IVIANUAL OF OPERATIVE VETERINART SURGERl }>^ o BY a'^^'LIAUTARD, M.D., V.M Principal and Professor of Anatomy, Surgery, Sanitary Med- icine AND Jurisprudence in the American Veterinary Col- lege ; Chevalier du Merite Agricole de France ; For- eign Corresponding Member of the Societe Cen- trale de Medecine Veterinaire (Paris); Hon- orary Fellow of the Royal College of Veterinary Surgeons (London); Hon- orary Member of the Societe Veterinaire d' Alsace-Lor- raine, Etc., Etc., Etc. Author of '■'■Fade Mecum of Equine Anatomy i^ '•'■How to Tell the Age of Domestic Animals i^ ^'■Animal Castration;^ '''■ Latneness of Horses T Translator of '■'• Bouley on Hydrophobia /" of " Zundel on Diseases of the Foot;'''' Editor of the '■'■Ameri- can Veterinary Review ^ WITH NEARLY 600 ILLUSTRATIONS. ( FEE G 1393 } New York : ^ '^^J^..^ ^'^l^ X, SABISTON & MURRAY, 916 Sixth Avenue,' 1892. / K-^ COPYBIGHTBD, 1891, By a. Liautard, M.D., V.M. All Rights Reserved. '^'; v^ TO DR. A. CHAUVEAU, Member of the Institute (Paris), General Inspector of tlw Veterinary Schools {France), Professor to the Museum of Natural History (Paris), As a humble token of the high appreciation of his scientific labors in behalf of Veterinary and Comparative Medicine, this -work is, with kind permission, dedicated by THE AUTHOR. PREKACE. If an apology should be deemed necessary for any apparent tardiness in the execution of the special undertaking of which the present work is the result, it will not be very far to seek, but may be readily found by a reference to the various and unceasing vocations in which the author of the Manual of Operative Veterinary Surgery is habitually engaged. The labor of its preparation has, in fact, been alternated and shared with that of other literary engagements of an imperative and unremittent char- acter, and the onerous and exhaustive duties pertaining to his collegiate functions, to say nothing of the demands of an extensive practice. Engaged for years in the work of teaching this special department of veterinary medicine, and having abundant opportunities, which have not been neglected, of realizing the difficulties which the student who earnestly strives to perfect himself in his calling is obliged to encounter, I formed the determination long since to do what lay in me to facilitate his acquisi- tion of knowledge; and it was then that I projected the present volume, and began the accumulation of material by the compilatioi of data and arrangement of memoranda, with the recorded notes of my own experi- ence, the fruit of a long and extended practice before referred to ; and of course a careful study of the various authorities who have illustrated and organized our copious veterinary literature. Moreover, haste in the pub- lication, and a thorough digestion of the subject and the systematic order- ing of material, could not be very easily combined, and a little delay in the issue will prove no detriment to the value of the book. With his own kind permission, the work is dedicated to Professor A. Chauveau, General Inspector of the Veterinary Schools of France, as a token of my high appreciation of his services as a scientist, and in recog- nition of his standing among the lights of our profession ; and especiall}^ of my estimation of his excellent book on anatomy, in which he so ably lays the foundation of the knowledge which constitutes the indispensable condition of all success in surgical practice. Vl PREFACE. I have been liberal with European authors, not only in freely cred- iting them with their discoveries and theories, and in many cases quoting literally their opinions and arguments, but especially so in adopting their illustrations and enriching the work with the artistic representations orig- inating in their's— an emphatic manifestation of my high estimate of their value and the skill of their execution. And it is thus that the names and accomplishments of Rigot, Bouley, Gourdon, Peuch, Toussaint, Cadiot and Zundel, of France ; of Brogniez and Degives, of Belgium ; of Hert' wig, Hering, Moller and Hoffman, of Germany; of Lanzillotti-Buonsanti, of Italy ; and of Williams and Fleming, of England, will become famil- iarly known to our readers. But while I have in great part been guided in my work by the char- acter of that of our predecessors, I have not restricted myself to the lines observed by them, or exclusively respected the authority or prece- dents of European surgeons, but have sought to do justice to the progress of American veterinarians by honoring the contributions they have made to our surgical knowledge ; and it is due to accident alone, and to no in- vidious design, if any omission or oversight has been committed, by which any to whom credit should be awarded have failed to receive it. The chapters of the Manual vt^hich treat respectively upon "Frac- tures" and upon "Operations on the Foot" are reprinted from my own previous writings. Thus, in the first instance, the remarks upon frac- tures, with the kind permission of the Hon. Jeremiah M. Rusk, Secretary of the Department of Agriculture, are extracted from an article published in " The Special Report on Diseases of the Horse;" and in the second in- stance, touching the subject of operations on the foot, I have not hesitated to utilize my own translation of Zundel, produced as long ago as the year 1881. In both cases improvement has been made upon the previous treat- ment of these topics by the addition of numerous illustrative plates which accompany the text. In the chapter upon operations on the genito-urinary apparatus the reader is referred to my special work on the subject of " Castration," which is not included in the present volume. In completing the task undertaken in the preparation of the Manual, however perfect or imperfect may be the manner of its execution, while I have been influenced by a desire to effect something for the benefit of all classes of practitioners, including those of recent graduation, my ob- ject above all has been to facilitate the labors of the young student while industriously and anxiously toiling for the knowledge which is to qualifj'' him for a successful career in a useful and honorable profession ; and if I shall have succeeded in this object, and the success shall be certified by the verdict yet to be pronounced, I shall feel fully satisfied and more than ever encouraged to persevere in my efforts to elevate the standard of vet- erinary science in America. No toil has been spared, no effort relaxed, in the prosecution of the design and desire to compel the approval of the judicious, and even to escape the strictures of the critical, and I have not failed to seek for aid and counsel from competent coadjutors. The entire text has undergone revision, with a view to the improvement of its idiomatic structure, by my esteemed friend, H. D. Holt, M. D., of Jersey City, N. J., to whom I am also indebted for the favor of supervising the proof and overlooking the issue and arrangement of the various chapters ; and my publishers, Messrs. Sabiston & Murray, have exercised a true liberality in providing an exter- nal garment and garniture for the contents of the book, in all respects correspondent with their value and interest. To these gentlemen, there- fore, are due my warmest acknowledgments for whatever of internal and external attractiveness may characterize the Manual of Opeeative Vet- EEiNAEY SuEGEEY, and they are cordially and freely tendered. I have now only to express the hope that this contribution to the cause of veterinarj^ progress may be as kindly received and favorably judged by my colleagues as it is honestly designed to effect its object by me, and that any shortcomings in the execution of the work may be len- iently regarded. And so it goes into the hands of the public, to share the fate of all human ventures, for better or for worse, as its fate may be. THE AUTHOR. CONTKNTS. PAGE. Inteodtjction 1 CHAPTER I. Means of Restraint 14 Means of Securing Solipeds 14 Derivative or Painful Method 14 Mechanical or Restraint Method 17 Standing Position 17 Recumbent Position 27 Casting with Hobbles 30 Securing the Legs. . . 