in some cases it 1s necessary; in other cases, where the patient is of an irritable temperament or the weather is very warm, it is apt to do more harm than good. Secrotal Hernia. Fortunately this condition is not very common, as when met with it is most troublesome to permanently relieve, Fig. 150.—A Pug-dog with Scrotal Hernia. unless castration is allowed to be performed at the same time. It consists of a swelling, usually reducible in the scrotum, the hernial sac containing a loop of omentum or intestine. It is a very serious condition if intestine is present, as at any time the accumulation of food material may cause HERNIA 233 the bowel to become so much enlarged that it becomes in- carcerated, and would lead to gangrene of the bowel and septicemia if unrelieved. Operation.—If castration is done matters are greatly simpli- fied, as the prolapsed intestine is carefully returned under chloroform (the usual antiseptic precautions having been adopted), and an incision made into the scrotum down as far oa & Fig. 151.—An Aged Yorkshire Terrier with Scrotal Hernia." as the tunica vaginalis testis. At this stage the sac is clearly stripped from the surrounding tissues, and a silk ligature fixed around it above the testicle. The part below is excised, the abdominal cavity not being opened. The skin is sutured with silkworm gut, and covered with iodoform and collodion in the usual way. 1 For this photograph I am indebted to Mr. H. Gray, M.R.C.V.S. 234 CANINE AND FELINE SURGERY Another method consists in opening the sac, ligaturing the cord with aseptic silk as high up as possible, removing the testicle, and closely suturing the end of the sac, the skin being stitched and dressed afterwards in the usual way. Occasionally the intestine can be returned and the canal drawn together with sutures so that the neck of the sac is too narrow to admit the prolapsed gut again, and vet does not press upon the vessels or other structures of the cord. If castration is not to be practised, and the hernia keeps returning after being repeatedly reduced, laparotomy may be performed, the herniated intestine withdrawn and sutured to the abdominal wall (see p. 211). Perineal Hernia. This occurs as a soft swelling at the side of the anus; it is not so common as the inguinal or umbilical varieties. The herniated organs are usually omentum or bowel, and the bladder is not infrequently included. The author has met with five such cases within a comparatively short time. If the latter is present, it is of considerable danger to the patient, and may cause retention of urine and excessive pain. Under such conditions the urine must be withdrawn either by the catheter or, if that is impossible, by a fine trocar and cannula. In the case of the dachshund, represented by the photograph in Fig. 152, the omentum was the only organ herniated, and the patient lived to a good old age, suffering no pain, but merely a certain amount of inconvenience. Fig. 153 represents a perineal hernia in an aged collie, which contained the bladder and a certain amount of omentum. The bladder used to become distended, causing great pain, and the urine was drawn away on numerous occasions with a catheter. On five separate occasions, however, this was impossible, and a fine exploring trocar and cannula was used, with most excellent results. It was an impossible case upon which to attempt the radical cure. HERNIA 235 Operation.—On account of the horizontal position of the patient, it is often difficult to perform a radical cure, and if the animal is in no apparent danger (particularly if the contents are only omentum), it is better not to interfere surgically. The only precaution necessary is to keep the patient under occasional observation and avoid constipation. Fig. 152.An Aged Dachshund with Perineal Hernia (Omentum).? If, however, the bladder is herniated, something should be done. Three courses are open: In a case such as that shown in Fig. 152, the sac may be opened, the protruding omentum ligatured and excised, the bowel returned, and the skin excised (if very pendulous) and sutured in the usual way ;° secondly, laparotomy may be performed, the con- tents withdrawn into the abdomen, and the sac sutured to 1 For this photograph I am indebted to Mr. S. E. Holman, M.R.C.V.S. 2 Journal of Comparative Pathology and Therapeutics, vol. X1L., p. 260. ‘ 236 CANINE AND FELINE SURGERY the abdominal wall (see Fig. 141); or, thirdly, the hernial sac may be dissected out, ligatured and excised, and the stump sutured to the peritoneal wall. The ring is then closed with interrupted sutures. Fig. 153.—Perineal Hernia in a Collie. The bladder was herniated, and was punctured on five separate occasions, with excellent temporary results. Fig. 154 illustrates a case in which a perineal hernia had caused great pain and formed a fistula. The bladder was opened, and for eleven days urine escaped through this orifice, the normal passage being blocked by a purulent swelling of the urethra. Under antiseptic treatment the HERNIA 237 wound healed, and the patient made an excellent recovery. The perineal hernia, however, remained, as the owner did not desire any further operation, the fundus of the bladder adhering to the wall of the sac. Fig. 154.