SUI^GICAL DISEASES SURGEftY OF THE DOG CECIL FRENCH Class _ Book_lXX7_ Copyright N"* COPyRIGHT DEPOSIT. SURGICAL DISEASES AND SURGERY OF THE DOG WITH NINETY-ONE ILLUSTRATIONS BY CECIL FRENCH Doctor of Veterinary Science (McGill Unirersity) WASHINGTON, D. C, U. S. A. WASHINGTON, D. C . U. S. A. PUBLISHED BY CECIL FRENCH GREAT BRITAIN London : Henry Kimpton, 13 Furnival Street, Holborn, E. C. Glasgow : Alexander Stenhouse, 40 and 42 University Avenue .: 1906 Entered accordinc to Act of ConEtess, in the year 1905, by Cecil French, in the Office of the Librarian of Congress, at Washington. [aU Rights Reserved.] I LIBRARY »f CONGRESS I Two Copies Received NOV 6 1906 _, Copyright Entry . CUSS A XXcNo. COPY B. GEO. E. HOWARD PRINTER AND BINDEB WASHINGTON, D. C. Contents CHAPTER I. GENERAL SURGERY Pages i to 35 Antisepsis. Asepsis. Antiseptics. — Suturing and Ligating Material. — Absorbents. — Sutures. — Appa- ratus and Metliods of Restraint. — Anesthetics. — Gen- eral Anesthetics. — Local Anesthetics. — Narcotics. Hypnotics. — Inflammation. — Contusion. Hematoma. — Wounds. — Shock. — Abscess. — Ulcer. — Fistula. Sinus. — Burns. Scalds. — Frost-Bites. — Erysipelas. — Toxemia. Septicemia. Pyemia. — Gangrene. CHAPTER II. THE HEAD AND NECK Pages 36 to 71 Congenital Malformations. — Traumatic Lesions.- — Abscess of the Scalp. — Foreign Bodies. — Neoplasms. The Eyes. Congenital Malformations. — Traumatic Lesions. — Parasites. — Conjunctivitis. — Superficial Keratitis. Ul- ceration of the Cornea. — Interstitial Keratitis. — Oph- ^"^"^^--^^ jthalmitis. — Glaucoma. — Hydrophthalmia. — Amblyopia. Amaurosis. — Cataract. — Luxation of the Lens, — Strabismus. — Exophthalmia. — Neoplasms. Surgery of the Eye. Paracentesis. — Enucleation of the Eyeball. — Dis- cission of the Lens. — Extraction of the Lens. The Eyelids. Congenital Malformations. — Traumatic Lesions. — Blepharitis. — Ectropion. — Entropion. — Trichiasis. — Neoplasms. — Lachrymal Fistula. iii iv Contents The Ears. Examination. — Traumatic Lesions. — Ulceration of the Concha. — Otitis. Otorrhea. — Sinus. — Neoplasms. Amputation of the Concha. CHAPTER III. THE HEAD AND NECK (Continued) Pages 72 to 117 The Lips, Mouth, Tongue, and Jaws. Examination. — Immobilization of the Jaws with the Speculum. — Congenital Malformations. — Traumatic Lesions. — Stomatitis. Gingivitis. Glossitis. — Par- tial Amputation of the Tongue. — Foreign Bodies. — Neoplasms. The Teeth. Structure, Disposition, and Development. — Conge- nital Malformations. — Traumatic Lesions. — Incrusta- tions of Tartar. — Calcic Pericementitis. — Alveolar Abscess and Maxillary Fistula. — Caries. — Scaling. — Extraction. The Salivary Glands. Traumatic Lesions. — Fistula. — Inflammation. The Pharynx. Examination. — Pharyngitis. — Foreign Bodies. — Neoplasms. The Esophagus. Examination, — Congenital Malformations. — Trau- matic Lesions. — Foreign Bodies. — Esophagotomy. — Neoplasms. The Thyroid Gland and Glandules. Struma. Goiter. Bronchocele. — Unilateral Thy- roidectomy. — Simple Thyroidectomy. — Exophthalmic Goiter, Contents v The Lymphatic Glands. Lymphadenitis. — Neoplasms. The Nose. Epistaxis. — Foreign Bodies. — Neoplasms. The Larynx and Trachea. Foreign Bodies. — Neoplasms. — Fracture of the Trachea. Surgery of the Trachea. Tracheotomy. CHAPTER IV. THE THORAX Pages ii8 to 133 The Lungs and Pleurae. Examination. — Traumatic Lesions. — Pleuritis. — Hernia. Surgery of the Lungs. Thoracentesis. The Heart and Pericardium. Traumatic Lesions. — Pericarditis. — Hydropericar- dium. Surgery of the Heart. Suture of the Heart. — Pericardicentesis. CHAPTER V. THE ABDOMEN Pages 134 to 153 Abdominal Section. Celiotomy. Laparotomy. The Peritoneum, Mesentery, and Omentum. Traumatic Lesions. — Peritonitis. — Ascites. — Para- centesis. — Foreign Bodies. — Neoplasms. vi Contents CHAPTER VI. THE ABDOMEN (Continued) Pages 154 to 214 The Stomach. Examination. — Traumatic Lesions. — Peptic Ul- cer. — Torsion. — Foreign Bodies. — Neoplasms. Surgery of the Stomach. Gastrotomy. — Gastro-Enterostomy. Gastro-Enteral Anastomosis. The Intestines. Examination. — Traumatic Lesions. — Intestinal Ob- struction. Surgery of the Intestines. Enterorraphy. — Enterotomy. — Enterectomy and Entero-Enteral Anastomosis or Entero-Enterostomy. — Ventrofixation. — Rectal Irrigation. Enemeta. The Rectum and Anus. Examination. — Congenital Malformations. — For- eign Bodies. — Pseudocoprostasis. — Suppuration of the Anal Pouches. — Anal Fistula. Anal Sinus. — Hemor- rhoids. Piles. — Prolapse of the Anus. Procidence of the Rectum. — Neoplasms. The Liver. Examination. — Traumatic Lesions. — Neoplasms. — Cholelithiasis. Surgery of the Liver. The Pancreas. Surgery of the Pancreas. The Spleen. Examination. — Congenital Malformations. — Trau- matic Lesions. — Neoplasms. ' Surgery of the Spleen. Complete Splenectomy. — Partial Splenectomy. Contents vii CHAPTER VII. THE ABDOMEN (Continued) Pages 215 to 250 The Urinary Organs. Urolithiasis. The Kidneys. Examination. — Calculi. — Neoplasms. — • Parasites. Surgery of the Kidney. Nephrotomy. Nephrolithotomy. — Nephrectomy. The Ureters. Calculi. — Surgical Wounds. Surgery of the Ureters. Ureterolithotomy. — Uretero-Ureteral Anastomosis. Uretero-Ureterostomy. — Uretero-Vesical Anastomosis. Uretero-Cystostomy. The Bladder. Examination. — Traumatic Lesions. — Cystitis.— Calculi. — Torsion. Retroflexion. — Neoplasms. Surgery of the Bladder. Passage of the Catheter and Sound. — Passage of the Catheter in the Male. — Passage of the Catheter in the Female. — Irrigation. — Puncture. — Cystorraphy. — Prepubic Lithotomy. Cystotomy. — Litholapaxy. — Resection. — Vesico-Rectal Anastomosis. Cysto-Enter- ostomy. The Urethra. Examination. — Congenital Malformations. — Trau- matic Lesions. — Stricture. — Obstruction. — Urethro- tomy. Urethrolithotomy. viii Contents CHAPTER VIII. THE ABDOMEN (Continued) Pages 251 to 287 The Reproductive Organs of the Male. The Penis and Prepuce. Examination. — Congenital Malformations. — Trau- matic Lesions. — Orchitis. — Neoplasms. — Parasitic Emasculation. — Orchectomy. — Castration. The Prostate Gland. Examination. — Prostatitis. — Neoplasms. The Reproductive Organs of the Female. The Ovaries. Examination. — Congenital Malformations. — Ooph- oritis. — Neoplasms. — Oophorectomy. The Fallopian Tubes and Uterus. Examination. — Salpingitis. Pyosalpinx. — Metri- tis. — Procidence. — Torsion of the Cornua. — Rup- ture. — Neoplasms. Surgery of the Uterus. Hysterotomy. — Hysterectomy. — Ventrofixation of the Cornua. The Vagina. Examination. — Congenital Malformations. — Vagi- nitis. Vulvitis. — Prolapse. — Rupture. — Neoplasms. CHAPTER IX. THE ABDOMEN (Continued) Pages 288 to 306 Hernia. Abdominal Hernia in General. — Abdominal Hernia in Particular. Contents ix The Mammary Glands. Traumatic Lesions.-^ Congestion. — Mammitis. Ma- stitis. — Neoplasms. CHAPTER X. THE EXTREMITIES Pages 307 to 322 The Legs and Feet. Congenital Malformations. — Traumatic Lesions. — Inflammation. — Foreign Bodies. — Neoplasms. — Am- putation. — Amputation of the Dew-Claw Digit. — Disarticulation of the Phalanges. The Tail. Congenital Malformations. — Traumatic Lesions. — Inflammatory Affections. — Neoplasms. — Amputation. CHAPTER XI. THE OSSEOUS SYSTEM Pages 323 to 349 Traumatic Lesions. — Fractures in General. — Frac- tures in Particular. — Pseudarthrosis. — Osteitis. Peri- ostitis, Osteo-Myelitis. — Rachitis. — Osteomalacia. — Neoplasms. — Osteoplasty. — Osteotomy. CHAPTER XII. THE ARTICULATIONS Pages 350 to 362 Traumatic Lesions. — Luxations in General. — Lux- ations in Particular. — Synovitis. — Arthritis. CHAPTER XIII. NEOPLASMS Pages 363 to 393 Hypertrophy and Hyperplasia. — Inflammatory Neo- plasms. — Tumors Proper. — Cysts. — Treatment of Tumors. List of Dlustrations NO. PAGE. i.a, b, Halsted's Subcuticular suture 6 2. Thomas suture ' 7 3. Simple Muzzle of tape or rope 8 4. Dawson-French Portable Hopples 8 5. Hobday's Hopples 9 6. Extension Grate 9 7. Young's Operation Trough 9 8. a, b, c. "Cherry" method of treating gaping wounds . . 26 9. Carcinoma of the Neck facing 39 10. a, b. Operation for Ectropion 58 11. Operation for Entropion 59 12. Papilloma of the Eyelid , facing 60 13. Hypertrophy of the Orbital gland " 60 14. Ear Speculum 63 15. Papillomata of the Ear " 65 16. Operation for Hematoma of the Ear-flap 67 17. Amputation of the Concha ,. . 69 18. Amputation of the Concha 69 19. Amputation of the Concha 71 20. Improvised Bourrel Gag ^2 21. Examination of the Buccal cavity facing "^2 22. French Mouth Speculum 73 23. Baker Mouth Speculum 73 24. Papillomata of the Buccal mucosa facing 78 25. Retention-cyst appearing in the Buccal cavity, " 79 26. Retention-cyst burrowing down the Neck ..... . 79 27. Epithelioma of the Lip with secondary lym- phatic enlargement " 81 28. Osteo-sarcoma of the Superior Maxilla " 82 29. Pedunculate Osteo-sarcoma of the periosteum of the Inferior Maxilla " 82 30. Maxillary fistula 89 31. Scaling chisel , 91 xi xii List of Illustrations NO. PAGE. 32. Thyroid Gland and Glandules facing loi 33. Goiter " loi 34. Acute Lymphadenitis " 109 35. Tuberculous Lymphadenitis. Fistulous tract. . 109 36. Tuberculous Lymphadenitis. Fistulous tract.. " 109 37. Extra-uterine gestation showing two pseudo- uteri and numerous cysts " 151 38. Rectal Douche-Curette 166 39. a, b. Simple Interrupted intestinal suture 182 40. a, b. Lembert intestinal suture 183 41. Halsted's intestinal Mattress suture 183 42. a. Hair-pin Method of intestinal anastomosis .... 187 42. b. Hair-pin Method of intestinal anastomosis, First stage 188 42. c. Hair-pin Method of intestinal anastomosis, Second stage 189 43. a, b. Anal Sinus 197 44. Procidence of the Rectum 200 45. a. Amputation of Rectal Procidence. First Stage 202 45. b. Amputation of Rectal Procidence. Second stage 203 46. a, b, c. Uretero-cystostomy 228 47. Male Catheter 238 48. Female Catheter 238 49. Vaginal Speculum 239 50. Venereal Granulomata facing 255 51. Malignant Neoplasm of the right Testis. ..... " 259 52. Diagram to show course pursued by the finger to quickly reach the cornu 269 53. Diagram illustrating technic of excision of the Ovary 270 54. Procidence of the Vagina, Os Uteri, Uterus, and both Uterine Cornua. facing 275 55. Ventrofixation of Abdominal Viscera 281 56. Fibro-lipoma of the Vaginal wall facing 284 57. Estrual Hypertrophy of the Vaginal mucosa. . " 285 58. Herniotome 291 59. Inguinal Hernia in the Female facing 293 60. Inguinal Hernia in the Female " 293 List of Illustrations xiii NO. PAGE. 6i. Diagram illustrating normal position of parts. . 295 62. Diagram illustrating mechanism of Inguinal Hernia 295 63. Inguinal Hernia in the Male facing 298 64. Scrotal Hernia in the Male , " 298 65. Perineal Hernia " 299 66. Mammary Tumor simulating Hernia " 303 67. Lipoma of the Mammary region " 304 68. Illustration showing situation of primary Mam- mary Growth and the palpable Metastases. . " 305 69. True Carcinoma of the Mammary gland " 305 70. Chronic interstitial Fibrosis of the Teat " 306 71. Position assumed by the leg after division of the Tendo-Achilles " 308 72. Nail Clippers , 311 73. Elastic band on the Leg facing 312 74. Fibro-adenoma of the Skin of the leg exhibit- ing impending malignancy " 313 75. Multiple Verruca " 314 76. Interdigital Serous Cyst " 315 77. Eflfect of too tight or too early bandaging. ... " 328 78. Diagram illustrative of Bone-suturing 336 79. Bone Gouge 341 CHAPTER I General Surgery ANTISEPSIS. ASEPSIS. ANTISEPTICS. Since Lister first advocated the employment of chemical agents to prevent bacterial development in wounds, the principle has been generally adopted, though it has received modification in recent years. The original plan of antisepsis comprehended the disinfection of instruments, suturing material, operator's hands, area of opera- tion, and everything coming in contact with the wound, by means of chemical germicides supplemented by post-operative treatment of the wound with antiseptic agents to inhibit the growth of bacteria. Antisepsis is still practised, but on this continent has given place largely to the aseptic method in which the use of chemical agents is limited solely to the disinfection of the operator's hands and the cutis of the area of operation, sterility of instruments and suturing material being obtained by means of heat; no antiseptics are per- mitted to come in contact with the wound, chemical agents being regarded as irritants to the tissues. Whatever advantages either method may have over the other in its application to human surgery it is not within our province to consider and we need only concern ourselves with the one best adapted to canine surgery. There can be no question whatever that the necessity for the application of the principle in the latter instance has been greatly over-rated and that, with a few exceptions, equally as good results are obtainable when nothing more than the ordinary rules of cleanliness are observed. The danger of starting up pyogenic processes consists not so much in introducing bacteria from without as it does in creating condi- tions within under which such bacteria can thrive to the point of producing a toxic effect. It is when putrescible matter exists in spaces removed from direct contact with the phagocytic action of the living tissues that the conditions are ripe for bacterial multiplication. Putrescible matter is easily creatable by the ligating of portions of tissue, such as the omentum and large vessels, so as to form stumps ; 2 2 Surgical Diseases and Surgery of the Dog it is also ready existent in the form of certain natural secretions, especially those of serous cavities, such as joints and the pleural sacs, where septic surgical interference is commonly followed by pyogenic processes, particularly when abnormal accumulations of fluid are present. The normal peritoneum must be excepted on ac- count of the well-known comparative immunity it enjoys, probably by reason of the numerous recesses existing between the coils of the viscera where there is a chance for microbic activity to become local- ized, the pleura and joints on the other hand offering an unbroken extent of space for the accumulation of fluids. Hence, the object should always be to avoid the creation of putrescible matter, but inasmuch as this is a matter of impossibility in some parts of the body, it is necessary to take precautions to prevent infection by the practice of aseptic methods, or resort to the alternative of drainage. Aseptic methods are indispensable in operations involving interfer- ence with the thorax, the cerebro-spinal canal, joints, and deeply situated organs such as the thyroid gland ; they are not so necessar>' when the peritoneum is concerned, excepting when ascites is present, but are advisable as a precautionary measure; they are also expe- dient in operations on the surface of the body but can be dispensed with where local infection has already occurred, as in wounds and abscesses. The preliminary steps in an operation on the lines indicated above consist of sterilization of instruments and material and dis- infection of the hands of the operator and the cutis in the area of operation. Sterilization of Instruments. Instruments are best sterilized by boiling for at least ten minutes, and if some powdered carbonate of soda is added to the water to the amount of one drachm to the pint, so much the better. Sodium carbonate dissolves the capsules of the germs and the latter are destroyed in much shorter time, and moreover, it inhibits rusting. Chemical disinfectants are unreliable but should be used to receive the instruments during the course of the operation to prevent fresh contamination. For the latter pur- pose a solution of carbolic acid (5:100) is suitable. Sterilization of Hands. The hands of the operator always re- quire thorough cleansing. They should first be scrubbed in hot water and soap, particular attention being bestowed on the nails. They should then be immersed for a few minutes in a strong solu- General Surgery 3 tion of permanganate of potash until stained dark brown. Decolor- ization can be effected by soaking them in a warm saturated sohition of oxaHc acid, and the effect of the latter can be neutraHzed with lime water. If it is desired to conduct an operation under un- doubted absolute asepsis the only alternative is to wear thin rubber gloves. Sterilization of Region of Operation. It is practically impos- sible to completely disinfect the skin. Only the microorganisms in the superficial layers can be destroyed by chemical agents. Those existing in the deeper layers can not be reached by any agent short of a gas, but it is known that they possess but feeble pyogenic capacity which the living, healthy tissues have the power to over- come. Welch proved that the white staphylococcus occurs in wounds where every possible antiseptic precaution has been taken, but it seldom exerts interference with the process of healing. Of course, what has been written concerning the hands of the operator applies equally as well to the cutis of the area of operation, but in addition the hair should always be removed by means of clippers or razor. Antiseptics. There being such a variety of antiseptic agents, I shall only briefly refer to a few which are specially adapted to the particular purpose in view. Permanganate of potash is most valu- able possessing as it does both microbicidal and deodorant proper- ties and being at the same time free from toxicity. It owes its power to its capacity to rapidly give up oxygen in the presence of moisture. It is effectual for both dermal and mucosal surfaces. It is used in the strength of i :ioo to 10:100. Corrosive sublimate is very useful as an inhibitory agent, particularly in exposed joints, but it is poisonous and corrodes metal. It is prepared by manu- facturing pharmacists in tablets of definite strength and is used in solutions of 1:2000, 1:1000, and 1:500. Carbolic acid is effective in the strength of 2:100 to 5:100, but must be used with great cau- tion as dogs are peculiarly susceptible to its toxic effect. Creolin is an effective agent widely used. It is only slightly toxic and does not corrode instruments. It is used in strength of 1:100 to 5:100. Boric acid is a mild antiseptic particularly useful for eye work in saturated solution of 4:100. Peroxide of hydrogen is an unstable oxidizing agent usually of uncertain strength, capable of setting free ten or twenty times its volume of nascent hydrogen. Its sole use is 4 Surgical Diseases and Surgery of the Dog for evacuation of pus cavities. Being without irritant effect, it may be poured in full strength into a septic wound. It immediately lib- erates its oxygen, effervesces and forms a frothy foam which brings dead and moribund matter to the surface. Boiled salt water in the strength of 5 :iooo to i :ioo is used for flushing the abdominal cavity and the bladder. Of the dry antiseptics the synthetic powder Tri-brom-phfnol- bisntuth, commercially known as Xeroform, is without a peer. It not only promotes active healing but exerts a pronounced anodyne effect as well. Whether used on ulcers or freshly infected wounds the beneficial results are quickly apparent. Other excellent prepa- rations are Aristol, lodol, and Bismuth Formic-Iodide. SUTUBING AND LI6ATIN6 MATERIAL. The materials commonly used for suturing and ligating are silk, silver wire, silkworm gut, catgut, linen thread and rubber bands. Pure Chinese twisted silk forms an excellent suturing material for general purposes. Either white or black is used, the latter being more easily seen, which is a matter of some advantage in suturing hollow viscera. When used in the skin, the texture should be mod- erately stout (Nos. 6-12), but for hollow visceral organs it should be as fine as is consistent with strength (No. 2). As a buried suture or ligature it is also very desirable as it readily becomes encap- sulated in the tissues and remains inert. It is best rendered sterile by boiling just before using. Silver wire is indispensable in bone suturing. If rendered perfectly sterile when inserted and the wound remains free of infection, it may generally be allowed to remain per- manently in place without fear of its giving rise to irritation, though the latter sometimes happens, which necessitates its removal after it has served its purpose. Silkworm gut being non-absorbable and at the same time having a perfectly smooth surface, is preferred by some to silk. It is rendered sterile by boiling and the knots possess little tendency to become undone or loosened. Catgut is theoreti- cally a very valuable suturing material on account of its being ab- sorbed and not requiring removal. But it is sterilized with diffi- culty (it can not be boiled), it is apt to be absorbed too rapidly, and it becomes untied too easily through swelling and softening by absorption of moisture. Chromicized catgut is said to be capable of resisting absorption from three to four weeks. Any one of the other General Surgery 5 materials, if properly sterilized, is used to better advantage, because, though they do not become absorbed in buried positions, they are safely encapsulated by natural processes and rendered perfectly harmless. It is only rarely that a buried non-absorbable suture needs to be removed. Linen thread, as supplied for sewing ma- chines (it is specially spun so as to travel evenly through the eye of the sewing machine needle) is strong, ties a good knot, is steri- lized by boiling, is not irritative, and can be obtained anywhere where sewing machines are sold, and is therefore a desirable material for fine sutures or ligatures. Rubber bands form an excel- lent material for use as ligatures where portions of vascular internal organs are extirpated. They never slip from position, do not cut through delicate tissues and offer no impediment to the healing pro- cess. Gluck advocates their use in operations where portions of the liver, lungs, or spleen are removed, and Senn has used them to ad- vantage in surgery of the pancreas. ABSORBENTS. The best sort of absorbent to swab up blood and other fluids during an operation is a pledget of sterilized gauze. SUTURES. Of the various sutures used in general veterinary practice, I can commend but two for application to cuticular wounds. These are the "simple interrupted" and Halsted's "buried" or "subcuticu- lar" suture. The Subcuticular Suture is undoubtedly superior to any yet de- vised for canine work. Halsted contrived it whilst making a series of experimental extirpations of the thyroid gland owing to the diffi- culty which he experienced in maintaining aseptic wounds with the ordinary suturing which penetrates superficially. It is well-known that the skin, particularly in its upper layers and in the hair follicles, swarms with microbes, and while these in large proportion are non-pathogenic and do not inhibit the healing process, any suture which passes from without to the subcutaneous tissue of necessity creates a highway for microbic migration. The result is subcuta- neous infection and a wound which, perforce, must heal by sec- ondary intention with suppuration, which is always a slow process 6 Surgical Diseases and Surgery of the Dog and one subject to more or less cicatrisation. In non-infected surgi- cal wounds this suture, applied under aseptic conditions, will secure healing by first intention. In traumatic wounds, which are invaria- bly more or less infected, such desirable result is not always obtain- able, though, at times, the two cut cuticular edges will speedily unite whilst the subcuticular wound heals by the slower process of suppurative granulation. This suture is particularly adapted to linear wounds. The subcuticular suture is applied in the following manner : The needle is introduced on the under surface of the skin, as near to the upper commissure of the wound as possible, and including only the deeper layers of the skin, is made to emerge at the cut edge. Cross- No. 1. The Subcuticular suture (a) in course of application (b) completed. ing over, the same process is repeated on the opposite side, and so on alternately. Sebacious follicles and hair follicles should not be perforated by the stitches. If the wound is believed to be aseptic and free of spaces the suturing is extended as far as the inferior commissure, but if it is known to be infected, the suturing should be carried only to a point which will allow a proper orifice for drain- age. When the entire row is completed both free ends are pulled on in opposite directions which brings the edges of the wound into close ap- General Surgery position. Knots are unnecessary because the tissues hug the unin- terrupted suture so closely that slipping does not occur. The ends should be cut off quite close or the animal may seize them and drag the suture out. When reunion of the parts is established, which is usually the case at the end of ten or fourteen days, provided the healing process has proceeded without check, the suture may be easily withdrawn by seizing one end and applying traction on the same. The Simple Interrupted Suture needs but a passing reference. In ragged, angular and uneven wounds, where the subcuticular su- ture can not be employed, and in those cases where the latter does not succeed, recourse must be had to it. This suture should be tied in a reef knot, and the latter should be made to one side of the wound. Each suture should be placed from one-third to one-half inch from its neighbor. For severed mucous membrane the best suture is that figured in the accompanying illustration. It was devised by Thomas. It is sitperior to the simple continuous suture because it brings the cut edges of the mucosa tightly together and divides the wound into independent segments. Each end of the suture is threaded on a cambric needle. Commencing at the top end of the wound, one needle is passed through, and the silk or catgut follows until there is half the length of the suture on each side with its needle attached. A reef knot is tied and the needle which is on the right side is brought over the left and passed through lower down and back again to the right, while the needle which is on the left is taken over to the right and passed through back to the left immediately ad- joining the previous one. A reef knot is again made and so on throughout the extent of the wound. The various sutures employed in surgery of hollow vis- cera are fully described under Enterorrhaphy. No. 2. Thomas eature. 8 Surgical Diseases and Surgery of the Dog No. 3. Simple muzzle of tape or rope. APPARATUS AND METHODS OF RESTRAINT. Muzzles. Mouth Speculums. The simplest method to pre- vent the dog from biting is to select a piece of tape or soft rope, make an overhand knot or a half hitch in the same, slip the loop over the closed jaws with the knot or hitch undermost, tighten the latter, carry the free ends under the ears to the back of the head and tie there in a bow-knot. Fractious animals should be held by their owners and prevented from backing away or turning the head while this is being done. All short- faced animals (Bulldogs, Boston Ter- riers, Pugs, Toy Spaniels), in which the capacity of the nasal passages is small must be secured in this manner with ex- treme caution. Under even a moderate degree of excitement their nasal pas- ages are insufficient to accommodate the increased respiration, and these animals are forced to breathe by the mouth. If this avenue is closed suffocation results, and the heart may be overstrained or rupture of the pulmonary vessels take place, to be followed by death within a few hours. The jaws may also be secured with the ordinary muzzles sold in the stores, but very few of the latter are really effective for this purpose. In some cases, particu- larly of fractious animals, mor- phine is very useful as a means of control, injected hypoder- mically. It renders an animal contented, more or less obliv- ious to its surroundings and unmindful of slightly painful manipulations. Hopples. There are sev- eral patterns sold by the in- strument makers, but of these I can confidently recommend as the best the portable Daw- ^o. 4. Dawson-Frencn Portable Ho»]>le>. General Surgery 9 son-French model. Its main feature is its self-locking action. A swinging cam is suspended in a frame through which the control rope passes. The fraine is supplied with a screw-clamp by means of which it is attachable to and detachable from any part of any table at will. One set of four large and one set of four small noose leg- bands are provided. These will fit an animal of any size, and are connected to the control ropes by steel snaps. Should the operator wish to tighten the control rope he does so by merely pulling on it, and the moment he lets it go it is firmly clinched by the cam. The aniinal can be quickly released from the control position at any mo- ment by simply holding back the handle bars, by which the cam is prevented from clinching and allows free passage of the rope. A simpler but less effectual instrument was invented by Hobday, in No. 5. Hobday's Hopples. England. Lacking any of these devices a very simple method of hoppling is to take four pieces of soft rope of good length and con- vert one extremity of each into a noose. This is slipped over the foot and tightened while the other end is fastened to the leg of the table. Operating Table. An ordinary kitchen table ans- wers all purposes. Where may be covered with zinc practice warrants it, this which should drain to the center. Here a small pipe should carry off fluids to a bucket suspended beneath. To prevent the coat of the animal from becoming sat- urated with blood or other No. T. Young's Operating Trough. lo Surgical Diseases and Surgery of the Dog fluids the extension grate made of enameled iron or improvised out of wood will be found very useful. Another simple device is known as Young's operating trough. BIBLIOGRAPHY. Gluck — Langenbeck's Archiv. f. klin. Chirurg. 29, p. 143. Halsted — Johns Hopkins Hospital Reports. 1, p. 398. Scliloffer — Langenbeck's' Archiv. f. klin. Chirurg. 1898, p. 334. Thomas — Brit. Med. Journ. Nov., 1898. Welch — Trans, of the Congr. of Amer. Phys. & Surg. 1891, 2, p. 1. ANESTHETICS. General anesthetics should be administered prior to the com- mencement of all operations involving severe or protracted pain. Not only is their employment prompted by humane consideration but without it the accurate conduct of delicate operations is ren- dered a matter of great difficulty and often an impossibility, owing to struggling on the part of the animal. Their employment is con- traindicated when cardiac or pulmonary diseases exist. Local anesthetics, hypnotics, or narcotics are employed to dull the peripheral or central sensibilities in operations of a minor nature. Narcotics are also useful for the control of refractory or vicious animals when under examination. Both hypnotics and narcotics are also used for the production of complete general anesthesia, but in this case very large doses are necessary, from which the animal is slow to recover and which are not free from danger, k will be found convenient to resort to them when the services of an assistant are unobtainable. GENERAL ANESTHETICS. Choloroform and Ether, either alone or combined and di- luted with ethyl alcohol are the drugs most extensively used for the production of general anesthesia. The vapor of chloroform, if administered under proper condi- tions allows of no comparison with other anesthetic agents. There can be no doubt that any danger attending its use has been much overrated, owing to neglect of the observance of fundamental rules governing its successful administration. Nevertheless, I would warn those unaccustomed to giving it, not to employ it for valuable animals. The principal advantage derived from chloroform administra- General Surgery ii tion is: Production of profound narcosis unaccompanied by reflex movements which is preceded by a mild preHminary period of excitement and succeeded by a rapid recovery from its effects. It is dangerous only when administred in concentrated form. It is then liable to produce rapid fall of blood-pressure through paraly- sis of the vaso-motor center, which is quickly followed by paralysis of the respiratory center. At the same time the heart's action grows weak under the combined influence of vagus inhibition, vaso- motor paralysis and dilation of its cavities from the direct action of the drug, though it may continue to beat two to five minutes after respiration has ceased. In a small percentage of cases the heart's action may be the first to fail. Ether is safer than Chloroform on account of its stimulating properties. But there are well-deserved objections to its use, the stage of excitement being very great and prolonged, even if the administration be pushed without admixture of air; it is usually productive of reflex movements and tetanic contractions of the ex- tremities ; and complete narcosis is only possible under continuous administration. These objectionable features can, however, be over- come in large measure by previous administration of narcotics. Only the best quality of ether fortior should be used. But ether is liable to produce undesirable after-effects in the form of affections of the respiratory tract, whereas the danger from chloroform ceases with its withdrawal. Under ether-anes- thesia there is always great secretion of saliva and mucus, while under chloroform the amount is infinitesimal. This matter was care- fully studied by Hoelscher in a series of experiments on dogs. The animals were subjected to anesthesia lasting one hour. They were laid in various positions — in the horizontal, with head elevated, and with the head depressed. The buccal secretions were also stained by injections of gentian violet. In all the animals that lay in the horizontal position, the colored secretions were found to have pene- trated to the smallest bronchii, showing that the force of the in- spired air current was sufficient to drive back the buccal contents into the bronchii. Moreover, the secretion acted as an obstruction to the passage of the air and the animal was forced to breathe harder. When the animal lay on the left side it tended to reach the left lung more, and only slightly the right. In animals whose heads were greatly elevated, this was sufficient to cause death by oc- 12 Surgical Diseases and Surgery of the Dog elusion of the respiratory tract. When the head was depressed slightly there was rattling in the throat, but the secretions did not penetrate any further. When the head was allowed to hang free, the secretions escaped from the mouth and none were inspired, but when with the head thus held the fluids were prevented from escap- ing they were inspired. Hence, in the administration of ether the position of the head is a matter of great importance and must be such as to permit of drainage of the buccal secretions. Rattling in the throat is significant of their inspiration, and is to be avoided. Vomiting is also more apt to occur with ether, and this with labored breathing is productive of inspiration-pneumonia. For the safe administration of either of these drugs a certain proportion of air is necessary. This is particularly true of chloro- form to which a large admixture is essential for safety. The pro- portions have been worked out by Bert. He found that when the anesthetic vapors and air were mixed in certain definite proportions, and continuously inspired, safe anesthesia was established. If the proportion of the medicamentary substance was increased, death re- sulted. The interval between the anesthetic and lethal dose he designated the "maniable zone." In carefully determining the limits of this zone with various agents, he arrived at the singular conclusion that in every instance the lethal dose is precisely double the anesthetic. To illustrate, the following table is useful : Anesthetic Dose Lethal Dose Chloroform 9 19 Ether 37 "maniable zone" 74 Ethyl Bromide 22 45 The figures indicate the number of grams of the anesthetic liquid mixed with 100 liters of air, and then reduced to vapor. If an animal is made to inspire a mixture corresponding to about the middle of the maniable zone, it is rapidly anesthetized and will remain so as long as the administration is continued. But the maniable zone is singularly limited, a few extra drops converting the active dose into a lethal one. This is particularly true of chloro- form. Eight grams volatilized in one hundred grams of air did not General Surgery 13 narcotize a dog, but twenty grams killed it. The range is twelve grams. Ether has the same power in proportion, but is infinitely less dangerous, since between active and lethal dose there is a range of nearly forty grams. According to Embley, the chief factor in the causation of sudden death under chloroform is vagus inhibition. Chloroform vapor not stronger than one and one-half per cent in air after a period of mild excitation, slowly depresses vagus ex- citability, and if administered in strength of over two per cent may cause dangerous or persistent inhibition. This action is all the more intense and fatal from being exercised upon an organ whose spontaneous excitability is diminished by the paralytic effect of the drug upon the heart muscle itself. The failure of respiration is due to fall of blood-pressure, and takes place invariably long before the heart stops. Hence respiration should be watched as an index to the circulatory condition. If atropine is administered prior to the chloroform the vagus is never inhibited and cardiac arrest does not follow. Rudolf and others have made similar observations. Hence, we have in atropine, administered hypodermically previous to chloroformization a very convenient antidote, one which reduces all risk of vagus inhibition to a minimum. If a little morphine is combined with the atropine the primary excitant period attending the chloroform administra- tion is suppressed, but the atropine should be in amount somewhat in excess of what would be given alone, to provide for the mutual neutralization of the two alkaloids. A suitable mixture for this purpose is made in the following proportions : Morphine sulphate three-quarters of a grain, atropine sulphate one-twentieth of a grain, distilled water one drachm. Of this, small dogs take five to ten minims, medium sized dogs ten to twenty minims, and large dogs twenty to thirty minims, hypodermically. Some twenty min- utes later the chloroform should be administered. In this manner very little of the latter drug suffices to induce a profound and safe narcosis of considerable duration. During administration the action of the iris should be closely observed. It is an almost infallible guide in the estimation of the blood-pressure. Insensibility of the conjunctiva is often re- garded as an indication of insensibility of the higher centers ; but as a matter of fact, the former is established before the latter, GOOse- 14 Surgical Diseases and Surgery of the Dog quently it can not be regarded as a satisfactory test. The first effect of chloroform on the pupil is dilation from excitement, varying in degree and duration in different individuals. Coincident with the approach of the stage of narcosis and fall of blood-pressure, the pupil commences to contract and continues to do so slowly until either the return of sensibility or the stage of asphyxia. The stage of complete or operative narcosis is reached when the pupil no longer dilates in response to otherwise painful stimuli. It is the degree of contraction which must govern the administrator in the exercise of his judgment as to the quantity of vapor permissible. Should the pupil become strongly contracted and immobile the danger point is reached and the vapor must be immediately with- drawn and fresh air supplied. Otherwise, the pupil will be seen to dilate suddenly and completely and almost at the same time the breathing will cease, an indication of vaso-motor paralysis and as- phyxia, a state from which it is difficult or impossible to resusci- tate the animal. There is, therefore, no pronounced change to give warning of impending danger, and as soon as the pupil is strongly contracted the supply of vapor must be cut off and air sup- plied until dilation again commences, when, if necessary, more vapor may be supplied and withdrawn as before, and this procedure kept up until the completion of the operation. To resuscitate from the asphyxial condition free access of air to the lungs must be secured. The inhaling mask is cast aside and the tongue grasped and drawn forward. Artificial respiration is then resorted to. The eflfect is twofold. It not only brings fresh air to the alveoli, but acts as a mechanical heart-stimulant and restorer of blood pressure. Hence to be effectual it should be mod- erately vigorous to the point of compressing the chest. A good plan is to suspend the animal with the head downward. It is believed that this causes a determination of blood to the brain to stimulate the flagging centers, and the vapor of the drugs being heavier than air tends to gravitate. Some practitioners place much confidence in medicinal anti- dotes, such as the vapor of ammonia, medicinal doses of official dilute hydrocyanic acid, hypodermic injections of ether and strych- nine, but it should be remembered that if the respiration and circu- lation are nearly at a standstill, drugs have little chance of being car- ried to the vital centers, and moreover, many valuable seconds may General Surgery 15 be lost in administering them. Prudence suggests that the best course to pursue is to quickly supply as much as possible of Na- ture's stimulant — pure air, by promptly resorting to artificial respi- ration in the open air, and to place little if any dependence on medi- cinal antidotes. Wood reported before the Berlin Congress in 1890 that he had repeatedly taken dogs in which both respiratory and cardiac movements had been absolutely arrested by chlorofonn or ether and had restored them to life by pumping air in and out of the lungs. Artificial respiration should be persisted in for some min- utes after all signs of vitality have disappeared. When recovery follows the animal needs to be closely watched until the practitioner is thoroughly satisfied that danger no longer threatens. If strych- nine is used it should be injected hypodermically in minute doses. Hobday recommends placing hydrocyanic acid on the back of the tongue. He uses one-eighth of a minim of the four per cent strength to each pound body-weight of the animal. For the proper dilution of chloroform with air the employment of some special apparatus is desirable, and it is also advantageous in economizing the drug. In Britain two or three patterns are in use, devised respectively by Hoare, Junker and Hobday, all being worked by manual or pedal compression. But when an animal is pre- viously atropinized a simple inhalation mask suffices. No such care is necessary with ether and the mixtures, which are preferably admin- istered by the simple inhalation mask. When the latter is not avail- able a tumbler or flower-pot may be substituted. Chloroform should not be administered in the presence of gas or candle flame, as it is decomposed thereby and sometimes causes a persistent and harassing cough in the operator. On account of the depressant action of chloroform and the excitant action of ether, it was believed that the narcosis could be in- creased and the eflfect on the circulation better controlled if the two drugs were mixed. The first mixture was tried by Weiger, a Vien- nese dentist, in the year 1850. It was composed of nine parts of ether to one of chloroform, and received the name of the Vienna Mixture. In Germany the Billroth Mixture, consisting of ten parts of chloroform, three of ether and three of alcohol, has found much favor. It is undoubtedly the best of the mixtures. It produces pro- i ji\nd insensibility after a very short period of excitement (one to i6 Surgical Diseases and Surgery of the Dog three minutes) and one-half to one ounce sufiices to maintain com- plete anesthesia for thirty to sixty minutes. The English or A. C. E. Mixture, consisting of ethyl alcohol one part, chloroform two parts and ether three parts, is an excellent one, producing a nareosis equally as deep as the Billroth but induces greater preliminary ex- citement and salivation. One ounce is sufficient to produce a sleep lasting twenty to thirty minutes. The Hyderabad Chloroform Com- mission found that only by respiration of the concentrated vapor of this mixture could death result with difficulty, and respiratory fail- ure always appeared first. The comparative rate of evaporation of the drugs composing the mixtures was studied by Ellis. A definite quantity of ether evaporates in ninety seconds in the usual room temperature of 6s°F. The same quantity of chloroform takes five minutes to evaporate under the same conditions, and the same quantity of alcohol takes twelve minutes. If equal parts of alcohol and ether are mixed evaporation of the ether is retarded — instead of seventy-five seconds it takes two minutes, and the remaining alcohol takes another nine minutes. The A. C. E. Mixture evaporates as follows : In the first sixty to seventy-five seconds all the ether with some chloroform is evaporated, in the next three to four minutes chloroform and alco- hol, the first preponderating, and in the following two minutes the rest of the alcohol. LOCAL ANESTHETICS. Cocaine is the principal local anesthetic. Caution should be exercised in the selection of the drug, as it often contains impurities when it is necessarily disappointing in its action. The crystals should be rather large, colorless and nearly odorless. Great cau- tion must also be observed in its employment, since in overdose it is rapidly toxic. Lethal effect is manifested by mental distress and violent muscular spasm. In text-books it is the custom to direct the employment of solu- tions of varying degrees of strength rather than mention the maxi- mum dose which can be safely borne by the dog, a system which is vague and confusing and opens the door to disastrous consequences. Accordingly, no mention is herein made of solutions, that being a matter which must be left to the judgment of the operator, bearing General Surgery 17 in mind that the greater the concentration the quicker to develop and the more widespread the anesthesia. The maximum dose which can be employed hypodermically without causing any constitutional disturbance must not exceed one-sixteenth of a grain per pound bodyweight. On mucous surfaces this amount may be slightly ex- ceeded, particularly in parts possessing much density of mucosa, such as the vagina where absorption does not readily occur. The anesthetic effect develops in from two to eight minutes and lasts from fifteen to sixty minutes and covers an area about an inch in diameter. It may be intensified by dissolving the cocaine in a quarter per cent c. p. sodium chloride or a five per cent phenol solution. It may also be considerably prolonged by the addition of one-fifth the amount of morphine. There is an additional advantage in combin- ing the last named drug in that it possesses antidotal power over cocaine. Cocaine is most conveniently carried in the form of tablets of definite strength as prepared by the manufacturing phar- macists. Solutions are applied to the conjunctiva and other mucous surfaces by means of the camel's hair brush or medicine dropper. In this manner some slight anesthetic effect may be obtained on the skin itself in parts where the latter is thinnest. To properly anesthetize the skin in the area of operation, the point of the needle should not be immediately thrust through the skin as in administering an ordinary hypodermic injection but must first stop within the skin which should receive a few drops of the fluid. When an extended area is to be operated on, a series of in- jections should be made, the point of the needle being reinserted within and near the periphery of the wheal produced by the pre- vious injection. In the case of a tumor, a circle of injections can be made to surround the area. Encaine is preferred to cocaine by some practitioners. Its anesthetic effect is somewhat slower to develop but it lasts longer and is just as complete and is also less toxic and may be safely ad- ministered in doses of one-half grain per pound bodyweight. Eudrenine is a combination of cocaine and adrenalin. It pos- sesses an advantage over cocaine alone in that the adrenalin dimin- ishes vascularity of the part and thereby hinders absorption of the cocaine, besides tending to render minor operations bloodless. 3 1 8 Surgical Diseases and Surgery of the Dog NAECOTICS. HYPNOTICS. Morphine and Chloi!^tone are very useful narcotic and hyp- notic agents in canine practice. With full somnific doses of the former, hypodermically injected, most dogs can be rendered indif- ferent to minor operations, but with few exceptions it is rarely pos- sible to obtain complete anesthesia with loss of reflexes. It is a very valuable agent in controlling fractious animals either for exam- ination or operation. It speedily produces a contented frame of mind which enables a complete stranger to safely proceed with ex- amination. Subcutaneous injection of somnific doses causes a slight and sometimes irritant swelling at the point of injection which, how- ever, quickly subsides. In from three to ten minutes weakness of the hind quarters, restlessness and salivation develop. Nausea and vom- iting frequently occur and less often evacuation of the bowels. On this account the practitioner should never administer the drug in rooms where carpets or rugs might be damaged. In some thirty minutes a light slumber is induced from which the animal can be awakened without much difficulty. The somnolence lasts five or six hours and the after-eflfects persist ten to twenty-four hours. Ac- cording to Guinard, who studied the action of this drug experimen- tally, a safe hypodermic somnific dose for mature animals is one- twelfth of a grain per pound bodyweight, while half a grain per pound bodyweight is lethal. In other hands one-seventh of a grain per pound bodyweight has proven lethal. Guinard found puppies much more susceptible and that their death might be produced by one-seventy-fifth to one-twentieth grain per pound bodyweight. Chloretone may be given in dose sufficient to entirely abolish nervous reflexes. For this the dose must be one and one-half grains per pound bodyweight. Less than that amount will produce but partial anesthesia, and is not sufficient to prevent the dog from howl- ing. Two grains per pound bodyweight is dangerous and two and one-quarter grains is generally fatal. The drug should be given in large capsules, or better still, in konseals as the latter dissolve quicker, or it may be dissolved in whiskey or sherry wine. It is only sparingly soluble in water. An animal that has received a full dose of this drug is slow to recover its senses and equilibrium. Given as a general anesthetic, chloretone acts on the central nervous system, but unless given in poisonous dose does not depress the circulatory system. Besides its central action, it possesses local General Surgery 19 anesthetic properties. It may be substituted for cocaine, but should not be injected hypodermically other than in warm aqueous solution. BIBLIOGRAPHY. Bert — Comptes rendus des Sc^ances. 9.3, 1881, p. 768. Bills — On the Safe Abolition of Pain In Labor and Surgical Operations by Anes- thesia with Mixed Vapors. London, 1866. Bmbly— British Medical Journal. April, 1902. Qnlnard — Le Morphine et rAporaorphlne. £tude Experiment. de Pharraaco-dy- namie compart. Paris. 1898. Hoelscher — Langenbecb's Archlv. f. kiln. Chlrurg. 57, 1898, p. 175. Rudolf— Univ. of Toronto Studies. Physiologic Series. No. 3, 1901. INFLAIOIATION. Inflammation is the reaction to injury. It is tersely defined by Professor Adami as "an attempt of the organism to repair injury to a part." It is to be regarded as a physiologic process following a pathologic action, its one aim being to remove foreign matter from the part and bring about normal restitution. The phenomena of in- flammation are essentially the same in whatever part of the body they occur, the characteristic gross changes being heat, redness, pain and swelling, of various degrees ; the minute consecutive changes being temporary contraction of the capillaries followed by their dilation, effusion of serum, thickening and slowing of the blood stream, peripheral migration and diapedesis of leucocytes, and in advanced stages extravasation of the red cells. The causes are either mechanical injury (friction, heat or cold, acids or alkalies) or pathogenic microorganisms. Most surgical inflammations are of a septic nature. The inflammatory process may have one of the fol- lowing several terminations: Resolution with preservation of the integrity of the part, fibroid induration replacing the injured tissue, abscess formation or ulceration with formation of cicatricial tissue, gangrene with formation of cicatricial tissue, and in the extreme degree generalized infection and intoxication and death of the organism. Treatment. It must be remembered that a normal grade of in- flammation is healthy and physiologic, and that treatment is only required to assist the organism when either ( i ) it is too weak to re- sist adequately, or (2) where the infective agent is too strong, or (3) when the reaction on the part of the tissues is excessive (exu- 20 Surgical Diseases and Surgery of the Dog ■ berant granulations, etc. ) We treat, in short, in order to aid the or- ganism to an orderly reaction and, inasmuch as, in the vast number of cases, the inflammation is of microbic origin, most often our endeavor is to assist by removing the cause of irritation. The treatment of inflammation comprises both local and consti- tutional measures. The cause must first be sought and displaced or rendered inert. Irritants must be removed and microbic activity re- duced. The agents employed locally are cold, heat and moisture, astringents, irritants and counter-irritants, and blood-letting. Cold in the form of an ice-pack, a stream of water from a hose, or a refrigerant lotion (potassium nitrate 5 parts, ammonium chlor- ide 5 parts, water 16 parts) is valuable in the early stages as a pre- ventive, to contract the arterioles and diminish the local blood-sup- ply, but its action must be maintained without intermission, other- wise it does more harm than good by inducing a reaction after each application. Heat and moisture, in the form of hot water applica- tions with a sponge, or poultices, are indicated to relieve tension and cause dilation of the vessels with increased flow of blood, when the inflammatory process is fully established and suppuration imminent. Heat and moisture tend to confine the suppurative process and bring it to the surface. Astringents are of service to constrict blood- vessels and are employed more often to combat inflammations of mucous membranes as the mucosa of the mouth and penis and the conjunctiva. For this purpose one of the most useful preparations is the supra-renal liquid which exerts an almost immediate eflFect. Other remedies commonly employed are aqueous solutions of zinc sulphate (2:iocx) — 6:1000), crystalized alum (i :ioo — 1 1400), tannic acid (1:100 — 1:200). Irritants and counter-irritants are useful in some of the chronic forms, but only the milder kinds should be used, such as tincture of iodine and non-blistering liniments. Blood- letting is seldom practiced, but light scarification is an effective means to relieve tension in conditions of extreme congestion. Constitutional treatment is exceedingly helpful in many cases. It must always be instituted with regard to the physical condition of the animal. In the asthenic type of inflammation saline purgatives should be administered, and their action supplemented with diuretics. Both these remedies relieve distended vessels and determine a flow of blood to the excretory channels. The diet should also be restricted. In the asthenic type, tonics and stimulating diet are indicated. General Surgery 21 CONTUSION. HEMATOMA. A contusion is a traumatic lesion in which the subcutaneous tissue elements are lacerated, but in which there is no manifest ex- ternal solution of continuity. The amount of damage may be of any grade from simple capillary extravasations of blood into the are- olar tissue (ecchymosis) to rupture of large vessels with profuse hemorrhage producing a sac of blood (hematoma), to pulpification of a large mass of tissue with impairment or destruction of tissue vitality. In a hematoma the blood accumulates in a distinct cavity in the tissues. The blood soon coagulates excepting when it exists in serous sacs. Cell proliferation takes place at the border and the blood pigment is gradually absorbed until only a clear serum re- mains. Suppuration may also occur. Besides the local disturb- ances, it is a remarkable fact that deep-seated and grave lesions often occur at remote points following violent shocks, notably dis- turbances of the cerebro-spinal fluid and rupture of visceral organs. Cadeac has recorded instances of death from rupture of the portal vein, right auricle, anterior and posterior vena cavae, respectively, and Goubaux and myself cases from rupture of the liver. Symptoms and Diagnosis. Contusions give rise to tenderness and swelling. There may or may not be discoloration of the skin. Recent hematomata fluctuate, but old-standing ones have a firm circumscribed border with a soft fluctuating center, owing to fibrous tissue formation. They are distinguished from abscess by a his- tory of occurrence of the swelling immediately after the trauma- tism and by absence of inflammatory phenomena. In the region of the abdomen they must be carefully differentiated from hernia, for which they are liable to be mistaken. Treatment. Simple contusions are best left to natural processes of repair. Recent accumulations of blood should not be incised, unless infection has taken place, but they should be aspirated. Ex- ception to this rule must be noted in the case of hematoma of the ear-flap, where experience has shown that the shortest road to repair is by free incision, turning out of the fluid blood and clots, and bringing the separated tissue into apposition with sutures passed right through the thickness of the flap. Hematomata undergoing organization are best removed by enucleation after exposure of the 5ac by incision through the skin. In severe contusions hot antis- 22 Surgical Diseases and Surgery of the Dog eptic applications are indicated, and later inunctions, as the inflam- mation subsides. WOUNDS. A wound is a traumatic or surgical lesion involving a breach of surface continuity. A wound is said to be simple when it has a clean edge and contains no foreign body ; it is said to be complicated when it gives lodgment to a foreign body or has been exposed to infection. The local phenomena of wounds are pain, hemorrhage and loss of function, of degree depending upon the extent of injury. Division of a large or important vessel may be followed quickly by death, and severe hemorrhage may terminate in death some hours later by in- ducing cerebral anemia and consequent depression of the vital nerve centers. Division of a motor nerve results in limited paralysis, while the severing of a tendon causes at least temporary functional impotency. An ever possible constitutional phenomenon is reflex shock, which, however, is rare. The result of infection may be abscess, erysipelas, septicemia, or pyemia, but wounds that have com- menced to granulate are proof against infection, the granulating tissue forming a protective barrier. This has been demonstrated by Billroth's well-known experiment of binding up a wound in such condition with a fetid bandage without any reaction following. The occasional more remote effects are thrombosis and embolism, and entry of air into the veins. Amussat made experimental wounds in the veins of the breast in numerous dogs into which air entered spontaneously, the animals dying in from one to twenty-seven min- utes thereafter, while Erichsen found that the entry of a cubic inch of air would not cause death. Wounds are usually classified according to their character, viz, incised, punctured, contused, bite, gun-shot, and poisoned. Incised wounds are produced by sharp instruments and are usually simple, free of complications, and heal kindly without leav- ing much scar, though they may give rise to considerable hemorr- hage and complete temporary functional impotency of a part when tendons or nerves are severed. Punctured wounds are caused by penetrating sharp bodies, hooks, etc. Such bodies may break off, the extremity remaining within the wound. If aseptic, it becomes encapsulated, but if septic gives rise to purulent inflammation. As a General Surgery 23 rule, there is little hemorrhage. In the absence of foreign bodies puncture wounds heal kindly. Contused wounds are caused by blunt bodies and are character- ized by more or less mangling of the subcutaneous tissues and irreg- ular laceration of the skin. They are very liable to be infected. Bite wounds are usually caused by animals of the same species, and constitute one of the commonest forms of injury the practitioner is called upon to treat. They are often multiple and usually the flesh is torn and lacerated. The bites of vicious dogs or wild ani- mals are sometimes sufficient to produce eventration and dislocation of the eyeball. Bite wounds are commonly followed by suppurative processes, the pus burrowing beneath the skin and forming ab- scesses. The possibility of the virus of rabies having been intro- duced into the system must always be considered, and steps be taken accordingly. Gun-shot wounds occur principally in hunting dogs. Ordinary shot, when not fired at long range, enters the tissues at isolated points. Should it lodge in the skin it invariably sets up suppurative foci, but when it passes through the dermis and lodges in the deeper tissues it may become encapsulated without causing any trouble. When discharged at close quarters it may cause mutilation of tissues. In the case of missiles of greater caliber the possibility of remote lesions must always be considered. Vessels and nerves may be severed, bones fractured, and viscera punctured. Bullet wounds of the abdominal organs are considered elsewhere. Poisoned wounds comprise those in which vegetable alkaloids, minerals, ptomaines, snake poison, the sting of wasps and hornets are deposited. They vary in their effect upon the organism accord- ing to their toxicity, some producing violent local inflammatory phenomena, gangrene, etc., others systemic intoxication. In general, it may be said that wounds in the dog heal well when the animal is healthy, but the presence of chronic and infec- tious diseases tends to hinder the process. That pyogenic bacteria may be derived from the circulation has been shown experimentally by Rinne, who injected sterilized putrid fluids, together with staphylococci, into the peritoneal cavity and found that suppuration of all open wounds followed, which otherwise healed kindly. Open serous sacs also retard healing. The healing of wounds, whether surgical or adventitious, has 24 Surgical Diseases and Surgery of the Dog been variously classified, but for our purpose the following is the best and simplest division: (i) By first or primary intention, and (2) by secondary intention i. e., through formation of granulating tissue either (a) without suppuration, or (b) with suppuration. What is termed healing by direct union, as may apparently take place between two wounded peritoneal surfaces during intra-abdominal operations, has no existence in fact, but is in reality healing by first intention, as a certain amount of serum is thrown out indistinguish- able from the inflammatory condition, and it is the organization of this serum through fibrin which binds together. Healing by first intention is always aseptic, and theoretically, it should be the aim of the practitioner to ensure its sequence to surgical operations, but owing to the conditions under which our patients have their being, it is rarely possible to attain this desirable result. Hence, in the majority of cases, healing of surgical wounds in the dog takes place by secondary intention either without or with suppuration, but most often with suppuration. This, however, is a matter of little moment, provided adequate drainage is afforded. Adventitious wounds in- variably heal with suppuration. Treatment. The treatment of wounds comprises arrest of hemorrhage, removal of foreign bodies, drainage, and coaptation of edges. Hemorrhage from the larger vessels is controlled by liga- ture, preferably with silk, a tourniquet being employed in the mean- time if deemed advisable ; bleeding from capillaries is controlled by hot water or compression. To secure the best possible conditions for healing it is important thkt all oozing be completely checked. While experiment shows that blood-clot contains a large amount of bacteri- cidal substance it is known that the pyococcus aureus is very resistant to the latter, and if present renders a clot putrescible and conducive to suppuration. In case of considerable hemorrhage large quantities of hot saline solution (5:1000 — 1:100) should be injected into the bowel or hypodermically. Foreign bodies must be extracted with forceps, and if necessary, their point of entrance enlarged. Usually, it is best to clip away the hair from the immediate vicinity of a wound. Antiseptic irrigation should be avoided, particularly in recent wounds, as all antiseptics tend to irritate the tissues more or less. A single exception is hydrogen dioxide, which may be used for the purpose of breaking up and removing septic material. It is better to cleanse with a stream of warm sterilized water directed General Surgery 25 from a fountain syringe. Even in suppurating wounds antiseptics may be dispensed with where good drainage is provided. Abscesses must be opened and carefully inspected for presence of foreign bodies and dependent drainage openings established. The edges of fresh wounds should be adjusted with regard that no cavity be left in the deeper parts in which serum and blood may collect. Where this is not possible ample provision must be made for drain- age, to prevent abscess formation. The part of a wound most diffi- cult to treat is always the subcutis. Here the defensive power of the organism is poor, and should there occur any intervening spaces they form suitable pockets for the reception of blood and serum which, for the first few hours, exude in considerable quantity from the surrounding wounded capillaries and veinlets, and which, as already stated, form putrescible material. Should there be the slightest degree of infection present, the microorganisms, being re- moved from contact with living tissue, are free to multiply beyond the area of its phagocytic action, and thereby establish abundant suppuration. It is very difficult to prevent the formation of spaces in the subcutis, especially in fat animals. To ensure drainage the most dependent extremity may be left gaping, but in some cases it will be necessary to insert a strand of plain sterilized gauze, one end being allowed to protrude slightly, and leave it in place three or four days. This holds good, of course, where bandages can be ap- plied or other means taken to prevent the animal from reaching the parts with its teeth or feet. Where the entire surface of the wound can be brought into apposition so that no cavity remains drainage can be dispensed with, but all doubtful cases should be drained. The edges of fresh wounds are best united with subcuticular sutures. But wounds the edges of which indicate the development of cicatri- zation, and from which an animal has once torn the sutures, are pre- ferably to be permitted to fill up by granulation. H[t is remarkable what large-sized wounds will fill up completely by granulation and leave hardly a semblance of a scar particularly in animals with abundant hair. Wide-open or gaping wounds very often do not permit of approximation or if they do the tension is so great as to preclude any possibility of sutures remaining in position. Such wounds are treated by the "Cherry" process. This consists of making a longi- tudinal incision on either side a short distance to the outside of and 26 Surgical Diseases and Surgery of the Dog parallel to the edges of the wound to relieve the tension, these incis- ions being allowed to fill in by granulation. But these supplementary- No. 8a. "Cherry" method o reating gaping wounds. (A Original wonnd. (B) Site of re ief-inclBions. No. 8b. "Cherry" method of treating gaping wounds. (A) Original wound re- dnced by (B) relief-Inclslons and (0) site of secondary relief-inclsloiw. I\ y A incisions may in themselves present such gaping as to threaten a very long drawn-out filling in by granulation. That being the case secondary incisions are made to the outside of them. Where tendons are severed splints are often required to main- tain the part in rest. Shot, unless giving rise to irritation, should be left un- touched. The treatment of perforating thoracic and abdominal wounds is described elsewhere. Poison wounds call for ad- ministration of stimulants, which in the case of snake-bite should be coupled with local cauterization. il l\ J» II ft If No. 8c. "Cherry" method of treating gaping wounds, showing (A) much-re- duced original wound and (B) (C) pri- mary and secondary rellef-indsione. General Surgery 27 SHOCK. Shock is a profound reflex depression of the nerve centers re- sulting in vaso-motor paresis. The arteries losing their tone, the veins become distended, and less blood than normal reaching the brain, the vital centers are insufficiently nourished. It is due to afferent impulses set up by injury or operation. It may occur even under anesthesia, for though the afferent impulse constituting pain is abolished by general anesthesia, those affecting the vaso-motor, respiratory, and cardiac mechanisms are not controlled thereby. Happily, the condition is rare in the dog, but it sometimes occurs in animals of high nervous excitability, particularly where the injury concerns the genital apparatus. It has occurred during the removal of large tumors. I have experienced it following ablation of cancer- ous testicular tumor, and Goubaux and Cadiot and Almy have re- corded instances following removal of mammary tumors. This form of shock is to be distinguished from that following profuse hemorr- hage, or removal of a quantity of fluid from the abdomen, though in either instance, the effects are the same. Both the latter forms are of the nature of mechanical syncope, in the one case owing to cerebral anemia, in the other to sudden removal of pressure and consequent rapid distension of intraabdominal veins. Symptoms and Diagnosis. The temperature is subnormal, the pulse is rapid, irregular, weak and compressible, the respiration shallow and irregular. The pupils are dilated and react but slowly to light. One peculiar symptom is a sort of stupid expressionless indifference to the surroundings. Treatment. The indications are to raise the blood pressure as quickly as possible. This may be accomplished by injecting large quantities of hot saline solution (5:1000 to i :ioo) both hypodermi- cally and by the bowel. Eichel has shown that absorption of salt solu- tion will compensate for considerable loss of blood in a short while, particularly when transfused intraperitoneally. Heat should be ap- plied to the body, adrenalin chloride solution administered internally and hypodermics of trinitrin, digitalin, and minute doses of strych- nine given. It may be necessary to practice artificial respiration. ABSCESS. An abscess is an accumulation of pus in any tissue of the body, 28 Surgical Diseases and Surgery of the Dog but usually in the connective tissue. It is the result of inflammation caused by pyogenic bacteria and the toxins which the latter elabo- rate. The bacteria generally find access to the tissues through a lesion of the cutis or a mucous membrane, but may be carried to their ultimate destination by way of the blood or lymph streams. The course of abscess formation is as follows : The provocative fac- tor having gained access to a certain area of tissue, there is first multiplication of the same followed by concentration of leucocytes and other tissue cells. Many of these dying, liquefaction takes place in the center of the inflamed area, but at the outer zone of inflamma- tion a sort of wall of granulation tissue forms, protecting the sur- rounding healthy tissues from the infected area. It is this wall which was formerly regarded as a secreting membrane of the pus and erroneously known as the "pyogenic membrane." When, how- ever, the process is of an acute nature, the germs may multiply so rapidly that the walling in is incomplete, and, carried to surround- ing tissues, more pus may form which must perforce burrow along a course of least resistance, principally through intermuscular spaces and along subcutaneous connective tissue, avoiding in its path joint capsules, bone and fasciae, until, upon reaching a dependent position, it begins to point and finally breaks through the skin or it may invade vital organs and produce grave results. Two forms of abscess formation are recognized, viz, "acute" and "cold," according to the rapidity of their development. A cold abscess is ordinarily caused by tubercular infection, and it is gen- erally well encapsulated owing to its chronicity. The lesions leading to the production of acute abscesses are of diverse nature. Probably bites by other dogs figure in the majority of cases, while contusions and the lodgment in the tissues of infected foreign bodies either of external traumatic origin or by way of the alimentary tract are frequently responsible. Among some of the rarer forms may be mentioned: lympho-sarcomatous abscess occur- ing in the neck, abscess of the perineal region proceeding from sup- purating prostate gland, abscess produced by passage of transmi- gratory strongyles as witnessed by Megnin in the mammary region, and actinomycotic abcesses. Symptoms and Diagnosis. The symptoms of abscess may be local or both local and general. Superficial abscesses are character- ized by extensive local heat and swelling and but little constitutional General Surgery 29 disturbance. They commence as a tumefaction with edematous peri- phery. Within some thirty-six hours the center of the swelHng be- comes soft and fluctuating and surrounded by a zone of indurated granulation tissue. With deep abscesses the initial symptoms are fever, refusal of food, pain upon motion of the affected part, and edema of more dependent parts. Most abscesses cause more or less functional disturbance. Those of the legs interfere with locomotion and even suppo't of the body, those about the throat inhibit deglutition and respiration, while pelvic abscesses lead to suppression of defecation. The lesions with which abscesses are most liable to be con- founded are cysts, soft tumors, and hernia (in abdominal and peri- neal regions.) For differential diagnosis, the aspirating syringe should be employed. When a cachectic, wasted condition of the sys- tem is evident, the tuberculin test is indicated. Treatment. All acute abscesses in process of formation should be closely watched. Wherever feasible, their development should be assisted by hot fomentations. Immediately the presence of pus is detected, the latter must be promptly evacuated by an incision made with a sharp curved bistoury at the most dependent point. The open- ing should be free to permit of subsequent drainage. In those cases where the initial lesion is superficial and the fundus of the abscess so deeply situated that its actual location can not be determined, it is better to pass a probe or trocar through the initial lesion down to the depths of the sac and thence towards the skin. Where the point of the instrument is felt through the skin, the latter is snipped with scissors and the passage through the connective tissue enlarged. Some deep-seated abscesses, as in the parotid region, can only be safely reached with a trocar after a simple skin incision is made. The exit of the pus is to be favored by compression of the part and also by injection of peroxide of hydrogen. The next step is to remove any foreign body and thep to irrigate the sac. Most authors recom- mend irrigation with antiseptic solutions, but this is really a matter of little moment, the object aimed at being to hasten repair by flush- ing the cavity and washing away all trace of dead and moribund tis- sue, and this can be accomplished equally as well with plain water as with antiseptic solutions. A fountain syringe is well adapted for this purpose. The drainage tract must be kept open for a few days. The treatment of cold abscesses requires more energetic measures. 30 Surgical Diseases and Surgery of the Dog They must be opened, irrigated, thoroughly curetted, irrigated again, and packed with antiseptic gauze. ULCER. An ulcer is an open sore of a superficial structure. It is brought about by ordinary pyogenic or specific bacteria acting the same as in abscess, an ulcer being a molecular death of a part of a free surface, an abscess the same thing within the tissues, pus being secreted in either case. But before such pyogenic bacteria can exert any ill- effect in a tissue, there must be some impairment of vitality of the latter either through destruction of its integrity by local irritation, mechanical violence, etc., or interference with its nutrition owing to disturbance of the local circulation or malnutrition of the body in- duced by disease. Ulceration may be regarded as an inflammatory disturbance which has continued past the point where healing takes place by granulation, or a sort of continued local dying of a part, though it is quite possible for an ulcer to heal spontaneously. A wound that does not heal by primary intention or scabbing becomes an ulcer. The process of ulceration consists of an infiltration of the inflamed area with leucocytes which destroy and replace the tissues. The leucocytes dying they are thrown off with the fluid elements de- rived from the blood as pus. Common seats of simple ulceration are the edges of the ear- flaps, the external auditory canal, the tail, and the digits. Of specific origin are tubercular ulcers particularly of the neck and the ulcers of stomatitis. Symptoms and Diagnosis. As already stated, any sore or wound which does not heal by granulation is to be regarded as an ulcer. But the process of ulceration may be healthy, or it may be indolent, or exuberant. In a healthy ulcer the edges are smooth, the base level and covered with healthy granulations, the surround- ing parts normal, and an inodorous pus is discharged. An indo- lent ulcer is known by its sunken surface, its raised irregular edges. The discharge may be thin and watery. An exuberant ulcer is characterized by development of so-called "proud flesh," gelatinous granulations rising above the level of the surrounding parts. It is dark red and bleeds freely and discharges pus. Treatment. In the treatment of ulcer it is important to protect General Surgery 31 the sore from any kind of irritation, whether it be by the animal's own teeth, or from accumulated discharges. Healthy ulcers require soothing treatment by means of dessicant antiseptic powders. On external parts they should always be protected with gauze and band- ages, though this is often a difficult matter to accomplish, owing to the persistence with which any kind of application and even muzzles are torn off. Indolent ulcers require gentle stimulation with weak distilled aqueous solutions of nitrate of silver (4:100) before the powder is used. Exuberant ulcers should be cauterized with the solid nitrate of silver stick or the actual cautery. Drainage must be provided for discharges where there is a tendency to accumulation. The general health should be attended to, laxatives and tonics being administered when the nutrition of the body is at fault. The ulcera- tion of malignant tumors can only be treated by eradication of the growth. FISTULA. SINUS. A fistula or sinus is any abnormal tract in the tissues forming a communication between a septic focus or secreting gland and any other part of the body, either the surface or a natural cavity or canal. The term fistula is applied when the tract is open at both ends and the term sinus when it is open only at one end. The great majority of sinuses arise from abscesses which do not close up by granulation, and their failure to close is usually due to the presence of a foreign body or dead bone, but may also be due to protracted discharge bringing about induration of the tissues in the line of evacuation, and in rare cases to tubercular disease and actinomycosis. Occasion- ally fistulae originate as congenital defects. Where the tract com- municates with a secreting gland, the secretion itself independent of any septic process may be sufficient to inhibit the healing process. Treatment. The first step is to seek the cause. If a foreign body be present, steps must be taken to remove it. Dead bone must also be displaced. Next, the wall should be curetted or stimulated by injections of strong distilled aqueous solutions of nitrate of sil- ver (5:100 — 10:100). Failing in this, the tract must be laid freely open, the lining membrane cut away, and the wound packed with antiseptic gauze so that healing may proceed from the bottom. Where it is considered inadvisable to open up the tract by reason of ^2 Surgical Diseases and Surgery of the Dog the proximity of large vessels or other important structures, instead a counter opening may be made by inserting a director and cutting down on the same. It is hardly necessary to point out that provision must be made for drainage to guard against the reconversion of the sinus into an abscess. Special forms of fistula and their treatment will receive notice under their respective headings. BURNS. SCALDS. This form of injury varies in degree, from mere scorching to destruction of the cuticle and hair with production of blisters, to charring of the whole thickness of the skin, including often the deeper tissues, with consecutive gangrene. Deep and extensive burns are very apt to terminate fatally either through shock or ab- sorption of toxic products produced by tissue destruction. Burns may be caused by superheated liquids or solids, or by caustic sub^ stances. Treatment. In light burns very satisfactory results are obtained with applications of picric acid in solution (saturated while hot and decanted when cold). Soothing ointments are also efficacious. In severe burns treatment must be directed to prevention of sepsis, by dusting with analgesic antiseptic powders. Blisters should be opened by pricking with a needle. In gangrene, antiseptic irrigations and dressings are indicated. To quiet the nervous system and give relief from pain morphine and atropine should be administered hypodermically. FEOST-BITES. The local effects of frost-bites resemble burns, and like the lat- ter, may vary in degree from simple hyperemia and infiltration to separation of the epidermis by serous exudation, to mortification of the part. Frost-bites are usually confined to the extremities of the members, but it is very rare to observe extreme cases. Treatment. The object to be aimed at is to restore the circula- tion as slowly as possible. For this purpose, the affected parts may be immersed in cold water, the temperature of which should be grad- ually raised, or they may be rubbed with snow. In severe cases leading to gangrene, the ordinary antiseptic treatment of wounds must be followed. General Surgery 33 ERYSIPELAS. This is an extremely rare disease, the dog being almost immune to the pathogenic action of the pyogenic streptococcus. Froehner has recorded witnessing only four cases in seventy thousand animals treated at Berlin. The infection, when it occurs, is apt to be metas- tatic and induce remote troubles, one of Froehner's cases having exhibited myocarditis, pericarditis, hepatitis and nephritis. Symptoms and Diagnosis. The local symptoms are much less evident than in the human being, owing to the skin being hidden by the hair. The area of infection is swollen and intensely red or bluish red and sensitive. The usual constitutional symptoms of fever are also present. Treatment. Locally, the inflamed area must receive a thorough cleansing with antiseptic solutions. The hair should also be re- moved with clippers. Following this, ichthyol or thiol should be ap- plied in the form of ointment, the strength of the ointment being at least half and half. This dressing is to be freely and repeatedly applied. Internally, tincture of the chloride of iron should be ad- ministered in large doses, four or five times daily. Excessive febrile manifestations may be combatted with antipyretic drugs, or better still, by application of ice-packs to the body. TOXEMIA. SEPTICEMIA. PYEMIA. No sharp distinction can be drawn between these three forms of systemic poisoning, since, properly speaking, the difference is one of degree rather than of kind. By Toxemia is meant the absorption of and intoxication by the products of microbic activity (toxalbu- mins) having their origin in some local infective process. The term Septicemia is used when living pyogenic bacteria enter the circula- tion, while by Pyemia is meant the condition where these bacteria are deposited in distant tissues with resultant production of multiple abscesses. In the two latter conditions, therefore, the localization of the bacteria in vital organs is what is most to be feared. There may then result a train of disorders (cardiac, pulmonary, hepatic, renal, or cerebral), any one of which may be sufficient in itself to bring about a fatal termination. The microorganism most com- monly concerned is the staphylococcus aureus, the streptococcus being but slightly virulent in the dog. Metastasis may be by the blood or lymph channels. 4 34 Surgical Diseases and Surgery of the Dog The commonest provocative factors are suppurative conditions following traumatic or unclean surgical wounds, retention of fetal tissues, intestinal lesions, and omphalo-phlebitis in young subjects. In some cases the origin is obscure. Symptoms and Diagnosis. Differential diagnosis is difficult. The chief symptoms are high intermittent fever with rigor, complete anorexia, diarrhea, albuminuria, feeble cardiac action, vomiting, and great prostration. In pyemia, the secretion from the initial wound, is, as a rule, scanty but greyish or bloody. Symptoms of metastatic abscess formation are sometimes evident. Recovery from pyemia is rare. In young subjects, where the disease follows omphalo-phleb- itis, it is common for suppurative foci to develop in superficial parts of the body, and these cases usually respond favorably to proper treatment. Treatment. Treatment must be prophylactic rather than cura- tive, i. e., any possible further contamination of the blood stream must be prevented. Deep suppurative and gangrenous foci must be thoroughly drained and cleansed, and if necessary, amputation re- sorted to. Superficial metastatic abscesses must be freely opened. Constitutional treatment should be directed toward supporting the strength with stimulants, but drugs are of little avail. Antistrepto- coccic serum is worthy of a trial. GANGRENE. By gangrene is meant the mortification of tissue in bulk as distinguished from ulceration or molecular death of a part. Gan- grene can occur with or without the presence of bacteria, the essen- tial cause being the cutting off of the blood supply. Interference with local nutrition may result from crushing, the action of chemi- cals, bums, frost-bites, embolism, tight bandages, strangulated her- nia, paraphimosis, and the products of specific microorganisms. A few instances are on record of infection by the bacillus of malignant edema which usually terminated fatally. Symptoms and Diagnosis. Gangrenous tissue is recognized by its coldness, change of color, loss of sensation, and inability of the part to perform its function. Where the disease process has ceased to spread, there develops a so-called line of demarcation, which is a zone of inflammation and actively proliferating repair tissue. General Surgery 35 Treatment. The cause must be removed, and spread of the con- dition prevented by separation of the dead from the Hving part. Where possible, return of the circulation may be encouraged by gen- tle friction, above the gangrenous area. BIBLIOGRAPHY. Amnseat — Recherches sur I'lntroductlon Accldentelle de I'Air dans les Velnes. Billroth— cited by Noetzel in Langenbeck's Arcliiv. f. klin. Cliir. 55, 1897, p. 544 Cadeac— Rec. de M§d. V6t6r. Jan., 1902. Eichel— Langenbeck's Archiv. f. klin. Chir. 58, 1899, p. 105. Erichsen— cited by Horsley in Brit. Med. Journ. 1885, p. 213. Froehner — Berl. thieraerztl. Wochenschr. 1894, p. 308. Gonbaux— cited by Cadlot & Almy in Traltfi de Th6r. Cliir. d. Anlm. Dotn. M^gnin — Comptes rendus de la Soc. de Blolog. 