t^A** (^f < < < \ t < < < f ^<^*< < * '^j* < ■ Class _S£^i/ Book, 14^7 — Gopyii^htN" ^07 COPYRIGHT DEPOSIT, Surgical and Obstetrical Operations BY W. L. WILLIAMS Professor of Surgery and Obstetrics in the New York State Veterinary College, Cornell University. Embodying portions of the Operationscursus of Dr. W. Pfeiffer, Professor of Veterinary Science in the University of Giessen. SECOND EDITION, REVISED Published by the Author Ithaca, N. Y. 1907 \\ .-^s \^^^ PRESS OF ANDRUS & CHURCH, ITHACA, N. Y. LIBRARY of CONGRESS Two CoDles Received DEC a «906 * Copyright Entry CLASS A XXc, No, liol Z'^. COPY B. COHYRIGHT, I906, BY W. t,. WII,I.IAMS. J.. PREFACE. The author caused to be pubHshed in 1900 a booklet entitled : "A Course in Surgical Operations b}^ W. Pfeiffer and W. L. Williams," consisting of an authorized transla- tion of Dr. Pfeiffer' s Operations-Cursus with such changes, omissions and additions as were deemed desirable. Three years of constant use, with such criticisms as have come to the author from others, have served to point out desirable changes of so sweeping a character as to demand a practi- cally new treatise and to render the continuance of a formal joint authorship inexpedient. The author has drawn freely upon Dr. Pfeiffer' s Operations-Cursus in the preparation of the text which in man}' chapters is practically copied there- from, including the illustrations, and gratefully acknowl- edges his profound obligations thereto. On the other hand nothing has been copied or extracted except it could be freel}' adopted as the author's own view, releasing Dr. Pfeiffer from all responsibility for the character of au}^ of the con- tents. The volume is primarily designed for the use of the auth- or's classes in laboratory surgery and embrN^otomy in which the student performs the surgical operations described, on animals procured for the express purpose, under chloroform anaesthesia whenever possible, after which the subject is destro3^ed while still anaesthetized ; at the same time it has been aimed to render the volume of the greatest possible value to the practitioner consistent with this plan. The operations included under this scheme are necessaril}^ limited to those which can be reasonably well performed on com- paratively sound animals of little value and regularly pro- curable for laboratory purposes. The list covers a wide range and is designed to give to the student as thorough training as is practicable in a laboratory course and includes well* nigh all the more important varietes of confinement, anaesthesia, disinfection, sutures, bandaging, dressing and other adjuncts to operative work. The chapter of trephin- IV PREFACE. ing of the facial sinuses had been dealt with at length in order to fully and clearly describe the author's method of operating ; a new operation for poll evil has been inserted and there has been included a description of some of the most important embryotomy operations as the}^ are carried out in the laboratory by means of freshly killed, new born calves which are placed in the position described, in the arti- ficial uterus of a specially prepared skeleton . Generally but one method of operating is described, the one chosen being that which in the author's experience has proven the most valuable in actual practice, and no opera- tion has been introduced purely for practice but each one has been tested and known to have practical value. Where two methods of operating are given, they are inserted because each has definite points of superiority over the other and one method may be specially applicable in a given case, another in a different patient where the same operation is to be performed as for example, a milk cow is best spayed through the vagina while a heifer must be operated on by an incision through the abdominal walls. Considerable stress has been laid upon the surgical an- atoni}^ of the parts involved in each operation ; some uses of the various operations are mentioned ; some of the chief dangers of each are pointed out and in some cases references to literature upon the operation or the diseases for which the operation is designed, are cited. The figures in the text except Nos. 5, 10 and 11, and the Plates Nos. I, II, VIII, X, XII, XIV, XVII, XVIII, XXI, XXII, XXIII, XXV, XXVIII and XXIX are from Dr. Pfeifi'er's Operations-Cursus ; Plate No. Ill was drawn by Dr. C. F. Flocken, Bureau of Animal Industry, Wash- ington, D. C, and the remaining Plates were drawn under the direction of the author by Mr. C. W. Furlong, in- structor in Industrial Drawing and Art in Sibley College, Cornell University. W. L. W1LI.IAMS. Cornell University October, igoj. . PREFACE TO SECOND EDITION. The rapid exhaustion of our first edition has been highly gratifying to the author by indicating the appreciation of students and practitioners. We now submit a second edition which has been revised and somewhat extended. In our revision we acknowledge with thanks numerous valued suggestions from Drs. Liau- tard, Adams, Udall and others to which we have given careful consideration. As before it has been aimed to continue the volume as a brief, concise handbook of the technic of a number of the most important surgical proceedures, omitting the details common to all or most operations, and assumed that the student or practitioner has learned these otherwise. Our illustrations have been materially changed from the first edition. Plates IX, XI, XIV, XX, XXI, XXIV, XXV, XXVI, XXVIII, XXXI, XXXII, and Figures I to 8 and 12 to 14 are from Pffeiffer's Operations-Cursus, while the other plates and figures have been made especially for this work under our personal supervision. The present edition is submitted with a full conscious- ness of its many defects. W. L. Williams, Cornell University , Ithaca, N, Y. December, 1906. CONTENTS. I. I. OPERATIONS ON THE HEAD : Page. 1. Kxtraction of Teeth i 2. Repulsion of Teeth 8 Trephining the Facial Sinuses i6 3. Trephining of the Frontal Sinuses 19 4. Trephining the Maxillary Sinuses ^ 31 5. Trephining the Nasal Fossae 37 6. Poll Kvil Operation 41 7. Ligation of the Parotid Duct 45 8. Entropium Operation 50 9. Staphylotomy 51 10. Trifacial Neurotomy 55 II. OPERATIONS ON THE NECK : 11. Opening the Guttural Pouches 57 12. Tracheotomy ^ 63 13. Arytenectomy 65 14. Roaring Operation by Kxcision of the Vocal Cords and Ven- tricle of the Larynx 70 15. Intra-tracheal Irrigation 75 16. Intravenous Injection 75 17. a. Phlebotomy with Fleams 77 b. Phlebotomy with Lancet 78 c. Phlebotomy with Trocar 79 18. Ligation of the Carotid Artery 79 19. CE^sophagotomy 84 III. OPERATIONS ON THE TRUNK AND ON THE GENITAI. ORGANS : 20. Puncture of the Chest 86 21. Puncture of the Intestine 87 22. Subcutaneous Caudal Myotomy 89 23. Caudal Myectomy for Gripping of the Reins 91 24. Amputation of the Tail 95 25. Urethrotomy 100 26. Amputation of the Penis 103 27. Vaginal Ovariotomy in the Mare 108 CONTENTS. vii 28. Vaginal Ovariotomy in the Cow 119 29 Ovariotomy in the Cow by the Flank 121 30. Ovariotomy in the Bitch by the Flank 122 31. Ovariotomy in the Bitch by the Linea Alba 129 32. Ovariotomy in the Cat i^i 33. Castration of Cryptorchid Horses 132 IV. OPERATIONS ON THE EXTREMITIES : 34. Tenotomy of the Flexor Tendons of the Foot 142 35. Tenotomy of the Peroneal Tendon (Stringhalt Operation )___ 144 36. Tenotomy of the Cunean Tendon (Spavin Operation) 146 Neurotomy j^3 37. Digital Neurotomy i^i 38. Plantar Neurotomy jcg 39. Median Neurotomy . i5q 40. Ulnar Neurotomy j5y 41. Sciatic Neurotomy ^j-i 42. Anterior Tibial Neurotomy 183 43. Resection of the Lateral Cartilages 185 44. Resection of the Flexor Pedis Tendon 192 45. Amputation of the Claws of Ruminants 194 46. Bayer's Sutures 190 II. EMBRYOTOMY OPERATIONS ! 47. Cephalotomy 203 48. Decapitation 205 49. Subcutaneous Amputation of Anterior Limb 206 50. Amputation at the Humero-radial Articulation 208 51. Detruncation 208 52. Destruction of the Pelvic Girdle, Anterior Presentation 212 53. Amputation of the Limbs at the Tarsus 216 54. Intra-pelvic Amputation of the Posterior Limbs, Breech Pre- sentation- 220 55. Evisceration of the Fetus 229 INTRODUCTION. Many details must be omitted in the succeeding text which are of importance in each operation, but which, if inserted, would render the volume unwieldy in size for the purposes designed. These details are in a measure alike in each case, and it is assumed that the student has already familiarized himself with them. The more important of these may be summa- rized as follows : 1. The subject should be securely confined in each case as directed, because the method designated has been found effective in the operation under description, and serves to fix the relations of the parts in such a way as to conform to the surgical anatomy of the region as outlined in the text. It is to be constantly borne in mind that a change in the atti- tude of the animal is capable of causing profound alterations in the relations of parts which may greatly embarass the operator, or even prevent his carrying out the operation according to the technic given. In securing an animal for operation we must confine the whole body in a way that will sufficiently control its movements and will insure safet}^ to the patient and operator and the part to be operated upon must be so fixed as to properly limit its motion and in the position which affords the greatest facility for the carrying out of the operation according to the best technic known. 2. Anaesthesia should be carefully carried out everywhere possible, because in addition to the humane sentiments in- volved, the resulting most perfect control of the animal is an essential in aseptic or antiseptic surgery. The student should make a careful study of anaesthesia in these exercises and acquire invaluable experience and confidence for use in actual practice. 3. Disinfection must be scrupulousl}^ applied in every de- tail since upon its effectiveness must hang the verdict of INTRODUCTION. ix success or failure as measured by modern surgical knowl- edge. The operator's hands and, if need be, his arms should be thoroughl}^ scrubbed with a stiff brush in hot water with soap for a period of fifteen minutes, the finger nails well trimmed and cleansed, and all dirt and old epider- mal scales removed. The parts may then be disinfected by immersing in a hot concentrated solution of permanganate of potassium for ten minutes and then decolorized in a strong solution of oxalic acid in sterile water. Or the hands may be disinfected after the washing with soap and water by im- mersing and scrubbing them for ten minutes in a i to looo solution of corrosive sublimate, but in order to make this thoroughly effective the solution needs be alcoholic, or the hands should first be immersed in alcohol, ether, or other substance capable of dissolving fats and permitting the dis- infectant to penetrate the sebaceous glands. Great care should be exercised by the student to not touch any object after the hands have been disinfected for the operation unless it also has been disinfected or sterilized, or in case it becomes necessary to touch objects not sterile, the disinfecting process should be repeated before proceeding further with the oper- ation. This constitutes one of the most difficult of all de- tails for the beginner to acquire, and each failure should be remedied by repeating the disinfection over and over until the habit of maintaining effectual steriHzation is acquired and fixed. The operation field should always be carefully shaved be- fore beginning the operation, and the shaved area should always be very ample, so as to insure against contamination from adjacent hairs, as well as to give a clear view of the field. The area should then be disinfected in a reliable manner, that advised for the operator's hands serving as a t3^pe. Whenever circumstances will permit the operation field should.be kept in an antiseptic bath or pack for twenty- four hours prior to the operation in order that the deeper parts of the skin, especially the hair follicles and sebaceous X IN TROD UCTION. glands, shall become thoroughly disinfected, a process well nigh impossible in a short period. The suturing, dressing and bandaging of the wound should be carried out carefully in every case and no opera- tion left w^ithout completing it in the best manner possible. The student should make each operation as real as possible and not omit any detail, even if he thinks he already knows it sufficiently well, as the repetition of a supposedly familiar detail serves an important purpose in the fixing of a habit which is inestimably more valuable to the surgeon than any theoretical knowledge of technic. The safe surgeon is he who has so accustomed himself to the technic of asepsis and antisepsis that he carries them out rigidly in an automatic manner and can leave his atten- tion riveted on the surgical problems before him. The student who consults his interests will go yet farther and prior to undertaking any operation on the living subject will study the regional anatomy of the part on the cadaver and learn therefrom all that he can of the structure of the part which he must finally complete upon the living animal. No dissection of the cadaver can ever teach true surgical structure as the dead tissues can not be like the living, but such dissection can and does give great aid and should be pursued as far as it can lead and enough will still remain to be learned on the living subject. He should further take occasion to study in connection wnth each operation the object or objects for which it is performed in practice, its effect on the diseased or other parts, the untoward results to be anticipated, etc. Suggestions occur from time to time in the text designed to aid the student in these lines and help weave connecting bands between the operation, its objects and results. Surgical operations are in themselves valueless or worse and acquire value only when properly correlated to disease and skillfully performed. \ % Surgical and Obstetrical Operations. L SURGICAL OPERATIONS. OPERATIONS ON THE HEAD. I. EXTRACTION OF TEETH. PlvATE I. Prefatory remarks. The grinding teeth of the horse, consisting of three molars and three premolars in each row, are of such dimensions and attachments that their removal in case of disease or defect often presents difficulties of no small degree. These teeth attain their greatest size at the time of erup- tion and most of each remains firmly imbedded in its alveolus while a very shallow crown projects into the buccal cavit}^ The teeth are gradually pushed out of their alveoli as their crowns are worn away with age and the proportion of the intra to the extra-alveolar part gradually