—Catheter inserted into the Bladder, illustrating a Perineal Hernia which had been opened and formed a Fistula. Femoral Hernia. This hernia is of such extremely rare occurrence as to only merit a passing allusion to it. According to Miiller,! it is occasionally seen after fractures of the pelvis, occurring as a soft painful swelling in the inner fascia of the thigh. The principles of operation are the same as with other herniz, very great care being necessary on account of the close proximity and size of the bloodvessels in this region. 1 ‘Diseases of the Dog’ (Glasse’s translation). 238 CANINE AND FELINE SURGERY Prognosis and Sequele. The sequelz of the operative treatment of hernia are as a rule satisfactory, provided the displaced organs have not become strangulated. The chief mishaps likely to occur afterwards are: (1) Violent removal of the sutures by the patient, and subsequent descent of the bowel or other organ. (2) Hemorrhage either at the time of operating or afterwards. All arteries and veins should be ligatured during the progress of the operation. Two of the author’s most promising patients Fig. 155.—Curved Hernia Needles (MacEwen’s) for suturing the Inguinal Ring. (inguinal cases) slowly bled to death within three days after the operation, from uncontrollable hzemorrhage due to injury to some veins at the time of operating. (3) Peritonitis, which can only be avoided by absolutely following out the principles and details of aseptic surgery. These statements are based upon the notes made upon forty-four consecutive cases,! of which twenty-five were inguinal, ten umbilical, two abdominal, two scrotal, and five perineal. 1 Veterinarian, March, 1896; Journal of Comparative Pathology and Therapeutics, vol. viil., p. 151, vol. x., p. 170; Veterinary Record, vol. x, p. 282. CHAPTER NXVIII THE URINARY ORGANS Examination of the Urethra and Bladder; Passing the Catheter. In the male the bone of the penis, which is furrowed to allow of the passage of the urinary fluid, makes the choice of a sound or catheter of small calibre a necessity. In fact, in cats and in puppies of some of the very small toy breeds the passage of the instrument through this furrow is a matter of impossibility. To examine the urethra and bladder for stricture or for calculi and other foreign bodies, a catheter, bougie, or flexible metal sound, is used. Catheters and oT a a Fig. 156.—Flexible Metal Sound. bougies are made in sizes, known according to the diameter, as Nos. $ to 12. For canine and feline work Nos. 3 to 5 answer in the majority of cases. The metal sound is of especial value when a calculus is present, as, when its extremity strikes the hard stone, a distinct ‘jar’ is communicated to the operator’s fingers. In the female of the larger breeds the instrument can be passed whilst che animal is standing, but in the smaller ones 239 240 CANINE AND FELINE SURGERY it is often of advantage to place the patient in the dorsal position, and introduce a speculum (Figs. 49 or 182) as an aid to finding the urethral entrance. The catheter, which in the female may be gum elastic or metal instrument, is guided gently by the forefinger into the orifice of the urethra, this being found as a small opening on the floor of the vagina, and carefully introduced in a slightly downward and back- ward direction into the bladder. To pass the catheter in the male, the animal should be placed on its back or side, the operator naving both hands free to manipulate the instrument and penis. The penis is forced gently but firmly out of the prepuce, the latter being pushed back at the same time, and the catheter carefully introduced into the urethra. Gentle pressure is then exerted, and the catheter slowly passed into the bladder. Sometimes resistance 1s met with when the instrument reaches the perineal arch, but this can be readily overcome by withdraw- ing the stylet for a short distance, and thus allowing the more flexible cannula to go forward by itself. Having thus introduced the catheter into the bladder, the only remaining procedure is to carefully withdraw the stylet and allow the urine to come away. Attention must always be paid to the cleanliness of the catheter, and, before being introduced, the instrument should be lubricated with some antiseptic, such as pure vaseline, boracic acid ointment, or oil containing some antiseptic, the parts of the animal being also well washed with soap and water. Imperforate Urethra or Vagina. An imperforate urethra or vagina is occasionally met with in the newly-born puppy or kitten. It is readily discovered upon careful examination, although, unless looked for, it may not cause sufficient inconvenience or discomfort for some days, or even weeks. Its presence may be suspected by an THE URINARY ORGANS 241 abnormal distension of the abdomen of the patient, and moans or cries indicative of pain or discomfort. In one case met with by the author! the patient was 1 female kitten, six weeks old. Its bladder was distended, and could be felt without difficulty through the abdominal wall, whilst the urethral orifice was entirely absent, the opening being replaced by a very thin skin, the exterior being moist owing to the presence of urine in the vaginal passage. The urine appeared to filter slowly through this. When an incision was made with a lancet, the urine flowed out with a rush. The edges of the wound were cauterized (with nitrate of silver) to prevent them from uniting too quickly, and the animal made an excellent recovery. Opcration.