1889, p. 304. Rinne — Ueber den Eiterungsprocesa and seine Metastasen 1889, p. 61. CHAPTER II. The Head and Neck# CONGENITAL MALFORMATIONS. Leaving out of account the malformations of the eye, ear, etc., which are treated of elsewhere, there is little of any surgical signi- ficance. Occasionally anencephalic monsters are bom, and it is note- worthy that the shape of the head of the Bulldog and Pug is an inherited congenital malformation, brought to perfection, if I may use the term, by artificial selection. What is known as Cervical Rib has been observed in the dog. Gruber recorded an instance in which the transverse process of the seventh cervical vertebra possessed a joint surface with which a supernumerary rib articulated and between which and the first sternal rib was a supernumerary muscle. On the opposite side the corresponding transverse process was somewhat lengthened. This condition is important only in that it may give rise to errors in diag- nosis. Bournay has described a congenital arterial-venous Aneurism in the neck resulting from abnormal termination of the two carotids and jugulars. It presented a subcutaneous pulsating tumor, which was augmented in volume when the head was lowered and dimin- ished when the latter was raised. TRAUMATIC LESIONS. The commonest wounds about the head and neck are those re- sulting from bites by other dogs. When they suppurate they are very apt to terminate in abscess formation of considerable extent owing to the burrowing tendency of the pus. Spiked collars em- ployed to restrain bulldogs are also a source of mischief, and one in- stance is recorded of an intractable sinus resulting from such a spike becoming detached and driven into the tissues. Puppies sometimes sustain parturition hematoma of the scalp during birth. 36 The Head and Neck 37 Treatment. All wounds about these parts should be closely watched for signs of subcuticular suppuration. Gaping wounds should be sutured with the buried suture with provision for drainage. Smaller wounds are best left to heal by granulation. If an abscess develops free exit must be given to the pus at its most dependent part. Fistulous tracts must be searched for foreign bodies. ABSCESS OF THE SCALP. This trouble is seen more particularly in young nursing pup- pies, but it also occurs in adult animals. In puppies it may be of pyemic nature following omphalo-phlebitis, but may also result from local traumatic influences as is the case in the adult. Symptoms and Diagnosis. The condition is recognized as a large swelling on the top of the head, which very closely resembles that peculiar to hydrocephalus, in fact, the first sight of the trouble in the puppy may give the practitioner the impression that the animal is the subject of the latter condition. By palpation the subcutaneous situation of the fluid can easily be determined. Treatment. The purulent matter must be evacuated by lancing at a dependent point, and reaccumulation prevented. Hydrogen peroxide may be injected to cleanse the cavity but if free drainage is provided, unassisted recovery is quick to follow. FOREIGN BODIES. Foreign bodies in the form of rubber bands are sometimes mis- chievously slipped over the head on to the neck or string may be tied tightly round the neck by children. Such bands by constant pres- sure soon cut through the skin and may dangerously constrict the trachea. Symptoms and Diagnosis. If a linear wound is observed en- circling the neck, such a foreign body may be suspected. At the outset, the animal makes repeated efforts to rid itself of the body. Later, as the constricting action encroaches on the trachea all the signs of dyspnea are exhibited. Treatment. The indications are to remove the constricting agent by dividing it, and in order to do this it may be necessary to cut into the neck. 38 Surgical Diseases and Surgery of the Dog NEOPLASMS. The growths affecting the eyes, ears, alimentary and respira- tory tracts, thyroid and lymphatic glands, are treated of under their respective headings and only the more common ones which occur in the skin and subjacent tissues will be described here. These con- sist of papilloma, fibroma, hematoma, cutaneous horns, sarcoma, and carcinoma. Papilloma. Warty growths occur about the head and neck, principally in old animals, but not so plentifully as on the extremities. Favorite seats are the vicinity of the eyelids and the nose. Symptoms and Diagnosis. They are sharply defined and some- times pedunculate. In consistence, they may be soft or hard with a smooth or slightly puckered surface. They are distinguishable from malignant growths by their limited dimensions and slow rate of growth. Treatment. Simple excision with curved scissors is sufficient, but it is best always to cauterize the base with the actual cautery or lunar caustic. Fibroma. These tumors are found about the ears and eyelids and the cheeks. Symptoms and Diagnosis. Fibromata are always well demarked and hard. They have their seat in the skin itself and with it are mobile from the subjacent tissues, or they are situated subcutaneously when of connective tissue origin. Occasionally they are pedunculate. Treatment. The same as for Papilloma. Hematoma. Contusion cysts occasionally occur as the result of traumatism, usually a blow from a club or stone. One case re- corded by Siedamgrotzky resulted from a bite. Rupture of vessels taking place, there follows a condensation of connective tissue around the extravasation, and the blood is either quickly absorbed or undergoes organization and is more slowly absorbed, or it may suppurate. Some cases seem to arise spontaneously and to have communication with the veins, for if they are opened they continue to bleed persistently. Symptoms and Diagnosis. Blood tumors are known by their subcutaneous position and their painless, tense, or fluctuating char- acter. In the upper part of the neck they require careful differentia- tion from burrowing ranula and cystic goiter. Aspiration may be resorted to in doubtful cases. No. SI. Carcinoma of the Neck. The Head and Neck 39 Treatment. Hematomata should not be interfered with but allowed to undergo absorption. Cutaneous Horns. There are a few cases of this peculiar form of growth on record. Favorite positions are the forehead and inner surface of the ear. The manner of their formation from sebaceous cysts and papillomata is described in the chapter on Neoplasms. Symptoms and Diagnosis. As the name indicates, they are circumscribed outgrowths much resembling a horn. Treatment. Extirpation should be practised, but the cyst at the base of the horn must be removed at the same time. Sarcoma. Sarcoma of periosteal origin occasionally arises in the forehead. Being of highly malignant character with a great tendency to invasion of adjacent parts, the prognosis must always be grave. Sarcoma of cuticular or subcuticular origin is occasion- ally seen but it is not common. It has been observed to follow scratches or wounds. Symptoms and Diagnosis. Periosteal sarcoma occurs as a sub- cutaneous enlargement or upheaval which exhibits a very rapid growth and soon attains an enormous size. The consistence of the growth is variable. Usually it is bone-hard at its base, but may fluc- tuate in the center of its surface. If adjacent bones are involved when the tumor has its seat in the forehead, there may be a hemorr- hagic discharge from the nasal passages. Sarcoma of the skin ap- pears as an irregular tuberculate growth and assumes a fungoid character when it breaks through the dermis. Treatment. An operation in the early stages offers some chance of effecting complete eradication of the growth. Not only the actual tumor but the healthy tissues in the immediate neighborhood must be freely removed. Epithelioma. Carcinoma. These tumors, formed of prolifer- ating atypical epithelial or glandular (sebaceous or sudoriferous) cells show a predilection for the head, notably the forehead and vicinity of the ears, but occur also in other parts. Symptoms and Diagnosis. Cancerous tumors vary in size from a pea to the infantile head. In consistence, they are moderately firm or hard, they are intimately united with the skin, and mobile from the underlying structures, have a rather circumscribed, irregular, puckered surface, and exhibit a tendency to ulcerate and become metastatic to the nearest lymphatic glands. 40 Surgical Diseases and Surgery of the Dog Treatment. Early and free removal is indicated, before the lymphatics become implicated. BIBLIOGRAPHY. Bonrnay— Rev. V6t6r. Oct., 1899. Grnber— Arch. t. Anat. und Phye. 1867, p. 542. The Eyes CONGENITAL MALFORMATIONS. Sequestration Dermoid is a not infrequent form of growth of congenital origin consisting of a patch of skin usually bearing tufts of hair, situated on the mucosa lining the surface of the eyeball. The explanation of its occurrence will be found in the chapter on Neoplasms. It may be unilateral or bilateral and while it is usually confined to the conjunctiva covering the sclera at the outer canthus, it may also involve the corneal surface. Treatment. The growth is operable, indeed, if not removed, it will sometimes slowly enlarge. The animal should be narcotized and the cornea anesthetized with cocaine. The growth is then seized with forceps and detached by cautious dissection. To prevent blood from beclouding the area a stream of warm sterilized water should be played over the eye during the operation. A white cicatrix usually develops which, however, is scarcely noticeable. Should the growth extend far over the cornea, it is best to leave that portion of it untouched. Congenital Opacity of the Cornea. This is occasionally seen in the form of minute whitish spots which tend to clear up sponta- neously. Persistent Pupillary Membrane. As the term indicates, this is a condition in which the delicate membrane covering the anterior surface of the lens during the greater part of intrauterine life, fails to undergo complete resolution and persists as fibers, either singly or in strands, passing across the pupil, or as a vascular, slightly opaque membrane, floating or adherent to the capsule of the lens. The condition would seem to be hereditary in some cases, for Bar- rier recorded an instance in an animal whose dam had the same affec- tion and had given birth to another blind litter, and whose sire had suffered from some visual defect the nature of which was not de- termined. The Head mid Neck 41 Symptoms and Diagnosis. Where but a few fibers persist, vision is not impaired and their presence is usually unnoticed until some disorder prompts a close inspection of the eye, but where the membrane persists as such the animal experiences difficulty in see- ing, particularly in brilliant light, and walks with hesitancy. Treatment. Strands and floating membrane are operable with technic similar to that observed in cataract or iridectomy. Congenital Cataract. This is a rare affection appearing as a partial or complete opacity of the lens, which may be calcareous, and is in all probability due to hereditary influences. It tends to remain stationary. Treatment. Treatment must be by discission or extraction of the lens. Congenital Dislocation of the Lens. This condition has been recorded by Fromarget in bilateral form, the dislocated body being intimately adherent to the cornea. It is probably of hereditary na- ■ture, since in Fromarget 's case another animal in the same litter was likewise affected and the sire was also blind. Treatment. The indications are to extract the lens, exerting traction when it is adherent to any part of the chamber. TRAUMATIC LESIONS. The eye is liable to all forms and degrees of injury, chief among which are contusions and wounds either of which may be slight or severe. Contusions are usually produced by blows from blunt instruments and the resultant lesion may be anything from mere superficial loss of epithelium by the cornea to intraocular hemorrhage, luxation of the lens, or even disruption of the optic nerve. Slight injury to the cornea may, however, lead to severe ulceration by septic infection. On account of the incompleteness of the orbital arch a forcible contusion sustained immediately over the eye commonly results in luxation of the latter, particularly in breeds possessing prominent eyes, notably Pugs and Toy Spaniels, and this lesion may also occur when a body presses between the eye and the wall of the orbital cavity, as for instance, the tooth of another dog. In other words, one dog may actually bite out the eye of another. Wounds are mostly caused by sharp-pointed instruments, the tooth of another dog, the claw of the cat, or as is not uncommon, by minute 42 Surgical Diseases and Surgery of the Dog particles of sand or splinters of steel. The latter are apt to find lodgment in the substance of the cornea. Hunting dogs sometimes receive gun-shot wounds. Wounds are non-penetrating or penetrating. Non-penetrating wounds are limited to the conjunctiva, the cornea, or sclerotic. When free from virulent infection they heal kindly, but microbic activity results in conjunctivitis or keratitis and its possible complications. Penetrating wounds are always serious when they pass the anterior chamber, owing to the liability to suppurative inflammation. Even when only the aqueous humor escapes the possibility of hernia of the iris is always imminent. Penetration of the lens by a foreign body may result in cataract. Symptoms and Diagnosis. Contusions give rise to acute in- flammation, lachrymation, pain, and photophobia, according to their severity, and edema of the lids. When intraocular hemorrhage oc- curs, the chambers become greatly distended and the eye acquires a volume two or three times the normal and bulges. The lids become everted and the humors assume a livid color, giving a hideous aspect to the animal. Relief is sought by rubbing the eye against hard sur- faces. Wounds and foreign bodies are easily seen upon close exam- ination, but the organ is sensitive to manipulation. Treatment. In all contusions and wounds soothing antiseptic applications are indicated, as described under conjunctivitis and keratitis. Recent luxations are amenable to reposition, and if the optic nerve is not lacerated the sight may be preserved. To replace the globe, it is first cleansed and an assistant required to hold open the lids as wide as possible. Steady, firm pressure is then exerted over the globe outside the border of the cornea on both sides with the balls of the thumbs, until the organ slips back, which it generally does with a slight sound. It may be necessary to slit the external commissure before reduction can be effected and reunite it with a stitch later. Protective antiseptic bandages should be applied for a few succeeding days and the organ closely watched for signs of in- flammation. Luxation of some hours' duration or accompanied with irremediable injury calls for enucleation of the globe. Foreign bodies must be promptly removed after five to ten minutes of local cocaine anesthesia (2:100). They are best lifted with a fine sterilized forceps or needle. When firmly embedded it may be necessary to pass a broad needle into and through the cornea and behind it to The Head and Neck 43 form a surface against which to work so that the body be not pressed entirely into the anterior chamber. In human surgery the Haab magnet is employed to remove steel splinters. It compels the splin- ter to retrace the tract by^ which it entered, even from the lens. When a foreign body is within the anterior chamber it must be extracted by means of fine forceps or curette through an incision made at the in- ferior border, everything being done aseptically. In case of hernia of the iris the latter may be replaced with a sterilized sound or the protruding portion excised and the stump returned, instillations of eserine being used afterwards to cause its withdrawal from the wound. Intraocular hemorrhage is a serious condition, and it is seldom that any treatment short of enucleation is of use. Puncture is useless. PARASITES. Filaria may occur as evidenced by an observation made by Rossi. In this case there was kerato-conjunctivitis, which devel- oped into ophthalmia. A fistula and staphyloma formed, and the eye was extirpated. The anterior chamber contained a purulent exudate in the center of which a female filaria was found. At the Pisa College an instance of a tick attaching itself to the lower border of the cornea has been noted. In this case there were profuse secretion of tears and spasmodic closure of the lids. Treatment. In the case of filaria, its exit must be prompted by puncturing under cocaine anesthesia the cornea at its superior border with a fine scalpel introduced flatwise and causing it to escape with the flow of aqueous humor. Ticks may be detached, under local cocaine anesthesia. CONJUNCTIVITIS. Inflammation of the conjunctiva is the commonest ocular trou- ble with which we have to deal. It is induced by ordinary pyogenic microorganisms or a mixed infection, and it is also probable that it is due in some instances to a specific infection. The provocative fac- tors are traumatic lesions, foreign bodies, primary infectious diseases such as distemper and inflammations of the respiratory tract, and any condition tending to expose or irritate the con- junctiva, such as ectropion, entropion, sequestration dermoid, neo- 44 Surgical Diseases and Surgery of the Dog plasm of the membrana nictitans, and trichiasis. It may be brought about by dust in animals which habitually run under carriages. Two principal forms are recognized — the catarrhal and the pur- ulent — and either may run an acute or chronic course. The term "follicular conjunctivitis" is applied to a Idealization of the disease on the membrana nictitans, generally on its inner surface. Catarrhal conjunctivitis is a simple malady of mild type, usually of short dura- tion, and characterized by vascularization and the secretion of a mu- cous or muco-purulent discharge. Purulent conjunctivitis is of a much more intense type, accompanied with considerable pain, a pro- fuse distinctly purulent secretion, and commonly corneal lesions. Symptoms and Diagnosis. In the catarrhal form the vessels be- come injected and a watery secretion at first forms and tends to run over the lids and excoriate the neighboring skin. The secretion soon changes to a greyish muco-pus and collects in the canthi and at night-time glues the lids together with a scab. The animal seeks to free itself of the matter by rubbing its eyes with its paws, but that there is little or no pain is evidenced by the lack of photophobia. In the purulent form the disease first appears mild, but in a few hours grows severe. The vessels become deeply injected, the lids swollen, there is great pain, photophobia, and sensitiveness to ex- ploration, and tears are secreted profusely and run down the face. The inflammatory secretion at first is thick and ropey but later be- comes distinctly purulent of a yellowish or greenish color. Keratitis frequently develops and quickly leads to corneal ulceration, and sometimes to panophthalmia. When the cornea becomes involved the disease runs a lengthened course and the acute symptoms pass to a more chronic state, in which the abnormal sensitiveness disap- pears. In follicular conjunctivitis the mucosa, principally of the in- ner surface of the third eye-lid, is studded with minute dark red round elevations which, when numerous, resemble granulation tis- sue. Under these conditions the membrana appears red and tume- fied and projects more or less over the globe. Treatment. The first step is to search for and remove any ap- preciable active irritant, such as a foreign body, entropion, or neo- plasm of the third lid, and where there is any photophobia, confine the animal to a darkened room. In the catarrhal form any of the following lotions are useful: Boracic acid (i:ioo), permanganate of potash (i :200o), sulphate of zinc (i :25o). In many cases, and The Head and Neck 45 particularly where there is active congestion, it is possible to abort the trouble with instillations, repeated every two or three hours, of from one or two drops of adrenalin chloride solution (1:10,000 — 1:2,000), a remedy which is remarkably active in blanching con- gested membrane. It has a slight smarting effect to which some dogs strenuously object, but this can be averted by previous instillation of cocaine solution. Purulent secretions may be gently wiped away with a wad of absorbent cotton, and the conjunctival sac should then be copiously irrigated with any of the above-mentioned antiseptic solutions, and finally receive a few drops of nitrate of silver solu- tion (1:200 — 2:100). When the condition assumes chronicity, the yellow oxide of mercury ointment (1:60) is indicated. The best way to treat the follicular form is to remove the membrana nictitans un- der cocaine anesthesia. It is seized with forceps, drawn forward, and quickly snipped oflf with fine curved scissors. The hemorrhage is insignificant. SUPERFICIAL KERATITIS. ULCERATION OF THE CORNEA. This is an inflammatory affection of the cornea which results from causes similar to those which are operative in producing conjunctivitis. But, it would seem that keratitis may also arise as an idiopathic manifestation to which the young of certain breeds, such as the Boston Terrier, show a marked predisposition. It is most often unilateral but is also frequently bilateral, and it is commonly associated with conjunctivitis. The in- flammation may run one of several courses. Resolution by absorption may take place in the stage of infiltration. Should the process progress past this point to cell necrosis, it is most com- mon for the superficial corneal layers to disintegrate and develop an open ulcer. In some cases the ulcer extends inwardly and destroys all the layers and perforation follows. When this happens, partic- uarly at a lower peripheral situation, the iris is apt to fall forward and protrude through the opening and become united with the cornea by formation of repair tissue, when the condition is known as Anterior Synechia. Or, the ulcerative process may stop short at the superficial layers and the intraocular pressure cause the remain- ing layers to bulge forward (Kerectasia), or all the layers may be destroyed except the posterior one when the latter protrudes through 46 Surgical Diseases and Surgery of the Dog the opening in the form of a small pouch (Keratocele). Should the superficial layers remain intact, the pus infiltrates the deeper layers and an abscess results. Such an abscess may undergo resolution, but it tends to burst on the surface, or as sometimes happens, it dis- charges inwardly into the anterior chamber (Hypopyon) and there may inaugurate an acute ophthalmia. In rare instances, through failure of an ulcer to heal, a fistula develops. In some cases the ulcer becomes exuberant as in other parts of the body. As a result of corneal ulceration and the consequent formation of scar tissue an opacity remains which may vary in degree, receiving the name Nebula, Macula, or Leucoma according to its intensity. Sometimes the scar tissue formed after perforation fails to withstand the in- traocular tension, and that portion of the cornea is forced forward to form a pouch-like protrusion. This is termed a Staphyloma. Ordinarily, a Nebula or Macula decreases little by little and finally disappears, but dense Leucomas are usually a permanency. Kera- titis is generally accompanied with more or less pericorneal injection or conjunctivitis, but an asthenic type without manifest inflammatory reaction is sometimes seen during the course of exhaustive diseases. Symptoms and Diagnosis. The earliest symptoms are photo- phobia, manifested by spasmodic closing of the lids, and increased sensitiveness and lachrymation. The cornea becomes infiltrated and opaque. This condition can last some weeks and be accompanied with suppuration and new vessel formation. The process continu- ing to the ulcerative stage, a grey or greyish white depressed or excavated area appears, of variable breadth and depth, surrounded by a zone of hazy cornea and sometimes vascularization. Threat- ened perforation is recognized by bulging of the floor of the ulcer, Kerectasia by a bulging opaque elevation, and Keratocele by a translucent, hernia-like pouch surrounded by a border of opaque cornea. Staphyloma is at first reddish, but later becomes densely opaque. Abscess formation, which may be of variable extent and occur at any portion of the cornea, is characterized by great photo- phobia, secretion of tears, and pericorneal injection, and by a spot which is at first grey but speedily grows yellow, and which may be sharply defined by normal cornea or surrounded by a zone of opacity. As already has been stated, an abscess, unless previ- ously opened, discharges, as a rule, externally. When it empties into the anterior chamber, the pus appears as a yellow mass within. The Head and Neck A7 Treatment. As in conjunctivitis, irritants must first be sought for and removed, and the animal should then be confined to a darkened room. During the stage of infiltration soothing appli- cations are indicated and for this purpose a warm solution of boric acid (2:100) should be instilled by means of a medicine-dropper. If there is much congestion present atropine is to be added in the same proportion. In the stage of resolution yellow oxide of mer- cury ointment (1:60) may be smeared under the lids. Cocaine should not be employed as it hinders the healing of ulcers. The best treatment for ulceration is frequent instillations of distilled aqueous solution of nitrate of silver (1:100) or of permanganate of potash (1:2000); sublimate solution (1:5000), or fontialdehyde (1:3000) are also excellent. In the torpid stage, after subsidence of the acute symptoms, gentle stimulation is needed, ointments of yellow oxide of mercury, iodol, or aristol, or insufflations of calomel, producmg the best results. Indolent ulcers, keratocele, fistula, and kerectasia require touching with the solid nitrate of silver stick. In threatened perforation the intraocular tension should be dimin- ished by aseptic paracentesis of the cornea. When perforation has taken place atropine (1:100) should be used to produce mydriasis or dilation of the pupil when the opening is in the center of the cornea, and eserine (1:1000) to produce myosis when it is at the periphery of the cornea, the object in both instances being to cause the iris to retire from the lesion and thereby lessen the liability to adhesien. Recent staphyloma is treated with instillations of eserine. or paracentesis to allow escape of the aqueous humor. Failing m this, the protruding portion should be ligated with fine silk under cocaine anesthesia, the ligature being allowed to remain in position for a day or two, when the occluded portion is excised, but in the interim the animal should be kept under morphine or it may otherwise damage the eye by scratching. Abscess should be opened, puncture with a needle suflScing. For nebula and leucoma yellow oxide of mercury ointment or insufflations of white sugar may be employed, together with internal tonic medication. INTERSTITIAL KERATITIS. This is a diflfuse form of the disease in which the inflammation involves the several layers of the cornea. It is characterized by mul- tiple opacities and profuse intracorneal vessel formation. Ulcera- 48 Surgical Diseases and Surgery of the Dog tion rarely takes place. It is seen in poorly nourished animals and also those with rheumatic tendencies. Symptoms and Diagnosis. The disease commences as a hazi- ness which is sometimes streaky, near the center of the cornea. This gradually spreads over the whole cornea, at the same time showing scattered spots of greater density. There is usually a slight flow of tears and some photophobia. Soon new blood vessels commence to grow out into the layers of the cornea from the ciliary vessels towards the center, producing a dull-red or salmon color. In the course of time, generally some months, the eye com- mences to clear from the periphery and the vessel formation sub- sides, although slight haziness and even minute vessels sometimes persist. Treatment. The indications are to allay the inflammation and maintain mydriasis and for this purpose nothing is better than fre- quent instillations of atropine solution (i :ioo). Internally, the sali- cylates should be administered in rheumatic subjects and tonics in asthenic animals. In the clearing stage, after irritation has sub- sided, the yellow oxide of mercury ointment ( i : 60) may be ap- plied with advantage. OPHTHALMITIS. This term is applied to acute inflammation of part or all of the eye. It is generally of a suppurative type. As a rule, it results from causes of external origin, such as traumatism, perforating ulcer of the cornea, infected operations, burns, etc. One case is on record as having followed washing of the animal with strong lye. Accord- ing to some authorities, it may arise by endogenous infection. When limited to the anterior chamber the disease remains unilateral, but when the entire eye is affected, the fellow usually sooner or later becomes involved. Symptoms and Diagnosis. The eye is tumefied and projecting, and very sensitive. The conjunctiva are red and swollen. The cornea loses its transparency, or if a perforation has occurred, a wound is seen with injected or granular edges through which issues a purulent matter. There is some fever present and the animal is depressed and refuses to eat. When there is absence of a wound, an ophthalmoscopic examination is necessary to detect the presence of inflammatory debris. The Head and Neck 49 Treatment. When the disease is confined to the anterior chamber, antiseptic irrigation is indicated, and when the entire or- gan is imphcated there is nothing to do but to practise early enu- cleation. GLAUCOMA. Glaucoma is a disease in which there is an augmentation of the intraocular fluids, and as a consequence, increased intraocular tension. It may arise as a primary affection or secondarily as a complication of some other pre-existing disease. Acute, subacute, and chronic types are recognized. The disease is most often seen in aged animals and is more common in females than in males. Symptoms and Diagnosis. Attention is usually first drawn to the condition by a haziness or opacity of the cornea which is more pronounced in the center than at the periphery, and by injection of the conjunctival veins. On palpating the ball with the finger-tips a hard feeling is imparted and usually the cornea is devoid of sensation owing to the edema. There is no reflex movement of the lids though compression of the globe itself may be painful. The pupil is dilated and moves sluggishly, and the iris is discolored. The pressure of the increased fluid in the posterior portion of the globe forces the lens and periphery of the iris forward so that the depth of the anterior chamber is depreciated. Vision is partly or wholly inhibited and the eye slowly atrophies. Treatment. The results of treatment are rarely satisfactory and a guarded prognosis should always be given. Myotics are in- dicated, instillations of solutions of eserine ( i : 300) or pilocarpine (1:200) being employed every two or three hours. Eserine has the additional advantage of diminishing abnormal intraocular ten- sion. Brisk purgatives should also be administered. Should these measures fail, the only alternative is to practice partial iridectomy as is done in the human subject with variable success, about one- fifth of the muscle being removed up to the ciliary border. HYDROPHTHALMIA. This condition — so-called dropsy of the eye — is one of ex- cessive secretion of the aqueous humor. It differs from Glaucoma in that the cornea and sclerotic become distended. It is most com- 50 Surgical Diseases and Surgery of the Dog mon in animals possessing naturally prominent eyes, such as Pugs and Toy Spaniels. Symptoms and Diagnosis. In the early stages the only symptom is that of prominent bulging. If the condition is allowed to persist, the tension to which the cornea is subjected brings about its dis- solution and permanent loss of sight results. Treatment. To relieve the tension the cornea should be punc- tured repeatedly if necessary and this followed up with instillations of eserine solution ( i :20o) . AMBLYOPIA. AMAUROSIS. These terms are applied respectively in those cases where vision is subnormal or is entirely abolished, but where there is no ophthal- moscopic change. The disorder may be unilateral or bilateral. The causes are manifold. Some cases are due to inflammatory changes or deposits in the retina. Others result from traumatism, encephalic disturbances, severe hemorrhages, and atrophy of the optic nerve as may follow infectious disorders, notably Distemper. Symptoms and Diagnosis. The eye has a staring look. The pupil is immobile and widely dilated, though there is slight pupillary action in the incomplete form. Ophthalmoscopic examination may disclose a local lesion, particularly in atrophy of the optic nerve when the vessels which are normally numerous and red in appearance, for the most part disappear, the few remaining assuming a greyish color. Excepting in those cases resulting from sudden transitory disturbances the evolution is usually slow, though Distemper cases may develop in two or three weeks. Slowly developing cases have usually graver import than those of the opposite nature, where the condition may disappear with the passing of the provocative factor. Treatmenjt. By far the best remedy is strychnine. This should be injected hypodermically every three days in the temporal region as advocated by Froehner. Very minute doses must be employed, I to 3 mg. sufficing. So effective is this treatment that improve- ment has been noticed after the second injection, and if the ophthal- moscope is again employed neoformation of vessels may be ob- served. In cases due to retinal deposits, iodine is indicated in fhe form of the iodides internally. The Head and Neck 51 CATARACT. This term is used to denote any opacity of the crystalline lens or its capsule. It is a common trouble. It is sometimes congenital in origin, and sometimes traumatic from contusions and wounds, but most frequently occurs incident to senility. The nature of its development is not properly understood but it is believed to be due to some condition interfering with the nutrition of the lens, and heredity is known to play a part. Cataracts are also seen in cases of diabetes mellitus. A cataract may be partial or complete, unilateral or bilateral, and according to the stage of its development may be soft or hard and consist of isolated spots, striae, or peri- pheral, central, or total opacities, of white, bluish, or amber color. Congenital cataracts show little tendency to further development, but those arising in young animals increase in density at a rapid rate. Senile cataracts on the other hand run a protracted course. A cataract sometimes undergoes displacement or complete lux- ation. Symptoms and Diagnosis. The first symptom is impairment of visual acuity and this becomes more and more marked as the con- dition increases in intensity until total blindness is established. The eye being examined, the telltale opacities are discovered, though these, when slight, may be imperceptible without an ophthalmo- scopic examination. Pupillary action may remain normal. Treatment. As has been observed by Cadiot and Breton, cat- aract never retrocedes in the dog and its treatment is exclusively surgical and an operation beneficial. Theoretically, removal of the lens could leave the subject capable of but vague sensation of near- by objects. But, in reality, as has been observed by Cocteau and Leroy, Contejean, Randolph, Moeller, and others, recovery of almost perfect vision is the rule. This takes place progressively in one to three months. At first the animal runs into obstacles and scents its food before partaking. Distant objects and particularly persons calling, are seen perfectly, and the animal runs at once ; but in approaching, it can no longer see and hunts around guided by the voice. As the improvement takes place, accommodation, which is always within narrow limits under normal conditions, is re- established. Contejean holds that the lens is not regenerated and cites the absence of Purkinje's images as evidence. But this he regards as unnecessary suggesting that certain muscular fibers can 52 Surgical Diseases and Surgery of the Dog contract and diminish the equator of the eye, and this organ being filled with liquid or semi-liquid, the cornea and retina become separated, thus enabling focussing to take place. This view is sup- ported by Randolph who points out that the dog is not possessed of human visual acuteness, so that few demands are made on the ac- commodative apparatus and consequently loss of the lens is at- tended with comparatively little or no inconvenience. On the other hand, Cocteau and Leroy in a series of experiments found that the lens fibers were reformed in a certain length of time after their re- moval. There are two methods of producing removal of a cataract in the dog, viz., by Discission and by Extraction, The best results attend discission, though this method is not adapted to cases of senile or hard cataract. Discission comprehends the laceration of the anterior capsule of the lens with a specially constructed needle, so as to cause the aqueous humor to invade the spaces between the lenticular fibers, which causes the latter to swell and gradually soften and finally undergo absorption. The reparative process is initiated by the surgeon, so to speak, and the rest is left to Nature. It is followed by little or no irritation and an uneventful recovery is the rule. Extraction or immediate removal is not always followed by favorable results ; it gives rise to considerable irritation during the healing process and there is an ever-present menace that the animal will irretrievably injure the eye in its efforts to allay this irritation. Still, the operation has several times been performed without untoward results. LUXATION OF THE LENS. This lesion occurs through traumatism or as a complication of cataract. The congenital form has already been noted. It may be complete or incomplete and take place into either the anterior or posterior chamber. It necessarily causes partial or total abolition of vision. Treatment. In anterior luxation the lens may be completely removed by operative measures similar to those for cataract. STRABISMUS. G)mmonly termed "squint" this is a condition where the visual The Head and Neck 53 axis is deviated from the point of fixation. It is a very rare con- dition but ha,s been seen by Hobday in which case it was congenital, there being a convergent squint in both eyes. It may also result from paralysis of the ocular muscles, their unequal contraction, or from neoplasms of the orbit. Treatment. Under general anesthesia the abnormally con- tracting or contracted muscle is divided in a manner similar to that in enucleation with some slight modification of technic. The con- junctiva at the canthus on the affected side only is incised, the probe-pointed hook passed inward and under the muscle, and made to raise the latter which is then severed. Subsequent treatment is directed to maintaining the wound free of infection by antiseptic irrigation. In Hobday's case the condition of one eye only was improved by the operation. EXOPHTHALMIA. Reference has already been made to prominent bulging of the eyes seen in Hydrophthalmia and Intraocular Hemorrhage. But these must be differentiated from the protrusion of Exophthalmic Goiter. Symptotns and Diagnosis. In the latter disease the protrusion is so great that the eyelids cannot close, and the exposure to which the eye is subject results in drying of the corneal epithelium and ulceration. The accompanying and characteristic symptoms, viz., enlargement of the thyroid and palpitation of the heart, serve to distinguish it from other eye lesions. Treatment. This is described under The Thyroid Gland. NEOPLASMS. Growths of the eye are uncommon, but both innocent and ma- lignant types have been observed. Of the former, Pinguecula is a term applied to a small nodule which sometimes appears in the con- junctiva, and Pterygium to a peculiar hypertrophy of conjunctival connective tissue. Granuloma of the cornea sometimes results from a wound of that membrane. Reference has already been made to congenital sequestration dermoid. Sarcoma and Carcinoma repre- sent the malignant types. Symptoms and Diagnosis. Pinguecula occurs near the margin 54 Surgical Diseases and Surgery of the Dog of the cornea, usually at the inner side ; it has the appearance of fatty tissue. Pterygium has a similar situation but has a striking shape, being fan-shaped and convergent towards the cornea, upon which it tends to encroach. Granuloma presents a granulating flesh-like appearance and a hard consistence and is painless to pressure. When extensive it may project from the eye and cause separation of the lids. The surface is covered with a slimy secretion. Sarcoma appears first as a small flesh-like wart or polypoid outgrowth on the surface of the globe and spreads over the cornea and posteriorly. Carcinoma is accompanied with swelling of the neighboring lymph- glands. Treatment Pinguecula should be excised with scissors under cocaine anesthesia. Pterygium must be seized with forceps, raised from the surface of the globe and carefully severed from its corneal attachment with a knife. It is then dissected from its conjunctival bed and the edges of the wound united with sutures. Minute granuloma may be excised or cauterized with the solid nitrate of silver, but extensive granulomata and the malignant growths re- quire enucleation of the globe. Surgery of the Eye In any major operation on the globe complete anesthesia is essential. As far as inhibiting pain is concerned the local use of cocaine is quite sufficient, but there is always danger that an animal in possession of consciousness may start suddenly and cause acci- dents. It is extremely important that all instruments be rendered sterile as it is very difficult to combat infective processes in the in- terior of the eye. Where instruments are to be introduced within the eye, the conjuctival sac must also be thoroughly disinfected with a bichloride solution ( i :5ooo) . Subsequent to operative measures, the animal should be kept in a small darkened en- closure to prevent active movements and the irritative effect of strong light. PARACENTESIS. Puncture can be made under local cocaine anesthesia, and near the lower margin on the outer side with a sterilized broad needle. The Head and Neck 55 the conjunctival sac being previously disinfected with any of the antiseptic solutions indicated in Keratitis. The lids are widely separated either with the finger and thumb or a stop-speculum, and the needle inserted flatwise and manipulated so as to separate the lips of the opening and allow the aqueous humor to escape. It should be withdrawn cautiously to guard against prolapse of the iris as may take place with a too sudden gush. ENUCLEATION OF THE EYEBALL. For this operation certain instruments are indispensable to its proper performance, to wit: a stop-speculum, fixation forceps, a probe-pointed hook, and a pair of scissors curved on the flat. The stop-speculum is first introduced to hold the lids apart. Next, the cornea being seized with fixation-forceps (the latter being employed to steady the ball), the conjunctiva and adjacent fascia are divided in a circle close to the margin of the cornea by snipping at them with scissors. The hook is then passed successively under the tendon of each ocular muscle and made to raise the latter prominently to view, when they are divided close to their ocular attachment. To sever the only remaining attachment, viz., the optic nerve, the blades of the scissors are passed between the divided conjunctiva and the eyeball until the optic nerve is reached, when they are expanded and made to cut the nerve squarely off. The hemorrhage is insignfi- cant and can be controlled by pressure or packing. No after-treat- ment is necessary, nor should any kind of bandage be applied. An artificial eye may be worn, selected to match the sound one, and it should first be introduced about a week or ten days after the operation, but only worn for a few hours at a time at the outset. DISCISSION OF THE LENS. For this operation only two instruments are essential, viz., discission needle and fixation forceps. In bilateral cataracts only one eye should be operated upon at a time. The pupil being previously dilated with atropine, the conjunctiva is grasped with the forceps to steady the globe, and the needle is passed through the cornea at a point in its lower and outer quadrant corresponding to the margin of the dilated pupil. It is then directed upward to the upper margin of the pupil, made to enter the capsule and drawn boldly through the latter. A second crucial incision is made in like manner and 56 Surgical Diseases and Surgery of the Dog the needle is withdrawn. It should be borne in mind that the larger the opening is made in the capsule, the more freely will the aqueous humor produce the desired effect. Following the operation, the iris must be kept well dilated with atropine (1:100) dropped in the eye three times daily, until absorption of the lens is complete. This takes place in varying periods, according to the density of the cataract, three weeks being about the shortest time, the more pro- tracted cases running into months. The operation should be re- peated if absorption is slow or incomplete. EXTRACTION OF THE LENS. This operation is really an elaboration of the preceding one. Extra instruments are necessary, namely, a Graefe cataract knife and a Daviel spoon. The pupil being previously dilated with atro- pine, and the speculum inserted, the eyeball is steadied by seizing a fold of conjunctiva below the inferior border of the cornea with the fixation forceps, and drawing it downward. The next step is corneal section and the flap should embrace the upper half of the diameter of the cornea. The point of the Graefe knife with the edge directed upward is made to enter the anterior chamber at the corneo-scleral junction and to emerge at a point exactly opposite and the section completed with a gentle sawing movement. This causes escape of the aqueous humor. The discission needle is next introduced and with it the capsule is incised crucially as in the pre- ceding operation. The back of the spoon is then laid against the inferior portion of the cornea and firm but gentle pressure exercised with upward motion to coax out the cataract. During the operation the iris sometimes prolapses, when it is to be carefully replaced, or failing in this it may be snipped off with scissors close to the border of the cornea. The after treatment is the same as for the preced- ing operation, but in this case, to prevent injury to the eye by scratching, it should be bandaged with a piece of lint soaked in bi- chloride solution and changed twice daily. BIBLIOGRAPHY. Barrier— Bull, de la Soc. de M6d. V6t§r. 1898, p. 476. Coctean & Leroy — Journ. de Phy. Exper. et Pathol. 7, 30-44. Contejean— Comptes rendus de la Soc. de Biol. 1896. p. 1032. Fromarget— Rec. de M6d. V6ter. 1898, p. 89. Hobday — Journ. Comp. Path. & Ther. 8, p. 250. Moeller — Zeltschr. f. vergleich. Augenhellk. 1885, p. 65. Plsa—Schwelz. Archlv. 1897, p. 230. Randolph — Johns Hopkins Hospital Bulletin. Feb., 1895. Rossi — TJdsch. Toor Vecartsenljkunde. Jan., 1895. The Head and Neck 57 The Eyelids CONGENITAL MALFORMATIONS. At birth the margins of the lids are united and they do not separate for some ten days thereafter. When separation fails to take place, the condition is known as Ankyloblepharon. It is also some- times seen in after life occurring as a result of inflammation of the lids. Treatment. In the partial form a grooved director is inserted in the opening remaining and made to pass to the opposite canthus in a line with the ciliary border; the tissue is then divided with a bistoury or scissors. In the complete form, a primary incision is made in a fold of skin gathered up with forceps and the operation completed in like manner. To prevent reunion of the severed edges, they must be frequently stretched apart and oil dropped in. TRAUMATIC LESIONS. The lids sometimes sustain lacerations which, if not attended to, may result in deformity, entropion, ectropion, etc. Edema of the lids often follows a blow, and abscess formation is an occasional termination. Treatment. The edges of wounds must be carefully approxi- mated with fine silk sutures. BLEPHARITIS. Inflammation of the lids occurs as an idiopathic trouble con- fined to the free border, often as a manifestation of eczema or follicular mange. It has been known to terminate in ankyloble- pharon. Suppurative inflammation sometimes results from con- tusions and wounds and leads to abscess formation which may dis- charge spontaneously into the conjunctival cul-de-sac. Treatment. In blepharitis confined to the free border remedies must be used to combat the condition present, whether eczematous or parasitic, always, however, with the precaution to avoid irritating applications. In abscess formation, the pus should be evacuated by an incision made just external and parallel to the free border. 58 Surgical Diseases and Surgery of the Dog ECTROPION. Eversion of the edges of the lids is a rare trouble, being not nearly as common as Entropion. It results from cicatricial forma- tion following inflammation or injuries to the periocular tissues, but may also be produced by swelling of the conjunctiva. It is gen- erally seen in the lower lid and may be bilateral, Sytnptoms and Diagnosis. The condition is recognized by turning outward of the lid coupled with undue prominence of the conjunctiva. Through the constant exposure to which the latter is subjected it is more or less inflamed. Mucus and tears are freely secreted. Treatment. When due to conjunctivitis, scarification of the con- junctiva will at time suffice, but if this fails, the operation for the cicatricial form must be undertaken. This consists in excising under cocaine anesthesia an elliptical piece of the conjunctiva in the long axis of the lid, or if this fails, in removing a V-shaped seg- No. 10. Operation for Ectropion. ment of the lid including all the tissues and skin and bringing the edges of the wound together with silk sutures. ENTEOPION. Inversion ot part or the whole of the edges of the lids is not an uncommon deformity and is frequently complicated with trichiasis. It is most often seen in hunting dogs and dogs of the larger breeds. The Head and Neck 59 As in Ectropion, it may be caused by the formation of cicatricial tissue following wounds, by chronic blepharitis, eczema, follicular mange, etc. Spasmodic inversion accompanying acute conjuncti- vitis and keratitis must not be confounded with the true deformity. This lesion occurs most often in the upper lid, but both lids may be affected. Symptoms and Diagnosis. The lid is turned inward and com- ing in contact with the eye actively irritates the latter, sometimes to the extent of starting up ulcerative keratitis. There is usually convulsive closure of the lids and much secretion of mucus and tears. The conjunctiva are injected. Treatment. This trouble is remedied by excision of an elliptical portion of skin covering the lid. With entropion forceps a fold of skin is seized, parallel to the ciliary border, of sufficient size to cause the inturned lid to assume a normal position, care being taken to avoid including the conjunctiva. The strip of skin in the grasp of the forceps is then excised with scissors close to the forceps so that at least a quarter of an inch of skin exists between the wound and ciliary border. The margins of the wound are brought together with subcuticular silk sutures. No. ll. operation for Entropion. TRICHIASIS. Turning in of the eye-lashes occurs as a complication of en- tropion, but it also takes place independently of the latter trouble. It may lead to serious results as the constant rubbing of the cilia against the cornea causes ulceration. Treatment. The offending lashes must be plucked out with for- ceps as often as is necessary. If this proves insufficient total ex- cision of the hair follicle must be practised by making two parallel incisions along the margins of the lids on either side of the row of hairs, and of such depth as to ensure complete removal of the roots. 6o Surgical Diseases and Surgery of the Dog NEOPLASMS. The commonest form of growth seen in the eye-lids is Papilloma or Wart. It is innocent but in aged animals may become malignant by assuming epitheliomatous character. Fibroma also occurs, as does Sarcoma. The Membrana Nictitans and the Orbital Gland with which it is closely associated are frequently the seat of swelling from acute inflammation, hypertrophy from chronic inflammation, or myxoma. Treatment. Warts are seized with forceps and snipped off with curved scissors. As a rule, no anesthetic is necessary but nervous subjects should previously be narcotized to prevent accidental injury to the eye through sudden movements. The hemorrhage amounts to nothing and soon stops spontaneously. When the growth is ex- tensive it is necessary to remove a wedge-shaped portion of the lid with scissors under cocaine anesthesia and suture the cut edges. In either case, the base should be cauterized with the solid lunar caustic. Enlargements of the Membrana Nictitans and Orbital Gland call for removal under deep cocaine anesthesia by seizing the mem- brane with forceps, drawing it forward and snipping it off with fine curved scissors as close to its base as possible. The cocaine anes- thesia must be thorough and no attempt should be made to remove the membrane until the full effect of the drug is procured. LACHRYMAL FISTULA. This is a very rare affection. It may occur as a sequel to traumatism, through extension of inflammation of the nasal pas- sage causing obstruction within the duct, or through lodgment of foreign bodies. The obstruction occurs where the duct emerges from its bony casing and continues as a membranous tube to the nose. Chronic suppurative inflammation starts up, the pus burrows and perforates the bone and discharges externally. Symptoms and Diagnosis. Lachrymal fistula appears as a tiny trumpet-shaped orifice with pouting granulations a little below the inner angle of the eye. Tears, muco-pus, or pus exude and soil the hair. The eye swims in tears. To differentiate from maxillary fistula a fine probe must be employed and it should be remembered that in the latter condition the discharge is invariably purely ourulent. Xo. 12. Papilloma of the Eyelid. No. 13. Hypertrophy of the Orbital gland. The Head and Neck 6i Treatment This is a delicate undertaking. An attempt should be made to divert the flow to the nasal cavity by establishing a new opening directly into the latter, and promote healing of the outer wound by cauterizing it. The Ears EXAMINATION. The external ear, when healthy, can be easily inspected in a favorable light if the flap is held aside, but for examination of the external canal and drum an expansible speculum and mirror are necessary. When the parts are inflamed they are very sensitive and the animal usually offers more or less objection to manipulation and it is sometimes necessary to apply a muzzle and even the hopples. TRAUMATIC LESIONS. The wounds most commonly met with are bites by other dogs. Contusions caused by the animal shaking its ear-flaps are not un- common and these are referred to under Hematoma. Bite-wounds vary in extent and position and are often irregular. Division of the anterior auricular artery can give rise to severe hemorrhage.' As a rule, wounds of the ear are tardy to heal through continual scratch- ing and agitation on the part of the animal. According to Cadiot and Almy, the base of the concha may suf- fer fracture and as a result the auditory conduit be more or less completely obstructed if reunion should take place with defective position of the parts. Treatment. The edges, if severed, must be nicely sutured and every effort made to avoid resultant deformity through irregular cicatrization. In some cases it may be advisable to amputate a por- tion of the flap, when the opposite ear should be treated in like manner. During healing a protective ear-cap and soothing applica- tion may be necessary. ULCERATION OF THE CONCHA. This disease is most commonly observed in fine-haired sub- jects possessing long, pendant ears. The lesion is always situated at 62 Surgical Diseases and Surgery of the Dog or near the edge of the concha. In most cases it occurs as a compli- cation of otitis resulting from the bruising caused by violent or constant shaking of the flaps, and it is then usually bilateral. It may also result from traumatism and may develop as a manifes- tation of eczema. Symptoms and Diagnosis. One or more raw or scab-covered ulcers are observed, with sensitive edematous edges. When raw, and the flaps are violently shaken, blood may be swished in all directions. The disease is generally progressive owing to the incessant irritation of the shaking. Treatment. When uncomplicated with otitis this lesion is very stubborn and unresponsive to treatment. The flap should first be soaked in a moderately hot antiseptic solution, and the same treatment pursued as advocated for otorrhea, viz., application of distilled aqueous nitrate of silver or protargol solution (3:100 — 5:100), twice daily, supplemented with xeroform or other analgesic antiseptic powder to which a little orthoform may be added to get a more pronounced anodyne effect. At the same time the ears should be securely bound to the head, as further shaking counter- acts all good eflfect of treatment. Failing in this after perseverance a reasonable length of time, a portion of the flap must be ampu- tated in as artistic a manner as possible. When developing as a complication of otitis, treatment is seldom necessary, the inflammation usually subsiding as the primary trouble disappears with treatment. OTITIS. OTORRHEA. Inflammation of the ear is a very common affection, particu- larly in long-eared animals. It is usually unilateral but it may be bilateral. It exhibits all the phenomena of inflammation and ter- minates in ulceration. The disease has been attributed to a variety of causes, such as excessive animal diet or lack of exercise, but these conditions bear little relation to it. In the great majority of cases, it is a purely local pyogenic infection engendered by irritation pro- duced by accumulation of cerumen and dirt. Such accumulation is particularly provocative of irritation in ears with pendant flaps, in which ventilation cannot freely take place. It is for the latter reason that the disease is less common in animals with erect or cropped ears. There is also a parasitic form of the disease caused The Head and Neck 63 by the presence of the Symbiotes auricularum, which, however, is extremely rare. Should ulceration once disturb the integrity of the parts a further and constant irritant exists in the presence of the resultant tissue debris which has no chance to escape by drainage. The condition then assumes chronicity, the integument of the audi- tory canal becoming thickened, sometimes to such degree as to oc- clude the passage. This thickening is to be distinguished from the not uncommon papillomatous excrescences. While the inflamma- tion may extend as far as the tympanic membrane, it is very rare that the latter becomes involved. When the disease is allowed to become chronic it sometimes gives rise to the neoplastic forma- tion known as papilloma. Complications in the form of hema- toma of the concha or ulceration of its borders frequently arise as a result of the violent shaking and scratching. Symptoms and Diagnosis. In the acute form the animal inces- santly shakes its head, scratches its ears, or rubs them along the ground. Examination of the ear reveals a hot, congested, and tender internal integument, which in the inner recesses is generally coated more or less with dirt and wax. A mirror and ear speculum may be employed to facil- itate inspection, and the latter is indispensable to permit of free view of the ulcers. As the inflam- mation progresses, sup- .. . 1 , J ■ No. 14. Ear Speculum. puration takes place and a fetid purulent liquid is discharged. The presence of ulcers and pus may always be as- certained by the characteristic suction sound given forth by manipu- lation of the base of the ear. If the disease is unilateral the head is inclined sideways towards the affected sac. Hearing is often im- paired. In the parasitic form epileptiform seizures have been ob- served to take place, usually when the animal was excited. Treatment. Attention must first be directed towards removing all dirt and wax and tissue debris and thoroughly cleansing the auri- cula and external canal, particularly the innermost recesses of the latter. This is best accomplished by irrigating the parts with moder- ately hot water by means of a gentle stream from a fountain syringe. Antiseptic solutions may be used for this purpose but their employ- 64 Surgical Diseases and Surgery of the Dog ment carries no advantage with it. The animal usually objects the less the further the nozzle is inserted within the passage. Another method, which is, however, more painful, is to grasp a small wad of absor- bent cotton with the beak of a hemostatic forceps, dip it in the fluid, and swab out the ear. In either case the passage should be finally freed from all moisture with dry absorbent cotton in this manner. Hair in the vicinity of the passage should be removed with scissors. In cases exhibiting advanced ulceration and which con- sequently would give rise to much pain upon manipulation, mor- phine should previously be administered hypodermically. A great many remedies have been advocated and employed in this affection, but two or three are pre-eminent in their curative power, and with them alone the worst form of the disease may be eradicated. It should be remembered that this disease is an in- flammatory one due to the action of pyogenic microorganisms, and differs in no wise from inflammatory disturbances of the same origin and nature in other parts of the surface of the body and re- quires similar methods of treatment. In the active hyperemic stage irrigation of local bathing with moderately hot water is beneficial followed by soothing applications. As a soothing application a remedy combining antiseptic, dessicant, and analgesic properties is desired and nothing meets the requirement better than the synthetic powder xeroform. The milder ulcers call for gentle stimulation and for this purpose nitrate of silver in distilled aqueous solution (3:100 — 5:100) cannot be excelled. The employment of such solu- tion for stimulating purposes may be limited, usually to three or four instillations. It should be instilled night and morning into the external meatus and retained there for a few minutes, the animal then being allowed to shake it out, or in the case of a light-coated animal, absorbed with a piece of cotton or sponge to prevent it staining the hair. Indolent and exuberant ulcers may be actively cauterized with the solid stick or powerful solutions. As the action of the caustic is very painful the parts must be well anesthetized with an instillation of a strong solution of cocaine. Local anesthesia being established, the canal is dilated with a speculum to expose the ulcers, which are then freely cauterized. A few hours after the ap- plication of the nitrate a more profuse discharge takes place, which, however, soon subsides. Severe and long-standing chronic cases treated in the manner thus outlined may be permanently cured in X(i. ITi. Pnpilloniiita of the Ear. The Head and Neck 65 from two to six weeks, but as the trouble is prone to recur the ears should subsequently be periodically examined. In the parasitic form, parasiticides are, of course, indicated. To ensure local applications reaching all parts of the canal the base of the ear must be manipulated between the thumb and finger. If the shaking of the flaps is violent enough to threaten the production of hematoma or ulceration of their borders the protective ear-cap may be ^employed. SINUS. A very rare form of sinus which is caused by the presence of a dermoid dentigerous cyst in the temporal region may have its orifice of discharge within the auditory canal (See The Teeth). Suppura- ting lymphatic glands will also sometimes break through and dis- charge into the auditory canal, thereby simulating otorrhea. NEOPLASMS. Two forms of neoplasms are commonly met with in the ear. They are both innocent. They occur as papillomata which develop in the vestibule of the outer ear, and as contusion or extravasa- tion cysts (hematomata) which form beneath the integument of the concha. Sebaceous adenomata have also been observed. Papillomata. These tumors occur as single or multiple, flat, coin-shaped or cauliflower-like excrescences. When numerous they may extend well within the vestibule and block the canal. From their surface they usually discharge a fetid, greasy matter. They occur as the result of chronic otitis. Symptoms and Diagnosis. The symptoms are identical with those of chronic otorrhea, and the presence of the growths is as- certained only by close inspection of the auditory canal. The animal is often deaf. Treatment. By far the most eflfective method of treating this disease is complete destruction of the tumor with the thermo-cautery. Ablation by snipping at the base of the growth with curved scissors, as advocated by some authors, I cannot recommend, as it is uncer- tain in result and is usually followed by recurrence of the trouble. Cauterization is effected with the animal in the lateral position under complete anesthesia. The burning process must be thorough. The 6 66 Surgical Diseases and Surgery of the Dog ear-speculum should always be inserted while the cautery is in use, partly for the purpose of dilating the canal, but also to protect adjacent parts. A day or two later a mass of resultant necrotic tissue needs to be removed with forceps and irrigation. Subsequent treatment consists in irrigation with antiseptic solutions, thorough drying with absorbent cotton, and insufflation or packing with ab- sorbent powders, such as xeroform, aristol, etc. Any sluggishness in healing or tendency towards unnatural secretion should be treated with injections of silver solution in the strength employed in otorrhea. Extensive cutting or burning of the canal involving re- moval or destruction of all or most of the integument leads to oblit- eration of the canal. It will be remembered that it is the epithelium of the free surface of the body which prevents union of contiguous parts. When a raw surface, denuded of all epithelium, is brought in contact with another similar surface, union of the two takes place by interformation of connective tissue. Even a deep sac-like wound fills up with reparative tissue, because the latter grows more quickly than does the epithelium from the neighboring surface. If the epithelium were the quicker to grow, it would extend over the wounded surface, prevent the filling-up process, and lead to the for- mation of pits and depressions in all wounds deeper than the skin. And it is exactly this process of connective-tissue reparation which tends to develop as a consequence of radical surgical measures af- fecting the external auditory canal. A free granulating surface is left, which fills up and coalesces and completely obliterates the canal. The indications in these cases are daily irrigation of the parts and packing with gauze impregnated with dessicant powders, until the epithelium has had time to spread inwards over the raw surface to the depths of the canal. A case presenting complete obliteration of both canals following excesssive ablation of the parts, and which I endeavored to remedy by making an artificial opening and canal, terminated in failure after a four months' attempt at keeping it open. Strangely enough the hearing of the animal seemed very little impaired, which suggests that this result is not to be re- garded as altogether undesirable since it certainly protects from future troubles of a like nature. Hematoma. This lesion is characterized by rupture of ves- sels and an extravasation of blood or hemorrhagic exudate beneath The Head and Neck 67 the perichondrium of the conchal cartilag-e. It may occur on both sides but it is more often confined to the internal one. Ordinarily the fluid remains unchanged other than to clot but it may suppurate. If it undergoes resorption, which it is very slow to do, the re- sultant cicatrization usually causes considerable shriveling and de- formity. A spontaneous cure is rare. Its origin is always traumatic, in most cases resulting from the shaking and scratching provoked by otitis or conchal ulceration, but it may also be caused by bites, or bruises. Symptoms and Diagnosis. The affected ear-flap exhibits a characteristic bulging generally confined to the inner side but some- times involving both. When of recent origin, the swelling is hot, tense, and sensitive, and the head is depressed towards the affected side. When of long-standing, it is insensitive, devoid of inflamma- tory phenomena, somewhat indurated at its borders, and fluctuates. Treatment. The indications are to evacuate the fluid and as speedily as possible promote reunion between the separated peri- chondrium and its subjacent cartilage. The latter step is accom- plished by mechanical or chemical means. Simple lancing and with- drawal of the fluid is ineffectual, for the sac continues to refill for a lengthened period as often as it is emptied, and the longer the healing process is protracted the greater is the resultant deform- ity of the parts. The most satisfactory results are obtained by the following procedure: Evacuate the fluid by incision at the most dependeat portion of the flap. Then, after the manner first suggested by Mc- Queen, pass interrupted radiat- ing sutures through all the tis- sues of the flap at intervals of about one-third of an inch, throughout the cystic area, tying the kfiots on the surface where the flap is free from hair. On each succeeding day examine the fl-ap and squeeze out any little fluid which may have accumu- lated, through the original in- cision. Remove the sutures in . the course of a week. In some no. le. operation for Hematoma of the Ear-aap. 68 Surgical Diseases and Surgery of the Dog cases a protective cap will be found expedient but usually the shaking ceases as soon as the irritation which provokes it is allayed, and no further bruising occurs. Another method for promoting reunion of the tissues is to inject a strong solution of iodine (iodine i part, potassium iodide 2 parts, alcohol i6 parts) after the exudate has been evacuated, but it is neither as certain nor as speedy as the preceding one. AMPUTATION OF THE CONCHA. Under the term "cropping" this operation is extensively per- formed on this continent for cosmetic purposes, or in other words, to improve the appearance of the animal. Fashion, led by the fanciers, regards the Great Dane, the Bull Terrier, the Boston Terrier, the Black-and-tan Terrier, and certain French toy breeds as fit subjects for improvement, and while such an operation cannot be regarded as strictly legitimate surgery, yet it is described here so that the practitioner may become conversant with the technic in order that he may fit himself for undertaking it if he so elects. Amputation is also indicated when the flap has suffered irre- mediable laceration and in intractable ulceration of the concha, in which case both ears should of course be fashioned as artistically as practicable. Various designs of clamps have been invented to facilitate the operation and they are useful to employ as "markers," so that both flaps may be evenly cut, but there is none wholly satisfactory, for the reason that it is impossible to construct a clamp of such shape as to include in its grasp at one time all the parts to be removed. One of my own design is figured in the accompanying illustration. The Great Dane "crop" is the simplest of all. It is what is known as a "straight crop," and the straight clamp is employed. It is best done at the age of about three months. General anesthesia may be employed, but as the operation is one which can be done rapidly, morphine narcosis is sufficient. The first step consists in juxtaposing the flaps above the head and snipping them with scissors together at a spot which is to form the superior extremity of the "crop." This secures equal length to either ear. The clamp is then adjusted on the concha or flap, the outer edge of the upper end of the instrument corresponding to the snip, the lower end being pressed close to the head so as to include The Head and Neck 69 as much of the burr or lobe as possible, and it is then screwed tight. Quickly following, the blade of a scalpel is run along the outer edge of the clamp, thereby severing the projecting portion of the flap. The clamp is then immediately re- leased. A slight hemorrhage fol- lows but this soon subsides. It usually necessary to trim slightly the lower extremity of the cut border ^" Xo. 17. First step In amputation of the Concha. No. 18. Second step In amputation of the Concha. with scissors. After the opposite ear has been similarly treated, the operation is complete. During healing, however, the resultant scar tissue forming at the wounded edge is very apt to cause the forma- tion of kinks oftentimes sufficient to prevent proper erection of the ears in after life. This must be guarded against by submitting the ears to a "pulling" process, or in other words, tearing apart any too freely contracting cicatrization. For this reason, no animal which has undergone the operation should be dismissed by the practitioner until complete regular healing has been established. It is generally a few weeks, or until all soreness has departed, before the ears are held fully erect. 70 Surgical Diseases and Surgery of the Dog The correct "crop" for the Bull Terrier and Black-and-tan Ter- rier differs considerably from that given to the Dane. It is a very close "crop" the greater part of the lobe being removed, and the flap being cut long and narrow. When properly done, this "crop" gives to the animal a very alert and sharp appearance. It is best done at the age of six to twelve months, i. e., not until the flaps are well developed. Persons who are expert in cropping animals of these two breeds rarely use clamps, depending rather upon their skill to pro- duce an even result. As already stated, clamps cannot be applied so as to render the completion of the operation possible at one step, nevertheless it is wisest for the beginner to make use of them to the extent that it is possible. A curved clamp is necessary in this case, and general anesthesia should also be employed. The flaps are first juxtaposed and snipped as in the preced- ing case. The next step is to apply the curved cXdim^ with its concave side towards the portion to be excised, the outer edge of its upper end corresponding to the snip, its lower including as much of the burr as possible. The clamp being screwed tight, the projecting portion of the flap is severed as already described, and the clamp is removed. The burr must now be removed, and this is accomplished with scis- sors by extending the section from the inferior extremity of the new border. The other ear having received similar treatment the first part of the operation is complete. The after-treatment is no less important than the actual cutting process. A "crop" of this nature can rarely be depended upon to heal as is desired, i, e., with certainty that it will stand properly erect, without some sort of support being afforded during cicatrization, for the reason that kinks are apt to form at the wounded border if the flap is allowed to hang over. Hence, it is necessary to provide some sort of splint. The best device to meet this exigency consists of a strip of stout paste-board shaped somewhat larger than the modified flap. Two such pieces being prepared, holes are bored in them near either end and short lengths of twine or tape are passed through these and fastened by tying. This splint should not be applied until a few days succeed- ing the operation or until all hemorrhage has subsided. It is then smeared on its side opposite to that from which the tapes project, with ordinary carpenter's glue, and fitted and pressed firmly against The Head and Neck 71 the hairy or outer side of the flap until the glue hardens and firm adhesion is obtained. The two modified flaps are then raised into position by tying together the opposite tapes of each splint. The erect position is thereby secured and should be so maintained until healing of the border has fully taken place, the splints being renewed if necessary. The splints can then easily be removed by "peeling" them from the flap, as, in the meantime, the hair in growing, has forced the glue away from the skin. Some animals will not fully erect the ears until a few weeks have elapsed. The Boston Ter- rier is given a "crop" very similar to that just described but the flap is cut somewhat shorter and sharper. Nn Amputation of the Concba. positloD. Splinta In CHAPTER III The Head and Neck — Continued The Lips, Mouth, Tongue and Jaws EXAMINATION. In docile animals examination of the buccal cavity is easily ac- complished. The best way to expose all parts of the mouth is to assume position facing the animal, place the fingers of the left hand over the upper jaw, and extending the thumb, direct its extremity on to the palate through the interdental space immediately posterior to the canine tooth. This causes the animal to open its jaws, and the right hand is then employed to raise or depress the lips or tongue, as desired. By another method the upper lips are pressed in between the molars and the lower jaw gently forced apart by pressure over the lower incisors. In vicious animals the procedure may be rendered safe by previous hypodermic narcotization with morphine. IMMOBILIZATION OF THE JAWS WITH THE SPECULUM. For protracted examination and some operations it is necessary to secure immobilization of the jaws by application of some form of speculum. The simplest of the various devices in use is the well-known im- provised gag of Bourrel. A stick of wood somewhat longer than the width of the jaws is selected and to either end a tape or cord is fastened. The stick is placed transversely be- tween the molars, close to the commissures, and held No. 20. Improvised Bourrel Gag. iu pOsitioU by tying the 72 No. 21. Examination of tlie Buccal cavity. The Head and Neck 7Z tape or cord back of the poll. An additional tape or cord is then tied round the muzzle back of the stick to prevent the jaws opening any further. Of the manufactured articles my own device meets all re- quirements. It is constructed on the same principle as the Wingrave mouthgag used in human surgery. It is very light and strong, can , y? •■•--~;".?---'---.-.i.-7>''«3S\ — •■; .•*■-. ••••■■•- No. 22. French Mouth Speculum. No. 23. Baker Mouth Speculum. be adjusted to fit any sized mouth and is self-expanding. Another good instrument is the Baker speculum. One invented by Hobday consists of spreading horizontal bars supported by perpendicular bars which are secured immediately behind the canine teeth, but it necessarily obstructs lateral passage of instruments and fingers of the operator, and is too clumsy for small animals. CONGENITAL MALFORMATIONS. The young of the shortnosed breeds are occasionally bom with fissure of the upper lip — the so-called hare-lip. This deformity may be unilateral or bilateral and may exist independently but is gener- ally complicated with cleft palate. It exists by virtue of incomplete fetal coalescence of the parts. It does not occur in the median line but always to one side by reason of the central part of the upper 74 Surgical Diseases and Surgery of the Dog lip being developed from a different center from that forming the outer part of the upper lip. Cleft palate forms a communicating channel with the nasal cavities so that portions of alimentary mat- ter pass out by the nose. Affected animals in which this occurs suffer emaciation and usually succumb within a few days after birth. In animals that manage to imbibe nourishment there is opportunity for the giving of surgical relief at a later stage. Treatment. Hare-lip may be successfully remedied at any age. - The position of the canine teeth must be noted and if by reason of their prominence they offer any interference are to be ex- tracted. Cocaine anesthesia is sufficient for the operation. The edges of the deformity are "freshened" by cutting away a narrow strip of tissue at their borders and the parts loosened from the sub- jacent gum by appropriate dissection. The edges are then approx- imated and secured by stout silk sutures. If the sutures are subse- quently torn out by the animal they are to be replaced. Qeft palate is relieved preferably under chloretone narcosis along similar lines but the technic is a good deal more difficult. Before the separated edges can be approximated, the palate, which owing to its intimate connection with the bone is not extensible like the lips, must be separated from the bone by blunt dissection a short distance on each side of the edges, and incisions made parallel to the latter on both sides at the outer extremity of the freed area. The edges are then "freshened" and drawn together with interrupted sutures, the gaping incisions being left to fill up by granulation. TRAUMATIC LESIONS. Wounds of every variety may occur in or about the mouth. Bites by other dogs and penetration by foreign bodies are common lesions. Treatment. The ordinary methods of cleansing, suturing and giving drainage are indicated. STOMATITIS. GINGIVITIS. GLOSSITIS. Inflammation of the buccal tissues may be diffuse or limited to the gums (gingivitis), the tongue (glossitis), the palate, the cheeks, etc. Catarrhal and gangrenous forms are recognized, the latter be- The Head and Neck 75 ing commonly designated "noma" or "canker." The gangrenous form may lead to fatal termination by production of septicemia. The disease occurs as the result of local infection, probably through invasion by ordinary pyogenic microorganisms which un- der normal conditions inhabit the mouth in large numbers together with other varieties which are entirely innocuous. But for these microorganisms to produce pathologic lesions it is essential that some favoring conditions should exist, and such conditions are generally believed to be either a local or general reduction of vi- tality and diminished resistance of the tissues of the organism, or an increased virulence on the part of the microorganism. Amongst the local conditions are irritation produced by the prehension or administration of hot or caustic liquids, by trauma- tism, by penetration of foreign bodies such as needles, bones, etc., by the constricting action of certain bodies such as threads, rub- ber-bands, and annular objects mischievously placed on the tongue or accidentally prehended, by the presense of calcic incrustations on the teeth, by carious teeth, and by neoplasms. Amongst the general conditions are certain states of infection of the entire alimentary tract such as gastro-enteritis, and toxemias such as distemper. Symptoms and Diagnosis. Mandibular action is inhibited, the mouth exhales an obnoxious odor, and saliva dribbles and hangs in filaments. In the catarrhal form the mucosa exhibits all the char- acteristic signs of inflammation and is often covered with greyish sordes.