decreases until in very old animals the alveolar cavities become obliter- ated and the last vestige of what was once the apex of the fang rests insecurely in the buccal mucous membrane. The facility with which teeth may be extracted increases as the age of the animal, being easily drawn with forceps in the old, while in case of freshly erupted teeth in the young horse we have usually been unable to extract them with forceps of'any kind, except in those where they have become somewhat loosened as a result of disease or accident. When aberrations in development occur, leading to the for- mation of dental tumors or odontomes the possibility of ex- traction by means of forceps is frequently wholly excluded and in cases where dental disorder has led to empyema of the facial sinuses, even if the tooth may be drawn by means of forceps, further operation is generally necessary, in order 2 EXTRACTION OF TEETH. to assure a prompt recover}^, by the removal of the effects of the disease of the tooth. The removal of molars may therefore involve extraction with forceps, trephining the dental alveolus and repulsion of the tooth and trephining of the sinuses because of em- pyema or other pathologic conditions referable to the dental affection ; consequently all of these should be studied as re- lated topics. Instruments. Extracting forceps, fulcra of various sizes, mouth speculum with abundant lateral working room, exporteur forceps, toothpick, splinter forceps, reflecting lamp. Technic. In simple cases with a quiet animal the pa- tient may be sufficiently confined by being backed into a corner or very much better b}^ securing in stocks. In com- plicated cases or very resistant animals it is best to place upon the operating table or in default of this, cast and secure in lateral decubitis on the sound side. Apply the speculum and identify the diseased tooth by manual exploration ; determine if the tooth is of unnatural size or form, if it is loose, if the gums are separated from the neck at any point, if it is out of line with the other teeth in the row, if it is painful to the touch, if it be split, etc. An external tooth fistula or a tumefaction over the affected member may aid in distinguishing it. Aid may also be had by illuminating the mouth with a reflecting electric or other lamp. Remove any accumulations of partiall}^ masticated food by means of the toothpick or with the fingers. In applying the forceps, have an assistant draw the tongue out at the commissure of the lips on the side oppo- site to the affected member and introducing one hand into the mouth, place the index finger on the posterior border of the diseased tooth and with the other, push the opened forceps backward upon the dental row until they reach it, then firmly grasp the diseased tooth with the instrument, EXTRACTION OF TEETH. 3 pressing the jaws down as deeply as possible against the alveolus. In many cases the diseased tooth can be clearly seen, especially with the aid of the reflecting lamp, and the forceps may be readily applied by visual aid and this is frequently preferable to the sense of touch. Withdraw the free hand from the mouth, grasp the handles firmly and loosen the tooth in its alveolus by establishing and maintain- ing as long as necessary a gentle to and fro lateral move- ment. The tooth is thus loosened in its alveolus by caus- ing it to revolve very slightly back and forth on its long axis, thereby spreading the cavity. When the tooth has become well loosened, as indicated by its revolving with the forceps and by the audible crepitant sound caused by the passage of air bubbles to and fro through the blood and lymph in the alveolus, maintain the forceps in position with one hand and with the other introduce the fulcrum to a point where the depression on its superior surface will receive the projecting rivet-head of the instrument or in an otherwise secure position and give it a safe support, while the inferior surface rests evenly upon the crown of a tooth anterior to that which it is desired to extract, as is shown in Plate I. The fulcrum needs be held firml}^ in place in order to prevent it from gliding forward under pressure. In extracting the first premolars there is no opportunity for resting a fulcrum on teeth anterior thereto and con- sequently forceps have been made with fulcra beyond the forceps jaws resting upon teeth more posteriorly situated- This is not essential. If the tooth is thoroughly loosened, as it should be, one hand placed in the interdental space with the dorsal surface against the jaw and the volar grasp- ing the instrument, will serve as an effective fulcrum. In other cases an iron or steel fulcrum is not essential, but a stick of hard wood of proper size and form acts quite as efficiently and may even keep its position better because the teeth upon which it rests sink into it somewhat. On Pirate I. Extraction of Teeth. Sagittal section through the oral cavity, show- ing plan for extracting the third inferior pre- molar, viewed from within the mouth. A Forceps ja\\s applied to third premolar. B Fulcrum resting upon first premolar. CC, Plates of mouth speculum resting up- on incisor teeth. EXTRACTION OF TEETH. 7 the whole the fulcrum is not so important as some have considered it, since, after a tooth is loose enough to be drawn with its aid, a very trifling additional loosening will permit it to be easily lifted from its alveolus without it. The tooth fang is extracted by forcing the handles of the forceps toward the jaw in which it is located, so that as it is gradually drawn out the forceps tend to pivot on the fulcrum in a way to permit it to emerge from the alveolus in the direction of its long axis. B}^ referring to Plate II it will be seen that the axes of the different teeth vary, that of the molars being obliquely forwards towards the incisors while the crowns of the premolars are directed obliquely backwards toward the molars. The slant of the teeth is most marked at the ends of each arcade while at the middle they acquire a practically perpendicular position. In drawing the last molar the forceps will generally strike against the opposite dental arcade before the tooth has codipletely emerged from its alveolus and in order to com- plete its removal it may be necessary to take a deeper hold with the extracting forceps or withdrawing these complete the operation with the aid of exporteur forceps, or still better frequently with the hand. In young horses where the teeth are very long we have found it impossible to complete the extraction until the tooth had been divided transverse!}^ by means of the tooth cutting forceps. The dangers in the extraction of teeth are chiefly : I. The fracture of the tooth, leaving the fang still fixed in the alveolus, a danger not infrequently unavoidable when the crown has become greatly weakened by disease so that it lacks the power of resistance necessary to its extrac- tion ; under most other conditions it may be largely guarded against by the careful securing of the patient in a manner to effectively prevent sudden throwing of the head while the forceps are applied, and by using good judgment in the amount of force exerted while loosening the tooth in its 8 REPULSION OF TEETH. alveolus. As stated above we should not expect to be able to extract with forceps the teeth of very young horses which have not become partly detached by disease or in which the fangs are the seat of adontomes. 2. Fracture of the alveolar walls is an accident which may generally be prevented by proper care in the application of force and the avoidance of any attempt to extract a tooth when the existence of an enlargement of the fang is apparent or suspected. 3. The tooth may slip from the forceps into the pharynx and be swallowed, an accident avoidable by inserting the hand into the mouth along with the forceps as the tooth be- gins to emerge and if need be grasp it with the fingers. 2. REPULSION OF TEETH. Platk II. Uses. The removal of molars, pre- molars, tooth fangs from which the crowns have been broken away, alveolar odontomes, etc., which can not be removed safely by means of the forceps. Instruments. Razor, convex scalpels, trephine, bone gouge, Luer's sharp bone forceps, (rongeur forceps) light and heavy bone chisels, mallet, tooth punch, curette, com- pression artery forceps, scissors, needles, thread, absorbent cotton, antiseptic gauze, extracting forceps, splinter forceps, tenacula, metal probe, mouth speculum. Technic. Secure the animal in the lateral recumbent position with the affected side up. The operating table affords by far the best means for securing for the conven- ience and safety of operator and patient. If the sinuses are so involved as to make possible the inhalation of pus, blood or other injurious matter, perform tracheotomy in ample time to avert danger. Anaesthetize locally or generally as required. Shave and disinfect the operative area and \ REPULSION OF TEETH. 9 trephine according to the method described in the following chapter down through the alveolar plate immediately over the fang of the affected tooth. Avoid dulling the trephine by striking it against the tooth fang itself. If an external fistula exists the identity of the affected tooth is best determined by passing a metallic probe through it against the diseased fang while one hand is passed into the mouth and the location of the probe more fully ascertained. Care should be exercised in trephining to not injure the adjoining teeth. After removing the disc of bone isolated by the trephine, control all hemorrhage and then enlarge the open- ing and remove the bony tissues till the tooth fang is bared its entire width. Insert a scalpel or bone chisel between the bone and soft tissues at the margin of the trephine opening nearest the mouth and with one hand in the oral cavitj' with the fingers resting upon the alveolar border on the lateral side of the tooth to serve as a guide, push the scalpel or chisel along between the bone and soft tissues until it emerges from the gums alongside the affected tooth and extend this separation backwards and forwards until the soft tissues are completely detached from the alveolar wall over the entire area of the diseased member. When operating upon the superior molars the fangs of which are covered by the zygomatic ridge, the chisel or scapel cannot be pushed directly from the trephine opening into the mouth between the soft tissues and the bone because the line is concave instead of direct. In these cases it is best to detach the soft parts only from the zygoma at first and then remove the alveolar plate of the ridge, after which the line into the mouth is direct and the instrument can then be readily pushed between the soft and osseous tissues for the remainder of the distance and the separation completed. In operating upon the inferior molars covered by the masseter an opening may be made near its lower border large enough to admit the trephine or the muscle may be 'S o _o rt (V (U CA a a, >-i 3 s U3 cfl to 'd ~ Vh S 2 c *3 CO O 'O 'o s « § 3 O 2i ^ to < TS OS O iJ a .2 S fe CO W o i) CO ^ ^; CO ^ 1-1 Ti o ■^ 22 * i S 9 p ^ v-l o 2-§ P^ 2 ^■^ u a o CO "^ J^ ^ - rt PQ 3 .- 1 o o ^ CO S S 0) |1 3 S / / "t •«c^* REPULSION OF TEETH. 13 detached at its point of insertion and two parallel incisions carried upwards a short distance, permitting the raising of a flap or what is generally best, a curved incision is made along its antero-inferior border parallel to the parotid duct and satellite vessels and just anterior to them (or posteri- or if preferred ) and the muscle lifted up and drawn back- wards sufficiently exposing the parts. With a light, narrow bone chisel cut away and remove the external alveolar plate over the entire extent of the tooth, from the oral maigin of the trephine opening into the mouth cavity. Hold the chisel so that the outer edge is inclined from the affected tooth toward the adjoining one, thus making a bevelled channel through the alveolar plate tending to loosen the isolated section of bone by driving it outwards. Drive the chisel for a short distance on one side, then upon the other, and thus break the alveolar plate away in small sections and avoid an extension of the fracture to neighboring alveoli and damage to adjacent teeth. Care should be taken that the bone chisel is sharp otherwise extensive fractures of the bone may occur. With gouge and chisel remove all remnants of bone over the lateral side of the tooth laying it completel}' bare as shown in Plate II. The soft tissues of the part should not be dis- turbed be3'ond the excision of the circular piece, correspond- ing to the disk of bone removed by the trephine and the detaching of them from the portion of bone to be chiseled away. When the tooth has been bared so that every part of its lateral surface can be seen or felt, the punch may be placed against the end of the fang, a few firm, quick blows given with the mallet, so directed that the force is in a line with the long axis of the tooth, and the organ driven into the mouth where it is seized by the forceps or the hand and removed. If it is not readily and safely dislodged in this way, place the heavy bone chisel against it and with the aid of the mallet comminute the tooth by breaking it 14 REPULSION OF TEETH, transversely and splitting it longitudinally, in which pro- cess the fragments are generally loosened and can then be readily removed with the aid of the gouge or heavy dress- ing or splinter forceps. Remove carefully all fragments of tooth or of loosened bone, cleanse and disinfect the wound, pack with iodoform gauze and dress daily. In cases where a fistulous opening remains after repulsion of molars without the removal of the alveolar wall, or if a tooth has been drawn by means of the forceps and the alveolus fails to heal, the bony plate should be removed in the above manner. Dangers. Wounding of the adjoining tooth is to be avoided chiefly by carefully locating the fang of the affected one and placing the instrument as exactly as possible over its centre, by using a trephine not exceeding 2 to 5 cm. in diameter and cautiousl}^ sawing through the compact layer of the external plate only, removing the cancellated tissue with the gouge and extending the opening in the desired direction after the outlines of the tooh fang have been clearly determined. If an adjoining fang is wounded, the tooth should be removed as it will not heal but will result in a permanent tooth fistula. Fracture of the alveolar walls of the inferior maxilla may occur during the removal of the external alveolar plate with the chisel or of the repulsion of the tooth with the punch and mallet. The first is to be averted by care in having the chisel sharp, by observing the precaution of making a bevelled cut through the bone, by using only moderate blows and driving the instrument alternately for a short distance on each side. The second danger of ex- tensive fracture may be averted by being cautious to see after each stroke on the punch that it has not slipped in- ward along the median side of the tooth, pressing the in- ternal plate awa}^ from the tooth row and tending to pro- duce a longitudinal fracture nearly or quite as long as the REPULSION OF TEETH. 