—If the obstruction is due to a severe malforma- tion, the probability is that the most humane course would be to kill the animal painlessly. It must be left to the discretion of the operator to say whether an operation would be likely to give permanent success or not. If the stoppage occurs at the extremity, and is merely due to a fold of skin, an incision with a scalpel will give immediate relief. Precautions must be taken to prevent union of the edges of the wound, either by making a fairly large orifice or by the application of some caustic. Caleuli in the Urethra. In the dog and cat, particularly in the male animals, small calculi are frequently met with in the urethral canal. They cause acute pain during their passage through the urethra, and frequently give rise to cystitis, and even rupture of the bladder. The obstruction may be due to one stone alone, to gravel (especially in the cat), or to many small calculi following one after the other. They vary in size up to that of a pea, and may be rounded or uneven on their external surface. In the bitch they may be much larger. 1 Journal of Comparative Pathology and Therapeutics, vol. ix., p. 155. 16 242 CANINE AND FELINE SURGERY In one instance the author removed eleven calculi at one urethrotomy operation, the patient being a St. Bernard dog whose owner had un- fortunately allowed the case to progress so far before surgical aid was called in that the extremity of the penis was gangrenous. On each of two other occasions the author counted more than fifty small calculi in the urethra and bladder. Fig. 157.—Usual Position of Incision in Urethrotomy, with Two Calculi 27 s7¢z. ® On account of the short and comparatively elastic urethra of the female, it is not common for calculi to lodge there, but occasionally such cases are met with. Gray’ has re- corded one instance in which eight were discovered to be present in the urethra of an aged female terrier. It may occur at almost any age, but is more common in the adult or aged 1 Journal of Comparative Pathology and Therapeutics, vol. x., p. 88. THE URINARY ORGANS 243 than in puppies or kittens. In cats it is more frequently seen in the castrated male than in the uncastrated animal. Syntptoms.—The animal is restless, appearing dull and uneasy, looking at the flanks, and making frequent long but ineffectual attempts to pass his urine. A few drops may come away, these being of a dark colour or blood-stained, and during the act of attempting to micturate the pleading expression of the eyes and anxious features give distinct evidence of the pain produced. When approached, the patient will wait until touched before moving from its posi- tion. In the case of the dog the animal may raise its leg in the usual normal manner, or stoop down like a bitch; and in the cat the penis protrudes to its fullest extent, the extremity moving jerkily with the efforts produced. If neglected for more than twenty-four hours, the distended bladder can be readily felt as a large, hard, pear-shaped body by manipulation through the abdominal wall. This manipu- lation must be done between the thumb and fingers very cautiously, as otherwise, if too much pressure is put upon it, the bladder can readily be ruptured. If relief can be brought about at this stage, the urine is practically normal in colour, but, of course, increased in quantity. After twenty-four or thirty-six hours’ enforced retention it becomes of a darker colour, and possesses a strong ammoniacal odour, ultimately becoming coffee-coloured and feetid. The stone can readily be diagnosed when an attempt is made to pass the catheter or sound, as it forms an obstruction which prevents the instrument from going beyond a certain point. In the majority of cases the calculi become lodged in that portion of the canal which runs through the os penis or immediately behind that bone. Occasionally it will be found nearer the entrance to the bladder, and in the cat the gravel may be at the extreme end of the penis, near its orifice. Sometimes the catheter can be so manipu- lated as to dislodge the stone, when, if it is not of too large 16—2 244 CANINE AND FELINE SURGERY a size, it may be washed out of the urethra with the next outflow of urine. In large dogs a pair of long thin urethral forceps can be passed up the urethra, and the stone crushed or removed intact, but this is rendered impossible in small patients on account of the narrowness of the groove in the bone of the penis. It is always worth while, before deciding upon urethrotomy, to try whether manipulation and careful pressure upon the bladder between the ball of the thumb and the fingers will not remove the obstruction. This is especially the case in the cat, and the end of the urethra should first be carefully squeezed and picked out. For this purpose, on account of the small size of the opening, a fine probe or a thin wire (such as the stylet of the catheter), if used cautiously, improvises very well. If, by mischance, during manipulation the bladder does rupture, the operator has warning of it in the sudden collapse, and perhaps attempt at vomiting, of the patient. Immediately previous to that he has probably heard or felt it go, the bursting making a distinct * popping’ sound, and the collapse of the structure in the hand being very sudden. In the event of such an accident, the only chance lies in immediate laparotomy (see p. 158), suture of the rent in the bladder wall (see p. 259), and careful swabbing out of the abdominal cavity with antiseptics. The chance of success, on account of the patient’s condition, is a very slender one; otherwise, under healthy circumstances, the bladder wall heals well when sutured, and even if urine does escape into the abdomen, a fatal result does not necessarily follow (see p. 297). Operation.