- In gingivitis the gums are dark red, swollen, bleeding and separated from the teeth. In glossitis the organ is considerably swollen and in ad- vanced stages of constriction cases may be many times larger than normal so that it protrudes from the mouth and impedes respiration. In the gangrenous form of stomatitis, the gums, internal face of the lips and cheeks, and sometimes the entire buccal mucosa and even the cuticular border of the lips are studded with fetid, grey- ish necrotic patches, or round or oval ulcers. In gangrenous glos- sitis the lesion is partial, being distinctly demarked and confined to the tip and edges, the diseased portion being cold and of brown- ish black color. Treatment. In inflammation due to local conditions the indi- cations are to remove the provocative agent and disinfect the mouth, preferably with permanganate of potash solution (2:100). Atten- 76 Surgical Diseases and Surgery of the Dog tion must also be paid to alimentation when the animal refuses to eat. When the tongue is much tumefied the swelling may be modi- fied by light scarification of the organ. The incisions are made on the inferior sulrface, the operator being caifeful not to incise too deeply. Gangrenous inflammation demands energetic treatment. The sloughing tissue must be removed with forceps and scissors and the entire diseased surface gently cauterized and subsequently treat- ed with disinfectant solutions. Gangrene of the tongue is treated by amputation of the diseased portion, but conservatism should always be observed when surgical interference of this organ is contemplated. PARTIAL AMPUTATION OP THE TONGUE. For this operation scissors and wire ecraseur are employed. The animal being anesthetized and its jaws immobilized with a speculum, proceed as follows : Depress the muzzle in order to avoid entrance of blood into the air passages. Insert two ligatures in the healthy tissue, one on each side of the median line, by which draw the tongue forward. If necessary, separate the diseased part from the floor of the mouth by dividing the frenum with scissors. Pass a couple of straight needles or pins through the organ at the proposed line of section and apply the loop of the ecraseur behind these. The needles or pins will suffice to keep the loop in the desired position. Then remove the affected part by tightening the wire. Should any hemorrhage supervene, control it by seizing the stump with fixation forceps and draw it far forward which stretches the lingual ar- teries, or ligate the latter. Another method is to use only broad- bladed scissors with a dull edge. It must not be forgotten that an animal which has been de- prived of the greater part of its tongue will have difficulty in drink- ing, and must thereafter be allowed to quench its thirst from, a run- ning spigot above the level of its head. FOREIGN BODIES. These consist principally of fragments of animal or fish bones, pieces of wood, skewers, fish hooks, pins, needles, or other hard sub- stances, which are usually accidentally prehended with the food. The Head and Neck 77 They may become wedged in between the teeth or perforate the soft tissues. Youngs treated a case in which he found a splinter of wood lodged between the upper gums behind the incisors, and observed also a small wound on the left side of the frenum. Later, an abscess formed in the throat and burst, and this led to the dis- covery of another piece of wood which had penetrated the tissues from the mouth and had lodged in the subcutaneous tissue slightly to the right of the trachea. Annular bodies, rubber bands, or threads may encircle the tongue, the ends of threads extending into the esophagus. Servais recorded a remarkable case of constriction of the base of the tongue by an annular portion of the aorta of a cow, which had slipped over the tongue while the animal was feeding and had become worked back by muscular movements of the organ. In districts where porcupines abound, it is not uncommon for dogs, in attacking these creatures, to receive a mouthful of quills. The latter make a very awkward foreign body as it is hopeless to ex- tract them without causing extensive laceration. When they pene- trate out of sight, they usually work their way through the skin in course of time and cause considerable pain in so doing. Symptoms and Diagnosis. The presence of foreign bodies in the mouth may be recognized by the persistent attempts of the ani- mal to rid itself of the offending object by pawing at the mouth and shaking the head. The jaws are champed or held open and immobile, and saliva dribbles from the mouth. The presence of pins and needles does not always give rise to indicative symptoms. They may penetrate the base of the tongue so deeply as to be invisible and only discovered by digital exploration, or they may gradually work their way through neighboring tissues and ultimately find exit at some other part of the body. In Servais's case of constriction of the tongue the latter was enormously swollen and gangrenous. Treatment. Substances wedged in between the teeth are re- moved without much difficulty with suitable forceps or they may be displaced by drawing a piece of silk or catgut to and fro in the interdental space. Needles and pins lodged in the tongue are ex- tracted with forceps. The tongue should be firmly grasped and drawn well forward to permit of more easy removal. If the point of the needle has penetrated in an anterior direction, the visible por- tion is seized with forceps and extracted by traction in the opposite direction. Bodies lodged in the cheeks may be removed by exter- ^S Surgical Diseases and Surgery of the Dog nal incision if considered advisable. Porcupine quills must be pushed forward through the cheeks, or left to emerge. NEOPLASMS. Both innocent and malignant growths occur in the mucosa and submucosa and in the subjacent tissues of the buccal cavity. The former class comprises the wart-like papillomata, fibroma or so- called benign epulis, the buccal and salivary retention-cysts or so- called ranula, and osteoma of the jaw. The malignant growths con- sist of epithelioma and sarcoma or so-called malignant epulis. The term epulis literallly means "situated on the gums," and as it possesses no pathologic signification and is equally applicable to one form of growth as to another, should be excluded from nomen- clature. The Papillomata occur fairly commonly in young animals and are undoubtedly contagious or infectious in character (see Chapter on Neoplasms, Papillomata). Symptoms and Diagnosis. They are observed as small, isolat- ed or confluent, pedunculate or sessile, whitish, dendritic, multiple growths, springing from the mucosa and situated on the inner aspect of the cheeks and lips, on the gums, and sometimes on the tongue and hard palate. When numerous they interfere with mastication and induce a buccal secretion of foul odor. Treatment. This disorder does not actually require any treat- ment, as after remaining in evidence for a few weeks the growths disappear as spontaneously as they arise. To hasten their removal, the larger ones and confluent masses may be removed with curved scissors. The mouth should be swabbed out daily with deoderant solutions, a solution of permanganate of potash (2:100) answering the purpose. Fibroma. This form of tumor is a hyperplasia of connective tissue elements which may be a pure fibrous growth or of mixed character, containing cartilaginous matter and spiculae of bone. It has its origin either in the submucous tissue or the periosteum of the maxilla. It occurs as a single growth and is not very common. Symptoms and Diagnosis. It grows at the edge of the gums as a firm reddish enlargement varying in size from a pea to a hazel- nut. Its usual position is the neighborhood of the incisors and it may occupy the entire area between the two canines. Its evolution No. 24. Papillomala of the Buccal Mucosa. r tf t- The Head and Neck 79 is slow and it may remain quiescent for months. This feature serves to distinguish it from the mahgnant sarcoma of the periosteum. Treatment. The tumor must be freely excised and the wound cauterized with the thermo-cauter}-. Ranula. Retention-Cyst. The term Ranula is generally ap- plied to all cystoid formations appearing in the buccal cavity. The designation is inappropriate and should not be employed in medical or surgical nomenclature. The correct term to employ is reten- tion-cyst and the particular organ or issue concerned should at the same time be specified. Thus, there may be a retention-cyst of Wharton's duct, through cohesion of its margin, or the cyst may be brought about by destruction and dilation of sublingual buccal glands. The latter form is the more common. By augmen- tation, such cysts may burrow into the neck and have for their external limitation the dermis. Symptoms and Diagnosis. When the cyst appears in the buccal cavity, one or perhaps two or three swellings are observed adherent to the floor of the mouth on either side of the frenum. The tongue is seen to be raised somewhat and displaced to one side. The swellings may vary in size and shape, being sometimes cylindri- cal, at other times round or oval, and may attain the size of a hen or goose tgg. The surface is glairy and slippery and in some cases so translucent as to render the greyish or reddish-yellow, more or less viscid contents plainly visible. When the cyst burrows down the neck the formation is charac- terized by its subcutaneous position in the submaxillary region or at the superior extremity of the neck, the mobility of the skin over the cyst, the viscid fluctuating contents, seemingly hard capsule, and entire absence of inflammation. These cysts grow slowly and de- velop without apparent cause. They need not be mistaken for any other condition, excepting perhaps hematomata, but the latter de- velop quickly and have a history of traumatism, and the skin is usually adherent to them. A positive diagnosis can always be made with the aspirator, the thick viscid contents of the retention-cyst not being extractable with a needle of ordinar}^ caliber. Treatment. Operative measures are followed with good results. The operator must seek to accomplish the complete excision or des- truction of the cyst wall, and not merely lance and evacuate the contents. Unless the entire capsule is destroyed, secretion will con- 8o Surgical Diseases and Surgery of the Dog tinue and the cyst be reformed or a fistula established. While the latter condition is of little importance when the orifice of discharge is situated within the buccal cavity, it is a different matter when the tract opens externally after an external operation. Small and medium-sized cysts are not difficult to extirpate and the sooner they are attended to the better. They should be seized with forceps, incised throughout their entire length, and the lining membrane dissected out or destroyed with the thermo-cauter\', the jaws being immobilized with the mouth speculum. Quite large cysts may in like manner be totally extirpated, but the operation is some- times rendered very difficult owing to extensive burrowing which may extend behind the esophagus and larynx. In these cases Froehner recommends the establishment of a suppurative inflamma- tion within the sac to accomplish the destruction of the secreting membrane. This may be done by injections of strong solutions of iodine, as follows : Insert an aspirating needle and withdraw the mucoid contents. The needle need not be aseptic, as the en- trance of pyogenic microorganisms is desired, and it should be of large caliber to permit of passage of the tenacious contents. In some cases the latter can only be extracted by lancing the sac. Then inject an equal quantity of an alcoholic solution of iodine (2:100 — 5 :ioo) until the cyst resumes its original size. Local pain and fever will soon be evident. In two or three days' time again employ the aspirator to ascertain the presence or absence of pus. Should sup- puration have failed to develop, repeat the injection again and again, if necessary at intervals of three or four days. As soon as the desired efifect is produced freely lance the abscess to evacuate the pus, and introduce a tampon of antiseptic absorbent cotton to stim- ulate healthy granulations. Recovery is generally complete in from three to six weeks. Osteoma. Exostoses or osseous tumors occasionally arise on the jaw bone as a result of diffuse inflammation of the periosteum caused by external violence. Symptoms and Diagnosis. These growths are characterized by excessive hardness and their attachment to the bone by a broad base. They are differentiated from malignant tumors by their local character. Treatment. Removal is effected by exposing the growth by -Incision through the skin and then using a chisel. No. 27. (After Cadiot and Breton). Epithelioma of the Lip with secondary lymphatic enlargement. The Head and Neck 8i Epitheliomata. This malignant form of neoplasm occurs only in animals of advanced age, growing at the inner edge of the lip, usually the lower one. Symptoms and Diagnosis. The tumor is observed at the outset as a small flat growth, which later progressively ulcerates. The ulcer has a raw, granulating appearance, or it may be hidden by a thin scab. In some cases it is mammillated. It gradually increases in size and may invade the entire lip or extend to the maxilla. Secondary enlargements of the cervical and submaxillary lymphatic glands generally develop. Differentiation from labial ulcers is not difficult. Treatment. Total excision must be practised. When the tumor is small it is removed by A-shaped section through the entire thickness of the lip the base corresponding to the free border of the lip. The edges of the wound are then brought together with interrupted sutures carried completely through all the component textures. When the growth is extensive, the autoplastic operation of Syme should be undertaken. Syme's operation consists in pro- longing the A-shaped incisions to form an X and continuing them in an oblique direction downwards. The two quadrilateral sections of skin • thus formed are separated from the subjacent tissues by dissection and made to pivot on their base, and are then united by sutures, the margfin of each portion becoming the free border of the lip. The operation is completed by stitching the mucosa to the skin. The two small triangular spaces gradually fill in by granulation. When the lymphatics are only slightly involved they should also be ablated, but when they are extensively involved operative meas- ures are contraindicated. Sarcoma. This is, properly speaking, a tumor of the maxilla, as it originates either in the periosteum, the medulla, or the en- dosteum, but as it encroaches on the buccal cavity, it will be con- sidered here. It is observed more often in the upper jaw than in the lower. It may attain great dimensions and tends to rapidly in- vade neighboring parts, such as the nasal chambers, the orbits, and even the cranium. It often recurs after ablation but is not very metastatic to the neighboring lymphatic glands, though it some- times undergoes generalization. Symptoms and Diagnosis. This neoplasm is frequently over- looked in the earlier stages particularly when situated on the inner 7 82 Surgical Diseases and Surgery of the Dog aspect of the jaw. As a rule, it is first noticed when it has attained the size of a nut or small apple and by the animal exhibiting diffi- culty in the act of prehension. The growth is insensitive and of a pinkish or reddish tint, the size varying according to the stage of development and the breed of dog affected. Its surface is irregular, knotty, or lobulated, and covered with intact mucous membrane. It is generally sessile with broad base and immobile from the sur- rounding textures, but may be pedunculate. Contrasted with other sarcomata its consistence is firm. In most cases but one rapidly- growing tumor is present; at other times several may be seen with confluent base. It may develop to such extent as to cause separation of the lips. The adjoining teeth are hidden or forced out of their sockets by upheaval. Treatment. The entire growth should be excised as soon as possible by means of a strong pair of short-bladed scissors or bone forceps and the wound thoroughly cauterized to assist in the elimina- tion of the morbid cells as well as to arrest the attendant hemorrhage. It may be found necessary to remove one or more teeth. It is better to remove too much tissue than too little in dealing with sarcoma. Very large tumors require the use of hammer and chisel, and sub- sequently the curette to effect their removal from the bone. During the operation, which must be done under anesthesia, the muzzle should be depressed to guard against escape of blood into the trachea. Rizzieri recorded having treated and completely cured a case in which the growth had invaded the whole of the right face, ex- tending from the inner angle of the orbit to the lips. Cadiot and Almy claimed a definite cure after a second operation in which deep excision, curettage of suspected points, and cauterization were practiced. BIBLIOGRAPHY. Cadiot & Almy — Traitg de Therap. Chir. des Anlm. Domestv Mggnln— Rec. de M€d V6ter. 1873, p. 639. Rizzieri— Clin, veter. May, 1891. Servals— Ann. de M6d. VSter. 1893, p. 84. Youngs — Vet. Record. 1900, p. 423. s w o = J! o The Head and Neck 83 The Teeth STRUCTURE, DISPOSITION, and DEVELOPMENT. In the typical mouth there are twenty permanent teeth in the upper jaw and twenty -two in the lower. The structure of the incisors is noticeable for the arrangement of three cusps of which the central is the largest. The four inner incisors of both jaws have these well developed, but in the corner incisors the middle cusp is very large and the lateral ones rudi- mentary or absent. The base of the crown on the inner aspect is marked by a ledge which is extended to each cusp as a ridge or cingulum. The canines are large and firmly and deeply embedded in the maxillary bone immediately behind the maxillo-premaxillary suture. Their pulp cavity is capacious and extends almost the entire length of the tooth. Posterior to the canines are four teeth which were designated by Owen as premolars, owing to deciduous or milk teeth being dis- placed by them. As a matter of fact, the first of this group, count- ing from before backward, has more the character of a true molar, it having only a germinal deciduous predecessor, which seldom be- comes calcified and generally disappears before birth, after being transitorily manifested in the papillary stage. It is the smallest of the four and has a single root and well-defined neck. The second and third premolars resemble one another closely, are considerably larger than the first, and possess two roots, of which the posterior is the larger. The three anterior premolars are not in as close con- tact as the posterior teeth, being separated by slight intervals. The fourth premolar is the largest and strongest of the premolar series. It is known as the superior sectorial. It is implanted by three roots, two external and one internal. The crown is composed of two main lobes supported by the external roots and a small one supported by the internal root. The premolars of the lower jaw are similarly arranged with the exception of the fourth which corresponds in po- sition, approximate size, and number of roots, to the third premolar of the upper jaw. The true molars of the upper jaw are two in number and are situated behind the premolars. They are permanent from the the outset and do not displace milk teeth. They possess three roots, 84 Surgical Diseases and Surgery of the Dog two external and one internal, each supporting a tubercle. The first true molar of the lower jaw is the sectorial of that series and is the largest tooth in the entire mouth. It possesses two firmly implanted roots. This tooth opposes the fourth premolar of the upper jaw in a scissor-like manner. When the dog wishes to divide tough meat or bones he passes them back to these teeth and makes a shearing movement by several short quick strokes of the jaw. The remain- ing two true molars are quite small. The second is two-rooted but the last possesses only one root. The period at which both deciduous and permanent teeth are erupted varies in different races and the sexes. In the larger breeds and in females they appear somewhat earlier than amongst the smaller animals and males. At birth the gums are smooth. Towards the end of the third week the deciduous canines make their appear- ance, about the twenty-fifth day the comer incisors, about the twenty-eighth day the middle incisors, and about the thirtieth day the pincers. The superior temporary incisors are cut before the inferior. At two months the permanent inferior pincers are seen to pierce the gum, and by the fifth month all the permanent incisors are up and in wear. The permanent canines are cut between the fifth and sixth months. At the end of the sixth or seventh week the second, third, and fourth premolars are in place, and between the fourth and sixth months they give way to their permanent successors. The first molar is erupted at about the sixth month and the second during the seventh month. The first premolar appears between the fourth and fifth months. Between the sixth and eighth months the dog has acquired a full set of permanent teeth. During the first few years of life the age may be approximately gauged by the appearance of the four inner incisors of both jaws, the lateral cusps of which gradually disappear. These changes can- not, however, be absolutely relied upon since the extent to which they take place depends more or less on the wear occasioned by the animal's food, and the health of the organs themselves. After the first year the middle cusps begin to wear even with the lateral from the two central incisors of the lower jaw. The same change takes place in the two adjoining teeth in the following year. After the third year the cusps are lost in the two central incisors of the upper jaw, and their two neighbors undergo the same change after the fourth year. The Head and Neck 85 As the animal ages the prominences of the molars are worn away, only the largest tubercles remaining. The posterior face of the lower canine impinges against and abrades the anterior face of the upper, in front of which it closes. The anterior face of the lower canine also comes in contact with the corner incisor and an abrasion takes place at this point. The older the animal the more apparent are these abrasions. The crowns of the incisors become much re- duced in size in aged animals, mere stumps remaining after eight or ten years, while they are completely worn away after ten or twelve years, or the whole tooth may be shed, together with the first premolar. Gradual discoloration talces place in late years. CONGENITAL MALFORMATIONS. Certain breeds possess defective atypical dentition. This pecu- liarity was referred to by Darwin and Magitot. The breeds invari- ably having imperfect dentition are the Chinese, Turkish, and Mex- ican Hairless. The phenomenon is not to be wondered at when it is remembered that the teeth and dermis have a common epiblastic origin. Individual members of the Mexican breed examined by Waugh were found to have the tricuspid arrangement of the in- cisors wanting, absence of the canines, and slower and later develop- ment of the molars than other breeds. Half-breeds had canines in the upper or lower jaw but not in both jaws. In several members of both sexes of this breed that I have had the opportunity to ex- amine I have found the arrangement generally as follows: In the upper jaw there is a reduced number of rudimentary or fairly well- developed incisors, but without the cuspid arrangement. Well-de- veloped canines are in evidence, and on either side well-developed first premolars and first molars, the animals being thus minus the superior sectorials. In the lower jaw the incisors are developed in about the same degree as those of the upper, but the canines are less constant and sometimes entirely absent. Premolars are also inconstant but first and second molars are often present showing the inferior sectorials to be intact. When the molars have no teeth to oppose them they may cause the formation of indentations in the opposite jaws. As is natural to expect, these animals do not care to eat hard foods, but prefer slops and soft bread and cakes. Meat can only be swallowed if cut fine, as they are without the ability to re- duce the size of tough or hard articles of diet, which dogs with nor- 86 Surgical Diseases and Surgery of the Dog mal mouths accomplish by the scissor-like movements of their sectorials. In all breeds the deciduous teeth sometimes persist, while su- pernumerary teeth, usually molars, are not uncommon. As a rule, the larger breeds have a full complement of teeth, while the smaller ones often lack the third molar of the lower jaw. The teeth may occupy anomalous positions. Distortion of the bones of the skull may throw the opposing jaws out of their proper relationship so that the teeth cannot meet. An instance of such deformity was witnessed by Gurlt. Dentigerous Cysts. Through inclusion of epiblastic tissue dur- ing fetal development teeth may occupy obscure positions. These sequestered teeth have been found in the ovaries but their occur- rence is perhaps more common in the temporal region, where they give rise to cystic formation. Instances have been observed by Werwey and Cadiot and Almy. Such cysts ordinarily remain quies- cent but if pyogenic microorganisms gain entrance into their interior inflammation takes place and a fistula results having its orifice of discharge within the auditory canal. Its presence is first made known by the appearance during the early months of life, particularly about the period of dentition, of a soft, insensitive, hemispherical tumor, which may persist as such or become fistulous. Treatment. The proper treatment is complete extirpation of the cyst as it is liable to return if any portion of the wall is allowed to remain. If a tooth is found present it should be extracted. In Cadiot and Almy's case simple extraction of the tooth was all that was necessary and healing was complete within a month. TRAUMATIC LESIONS. Fracture with exposure of -the pulp sometimes occurs in a me- chanical way, being generally sustained during a fight or from at- tempted extraction by inexperienced hands. Darwin has remarked that wild camivora kept in cages frequently sustain fracture of the teeth through their habit of seizing the bars, and so we find to be the case in dogs under similar conditions. Dogs in jumping over iron fences sometimes get caught in the railing or are impaled, and in their attempts to break loose, tear at the iron with their teeth, and thus sustain fracture. Some animals have naturally brittle teeth which are fractured with very little force, while others suffer from The Head and Neck 87 erosion of the enamel in an unaccountable manner, particularly dur- ing a severe attack of Distemper. Treatment. Fractured teeth where there is evident pain from exposure of the pulp cavity, should be extracted or filled. INCRUSTATIONS OF TARTAR. Incrustations of tartar occur very commonly, especially in city dogs. Chemically, tartar consists of calcium and magnesium car- bonate, calcium phospate, and some organic substances, and is re- garded as a precipitation of these salts from their soluble condition in the saliva by the action of certain microorganisms. The latter have been isolated by Galippe and cultivated by Vignal. The effect of tartar on the neighboring tissues is purely an irri- tative one. By constant accretion, the deposit gradually works its way in between the neck of the tooth and the wall of the alveolar cavity, so that the tooth becomes loosened and may eventually drop out. Should these accretions continue to extend, the peridental mem- brane (alveolar periosteum) becomes involved, when a far more severe condition exists, viz.. Calcic Pericementitis. A brief reference here to the popular notion that the gnawing of bones serves to "keep the teeth clean" will not be out of place. This is surely a misconception, since tartar collects round the roots of the teeth where any rubbing process of bone on tooth can scarce- ly take place. On the other hand, bone-eaters are notoriously prone to suffer from worn teeth, not to speak of other internal disorders engendered by splinters and fragments of bone. Hence, bone can hardly be regarded as a suitable diet for the dog. Symptoms and Diagnosis. In the early stages tartar is observed on the teeth as a yellowish or greenish-brown deposit. The seat of the deposit is usually the base of the external face, but the whole crown may be encircled. When it has invaded the alveolar cavity the gums assume a more or less livid color and evince tenderness to the touch. At the same time a foul odor is emitted from the mouth. Treatment. Calcic incrustations are removed by the operation of Scaling. CALCIC PERICEMENTITIS. This term is applied to inflammation of the peridental mem- brane dependent upon deposits of tartar, sometimes described as 88 Surgical Diseases and Surgery of the Dog alveolar periostitis. It usually affects a number of teeth, old dogs sometimes losing almost the entire set. The calcic deposit leads to ulceration of the peridental membrane and exposure of the neck of the tooth. The membrane is gradually detached from the root of the tooth, the border of the alveolar wall is absorbed, and the inflammatory process finally leads to separation of the tooth from its socket. This condition is often accompanied with ulcerative stoma- titis. Galippe regards it as an infectious disease. Symptoms and Diagnosis. The gum recedes, becomes livid and swollen, and bleeds easily to the touch. There is a purulent dis- charge from the alveoli (Pyorrhea alveolaris) accompanied by a foul, penetrating odor. Saliva flows freely, and the animal shows no disposition to partake of food. Treatment. Extraction of all affected teeth is indicateo with ample daily disinfection of the parts, preferably with solution of permanganate of potash (2:100). ALVEOLAR ABSCESS AND MAXILLARY FISTULA. Reference has been made to the suppurative process (Pyorrhea alveolaris) occurring in connection with inflammation of the peri- dental membrane owing to calcic incrustations, and which is mani- fested by purulent discharge at the edge of the alveolar cavity. Sup- puration of the alveolar tissues may also have its inception on the side of the root of a tooth as the result of injury, complicated wounds, or fractures, or it may originate in the apical space inde- pendent of any disease of the external parts, the tooth remaining perfectly sound. A sudden jar sustained by the tooth in crunching bones and animal membranes may result in injury to the nerve at the apical space, to be followed by suppuration and subsequent death of the pulp. The fourth premolar, which is the sectorial or masticatory organ in the dog, is the tooth usually affected. The disease is characterized by burrowing of pus, which may either follow the peridental membrane down the side of the root and find discharge at the margin of the gum or it may set up an inflammation by fistulous tract either through the gums into the mouth or externally on the face to form a maxillary fistula. The last named condition usually takes place in the upper jaw near the lower eyelid, the exact position varying according to the con- formation of the head. According to Reul, the condition may be The Head and Neck 89 bilateral through sympathy and may give rise to a symptomatic ca- tarrhal inflammation of the nasal passages through contiguity of tissue. The sympathetic hypothesis is very doubt- ful. Symptoms and Diag- nosis. A fistula existing in the position mentioned, should be probed. The affected tooth can gener- ally be determined in this manner. The tooth may or may not be painful to percussion. Maxillary fis- tula must be carefully differentiated from Lachrymal fistula. An animal suffering from the former disease masticates with difficulty and prefers a semi-solid or liquid diet. In some cases the progress of the disease is accompanied with much emaciation. Treatment. The tooth belonging to the affected alveolus must be removed, and the fistulous tract irrigated. Recovery is usually quick to ensue. No. 30. Maxillary fistula. CARIES. True decay of the teeth with molecular disintegration of the constituent dental tissues, from which mankind so conspicuously suf- fers, is exceedingly rare in the dog. It has been observed by Baume Moeller, and Hoifman. The disintegration always commences on the surface of the tooth, generally in some pit or crevice in the enamel or at the neck, where protection from the movements of the tongue as well as from the friction produced by the gnawing of hard foodstuffs, bones, etc., favors the lodgment of alimentary particles The degenerative process having commenced (the spot may or may not be marked by a dark color) it spreads towards the interior of the tooth, and the dentine being more susceptible to its action than the enamel, a cavity is formed whose interior is larger than its orifice. This disease must not be confounded with pericementitis which is very common. The observations of Miller have established the fact that the degenerative process is due to a direct chemical cause, food par- 90 Surgical Diseases and Surgery of the Dog tides undergoing fermentation through the agency of felt-like masses of microorganisms and resulting in the formation of lactic acid. The formation of the acid is dependent on the splitting-up of sugar, the organized or digestive ferment of these microorganisms acting upon cane-sugar in a manner identical with that exhibited by the un- organized ferment of the yeast plant, by converting it into levulose and dextrose and producing the acid as a waste-product. The rela- tive immunity of the dog to this disease may be attributed to the well known inactivity of his parotid saliva and the feeble capacity of the submaxillary. It will be remembered that in the human mouth the ptyalin of the saliva is very active in the conversion of starch into fermentable sugar, thus producing an ample supply of the pabulum necessary to sustain the fermentative potentiality of the microorganisms. But as these conditions do not exist in the dog's mouth the amount of fermentable sugars present is infinitesimal, and in the absence of sugars the microorganism is powerless to effect a decaying influence. Miller found that the particular microorganism is capable of growing in bouillon free from the presence of sugar, but without the production of acid. This experiment was confirmed by Sewill, who found, while making certain experiments in the arti- ficial production of caries, that sound teeth immersed in a mixture of meat and saliva remained alkaline, and even if small quantities of acid were added, rapidly returned to alkalinity. Albumen as white of egg or other form, was acted upon in the same manner. Caries does sometimes result from a bountiful diet of sweet- meats. Symptoms and Diagnosis. This disease gives rise to sharp pain manifested by cries, depression of the head towards the affected side, and indisposition to eat. The characteristic cavity should then be sought for by careful examination of every tooth. Treatment. Ordinarily, carious teeth are extracted, but there is no reason why the disease process should not be arrested by the methods in vogue in human dentistry, when the owner so desires. In this event the services of a competent dentist should be secured, the animal being controlled with anesthetics by the attending veter- inarian during the operation. SCALING. Removal of tartar is effected with the spring-tempered scaling The Head and Neck 91 chisel commonly used by dentists, the point of which should be kept sharp. It should be used with a pushing motion preferably in a No. 31. Scaling cbisel. direction away from the gum, but the opposite direction may be necessary to reach out-of-th^e-way places hidden by the gum. The removal process must be thorough, since any particle left remain- ing, by acting as a nucleus, favors further accumulation. What cannot be removed with the instrument can be cleaned up with a small piece of wood whittled to the shape of a chisel and dipped in weak acid. The operation should be supplemented with free use of some disinfectant solution, preferably permanganate of potash (2:100). The latter is easily applied by saturating a small piece of absorbent cotton, holding it by hemostatic forceps, and swabbing the parts. In most animals, if patience and tact are observed, the operation can be completed without muzzling or other means of control. In- tractable animals should be narcotized. Dogs of small size are best held in the lap during the operation. After removal of deposits, the . importance of maintaining the teeth clean should be impressed on the owner, otherwise the con- dition will soon be again in evidence. Some animals seem to be pre- disposed to the affection and require to undergo periodic cleaning in order to maintain the teeth intact. In these cases the daily use of the permanganate is advisable. EXTRACTION. Single incisors or small molars may be extracted in most ani- mals without recourse to anesthesia, but where several of the smaller teeth are to be withdrawn it is well to narcotize with morphine. Firmly embedded canines or molars, particularly in large ani- mals, should be extracted only with the animal under general anes- thesia. The employment of a mouth speculum is usually necessary. In extracting a tooth, it must be remembered that the operation does not merely consist in "pulling" it, excepting where it has been 92 Surgical Diseases and Surgery of the Dog already loosened in its socket. The tooth is grasped with the beaks of the forceps, the latter being forced as far up the root as possible. Incisors and other single-fanged teeth are loosened by application of rotary motion (a half turn each way). Compound molars are loosened by pressure inwards and outwards. In spite of the exer- cise of due care, the roots are occasionally broken. This accident need not cause anxiety as they are usually gradually forced out of the socket by thickening of the peridental membrane occasioned by the inflammation the extraction sets up. Their immediate removal may be accomplished by employment of root forceps. Hobday and Mosley, the latter a dental surgeon, have demon- strated that false teeth may be successfully affixed to the jaws of the dog, thereby enabling him to tear animal tissues. BIBLIOGRAPHY. Banme — Odontologlsche Forshungen Leipzig. 1882. Darwin — The Origin of Species. Gallppe — Comptes rendus d. Sc6anc. d. I'Academ. d. Seienc. 116. Gurlt— ated by Kitt in Lebrb. d. Path. Anat. Diagnost. 1. Hobday — Journ. of Comp. Path. & Therap. 10, p. 362. Magltot — Traits d. Anom. d. Syst§me Dentaire chez I'Horame et 1. MammifSres. Paris, 1877. Miller— Independent Practitioner. Feb., March, May, 1884. May, June, 1885. Moeller & Hoffman— Cited by Mueller In Die Krankhelten des Hundes. Owen — Odontography. Reul— Ann. de. M6d. VCtSr. 1885, p. 34. Sewlll— Brit. Journ. of Dental Science. 1891, p. 629. Waugh— Journ. of Comp. Med. & Veter. Archives. 1890, p. 235. Werwey — Cited by Cadiot & Almy in Traitfi de Ther. Chir. d. Anim Domest. The Salivary Glands TRAUMATIC LESIONS. Division of Steno's Duct. A clean division would seem to be remarkably free of any untoward result. Harms divided Steno's duct about half an inch from its orifice for the purpose of experi- menting with the saliva. For five days the saliva flowed freely. On the sixth day the wound was covered with a scab which the dog scratched oflf. On the seventh day the scab had reformed permitting but little saliva to escape. In twelve days there was a dry scab under which the wound quickly healed. The animal was killed on the fifty-first day, and examination showed that the continuity of the duct had become reestablished. FISTULA. This condition is very rare. It may develop from the presence The Head and Neck 93 of foreign bodies, swch as needles, which have found lodgment in the gland, and certain other conditions. Favresse treated by in- unction a year-old female suffering from a fluctuating swelling of the right parotid. In two days the abscess burst and emitted a great quantity of purulent liquid. A second orifice of discharge appeared lower down. Both assumed a fistulous character, and saliva flowed freely when meat was offered to the animal. Treatment by injec- tions of nitrate of silver and inunction of vesicants produced no improvement. The actual cautery was then employed — three times within eight days — and was likewise barren of result. Finally, when the animal had become greatly weakened it was decided to extirpate the gland. The operation being completed, a simple dressing was applied. Two days later this was removed and to the astonishment of the operator, a threaded needle was found lying in the depths of the wound. The needle had evidently originated the trouble and had been overlooked at the time of the operation. A maxillary fistula, supposed to have been caused in some man- ner by the buckle of the animal's collar was treated by Brissot with an injection of carbolic acid. The following day the orifice had become closed by peripheral edema thus arresting the discharge of saliva, and in three days was completely cured. Siedamgrotzky saw a fistula in a seventeen-year-old animal opening by two orifices at the lower angle of the jaw and which it was supposed proceeded from the parotid gland. The animal also suflFered from otorrhea. The latter condition responded to treatment but the fistula stubbornly refused to heal. Later the dog died from another trouble, and at the necropsy it was found that a mixed tumor, partly an osteo-chondroma and partly an adenoma of a sweat gland, was filling the tympanic cavity and the outer ear passage. INFLAMMATION. Specific inflammation of the salivary gland is a rare disease. It is frequently confounded with the rather common inflammation of the ^submaxillary and retropharyngeal lymphatic glands. Simple inflammation through infection by ordinary pyogenic microorgan- isms may take place as a result of external traumatism and the pas- sage and lodgment of foreign bodies. An occasional termination of the disease is cystic transformation. 94 Surgical Diseases and Surgery of the Dog The specific variety has been described as occurring in epizootic form by Schuessele, Whitaker, and Hertwig. Busquet and Bon- deand investigated a couple of cases and concluded that the disease was contagious among dogs, was associated with the presence of a microorganism which assumed the character of a diplo-strep- tococcus in the saliva, and a diplococcus in the blood, and was analo- gous or identical with Mumps of the human race. Symptoms and Diagnosis. After three or four days of incuba- tion, symptoms of lassitude and sneezing appear. Then a cough develops and coincidently painful swelling of the parotid and sub- maxillary glands, and edema of the neighboring tissues and lym- phatics. Steno's duct is rendered very prominent by swelling and the salivary flow is meager. The general condition is unaffected and the disease runs its course in less than two weeks. Treatment. Hot fomentations or poultices, preferably the for- mer, should be applied externally. If the swelling fluctuates vent should be given to the pus by lancing, and any further accumulation prevented. If a, cyst forms the sac and its contents should be care- fully dissected and enucleated, or it may be partially excised, the contents let out, and the wall cauterized or subjected to iodine in- jections. BIBLIOGRAPHY. Bondeand — Comptes rendus d. 1. Soc. de Biol. July, 1900. Brlssot— Rec. de Med. V6ter. 1887, p. 487. Fayresse — Ann. de M6d. V6t6r. 1853, p. 2. Harms — Jahresber. d. koenlgl. Thierarznelsch. z. Hannover. 1869, p. 118. Hertwig — Cited by Cadeac in Pathol, d. Anlm. Domest. Schuessele — Veterlnaer Chlrurgle. Sledamgrotzky — Ber ue. d. Veterlnaerw. Im Koenigr. Sachsen. 1871, p. 75. The Pharynx EXAMINATION. The pharynx is exposed to view by opening the jaws and de- pressing the tongue or drawing it forward. PHARYNGITIS. This disease partakes of the same nature and is caused by the same conditions which produce inflammation of the mouth. It is also seen in certain specific diseases, such as rabies and distemper. It is sometimes complicated with abscess formation in the submucous The Head and Neck 95 tissue or retropharyngeal lymphatic glands, the lymphatics being the highway of migration of the pyogenic bacteria. Symptoms and Diagnosis. The symptoms are dysphagia, abundant salivation, cough, retching and fever. The throat is sen- sitive to pressure. Inspection reveals an inflamed, tumefied mucosa. Soon the retropharyngeal lymphatics swell, but it is not often that they suppurate. Treatment. Hot fomentations give relief, but unless applied continuously and the throat muffled subsequently, should not be employed. The application of hot salt-bags is preferable. A lini- ment composed of equal parts of ammonia, turpentine, and olive oil is beneficial. Internally vaseline may be administered with ad- vantage. Foreign bodies must, of course, be removed. FOREIGN BODIES. Any of the bodies which may lodge in the buccal cavity are equally liable to be arrested in their passage through the pharynx. When a dog is excessively hungry, or two or more are fed from the same dish, they sometimes attempt to swallow foodstuffs too large for passage of the pharynx which become retained there by muscular spasm and produce the condition known as choking, which, as a rule, quickly terminates in death. Symptoms and Diagnosis. The symptoms of pharyngeal ob- struction are : coughing, dysphagia, dribbling of saliva, and attempts to vomit. Choking is characterized by suffocation. Treatment. Forceps may be used to remove bodies which are not productive of acute symptoms but when boluses of foodstuffs are lodged in the pharynx no time must be wasted in seeking instru- ments but the finger must be employed in an endeavor to dislodge the body, preferably by retracting it, or by forcing it onward into the esophagus. NEOPLASMS. Myxoma. This form of tumor occasionally occurs as a poly- poid outgrowth of the pharyngeal mucosa. Dierix saw one suspended from the pharyngeal wall at the level of the supero-posterior as- pect of the larynx. Moeller mentions the occurrence of one which was two inches in length. During the act of deglutition or even locomotion they are apt to become projected into the esophagus. g6 Surgical Diseases and Surgery of the Dog Symptoms and Diagtvosis. The chief symptom is sudden suf- iocation with as sudden recovery. Fits of vomiting may be pro- voked particularly when pressure is applied over the pharynx. Treatment. Removal should be effected by means of the wire ecraseur. Epithelioma. Malignant tumor of the Pharynx, while very rare, is occasionally observed in aged animals. It is apt to exist some time before being discovered, long enough for metastasis to the cervical glands to take place. Symptoms and Diagnosis. The appetite is very indifferent, and the animal has difficulty in swallowing, and a fetid salivation de- velops. Examination of the buccal cavity reveals the presence of a raw ulcer. This ulcer must not be mistaken for a fistula pro- ceeding from some foreign body which has found lodgment in the subjacent tissues. The animal progressively emaciates and fanally the cervical glands become involved. Treatment. There is no treatment for this disease. BIBLIOGRAPHY. Dlerlx — Cited by Cadfac in Path. des. Anim. Domest. MoeUer — Lehrb. d. spec. Chir. f. Thleraerzt. The Esophagus EXAMINATION. The esophagus is examined by palpation over its course on the left side of the neck, by passage of the probang, and by means of the Roentgen rays. CONGENITAL MALFORMATIONS. Ectasia has been observed by Cadeac, and Stricture by Smith. TRAUMATIC LESIONS. Rupture and Perforation. These lesions are ordinarily caused by bones and foreign bodies owing to the extraordinary peristalsis or violent fits of retching engendered by their presence. Abscess formation invariably results. When the thoracic portion of the or- gan is pierced, purulent pleuritis results with fatal issue. Siedam- grotzky recorded an instance of this kind where the perforating body The Head and Neck 97 was a piece of bacon rind. Morey witnessed a case where a sharp piece of bone perforated both esophagus and trachea and induced gangrenous pneumonia, and Cadeac saw one where a peach stone perforated the aorta. Symptoms and Diagnosis. The symptoms of these lesions in the cervical portion are painful swelling of the neck and suppuration. In the thoracic portion, there are early collapse, febrile symptoms and prostration. Treatment. When the lesion is in the cervical portion it is treated by exposing the gullet as in Esophagotomy and subjecting it to frequent antiseptic irrigation. Unless the rent is extensive it need not be sutured. Stricture. Stricture sometimes results from cicatrices fol- lowing wounds by foreign bodies, improper use of the probang, esophagotomy, and fistula. Similar effects are produced by com- pression of extrinsic neoplasms usually of the bronchial glands, ver- tebral exostoses, tubercles, goiter, and verminous aneurism of the aorta. , Symptoms and Diagnosis. Characteristic are the efforts at swallowing. Liquids pass more easily than solids, which accu- mulate above the stricture and distend the esophagus so that the trachea and neighboring vessels and nerves are compressed result- ing in dyspnea, etc. Treatment. Stricture is treated by progressive dilation by daily passage of the probang, a series of graduated instruments be- ing employed. The latter are passed every two or three days and left in place from five to ten minutes, each size being used three or four times. Diverticula. A Diverticulum was observed by Schellenberg in which a bite and subsequent abscess formation were the causative factors. Treatment. Diverticula are treated by excision of a fusiform portion of the stretched wall. POEEIGN BODIES. In the esophagus, obstructions usually occur either at the proxi- mal end immediately behind the pharynx, at the lower extremity of the cervical portion, or at a short distance anterior to the cardiac orifice where its caliber is smallest. Sharp bodies may lodge at any 8 98 Surgical Diseases and Surgery of the Dog part of the tube. Obstructions usually consist of bones, gristle, large pieces of fat, fragments of tendon, skewers, etc. Large bodies remaining in position for any length of time are very liable to pro- duce local pressure gangrene and perforation. Sharp bodies may also perforate at the outset. Symptoms and Diagnosis. The animal refuses food or mani- fests pain in the act of swallowing. There are spells of gulping and choking with vomiting, salivation, scratching at the neck, the head held extended, difficult respiration, and frequent outcries of pain. The seat of obstruction, when it exists in the cervical region, is evi- dent from painful swelling of the neighboring parts and this be- comes intensified the longer the object remains. Such swelling may interfere with the natural gait of the fore-legs through the edema involving the shoulder muscles. Sometimes the body may be recog- nized by palpation. In the thoracic portion the symptoms may be obscure, there being absence of swelling and at times merely refusal of food with rapid emaciation. Treatment. Obstructions are removed by production of emesis, by extraction with throat forceps, by propulsion with the probang, or by esophagotomy or gastrotomy, according as the conditions present warrant the application of either method of relief. Vomiting will often displace a foreign body. It is best brought about by hypo- dermic administration of apomorphia in doses of 1-40 to i-io of a grain. If the object is situated in an accessible position an attempt should be made to grasp and extract it with the curved throat for- ceps, after the jaws have been immobilized with a speculum. Fail- ing in this and in cases where the object is beyond reach with the forceps, the probang must be resorted to in order to push the body on into the stomach. To pass this instrument the tongue is de- pressed with the fingers of the left hand and the instrument, pre- viously oiled, is made to pass into the median line and follow the posterior wall of the pharynx into the esophagus. The bristle pro- bang is a very convenient instrument, as it may be used for push- ing obstructions into the stomach or equally as well for extracting them by the mouth, when they do not entirely occlude the lumen. It is closed and passed until the bristles are well beyond the point of lodgment, when they by pressure upon the whalebone, are projected, completely filling the tube, umbrella-like, and the probang is with- drawn. In the absence of this or any other special make of pro- The Head and Neck 99 bang a horse catheter may be substituted for propelling the body into the stomach. Round or smooth obstructions may be pushed onwards but excessive force must on no account be employed. Sharp bodies should always be extracted by the mouth, when possible. Failing in this, if the foreign body is lodged in the cervical por- tion it must be extracted by esophagotomy, but this operation should not be undertaken till every attempt at removal with the probang has failed, unless asphyxia from pressure on the trachea is threatened. Cadiot and Breton say that the operator should temporize with the probang for two or three days and that it is rare tliat the symptoms become alarming enough to render the operation necessary before the fourth day. It is sometimes necessary to resort to Gastrotomy in order to deliver foreign bodies from the lower third of the esophagus, when such bodies are too large or peculiarly shaped to be voided by vomit- ing, or when it is feared that violent attacks of retching may lead to perforation of the wall. They are extracted with the aid of for- ceps or pushed upward into the mouth. ESOPHAGOTOMY. Interference with the continuity of the esophagus is borne well by the dog. Billroth has shown that the continuity may be re- established after ablation of a short portion of the tube. Incision of the tube is performed in the following manner: Secure the animal with hopples in the right lateral position with the head extended. Remove the hair with clippers or razor and administer a general anesthetic. Make the skin incision over the obstructing body and on the left side of the neck on account of the inclination of the esophagus to that side. Cut cautiously in between the anterior border of the sterno-cleido mastoideus muscle and the jugular vein until the great vessels of the neck are exposed. The esophagus is asso- ciated with these and is distinguished by its pinkish color and tu- bular muscular appearance. Grasp the organ with one finger and draw it through the wound at the same time pushing the trachea to one side. Incise its wall on its postero-lateral aspect. The ves- sels are disposed mostly longitudinally and are more abundant at the upper than the lower part, and the mucosa is recognized by its folds and whitish color. Vomiting may occur at this point. Extract LOFC 100 Surgical Diseases and Surgery of the Dog the obstruction. Leave the wound in the esophageal wall open to heal by granulation, but if it is extensive suture it with catgut In ordinary cases the wound is healed at the end of two or three weeks, and seldom later than two months. If gangrene of the wall is present, do not attempt to stitch the latter, but let it heal by granu- lation, in the meantime subjecting the wound to frequent antiseptic irrigation. In one case of obstruction by a large bone in a puppy, the body was pushed from the right side towards the left side until it was plainly perceptible under the skin. A simple incision was then made through the skin and subjacent fascia and the wall of the esophagus down on to the bone which was extracted. Nothing further was done to the wound and the animal made an uneventful recovery. The whole procedure was exceedingly simple. Vomiting sometimes occurs during the operation. No solid food should be given for two weeks and none at all by the mouth for the first few days. NEOPLASMS. Intrinsic tumors occur with great rarity. Myxomatous polypi are referred to by Cadiot and Almy and multiple cysts formed of dilated mucous glands have been observed by Eichenberg. Fibroid enlargements caused by Spiroptera sanguinolenta occasionally occur on this continent and are common in the South of Europe, South America, and Asia. According to Manson, who frequently observed the condition in China, these enlargements may bring about more or less complete occlusion, particularly when they are large or numer- ous near the cardiac end. BIBLIOGRAPHY. Cadiot & Almy — Trait§ de Th^r. Chir. des Anlm. Domcet. Cadiot & Breton — MM£clne Canine. Blcbenberg — Cited by Cadfac in Path. d. Anim. Domest. Manson — China Customs Med. Reports. 1876-77. Morey— Journ. de M4d. Vfeter. et d. Zootech. July, 1900. Schellenberg — Schweiz. Archlv. 1891. Siedamgrotzky — Ber. ue. d. Veterlnaerw. im Kocnlgr. Sacbsen. 1871, p. 67. Smith — Cited by Cad6ac In Path. d. Anim. Domest. The Thyroid Gland and Glandules Before considering the diseases to which the Thyroid is subject and the extent to which surgical interference may be employed, it < \ 1 » 1 ^---fj ^ The Head and Neck loi will be in order to briefly review the relationship which the Gland and the recently discovered Glandules bear to one another, for it is now known that both Gland and Glandules have each a separate and specific function to perform in the animal economy. In the immediate neighborhood of the gland, lying in the fas- cia, are numerous separate nodular bodies, consisting of lymphoid or of true thyroid tissue and designated "accessory thyroids." They are usually enlarged and more easy to find in animals having hypertrophied thyroids, while in perfectly normal animals they are at times so small that they can hardly be seert Besides these ac- cessory thyroids there are constantly present on each side two bodies — the Glandules, one external to the gland and the other within the gland. The external show considerable variation of position, but usually one of proximity to the thyroids, and union of the two portions is quite exceptional. Gley examined their disposition in thirty-three dogs, and found them situated about the superior third of the external face of each lobe, nearer the anterior border than the posterior, superficially inserted in the face of, but never- theless perfectly distinct from, the thyroid lobes, in fourteen of the animals. In seven of the remaining nineteen animals one glandule was enclosed in the external face, and the other isolated at the su- perior extremity of the corresponding lobe. The internal are sit- uated toward the internal or tracheal surface of the lobe, and as a rule are completely covered by thyroid tissue and regularly enter into extensive combination with it. Structurally, neither of these bodies corresponds at any time of its development to the thyroid. Numerous experimenters, among whom may be mentioned Halsted, Schiff, Gley, Moussu, and Vassale and Generali have demonstrated that suppression of the function of the thyroid gland, including its total extirpation, is not productive of lethal effect but results only in myxedema and cretinism, while removal of all the glandules rapidly leads to a fatal issue. The leaving intact of one glandule is sufficient to sustain life, but it is safer to leave all the glandules possible. STRUMA. GOITER. BRONCHOCELE. Enlargement of the thyroid is quite common in the dog. It is sometimes congenital and may be of such dimensions as to hin- der delivery. Halsted has seen puppies born with glands twelve I02 Surgical Diseases and Surgery of the Dog times as large as normal. The lobes and isthmus in these cases were so developed that they formed a single horseshoe-shaped body al- most encircling the trachea. The swelling generally disappears later. It is believed that heredity plays some part in its development, but it is also witnessed in puppies whose parents possess thyroids show- ing no deviation from the normal. In point of development even the normal gland may show considerable variation in the newly-born animal, the difference de- pending essentially upon the degree of development of the colloid- containing vesicles. Very young dogs are often seen with enlargement of the gland. It may commence soon after birth particularly in members of cer- tain breeds, namely, Pomeranians, French Pointers, Dachshunde, Spaniels, and lap-dogs, Greenhow saw it in India, and Bramley, writing in 1833, found it to be quite common as a "lobulated bron- chocele" among puppies one month old bred from English dogs in the trans-Himalayan regions. It seldom becomes large when arising in young dogs, but gradually becomes reduced in size, though in some instances will recur periodically. Enlargements commonly occur during the course of general diseases. In the experience of Zschokke it is a rare thing to find dogs free of thyroid enlargements in some of the cantons of Switzer- land. Several forms of Struma are recognized. The enlargement may be the expression of extreme vascular engorgement (Hypere- mic struma). This is of a transitory nature and with little if any pathologic significance. Muehlibach pointed out that it occurs dur- ing the estrual period, and Bardeleben saw it in pregnant females. Pflug refers to a remarkable periodic recurrence in members of certain breeds, particularly Blenheim Spaniels, the swelling appear- ing coincident with even a slight cold, but disappearing within two weeks. The commonest form is that of diflfuse parenchymatous hyper- plasia (Hyperplastic, Follicular struma) with or without a certain amount of proliferation of the stroma and increase of gelatinous contents in individual vesicles. When a hemorrhage occurs in one of the goitrous nodules, the extravasate undergoes an absorptive change, and according to its age there may be anything from true bloody contents The Head and Neck 103 through dark yellowish to perfectly clear serous fluid. (Cystic struma). Blood may also be extravasated into and infiltrate the con- nective tissue adjacent to the gland, or even of the entire length of the neck (Hemorrhagic struma). Sometimes thick septa of the interstitial connective tissue de- velop with consequent atrophy of the vesicles (Fibrous struma). A very rare form of osteochondroma (Osseous struma) has been observed by both Siedamgrotzky and Kitt, and I have also wit- nessed the same condition in an aged Collie female. There was unil- ateral enlargement fully the size of the subject's own cranium. The gladular tissue had almost completely disappeared, a few minute isolated cysts and cell clusters marking the areas of functional per- sistence. Malignant neoplasm (Malignant struma) not uncommonly affects old animals. It is usually of carcinomatous character. Ac- cording to Kitt, sarcoma has never been observed for a certainty, but Cuille and Sendrail have recorded an instance and referred to another case witnessed by Lienaux. Wells, Loeb, and others have recently published observations indicating that not infrequently a curious mixed tumor may form, in parts sarcoma, and in parts car- cinoma. Malignant struma tends to infiltrate neighboring structures and to lead to formation of secondary growths in the veins and in the lungs by way of the veins and lymphatics and also within the bones. Symptoms and Diagnosis. The effect on the organism of the different forms of goiter varies according to the nature, size, and position of the growth. Some of the largest simple goiters hardly affect the animal other than to render him unsightly. On the other hand, quite insignificant growths have been known to produce seri- ous respiratory disturbances, with spasm of the glottis, owing to compression of the vagus and sympathetic nerves. Very voluminous goiters may induce suffocation by causing a narrowing of the lumen of the trachea and larynx. This is true also of the hemorr- hagic form. Siedamgrotzky saw the esophagus completely encircled. Moeller has seen dogs with enormous goiters unable to lie down on account of the pressure on the trachea induced by that act. Van Gemmern and Mecke saw vomiting (probably reflex) induced in a one-year-old Italian greyhound when the gland was enlarged, which I04 Surgical Diseases and Surgery of the Dog however, ceased when the swelling subsided. Cadeac says laryngeal hemiplegia may result from pressure on the recurrent laryngeal nerve. Complete suppression of thyroid function is followed by cretinism and myxedema, conditions characterized by physical de- generacy and deformity and grave nerve disturbances. There occur an increase in the general connective tissue with a mucoid conversion of the ground substance, and marked idiocy. Rougieux has recorded cases of cretinism, and Raynard has seen the con- genital form accompanied by imperfect development of the body and legs, thickened head, shortened neck, and feeble mental power. Experimental myxedema and cretinism have been produced by Moussu by complete extirpation of the gland, leaving the glandules intact. Struma can be comparatively easily diagnosed. Generally the enlargement is bilateral, but not necessarily of uniform development. This bilateral character is of assistance in making a differential diagnosis from mucous cysts, abscesses, and hematomata. Further- more, its mobility, sharp demarcation, and freedom from sensitive- ness aid in the diagnosis. It can hardly be confounded with any other lesion unless it be lymphosarcoma involving the neighboring lymphatics, but in the latter disease other lymphatics are usually found to be involved. The enlargement may be so deeply embedded that its presence is hardly suspected, and in other cases may be so extensive as to occupy the entire distance between the trachea and sternum. Leisering saw such a growth, it being a carcinoma, with secondary growths in the walls of the internal jugular. Malignant struma is distinguished from other forms by its tu- berculate character and by the cachexia which accompanies it. The hemorrhagic form involving extravasation of blood into the connective tissue of the neck is sometimes a little difficult to diagnose. It is accompanied by diffuse swelling of the neck with local pain and heat, which may or may not terminate in suppuration. The accessory bodies may also become hypertrophied, when they receive the name of "aberrant struma." They are often seen in animals possessed of congenital struma. Woelfler and Wagner observed one instance of a veritable enlargement of a nodule of true thyroid tissue in an animal whose lobes only slightly exceeded the normal in size. The tumor was as large as a hazel-nut, and hung from the aorta by a pedicle. The Head and Neck 105 The pathology of the Glandules does not appear to have been stiidied up to the present. Treatment. Soft goiters generally respond to iodine medication administered internally and by local inunction. Very large and con- tinuous dosing is usually necessary. Exceedingly large growths may be reduced by these means within a few days, but they tend to recur. Fibrous goiters should be treated by strictly aseptic intra- ^andular injections of a few drops of tincture of iodine. After the needle has been inserted it should first be ascertained that the point has not lodged within the lumen of some enlarged vein, other- wise it must be partially withdrawn and then reinserted. The dan- ger consists in the immediate entry of the iodine into the venous circulation. Horsley experimentally injected 15 c. c. of tincture of iodine into the external jugular vein and brought about instantan- eous death from cardiac paralysis by plugging of the right heart with a hard clot. The injections should be repeated at intervals of several days as soon as the inflammatory reaction has subsided. In some cases several injections, lasting over a period of some months, are needed to effect a cure. Bizard succeeded in producing absorption of an en- largement in a dog aged five months by injecting the iodine into the neighboring connective tissue instead of into the gland itself. Cystic struma is treated by free lancing of the sac and evacua- tion of the contents, but it must be remembered that the secreting membrane needs to be destroyed, which can be accomplished by iodine injections directly into the sac; otherwise a fistula is likely to be established. An antiseptic tampon is then introduced in order to stimulate healthy granulations. Malignant goiters being so extremely metastatic to important internal organs, and being usually accompanied by profound cachexia, scarcely warrant any attempt at giving relief even by sur- gical means. Unilateral neoplasm in the early stages would justify unilateral extirpation of the gland, provided the glandules were healthy and left in situ. In any case of surgical interference it is absolutely essential that at least one external glandule together with its blood-supply be left intact and a successful outcome is more likely to take place if both external glandules are allowed to remain undisturbed. io6 Surgical Diseases and Surgery of the Dog It becomes then necessary, in considering operative measures on the thyroid gland, to speak of unilateral and complete thyroidectomy, and unilateral and complete external and internal parathyroidec- tomy or extirpation of the thyroid glandules. UNILATERAL THYEOIDECTOMY. Unilateral Thyroidectomy, without regard to conservation of the glandules, is carried out as follows : Make the skin incision in the median line. This enables the operator to get down easily between and without severing the muscles, which is conveniently done by tearing with the finger or with the aid of a blunt instrument. The lobes are found one on each side under the sternothyroid muscles. Their mobility and slipperiness make their removal somewhat diffi- cult. Draw the lobe up out of the wound by means of a suture passed through it, and secure the ramifications of the superior thyroid artery with a ligature, including the tissue surrounding them, apply another ligature around the anastomosing termination of the inferior thyroid, and, lastly, divide all the attachments on the distal side of the ligatures, leaving as small a stump as possible. It is worthy of note that the necessity of maintaining an aseptic wound in thyroid operations was particularly emphasized by Munk in his experiments, and latterly by Halsted, who found it expedient to devise his ''sub- cuticular suture." SIMPLE THYROIDECTOMY. Simple Thyroidectomy, leaving the glandules intact, is thus de- scribed by Gley (translation) : When the glandules are isolated at the superior or inferior extremity of the gland the operation is not dif- ficult. But this disposition is not the most frequent, consequently it is often necessary to explore for and enucleate them from the thyroid body. Secure the superior and inferior extremities of the lobes by two separate sutures. One of these sutures may often be made to include the thyroid artery, but it is particularly essential that the minute vessel which detaches itself to furnish the glandule be left free. By means of these two sutures have an assistant draw up the lobe in such manner as to render the glandule visible. Separate the latter little by little from the adjacent tissues with a blunt instru- ment. Now pass a fine ligature behind it, but in such a manner as The Head and Neck 107 not to include a veinlet which receives branches from the lobe at this level. If necessary, a portion of the lobar tissue may be in- cluded. Finally, remove the lobe. There is only a slight oozing of blood during the operation. Moussu found it very difficult to preserve the veinlets, which are necessary for the proper performance of the parathyroid function. Gley and Nicolas found that the glandules underwent hyper- trophy after extirpation of the gland. Breisacher noticed that dogs fed on raw meat suffered more acutely from thyroidectomy than those fed on milk and boiled meat, and Victor Horsley observed that a vegetarian diet was that which led to the fewest symptoms after thyroidectomy. Moreover, gram- nivorous species do not show acute symptoms after extirpation. EXOPHTHALMIC GOITER. This disease is extremely rare. It has been observed by Fried- berger and Froehner, Albrecht, and Jewsejenko. It is believed to be a toxic condition dependent upon hyperactivity or perversion of thyroid function. It is characterized by three principal features, viz., thyroid enlargement, extreme protrusion of the eyeballs with immobility or retraction of the lids, and cardiac palpitation. Symptoms and Diagnosis. The disease is ushered in by palpita- tions which generally appear consequent upon some physical or mental shock, such as prolonged exercise, violent emotions, or fright. Its evolution is ordinarily slow and may be interrupted with epilep- tiform paroxysms (Jewsejenko). In very young animals restless- ness, whining, occasional spasms, arhythmical pulsations and general unthriftiness are apparent. The glandular enlargement is soft and elastic and uniform in both lobes or is more pronounced in one than in the other. The bulging of the eyeballs is so acute that disloca- tion appears imminent. The cornea is usually ulcerated. Besides these symptoms others may make their appearance, viz., trembling of the extremities, anorexia, emaciation, pruritis, and subcutaneous ab- scesses. Treatment. Iodine medication internally and externally is indi- cated, together with administration of digitalis to combat the cardiac irregularity. A case which terminated in complete recovery was treated by local disinfection of the eyes, and inunction of belladonna io8 Surgical Diseases and Surgery of the Dog and iodine, supplemented by injections of iodine into the gland with cold baths. Moussu found that administration of thyroid glandules of the horse (eight per diem) materially modified the course of the disease in human beings, though other observers have got absolutely nega- tive results, but it is worthy of note that this form of struma can be cured in the human subject by partial removal of the gland (Whar- ton and Curtis), BIBLIOGRAPHY. Bardcleben — Cited by Pflng in deutscb. Zeitschr. f. Thiermed. 1875, p. 340. Blxard— Arclilv. V6t6r. 1878. Bramley— Trans. Med. & Phys. Soc. Calcutta. 1833, p. 195. Breieacher — Archiv. f. Anat. u. I'hys. 1880. Cad^ac Pathol, d. Anim. Dom. Case — Journ. Comp. Med. & Surg. Oct., 1888. Cuilie & Sendrall— Rey. VH6r. Oct., 1898. Froehner — Cited by Albrecht in Wochenschr. f. Thlerhellk. 1895, p. 308. Gley— Comptes rendns d. 1. Soc. d. Biol. 1893, pp. 217, 396. Archiv. d. Phys. Norm, et Pathol. 1892, p. 81. 1893, p. 767. Gley & Nicolas — Comptes rendus d. 1. Soc. d. Biol. 1895, p. 218. Greenhow — Indian Annals of Med. Science. 12. Halsted — Johns Hopkins Hospital Reports. 1. Johns Hopkins Hospital Bulletin. 1. Horsley— Brit. Med. Journal. 1885, p. 213. Jewsejenko — Cited by Kitt in Lehrb. d. Path. Anat. Dlagnost. 2. Kitt— Lehrb. d. Path, Anat. Dlagnost. 2. Leisemng — Ber. ne. d. Veterlnaerw. im Koenigr. Sachsen. 1872, p. 59. MooBsn— Comptes rendus d. 1. Soc. d. Biol. 1893, p. 394. 1897, p. 82. 1898, p. 867. 1899, p. 242. Muehllbach— Der Kropf. 1822. Mneller — Jenaische Zeitschr. f. Medlzin n. Naturwissensch. 1871. Pflug— DentBch. Zeitschr. f. Thiermed. 1875, p. 340. Raynard— Rec. de M6d. V6t^r. 1836, p. 8. Uongienx— Cited by Morel in Ann. MM. Psych. 1874. Koeberle in Essal snr le CretlniBm. Strassburg, 1862. Schlff— Rev. M6d. d. 1. Suisse Bomande. Feb., 1884. Sledamgrotzky — Ber. ue d. Veterlnaerw. im Koenigr. Sachsen. 1871, p. 58. Vassale & Generall— Rlvista dl Patol. nerv. e ment. 1896. Archiv. Ital. de Biol. 1896. Wharton & Curtis — Practice of Surgery. Woelfler & Wagner — Wiener med. Wochenschr. 1879. p. 198. Zsehokbe — Schweia. Archiv. f. Thiermed. 1881, p. 52. The Lymphatic Glands LYMPHADENITIS. The lymphatic glands in the region of the throat are not uncom- monly the seat of acute suppurative conditions, which are entirely different from, and not to be confounded with, inflammation of the salivary glands, which is a comparatively rare disease. The glands most commonly affected are those draining the mucosal areas of the mouth, pharynx, and larynx, viz., the Submaxillary, consisting of a bilateral group of three glands lying subcutaneously between the posterior border of the masseter muscle and the submaxillary sali- vary gland, and the Retropharyngeal. The disease always results No. 34. Acute l.vnipliadenltis. No. 36. (After Cadiot aiul Breton). Tuberculous lyiiiplia- denitis. Fistulous tract. The Head and Neck 109 from migration of pyogenic or tubercular bacteria. It commonly develops during the course of inflammations of adjacent mucosal areas, notably during pharyngitis. There would also seem to be a specific form, or the disease may at least be enzootic in certain local- ities, for Dessart, a Belgian practitioner, wrote that it was common as a phlegmonous angina in the vicinity of Genappe, Belgium. Acute Lymphadenitis. This, the pyogenic form, always runs a very rapid course and terminates in suppuration, the pus tending to be discharged spontaneously. Symptoms and Diagnosis. The trouble commences as a hot, pain- ful, unilateral or bilateral tumefaction at the site of either or all the glands, sometimes together with edema of the facial tissues. The head is held stiffly and eating is generally suspended. In severe cases there may be considerable dyspnea and some danger of asphyxia. The inflammation quickly spreads beyond the capsule of the gland to the surrounding connective tissue giving rise to a diffuse peria- dentitis which then obscures the outline of the gland. Suppuration taking place, individual suppurative foci become confluent and form a large abscess, which fluctuates, and if not relieved by lancing, points, bursts spontaneously and discharges a great quantity of pus. Treatment. Hot fomentations should be employed externally and as soon as fluctuation is per- ceived, the pus should be evac- uated by free lancing and further accumulation prevented by keep- ing the opening free during the few succeeding days. Chronic or Tuberculous Lymphadenitis. Tuberculous lymphadenitis occurs in the glands of the neck, which be- come infected by auto-inocula tion in the same manner as in acute lymphadeni- tis. It may develop as a ^' primary lesion through absorption of bacilli ar- rested in the upper pas- ctrroc K,if r^n^a ««»*, ^^ ^' < After Cadlot and Breton). Tabercnlons lyui- S>agC!>, UUl more com- phadenitls. Fistulous tract. 1 10 Surgical Diseases and Surgery of the Dog monly secondary to pulmonary tuberculosis through absorption from the tuberculous matter coughed up into the pharynx. The disease runs a course common to tuberculous inflammations with caseation and eventual breaking down. Symptoms and Diagnosis. At first but little change is noticeable in the glands, and they appear solid, mobile and freely defined. As the disease progresses the inflammation extends to the periglandular tissue and implicates the skin, the swelling then becoming diffuse, soft, and fluctuating. Discharge takes place and a fistulous tract is formed leading to the trachea or larynx. The external lesion pre- sents a circular, oval, or irregular cavity with a thin, jagged border denuded of hair, and gives vent to a greyish or sanguineous bacilli- bearing purulent matter. Treatment. This lesion being in most cases secondary to pulmo- nary tuberculosis, is rarely suitable for treatment and only when it exists as a primary focus in superficial regions should curative meas- ures be attempted, and then only if spread of infection can be guard- ed against. If the case is presented in the early stages, before the development of periadenitis, and there is undoubted evidence of softening, the entire gland should be enucleated by blunt dissection, without opening its capsule. If the disease process is found to have extended and involved the surrounding tissues, the entire mass must be carefully dissected out. And if discharge has already occurred, the cavity should be thoroughly curetted, enlarged, and irrigated daily with corrosive sublimate solution (i:iooo). NEOPLASMS. The primary growths affecting lymphatic glands are Lymphade- noma and Lymphosarcoma. Both innocent and malignant types of the former are seen but the latter is essentially malignant. Malig- nant lymphadenoma occurs in two forms, both characterized by gen- eral hyperplasia of the glands, but one of which is also associated with increase of lymphocytes. Secondary growths in the lymphatics are a feature of cancerous tumors, though they are less common in sarcoma than in epithelioma and carcinoma. Benign Lymphadenoma. Lymphoma. This is a purely local affection occuring as a single nodule or a series of nodules but lim- ited to one region of the body. Such growths occur usually second- ary to catarrhal inflammations. The cause is unknown. They do The Head and Neck 1 1 1 not affect the health, except in the case of the bronchial glands where they may give rise to impairment of cardiac and respiratory function by compression of the intramediastinal vasculo-nervous structures. Symptoms and Diagnosis. To the touch they are smooth, hemis- pherical lumps, firm, elastic, and painless. They are freely mobile one on another in external glands and do not become adherent to surrounding parts. Treatment. Where these growths appear as a blemish, they may be presented for treatment, when they will be found amenable to arsenic administered internally. Malignant Ljrmphadenoma. Hodgkin's Disease. This is a rare disease in which there is an extensive and progressive symmet- rical enlargement of the glands throughout the system, including not only external lymphoid tissue, but also that of the spleen, the kid- neys, the liver, and the bone marrow. In the human subject it is most common in the young adult male, and this would also seem to be true of the dog, as I have observed it in males of the age of two or three years. The cause is unknown. Symptoms and Diagnosis. The enlargement develops progres- sively in one gland after another until a whole cluster of glands is implicated. Another group becomes likewise affected until all the external glands are involved, and finally the internal lymphoid tissue. The submaxillary glands are usually the first to show the change, and at this stage are liable to be mistaken for goiter, then the cervi- cal, then the axillary, and then the inguinal. The enlargements are not painful and show no tendency to break down. They adhere together forming lobulated masses, but do not form adhesions with the surrounding tissues and remain freely mobile. This feature serves to distinguish the condition from acute or chronic lympha- denitis or lymphosarcoma. As the disease progresses the pulse be- comes rapid and the appetite capricious. Lethargy develops, the ani- mal showing disinclination to mount steps or to travel far. The ab- domen becomes abnormally distended and by careful palpation the internal enlargements can be distinguished, particularly of the spleen. Treatment. There is no treatment possible and the prognosis must always be unfavorable, a fatal termination ensuing in the course of one or two years. Lymphatic Leukemia. Leukemic Lymphadenoma. This dis- 112 Surgical Diseases aitd Surgery of the Dog ease is also rare and is distinguished from the former by marked changes in the blood, but there is the same widespread enlargement of lymphoid tissue and increase especially in the lymphocytes. In- stances have been recorded by Siedamgrotzky, Leblanc and Nocard, and Bouchet. Cadeac says the disease may be mistaken for tubercu- losis. The changes taking place in the blood are highly characteris- tic, the red corpuscles steadily, continuously, and rapidly decreasing in number and suffering a diminution of hemoglobin, while the leu- cocytes are greatly increased in number. The arteries sustain a diffuse sclerosis. Symptoms and Diagnosis. Usually there is the same progressive enlargement of the external lymphatic glands, but it is occasionally absent. Conspicuous among the symptoms are : inappetence, inter- mittent fever, conjunctival injection, anemia, progressive emacia- tion, increased and throbbing cardiac action, tendency to hemorr- hage, languor, and respiration normal at rest but accelerated during movements. The proportion of white to red cells varies at different stages of the disease. In Siedamgrotzky's observations it was as one to fifteen to twenty to thirty, and in those of Leblanc and Nocard as one to eighty-five. The normal is as one to five or six hundred. In Bouchet's case there was abdominal pulsation which was thought to be due to an aneurism of the aorta, but at the necropsy it was shown to have proceeded from abnormal development of the splenic vessels. Treatment. As in the preceding form, the prognosis is hopeless, death being inevitable within a few months, and seldom later than one year. Lymphosarcoma. This type of growth differs from the pre- ceding in that it infiltrates neighboring parts and involves the skin and forms metastases. It has also an extremely rapid growth. The most common seat of the disease is the lymphoid tissue of the neck and groin, but it may also occur in the mesenteric glands (Semmer, Hobday), the vagina (McFadyean) and the bronchial glands (Johne). When arising in the neck it is most apt to be mistaken in the early stages for goiter, and also for traumatic and tuberculous abscesses, all of which are prone to form in these parts. Symptoms and Diagnosis. In external parts the first symptom to be observed is a rapidly growing nodule or tumor, which, thougfi at first firm, elastic and painless, later on becomes tender and pain- ful. The tumor soon gives rise to secondary growths in neighboring The Head and Neck 113 glands and extends to the skin. It then breaks down and becomes a bleeding fungatirig mass and discharges an ichorous matter. There is usually considerable collateral edema of the head and neck. In internal parts these growths may give rise to ascites. Treatment. The prognosis must always be unfavorable and no treatment is practicable. Martin attempted the removal of one of these tumors from the groin in a three-year old animal. A month later several small nodular growths were observed near the edge of the almost healed wound, and one larger one situated in the opposite groin. These were not interfered with and the animal succumbed in ten weeks' time. BIBLIOGRAPHY. Bouchet— Bull, de la Soc. Cent, de M6d. V6t«r. 1897, p. 184. Hobday — Journ. of Comp. Patb. & Therap. 10. Jobne — Ber. ue. d. Veterlnaerw. Im Koenlgr. Sachsen. 1881, p. 70. LeWanc & Nocard— Ann. de Mfd. Vet6r. 1878, p. 164. Martin— Journ. of Conap. Patb.& Therap. 1896, p. 226. M'Fadyean— Journ. of Comp. Path. & Terap. 3. p. 337. Semmer — OeBterr.Vlerteljabresschr. f. Veterinaerk. 1873, p. 20. Sledamgrotzky — Ber. ue. d. V«terlnaerw. Im Koenlgr. Sachsen. 1871. The Nose. EPISTAXIS. Bleeding from the nasal passages depends upon various causes the chief of which are traumatic influences, local inflammatory and ulcerative changes, or the presence of neoplasms or parasites in the nasal cavities. It is sometimes brought on by violent coughing and it may also take place in cachectic subjects suffering from leukemia or the pernicious anemia induced by the presence of uncinaria in the intestine. It is in every case the result of rupture of the vessels of the mucosa, whether arterial, venous, or capillary. As a rule the hemorrhage is insignificant but it may be copious and recur at intervals and even lead to fatal termination. Treatment. When the bleeding is excessive the measures to be adopted are both medicinal and surgical. Medicinally adrenalin chloride solution (1:1000) should be prescribed in ten to twenty drop doses every hour. Surgical measures consist in directing a stream of cold water from a hose over the roof of the nasal pas- sages, or pressing a piece of ice against the same spot. 114 Surgical Diseases and Surgery of the Dog FOREIGN BODIES. Foreign bodies and Pentastomes sometimes find lodgement in the nares. Dieterichs recorded a case in which a long bristle of a hog had penetrated the pituitary membrane. Symptoms and Diagnosis. Respiration is impeded, and there may be epistaxis and fits of sneezing, and later a muco-purulent dis- charge. Treafmrent. The removal of a foreign body is extremely diffi- cult when it is situated at any distance from the orifice. Agents which induce sneezing and warm antiseptic injections are recom- mended, and if this treatment fails, the nasal chamber should be tre- phined and the body extracted or pushed forward out of the orifice. NEOPLASMS. Nasal tumors are not very common. When present, they are usually found to be of myxomatous nature and polypoid in form. These tumors may exhibit a tendency towards sarcomatous transfor- mation. Polypoid fibromata are also seen. Chondroma, osteosar- coma, and carcinoma occasionally occur, but usually as secondary manifestation of a primary growth which has had its origin in either the buccal mucosa or the maxillary bones and has invaded the nasal passages. These malignant growths are recognized by the upheaval, and eventually, perforation of the superior maxilla which they produce. Symptoms and Diagnosis. Growths of any size interfere with respiration. Malignant neoplasms give rise to purulent or hemorr- hagic discharges, frequently of fetid character. They are painful to manipulation. When of long standing, the facial bones become distorted or necrotic. Treatment. Constitutional treatment of polypi has been suffi- cient to cause their disappearance. Gohier verified this in an animal he tried to poison with large doses of arsenious acid after having given up an attempt at extirpation. When surgical measures are em- ployed, the wire snare should be tried, but failing with this, it is necessary, owing to the conformation of these parts, to make an opening in the superior wall of the nasal passage with a trephine, and extirpate the tumor through the same. It is usually futile to attempt the removal of malignant growths. The Head and Neck 115 The Larynx and Trachea. FOREIGN BODIES. Though common enough in the pharynx, lodgment of foreign bodies in the larynx is an accident of great rarity. The extreme sen- sitiveness of the larynx is responsible for this immunity, for if they do not become firmly wedged they are expelled by reflex cough- ing. Bournay treated a dog one week for sore throat, accom- panied by symptoms of dysphagia, whistling and roaring, coughing, and occasional vomiting. It succumbed to asphyxia. The necropsy revealed the presence of a small pebble near the vocal cords which completely obstructed the orifice. The tracheal mucosa was edem- atous and covered with a fibrinous exudate in which the stone was also embedded. Foreign bodies may also fall into the trachea, and this accident has happened where the tracheotomy tube has been employed. As a rule, if an obstruction more or less completely blocks the passage, death quickly follows, but insignificant bodies are often tolerated. Symptoms and Diagnosis. Where complete obstruction exists, symptoms of sudden suffocation develop. Where incomplete ob- struction occurs, the symptoms are those of a subacute type of laryn- gitis, with dyspnea, coughing, vomiting, and expression of anxiety. There may or may not be spasm of the glottis. Differentiation in the latter case lies between displaced polypi and laryngeal edema occurring as a complication of laryngitis. Treatment. If asphyxia threatens, immediate tracheotomy is indicated. The opening should be made close to the larynx. If the body is located above immediate relief is obtained, but if the dyspnea persists it is evidence that the body is lower down in the trachea. In the latter case a second opening should be made as low down as possible. The next step is to endeavor to dislodge the body. If it is in the larynx an attempt should be made to extract it by the mouth, but if this fails, to dislodge it by manipulating with the finger through the opening in the trachea. If the object is lower down, it may be necessary to employ forceps, when great care should be exercised not to force it further into the lungs. When bodies reach the latter position they are beyond surgical intervention. ii6 Surgical Diseases and Surgery of the Dog NEOPLASMS. The trachea and larynx are occasionally the seat of single or multiple papillomata. Cadiot and Almy and Mouguet have seen instances. Tubercles also occur as a manifestation of pulmonary or generalized tuberculosis. Symptoms and Diagnosis. According to the authorities just noted, dyspnea and violent fits of coughing are prominent symptoms of papilloma. Treatment. When the growth is situated in the larynx removal by means of a snare is indicated. FRACTURE OF THE TRACHEA. This lesion was seen and described by Walley. The trachea had sustained a complete transverse fracture which was supposed to have been caused by violent traction. There was a space of an inch between the severed ends. The first symptom noticed was a slight tumefaction of the tissues round the throat. This was followed by emphysema of the neck, chest, and one side of the body, which increased in the neck at each expiration. An attempt at relief was made by incising and stitching the edges of the aperture to the skin above and below, but, the animal died soon after from pulmon- ary congestion and emphysema of the mediastinal connective tissue. That it is possible to treat this lesion successfully if attended to in time would seem to be the case in view of the experiments of Mesnard and Gluck and Zeller which are quoted below. Surgery of the Trachea, Gluck and Zeller divided and reunited the trachea experimental- ly with good results. The division was made between the third and fourth rings. Both sections were at first sewn into the skin wound, eight to ten stitches being sufficient for each. Some days later the cut extremities of both sections were brought into apposition and sutured and the animal recovered the use of its voice. These experimenters also practiced extirpation of the larynx. Mesnard also removed two, three, and five rings from different dogs and sutured the cut ends with catgut. Reunion was complete in ten days. The Head and Neck 117 TRACHEOTOMY. This operation is indicated whenever dangerous dyspnea is induced by the following conditions : acute inflammatory and edema- tous affections of the larynx and tongue, and the presence of impact- ed foreign bodies in the larynx and pharynx. It is also resorted to for the removal of foreign bodies from the larynx and trachea. The technic is as follows: Place the animal in the dorsal position and extend the head and neck fully. Divide the skin and sub- jacent fascia with one firm incision. Quickly separate the fibers of the sterno-hyoid and sterno-thyroid muscles by teasing until the rings of the trachea are exposed. Pass a sharp hook into the lower border of the cricoid cartilage and elevate this. With a sharp curved bistoury cut through two or three rings of the trachea in the middle line but not too deeply. The incision may be simple, the edges of the severed rings being stitched to the cutaneous wound or a cir- cular portion may be removed and a tracheotomy tube inserted, the latter being held in position by tapes tied round the neck. The inner tube must be removed every few hours for the purpose of re- moving accumulations of mucus which if allowed to take place quickly obliterate the passage. Stitching of the trachea should be avoided if possible, as the stitches tend to cut through the cartilage, and if renewed very often lead to necrosis of the parts. A dog wearing a tracheotomy tube must be closely watched, as some ani- mals make persistent efforts to rid themselves of the instrument. BIBLIOGRAPHY, Bonrnay — Rec. de Mfd. Vetfir. May, 1894. DJeterlcha— Cited by Cadlot & Almy In Traltfi de Thfir. Chlr. d. An. Dom. Gluck & Zeller — Langenbeck's Archlr. t. kiln. Chirur. 