15 dental arcade. Careful digital exploration in the mouth may discover this fracture while still ' ' simple ' ' but a stroke or two more will convert it into the very much more serious "compound" fracture opening into the oral cavity. Keeping one hand constantly in the mouth at the point of impact is always desirable as a precautionary measure. Transverse fracture of the tooth while yet in situ by means of the bone chisel, as above described, is a great safeguard against this injury by lessening the force required in repulsion and by the removal of the tapering fang, which then leaves a more secure base for the punch to act upon. It should never be forgotten that the impact from the punch must always be as nearly parallel to the long axis of the tooth as is possible. The fracture of the superior maxilla and bony palate is not so probable as the preceding and is preventable by mod- erate care in the denuding of the tooth before punching, by comminution of the tooth in bad cases, by the careful ad- justment of the punch and applying the force in the proper direction. Literature. Odontomes, Sir Bland Sutton, Jour. Comp. Med. and Vet. Arch, Vol. XII. p. i ; A Clinical Study of Odontomes, W. L. Williams, Am. Vet. Review, Vol. XV, p. I ; Notes on Odontomes, do ; Am. Vet. Rev. Vol. XXIII, p. 82 and Oest. Mon. Thierheilkunde, Bd. XXIV, s. 122. 1 6 TREPHINING OF THE FACIAL SINUSES. TREPHINING OF THE FACIAL SINUSES. PI.ATES in, IV, V, VI, VH AND vin. Prefatory Note. The facial sinuses of the horse consti- tute an exceedingl}^ intricate and extensive group of cavities, communicating more or less freely with each other and with the exterior through the medium of the upper air passages, of which they are to be regarded as a part. Their arrangement and relations permit them to frequently become the seat of, or central figure in many forms of disease which require for their differential diagnosis, amelioration or cure, the operation known as trephining. Their extent and relations to each other and to surrounding parts varies greatly with age and ma}^ be profoundly changed as a result of disease, amounting not infrequently in the frontal, superior and inferior maxillary sinuses ceasing to exist as separate cavities and becoming merged into one vast diverti- culum. Similar changes may occur in the nasal and tur- binated cavities. The general position, extent and relations of these are indicated by Plates IV, V, VI, VII and VIII. It is to be noted that in cross sections the superior and inferior maxillary sinuses appear to be reversed in relation to their nomenclature. It is difficult to make a cross sec- tion of these sinuses in such a manner that the superior sinus does not show between the inferior one and the oral cavity. The inferior maxillary sinus is inferior in the sense that it is nearer to the nasal opening so that with the head in a vertical position or in a longitudinal section the inferior sinus is below the superior, while if the head be placed horizontally or a cross section made the superior sinus is below the inferior. The uses of trephining are in a measure common to all the sinuses and are chiefly for the relief of empyema of the cavities involved, necrosis of the bony or cartilaginous walls, tumors of various kinds, especially dental in the young and malignant growths in the old, foreign bodies in the sinuses, differential diagnosis of diseases of this region, etc. TREPHINING OF THE FACIAL SINUSES. 17 Veterinarians trephine the sinuses by two fundamentally different plans ; with, and without excision of the cutaneous disk corresponding to the piece of the bone removed. The first is generally used in Great Britain and North America, while the last is the prevailing method in continental Europe and other parts of the world. The reason assigned for these variations in method are conflicting. To us there seem to be adequate reasons for preferring the excision of the cutaneous disk. We regard as the chief considerations in an operation the following : the avoidance of infection ; the prevention of pain during the operation or the after- treatment ; the reduction of the scar to a minimum ; rapidity and certainty of recovery ; convenience in operating and dressing. Infection is largely dependent, aside from aseptic operation and protective dressing, upon the area of the wound, the facility for maintaining cleanliness and the degree of disturbance to the tissues while being dressed. The wound area in the bone is alike in all cases but that in the skin varies greatly. If we take as a type the usual European technic and compare it with that given below we w^ould find the wound areas approximately as follows : in the European method 2.2 sq. in. while in the operation as given below we have only about .44 sq. in. or proportion- atel}- the wound area in the soft tissues in the European operation to that given below would be as 5 : i . It is very evident that the technic given below affords immeasureabh^ better facility for maintaining cleanliness in the wound and with a minimum amount of insult to the tissues in the process of dressing. The amount of pain caused in the operation would depend chiefly upon the extent of the skin incision which is equal in the two plans so that the onl}- difference would be in the dissection of the skin from the bone in the European operation. Tht pain caused in dressing must be greater in the European method because the detached, overhanging 2 1 8 TREPHINING OF THE FACIAL SINUSES. skin must be moved and disturbed each time causing pain and inviting infection. The question of pain must always be seriousl}?- considered as it not only affects the time re- quired for dressing and its efficacy, but has an important relation to the docility of the animal after recovery, some horses having their dispositions permanently ruined by the irritation due to the oft repeated painful dressing of wounds. The cicatricial contraction of the tissues of the horse is so great that the removal of a circular disk of skin J^ to i}^ in. in diameter on the face does not leave a visible scar so that the question of blemish falls back upon that of in- fection, which, as we have asserted above is far more probable by the European method. The rapidity and certanity of recovery are dependent upon the considerations above discussed. The removal of the cutaneous disk is certainly easier and quicker than the other method. The convenience for dressing is evidently superior by the English and American method. The opening of the maxillary sinuses into the nostrils is based upon the surgical principle that suppurating cavities should be provided with ample drainage from the most dependent part. The direction to leave the external wound open, at first thought seems antagonistic to general surgical principles but it should be remembered that the wound consists only of the incision through the skin, connective tissue and bone, and that au}^ plug which we can put in this opening can only serve to dam back the secretions of the cavity and can not prevent it from coming in contact with the wounded surface. It must further be regarded that the respiratory mucosa of the upper air passages are not irritated or injured in any manner so far as we can ob- serve clinically by the direct admission of air into them through a trephine, or other artificial opening, but on the contrary the suppuration in a sinus is constanth^ aggravated b}^ the retention of the pus and exclusion of air and re- covery facilitated b}' thorough drainage and aeration. TREPHINING OF THE FRONTAL SINUSES. 19 3. TREPHINING OF THE FRONTAL SINUSES. PI.ATES III- VIII. Uses. Fracture of the bony walls, necrosis, tumors. The ample communication below with the superior maxillary sinuses prevents the accumulation of pus or fluids in the frontal cavities even if formed therein unless the former become filled and the contents back up into the latter. In the case of empyema of the frontal sinus, trephin- ing does not generally give full relief but calls for a re- petition of the operation on the maxillary sinuses also. Instruments. Razor, scissors, convex scalpels, artery forceps, tenacula, probe, trephine, curette, gouge, Luer's sharp bone forceps (rongeur forceps), hammer, chisel, bone screw, lens-shaped bone knife, probe-pointed bistoury, dressing forceps, disinfecting and dressing materials. Technic. The operation may be performed upon the standing animal with the aid of local anaesthesia of the skin, the bone having virtually no sensation. Restless animals may be further secured with the twitch, in the stocks, upon the operating table or by casting on the sound side. Clip and shave the hair from the region of the front- al bone on a level with the superior border of the orbital cavity as indicated in Plate III or at any point below on a line extending from F toward a point midway between N and I M down to a level with the dotted line, S M, and dis- infect the area carefully. F represents the highest point at which the frontal sinus can be penetrated without injury to the cranium. " Within the shaved and disinfected area locate the point for trephining, F, Plate III so that the in- ferior border of the opening on a medium sized horse will be not higher than on a level with the superior border of the orbital cavity at the dotted line below F and the inner margin about i cm. from the median line of the face. With a heavy convex scalpel make a circular incision as large as the area of the trephine, directl}^ through the skin, subcutem Pirate III. Trephining the Faciai, Sinuses. F, highest point at which an opening may be made into the frontal sinus without wounding the cranium acd brain ; N, opening into nasal sinus ; SM, opening into superior maxillary sinus ; IM, opening into external portion of in- ferior maxillary sinus ; IM^, opening into the median portion of the inferior maxillary sinus. ,N — 5M TREPHINING OF THE FRONTAL SINUSES. 23 and periosteum down to the bone and remove in one piece the entire mass of encircled soft tissues by seizing the skin with a tenaculum and forcibly separating the periosteum, from the bone with a scalpel or bone scraper. Control the hemorrhage. With the centre extended place the trephine accuratel}^ upon the denuded area perpendicular to the surface of the bone and grasping the handle firmly turn it to and fro until the bit has penetrated the bony plate and the saw has cut a distinct groove to serve as a guide w^hen the center should be retracted and the operation con- tinued until the disc of bone is detached, being careful to maintain the trephine prependicular to the surface. The operation is facilitated by grasping the shaft of the trephine between the thumb and fingers of one hand, constituting a support in w^hich it can glide back and forth. The pressure under which the sawing is carried out must not be too great. When the bony plate which has been isolated begins to loosen, remove the trephine and insert the bone screw into the centerbit opening and break out the piece of bone or pry it out with the bone gouge or chisel. Smooth any uneven edges of bone with the lens-shaped knife. The ab- normal contents of the frontal sinus can now escape through the opening or be removed with the curette, forceps or scis- sors, and the cavity irrigated with an antiseptic fluid. Leave the trephine wound entirel}^ open and dress daily with anti- septics. The frontal sinuses being in free communication with the superior maxillary, and the superior turbinated bone of the same side forming its median wall, indirectly the irrigating fluid can escape through the nasal opening by way of the former or by a perforation through the latter. In order to prevent the aspiration of the contents, which are generally purulent, or ma}^ consist of blood or irri- gating fluids, and to facilitate their escape, irrigation should be carried out with the poll elevated and the head flexed. Pirate IV. Trephining of Faciai, Sinuses. Cross section of the right half of the head of a horse at the posterior border of the last molar. F, frontal sinus ; IM, lateral portion of inferior maxillary sinus at extreme posterior or superior part ; IM^, median portion do. ; N, nasal chamber opposite the communication between it and the superior maxillary sinus ; NF, con- duit of superior maxillary branch of the trifacial nerve ; S M, superior maxillary sinus ; M^, fragment of last molar. IM — ~-- — M TREPHINING OF THE FRONTAL SINUSES. 27 By studying Plates IV-VII it will be seen that any collec- tion of pus or other disease products at F would result in poor drainage so far as may be obtained by trephining through the external wall only, and consequently in order to com- plete it aside from that through the superior maxillary sinus an artificial communication between it and the nasal fossa may be made at ST, Plate VIII by a second opening oppo- site that point near the median line midway between F and N, Plate III, and then breaking through the thin walls of the turbinated bone b}' means of a probe or other suitable instrument and enlarging it sufficiently with the probe pointed bistoury or with the finger. In locating the exact point for making this opening in the turbinated bone it is advisable to pass a slightly curved heavy probe, a pair of long curved uterine dressing forceps or some other slightly curved and somewhat rigid instrument up the nostril to the operative region and having an index finger in the sinus against the median wall, the movements of the sound can easily be felt and the wall be broken down either by pushing the sound up into the sinus or thrusting the finger downwards into the nasal passage. In order to prevent aspiration of fluids, the animal must be allowed to get up immediatel}^ or if under anaesthesia a trachea tube should be inserted sufficiently early to avoid danger. Thread a long probe with a heavy suture about 75 cm. long and inserting it through the trephine opening into the nasal passage draw it out through the nostril and removing the j)robe, attach a strip of gauze 75 cm. long to one end of the suture, draw it out through the nostril and tie the ends together on the side of the face to prevent dis- lodgement. Retain the gauze in position for about forty- eight hours to insure the permanency of the opening through the turbinated bone. In case of severe hemorrhage the cavity can be tamponed for twenty- four hours with a long strip of gauze which may be secured if necessary by sutur- PI.ATE V. Trephining the Faciai, Sinuses. Cross section of the left side of the head of an aged horse at the second molar, seen from the front. F, frontal sinus ; N, nasal sinus, oppo- site the communication between the nasal and inferior maxillary sinuses ; IM, lateral portion of inferior maxillary sinus ; IM^, median portion of inferior maxillary sinus ; SM, superior max- illary sinus ; NF, superior maxillary division of trifacial nerve in its bony conduit ; SZ. subzygo- matic artery ; P, palatine artery ; M2, second molar. -SM TREPHINING THE MAXILLARY SINUSES. 