—If external manipulation fails to give relief, and the above-mentioned accident has not occurred, the surgeon must choose between puncture of the bladder or urethrotomy. Puncture of the Bladder.—This operation is most com- monly done in cats and the smaller varieties of dogs in which it is impossible to pass the catheter. It is performed THE URINARY ORGANS 245 in order to evacuate the contents of the bladder when this organ is over-distended. In addition to over-distension from the presence of calculi, this condition may arise from any excessive pressure on the neck of the bladder, such as is met with in perineal hernia (see Fig. 153). The most convenient situation for operating is a spot in the linea alba from about 1 to 3 inches (depending chiefly upon the size of the animal) behind the brim of the pelvis, the object being to pierce the bladder in a part where it is tense and yet fairly close to the neck. The patient is very gently placed on the back or side, the bladder being grasped care- fully but firmly through the walls of the abdomen with one hand, and held as near the seat of operation as possible. Having carefully shaved off the hair, under antiseptic pre- cautions a trocar and cannula (which should be of a fine bore) are inserted subcutaneously for a short distance, and then directly into the bladder. The trocar is withdrawn and the urine allowed to escape. After-treatment consists in with- drawing the cannula carefully, drying the surface of the wound and covering it with iodoform (or orthoform) and collodion. It is risky to administer a general anesthetic in the majority of these cases, or even to fix the patient firmly, because, if the bladder is much distended, rupture or sudden collapse is apt to occur during the struggling; the author has seen this happen in three instances. As regards sequele, in so far as the operation itself is concerned, if antiseptic pre- cautions are observed, no evil results need be feared. It can be depended upon to give great relief, and, if the patient is not too much exhausted or the cause of the distension is not some permanent obstruction in the urethra or neck of the bladder, the benefit is usually immediate and permanent. By way of illustrating the slight element of risk when the bladder is punctured under strict antiseptic conditions, attention may be drawn to the patient in Fig. 153. The operation was performed five times within 246 CANINE AND FELINE SURGERY three months, the result being on each occasion to give instant relief. In several other patients, too, the author has punctured the bladder three ‘ or four times, and the histories of the patients have been followed for several years afterwards. Even in cats with the urethra apparently blocked with gravel which could not be sufficiently removed to enable the urine to flow away, if the end of the passage is cleaned out as much as possible, and the bladder punctured, in by far the majority of instances the patients will presently pass urine voluntarily. The explanation of this is that the relief of the pressure from behind the obstruction alters the position of some of the gravel and, instead of being one semi-solid blocked-up mass, it becomes converted into small particles which are washed away by the time the bladder is Fig. 1§8.—Urethral Forceps. again full enough to be evacuated. The muscles, too, are put at rest as their tonic contraction is relaxed. Urethrotomy.—For this operation in the male the dorsal position (Fig. 15) is the best, but struggling must be avoided as much as possible, on account of the risk of rupturing the bladder. A local or general anesthetic is made use of, the parts are thoroughly cleaned with some antiseptic, and a catheter is passed up the urethra as far as the obstruction. An incision is made in the median line directly over the calculus (see Fig. 162), which is then removed together with any others within reach, and the parts are thoroughly washed with a fluid antiseptic. The catheter should be passed right into the bladder to make sure that the passage is clear, and the bladder itself washed out with a solution of some non- irritating antiseptic, such as chinosol (gr. ss. to 31.) or boracic THE URINARY ORGANS 247 acid (grs. x. to 3i.). In some cases it is a wise plan to leave the cannula of the catheter in situ for some hours after the operation. The wound itself is treated with antiseptics in the usual manner. If only small, it is better to suture and cover with iodoform and collodion; but if of some length, a small orifice should be left for drainage, as otherwise the urine will find its way through and disturb all the sutures. In any case it does not much matter, and many operators advise using no sutures at all, but treating the