38 Casting with Ropes 44 Casting on the Operating Tables 47 Means of Securing other Domestic Animals 54 Bovines 54 Ovines and Caprines 62 Swine 62 Dogs and Cats 64 SxTRGiOAL Anesthesia 66 Local Anesthesia 67 General Anesthesia 70 Accidents of General Anesthesia 75 Accidents Incidental to the use of means of Restraint 76 Fractures 76 Injuries of Soft Tissues 79 CHAPTER 11. Surgical Diagnosis. Sight 81 Touch 86 Hearing 88 Smell 88 Taste 88 X CONTENTS. CHAPTER III. StJEGIOAL ThEBAPBUTICS. PAGE. Dressings 90 Retentive Dressing 98 Uniting " 99 Suspensory " : 99 Compressive Dressing 99 Dividing Dressing 99 Expulsive " 99 Antiseptic " 100 Bandages 103 Varieties of Bandages 105 CHAPTER IV. Elementaet Opebations. Division 125 Incisions 125 Dissections 137 Puncture 138 Reunion 142 Position 144 Uniting Bandages 144 Sutures 146 CHAPTER V. Opebations on the Skin and Cellular Tissue. Cauterization 158 Actual Cauterization or Firing 158 Transcurrent or Firing in Lines 160 Firing on the Surface or " a la Gaulet " 171 Firing in Superficial Points 172 Objective Firing 174 Deep Cauterization 175 Rapid, Deep Cauterization 175 Inherent Firing 178 Subcutaneous Cauterization , 180 Cauterization with the Thermo-Cautery 182 Cauterization in other Animals 183 Accidents of Actual Cauterization 184 CONTENTS. XI Opkeations on the Skin and Cellular Tissue — Continued. page. Exutoriea 186 Setons 188 Tape Seton 188 Regions to apply Setons 193 Rowel Seton 197 Trochiscus 198 Accidents or Sequelse of Setons 198 Ablation of Tumors 200 Excision 201 Ligature 205 Elastic Ligature 210 Removal by Tearing 211 Puncture 211 CHAPTER VI. Opkeations on Bones. Fractures. (Generalities) 212 Fractures of Different Bones 239 Dislocations 262 Amputations 266 Amputation of Members 268 " " Horns, 274 " the Tail 277 Trephining 283 Periostotomy 291 Resection of Bones 293 CHAPTER VII. Operations on Muscles and their Annexes. Caudal Myotomy 296 Caudal Myotomy by Transverse Incisions 299 " " " Longitudinal " 300 " •' " Mixed " 301 " Subcutaneous " 302 Accidents following Caudal Myotomy 306 Crural Myotase. Crural Myotomy 308 Complications of Crural Myotomy 311 Operations upon Fibi'ous Tissues 312 Xii CONTENTS. Operations on Muscles and their Annexes — Continued. page. Tenotomy 312 Plantar Tenotomy 312 Accidents Following 320 Carpal Tenotomy , 321 Anti-Brachial Tenotomy 323 Tarsal Tenotomies 323 Cunean Tenotomy 323 Peroneo-Phalangeal Tenotomy 326 Tenotomy in Birds 337 CHAPTER VIII. Operations on the Digestive Apparatus. On the Teeth 328 Operative Dental Surgery 335 Leveling of the Teeth 335 Extraction of Teeth 343 Filing Teeth 356 Canine Dentistry. . .- 356 Operations on tlie Tongue 358 Suture 360 Amputations. Glossotomy 361 Operations on Salivary Glands 361 Adenotomy •. . 361 Maxillary Adenotomy 363 Operations on the (Esophagus 364 (Esophageal Catheterism 366 The Taxis 370 Crushing the Foreign Body 372 CEsophagotomy 373 Accidents Following 377 OasProtomy. Rumenotomy 377 Incision of the Rumen 378 Enterotomy 380 Paracentesis 383 Hernia 385 Inguinal Hernia 394 Recent Inguinal Hernia 397 Accidents Following 411 CONTENTS. XIU Opkeations on Salivary Glands — Continued. page. Old Inguinal Hernia 411 Inguinal Hernia in Geldings 418 Crural Hernia 420 Perineal " 431 Pancreatic " 421 Pelvic or Internal Hernia of Oxen .... 421 Umbilical Hernia 425 Diaphragmatic Hernia 439 Ventral Hernia 443 Eventrations 447 Laparotomy 449 CHAPTER IX. Opebations on the Respiratory Apparatus. On the Guttural Pouches. Hyovertebi'otomy 453 Laryngotomy. Arytenectomy 463 Fleming Method 463 Cadiot Method 468 Tracheotomy 477 Accidents Following 486 Thoracentesis 488 CHAPTER X. Operations on the Circulatory System. Bleeding. Venesection 493 Phlebotomy 498 Phlebotomy in Solipeds 496 " at the Jugular 497 " at the Cephalic 499 " on the Subcutaneous Thoraciq 501 " at the Internal Saphena 501 " on other Superficial Veins 503 " in Large Ruminants 503 " on the Jugular 504 '• at the Subcutaneous Abdominal 504 " on Small Animals 505 Accidents Following Phlebotomy 506 Xiv CONTENTS. Operations on the Circulatory System. — Continued. page. Arteriotomy 514 Arteriotomy at the Transversal of the Face 514 " " " Posterior Auricular 515 " " " Median Caudal 516 Ccurillary Bleeding 517 Bleeding at the Palate 520 '• '■ " Coronet.... 521 " " Foot : 523 Surgical Hemostasia 523 Temporary or Preventive 524 Permanent or Definite 526 Physico-Chemical Hemostatics 526 Surgical Hemostatics 530 CHAPTER XI. Operations on the Nervous Apparatus. Plantar Neurotomy 541 CHAPTER XII. ■Operations on the Genito-Urinart Apparatus. Catheterism of the Urethra 558 Urethrotomy 558 Preputial Urethrotomy 561 Scrotal " 561 Ischial " 563 Cystotomy 565 Lithotrity 565 Amputation of the Penis 569 CHAPTER XIII. Operations on the Foot. Anatomy 576 Diseases and Defectuosities 583 Vices of Conformation 583 Instruments 589 General Operations 590 Dressings . . 591 CONTENDS. XV Operations on the Foot— Continued. page. Diseases. Canker of the foot 591 Corns 607 Sandcracks 616 ■Calk 627 Punctured "Wounds of the Foot 629 Contracted Heels. Hoof Bound 640 Diseases of the Frog 665 Keraphyllocele 668 Laminitis 669 Navicular Disease 694 Quittor 702 Cutaneous Quittor 703 Tendinous Quittor 706 Sub Horny Quittor 711 Cartilaginous Quittor 714 CHAPTER XIV. Opep.ations on the Eye and Ear. On the Eye. Operations on the Accessoi'y Ocular Organs 739 Traumatic Lesions 740 Solutions of Continuity 740 Defective Congenital Conformations 741 Pathological Growth and Caries of the Membrana Nictitans . 742 Operations on the Lachrymal Apparatus 743 On the Caruncula 743 On the Lachrymal Ducts 744 On the Lachrymal Canal 745 Operations on the Essential Organs of Sight 746 Extraction of Foreign Bodies on the Surface of the Globe . . . 748 Paracentesis of the Cornea 748 Staphylonna 749 Cataract 749 Amputation of the Eye 754 Ocular Prothesis 755 On the Ear. Amputation 756 Xvi CONTENTS. ^ CHAPTER XV. PAGE. Diseases of the Withebs 759 Excoriations 765 Warm (Edema : 765 Hematoma 766 Core or Stickfast 766 Abscess 769 Wounds 770 Diseased or Fistulous Withers 771 Terminations of Diseased Withers 774 Diseases of the Poll 779 Excoriations, CEdematous Swellings, Core, Bloody Tumors . . 781 Cyst 781 Abscess 783 Poll Evil 784 INTRODUCTION. Under the designation of operative surgery is understood that department of medical science and practice which includes the external and instrumental manipulations required in the treat- ment of surgical diseases and accidental injuries or deformities; or perhaps it might be succinctly defined as surgical science me- chanically applied. The two branches — the science and the art — which constitute the study of operative surgery cannot, of course, be dissociated in a treatise on the general subject, and it will therefore be neces- sary, as we proceed with the detail of our observations, to give due consideration to the aetiology, the symptomatology, the pathol- ogy and other characteristic features of certain diseases, in their relations to the indications of treatment and the manipulations which they involve at the hands of the surgeon Viewed from the standpoint of comparative importance ia re- spect to the value of the results of human and veteiinary surgery, as relating to the vital status of the patients who become respect- ively the subjects of both — the human being and the quadruped races — veterinary surgeiy must of course consent to occupy the subordinate place ; a fact, however, by no means tending to dis- parage the value or the just estimation of the calling of the scien- tific veterinarian. In human surgery the one paramount result held up to view is the prolongation of the life of the patient. This is a consum- mation to be achieved regardless of any considerations of cost or trouble, while in veterinary siu'gery the prime motive is the res- toration of the patient's interrupted ability to fulfil his function as an animated machine for supplying a certain amount of valu- able force. For these reasons the scope of veterinary practice is 2 INTKODUCTION. a circumscribed one, in comparison to that of human surgery, by- having the aim and being brought to the test of mere econoi^ic utihty. While the human life is prolonged at any cost, moreover, the treatment of the animal is always supplemented and influ- enced by the consideration that if curative efforts fail, the suffer- ings of the patient may be terminated by the administration of a prescription which will at once release him from pain and de- prive him of hfe, with the full sanction both of self-interest and benevolent feeUng. Another element which operates to define the sphere of the veterinary surgeon is the natural disinclination of the owner of a sick or disabled animal — perhaps a man of limited pecuniary resources — in a tedious and unpromising case, to add to the ex- pense of surgical attendance the cost of the unremunerated " keep " of his disabled and unproductive servant. It ought to be true, as a matter of course (perhaps it is so in point of fact), that no man of intelligence and integrity will as- sume the duties and responsibilities of surgical practice without the due preparation and equipment, which is only to be acquired by conscientious study and competent knowledge of medical science at large. Especially and indisj)ensably a surgeon must be an accomplished anatomist. His knowledge must be thorough and practical in the several divisions of anatomical science — he must possess a familiar a^cquamtaxice vrith. descriptive anatomy; he must be fully instructed in surgical anatomy or the anatomy of regions ; he must have mastered the last chapter in pathologi- cal anatomy ; and if there are any other kinds of anatomy, he must master them all, and then he will have become an anatomist in fact, and qualified to practice surgery. Yes; a surgeon must be an Anatomist. And it ought to go without saying, that only a surgeon should practice surgery, whether his patient be biped or quadruped. No untrained layman should presume to wield the knife and the cautery with their associated arsenal of