26, p. 427. Gohler — Cited by Cadfiac In Pathol, dea An. Dom. Mesnard— ReT. V6t6r. 1902. Walley — Jonrn. Comp. Pattiol. & Therap. 1893, p. 80. CHAPTER IV The Thorax The Lungs and Pleurae EXAMINATION. Examination of the lungs and pleurae is conducted by means of auscultation and percussion. With the naked ear ap- plied to the chest wall, respiratory sounds can be heard with sufficient distinctness, but the employment of a stethoscope or phon- endoscope accentuates them. Percussion is best accomplished by tapping with the second finger of one hand on the corresponding finger of the other hand laid flat against the chest wall. When using these means for disgnostic purposes the position of neigh- boring and more solid organs must always be taken into account. TRAUMATIC LESIONS. Wounds of the lungs and pleurae occur for the most part as a complication of penetrating wounds of the thoracic wall. Their gravity depends upon the degree of resultant hemorrhage and the entry of either atmospheric air or pyogenic bacteria within the sacs. If air beyond a certain quantity enters a pleural sac, the condition known as pneumothorax is established, and both lungs collapse . The animal makes violent respiratory efforts which gradu- ally become less frequent and finally cease, cyanosis meanwhile developing. If, however, an open wound becomes quickly sealed, either spontaneously or by surgical measures, the air is gradually absorbed and the lung again takes on its function. This is also true of hemorrhage exudates. Slight rents in the pleura are not as a rule followed by entry of air. In rents or incisions of at least a half to an inch in diameter the lung may be seen to glide over the incision hole with each act of respiration, the cohesive force of the two pleurae being sufficient to overcome the pressure of the atmosphere through the incision. Delafond probed a wound Il8 The Thorax 119 with his finger until he felt the heart, and the animal recovered. Theoretically, when only one sac is opened, sufficient for air to gain entry, and the opposite sac remains intact, the condition is not incom- patible with life, because unilateral respiration would still be pos- sible. But, though the dog has two separate and distinct pleural sacs, they are separated only by a thin diaphanous mediastinum, and as a matter of fact, as has been established by all those who have experimentally opened the chest-wall, air apparently readily passes through this membrane and causes the collapse of the ad- joining lung. At any rate, it has been found impossible to open either sac to any extent without making provision for the main- tenance of respiration by artificial means, and this involves the temporary introduction of a tube into the trachea and the employ- ment of bellows. The other great danger lies in septic infection, which is very apt to take place. In this respect, the pleura offers a striking con- trast to the peritoneum, which possesses a well-known relative immunity to infective processes. Sherman believes that this may be due to the fact that the pleura does not, like the peritoneum, offer pockets or recesses in which an infection may be confined, and that constant motion incident to respiratory and cardiac ac- tion tends to disseminate pathogenic microorganisms. Were it possible to drain the pleura, sepsis might be combatted, but inas- much as drainage of the pleura inevitably results in collapse of both lungs, no steps in this direction can be taken. Symptoms and Diagnosis. Wounds of these parts are difficult of both diagnosis and prognosis. If hemoptysis ensues it is in- dicative of wounding of the lung. When air is entering a pleural sac in small quantities, the fact is easily recognized by the sound at every act of respiration. In any case, respiration is usually greatly accelerated, and this is particularly true when hemothorax exists. Penetrating or deep wounds of the chest-wall should never be probed for fear of bringing about pneumothorax and in- troducing microorganisms. Prognosis must always be guarded. Treatment. Penetrating wounds of the thorax should be closed as quickly as possible by suturing and application of anti- septic bandages. No attempt should be made to evacuate hem- orrhagic exudate in the pleural sac because it soon coagulates, and is gradually absorbed even if present in considerable quantity. I20 Surgical Diseases and Surgery of the Dog Thierry treated a dog whose chest had been ripped open by a wild boar between the seventh and eighth left ribs. At each inspira- tion a portion of the lung would protrude. He sutured the wound with a rusty needle and dirty suture, and the animal completely re- covered within three weeks. Delafond had a similar experience. PLEURITIS. (Largely translated from Cadiot and Breton.) Two principal types of this disease are recognized, viz., the sero-fibrinous and the purulent. Both are believed to be of infec- tious origin. The sero-fibrinous form is now known to be most commonly associated with tuberculosis, but it is also known that the disease may follow a sudden chill, such as hunting dogs sometimes sustain when following their quarry into water in mid- winter, or which house dogs suffer after being washed and ex- posed to the cold air before their coats are sufficiently dry. Cadeac places the percentage of tuberculous pleurisies at ninety. Para- sitic infestation may also be responsible. Magnie attended an animal which died suddenly with symptoms of vomiting and as- phyxia. In the left sac he found a plastic exudate and signs of pleuritis, but without effusion. A strongylus gigas which was present was supposed to have excited violent contraction of the diaphragm and produced asphyxia. The disease occurs in all ages, but most frequently about the third year. Spring and Fall seem most propitious for its de- velopment. The lesions most commonly found at necropsies are ecchymoses and multiple granulations of diverse form, covered with a fibrinous exudate and macroscopically resembling sarcomatous nodules. On this account this type of the disease was formerly regarded as can- cerous pleurisy. The tubercle bacillus is often found swarming in the nodules. In acute exudations of recent origin microorganisms of suppuration, particularly staphylococci are usually also present. The lesions are rarely confined to portions of one pleura, but usu- ally invade the whole of the sac, or the opposite sac may be in- volved. The lung of the affected side is generally more or less atelectasic. Contingent lesions are often present. There may be hydro- thorax of the healthy side, pericarditis, ascites, and anasarca of the The Thorax 121 lower extremities. Mathis saw a complete torsion of the posterior lobe of one lung in an animal destroyed suffering from pleurisy, which he attributed to the varied positions in which it had been placed for examination. Symptoms and Diagnosis. Pleurisy is ushered in by an in- termittent chill lasting three or four days. This is followed by fever and dyspnea, thirst, injected mucosae, accelerated pulsations, and anorexia. The urine is scant, and sometimes albuminous. The dyspnea is very apparent, respiration being superficial and painful, and characteristically abdominal. There may or may not be a cough. When present it is short, dry, and painful. The thorax is particularly immobile on the diseased side, primarily from pain, but later from interference by the eflFusion. Auscultation prior to the stage of effusion and during the course of resolution reveals friction. After effusion has taken place percussion with the animal in the standing posture shows dullness up to a certain level cor- responding with that of the contained fluid. Above this there is a tympanitic sound. If the position of the animal be changed, dis- placement of the fluid occurs with corresponding shifting of the dull area. The vesicular murmurs become inaudible, bronchial breathing alone being apparent. In the later stages mucous rales may be present owing to pulmonary edema engendered by stasis of the circulation. If the ear is applied to the diseased side and the chest struck sharply, a wave-sound is heard. On the healthy side respiration is labored. The course of the malady is variable and the prognosis must be guarded. In some cases effusion takes place almost at the outset, in others particularly of tubercular origin, friction sounds are audible for several days. The liquid may fill the sac very quickly, or it may take from fifteen to twenty days. The disease may terminate in resolution, the liquid becoming totally absorbed, or it may assume a chronic character, or death may supervene. Resolution is indicated by progressive disappearance of the func- tional derangements. It is always slow to take place when the fluid is not removed by thoracentesis. Death may occur through colla- teral congestion and edema, or through asphyxia when both sacs are involved. Syncope may be suddenly produced by secondary pericardial effusion, myocarditis, or metastatic tuberculosis, particu- larly of the liver. Should friction sounds continue, it may be re- 122 Surgical Diseases and Surgery of the Dog garded as an indication of the existence of tuberculous nodules, in which case the animal becomes a menace to its kind, and possibly to the human race. Tuberculin should always be injected to con- firm the suspicion. Inoculation tests may also be made on rabbits and cavies, but no reliance is to be placed upon them in case of a negative result, for the reason that old effusions are sometimes completely sterile, while the nodules may contain large numbers of bacilli. A not infrequent sequel to pleurisy is atelectasis or pulmonary collapse, caused by peripheral compression of the lung proceeding from pleural or pericardial effusion. The presence of the fluid interferes with the inspiration of air, and the pressure gradually forces out the residual air in the alveoli. It is usually confined to part of a lung, but may involve the whole. Treatment. At the outset of the disease counterirritation in the form of mustard plasters should be applied, and the costal and sternal regions protected by a flannel chest jacket. After effusion has taken place medical measures are directed towards producing purgation and diuresis and sustaining the heart. The fluid is best removed by thoracentesis, and this operation should always be resorted to when dyspnea is intense. Purulent Pleuritis. This disease is always of pyogenic ori- gin through accidental penetration of microorganisms (staphy- lococci and streptococci) into the pleural sacs. Delafond regarded traumatism as a frequent cause. A violent blow, such as by the hoof of a horse or by the horn of an ox, resulting in fracture of one or more ribs, may so enfeeble the resisting power of the tissues as to permit of incursions by microorganisms. Another manner in which the disease may originate is through perforation of the esophagus by foreign bodies, such as animal or fish bones. In one instance Siedamgrotzky found an ear of wheat in the left pleural sac, the channel of entry of which could not be determined in spite of careful search. In another, Weber found a spikelet of rye which had perforated a bronchus. Leclerc saw a fatal purulent pleurisy caused by the discharge of pus from an abscess in the lung resulting from the presence of a briar thorn. Cancerous tumors are also productive of purulent lesions. Symptoms and Diagnosis. The symptoms are fever with a tem- perature of about 105° F., profound prostration, arched back, a slight The Thorax 123 thoracic distension and tension of the abdomen. A positive diag- nosis of the presence of pus can be made by thoracentesis. The disease is quickly fatal by toxemia or pyemia. Hydrothorax. This term is applied to a secondary affection, which consists of an effusion of the serous fluid into the pleural sacs as a result of stasis of the circulation. It may be brought about by neoplasms of the bronchial and mediastinal glands, chronic diseases of the heart, pericardium and lungs. Symptoms and Diagnosis. The symptoms are dyspnea, res- piration with open mouth, fainting spells, and incapacity to ascend stairs or move far. It may be distinguished from pleurisy by the physical signs, and by the effusion being bilateral and symmetrical. This affection being dependent on other lesions, thoracentesis can effect but a temporary improvement. HERNIA. This is a lesion of rare occurrence. An observation has been recorded by Peuch. The animal at each expiration, presented a soft, quivering, spherical tumor about the size of a hen's egg, at the lower part of the left side of the thorax, between the sixth and seventh rib. When the animal barked, the swelling attained the size of the human fist. Palpation revealed a rent of the entire thickness of the intercostal muscles, about two inches in length. Peuch treated this case by maintaining a pledget of pitch and resin over the seat of hernia by means of a bandage rolled round the chest. In eleven days complete recovery had taken place. Surgery of the Lungs A good deal of major surgery has been done on the lungs in an experimental way, showing that interference with these vital organs is feasible. Wm. Koch experimented to test the susceptibility of the lungs to various surgical procedures. He performed acupuncture with aspirating needles or pointed instruments on over twenty dogs. Later on he injected iodide of potassium in solution of various strengths. On examining the organs some weeks later scarcely any scar could be found, and he came to the following conclusions: (i) 124 Surgical Diseases and Surgery of the Dog the lung is insensible to wounds with little or no reaction, (2) portions of lung may be destroyed by injections or by the galvano- cautery without killing the animal. Gluck went further than this. He extirpated the whole of one lung in six animals. The animals were chloroformed, and strict antisepsis and careful arrest of hemorrhage observed. A bow- shaped incision with the convexity towards the sternum was made through the skin and pectoral muscles between the third and sixth ribs, and the edges separated with a tenaculum. The broad in- sertions of the serratus anticus major muscle were detached, and portions, three to five inches in length, of the third, fourth, and fifth ribs resected, external to the course of the internal mammary artery. The intercostal muscles of the parts noted were also ex- cised, and all bleeding carefully stopped. The intact pleura was now seized with forceps and divided the entire length of the wound. At the same moment the lung collapsed, and breathing became accelerated. Then the entire left lung was ligated at the root and removed en masse, or it was extirpated piecemeal. After extirpation, the entire contents of the mediastinum were visible, in- cluding trachea, esophagus, both vagi nerves, vena azygos, ductus thoracicus and heart with great vessels. Most of the animals re- covered, though this has not been the experience of experimenters in this country. Schmid also resected portions of one lung in eight dogs, and of these three recovered and five died. Four of the latter suc- cnmbed to empyema, in Schmid's opinion, owing to entrance of septic matter from the divided bronchii. THORACENTESIS. This operation consists in removing pleural effusions by means of trocar and canula, or preferably the aspirating syringe. In cases of true pleurisy the necessity for its performance first occurs from the tenth to the fifteenth day after the onset of the disease. It is best performed with the animal in a sitting or standing posture. Pfeiflfer directs that the dog be laid on the table, but Moeller has seen an animal die within a few minutes from being placed on its side. The site of puncture should be disinfected and the instrument rendered sterile. A fine trocar and canula, or preferably an aspirating needle The Thorax 125 may be employed. The latter is best, for the reason that entrance of air into the thorax can be guarded against, and the flow of liquid being more gradual is less liable to interfere with intra- thoracic pressure and cardiac action. The needle should be inserted in a somewhat forward direc- tion at the anterior border of the sixth, seventh, or eighth rib, after first pulling the skin slightly to one side. The intercostal space can be widened by pushing one finger into it. Slight pain is evinced on puncturing the skin. The cavity is reached as soon as resistance to the passage of the needle has ceased. If a canula is used the fluid at first gushes out in a continuous stream, then rhythmically synchronous with respiration. During expiration the flow ceases and air rushes in, which must be prevented by plac- ing the finger over the end of the tube after each inspiration. If the flow suddenly ceases it is through plugging by flakes of fibrin, which can be forced back by reinsertion of the trocar. From two to five ounces of fluid should be withdrawn, and the operation repeated daily at a new site of puncture, until no liquid remains. When the effusion shows no sign of abating, Cadiot and Breton advise irrigation of the sac with normal sodium chloride solution, at a temperature corresponding to that of the body. No other or antiseptic solutions should ever be injected. BIBLIOGHAPHY. Cadiot & Breton — Mfidecine Canine. Delafond-^ourn. d. M6d. vetfr. Theo. et Pract. 1829, p. 445. Leclerc— Rec. de M6d. V6t6r. 1886, p. 937. Magnie— Rec. de M6d. V6t6r. 1870, p. 861. Peuch — Cited by Cadiot & Almy In Traite de Ther. Chlr. d. An. Dom. Pfelffer — Operations Cursus. Sherman — American Medicine. June, 1902. Thierry— Cited by Cadiot & Almy In Traite de Thfir. Chlr. d. An. Dom. Weber — Adam's Wochenschrlft. 1861, p. 64. Wm. KocU — Langenbeck's Archlv. f. kiln. Chlrurg. 15, p. 706. The Heart and Pericafdium TRAUMATIC LESIONS. Not very long ago it was generally believed that a wound of the heart was necessarily if not immediately fatal, but thanks to the experimental researches of Fischer, Kronecker and Schmey, Elsberg, Ricketts, Sherman, and others, we now know that the gravity of a heart wound depends on its size, location, and certain 126 Surgical Diseases and Surgery of the Dog other factors, and that even with fatal outcome death may be de- layed to the extent of several hours. Between five and ten per cent of all heart wounds terminate in recovery. It is known, how- ever, that there is a spot in the septum, between the ventricles, where simple puncture with a fine needle is followed by immediate arrest of cardiac action. In other respects, when a heart wound proves fatal it depends upon either of two factors, viz., acute hemorrhage or intracardial pressure. In either case the same re- sult ensues, viz., starvation of the organ. In the former case the wound in the pericardium is sufficient to allow the escaping blood to pass out through the external wound or into the pleural sacs in such quantity that it no longer enters the organ in sufficient volume to stimulate the muscle of the latter to contract. In the latter case the rent in the pericardial sac becoming sealed from one cause or another, the accumulating blood reacts on the organ by compression. Cohnheim has shown this by injecting various quan- tities of fluids into the pericardial sac, the pressure being mainly sustained by the auricles and great vessels at the base of the heart. The ventricles continue to contract, but the auricles and great ves- sels being compressed the entry of blood gradually decreases until the heart pumps itself dry, and finally the ventricles also cease. Wounds may be penetrating or non-penetrating, but the hem- orrhage from the former is usually more copious than from the latter, though from the latter a hemorrhage may be as serious in its re- sults as from the former. The hemorrhage usually takes place during systole, but it may also occur during diastole when the wound is very large. Wounds of the right ventricle bleed more freely than do those of equal size in the left, the latter closing by coagulation more rapidly than the former, owing to the greater length of the wound canal and thickness of the wall. For the same reason perpendicular penetrating wounds bleed more freely than do oblique. Hemorrhage is more severe in wounds from sharp instruments than from bullets. When a penetrating body plugs the wound, so to speak, a fatal outcome may be averted, or at least delayed, some hours. In Nocard's clinic at Alfort a dog was re- ceived whose heart was transpierced by an arrow. Its master had endeavored to extract the missile, but the latter had broken off short in the wound. The animal had then run for miles, and did not succumb until the following day. Nocard remarked that had The Thorax 127 the owner succeeded in extracting tne arrow the animal would have died ahnost immediately from acute hemorrhage. Symptoms and Diagnosis. Heart wounds are recognized by the location of the external wound, the general evidence of hem- orrhage, the acute anemia, the disturbance of cardiac function, and the local signs of filling of the pericardium and pleura. Treatment. For the class of wounds in which the hemorrhage is confined to the pericardial sac the operation of pericardicentesis is theoretically indicated, but it must be remembered that even if the pressure is successfully removed the hemorrhage may begin anew. For the other class of wounds in which the blood escapes ex- ternally or into the pleural sacs there is only one alternative, and that is to open the thorax and suture. Modern surgery has shown that suture of the heart is a perfectly feasible operation. But, there are certain difficulties to be overcome in the case of the dog which are likely to cause even the most skilful and progressive operator to hesitate. PERICARDITIS. The term pericarditis comprehends any inflammation of the external serosa of the heart and roots of the great vessels. Every inflammation of this membrane is essentially of infectious origin, the inflammatory products invariably disclosing the presence of microorganisms. Idiopathic pericarditis is an unknown entity, aseptic lesions always cicatrising without inflammation. The pro- cess of infection is said to be primary when the pericardium is the original seat of attack by microorganisms ; it is said to be secondary when the pericardium is invaded during the course of a general infectious malady. The disease may be acute or chronic, and two principal types are recognized, viz., the sero-fibrinous and the purulent, depending upon the properties of the causative microbe. Sero-fibrinous inflammation of the pericardium, while being rarer than that of pleura and peritoneum, is, nevertheless, by no means uncommon. Its development is usually secondary, either from pyemia, rheumatism, pneumonia, or distemper, but most often from tuberculosis, when it may occur either singly or complicated 128 Surgical Diseases and Surgery of the Dog with pleural and pulmonary lesions. Trasbot and Rousseau have observed it to occur primarily as the result of a chill, such as an animal may receive on entering water during the heat of the chase. Such instances are probably due to the attack of microorganisais already present in the blood, under a condition of lowered vitality of the animal. The investigations of Porcher and Desoubry have demonstrated that bacteria are constantly entering the circulation by way of the alimentary canal under normal conditions. In the acute form the sac is filled with a sero-fibrinous liquid, which is often blood-stained. At times a profuse hemorrhage takes place, causing extreme distension, which may lead to rupture. Both parietal and visceral layers are beset with villosities and false membranes, and the presence of tubercle bacilli may usually be demonstrated. The slowly developing chronic form is commoner, but it fre- quently succeeds the acute. Most tuberculous dogs affected with pleural lesions also suffer from chronic pericarditis. The effusion is liquid, serous, more or less profuse, clear or yellowish, tranfc- parent, and often free from microorganisms. The surface of the visceral membrane is studded with bacilli-containing neoplasms, varying in size from a grain of millet to a pea. In the vicinity of the base of the heart, where there is least mobility, it is usually consolidated with the parietal layer, and sometimes there is com- plete fusion of the two membranes. When the latter condition is present the heart sustains compression and atrophies, so that its chambers can no longer contain the normal quantity of blood. When there is considerable effusion present the lungs frequently suffer from atelectasis owing to compression. Pyemic pericarditis is characterized by miliary whitish foci of suppuration. Both conditions usually lead to more or less myocar- ditis, softening of the muscle, and dilation of the chambers, or there may develop a diffuse fibrosis, particularly in narrow-chested animals. The chief secondary complications to which pericardial effusion may give rise, are: venous stasis owing to partial collapse of the veins entering the heart through pressure of the fluid in the peri- cardium ; impairment of cardiac action ; mechanical valvular in- sufficiency ; one or all of which may give rise to hydrothorax, ascites, and anasarca, the latter sometimes limited to the posterior ex- The Thorax 129 tremities, and to the sheath in males. In two animals examined post-mortem by Siedamgrotzky there were also hepatic cirrhosis and interstitial nephritis. Rupture of the sac may take place when there is much dis- tension and softening of the wall during hemorrhage or tuberculous pericarditis. Symptoms and Diagnosis. The disease is rarely detected in its incipiency. It may continue until the end of the animal's natural life without being suspected, its existence being only discovered post-mortem. When effusion commences dyspnea is observed, which becomes very marked as the amount of fluid increases. Later, when it is present in profuse quantity the interference with the heart's action becomes a serious matter, the animal is prostrated, its orbits project, its expression is anxious, it breathes with great difficulty, cyanosis develops, and distension of the jugular takes place at the slightest exertion. The pulse is frequent, small, and feeble, or it may be slower than normal and irregular. There is an active thirst, but infrequent micturition, and the animal pro- gressively emaciates. In making a diagnosis pericarditis must not be confounded with pleuritis. With a phonendoscope or good stethoscope the heart beat can be plainly heard when the effusion is exclusively pleural, whereas it can scarcely be detected when the effusion is confined to the pericardium. In the latter case a splashing sound isochron- ous with the cardiac movements can generally be heard, and there is an area of dullness corresponding to the distended cardiac sac. It must be remembered that both pleuritis and pericarditis may co- exist. Accordingly, in every instance where thoracentesis is prac- ticed, auscultation and percussion over the region of the heart is indicated after removal of the pleural effusion. A test injection of Tuberculin should also be employed for prognostic purposes. Treatment. Medicinal treatment is directed towards sustain- ing the heart, reducing the inflammatory process, and preventing complications. Vesicating agents, such as mustard and blisters are said to produce good results. Digitalis, caffein and diffusible stimulants are administered to combat cardiac asthenia. The best way to remove the effusion is by the operation of pericardicentesis, but many practitioners place much faith in hypodermic injections of 10 130 Surgical Diseases and Surgery of the Dog pilocarpin. When the symptoms are grave operative measures are imperative. (See Pericardicentesis.) H7DR0PEBICAKDIUM. By this term is meant any non-inflammatory, passive effusion of serous fluid into the pericardial sac. Like any other hydropsy this condition is always of a serious nature, developing through local stasis of the circulation owing to valvular lesions, auricular tumors, pulmonary affections and chronic pleurisy, whereby starva- tion of the pericardial capillary cells and filtration of some of the fluid constituents of the blood take place. It may also develop through capillary poisoning incident to chronic nephritis and cancer- ous and tuberculous cachexia, and more or less during the agonal period. It is nearly always associated with hydrothorax, the origin of which generally precedes it, and very frequently with ascites and anasarca. The exuded liquid is clear and yellowish, or slightly tinged by admixture of hemoglobin or blood. It contains less albumin than blood serum, and a certain quantity of fibrinogenous material, which causes it to undergo coagulation when exposed to the air. The walls of the sac are pale and lack inflammatory adhesions. Benja- min saw a case of hydropericardium associated with thoracic adeno- pathy, in which the parietal serosa was beset with slightly granular patches. Symptoms and Diagnosis. The same physical and functional signs are present as in pericarditis proper, but without elevation of temperature. Treatment. The same treatment is indicated as for pericar- ditis. Surgery of the Heart That the heart is capable of sustaining operative interference with subsequent perfect recovery of the animal has been amply proved experimentally. In 1895, Rosenthal, who up till that time was the first to attempt treatment of a wound of the heart by direct means, exhibited to the Medical Society of Berlin a dog, which had survived and fully recovered from resection of the sternum and an experimental cardiac wound. Shortly after, Del The Thorax 131 Vecchio succeeded in saving a dog which had sustained two ex- perimental perforating wounds of the left ventricle and subsequent suturing of the same, and since then, Salomoni, Philippov, and the other experimenters previously mentioned have determined the feasi- bility and usefulness of suture of the heart and pericardium with vari- ous results. More recently Tuffier and Hallion have made a very in- teresting demonstration. They anesthetised a dog until respiration and cardiac pulsation had ceased. After a minute's waiting, with no sign of return of life, they incised the sixth intercostal space and forced the ribs apart. The heart was seen to be perfectly still. It was then seized between the fingers in such a manner that the apex lay in the palm of the hand, while the ventricles were encircled by the fingers. The next step was massage of the organ by com- pression. For a period of one minute it remained motionless; then very feeble intermittent contractions were apparent. It pro- pressively recovered its functions and respiratory efforts recom- menced. The thorax was closed, and the animal eventually re- covered. As has been pointed out under Traumatic Lesions of the Lungs, it is impossible to open the pleural cavity to any extent without re- sorting to artificial respiration, and for the same reason provision cannot be made for drainage, and since it is rare to accomplish surgical interference with this part of the organism without the introduction of pathogenic microorganisms, in spite of the utmost care, the usuai termination is a lethal one from septic infection. However, there have been several recoveries from experimental wounding and opening of the pleura and pericardium, and a clinic case has been recorded by Delafond in which the pericardium having been perforated by a wild-boar, the wound in the thorax was closed with sutures, and in eight days the animal recovered. SUTURE OF THE HEART. The technic of this extremely delicate operation is as follows: Every aseptic precaution being observed and the animal being secured and anesthetised, the first step is to perform tracheotomy, insert a tube in the trachea and connect the same with bellows, which must be entrusted to the hands of a capable assistant, whose whole attention must be bestowed on this important part of the operation. A free longitudinal incision is made on the left side 132 Surgical Diseases and Surgery of the Dog through the skin and pectoral muscles along the border of the sternum from the third to the sixth ribs. The broad origin of the serratus anticus major muscle is dissected, and the third, fourth and fifth ribs divided beyond the course of the internal mam- mary artery, and the intercostal muscles carefully severed. The edges of the wound must then be retracted, or about an inch of each rib may be removed. The intact pleura is now observed. All bleeding being absolutely stilled, the pleura is incised along the course of the wound. At the same moment the lung collapses and respiratory efforts become labored. At this point artificial respira- tion must be started up. The pericardial sac is quickly grasped, drawn up into the wound, sutured to the muscles round the edges of the thoracic wound, and opened by longitudinal incision. There is no bleeding from the pericardium. The heart is brought up into the opening in the chest wall by means of two long traction sutures inserted on either side of the wound, and carried deep into the ventricular wall, such manipulation in no wise interfering with its function. Bleeding from the wound can be immediately stopped by crossing the sutures and holding them taut. The permanent sutures of silk are next placed, and these should be continuous, superficially inserted and tied during diastole, the knots being firmly secured. The next step is to make a complete toilet of the sac. The latter is then closed by continuous silk suture, the chest wall is sutured, including the divided muscular tissues, and finally a subcuticular suture is inserted in the skin. The bellows should be forcibly blown up just as the chest is closed, in order to expel all the air possible. Natural respiration shortly recurs, the bellows are withdrawn, and the tracheotomy wound closed. PERICARDICENTESIS. This operation is resorted to whenever extinction of life is threatened through distension of the sac by effusion, or when secondary hydropsies have developed. There is little or no danger attending it, as Elsberg has shown in his experiments that needle punctures are always small, and though there is slight hemorrhage, which is more considerable in the auricles than in the ventricles, it soon ceases, and is never enough to endanger life. The operation should be performed with an aspirator provided with a short needle of minute caliber thoroughly sterilized. Em- The Thorax 133 ployment of such a needle reduces the danger of syncope from too rapid or sudden withdrawal of fluid to a minimum. The instru- ment is used in the following manner : Shut the cock and withdraw the piston to form a vacuum within the barrel of the syringe. Select a portion of skin inferior to the area of dullness and disinfect it as thoroughly as possible. Introduce the point of the needle under the skin at this spot, open the cock, and press the needle slowly inward until resistance ceases and the liquid is seen to gush into the syringe. Shut the cock and empty the syringe, and repeat the same action until the fluid is nearly all removed. Perform the operation again and again if the effusion recurs. BIBLIOGRAPHY. Delafond— Hec. de M6d. VetCr. 1829, p, 714. Del Vecchio— Klf. med. 1895, p. 50. Elsberg — Journ. of Bxper. Medicine. Sep.-Nor., 1899. Fischer — Langenbeck's Archlv. f. kiln. Chlnirg. 186T, p. BTl. Nocard — Arch. V€t6r. 1882, p. 401. Phllllppov— Russ. med. 1886, p. 187. Porcher & Desoubry — Comptes rendns d. 1. Soc. de Biol. 1896, p. 844. Blcketts — American Medicine. June, 1902. Rosenthal — Deutsch. med. Wochenschr. 1895. Salomonl — Centralb. f. Chlnirg. 1896. Sherman — American Medicine. June, 1902. Sledamgrotzky — Ber. ue. d. Veterinaerw. ira Koenlgr. Sachsen. 1872, p. 50. Toffler Sc Halllon — Comptes rendns d. 1. Soc. de Biol. 1898, p. 988. CHAPTER V The Abdomen Abdominal Section. Celiotomy. Laparotomy The operation of opening the abdominal cavity of a healthy- animal is ordinarily remarkably free from any ill-effect. It is ex- ceedingly rare that peritonitis supervenes, even when the precau- tions amount merely to an observation of the ordinary rules of cleanliness. In fact, it may be unreservedly asserted that the necessity for antisepsis, so far as fear of infecting the peritoneum is concerned, has been greatly overrated. Numerous experiments and abundant clinical observation have demonstrated beyond any doubt that the peritoneum of the dog possesses extraordinary re- fractory power against the action of pyogenic microorganisms. (See The Peritoneum). There is little risk of peritonitis resulting from introduction of any limited infection from without, such as may occur during the course of an operation when the peritoneum comes in contact with even the unwashed hands. Neither is there any greater risk after it has been sealed by suturing of the muscular wall. This is due to the well-known fibrinoplastic property of the peritoneum. Wounded peritoneum possesses a remarkable power of adhesiveness when brought in contact with peritoneum. This fact is beautifully demonstrated during suturing operations of the peritoneum, when fibrinous adhesions may be observed to form and firmly bind apposed surfaces within a period of some half- dozen minutes. The chief danger arises from the presence of much putrescible matter, such as large blood clots and portions of organs isolated from their vascular supply by ligature, etc., and allowed to remain. The slightest infection sustained by quantities of such matter is very liable to lead to general peritonitis. Extravasations from the alimentary tract following imperfect apposition or suturing of surgical wounds of the intestinal walls are always highly danger- ous. In the various visceral-suturing experiments that have been 134 The Abdomen 135 carried out on dogs these conditions have been chiefly the cause of fatal termination. But even when infective processes have started up the disposition of the membrane with its pockets and recesses offers opportunity for localization. While the above remarks are true with regard to the dog in health, the conditions are changed when, for instance, the peri- toneum has already been subjected to infection, as may occur in cases of intestinal obstruction, and there is then some risk to be considered. Infective processes are then more likely to arise, not only by direct migration of bacteria, but through their deposit from the circulation. When an intestinal obstruction has existed for any length of time a state akin to septicemia is produced, namely, copremia, or in other words, the blood is charged with the pro- ducts of intestinal putrefaction, together with the bacteria causing the same. Under these and like circumstances, the wound may tend to heal unkindly, and may even lead to unfavorable termina- tion, but even here the risk may be greatly reduced by adequate provision for drainage. Because of this remarkable tolerance of abdominal sec- tion, the practitioner need never shrink from undertaking the operation as an explorative measure. It is not always pos- sible to corroborate a ^diagnosis of internal lesion by external appearances or palpation. Especially is this the case in plethoric animals and where the lesion is situated in a position remote from the surface of the body. For instance, an animal may exhibit all the symptoms of acute impermeability of the intestinal canal — in- tractable vomiting and suppression of defecation, with extreme pros- tration — and yet the abdominal wall may be so tense as to preclude the possibility of diagnosis by palpation. Again, it is very difficult in gunshot cases to decide whether the intestine or any other organ has been perforated or not. The appearance of the external wounds has no diagnostic value, since there is no gaping of the parts owing to contraction of the abdominal muscles, and it is often impossible, and in most cases inadvisable, to use a probe. Sometimes the sexual impulse is manifested after ablation of the ovaries. This is generally due to the persistence in situ of a portion of the ovarial tissue, which can be ascertained by an explorative operation. It is recognized that the sudden accidental application of a violent compressive force to the abdomen when the bladder is distended is very apt to cause rup- 136 Surgical Diseases and Surgery of the Dog ture of the latter or even of other organs and bloodvessels. In such cases it is a wise procedure to open the cavity when there is evi- dence of systemic collapse. Internal hemorrhage through rupture of even lesser vascular branches is always dangerous. Divided ves- sels of the abdominal cavity possess a remarkable tendency to bleed persistently. If, however, air be admitted through abdominal sec- tion the conditions are quickly altered, clots commencing to form. Such vessels, however, should always be secured to guard against a recurrence of the hemorrhage when the cavity is closed and it thereby returns to its former condition. The operation should invariably be performed with the subject under the influence of an anesthetic. Not only do humane con- siderations demand this, but the accurate conduct of a delicate operation on a struggling animal is an impossibility. Before the abdomen is opened every possible contingency must be fully con- sidered, so that the necessary instruments, surgical aids and sutures be prepared, rendered aseptic and laid handy. If it be possible to arrange, the animal should receive no food for twenty-four to forty-eight hours previously, and also receive a purgative. A distended bowel is always a particular annoyance to the operator by reason of its tendency to extrude itself. With regard to the selection of a site for section, it may be said there are two main positions — the lateral and the median. Each has its advocates, and without doubt each certain advantages over the other. But it must be borne in mind that no absolute rule can be laid down in the matter. Neither position is peculiarly suitable for reaching every organ, and the operator must be gov- erned by the conditions present. Most of the organs can be reached by the median line, and this position has much to com- mend it. It can be performed almost bloodlessly, it can be easily enlarged, it aflfords better access to all parts of the cavity for ex- plorative purposes, and it permits of perfect drainage. Further, any resultant scar is not observable when the animal is in the standing position. The chief objection offered against it is said to be the gfreater risk of the dissected parts failing to become united. I can- not concur in this opinion, never having experienced the misfortune of hernia. La Torre holds that such risk is reduced to a minimum if the incision is made through the muscular tissue of the rectus abdominis, slightly to one side, and not through the aponeurotic The Abdomen 137 tissue of the linea alba. Union of muscular fiber, particularly by first intention, is always stronger than union by granulating cicatri- cial tissue. Human surgeons recognize that the commonest factor in the development of hernia is an infection causing the wound to fill in slowly with scar tissue. Median section has a disadvantage in males, in that the wound may become soaked with urine. Even if the incision be made posterior to the preputial orifice, and this difficulty thereby avoided, there still remains a pronounced tendency to the development of suppurative processes. The reason for this is to be attributed to the proximity of the penial mucosa, which is so often the seat of catarrhal discharges, and whence microorganisms can so easily be transmitted to the wound during the course of an operation, and later by the animal licking the parts. In the lateral position the risk of hernia is almost nil, but among the drawbacks are : the greater thickness of muscular tissue which must be divided; the necessity of securing the epigastric vessels; and the tendency of pus to burrow between skin and wall, and even into the peritoneal cavity in the event of the wound sup- purating during healing. Should purulent peritonitis intervene, either from such burrowing or incident to secondary operations on internal organs, the chances of recovery are remote, in consequence of absence of drainage. Generally speaking, the organs are best reached as follows : the stomach, spleen, pancreas, and liver, in the anterior third — i. e., immediately posterior to the thorax; the ovaries and intestines ex- actly in the center of the distance between the ensiform process and the symphysis pubis; the uterus, bladder, ureters, and rectum imm.ediately anterior to the pubis. When the operation is undertaken as an explorative measure the surgeon is, figuratively speaking, groping in the dark. In such instances the middle third should be chosen. Instances have been recorded where it has been found neces- sary to close the first incision and make a second one before the seat of lesion could be reached. Venneholm described an opera- tion for fecal impaction, the mass of which was lying in front of the pubic bone. The mass was mobile, and the operator expected to reach it without any trouble. The first incision was made in the linea alba, but the obstructed portion of the bowel could not be extracted. It was then necessary to make a second incision to the side of the prepuce. 138 Surgical Diseases and Surgery of the Dog Gluck, in his experimental extirpation of the liver, found the organ could be reached most conveniently by incising from the ensiform process to the costo-vertebral articulation of the eighth rib, and resecting the eighth and ninth ribs. Griffiths, in his ex- perimental surgery of the pelvic viscera, found he could expose the latter to better advantage by dividing the symphysis pubis and then separating both sacro-iliac synchondroses by forcibly turning the iliac bones outward. The bones can be separated two inches or more. The animal being secured in the proper position with hopples, the skin in the immediate vicinity of the contemplated incision is clipped or shaved of its hair and scrubbed with warm water and soap. The incision is made with a sharp scalpel, and should not be less than two inches in the smallest animals, while in the larger breeds it may be found necessary to make the wound large enough to admit the whole hand. To reach the cecum and kidney always requires a large incision, owing to their remote position. The skin, subcutaneous connective tissue and muscles are successively divided, the fibers of the latter being separated according to the direction in which their course runs. Three muscular coats require to be divided in the extreme lateral position — the obliquus externus, the obliquus internus, and the transversalis. In the median line there are the aponeuroses of these muscles and a single true muscular coat — ^the rectus. In the male prepubic median section is made by incising the skin immediately to one side of the penis and dislo- cating the latter — i. e., by pushing it in the opposite direction. In making this incision one must avoid wounding the posterior epi- gastric vein — a prominent vessel which runs on either side a short distance from the penis. There is always slight hemorrhage in this region. Section of the muscular wall can then be made in the median line as in females. Froehner believes he can guard against contact with urine and secure better prospect of healing per primam in males by making always a lateral incision about one and one-half to two inches to one side of the linea alba, and subsequently painting the surface of the wound with a solution of iodiform in ether (20:100). Stoss opens the muscular wall by thrusting a grooved director through at one commissure of the skin incision, after making the latter, and passing it with the groove uppermost in contact with the inner surface of the wall along a The Abdomen 139 line corresponding to the contemplated incision. There is no danger of piercing the bowel with a blunt director, and if any portion of the former should be caught up it is perceptible through the wall as a slight elevation. In that case the director is withdrawn far enough to release the gut and again passed. With the director as a guide, the incision in the muscle wall is made with a bistoury. Any vessel being divided, it is grasped with hemostatic for- ceps, which generally suffices to arrest the flow within a minute or two. The epigastric vessels should always be ligated. All hem- orrhage being under control, the peritoneal coat may be picked up with the dissecting forceps and pierced with the scalpel, or it may be gently incised in situ, and the opening enlarged with the finger. Beneath is found the omentum major, excepting just in front of the pubic border. It may be gently pulled away from the hypogastric region and stowed away in the epigastric, or an opening may be made in it by tearing at a point opposite the incision. The viscera are now exposed to view, and the necessary sup- plemental operations demanded by the exigencies of each par- ticular case are immediately undertaken. There is generally some tendency to protrusion of intestinal coils. This must be guarded against as much as possible, though it is rare that any evil effects follow prolonged exposure. It may be prevented by temporarily inserting flat sponges or small cloths (sterilized) just within the wound. The radiation of heat incident to prolonged exposure tends to lower the vitality of the peritoneum, whereby its eliminative or absorptive power is checked. Vincent in his experiments found that there was more likelihood of peritonitis developing after exposure of the bowel, and regarded it as important not to let any escape. Should it be necessary to allow of any considerable protrusion of viscera it is advisable to carefully protect the exposed organs with sterile gauze wrung out in hot water and repeatedly applied. It is a good plan, when an opera- tion is likely to last a considerable time, to employ a "celiotomy cloth." This consists of a piece of cloth with a slit in it made to cor- respond with the skin incision, and sterilized. It is laid over the abdomen, and thus prevents contact of protruding organs with the skin. A full bladder, which is often an interference, may be emptied by direct pressure. The pelvic cavity is opened by extending the skin incision to 140 Surgical Diseases and Surgery of the Dog the hinder border of the symphysis pubis (passing to one side of the penis in the male). The symphysis is cut by means of a strong knife or small hand-saw. One must avoid injuring the dorsal veins of the penis in the male and the plexus of the veins from the clitoris in the female, as hemorrhage therefrom is somewhat difficult to control. A small block of wood is placed under the sacrum, and the iliac bones forcibly turned outward so as to pro- duce a fracture-dislocation at the sacro-iliac synchondroses. Resti- tution of continuity of these parts is accomplished by wiring the bones at the symphysis according to the methods employed in bone suturing. When it is desired to close the abdominal wall a careful in- spection must be made to ascertain whether any blood clots or other putrescible material or sponges remain in the cavity. These are to be removed, as their presence is conducive to peritonitis. No antiseptic solution for cleansing purposes should ever be allowed to come in contact with the delicate peritoneum. Sterilized water is the only permissible liquid. If the omentum has been misplaced it should be returned as nearly as possible to its original position. Any rents in this organ should be sutured, otherwise there is risk of a loop of bowel pass- ing through the same, when the condition would be ripe for strangulation. Though I have never known strangulation to re- sult from such conditions, once, while performing a necropsy, I found a coil of small intestine protruding through a rent I had made some two weeks previously in the course of a resection ex- periment. In intestinal operations the omentum is sometimes soiled, in which case it may be advisable to remove the contaminated por- tion, but it is very important to securely ligate any bleeding vessels. In one of Senn's experimental cases it was deemed advisable to remove a portion of the omentum. The animal died the next day owing to hemorrhage of the omentum by slipping or loosening of a catgut ligature. Senn advises against ligaturing of the omentum or mesentery en masse, but each individual vessel should be searched for and secured separately with aseptic silk. One reason for this is that tissues often shrink after operation, whereby ligatures be- come loosened, so that it is dangerous to include a large area in a single ligature. Parks has also pointed out that the stumps of The Abdomen 141 ligated omentum tend to give rise to trouble through mortification of the occluded end. But, unless the conditions actually demand its removal, it is bad surgery to excise this organ. For the omen- tum performs an important function in the healing of abdominal and visceral wounds. It plays the part of an operculum, invariably be- coming adherent to the internal face of the wound or to wounded surfaces of organs. In certain cases of hernia where its reduction would present considerable difficulty it may be removed with ad- vantage. Because of this protective capacity of the omentum, which is in reality a fold of peritoneum, it is quite unnecessary to stitch the parietal peritoneum. In certain cases provision must be made for drainage. I have reference to conditions threatening to give rise to peritonitis. Wherever perforation of the bowel or infected uterus is on the verge of taking place, or has taken place, or microbic invasion has al- ready occurred, the necessity for drainage becomes imperative. The method is simple, and requires only the insertion of a strip of sterile gauze in the course of the wound, one extremity being placed within the peritoneal cavity, the other being allowed to protrude through the skin. This should be left in place some five or six days. In bringing the edges of the muscular wound into contiguity some operators apply independent sets of sutures to each of the divided coats. Others use but one set of sutures to include all the coats. In the median position there is but one small muscular coat to unite, though the aponeuroses of the others should be included. Much of the strength of the abdominal wall lies in the fascia in front of the recti muscles. When interrupted sutures are used no stitch should be tied until all are inserted, the curved needle being employed, and then tying is to be commenced at each commissure and gradually completed toward the center. When the opening has been made directly through the linea alba, La Torre advises that the aponeurotic tissue be removed as far as the muscular sub- stance of the recti muscles, owing to the yielding tendency dis- played by cicatrices of the former class of tissue. When the epigastric artery and veins have been tied, the liga- tures are very apt to become displaced or slip while the sutures are being applied to the wall. This accident may escape the operator's 142 Surgical Diseases and Surgery of the Dog notice, and a fatal hemorrhage result. Znamensky lost a case in this manner. Wherefore, careful attention should be paid to this matter. I consider the best way to suture the muscular wall is to em- ploy the continuous suture of silk and allow both ends to protrude through either extremity of the wound in the skin, along with the ends of the buried skin suture. At the end of seven or eight days the stitches may be removed by pulling sharply on one of the pro- truding ends with forceps. Permanent sutures, i. e., sutures which are desired to remain permanently in the tissues, are capable of giving rise to further trouble, hence it is always advisable to em- ploy temporary ones. Divided muscle unites very readily by first intention, i. e., by adhesion of the cut edges through organization of inflammatory serum by fibrin, provided the edges are brought into accurate ap- proximation by sutures, and no suppurative process takes place in the subcutaneous connective tissue to hinder. If reunion of the divided muscle takes place with a minimum formation of connec- tive tissue, the strength of the wall is little impaired, and the chances of a resultant hernia are remote. The importance of securing accurate approximation of all di- vided subcutaneous tissue cannot be overestimated. The formation of spaces must be guarded against as much as possible, for, as has already been pointed out, such spaces, if infected, form suitable foci for suppuration. The reason why pus is so apt to form in males is owing to the proximity of the penial mucosa, which is so commonaly the seat of catarrhal disorder, and the ease with which bacteria are carried thence by the tongue of the animal or by the surgeon during the course of an operation. The wound made when the penis is dislocated in order to reach the median line is particularly prone to suppurate. The connective tissue in this locality is deep, and when divided tends to form quite a cavity under the sutured skin. Therefore, it is always a wise precaution to draw the divided subcutis together with a few sutures whenever any gaping is evident. For the skin by far the best suture is the subcuticular, insuring, as it does, the utmost protection from in- fection from without. Any of the non-absorbable material may be used, as it is easily removed, but silk is to be preferred. The wound should be examined closely for the succeeding day The Abdomen 143 or two for signs of suppuration, and if such be discovered it must be promptly opened and the matter evacuated. A subcutaneous abscess without drainage is always dangerous. Indeed, fatal ter- minations have been recorded where such seemed to have been the sole cause of death either through septicemia or pyemia. Peter- son lost two cases in this manner, eight and thirteen days after the operation, respectively. Froehner says they are productive of septic endocarditis. Where there is no infectious disease of the teeth, or no discharging wound or disease process present, whereby infection of highly virulent microorganisms could be trans- mitted by the tongue of the animal, anything in the nature of a protective bandage is best dispensed with, particularly when the subcuticular suture is employed. As a rule, a dog soon learns to work its muzzle in under a bandage to lick the wound. But, in the excepted instances noted, it is advisable to protect the wound as much as possible with gauze and linen bandages and a plentiful supply of antiseptic powder. An animal that has been subjected to laparotomy should be restrained from taking active exercise for a few days, so that no risk be run of the sutures tearing out from some sudden movement. Occasionally, if non-absorbable sutures have been inserted in the muscular wall, they fail to become encapsulated, and a sinus is established long after apparent healing of the skin has taken place. In such cases a director must be passed into the extremity of the tract, and by means of a curved bistoury sufficient of the parts laid open again to permit of the offending thread being ex- tracted. As has already been stated, purulent peritonitis occurring as a result of intestinal perforation owing to imperfect suturing in sec- ondary operations, or from the presence of 'putrescible material, or other causes, is an occasional sequel. If from symptoms of collapse or local manifestations such condition can be diagnosed, no time must be lost in reopening the cavity to establish drainage, either in the same position or a new one. Internal lesions must be attended to and the cavity irrigated with moderately hot water. Kummer related an instance of a dog tearing out the abdominal strtures three weeks after operation, and succumbing as a result thereof in thirty-six hours, and Moeller recorded a similar occur- rence. Caution must be observed in the feeding of an animal 144 Surgical Diseases and Surgery of the Dog subsequent to this operation. Hobday found that a hearty meal of soUds is apt to induce violent peristalsis after the bowel has been at rest for a longer or shorter period, and may cause tearing out of the sutures and protrusion of the intestines through the abdominal wound. For similar reasons vomiting must be guarded against BIBLIOGRAPHY. Proehner— Monateh. f. prakt. Thierhellk. 1893-94. Gluck — Langenbeck's ArchiT. f. kiln. CUir. 28, p. 3. Griffiths— Journ. Anat. & Phye. 1894-95, 29, p. 62. Hobday — Jonrn. Comp. Path. & Therap. Sep., 1899. Kummer — Langenbeck's Archlv. f. kiln. Chir. 13, p. 534. La Torre — La Gyn6c. April, 1897. Moeller— Lehrb. d. spec. Chir. f. Thieraerzte. ParkeB — Gunshot Wounds of the Small Intestines, p. 27. Peterson — Journ. Amer. Med. Assn. 1901, p. 808. Senn — Intestinal Surgery, p. 181. Stoss — Monatsh. f. prakt. Thlerheilk. 1896-97. Venneholm— Thleraerztl. Centralb. June, 1898. Vincent— Rev. de Chir. 1881, p. 556. Znamensky — Langenbeck's Archlv. f. klla. Cblr. 31, p. 148. The Peritoneum, Mesentery, and Omentum The Omentum and Mesentery being but duplicatures of the Peritoneum will be considered together with the latter. TRAUMATIC LESIONS. Wounds of the peritoneum occur as a complication of pene- trating wounds of the abdominal wall. So long as such lesions do not bring about the presence of putrescible material they usuaHy terminate favorably, repair by fibrinoplastic formation quickly fol- lowing. Treatment. In general, uncomplicated peritoneal wounds should be left to themselves, the only indication for surgical inter- ference being the presence of putrescible material, when removal of the latter and irrigation should be practised. It would seem as if Nature had destined the Omentum to play the part of a reparative or protective operculum, for this organ invariably be- comes adherent to the site of peritoneal wounds. Mesenteric and Omental wounds should always be sutured as they predispose to strangulation by passage of a loop of bowel through them. But omentum and mesentery should never be H- gated en masse, but each individual vessel should be searched for and sutured separately, because tissues often shrink after operation The Abdomen 145 whereby ligatures become loosened, and because the stumps tend to give rise to trouble through mortification. PERITONITIS. It will be remembered that the peritoneum is a large lymph sac normally possessed of a remarkable absorptive capacity. Pro- vided this property remains unimpaired it is rendered but moder- ately susceptible to the action of pathogenic microorganisms. The experiments of Wegner and Grawitz have shown that considerable numbers of the ordinary forms of pyogenic microbes may be in- troduced into the peritoneal cavity without any particular effect on the animal, provided the absorptive power of the peritoneum is not impaired. Reichel found that peritonitis developed only when the quantity of putrescible material exceeded that amount which could be eliminated within a limited time. Waterhouse injected 6 cc. of cultures of staphylococcus aureus, streptococcus, and intestinal bacteria, respectively, and found the animals survived. He then tried to produce the same conditions which sometimes exist after operations by introducing 8 cc. of urine and small quantities of blood with the cultures, and still the animals lived. But the presence of considerable quantities of putrescible material, such as blood clots 3 cc. in size when the cultures were introduced, was followed by death in twenty-four hours. Cats suflfering from ascites quickly died from peritonitis, owing to diminished absorptive activity of the peritoneum and the presence of a favorable culture medium. Hal- sted introduced pieces of sterile potato, and found they became en- capsulated without producing any disturbance, but when infected with pyogenic organisms invariably caused peritonitis. Welch made similar observations, and found further that an infected wound readily and uniformly suppurated when it contained masses of tissue strangulated by ligature. He made a large number of ex- periments by ligating portions of omentum and then injecting cul- tures of staphylococcus aureus into the peritoneal cavity. In most cases general peritonitis developed, in some cases localized peritoni- tis and in others no peritonitis followed the inoculation. The conditions which impair the refractory power of the peri- toneum are: General systemic conditions producing a lowering of vitality, and presence of putrescible material in quantity in excess II 146 Surgical Diseases and Surgery of the Dog of a certain amount which can be eliminated within a limited period. The actual cause of the disease is always a septic infection. It is customary to speak of a plastic type of peritonitis but this is purely a regenerative process produced by aseptic causes, such as trauma- tism or the passage of an aseptic fetus from the uterus (Blanc). It attends every healing of aseptic wounds. Certain cysticerci also provoke inflammatory secretions, but this is very rare. Pathogenic microbes gain access to the peritoneum through penetrating ab- dominal wounds, including septic surgical wounds, perforation of any part of the gastro-intestinal tract, the spontaneous opening of an abscess into the cavity, the perforation of the uterine wall in cases of pyometra, by migration from contiguous tissues in septic inflam- mation of the latter or following a sudden lowering of vitality as may take place when a chill is sustained, and even by localization of circulating bacteria as occurs in tuberculosis. The disease may be acute or chronic, circumscribed or diffuse. Contrasted with the other great serous sac of the body, the pleura, the peritoneum offers opportunity for localization of infection by reason of the coils of viscera forming pockets and recesses wherein it rp^y be and often is confined. The progfnosis of the acute diffuse form is always grave. Symptoms and Diagnosis. In the acute form the disease is ushered in by depression, coldness of the extremities, rapid pulse, and tenderness of the abdomen to palpation. In the early stages the temperature is elevated but later becomes subnormal. Soon retch- ing or vomiting appear and death takes place by toxemia. In some cases the symptoms closely resemble those of intestinal obstruction, but the distinguishing feature of the latter diseases is the stercora- ceous vomiting. The circumscribed form is often unrecognizable on account of the absence of any indicative symptoms. Treatment. As this disease is caused by pyogenic microbes the early removal of pathogenic foci which threaten to rupture into the cavity is indicated. If septic material is already present or the con- ditions are such that accumulation of putrescible material is likely to ensue the cavity must be opened, flushed with warm sterilized water, and free drainage established by means of folds or strands of aseptic gauze introduced well within the cavity and the dependent extremity carried outside the skin wound. These should be left in place some four or five days. At the same time efforts must be di- The Abdomen 147 rected towards keeping up the heart's action, and encouraging the elimination of morbid matter through the excretory organs. ASCITES. This is a trouble of purely mechanical nature, the result of im- " paired circulation. It must be remembered that there are two cir- culatory systems in connection with the abdominal cavity — the sys- temic and the portal, and that anything which arrests the circulation in either of these is liable to lead to ascites. The most frequent cause would seem to be cardiac lesions, producing altered relationship be- tween arterial and venous blood pressure and blood flow. There then follow venous stagnation, capillary starvation and distension, and transudation of certain of the fluid constituents of the blood. Cadiot witnessed thirty-seven cases in less than three years and based thereon statistics of the relative frequency of occurrence of the various causes of the disease. Of twenty-eight cases, ten of the ani- mals were afflicted with cardiac disease (pericarditis-7, mitral lesions-2, tricuspid lesions-i). The next most frequent factor was tuberculosis of the liver, omentum, or mesentery, eight of the ani- mals being thus affected. Pleuritis was responsible for four of the cases, malignant tumor of the liver and lungs two, hepatic cirrhosis without cardiac lesion three, and carcinoma of the liver one. Of the remainder of the animals, five suffered primary ascites proceeding from chronic peritonitis, and in six which were seen but once, the causative disease was not definitely diag- nosed. Chronic renal diseases and compression or obliteration of the portal vein by neoplasms may also cause ascites. The amount of accumulated fluid in ascites may be very con- siderable, sometimes amounting almost to the actual body-weight of the animal. Hobday removed five and one-half gallons from a Mastiff by canula. It may be clear or yellowish and opalescent, and sometimes contains white and red cells and endothelium. It rarely coagulates. It is often of a pinkish tint when malignant neoplasm is the causative factor, owing to rupture of vessels on the surface of the tumor. A remarkable condition known as chylous ascites may result from traumatic rupture of a lymphatic trunk whereby the cavity becomes filled with a thick opalescent or milky fluid rich in proteids and fine fatty globules with a tendency to coagulate. 148 Surgical Diseases and Surgery of the Dog Symptoms and Diagnosis. Ascites is recognized by the gradual enlargement of the abdomen together with a sinking in of the flank and the acquirement of a pronounced concavity by the vertebral column. A wave or fluctuation of the contained fluid may be per- ceived by placing the hand on one side of the abdominal wall and tapping the side opposite. Percussion gives rise to a tympanitic sound superiorly where the intestines are floating, and a dull one in- feriorly. In very chronic cases there may be edematous swellings of the abdominal wall, prepuce, and extremities. It is important to diflFerentiate from hydro- and pyometra. In these latter conditions the outlines of the bicornate uterus can generally be made out, percussion always calls forth a dull sound and fluctuation is imper- ceptible. Differential diagnosis from such condition as chyle-cyst is extremely difficult, but this form occurs with suddenness. As- cites is occasionally confounded with other conditions. It is dis- tinguished from the enlargement of gestation by palpation, and from obesity by palpation and negative results attending aspiration. Differential diagnosis between the various causative factors is comparatively easy in some cases, while in others it is almost an impossibility. There is little difficulty in diagnosing pericarditis, pleuritis, and valvular lesions, by auscultation, but when the condi- tion is the result of primary inflammatory changes, or secondary to lesions of the abdominal cavity, the fluid must be first drawn oflf to make palpation of value. If much emaciation or cachexia is present, malignant tumor or tuberculosis may be suspected. To differentiate between the two latter diseases, tuberculin should be employed. The prognosis must be guided by the causative factors present. Only when the condition is idiopathic of simple peritonitis or is de- pendent on the simple forms of hydrothorax or hydropericardium, or compression of the portal vein by benign neoplasms, may any per- manent amelioration be expected by eradication of the primary cause. With these few exceptions, treatment can give but temporary relief. Treatment. Diuretics and saline purgatives are employed to lessen the amount of fluid. A case is on record of apparent recov- ery by the daily internal administration of pilocarpine hydrochlorate. Cadiot and Breton favor the employment of this drug. Paracentesis is a more certain and rapid method and is employed when the dis- tension and dyspnea are very considerable, but with the exceptions The Abdomen 149 noted above the cavity fills up again in three or four days' time. When the condition is secondary to pericarditis or pleuritis the peri- cardium or thorax must also be tapped. Numerous cases by Morrison and others are on record in which ascites due to portal obstruction has been overcome by ligaturing the omentum to the chest wall, whereby anastomoses between the vessels are set up and the blood finds its way to the heart without passing through the liver ; but this does not succeed in every case. PABACENTESIS. For this operation a relatively large trocar and canula should be employed. They should be previously sterilized and the skin over the area of puncture disinfected. This is important because the in- troduction of pyogenic microbes into the peritoneal cavity when its absorptive capacity is inhibited may be followed by rapid infection, the intra-abdominal fluid acting as a highly favorable culture medium. The instrument is introduced at the most dependent part of the abdomen, the animal being made to assume the standing po- sition, and the trocar immediately withdrawn. There is no danger of wounding the intestine as the latter is floating on the surface of the fluid. Only part of the fluid should be removed and that grad- ually as sudden and total removal has been followed by syncope. In- terruption of the flow indicates obstruction of the canula by false membranes or coagula and is corrected by again passing the trocar. When the condition is secondary to pericarditis or pleuritis, the pericardium or pleura must also be tapped. (See Pericarditis and Pleuritis). FOREIGN BODIES. Three classes of foreign bodies may gain access to the peritoneal cavity. They consist of inanimate objects, verminous parasites, and fetuses. Inanimate Objects. Comprised in this class are : missiles which have perforated the abdominal wall, bodies which have traversed part of the alimentary canal and finally perforated the gastric or intestinal walls, and surgical requisites such as sponges, which have been inadvertently left in the cavity after being intro- •duced during the course of operations. Their presence is not neces- 150 Surgical Diseases and Surgery of the Dog sarily productive of ill-effect. There are many cases on record of the passage of such bodies as needles and skewers from the stomach and intestines to the surface of the body without inducing any un- toward symptoms, and it is well known that aseptic absorbable bodies are removed by phagocytic action within comparatively short time. There is always risk, however, that their exit from infectious centers may establish tracts by which pathogenic microbes may in- vade the peritoneum. Moreover, they may provoke epileptiform sjmiptoms by reflex irritation of nerves. (See The Stomach and the Intestines). Symptoms and Diagnosis. When the passage of foreign bodies is attended with infectious processes the symptoms are those of peritonitis. There is often a history of the previous swallowing of a body. As already stated, epileptiform seizures may attend the presence of non-absorbable bodies unaccompanied with infective processes. An explorative celiotomy may be necessary to establish a diagnosis. Treatment. Inanimate objects of all kinds should be removed by celiotomy, as by remaining in the abdominal cavity they are al- ways potent pathogenic factors. Tracts by which they have entered must be sealed by suturing, and if peritonitis is present the cavity must be irrigated and free drainage established. Cases have been recorded which have been successfully treated by operative meas- ures. (See The Stomach). Verminous Parasites. The parasites which may enter the peritoneal cavity by perforating tract are teniae, ascarides, and the giant eustrongyle. Cysticerci and pentastomes have also been found present but their mode of ingress is undetermined. Instances of perforation of the intestinal wall by teniae and ascarides have been recorded by Cadeac, Lahogue, Dell, Morey, and others. A case was brought to my notice where a multitude of round-worms had ascended the bile-ducts and emerged through the liver tissue. These parasites generally produce sub-acute peritonitis or rabiform symp- toms. The giant eustrongyle enters by perforating tract by w^ay of the kidney. It is also productive of rabiform symptoms (Lisi). Symptoms and Diagnosis. The symptoms being those of peri^ tonitis or nervous seizures, are naturally obscure, and a pre-mortem diagnosis could only be established by explorative celiotomy. Treatment. The indications are to remove the parasites, close No. 37. Extra-utei'ine Kestatinn .showing twd pseudo uteri nnd ininiennis o.vsts. The Abdomen 151 perforating tracts, irrigate the cavity, and establish drainage; in fact, treat such a case exactly as if it were peritonitis. Fetuses. Fetuses may find their way into the cavity through a rent in the wall of the uterus at any stage of their development, but most commonly at the parturition period through operative bungling, or they may pass the whole period of their existence there by reason of the fecundated ova escaping from the ovary at the fimbriated extremity of the Fallopian tube. True ectopic gestation due to implantation of the ovum in the oviduct, which is common in the human female and which is frequently associated with rupture of the tube when the embryo has grown to a certain stage would seem to be an extremely rare condition if the absence of recorded cases is to be taken as indicative. When a fetus falls into the cavity during parturition it may or may not carry pathogenic microbes with it, according to whether the uterus is infected or not. If it is aseptic it macerates and is absorbed, though the hard parts take considerably longer to disappear than the soft. This process may have cachectic and even lethal effect by autointoxication. Blanc recorded a case which proved fatal within a month. A septic fetus produces peritonitis. In extra-uterine gestation a sac or pseudo-uterus develops around the fetus by formation of fibrous tissue. Such sacs have been found attached to various portions of the peritoneum such as the neigh- borhood of the ovaries, the omentum, and broad ligament. The fetus may continue to develop to full term and then decompose and develop into a suppurative focus, probably by becoming a locus minore resistentiae to the action of microorganisms circulating in the blood, but it usually macerates and is partially absorbed. The internal surface of the sac sometimes undergoes a sort of calcifica- tion. An animal may conceive in the uterus while having a mace- rated skeleton of a fetus in the peritoneal cavity. Undoubted cases have been recorded by Vemaux and myself. Symptoms and Diagnosis. As in the case of perforating in- animate objects, so with fetuses, when they are accompanied by pathogenic microorganisms in their passage from the uterus, the symptoms are those of peritonitis. At the time of parturition the lesion is sometimes discoverable by digital palpation. In Blanc's case referred to above, a fibrinoplastic peritonitis had been pro- voked which had caused an enlarged fluctuating abdomen. 