place as an open wound. In the female the shorter urethral canal does not offer quite so many difficulties. A calculus lodged in it can some- times be grasped and crushed or withdrawn by a pair of fine forceps, or if necessary a fine blunt-pointed tenotome or Paget knife may be used to enlarge the orifice. Material assistance in removing calculi from the urethra of the bitch can often be obtained by manipulation with the fingers through the rectum and vagina. The Prognosis of these cases is excellent except where the patient has been left until almost in a state of collapse before surgical aid is attempted. The internal administration of bladder and urethral sedatives, such as urotropin, hyoscyamus, buchu, pearl-barley-water, etc., afterwards are useful aids to convalescence. The chief dangers in the future are those of stricture or the presence of another stone which may escape from the bladder. Stricture of the Urethra. This condition is liable to follow any operation involving cutting into, or other injury of, the mucous membrane of the urethra of either male or female. To avoid its formation, a patient whose urethra has been the subject of operation should be brought at least once a week or once a fortnight to the surgeon for some months afterwards (at his discretion), in order that a bougie or catheter may be passed and the 248 CANINE AND FELINE SURGERY urethra kept open; the instrument should remain there about ten minutes. The size of catheter is small at first, being gradually increased. In cases where adhesions have to be forcibly broken down, the instrument should be passed twice, or even three times, a day for a time, plenty of oil or vaseline being used as a lubricant. If it is impossible to break down the stricture, an orifice may be made behind the bone of the penis, and kept open by the insertion of a catheter; but this can only, in the case of the dog, be looked upon as a temporary matter, and unless there is some urgent reason for keeping the patient alive, it had much better be painlessly put away. Prolapse of the Urethra. This condition, although rare, has been observed in the bitch, the mucous membrane of the urethra itself becoming much relaxed and protruding below the urethral orifice into the vaginal passage. It is sometimes very troublesome to treat. In a small French bull bitch which came under the author’s observa- tion there was fully 14 inches prolapsed. Operation.—The prolapsed portion is returned with some smooth object, such as a clean thermometer-case or a catheter of sufficient calibre, an astringent injection of alum (or tannic acid) and opium diluted with water being used two or three times a day at the operator’s discretion for a week or ten days. Internally the patient should receive quinine or other tonics, and absolute rest should be prescribed. Renal Calculus ; Nephrolithotomy ; Nephrectomy. Although calculi of the kidney are by no means common, they are not infrequently met with by those who have a large number of canine patients to deal with. As a general rule, THE URINARY ORGANS 249 they are not diagnosed until the post-mortem examination is made, and it is the difficulty of making a certain diagnosis which is at present so hard to overcome. Fig. 159.—Kidneys cut open to show Calculi 27 s¢/w. (The patient from whom these kidneys were taken was only four years old.) In the patient from which the kidneys shown in the above sketch were taken, the animal (a2 bulldog) was only four years old, and showed no signs whatever of kidney trouble, dying from pneumonia. 250 CANINE AND FELINE SURGERY By the term nephrolithotomy is indicated the operation of cutting into the kidney in order to remove a stone. A laparotomy is performed in the usual way in the flank on the side suspected to be affected, and the kidney is exposed to view. Asatrule, the calculus is situated in the pelvis. An incision is made directly down on to it, it is removed, and the wound is drawn together with fine sutures. The peritoneal wound is treated in the usual way. Nephrectomy (removal of the kidney) has been performed many times experimentally on healthy animals, and in human surgery it has taken its place amongst the useful operations. In canine practice, in addition to the difficulty of diagnosing a tumour, calculus, or other disease of the kidney Fig. 160.— Small Renal Calculi showing Two of the Shapes assumed. necessitating its removal, we have the fact that (in the case of calculus at all events), as a rule, when one kidney is affected the other has generally become affected before pro- fessional aid has been sought. In thin animals the kidney can be removed by an incision made in the median line, and this gives a little advantage when uncertainty exists as to which is the diseased side. In larger patients an incision is made in the flank just below the lumbar region. The operation is not difficult; the kidney is carefully separated from its situation under the loins, two silk ligatures are passed round its pedicle, and an incision is made between them. ‘The peritoneal wound is sutured and treated in the usual way. THE URINARY ORGANS 251 Hernia of the Bladder. The bladder sometimes passes backwards through the bony pelvis and becomes involved in a perineal hernia (see p- 236). It is apt to have serious consequences for the patient when the bladder becomes distended (as in dogs of clean habits when kept for too long a time in the house with- out a chance of passing urine), because the animal may not be able to voluntarily exercise sufficient pressure on the bladder wall to overcome the resistance offered by the ‘kink’ in the bladder neck. The bladder in a severe perineal hernia is so placed that it cannot be acted upon by the abdominal muscles. Fig. 153 was a case of this kind, and the urine had repeatedly to be withdrawn by a trocar and cannula (see p. 61). Under such a condition an operation becomes a necessity. Operation.