weapons and other appli- ances for the subjugation of the enemy whose assaults it is the special province of the surgeon to repel. An ignorant operator may easily become, himself, a more dangerous "lesion" than some of those which he presumes to treat. The man who can cut into the living, and usually hypersensitive, flesh of a suffering animal, without knowing what tissue or organ he is attacking, what artery INTEODUCTIOK. if he is likely to sever, what nerve to wound, what organ to lacerate, what function to paralyze ; who would essay the operation of neu- rotomy without knowing where to look for the plantar nerve ; who would undertake a case of vaginal spaying in ignorance of the location of the flying ovaries; or who woiild operate for strangu- lated hernia unaware of the mode of avoiding the infliction of injury upon the posterior abdominal artery — such a man, if to be found, should simply be subjected to an odium which should ostracise him from honorable and equal association with others of his species, besides being held criminally amenable to the law providing penalties for the perpetrators of cruelty to animals These reflections may be unnecessary, but it is aU too true that our domestic animals too often become the victims of worse than brutal masters, who take advantage of their helplessness and inferiority to inflict upon them cruelties so gross and aggravated, that right-feeling men are often compelled to blush to call them feUows. It is no excuse for this that it is done through the agency of a pseudo-surgeon : such a plea merely doubles the number of the wrong-doers. In offering these suggestions, and in formulating the informa- tion which follows, derived from the experiences of many studious and observant men, and which in their aggregate and connected form constitute the substance of this volume, it is assumed that it is only from competent and quahfied minds that the apprecia- tion which it hopes to merit and to receive must come, and we trust that to the extent of its justice and truth it will not be withheld. With the skill of the expert anatomist must be associated, of course, the necessary mastery of therapeutics and a familiar knowl- edge of special and general pathology^ and all should be supple- mented by a knowledge of the theory and practice of the farrier. The science and the application of the laws of hygiene, so generally, indeed almost whoUy, ignored by our fathers, and so largely a discovery of the present time, will never be overlooked or depreciated by the genuine surgeon ; and while possibly the effects of meteorological influences may have become of less importance than they were considei'ed to be in times gone by, a careful ob- servance of their phenomena will never be a useless item of acqui- sition. The fullest attention to the theories and appUcation of what may be denominated the science of antisepsis, and the adap- 4 INTROBUCTION. tation of antiseptic measures, now so universally and unintermit- ting an adjunct to all medical and surgical practice, and so utterly indispensable in the departments of dressing and nursing, and so often an available and valuable aid in the very act of operating, must be considered now to have become an incorporated and con- stituent department of the domain of surgery, and medicine as well, and the cultured veterinarian will of course so regard it in his practice. Without being necessarily a practical worker at the anvil, the surgeon, as we have intimated, must acquire a familiar acquaint- ance with the theories and the art of the farrier. No one can place too high an estimate upon the importance of the position occupied by the foot among the anatomical regions where lesions may be expected to occur, and whereas the shoe becomes practi- cally identified with the living member, and is, in use, a portion of the hoof itself, by the act of nailing the shoe and the hoof together the inference becomes palpable. An occasion may easily arise when a serious blunder in treatment may be traced to a previous blunder in diagnosis, which again may be referred to an earlier blunder still, which has consisted in neglecting to examine the foot, and the shoe which has injured it. What is the status, in respect to his market value, of a horse with poor feet, or whose good feet have been ruined by bad shoeing ? So the veterinary surgeon, though not required to be able to make a set of shoes, should be expected to know how they ought to be made and fast- ened. And when a special shoe is required for the correction of a deformity, or as indicated in some diseased condition of the foot, it will of course become the exclusive province of the surgeon to dictate the whole process of forging and fastening, and to see that his instructions are not ignored. Besides the special scientific attainments to which we have referred, there are many other qualifications which must enter into the character of the good and skillful surgeon, in order to round it into true symmetry and proportion. Bouley remarks that "he must not only be a man of science, but a man of art," meaning, we suppose, that he should not only possess knowledge, but know how to make it available. First, he must possess the faculty of knowing how to gauge the necessity of his interference, with its manner and its duration; or, on the other hand, whether any interference is necessary, and whether the true indication is INTRODUCTION. 5 not to refrain entirely from active measures. The result of bis decision will afford a good test and gauge of the extent to which he has profited by bis clinical and theoretical study. He is a sound philosopher who can wisely determine when to let alone, in opposition to the temptation to do something. The acqmsition of manual dexterity is an accomplishment of prime importance and should be acquii'ed, and can only be earned by dibgent practice upon the cadaver, or, what perhaps is more effectual, besides being in itself real work, by utilizing every op- portunity of performing minor operations, under suitable instruc- tion, upon actual patients. Of course, expertness without practice is impossible. It is not fully correct, perhaps, to speak of manual dexterity in the singular number. The dexterity required shovdd be bi-manual or ambi-dexterity, and any surgeon who has not mastered the art of using both hands indifferently, though he may have learned all else pertaining to his profession, lacks yet one thing. Cases will continually arise in which the inability to change hands may interrupt the progress of an operation and involve the practitioner in great inconvenience, if not embarrassment, and possibly prejudice the case itself. Coiirage and coolness, with patience, are essential qualities of temper in an operating surgeon. To become alarmed and lose his balance on the occurrence of some untoward incident, or the ap- pearance of some unlooked-for abnormal development or compli- cation, or to give way to a spirit of impatience because of unex- pected delays, or, especially, to resent the fractious movements of the suffering animal, writhing under the knife or the glowing cautery, is both unprofessional and unmanly. The terms cour- age, coolness, patience and kindness should describe his state of mind while operating. The whole axiom of Asclepiades, cito, tuto and J ucunde, re- veals the entire scheme of conduct proper for the sui'geon under all circumstances. Every movement of the surgeon should be prompt and precise. Indeed, by operating rapidly he shortens the duration, and consequently the sum of the inevitable pain, and thus diminishes the anguish of a long and torturing infliction on behalf of the patient. The maintenance of his own self-possession will make him master of the situation, and assure a neat and ar- tistic finish to his task, with no imnecessary divisions of tissues, no mistaking of localities, and generally with no betrayals of 6 INTRODUCTION. doubt and hesitation or awkward and aimless manipulations, such as mark the attempts of the tyro and the novice. The confidence and facility with which each movement is accomplished will not fail to impress favorably those who are spectators of the opera- tion, and to react favorably and profitably for the operators. Although, of course, the qualities of accuracy, neatness and rapidity must favorably impress the spectator, as well as benefit the patient, it must not be forgotten that the true success of the surgeon must find its evidence in the favorable result which finally crowns his work. If that is assured, it is but a small matter whether it is or is not applauded while in progress — the applause will follow, in any case. We quote from Bouley, in the Dlctionnaire de Medecine et de Chirurgie Vtterinaire, where he remarks, on another important practical point: "The operative function of veterinary siu'gery requires, on the part of the man who practices it, a certain cor- j)oreal vigor, associated with sufficient agility to be able effectually to overcome the resistance of animals under torture, and counter- act the efforts and avoid the injuries they are always so