31 ing to the lips of the wound. In practice the operation can be best carried out generally with the animal in the standing position the operative area being first anaesthetized by the use of cocaine or by inducing artificial oedema. In the standing position we largely avoid the danger of aspira- tion of fluids and the hemorrhage is greatly lessened. 4. TREPHINING THE MAXIIvI,ARY SINUSES. Pirates III-VIII. Uses. Empyema, diseased teeth, odontomes, tumors. Instruments. Same as for the frontal sinuses. Anatomically there are two maxillary sinuses, superior, SM, and inferior, IM, Plates III-VII, having a thin im- perforate bony partition between them. This partition shifts somewhat in position with age and in case of disease undergoes profound changes in location and is frequently totally obliterated in cases of emp3^ema, dental cysts and other affections. If present, good drainage of the superior sinus may demand its surgical destruction so that some authors advise trephining directly over it in order to open the two cavities simultaneously. In extensive disease the prior destruction of the partition renders such an aim super- fluous ; in limited disease the opening of both cavities is ill advised. The partition may be ignored in operating for extensive disease and the trephine opening be aimed at the probable focus of the malady and, if missed, it should be located through the primary, or what now becomes an ex- ploratory opening, and a second operation made to directly reach the seat of the affection and if need be, 3^et a third to secure proper drainage. Shave and disinfect as much of the area as may be required bounded above by the inferior border of the orbital cavity, laterally by the zygomatic ridge, inferiorly by the lower end of the zygoma and medianwards by the middle line of the face. Determine 32 TREPHINING THE MAXILLARY SINUSES. the proper point for operation by percussion or otherwise. If it is desired to enter only the superior maxillary sinus, SM, Plates III-VII locate the opening imniediateh' beneath the orbital cavit}' and in front of the zygomatic ridge, SM, Plate III, or at any point directh^ beneath this to midwaj^ between SM and IM, Plate III, at about the level of the dotted line IM'. In order to penetrate the inferior maxillary sinus at its lowest part, the trephine opening needs be located just in front of the lower end of the zygomatic ridge at IM, Plate III, or on a line obliquel}' upwards there- from as far as the furrow marking the suture between the maxillary and nasal bones at IM'. The trephining is carried out as described for the frontal sinuses. After the trephining has been completed remove any purulent collect- ion or tumors or carry out any other necessary operation in the affected sinuses and after cleansing, if the trephine opening does not insure perfect drainage of the lateral sac, either lower it by cutting away its inferior border with the bone forceps or make a second one at the necessary point. Under the influence of disease the sinuses may extend far beyond their normal location or may contract or become largel}" obliterated b}' being filled with new bone or soft tissue. The median portion of the sinuses on the inner side of the bon}^ conduit of the trifacial nerve, NF, Plates IV-VII, can not be drained properly through the openings SM and IM Plate III, and provision for this must generally be made by trephining into the inferior maxillary sinus at IM', Plate III, and then making an opening 3 to 5 cm. in diameter through the inferior turbinated bone at IT, Plate VIII, either with the finger, probe-pointed bistoury, or other suitable instrument, and inserting through this open- ing a long and thick strip of gauze which is brought out through the nostril and the ends tied together on the side of the face to prevent displacement. Retain this in position, renewing daily until the permanency of the opening is as- sured. ^ TREPHINING THE MAXILLARY SINUSES. 33 If the partition between the two sinuses is intact it may be necessary to destroy it immediately above IM', Plate III, in order to drain the median portion of the superior maxil- lary sinus if that is required. If a molar has been removed and in so doing the bony wall leading down from the nerve conduit, NF, Plates IV-VII, destroyed in the operation, sufficient drainage may be afforded into the mouth and the opening through the turbinated bone rendered unnecessary. It generally occurs in extensive empyema of the sinuses that an opening in the turbinated bone takes place by necrosis and in some cases affords the desired drainage while in the majority the pathologic opening is so placed that it is incomplete. I^eave all wounds entirely open and irrigate daily with antiseptic solutions. Dangers. Care must be exercised to not injure the superior maxillary division of the trifacial nerve, NF, Plates IV-VII, either in trephining or after the sinuses have been opened. The bony conduit of this nerve is in rare cases entirely resorbed by pressure from dental cysts or other causes, leaving it stretched across the cavity as a white nacrous cord, intensely sensitive. Any injury to this nerve causes intense pain and renders the animal very resistant to the necessary manipulations in the after care of the wound and may leave it pernamently nervous about the handling of its face. Hemorrhage is generally not severe and may occur from the skin, where it should be controlled by compression or ligation ; from the inter-osseous vessels, where it may be checked by pressure with absorbent cotton, by pushing a small portion of cotton into the channel of the vessel with a needle or tenaculum or by plugging the vessel with a conical piece of wood ; from the wounded turbinated bones w^here it may be stopped by packing with cheese cloth. These tampons should be removed after twenty-four hours. PivATE VI. Trephining the Facial, Sinuses. Cross section downwards and backwards oblique through the half of the head at the first molar in a two year colt. F, frontal sinus ; N, nasal passage at point of communication with the inferior maxillary sinus, IM ; IM\ median portion of inferior maxillary sinus ; SM, ex- treme lower end of superior maxillary sinus opened ; Mi, first molar; M2 second molar; P, palatine artery ; SZ, sub- zygomatic artery. p- Ml 52 m •^;^ TREPHINING THE NASAL FOSSAE. 37 5. TREPHINING THE NASAL FOSSAE. Uses. Operations on the septum nasi, upon the tur- binated bones, the removal of tumors or foreign bodies. Instruments. Same as for the frontal sinuses. Technic. The trephining is carried out by the method described above, in the region of the nasal bone, close by the median line of the face and according to indications at any point from a level of the dotted line, SM, Plate III, to the upper extremity of the false nostril. The operation should be immediately against the median line since other- wise the frontal or superior turbinated sinuses may be opened, the highly vascular superior turbinated bone wounded or an important inter-osseous artery in the nasal, just above its union with the superior turbinated, bone as shown in Plate VI, may be served. Special care is also necessary that the trephining should not be carried too deeply and that the osseous disc be carefully removed in order to avoid wounding the highly vascular turbinated bone, which lies in close proximity to it. The operative area is narrow and the trephine used should not exceed 2 cm. in diameter. Whenever possible the operation should be carried out on the standing animal which decreases the hemorrhage and the danger from aspiration of fluids. The hemorrhage may be further controlled in operations upon the septum nasi and turbinated bones by spraying the parts with adrenaline chloride and cocaine. Even in the standing animal, if extensive operations are to be carried out on the very vascular septum nasi or on the turbine it is generally advisable to preform trachetomy before trephining, and re- tain the trachea tube in position until all danger has passed. When the animal is confined in the recumbent position the patient's safety demands that tracheotomy be performed before the operation is begun in almost all cases. Anaes- thesia may be maintained in such cases by means of an ordinary funnel with its tube bent at right angles and in- PI.ATE VII. Trephining of Faciai. Sinusks. Cross section of the left side of the head anterior to the last molar, and through the widest part of the inferior maxillary sinus. M^, last superior molar ; SM, superior maxillary sinus at its antero-inferior extremity ; IM, in- ferior maxillary sinus, lateral portion ; IM^ do. median portion ; N, nasal fossa ; S, sound lodged in lachrymal duct ; NF, trifacial nerve ; F, frontal sinus. — SM '■V •<^ ^^-M POLL EVIL OPERATION. 41 serted into the trachea tube while the chloroform is dropped on a towel spread over its mouth. After completing any required operation on the septum, turbinated bones or other parts, hemorrhage may be controlled b}' plugging one or both nasal fossae with single strips of gauze of sufficient size and carefully securing them by sutures to the sides of the trephine wound or otherwise. 6. POI.L EVIIv OPERATION. Plate VIII. Instruments. Clipping shears, razor, sharp scalpels, probe-pointed bistoury, probe, lyUer's bone forceps, bone gouge, curette, suture and dressing material. Technic. Confine the animal in lateral decubitis prefer- ably upon the operating table, place under complete anaes- thesia and remove the halter or other headgear. Clip the foretop and mane and shave the forehead and the top of the neck back to a distance of 8 or 10 cm. or as much farther as may be required to pass beyond and be- hind the supposed extension of disease, and disinfect the area. With sharp scalpel make a longitudinal incision on the median line of the head and neck beginning at a point presumably posterior to the diseased area and carry- ing it over the poll down onto the forehead for a distance of 4 or 5 cm. "below the foretop. Continue this incision through the skin, the subcutem, the adipose tissue, AT, Plate VIII and either through or passing around alongside the neck ligament, LN, into the diseased area beneath the latter. Dissect the ligamentum nuchae away from the ad- joining tissues as far back as diseased and divide obliquely upward and backward as indicated at AA, and detach anteriorly from the base of the occiput. Be careful to re- u u a (V s o o IJ >-i <^ .5 3 .2 1» ri tn OJ o o '^ a ^ S ^ C/3 TS 'o O D o 3 e j3 V "cfl 1 a H ^ w c 2 < > c c 51 o o h-r W cC a; -M P^ niJ a o a ^ cd cC g bjo .2f s 13 c 2 tn a a 4-J h^ w H-H o >> o Cii a (33 fl .-zi' H o H )— 1 5 .2 '> ■*-l X 'o to 'c a o CO a u .2 CO ;_ (X 'C ti ^ o 1 ca ^ '& d H ^ 0} o 05 a 0) \ \, ; -^- LIGATION OF THE PAROTID DUCT. 45 move every portion of the ligament in the area indicated and all calcareous deposits or diseased tissues. With Luer's forceps groove a channel about 2 cm. wide from behind to before directly upon the median line through the occipital protuberance to the depth of about 2 cm. making the bottom as near as possible on a level with the wound in the soft tissues as indicated by the dotted line, A A. Using Luer's forceps as a curette detach all vestiges of the neck ligament from the base of the occiput and leave the bone bare and smooth. If the Luer or ronguer forceps are not available the grooving of the occiput may be accomplished with a strong curved bone gouge. Be careful to avoid penetrating the cranial cavity or the occipito-atloid articulation. Con- trol the hemorrhage, cleanse and disinfect the wound, pack with iodoform gauze and suture for its entire length except the anterior part, where the tampon should slightly pro- trude, and dust the margin of the wound with iodoform and tannin. Remove the tampon after forty-eight hours and dress antiseptically daily. The sutures may or may not be removed according to conditions. In carrying out this operation our chief aim should be to remove all diseased parts, to afford perfect drainage anteriorly, to secure and maintain antisepsis, and to keep the wound directly on the median line from which no visible scar will result. 7. LIGATION OF THE PAROTID DUCT. Plate IX. Objects. The destruction of the parotid gland in case of fistula from wounds or abscesses. Instruments. Razor, convex scalpel, straight probe- pointed scalpel, tenaculum forceps, ligation forceps, tenacula needle holder, probe, suture and dressing material. Technic. In case of salivary fistula insert a probe through it into the duct toward the gland and with Pi. ATE IX. lylGATlON OF THE PAROTID DuCT. Pig, I. Segment of the left ramus of the in- ferior maxilla of the horse seen from the right and beneath, sp, usual operative field ; a, ex- ternal maxillary artery ; v, external maxillary vein ; st, st, parotid duct Fig. 2. Life size of operation field aXsp, fig. i; a, external maxillary artery ; v, external maxil- lary vein ; st, parotid duct ; ;//, masseter muscle. LIGATION OF THE PAROTID DUCT. 49 a sharp scalpel lay it free for a distance of from i to 2 cm. on the glandular side of the fistulous opening. If the fistula has its location on the side of the cheek, cast the horse and shave and disinfect the region on the inferior maxilla where the artery, vein and parotid duct turn around its inferior border. When the operator glides his finger over the vascular region from before backward there is felt a resistant cord, the external maxillary artery about 3 mm, in diameter, pulsating in the living animal. Between this and the oral border of the masseter muscle make an incision about 4 cm. long parallel with the artery through the skin and skin muscle. This incision is more readily made by gathering up a fold of skin about 2 cm. high and cutting through it. Pick up the loose connective tissue with a pair of forceps and excise it. Immediatel}^ behind the external maxillary artery, a, Figs, I and II, Plate IX, is the ex- ternal maxillary vein, v, and behind this and immediately on the border of the masseter muscle lies the parotid duct, st. In case of salivary calculi which cannot be removed through the mouth and cystic dilation of the parotid duct, make the cutaneous incision at the affected point, open the canal, and after the removal of the calculus, etc., close the duct wound by means of intestinal sutures in such a way that the external surfaces of the lips of the wound in the wall of the duct are brought in contact, or ligate the duct on the proximal side of the point of operation. Ligation is accomplished by passing a strong silk thread behind the duct by means ^ of a curved aneurism needle carrying the ligature around it and tying with a surgeon's knot. The parotid duct can also be previously split and an internal wound made at the point of ligation. Close the skin wound by means of a continuous suture and cover the operative surface with iodoform collodion or with wound gelatine. 