—Under general anzesthesia and strict antiseptic precautions, laparotomy is performed either in the median line (in the bitch) or about an inch on one side of the prepuce (in the dog). The bladder is withdrawn and carefully sutured to the abdominal wall either with silk or catgut (see Dp. 211) Prolapse of the Bladder. This condition, which might legitimately be included under the above heading of ‘hernia,’ is occasionally met with in the bitch, the bladder becoming everted through the relaxed and enlarged urethral opening. Rupture of the Bladder ; Washing out the Interior. This accident may occur during an operation, or from over-distension due to obstruction of the urethra from some tumour growth,! and subsequent cystitis; or as the result of violent injury, such as that caused by a blow or the wheel of a vehicle. It has also been known to occur when 1 Journal of Comparative Pathology and Therapeutics, vol, xi., p. 50. 252 CANINE AND FELINE SURGERY the interior of the bladder is being washed out for acute cystitis, the bladder wall being very easily torn, and usually with a large jagged rent which it is almost impossible to suture with any chance of permanent success. For washing out the bladder a double-channel catheter should be used wherever possible, but, on account of the small lumen of the urethra in all except the larger breeds, this is impossible in the male animal. It is, however, possible in many breeds in the bitch. A solution of chinosol (gr. S& to $1.) or boric acid (ers. vx. to 31.) to which a little belladonna or opium has been added acts well as a sedative and antiseptic, being injected by a syringe with a fine nozzle attached to the catheter. The bladder should be distended to about one half its normal size when full, and then emptied, the process being repeated once or twice daily at the surgeon's discretion. It is emptied by very gentle pressure through the abdominal wall. If it is ruptured during this process the operator hears a distinct ‘popping’ sound, and the patient may vomit or immediately collapse. That the escape of normal urine into the abdominal cavity is not necessarily followed by peritonitis or death is illus- trated by the following case :! An Irish terrier bitch, eighteen months old, was the subject of an odphorectomy, and whilst making the incision in the abdominal wall the bladder (which was enormously distended) was incised. A quantity of urine made its escape into the abdomen. This was swabbed up as com- pletely as possible, and the edges of the wound drawn together with three sutures. The odphorectomy was completed, and the patient made an uneventful recovery. Operation.— Under an anesthetic and_ strict antiseptic precautions, laparotomy is performed (see p. 158)—on the median line in the bitch, just over the pelvic region, or in the dog at one side or other of the prepuce. Where the ' Journal of Comparative Pathology and Therapeutics, vol. xii. p. 263 (Ridler and Hobday). THE URINARY ORGANS 253 bladder is distended, the operator can, if he prefers it, open the abdomen in the male immediately in front of the vx- tremity of the prepuce. The advantage of this is that there is less hemorrhage, as there is practically no muscle tissue to cut through. The bladder is exposed and brought through the incision on to a piece of boiled lint, jaconet, mackintosh, or some such material, and the lower part tightly packed. The rupture is sought for and sutured (Lembert’s pattern) with silk (see p. 55), the abdomen very carefully swabbed out with some antiseptic solution, and the wound of the abdominal wall covered with iodoform colloid, etc., as already described (p. 50). Tumours of the Bladder. Of these, the most commonly met with are papilloma, sarcoma, and carcinoma. Others are myxoma and fibroma. They may occur outside the bladder, and have adhesions or connections with surrounding structures, or be found inside, growing on the mucous membrane. In the latter case, after a certain time has elapsed, they have a villous or fungoid appearance, and bleed on the slightest touch. Svmptons.—In the early stage the only symptom noticed is hematuria, the urine being blood-stained. This is presently followed by pain whenever urine is passed, the bladder being irritable, and the act of urination more frequent. In the last stages the patient becomes emaciated through pain and want of rest, and the urine may be fcetid or purulent. Diagnosis is aided by the use of a sound (Fig. 156) or catheter, the tumour (if sufficiently large) being felt as a soft, spongy body resisting the progress of the sound inside the bladder. If small, however, this cannot be detected. A rectal examination should always be made. Treatment.