prompt and often so dexterous to inflict upon those who are causing them pain. The veterinary surgeon must be cool-blooded and patient, never losing his presence of mind while directing the manipula- tions, often so difficult and so dangerous, which are necessitated at his hands, especially when the large domestic animals are under treatment. He must then — always, in fact — be prepared for all difficulties and eventualities that may arise, whether before, during or after an oj)eration, and he must inspire confidence in his assist- ants by using full precautions for their safety and for his own, in his defensive dispositions against the dangers to which they are exposed " A surgical operation, as elsewhere described, is a mechanical action, practiced with more or less rapidity upon the living body, according to certain rules, either with the hand alone, or assisted by instruments, with a therapeutical or a prophylactic object in view, whether primarily necessary or facultative, of a prophylactic nature. It is especially as therapeutic measures that operations are necessitated in. the treatment of diseases and injuries; as, for ex- ample, in the case of the removal or extirpation of diseased or altered parts, whose morbid action injuriously affects the general INTRODUCTION. i health or prevents recovery from a pre-existing disease. This class of operations includes the opening of abscesses, the extirpa- tion of gangrenous parts, or of necrosed or carious bone ; or again, for the modification of the nature of a traumatic lesion, in order to stimulate cicatrization, as in the opening of a fistulous tract, or the resection of an ulcerated surface; or when the economy is to be reheved from the presence of a foreign body, or the abnormal product of a natural function, as in cases of oesophagotomy, or of calculi of the bladder, or of the saUvary ducts. Operations have also their prophylactic uses, esx^ecially in the various forms of in- oculation and vaccination as anticipatory and preventive of infec- tious diseases. They find their further obvious indications, again, in remedjing physical lesions when apphed to fractures, dislo- cations, deformities, and the endless hst of accidental injuries, wounds and hurts of every kind and degree. And, finally, they have their justifiable use in mutilating the larger domestic animals, designed for purposes of labor as beasts of burden or draught, in improving their adaiDtabihty by castration or spaying, or as prop- erly termed, '"altering." Thus the general pui-pose of an operation is to palliate, cure or assist in the recovery of surgical diseases ; to prevent diseases, and especially such as are known to be contagious ; and so to modify the condition of the domesticated animals as to enhance their usefulness and value to their human owners. In medical nomenclature, operations are variously designated according to the methods and characteristic manipulations attend- ing their performance, and the objects which they are designed to accomplish. Thus: (a) It is a liffht operation when superficial tissues or those of secondary importance are involved, like that of venesection, or the simple puncture of a vein. On the other liand, it becomes serious when it is performed upon important organs, or involves extensive and compHcated structures, as that for the reduction of strangu- lated hernia; the removal of the lateral cartilage of the foot in a case of quittor; the operation for chronic champignon, etc., etc. {b) Operations are also drt/ or bloodless when accompanied by little or no hemorrhage; and sanguinary or bloody when, on the contrary, much hemorrhage attends any of their various steps. (c) Again, they are simple or complicated according to the extent and multipUcity of the tissues or regions forming their 8 INTEODUCTION. seat ; simjyle if performed by a single manipulation, complicated when requiring several distinct or separate stages for their exe- cution. (d) Operations are called regular or determinate when per- formed according to rules in relation to the disposition of the parts, and, in general, upon sound structures; and they become irregidar or casual when the manipxilations are extemporized to meet the emergencies of the case, the necessity of the situation and the unanticipated complications which may arise while opera- ting, as particularly in cases of the removal of tumors. (e) They have also received various designations indicative of the time chosen by the surgeon for their performance ; or made imperative by the circumstances of the case ; or according to the object specifically in view : thus they are iirgent or of 7iecessity when a fatal event would be the alternative of delay, and imme- diate treatment becomes imperative, as the condition of the jDatient's survival, as in operation for the reduction of strangu- lated hernia, or that of tracheotomy in a case of threatening suf- focation; and in cases beyond hope of complete recovery, they may become necessary, indispensable, useful or palliative, according to the degree in which they may be made available as a means of relief, and may tend to the temporary respite of the sufferer, and in some degree improve his value by measurably enhancing his ability to continue to labor with some degree of comfort before he is overtaken by a final and total disabihty. There is another class of operations which justly deserves to be totally discountenanced and ignored, and in fact are fit objects for penal prohibition. They are known as operations of fantasy or fashion. They are without real utility; are abortive attempts to improve upon the symmetry of nature ; are devised simply to satisfy a mere whim of affectation; are in wretchedly poor taste; and probably subject their victims to a more aggravated and j)ro- tracted species of torture than any other form of wound known to veterinary surgery. There are sometimes conditions, however, in which they may lose their alleged aesthetic pretext and their ar- tistic character, and the object of their performance may be regarded as properly within the legitimate and beneficial sphere of professional work. The settlement of the point of the time, in connection with any piece of surgical work, is not always one of mere secondary INTRODUCTION. importance in deciding the matters pertaining to the details of an operation. ^Vhen there is any option in the case it pertains wholly to the siu'geon to determine the question. And when the period of abeyance has terminated by his decision in fixing the day and hovu' when the contemplated treatment is to be applied, the optional time becomes changed to the selected time. Of course it is not always left to the option of the practitioner to select the moment for the accomphshment of his task. He must be gov- erned by the nature of the case, and may be left without the opportunity of exercisiag any discretion in the matter. The urgency of the occasion may be extreme, with no interval allow- able for deUberation or choice, and the only available time, the peremptory present, must be accepted as that of necessity. The operation beiag now obUgatory, and the case understood, the surgeon's next thought is the choice of the locality of the operation, and that being finally decided, the point of selection has been reached. The case may easily present such features that this point becomes too obvious for hesitation by becoming that of selection as well as that of necessity, as indicated by the seat of the lesion or diseased process. With traumatic cases, there is, of course, but a single point of interest — it is ih.e jioint of injury I In surgical phraseology the terms method and procedure are often used convertibly. There is between them, however, a dis- tinction which, for the sake of precision, must not be lost sight of. By method should be understood the piincipal and primordial mode by which the operation is performed, while by p>rocedure is meant the special modifications and successive stages by which the manipulations of the operation itself are regulated. For ex- ample, in the removal of a vesical calculus there is one method by hthotrity and another by extraction, and with both are involved the insertion of instruments into the urethral canal, one being the procedure with the catheter, and the other the procedure by the injection of tepid water. Castration with clamps is a method, when comj)ared to double subcutaneous twisting {bistournaye) or to torsion; and it is performed by two procedures, that by covered and that by uncovered testicles. There are several important points which demand special at- tention at the hands of the surgeon before beguming an operation. Having finally reviewed the situation, and esj)ecially having men- tally rehearsed the anatomical disposition of the region and the 10 INTKODUCTION. pathological character of the lesion, with the necessary details of the work before him, not forgetting to anticipate possible acci- dents and compHcations ; and being assured that his arsenal of instruments, dressings, etc., is ample and in good and available order, with a liberal