152 Surgical Diseases and Surgery of the Dog In extrauterine gestation there may be entire absence of any indicative symptoms, but on the other hand rabiform symptoms may be induced by reflex nervous irritation. In these cases the fetus can generally be palpated as a firm tumor-like body. Treatment. In all cases of this nature the fetus together with any adventitious tissues should be removed. When rupture of the uterus has occurred the operation should be undertaken as speedily as possible. NEOPLASMS. Neoplasms occasionally develop on the peritoneum as primary growths but they are more often secondary. The primary manifes- tations are both innocent and malignant types. Of the former, fibroma of the gastro-colic omentum and chyle-cyst of the omentum have been observed, and emphysematous cysts of the mesentery, cysts containing pentastomes ; and hydatids of plerocercoides and echinococci have been recorded as rare occurrences. Of the latter, tubercular growths are comparatively common. Sarcomata of the omentum, mesentery, and of the peritoneum have also been de- scribed, while a neoplasm growing on the mesentery, the histologic identity of which was not determined and which was surrounded by secondary growths with metastases in the liver was witnessed by Born. Secondary neoplasms are of the malignant type. Miliary car- cinoma has been observed by Cadeac in an animal from which he had previously removed a mammary tumor. Secondary chondroma of the peritoneum occurring as a metastasis from a tumor of the same nature in the mammary gland has been described by Boutelle. Metastatic venereal granulomata occur occasionally, and the mesen- teric glands are often involved in cases of lympho-sarcoma. Symptoms and Diagnosis. Innocent primary tumors if of sufficient dimensions produce abdominal enlargement. The par- asitic hydatids usually provoke inflammatory secretion which may cause an ascitic appearance. Growths of both innocent and malig- nant types generally give rise to cachexia. The diagnosis of all forms of tumor is aided by palpation. Treatment. Innocent growths are eradicable by opening the peritoneal cavity and removing them by appropriate surgical me- thods. Malignant growths are best left alone. The Abdomen ico BIBLIOGKAPHY. '^J^'^T\ ^'^ ^^^- ^"^'- ^t <1« Zoot- Jan.. 1900 ^ Surgical Diseases and Surgery of the Dog obliteration of the urethral lumen. Contrasted with suppression resulting from prostatic enlargements and calcular obstruction it is complete and sudden in its advent. The animal makes ineflfectual attempts to urinate and has colicky pains. Distension of the organ is discoverable by abdominal palpation. To exclude calcular ob- struction from consideration the catheter or sound should be passed. Palpation with the index finger in the rectum or vagina permits of dififerentiation from prostatic enlargements. Uncertainty as to the condition present should be relieved by explorative celiotomy. Treatment. As soon as the bladder is found to be overtaxed it should be promptly evacuated by puncture. The condition must then be relieved by direct adjustment through the open abdominal cavity, according to the exigencies of the case. NEOPLASMS. Both innocent and malignant growths have been observed in the bladder but their occurrence is extremely rare. Myxoma, myoma, and primary and secondary sarcoma and carcinoma have been recorded. Tumors of the bladder offer but little scope for surgical inter- ference. Symptoms and Diagnosis. The dominant symptom is progres- sive, painful, and frequent dysuria coupled in the case of malignant tumors with cachexia and inappetence. The abdomen may or may not show enlargement according to the size of the growth. Palpa- tion of the abdomen or with the index finger in the vagina or rectum discloses the presence of an uneven growth. In cases of carcinoma, sarcoma^ and myoma, seen respectively by Demeurisse, Bournay, and Lienaux, there was no hematuria, but Schulz observed in a case of primary carcinoma straining at micturition for some time before a drop of urine was passed, the latter flowing in a thin stream and being followed by a few drops of blood. This was particularly noticeable after exercise. Treatment. Celiotomy and extirpation of the growth or par- tial resection of the viscus are indicated. If the terminal portions of the ureters are involved they can be divided and implanted else- where, while if the neck of the organ is diseased the only alternative is extirpation of the growth and anastomosis of the remainder of the organ with the rectum, as practiced experimentally by Frank, The Abdomen 237 Gluck, and Zeller, and others. But it must be borne in mind that a favorable termination to the latter operation could only be hoped for in a young or middle-aged animal free from cachexia. Lienaux attempted the removal of a myoma by blunt dissection, but experi- enced excessive hemorrhage from which the animal succumbed two days later. Surgery of the Bladder For all operations on the bladder the animal should be secured with hopples in the dorsal position. Simple operations, such as catheterization, irrigation and punc- ture are performed without the aid of anesthetics, but all operations involving celiotomy or perineal litholopaxy require general anes- thesia. When the continuity of the wall of the organ is interfered with Znamensky has advised the use of chloroform for the reason that it is the only anesthetic which prevents muscular contractions, the wound remaining its natural size, thus permitting of linear suturing. Chloretone, since invented, produces the desired effect equally as well. The opening in the abdominal wall should be made immediately in front of the pubic border, in the median line, the penis in the male being dislocated for this purpose. (See Celio- tomy.) The bladder is a prominent organ and easily reached. Some authors advise the introduction of a catheter by way of the urethra to facilitate its finding, but this is superfluous. When empty it is easily pulled forward out of the abdominal wound, but when distend- ed this becomes more difficult owing to hindrance offered by the most prominent ligaments — the two lateral and the median unbilical en- closing the obliterated urachus. On raising the organ and examin- ing its superior aspect, two prominent vessels are seen which bi- furcate and with others are distributed over the surface of the organ in an arborescent manner. They become still more prominent when the wall of the organ undergoes hypertrophy, as is commonly seen in the presence of calculi, enlarged prostate, etc. Most of the vessels lie just beneath the serosa and are therefore easily ligated. When the organ is distended they are stretched but when it is con- tracted they become very tortuous. The ureters find insertion im- mediately to the outside of the two prominent vessels just before 238 Surgical Diseases and Surgery of the Dog the bifurcation of the latter. They are embedded in more or less connective tissue and fat and must be carefully sought for when any extended operation is undertaken. The ureter crosses the vas deferens on either side, and the latter must not be mistaken for the former, an error which has befallen some experimenters. PASSAGE OF THE CATHETER AND SOUND. Catheters made of cotton web or soft rubber, preferably the former material, arc best adapted for use on the male. Their length should be from fifteen to eighteen inches, and sizes three to twelve No. 48. Female Catheter. '(metric scale) meet all requirements. A wire stylet facilitates pas- sage of the instrument, but it must be used with extreme caution as it is very easily thrust through the wall of the instrument. Bougies for treatment of stricture are used in somewhat larger sizes. For the female the catheter should be of the same material as for the male, or, better still, of metal in the same sizes. These instruments should always be rendered sterile and be well lubricated before being used. PASSAGE OF THE CATHETER IN THE MALE. Secure the animal in the dorsal position and stand facing its left side. Expose the penis by retracting the prepuce with the left hand. Holding the catheter in the right hand insert it within the urethral orifice and pass it gently along the canal. Some slight impediment is generally met with at the level of the posterior ex- tremity of the penial bone owing to a decrease in the caliber of the urethra at that point, but it is easily overcome by a little increased pressure. An obstruction at this point indicates a pathologic con- dition. As soon as the ischial arch is reached, the wire stylet is The Abdomen 239 gradually withdrawn to permit the instrument to pass the perineal curve. The bougie and metallic sound are passed in a similar manner. PASSAGE OF THE CATHETER IN THE FEMALE. Secure the animal in the ventral position and dilate the vagina with a specu- lum. Introduce the cath- eter into the vesti- bule, direct it within the urethral orifice, and pass it forward till it enters the bladder. IRRIGATION. No. 49. Vaginal Speculnm. This operation is productive of highly satisfactory results in inflammatory conditions of the bladder, the object being to bring disinfectant and other medicinal agents in direct contact with the diseased tissue. It is also resorted to as an adjunct to urethrotomy when the latter operation is performed for the removal of calculi, in order to produce immediate evacuation of any calculi which may still remain in the bladder. It is carried out by the siphonage sys- tem. The animal being secured in the dorsal position, a catheter is introduced within the bladder in the ordinary manner. The stylet being withdrawn, the urine is permitted to escape. Connection is then made with a small rubber tube and funnel and the latter are elevated. The solution is poured in, and when the organ is well distended is allowed to run out again by depressing the tube to a lower level. PUNCTURE. This operation is indicated whenever urine is prevented from escaping in the natural manner and there is risk of rupture of the bladder from its accumulation. The operation is a minor one and entirely devoid of any ill after-effects, owing to the remarkable capacity of the organ to contract under the stimulus of an instru- 240 Surgical Diseases and Surgery of the Dog ment however fine. Wounds of small size are thus promptly sealed. Vincent punctured the bladder of a dog with twelve needles of different caliber in an experimental way. There was no penetra- tion of urine and no inflammatory reaction on the peritoneal side. Znamensky had similar results. Rouville carried these investigations a point farther and discovered that if the organ is distended by in- jection, immediately after puncture, the fluid will escape at the ori- fice of puncture in a jet and thus gain entrance into the peritoneal cavity. On the other hand slow accumulation of urine after the operation was not followed by filtration. Rouville was of the opinion that in cases of unavoidable distension which necessitate repeated puncture, this should be done at intervals sufficiently short to prevent great accumulation. The best spot at which to make the puncture is immediately in front of the pubis in the median line. To reach the median line in the male, the penis can be pulled over to one side. A very fine trocar and canula, or preferably an aspi- rator should be used for the purpose. Puncture may be repeated as often as is considered necessary. CYSTORRAPHY. All surgeons who have extensively practiced suturing of vis- ceral organs advise the use of the ordinary milliner's needle. The surgical needle is very apt to wound vessels and induce local hemorrhage. Znamensky experienced this trouble in his bladder- resection experiments, the blood escaping into the interior of the organ and forming a clot which prevented the free outflow of the urine. Maksimow, Julliard, and Vincent had good results from the experimental use of carbolized catgut, Nos. o and i, as a suturing material, but occasionally the knots became loosened and it was too quickly absorbed. Metallic suturing was always effective but some difficulty was experienced in handling it. Vincent never had any bad results from the employment of silk and considered it the best material to use, an opinion in which I fully concur. It finally be- comes encapsulated by an organized exudate. Maksimow tried suturing throughout all the coats of the wall and the animals succumbed. The mucosa tended to interpose itself between the ap- proximated edges of the wound and hindered the reparative process, the gut being absorbed before reunion was established, and there was consequently extravasation of urine. Moreover, suturing mate- The Abdomen 241 rial which penetrated, as is the rule with all foreign bodies, sooner or later became the seat of deposit of urinary salts. Accordingly, sutures must only be made to take up serous and muscular coats. In other words, the proper method is that of sero-musculosa — sero- musculosa, with inversions of the margin of the wound. This method utilizes the well-known plastic activity of peritoneal surfaces, which exceeds by far that of primary union of wounded muscular tissue. It is important that sutures be applied not too far apart. The extent to which the bladder will contract under the stimulus of section is quite remarkable, being fully one-half the former capac- ity, and sutures placed apparently at sufficient distance from each other while the viscus is in this condition will be altogether too far apart when it is distended with urine. Sutures placed at a distance of 2 mm. from each other will be at 3 mm. after distension. A single row of sutures suffices in simple cystotomy or after resection of small portions of the wall, although this may be reinforced with a second one at the discretion of the operator. Znamensky found a double row imperative in cases where he resected the greater por- tion of the organ. Vincent advises that the operation be supple- mented by urethral injections of some colored fluid, such as milk, with sufficient force to distend the organ. This affords means for detection of permeability of the sutured surface, in which case a second row of sutures must be inserted. After suturing, the catheter should be used at least twice daily until normal micturition is established, not on account of the opera- tion interfering with the contractility of the organ, but because blood-clots may clog the urethra. After operations on the bladder the urine discharged for the first day or two is liable to be mixed with more or less blood. In simple operations the animal usually recovers its normal spirits within two days. PREPUBIC LITHOTOMY. CYSTOTOMY. The abdominal cavity being opened and the bladder drawn for- ward and surrounded with packs, an incision is made where vas- cularity is seen to be least. In the presence of calculi the organ is usually much hypertrophied and its vascularity increased ; hence persistent bleeding is prone to occur at the site of incision. All bleeding points should be ligated or twisted though they tend to stop of their own accord through the subsequent contraction of 17 242 Surgical Diseases and Surgery of the Dog the organ. The incision is made of sufficient length to effect de- livery of the largest body present, and the edges of the wound caught with hemostatic forceps. It is a good plan to apply the sutures without, of course, tying them, before making the incision, as it insures more accurate alignment being made than is afterwards possible, owing to the tendency of the organ to contract under the stimulus of the knife. Encysted calculi, i. e., calculi embedded in the mucosa, are removed by scraping with the scoop. All calculi being removed, the interior of the organ is flushed with a warm antiseptic or saline solution and the wall closed as described under cystorraphy. UTHOLAPAXY. The technic of this operation in the male is as follows: Administer a general anesthetic and secure the animal in the dorsal position with the hind legs drawn forward. Pass the catheter to the bladder, draw off the urine and inject a quantity of antiseptic or saline solution sufficient to distend the viscus. Open the urethra as in urethrolithotomy, making the incision in the perineum at the level of the ischial arch. Withdraw the catheter and introduce a lithotrite of suitable size through the wound and cautiously pass it through the prostatic urethra into the interior of the bladder. Turn the shaft of the instrument so that the blades will point towards the roof of the organ which is now undermost, and wait a few moments until currents generated by the passage of the instrument have sub- sided. Draw back the male blade and manipulate it until the stone is caught. It may be necessary to turn the blades to either side. Then lock the instrument and crush the body by screwing. Sudden cessation of resistance indicates that either the stone has slipped away from the grasp or it has been pulverized. Repeat the crushing process until no stones of any size remain and then proceed to evacu- ate. The latter part of the operation is accomplished with a bulb in- strument, know as the evacuator, by which a suction effect is pro- duced. In the absence of the instrument the next best means to em- ploy is irrigation with the catheter. Leave the urethral wound open to heal by cicatrization as in urethrolithotomy. In the female the operation is more practicable provided the stones are of very moderate size. It is conducted as follows: Anesthetise and secure the animal in either position. Dilate the vagina with a speculum. The Abdomen 243 and then the urethra, using for the latter purpose a conical blow-pipe such as is provided in dissecting sets, or enlarge by incision as in urethrolithotomy. Then introduce a lithotrite and extract or, if necessary, reduce the stone or stones to fragments and evacuate precisely as in the male. RESECTION. Extirpation of the bladder, whether partial or complete, is borne well by the dog. Many experiments of this nature have term- inated successfully. Tizzoni and Poggi who removed the greater part of the original organ and connected the ureters with the neck, found that the latter had undergone transformation into an entirely new bladder-like viscus at the end of three years. Gluck and Zeller extirpated the entire organ together with the prostate gland and implanted the ureters in the skin in four dogs without losing an animal. Fisher removed elliptical portions of the organ from eight different dogs. Of these five recovered and one of the deaths was apparently due to purulent accumulation in the abdominal wound. In four of the cases no antiseptic precautions were observed. In another series of experiments, carried out by Vincent, recovery was complete in from three to four weeks, healing taking place by pri- mary intention. Other successful experiments were made by Bren- ner, Thomson, and Znamensky. The latter authority found that one-third and even two-thirds of the wall could be resected and the animal make a good recovery. When, however, more than two- thirds were removed there was not sufficient of the detrusor muscle remaining to accomplish ejection of the urine. The organ had lost its power of contractility, the urine stagnated, dammed back, and a hydronephrosis resulted. Such a termination could be avoided in the human being by employment of a permanent catheter, an expe- dient which would hardly be practicable in the dog. It would be better to divert the flow of urine into some other channel, the rectum, for instance. In partial resection due care must be observed that the ureters be not destroyed. If it be found necessary to remove the part of the bladder at their point of entry, they must be implanted elsewhere. Vincent found scissors best for cutting all the coats at once. He also found that the mucosa tended to protrude through the edges of the muscular wound, owing to contraction of the latter. If this oc- 244 Surgical Diseases and Surgery of the Dog curs, it must be trimmed, but Znamensky cautions against unneces- sary cutting of it, because there is always more or less hemorrhage therefrom, which finding its way into the interior of the viscus re- tards healing, as pointed out under Cystorraphy. All vessels that have been severed during the operation must be securely ligated. The principal vessels are easily secured as they run under the serosa, prominently in view. Two rows of sero-musculosa — sero-musculosa sutures are advisable. VESICO-REOTAL ANASTOMOSIS. CYSTOENTEROSTOMY. It has been demonstrated by Frank that it is possible to under- take this operation with favorable result. This does not seem very remarkable when it is remembered that in early fetal life the renal secretions empty into the primitive cloaca, that this dispositon is normal throughout the life of birds, and that it may occur as a con- genital malformation in the dog (Varaldi). For practical purposes, however, the operation has little application, though, as has been pointed out elsewhere, its employment as a remedial measure for prostatic enlargements in stud dogs in which it is desired to con- serve the testes, is deserving of trial. Frank found that the bladder remained free from feces, that some cases were not followed by ascending infection, and that the presence of urine with feces in the rectum 'did not produce pathologic irritation of the latter. The feces were always passed in liquid form, being softened by the urine. To facilitate the operation Frank used the decalcified bone- coupler devised by himself for anastomosis of all hollow viscera, but the Murphy button would answer the purpose equally as well. The bladder and rectum are emptied of their contents by gentle squeezing and drawn forward into position. Two or three inter- rupted Lembert sutures are applied about half an inch below the lower ends of the incisions determined on in the bladder and rectum, care being exercised in selecting them that the button or coupler, when it is inserted, will not encroach on the ureteral openings in the bladder. A longitudinal incision is then made in the bladder for the coupler and the latter inserted and fixed in position with the puckering string. The rectum is treated in like manner and the two portions of the coupler united. Finally interrupted Lembert sutures are placed around the borders to make the union more secure. The Abdomen 245 BIBLIOGRAPHY. Bonmay— Jonrn. de M6d. Vet6r. 1892, p. 56T, Brenner — Langenbeck's archlv. f. klin. Chir. 35. Camardl— Glorn. di Anat. e Patol. degli animali. 1890, p. 327. Demeurisse — Rec. de UM. V6t6r. 1892, p. 408. Fisher — Langenbeck's Archlv. f. klin. Chlr. 27, p. 736. Frank — Journ. of Amer. Med. Assn. 1900, p. 1174. Gluck & Zeller — Langenbeck's ArchlT^ f. klin. Chir. 26, p. 016. Harrison— Amer. Veter. Review. 1881, p. 562. Hobday — Journ. of Comp. Path, and Therap. 1899. Johne — Ber. ue. d. Veterlnaerw. Im Koenlgr. Sachsen. 1877-80, p. 35. Juillard— Langenbeck's Archlv. t. kiln. Chlr. 31, p. 148. Kltt — Lehrb. d. Path. Anat. Dlagnos. 2. Lienaux— Ann. de Mgd. Vet6r. 1894, p. 662. Makslmow — Anveendungsversuche von Darmsaitenfaeden bei Blasennaht nach Bpicystotomle. St. Petersburg. 1876, p. 57. Malzew— Arch. Vetfir. de Petersburg. 1895, p. 238. Petit & Almy — Bull, de la Soc. Anat. de Paris. 1900. Rodloff— Gurlt & Hertwlg. 18, p. 212. Bouvllle— Comptes rendus de la Soc. de Biol. 1899, p. 646. Schuls— Monatsh. f. prakt. Thlerhellk. 1892-93, p. 506. Siedamgrotzky — Ber. ue. d. Veterlnaerw. Im Koenlgr. Sachsen. 1871, p. 73. 1897, p. 43. SImonds — Proc. of Vet. Assn. 1840-41, p. 57. Sutton— 111. Med. News. 1889. p. 11. Thompson — Langenbeck's Archlv. f. kiln. Chlr. 41, p. 410. Tlizonl & Poggl — Blcostruzlone della vesica orinarla Bologna. 1891. Varaldl- Mod. Zooj. 1893, p. 321. Vincent — Rev. de Chlr. 1881, p. 556. \^ehr — Langenbeck's Archlv. f. klin. Chlr. 30, p. 226. Wesbltt — Amer. Vet. Review. 1894. Znamensky — Langenbeck's Archlv. t. klin. Chlr. 31, p. 148. The Urethra EXAMINATION. The urethra is examined by palpation over its course and by passage of the sound or catheter. CONGENITAL MALFORMATIONS. Congenital occlusion of the urethral canal is occasionally met with both in males and females. Usually an orifice exists at some part of the tract higher up and the animal suffers no inconvenience. The term Epispadias is applied to the condition w^here the urethral orifice is situated at the root of the penis, and the term Hypospadias when it occupies a more distal and ventral position on the organ. Both Kitt and Raynard mention having observed these abnormali- ties. Sometimes the primitive cloaca persists. Veraldi recorded a case in which the urethra, one inch from the neck of the bladder, formed a junction with the rectum an inch and a half above the anus. The animal had never urinated by the natural channel. Symptoms and Diagnosis. An animal born with occluded ure- thral canal may go several days and even weeks before exhibiting 246 Surgical Diseases and Surgery of the Dog any peculiar symptoms, urinary secretion simply slackening up in response to the damming up that occurs, or if the obstructing mem- brane be thin enough the urine may ooze through by pressure. After a while the animal manifests uneasiness and the abdomen is observed to be enlarged. Upon manipulation the distended bladder can be made out. Treatment. Simple puncture of the membrane suffices, the subsequent flow of urine serving to keep the channel open. TRAUMATIC LESIONS. Wounds. Traumatic exposure of the urethral lumen sometimes occurs as a complication of a wound of the neighboring tissues. Mosse treated one inflicted by a knife in the hands of a miscreant. Symptoms and Diagnosis. A break in the continuity of the canal is recognized by a flow of urine through the wound. Treatment. In extensive wounds the urethra should be su- tured with fine catgut and the neighboring parts cleansed and freely drained. Minor wounds may be allowed to heal by granulation. Healing is usually uncomplicated and quick to follow. STRICTURE. Cicatricial contraction may follow wounds of the wall caused by lodgment of calculi or surgical interference to remedy this con- dition. Siedamgrotzky attributed a case of stricture to extreme torsion during coitus. A rather rare condition is the formation of small exostoses on the penial bone, which, by encroaching on the urethra, produce the effect of stricture. Symptoms and Diagnosis. Difficult or suspended urination accompanied by pain call for examination by passage of the sound, when a differential diagnosis between this and obstruction by cal- culi or prostatic enlargement can be arrived at. In using the sound the normal decrease in caliber at the level of the posterior extremity of the penial bone must be taken into account. Treatment. This condition can be considerably relieved by passing a sound or catheter every two or three days for a period of some weeks and allowing the instrument to remain within the canal for a few minutes. The Abdomen 247 Exostoses of the penial bone are removed by exposing the bone by cautious dissection without injuring the urethra, and removing them with suitable forceps. OBSTRUCTION. This usually takes place from the lodgment of calculi, but may also be occasioned by the parasitic giant Eustrongyle. Calculi. (See also Urolithiasis.) It will be remembered that in the male the Urethra is narrow in its prostatic portion, be- comes widest in its membranous portion, and again narrow as it passes into the cavernous portion, while it loses all power of ex- pansibility as it traverses the gutter of the penial bone. Sediment and the smaller stones very frequently pass into the urethra and lodge at one of the narrower points and form an obstruction. This takes place most frequently at the proximal extremity of the penial bone, and also occasionally just anterior to the prostatic portion. These stones may be present as an impacted mass of numerous small calculi, cemented together by mucus, and extending some dis- tance up the lumen of the canal. They often become embedded in the wall. Siedamgrotzky described a case of a three months' old animal which died suddenly suffering from inflammatory edema of the foreskin. He found a cylindrical calculus in the curved portion of the urethra, the latter having been perforated by it, thereby causing infiltration of urine. Tuffier found calculi in the prostatic portion of the urethra. Exostoses of the penial bone produce the effect of urethral cal- culi and may be mistaken for the latter. In the female also calculi sometimes lodge in the urethra, but this seldom takes place owing to the larger caliber, shortness, and dilatability of the canal. Lodgment of calculi in the urethra causes damming back of the urine in the bladder, which extends to both kidneys and results in bilateral hydronephrosis and rapid dissolution. It is rare that the bladder ruptures, owing to the compensatory hypertrophy which it undergoes. Petit and Almy have recorded an instance. The ex- tremity of the penis rhay also become gangrenous. Symptoms and Diagnosis. The symptoms are very marked. The animal is exceedingly uneasy, lowers its head, looks round at the flanks, arches its back, assumes a straddling gait or posture like 248 Surgical Diseases and Surgery of the Dog that of a female in the act of micturition, and makes frequent but generally ineffectual attempts to urinate, though it is quite common for a few drops of urine to be passed. Palpation reveals the ure- thra above the penial bone distended. The bladder is also some- what distended though not extremely so, but it is hard and painful. On passing a catheter or probe, its passage is arrested at the seat of lodgment of the body, and a sensation of something hard is con- veyed to the touch. Unless relief is given the animal shows signs of uremic poisoning in a very few hours. It becomes indifferent and stupid, lies on its side and moans if disturbed. Finally con- vulsions take place prior to death. Treatment. An animal received in this condition may be in considerable danger either through rupture from over-distension of the bladder or from hydronephrosis. Should the former lesion be deemed imminent, no time must be lost in giving relief by puncture of the bladder. The obstruction is next removed by the operation of urethrolithotomy. It must not be forgotten that the "urolithic habit" may subject the animal to the necessity of undergoing supplementary and re- peated operations in cases of impaction of the urethra. Siedam- grotzky mentions relieving an animal by operative measures, which, however, died later from the second impaction at the neck of the bladder. Pecus treated a case, where, after operating on the first occasion, a second impaction took place fifteen days later. After that he allowed the urine to permanently find escape by fistulous tract through the surgical wound. The successful outcome of this expedient suggests the advisability of its adoption in all such re- curring cases. Furthermore, the "urolithic habit" may be the cause of calculous formation in the higher portions of the tract at no dis- tant date, so that a guarded prognosis is always in order. Parasitic Obstruction. The giant Eustrongyle in its passage from the kidney has been known to enter the urethra. Here its further progress is usually arrested by the penial bone, whereupon it perforates the wall and lodges in the surrounding connective tissue producing rapid formation of a swelling the size of a fist in the perineal region immediately posterior to the testes. Leblanc saw three cases of this nature. In one instance observed by Lacoste the worm was expelled by the urethral tract, the host suffering acute pain. The Abdomen 249 URETHROTOMY. URETEROLITHOTOMY. For this operation on the Male the animal should be secured in the dorsal position with the hind legs brought forward, after having been previously placed under the influence of a narcotic. Local cocaine anesthesia should also be established. As a guide to the sight of incision, expose the penis and pass the catheter in the usual manner until its further progress is arrested. The point of the catheter is easily distinguished beneath the tissues and it is im- mediately over this spot that the incision is made in the median line. The median line of the perineum is not crossed by vessels of any size and like the linea alba is comparatively bloodless. Make the incision from one-half to one inch in length, and carry it through the skin, subcutaneous fascia, and urethral muscles to the lumen of the canal. The latter being exposed, remove the impaction with probe, blunt forceps or curette. It is sometimes necessary to crush before its removal can be effected. This being successfully accom- plished, it must not be forgotten that a large number of calculi may still remain on the proximal side of the obstruction. For this reason the extraction of the impaction should always be supplemented by irrigation of the bladder with a copious supply of warm sterilized water injected with the aid of a catheter through the wound. It is best to leave the wound open. Though the urine finds vent for a few days at the artificial opening thus established and there is always a slight risk of its infiltration into the neighboring tissues, in other respects it is an advantage, for the reason that additional calculi may be passed from the kidney after the operation and are thus more certain to escape, or may be dislodged should they be- come fixed at the upper extremity of the wound as is sometimes the case. The wound usually becomes entirely sealed up by granulation in from eight to fifteen days and the urine is again voided by the natural channel. If suturing is employed cicatrization may be com- plete as early as four days. In the Female. The animal may be sucured in either position and anesthetized. Dilate the vagina with a speculum and first at- tempt to extract the stone with forceps. Sometimes manipulation with the finger in the vagina is sufficient to efifect dislodgment. Failing in this, it becomes necessary to enlarge the urethra by in- cision. The walls of both urethra and vagina are intimately con- nected, which allows of the former being freely opened up. Intro- 250 Surgical Diseases and Surgery of the Dog duce a grooved director within the urethra until it comes upon the stone, and then slit up the wall with a probe-pointed bistoury, and employ forceps to complete the removal. BIBLIOGRAPHY. Kltt — Lehrb. d. Path. Anat. Dlagnost. 1. Lacoste — Mem. de la Soc. V6t6r. du Calvados et de la Manche. 1842-43, p. 228. Leblanc— Bull, de I'Acad. de UM. 1850, p. 640. Mo6B§ — Journ. de MM. Veter. et de Zootech. 1898. Pecus — Journ. de MSd. V6t6r. et de Zootech. 1896. Petit & Almy— Bull, de la Soc. Anat. de Paris. 1900. Raynard — Traltfi Complet de la Partur. des Anlm. Domest. Sledamgrotzky — Ber. ue. d. Veterlnaerw. im Koenlgr. Sachsen. 1872, p. 72. Tuffier — Arch, de Phys, Norm, et Path. 1893. Varaldl— Mod. ZooJ. 1893, p. 321. CHAPTER Vm The Abdomen — Continued THE REPRODUCTIVE ORGANS OF THE MALE The Penis and Prepuce EXAMINATION. To expose the penis, hopple the animal in the dorsal position, hold the prepuce lightly at its free extremity and retract it with the fingers of one hand, grasp the penis through the prepuce at the level of the posterior extremity of the penial bone with the fingers of the other hand, and push it forward till it is prominently free of the prepuce. Tie a piece of tape round the glans, and therewith draw the organ gradually out till it is fully exposed. CONGENITAL MALFORMATIONS. Abnormalities of the penis are rarely met with. Taylor has recorded a case of arrested development in which the organ, instead of protruding in the ordinary manner from the prepuce made its exit through an oval orifice in the skin in the raphe in front of the scrotum. Congenital phimosis is sometimes seen. It is described elsewhere. Hermaphroditism is also occasionally witnessed. TRAUMATIC LESIONS. Injuries to the penis most often result from the bites of other dogs, but there is another class of injuries occasioned by the male- volence of human beings which at times comes to the notice of the practitioner. I refer to strangulation resulting from the appli- cation of constricting material, and also to mutilation, by individ- uals of brutal instinct while the animal is in the act of copulation. Vatel witnessed a case of strangulation which resulted from the presence of a ligature which probably had been applied to the parts under these conditions. Bang found a ribbon twisted round the 252 Surgical Diseases and Surgery of the Dog organ in another case. The following instance of mutilation came to the notice of Moussu : A male being found accoupled with a fe- male, the owner of the latter barbarously severed the connection with a knife. The wounded animal was soon in a state of collapse, but the hemorrhage being successfully arrested its strength was sus- tained and it lived to an old age. The attendant practitioner being unable to use a sound to prevent occlusion of the urethra by cica- trization had to resort to urethrotomy. Moussu dissected the parts after death and found the penis about an inch in length, regularly rounded and presenting no trace of urethral orifice, though the lumen of the canal was still patent almost to the extremity of what remained of the organ. The opening made to give exit to the urine had persisted as a small fistula, the orifice of which was covered by the hair of the region. Perforating wounds of the prepuce occasionally result from bites. When they attain sufficient dimensions, the penis is apt to slip through and out. Symptoms and Diagnosis. Constricting agents produce great tumefaction and symptoms similar to those of paraphimosis. Treatment. The indications are to divide the constricting body with scissors or scalpel. The operation is rendered difficult by the local swelling. Subsequently the parts should be treated as for paraphimosis. In cases of criminal amputation, the hem- orrhage must be arrested as speedily as possible by ligating the divided vessels, if necessary after opening up the prepuce, and the urethra treated as in legitimate amputation. If cicatrical sten- osis results, a permanent opening must be established in the urethra beneath the ischial arch to give exit to the urine. Wounds from bites are treated in the ordinary manner. In one instance of stubborn healing of a preputial wound, Hobday reported success after resorting to the "Cherry" process of making longitudinal incision on either side of, and parallel to, the original wound in order to lessen tension on the same. BALANO-POSTHITIS. BALANORRHEA. These terms are applied to the familiar catarrhal inflamma- tion of the mucosa of the prepuce and free portion of the penis. The urethra is rarely involved. In many cases this disease or- iginates as a primary local infection. At other times it develops The Abdomen 253 secondary to venous stasis, paraphimosis and phimosis, or it may- be traced to an initial lesion produced by traumatism or the pre- sence of neoplasms or a foreign body. It is often seen during the course of distemper or eczema, Siedamgrotzky saw two cases of a fatal infectious disease which had its inception as a virulent preputial catarrh with edema of the scrotum, prepuce, inguinal and other external lymphatic glands, together with leucocytosis. Symptoms and Diagnosis. The prepuce is slightly injected and swollen, and emits a yellowish, greenish purulent liquid, which is generally licked away by the animal. The hairs surrounding the preputial orifice are often agglutinated. As a rule, the neigh- boring lymphatics are slightly enlarged, and in rare instances may suppurate. Treatment. This consists of injection of astringent solutions, such as sulphate of zinc (5:1000), nitrate of silver (1:100), citrate of silver (2:100), two or three times daily. Neoplasms, if pre- sent, must be ablated. PHIMOSIS. This is a condition of morbid contraction of the free extremity of the prepuce in front of the glans penis. It is not uncommonly of congenital origin, when the orifice is often exceedingly minute. It may also occur as a result of traumatism or of swelling induced by local inflammatory disturbances. Symptoms and Diagnosis. There is more or less obstruction to the flow of urine, and in extreme cases the latter is passed by drops. The animal is also unable to copulate. Treatment. Under local anesthesia and with a bistoury and grooved director, make a longitudinal incision in the middle of the inferior aspect of the prepuce of sufficient length to permit of free protrusion of the penis. A single incision is, however, usually in- sufficient, for the reason that the resultant cicatrization leaves the parts in the same or worse condition than before. Therefore, the preputial ring should be circumcised and the mucosa stitched to the outer skin. The stitches may be removed at the end of a week. Care must be exercised to remove as little of the free ex- tremity of the prepuce as possible or the penis will afterwards protrude. Supplementary treatment consists of antiseptic irriga- tion of the parts. 254 Surgical Diseases and Surgery of the Dog PARAPHIMOSIS. In this condition the prepuce, after becoming retracted behind the glans penis, prevents the latter from returning to its normal position. It is most commonly observed after coitus. During erection of the penis the hairs surrounding the preputial orifice sometimes adhere to the organ, and as retraction of the latter takes place the free border of the prepuce becomes inverted, thereby forming a constriction. The glans then commences to swell, and if the condition is not soon relieved it may terminate in gangrene. Symptoms and Diagnosis. The animal walks with a straddling gait, constantly licking the penis, and moves the hind quarters as if in the act of copulation. Examination of the parts establishes the diagnosis. Treatment. With the. animal in the dorsal position, first en- deavor to replace the glans by oiling and massaging, and at the same time drawing the prepuce forward. Withdraw and cut oflf any displaced hairs. Failing in this apply ice or direct a stream of hot water on the organ and scarify it. If this does not succeed, incise the prepuce as directed for phimosis. For a few succeeding days allay any tendency to inflammation of the parts by injections of warm antispetic or astringent solutions, as directed for balan- itis. If gangrene is present amputation must be resorted to. Haubner found it necessary to perform the latter operation. NEOPLASMS. Venereal Granulomata. A specific infective variety of neo- plasm affects the mucosa of the penis and prepuce. The disease is quite common on the European Continent and in Great Britain where one of the kennel clubs has found it necessary to issue a circular of warning against its perpetuation by breeding infected animals. In this country it does not appear to have gained any foothold. In twelve years I have only seen two cases, and both of these were in male dogs which had recently been imported from England. The area of invasion of the disease is not always limited to the mucosa, for in some cases it infiltrates the adjacent tissues. It may also exhibit metastatic tendencies to the inguinal glands. It is an inoculable disorder, and is probably always communicated X(i. TiU. Venereal Uramilouiata. The Abdomen 255 from an infected animal by the act of copulation. It may develop on any part of the organ, but most commonly occurs at the base and on the corresponding portion of the preputial mucosa. In some cases it is confined to the glans, while in others it covers the entire organ. Symptoms and Diagnosis. Usually, attention is first drawn to the condition by the emission of sanguineous non-purulent liquid from the prepuce, and by the presence of circumscribed or diffuse tumefaction of the latter. Palpation gives a subpreputial uneven- ness. On exposure of the penis the growths are easily discern- ible. In appearance, they vary according to the stage of their development. At the period of discharge they appear as greyish- reddish or pinkish vegetations, which are soft and friable, and bleed easily on being touched, and are generally sessile, but may be pedunculate. In the very early stages, i. e., a few days after the infection has been sustained, they have their inception as minute vesiculate solid pimples. The rate of growth is not rapid, and sometimes several weeks elapse before there is much increase in size. Nevertheless, the disease is progressive and the erstwhile papules gradually assume the vegetative character. A growth of several months' standing exists as a firm lobulated mass of purplish color, and is generally accompanied with cachexia and emaciation. Treatment. These growths, when of recent origin, may be easily removed and without liability to recurrence, but when long- standing and a considerable area of mucosa is involved they are eradicable only with difficulty. To effect removal of circumscribed, limited growths, expose the penis in the usual manner, anesthetise locally with cocaine and snip them with curved scissors, including with them a portion of the mucosa, to which they are attached. Considerable hemorrhage may occur which may be arrested by drawing the divided mucosa together with a few fine sutures. In some cases it is necessary to slit and afterwards sew up the prepuce in order to more effectually reach the tumors, and repeated opera- tions at intervals of fifteen or twenty days may be required to effect complete ablation. Thermo-cauterization should be tried when re- crudescence takes place. Curettage should not be employed, as it involves risk of recurrence of the growth by fresh inoculation of neighboring healthy mucosa. In extensive invasion of the parts amputation of both penis and prepuce is indicated. 256 Surgical Diseases and Surgery of the Dog Infected animals should not be allowed to mate. Papilloma of the Prepuce. Small growths, with or without a pedicle containing melanotic deposits, the so-called pigmented moles, are occasionally seen about the prepuce of black dogs. Treatment. Simple ablation with scissors serves to eradicate these little blemishes. Sarcoma and Carcinoma of the Prepuce. Malignant neo- plasm is of rare occurrence, and when it does exist is inoperable. Petit and others have recorded instances. AMPUTATION. This operation is indicated when the organ is the seat of malignant neoplasm or becomes gangrenous as a result of para- phimosis or strangulation from other cause. The animal should be anesthetised and hoppled in the dorsal position. The technic is as follows: Draw the organ well out of the prepuce by means of a tape tied round it, and apply a tourniquet above the proposed line of section, which should be posterior to the os penis. Sever the occluded portion of the organ with a scalpel. If section is made through the bone a saw must be employed. Seize and ligate all vessels with silk, expose the urethra and suture it to the free extremity of the trunk with silk. Establish a prominent meatus by incising the inferior wall of the extremity of the urethra for a short distance in order to lessen the tendency towards subsequent cicatrical stenosis. Remove the tourniquet and allow the stump to slip back within the prepuce. For a few succeeding days irrigate the parts with warm antiseptic solutions, and subsequently see that the urethral orifice is maintained, by passage of the catheter if necessary. Healing is usually complete in from ten to twenty days. Should cicatricial stenosis of the urethra follow the best plan is to establish a fistulous opening beneath the ischial arch by which the animal may discharge its urine. BIBLIOGRAPHY. Bang — Stockfleth's Chlrnrgle. Haubner — Ber. ue. d. Veterlnaerw. Im Koenlgr. Sachsen. 180S, p. 49. M0U8SU— Rec de M6d. VH6r. 1887, p. 484. Rldler & Hobday— The Veterinarian. 1905, p. 3S7. Sledamgrotcky — Ber. ue. d. Veterinaerw. Im Koenlgr. Sachsen. 1879, p. 81. 1880, p. 18. Taylor — The Veterinary Record. 1903, Vatel— Bee. de M6d. V6t6r, 1828, p. 590. The Abdomen 257 The Testes and Scrotum CONGENITAL MALFORMATIONS. The condition known as Ciyptorchism is not uncommon. Its recognition by the veterinary practitioner is important from a medico-legal aspect. Sometimes a whole litter of puppies is affec- ted. One or both glands may be involved (monorchism, cryptor- chism) and they are most frequently retained within the abdominal cavity, generally at the level of the internal ring. Less frequently they traverse the inguinal canal and reach the position normally occupied by the scrotum (ectopia), the latter being absolutely want- ing. Normal descent of the testicle occurs somewhat later, and is more liable to deflection on the right side than on the left. In a true cryptorchid the development of the glands is always arrested, the penis may be rudimentary, and sexual proclivity is lacking, though some subjects exhibit a roving tendency. It is well known that a retained testicle may grow to some extent at puberty, yet neither then nor at any subsequent period does it reach its full size and acquire its spermatozoa-producing powers, the tubules re- maining atrophied. While incapable of producing spermatozoa, the retained organ is capable of exerting that influence which the normal testis exerts upon the development and growth of the body. When one organ has fully descended and developed, the animal is capable of procreation, but, on the other hand, when both have failed to reach the scrotum it remains sterile, though it may yet possess enough virility to copulate. Griffiths experimented on several dogs, both young and full- grown, by replacing the testicle and cord in the abdominal cavity, with the following results : ( i ) When replaced in young animals it undergoes little change, growing somewhat, but not so much as the undisturbed organ until the approach of puberty. (2) The testicle of a full-grown animal, when replaced, soon dwindles to two-thirds or one-third its natural size, and after a short time presents precisely the same structure as that which is found in the replaced testicle of the young animal. There is no trace of sper- matogenesis in the degenerated epithelial cells, and no spermatozoa in the interior of the atrophied tubules. Retained testes are prone to tumor formation. Leisering and Sutton have seen tumors of retained testicles in monorchids. In 18 258 Surgical Diseases and Surgery of the Dog Sutton's case the enlarged gland had undergone axial rotation. Cadiot and Almy regard the condition as predisposing to tumor formation. Treatment. When it is considered advisable to remove the glands in a true cryptorchid they are most easily reached by open- ing the abdominal cavity in the vicinity of the inguinal region. They are then sought for with the index finger, and when found drawn outside the cavity, and excised after the cord has been securely Hgated with fine sterile silk. In one instance I ablated the glands in a cryptorchid to cure a mean disposition with successful result. Ectopic testes are removed by cutting down directly over them, the same technic being observed as for castration. TRAUMATIC LESIONS. The testicles occasionally sustain injury from the bites of other dogs, and in countries where the dog is used to hunt the wild boar he is often emasculated by the tusks of the latter animal. Treatment. Hot antiseptic irrigation or sitz-bath is indicated, and if gangrene is threatened the glands must be removed. ORCHITIS. Inflammation of the testicle is of rare occurrence. When it takes place it is usually due to traumatism, such as the bite of an- other dog or the kick of a miscreant, but it may also arise conse- quent upon infection. Symptoms and Diagnosis. The disease is characterized by tumefaction of the gland and its coverings, more or less febrile reaction, and acute pain when pressure is applied. It is to be dis- tinguished from eczematous inflammation of the scrotum. Treatment. Hot water applications are beneficial. This treat- ment may conveniently be applied by causing the animal to take a sitz-bath in any suitable receptacle containing a hot antiseptic solu- tion. NEOPLASMS. Neoplasms of both the testicle and scrotum have been observed a number of times. Some doubt exists among authorities as to No. .-,1. .Malif:iK.nl Xooi'Imsh, of tla' vv^M Testis. The Abdomen ' 259 the identity of the malignant type of growth (See Chapter on Neoplasms). It is usually unilateral. Cadiot has seen tubercul- osis. Enlargement of the gland may also exist as an indurated fibroid condition, in which there is a great increase of connective tissue with atrophy of the parenchyma, and sometimes presence of retention cysts. Symptoms and Diagnosis. The gland presents an indurated, insensitive growth, sometimes five or six times greater than normal, with uneven, knotty surface, and with or without fluctuating cystic areas. The corresponding cord is usually tumefied. Treatment. The only effective treatment is castration, and it should be practiced early, the cord being ligated as far above the thickening as possible. A very stout, double ligature should be used. The operation is contraindicated when metastasis has taken place. When the scrotum is involved, it may also be removed. PARASITIC EMASCULATION. Dogs on this continent are subject to attack by the emasculat- ing bot-fly (Cuterebra emasculator). The first recorded instance of this remarkable example of parasitism came to my notice in Montreal in 1893. Since then Glass states that he has seen it on two different occasions. Professor Fletcher, Dominion Entomolo- gist at Ottawa, informs me that squirrels are commonly affected to the extent of becoming emasculated either by the direct action of the parasite or through their own endeavors to relieve themselves of its presence with their teeth. Fitch also made this observation in 1856, in the environs of Lakeville, N. Y. The fly deposits its eggs by piercing the scrotum. In the instance which I observed a small part of one extremity of the larva projected through an orifice in the scrotum, the larger portion of it being buried and encapsulated by a zone of inflammatory fibrous tissue. It was seized with forceps and extracted without much difficulty. It is probable, that if allowed to remain, the parasite would bring about inflammatory changes in, or complete destruction of, the testicle, in the same manner that it does in the squirrel. ORCHECTOMY. CASTRATION. This operation is primarily of importance as a remedial measure 26o Surgical Diseases and Surgery of the Dog for local pathologic conditions, including prostatic enlargements. It is also sometimes resorted to as a means of improving the temper of vicious animals and to correct roving habits and also onanism. The operation being very painful, the animal should be anesthetised and hoppled in the dorsal position. Of the several methods by which the organs may be removed, viz., clamping with cauterization, torsion, emasculation, excision after ligation, the last-named is the best, because there is less risk of subsequent secondary hemorrhage than with the others. Owing to the dog's habit of licking his wounds bleeding may be started from vessels which have not been ligated. In any case the best results are always obtained by operating under strict asepsis and stilling all venous oozing, when the scrotal wound may be immediately closed with a buried suture, and healing is quick to follow. When blood clots are allowed to accumulate or pockets to form, there generally follows a violent inflammatory reaction and liability to peritonitis by extension. The technic of ligation and excision is as follows : Render instru- ments and suturing material sterile by boiling and thoroughly cleanse the hands and scrotum. Grasp the testicle between thumb and fore- finger of the left hand, thereby stretching the skin over the gland. Expose the latter by one free incision down to the tunica propria. Seize the gland and draw it out of the scrotal sac. The tunica reflexa becomes retracted some distance up the cord anteriorly, but remains adherent to the tail of the epidydimis posteriorly. Apply a stout silk ligature to include both cord and tunica reflexa, and re- move the gland with scissors, cutting the cord on the occluded side close to the ligature. The skin wound should be closed with a subcuticular suture. If the parts do not suppurate healing will follow per primam, but they should be kept under observation for a few succeeding days. If pus forms it may be evacuated in the usual way and granulation allowed to take its course. Cagny has proposed a somewhat novel method. He ties a cord temporarily round the scrotum above the testicles to keep these organs in the bottom of the scrotal sacs. He then makes an incision in the median line, draws both glands out and twists the two testi- cular cords one upon the other after the manner in which two strings are twisted upon each other. A catgut ligature is applied to the twisted cords, they are severed below the point of ligation, the stump is returned to the scrotum, and the integument sutured. The Abdomen 261 BIBLIOGRAPHY. Cagmy— Bev. V6t6r. 1894. Griffiths — Journ. of Anat. and Pbys. 1892-93, p. 200. Hobday — The Veterinary Record. 1899. Leiserlng — Ber. ue. d. Veterlnaerw. Im Koenigr. Sachsen. 1864-70. Sutton — Journ. of Anat. and Phye. 1884. The Postate Gland EXAMINATION. The prostate gland is examined by digital palpation, the index finger, which may be incased in a rubber glove and well-oiled being passed into the rectum. Enlargements are easily discernible in this manner. Pronounced enlargements may be felt by abdominal pal- pation in the pelvic region. PROSTATITIS. Acute inflammation of the prostate gland is uncommon. A subacute or chronic type is more often seen. The disease is caused by microbic invasion, usually by way of the urinary tract, and tends towards abscess formation. A unilateral or symmetrical swelling is formed which may attain the size of a hen's ^gg or the human fist. The pus may escap*by the urethra, or it may break through into the peritoneal cavity or into the rectum, or even discharge by fistulous tract in the perineal region. The swelling, by com- pression, occludes the urethral canal. Symptoms and Diagnosis. The principal symptoms are sus- pension of normal defecation and micturition, coupled with febrile manifestations. The animal makes frequent and often painful at- tempts to urinate. Urine may be voided freely or may pass by drops, or there may be complete suppression of the flow. Con- stipation may be present, the animal refraining from defecating on account of the pain induced by the act. By abdominal palpation the bladder is felt distended. Passage of the catheter calls forth expression of great pain when the instrument reaches the prostatic portion of the urethra. In some cases the compression is so great that the instrument cannot pass. Finally, rectal exploration with the index finger reveals the presence of a painful inflammatory enlarge- ment, which fluctuates when it contains pus. If pressure is applied the matter may be forced out by the urethra. In other cases the 262 Surgical Diseases and Surgery of the Dog matter does not tend to accumulate, but is constantly discharged by way of the urethra. Treatment. This should be directed towards relieving pain by administration of morphine or chloretone. Catheterization must be kept up every ten or twelve hours so long as the flow of urine is obstructed. If the catheter cannot penetrate, puncture of the bladder must be resorted to. Brisk purgatives should also be ad- ministered. A stream of cold water directed over the perineum is useful to allay the inflammation. When pus is present an attempt should be made to cause its evacuation by pressure over the gland through the abdominal wall or with the finger in the rectum. Haub- ner cured a case in this manner. Failing in this, the matter must be removed by the aspirating syringe or a fine trocar and canula introduced through the perineum, the finger in the rectum serving to guide the instrument, or the rectum may be dilated with a speculum and either instrument thrust through its wall into the gland. Prostatic abscesses discharging by way of the perineum are treated by antiseptic irrigation. NEOPLASMS. The growths which affect the prostate are the non-malignant hypertrophic enlargements and malignant carcinoma. Hypertrophy. Hypertrophic enlargement of the prostate is a very common affection among old animals. It may occur also in young animals. The condition is one of abnormal growth of pre-existing gland-tubules but without the power of producing the secretion as in the normal gland. After a variable time atrophy of the tubules and muscle-fibers of the stroma takes place, and in their place fibrous connective tissue develops. Small cysts are formed through small areas of gland-tissue becoming separated by trabeculae of fibrous or fibro-muscular tissue. It will be remembered that the gland is voluminous under normal conditions and sur- rounds the origin of the urethra and the neck of the bladder. Any increase in volume tends, by compression, to occlude the urethral canal so that micturition becomes a matter of difficulty and at times an impossibility. Prostatic enlargements are very prone to pro- lapse into the perineal region to constitute the contents of perineal hernia. Symptoms anl Diagnosis. The symptoms of hypertrophy are The Abdomen 263 very similar to those of prostatitis, but devoid of febrile disturbance. Dysuria is marked, the urine being passed frequently and in small quantities. Each act of urination, particularly if strained, may or may not be immediately followed by hematuria. When hemorrhage takes place it is produced as a consequence of the hypertrophy, the pressure from which, constantly exercised on the prostatic ven- ous plexus causes stasis of the circulation. This plexus being situ- ated superficially is easily ruptured by straining. The bladder be- coming distended, the animal exhibits great distress and later acute pain. As an immediate effect the bladder may rupture, but if the distension is not great enough to result in this lesion, and the con- dition goes unrelieved, more remote effects are apt to follow, the stagnation of urine resulting in cystitis or hydronephrosis. Usu- ally, constipation is also present, and may go on to complete copro- stasis. This symptom is also the result of pressure by the enlarged gland. When the latter is very voluminous it is sometimes possible to feel it in thin subjects by abdominal palpation in the pelvic region, but generally speaking, digital exploration by way of the rectum is necessary to verify the diagnosis. Passage of the catheter is met with obstruction in the pelvic region. As already stated, perin- eal enlargements must always be considered as of possible prostatic origin. Treatment. The animal must first be relieved of retained urine or feces. This is accomplished in the one case by catheterization, or if necessary by aspiration or puncture of the bladder, and in the other case by rectal injections and the use of the rectal scoop. Medication has little effect on hypertrophic enlargements. Mueller recommends injection into the gland by way of the rectum of a solution of iodine composed of potassium iodide 2 parts, tinc- ture of iodine 30 parts, water 60 parts. This preparation is in- jected at intervals of eight to fourteen days by means of a hypo- dermic syringe with a fine, long needle attached. Castration has permanent remedial effect. This has been proven both experiment- ally and clinically, first and most fully by White in America, and by Griffiths almost simultaneously in England. Helferich cites Guyon, Legueu, Pravone, Prezwalski, and Sackur to the effect that this operation induces atrophy of the gland. It is probable that changes in the vascularity of the gland play some part in its re- duction after castration, as the process of atrophy which takes place 264 Surgical Diseases and Surgery of the Dog is similar to that which occurs in the uterus subsequent to oophorec- tomy. The operation should comprehend both testes to ensure atrophy of both lobes, since when unilateral castration is practised, only the lobe on the corresponding side is affected. The benefit derived from the operation is apparent within a few days. That the growth of the prostate is dependent upon the growth of the testes is evident from the fact that it is not developed until the time of puberty. It is a purely sexual gland, having noth- ing to do with micturition, its function being to add certain con- stituents to the seminal fluid at the time of its discharge. Griffiths found that both the prostate and Cowperian glands remained small, lost their glandular character, and became transformed into masses of fibrous connective tissue, when the testes were removed before the age of puberty (about ten or twelve months in the dog), and that when the organs were removed after full development they underwent a retrogressive metamorphosis to the extent of the glan- dular epithelium becoming converted into the lower and function- less type, and the stroma losing muscular tissue. Kirby undertook castration experiments on dogs with the ob- ject of discovering whether this operation could be of use as a remedy for enlarged prostate in man. He found the average weight of the prostate of thirty-five healthy dogs of certain size to be 17.347 grams. When the gland was removed from eleven similar animals thirty to sixty days after castration, it weighed only one- fourth the original weight. In valuable stud animals, in which it is desired to leave the testes intact, the alternative operation is Cysto-enterostomy, but it entails considerable risk. Carcinoma. Malignant adeno-carcinoma has been occasion- ally observed, but it is not common. It occurs as a tuberous en- largement, with a tendency towards retrogressive metamorphosis and metastasis, particularly to the testicle. Symptoms and Diagnosis. The symptoms are similar to those of other forms of enlargement as regards the interference with normal micturition and defecation. It may be differentiated by the uneven, tuberous growth and the accompanying cachexia. Treatment. There is no practicable treatment for malignant neoplasm, excepting its extirpation and anastomosis of the stump of the bladder with the rectum. The Abdomen 265 BIBLIOGBAPHY. Glnck & Zeller — Langenbeck's Archiv. f. kiln. Chlrur. 26, p. 916. Griffiths— Journ. of Anat. and Phys. 1889, p. 34. 1892-93, p. 209. Haubner — Ber. ue. d. Veterinaerw. Im Koenlgr. Sacbsen. 1863, p. 49. Helferlch — Langenbeck's Arclilv. f. klin. Chlrur. 1897, p. 646. Kirby — The Veterinary Magazine. 1894. Mueller — Die Krankbelten des Hundes. THE REPRODUCTIVE ORGANS OF THE FEMALE The Ovaries EXAMINATION. The ovaries are examined for diagnosis of pathologic conditions by abdominal palpation or direct inspection. By palpation with the fingers of both hands on either side of the abdominal wall, the animal being in the standing position, it is possible, in thin subjects, to recognize the presence of cystic neoplasms. In doubtful cases explorative celiotomy 'should be resorted to. CONGENITAL MALFORMATIONS. The condition known as Dermoid Cyst, in which sequestered portions of the epiblast occur, has been observed by Esser. OOPHORITIS. Inflammatory diseases of the ovary are almost unknown, though the not uncommon cystic enlargements of this organ are looked upon by some as having their origin in thickening of the follicular wall caused by chronic inflammation. The organ is also occasion- ally the seat of congestive changes. A remarkable instance of purulent oophoritis was witnessed by Martin. The disease in this case was attributed to a piece of rye chaff which was found lodged in the ovary, and which had evidently worked its way thither from the vagina, where it was supposed to have been deposited in an injec- tion, as the entire tract it had traversed showed evidence of in- flammatory changes. Symptoms and Diagnosis. Congestion of the ovary is said to be productive of epileptic seizures. Purulent disease produces symptoms of toxemia. In both conditions there is extreme tender- ness to pressure over the seat of the organs. Treatment. This consists in the ablation of the glands by celio- oophorectomy. 266 Surgical Diseases and Surgery of the Dog NEOPLASMS. Practically the only growths we have to deal with in the ovary are the cystic formations. Sutton has recorded an instance of adenoma, where the tumor weighed fifteen pounds, and the occur- rence of dermoid cysts has also been observed. Cysts sometimes grow to a great size. They represent accumulations of unruptured ripe Graafian follicles, and may be unilocular or multilocular. None of these growths has any pronounced ill-effect on the animal. Symptoms and Diagnosis. The abdominal cavity is distended in proportion to the development of the growth, and the presence of the latter may be ascertained by careful external palpation. The cysts fluctuate on pressure. Differentiation lies between gestation, hydrometra, and hydronephrosis. It is hardly to be confounded with ascites. Treatment. All ovarial growths should be extirpated by celio- oophorectomy. OOPHORECTOMY. This operation, known in ordinary parlance as "spaying," is principally undertaken for the purpose of suppressing the sexual function. In some cities where a high tax is imposed on the keep- ing of females, and an altered female is placed in the same category as a male, owners submit their animals to be unsexed from motives of economy. This operation is also occasionally necessary as a remedial measure for certain pathologic conditions, such as neo- plasms, hyperemia, and purulent inflammation of the ovary. In any instance where it is necessary to remove the uterus in whole or part, the ovaries should also be ablated, otherwise their presence gives rise to the formation of retention cysts. It is claimed by some authorities that ablation of the ovaries is not a certain preventive of the sexual impulse and the concomi- tant uterine discharges. Leeney, a British practitioner, writing in 1890, asserted that regular periods of "estrum" might follow the operation unless the animals were operated upon when pregnant, and referred to a tradition existing in England that a female should be allowed to copulate some ten days before being spayed, though no explanation was offered. Hobday also believes that the effect of the operation on the sexual impulse is by no means certain, and The Abdomen 267 states that he has observed signs of "estruation" after the ovaries had been removed, the animals even copulating with the male. Such cases have occurred in my own practice, even where both ovaries and uterus had been removed, but only in animals that had estru- ated normally at least once, or had given birth to offspring. These cases are to be explained on the theory of habit, the organism once having experienced the sexual impulse continuing to exhibit it in spite of the loss of the essential organs. There seems little doubt that the operation performed before the advent of the first estrual period is an absolute preventive. In some cases, at least, mani- festations of this nature are due to the leaving behind of small portions of ovarial tissue. Owing to the fact that the enveloping sac of the ovary in adult animals is often the seat of considerable fat, which completely hides the organs within, their recognition in situ is a matter of impossibility, and it is then a very easy matter to leave behind a minute portion of the gland. A peculiarity of these cases of recurring "heat" is the appearance of the symptoms at irregular intervals or almost continuously. Another phenom- enon which occasionally occurs subsequent to the operation, is the so-called "false heat" or attraction of the male without concurrence on the part of the female, which seems to be dependent upon in- creased or changed mucosal secretions. There are no physical signs of estruation, but members of the opposite sex are persistent in their attentions. The condition may last some months, but finally ceases. It is due to the remnant of the reproductive tract under- going certain changes after castration. At first, there occurs a marked hyperemic injection of the mucosa, which becomes soft and swollen. Secondly, the normal secretion is appreciably increased. This condition lasts for a few months, when it is succeeded by shrinkage and atrophy. The ultimate effect of the operation, upon the organism varies according to individual temperament. Some animals become fat and inactive, while others are in no wise affected. There is little doubt that metabolism is influenced. Curatulo and Tarulli believe that the reproductive glands, besides developing ova, furnish a secretion which modifies tissue change. They found that the phos- phates in the urine were greatly and permanently reduced in quan- tity after removal of the organs, which explained the utility of castration for the relief of osteo-malacia. Poehl believes this se- 268 Surgical Diseases and Surgery of the Dog cretion to be an active oxidizing agent, which when eliminated from the economy, diminishes oxidation of the organic phosphates con- tained in the tissues, and these, combining with earthy bases, are deposited in the bones in the form of calcium and magnesium phos- phates. On the other hand, Mosse and Oulie claim that the quan- tity of phosphoric acid is increased and not diminished. The operation can safely be performed at any period of the animal's life, but the age to be preferred in virgin animals is be- tween five months and the advent of puberty (about ten months), selection of the time depending upon size of breed. It is not ad- visable to operate while estruation is imminent or in progress owing to risk of inflammation resulting from the congested condition of the parts. Francis recorded an instance of fatal termination from peritonitis after having operated under protest while the animal was passing through the period, and in my own practice I have experienced inflammation and chronic hemorrhage to follow, where the operation was undertaken shortly before the period. The best time to operate on matron females is a few weeks after. The animal should be placed in the dorsal position and se- curely hoppled and anesthetised, or a narcotic may be previ- ously administered. Some operators prefer to narcotise and then suspend the animal by the hind legs, this position having some ad- vantage in lessening the tendency to protrusion of other viscera. The abdomen may be opened by median or lateral section. The former is to be preferred, and the incision should be made slightly to either side of the linea alba, and immediately posterior to the umbilicus. If it is made further back than this it is difficult to separate the organs from their anterior attachments. When a flank incision is made, but one is necessary, as both glands can be removed through the same opening. With a little practice it is not a difficult matter to acquire dexterity in finding the ovaries. Their position is be- neath the fourth lumbar vertebra immediately posterior to the kidneys. One uterine comu should first be sought. The peritoneal cavity being exposed, the omentum is drawn forward and stowed away anteriorly. The index finger is then introduced and directed along the internal aspect of the wall on one side till it reaches the sublumbar region. Here it is made to hook round the comu, v/hich is immediately brought to the surface. By following this pro- cedure the comu can be almost immediately found, but to dive in The Abdomen 269 among the coils of intestine and grope about for it is time-consum- ing and some- times futile. This c o r n u being found it is fol- lowed up till the ovary is brought to view. With a little gentle traction the lat- ter is brought well without the abdominal wall. The index finger is then thrust through the broad ligament and ligatures are applied above and below the ovary. It is always safest to ligate and ligatures of silk are best. As has been pointed out in another part of this work, divided bloodvessels of the abdominal cavity possess a remarkable tendency to bleed when shut oflF from the clotting influence of the air, and while there are some mechanical devices (spaying scissors, spaying emasculators) on the market by whose action the vessels are crushed, it is infinitely safer to ligate and thereby reduce all risk of secondary hemorrhage to a minimum. It is extremely important to apply ligatures so that all ovarial tissue will be completely occluded. If any portion of the gland is left behind, the object of the operation, when suppression of estruation is aimed at, will be defeated. All tissue within the occluded area is next excised with scissors, the division being made at the upper extremity first. The one ovary being thus removed, the operator follows the cornu back to its junction with its fellow, and follows No. 52. Dlapram to show course pursued by the finger to quickly reach the cornu. 2/0 Surgical Diseases and Surgery of the Dog No. 53. Diagram illustrating techic of excision of the Orarj. (A) Rent In broad ligament made by finger. (B) Dotted line at site of excision. (C) Orary. (D) Ligatures. (E) Uterine cornu. (F) Uterine artery. this one up to the other ovary, which is removed in like manner. Both comua are then replaced within the cavity, and finally the wall is closed. Some operators believe the uterus may be more easily dis- tinguished by first introducing a probe, catheter, or sound into the fundus of the organ by way of the vagina. This is an amateurish method and hinders rather than expedites the operation. According to Mueller, it is the practice among some German veterinarians to secure sterility by applying two ligatures to the uterus and then completely severing the organ between them. It is hardly necessary to state that this sort of operation should never be countenanced, for not only has it no effect whatever in prevent- ing estruation and the desire for sexual intercourse, but it at once establishes a pathologic condition, to wit, the formation of a re- tention cyst, which if septic, develops into pyometra. The Abdomen 271 Whenever an animal is observed to estruate subsequent to undergoing oophorectomy, an explorative laparotomy should be un- dertaken, the abdominal wall being opened in the vicinity of the umbilicus. The first two fingers are then introduced and made to search for the former seat of the extirpated organs, and for the presence of cysts. These being discovered indicates the persistence of ovarial tissue, which must be removed in the same manner as the ovaries. BIBLIOGRAPHY. Cnratulo & Tarulll — La Secrezione Interna delle Ovale. Rome. 1896. Eeser— Cited by Mueller In Die Krankhelten des Hundes. Francis— The Amerlc. Veter. Review. 1894. Hobday — Canine and Feline Surgery. Leeny — The Veter. Journal. 1890, p. 11. Martin — Cited by Kitt in Lehrb. d. Path. Anat. Dlagnost. 2. Moseg & OuUe — Comptes rendus de la Soc. de Biol. 1899, p. 447. Poehl — Berlin, kiln. Wochensch. 1893, p. 873. Sutton — Jonrn. of Anat. and Phys. 1884. The Fallopian Tubes and Uterus EXAMINATION. Examination of the Fallopian Tubes is carried out by ab- dominal palpation in the same manner as for the Ovaries. Cystic and purulent accumulations and solid tumors can be recognized. In doubtful cases celiotomy is justified. SALPINGITIS. PYOSALPINX. Purulent inflammation of the Fallopian tubes occurs only as a complication by extension of purulent inflammation of the uterus. The symptoms and treatment are the same. METRITIS. Inflammation of the uterus occurs in three principal forms, viz., Catarrhal Endometritis, Puerperal Septic Metritis, and Proliferative or Fibroid Endometritis. CataiThaJ Endometritis. Like any other catarrhal inflamma- tion, this form of the disease is characterized by chronic secretion 2^2 Surgical Diseases and Surgery of the Dog of purulent matter which finds vent at the vaginal outlet. Under normal conditions pathogenic bacteria are constantly present throughout the vaginal canal, but the uterine cavity remains free, being protected by the mucus at the cervix. At times, howerer, especially when vaginitis occurs, microorganisms gain entrance and originate an inflammatory disturbance of the mucosa. It is rather remarkable that it arises most commonly as a chronic process in virgin females of advanced age. This I have found to be almost invariably the case, and Froehner has made similar observations. Should the cervical mucosa swell sufficiently to occlude the lumen, which it very often does, the matter is retained, gradually increases in amount, and forms a septic retention cyst. This condition is known as pyometra. From pyometra secondary septic endo- carditis is prone to result. In chronic cases the wall of the uterus is extremely thickened, the microorganisms present being very numerous and often located deep in the tissues. In one instance the diseased organ when sub- mitted to microscopic examination, exhibited a microorganism, which in shape and size resembled the ordinary diplococcus lanceo- latus of human pneumonia, which is found under normal conditions in the mucous passages of the dog. Symptoms and Diagnosis. When the cervical canal is patent, the vagina presents an injected and swollen appearance, and the discharge, which may be purulent, sanguineous or ichorous, takes place more or less constantly, but more particularly after locomotion or any expulsive effort of the abdominal muscles, such as accom- panies defecation. The animal usually licks the vulva a great deal. Abdominal palpation is painful. In the early stages of pyometra there is little change in outward manifestations, and the disease process may continue for some weeks, the abdomen all the while enlarging, until finally the appetite becomes capricious, fails alto- gether, and thirst and vomiting set in, accompanied by emaciation. The symptom of vomiting is always indicative of grave toxemia. By this time the abdomen is very much enlarged, and by careful palpation the two distended cornua may be made out on either side of the floor of the abdomen. The alteration in the contour of the abdominal wall partakes somewhat of a bilateral uniformly cylin- drical tense swelling, as contrasted with the pyriform outline of a cross section of the trunk in dropsical effusion of the peritoneum. The Abdomen 273 In addition to this, percussion fails to originate the wave character- istic of ascites. It is easily differentiated from coprostasis, where the mass is hard and unyielding and the outlines of the bowel can be distinguished. It is hardly to be confounded with pregnancy or obesity. Puerperal Septic Metritis. This condition results from the re- tention of septic matter (fetal membranes, etc.,) in the uterus in connection with abnormal fetations or fetal deliveries. It com- monly occurs in those cases where intrauterine death and non-de- livery of fetuses takes place. Bacteria gain entrance from the vagina and induce putrefactive changes. The latter are of ichorous character. The inflammatory process extends and involves all the coats of the organ and focal ulcerative degenerations occur and lead to perforation. This results in general purulent peritonitis if the animal has not already succumbed to toxemia. There, are, however, rare instances recorded where retention of fetuses has not led to extension of inflammation beyond the uterus. Welch reported operating on an animal for the purpose of removing the ovaries and finding a bony skeleton within the uterus, the remainder of the fetal tissues having disappeared by decomposi- tion. At the previous whelping period the animal had shown symptoms of toxemia. Symptoms and Diagnosis. There is a discharge of foul, green- ish, or sanguineous, purulent matter. There is rarely any rise in temperature, but the latter frequently falls below normal. The animal ignores the offspring, and is listless, and total collapse rapidly supervenes. The appearance of vomiting is to be regarded as a grave symptom. As in intestinal obstruction, it marks the advent of that phase in the struggle between bacteria and the organism where the latter commences to succumb to septic infection. Proliferative or Fibroid Endometritis. This condition is char- acterized by chronic proliferative overgrowth of the submucosal layer. This leads to great thickening of the mucosa, which acquires a mammilliform appearance. Here and there may be seen minute cysts. These represent generalised dilations of the mucosal glands which have resulted from stricture of their mouths by the fibroid growth. The entire organ may be much shrunken. As in pyometra, estruation and the attendant uterine discharges no longer occur. The disease is peculiar to aged animals, and produces little 19 274 Surgical Diseases and Surgery of the Dog or no morbid effect on the organism, so that surgical interference is superfluous. Treatment. Catarrhal endometritis is difficult to treat short of extirpation of the organ. In only the largest animals can any attempt be made at irrigation, and even then it is practically impos- sible to wash out the whole extent of the two comua. Very good results are obtainable by a course of administration of official em- menagogue pills, which contain ergotin and other ecbolics. Should the latter treatment fail after a thorough trial, celio-oophoro-hys- terectomy is indicated. When pyometra is established it is always best to remove the uterus as soon as possible before the condition has become so ad- vanced as to render a successful issue doubtful, owing to the great tendency to formation of metastatic abscesses in the liver, spleen, and kidneys. As in catarrhal endometritis proper, discharge of the contained matter can be induced with emmenagogue pills, but the disease is in no wise abated, the infective process having its seat deep in the wall of the organ. These pills are very useful for ad- ministering as a diagnostic agent in doubtful cases, as they invari- ably cause the organ to expel its contents. Burke claimed to have cured an animal suffering from a disease, which from his descrip- tion was evidently pyometra, by administration of a mixture of er- got, iodide of potash, and digitalis. But as he did not see the animal again after the lapse of three weeks, the claim can hardly be credi- ted, what took place having been in all probability expulsion of the accumulated matter with temporary relief. The puerperal form of the disease is to be treated by prompt celio-oophoro-hysterectomy. Attempts at extraction of the fetal remains and irrigation are not to be countenanced. The disease is so rapid in its course that hesitancy on the part of the surgeon may result in fatal termination. Moreover, the fact that all the coats of the organ are involved in the inflammatory process renders local disinfection an impossibility. Immediately after an operation of such gravity, powerful stimulants, such as trinitrin, should be hypodermically administered, and the physiologic salt solution in- jected through the wound into the peritoneal cavity, or hypodermi- cally for several minutes, as fast as absorption takes place. Provi- sion should also be made for drainage as the peritoneum is ex- tremely apt to have become infected. N'o. ."4. rrooiiUiu-e nl' tl.e \';ii;ir.ii. ds I'tevi. I'terus, aiul butli I'teriiie Co The Abdomen 275 PROGIDENCE. Eversion of the uterus is rarely seen. It is sometimes con- founded with estrual hypertrophy of the vaginal mucosa, polypus and prolapse of the vagina. Its occasional occurrence is associated with the whelping period. Recent writers describe the lesion as being of a partial nature one of the comua only taking part in the protrusion. But that both comua may participate I can assert from a case in my own practice which is shown in the accompanying illustration. The double lesion is also attested by the record of Cros, a veterinarian at Milan, in the year 1832. This practitioner was requested to treat a toy bull female, six years of age, which had previously brought forth different litters of five and six puppies without difficulty. On the occasion in question the uterus had be- come completely everted and by pressure on the urethral orifice in- terfered with urination. Three days after its first appearance the organ was greatly tumefied and gangrenous. Recognizing the risk involved in replacing tissues in such condition, Cros decided on amputation. This was performed by application of a tight ligature round the neck of the protrusion as far within the vagina as possible. On the following day the ligature was further tightened to complete the isolation and mortification. On the third day the protruding portion was extirpated with bistoury with but slight hemorrhage. The mass on examination was seen to include both right and left cornua. The right horn which had carried the young of the last litter was considerably longer than the left. The anterior extrem- ities of both terminated obtusely from which Cros surmised that they had been torn from their connections with the ovaries, the latter organs remaining within the abdominal cavity. The opera- tion was followed by complete recovery. Ridler and Hobday have also witnessed and treated in like manner, but by immediate extir- pation, a prolapse of both cornua. In one case, recorded by Leech, the everted organ contained the bladder and portion of the intestine. Symptoms and Diagnosis. At first a tumor appears protruding from the external genitals. It soon becomes swollen and inflamed and later ulcerates. Patches of gangrene develop. The animal strains as if at micturition. The tumor must be carefully differen- tiated from the not uncommon condition of protrusion of the vaginal mucosa which occurs at the estrual period. 276 Surgical Diseases and Surgery of the Dog Treatment. If the procidence is recent an attempt should be made at reposition, after first cleansing the parts with some disin- fectant solution. To effect this it may be necessary to open the abdominal wall and withdraw the cornua. They should then be suspended to the abdominal wall with sutures (Ventrofixation). If the parts are gangrenous or there is objection to celiotomy, the protrusion should be ligated with stout silk as far within the vagina as possible, the occluded portion being excised, not, however, until the operator has satisfied himself that no other viscera are contained within the mass. Following this operation the vagina should be irrigated daily with antiseptic solutions. In one case treated by Funk the everted cornu prevented the delivery of the fetuses from the other so that Cesarean section be- came necessary. TORSION OF THE CORNUA. This is a very rare condition. It has been described by Eichen- berger, Guillebeau and Bonnet, and twice by Kitt. The uterus was always gravid. In Eichenberger's case the animal had previously whelped without mishap, but on this occasion could not deliver. Ergotin was administered and two dead fetuses appeared. Death occurred ten days later from peritonitis. The left uterine cornu and broad ligament were twisted and torn. The former contained two fetuses. The posterior part of the canal was obliterated and its wall atrophied, showing the condition to have been one of long standing, probably a few weeks. In Guillebeau's case the bitch was delivered of one fetus. Labor continued but without any result until death took place a week later from peritonitis. The left cornu containing two dead fetuses and distended to a diameter of six inches was twisted in its long axis at its junction with the body of the organ. The broad ligaments of both cornua were lacerated. Torsion may also occur independent of pregnancy as I have had occasion to observe. A Yorkshire Terrier, aged seven years, which had previously enjoyed good health, estruated sparsely. Two weeks later it succumbed without any special symptoms other than toxemia and a constant slight discharge of a bloody purulent matter. On making a necropsy, the right cornu was found to be highly in- flamed and to contain a purulent hemorrhage matter (evidently The Abdomen 277 pent-up uterine secretions). A twist existed at its junction with the body of the organ and this had prevented free discharge. Treatment. The cases cited above emphasize the importance of ascertaining whether any fetuses remain behind or not in all difficult parturition cases. This can be done in almost any case by digital palpation of the abdomen and genital passages. The pres- ence of such being suspected, explorative celiotomy must be under- taken. Relief is afforded either by reduction of the torsion, or if necessary by complete extirpation of the organ. JRUPTURE. This is a very rare accident and when it takes place it is usually due to rough use of obstetrical instruments. It is said to occur also spontaneously. If the organ contains fetuses the latter may pass through the rent into the peritoneal cavity. The lesion is always serious either from shock or infection of the peritoneum, and the animal usually succumbs. Symptoms and Diagnosis. When rupture occurs during par- turition the contractions of the organ immediately cease and the animal is prostrated. On the finger being introduced within the uterus, the muscular wall is felt interposed between it and the fetus, particularly when the latter is pushed up towards the pelvic region by external abdominal manipulation. Suspicion of the condition calls for prompt explorative celiotomy. Treatment. The abdominal cavity being opened, fetuses and membranes must be removed, the cavity flushed with moderately hot sterilized water and drainage provided to carry off peritoneal fluids. It is not necessary to suture the rent in the wall of the uterus. NEOPLASMS. The growths affecting the uterus are usually innocent in char- acter. The commonest are fibromata, while myomata and lipomata and cystic accumulations occur with less frequency. Malignant car- cinomata have also been observed but they are rare. Fibromata. These tumors spring from the muscular wall and are often in part myomatous, in fact, Sutton believes that many tumors described as fibroids are primarily leiomyomata and later undergo fibrous degradation. They may grow either towards the 278 Surgical Diseases and Surgery of the Dog lumen of the organ or in the direction of the peritoneal cavity. In the former case, the larger growths may project through the os and even past the vulva. Symptoms and Diagnosis. Presence of these growths is recog- nizable by external appearances supplemented by digital palpation. In one instance reported by Romani the tumor seemed to provoke reflex coughing. It prolapsed through the vagina and vulva during a fit of coughing and the coughing recurred when it was pushed back within the vagina, but again ceased on further prolapse. It is important in diagnosing growths occupying the vaginal passage to carefully ascertain whether they are of vaginal or uterine origin. Treatment. Extirpation is indicated. If it is not desired to preserve the reproductive capacity it is better to remove the entire uterus together with the ovaries. Tumors which project into the vagina should be removed by way of abdominal section and not by ligation within the vagina. Hydrometra. This condition is characterized by accumulation and retention of the products of normal glandular secretions within the uterus. It may arise from any of the following causes : Occlu- sion of any part of the canal (generally the cervical extremity) through cicatrization occurring as a result of endocervicitis origi- nating from injury received during parturition; Occlusion through pressure by the ring in inguinal hernia ; Occlusion by surgical means in those instances where the organ is ligated and severed as a simple but bungling method of preventing gestation. In any case, unless pyogenic microorganisms gain entrance, or strangulation takes place, the condition has no ill-efifect on the animal. Symptoms and Diagnosis. An animal affected in this manner is generally regarded as being pregnant owing to the distension of the abdominal cavity, but persistence of the enlargement and ab- sence of lactation serve to correct this impression. Contrasted with the condition known as Pyometra, there is no change in the ap- pearance of the external genitals, no pain on palpation, anorexia, nor emaciation; in fact the physical equilibrium is in no wise dis- turbed. It may be more easily confounded with obesity. Operative measures are unnecessary except in inguinal hernia where there is danger of strangulation. Treatment. This consists in total ablation of the organ to- gether with the ovaries. The Abdomen 279 Surgery of the Uterus All operations on the uterus should be done under general anesthesia, the animal being secured in the dorsal position for median celiotomy and in the lateral position for lateral celiotomy. The organ is best reached by opening the abdominal cavity in the median line in the center of the distance between the ensiform pro- cess and the pubic border. HYSTEROTOMY. This operation is resorted to in cases of fetal retention in which decomposition has not occurred nor induced changes in the uterine wall, when the fetus is too large to pass through the natural pas- sages, and in inguinal hernia where the gravid uterus forms the protrusion, and when it is considered dangerous to the dam to allow completion of full term owing to the difference in size between her and the sire. Under the latter conditions the chances of favorable result are greater when the operation is undertaken any time up to seven weeks of gestation. Fractures of the pelvis are apt to reduce the caliber of the passage to such extent as to completely inhibit parturition, when the operation becomes imperative. Brooks and Whitworth and Menveux have recorded instances with successful termination. Funk had to resort to the operation in an animal in which one of the cornua had become inverted thus preventing the expulsion of the fetuses in the other cornu. Where the safety of the progeny is desired it is interesting to know that the fetus may survive the death of the dam for some minutes. Kehrers, in experimental observations, found that three minutes after death the fetus began to show symptoms of asphyxia, and in thirty-six minutes it was dead. Sauer extracted some fetuses alive by this operation eight minutes after the death of the dam. The technic of hysterotomy is as follows : The abdominal cavity being opened with as little wounding of the mammae as possible, draw out the organ in its entirety and protect it with cloths wrung out in hot water. Some difficulty may be experienced in exposing the organ, particularly if it contains several fetuses, but it must be handled with gentleness and the opening in the abdominal wall should be large enough to permit of free passage of the distended organ. Make a single incision cautiously through the uterine wall 28o Surgical Diseases and Surgery of the Dog opposite the insertion of the broad ligament, over one of the fetuses nearest to the fundus of the organ, avoiding wounding the fetal membranes. Extract the fetus and membranes intact and push along the others to the same opening. The fetuses being removed, a few Lembert or Halsted sutures should be applied to close the incision. Some authorities regard this as not being absolutely ne- cessary as the organ very quickly diminishes in volume, the wound closing by its contraction and quickly cicatrizing. In inguinal hernia of the gravid uterus, the operation is per- formed in a similar manner after the hernial sac has been opened. Pregnancy with normal delivery of fetuses may subsequently take place. HYSTERECTOMY. This operation is indicated in hydrometra, pyometra, purulent metritis, in cases of fetal retention and decomposition where the wall of the uterus is involved, in torsion, and in inguinal hernia where the gravid uterus forms the protrusion and it is not con- sidered advisable to replace it in its proper position. It is also sometimes undertaken in preference to hysterotomy and removal of the fetuses in those cases where dystokia is feared as a result of the animal having mated with a male of superior size. The ovaries should always be removed at the same time. The operation is performed in the following manner: Open the abdominal cavity and draw out the organ as in hysterotomy. Apply stout silk ligatures immediately anterior to the cervix and on the further side of the ovaries, and to sections of the broad ligament, excise the intervening parts with scissors, and return the stumps to the cavity. In the case of the gravid uterus and in the larger animals ligate the arteries separately as one ligature at the cervix is not sufficient for safety. There is liability of such ligatures slip- ping from the stump with secondary hemorrhage a3 a result. It is well-known that there is a remarkable persistency in the flow of blood from severed vessels of the abdominal cavity even when only small arteries are divided. Larkes had two such unfavorable re- sults attending the removal of the gravid uterus. In cases of puer- peral septic metritis drainage should always be provided for by inserting a fold of sterile gauze within the cavity and carrying it The Abdomen 281 through the wound to the outside. This is removed in the course of five or six days. Whenever the continuity of the uterus is destroyed, either in one or both cornua, all portions of the organ lying above, as well as the ovaries, should invariably be removed, otherwise there is every probability of a retention-cyst developing from accumulation of glandular secretions, and this may possibly be converted into a pyometra. The practice of severing the continuity of the organ as a sub- stitute operation for oophorectomy in order to prevent gestation is bad surgery and should never be undertaken. In like manner when the operation becomes necessary in cases of inguinal hernia, and only the middle portion of a cornu forms the protrusion, the upper extremity should be pulled through the ring until the ovary is ex- posed and the whole of the parts then be removed. VENTROFIXATION OF THE CORNUA. This operation consists in producing the formation of adhesions to hold the uterus in position against the abdominal wall. This object is attained by suturing the organ to the inner aspect of the wall. The operation is performed as a remedial measure against eversion of the uterine cornua. The technic is as follows : The ab- dominal cavity being opened in the median line, the cornua are No. 55. VontroflzatioD of Abdomiual Viscera. 