— Before resorting to surgical aid medicinal remedies may be tried. The bladder should be washed out with a solution of non-irritating antiseptic, such as adrenalin, 254 CANINE AND FELINE SURGERY boric acid, saline solution, Condy’s fluid, or chinosol, con- taining a little sedative, such as belladonna or opium, and internal bladder sedatives (such as urotropine or hyoscyamus), or astringents and anti- Tit tates, -® aN septics (such as ergot or buchu), administered by the mouth. When these appear to be valueless, the only chance (a remote one with most tumours) lies in an operation. Operation. — Supra- pubic lithotomy is per- formed (see p. 257), the bladder is exposed, and if the growth is ex- ternal, it is removed if possible. If internal, the bladder is opened and the growth removed by scalpel and curette, the bladder being sutured Fig. 161.—Pedunculated Tumour of the and after Pera Bladder.! adopted as described on p. 259. Prognosis should be extremely guarded, and, before com- mencing the operation the surgeon should obtain the owner's permission to painlessly put the patient away before con- sciousness returns, if the case seems hopeless. Rievel reports a case* in a pointer in which a large round-celled ! The specimen from which this sketch was made was taken from a Yorkshire terrier, male, about six years old, and proved on microscopical examination by Professor McFadyean to be a mucoid polypus. 2 Veterinary Record, vol. xiii., p. 724 (Berliner Thierarst. Woch., Mayall’s translation). THE URINARY ORGANS 255 sarcoma was present in the abdomen, occupying the body and neck of the bladder and extending to the umbilicus, about twenty other growths being present in the pelvic and lumbar region. The case was quite inoperable. Cystitis ; Calculus, or Stone, in the Bladder. Cystitis, or inflammation of the bladder, may proceed from various causes which give rise to irritation of the mucous membrane lining the interior. Tumours (especially papilloma and carcinoma) are occasionally met with, septic organisms may gain access through the passing of a dirty catheter and other causes, overdoses of certain medicines (such as can- tharides), or the presence of a calculus or a number of calculi, may be at the root of the mischief. There may be only one stone present (as in specimen No. 3, Fig. 163), or there may be a very large number. The author has known one instance in which no less than eighty- four stones were counted in this situation. Calcul are most commonly met with in old, or at all events adult, animals, but even young ones are not exempt. They are as frequently met with in the cat as the dog, especially the castrated male. Bitches seem to be more predisposed than dogs, and the stones certainly attain larger size in the former. The Symptoms which first draw the owner’s attention to the animal are a continual restlessness and constant attempts at urination, during which efforts only a few drops are passed. This may be discoloured or blood-stained, but the presence of blood is by no means a necessary aid to diagnosis, as this depends entirely upon whether the mucous membrane of the bladder has become abraded or not. If matters are allowed to proceed further, great pain is evinced, the appetite is capricious, and the patient is feverish and becomes emaciated. Examination should be made through the abdominal walls 256 CANINE AND FELINE SURGERY with the fingers or per rectum, and a catheter or metal sound (see Fig. 156) should be passed into the bladder. With this instrument a distinct ‘jar’ and a metallic * click’ can be felt when it strikes against the calculus. When a calculus Fig. 162.—Bladder Calcul 27 s2¢ve. U, Ureter; V, vagina. has been discovered, surgical treatment is the only one which gives a chance of permanent success. For cystitis due to other conditions the cause itself must be discovered and treated. If septic organisms are suspected, the bladder must be washed out (see p. 252), and urotropin, buchu, creolin, THE URINARY ORGANS 257 cresosote, carbolic acid, hyposulphite of soda, or other such urinary disinfectant agents, administered by the mouth. Urotropine and hyoscyamus stand high in therapeutic value as bladder sedativesand diuretics, whilst potassium bicarbonate and other alkalies are useful agents. Tincture of cantharides in small medicinal doses gives immediate relief in some cases of hematuria, whilst pearl-barley-water or linseed-tea are useful fluid demulcents. Operations —The diagnosis having been made with cer- tainty, either a lithotomy or a lithotrity (litholapaxy) may be performed, the surgeon having the choice of two situa- tions in which to operate. I 2 3 Fig. 163.—Shapes assumed by Calculi in the Bladder. In either dog or bitch the bladder can be reached from the suprapubic region, or in the former the incision may be made in the perineum, and in the latter the stone can often be extracted through the urethral orifice, and so into the vagina. The term ‘lithotomy’ is used when the bladder is incised and the stone or stones extracted whole, and the term ‘lithotrity’ when the calculi are first crushed or broken up into fragments before being removed through the urethra. Suprapubice lithotomy is performed as follows: After the bladder has been emptied with a catheter, and carefully washed out with solution of chinosol, boric acid, or some 17 258 CANINE AND FELINE SURGERY other antiseptic, the patient is anzsthetized and placed in the dorsal position, laparotomy being performed as already described. The site of the cutaneous incision in the male is either in the median line immediately in front of the penis, or else in the flank a little to the right or left of that organ, and in the female in the median line immediately in front of the edge of the pelvis. Fig. 164.