provision of sponges, antiseptics, etc., and duplicates of such of the instruments as are liable to be broken or otherwise disabled, the condition of the patient should then be ascertained. It will, of course, have been thoroughly understood by the surgeon previously, but it is always among possibilities that even at the appointed moment for operating, some changes may be discovered or some new cii'cumstances developed which may modify or contraindicate the entire proceeding. Some final preparation of the patient is always necessary. One item of this consists in clipping the hair from the skin over the seat of the operation, and thoroughly cleansing the part. In some cases it is necessary to soften the tissues by means of poul- tices, baths or wet bandages. There is also a constitutional and general preparation which must not be neglected, with a view to so modify the organism as to improve the ability of the animal to withstand the shock of the operation. If weak and debilitated, his strength and condition must be improved; if of an irritable and nervous disposition, precautions must bo taken to control it. A comparatively low diet is almost always a salutary measure, and sometimes even complete diet an essential preliminary to an oi^eration, and the surgeon must assure himself that they have been properly taken into consideration. In many cases the surgeon needs the co-operation of assistants, either professional men or laymen. The aid rendered by a profes- sional brother or by a student of medicine will of course be such as wlU be assigned to him by the responsible surgeon, and cannot be specified here — it will vary with every case. The facility and •success of an operation will be greatly promoted by their intelli- gent and sympathetic aid, which will be quite of an indispensable character. In enlisting laymen as assistants, it will of course devolve on the surgeon to instruct them as fully as possible in the nature of the services expected from them ; and in making his selection of individuals it v.dll be an important point gained if he can obtain those who are accustomed to the management of ani- mals, and who are expert in handling and successful in controlling them. INTRODUCTION. 11 There is still another party to be considered while referring to the study of "preparation." It is neither the animal, the surgeon, the assistants, the instrument case, nor the lint and bandages. It is the owner of the ailing animal. And to " prepare " him for the event is oftentimes a performance requiring a larger amount of judgment, tact, knowledge of human nature and jDatience than the average man possesses. On the one hand there are those of the optimist class who have quite an unwarranted opinion of the power of surgery, and who, in despite of the most unfavorable prognosis, insist upon a resort to the knife, even upon inadequate occasions. And' on the other hand are those who interpret any suggestion which involves a solution of continuity professionally proposed, however artistically consummated, as only a mild form of sentence of death to the patient. But however antijDodean may be their views in other respects, they are in common quite assured that for an ojaeration which fails to restore the dilapidated patient to a condition a httle better than new, whatsoever may have been the accident or lesion which he may have encountered, and whatsoever may have been the skill and intelligence exhibited in the treatment of his wounds or ailments, the only legitimate and orderly conclusion is a suit at law for malpractice. It is the function of the doctor to cure disease ; if he treats disease without curing it, he is an incompetent; this is the irrefragable logic! Though the hving animal had failed to return any remuneration for his subsistence, and for the care lavished (?) on him during the period of his disabihty, yet when reduced to the state of a cadaver he should be compelled, if possible, in an indirect way to net his bereaved owner a sum hkely to prove largely anodyne to the poignancy of the grief which the loss of so much property had excited. But aside from this, the owner of the Hving property, the value of which is about to be jeopardized, is entitled to a full and candid statement of the nature of the case, with its possibihties and its dangers, and it is in the interest of the sui-geon himself to observe perfect frankness with his employer — not, however, to the extent of compromising his position as doctus in the case, or foregoing his self-respect by making concessions upon points of scientific acqviisition to a layman, however generally iutelhgent or specially interested. The surgeon mxxst assert himself as the representa- tive and exponent of an honorable and learned profession, able 12 INTRODUCTION. and prepared to acquit himself of his just responsibilities; and, indeed, it is in this assumption by him, with the conceded assent of the owner, that the virtue of the contract lies, which binds the two parties with equal force, moral and legal. This point, being understood and settled, should be looked upon as furnishing the best preparation which the owner can ac- quire, and he will need no other when he is thus made to under- stand that he must have full confidence in the skill which he has called into requisition, and must be guided by its imphed guar- antee that every possible precaution will be taken to carry the patient through his trouble ; and that if accidents of any nature should occur, when not incurred through carelessness or error, the risk is the owner's, and he alone must assume it. Such an understanding on the part of the owner will impose u^Don the honorable surgeon an imperative sense of the conscientious care with which his task should be performed, while at the same time it will relieve his mind from the laressure of a possibly embarrass- ing anxiety while engaged in his work, and it cannot fail to be of advantage in various ways to all the parties concerned. Minor matters, such as the condition of the weather, the time of day, the selection of a place, the position which the oper- ator must assume for himself, with that which he assigns to the patient — these are points which are also to be carefvilly taken into consideration. They have, one and all, more or less influence on the facilities of execution of an operation, and perhaps also on the results that may follow it. CHAPTEE I. MEANS OF RESTRAINT. The final preliminary before operating upon animals, is to place the patient in such a condition of restraint as will assure the entire safety of the surgeon and his assistants from injury likely to result from the violent struggles of the terrified and suffering creature. The severity or the duration of the operation fiu-nishes no acciirate measure of the necessity of the restraint, or of its continuance or degree. Any unusual or violent aggressive treatment will excite his fears, and consequently his opposition, and whether the occa- sion be a painful and protracted dissection, or the simple apj)hca- tion of a dressing, the surgeon may usually rely on the strenuous resistance of the patient. It is of little account that there are differences of dispositions in horses, as in men. With any un- reasoning animal the case is the same, and with the excitement, the anxiety, and no doubt, a vague terror of something unknovsm impending, too often qvdte explainable by the treatment to which he has been long accustomed at the hands of an unfeeling owner, he is prompted by the mere instinct of self-preservation to defend himself with such means as nature has taught him to use. The necessity of enforcing a passive condition in the animal being thus apparent, it ought not to be necessary to say that the means of accomplishing it should be employed with reserve and moderation, especially when they are painful in themselves, and that no man claiming to be the possessor of humane iastincts will permit himself to increase the severity of their appHcation by supplement- ary ill treatment, in the infliction of "punishment," upon the alarmed and suffering brute, a course which is quite likely, more- over, to be as ill judged as it is otherwise reprehensible, from the fact that in most instances its effect is contrary to its intention, in aggravating the evil it would remedy. It should never be forgotten how easily the most fractious and timid animal may sometimes be controlled by kindness and patience, and his agitation soothed by 14 MEANS OF KESTRAINT. the sound of a familiar voice with which he has become accustomed to associate acts of gentleness and friendliness. Under any cir- cumstances, a habit on the part of the surgeon, of brutal treatment, the exhibition of a bad temper, in the indulgence of fits of anger, leading to acts of cruelty in the iafliction of unnecessary paia on his dumb and helpless victim, is not only ia every way useless, as being of no possible advantage in any direction, but tends to a degree of moral harm in those who are thus culpable for which no counterbalancing benefit can be imagined, and which certainly can never facilitate the