282 Surgical Diseases and Surgery of the Dog sought, straightened out, and brought forward. The same sutures which are made to close the opening in the muscular wall are passed through the muscular tissue of the cornua in the manner figured in the accompanying illustration, while separate sutures are used in the skin wound. BIBLIOGRAPHY. Bonnet — Cited in Veterinary News. April, 1905. Brooks & Wliitworth — The Veterinarian. 30, p. 33. Burke — The Veter Journal. 1890, p. 12. Cros— Rcc. de M^d. Veter. 1832, p. 599. Eichenberger — Schweiz. Archiv. 1883, p. 91. Froebner — Monatsh. f. prakt. Thierheilk. 1892-93, p. 382. Punk — Cited by Fleming in Veterin. Obstetrics. Guillebeau — Schweiz. Archiv. 1890, p. 32. Kehrers — Cited by Fleming in Veterin. Obstetrics. Kitt— Lehrb. d. Path. Anat. Diagnost. 2. Leech — The Veterinarian. 39, p. 790. Menveux — Rec. de M#d. Vf-tfr. 1894. Ridler & Hobday— The Veterinarian. 1905, p. 334. Romani — Clinica Veterinaria. 1889, p. 203. Sauer — Cited by Fleming in Veterin. Obstetrics. Sutton — Journ. of Anat. and Phys. 1884. Welch — Journ. of Comp. Med. and Veter. Archives. 1900, p. 761. The Vagina EXAMINATION. The vagina is examined by direct inspection, the animal being secured in the dorsal position with the hind legs brought forward. By separating the labia of the vulva with the fingers it is possible to see a short distance within, but to properly inspect the whole extent of the canal an expansible speculum should be employed and light reflected with the aid of a mirror. CONGENITAL MALFORMATIONS. According to Kitt, many typical instances of the condition known as Anus-vulva-vaginalis have been recorded. This is a con- genital malformation or imperfect development. It will be remem- bered that during fetal life a depression forms at the site of the anus, which joins the rectum and genito-urinary organs. It later becomes separated from the latter, but if this process should not continue to completion the above-named conditon results. Stenosis of the vagina I have seen in a Collie, where copulation was im- possible. VAGINITIS. VULVITIS. Inflammation of the vagina and vulva occurs in both acute and The Abdomen 283 chronic forms. It most commonly arises as a result of dystokia particularly in primiparous subjects. It may also be caused by the presence of foreign bodies and neoplasms. Symptoms and Diagnosis. Acute vaginitis is characterized by the discharge of a mucous, purulent, or sanguineous matter. The labia of the vulva are injected, swollen, and painful, as is also the vagina. In the chronic form a whitish or greyish muco-purulent matter is discharged which agglutinates the hairs at the inferior commissure. Treatment. In either form irrigate the vagina two or three times daily with moderately hot antiseptic solutions and follow with injections of astringent solutions such as nitrate of silver and sul- phate of zinc (1:100). Citrate of silver solutions (2:100) are highly recommended by Italian authorities. PROLAPSE. This lesion is of rare occurrence. Estrual hypertrophy of the mucosa is commonly mistaken for it. It may occur as a contingency of the act of copulation when the male exceeds the female much in size and drags the latter about. Symptoms and Diagnosis. A reddish congested mass appears at the vulva. If not soon replaced it may ulcerate through contact with the ground when the animal sits on its haunches. Treatment. The everted part should be irrigated with warm water and then replaced. If the protrusion shows a tendency to recur, the vulva should be stitched, the stitches being withdrawn in the course of three or four days. RUPTURE. This lesion has been observed by Raynard, Pflug, and Kitt. It is apt to be complicated by incarceration of the bladder through the rent. It is usually occasioned by the careless use of instruments in difficult parturition. Raynard regarded it as always a very serious accident from which the animal never recovered, owing to development of peritonitis. Symptoms and Diagnosis. When the bladder is incarcerated it projects from the vulva and is recognized as a fluctuating tumor 284 Surgical Diseases and Surgery of the Dog appearing at the entrance of the vagina or between the lips of the vulva. Micturition is suppressed or but a small quantity of urine escapes at a time. An exact diagnosis can be made by puncture with an aspirator. Treatment. The abdominal cavity should be promptly opened and displaced organs returned to their normal position. In view of the great risk of peritonitis supervening it is advisable to secure ample drainage with strands of gauze or tubes inserted in the wound. NEOPLASMS. The growths most commonly met with in the vagina are inno- cent in character. They occur as fibromata either pure or mixed with myxomatous, myomatous, or lipomatous elements, and as hypertrophy of the mucosa. Adenomata have also been observed. Malignant growths occur with comparative rarity. They have been observed as transformed sarcomata and as contagious venereal granulomata which have been variously described as carcinoma, sarcoma, etc. (See Chapter on Neoplasms). Fibromata. These occur in the form of polypi or as an en- largement of the Cervix and in their gross appearance closely re- semble the hypertrophic enlargement peculiar to the estrual period and for which they are often mistaken. It is said of the myxo- matous growths that they may remain quiescent for a long period, but may finally assume a true sarcomatous character and at the same time invade the deeper layers of the vaginal wall. The purer fibro- mata are firm in consistence and insensitive, and have an intact surface, though the latter may become ulcerated by contact with the ground when the tumor is so large that it protrudes through the vulva. These tumors are apt to interfere with free coition and fetal delivery. Treatment. Extirpation is indicated. Operative technic is the same as for removal of the hypertrophic enlargement peculiar to the estrual period. In the case figured in the accompanying illus- tration which was operated on at the Johns Hopkins Laboratory the tumor was enucleated through a median external incision, which was made to extend from near the tip of the vulva to the mid-hy- pogastric region. Mueller treated a fibro-myoma by daily hypo- dermic injections of ergotin. In one month the growth was con- The Abdomen 285 siderably reduced and the animal subsequently made a good re- covery. Estrual Hypertrophy of the Mucosa. This condition is not at all uncommon in young females. In my experience, members of the St. Bernard breed are most apt to suffer. Pathologically, it consists of an hypertrophied area of mucosa, a sort of elephantiasis, the seat of which is usually the floor of the vagina anterior to the urethral orifice, but the whole circumference may be involved. It is very generally mistaken for and described as prolapse of the vagina, but while the turgid mass of tissue protrudes more or less through the vulva, with the exception of this feature it has nothing in common with true eversion of the vagina. In its morphologic and microscopic features the neoplasm resembles a myxoma and is sometimes mistaken for such, but it is purely a temporary congestive condition associated with the advent of sexual excitement. It gen- erally makes its appearance towards the end of the estrual epoch and subsides as the latter declines. It tends to recur periodically and is then described as being habitual. Symptoms and Diagnosis. A globular or pyriform tumor is observed protruding through the vulva during the estrual period. It is most prominent when the animal is in the sitting posture, be- coming considerably retracted within the vagina when the standing posture is assumed and if small may disappear altogether. Through contact with the ground it may ulcerate in places and become gan- grenous. There may or may not be a history of previous appearance of the enlargements. Treatment. The only effective way of dealing with this form of enlargement and at the same time prevent recrudescence is to extirpate it. Authorities in general advise that the protrusion be reduced, a pessary or packing inserted within the vagina and the vulva stitched, the stitches being left in position for several days. All such measures are superfluous for the reason that the swelling will usually subside of its own accord at expiration of the estrual period. If treatment is undertaken it should be radical. The most satisfactory method of removing the growth is as follows : Draw the mass well out of the vagina by means of a stout silk suture passed through its substance. Seek the urethral orifice and insert a probe or catheter in the same, to serve as a guide, as particular care must be exercised to avoid wounding it. If the mass 286 Surgical Diseases and Surgery of the Dog has sufficient pedicle, remove it by means of the small-sized emas- culator; if it possesses a broad base, use a scalpel, making a fusi- form incision. The mucosa must be sutured to prevent hemorrhage which is otherwise copious owing to the turgescence of the parts. Previous application of adrenalin chloride solution minimizes hem- orrhage. The Thomas stitch should be employed (see Sutures). Suturing the vagina is always difficult but this part of the operation may be simplified by applying the sutures immediately beneath the clamped emasculator before the latter is removed and while the area of operation is within easy reach. Or if the mass is to be removed by dissection apply the first stitch just beyond the upper angle of incision, before using the knife. By means of this presection stitch the field of operation can be kept in view while the suturing is being completed. No after-treatment is necessary, but the urinary ap- paratus must be closely watched for the first few succeeding days for occlusion of the lumen of the urethra from swelling incident to the wounded mucosa. Other methods of removal are by clamp and cautery, by ecra- seur or by ligature and subsequently allowing the mass to slough oflf, but they are none of them so satisfactory as the method advo- cated. Venereal Granulomata. These tumor-like formations which have already been described as occurring in the male similarly affect the vaginal mucosa of the female. It is an inoculable disease and is probably always conveyed by the act of copulation, hence sexual intercourse should be prohibited. The growth appears as a soft or firm, single or multiple, not particularly sensitive, wart-like nodular protuberance. It is commonly situated on the floor of the vagina between the vulva and the urethral orifice, though when long- standing it may extend throughout the length of the vagina and protrude from the vulva. It is a progressive neoplasm, grows slowly at first but quite rapidly later and may reach its maximum growth within a year. It then infiltrates the perivaginal tissues. Occasionally metastasis takes place to the inguinal glands. In the advanced stages it is accompanied by cachexia and emaciation. Symptoms and Diagnosis. As in the male, it usually escapes notice until it has advanced to the ulcerative stage when a non- purulent evil-smelling, bloody discharge escapes from the vagina. Palpation and examination with the aid of a speculum reveals the The Abdomen 287 condition. Some males manifest an aversion to, and refuse to mate with, a female affected with this disease. Treatment. Surgical treatment is, as a rule, ineffectual, unless the growth is limited, in which case a fusiform piece of mucosa, to include the affected area, may be removed, and the edges of the wound drawn together and sutured with catgut. If necessary to reach the growths the perineum must be divided and afterwards sewn up. Complete anesthesia should first be established. Recurrence of the growths often takes place, when operative measures should be repeated. Hobday says the growth may be re- tarded by performing oophorectomy in addition to ablation. This is comprehensible in view of the fact that uterine myomata in women shrink and ultimately disappear after the menopause, and surgeons take advantage of this by removing the ovaries and producing artificial amenorrhoea. BIBLIOGRAPHY. Hobday — Canine and Feline Snrgery. Kltt— Lehrb. d. Path. Anat. Diagnoat. 1. 2. Pflng— Cited by Kltt In Lehrb. d. Path. Anat. Dlagnost. Baynard — Traits Comp. de la Partur. des Fem. des. Anlm. Domest. Paris. 1845. CHAPTER DC The Abdomen — Continued Hernia ABDOMINAL HERNIA IN GENERAL. The term Hernia is applied to any protrusion consisting of an organ or part which has escaped from the abdominal cavity where it normally belongs and protrudes through some natural or accidental opening in the walls of the latter. The contents of an abdominal hernia may consist of portions of the bowel alone (enterocele), of the omentum alone (omentocele, epiplocele), or of both these together (entero-epiplocele), of the round ligament with more or less of the broad ligament (mesome- trocele), and of one or both uterine cornua in addition to the latter (metro-mesometrocele). The bladder, enlarged prostate gland, spleen, and pancreas have been found present in a limited number of cases. A peculiar instance of protrusion through the abdominal wall has been recorded by Edgar, two fatty (?) tumors being found at- tached to the uterus, one of which had grown through the abdominal muscular wall. The protruding organs are contained in a sac which consists of an extension of the peritoneum. In some forms, such as the scrotal and perineal, no true sac of neoformation exists, the pro- truding organs passing into dilated cavities which are already lined with prolongations of the peritoneum. The sac is covered by the integument and subjecent connective tissue. Hernia may be congenital or acquired. A familiar example of the former is often seen in puppies soon after birth when the umbi- licus remains patulous and a portion of the omentum passes through to form a subcutaneous swelling. The inguinal ring is also occa- sionally the seat of congenital hernia in females, in whom the round ligament and part of the broad form the protrusion. Acquired hernia is the result of either increased intraabdominal pressure, 288 The Abdomen 289 weakness of the abdominal parietes, traumatism, or the presence of a predisposing factor in the form of a dilated inguinal canal and congenital herniated broad ligament. It occasionally occurs subse- quent to abdominal section, especially when the incision is made in the aponeurotic tissue of the linea alba, through yielding of the cica- tricial tissue of the wound. Hobday places the general percentage of hernias resulting from celiotomy at four or five. In an extensive experience, both clinical and experimental, I never have had the misfortune to meet with it, which I attribute to the fact that I have always avoided incising directly in the linea alba. La Torre experi- mented on twenty-five dogs and determined that hernia after celio- tomy was chiefly due to defective union of the muscular layer or relaxation of the cicatrix, following incision through the linea alba. This was not likely to occur when the incision was made through the muscle. If made directly in the linea alba, before closing it, the aponeurotic tissue should be removed as far as the muscular sub- stance of the recti muscles. There is always risk to be encountered from the presence of a hernia, through incarceration or strangulation taking place or through parturition being rendered impossible. In one fatal case of inguinal hernia which I attended, the lesion had existed four years, the portion of protruding bowel finally becoming strangulated. A hernia is said to be incarcerated when the peristalsis of the re- tained gut is arrested, generally through adhesions having formed, and the lumen is obstructed by impacted feces. A hernia is said to be strangulated when the return of the venous blood is impeded. This is followed by stasis of the arterial flow, edema, and serous exudation, which increases the distension of the sac. Finally, these changes lead to migration of intestinal bacteria and gangrene. Both these conditions are treated of fully under Intestinal Obstruction. Symptoms and Diagnosis. Hernia is recognized as an elastic fulness or swelling, by more or less disappearance of the same when the animal is placed in the dorsal position, and by its reappearance when placed in the erect, excepting in the case of the gravid uterus and irreducible and strangulated forms. It may also be replaced by taxis. It is often tympanitic, disappears with a gurgling sound, and becomes tense if the subject is made to cough. It is never painful unless inflamed. In a recent hernia the contents are, as a rule, easily reducible and the sac retains its natural thin, translucent condition, 20 290 Surgical Diseases and Surgery of the Dog but in a hernia of long standing it may become thickened and some- times adherent to the contained organs or neighboring tissues. Dif- ferential diagnosis lies between it and neoplasms and abscesses. Treatment. It has already been remarked that a hernia con- stitutes an ever-present menace to life. It naturally follows that such a lesion should always be remedied at the earliest possible opportunity. The owner must be informed of the possible termi- nations and of the advisability of submitting the animal to treatment. Treatment of hernia should be operative in all cases, there being no more danger to the animal from opening the peritoneal cavity in this manner than there is in any other abdominal section, provided due care be exercised to avoid wounding blood-vessels and punctur- ing viscera. The operation is termed Herniotomy. It is advisable to deprive the animal of all food for two or three days prior to operation and to administer an active purgative. The fundamental principles governing operative measures for either form are : reduction of the contents, dissection and complete extirpation of the sac, and closure of the opening in the abdominal wall, whether accidental or natural, by suture. The technic is as follows: The animal being hoppled in the most convenient position and anesthetised, an incision is made in the skin directly over the protrusion. The subjacent fascia is next cautiously dissected until the sac is reached, and the dissection continued until the latter is completely enucleated. To distinguish the sac, when it is not ad- herent to the surrounding connective tissue, it may be picked up between the index finger and thumb when the intestine will slip away, leaving the sac alone in the grasp. In a hernia of some du- ration it is recognized by its whitish appearance, but if strangulated it may be of dark-reddish color and not easily discernible. Some writers, evidently borrowing from the principles of human surgery where the possibility of infecting the peritoneal cavity always has to be considered, advise that the contents be reduced without or before opening the sac. I am a firm believer in opening the sac at the outset, being no more fearful of any probability of inducing peri- tonitis than I am when performing simple celiotomy. With an open sac the operator can see what he has to handle, can see whether adhesions have formed at the neck to interfere with reduction, and can see whether any organs need to be extirpated. I have in mind a few instances where the operation was needlessly prolonged for The Abdomen 291 several minutes by vain attempts to return the organs without open- ing the sac. When the latter alternative had finally to be adopted it was found that adhesions had effectually prevented the efforts from being crowned with success, and in one case the presence of a diseased uterus was laid bare. But it sometimes happens that the size of the ring prevents re- duction of the contents. In this case it must be enlarged by means of an instrument specially designed for the purpose, or if the latter No. 58. Hernlotome. be not at hand a probe-pointed bistoury guided by a grooved director will answer the purpose almost as well. The enlargement must be made with due regard to the proximity of vessels. The contents being returned, the sac is next removed. This should be pulled well out, twisted, and excised after first applying either a simple, multiple, or purse-string ligature to its neck as high up as possible. The stump is then pushed within the abdominal wall. The next step comprises closing the opening in the wall. This is accomplished, as in celiotomy, by suturing the margins. The skin wound is closed as in celiotomy. The subcutaneous ap- plication of tampons with the object of giving additional support is unnecessary, if not useless for the purpose for which it is intended. Neither need supporting bandages be employed. The best suturing material to use during the various stages is silk. In strangulated hernia, treatment, to be effectual, must be undertaken in the early stages, as the lesion is quickly fatal, usually within twenty-four to twenty-eight hours. The sac is opened, the ring enlarged by cutting, and the bowel slightly drawn out and the entire mass carefully examined. Congested bowel, even if dark-red in color, usually possesses sufficient viability for complete recovery and may be safely returned, and the operation completed as already described, but if any part is found to be gangrenous recourse must be had to resection. ABDOMINAL HERNIA IN PARTICULAR. Umbilical Hernia. Umbilical hernia occurs either congenitally 292 Surgical Diseases and Surgery of the Dog or develops during the first few days after birth. The ring in this case is formed by a patulous condition of the omphalo-mesenteric duct and the sac by the sheath of the umbilical cord covered by the integument. Under normal conditions the umbilical orifice becomes obliterated by fibrous organization during the first few days suc- ceeding birth. When this development proceeds tardily the em- bryonic tissue in the neighborhood of the orifice gradually recedes before the pressure of the viscera and a hernia is formed. The con- tents consist usually of omentum alone, though sometimes large intestine accompanies it. In acquired umbilical hernia of later life, parietal peritoneum forms the sac. Symptoms and Diagnosis. This form of hernia is easily recog- nized as a soft or firm tumor at the umbilicus. Treatment. The majority of cases of umbilical hernia among newly-born puppies result in spontaneous cure, so that treatment of this form is rarely necessary. Sometimes a small swelling persists during life through adhesions forming between the ring, sac, and omentum without complete return of the protrusion. It is a good plan to apply adhesive bandages over the swelling to assist the tardy closing process. Some practitioners claim to have good results from the injection of a few drops of a ten per cent solution of chloride of zinc. When it is necessary to treat by herniotomy the best results are obtained by completely excising an elliptic portion of the wall surrounding the umbilicus (omphalectomy). Ventral Hernia. This term comprises all hernias which arise through subcutaneous disruption of the abdominal muscles. It originates either traumatically or by spontaneous rupture under extreme intraabdominal pressure or it may result from surgical wounds. The lesion is not very common. The symptoms and treatment have already been outlined. Inguinal Hernia in the Female. This form of hernia is most common of all. It is characterized by passage of a fold of peri- toneum and visceral organs through either or both inguinal canals. The inguinal canal in the female is very short, and its diameter varies according to the sex and conformation of the animal, being more pronounced in the female than in the male. The internal ring in the female is normally covered by parietal peritoneum, and con- sequently sealed. For some unknown reason the lesion occurs more frequently No. 59. Inguinal Hernia in the Teniale. No. GO. Inguinal Hernia in the Female. The Abdomen 293 on the left side than on the right. In this connection it is worth remembering that normal descent of the testes in the male is said to be naturally later and more liable to deflection on the right side than on the left, suggesting that the mechanism of descent is more ample on the left. It is sometimes congenital in origin, and it may not be detected until, the uterine cornua forming the contents and becoming gravid, it commences to enlarge with the growth of the contained fetuses. It may often be observed to occur in animals after giving birth to litters sired by males very much their superiors in size. In these cases the ring seems to dilate in sympathy with the enormous distension of the abdominal cavity, its caliber being increased with the stretching of the wall. As soon as delivery is accomplished, a part of the collapsed uterus falls through, Carrying the peritoneum before it. It is most common to find the round ligament together with the peritoneal fold by which it is connected with the broad ligament, and this is often the seat of deposit of a mass of fat. Some writers in describing inguinal hernia refer to this ligamentous tissue as omentum, evidently owing to the similarity between the two struc- tures, but my investigations have shown me that it is a rare ex- perience to discover omentum forming part of an inguinal hernia. A condition of hypertrophy of the round ligament has been designated pseudo-hernia. It is easily differentiated from the true form. Next in frequency we find one or both uterine cornua, in part or whole, together with the broad and round ligaments, forming the contents of the sac. As already remarked, should pregnancy occur, a rapidly growing enlargement soon becomes apparent. The increase in size may be first detected about one week after impreg- nation has taken place. Delivery of the fetus per vias naturales is, as a rule, impossible, the inguinal ring forming an impassable con- striction. Unless removed by operation of hysterotomy it dies and either macerates or decomposes and induces infective inflammation and gangrene of the maternal parts. Instances have been recorded, however, in which the young have been brought forth in a natural manner. Prange described a case of hernia of a portion of the uterus which contained three fetuses, all of which were delivered naturally a few hours after birth of six others. Roell had a similar experience. In one instance which I relieved by operative measures 294 Surgical Diseases and Surgery of the Dog the entire uterus and one ovary together with the greater portion of the small intestine formed the protrusion. In this case the uterus was the seat of an enormous hydrometra formed from ac- cumulated uterine secretions through occlusion of the cervical lumen by compression at the ring. Descent of other visceral organs may also occur. In cases recorded by Hobday, Friedberger, Cadeac, Cadiot and Almy, the sac has been found to contain portions of the small intestine, spleen, pancreas, omentum, bladder, uterine comua, cecum, and part of the colon. Adhesion of the pedicle of the protruding viscera to the bor- ders of the ring is quite common, but it is rare that strangulation takes place when the uterus alone is concerned. Prudhomme wrote of seeing such a case, which terminated fatally. But when a knuckle of bowel slips into the sac the risk of strangulation is greatly in- creased. In order to acquire a clear conception of the manner in which congenital hernia of the round and broad ligaments and the uterine cornua takes place, it will be necessary to review the prenatal de- velopment of the sexual organs. In early fetal life there exists an intra-abdominal glandular structure on either side of the lumbar region — the Wolffian body — the structure which gives rise to the reproductive gland of either sex. Connected with the Wolffian body are two tubular structures leading to the uro-genital sinus, the Wolffian and Muellerian ducts respectively, the former becoming the vas deferens and epididymis in the male, and the latter the ovi- duct, uterus, and vagina in the female. The Wolffian body is sus- pended from the abdominal roof by a duplicature of peritoneum from which a fold (the plica gubernatrix) is projected to and through the inguinal region. This fold subsequently becomes the gubernaculum testis in the male and the ligamentum teres in the female. It is invested throughout with peritoneum which forms a tubular sheath about it. Beneath this sheath are certain muscular fibers having their origin in the abdominal muscles, and which are known as the cremaster muscle in the male but are not specially named in the female for the reason that in the latter sex they are normally rudimentary. We see that in the female there is an arrangement of struc- tures almost identical with that which serves to bring about migra- The Abdomen 295 tion of the testes in the male, and it would appear as if Nature had almost intended the same phenomenon should occur in the female. As a matter of fact, we often find evidence of an attempt on the part of Nature to bring about migration of the female organs. When the muscular fibers of the ligamentum teres are sufficiently- developed, the natural result is contraction, and there follows the No. 61. Diagram Illustrating normal position of the parts. \\lt No. 62. Diagram Illustrating mechanism of Inguinal Hernia. 2g6 Surgical Diseases and Surgery of the Dog formation of a pouch communicating directly with the peritoneal cavity, and constituting a sort of diverticulum as in males. This pouch forms the hernial sac in female inguinal hernia, and in pro- portion to its development and the potential contractility of the muscular fibers, predisposes the animal to this lesion. Symptoms and Diagnosis. The swelling is situated behind or beneath the inguinal mammae. It may be of such dimensions as to reach the ground, when it is usually rendered sore by friction. Contrasted with neoplastic formations, it lies deeply, is more or less reducible, and decreases in size when the animal is placed in the dorsal position, when there is absence of adhesions. Its consistence varies according to the contents and the condition of the latter. A slight hernia is moderately firm and resistant. The presence of fluid, whether serous, mucous, or fetal, may cause fluctuation. The forms as well as the movements of one or more fetuses may sometimes be distinguished. By palpation a sort of pedicle can be recognized leading to the inguinal canal, and the circumference of the latter can often be plainly made out. If the bowel be involved, intestinal murmurs may be heard with the aid of a phonendoscope. The fact is worth remarking that nursing puppies, as a rule, refuse the teat or teats under which the hernia lies. A word of caution as to exploration of enlargements in the inguinal region with instruments. Robb recorded having observed an enlargement of the posterior mammary gland of the left side which fluctuated, showing the presence of liquid. An unsuccessful attempt was made to draw oflf the fluid with the aid of a canula. Finally the tumor was opened and hysterotomy performed and a fetus removed. The mother died of peritonitis, which evidently had its origin at the site of the puncture. Raynard described a case in which the pregnant uterus protruded until it had lodged in the connective tissue immediately beneath the vulva. The owner suppos- ing the enlargement to be an abscess opened it with a penknife, and thereby established a fistula. Raynard explored the tumor and found it to be the uterus containing a three-to-four-months'-old fetus. The hernia was irreducible owing to adhesions having formed between the uterus and connective tissue, and the animal died the following day. Treatment. Herniotomy in the following manner is indicated: Incise the skin along the axis of the enlargement and enucleate the The Abdomen 297 sac up to the inguinal ring by blunt dissection of the cellular tissue connecting it with the skin. Some practitioners make a V-shaped incision with its apex towards the anterior extremity of the sym- phisis pubis, and the flap of skin supporting the inguinal mamma is then turned over. There is no advantage to be gained by this pro- ceedure as the canal can always be reached when the incision is made beside the median line. In any event, there is usually a certain amount of redundant skin to be removed. Next open the sac and endeavor to reduce the contents. Sometimes this is easily accom- plished, but at other times it is impossible. In the latter case the ring must be enlarged by incision. The incision should be at the extremity of the ring furthest from the median line, in order to avoid wounding the external pudic vessels which make their exit from the cavity tov/ards the inner extremity. It should also be made to avoid the peritoneum. If the bladder forms the contents and is irreducible, it may be punctured to facilitate matters. When the gravid uterus forms the protrusion, and is irreducible, removal of the fetuses must be effected by Cesarean section or the entire pro- truding portion may be excised, the stump being returned to the cavity. In case the latter alternative is adopted the corresponding ovary should be drawn out and also removed. Fetuses contained in the opposite cornua are not necessarily disturbed by such extreme measures, but may continue to develop till full term. Hobday has recorded an instance, and Nauraux has experienced equally favor- able results where the remainder of the uterus has been conserved. The next step is ablation of the sac. The latter should be twisted and ligated as near to the ring as possible, cut off on the occluded side, and the stump returned to the cavity. The ring should then be sutured, three or four sutures usually answering the purpose. By using mattress sutures and at the same time slightly inverting the edges, the ring can be permanently obliterated. Par- ticular care must be exercised against wounding the pudic veins which stand out very prominently. It may sometimes be found advantageous to ligate them. Redundant skin should be removed. Healing generally takes place by second intention, chiefly owing to the large subcutaneous cavity which must of necessity be left in the groin, and post-operative infection which it is difficult to prevent. Inguinal and Scrotal Hernia in the Male. In the male the inguinal form of hernia is relatively uncommon. It may occur, as 298 Surgical Diseases and Surgery of the Dog in the female, owing to dilation of the inguinal canal. The intestine then protrudes into the subcutaneous tissue carrying a fold of peri- toneum before it. In scrotal hernia the sac is formed by the pro- cessus vaginalis, and the contents, consisting usually of intestine, rarely of omentum, protrude as far as, and rest in contact with, the testicle. Under normal conditions the caliber of the processus vaginalis formed by the descent of the testis becomes much re- duced at its upper extremity after passage of the gland, but never becomes entirely obliterated. If this contraction fails to take place the neck of the pouch in the vicinity of the internal ring presents an abnormal opening continuous with the peritoneal cavity thus forming a ready avenue for escape of visceral organs. Symptoms and Diagnosis. In the inguinal form the swelling is formed between the penis and abdominal wall, while in the scrotal form it exists as a very thick sausage-shaped tumor along the course of the spermatic cord. Treatment. Inguinal hernia is treated as in the female. Scro- tal hernia necessitates some slight modification of technic. Opera- tive measures consist in cutting down on the swelling in the groin over the inguinal canal, opening the processus vaginalis, returning the protruding organs, and suturing the dilated inguinal ring, as in the female, at the same time allowing sufficient room for the spermatic cord and vessels, which are left intact. Some writers seem to regard it essential to remove the testes at the same time, but there is no reason why they should not be retained, their pre- servation being a matter of paramount importance in valuable stud animals. Griffiths has demonstrated by experiments and obser- vations on artificial and natural mono- and crypt-orchids that testis may be manipulated without injury to itself or the structures of the cord. In one instance he resected the cremasteric muscle and the parts healed entirely. Barnard suggested an alternative method by which the testis and cord are separated from the surrounding structures and placed within the abdominal cavity outside the peri- toneum. The tunica vaginalis is removed and the inguinal canal completely closed by suture. Of course the object in preserving the gland in this manner was the maintenance of the procreative faculty. But Griffiths has proved that the full-grown testicle, when so replaced, undergoes a degenerate change and loses its power of spermatogenesis, so that no object would be obtained by this pro- cedure. No. t::>. Inguinal Hernia in the Male. No. 04. Senilal lleiMiia. Xo. Co. reriiu-iil Ileniiii. The Abdomen 299 It has been suggested that in the scrotal and perineal forms celiotomy should be performed, the herniated portion withdrawn through the ring and then stitched to the abdominal wall to prevent its return to the sac. This would surely be an error for the very simple reason that the ring and sac would still persist, and there would be no provision to prevent the escape of some other portion of the bowel or other organ. Perineal Hernia. The fold of peritoneum which in males is reflected from the bladder to the rectum on either side, gives rise in the center to a prolongation of the peritoneal cavity — the fossa or cul-de-sac of Douglas, or excavatio recto-vesicdis. In females two such prolongations are formed, one between the uterus and rectum — the excavatio vesico-uterina. Perineal hernia constitutes the passage into one of these cul-de-sacs of a portion of the bowel, the omentum, the uterus, the bladder, or enlarged prostate. The lesion is observed quite frequently in old males, and it is said, par- ticularly in performing animals which are taught to walk on their hind legs. It is otherwise usually produced as a result of expulsile efforts necessitated by the presence of hypertrophied prostrate. It can exist for a long time without interfering with the animal's health. It seldom becomes strangulated, though torsion of the bladder is apt to take place, when that organ forms the contents, or even a fistula may form. Lienaux has recorded witnessing a displaced rectum caused by an enlarged prostate. Symptoms and Diagnosis. This form of hernia appears in the male as a subcutaneous swelling between the root of the tail and the ischial tuberosity. In the female the swelling occurs in the region of the vulva. Lucet saw a double perineal hernia, the swell- ing on the right side being formed by the bladder, that on the left by a portion of the omentum. In Lienaux's case, above referred to, the swelling appeared beneath the anus. When the contents consist of the bladder the tumor has a soft elastic consistence, resembling a cyst. In this case there is usually dysuria. To determine the condition with accuracy the aspirator should be employed. A large perineal hernia may interfere with defecation and force the anus out of its natural position to one side. It may be mistaken for enlarged anal pouches, from which it must be carefully differentiated. Treatment, If dysuria is present the bladder must be replaced 300 Surgical Diseases and Surgery of the Dog in its natural position by the following method: Empty the rectum with an enema, elevate the animal's hind-quarters, insert the thumb in the rectum and exert pressure with it through the rectal wall, and at the same time manipulate the tumor from the outside. Usually this maneuver is sufficient to cause the bladder to glide back into place. When it fails herniotomy must be undertaken as already described. It is best to insert a temporary tampon of aseptic gauze in the wound to stimulate the formation of adhesions, the skin being sutured over it. If the prostate is enlarged castra- tion is also indicated. In one instance, where the prostate, much enlarged, formed the protrusion, I removed the latter by a process of dissection and tearing away. In doing this the urethra was acci- dentally ruptured. No attempt was made to suture it, and for a week succeeding the operation urine flowed through the outer wound, just as it is allowed to do after an operation for removal of stone from the urethra. But the wound soon closed and urina- tion by the natural channel was reestablished and the animal made an uneventful recovery. In a female in which the uterus formed the contents, Benkert performed celiotomy in the inguinal region, in- troduced his hand and replaced the organ in its natural position. The animal produced young regularly thereafter. Lienaux treated his case by opening the abdomen, straightening the bowel and sutur- ing the latter to the abdominal wall. Crural Hernia. This form is very rare. Kitt cites Lafosse and Bruckmueller as authority for its occurrence, Hertwig refers to it, and Girard has also seen it. Cadix recorded a case of bilateral crural hernia in a female. It is characterized by protrusion of por- tions of the viscera, usually the intestine enveloped by parietal peri- toneum, through the crural ring in the course of the crural or femoral vessels. Crural hernia emerges beneath Poupart's liga- ment, inguinal above it. The condition tends towards strangulation. Symptoms and Diagnosis. The usual form of swelling is ob- served but in addition there is lameness on the affected side. Treatment. This is the same as already outlined, only the technic involves particular caution in the avoidance of the vessels which traverse this region. Diaphragmatic Hernia. This lesion may be congenital or ac- quired. It is characterized by protrusion of abdominal viscera into the thoracic cavity with or without the peritoneal coat remaining The Abdomen 301 intact. The acquired form may occur as a result of dilation of the foramen sinistrum through relaxation of the cardiac, gastro-hepatic, and gastro-colic ligaments when the empty stomach is primarily the herniated portion. Fuenfstueck saw a case of this kind, the stomach having become wedged in between the lungs and appeared at the necropsy as a large distended bladder. It was supposed to have resulted through a habit possessed by the animal of bounding down a winding stairway. Caparini and Bernard have seen it re- sult from violent expiratory and defecatory efforts. In these cases there is rupture of either the tendinous or muscular portion of the diaphragm. In Bernard's case portions of the liver and intestine formed the protrusion. In Caparini's case there were two super- imposed perforations, each giving passage to portions of the bowel. The portion passing through the inferior aperture was strangulated, while that passing through the upper rent had penetrated the in- terior of the pericardium, distending it and displacing the heart laterally. Symptoms and Diagnosis. In the acquired form there is sud- den restlessness, crying, anxious facial expression, dyspnea, and meteorism, which are followed by death within a few hours. The congenital form may exist for years without giving rise to any symptoms. Pancreatic Hernia. Under this name the earlier writers de- scribed passage of the small intestine through the hiatus of Wins- low, the foramen formed by the great omentum between the poste- rior vena cava and portal vein, and bordered by the anterior ex- tremity of the pancreas and the lesser curvature of the stomach. No particular mention is made of its occurrence in the dog, the only reference I have been able to find being a suggestion of such a possibility in an article by Pecus. BIBLIOGRAPHY. Benkert— cited by Cadiot & Almy in Traltg de Th6r. Chlr. d. Anlm. Dom. Bernard — Rev. VStfir. 1886. p. 452. Correspondenzbl. f. schweiz. Acrzte. Nov., 1897. Cadlx— Rec. de Med. V6t6r. 1898, p. 102. Caparini — II Bulletino veter. 18S0, p. 129. Edgar — Veterinarian. 1894, p. 135. Fuenfstueck — Her. ue. d. Veterinaerw. Im Koenigr. Sachsen. 1878, p. 106. Glrard — Rec. de Med. V6t6r. 1824, p. 114. Gonbaux— Rec. de M6d. VStSr. 1858, p. 984. Grlffltlis — Jpurn. Anat. & Phye. 1892-93, p. 209. Hobday— Canine & Feline Surgery. Journ. Comp. Path. & Ther. 8, p. 153. Kltt— Lehrb. d. Path. Anat. DIagnost. La Torre — La Gynec. April, 1897. Lienaux— Ann de M6d. VetSr. March, 1903. 302 Surgical Diseases and Surgery of the Dog Lucet— Rec. de Med. V6t6r. 1892, p. 83. Nauraux— Rec. de M6d. V6t6r. 1888, p. 12. pgcus — Journ. de. M6d. V6t6r. et de Zootechn. 1894 Prange — Rec. de MSd. V6t6r. 1844, p. 619. Prudhomnie — Rec. de M6d. VetSr. 1844, p. 356. Raynard — Traitfe Oompl. d. 1. Partur. d. Anlm. Domest. 1, p. 443. 2, p. 302. Robb— Journ. Comp. Path. & Ther. 6, p. 281. Roell — cited by Fleming in Veter. Obstetrics. The Mammary Glands TRAUMATIC LESIONS. The mammae sometimes suffer contusion, which according to the degree of violence, may result in rupture of a few subcutaneous vessels or intraglandular hemorrhage (hematoma) with destruction of glandular tissue. Such injury may terminate in suppuration. Treatment. Slight contusions require no treatment but are best left to natural processes of repair. If suppuration takes place vent must be given to the pus. In severe contusion ablation of the gland may be advisable. CONGESTION. Towards the end of gestation and during lactation there de- velops a normal turgescence of the parts. This turgescence and also lactation is common in virgin and non-pregnant animals about eight weeks after estruation — a sort of mistaken anticipation on the part of Nature. Symptoms and Diagnosis. The mammae are hot, tumefied and slightly sensitive to pressure. Treatment. Restricted diet, free purgation, and massage of the parts are indicated. MAMMITIS. MASTITIS. This is an uncommon disease. It generally occurs during the period of lactation shortly after parturition. It is caused by pyo- genic bacteria which probably migrate through the galactophorus ducts to the acini and thence spread through the perilobular lym- phatics. Lucet and Leblanc have found a white staphylococcus present, and Gaucher and Surmont have experimentally injected a pure culture of a white coccus obtained from a case of chronic mam- mitis in a human being and produced subacute inflammation of the gland. One or more glands may be affected and usually the ante- Nil. (■•(;. Miiiiuiiary Tuiiiur siiinilntiMi;' Hernin. The Abdomen 303 rior ones. As a rule, the inflammation terminates in multiple abscess formation. Pyemia sometimes follows. A rather remarkable case should be mentioned here in which a swelling of the mammary region was observed by Megnin, which upon lancing was found to be due to the presence of a giant strong- yle emerging from the body. Chronic mammitis may succeed the acute form but it commonly originates independently of the latter. It occurs as a sclerotic inter- stitial fibrosis with gradual destruction of the glandular tissue. This form will be referred to as Fibroma and it also is believed to be due to irritative action of the white staphylococcus. Neither form is to be confounded with simple congestion inci- dent to sudden cessation of nursing by the offspring. Symptoms and Diagnosis. In acute mammitis the glands are hot, sensitive, greatly swollen, and edematous, and the milk is replaced by a greyish or purulent matter. There is usually some fever present and also suppression of appetite. The animal lies down frequently and is indifferent to its surroundings. In a few days multiple abscesses form and come to a head externally as dark- red angry-looking foci. These, if not treated may persist as ulcers and fistulae for some time after discharging, healing but slowly. Treatment. The offspring must be removed and the remaining healthy glands milked by hand. Hot fomentations must be applied to the part and kept up as long as possible. The best way to carry out this treatment is to stand the animal over a tub and apply the hot liquid by means of a sponge. Purulent accumulations must, of course, be opened up with a knife. The bowels should also be freely evacuated with purgative doses of epsom salts. NEOPLASMS. The mammary gland is frequently the seat of neoplasia of both innocent and malignant types. It is believed that in some cases the innocent growths may undergo transition into malignancy. This is particularly true of the adenomatous type of growth, and certain it is that pure chondroma, which is ordinarily non-malignant, may occur (Petit), while on the other hand chondromata are usually associated with sarcomatous, myxomatous, and fibrous tissues, and often osseous elements. The strictly innocent growths consist of fibroma, myxoma, lipoma, adenoma, or very often mixtures of these, and cysts. They are characterized by slow development, freedom from 304 Surgical Diseases and Surgery of the Dog pain, and after attainment of a certain size, quiescence. The malig- nant growths comprise sarcoma, carcinoma, and, as already stated, mixed chondromata. They are distinguishable from the former type by their more rapid growth, though they sometimes have periods of quiescence, by extension to neighboring lymphatics, by the pain and emaciation they induce, and by their tendency to ulce- rate and undergo generalization. Either type must always be carefully differentiated from inflammatory swellings and hernia, particularly the inguinal variety (see Hernia). Hematoma resulting from injury has been recorded by Rodet. Fibroma. This is a common form of mammary tumor. For- merly much confusion existed as to its proper classification and it was not infrequently confounded with adeno-fibroma. But, inas- much as the essential element in a fibroma is fibrous tissue and this type of growth develops as a pericanalicular fibrosis or proliferation and projection of connective tissue round the glandular acini, it is now recognized as pure fibroma. By this process of fibrosis groups of acini become isolated, and these undergoing compression, lose their glandular structure and appear as "islands" of cells. It was these "islands" of cells which were once mistaken for true neoplastic or adenomatous formations. Fibroma sometimes undergoes transformation into a myxo- matous condition. Symptoms and Diagnosis. This growth develops as a hard, knotty, mobile, and sharply-demarked swelling, varying in size from a pigeon's egg to the human fist, but may attain very large dimen- sions. The myxo-fibroma is considerably softer. Lipoma. The fat tumor occurs not uncommonly in plethoric females. Symptoms and Diagnosis. In consistence it is soft and larda- ceous. It grows slowly and is sharply demarked from the neigh- boring tissue. Adenoma. True adenoma occasionally occurs in the gland and is usually associated with more or less increased development of fibrous tissue. Adeno-fibroma is the commonest type of growth met with in this region. It may undergo progressive transition into malignant carcinoma. Isolated or generalized cystic degeneration is not at all uncommon. Symptoms and Diagnosis. In macroscopic appearance adenoma is very similar to fibroma, and is hard to differentiate, but is some- No. G7. Lii)oma of iMiumiiarv re No. 68. (After Ortscliild) Showing situation of primary Mammary Growth and the palpable Metastases. Site of nipples indicated by solid black dots. No. 69. True Carcinoma of the Mammary gland. The Abdomen 305 what softer, particularly when the cellular elements predominate over the fibrous. Sarcoma. Sarcoma occurs in pure form but more commonly associated with osseous and cartilaginous structures. Pure sarcoma is seen as a tuberculate growth, which may attain an enormous size. The neighboring lymphatics and subcutis are usually infiltrated, and the growth sometimes breaks through the skin. It is not common. Symptoms and Diagnosis. The growth is reddish in color with somewhat puckered surface and exceedingly soft and succulent and contains a jelly-like substance. The skin covering it may be mobile. It develops with great rapidity and is extremely metastatic. Garcinama. Carcinoma may arise from the glandular cells proper or the epithelium of the ducts. The skin covering the glands may also be primarily the seat of carcinoma which is not to be con- founded with that of the glands, though in the latter case the skin usually participates eventually. Myxoid transformation is not un- common, and such tumors may also become cystic through retro- gressive metamorphosis of the secretion of isolated normal acini. Metastasis to internal and vital parts is the rule. Carcinoma may originate as such per se, or as has already been pointed out, may become progressively such by metamorphosis from pre-existing adenoma. Primary carcinoma is infrequent. Symptoms and Diagnosis. Carcinoma occurs most commonly as a lobulated tumor, varying in size from a pea to a goose-egg, which may remain quiescent for longer or shorter period, and finally coalesce with the skin and degenerate. It usually occurs singly, bu^ secondary smaller growths are sometimes observed in the imme- diate neighborhood of the main one. More than one gland, how- ever, may be involved at the same time. Sudden increase in size may take place, due to interstitial hemorrhage. Symptoms and Diagnosis. Carcinoma is moderately hard and usually knotty. When cystic degeneration has taken place, fluctu- ating centers are perceived. Coalescence with the skin is recognized by the bluish or reddish appearance of the latter, and usually by eventual ulceration. Chondroma. Cartilaginous growths are common but they in- variably occur associated with other tissue elements, assisting in the formation of a complex structure into the constitution of which osseous, fibrous, and myxoid tissues enter. In some cases complete ossification takes place. These tumors are to some extent metas- 21 3o6 Surgical Diseases and Surgery of the Dog tatic and therefore possessed of malignant character. The manner in which this process takes place is described in the chapter on Neoplasms. Symptoms and Diagnosis. These tumors are easily recognized by their hardness. They are usually encapsulated, often lobulated, sharply demarked, free from the skin, and when removed surgically can be shelled out. In size, they vary from a corn-kernel to the human fist. More than one gland may be involved at one time. Treatment. Treatment of mammary tumors should always be operative, and no better rule can be observed than to practice early and free removal. When tumors are encapsulated or limited to definite areas the results are good, but when a primary growth is surrounded by a zone of infiltration, or when metastasis has taken place, or cachexia is present, the prognosis is unfavorable and re- currence may be looked for. The technic is very similar to that prescribed for neoplasms in general, the principal difference being that mammary tumors are usually very vascular and require greater precaution to guard against hemorrhage. Chronic Interstitial Fibrosis of the Teat. This condition can occur without the mammary gland proper being involved, but it is identical with chronic interstitial fibrosis or fibroma of the latter. The accompanying picture illustrates the extent to which it may develop. The cause is undetermined, but is probably microbic in origin. Irritation incident to sucking by the offspring is cer- tainly not necessary for its production, for it occurs in virgin females. Hereditary tendencies would seem to play a part, for I have seen it develop in identical teats in members of certain families. Symptoms and Diagnosis. One or more teats are observed to be considerably thickened and elongated. Taken in the hand the teat does not impart a hard feeling, but one of decided aug- mentation in volume. The gland to which the affected teat belongs is still capable of functioning, and the milk can readily be drawn off, but the teat itself is usually declined by the offspring. Treatment. The condition being an unsightly blemish calls for removal by surgical means, the technic of which differs in no wise from that prescribed for ablation of dermal tumors. BlBLIOaEAPHY. Lucet— Rec. de M6d. Vetfir. June, 1896. „. , , ^ MSgnln— Comptes rendHs de la Soc. de Biol. 1880, p. 30. Rodet— Eec. de MM. Veter. 1827, p. 42. No. 70. Chronic interstitial Fibrosis of the Teat. CHAPTER X The Extremities The Legs and Feet CONGENITAL MALFORMATIONS. A congenital malformation of the anterior legs is not infre- quently met with. The deformity is ordinarily confined to one member but may exist in both, and consists of a contracted condition of the flexor tendons, of variable degree, resulting in an unnatural flexion of the metacarpals or even a true club-foot (carpipes). The head of the radius may be dislocated. Symptoms and Diagnosis. Where the deformity is of minor degree, the foot can still be brought to the ground, but never in straight line, and lameness is evident. In extreme cases where the metacarpals are completely flexed on to the forearm, the carpus forms the point of contact with the ground. Treatment. In cases of minor deformity good results are obtainable by sub-carpal tenotomy, but the reverse is the case in true club-foot. Tenotomy is performed as follows: The animal being narcotized with morphine and securely hoppled, the hair shaved and skin cleansed, and cocaine injected locally, the skin is incised longitudinally on one side of the tendon. The leg is next flexed and the blade of a blunt-pointed tenotome inserted and di- rected flatwise to the anterior border of the tendon. The cutting edge of the blade is then turned towards the tendon, the leg is ex- tended, and the tendon severed from before backwards. Any re- sultant hemorrhage must be controlled by compression. Finally, a light splint is applied to maintain the leg in extension while reunion of the tendon is taking place. Nothing is done to the wound, which heals in the course of a week, but provision should be made for drainage in applying splints. TRAX7MATIC LESIONS. Fractures. See The Osseous System. 307 3o8 Surgical Diseases and Surgery of the Dog Rupture of the Tendo-Achilles. This contingency arises or- dinarily through traumatism. A severe gash accidentally or malev- olently sustained, a violent contusion, or crushing are the most common causes. In one instance, witnessed by Simonds, the animal, a Greyhound, had become impaled on an iron palisade, the point of the latter penetrating between the tibia and tendon and lacerating the tendon. Extreme muscular effort may also be responsible. Bayer and Bruckmueller have both recorded instances of tearing away of the tendon from its point of origin in the body of the muscle. Thus, it will be seen that the skin may or may not be involved. When complete division of the tendon has taken place the divided ends immediately separate, but if the lesion be only partial, separation may not occur for some days though it usually does so eventually through muscular contraction. Symptoms and Diagnosis. The behavior of the affected leg is characteristic. Functional impotency of the metatarsus is com- plete, the whole of the leg from the point of the hock to the toes coming in contact with the ground, after the manner of the rabbit. The animal is forced to walk on three legs. Examination of the postero-inferior aspect of the leg reveals either a wound or a de- pression corresponding to the separation of the divided ends. Treatment. This lesion, if left to Nature, usually terminates in spontaneous recovery, the continuity of the tendon becoming reestablished in the course of a few months by fibrous cicatrization. Collin recorded the history of four dogs whose master divided the tendon of one leg each in order to prevent them going off to hunt. In four months' time the animals were at their old habits, the lesion having completely recovered. The tendons in both legs were then severed, but six months later the dogs again returned to the hunt. In the larger breeds, where the distance separating the divided ends is more considerable, there is more risk of permanent im- potency through failure of reunion. Therefore, treatment should always be directed towards maintaining the leg immobilized in ex- treme extension by means of splints and bandages applied so as to extend from the patella to slightly beyond the digits, a drainage window being provided where the skin is involved. It is not ne- cessary to suture the divided ends, and the strain usually causes the sutures to tear out. Xo. 71. (After Ciididt and Breton.) Position assuniod b.v the Ipk after division of the Tendo-AclilHes. The Extremities 309 Traumatic Division of Tendons. This accident sometimes takes place through the legs coming in contact with a mowing ma- chine in the hayfield. Treatment. The same treatment is indicated as is described above. Wounds. Various wounds are received in the feet, among which may be mentioned cuts, pricks, crushing, burns, frost-bites, etc. Sometimes the pads become worn to excess by traveling over rough roads. The gravity of wounds depends upon their nature, extent, and presence or absence of foreign bodies. Symptoms and Diagnosis. In most lesions of the feet the pre- vailing symptom is lameness with a tendency to rest the injured foot by raising it, or, if both feet are affected, an assumption of the recumbent position. This being observed, it only remains to make a careful differential diagnosis. The practitioner must particularly distinguish between traumatisms and interdigital eczema, a trouble which is very common and which is usually mistaken for an injury by the laity. Worn pads are recognized by the animal constantly licking them. Fractured digital bones are often productive of fistula. Treatment. The first step is to examine carefully for the presence of foreign bodies, including fragments of digital bone, and if such are found to promptly remove them. The foot should then be thoroughly cleansed by irrigation with, or soaking well in, moderately hot water. If the injury is confined to one foot, the rest may be left to Nature, the healing process being closely watched, but the animal should be confined on a clean wooden or concrete floor. But if there should have been any considerable loss of tissue on the plantar surface of both feet, thereby causing the animal great pain during locomotion, protection should be afforded to the parts in the following manner : Some antiseptic powder is freely sprinkled over the plantar surface, a strip of gauze is placed over this, a pad of absorbent cotton over the latter, and over all a boot constructed of stout linen or thin leather. The dressing should be changed twice daily. In all cases of this nature absolute rest is to be en- forced. It requires about two weeks for the epithelium of worn pads to become regenerated. Fracture of the Nail. This is a quite common accident and may be partial with the nail only slightly disturbed in its matrix, or complete, when it is either suspended from its matrix or entirely 3IO Surgical Diseases and Surgery of the Dog torn away. It is accompanied with considerable pain and lameness. Treatment. Slight fractures are capable of recovery if left to Nature, but where there is much displacement of the nail it must be extirpated by grasping it with forceps and jerking it quickly away. When the phalanx is involved in the injury, it must also be removed by disarticulation. After-treatment is usually unnecessary, but the animal should be kept out of dirt as much as possible. INFLAMMATION. Inflammation of the Pads. This condition is observed prin- cipally in animals which have traveled over hard, rough ground, stubble, or asphalt during hot weather when the sun is strong. Symptoms and Diagnosis. The plantar surface of the feet is hot, swollen, and extremely sensitive to pressure. The animal seeks the recumbent position, shows great disinclination to rise, and walks with evident pain, but trots with comparative freedom. Treatment. The inflammation, when mild, responds quickly to complete rest supplemented with hot fomentations. When intense, the parts should be constantly fomented or covered with compresses soaked in astringent solutions (alum 3:100 — 5:100), to which some laudanum may be added with advantage. Inflammation of the Matrix of the Nail. Onychia. This is an ailment affecting the bed of the nail and occurs usually as a com- plication of traumatism or interdigital eczema. It may be acute or chronic and may lead to ulceration and destruction of the nail. Symptoms and Diagnosis. The animal walks with short, pain- ful step, and prefers the recumbent position or holds up the affected member. The matrix is hot, red, swollen and sensitive to pressure. If suppuration takes place purulent matter oozes from the matrix. Treatment. Acute cases are treated with fomentations. If the presence of pus is detected vent must be given to it by lancing. Ulcers are treated by touching them with the solid nitrate of silver stick, or by application of tincture of iodine. Old-standing cases, where the nail has suffered destruction, sometimes require complete extirpation of the affected phalanx. In-Growing Nail. This is a common trouble and affects the supplementary digit or dew-claw, the nail of which, not coming to the ground, escapes friction, and curves and grows to an abnormal The Extremities 311 length. Its point may penetrate the pad and provoke suppuration and lameness. For this reason dew-claws are frequently removed as a preventive meas- ure, otherwise it is necessary to cut the nails periodically (about every six months). Cutting is best done with bone- forceps or specially constructed clippers, no. 72. Naii cuppers, but care must be ob- served to avoid cutting to the quick. Interdigfital Eczema. This is a disorder of rather frequent occurrence and while it lasts is productive of considerable lameness. Among the laity the pathologic lesions and lameness are usually ascribed to traumatic influences. As the name indicates, the inflam- matory disturbance is confined to the skin of the interdigital region, but it is very apt to extend to and involve the matrix of the nail. Symptoms and Diagnosis. The animal is observed to be con- stantly licking or gnawing the parts and lameness is often very pronounced. On examining the foot, the skin of one or more inter- digital spaces is found to exhibit the characteristic appearance of eczema of other regions, viz., redness, edema, suppuration and ulceration. Treatment. The foot should be daily soaked for a good while in hot water or antiseptic solution. This is followed with a liberal application of absorbent antiseptic powder to the inflamed area. The foot should be protected with a bandage or boot, both to main- tain it free of dirt and to prevent the animal licking. Ulcers should be touched with the nitrate of silver stick. FOREIGN BODIES. Various substances may find lodgment in the foot, either acci- dentally or through human malevolence or carelessness. Among the recorded articles may be mentioned : shot, spikelets of grain, and sharp bodies such as splinters, thorns, and short lengths of wire. Elastic bands rolled on to the leg by children, ligatures applied by malevolent persons, snares in which the animal may get caught 312 Surgical Diseases and Surgery of the Dog while hunting, have each and all been known to result in serious in- jury to the parts. Foreign bodies may produce immediate or remote effects or they may be perfectly harmless. Aseptic bodies, and par- ticularly shot, often become encapsulated and exert no ill-effect. Infected bodies provoke inflammatory reaction and fistula. Any kind of sharp body may work its way up through the tissues to a distant area, leaving a fistulous tract behind it. A remarkable in- stance is recorded by Ducourneau who, on exploring an abscess in the digital region with a probe, found a fistulous tract extending as far as the knee. On opening at the latter point he found a spikelet of grass. The wound healed, but a new abscess developed higher up some days later, which on being opened was found to contain a second spikelet. Elastic bands impede the return circu- lation and may induce gangrene of the extremity when their tension is strong. When it is weak, they cut slowly into the tissues, causing a circular section of the skin and subcutaneous tissues with edema of the extremities. Non-elastic bands, such as thread, cause analo- gous results but their constricting action is quick. Treatment. The indications are to promptly extract foreign bodies of any nature, if necessary by incising the skin, with the ex- ception of aseptic ones which should be left alone unless they render the animal lame. The wounds are then treated as already outlined. If gangrene has set in the mortifying portion of the leg must be amputated, NEOPLASMS. All varieties of tumor occur in the legs, but only the more common growths affecting this part of the body will receive special consideration. These are the innocent adenoma, fibroma, lipoma, verruca, tyloma and hygroma of the elbow, hypertrophy of the stra- tum corneum of the pads (corns), interdigital serous cysts, and malignant carcinoma and sarcoma. Other forms, such as heman- gioma and chondroma, observed by Gurlt on the digits, are so extremely rare that they are to be regarded as pathologic curiosities and merit but a passing reference. Adenoma. These may be of sebaceous or sudoriparous origin. They usually occur mixed with fibrous tissue and are liable to undergo cystic degeneration. Common seats are the region of the knee and hock. There is good reason to believe that they may No. 73. (After Cadiot and Breton.) Elastic band on the Leg. N(i. 74. Filiro-adenonia of the Skin of the les exhiliitiiifr ii peiuling malignancy. The Extremities 313 undergo transformation into malignancy. The accompanying pic- ture illustrates a fibro-adenomatous growth which had arisen as a result of chronic irritation, that part of the leg having suffered constant friction from a chain. When removed and examined microscopically it showed evidence of impending malignancy. This case is referred to more fully in the chapter on Neoplasms. Symptoms and Diagnosis. As adenoma arises from the glands of the skin, it is intimately connected with the latter. It grows very slowly. Sudden rapid increase in size is to be regarded with suspicion as evidence of malignancy. It is usually rather firm but may be soft in places owing to cystic degeneration. When of long standing its weight may cause it to become pedunculate. Constant licking on the part of the animal may render it sore. , Treatment. Early and free removal should be practiced, par- ticularly on account of the possible malignant termination. Fibroma. This is a fairly common form of neoplasm about the extremities, particularly in young animals. It usually springs from the skin proper, but sometimes from the subcutis. Symptoms and Diagnosis. A tumor of this nature is recog- nized without much difficulty. It is sharply defined from the sur- rounding parts, has a regularly firm or hard consistence, smooth intact surface, is often pedunculate, and has a slow growth. Its average size is that of a walnut. Treatment. Ablation by the ordinary methods is indicated. Lipoma. Fat tumors are usually seen in plethoric animals advanced in years. Common seats are the shoulder and inner sur- face of the thigh. Symptoms and Diagnosis. Lipomata have a soft consistence, with a dermal covering, and may be round or cylindrical in shape. They are frequently pendulous, one observed by Huidekoper hang- ing from the thigh, having very nearly touched the ground. Treatment. These growths are removed in the ordinary way. Verruca. This occurs in the form of the familiar wart, which is fairly common in old animals, occurring at almost any part and often multiple. Symptoms and Diagnosis. Warts are recognized as smooth hemispherical elevations, sharply defined from the neighboring parts and sometimes pedunculate. Beyond forming a blemish they have little significance. 314 Surgical Diseases and Surgery of the Dog Treatment. Where it is desirable to remove them they are best excised by a snip of the scissors and the base touched with lunar caustic. Tyloma. Capped Elbow. This term is applied to the un- sightly callosities which develop in the skin principally in the region of the elbow but also elsewhere about the legs, and which are fre- quently complicated with hygroma, to be next described. They are particularly common in members of the larger breeds, viz., Great Danes, Mastiffs and Greyhounds, and develop as a result of constant intermittent friction and pressure, through the habit these animals have of lying in the sternal position and resting the elbow on the ground. Pathologically, they are an epidermal hypertrophy and hyperplasia, consisting of laminae of horny cells with but slight fibrous development. They sometimes ulcerate. Symptoms and Diagnosis. The condition exists as a callous thickening with bare, greyish surface. When ulceration takes place collateral edema may occur. Treatment. No treatment is advisable for the reason that the condition is merely a blemish and does not incommode the animal and would soon recur because of the persistence of the causative factor. Ulcers should be treated with nitrate of silver. Hygroma. As distinguished from tyloma, the term hygroma is applied to the fluctuating adventitious bursae which are frequently associated with it. They are cysts of contusion or true neoforma- tion, intermediate connective tissue becoming'bruised and torn, and spaces forming in which serous fluid and sometimes blood collect, which may (rarely) suppurate and discharge by fistulous opening. Organization by condensation of the adjacent connective tissue may take place when the condition again resolves itself into uncompli- cated tyloma. Symptoms and Diagnosis. Hygroma exists as an indolent, round or oval, uniformly fluctuating tumor, without peripheral in- duration and ordinarily without inflammatory reaction. It does not incommode the animal in any manner. Treatment. A cure is difficult of attainment, for the same rea- son as in tyloma. Simple puncture is valueless, for the cyst recurs as soon as the outer wound has healed. An attempt should first be made to excite an imflammation within the sac. By means of an aspirating syringe with large needle, the fluid is withdrawn from the No. 75. Multiplu Vorruca. No. 76. Intel-digital Serous Cyst. The Extremities 315 sac and some weak tincture of iodine injected in its place. The surface of the enlargement should also be painted daily with a strong tincture. Suppuration may or may not result; if it does, free exit should be given to the pus by lancing. Considerable collateral edema may develop. This treatment should be repeated a few times before being abandoned. The only other alternative is ablation in the following manner : The animal being narcotised and secured with hopples, the region cleansed, and hypodermic injections of cocaine administered locally, expose the sac by an incision in the skin in the direction of the long axis of the leg and carefully enucleate it. It is usually adherent to the olecranon. Finally, suture the skin with subcuticular silk sutures and provide the animal with a soft bed. Epithelial Hypertrophy of the Pads. Corns. This is an infrequent form of growth, but troublesome when it exists. Patho- logically, it is a circumscribed callosity which projects outwardly and inwardly, and forms a depression in the corium. Symptoms and Diagnosis. Corns are observed on the plantar surface of the digits as circumscribed projecting callosities, with regular or festooned contour, and possessed of a deep root. They give rise to much lameness. Treatment. Radical treatment is the shortest road to a cure. The callosity should be extirpated or eradicated by means of the actual cautery, and the foot subsequently protected with antiseptic powder, gauze, raw cotton, and a boot, until the parts are regener- ated. Interdigital Serous Cysts. These little enlargements are only occasionally met with. They are rather troublesome to deal with. Symptoms and Diagnosis. Attention is usually first drawn to their presence by constant gnawing and licking on the part of the animal at the interdigital region. There may be pronounced lame- ness. The little bladder-like sacs are easily discerned. Treatment. Radical measures are indicated. Complete re- moval of the cyst-wall, either by dissection or cauterization with the thermo-cautery or silver nitrate pencil is the only alternative to effectually eradicate the trouble. Carcinoma. As has already been stated, carcinoma may de- velop from a pre-existing non-malignant growth, but it also occurs as such per se. It is comparatively rare. 3i6 Surgical Diseases and Surgery of the Dog Symptoms anl Diagnosis. Carcinoma is recognized by its rapid growth, its hard consistence with occasional fluctuating or ulcerating foci, its puckered surface of reddish blue color denuded of hair, its intimate cohesion with the skin and its mobility from underlying structures. Treatment. Growths of this nature may be removed as soon as possible, together with a considerable area of the surrounding skin. When early and free removal is practiced, recidivation need not be feared. Sarcoma. Sarcoma arising either from the soft tissues or the bones occurs about the legs. In the former case it may spring from the skin proper or subcuticular tissues, and in the latter either from the periosteum or the interior of the bone cavites (myelogenic sarcoma). Myelogenic sarcoma usually develops in the cancellous tissue near the joints and the usual seat is the forearm or shoulder and lower extremity of the femur. The growth gradually causes expansion and distortion of the osseous shell, which, however, is continually being reformed from the greatly thickened periosteum, so that there ultimately results a local deformity of enormous di- mensions. Finally, it breaks down and discharges by fistulous tract. It may be remarked here that owing to the fact that myeloi.i sarcoma (of the center of the bone) is of distinctly low malignancy and very rarely forms secondary growths at a distance, the tendency now is to speak of this as "Myeloma" and separate it from the sarcomas proper. Symptoms and Diagnosis. Sarcoma arising from the soft tis- sues is characterized by very rapid growth, soft consistence and tendency to ulcerate. It is either intimately blended with the skin, when it is usually mobile from the subcutaneous structures, or lies subcutaneously when it is sessile. Periosteal and Myelogenic sar- coma is recognized by the local deformity and rapid increase in size of the enlargement. All the deeper forms are generally accom- panied with lameness. Treatment. Only the more superficial forms are eradicable by operative measures, though there are a few instances on record of treatment of bone sarcomata of the lower extremities by ampu- tation of the member above the seat of disease. The Extremities 317 AMPUTATION. Amputation of the leg is not very often practiced on the dog, for the reason that few people care to see their animals going about in a crippled condition, nevertheless occasions sometimes arise, when, either on account of value for breeding purposes or because of sentimental considerations, the practitioner is called upon to undertake the operation. The dog seems to be but little incom- moded by the loss of one leg, for he soon learns to run about fairly well with the remaining three, and particularly is this true when the lesion has occurred in the hind parts. Even when both fore-legs are missing he manages to progress by hopping on the hind-legs after the manner of the kangaroo. Furthermore, the wearing of an artificial support is perfectly feasible, and several cases of successful substitution have been recorded. A simple prop can be fashioned out of some light wood, around the upper end of which a strip of leather is attached to form a socket to snugly fit the stump of the member. The contrivance is held in place by means of a light leather harness reaching to the joint immediately above. Or if something more elaborate is desired the skill and experience of the artificial limb manufacturer may be sought. The lesions for which amputation is indicated are severe frac- tures, and malignant growths and gangrene of the extremities. The best way to perform the operation is as follows : The animal being hoppled and under general anesthesia and the parts freed of hair and thoroughly cleansed, a tourniquet is first applied above the area of the operation. A circular or wedge-shaped in- cision is made through the skin around the leg, a little distance below where the bone is to be divided. In order to provide for a flap to cover the extremity of the bone, the skin must then be retracted by gently drawing it towards the root of the member. Some slight dissection of the subcutaneous connective tissue may be necessary to properly free the skin. At the level of the retracted skin the muscles, tendons, and vessels are next severed to the bone. The latter is then divided with a saw. The amputated portion being removed, the vessels are sought for, clamped with artery forceps, and ligated with silk. All hemorrhage being stilled, the parts are irrigated with hot sterilized water, and the skin is gathered together with a subcuticular suture, the ends of the latter being 3i8 Surgical Diseases and Surgery of thei Dog allowed to protrude from the wound, to be removed later on when healing is complete, A dressing of antiseptic powder and gauze should be applied and held in place with bandages and renewed daily. A close watch must be kept for suppuration for a few succeeding days, and if such takes place an opening be made to give exit to the pus. As a rule, healing is quick to follow. AMPUTATION OF THE DEW-CLAW DIGIT. Dew-claws are unsightly, and it is frequently desirable to re- move them for this if for no other reason. But they may also become the seat of painful in-growing nail and of injury from extraneous causes. When the digit exhibits no union with the main bone it is a simple matter to snip it off with scissors, and if necessary, ligate the nutrient vessel. In this case, no sutures are necessary, the animal being allowed to attend to the wound itself. Where there is true bony connection, the operation partakes of the nature of true amputation, as described above. Suturing is generally advis- able, but the lower extremity of the wound should be left open to afford drainage. As in the preceding instance, the animal should be allowed to lick the wound, though by so doing it may rid itself of the stitches. DISARTICULATION OF THE PHALANGES. The various steps of this operation differ but little from those proper to Amputation, except that the section is made at the joint by division of the ligaments. BIBLIOGRAPHY. Bayer — Monatsh. f. prakt. Thlerhellk. 1896-8T) p. 18. Bruckmneller— Cited by Kltt In Lehrb. d. Path. Anat. Diagn. 