—The Bladder exposed to show the Site of Incision for Supra-pubic Lithotomy in the Male. The bladder is carefully raised and drawn into the wound, where it is packed round with aseptic lint, and, if con- sidered necessary, held in position by a loop of silk passed through its muscular and serous coats, but not through the mucous membrane. A longitudinal incision is made down its centre in the least vascular portion, as near as possible directly over the stone. This is carefully removed with forceps, after having been first broken up with a litho- THE URINARY ORGANS 259 trite, if of very large size. If, as is not uncommon, it is adherent to the interior, care must be taken to loosen it very gently from its attachments. If a number of small stones are present, they must be. removed with a blunt scoop or forceps. The interior is then carefully washed or swabbed out with some trustworthy non-irritant antiseptic (such as boric acid or chinosol), and the edges drawn together with silk sutures of Lembert’s pattern (see p. 55). In four cases? in which we have sewn up wounds of the bladder, Lembert’s Fig. 165.—A Dog secured for Perineal or Posterior Pubic Lithotrity. sutures of silkworm gut were used, but silk is undoubtedly better, as it becomes absorbed in time. Some operators suture through the whole of the coats at once in the ordinary way with interrupted sutures, but it is better that there shall be no foreign body protruding into the interior of the bladder, as it is apt to form a nucleus for future deposit. Asa rule, the wound in the bladder heals by first intention, and there is no need to insert a drainage-tube if antiseptic precautions have been rigidly carried out. In the cases illustrated in Fig. 163, No. 3 was the only stone present, the patient being a whippet four years old. The operation, a supra- 1 Journal of Comparative Pathology and Therapeutics, vol. xii. p. 203. 17—2 260 CANINE AND FELINE SURGERY pubic lithotomy, passed off quite satisfactorily, the bladder and abdominal wounds being each sutured without drainage and healing by first inten- tion, the external sutures being removed on the ninth day afterwards.! Nos. 1 and 2 illustrate the facets which form from the friction produced when one stone is continually rubbing against another. In the one instance there were three stones, and in the other five, present. In lithotrity the abdomen is not opened, the stone or stones being reached through the urethra. In the male, after anesthesia has been established, the animal is fixed on the operating-table in the position illustrated in the photo- graph, the hind-legs being drawn forward so as to efficiently expose the seat of operation, which has already been shaved and rendered thorcughly aseptic. The urine having been previously drawn off, and the catheter left in position in order to define clearly the outline of the urethra, an incision Fig. 166,—Lithotrite. is made directly on to this in the perineal region, about midway between the testes and the anus. An aperture of sufficient size to introduce the lithotrite is made in the urethra, and the catheter steadily withdrawn. The curved end of the lithotrite is introduced, passed round the pelvic border, and into the bladder. Search is made for the calculus, which must be manipulated until it is firmly fixed between the jaws of the instrument, when steady pressure is exerted upon it in order to break it up into small pieces, care being taken not to include the mucous membrane of the bladder. Some of the larger pieces may require a second application. The fragments are then got rid of, either by forceps or by continual irrigation with an antiseptic fluid, such as solution | Veterinary Record. Proceedings of the Central Veterinary Medical Society (Garry and Hobday). THE URINARY ORGANS 261 of chinosol or boric acid, after the introduction of an evacuating catheter into the bladder. The wound is then sutured, the urethra itself with fine silk, and the muscles and skin separately, the whole being covered with iodoform or orthoform and collodion. In small patients it is sometimes impossible to suture the urethra, and even in the larger ones some operators prefer to merely suture the skin and muscles. Where the animal is of a quiet disposition, a catheter or drainage-tube may be left in the urethra for two or three days with advantage; but if it gives rise to irritation, and consequent continual efforts to lick the parts, its continued use is best avoided. If the wound is not sutured, it must be kept clean and treated antiseptically. In the bitch, the vaginal method is one which has given Fig. 167,—Urethral Dilator (Sewell’s Modification of Barnes’ Pattern). excellent results in cases where the patient is of sufficient size to allow it to be done. The method of fixing is the same as already described for urethral lithotrity in the male. A conical-shaped dilating speculum—a