remedial effect — but quite the reverse — of the pending operation. A benignant method of controlling animals for the special purpose for which treatment by the surgeon is invoked, is not, however, alone sufficient, and it is thus that a resort to effective means of physical restraint becomes unavoidable. These are of two kinds : one consists in inflicting upon some given part of the body, more or less remote from the seat of the operation, a severe and continuous pain, which, by a process of derivation, reduces that which is incident to the steps of the operation, by distracting or diverting the consciousness from the influence of the new suffering, against which he feels resistance would be in vain, to that of which he is sensibly cognizant, and thus the animal submits himself, with a comparatively voluntary surrender. The other kind consists of restraints proper, and are constituted of mechanical devices for securing immobihty by the process of overcoming opposition by means of a dominating physical force. Their use is not affected by the position of the subject, and they are therefore applied in both the upright and decubital posture. The first comprehends the derivative or painful method of Peuch and Toussaint's division ; the second, the method by direct me- chanical restraint. MEANS OF SECURING SOLIPEDS. A. — Derivative or Painful Method. This method is in very common use, and usually proves to be sufficiently effective to secure a degree of quiet and passi\dty in the patient for the safe performance of many light oj)erations. Under some circumstances it is used in connection with the means SECURING SOLIPEDS. 15 of direct restraint. The instruments mostly employed in the first method consist of the twitch, the old fashioned barnacle, and the gag. Fig. 1.— The Twitch. The twitch is the instrument most commonly used and, un- fortunately, too commonly abused. In horses, it is sometimes applied on one of the ears, and sometimes on one of the hps ; and is very severe in its action, wherever appUed. In applying it, the operator, passing his right hand through the loop of cord of the instrument, grasps the tip of the upper or the mass of the lower Hp, leaving the loop to sHp over his fingers close to the skin which it then encloses, and with his left hand turns the handle of the instrument until the cord is sufficiently shortened to form a true Hgation of the tissues which it circum- scribes. The paiu caused by this constriction may be graduated by the rotation of the handle of the instrument. When iu place it is either held by an assistant or tied on the halter. If the animal proves to be especially refractoiy under the infliction, the assistant should be cautioned against aggravating the trouble by forcibly dragging upon or jerking the instrument, violence of that nature becoming in some instances the cause of severe injuries to the muscular or nervous structm-es of the Hps. We have ourselves met with several cases of labial paralysis resulting from such an improper and repeated application of the twitch. Some- times the length of the wooden portion of the instrument is con- siderably reduced, varying in its application in such a way that when the open loop is placed on the lip the wooden part which takes the place of the handle is placed on the lips through it, and the cord is twisted by turning it. The barnacles are formed of two articulating branches, made of either wood or iron, with sundry notches at one end and a ring at the other to fit into the notches. The degree of pressure re- q^uired is regulated by shifting the ring until the projDer notch is 16 MEANS OF BESTRAINT. Fig. 2.— Short Twitch. ascertained. The iron instrument is severe in its effects, probably more so than the twitch, but is less easy of application. In apply- ing the barnacles, the surgeon grasps the upper lip, and placing Fig. 3.— Iron Barnacles. each of the branches severally on opposite sides of the organ, brings the ends together, immediately fixing them in place at the desired point of pressure, and secures them by fitting the ring into the proper notch. Fig. 4. — Wooden Barnacles. The wooden barnacles are made with circular sharp ridges cut in both branches in order to intensify the pain, the ends, when they are approximated, being secured by means of cords. The gag is a means of derivation used principally in Central Europe. It consists of a cord about one-quarter of an inch in diameter, which is placed in the mouth, and passing upward on each side of the face, is tied on the top of the head. This is twisted to any degree of tightness by means of a small, round piece of wood, which is passed between the cheek and the cord, the result being excessive traction upon the commissure of the lips and great SECURING SOLIPEDS. 17 Fig. 5.— The Gag. pain to the animal. Lacerations of the commissure, or wounds of the skin at the poll are to be anticipated if this manner of punish- ment is not guardedly used. There are besides these some milder appHances which must not be overlooked. Among them is the repeated pricking of the tip of the nose with a pin, and the introduction of foreign bodies, such as musket balls in the ears. The origin of this last method dates back to 1607, when Uttle round stones were recommended for the same object. When musket balls are used, holes should be drilled through them for the insertion of a string, in order that they may be withdrawn when necessary. ^. — Mechanical or Restraint Method. The means employed in this method vary according to the po- sition, whether upright or recumbent, in which it is desirable to confine the animal during an operation. STANDING POSITION. The necessity of imposing restraint upon the patient while under treatment in the standing position arises not alone from the danger of injury to the operator and his assistants, from the biting and kicking of the excited animal, but because he is so thoroughly impartial in the distribution of his attentions that he even requires protection from his own violence, and his own flesh must be guard- ed from the contact of his own teeth. They are usually resorted to in order to facilitate operations of comparatively trifling importance, and which are not of a par- ticularly painful nature, or are of easy and rapid execution, or 18 MEANS OF RESTRAINT. under circumstances when the animal can be controlled by being merely held by the head against a wall, or with the hind quarters in a corner, or perhaps tied to a wall, a post, or a tree. Certain minor precautions are necessary on these occasions. For exam- ple, the groiind on which they stand must be smooth, though not slippery ; of a good holding character, and neither too hard or too damp, in order to avoid falling, or sHpping, or other possible ac- cidents. Attention to these matters will be of great benefit to the operator by leaving him a good foothold, with facilities for free- dom of movement, and more at Hberty to guard himself against his patient, unexpected changes of attitude. The means by which the movements of the head are kept under control are the halter^ the bridle, the hridoon and the cavesson — instruments which need no description here. If the animal is left unconfined, the assistant having passed the rope of the halter or bridoon through his mouth, holds him close to his head, places himself in front of him, or slightly on one side, and being atten- tive to every movement the animal may attempt, anticipates it, by pulling the head downwards if the animal is about to rear, or rais- ing it upwards to prevent him from kicking with his posterior legs, or inclining it to one side or the other, as the animal moves it in one or the other direction. An animal should never be tied with the halter-rope in his mouth or over his nose. There is danger in both methods of se- rious accidents, in case of a violent backing or jerking of the head. In one case the result might be a section of the tongue, and the other might involve a fracture of the maxillary. For simi- lar reasons the bridle is also dangerous. The height at which the head shotdd be secured must vary with the movements attempted by the horse. Thus, to prevent him from rearing or striking with his fore legs, it should be placed low, but high when it becomes necessary to guard against his elevating his posteriors in order to kick with his hind legs. To protect his head against possible self-inflicted blows result- ing from his defensive struggles, and to prevent him from seeing surrovuiding objects likely to alarm him, are precautionary items of not a Httle importance, and the employment of the mask or cap (Fig. GC) is very effectual for that purpose. Fractious patients, dangerous to handle and difficult to control, often become perfectly quiet and thoroughly docile on finding themselves involved in dark- SECUBINO SOLIPEDS. 19 Fig. 6.— C, the Cap. O, the Cradle. ness, and submit to tlie necessary manipulations of the sui'geon with- out further resistance. When a proper cap is unobtainable a bridle with blinders can be substituted, or a blanket placed over the head. Biting the attendants may be prevented by applying a muzzle, Fig. 7.