50 EN TR OPIUM OPERA TION. 8. ENTROPIUM OPERATION. Instruments, Razor, convex scalpel, tenaculum and ligation forceps, tenacula, needle holder, needles, thread, absorbent cotton. Technic. Quiet adult horses may be operated upon in the standing position with the aid of local anaesthesia, other horses and small animals should be secured in lateral re- cumbency preferabl}^ upon the operating table. Shave and disinfect the skin of the inverted e^^elid. Grasp the skin of the eyelid midwaj^ between the inner and outer canthi either with the fingers or the forceps and elevate a skin fold parallel with the border of the eyelid to such a height that the inverted member assumes its normal position. Pass Fig. I. Entropium operation on the superior and inferior eyelids of the dog. one finger into the conjunctival sac to make sure that the conjunctiva is not drawn into the skin fold. Clip the fold off with the scissors immediately below the forceps, remov- ing an oblong piece. Between the border of the eyelid and that of the wound the skin should be left intact for at least .5 cm. Ligate any bleeding vessels and close the wound by means of interrupted sutures. The wound may be covered with iodoform collodion or wound gelatine or dusted over with iodoform-tannin. It is usually un- necessary and inadvisable to cover the parts with hood or other appliance since so long as the wound is healing properly the animal will not disturb it. STAPHYLOTOMY. 51 9. STAPHYLOTOMY. Object. An operation devised by Dr. M. H. McKillip for making a manual exploration of the Eustachian tubes, guttural pouches, larjnix, pharynx and posterior nares ; and for operations upon these structures. The form and extent of the soft palate of the horse is such as to render it ex- tremely difficult to make a manual exploration of the parts above and behind it, and impossible to make a visual ex- amination except with the aid of the expensive and compli- cated rhino-laryngoscope, which only aids in diagnosis while staph^dotomy combines with this operative advantages, per- mitting the free introduction of the hand into the laryngo- pharyngeal region. Instruments. Mouth speculum, short curved probe pointed bistoury with a ring to fit the middle finger. Technic. Cast the patient or secure on the operating table in lateral recumbency and turn the nose upward. Adjust the mouth speculum and open the mouth as wide as possible ; draw the tongue well out with the left hand while the right carrying the knife on the middle finger is passed carefully through the fauces until it hooks over the posterior border of the soft palate. The knife is then gently drawn forward making an incision along the median line of the soft palate from its posterior, free border to its attachment on the palatine bone. The hand is then withdrawn and the speculum removed for a few minutes to permit the patient to rid its pharynx^ of any blood clots or mucus that may have accumulated. Readjusting the speculum as before, the right hand is again passed through the fauces and now that the palate is divided a digital exploration may perfectl}^ re- veal the presence of any abnormality in the region. Plate X. Trifaciai. Neurotomy. LIv, Levator labii superioris proprii muscle ; lOF, infra-orbital foramen ; NF, superior max- illary division of the trifacial nerve. TRIFACIAL NEUROTOMY. 55 lo. TRIFACIAL NEUROTOMY. Plate X. Object. The relief of involuntary shaking of the head. Instruments. Razor, .scissors, convex scalpel, tenacula, aneurism needle, compression artery forceps, needles, thread, absorbent cotton, a strong piece of muslin 12 cm. square, Technic. Secure in lateral recumbency, preferabh^ upon the operating table, and produce complete anaesthesia. Re- move the halter, bridle, or other head gear. Shave and disinfect an area 8 to 10 cm. square over the infra-orbital foramen. Locate by touch the infra-orbital foramen, I OF, Plate X, below the levator labii superioris proprius muscle and displace this slightly upward toward the median line of the nose until the foramen can be clearly felt below the muscle. With the scalpel begin an incision somewhat superior to the foramen and near its nasal border and make a w^ound downward and forward in the direction of the commisure of the lips about 5 cm. long through the skin, muscle and connective tissue down to the nerve and control hemorrhage with the greatest care. If the larger branches of the glosso-facial vessels are severed they should be ligated or twisted. Some times it may be well to ligate these vessels prior to making the incision. Hold the lips of the wound apart with two tenacula, disect away the connective tissue from the nerve until every part of it is clearly in view. Pass an aneurism needle beneath the nerve trunk and lifting it from the bone make a search for a small arter}^ which usually passes along beneath it through the foramen and if this can be found either ligate it immediately at its point of emergence and again 5 cm. lower down and divide between the two ligatures or sepa- rating it from the nerve protect carefully against injury. With a probe-pointed bistoury or scissors .sever the nerve at the foramen and grasping the distal end disect away about 5 cm. of the trunk and excise. Be very careful to include all branches and especially one or two superior or dorsal 56 TRIFACIAL NEUROTOMY. twigs which are directed upward near the foramen. After the hemorrhage has been brought under complete control and all blood clots have been removed cleanse the wound carefully and dust over with iodoform and close with con- tinuous sutures. Owing to the great difficulty of securing complete asepsis, it may be better in some cases to not suture but to insert instead an antiseptic tampon retained by sut- ures for 24 hrs. after which remove and dress the wound antiseptically 2 or 3 times daily. In order to protect this first wound during the operation upon the other side take the piece of muslin mentioned among the needs for the operation, and folding it several times in a square, place it over the wound and suture it firmly at each corner. Turn the animal to the opposite side and repeat the operation on the other nerve except the application of the square piece of muslin which is here unnecessary. As soon as the animal stands, remove the protective piece of muslin from the first wound, disinfect both, dust them over with iodoform and tannin or cover with wound gelatine and leave undisturbed to heal by primary union. Avoid halter, bridle or other fixtures which might injure the wounds after the operation. Dangers. The chief danger in the operation is from in- fection, which sets up a severe neuritis in the proximal end of the nerve, aggravates the symptoms and causes much suffering. In order to prevent infection the aseptic precau- tions need be unusually strict in ever}^ detail and the anaes- thesia profound. Carefully avoid wounding the neighbor- ing vessels and control completel}^ any hemorrhage that occurs in order to avoid a hematom in the wound, which would invite infection. Literature. Involuntary twitching of the head relieved by trifacial neurectomy. W. L. Williams, Jour. Comp. Med. and V. A., vol. XVIII, p. 426. Involuntary shaking of the head and its treatment by trifacial neurectomy, do. Am. Vet. Rev., vol. XXIII, p. 321 and CEst. Monatsch. Thierheilkunde, Bd. XXIV, 3. 211. II. OPERATIONS ON THE NECK. II. OPENING OF THE GUTTURAL POUCHES. Pirate XI. Instruments. Razor, scissors, convex pointed and straight probe pointed scalpels, artery forceps, tenacula, probe, trocar, curette, drainage tubing, suture and dressing material. Technic. I. Viborg' s method. The operation is possible on the standing animal, but generall}- the patient must be cast or placed on the operating table and secured in lateral decubitis with the head extended. By extending the head and compressing the jugular vein there is brought out the triangle immediately behind the posterior border of the in- ferior maxilla and below the parotid gland comprised be- tween the posterior angle of the inferior maxilla, the terminal tendon of the sterno-maxillaris muscle and the external maxillary vein. In this so-called Viborg's triangle after the removal of the hair and the disinfection of the skin which is maintained stretched, make a 5 cm. long incision through the skin and skin muscle immediately beneath the afore- mentioned tendon and parallel to it. In case of pronounced swelling in Viborg's triangle the operator must determine the location for the incision by the position of the sterno- maxillaris muscle. The skin and subcutem having been incised to a sufficient extent, force a passage with the finger or with probe pointed scissors closed or other blunt instru- ment through the loose connective tissue on the median side of the parotid gland, to the guttural pouch and penetrate it at its lowest point with the finger or trocar. In order to open the empty guttural pouch it is desirable to grasp a portion of its wall by means of forceps. Through the operative wound a drainage tube can be introduced into the pouch, and fixed in its position by sutures. The opening PI.ATE XI. Opening of the Gutturai. Pouches (Hyo- yertebrotomy) According to Viborg AND Chabert. Head and neck of recumbent horse viewed from the side. 5w, Stylo maxillaris muscle ;/>, parotid gland ; /, guttural pouch ; k, larynx ; st, sterno-maxillaris muscle ; r, rectus capitus anticus major muscle ; c. external carotid artery ; e, external maxillary artery ; z, internal maxil- lary artery ; z/, external maxillary vein ; 5, probe ; a, wing of atlas. OPENING OF THE GUTTURAL POUCHES. 6i can be enlarged in an anter-posterior direction to the extent of 5 to 8 cm. or large enough to admit the operator's hand. A far more common operation in veterinary practice than the opening of the guttural pouches, is the opening of abscesses of the sub-parotid lymph glands, lying between the inner face of the parotid and the external face of the guttural pouch. The operation here used is the same as Viborg's for the guttural pouch but does not penetrate that cavity because the inner wall of the abscess has pushed the ex- ternal wall of the pouch inward so that the former largely occupies the usual location of the latter. The d3^spnoea generally prohibits casting the animal and necessitates operating in the standing position. In some cases the dyspnoea is so severe as to demand tracheotomy before the opening of the abscess can be undertaken because the ex- citement aggravates the difficult respiration to the point of suffocation. II. ChaberV s method. Secure the horse in the lateral re- cumbent position, remove the hair and disinfect the skin beneath the wing of the atlas. Make an incision about i cm. in front of the lower half of the wing of the atlas and parallel to it, about 6 cm. long extending through the skin and skin muscle down to the parotid gland. The incision is facilitated by rendering the skin tense with the left hand and care is to be taken not to wound the auricular nerve which passes directly along the atlas. Then draw backward the posterior lip of the wound and separate with blunt in- struments the posterior border of the parotid gland from the atlas, to which it is bound by loose connective tissue, and draw it forward with tenacula. At the bottom of the opening thus formed there is seen the stylo-maxillaris muscle, sm, Plate XI, lying against the median side of the parotid gland covered only by the aponeurosis of the mastoido-humeralis muscle. With the handle of the scalpel inclined toward the wing of the atlas penetrate in the 62 OPENING OF THE GUTTURAL POUCHES. direction of their fibers the aponeurotic expansion of the mastoido-humeraUs, and the stylo-maxillaris muscle. The puncture is thus located between the ninth and tenth nerves on one side and the internal carotid on the other. Since the wall of the guttural pouch rests against the median side of the digastricus muscle it is opened b}^ this incision. The operator inserts an index finger along the blade of the knife at first and then withdrawing the instrument passes the other index finger also in the penetrant wound and by forcibly parting these, dilates it. The abnormal contents are then removed by means of forceps, curetting and irrigation. In order to prevent adhesion of the wound lips in the firmly stretched st3do-maxillaris muscle, introduce a strong drain- age tube into the pouch and fix it to the external borders of the wound by a suture. III. Dideridi' s method. This combines the operations under I and II, with the difference that the superior opening of the pouch is made immediatel}" behind the stvlo-maxillaris. In order to accomplish this the cutaneous wound over the wnng of the atlas must be prolonged below it. After detach- ing the posterior border of the parotid gland the operator searches in the loose areolar tissue with the index finger of the left hand for the vascular angle which is formed b}^ the occipital, internal carotid and external carotid arteries which may be detected by pulsation — the same is located at a depth of somewhere from 8 to lo cm. Place the volar surface of the finger in the vascular angle and push a sharp scalpel along its dorsal side to the pouch which here becomes opened on its posterior lateral surface. This method has the advantage over Chabert's that for the removal of hard contents (chondroid) the opening can be readily dilated, even to such an extent that the entire hand can be passed into the air sac and the opening of the Kustachian tube be exolored. TRACHEOTOMY. 