1. Collin— Rec. de MM. V6t&r. 1824, p. 403. Ducourneau— Rec. de MM. V6t6r. 1000, p. 188. Hnldeboper — Jonrn. Comp. Med. & Surg. 1888, p. 160. Slmonds — Proceedings of the Vet. Abbu. 1840-41, p. 5T. The Tail CONGENITAL MALFORMATIONS. Anomalous formations are occasionally seen in newly-born animals. Heredity would seem to play a part. In one instance which came under my notice, in a family of Skye Terriers, some The Extremities 319 of the puppies of three consecutive generations were born with the two terminal coccygeal vertebrae bent at right angles. Fox Terriers and Poodles and other breeds which are ordinarily docked soon after birth sometimes come into the world with bobtails. Whether this variation can be regarded as a result of long-continued disuse through the practice of docking from remote times, it is difficult to say, though Darwin has pointed out, mutilations occasionally produce an inherited effect. A good example of artificial selection is seen in the Bob-tailed Sheep dog. TBAUMATIC LESIONS. The most common lesion to befall the tail is brushing or crush- ing from its being caught in a closing door. Usually, in these cases the wound is a compound one, but in some instances, as when the organ is trodden upon, a simple fracture may result. A very troublesome lesion is frequently seen in Great Danes. These ani- mals are possessed of very long tails, which they wag with great force. When confined in narrow quarters, constant pounding of the organ against a hard surface soon renders the extremity bruised and sore. Ulceration develops and the wound bleeds at the slightest irritation, the blood being swished about in all directions, to the disgust of everyone with whom the animal comes in contact. Fin- ally, the bone becomes necrosed. Prevention in these cases is in- finitely better than cure. If it is absolutely necessary that an animal be confined in narrow quarters the conditions which are productive of the trouble can be rendered nugatory by the adoption of a simple device. Strips of wood three or four inches in width are nailed to the wall lengthwise above the level of the animal's head on both sides and the back. From these some heavy draping made of stout material is suspended and allowed to reach almost to the floor. This acts as a buffer to the pounding tail, and the latter es- capes injury. Treatment. When the parts are badly crushed, amputation is necessitated, but as long as the bone is intact and only the soft parts injured, efforts should be directed towards saving the organ by the usual soothing antiseptic measures employed in wounds of this nature. Fractures, when simple, are treated as outlined in the chap- ter on Fractures, but the bandages must be of the very lightest character possible. Compound fractures generally necessitate am- 320 Surgical Diseases and Surgery of the Dog putation. Bruises of the extremity as observed in Great Danes, when there exists chronic tumefaction and ulceration are usually accompanied with necrosis of the terminal vertebra, when the latter must be disarticulated, by the flap method. Provision must then be made to prevent a recurrence of the trouble until the wound is healed. Besides the protective curtain advocated above, a sort of flange should be applied to the tip of the tail, just above the wound. This is best fashioned out of a long strip of felt about three quarters of an inch in width, which is smeared on one side with ordinary carpenter's glue. The hair being clipped short, this is then wound round the tail and on itself till a projection an inch or more in width is thereby formed. Glue is the best adhesive material for the skin, and when sufficiently thick, will hold any bandage in place, till the hair in growing out forces it away from the skin, when it can be peeled oiif with ease. When the tail is pounded against any surface, the flange forms the point of contact and saves the tissues, and if desired, bandages can be kept in place by tying above the flange. The flange is left in place until complete healing has occurred, and if it becomes displaced sooner must be reapplied. INFLAMMATORY AFFECTIONS. Circumscribed dermal inflammation may occur as a local mani- festation of eczema. Further irritation on the part of the animal itself by incessant scratching and biting soon sets up an ulcerating sore. Treatment. Treatment is difficult, and at the best, tedious, for most animals rebel at the application of bandage or muzzle. Nevertheless, persistence in this as in every difficult undertaking is usually crowned with success. The treatment most productive of good results consists of cauterization of the ulcer with the solid nitrate of silver, until a cicatricial inflammation is established, and subsequent liberal sprinkling of the inflamed area with some des- sicant analgesic powder, preferably xeroform, to which a little ortho- form may be added with advantage. The parts should be protected from further irritation by antiseptic gauze and cotton bandages whenever possible, every known device to keep the same in posi- tion being tried in rebellious animals. At the same time, the general health must be attended to, intestinal parasites eradicated, the bowels freely opened, and a course of tonic treatment instituted. The Extremities 321 Bad cases sometimes require weeks of persistent treatment. Some authors advise amputation as a last resort, the site of opera- tion being selected well away from the inflammatory area, but such radical treatment is rarely called for. NEOPLASMS. Besides fibroma, which is of occasional occurrence on the tail, malignant carcinoma is not uncommonly met with about the root of the appendage. It exhibits all the characteristics of the typical cancerous growth, developing rapidly, and having a hard con- sistence with uneven, ulcerating surface, and tending to infiltrate neighboring lymphatics. The method of treatment differs in no wise from that applied to tumors of the skin in other regions, the sole object being to cause total ablation. AMPUTATION. "Docking" of the tail is universally practiced as a fashionable measure on certain breeds, among which may be mentioned: Fox, Irish, Airedale, Welsh and Yorkshire Terriers ; Field, Cocker, Sus- sex and English Water Spaniels ; Griffons, Schipperkes ; and French Poodles. The puppies of the Bob-tailed Sheep dog sometimes re- quire a slight reduction of their appendages to make them conform to the standard. The length of stump allowed to remain in the different breeds varies. The Yorkshire Terrier is allowed a stump of medium length, about three inches (adult measure- ment), French Poodles one of three to five inches, Airedale Terriers of four to six inches, Sussex Spaniels of five to seven inches, and English Water Spaniels of seven to ten inches. The Bob-tailed Sheep dog is allowed only a maximum of two inches, and the re- moval is effected three or four days after birth. In the other an- imals, the operation is best performed a few days after birth, when the undesired extremity of the appendage may be snipped off with a pair of scissors, or removed with the tail gullotine, the skin being pulled towards the root of the tail while the action is being made. The bleeding rarely amounts to anything, and it can be easily con- trolled by temporary application of an elastic ligature or strip of tape. In adult animals, when the operation is necessitated as a gen- 22 322 Surgical Diseases and Surgery of the Dog uine surgical measure, more minute technic is required. It is practically identical with that of amputation of the leg, but the section is generally made at a joint so that it is in reality a dis- articulation. The animal should be narcotized with morphine and receive local injection of cocaine. The technic is as follows: The hair being clipped or shaved off at the site of operation the latter thoroughly cleansed, and the tourniquet applied above, the skin and subjacent tissues are divided by circular incision at a line from a half to one inch below the joint, and two opposite longitudinal in- cisions extended up to the level of the joint. The soft tissues of this area are next dissected from around the bone and the caudal vessels ligated. The joint is then severed by division of the liga- ments. The resulting flap should be secured with a single suture only, in order that drainage may be unhindered. The tourniquet is finally removed, and if any post-operative hemorrhage takes place it can be controlled by an elastic ligature slipped over the stump immediately above the wound. It is best to dispense with pro- tective bandages and not restrain the animal from licking the wound. It may be noted here that Dell attributed a case of pyemia which he experienced, to an amputation undertaken to relieve a crushed tail, the animal having been run over by a street car, but it is not unlikely that the disease had its origin in the lesion which necessitated the operation. BIBLIOGRAPHY. Darwin- — The Descent of Man. Dell — Joum. Comp. Med. & Vet. Archives 17, 1896, p. 100. CHAPTER XI The Osseous System TRAUMATIC LESIONS. Fractures FRACTURES IN GENERAL. Some interesting statistics of fractures have been tabulated by Froehner based on seventy-four thousand eight hundred and seventy-two cases of sickness and accidents treated by the staff of the BerHn Institution between the years 1886 and 1894. In this number one thousand six hundred and ninety-three were fractures, making a percentage of 2.3, or in other words, in every forty dogs treated, one had sustained a fracture. Fractures of the extremities were most common, amounting to ninety per cent of the whole, and one-half of all the fractures were observed to have occurred in the larger of the long bones. The prognosis of fractures in general must be regarded as very good, eighty-five per cent of Froehner's cases having com- pletely recovered, the remaining fifteen per cent having comprised the complicated, comminuted and pelvic fractures. In one-hundred and fifteen cases recorded by Stockfleth ninety-two completely re- covered. Froehner regards the prognosis of fractures in the dog as four times more favorable than in the horse. The causes of fractures are manifold, but result mostly from traumatism, such as run-overs, blows from clubs or balls, kicks from horses, falls from heights on to hard surfaces, bites of other dogs, gun-shots, and even extreme muscular action on the part of the animal itself, as occasionally occurs to the olecranon. Various local or general conditions such as necrosis and old age may exert a predisposing influence on the resisting power of the bones. Fractures may be partial or complete, compound or comminuted. Partial fractures commonly occur as fissures, splinters, per- 324 Surgical Diseases and Surgery of the Dog forations, or depressions, usually in flat bones, such as those of the skull. To these must be added subperiosteal or the so-called green- stick fractures in which the periosteum remains intact. Complete fractures are observed in long bones and form the majority of all fractures. A fracture is said to be compound when a wound exposes it to the atmosphere. A fracture is said to be comminuted when it is shattered into a number of fragments. The immediate result of a fracture is hemorrhage from the local vessels or those of adjacent parts which may be involved in the injury. Inflammation is precipitated, giving rise to hypere- mia and swelling of the contiguous tissue. In a few days these subside, and finally there arise reparative processes associated with callous formation. The process of solidification of the callus is complete within fifteen to thirty days. Stockfleth observed com- mencing ossification of the callus in a fracture of one of the lower extremities, twelve days after receipt of the injury. It is more rapid in the young and slower in the old. The ensheathing portion becomes absorbed within thirty to sixty days, while the central callus remains for a while, completely occluding the medullary canal, but it also undergoes absorption at a later period. Muscular action, particularly in cases of oblique fracture, may cause considerable overriding of the broken extremities, the latter being sometimes separated from one another such distance as to make it no easy matter to replace them in correct apposition. Separation of the epiphyses frequently occurs in very young animals through slight traumatic influences or excessive motion. Symptoms and Diagnosis. The chief symptoms are: Local pain and swelling, more or less distortion of natural outlines, loss of function, preternatural mobility in all directions, and crepitus. Crepitus, however, is not invariably present, as when muscular fibers or tendons become interposed between the fractured extremities or when the hemorrhage is considerable. Separated epiphyses are distinguished from luxations with diffi- culty. Crepitus is less noticeable than in true fracture, being "softer," and it may be entirely absent. Treatment. The object to be attained in treating a fracture is reduction of any existing displacement of the broken ends and The Osseous System 325 their retention in normal alignment. This is accomplished by rend- ering the parts immobile by means of suitable splints and bandages. As a rule, immobilization is indispensable, but exceptional cases occur, as when a broken rib, which is in constant motion, becomes reunited in a short while. The authorities in general teach that a broken bone should be set and immobilized as soon after receipt of the injury as possible. I have long ago discarded this method of procedure, close observation of a great many cases having taught me that it is far better surgery in the dog to await the dis- appearance of all swelling incident to the injury before attempting surgical interference. Following almost every fracture there occurs more or less in- flammation of the adjacent soft parts which is attended with con- siderable tumefaction and pain. The application of non-resistant bandages before the swelling is in evidence cannot be made to diminish the interstitial effusion and tension to any extent with safety, but rather serves to increase the latter, menacing free circu- lation, involving risk of constriction and consequent gangrene, and augmenting the discomfort of the animal. Moreover, it necessi- tates frequent inspection at short intervals. If such bandages are applied after the parts have become swollen they are soon rendered so loose by subsidence of the swelling as to need renewal. Hence, it is my practice to wait some three or four days for a reaction. It may be argued that postponement involves risk of converting a simple into a compound fracture. This is a matter which may be left with absolute safety to the injured animal itself, provided the latter is allowed to rest. I have never known such an accident to happen. The advocates of immediate bandaging find it necessary to advise that the foot be included in the bandage in order to prevent dropsical swelling and stasis of circulation. By covering up the foot we deprive ourselves of our best means of ascertaining whether the bandage is too tightly applied or not, but on the other hand, if we do not apply the bandage until the primary swelling has sub- sided, the foot may be left free with perfect safety, as all danger of pressure-necrosis from inflammatory swelling is past. Too firm application must, however, still be guarded against. Reduction and setting with dressings is effected in the follow- ing manner : Correct overriding by grasping the lower segment and submitting it to firm and steady traction. When the ends arrive 326 Surgical Diseases and Surgery of the Dog in contact, correct the lateral displacement by direct pressure. Re- duction may usually be effected by steady traction and manipulation, but in some cases where overlapping is great and muscular rigidity marked, general anesthesia should first be induced. Instead of chloroform or ether, chloretone or chloral hydrate may be admin- istered. The help of an assistant may also be required. The de- gree of overriding present may be approximately ascertained b}- measurement of both legs with a tape measure, the injured member being found shorter than its fellow. The actual condition or posi- tion of the fractured ends may be ascertained with the aid of a skiagraph. In some cases even if the overriding is successfully reduced, the ends of the bones cannot be maintained in apposition owing to the conformation of the parts preventing accurate bandaging. This is particularly true of oblique fractures of the scapula, upper ex- tremity of the humerus, and the femur. The only alternative is to inidertake suturing of the broken ends. Normal apposition being secured, smear the leg freely with oil or vaseline. A protective layer of any material is bulky and un- necessary, the oil being sufficient to prevent friction, except at pro- minences, which should be protected by padding about, but not on them. If supporting splints are to be used, have them previously moulded or shaped to conform to the contour of the leg, lay them in place, and secure them with strips of adhesive plaster. For large and medium sized animals splints are best made with strips of poro- plastic felt, which can be moulded to the desired shape after moisten- ing in hot water. A very light and inexpensive splint for the smaller animals may be made out of the thin wooden platters on which pastry-cooks serve pies, and dairymen butter, to their customers. Rectangular splints may be made out of stout cardboard, cut, bent, and glued together as desired. Supports should always be longer than the broken bone. Wind the bandage round the leg, commencing from the inferior extremity and giving it a turn as found convenient, and taking care to include the joints at either end of the broken bone. See that the dressing is perfectly dry before the animal is allowed to move. The permanent dressings which find most favor are made of strips of gauze or cheesecloth thoroughly impregnated with dry plaster of paris, sodium silicate, or starch, and rolled. A bandage The Osseous System 327 so prepared is soaked in warm water until air-bubbles no longer rise from it to the surface, which indicates that all parts of the roll have become saturated. It is then immediately applied. To afford additional rigidity the ingredients may be smeared over the bandage while it is being applied. Plaster of paris sets quickly, but makes a very heavy dressing. A little salt added to the water makes it harden still quicker, but so rapidly as to be of dis- advantage. Pure silicate of soda bandages, while having the ad- vantage of lightness, are impracticable, as a rule, as they take several hours to become perfectly hardened. Mueller overcomes this drawback by interposing small splints of wire gauze, or smear- ing plaster of paris thinly in between the layers. Starch is also slow to harden. Stockfleth advises the addition of a little mucilage to assist the process. Another very useful immobile bandage, par- ticularly for small animals, may be made by the addition of thick mucilage or glue to strips of cotton. I consider the best preparation to consist of a mixture of resin and beeswax, two parts of the former to one part of the latter. This is heated together until the ingredients are dissolved. It is smeared over strips of bandaging material, and the latter applied while it is still warm. This makes a very light, strong dressing, and it is also quick to harden. Where there are no pronounced prominences or angularities to be included, shoemakers' leather makes an excellent support with- out any need of bandages. It is cut in one piece slightly smaller than the circumference of the parts and moulded to the normal shape of the leg in the same manner as felt, and allowed to dry. Holes are punctured at short intervals near both margins, and it is applied and kept in place by lacing. Bandages can be removed by cutting with scissors, bone-for- ceps, or any of the various makes of bandage shears. Plaster of paris may be removed by pouring dilute acetic acid or vinegar along the line to be cut, and then cutting the cloth with a knife, layer after layer. Mucilaginous bandages may be immersed in hot water, leg and all. In general, fractured large bones need support by immobiliza- tion for a period of at least four weeks, and the small bones some two weeks. It is sometimes found necessary to muzzle dogs under treat- 328 Surgical Diseases and Surgery of the Dog ment for fracture to prevent them from tearing off the bandages I have never found smearing the latter with bitter or noxious sub- stances to answer the purpose, for an antagonistic dog will go to almost any extreme to rid itself of what it regards as an imposition. Too firm application of bandages becomes manifest by exhi- bition on the part of the animal of pain, uneasiness, anorexia, fever, and local swelling. Sometimes the edges of a bandage will abrade the skin and originate local ulceration. In either case the bandage must be removed in whole or part. Persistence of functional im- potency after a reasonable course of treatment indicates pseudar- throdic formation or anchylosis following intraarticular fracture. In compound fractures it must first be decided whether ampu- tation is indicated or not. If it is believed that the leg can be re- stored to usefulness, thorough antisepsis must first be employed. The interior as well as the exterior of the wound is cleaned and disinfected, detached portions of bone removed and counter-open- ings made for drainage if necessary. The application of fixed band- ages may be postponed until healing of the superficial wound has taken place, though if it is considered advisable some support may be given by the use of temporary splints. Or, the fracture may be treated as a simple one, but a "window" must be arranged over the wound to permit of free drainage. FRACTURES IN PARTICULAR. The Cranial Bones. Fractures of the cranial bones are uncom- mon. In five hundred and forty-eight of Froehner's cases there were only four. The chances of recovery depend upon the pre- sence or absence of intracranial complications, septic infection, and the degree of injury sustained by the brain. Froehner says these cases usually terminate fatally. Moeller states that he has witnessed and successfully treated several cases in which both skull and brain were injured. There may be many degrees of injury from simple fissure in the external lamellae to penetrating, depressed, or compound fractures and those accompanied by intracranial hemorrhage. Martin in- stanced a case of simple external fracture, in which he removed two pieces of bone consisting of almost the entire covering of the frontal sinus, from the depths of a fistula, which had been discharging just above the left eye for more than a month. Whitlamsmith sue- No 77 (After Cadiot and Breton.) The effect of too tight or too early bandaging. The Osseous System 329 cessfully treated a penetrating fracture of the frontal bone, half an inch in length and one eighth of an inch in width caused by a butcher's knife which had been thrown at the animal. Part of the brain substance, the size of a horse-bean, protruded through the wound. The symptoms to which these injuries gave rise were: partial paralysis of the right side but without loss of consciousness, knuckling over of the knee whenever weight was put on that limb, and aimless movements to the right in an irregular sort of circle. The protruding portion of brain was removed, the skin shaved and dressed antiseptically and the edges of the wound drawn tightly together by silk sutures. Complete recovery ensued in a week. The great danger of penetrating fractures which are not of sufficient extent to immediately cause death is the liability to intra- cranial suppuration. Depressed fractures are always dangerous through their causing compression of the brain. The cranial cavity is completely filled by the brain, its meninges, blood vessels and fluids. Any decrease in its capacity necessarily results in com- pression of the contained organs. While it is known that the cerebro- spinal fluid under the influence of pressure is forced into the spinal canal, thus permitting of a certain degree of accommodation to new conditions, experiments have established the fact that compression of the brain by one-sixth of its volume of any material is fatal, and attended by very serious results under much less. Pagenstecher studied the effects of brain-compression produced by injecting wax between the dura mater and cranial vault. His researches showed that the capacity of the skull could be diminished about one-thirtieth without inducing cerebral phenomena. Depressed fractures become evident through change of contour and by examination with finger and eye. The symptoms appear concurrently with the receipt of the injury. Owing to the increase of intracranial pressure the blood flow is retarded and together with the direct influence of the compressing body there ensue either restlessness, stupor, or coma, with slow respiration and hemiplegia or limited paralysis of certain groups of muscles. In one of Moel- ler's cases the animal remained deaf during the rest of its life, and subsequently it was demonstrated at the necropsy that the temporal bone had sustained marked injury. Uebelen treated a Pointer which was in a comatose condition. The kick of a horse had shattered the whole of the left side of the 330 Surgical Diseases and Surgery of the Dog cranial vault. Part of the muscular tissue covering the skull was dissected and the splinters (sixteen in number) were removed, some of them having to be loosened from the dura. Sharp projections remaining were smoothed, the wound treated with carbolized oil and the skin sewed up. Immediately after the operation the dog recovered consciousness and evinced a desire to run about. In three weeks the wound had healed but the parts remained soft underneath. There was no permanent disturbance of mental function. Fractures of the basal bones are invariably fatal either from severe concussion or laceration of brain tissue, or rupture of intra- cranial vessels with formation of blood-clots in consequence of which compression of the vital centers takes place resulting in their para- lysis. In these cases the onset of the symptoms may be gradual though the animal may be at first rendered temporarily unconscious from concussion. In addition to well-defined examples of fracture the practitioner may be confronted with obscure cases of injury in which there is good reason to believe that the main lesion consists solely of con- cussion and which completely recover in a very short while. Among the symptoms are : total loss of consciousness, inability to coordinate movements, weakened pulse, and occasional vomiting. Treatment. This is varied according to the presence or absence of intracranial complications. Simple fractures require but local treatment of any parenchymatous contusion and removal of bone splinters, the rest being left to natural processes of repair. In pene- trating wounds the chief danger consists in the liability to septic inflammation. Accordingly, antisepsis must be maintained until recovery. It may be found advisable to trephine for purposes of ample disinfection, removing the portion of bone which has sus- tained the perforation. Unless there be absence of any brain dis- turbance depressed fractures should always be remedied by surgical interference. If this cannot be accomplished in a simple manner the skull must be trephined close to the depression, and in the hole thus made a suitable instrument introduced to elevate the depressed portion of bone. Compound cases are treated by antisepsis. Comminuted cases with loss of substance may be treated on the plan outlined by Uebelen, but unless the periosteum is preserved no true ossific regeneration can take place, the open space becoming The Osseous System 331 filled with dense connective tissue. Ossification can, however, be promoted by the practice of Osteoplasty. The Inferior Maocilla. Of all the head bones the inferior maxilla is most commonly fractured. The lesion usually occurs either at about the level of insertion of the second premolar imme- diately posterior to the root of the canine tooth, or at the symphisis. In the former position the fracture may exist simultaneously in both halves or be confined to one side. This fracture is frequently com- pound through laceration of the mucosa. It generally results from direct violence, but in rare instances may be attributable to indirect force exerted at a distant point. Such a case came under my notice. A bullet shattered the bone posterior to the last molar and it was concluded that the force of the missile exerted at this point had tended to bend it downward or inward to the extent that it snapped at its weakest spot, as a separate and distinct fracture also existed just posterior to the root of the canine tooth and involved the second premolar which was split into two distinct portions. This specimen is in the Museum of the Army Medical Department. Chronic mercurial poisoning has a peculiar effect on the lower jaw bones. There is an interesting specimen in the Pathologic Museum at the Copenhagen School. It consists of the skull of an aged hunting dog which had suffered from chronic mercurial poison- ing through excessive dosing of the drug for a cancerous growth of the mammae. The lower jaw is carious, some molars are missing and the left ramus is broken across the middle (Stockfleth). Symptoms and Diagnosis. Characteristic are displacement of the jaw so that the level of the teeth on one side is lower than on the other, associated sometimes with lateral displacement, local tume- faction and crepitation, salivation, difficult or suspended prehension of food, and at times bleeding at the mouth. Treatment. This is beset with difficulty. For fractured sym- physis interdental splinting should first be tried. This is accom- plished by passing and securely binding a piece of silver wire round the canine and incisor teeth as near to their necks as possible but free from the gums. It is sometimes necessary to file a slight groove in the postero-lateral aspect of the canines to retain the wire in position. Should this method prove unsuccessful the two separated rami must be wired together with silver wire, the latter operation being performed externally with the animal under general anesthesia 332 Surgical Diseases and Surgery of the Dog as follows: Make a transverse incision through the skin over the symphysis until the bone is exposed. Approximate the fragments and drill a hole with a fine drill or bradawl transversely through both halves midway between either extremity and near to the margin of the symphisis, so as to avoid the roots of the canines. Then intro- duce the wire, twist it, cut the ends off short and let them protrude through the skin wound. With favorable progress, withdraw the wire at the expiration of three or four weeks and promote healing of the superficial wound. Fractures through the body are best treated by application of a permanent well-padded leather or wire muzzle, to remain on the animal some three or four weeks. This muzzle must be firmly ap- plied so that no mandibular motion is possible. The animal can be fed on liquids administered by means of a funnel and tube, and allowed to trickle through the teeth. Thirst must also be assuaged in like manner. The mouth should be cleaned and disinfected daily. Stockfleth successfully treated a case of unilateral fracture by application of a splint of gutta percha. This was moulded to the normal shape of the jaws and held in place with bandages to include the muzzle and neck. In another instance he observed a comminuted fracture heal by ligamentous union, but the animal experienced considerable difficulty in gnawing bones, etc. When reunion fails to take place by this method, the fractured parts must be wired together as described above. Froehner com- pletely removes the broken fragment, but this should not be done until every other method has been tried and found unavailing. The Hyoid Bone. Fracture of this bone generally occurs in one of the greater cornua. It may follow violent seizure of an animal by the throat, a method of apprehension in vogue among members of the pound corps in some cities. Symptoms and Diagnosis. The symptoms are local swelling, dysphagia, and bleeding from the mouth when the mucosa is per- forated by fragments. Treatment. No treatment is possible. The Vertebral Column. Fractures in this region are mostly observed in the cervical, lumbar, and coccygeal portions. The prog- nosis depends on the presence or absence of dislocation and the amount of damage sustained by the cord. Unless the spinous pro- cesses alone are concerned, when the cord is seldom injured, dis- location is the rule. The Osseous System 333 The coccygeal vertebrae become broken mostly through the tail being run over or caught in doors. Symptoms and Diagnosis. The principal symptoms are ten- derness, crepitus, and motor and sensory paralysis. Crepitus and tenderness alone must not be regarded as serious symptoms since they may arise merely from fracture of a spinous process. When the lesion is in the cervical region, death is usually im- mediate, owing to paralysis of the phrenic nerve, that nerve having its origin in the fifth, sixth, and seventh cervical pairs. If the frac- ture occurs at or posterior to the seventh cervical vertebra, the phrenic nerve still functions and supports respiration which becomes then wholly diaphragmatic, the function of the intercostals being destroyed. The neck is held stiffly and crepitus may be noticed if the head is submitted to a twisting motion. In the lumbar and sacral regions the symptoms are : paraplegia, and paralysis of the rectum and bladder. The intestines become tympanitic from reduced innervation. It is sometimes a matter of difficulty to make an early differ- ential diagnosis between true dislocation, fracture of the vertebral column and simple injury sustained by the cord from violent con- cussion resulting from falls from great heights, which are far from common. The cord may become ruptured or hemorrhage take place into the canal. In these cases the symptoms usually disappear within one or two weeks and recovery is often complete but will of course depend upon the presence and extent of hemorrhage or degene- ration. Treatment. No treatment of fracture is possible. Concussion cases must have rest, administration of water and liquid nourish- ment and assistance in evacuation of the bowels with the aid of enemata if necessary. The animal must be frequently turned to prevent the formation of bedsores. Simple fracture of coccygeal vertebrae is treated in the same manner as a broken leg, but the bandage must be of the lightest character possible, and made to include three or four vertebrae on either side. When compound the prognosis is unfavorable and the tail has eventually to be amputated above the seat of injury. The Stemum. Fracture of this bone is a lesion of great rarity. Koenig and Zundel have seen instances in which a run-over was the productive factor. 334 Surgical Diseases and Surgery of the Dog Symptoms and Diagnosis. Where no displacement exists there are no significant symptoms. There may be crepitation during respiratory movements. Treatment. If the fragments are in apposition the animal should be maintained at rest until consolidation is effected. If displacement is evident it may usually be reduced by simple manipu- lation. The Ribs. These bones are more often fractured than those of the vertebral column. One or more may be broken, but unless this takes place simultaneously there is not necessarily much, if any, displacement. The prognosis is favorable provided pleuritis or pneumonia do not supervene. Laceration of lung tissue may occur when the violence is great. Symptoms and Diagnosis. Displacement is recognized by ele- vation or depression at the seat of fracture and local pain. Cellular emphysema will be present, and may extend over a large area, when the lung tissue is wounded. Crepitus is not always distinguished, but its presence is best determined by auscultation immediately over the area. The affected side of the thorax may be held rigid. Treatment. This fracture is treated by securing immobiliza- tion of the chest by means of broad bandages tightly applied. Re- covery is the rule. The Scapula. The scapula sustains fractures mostly in the vicinity of the head and neck. As a rule, there is very little displacement. Separation of epiphyses is not uncommon in puppies. Symptoms and Diagnosis. The entire leg hangs loosely with the phalanges dragging on the ground, leading to considerable abrasion of the latter. Treatment. In my own practice I have often left these frac- tures to Nature, in nearly every case with favorable result. Where there is much overriding or tendency to pseudarthrodic formation it is advisable to undertake internal splinting or wiring of the frac- tured extremities. German practitioners apply a saddle-bandage which is well-padded and made to pass over the shoulder. English veterinarians apply a plaster consisting of a mixture of resin one part, Venice turpentine three parts, and burgundy pitch five parts, put on with a spatula while hot. The exterior is covered with some material to prevent it sticking to other objects. The Humerus. According to Froehner, this bone sustains The Osseous System 335 fracture mostly in the lower extremity just above the trochleas where the shaft is weakest. In fifty-four of Froehner's cases eighty-three per cent were in the lower third. Fracture may also take place in one or both condyles in one or both legs. Moeller quotes Stock- fleth to the effect that in twenty-six cases observed by him nineteen were of fractured condyles and the remainder of fractured shaft. The external condyle is more frequently fractured than the internal, and usually the displacement is not great, the fractured portion of bone being retained near its normal position by the external lateral ligament. Symptoms and Diagnosis. In fracture of the shaft or condyle of one leg the animal moves about on three legs or sits on its haunches without placing the injured member to the ground. When the condyles of both legs are broken locomotion is peculiarly char- acteristic, the animal either creeping or depending wholly on its hind legs for propulsive power, kangaroo fashion. At rest, the weight of the body is supported mainly by the haunches, the fore- legs propped out in front. In severe bilateral fractures of leg-bones a prone position is assumed. Treatment. Fracture of the shaft, being high up, is rather difficult to treat, and if little displacement is evident is perhaps best left to natural processes. In cases of much overriding, the wiring operation should be performed. The lower extremity of the shaft is more amenable to bandaging, and there is a belief that the joint should be flexed to avoid imperfect reunion. Fractured condyle should be bandaged with the joint in full extension. Healing of the latter class of cases is apt to be imperfect through ligamentous union. Hertwig states that perfect reunion is the rule in young dogs. In one of Stockfleth's cases the animal regained complete use of the leg, though the fractured portion became almost entirely absorbed and the union was ligamentous. When ossific reunion has taken place and the splints have been removed, there is usually considerable stiffness, which, however, soon disappears with use of the parts. The Radius and Ulna. These bones form the seat of about one-half of all the fractures of the fore-legs, and from one-half to two-thirds of these occur in the lower third of these bones. Usually both bones are broken together. When one bone alone is concerned it is generally the ulna and in the olecranon, owing to the prominence 336 Surgical Diseases and Surgery of the Dog of the latter. The olecranon has been known to become fractured through great and sudden exertion of the triceps muscle. Fracture of the radius alone may escape notice, through its consort sufficing to support the weight of the body. The prognosis is most favorable of all fractures, only three in one hundred and twenty-two of Froeh- ner's cases haying failed to become reunited. In the early part of the last century Sir Astley Cooper made some experimental obser- vations on fracture of the olecranon. He found that in a transverse fracture the action of the triceps muscle drew up the fractured portion from one-half to two inches, the extent of separation de- pending on the degree of laceration of the ligamentous fibers pro- ceeding from the coronoid process to the olecranon. If the ole- cranon was broken off within the insertion of the coronoid ligament, and the fibers of the latter remained intact, the detached portion moved laterally but separated little from the ulna, and bony reunion easily took place. If, however, the break took place beyond the liga- mentary insertion, and the detached portion was separated by the action of the triceps muscle ligamentous union ensued from lack of adaptation. A longitudinal fracture produced with but slight obli- quity, so that the broken portions still remained in contact, readily gave place to osseous reunion. Treatment. Treatment of transverse fracture of the olecranon with separation must therefore include adaptation to the detached portion, which is best secured by suturing with silver wire, as fol- lows: Under strict asepsis, expose the ulna by a longitudinal in- cision, and clean away all blood-clots, etc. Drill corresponding holes by means of a bradawl or small drill from the posterior surface of No. 78. Diagram illustrative of Bone-suturing. each portion of the bone through its thickness to the fractured sur- face. Introduce the wire, approximate the parts, twist the wire and leave the ends long to hang out of the wound to permit of their The Osseous System 337 subsequent removal. The leg should be further secured with splints, the joint being kept fully extended. Treatment of other fractures of these bones is on the general principles already described. In young dogs imperfect reunion of separated epiphyses is occasionally seen. Such cases are treated by refracture, which is usually easily accomplished manually. The Carpus. The carpal bones are rarely fractured. The Metacarpal Bones. These bones are quite commonly the seat of fracture, especially in their upper or middle third, and one or all the bones may be involved. Fracture of a single bone, not being sufficient to cause a deviation of the parts from normal posi- tion, the local swelling may at first sight suggest nothing worse than simple contusion, consequently injuries in this region should always be carefully examined before a diagnosis is given. Treatment. The necessity of treatment will depend on the ex- tent of the fracture. The Digital Bones. These usually sustain compound fractures from the foot being caught in doors, run over, or trodden on by horses. The broken extremities can be seen and felt through the external wound. Treatment. In the treatment of these cases all splinters must be removed, and it is sometimes necessary to resort to amputation. The Pelvis. The pelvis may be fractured in any or all por- tions. Fractures of this bone are often comminuted and compli- cated with damage to the lumbar and sacral vertebrae, and have their seat mostly in the external angle of the ilium, in the acetabulum, or at the symphysis. They are often bilateral. An occasional com- plication is rupture of the urethra. Rectal or vaginal palpation is often of assistance in arriving at a correct conclusion. The prog- nosis is doubtful, permanent lameness often remaining, though simple fractures will sometimes make a good recovery provided the animal is restrained in its movements. In brood-females this acci- dent is particularly dangerous owing to resultant constriction of the pelvic apertures which may necessitate delivery of the young by Cesarean section. Hertwig believed that fracture was the most common cause of pelvic deformity though rachitic conditions might produce distortion in some instances. F. Mueller witnessed a case in which the passage was so narrow that it would scarcely admit of introduction of the finger. 23 338 Surgical Diseases and Surgery of the Dog Treatment. There is no treatment possible except for frac- ture of the symphysis, and reunion of these parts is assisted by suturing with silver wire, as follows : Make the skin incision imme- diately over the symphysis and to one side of the penis in the male. Avoid injuring the dorsal vessels of the penis in the male and the plexus of veins from the clitoris in the female, as hemorrhage there- from is somewhat difficult to control. Separate the subjacent mus- cular tissue until the fractured parts are exposed. Drill correspond- ing holes in each half, close to the symphysis, introduce the wire, approximate, twist the wire, and treat it and the wound in the way already described. After this operation allow the animal perfect rest and quiet until reunion is accomplished. The Penial Bane. Ben-Danou has recorded an instance of fracture of this bone in a Bulldog which was probably the result of brutal handling by some person immediately after the animal had copulated. Taylor has also recorded a case resulting from a fight. Symptoms and Diagnosis. In the Ben-Danou case the penis was tumefied and discolored. The animal made fruitless attempts to urinate during which a few drops of blood escaped from the meatus. Passage of the sound was arrested by an obstacle the na- ture of which could not be determined. Anuria being complete the bladder became much distended. The animal died three days later. At the necropsy it was found that the bone was fractured at its narrowest portion and the two broken extremities were overriding and embedded in the penial tissues. The urethra was twisted out of its natural position. Treatment. Treatment in case of this nature would be by slitting up the prepuce and amputating the organ at the seat of in- jury, in the meantime withdrawing the urine by aspiration of the bladder. The Femur. Fractures of the femur occur mostly in the middle third in adult animals and in the lower third in young ones. Stockfleth saw one case in which both the neck and inferior third were broken. They are usually accompanied by considerable over- riding or displacement through muscular action, thereby causing shortening of the leg. In fracture of the shaft the broken ends are sometimes forced so far apart as to result in ligamentous union with permanent lameness unless remedied surgically. According to Sir Astley Cooper's experimental observations, The Osseous System 339 fractures through the cervix entirely within the capsular ligament are incapable of ossific reunion. He ascribed this deficiency to the feebleness of ossific action in the heads of long bones and to the fact that the trochanter was much drawn up by muscular action so that the head and cervix were not in apposition. Where the experi- mental fracture continued compound the head of the bone became absorbed or discharged by ulceration. By way of contrast he di- vided the bone external to the capsule in five dogs and all healed by ossific union, as was also the case in longitudinal fracture. Symptoms and Diagnosis. Dislocation of the hip-joint has been mistaken for fracture through the neck. In both accidents the leg is seen to be shorter than its fellow. In fracture through the neck this is due to muscular action drawing up the trochanter, and it is to be distinguished from dislocation by greater mobility of the leg. In fracture of the lower third the stifle is held fixed with the leg pointing backward, and with the foot raised from the ground. Such accidents are apt to result per- manently in more or less lameness owing to distorted reunion or changes in the relationship of the fractures composing the stifle- joint. Treatment. The German and English methods of treatment of shaft fractures are the same as for the upper bones of the fore- leg, viz., by means of the saddle bandage and pitch plaster, respec- tively. French veterinarians use strips of bandaging material which are wound round the parts and coated with pitch. Where there is much overriding and consequent risk of pseu- darthrodic formation bone suturing should be undertaken, the in- cision being made on the inner aspect of the leg with due regard to the position of the femoral vessels. Felizet treated a dog suflfer- ing from a fracture of the neck of the femur by strapping the animal to a board. In twelve days consolidation had taken place. As a rule, fractures of the femur heal kindly, and some ap- parently hopeless cases of fracture near the neck will entirely re- cover without any treatment whatever. The Patella. This bone being small in the dog is rarely frac- tured. Sir Astley Cooper's experiments on this bone show to what extent recovery may be expected. He was unable to produce bony reunion in transverse fractures, even when the rectus femoris was divided just above. In longitudinal fractures there followed com- 340 Surgical Diseases and Surgery of the Dog plete reunion provided the lesion did not extend into the tendon above or the ligament below so that the parts remained in apposition. Where both tendon and ligament participated there resulted separa- tion of the broken portion and ligamentous union. The Tibia and Fibula. Like the corresponding bones in the anterior extremity, the tibia and fibula sustain fracture mostly in the lower third. They require no modification of the general method of treatment. Fractures of these bones heal very kindly. PSEUDARTHROSIS. When, through extensive overriding or defective immobili- zation, approximation of the separated periosteum fails to take place, the indispensable source of bone supply is wanting, and reunion stops short at connective tissue formation without ossification, and thus is produced a false- joint. This is particularly true in old ani- mals in which the potency of the regenerative power is often im- paired. Symptoms and Diagnosis. The symptoms of false- joint consist of persistence of functional impotency of the affected member, and mobility of the distal extremity but without crepitus or pain. Treatment. The best method of remedying the defect is by resection operation, in which the false tissue is cut away, broken down, or cauterized. With the animal under general anesthesia, the part to be attacked is freely exposed by dissection. By means of a gouge or curette the fibrous tissue is scraped away. The opera- tion is completed by drilling the ends of the bone and suturing them with silver wire, which will be found described more fully under Fractures. (See also Osteoplasty). OSTEITIS. PERIOSTITIS. OSTEO-MYELITIS. Inflammation of bone will be better understood if it is remem- bered that the essential element of osseous structures is connective tissue, forming a framework which, in the bone proper, is impreg- nated with earthy salts, in the central portion supports a vascular nutritive medulla, and on the surface is modified by the presence of an osteo-genetic or bone-constructive layer to form the perios- teum, all parts freely intercommunicating by means of the Haver- sian canal system. Because of this intimate connection, inflam- The Osseous System 341 matory processes do not long remain confined to one part, but quickly extend to another. Most inflammatory disturbances of bone with which we have to deal in the dog are of a septic nature, and involve the bone proper and medulla. They are acquired either in cases of compound fracture or amputation, or as a result of acute infection as may occur in the course of a severe infectious disease, or in septic thrombosis. But in many cases the cause is wrapt in obscurity. Contusions may favor the occurrence of infection by production of a locus minoris resistentiae to the bacteria which may have gained access to the adjacent soft parts or which may be cir- culating in the blood. The course of the disturbance is similar to that of any other purulent inflammation with migration of leuco- cytes, occlusion of the Haversian canals, arrest of circulation, ne- crosis, and establishment of purulent foci. The latter coalescing, extend along the tract of the marrow and lead to its rapid dis- integration. Pus breaks through the periosteum, burrows along the lines of least resistance, and finally reaches the skin. If the de- structive process is allowed to continue, the entire shaft may be involved, and there is risk of septicemia and pyemia. The disease, when of other than traumatic origin, most frequently attacks the long bones. Symptoms and Diagnosis. There is usually some lameness of the affected member. If there is not already a superficial wound when the animal is first seen by the practitioner, a swelling is ob- served in the soft parts covering the aflfected area, as soon as the pus penetrates the periosteum. The skin assumes a dark-red color and looks "angry." A fistula develops. The tract of the latter, when probed, leads to bone, and this is the chief diagnostic symptom. Treatment. This must be energetic and radical. It is useless to treat this disease by means of antiseptic injections. The infected focus must be removed and the only way to accomplish this is to lay the fistula open, expose the medullary canal and scrape away the inflamed marrow. The technic is as follows: The animal being hoppled and given a general anesthetic, and a tourniquet applied to the leg both above and below the wound, the diseased focus is exposed by free incision and dissection down to the bone. Sufficient No. 79. Bone Gouge. 342 Surgical Diseases and Surgery of the Dog of the outer compact tissue is next chiseled away with a gouge or curette to permit of inspection and direct treatment of the whole of the disease cavity. All adjacent granulating tissue as well as that which is necrotic is removed, and the cavity flushed out with a corrosive sublimate solution (i : looo). Then the wound is either packed with antiseptic gauze to stimulate the formation of granula- tion tissue or the cavity is allowed to fill with blood by loosening the tourniquet so that it may coagulate and become organized by connective tissue. The latter is known as the Schede aseptic moist clot method. It is described under Osteoplasty. In this case the outer wound is immediately closed. This is the preferable way to treat bone sinuses, but unless the parts are rendered perfectly asep- tic, is apt to give trouble. When the packing method is followed, the gauze is left in place a few days until granulation is well established, the outer wound being in the meantime left open, but protected with antiseptic bandages. This method makes regeneration more pro- tracted than the other. Osteitis Deformans. This is a rare diffuse form of osteo- periostitis, affecting principally the bones of the skull and the long bones of the extremities. It runs a very chronic course. The bones become enlarged, soft, and spongy and covered by osseous vege- tations. They are liable to become misshapen from bearing the weight of the body in their weakened state. Kitt has described a similar condition in a one-year old Great Dane, which he regarded as of myositic origin, since the vegetations were confined to the areas of muscular insertion, the region of the joints remaining free. The vegetations were limited to the lower jaw and the lower extremities. Symptoms and Diagnosis. The disease is recognized by the symmetrical uniform enlargement of the bones and by rheumatic symptoms. In Kitt's case, besides the deformity of the affected parts, there was little abnormal in the animal's ways, save an unwieldy gait. Treatment. There is no known method of arresting the pro- gress of this disease. RACHITIS. This disease, popularly known as "rickets," is characterized by incomplete ossification of the skeletal structure in young animals The Osseous System 343 with more or less arrest of development of the whole body. The ill-formed bone is produced principally in the epiphysial region of long bones, and the sutures of the cranial bones, which in new-bom healthy dogs are well closed, are usually large in rachitic dogs. The disease has been ascribed to malnutrition, particularly to food lacking lime salts, to digestive disturbances, and also to hereditary taint. It is highly probable that hereditary or congenital influences play a part in its production, through insufficiency of the thymus gland, in view of the symptoms following experimental ablation of the gland practiced recently by Mendel. Dogs of the larger breeds (Great Danes, St. Bernards) are most often affected, principally between the ages of three and six months. It is important, how- ever, not to confound with rickets a condition also seen in the young of the larger breeds, where, owing to the weight of the body the legs have to support before they are completely ossified, the latter become bent and misshapen. Symptoms and Diagnosis. A dog affected with rickets ex- hibits a general disturbance of the system — indigestion, inappetence, weakness and lethargy. In a little while the typical bone lesions develop. In the long bones the epiphyses become greatly enlarged and the shaft curved. In advanced cases the inferior extremities give way, causing the knee and hock to come in contact with the ground, the vertebral column becomes curved, the thorax sinks in, and the v ^bs exhibit nodosities. The facial bones also show de- formity. Sometimes the affected animal is unable to stand and experiences considerable pain at the slightest movement. The dis- tortion may involve the pelvic bones to such extent as to prevent fetal delivery (Reichenbach). Treatment. Practically nothing can be done in a surgical way to remedy rickets, the treatment being altogether medicinal. The diet must be stimulating and consist largely of meat, shaved green bone, milk, etc. Of medicaments, cod liver oil, lime water, and the official syrup of phosphate of lime are highly recommended. Treat- ment on similar lines is indicated for simple crooked development, but in the latter case the more the animal is confined and encouraged to rest the better. OSTEOMALACIA. This disease, somewhat similar in its nature to rachitis, is char- acterized by softening of the bones through resorption of their 344 Surgical Diseases and Surgery of the Dog earthy salts. While rachitis only affects the immature animal, osteomalacia is essentially a disease of adult life. It is very rare and the cause is unknown but it is believed to follow disturbances of nutrition. Any part of the skeleton may be attacked. Solby refers to some hounds in which the disease progressively affected one bone after another. Symptoms and Diagnosis. The symptoms resemble those of rickets but in addition to the deformity paraplegia may be present and the bones easily fracture. The alveolar margins of the jaws also absorb and the teeth fall out prematurely. Treatment. There is no remedial treatment known, and pro- phylactic measures must be depended upon when the disease is recognized. Prophylaxis comprehends a stimulating diet of animal food and administration of such preparations as are indicated for rachitis. NEOPLASMS. Both innocent and malignant types of tumor occur in bone. The innocent growths consist for the most part of osteoma, chon- droma, and fibroma. The only primary malignant growth met with is sarcoma, carcinoma, when it occurs, being always secondary. Osteoma. True bony tumors may spring from any part of bone, but most often from the periosteum. They are occasionally found attached to the jaw bone, and Mueller refers to an instance observed by himself of one attached to the transverse process of the fifth cervical vertebra. They are also found in other parts of the body. Symptoms and Diagnosis. They are recognized as regular, round, hard, insensitive enlargements, sometimes attaining con- siderable dimensions. Treatment. Under general anesthesia, such growth is exposed to its base by longitudinal incision and dissection of the skin. It is then removed with the aid of a sharp chisel and mallet, the ex- ternal wound being closed in the usual manner. Chondroma. Cartilaginous tumors are found attached to bone. They rarely ossify but may undergo calcification. Gurlt observed them in both the superior and inferior maxillae and on the digits. Symptoms and Diagnosis. Chondroma is always firm, round or lobular and well demarked, and grows slowly. Treatment. Removal is easily effected by ordinary methods. The Osseous System 345 Fibroma. Fibrous tumors of bone are of such rarity and in clinical features resemble chondroma so closely that they need not be considered here. Sarcoma. This, the malignant type of growth occurring in bone, will be found fully described in the chapter on Neoplasms, and needs but a passing reference here. Symptoms and Diagnosis. It is distinguished from the inno- cent growths by its steady, progressive and rapid development, and by other characteristics described elsewhere. Treatment. Ablation of this form of growth is difficult to attain. When practicable it must always be most thorough. Carcinoma occurs only as a secondary manifestation. Puetz has seen it in the epiphyses of the elbow joint. OSTEOPLASTY This term is applied to certain operations or processes by which defects in the continuity of bones are remedied. The value of its application to cases of severe comminuted fracture with absorption or necrosis of the detached portions, in the treatment of osteomye- litis, and the correction of pseudarthrodic formation following frac- ture, has long been recognized. We find the earliest known in- stance of its practice recorded by a Mongolian surgeon named Baber who lived between the years 1483 and 1530 and wrote his life-doings in the Turkish dialect. The reference concerns a man who broke his leg in such a manner that part of the bone of the size of the hand was completely shattered. He cut open the integuments, ex- tracted the detached portions and inserted in their place a pulver- ized preparation, which was said to have grown in place of the bone, and resulted in its complete recovery. A great many experiments in this direction have been carried out on dogs by Oilier, Schede, Schmitt (37 experiments), Adam- kiewicz, Rydygier and others in Europe, and by Senn and Mackie and others in this country. It was observed that cavities or serious breaks in the continuity of bones were always followed by protracted regenerative processes. Hence efforts were directed towards the finding of some substitute which, when implanted in the defect, would take the place of the missing bone and become intimately merged with the main body. Many substances were employed to act as substitutes, among them 34^ Surgical Diseases and Surgery of the Dog ivory, cork, fresh bone procured from other animals, and decalcified bone. But it was soon found that implantation of all these sub- stances was followed, as a rule, by their more or less rapid and com- plete absorption and the development in their stead of fibrous tissue which became ossified according as there remained sufficient peri- osteum, or not. The practice of heteroplasty {i. e., where implanted portions of fresh bone were taken from individuals of a different species) regu- larly resulted in encapsulation and absorption and rather hindered than hastened repair of the defect. Likewise portions of ivory and decalcified bone played but a temporary role and were very apt to induce pressure-atrophy or necrosis. Recently, however, Morton has claimed to have successfully supplied a deficiency of bone in a man by transplantation from a dog, vascular attachment being maintained while the regenerative process was going on, the animal being securely bound to the patient for several days to secure this object. Senn advises the packing of bone cavities with decalcified bone cut in thin slices or chips. If the periosteum is carefully sewn over the wound with catgut, repair is said to be much quicker than with- out the implantation, the chips serving as a temporary nidus for advancing granulations which permeate in all directions, until the embryonic tissue becomes sufficiently organized. In the skull discs of decalcified bone gave more favorable re- sults in as far as they formed a mechanical protective covering which became encapsulated. Senn says that the implantation of decalci- fied bone in skull wounds prevents direct union between the peri- cranium and the brain or its membranes, and that a cavity two inches long and five-sixteenths of an inch wide will fill with new bone in from seventy-five to ninety days. Repair is much more rapid in young than in old animals. Darkschewitsch and Weidenhammer have also observed normal bone development in place of implanted decalcified bone plates, in skull wounds. Decalcified bone is obtained by steeping fresh living bone in ten per cent nitric acid or dilute muriatic acid. It is then immersed in a weak solution of caustic potash to remove the acid and preserved in two-tenths of one per cent alcoholic sublimate solution. Homoplasty (i. e., the transplantation of living bone from another individual of the same species) gave doubtful results. In The Osseous System 347 a few instances true ossific union may take place, more especially when the periosteum is carried over with it, but in most cases the same results were obtained as in heteroplasty. Schmitt removed a portion of the ulna one and one-half ccm. in length and in its place transplanted a piece of bone from another dog. Complete bony union took place on one side and fibrous union on the other. No absorption was apparent and the vitality of the implanted portion seemed to be maintained by thickening of its periosteum. Only when autoplasty (i. e., where implanted portions were taken from the same individual) was practiced, was there indication of true union, and this was made more certain when the periosteum remained adherent or flaps were left intact at the site of operation. Even in this case there were signs of absorption. All the above operations were done strictly aseptically. When the parts were not rendered fully aseptic, they suppurated and ex- truded the implanted portions. Thus it became evident that re- generation of bone can only take place from periosteum, and where the latter is entirely removed no true ossification can follow. A displaced fragment, when replaced, must have connection with periosteum which in turn is in vital condition either by connection with neighboring periosteum or adjacent tissues. Hence the sur- geon aims to conserve the periosteum to secure its bone-constructive power. The periosteum is capable of remarkable vitality, for it may live and produce bone after its transplantation into an animal of a dif- ferent species. Trueheart recorded a case of a man in which he grafted pieces of periosteum to restore the middle third of a clavicle which had been shot away. Fresh transplants were inserted three times a month for two months when two and three-fourths inches of bone had been produced. The periosteum was from newly- killed dogs. A novel method was pursued by Rydygler. He tried separating flaps from the periosteum just above a pseudarthrodic defect, except at the border where it remained attached, turning them over so that the inner side lay outwards and vice versa, and laid them over the false tissue. Good results were achieved, but Schmitt who repeated the experiments, failed, on account of the movements of the animals, which could not wholly be restrained, tearing out the flaps. Schmitt then resected a piece of a long bone 34^ Surgical Diseases and Surgery of the Dog one and one-half ccm. in length, and transplanted in its place a piece of the same size and sewed both periosteums together. The result was good. All absorbable porous materials placed in bone cavities which create favorable conditions for healing do so by virtue of compres- sion, occlusion, and diminishing wound secretion. Instead of sup- plying artificial means to this end, Schede advocated the natural method of allowing the cavity to fill with an aseptic moist blood- clot. The principle of this method is that coagula between sur- faces of aseptic wounds do not undergo putrefactive or degenera- tive changes, but become supplied with bloodvessels and are organ- ized. The technic is as follows : Apply a tourniquet on the proximal side, remove all diseased bone, disinfect the cavity thoroughly, su- ture the soft parts, and remove the tourniquet. The cavity fills with blood. Protect the wound with a layer of oiled silk, which secures at the surface the formation of a moist blood clot. This is an important point. Small cavities heal in from twelve to fourteen days, while large cavities require from three to six weeks. The cavity must be allowed to fill completely or the balance closes by the usual tedious process of granulation. Neuber modifies this method by filling the cavity with iodoform with which the blood mixes, and thus lessens the chances of sepsis. OSTEOTOMY. This operation — the division of a bone — is sometimes necessary to straighten a leg, one or more bones of which having sustained a fracture have reunited in abnormal alignment. Complete anesthesia is necessary and the parts should be rested on a sandbag to give necessary support. A free incision is made down to the bone at the site of the callus, on the outer side, and an osteotome (beveled on both sides) introduced parallel to the long axis of the bone and then turned across, or at a right angle to it. With repeated strokes with a mallet it is made to penetrate the dense bone for two-thirds of its thickness, but this must be done with due caution to check any undue impetus on the part of the osteotome. The rest of the bone can be "snapped" with a little manual force. But, if difficulty is experienced in doing this, it means that the chisel must be used a little more. The two extremities are then approximated so as to bring them into alignment and a suitable splint applied, a window The Osseous System 349 being- arranged to permit of adequate drainage. It may be neces- sary to expose and "trim" the cut extremities with bone forceps to make them stay in alignment. BIBLIOGRAPHY. Adamklewlcz — Wien. med. Blaetter. 1889. Astley Cooper — Treatise on Dlsloc. and Fract. of the Joints. 2nd. Amer. Ed. from 6th. Lond. Ed. Boston. 1832. Baber — Translation. Leyden & Ersklue. London. 1826. Ben-Danou— Rev. Vet^r. July, 1898. Darkschewltsch. & Weldenharamer — Rev. In Contralblatt f. Chlrurg. 1892, p. 835, Fellzet— Bull, de la Soe. de .Mfd. Vgt§r. 1871, p. 193. Froehner — Monatsh. f. prakt. Thierhellk. Hertwig — Die Krankh. d. Hunde u. deren Hellung. 1853. Koenig— Cited by Cadiot & Almy in Traite d. Th6r. Chlr. d. Anim. Dom. Mackie — Med. News. Aug., 1890, p. 202. Martin — Veterinarian. 1896, p. 458. Mendel— Muench. med. Wochenschr. Jan., 1902. Morton — Amer. Med. July, 1902, p. 55. Mueller, F. — Oesterr. Vierteljahrsschr. f. Veterinaerk. 1878, p. 141. Neuber — Vlrchow's Archiv. 51. p. 683. Oilier — De rOsteogen^se Chirurg. Inter. Med. Cong. 1890. Traits Exper. et Clin. d. 1. He- genSrat. d. Os et d. 1. Product. Artlfle. d. Tissu Osseux. Paris, 1867. Pagenstecher— Cited by Almy & Cadiot in Traite de Tli6r. Chlr. d. Anim. Dom. Puetz — Berner Zeitschr. f. Thiermed. 1877. p. 335. Reichenbach — Schwelz. Archiv. 1899, p. 217. Rydygler — Deutsch. med. Wochenschr. 1878, Nob. 2T and 28. Schede — 15th. Congress d. Deutsch. Gesellseh. f. Chlrurg. Arch. f. kiln. Chlr. 34, p. 245. Schmitt — Langenbeck's Archiv. f. kiln. Chlr. 1892-93, p. 401. Senn — Amer. Journ. of the Med. Sciences. Sep., 1889. Solby— Medlco-Chir. Soc. Trans. 27. Taylor — Veterinary Record. 16, p. 505. Trueheart — Med. Press and Record. 1885, p. 382. Uebelen— Repertor. d. Thierhellk. 1876-77, p. 297. Zundel— Cited by Cadiot & Almy in Tralte d. Th6r. Chlr. d. An. Dom. CHAPTER XII The Articulations TRAUMATIC LESIONS. Wounds of Joints. The joints of the extremities are most subject to traumatic lesions. A joint may be merely punctured or it may be laid freely open and complicated with injury of the neigh- boring structures. A joint wound is dangerous only if infected, simple non-infected puncture wounds often healing by primary intention, but the larger the wound the greater is the liabiUty to infective inflammation and suppuration. Should the inflammatory process pursue a pernicious course, it terminates by destruction of the joint and local ankylosis, if in the meantime pyemia does not intervene. But if the cartilages escape destruction the usefulness of the joint may not yet be destroyed. Symptoms and Diagnosis. A non-infected joint-wound gives vent to a flow of synovia, which is recognized by its glairy appear- ance. This fluid must not be confounded with that emanating from an open tendon sheath with which it is very similar in appearance. There is but little swelling or pain. When infection occurs, all movements of the articulation are suppressed. The whole articula- tion becomes tumefied and as the disease progresses, discharges a grumous purulent matter. Collateral edema ensues, the function of the member is totally suppressed, fever appears, the appetite fails and the body emaciates. Treatment. All wounds of joints or of periarticular tissues should receive thorough antiseptic irrigation with a sublimate solu- tion (i: looo) the hair in the vicinity being removed. If infection is not apparent, the lesion should be occluded with iodoformized collodion and the region covered with an antiseptic bandage. When infection has occurred, the joint must be laid freely open, irrigated night and morning with the sublimate solution, protective bandages being also applied. Sprains of Joints. By this term is meant an imcomplete rup- The Articulations 351 ture of the ligaments of a joint but unattended with displacement of the articular surfaces. It is often accompanied with injury to the neighboring parts. It is generally produced by external violence, such as a blow or fall, but may be caused by a sudden twist of the joint during rapid progression. There results an increase of synovial secretion and consequent distension of the sac, or hemorr- hagic extravasation, according to the degree of injury sustained. The condition may become chronic owing to incomplete absorption of the inflammatory products, imperfect repair of the torn liga- ments, or periarticular fibrous ankylosis. The round ligament of the hip joint is a common seat of sprain. Symptoms and Diagnosis. The lesion is recognized by the fol- lowing symptoms: local tumefaction and pain particularly on pres- sure being applied, and pronounced limping or inability to bear weight on the leg. Absence of crepitus or modification of the out- lines and length of the member serve to distinguish a sprain from a fracture or dislocation, though very often the swelling is so great as to render it difficult or impossible to make a diagnosis until the former has subsided. Treatment. The indications are to enforce complete rest, and where possible to secure immobilization of the joint by bandages. A stream of cold water from a hose repeated several times daily is beneficial. Resolution takes place usually in from one to two weeks. Chronicity is recognized by persistent limping, in which case external painting with tincture of iodine may be tried. Luxations* Dislocations, LUXATIONS IN GENERAL These terms are employed when the articular ends of one or both bones are displaced from their normal position. There are two principal types — the Traumatic and the Congenital. Tk-e first results from direct or indirect violence while a dislocation is said to be congenital when from errors or failure in development the normal contiguity of articular surfaces cannot be maintained. A luxation may also result from relaxation of ligaments owing to constitu- tional debility, or from pathologic changes in ligaments or tissues entering into the formation of a joint. 35^ Surgical Diseases and Surgery of the Dog A luxation may be partial or complete, according to the degree of displacement present. Complete luxations are seen mostly in enarthrodial joints such as the femoro-coccygeal, but they are also very frequently partial in such joints. Partial luxations commonly occur in the digits. This lesion generally carries with it more or less bruising of the articular cartilages, rupture of ligaments, and con- tusion of the neighboring parts. Symptoms and Diagnosis. The symptoms are : pain, deformity, either lengthening or shortening of the affected member, and immo- bility. In general, a luxation may be differentiated from a fracture by the absence of crepitus, but this is not invariably a guide since the synovia may become inspissated and crackle under motion. The chief distinguishing feature is the abnormal immobility, though movements are sometimes possible in certain directions, while in fracture there is abnormal mobility in all directions. The diagnosis may be rendered difficult by the presence of tumefaction sufficient to prevent the exact extent of the injury from being ascertained. Treatment. The sooner a reduction is effected the greater are the chances of repair and restoration of function in the joint. If a luxation is allowed to remain undisturbed for a longer period than two or three weeks a change takes place in the relation of the parts. The head of the displaced bone becomes enveloped in a new cap- sular ligament formed from the surrounding cellular tissue, and reduction is no longer possible. While the displaced bone gradually adapts itself to its abnormal environment, so that a certain degree of motion becomes possible, lameness invariably remains perma- nently. A case of luxation being presented, the first step is to secure the animal, place it in a convenient position and proceed to examine the seat of injury. If much swelling is present, the operation should be postponed until it has subsided. Subsidence of the swelling may be aided by playing a stream of cold water from a hose over the parts, or by applying a refrigerant lotion. Recourse to general anesthetics or preferably chloretone narcosis is of considerable as- sistance and in some cases absolutely essential in order to overcome muscular spasm. The parts are then manipulated with the aim to restore the normal contiguity of the articular surfaces. Traction is exerted on the member, sufficient to overcome muscular effort, and then either extension, flexion, lateral pressure, or rotatory move- The Articulations 353 ments of the joint, according to the direction of dislocation, the movements being made in inverse direction to that in which the lesion has taken place. Reduction being effected, the joint does not, as a rule, tend towards reluxation, excepting in certain cases to be noted hereafter. But the joint should be maintained immobile until the local inflammatory changes have subsided and the parts assumed their normal relationship. For this purpose bandages and splints are utilized. At the expiration of fifteen days the latter may be re- moved and the joint submitted to massage and passive exercise. LUXATIONS IN PARTICULAR. The Temporo-Maxillary Articulation. The most frequent cause of this luxation is excessive opening of the jaws, as may oc- cur at clinical examination, when dogs in worrying oxen attempt to seize them or are kicked by them, when a greyhound seizes a hare in the chase, or even when the animal yawns. The lesion may be unilateral or bilateral and it takes place in a forward and upward direction. Symptoms and Diagnosis. In unilateral dislocation the symp- toms are local paralysis with lateral displacement ; in bilateral dis- location there is forward displacement. The facial expression is anxious, the animal salivates freely, howls with pain, and paws at its head. The head is depressed when the lesion is bilateral and in- clined to one side when it is unilateral. The interior of the mouth is plainly visible, the back molars are seen to be separated, and in- clined to one side in the unilateral form, and the tongue is discol- ored and protruding. The eyeballs may also protrude owing to pressure by the displaced coronoid processes. This condition has many points of resemblance to paralytic rabies, but anyone con- versant with the symptoms of the latter disease need not confound the two. In rabies the jaw can be closed ; in dislocation it cannot. The prognosis is good when there is no complication of fracture. Treatment. Reduction is effected by depressing the angle of the jaw, and entails the exercise of considerable force and patience. An anesthetic is necessary and the animal should be secured on its back with the face flat on the table. The jaw is used as a lever, a fulcrum being formed of a stick from six to twelve inches in length and from one-quarter to one-half an inch thick, with a wrapping of 24 354 Surgical Diseases and Surgery of the Dog protective material. This is inserted crosswise between the jaws as far back as possible. An assistant must then bear down on the anterior extremity of the lower jaw, and endeavor to approximate incisors to incisors. The operator at the same time exerts traction on the stick in a forward and upward direction till the condyles are raised to a point where they slip back into the articular fossae. No solid food must be given for several days. The Vertebral Articulations. Reference has already been made to this luxation in the chapter on Fractures. Complete luxa- tion is rarely seen without being accompanied by fracture. It may be recognized by the unnatural curvature of the neck, and the pres- ence at the site of lesion of a depression on one side and an enlarge- ment on the other. It is necessarily fatal. Partial luxation is occa- sionally met with. Symptoms and Diagnosis. When it occurs in the cervical vertebrae the neck is curved with the head turned towards the side from which the displacement has occurred, and the animal prome- nades in a circle with a staggering gait. On the concave side of the neck there is a depression, and on the convex side an enlargement. If the head is straightened out and let go again it immediately re- turns to the abnormal position unless by chance the luxation should become reduced by this procedure. If there is any pronounced pressure on the cord convulsions occur, and they are generally more manifest in the muscles on the opposite side of the body. Treatment. If after three or four days a gradual im- provement is noticed in the distorted parts the prognosis may be regarded as favorable, recovery taking place in the course of a month, but should the animal become progressively weak and emaciated, it should be destroyed. The Scapulo-Humeral Articulation. The capsular ligament enclosing this joint is remarkable for its looseness, where- fore it possesses little power to oppose displacement. As a rule, the head of the humerus is thrust to the anterior or external aspect of the joint, internal or posterior luxation occurring when compli- cated with fracture. Complete luxation is seldom seen, whereas the partial form accompanied by little if any laceration of the ligament, is not at all uncommon. It is brought about by extreme flexion of the joint or traumatic influences. Symptoms and Diagnosis. Lameness appears suddenly, the The Articulations 355 leg seeming shorter than its fellow. The humerus can be extended and flexed only with the greatest difficulty. The position assumed by the head of the humerus is indicated by an enlargement, a hollow existing at the site of the joint, and the parts are painful. Partial luxations generally get well with treatment, but the prognosis of complete luxation is less favorable. Hertwig had one complete recovery. Treatment. Reduction is effected by extension of the humerus and pressure over its head in the direction of normal position. The Hmnero-Radio-Ulnar Articulation. This luxation may take place either inwardly or outwardly. It may be complete or partial between the humerus on the one hand and the radius and ulna on the other. The head of the radius may also be displaced alone and, as a rule, to the outside. In these cases the annular liga- ment uniting the heads of the radius and ulna is coincidently rup- tured. Curiously enough, luxation of the head of the radius, and sometimes of both radius and ulna, is often congenital in the Black- and-tan Terrier breed, involving one or both elbows. When it occurs under these circumstances the young are usually born in this condition, but may also acquire it in the first few weeks of life. I have also seen the congenital form in other breeds, and in one in- stance there was an additional deformity in the shape of a club-foot. According to Carougeau, humero-radio-ulnar luxation may arise from various traumatic influences, from extreme flexion of the forearm with external displacement and rupture of the internal lateral ligament, or from twisting of the joint with slipping of the coronoid process from the trochlea of the humerus, in which case all the ligaments are ruptured. Luxation of the head of the radius with rupture of the annular ligament con- necting this bone with the ulna is chiefly caused by leaping or falling from great heights. Symptoms and Diagnosis. The symptoms of humero-radio- ulnar luxation are depression on one side of the articulation and enlargement on the opposite with infiltration of the neighboring tissues and muscles. In addition to the change of contour may also be noticed : turning of the foot in the opposite direction to that in which the displacement has taken place, shorter appearance of the leg than its fellow, a limping gait, and expression of pain when the seat of luxation is handled. 356 Surgical Diseases and Surgery of the Dog In dislocation of the head of the radius, there is a bulging postero-externally, making the region of the articulation look broader than natural. The forearm is flexed with the elbow held immobile, the animal going on three legs. The displaced bone can be plainly felt and if the elbow joint be forcibly extended and flexed a slight resistance is encountered in the parts and the animal exhibits considerable pain. The luxation is reducible and the joint moves freely, but as soon as the animal uses the leg again, it recurs, be- cause the annular ligament, which supports the two bones in place, is ruptured. If the lesion is left to itself, the leg is permanently incapacitated, and is always extremely flexed and carried free of the ground. When both legs are affected, a standing posture is impossible, the animal being forced to sit on its haunches. The prognosis is unfavorable without operative measures, the lacerated annular ligament showing little tendency to heal. In the congenital form there is absence of inflammatory phe- nomena and simply deformity which cannot be mistaken. Treatment. The prognosis of acquired complete dislocation of the joint is good in recent cases when uncomplicated with frac- ture or extensive rupture of ligaments. It is reduced without much difficulty by extension, flexion, and lateral pressure, but tends to recur rather readily, so that it is imperative to keep the parts for some days in a permanent bandage until repair of the ligaments has taken place. Congenital luxation of the whole joint is seldom amenable to treatment. The only possible way to treat radial luxation, whether acquired or of congenital origin is by wiring the bones together in the follow- ing manner : The animal being hoppled and anesthetized, an incision is made immediately over the annular ligament and the shafts of the two bones freely exposed by blunt dissection. Holes are bored through the radius and ulna, as describel under Bone-Suturing, silver wire is passed through the holes, the two bones are brought into normal apposition, the wire twisted, the ends of the latter cut oflF close, the wound closed, and suitable splints and bandages ap- plied to immobilize the parts, provision being made for free drainage. To prevent suppurative inflammation the operation must be done strictly aseptically. The wire should be removed after five or six weeks. The results of this operation often exceed the expec- tations of the practitioner, the leg being used with freedom though perfect use of the joint is not attained. The Articulations 357 The Radio-Ulnar-Carpal Articulation. Both the radius and ulna may be displaced from their articulations with the upper row of carpal bones, either singly or together. The capsular band unit- ing the lower extremities of the two bones is ruptured in either case. Symptoms and Diagnosis. Dislocation of either of these arti- culations deprives the animal of the use of the leg, and is attended with a change in contour of the parts, a bulging taking place in either an anterior or posterior direction. Treatment. This lesion is easily reducible but recurs if not remedied by wiring the two bones together. The Carpal Articulations. Any bone in this joint may become separated from the remainder. Symptoms and Diagnosis. The symptoms are local stiffness and swelling with pronounced lameness and the joint may be bent either inward or outward. Treatment. The prognosis is good, recovery taking place in about three or four weeks, when the bones are replaced in the or- dinary manner and bandaged. The Metacarpal Articulations. Luxations of these articula- tions may occur at either their superior or inferior extremities. A single bone may be displaced. Symptoms and Diagnosis. In the case of a single bone the symptoms are only slightly in evidence. In complete luxation of the whole row the foot is raised from the ground and held ob- liquely. Treatment is the same as already outlined. The Phalangeal Articulations. The digits are quite com- monly put out of joint. Symptoms and Diagnosis. The animal limps and manifests pain at manipulation. The affected joint is found to be abnormally mobile. Treatment. Reduction is effected in the usual manner, and the parts immobilized for some days. The Coxo-Femoral Articulation. Luxation of this joint oc- curs not at all uncommonly. As a rule, the head of the femur is displaced in a direction immediately above the acetabulum, but may be forced into the foramen ovale. The displacement is more often partial with slight damage to the capsular ligament than complete. If complete, it is accompanied with rupture of both the capsular ligament and the ligamentum teres. 