— The Side Bar. 20 MEANS OF EESTRAINT. and he may be protected from his own teeth by the use of the cradle (Fig. 60) or beads, or the side bar (Fig. TAB). With the cradle around his neck, the horse is j)i'evented from carrying his head on either side ; its use, however, must be carefully watched lest the friction of the cord, which secures it in place upon the superior border of the neck, should cause severe complications by chafing or even cutting through the skin. Peuch and Toussaint have reported one case of fatal tetanus from this cause, but no such accident ought ever to occur, for the means by which it may be avoided are easy and obvious, protecting the border of the neck with pads. The side bar prevents the flexure of the neck toward the side upon which it is placed, and when in use during an operation is applied on the side occupied by the operator. It is used both singly (on one side only), and doubly (on both sides). The danger of accidents arising from the iinrestrained mobiHty of the head of the animal being thus guarded against, those which may be caused by striking and kicking with the feet are next to be considered. In many instances it may be sufficient to simply raise the foot from the ground, and to keep it thus suspended by holding the leg in a position of flexure (Fig. 6). No violent measures are necessary in order to obtain such con- trol over the movements of the horse as are consequent upon com- pelhng him to support his weight on three legs only. The method of raising the foot and keeping it off the ground is a matter too familiar to every stable hand to need detailed instructions. But a little art may be necessary, with a little compulsion added, to induce him to contiaue to sustain the role of a tripod long enough for the purpose of the operator. But this cannot always be de- pended on, and therefore when he betrays an evident unwilling- ness to submit quietly to such a confinement of the foot, the com- pulsion of the ropes or straps must be resorted to. For the fore leg the strap is attached below the fetlock and passed around the forearm, and either buckled or held in place by an assistant. When the rope is used it is passed around the coronet, the leg flexed and the rope either passed round the forearm and secured in the same manner as the strap, or thrown over the withers and held by an assistant on the opposite side of the horse. For the hind legs the rope, plaited rope or plate-longe, is necessary with the hobble. These are applied in different ways. SECURING SOLIPEDS. 21 Fig. 7a.— Plaited Rope. In tlie Jirst method a hobble is placed on the coronet of the foot to be raised, with the buckle outward, and the ring looking backward; then a loop made at the flat end of the plate-longe is Fig. 8.— Securing the Hind Foot with Rope and Hobble. passed around the neck ; the rope is then carried along the back, and with a single turn around the tail, is passed through the ring of the hobble, from within outward. Pulling on the rope raises the foot and carries it backward, where it is held by the assistant. Second. — Sometimes the hobble is dispensed with, and the rope is passed from the neck straight to the coronet, where a double twist is made, and the foot controlled as before (Fig. 9). Third. — In other cases, the plate longe is secured to the tail, instead of around the neck, conditioned of course upon whether the tail is sufficiently long and furnished with hair of the strength 22 MEANS OF BESTRAINT. Fig. 9.— Securing one Hind Leg with Rope only. necessary. Wlien matters are favorable in tliis respect, the operator proceeds as follows : a loop being made at some distance from one end of the rope, it is laid flat on the top of the tail, close to its origin, and the short end being twisted aroimd that extrem- FiG. 10.— A, The Twitch. B, Side Bars. C, Surcingle. D, Securing Hind Foot. E, Fixing the Eopo on the TaiL SECURING SOLIPEDS, 23 ity with from two to four turns, and the remaining portion passed through the loop, and the other, or longer portion of the rope, drawn taut, the knot is tied and the plate-longe thus firmly secured. As in the two previous methods, by drawing upon the longer end of the rope the foot can readily be raised and held in position, either with or without the hobble. There are occasions, when, although it may not be required to have the leg and foot held up for the purposes of the opera- tion, it still becomes necessary to do so in order to prevent the animal from using his feet as weapons of combat, or to restrain him from motion. The plate-longe, and the single or double side-line, with one or two hobbles, are then put in use, for the purpose of either raising the leg from the groimd and compelling the animal to stand on three, or again to prevent motion ia the posterior biped. For example, in one case the flat part of the plate-longe is Fig. 11. — Another Means of Using the Rope. passed with a loop around the coronet of the leg to be kept steady, the rope is then carried forward between the fore legs, then on the side of the neck opposite to that of the leg to which the plate-longe is fixed, over the withers, back to that side, and twisted around itself behind the elbows, as it passes between the fore legs (Fig. 11). 24 MEANS OF BESTEAINT. In other cases a large loop of the plate-longe is thrown over the neck, and the rope carried back to the coronet of the foot to Fig. 13.— Securing both Hind Legs witb Hobbles. SECTJKING SOLIPEDS. 25 be secured, and by one or two twists around itself, is brought backward, where it is held by an assistant. Sometimes a single hobble is placed on the coronet, and the rope of this side-Hne runs through its eye, which is turned forward (Fig. 12). To prevent the animal from kickiag with both hind legs, a King hobble, carrying the chain, is put on one leg, and the chain passed through the eye of another hobble placed on the other hind leg, and the rope carried forward and secured as in the case of raising one single foot, viz., between the fore legs, on either side of the neck, over the withers and then after being twisted around itself back of the elbow, held by an assistant (Fig. 19). In some instances a double side-line is used, the loop being thrown over the neck, and the ropes carried backward, one towards each hind leg, and passed through the eyes of hobbles placed on them, and returned forward, where they are secured with a slijD-knot to the loop of the side-line on each side of the neck. For the same purpose, of securing the two legs of a biped, whether anterior or posterior, LeGoff has invented a pectdiar apjDaratus, consisting of a Y-shaped rope, single at one end and bifurcated at the other, each of the three ends having a running noose or loop. If the two hind legs are to be secured the loops of the bifurcated portion are placed on the coronets of these legs, and the loop of the single portion secured on one of the fore legs. If on the contrary, the fore legs are to be confined, the arrangement is simply reversed. Another excellent method of limiting the movements of the animal to prevent him from kicking, and keep him quiet, is to take a plate-longe, and beginning on one of his sides, at the girth, for example, pass it forward across one forearm, a Httle below the elbow, in front of him, on the other side across the other fore- arm ; then backward across the thigh, or a little below it, then passing it back of the animal, to the first side across the other thigh, to return to the starting point (Fig, 14). Passing the rope through the eye of the flat extremity of the plate-longe, the legs can be comparatively well kept together. To prevent the rope from dropping too low, it is thrown over the back and secured on itself on the other side by a knot. This part of the rope over the back supports the two horizontal portions which rim. on each side of the animal and keeps them in place. This mode of restraint is but a simplification of the apparatus 26 MEANS OF EESTKAINT. Fig. 14.— Securing all the Legs, with Rope all around the Animal. invented by Raabe and Lunel — the hippo-lasso (Fig. 15). This apparatus is called the straight jacket for horses, by the inventors, and is composed of a strong breast-piece or Dutch collar, and a breeching, placed over the withers and the croup. The breeching carries on each side, firmly sewn on, a long strap, and at each point, B, an iron eyelet. The breast-piece at B, carries also on each side an iron eyelet, and on the front strap a strong buckle. To place it in position, the Dutch collar is thrown over the neck and the breeching laid over his rump. Both straps of this part of the hippo-lasso are passed forward through the iron eyelet of the breast-piece at B, back through that of the breechiag at B, and then forward again to be buckled, more or less tightly, at h. The length of the strap of the Dutch collar piece which passes over the neck, and that of the croup, must be regulated in such a manner that the horizontal position of the lasso is for the fore legs, but a little below the forearm, and between the stifle and the hock for the hind legs. The hippo-lasso is an excellent means of restraint, and may even be utilized for vicious animals upon which operations would otherwise be impossible, except by throwing them. In shoeing SECUBING SOLIPEDS. 