63 12. TRACHEOrOMY. Fig. 2. Instruments. Razor, scissors, convex scalpel, tenacula, tenaculum and ligation forceps, trachea tube, and suture material. Technic. In the superior third of the cervical region, in the neighborhood of the fourth to the sixth tracheal ring, shave and disinfect the skin on the anterior surface of the neck to the extent of 10 cm. long by 5 cm. wide. The operation is best performed upon the standing animal with the head extended. In lateral decubitis of the horse the operation is carried out with some difficulty, and generally the operator fails to get the incision on the median line. Fig. 2. Tracheotomy. 5, stern o-thyro-hyoideus muscle ; /, trachea ; sch, mucous membrane of the posterior wall of the trachea ; /, interannular ligament. The operator stands before the right shoulder of the horse with an assistant opposite him. Make the incision by rendering the skin tense along the median line of the trachea with the left hand and then mak- ing a drawing cut from above to below with the scalpel. After the skin muscle is cut through, in order to avoid hem- 64 TRACHEOTOMY. orrhage, separate the two sterno-thyro-hyoideus muscles by means of tenacula along the median line in the white strip of connective tissue. The opening into the trachea may be made in a variety of ways. The quickest and most crude method is to slit it from above downwards through three or four tracheal rings, and pressing the severed ends apart insert the tube through the opening. Since the tracheal rings are incomplete, being open on their dorsal surfaces, cutting through the ventral portion divides each ring into two separate parts and their being pushed apart, distorts them and tends to the causation of chondritis and collapse of the trachea, a danger which increases with the duration of time that the tube is maintained in position. It is there- fore most suitable for hurried operation in impending suffocation where the tube will probably be needed for a short time only. A second method of operation, illustrated in Fig. 2, con- sists in making a transverse incision through the inter-annu- lar ligament between the two last exposed tracheal rings the length of the diameter of the tube to be inserted. Make a perpendicular incision upward from each end of this at a point I to 1.5 cm. from the median line through one or two tracheal rings, according to the size of the tube. With forceps or tenaculum grasp the segments of partially de- tached cartilage and remove them by cutting through the inter-annular ligament. A third and to us preferable method is to insert a narrow bladed scalpel transversely at about the lower third of the lowermost bared tracheal ring and cutting outwards and upwards in a curved line, pass through the first inter-annu- lar ligament and continue into the succeeding segment until near its superior border, when the incision is curved down- ward to eventuall}^ reach the starting point, the isolated section of the trachea being securely grasped with a pair of forceps before its excision is completed. By this method no tracheal ring is severed. ARYTENECTONOMY. 65 The trachea tube is to be removed and cleansed daily as long as its use is necessary, and when discontinued the wound should be left open and dressed antiseptically. 13. ARYTKNECTOMY. PIRATE XII. Object. The relief of roaring or laryiiigismits paralyticus . Instrumenst. Razor, scissors, scalpel, razor shaped knife with long handle, long curved scissors, long curved uterine dressing forceps, double tenaculum forceps, trachea tube, retractors, reflecting lamp, absorbent cotton and dress- ing material. Technic. Perform tracheotoni}^ as advised in preced- ing chapter. Secure the animal in lateral recumbency preferably upon the operating table and induce complete anaesthesia closing the trachea tube in the meantime or administering the chloroform through this by means of a bent funnel while the nostrils are occluded b}' tampons. Shave and disinfect the skin over the laryngeal region. Place the animal upon its back with the head extended and remove the halter or other head gear. If necessary continue the adminstration of chloroform through the trachea tube by means of a funnel the small end of which is inserted in it while the chloroform is dropped on a towel spread over the larger end. The operator takes his place on the right side of the animal and the assistant on the left. Make a longitudinal incision through the skin and subcutem be- ginning at the anterior part of the thyroid cartilage and ex- tending backward on the median line of the 3rd. or 4th. tracheal ring. Control the cutaneous hemorrhage. Con- tinue the incision through the subjacent muscular tissue being careful to follow the median line exactly until the crico-thyroidean ligament, CTL, Plate XII, the cricoid cartilage C, and the first tracheal ring TRI, are laid bare. 5 PI.ATE XII. Arytenectomy. E, epiglottis ; TT, thyroid cartilage ; CC, cricoid cartilage ; TRI, first tracheal ring ; V. left vocal cord ; A, left arytenoid cartilage sur- rounded by dotted line of incision ; CTC, crico- thyro'ideau ligament. c--, TRl ARYTENECTOMY. 69 Again control anj^ hemorrhage. Phmge the scalpel with its cutting edge directed backward through the crico- th3'roidean ligament on a level with the dotted line T and extend this backward along the median line severing the cricoid cartilage, C, and the first tracheal ring, TRI. In- sert the retractors and have the larynx held well open by as- sistants. Illuminate the larynx by means of a reflecting lamp as may be required. After controlling any hemor- rhage caused b}^ the foregoing make an incision through the mucosa and the intervening connective tissue between the two arytenoid cartilages, A, beginning at the anterior part and extending backward to the cricoid, thence turn- ing upward and laterally, incise the mucosa across the posterior end of the arytenoid thence forward along its lateral border through the vocal cord, V, and turning down- ward as the animal lies, that is toward the dorsal part of the larynx, continue the incision to the point of beginning. In making this incision cut as closely as possible to the margin of the cartilage so that a minimum amount of the mucous membrane will be removed. Grasp the lateral border of the cartilage with the long tenaculum forceps and with a razor-shaped knife or the scissors separate the lateral and anterior portions of it from the adjacent tissues keep- ing always immediately against it in order to produce as clean a wound as possible and to avoid injuring adjacent vessels from which hemorrhage would occur. When the cartilage has been detached over the greater part of its surface locate the crico-arytenoid articulation and dis- articulate or cut through the arytenoid as close to the articu- lation as possible with the razor-shaped knife or the scLssors. Remove all blood by means of pledgets of absorbent cotton securely held in the long dressing forceps, or the clots may be pushed into. the pharynx when they will generally be swallowed. Carefully remove an}- cartilaginous remnants or tissue shreds and control the hemorrhage from any 70 ROARING OPERATION. visible vessels. Dust the wounds thoroughly with iodoform and tannin and if the capillary hemorrhage is great pack the larynx with a single strip of iodoform gauze and secure it by sutures through the margin of the skin wound. Re- move this tampon after twelve to twenty, four hours. Wash and disinfect the wounds daily. Remove the trachea tube daily and cleanse, and retain it in position for 6 to lo days or until the animal breathes freely without it. After about 8 days insert the retractors in the laryngeal wound, dilate it, examine the interior with the aid of a lamp and give any needed attention to unhealthy granulations or other untoward conditions. 14. ROARING OPERATION BY EXCISION OF THE VOCAL CORDS AND VENTRICLE OF THE LARYNX. Pr.ATE XIII Objects. The same as in the preceding operation except that we attempt to relieve roaring by causing the arytenoid cartilage to become fixed against the side of the glottis b}^ cicatricial adhesion. Instruments. Same as in the preceding. Technic. The technic of this operation is identical with the preceding until the larynx has been been opened. Grasp the left vocal cord with the double tenaculum for- ceps, one jaw of which rests in the ventricle and lift it up- wards until the parts are rendered tense. With the razor shaped scalpel make an incision parallel with the long axis of the vocal cord on the tracheal side of it through the mu- cous membrane and cord and continue this incision forward internally along the immediate border of the arytenoid car- tilage barely through the mucous membrane and laterally make a similar cut directed forwards approximately i to i}^ cm. distant from the preceding as indicated by the dotted line in Fig. i, Pla,te XIII. Keeping the parts in- ROARING OPERATION. 71 eluded in the tenaculum forceps tense, dissect the vocal cord and mucous membrane from the underl3nng parts from behind forward toward the apex of the arytenoid car- tilage and continue the two incisions forward until the ven- tricle has been passed when the}^ are made to converge and finally meet, thus isolating completeh^ the mucous mem- brane of that depression. Should the tension upon the vocal cord and mucous membrane by means of the tenac- ulum forceps be too great thej^ may tear asunder in which case the remnants must be grasped by means of the tenac- ulum forceps or better with the long dressing forceps and the operation continued. The mucous membrane should be carefully trimmed around the margin of the wound and care should be taken to not remove entirely the remnants of the wasted thyro-arytenoideus muscle because that tends to permit the cartilage to drop down too low in the larynx nor. should the incision in the ventricle be carried deeper than the mucous membrane lest we wound important ves- sels and produce annoying hemorrhages. Remove all blood clots and disinfect the parts. Apply no sutures to the wound in the vocal cords, mucosa or larynx. After the animal has recovered from the anaesthesia, cleanse the ex- ternal wound carefully and wash it daily with an antiseptic and if thought best apply this also to the wound in the vo- cal cord b}^ means of saturated absorbent cotton grasped with the long dressing forceps and pushed up to the area through the laryngeal incision. Cleanse the trachea tube daily and keep in position from six to ten days or longer, should the animal show difficult}^ in breathing when it is removed. PI.ATE XIII. Operation for Rkuef of Roaring. Fig. I. Longitudinal section through the ventricleof the larynx ; A, Arytenoid cartilage; TA, Anterior fasiculus of thyro-arytenoideus muscle ; TA^, Posterior bundle thyro-arytenoid- eus ; VC, vocal cords ; V, Laryngeal ventri- cle ; T, Thyroid cartilage ; E, Epiglottis. Fig. 2. Sagittal section of the larynx. C, cricoid cartilage ; C-T, crico-thyroidean liga- ment. Other lettering same as Fig. i. Fig I Fig. 2. INTRA-TRACHEAL IRRIGATION. 75 15. INTRA-TRACHEAL IRRIGATION. Objects. The washing of irritant or septic substances from, and the disinfection of, the trachea and bronchi. Instruments. Same as for tracheotomy, and a gravity irrigating apparatus fitted with 3 m. of rubber tubing about I cm. in diameter, 5 Hters of .6 percent, soda chloride solu- tion at a temperature of 37 to 39° C. Technic. Operate on the standing animal. Perform tracheotomy. Elevate the gravity apparatus containing the irrigating fluid i to 2 m. above the patient, have the animal's head sHghtly elevated, insert the free end of the rubber hose in the trachea tube and let the fluid flow into the trachea in a moderate stream until it is filled and the animal makes expulsive efforts, when the inflow is stopped and the animal permitted to lower his head and expel the fluid, then raise the head again and repeat until the fluid is expelled clear. Repeat the operation according to require- ment. In cases of suppurative bronchitis, peroxide of hydrogen may be added to the solution. 16. INTRAVENOUS INJECTION. Fig. 3. Instruments. Scissors, hypodermic S3^ringe. Technic. The operation is performed on the standing animal on either jugular vein at about the juncture of the upper and middle thirds of the neck ; to most operators the right jugular is the more convenient. At the place desig- nated the subscapulo-hyoideus muscle lies between the jugular vein and the carotid artery. After clipping the hair, the skin should be carefully disinfected. The vein lies in the jugular groove between the mastoido-humeralis and the sterno-maxrllaris muscles covered only by the skin and skin muscle. Stand by the shoulder of the horse and compress the jugular with the thumb as shown in Figure 3 or with the 76 INTRAVENOUS INJECTION. second to the fourth fingers, in which case the ball of the thumb rests on the mastoido-humeralis muscle, in a wa}^ that the vein becomes filled above the point of compression in the shorn area and stands out as a swollen cord. In the case of fleshy necked horses this compression is more readily attained if the htad is somewhat elevated and extended by an assistant. If the vein can not be made prominent in this Fig 3. Intravenous Injeclion. wa}^ the compression should be alternatel}' applied and with- drawn suddenly, the course of the vein then reveals itself by a wave-like movement along the jugular groove. Just above the point of compression the vein is the most fully distended and firmly fixed. After testing the hypodermic needle to see that it is open hold it between the second and third fingers while the thumb covers its basal opening and thrust it through the skin, cutaneous muscle and jugular wall, in the direction of the vein obliquely forwards and up- wards I to 2 cm. deep, so that the point of the needle enters the vessel at its most distended part. In this way it is easy to prevent injury to the median wall of the vein. If the PHLEBOTOMY. 