358 Surgical Diseases and Surgery of the Dog Symptoms and Diagnosis. At first the animal may walk on three legs but later gains imperfect control of the injured member. A swelling is observed over the joint, the trochanter has become prominent, and the leg appears shorter than its fellow. In displace- ment into the foramen ovale the leg appears longer than its fellow. When the animal walks, the stifle is turned outward and a certain swinging motion is evident. The prognosis is excellent provided re- duction is effected soon after the accident. If the luxation is neg- lected a false joint is formed through development of a new capsular ligament from the surrounding cellular tissue, and the movements be- come comparatively free, though the leg is dragged somewhat. The longest period intervening between receipt of the injury and treat- ment in my hands which turned out satisfactorily was two weeks. Stockfleth found a false joint completely formed with a thick flask- shaped capsule two months after the dislocation had occurred, and Peuch failed to effect reduction in a dislocation of one month's standing. Treatment. The leg must be forcibly extended by traction and abducted, downward pressure being at the same time applied over the trochanter. The Patella. In the dog, the lateral patellar ligaments are little more than rudimentary, while the middle one is well-developed. Consequently the patella is very liable to become displaced either to the inner or outer aspect of the joint, but as a rule to the inner. The chief factor concerned in the occurrence of this luxation is relaxation of the feebly-developed lateral ligaments, coupled with a feebly developed internal ridge of the patellar groove of the femur, and to complete the lesion it is only necessary for a violent or exces- sive contraction of the tendon of the quadriceps femoris muscle to take place, particularly in conjunction with inward or outward turning motion of the lower part of the legs as, for instance, when a dog jumps up and through a window. Toy breeds, such as the Black-and-Tan Terrier and Japanese Spaniel suffer most, and it is in these that we find the internal femoral ridge lacking in development. The displaced bone is easily replaced when the whole leg is in an ex- tended position forward but shows a great tendency to revert to the abnormal position upon flexion. Symptoms and Diagnosis. This luxation is characterized by a peculiar carriage of the affected leg. The latter can no longer The Articulations 359 help to support the weight of the body but is raised from the ground and flexed with the stifle adducted, the hock turned outward, and the foot carried inward and sometimes extending past the median Hne. When both bones are simultaneously displaced, the tarsal joint is extremely flexed and the hind parts assume a crouching attitude, the mode of progression resembling that of a ferret. In some cases locomotion is accomplished by a series of hops or the animal walks altogether on the forelegs and elevates the hind ones. Treatment. In treating this trouble the object to be aimed at is to rest the entire leg for a period of several days, all the while maintaining the leg in an extended condition in the anterior direc- tion, for it is in this position that the bone falls into its proper channel. The rest then gives the ligaments the opportunity to re- cuperate and recover their normal tone. The entire leg from the toes upward as far as possible above the stifle must be enclosed in a stiflf bandage, preferably of plaster of paris. To show how all- sufficient the rest treatment is may be mentioned the case of one of Stockfleth's patients, that of a restless female which was about to whelp. It was impossible to keep her quiet and the bone in place, but as soon as her offspring arrived she calmed down and lay quietly with them a sufficient length of time for recovery to take place. In another instance he bound the affected leg to the trunk by means of bandages, so that the animal was forced to rest it. Recovery followed in three weeks. In still another case of bilateral luxation in a small animal splints of gutta percha were moulded to both legs extending from above the stifle to the toes, so that the animal which previously had crawled, walked as if on stilts. Some two or three weeks of this support sufficed to effect a cure. In the cases dependent upon congenital structural defect in the femur the prognosis must always be doubtful for the tendency is towards recurrence. The Tibio-Tarsal Articulation. Stockfleth has recorded one instance of this luxation. A hunting dog in chasing a cat had its right foot caught in a vice attached to a joist, with the result that the skin, ligaments and flexor tendens were severed, exposing the tibia which was only suspended by the extensors. On account of the hemorrhage the animal was destroyed. The Caudal Articulations. Slight luxations sometimes occur in animals possessed of slender tails, as for instance, in the Grey- hound. 360 Surgical Diseases and Surgery of the Dog Treatment. Reduction being effected, as light a bandage as possible is to be applied, similar to that used when this extremity suffers fracture. SYNOVITIS. By synovitis is meant inflammation of the synovial membrane alone. When other structures of the joint are involved, the term arthritis is employed. It may be acute or chronic. In the acute form the synovial membrane becomes red, congested and swollen, and at first stops secreting but later pours out an excess of turbid fluid ; in the chronic it undergoes thickening. Either form is caused by some slight injury such as a sprain, contusion twist, or overuse. The articulations most commonly affected are the carpal, coxo- femoral, femoro-tibial, and digital. Symptoms and Diagnosis. In acute synovitis the leg is held in any position giving the greatest ease, and any movement of the joint gives rise to lameness. Examination shows the joint to be hot and fluctuating and painful to pressure. In chronic synovitis lameness only becomes evident after use of the joint, but the sac fluctuates. Treatment. Treatment comprises rest, immobilization of the joint with bandages, cold applications, and later painting with io- dine. When the effusion is great, the sac should be aspirated with antiseptic precautions. ANTHRITIS. This term is applied to general inflammation of all the struc- tures composing and surrounding a joint. It may occur as a local manifestation of rheumatism when it is of infectious origin though unaccompanied by suppuration, it may develop as a simple inflam- matory disturbance consequent upon local sprains, luxations, etc., or it may result from pyogenic processes, the germs entering either by a wound, through extension of periarticular suppuration or osteomyelitis, or in a pyemic embolus as may occur in cases of omphalo-phlebitis of the newly-born. Rheumatic arthritis may be acute or chronic. The former runs a rapid course, the symptoms appearing within twenty-four to forty-eight hours. The commonest seats of this form of the dis- The Articulations 361 ease are the knee, stifle, feet, and hip joints. The affection is am- bulatory in nature and tends readily to recur. Serous membranes are frequently involved, notably the pleura, pericardium, endocar- dium, and meninges. The chronic form commonly succeeds the acute, though it frequently occurs as such from the start, the femo- ro-tibial and carpal articulations being common seats. In this form there is thickening of the capsule with formation of peri- articular adhesions and sometimes osseous vegetations. Purulent arthritis may also be acute or chronic. When acute, pyogenic microorganisms figure as the causative factor, and when chronic, tubercular bacilli. In the acute form, a free purulent se- cretion is characteristic, and when of pyemic origin, several joints may be affected. The disease pursues the same course as in the case of infected wounds of joints, the joint tending to rapid disorganiza- tion. The capsule gives way and discharges externally. Should the inflammation subside, interarticular granulations spring up, and these undergoing ossification, ankylosis results. In pyemic arthri- tis of the new-born following omphalo-phlebitis, the foci ordinar- ily develop in the shoulder, elbow, knee, hip, and stifle joints, and often undergo spontaneous recovery. In the chronic tubercular form, the internal face of the sac is covered with vegetations, the synovia is slightly purulent and reddish in color, the bacilli are found present, and there are invariably tubercular lesions elsewhere. This form of the disease is very rare. A case has been recorded by Cadiot. Symptoms and Diagnosis. The symptoms of acute rheumatic arthritis are intense pain on the least movement as manifested by extreme lameness, marked local heat, constitutional disturbance, affection of one or more joints simultaneously, and very frequently, shifting of the disease from one joint to another. In chronic rheu- matic arthritis, the affected joints are stiif and painful, the symp- toms are aggravated by cold and dampness, and several joints may be involved. In simple arthritis of other than rheumatic ori- gin, there is distension of the synovial sac, the movements of the joint are suppressed, and the member may be unable to bear the weight of the body. When chronic, there is little pain but hydrar- throsis. The symptoms of purulent arthritis are similar to those that follow infected wounds of joints. There are fever and rapid pulse. 362 Surgical Diseases and Surgery of the Dog The joint is swollen, extremely sensitive, and fluctuates in places. Finally, the pus discharges by one or several fistulous tracts. Treatment. In acute rheumatic arthritis the internal admin- istration of alkalies and salicylates is indicated. Pending recovery absolute rest should be enjoined. The long-standing chronic form of the disease is incurable, but the symptoms can be somewhat mitigated by tonic treatment. Massage is also helpful. Excessive synovial effusions which do not tend to be resorbed may be as- pirated with antiseptic care. Purulent accumulations must be promptly removed, the procedure comprising free incision in two or more situations, antiseptic irrigation with corrosive sublimate solution (1:1000) morning and evening, drainage, antiseptic dress- ing and immobilization. Osteo-Arthritis. Arthritis Deformans. Differing from chronic rheumatic arthritis in extensive alteration in the joint structures, osteo-arthritis is a disease more commonly observed in members of the larger breeds particularly those which have been used for draught purposes. The pathologic changes are disposed to be sym- metric and consist in destruction of the articular cartilages and increase in length and thickness of the periphery of the bone by ossific deposit. In advanced cases the tendons about the joints ossify. The cause is obscure but the disease is probably due to some form of malnutrition of nervous origin. The articulations usually affected are those of the knee, elbow, and stifle. Symptoms and Diagnosis. Osteo-arthritis has a very slow evo- lution. As the deformity of the joints develops, lameness, rigidity, and articular crepitus appear. Treatment. The disease being incurable, no treatment is of any avail, but the general health may be maintained by tonics. BIBLIOGKAPHY. Cadlot— Bull, de la Soc. Cent, de M6d. Vet6r. 1895. Carougeau— Rec. de MM. V6t6r. Nov., 1899. Hertwig— Chlrurgie t. Thleraerzte. Stockfleth — Handbuch der thleraerztl. Chlrurgle. CHAPTER XIII Neoplasms This chapter is devoted to a description of the forms of Neo- plasms that I have been able to find recorded as occurring in the Dog. Certain forms, known to occur in other animals and in man, are purposely omitted, because I have not succeeded in finding re- liable data concerning their appearance in the Dog. Surgical Neoplasms comprise about five per cent of all diseases the practitioner is called upon to treat (Froehner). In other words, in every twenty dogs treated, one is afflicted with some form of growth. We may conveniently divide conditions of Neoplasia into four great groups : (a) (I) Hypertrophy (b) Hyperplasia In which there is excessive growlth of a tissue in its normal position, the enlargement being due to An increase in the size of the individ- ual cells. An increase in the number of cells. (2) Inflammatory Neoplasms: (a) Simple Granulomata — Tumors formed of excessive granulation tissue. (b) Infective Granulomata — Tumors produced by in- flammatory reaction in consequence of specific mi- croorganisms, (c) Strictures — In which there is diffuse overgrowth of connective tissue producing structural changes in the walls of canals. (3) Tumors Proper: (a) Simple Tumors — Tumors formed of tissues and cells of the individual, the type of which predomin- ates, and which have taken on a functionless and excessive growth, and in which the power of growth is indefinite. 364 Surgical Diseases and Surgery of the Dog (4) Cysts — Abnormal encapsulated collections of fluid. "(b) Compound Tumors — Tumors formed of several tissues. (1) Hypertrophy and Hyperplasia (a) H3rpertrophy is commonly seen in organs which have sustained an increase in functional activity. Thus, we see a simple "accommodative" hypertrophy of the Uterus during preg- nancy with increase of size in the individual cells. The Cervix Uteri is also occasionally the seat of hypertrophy. Hypertrophy of the muscularis of the Bladder is sometimes seen when that organ contains calculi of large size. Johne saw an increase two or three times above normal. A similar condition is seen in the wall of the Intestine on the proximal side of a constriction or chronic obstruction. When one of bilateral organs takes on the function of its fellow, it enlarges, and the condition is spoken of as "compensatory" hypertrophy. Thus, when one Kidney becomes hydronephrotic or is extirpated, or the renal artery is ligated, the opposite kidney enlarges. Gibson found the Mesenteric Glands distinctly enlarged in an animal that had undergone splenectomy six months previously. Hypertrophy of the Muscularis of the Heart is seen in varying degrees according to age, breed, sex, etc., in certain diseases, and particularly the character of the ex- ercise indulged in. Strictly speaking, that which is termed hyper- trophy of the Heart is both hypertrophy and hyperplasia. The hearts of hunting dogs are always relatively large. In old dogs a general increase in the amount of all the component tissues leads to hypertrophy of the Prostate Gland. The immediate cause of these cases of enlarged prostate is not known. Some have suggested increased vascular supply, but this is inadequate. Leisering de- scribed hypertrophy of the Sebaceous Glands situated on the pos- terior aspect of the fore-leg. According to Kitt, the Intestinal Villi may become hypertrophied to a size four times above normal through the irritation produced by the burrowing of tape-worms. (b) Hyperpla.sia. As will be mentioned under Fibromata, no sharp distinction can be made between this condition and fibrosis. Irritation will lead to proliferation of connective tissue. A familiar example is seen in the Skin at points exposed to friction or pressure. Enlargements of the Thyroid Gland depending upon in- Neoplasms 365 creased development of the parenchymatous tissue are commonly associated with proliferation of the connective tissue strcima. Other hyperplasias develop without adequate discoverable cause, particu- larly in the Viscera, of which cirrhosis of the Liver is an example. Hyperplasia of visceral canals will be referred to again under Strictures. (2) Inflammatory Neoplasms (a) Simple Granulomata. A simple granuloma Is a neoplasm which does not advance beyond the stage of granulation tissue and generally results from a wound. Wherever there is redundant granulation tissue it is probable that the excessive growth arises as a result of bacterial irritation. A granuloma involving the en- tire Cornea was witnessed by Beierle. (b) Infective Granulomata. Included under this heading are the tumor-like formations produced by the agency of mi- croorganisms. They are distinct from the simple granulomata in that they are produced as a rule not merely upon the surface, but throughout the various tissues. In some cases they are easily to be confounded macroscopically with true tumors. This is particu- larly the case with Visceral tubercular lesions which often assume a carcinomatous or sarcomatous appearance. At one time Pleural neoplasms were regarded as cancerous in nature, but the researches of Cadiot have shown the commonest form of growth in this lo- cality to be of tubercular origin. Among seven thousand dogs examined at the Alfort School two hundred and fifty were found to be tuberculous. In twenty-seven of these animals, twenty-one showed the Lungs to be affected, fourteen the Pleura, fourteen the Bronchial and Mediastinal Glands, three the Pericardium, one the Heart, thirteen the Liver, twelve the Kidneys, six the Peritoneum and Omentum, four the Spleen, and two the Intestinal Wall. Tu- bercles were also found in the Testes, Bladder, and Ureter. The mode of infection is believed to be by ingestion of sputum of phthysical persons or inhalation of finely attenuated bacilli-bearing sputum or dust. Of the twenty-seven dogs six belonged to res- taurateurs, in whose establishments it is not a rare thing to find infectious sputum, and where sweeping distributes the virulent dust in the lower strata of the atmosphere. The above statistics agree well with others recorded by Jenson who found the organs affected 2,66 Surgical Diseases and Surgery of the Dog as follows in a total of twenty-eight animals : Lungs nineteen, Kid- neys twelve, Spleen two, and Pericardium two. Cramer once saw the Ovaries involved, and Mueller witnessed tubercular ulceration of the Skin. Tubercles vary in size from a pin-head to a pea, and when confluent may be of irregular dimensions. In color, they are usually grey or white, and in consistence, rather solid on serous membranes. They are productive of effusions. Actinomycotic growths are occasionally witnessed in the dog. Torrance destroyed a pointer suffering from ascites, and at the necropsy found a large, solid, actinomycotic mass occupying the re- gion between the heart and the diaphragm, and involving the pos- terior part of the Right Lung, part of the Pericardial Sac, and the Diaphragm. Gohn treated a case following a bite over the Tibia with secondary infection of the Mouth. The disease is also re- ferred to by Cadiot & Almy and Friedberger & Froehner, while Murphy cites an instance in a woman whose dog had died with a large swelling under the Jaw. Rabe observed a microorganism resembling the actinomyces which he obtained from an animal suffer- ing from multiple abscesses. Under this heading I include conditionally the tumor-like for- mations which occur in the Genital Mucosa of both sexes. There is considerable diversity of opinion as to the histologic identity of these growths. Smith & Washbourn, in England, who have ex- perimented considerably with this disease, recognize it as sarcoma. But it must be remembered that it is by no means an easy matter to distinguish between granulomatous cells and those of true sar- comatous nature. Both arise from connective tissue elements, the process of development in either stopping short of cicatricial trans- formation. It was Virchow who originally employed the term In- fective Granuloma to emphasize the points of resemblance between such cellular growths and true forms of tumor. The growths in question have been variously described as papilloma by French authorities, as condyloma by Bruckmueller, as carcinoma by Wehr, Froehner, and other German authorities. Wehr inoculated minute portions of these growths in the subcutaneous tissue of healthy dogs with positive result in a number of cases. But with one ex- ception, the growths after attaining the size of a hazel-nut became absorbed completely. In the exceptional case, secondary nodules developed in the internal lymphatics and spleen and caused the death of the animal by inhibiting the urinary outflow which led to Neoplasms 367 rupture of the bladder. In Smith & Washbourn's investigations one male was mated with twelve females, eleven of which became affected. A second male contracted the disease from the females and conveyed it to one of the two females with which it was mated. In the vaginal wall the growth resembled a raspberry, and gradu- ally increased in size and extent until the whole passage was in- volved. It was situated most commonly in the neighborhood of the urethral orifice, but in some cases projected from the vulva. Sometimes the tumors were large enough to block up the vagina. Older animals suffered more particularly, and very old ones were severely affected. In the penis the growth was circumscribed, one about a quarter of an inch in width. The mass was lobulated, slightly constricted at the base, of a pinkish or purple color, and of a consistence varying between soft and firm, but never hard. On section, the surface was whitish and moderately firm. In one in- stance there was a secondary growth in the inguinal glands. Smith and Washbourn inoculated portions of the tumors into the sub- cutaneous tissue of dogs. In four, the experiment was unsuccess- ful, but tumors developed in the remaining thirteen. The follow- ing conclusions were reached: These tumors can be transplanted from the genitals, where they generally occur, to the subcutaneous tissue of other dogs. They can be transplanted from subcutaneous to subcutaneous tissue in other dogs. After reaching a maximum of growth they may disappear spontaneously with or without ul- ceration. They may continue to increase and cause death by secondary deposits forming in the viscera. If the tumor disappears, the animal is subsequently immune. Some animals are naturally refractory. (c) Organic Strictures. These are lesions of slow develop- ment and may not become obstructive for a lengthened period. Their origin in some cases is obscure, but they are generally re- garded as resulting from a true inflammatory process having its seat in the mucosa or submucosa. Stricture is occasionally seen in the Intestinal Canal, particularly in the Duodenal Region, as a cir- cumscribed hyperplasia. Generally, the walls are greatly thickened at the point of lesion, the mucosa remaining intact. Hobday has seen strictures in the Colon. The lesion has also been known to follow the separation of a gangrenous intussusceptum and the coalescence of the resected bowel after end-to-end anastomosis. Stricture of the Urethra sometimes follows cicatrization of surgical 368 Surgical Diseases ^nd Surgery of the Dog wounds or the irritation induced by the passage of calculi. Koch refers to stricture of the Vagina, and Siedamgrotzky and Almy have seen stricture of the Ureter. (3) Tumors Proper The effect of tumors on the organism is variable, but they all have their being at its expense, performing no physiologic function and contributing nothing to its support, and are therefore truly parasitic. Malignant growths have for their chief characteristics: inva- sion of all the textures of the part in which they develop, rapidity of growth, profound influence on the general health from the first, tendency to recurrence after apparent extirpation, whic-h means a continued growth of left-over particles, and metastasis to other and distant organs through the medium of the circulation or by the lymphatic channels. They commonly ulcerate. On the other hand. Innocent growths are generally well encapsulated, and do not in- filtrate the surrounding structures, they grow slowly and with few exceptions disturb the general health but little, they do not return if completely removed, and do not produce secondary growths in other parts of the body. While innocent tumors rarely undergo a true process of ulceration, yet they are very frequently rendered raw and sore by constant licking on the part of the animal, or by abrasion through contact with the ground. They are sometimes dangerous by reason of pressure they may exert on vital structures. For instance, simple enlargements of the prostate gland are fre- quently provocative of urinary troubles, and mediastinal neoplasms, whether malignant or innocent, tend to give rise to nervous, cardiac, respiratory, vascular, and digestive troubles. In the anterior me- diastinum are found two groups of lymphatic glands — the bron- chial, situated in the angle of bifurcation of the trachea, around the origin of the bronchi, adjacent to which they extend for a short distance into the pulmonary tissue, — and two trains of lo- bules extend along the inferior face of the trachea from the base of the heart to the first rib. Intimately related with these groups are the anterior aorta and vena cava, cardiac, recurrent, and diaph- ragmatic nerves, inferior cervical ganglia of the great sympathetic, base of the heart, and vena azygos. Inflammatory tumors, such Neoplasms 369 as tubercles, and tumors proper, and even simple adenitis following Distemper, may encompass or compress the intramediastinal vas- culo-nervous organs, the trachea, and the esophagus, giving rise to manifestations of impairment of cardiac and respiratory func- tions. It is not uncommon to observe a violently convulsive, dry cough, without the usual concomitant symptoms of bronchitis or pneumonia proceding from compression of the pneumogastric, a condition to which the name of whooping-cough has been given. Paralysis of the nerve finally develops and results in accelerated cardiac action of such violence as to be perceptible at considerable distance from the animal. (1) SIMPLE TUMORS. Connective Tissue Tumors (a) Approximating to fully formed tissue: Fibromata, Chondromata. Osteomata. Lipomata. Myomata. Hemangiomata. Neuromata. {b) Formed of immature tissue: Myxomata. Sarcomata. Epithelial and Glandular Tumors (a) Approximating to fully formed tissue: Adenomata. Papillomata. {b) Formed of immature tissue: Carcinomata. (2) COMPOUND TUMORS Formed of several tissues: Teratomata. (1) SIMPLE TUMORS. (a) Connective Tissue Tumors Approximating to Fully Form- ed Tissue. 25 370 Surgical Diseases and Surgery of the Dog Fibromata. A fibroma is an innocent growth composed of completely developed fibrous tissue grouped in irregularly arranged bundles. With other tissue elements the fibromata com- monly form mixed tumors, such as fibro-myoma, or fibro-lipoma. They are closely related to the hyperplasias of connective tissue re- sulting from chronic irritation, and in some cases can hardly be differentiated. For instance, the diffuse form of chronic interstitial mastitis characterized by the proliferation and projection of con- nective tissue might be equally well classified as a hyperplasia. Froehner regards the fibromata as standing second to the carcino- mata in frequency of occurrence, placing their percentage at thirteen. They exist generally singly, but are often found in numbers. They are commonly hard, but may be soft when situated in the looser textures, and are of variable size and shape. In contrast with the malignant tumors they are generally smaller, the average size being that of a walnut; their growth is very slow, and they remain quiescent for years. In further contrast with carcinomata they are seen in quite young animals (from one to two years or younger). Characteristic are their sharp demarcation from sur- rounding textures, regularly firm consistence, intact surface, and paucity of vascularity. They are sometimes rendered sore, how- ever, by licking and gnawing. In shape they resemble a pea or a nipple, and are occasionally pedunculate. Fibromata occur most frequently in the Dermis and Subcuticu- lar connective tissue and exhibit a predilection for the Breast, Extremities, Eyelids, Back, Tail, the Mammae, and Submucous Tissue particularly of the Vagina and Uterus (Petit, Leisering, Watson, Penberthy, Leblanc, Romani). Rigal saw a large fibroma attached to the Gastro-colic Omentum. Chondromata. Cartilaginous growths may be innocent or malignant. Innocent chondromata are frequently of mixed type, such as osteochondroma. Very often the chondromata are asso- ciated with sarcomatous elements when they are more or less malignant. Chondromata may also be malignant to the extent of forming metastases without the secondary nodules being histolo- gically true sarcoma. The following recorded cases will serve as examples : Virchow described a large ossifying chondroma of the mamma, and a large tumor with a cystic interior in the omentum. On the lungs there were numerous small nodules, most of which Neoplasms 371 were on the pleui-a. Histologically, these nodules were found to be composed of fibro-hyaline cartilage which had commenced to calcify in the center. Ramifications extended from some of the nodules into the lymphatics, and these had commenced to chondrify in the center, but at the periphery there were collected groups of cells without intercellular substance. Nocard removed an osteo- chondroma from the left inguinal mamma. A year later an anal- ogous tumor had developed in the anterior left pectoral mamma, which was also extirpated. In seven or eight months' time an in- cessant dry, harsh cough appeared without symptoms of bronchitis but with violent and rapid cardiac action. The animal was de- stroyed. At the necropsy were found: small osteo-chondromata in the kidneys, and a multitude of similar tumors in the parenchyma of the lungs. The right pneumogastric and cardiac nerves were compressed and atrophied. Generali saw a mammary chondroma form secondary growths in the lungs and kidneys, and one on the pons Varolii. Cadeac saw an ossifying chondroma in the neck, the size of a fist. It resembled abscess, which is often seen in this region. It was blistered, but continued to enlarge until respira- tion became impeded. Death followed in a few days. Post mortem examination showed a voluminous tumor compressing the trachea and esophagus. It was formed of a number of small nodules, some of which were hard and some soft. On the mucosa of the larynx M^ere small miliary tumors, and on the mucosa of the trachea, and in the lungs were other nodules. Boutelle worked out the pathology of one of these tumors. An encapsulated, slightly lobulated calci- fying chondroma of the mamma was removed surgically in Febru- ary, 1892. In August, 1894, the subject was destroyed suffering from abdominal tumor. The latter was found enclosed between layers of peritoneum and attached to the stomach, omentum, and spleen. A small portion of detached hepatic tissue was also ad- herent to it. There were other secondary growths in the lungs, pancreas, and axillary and mesenteric glands. The case also pre- sented another interesting feature. At the site of operation in the mamma a sinus had developed, and from this had arisen a small growth which was histologically a carcinoma. Following is the explanation of the process by which these tumors develop. In the growth of chondromata the new cartil- yj2 Surgical Diseases and Surgery of the Dog age cells do not develop from pre-existing cartilage cells, but from what may be termed "mother cells" of cartilage. At the edge of a growing chondroma there are cells of an embryonic type, looking like ordinary connective tissue cells, and it is these cells which proliferate, and their "daughter cells" develop a matrix around them and become cartilage cells. So that such a chondroma grows by the continuous accretion of new tissue at the peri- phery. The cartilage cell as such is so surrounded by the matrix, that manifestly it cannot form metastases, but these proliferative or "mother cells" can easily be carried by the blood stream to the various parts of the body, and coming to rest in suitable relation- ships will then proliferate and the resulting cells become true car- tilage cells. It is in these primary cartilaginous tumors that there occurs later on the osteoid or truly osseous change. Mixed chondromata have been found in the Lungs (Cadeac), the Thyroid (Siedamgrotzky, Kitt), the Tympanic Cavity (Siedam- grotzky), the Cardiac Valves (Hamburger), in the Nasal Cavity (Kitt), on the Digits, and they are very common in the Mammary Gland. Of two hundred and fifty-six tumors of the mammae re- moved at the Alfort School between October 1871 and December 1876, two hundred and eleven were osteo-chondromata. Osteomata. These, the bony tumors, are not very common. They are occasionally found on the Inferior Maxilla, the Penial Bone, and on the Internal Face of the Cranium, particularly in dogs suffering from ossifying pachymeningitis (Siedamgrotzky, Cadeac). They have also been seen attached to the transverse process of a Cervical Vertebra (Mueller), the Connective Tissue of the Neck (Leisering), and on the Pulmonary Pleura (Vulpian). Lipomata. Pure fat tumors are rare compared to other tu- mors. They are more liable to show other forms of connective tissue, such as fibro-lipoma, lipo-myxoma. They occur most com- monly as fibro-lipoma, and often attain enormous dimensions. They are characterized by their subcutaneous situation, soft, lardaceous texture, sharp demarcation, slow growth, and slight vascularity. They are generally lobulated, due to septa of connective tissue. In size, they may vary from a small nut to the human head. They are the largest of all tumors. They are sometimes pendulous, and not always round, but large and cylindrical, Froehner saw one ten inches in length. Huidekoper saw one growing from the in- Neoplasms -37^ side of the thigh which nearly touched the ground. They are ob- served mostly in well-nourished animals, and their favorite location is on the Extremities, the inner surface of the Thigh, the Breast, the Shoulder, the Belly, the Anal region, the Vagina (Oreste! Falconio). They also occur in the Medulla of the Kidney (Bruck- mueller), the Liver (Trasbot), the Trachea, Pleura, and Lungs (Kitt, Semmer), and the Intestinal Submucosa. Two tumors at- tached to the Uterus, one of which had grown through the muscular wall of the abdomen, were seen and described by Edgar as lipo- mata. It is doubtful if they could have been true lipomata, be- cause a feature of lipomatous tumors is that they do not tend to grow through surrounding tissues. Myomata. A myoma is a tumor composed of unstriped muscle fibers (leiomyoma) containing as a rule a considerable pro- portion of fibrous tissue. It is of fleshy consistence, pinkish in color, quite vascular, and may attain the size of the human fist. They are seldom seen, but have occurred in the Heart (Jungers), in the Bladder (Lienaux), within the Vagina (Mueller), and in the Pros- tate. They are occasionally found in the Genital Tract of females, but are extremely rare in the bicornate uterus. Fibromata of the uterus are often in part myomatous, and Sutton has sug- gested that many tumors described as fibroids are in the first in- stance leiomyomata, but become degraded into fibrous tissue. Hemangiomata. A hemangioma is a tumor composed largely of blood vessels. Some authors include in the term localized dila- tions of blood vessels, such as hemorrhoids and the scrotal vari- cosities seen by Moeller, but these are not true angiomata of pro- liferation. Virchow states that angiomata are comparatively rare in animals. A lobulated angioma composed of groups of vessels held together in a stroma of connective tissue and situated in the Subcutis of the Right Groin was observed by Siedamgrotzky. The term Cavernous angioma is used to indicate enlarged spaces lined with endothelium, forming an erectile tissue, such as exists norm- ally in the corpus spongiosum. They occur in the Liver, and while quite common in the cat are not often met with in the dog. Sutton has observed them as multiple enlargements, the size of walnuts, occupying the liver substance and forming prominences on its exterior. There is a very good specimen of this condition in the Army Medical Museum at Washington. Lucet saw a cavernous 374 Surgical Diseases and Surgery of the Dog angioma on the Left Shoulder. The term Plexiform angioma, "Aneurism by Anastomosis," is used to describe a condition where vessels become dilated and convoluted and their walls thickened at the spot. These by pressing on the intervening tissue cause it to atrophy. This condition, properly speaking, is not one of neoplasia, but a pathologic alteration of the vessels. It has been seen in the Pectoral Mammae, in the Inferior Eyelids, and on the Prepuce (Rigot). Crisp and Stibel also refer to this condition, the former having possessed a good specimen. Neuromata. This term is commonly applied to any tumor arising from nerve tissue, such as overgrowths of the perineurium and connective tissue of the nerve sheaths, but is properly only employed in describing growths of nerve fibers with the complete nerve cell undergoing proliferation. They are exceedingly rare, but occasionally appear in the form of bulbs, composed of newly- formed nerve fibers on the ends of severed nerves, and according to Sutton, particularly when the proximal end is irritated by the presence of a silk ligature. (b) Connective Tissue Tumors Formed of Immature Tissue. M3rxomata. These tumors are composed of connective tissue cells and an intercellular substance containing mucoid material, the whole being traversed by thin-walled vessels and forming a spongy structure. The more fully developed connective tissue tumors (fi- bromata, lipomata, chondromata, etc.,) sometimes show areas of my- xomatous growth. Myxomata are fairly common, and may at- tain considerable size. One as large as the human head was seen by Scoffie. A typical myxoma is soft and flabby, with a limiting capsule, and either projects from a surface or hangs by a narrow pedicle in the form of a polyp. Common situations are the sub- mucous and Subcutaneous structures. They occur in the Pharynx (Moeller), the Membrana Nictitans (Huidekoper), the Bladder (Van Tright, Johne), the Penis (Koch), the Mammary Gland (McFadyean), and the Vagina. Sarcomata. By the term sarcoma is meant a tumor composed of any variety of cell of connective tissue origin, which cells before reaching maturity proliferate and divide, so that the whole growth is composed of incompletely developed cells, like those of embryonal Neoplasms 375 connective tissue. Ordinary healthy connective tissue is formed from cells which have undergone a process of transition from cellular to fibrous condition. In sarcomatous tissue, these cells show a tendency to continuous proliferation instead of the formation of fibrous trabeculae. Consequently, the consistence of sarcomata is usually soft, but they may be mixed with more or less fibrous tissue, when they are hard. They are often enclosed by a capsule, but fre- quently infiltrate neighboring tissues. They are very prone to un- dergo partial or complete mucoid changes. The partially de- generate form is described as "sarcoma myxomatodes." Instances have been recorded by Creighton. The Sarcomata occur with less frequency than the carcinomata, Froehner placing their percentage at six or seven, but they are equally variable in appearance. A mixed form is rather common, such as fibro-,chondro-,osteo-,lympho-,myo-, and myxo- sarcomata. In their gross appearance the sarcomata often manifest a close resemblance to the carcinomata. They are remarkable for their development in young as well as adult dogs, for their rapidity of growth (some, however, grow slowly), their soft consistence (some are also hard), their partiality for periosteal surfaces, their inclination to metastasis, and their tendency to ulceration when located in the skin and mucous membranes. Metastatic dissemina- tion is mostly by the veins and particles becoming detached to be carried along as emboli. By reason of this it is a common thing to find secondary sarcoma in the lung or even right heart, and where the portal vein is invaded, the liver. The tendency to ulceration is probably dependent on the incompatibility of nutrition with rapidity of growth. Primary Sarcoma exhibits a predilection for the Frontal Re- gion, the Superior Maxilla, the Sternum, Bones of the Extremities, the Skin, the Muscles, and the Mammary gland. Other organs sometimes invaded are the Nasal Bones (Kitt), the Testes (Siedam- grotzky), the Vagina, the Uterus (Moeller), the Heart (Cadiot, Bourney, Kitt, Johne), the Thyroids (Cadiot), the Lungs and Pleura (Cadeac, Kitt, Leisering), the Stomach (Benoit, Megnin), the In- testine (Petit), the Omentum (Siedamgrotzky), and the Peritoneum (Bournay). The cases of round-cell sarcoma of the Penis and Vagina described by Smith & Washbourn are of very great interest, but there is some doubt as to whether they were dealing with ex- 376 Surgical Diseases and Surgery of the Dog cessive granulomatous formation or true sarcoma. This form of growth is referred to under Infective Granulomata. True sarcoma of the Vagina does, however, sometimes occur, for myxomatous growths have been observed to undergo sarcomatous transforma- tion. The disease occasionally occurs as a general sarcomatous for- mation (Megnin, Froehner). A variety known as myelogenic sar- coma is sometimes seen attacking the interior of Bone Cavities, principally of the fore-arm and the shoulder. The distinguishing feature between myelogenic sarcoma and periosteal sarcoma is that the former is an excessive development of the bone marrow and the letter of the periosteum, so that the cells forming the two are of a different type. L3nupho-Sarcoma is the term used to denote primary sar- coma of lymphatic structures. The lympho-sarcomata are com- posed of the same kind of cells, but have a stroma of reticulated lymphadenoid tissue. They are not to be confounded with lymph- adenoma nor with specific inflammatory enlargements involving lymphatic structures. The dividing line between lympho-sarcoma and lymph-adenoma is absolutely vague, as again between lymph- adenoma (Hodgkin's disease) and leukemic lymph-adenoma (lymph- atic leukemia.) Where the growth remains within the capsule of the lymphatic glands then the term lymph-adenoma or "Hodg- kin's disease" may be applied. Where accompanying such glandular overgrowth there is increase in the lymphocytes in the blood, the condition is one of leukemic lymph-adenoma or lymphatic leu- kemia ; where the excessive growth of the lymphatic tissue goes on to infiltration and metastases, it is lympho-sarcoma. The lympho- sarcomata are the most malignant of all the sarcomata, and are very infiltrating. On account of their rapidity of growth and profound effect on the general health it has been suggested that they are the product of some very active species of microparasite. Their con- sistence varies from soft to moderately firm with occasional calcar- eous deposits, and the color on section is pinkish or reddish, and they sometimes undergo cystic transformation, containing a red- dish viscous, inodorous liquid. The lymphatics of the Neck and Pubic region are most commonly affected, but any or all the glands of the body may be involved. These growths are extremely metas- tatic. Neoplasms 2>77 Melano-Sarcomata or Melanomata are characterized by de- position of a blackish pigment, both in the cells and intercellular substance. While common in the horse, they are rare in the dog. They arise especially from regions where there are already pigment- containing cells, notably from pigmented moles. They are ex- tremely malignant, and secondary deposits are often found at con- siderable distances. They have been found in the Lips and Mouth, whence they have traveled to the Lungs, appearing there in the form of black interlacing lines (Lafosse, Bruckmueller). This condition must not be confounded with the more common one of coal-dust deposits (anthracosis pulmonum). Melanoma has also been seen at the Base of the Brain in the form of little nodosities (Bruckmueller). According to Leblanc, mixed melanotic growths are not uncommon. There is a very good specimen of melanotic sarcoma of the Pectoral Mammae in the Army Medical Museum at Washington. Sutton refers to a variety of melanosarcoma which seem to become mainly a source of pigment, which may enter the circulation and be discharged in the urine as melanin. .Such a tumor was observed by Bunker. It was situated Subcutaneously and discharged an ofifensive black matter through several openings. Another tumor composed of fungoid growth mixed with melan- otic matter was removed from the Breast by Crisp, and the animal succumbed twelve months later to the same disease in the Lungs. Glio-Sarcomata. A glio-sarcoma is a tumor containing neuro- glia-cells mixed with sarcomatous elements, occurring in the central mass of the brain or spinal cord. With regard to gliomata and glio- sarcomata a difficulty presents itself in dividing tumors according to their embryology. The ordinary sarcoma is derived from or- dinary mesoblastic connective tissue. The glioma which closely re- sembles it in structure is derived from the neuroglia, the connec- tive tissue of the brain and retina, but this connective tissue, like the nerves themselves, is of epiblastic origin. A tumor of this nature, situated in the neighborhood of the Gasserian Ganglion was observed by Gratia. Endothelial Sarcoma or Cholesteatoma is a term applied to a proliferation of endothelial cells aggregated into nodules of a pe- culiar glistening pearl-like appearance. They originate from serous membranes, lymphatics, blood vessels, and from the pleural and cerebral membranes, and also occasionally in glandular organs. ^yS Surgical Diseases and Surgery of the Dog They are highly vascular, but run a slowly malignant course. They are extremely rare. They have been seen the size of a pea occur- ring on the Choroid Plexus and in the Lateral Ventricles (Cadeac, Dexler), and the size of a nut occurring in the Parotid region in two different animals (Lienaux). (a) Epithelial and Glandular Tumors Approximating to Fully Formed Tissue. Adenomata. An adenoma is an innocent growth originating from pre-existing glandular tissue and formed by proliferated gland cells arranged in an orderly manner, and supported by a fibrous stroma. But these cells differ from normal ones in that they have no power of producing the normal secretion peculiar to the gland tissue from which they grow. That is to say, if any secretion at all is produced, it is a modified one, and the gland has no means of discharging it externally by proper ducts. There are adenomas of the liver which clearly show bile pigmentation, and thyroid adenomas may lead sometimes to exophthalmic goiter brought about by excessive production of excretion, which often disappears upon removal of the tumors. Tumors of this class show no tendency to infiltration of neighboring lymphatics, but under certain conditions are capable of developing malignant characters. (See Carcinomata). The adenomata are often of mixed type, such as fibro-adeno- mata, myxo-adenomata. Common seats are the Mammary Glands (Sutton), the Peri-anal Glands, the Prostate Gland, and the Se- baceous and Sudoriparous Glands of the Trunk and Extremities (Lienaux, Leisering, Siedamgrotzky). Other organs in which this form of tumor has been observed are: Harder's Glands (Froeh- ner), the Liver (Hobday), the Ovary (Sutton), the Vagina (Cam- ardi), the Lungs (Stockman), the Thyroid (Woelfler), and the Cerebrum (Penberthy). Lymphadenoma. This term is used to denote a form of neo- plasm affecting lymphatic tissues and having the structure of lymph- adenoid tissue. It occurs as a purely innocent local affection, a common seat of which is the spleen, and also as a more or less malignant disease. The difference between the latter and splenic leukemia and lympho-sarcoma has already been pointed out under Neoplasms 379 Sarcomata. The malignant form of growth may or may not be associated with the condition known as splenic leukemia in which there is also an augmentation of splenic pulp and an actual increase in the number of leucocytes in the blood. There is no tendency to extension of the disease process beyond the capsule of the glands, the latter retaining their shape, so that the condition might be re- ferred to as one of malignant hyperplasia. Single or several groups of glands may be involved. The growths are soft or hard, accord- ing to the amount of connective tissue present. They are danger- ous in that they may exercise destructive compression of vital or- gans, particularly intrathoracic ones, and the disease is eventually fatal through production of cachexia and exhaustion. Papillomata. A papilloma is a benign tumor arising from a surface and having a framework of fibrous stroma and bloodvessels with a covering of squamous epithelial projections or proliferations. In common parlance it is termed a wart. According to Froehner, the papillomata form ten per cent of all tumors. They occur chiefly in young animals, and like other benign tumors, often in multiples, and seem to arise in a spontaneous manner through causes which are not understood. They also disappear with equal spontaniety. Two forms are recognized, the hard growing on the Skin, and the soft growing generally on Mucous Membranes. They are fre- quently seen at the junction of mucous membrane with the skin. The hard form exists as smooth hemispheric elevations, and the soft as dendritic growths, i. e., arborescent masses growing from a common base, or as cauliflower-like pedunculate growths. They are always sharply defined from the neighboring parts. In general, they are not very large, varying in size between a pea and a wal- nut. In the skin they appear commonly on the Head, Back, and Prepuce, and on the Extremities, particularly round the Pads of the Feet, but may occur in any part of the body. Skin warts are frequently the seat of melanotic deposits— the so-called pigmented moles. In old animals there is good reason to believe that they may become the starting point of true malignant epithelial in- growths, and it is noteworthy that they grow in places commonly the seat of epithelioma. Sometimes the epithelial layers decompose and ulcerate, especially when irritated, by which they undergo dessi- cation, and fresh material being continually added to the base, a Wart-horn is produced. In the Vestibule of the Outer Ear papil- 380 Surgical Diseases and Surgery of the Dog loma occurs as a peculiar flat, coin-shaped excrescence, which is very troublesome, invariably giving rise to a noisome otorrhea. On mucous membranes they occur at the edge of the Eyelids, on the Membrana Nictitans, and on the Lips, Gums, Hard Palate, Tongue, and Trachea (Mouguet). In the buccal cavity they are seen par- ticularly among puppies and young dogs, and as they are often observed to occur in several animals in the same kennel they are regarded as contagious or infectious in character. Experiments conducted by McFadyean and Hobday prove at least their inocula- bility. These gentlemen succeeded in inoculating other dogs by rubbing excised wart on a small area of scarified mucous membrane on the lips. The growth developed in that locality in from six to eight weeks, but failed to do so on the penis. Attempts to re-infect dogs which had recovered gave negative results. These tumors always disappear of their own accord, though successive crops of them will develop at intervals of a week or two for a certain period. They may be compared with the growth of warts on the hands of young boys. Papilloma have been observed in the Pelvis of the Kidney by Bruckmueller and Siedamgrotzky. Endothelial Papilloma of the Pleura has been described by Hutyra and Kitt. In the former's case there were fine villous clusters an inch in length, and those attached to the mediastinal portion formed a tumor as large as the infantile head, displacing the heart. The histologic structure was richly vascular with a simple endothelial lining. (b) Epithelial and Glandular Tumors Formed of Immature Tissue. Carcinomata. According to Froehner, these constitute by far the commonest of all the neoplasms, averaging forty per cent of the whole. Two main types are included in the term, viz., the EPITHELIOMATA and the MALIGNANT ADENOMATA. The Epitheliomata are derived from squamous epithelium, which proliferate and form new growths. They arise most commonly at the seat of junction of skin and mucous membrane, or where two different kinds of epithelium merge. The Malignant Adenomata are composed of proliferated glan- dular cells, appearing as an overgrowth of follicles with a tendency to retrogressive metamorphosis of cells and infiltration of neighbor- Neoplasms 381 ing textures. When such an overgrowth of follicles tends to retain the glandular form it is termed Adenoma, but when the overgrowth is characterized by infiltration and development of an embryonic type of cells it is termed Carcinoma. If both types are present in the same tumor it is termed Adeno-Carcinoma. The histo- genesis of cancer remains a mooted point. There are some who zealously advocate the parasitic theory, and others who as ardently oppose it. Still other authorities are willing to concede the pos- sibility of a parasitic origin in the first instance sufficient in itself to initiate the atypical cell proliferation, or so to speak, to start the cells running wild on a wrong track, but suggest that the habit once having been acquired may continue independent of the initial stimulus. At the present time the majority opinion is against the parasitic origin of the disease. Heredity is generally recognized as a potent predisposing factor in the dog as in man, but it must be remembered that the lineal and clinical histories of our patients are seldom traceable with accuracy. It is recognized that benignal adenomatous tumors offer conditions favorable to the development of carcinoma. As they contain both glandular cells and connective tissue cells it is easy to comprehend this capacity of transition. The phenomenon might be aptly described as "progressive carcino- matosis," and it is particularly prone to occur in consequence of repeated injuries or prolonged continuous irritation. A typical example is afforded by the following case which occurred in my practice : A male hound, aged eight years, for some years had been secured by a chain, one end of which was attached to a ring which ran on a wire about forty feet long. In this manner the animal was enabled to run to and fro within a limited area. On its right side, as it left its sleeping quarters, was a high wall, while on the other side, a short distance away, was its master's residence. Hence, on running to and fro the length of the wire, it would invariably get on the side looking towards the house, and it so happened that the chain tended always to get between its front legs and rub continuously on a certain spot on the posterior and inner aspect of the right leg. About two years previous to the time the case was brought to my notice, an abrasion was noticed on this spot, which gradually gave place to a sessile fibrous growth which en- larged slowly for eighteen months. It then suddenly began to in- crease at a much more rapid rate, its weight causing it to become 382 Surgical Diseases and Surgery of the Dog pedunculate. Having removed the growth, I submitted it to Pro- fessor Adami, who pronounced it a fibro-adenoma undergoing what could not be regarded as otherwise than an early cancerous change. In an instance recorded by McFadyean a carcinoma appeared to have developed as a secondary growth from an anal adenoma. But in no part of the body are such striking instances of progressive malignancy afforded as in the mammary gland. While true malig- nant adenoma of these glands is far from uncommon, the usual type of growth met with in this region is fibro-adenoma exhibiting a modified malignancy with proneness to recur after ablation but with a tardy tendency towards general dissemination. This recur- rence may take place in the area from which the initial tumor has been removed by continued growth of left-over particles, or it may take place in the neighboring mammae owing to a latent tendency towards this form of tumor-formation existing in the mammary glands as a whole, and which may break out in individual glands at different times, the growths forming in the later years of the animal's life being more inclined to exhibit malignant character. In an instance which I observed a firm mammary tumor appeared in a Skye terrier female at the age of eight years. After reaching a moderate size it remained quiescent for seven years, when it suddenly commenced to enlarge at an alarming rate in addition to giving birth to numerous secondary growths in the neighbor- ing glands. It proved on examination to be carcinoma. In the middle of the last century Leblanc observed this phenomenon and referred to "simple hypertrophic enlargements" as being commonly mistaken for cancer. He made some consecutive examinations of recurring mammary tumors and noticed a gradual transition into malignancy. The first growth removed was found to be simple adenoma, but malignant characteristics become more and more ac- centuated according as the recurrence increased in frequency. Froehner believes that the majority of such tumors are malignant in character, while McFadyean has expressed the view, after exam- ining a series of these growths that the commonest form of en- largement is of the nature of a fibrous induration, the groups of cells scattered through the fibrous stroma being in reality the compressed remains of the glandular acini, the compression re- sulting from the formation of new connective tissue. There is a specimen in the Army Medical Museum at Wash- Neoplasms 383 ington showing primary adeno-carcinoma of the mamma with secondary growth in the liver and spleen. The carcinomata are notable on account of their rapid growth, but curiously enough, they may remain quiescent after attaining a certain degree of development. Strong proof of carcinomatous character is the progressive extension of a tumor to adjacent tissues. Regional extension takes place through lymphatics with which they are abundantly supplied, while general dissemination mostly takes place through the venous system through perforation of a vein- wall by carcinoma cells. Dissemination is less frequent in epithe- lioma than in malignant adenoma. Adult animals are the principal sufferers, and the average age is in the neighborhood of eight years. Froehner based some statistics on sixty-five cases he had treated by surgical procedure, as follows : Number of dogs aflfected. Aged. 10 2 — 4 years. 18 5 — 6 years. 22 7 — 8 years. 12 9-10 years. 3 12-13 years. In a hundred observations on the part of Cadiot and Almy the proportions were similar: Number of dogs affected. Aged. 6 I — 3 years. 18 3—5 years. 33 6 — 9 years. 26 9-12 years. 14 12-15 years. 3 15-20 years. In microscopic appearance, carcinomata vary according to their situation and period of existence. A typical carcinoma as occur- ring in the skin is a more or less uneven, indurated, and sensitive growth with a metastatic tendency to infiltrate neighboring tissues. It has a circumscribed edge and a raw, ulcerating, crater-like center, from which an offensive discharge is emitted. Ulceration is often absent, and instead, the surface has an irregular scarred appearance. The tumor is freely mobile from the surrounding tissues but inti- mately adherent to its cuticular covering. Its dimensions may vary 384 Surgical Diseases and Surgery of the Dog from the size of a pea to that of an apple or even the infantile head. Carcinoma of the Skin manifests a predilection for the Ears and Eyelids or their proximity, the Edges of the Lips, the Root of the Tail, the Legs, the Paws, and the Scrotum. Carcinoma of the Testes is not uncommon though there has been some difference of opinion among veterinary pathologists as to the identity of these tu- mors. Malignant growths of the testes are peculiarly difficult to classify, as there may be every kind of deviation from the pure con- nective tissue tumor through the mixed connective, adenomatous, or cystic tumor, to the tumor of the almost purely glandular cancerous type. The liability for tumors to show both proliferation of the tubes and proliferation of the interstitial tissue, a peculiarity which is also seen to some degree in the kidney is the explanation of the so- called carcinoma-sarcomatodes. Kitt refers to the condition when confined to the testicle as Hypertrophia adenosarcomatosa testis but when it assumes a progressive character he names it Carcinoma testis sarcomatodes. In cryptorchids the retained organ is often cancer- ous. (Leisering, Sutton) Primary Carcinoma of the Viscera is a comparatively rare dis- ease. The organs in which either primary or secondary forms occur are: the Bladder (Schulz, Demeurisse), the Prostate Gland, the Kidneys and Supra-renals (Bruckmueller, M'Fadyean, Kitt, Bour- ney), the Ureters (Siedamgrotzky), the Uterus (Leblanc, Bruck- mueller, Camardi), the Thyroid (Siedamgrotzky), the Intestinal Canal (Mueller, Cadeac, Laborde, Huidekoper, Eberlein), the Pan- creas (Nocard, Cadeac), the Liver (Siedamgrotzky), the Spleen, the Peritoneum (Cadeac), the Lungs (Kitt, Cadeac, Lienaux), and the Heart (Cadiot). (2) COMPOUND TUMORS. Teratomata Comprising (a) Dermoid Tumors and Cysts and (b) Parasitic Fetuses. Dermoid Tumors and Cysts. These arise from sequestered por- tions of the epiblast, occurring usually in unnatural positions. A familiar example of Sequestration Dermoid is seen in the small cutaneous nodules furnished with vibrissae which are constantly present on the Cheeks in a line with the angle of the mouth. The mucosa lining the surface of the Eye-ball is occasionally the seat of congenital patches of skin, bearing tufts of hair, which have re- Neoplasms 385 ceived the name of congenital moles. The explanation of their oc- currence is based upon the development of the eye-lids. In early- fetal life the tissue covering the outer surface of the eye-ball which ultimately becomes the conjunctiva is directly continuous with the skin. Cutaneous folds arise and approach each other from the mar- gin of the orbit to ultimately become the eye-lids, and their surfaces, which are continuous with the covering of the eye-ball, become con- verted into conjunctival mucous membrane. This conversion (into mucous membrane) is dependent upon the complete occlusion of the covering of the eye-ball, and if a portion or even all of the latter remains uncovered, it persists as skin (Sutton). Dermoid Cysts occur in the Ovaries. They may be composed of skin or mucous membrane together with the appendages peculiar to these structures such as hair and sebaceous glands, and contain a mucoid fluid. Mueller quotes Esser as authority for their occurrence in the dog. Dermoid Cysts containing rudimentary molar teeth also occur in the Temporal Region (Werwey, Cadiot & Almy). They usually undergo regressive metamorphosis, the cells consti- tuting the lining of the cyst becoming detached to form part of the cystic contents. Inflammation of the interior follows entrance of pyogenic microorganisms, and the matter gains exit by fistulous tract in or near the auricular region. Parasitic Fetuses are composed of cells of parts of individuals parasitic upon another individual. They are not common. A v^ry interesting case was witnessed by Hodgkins where the parasite had two fully developed feet and was attached to the umbilicus of a normal puppy. (4) Cysts A cyst is a tumor containing one or more cavities filled with fluid or semi-fluid contents resulting from abnormal dilation of pre-existing tubules or cavities. Strictly speaking, a cyst is not a neoplasm, the whole style of a cyst being totally distinct from the tumor proper, and so many widely differing factors may lead to cyst formation that it is better to treat them as a totally distinct section. Nevertheless, the purpose of the work will perhaps be best served by including them in the same chapter. Closely following Sutton's classification, we recognize > in the dog: 26 386 Surgical Diseases and Surgery of the Dog (1) True Cysts. (a) Retention and Gland Cysts .... Hydronephrosis, Hydro- cholecyst, Ranula, Chy- lecysts, Ovarial, Uterine, Mamrriary, Sebaceous, and Mucous cysts. (b) Tubulo-Cysts Cystic tumors associated with remnants of the Ducts of the Fetal Mes- onephros. (c) Hydrocele Of the Tunica Vaginalis Testis. (2) Pseudo-Cysts. (a) Bursae Synovial, etc. (b) Contusion and Extravasation Cysts . . . . Hematoniata, etc. (c) Neural Cysts ..Hydrocephalus and Hydrocele of Ventricles (d) Parasitic Cysts Hydatids (e) Emphysematous Cysts Of the Mesentery (/) Degeneration Cysts Of solid Tumors (1) True Cysts. (a) Eetention and Gland Cysts are formed by accumula- tions of fluid which is hindered from escaping by some obstruction. Should the condition persist, the glandular tissue undergoes pres- ure-atrophy and finally the gland and its duct become converted into a cyst, the contents of which are usually of a brownish-yellow color. The condition known as Hydronephrosis is due to dilation of the pelvis and infundibula of the kidney as a result of intra- or extra- mural obstruction in some part of the urinary tract. If the obstruc- tion occur in the Ureter from tumor, calculi, etc., or at its vesicaj orifice, there is a unilateral accumulation, but if it occur at the Neck of the Bladder or in the Urethra from enlarged prostate or impacted calculus, the condition becomes bilateral. Unilateral hydronephrosis 7 Fracture of the Femur 338 Fracture of the Humerus 334 Fracture of the Hyoid Bone .... 332 Fracture of the Inferior Maxilla 331 Fracture of the Metacarpal Bones 337 Fracture o^ the Nail 309 Fracture of the Patella -^39 Fracture of the Pelvis 337 Fracture of the Penial Bone.... 338 Fracture of the Radius and Ulna 335 Fracture of the Ribs 334 Fracture of the Scapula 334 Fracture of the Sternum i2)Z Fracture of the Tibia and Fibula 340 Fracture of the Trachea 116 Fracture of the Vertebral Col- umn 332 Frost-Bites 32 Gall-stones 206 Gangrene ; . 34 Gastrotomy l6o Gastro-Enteral Anastomosis . . . i6i Gastro-Enterostomy i6i General Anesthetics lo General Surgery I Gersuny's Operation 202 Gingivitis 74 Gland, Carcinoma of the Pros- tate ; ... ...... 264 Gland Cysts 386 Gland, Examination of the Pros- tate ; . . . 261 Gland and Glandules, The Thy- roid 100 Gland, Hypertrophy of the Pros- tate 262 Gland, Neoplasms of the Pros- tate 262 Gland, The Prostate 261 Glands, Adenoma of the Mam- mary 304 Glands, Carcinoma of the Mam- mary 305 PAGE Glands, Chondroma of the Mam- mary ••• Zos Glands, Congestion of the Mam- mary 302 Glands, Fibroma of the Mam- mary 304 Glands, Fistula of the Salivary 92 Glands, Inflammation of the Sal- ivary 93 Glands, Lipoma of the Mammary 304 Glands, The Lymphatic 108 Glands, The iviammary 302 Glands, Neoplasms of the Lym- phatic I ID Glands, Neoplasms of the Mam- mary 303 Glands, The Salivary 92 Glands, Sarcoma of the Mam- mary ..... 305 Glands, Traumatic Lesions of the Mammary 302 Glands, Traumatic Lesixjns of the Salivary ;..... 92 Glandular Tumors 278, 380 Glaucoma 49 Glio-Sarcomata 377 Glossitis 74 Goiter lol Goiter, Exophthalmic 107 Granulomata, Infective ........ 365 Granulomata, Simple 365 Granulomata, Venereal 254, 286, 366 Halsted's Mattress suture 183 Hands, Sterilization of the .... 2 Harelip 73 Head and Neck, The 36, "ii Head and Neck, Carcinoma of the 39 Head and Neck, Congenital Mal- formations of the 36 Head and Neck, Cutaneous Horns on the : . . . . . 39 Head and Neck, Epitholioma of the 39 Head and Neck, Fibroma of the 38 Head and Neck, Foreign Bodies in and on the 37 Head and Neck, Epithelioma of the :;..... 38 Head and Neck, Neoplasms of the 38 Head and Neck, Papilloma of the 38 Head and Neck, Sarcoma of the 38 Head and Neck, Traumatic Le- sions of the 36 Heart and Pericardium, The 125 400 Index PAGE Heart and Pericardium, Trau- matic Lesions of the 125 Heart, Surgery of the 130 Heart, Suture of the 131 Hemangiomata 373 Hematoma 21 Hematoma of the Ear 66 Hematoma of the Head and Neck 38 Hemorrhoids 198 Hepatectomy 208 Hernia 288 Hernia, Crural 300 Hernia, Diaphragmatic 300 Hernia in the Female, Inguinal 292 Hernia in General, Abdominal . . 288 Hernia, Incarcerated and Stran- gulated 172 Hernia of the Lung 123 Hernia in the Male, Inguinal.. 297 Hernia in the Male, Scrotal.... 297 Hernia, Pancreatic ^01 Hernia in Particular, Abdominal 291 nernia, Perineal 299 Hernia, Umbilical 291 Hernia, Ventral 292 Hodgkin's Disease iii Hopples 8 Horns on the Head and Neck, Cutaneous 39 Humerus, Fracture of the 334 Humero-Radio-UInar Articula- tion, Luxation of the 355 Hydrocele 388 Hydrometra 278 Hydronephrosis 221 Hydropericardium 130 Hydrophthalmia 49 Hydrothorax 123 Hygroma 314 Hyoid Bone, Fracture of the... 332 Hyperplasia 364 Hjrpertrophy 364 Hypertrophy of the Pads, Epi- thelial 315 Hypertrophy of the Prostate Gland 262 Hypertrophy of the Vaginal Mu- cosa, Estrual 285 Hypnotics 18 Hypopyon 46 Hypospadias 245 Hysterectomy 280 Hysterotomy 279 Ileus 174 Immobilization of the Jaws with the Speculum 72 PAGE Inanimate Objects in the Peri- toneal Cavity 149 Incarcerated Hernia 172 Incrustations of Tartar 87 Infective Granulomata 365 Inferior Maxilla, Fracture of the 331 Inflammation 19 Inflammation of the Feet 310 Inflammation of the Matrix of the Nail 310 Inflammation of the Pads 310 Inflammation of the Salivary Glands 93 Inflammatory Affections of the Tail 320 Inflammatory Neoplasms 365 In-Growing Nail 310 Inguinal Hernia in the Female.. 292 Inguinal Hernia in the Male. . 297 Instruments, Sterlization of.... 2 Interdigital Eczema 311 Interdigital Serous Cysts 315 Interstitial Fibrosis of the Teat, Chronic 306 Interstitial Keratitis 47 Intestinal Obstruction 164 Intestinal Obstruction by Com- pression 171 Intestinal Obstruction by Con- striction 179 Intestinal Obstruction by Fecal Accumulation 165 Intestinal Obstruction by For- eign Bodies 168 Intestinal Obstruction by Ob- stacles 164 Intestines, The 161 Intestines, Examination of the. . 161 Intestines, Neoplasms of the 1T9 Intestines, Stricture of the 179 Intestines, Surgery of the i8i Intestines, Traumatic Lesions of the 162 Intestine, Torsion of the 174 Intestine, Ventrofixation of the 191 Intestines, Wounds of the 162 Intussusception 175 Irrigation of the Bladder 239 Irrigation, Rectal 191 Jaws, The Lips, Mouth, Tongue and 72 Jaw, Osteoma of the 80 Jaw, Sarcoma of the 8l Jaws with the Speculum, Im- mobilization of the 72 Joints, Sprains of 350 Joints, Wounds of 350 Index 401 PAGE Keratitis, Interstitial 47 Keratitis, Superficial 45 Keratocele 46 Kerectasia 45 Kidneys, The 2i8 Kidneys, Calculi in the 218 Kidneys, Examination of the. . 218 Kidney, Neoplasms of the 220 Kidney, Parasites of the 222 Kidney, Surgery of the 222 Lachrymal Fistula 50 Laparotomy 134 Larynx, The US Larynx, Foreign Bodies in the.. 115 Larynx, Neoplasms of the 116 Legs and Feet, The 307 Legs and Feet, Adenoma of the 312 Legs and Feet, Amputation of the 317 Legs and Feet, Carcinoma of the 315 Legs and Feet, Congenital Mal- formations of the 307 Legs and Feet, Fibroma of the 313 Legs and Feet, Lipoma of the.. 313 Legs and Feet, Neoplasms of the 312 Legs and Feet, Sarcoma of the. . 316 Legs and Feet, Traumatic Le- sions of the 307 Lembert Suture 182 Lens, Congenital Dislocation of the 41 Lens, Discission of the '. 55 Lens, Extraction of the 56 Lens, Luxation of the 52 Lesions of the Articulations, Traumatic 35o Lesions of the Bladder, Trau- matic 230 Lesions of Bone, Traumatic .... 323 Lesions of the Ears, Traumatic. 61 Lesions of the Esophagus, Trau- matic 96 Lesions of the Eye, Traumatic. 41 Lesions of the Eyelids, Trau- matic 57 Lesions of the Head and Neck, Tr umatic 36 Lesions of the Heart and Peri- cardium. Traumatic 125 Lesions of the Intestines, Trau- matic 162 Lesions of the Legs and Feet, Traumatic 307 Lesions of the Liver, Trauma- tic 205 27 PAGE Lesions of the Lungs and Pleu- rae, Traumatic 118 Lesions of the Mammary Glands, Traumatic 302 Lesions of the Mouth, Trauma- tic 86 Lesions of the Penis, Traumatic 251 Lesions of the Peritoneum, Me- sentery and Omentum, Trau- matic 144 Lesions of the Prepuce, Trau- matic 251 Lesions of the Salivary Glands, Traumatic 92 Lesions of the Spleen, Trauma- tic 212 Lesions of the Stomach, Trau- matic 154 Lesions of the Tail, Traumatic. 319 Lesions of the Teeth, Traumatic 92 Lesions of the Testes, Traumatic 258 Lesions of the Urethra, Trau- • matic 246 Leucoma 46 Leukemia, Lymphatic iii Leukemic Lymphadenoma iii Ligating Material 4 Lip, Epithelioma of the 81 Lips and Mouth, Congenital Mal- formations of the 74 Lips, Mouth, Tongue and Jaws, The 72 Lips, Mouth, Tongue and Jaws, Examination of the 72 Lipomata 372 Lipoma of the Legs and Feet. . . . 313 Lipoma of the Mammary Glands 304 Litholapaxy 242 Lithotomy, Prepubic 241 Liver, Examination of the 54 Liver, Neoplasms of the 206 Liver, Surgery of the 207 Liver, Traumatic Lesions of the 205 Local Anesthetics 16 Lung, Hernia of the 123 Lungs and Pleurae, The 118 Lungs and Pleurae, Examina- tion of the 118 Lungs and Pleurae, Traumatic Lesions of the 118 Lungs, Surgery of the 123 Luxations 351 Luxation of the Carpal Articu- lations 357 Luxation of the Caudal Articu- lations 359 402 Index PAGE Luxation of the Coxo-Femoral Articulation 357 Luxation of the Eyeball 41 Luxations in General 35^ Luxation of the Humero-Radio- Ulnar Articulation 355 Luxation of the Lens 52 Luxation of the Metacarpal Ar- ticulations 357 Luxations in Particular 35^ Luxation of the Patella 35^ Luxation of the Phalangeal Ar- ticulations 357 Luxation of the Radio-Ulnar- Carpal Articulations 357 Luxation of the Scapulo-Hume- ral Articulation 354 Luxation of the Tempero-Max- illary Articulation 353 Luxation of the Tibio-Tarsal Articulation ,..,.. 359 Luxation of the Vertebral Artic- ulations 354 Lymphadenitis 108 Lymphadenitis, Acute 109 Lymphadenitis, Chronic or Tu- berculous 109 Lymphadenoma 378 Lymphadendma Benign 1 10 Lymphadenoma, Leukemic ill Lymphadenoma, Malignant .... ill Lymphatic Glands, The 108 Lymphatic Glands, Neoplasms of the no Lymphatic Leukemia in Lymphoma no Lympho-sareoma 112, 376 Macula 46 Male, Reproductive Organs of the 251 Malformations of the Esophagus, Congenital 96 Malformations of the Eyes, Con-' genital 40 Malformations of the Eyelids, Congenital 57 Malformations of the Head and Neck, Congenital 36 Malformations of the Legs and Feet, Congenital 307 Malformations of the Lips and Mouth, Congenital 74 Malformations of the Ovaries, Congenital 265 Malformations of the Penis, Congenital , 251 PAGE Malformations of the Prepuce, Congenital 251 Malformations of the Rectum and Anus, Congenital 194 Malformations of the Spleen, Congenital 211 Malformations of the Tail, Con- genital 318 Malformations of the Teeth, Congenital 85 Malformations of the Testes, Congenital 257 Malformation of the Urethra, Congenital 245 Malformations of the Vagina, Congenital 282 Malignant Lymphadenoma in Mammary Glands, The 302 Mammary Glands, Adenoma of the 304 Mammary Glands, Carcinoma of the 30s Mammary Glands, Chondroma of the 30s Mammary Glands, Congestion of the 302 Mammary Glands, Fibroma of the 304 Mammary Glands, Lipoma of the 304 Mammary Glands, Neoplasms of the 303 Mammary Glands, Sarcoma of the 305 Mammary Glands, Traumatic Le- sions of the 302 Mammitis 302 Mastitis 302 Material, Suturing and Ligating 4 Mattress suture, Halsted's 183 Matrix of the Nail, Inflamma- tion of the 310 Maxilla, Fracture of the Inferior 331 Maxillary Fistula 88 Melano-Sarcomata, Melanomata 377 Membrana Nlctitans, Neoplasms of tlie 60 Membrane, Persistent Pupil- lary 40 Mesentery and Omentum, The Peritoneum 144 Metacarpal Articulations, Luxa- tion of the 357 Metacarpal Bones, Fracture of the 337 Methods of Restraint 8 Metritis 271 Metritis, Catarrhal 271 Index 403 PAGE Metritis, Puerperal S«ptic 273 Moles 379 Morphine 18 Mouth, Canker of the 75 Mouth, Congenital Malforma- tions of the Lips and 74 Mouth, Fibroma of the 78 Mouth, Foreign Bodies in the... 77 Mouth, Neoplasms of the 78 Mouth, Papillomata of the 78 Mouth, Retention-Cyst of the ... 79 Mouth, Speculums 8 Mouth, Tongue and Jaws, The Lips 72 Mouth, Traumatic Lesions of the 7A. Mucosa, Estrual Hypertrophy of the Vaginal 285 Muzzles 8 Myomata 374 Myxoma of the Pharynx 95 Nail, Fracture of the 309 Tail, Inflammation of the Ma- trix of the 310 Nail, In-Growing 310 Narcotics , 18 IM asal Neoplasms 114 Nebnla 46 Neck, Carcinoma of the Head and 39 Neck, Congenital Malformations of the Head and 36 Neck, Cutaneous Horns on the Head and 39 Neck, Epithelioma of the Head and 39 Neck, Fibroma of the Head and 38 Neck, Foreign Bodies in and On the Head and 37 Neck, The Head and 36, 72 Neck, Hematoma of the Head and 38 Neck, Neoplasms of the Head and 38 Neck, Papilloma of the Head and 38 Neck, Sarcoma of the Head and 39 Neck, Traumatic Lesions of the Head and 36 Neoplasms 363 Neoplasms of the Bladder 236 Neoplasms of Bone 344 Neoplasms of the Ears 65 Neoplasms of the Esophagus . . 100 Neoplr.sms of the Eye 53 Neoplasms of the Eyelids 50 PAGE Neoplasms of the Head and Neck 38 Neoplasms, Inflammatory 365 Neoplasms of the Ihtestlnesr 179 Neoplasms of the Kidney 22io Neoplasms of the Larynx 116 Neoplasms of the Legs and Feet 312 Neoplasms of the Liver 206 Neoplasms of the Lymphatic Glands no Neoplasms of the Mammary Glands 303 Neoplasms of the Metnbrana Nlctltans 60 Neoplasms of the Mouth 78 Neoplasms, Nasal 114 Neoplasms of the Orbftal Gland 60 Neoplasms of the Ovaries 266 Neoplasms of the Penis 254 Neoplasms of the Peritoneum . . 152 Neoplasms of the Pharynx 95 Neoplasms of the Prepuce 254 Neoplasms of the Prostate Gland 262 Neoplasms of the Rectum and Anus , . 204 Neoplasms of the Spleen 212 Neoplasms of the Stomach .... 158 Neoplasms of the Tail 321 Neoplasms of the Testes 258 Neoplasms of the Trachea 116 Neoplasms of the Uterus 277 Neoplasms of the Vagina 284 Nephrectomy 224 Nephrolithotomy 223 Nephrotomy 223 Neural Cysts 389 Neuromata 374 Nose, The 113 Nose, Foreign Bodies in the 114 Objects in the Peritoneal Cavity, Inanimate 149 Obstacles, Intestinal Obstruction by 164 Obstruction by Compression, In- testinal 171 Obstruction by Constriction, In- testinal 179 Obstruction by Fecal Accumula- tion, Intestinal 165 Obstruction by Foreign Bodies, Intestinal r68 Obstruction, Intestinal 164 Obstruction by Obstacles, Intes- tinal 164 Obstruction by the Urethra .... 247 Obstruction by the Urethra, Parasitic .: . . . 248 404 Index PAGE Omentum, The Peritoneum, Me- sentery, and 144 Onychia 310 Oophorectomy 266 Oophoritis 265 Opacity of the Cornea, Congeni- tal 40 Operating Table 9 Operation, Sterilization of the Region of 3 Ophthalmitis 48 Orbital Gland, Neoplasms of the 60 Orchectomy 259 Orchitis 258 Organic Strictures 367 Organs of the Male, Reproduc- tive 251 Organs, The Urinary 215 Osseous System, The 323 Osseous System, Fractures of the 323 Osseous System, Traumatic Le- sions of the 323 Osteitis 340 Osteitis Deformans 342 Osteoma 344 Osteoma of the Jaw 80 Osteomalacia 343 Osteomata 37^ Osteoplasty 345 Osteotomy 34^ Osteo-Arthritis 362 Osteo-Myelitis 340 Otitis 62 Otorrhea 62 Ovaries, The 265 Ovaries, Congenital Malforma- tions of the 265 Ovaries, Examination of the.... 265 Ovaries, Neoplasms of the 266 Pads, Epithelial Hypertrophy of the 315 Pads, Inflammation of the 310 Pancreas, The 208 Pancreas, Surgery of the 208 Pancreatic Hernia 301 Papillomata 379 Papillomata of the Ears 65 Papilloma, Endothelial 380 Papilloma of the Head and Neck 38 Papillomata of the Mouth 78 Papilloma of the Prepuce 256 Paracentesis of the Abdomen... 149 Paracentesis of the Eye 54 Paraphimosis 253 Parasites in the Eye 43 PAGE Parasites of the Kidney 222 Parasites in the Peritoneal Cavi- ty, Verminous 150 Parasitic Cysts 389 Parasitic Emasculation 259 Parasitic Obstruction of the Ure- thra 248 Passage of the Catheter and Sound 238 Patella, Fracture of the 339 Patella, Luxation of the 358 Pelvis, Fracture of the 337 Penial Bone, Fracture of the... 338 Penis, The 251 Penis, Amputation of the 256 Penis, Congenital Malformations of the 251 Penis, Examination of the 251 Penis, Neoplasms of the 254 Penis, Traumatic Lesions of the 251 Peptic Ulcer 154 Perforation of the Esophagus.. 96 Pericardicentesis 132 Pericarditis 127 Pericardium, The Heart and.... 125 Pericardium, Traumatic Lesions of the Heart and 125 Pericementitis, Calcic 87 Perineal Hernia 301 Periostitis 340 Peritoneal Cavity, Fetuses in the 151 Peritoneal Cavity, Foreig^n Bod- ies in the 149 Peritoneal Cavity, Verminous Parasites in the 150 Peritoneum, Mesentery and Om- entum, The 144 Peritoneum, Neoplasms of the.. 152 Peritonitis 14S Persistent Pupillary Membrane.. 40 Phalangeal Articulations, Luxa- tion of the 357 Phalanges, Disarticulation of the 318 Pharynx, The 94 Pharynx, Epithelioma of the ... 96 Pharynx, Examination of the. ... 94 Pharynx, Foreign Bodies in the 95 Pharynx, Myxoma of the 95 Pharyngitis 94 Phimosis 253 Piles 198 PlnRuecula 53 Pleurae, The Lungs and Ii8 Pleurae, Examination of the Lungs and 1 18 Pleurae, Traumatic Lesions of the Lungs and ii8 Index 405 PAGE Pleuritis 120 Pleuritis, Purulent 122 Polypi 114 Pouches, Suppuration of the Anal 19s Prepubic Lithotomy 241 Prepuce, The 251 Prepuce, Carcinoma of the 256 Prepuce, Congenital Malforma- tions of the 251 Prepuce, Examination of the.... 251 Prepuce, Neoplasms of the 254 Prepuce, Papilloma of the 256 Prepuce, Sarcoma of the 256 Pleurae, Traumatic Lesions of the the 251 Procidence of the Rectum 200 Procidence of the Uterus 275 Prolapse of the Anus 200 Prolapse of the Vagina 299 Proliferative Endometritis 273 Prostate Gland, The 261 Prostate Gland, Examination of the 261 Prostate Gland, Hypertrophy of the 262 Prostate Gland, Neoplasms of the 262 Prostatitis 261 Pseudarthrosis 340 Pseudocoprostasis 195 Pseudo-Cysts 389 Pterygium 53 Puerperal Septic Metritis 273 Puncture of the Bladder 239 Pupillary Membrane, Persistent 40 Purulent Pleuritis 122 Pyemia 33 Pyorrhea alveolarls 88 Pyosalpinx 271 Rachitis 342 Radio-Ulnar-Carpal Articulation, Luxation of the 357 Radius and Ulna, Fracture of the 335 Ranula 79 Rectal Irrigation 191 Rectum and Anus, The 194 Rectum, Congenital Malforma- tions of the 194 Rectum, Examination of the.... 194 Rectum, Foreign Bodies in the.. 195 Rectum, Neoplasms of the 204 Rectum, Procidence of the 200 Region of Operation, Steriliza- tion of the 3 Reproductive Organs of the Fe- male 265 PAGE Reproductive Organs of the Male 251 Resection of the Bladder 243 Restraint, Apparatus and Meth- ods of 8 Retention-Cysts 386 Retention-Cysts of the Mouth.. 79 Retroflexion of the Bladder.... 235 Ribs, Fracture of the 334 Rickets 342 Rupture of the Bladder 230 Rupture of the Esophagus 96 Rupture of the Tendo- Achilles. . 308 Rupture of the Uterus 277 Rupture of the Vagina 283 Salivary Glands, The 92 Salivary Glands, Fistula of the 92 Salivary Glands, Inflammation of the 93 Salivary Glands, Traumatic Le- sions of the 92 Salpingitis 271 Sarcomata 374 Sarcoma of Bone 345 Sarcoma of the Head and Neck 39 Sarcoma of the Jaw 81 Sarcoma of the Legs and Feet. . 316 Sarcoma of the Mammary Glands 305 Sarcoma of the Prepuce 256 Scalds 32 Scalding of the Teeth 90 Scalp, Abscess of the 37 Scapula, Fracture of the 334 Scapulo-Humeral Articulation, Luxation of the 354 Scrotal Hernia in the Male 297 Scrotum, The 257 Section, Abdominal 134 Septic Metritis, Puerperal 273 Septicemia 33 Sequestration Dermoid 40 Serous Cyst, Interdigital 315 Shock 27 Simple Granulomata 365 Simple Tumors 369 Sinus 31 Sinus, Anal 197 Sinus of the Ear 65 Spaying 266 Speculum, Immobilization of the Jaws with the 72 Speculums, Mouth 8 Spleen, The 211 Spleen, Congenital Malformations of the 211 Spleen, Examination of the 211 Spleen, Neoplasms of the 212 4o6 Index PAGE Spleen, Surgery of the 213 Spleen, Traumatic Lesions of the 212 Splenectomy 214 Sprains of Joints 350 Squint 82 staphyloma 46 Sterilization of the Hands 2 Sterilization of Instruments .... 2 Sterilization of the Region of Operation 3 Sternum, Fracture of the 333 Stomatitis 74 Stomach, The I54 Stomach, Examination of the . . IS4 Stomach, Foreign Bodies in the.. 156 Stomach, Neoplasms of the 158 Stomach, Surgery of the 159 Stomach, Torsion of the 155 Stomach, Traumatic Lesions of the 154 Stc«nach, Woimds of the 154 Strabismus 52 Strangulated Hernia. 172 Stricture of the Esophagus 97 stricture of the Intestines 179 Strictures, Organic ^67 Stricture of the Urethra 246 Structure of the Teeth 83 Struma loi Suppuration of the Anal Pouches 195 Superficial Keratitis 45 Surgery of the Bladder 237 Surgery of the Eye 54 Surgery, General i Surgery of the Heart 130 Surgery of the Intestines 181 Surgery of the Kidney 222 Surgery of the Liver 207 Surgery of the Lungs 123 i>urgery of the Pancreas 208 Surgery of the Spleen 213 Surgery of the Stomach 159 Surgery of the Trachea I16 Surgery of the Ureters 225 Surgical Wounds of the Bladder 2^1 Sutures 5 Suture, Halsted's Mattresa 183 Suture of the Heart 131 Suture, Lembert 182 Suturing Material 4 Syme's Operation 81 Synovitis 360 SynecUla, Anterior 45 System, The Osseous 323 Table, Operating 9 Tail, The 318 Tail, Amputation of the 321 PAGE Tail, Congenital Malformations of the 318 Tail, Inflammatory Affections of the 320 Tail, Neoplasms of the 321 Tail, Traumatic Lesions of the.. 319 Tartar, Incrustations of 87 Teat, Chronic Interstitial Fibrosis of the 306 Teeth, The 83 Teeth, Congenital Malformations of the 85 Teeth, Extraction of the 91 Teeth, Scaling of the 90 Teeth, Structure, Disposition, and Development of the 83 Teeth, Traumatic Lesions of the 86 Tempero-Maxiilary Articulation, Luxation of the 353 Tendons, Traumatic Division of 309 Tendo-Achilles, Rupture of the 308 Testes, The 257 Testes, Congenital Malformations of the 2S7 Testes, Neoplasms of the 258 Testes, Traumatic Lesions of the 258 Thoracentesis 124 Thorax, The 118 Thyroid Gland and Glandules, The 100 Thyroidectomy 106 Tibia and Fibula, Fracture of the 340 TIbio-Tarsal Articulation, Luxa- tion of the 359 Tongue and Jaws, The Lips, Mouth 72 Tongue, Partial Amputation of the 76 Torsion of the Bladder 235 Torsion of the Intestine 174 Torsion of the Stomach 155 Torsion of the Uterine Cornua. . 276 Toxemia 33 Trachea, Forei^ Bodies in t!ie.. 115 Trachea, Fracture of the 116 Trachea, Neoplasms of the 116 Trachea, Surgery of the 116 Tracheotomy 117 Traumatic Division of Tendons. . 309 Traumatic Lesions of the Articu- lations 350 Traumatic Lesions of the Blad- der 230 Traumatic Lesions of Bone .... 323 Traumatic Lesions of the Ears . 61 Traumatic Lesions of the Eso- phagus ^.... 96 Index 407 PAGE Traumatic Lesions of the Eye . 41 Traumatic Lesions of the Eye- lids 57 Traumatic Lesions of the Head and Neck 36 Traumatic Lesions of the Heart and Pericardium 125 Traumatic Lesions of the Intes- tines 162 Traumatic Lesions of the Legs and Feet 307 Traumatic Lesions of the Liver. . 205 Traumatic Lesions of the Lungs and Pleurae 118 Traumatic Lesions of the Mam- mary Glands 302 Traumatic Lesions of the Mouth 74 Traumatic Lesions of the Penis 251 Traumatic Lesions of the Perito- neum, Mesentery and Omentum 144 Traumatic Lesions of the Pre- puce 251 Traumatic Lesions of the Sali- vary Glands 92 Traumatic Lesions of the Spleen 212 Traumatic Lesions of the Stom- ach ;... 154 Traumatic Lesions of the Tail . . 319 Traumatic Lesions of the Teeth 86 Traumatic Lesions of the Testes 258 Traumatic Lesions of the Ure- thra 246 Treatment of Tumors 390 Trichiasis 59 True Cysts 386 Tuberculosis 365 Tuberculous Lymphadenitis 109 Tubes, The Fallopian 271 Tubulo-Cysts 388 Tumors, Compound 384 Tumors, Connective Tissue 369 Tumors, Dermoid 384 Tumors, Epithelial and Glandu- lar 378, 380 Tumors Proper 368 Tumors, Simple 369 Tumors, Treatment of 390 Tyloma 3^4 Ulcer 30 Ulcer, Peptic IS4 Ulceration of the Concha 61 Ulceration of the Cornea 45 Ulna, Fracture of the Radius and 335 Umbilical Hernia 291 Ureters, The 215 Ureters, Culculi in the 224 PAGE Ureters, Surgery of the. 225 Ureters, Surgical Wounds of the 225 Ureterolithotomy 227 Uretero-Cystotomy 227 Uretero-Ureteral Anastomosis.. 227 Uretero-Ureterostomy 227 Uretero- Vesical Anastomosis . . 227 Urethra, The 245 Urethra, Calculi in the 247 Urethra, Congenital Malforma- tions of the 245 Urethra, Examination of the.... 245 Urethra, Obstruction of the .... 247 Urethra, Parasitic Obstruction of the 248 Urethra, Stricture of the 246 Urethra, Traumatic Lesions of the 2^6 Urethra, Wounds of the 246 U rethrolithotomy 249 Urethrotomy 249 Urinary Organs, The 215 Urolithiasis 215 Uterine Cornua, Torsion of the 276 Uterine Cornua, Ventrofixation of the 281 Uterus, The 271 Uterus, Examination of the.... 271 Uterus, Fibromata of the 277 Uterus, Neoplasms of the 277 Uterus, Procidence of the 275 Uterus, Rupture of the 277 Uterus, Surgery of the 279 Vagina, The 282 Vagina, Congenital Malforma- tions of the 282 Vagina, Examination of the 282 Vagina, Fibroma of the 284 Vagina, Neoplasms of the 284 Vagina, Prolapse of the 283 Vagina, Rupture of the 283 Vaginal Mucosa, Estrual Hyper- trophy of the 285 Vaginitis 282 Venereal Granulomata . . 254, 286, 366 Ventral Hernia 292 Ventrofixation of the Intestine. . 191 Ventrofixation of the Uterine Cornua 281 Verminous Parasites in the Peri- toneal Cavity 150 Verruca 313 Vertebral Articulations, Luxation of the 354 Vertebral Column, Fracture of the 332 4o8 Index PAGE PAGE Vesico-Rcctal Anastomosis 244 Wounds of the Bladder, Surgical 225 Volvulus 174 Wounds of the Feet 309 Vulvitis 282 Wounds of the Intestine 162 ) Wounds of Joints 35° wart-horn 379 Wounds of the Stomach ....... 154 WartB 38, 60, 78, 313. 379 Wounds of the Ureter, Surgical 225 Wounds 313 Wounds of the Urethra 246 JV 6 i«'%>^