77 vein has been properly punctured blood will flow from the needle upon the removal of the thumb. If the vein is not entered at the first attempt the needle should be partly with- drawn and then pushed in again in a slightly different direc- tion. The compression is then removed and the hypo- dermic syringe in which no air is contained is connected and the contents slowly discharged into the vein. In with- drawing the needle be careful to press the skin firmly against the underlying part. The omission of this precaution fre- quently results in the formation of a subcutaneous hema- tome. 17. PHLEBOTOMY. Fig. 3. Instruments. Razor or scissors, fleams, lancet, phle- botomy trocar, spring lancet, pins, suture material. Technic. a. Phlebotomy zvith fleams may be performed on either jugular vein. The operation is preferably carried out on the standing animal, but is not difficult when the patient is recumbent. The point of operation is at about the boundary line between the upper and middle cervical regions, because it is here that the subscapulo-hyoideus muscle which separates the jugular vein from the carotid artery is most voluminous and consequently affords the greatest protection to the latter. At this point clip or shave and disinfect the skin. Grasp the extended blade of the fleam at the joint with the thumb and index finger of one hand, whiles the third and fourth fingers compress the jugular vein at a point far enough below the shaved part that the fleam blade rests upon it. In fleshy-necked animals the course of the vein may be clearly made out by causing its repeated distension and relaxation. It is well to be careful that the point of the fleam blade is not allowed to prick the skin prematurely and render the animal rest- 78 PHLEBOTOMY. less, and that it is held perpendicular to the surface and parallel to the long axis of the vein. The most elevated point of the vessel should be struck b}' the blade in such a way that the skin, subcutaneous muscle and jugular wall are penetrated parallel to the long axis of the vessel. Drive the fleam blade into the vein by a short, sharp blow with a small stick of heavy wood. The extension on the fleam blade prevents its being driven too deeply. The size of the blade to be used depends upon the thickness of the skin and other tissues covering the vein. If the vein is opened, dark red blood escapes from the wound in a large stream. If the operation does not succeed at the first effort, one should select an undamaged portion of the skin for a second attempt so that the opening into the vein may be direct and clean. When the vein is opened lay the instrument aside, the compression of the vessel being continued in order to prevent aspiration of air into it and also that the lips of the skin wound shall not become displaced in relation to that of the vein by which the escape of blood would be impeded or stopped. The flow of blood ma}^ be favored by inducing masticatory movements by the animal. The amount of blood withdrawn varies between 3 and 8 liters, according to size of the animal and the object to be attained. The wound may be closed by an interrupted or a pinned suture. For the latter, relieve the compression on the vein aiid grasp the lips of the skin wound between the finger and thumb and stick the pin perpendicularly through the middle of it a few mm. from its borders. Apply a noose of silk ligature previously prepared over the pin and close and tie the loop. In applying the pin and loop, take care not to devate the skin from the underlying part, which tends to the production of a hematome. b. With the lancet the operation is preferably performed on the right side of the neck. Compress the vein as illus- trated in Fig. 3, and hold the lancet between the thumb and LIGATION OF THE CAROTID ARTERY. 79 index finger in such a manner that it can only penetrate as far as into the vein, and then push it in quickl}^ just in front of the compressing thumb through the skin, subcutem and venous wall as deep as the fingers holding the lancet will permit. Hold the blade perpendicular to the long axis of the vein, and avoid directing the point dorsalwards, which would endanger the superior wall of the vessel or cause the lancet to glide over the wall and not enter the vein. When the lancet has entered the vein, extend the wound somewhat toward the head by flexing the hand dorsally. In cattle it is necessar}^ to compress the vein b}^ means of a cord tightlj^ drawn around the neck, the operator taking the same posi- tion as in the horse while an assistant holds the animal by the horns or nose. Close the wound as in a. Phlebotomy with the spring lancet is carried out in a sim- ilar manner, the jugular being compressed in the same way, and the lancet, with the spring set, placed over the vein in such a way that the opening will be made in the same direc- tion and manner as with the fleams. The lancet blade is then released and penetrates the vein. The compression be- low is continued as in other cases. c. Phlebotomy zvith the tiocar is performed in the same manner as has been described for intravenous injection. So long as the flow of blood continues the compression of the vein must not be intermitted. The phlebotomy trocar should be about 5 mm. in diameter. 18. LIGATION OF THE CAROTID ARTERY. PI.ATE XIV. Objects. The control of hemorrhage from wounds or the prevention of hemorrhage during the removal of tumors or other operations iu the parotid region. Instruments. Scissors, scalpel, tenacula, aneurism Pirate XIV. Fig. I. — a, Ligation of the common carotid artery ; b, CBsophagotomy. Fig. 2. — Ligation of the common carotid artery, ^.common carotid artery ; 7, jugular vein ; v, vagus nerve ; s, sympathetic nerve ; r^ recurrent nerve; />, cervical pauniculouscarnosus muscle; in, sternomaxillaris muscle ; st, levator humeri muscle. Fig. 3. — O^sophagotomv. c, com- mon carotid artery;/, jugular vein; 0, o\ oesophagus ; s, sympathetic nerve ; t, trachea ; st, mastoido hum- eralis (lavator humeri) muscle. Fig. I. LIGATION OF THE CAROTID ARTERY, 83 needle, mouse-toothed forceps, ligation forceps, suture material. Technic. The operation is possible on the standing animal with the aid of cocaine or other local anaesthetic but it is preferable to confine the patient in lateral recumbency and anaesthetize. The operatioD is made at the same point as for phlebotomy and the same cutaneous wound, a, Plate XIV, ma}^ be used for this purpose. The incision should be at least 10 cm. long extending through the skin, flesh}' panniculus and subscapulo-hyoideus muscles and then a passage forced with the fingers, to the trachea. At the region of the neck indicated, the carotid passes along the border between the lateral and dorsal surfaces of the trachea, accompanied dorsalh' b}- the vagus and sympathetic nerves and ventrally b}' the recurrent. (In Figure 2, Plate XIV, the vagus and sympathetic nerves, v and s, are pushed out of their normal position and appear ventrally to the carotid.) Pass the index finger over and behind the carotid until the trachea is reached, and encircling the inner and lower sides of the arter}^ force a way through the surrounding areolar tissue and draw the vessel out through the wound. As a rule the carotid is still loosely surrounded by connective tissue, which comes from the deep fascia of the neck and in which also the three above mentioned nerves are found. These nerves must be carefuU}- separated from the carotid and must on no account be included in the ligature. Ligate the carotid twiqe with an interval of about 2 cm. between the two ligatures and divide the artery midwa}^ between them. The second ligature is necessary in order to prevent hemorrhage from the distal end through collateral anasto- moses and it is essential to sever the arter}' in order to avoid its rupture by the stretching of the undivided carotid dur- ing movements of the neck where the nutrition has been cut off at the point of ligation. Provide drainage for the wound and suture the muscle and skin. 84 CESOPHAGOTOMY. 19. ce:sophagotomy. PlvATE XIV. Instruments. Razor, scissors, convex scalpel, straight probe-pointed bistour}^, tenacula, artery forceps, absorbent cotton, suture material. Technic. The operation can be carried out on the standing or the recumbent animal. At its origin the oesophagus lies above the trachea somewhat to the left of the median line and as it descends it gradually deviates farther until in the lower cervical region it lies down along the side. The operation is performed at any point between the pharynx and chest where the lodgment of a foreign body or other condition may demand it. When the oesophagus is empty the operation is best performed in the lower third of the neck at b, Figure i, Plate XIV. An incision 10 cm. long through the skin and skin muscle is made on the left side between the anterior border of the mastoido-humeralis muscle and the jugular vein. With the two index fingers divide the loose connective tissue down to the oesophagus, which lies between the left scalenus muscle, trachea and jugular vein. Along the supero-external border of the trachea runs the carotid, accompanied dorsally by the vagus and sympathetic and ventrally by the re- current nerves. The oesophagus feels like a round muscle within which one can distinguish a firmer cord, the mucous membrane. When brought into view the organ has a pale red color, and it, with the trachea is surrounded by the deep fascia of the neck. Pass one finger around the oesophagus from behind, draw it away from the trachea, force a passage through the deep fascia of the neck and draw it out through the external wound. After making an incision through the muscle and mucous membrane intro- (BSOPHAGOTOMY. 85 duce a probe pointed bistoury or a scissors blade into the lumen of the oesophagus and split its wall. The mucous membrane is white and lies in thick longitudinal folds. When there is a foreign bod}^ in the oesophagus the opera- tion is performed at the point where it is lodged in the manner described and the incision should be made only large enough to permit its removal. In diverticuli of the oesophagus an elliptical piece of the mucous membrane which has been overstretched is cut out. The oesophageal wound is closed by a laminated suture, that is, the mucous membrane is united by means of an intestinal suture and the muscular wall closed over this. The skin and muscular wound may either be left open or closed with the Baj-er suture and bandaged with a drainage tube in the lower angle. III. OPERATIONS ON THE TRUNK AND GENITAL ORGANS. 20. PUNCTURE OF THE CHEST. Fig. 4. Objects. The relief of hydrothorax or pyothorax. Instruments. Razor, scissors, trocar, i m. of rubber tubing of the same size as the trocar, vessel for receiving the escaping fluid, dressing material. Technic. Operate upon the standing animal, the point of operation being the seventh intercostal space on the left side, and the sixth on the right. Dogs may be laid upon Fig. 4. Puncture of the ciiest ; puncture of the intestine. the table. The anterior ribs are so covered by the shoulder that they cannot be counted from before backwards and must be enumerated from behind forwards. In the horse we estimate eighteen ribs and in the dog fourteen. Count- ing II or 12 intercostal spaces from behind we reach the PUNCTURE OF THE INTESTINES. 87 point of operation on the left and right sides respectively. Clip or shave the designated intercostal area immediately above the thoracic vein. Grasp the trocar firmh^ with the thumb and index finger of one hand at such a distance from the point as will permit the canula to enter the chest. After the skin over the seat of operation has been drawn aside by the hand, place the trocar at the anterior border of the rib with the point inclined slightly forward and with a sharp blow with the palm of the other hand drive the in- strument through the skin, cutaneous and intercostal mus- cles, internal thoracic fascia and pleura into the pleural sac. When the resistance ceases, the thoracic cavity has been entered. Remove the stilette and permit the pus, l3'mph, or other fluid to escape. This flow is at first continuous, but later becomes rythmic, synchronous with respiration. The intermission of the flow during inspiration permits air to enter the pleural cavit}^ unless precautions are taken against it ; this is most readily obviated by slipping one end of the rubber tubing over the exposed part of the can- ula and placing the other extremity in the receptacle for the fluid where it will be submerged. This wiil not only prevent aspiration of air into the chest but will act as a sj^phon to aid in the withdrawal of the fluid from the pleu- ral cavity. In the absence of the tubing the entrance of air may be avoided by closing the canula with the finger after each expiration. 21. pqncture; of the intestines. Figs. 4, 5. Object. The relief of intestinal t3'mpany. Instruments. Razor, scissors, trocar. Technic. Puncture of the intestine is preferably per- formed on the standing horse but may be carried out on the recumbent animal. The point of operation is in the right 88 PUNCTURE OF THE INTESTINES. flank about equi-distant from the last rib, the extremities of the transverse processes of the himbar vertebrae and the ex- ternal angle of the ilium in the standing horse ; at the upper- most point of the abdomen in the recumbent animal, that is, at the most prominent part of the distension. After the skin at this place has been clipped or shaved and disinfected grasp the trocar with the index finger and the thumb of the left hand and holding the instrument perpendicular to the bod}^ surface, give it a firm, quick blow with the palm of the right hand and drive it through the abdominal wall into the intestine. With a properly constructed trocar of the dimensions suggested in Figure 5 no preliminary puncture with the lancet is required or advisable. The cutting end of the stilette should be very long, tapering and sharp so that it will cut as freely as the lancet. By performing the operation as directed the trocar ordinarily punctures the Fig. 5. Intestine trocar with sheath. Outside diameter of canula 3 mm., length of canula, 16 cm. caecum. Withdraw the stilette and permit the gas to escape through the canula. The canula may become occluded by particles of ingesta entering it and these should be removed by reinserting the stilette. The intestine first punctured may collapse and the flow of gas cease while the tympany continues in other parts ; this may be overcome by reintro- ducing the stilette and pushing the trocar through the distal wall of the bowel and into the next section of intestine beyond. If this does not succeed the trocar may be with- drawn and reinserted in a neighboring area or if need be on the opposite side of the animal. In withdrawing the canula replace the stilette and press the skin against the abdomen SUBCUTANEOUS CAUDAL MYOTOMY, 89 with the thumb and finger of one hand while the trocar is drawn out with the other. This tends to prevent particles of ingesta from following the canula out of the intestine and becoming lodged at some point in the track of the wound to set up inflammatory processes there. Before introduction, the trocar should alwa5's be rendered sterile but should not bear irritant antiseptics, which becoming lodged in the wound tend to irritate the tissues and produce abscesses. Puncture of the intestine is so often extremely urgent that deliberate aseptic precautions are not always practicable and trocarization only too frequently results in abscesses in the abdominal wall. Its prevention must depend chiefly upon the disinfection of the skin and instrument. It becomes important to use an instrument which is clean in advance. If the one shown in fig. 5 is well disinfected after using and the sheath is filled with alcohol before it is screwed on, the instrument will remain sterile until it is again unsheathed and then the alcohol will quickl}^ evaporate and leave it aseptic. 22. SUBCUTANEOUS CAUDAI, MYOTOMY. Fig. 6. Object. The correction of curved tail. Instruments. Sharp straight tenotome, bandage. Technic. The point or points of curvature and their extent are to be caref ull}^ noted by having the animal trotted away from the operator. The curvature is generally due to unequal development of the two levator or extensor muscles. Fig. 6.-6', though quite rarely the depressors, /, may be implicated. Confine the animal in stocks, or in default of these, control by means of a twitch and sideline. Cleanse and disinfect the tail and have it sharply bent by an assistant in the opposite" direction to the curvature. Locate the longi- tudinal furrow between the levator and depressor muscles on 90 SUBCUTANEOUS CAUDAL MYOTOMY. what has now become the convex side and at the lower margin of the levator and just above i\ Fig. 6, insert the tenotome at the most prominent part of curvation, the incision being paral- lel wath the muscular fibers, and push the instrument entirely through the muscle to the vertebra, then turning the cutting edge upwards, at the same time advancing the point toward the median line, sever the entire muscle. The superior lateral caudal artery, s, P'ig. 6, bleeds profusely if severed, and wounding of it may usuall}^ be avoided by withdrawing the tenotome a trifle in passing that point. Wounding the Fig 6. Transverse section of the tail, w, caudal vertebra ; c, sacro- coccygeus lateralis muscle;^, sacro coccygeus superior;/, depressor longus and brevis muscles (sacro-coccygeus infer- ior) ; z, intertraiisversales muscles ; a, coccygeal artery ; s, sa- pero-lateral coccygeal artery ; /, infero-lateral coccygeal ar- tery ; V, caudal veins (dorsal, ventral, lateral) ; sch, caudal fascia ; h, skin, skin over the muscular incision is avoided by placing the thumb of the left hand over the line of incision so the knife will be recognized as soon as the muscle and cau- dal fascia are cut through. Remove the knife in the same manner as introduced. Release the horse and have him trotted again. If the operation is sufficient, the tail should curve in about the same degree as before, but in the opposite direc- CAUDAL MYECTOMY. 91 Hon. If this has not been attained examine carefully and sever any remaining bundles of muscle, and this not suffic- ing repeat the operation as before at another point 5 or 6 cm. above or below the first, severing the muscle again. Or if the depressor appears implicated, sever it in a similar manner. In extreme cases the entire lateral half of the caudal muscles, tendons and aponeurosis may be severed. Apply an antiseptic pad to the wound and retain it by a moderately firm bandage, which serves at once as an occlu- sive dressing and effective hemostatic. Remove the band- age after 24 hours. By this plan of operation it is not intended to tie the tail to the side of the animal during the time of healing but when bandaging it immediately after the operation, it should be held away from the side toward which it formerly curved so that the bandage would tend to prevent the return of the organ to its former position. 23. CAUDAL MYECTOMY. Fig 6 AND Plate XV Objects. For the prevention of the gripping of the reins by the tail. Instruments. Elastic Hgature, straight bistoury, tenacula, absorbent cotton, bandages. Technic. Confine the animal in lateral decubitis or in stocks, cleanse and disinfect the parts and apply the elastic ligature as close as possible to the root of the tail. Have an assistant hold the tail upwards, z. e., dorsalwards, and tightly stretched. Make an incision 15 to 20 cm. long, over the middle of the inferior surface of each depressor longus muscle, beginning close against the elastic ligature and ex- tending toward the apex, severing at once the skin and caudal fascia down to the muscle. Let an assistant retract the lips of the incision with tenacula while the operator dissects the depressor longus muscle, DC, Plate XV, from Pr.ATE XV. Caudai, Mykctomy To Prevent Gripping OF THE Reins. DC, Depressor coccygeus longus muscle ; T, tourniquet. \ AMPUTA TION OF THE TAIL. 95 the adjacent tissues at either side, sever it b}^ a transverse incision close against the Hgature and dissect away the en- tire muscle down to the lower end of the w^ound and there excise it. Repeat the operation on the opposite side. Make two elongated tampons of absorbent cotton, of the size and form of the muscles removed, saturate these with i-iooo sublimate solution, insert neatlv in the wounds and over this to aid in securing antisepsis and to equalize the pressure apply a pad of absorbent cotton, saturated with sublimate solution, covering the wounds and encircling the tail and secure by a moderately firm bandage as closely as possible to the elastic ligature. Remove the ligature, when hemor- rhage may ensue, which is to be controlled by the applica- tion of a second bandage extending higher up on the tail. Remove the bandage in 24 hours and dress as before for a second day after which treat as an open wound. Care should be taken to not apply the bandage too tightly or leave it in place for more than 24 hours, since otherwise necrosis of the tail is liable to occur and necessitate amputation. 24. AMPUTATION OF THE TAIL Plate XVI. Objects. The treatment of malignant, or incurable dis- eases of the tail. Instruments. Elastic bandage, scalpel, razor, artery forceps, bone cutting forceps, suture material. Technic. The animal may generally be operated upon in a standing position secured in the stocks or with the aid of the side line. Local anaesthesia may be applied by in- jecting cocaine or other drug deeply upon the nerve trunk as well as just beneath the skin. The animals' attention may be attracted by means of the twitch if found necessary. The point of amputation is determined by the location of PI.ATE XVI. Amputation of Taii.. Fig. I. — Tail amputated showing flaps un- sutured ; B, Bandage securing hairs turned upward out of operator's way. Fig. 2 — Operation completed showing su- tures ; B, Bandage applied to secure hair of tail upwards out of operator's way. Fig Fig. 2. AMPUTATION OF THE TAIL. 99 the disease. Over the area of operation dip the hair, shave and thoroughly disinfect. Apply the tourniquet or elastic bandage at the base of the tail so as to render the operation bloodless. Above the seat of operation turn the hair upward toward the root of the tail and secure it there by means of the bandage, B, Fig. i. Locate as accurately as possible the position of a joint at the point where it is desired to oper- ate and with the scalpel begin an incision on the median line on the upper side of the organ about i cm. above the articulation and carry this obliquely outward for a distance of 4 to 6 cm. according to the size of the tail and then con- tinue it downward, backward and inward along the side and inferior surface until directly opposite to the place of begin- ning. Make a similar incision upon the opposite side of the tail, cut through all the connective tissue and muscles down to the bone and then disarticulate wdth the aid of the scalpel. Search for the arteries and control the hemorrhage b}^ torsion or ligation. The vessels will be more readily found by loosening the tourniquet so as to permit the blood to flow. Some operators prefer to begin the incision at the side of the tail instead of upon the dorsal surface and in that way have a dorsal and ventral flap instead of right and left as indicated in Fig. i . The excision having been completed the flaps are brought together by means of strong silk or silk worm gut sutures as shown in Fig. 2. The sutures should be begun at the apex of the two flaps and comparatively deep. Disinfect the stump thoroughly and if the hair is sufficient- ly long it may be well to draw it down over the wound, to which an antiseptic covering has been applied, and retain it in position by tying a cord around the hair just be^^ond the point of amputation. LOfC. lOO URETHROTOMY. LITHOTOMY. 25. URETHROTOMY. LITHOTOMY. Fig. 7, 8. Objects. For the removal of calculi from the bladder or urethra or performing other operations on these parts. Instruments. Catheter, convex scalpel, scissors, artery and compression forceps, tenacula, lithotome, lithotomy forceps, lithotrite, absorbent cotton, drainage tube, suture material. Technic. Urethrotomy ma}^ be performed on horses in a standing position, the hind feet being secured with hobbles. It is best, however, to operate under anaesthesia with the patient in lateral or dorsal recumbency, either on the operat- ing table or cast, being careful to secure as gently as possi- ble, having first emptied the bladder if practicable, since rupture of an overdistended viscus may readily occur during violent struggles by the animal. The point of operation will depend upon the location of the calculus or other obstacle. If it is found in the pelvic portion of the urethra or in the bladder, the operation is made at the ischial notch, Fig. 8. First the penis is drawn out from the prepuce and the catheter introduced into the urethra and pushed upward until it has passed the ischial notch. After disinfection of the skin, render it tense and make a 5 cm. long incision on the median line at the ischial arch through the skin, bulbo-cavernosus muscle, spongy portion of the urethra, and the urethral mucous membrane down to the catheter. Fig. 8, k. In order to prevent infiltra- tion of urine after the operation, special care is to be taken to make the lower end of the wound slanting in such a manner that the inner margin is higher than the outer. After the catheter has been drawn back away from the ischial arch, introduce the lithotomy forceps into the urethra or bladder, grasp the stone and draw it outward in its natural direction. The grasping of the stone by the forceps is materially aided by means of the left hand introduced into URETHROTOMY. LITHOTOMY. lOI the rectum. One must avoid grasping, along with the stone, the mucous membrane of the bladder. Partial filling of the bladder with a tepid aseptic solution will aid in grasping the calculus and in avoiding the implication of the bladder walls. By careful rotary movement and pushing the forceps back- ward and forward the operator can determine before the ex- traction of the stone if the forceps can be withdrawn easily and without much resistance through the neck of the Fig, 7. Urethrotomy at the ischial notch. bladder. If the stone is so large that it can not pass the neck of the bladder lithotripsy may be performed. This operation requires time and patience, since as a rule it is not possible to encompass the entire calculus with the forceps. That is, the narrowness of the neck of the bladder prevents the sufficiently wide opening of the forceps. The stone con- sequently must be gradually broken off at its periphery and the individual pieces of calculus removed. The character of the surface of the stone has an evident bearing upon the practicability of lithotripsy. When this operation is impossible, the surgical dilation I02 URETHROTOMY. LITHOTOMY. of the pelvic urethra with the Hthotome can be undertaken as a last resort. Introduce the instrument and divide the urethra upward and laterally as the instrument is withdrawn. In order to prevent injury to the rectum it should be emptied before the operation is undertaken. After the removal of the stone, push the catheter again over the ischial arch and unite the lips of the wound in the urethral mucous mem- brane by means of intestinal sutures. Flush the bladder Fig. 8. Urethrotomy (life size). A, skin ; a, retractor penis muscle ; b, bulbo- cavernous muscle ; c, spongy urethra ; «, urethra ; k^ catheter, and urethra by means of a warm, 3 per cent, boric acid solu- tion injected through the catheter and then withdraw the latter. Finally, suture the skin wound and insert a drainage tube or iodoform gauze in the lower angle. The whole wound may be left entirely open and dressed daily with antiseptics. In case the pelvic urethra has been divided the suturing of the external wound is of questionable utility. (For student practice on an anaesthetized horse, intro- duce a stone into the bladder through the urethral wound and practice grasping and removing it with the lithotomy forceps. ) AMPUTATION OF THE PENIS. 103 26. AMPUTATION OF THE PENIS. Platk XVTT. axd Ftg. 9. Instruments. Scalpel, elastic ligature, strong silk thread, strong piece of tape i m. long, artery and compres- sion forceps. Technic. The operation is carried out on the recumbent animal under complete anaesthesia, the upper hind foot being drawn backward or upward or otherwise so fixed as to not obstruct the field of operation. The point of opera- tion is determined by the character of the disease and the object to be attained. It may be made at any point from the glans penis to the attachment of the corpus cavernosum to the ischium. If possible amputate in front of the pre- putial ring. After the penis is drawn out, and the pre- putial region is carefully cleansed with warm water, soap and brush and disinfected, an assistant grasps the organ just behind the preputial ring and holds it firmly. A temporary elastic ligature, T, is then applied above the assistant's hand around the penis, or a piece of tape is looped around it above the hand and is made to serve both as a tourniquet and as a means for holding the penis or it can be grasped in front of the ligature with double tenaculum forceps and held. Insert a catheter into the urethra and push it beyond the elastic ligature or tourniquet. Apply a small cord just behind the glans penis, L, Fig. i, Plate XVII, and then make a triangular incision on the ventral surface of the organ about 4 cm. long by 3 cm. wide, the base of the triangle being forward as shown in Fig. i ; carry this incision thrbugh the skin, S, the corpus spongiosum, CS, and along the corpus cavernosum, CC, down to the urethra, U. Disect away the tissues in the triangular area without opening or wounding the urethra and when this has been completed make a longitudinal incision from near the apex of the triangle to its base through the urethral walls to the catheter. Beginning at the commissure insert a series of .^ (J/) >^ Ih' (0 ^ 2 > -*-■ *-i CO O J^ K 3 w g-Sa s tn . S S ^ '1 5 a o a •" o W operatio let ; CS, n; CC, I^igature ration sh > PL, o X «.- E3 •»-'