27 Fia. 15.— Hippo-lasBo of Raabe & Lunel. vicious and clijDping nervous horses it has given most excellent results. Among other varieties of apparatus used for controlling animals in the standing position, are the various machines known as stocks or travis. They are of many forms, and consist of heavy wooden frames, firmly secured ia the ground, with peculiar arrange- ments for supporting the animal in shngs, if necessary. They are padded on the inside, for security against injuries and have on one of their narrow sides a system of iron bars, against which to secure the feet when the animal is raised from the ground. The stock illustrated ia Peuch and Toussaint's work (Fig. 16), will give a good general idea of one of the most approved forms of this means of restraint. The stock of E. Winsot (Figs. 17, 17a and 18) is another form, which can be used for securing the animal iu either standing or laying position. BECTJMBENT POSITION. Notwithstanding the many advantages attending the applica- tion of the means already described, devised for securing the immobility in the standing position of animals undergoing sur- gical treatment, there are circumstances in which their efficiency becomes wholly lacking. Sometimes it is because of the invincible restiveness of the animal, but more often because of the serious nature of the pending operation, which may require for its safe MEANS OF KESTEAINT. Fig. 16— The Stock. performance a degree of deliberation and an amount of dissection of the most painful character, with which only the most absolute passivity, if not complete unconsciousness, is compatible. In this class of cases the recumbent position in the patient becomes sim- ply an indispensable requirement. To throve or cast a horse signifies simply to apply the force necessary to compel or induce him to lie down, and to continue in that position during the pleasure of the surgeon. The forms of compulsion by which the desired result is to be effected are next to be considered. It would be improper to construe the word "throwing" as SECURING SOLIPEDS. 29 Fig. 17a.— Firing a Horse while Secured in Winsot's Stock. Fig. 18.— Laying a Horse Down with Winsot's Stock. 30 MEANS OF RESTRAINT. literally designating tlie act of violently casting down, as in a wrestling match. On the contrary, it must be quahfied as refer- ring to a method of so manipulating the patient and directing his movements as to briag about a change of postvire with all the appearances of a voluntary act on his part, which indeed it essen- tially becomes. The prejDaration of the bed upon which the animal is thrown, and of its location, will require some judicious attention from the surgeon. A convenient place, with sufficient space to allow per- fect freedom of movement about the patient, such as a large yard, a barn or an open field will fulfil the requirements. The ground should be smooth, and, if possible, soft — a pasture lot or farm- yard, or a manure heap often offering good facihties for the pur- pose in country practice. In any case it should always be covered with a layer of straw, sawdust or tan bark of sufficient thickness to prevent a violent concussion when the patient falls, and ought to be sufficiently wide to allow him to fall as nearly in its center as possible. Its dimensions should be approximately from nine to ten feet square. An important point ia its construction is that it should be free from any hard foreign substances, such as stones, bones, pieces of wood or iron, etc., for fear of contusions or other similar lesions against any parts of the body of the patient. Several methods are in use for throwing a horse, among which are the peculiar apparatuses known as the hobbles. The rope.s and the operating tables are also used. The previous preparation of the animal for the operation ought not to be forgotten. This usually consists in a fast of not less than twelve hours, and will always be found to be a good measure. A. — Casting with Hobbles. These are of various kinds. Some are made of leather, others of rope, but they are all constructed upon the same principle. The English style, invented by Bracy Clark and afterwards improved, which are in most general use, present so many advantages in their facility both of application and removal from the legs after the op- eration, that we shall limit our consideration to them alone (Fig. 19). A set is composed of four hobbles, a chain and a spring hook. Each hobble is formed of two straps of leather of unequal length, the shortest (a) having attached on one end a strong buckle (^), SECURING S0LIPED8. 31 Fig. 19— English Hotobles. A, Hobble Unbuckled. B, King Hobble. C, Hobble In Position, witli Kope through the Eye. and at the other an iron eyelet, narrow and somewhat elongated (n), the eyelet of the longest {b) being somewhat square in form (e), in order to allow the ring (n) to pass through it, and having in its Fig. 19a.— Self-locking Hobbles of Prof. Barker. 32 MEANS or EESTKAINT. length a number of holes to aUow it to be buckled with the short strap. Three of each set are of this construction. The fourth, which is the main, chief or king hobble, differs from the others in the form of the iron eyelet of the shortest strap. In this hob- ble it is made of a peculiar shape, and with a small slot, through which the chain is passed and secured by a pin-screw running through it. The chain belonging to this set measures four or five feet in length, and has spliced at one end a casting rope some fifteen feet long. At the other end the link of the chain is flattened and made to slip easily through the slot of the main hobble. Fig. 20.— Spring and String-Hooks. There are many forms of spring-hooks used. In our own practice we use two strong spring padlocks, as being of easier appHcation and less liable to liberate the animal by becoming loosened or breaking. Besides the set of hobbles, a long plate-longe and a Bernardot & Buttel apparatus are necessary. This consists of a wide and strong svircingle, having on both sides two straps, joined together in front, and a strong halter, which from the nose-band carries another strap, which passes in front of the head, between the ears, through an iron ring on the pole-band of the halter, and is to be buckled to the single strap of the surcingle. By shortening this strap, the head and neck are placed and kejpt in as much exten- sion as may be desired. Prehminaries being completed and instruments ascertained to be in efficient condition, the horse is placed at the side of the bed ; and we may here repeat that the manipulations which are next to succeed are not designed to throw him off his feet with a violent SECURING SOLIPEDS. 33 Fig. 21.— Bemardot & Buttel Apparatus. shock, but simply to place him in a posture of such discomfort, and so to disturb the center of gravity that lying down becomes an instinctive act, and is done voluntarily, in order to avoid the act of falling ; it may be termed a voluntary compulsion. When brought to the bed, a cap is placed over his head, and aU the hobbles are applied, simultaneously if possible, by four assistants acting in concert. They should carefully observe that the large buckle of each hobble is placed on the outside of the leg, and that the eyes of the straps are turned toward the center of gravity of the animal, those of the front hobbles looking back- ward, and those of the hinder hobbles looking forward. The chief hobble must be placed on the fore or hind leg of the side opposite to that on which the animal is to lie. The apj)Hcation of the hobbles on a timid and restive horse is not always an easy matter. Remembering, perhaj)s, some similar experience at some former period, he rebels, resists and kicks as a natural consequence. If speaking soothingly and kindly, and employing the usual tranquihzing and assuring processes, with the raising of one of the fore feet, fails to quiet and control him, a twitch is placed on his nose and left on untU, at a preconcerted moment, the hobbles are put in place; quickly, but as noiselessly as possible, the chain is passed through the ring of the chief hob- ble — on, say the fore leg for facility of description — then through the ring of the other fore leg, back to the ring of the hind leg of 34 MEAKS OF EESTEAINT. the same side, through the ring of the other hind leg, and back to the slot of the main hobble, where it is secured by the pin- Bcrew. The Bernardot & Buttel apparatus is then put in place and buckled by an assistant, with the surcingle on the side of the patient ojyposite to that on which he is to be made to he. Previ- ous to this, another assistant will have passed a long rope around the body of the animal a httle back of the withers, and with still another holds it on what will be the under side when the patient lies down. Still another assistant is placed at his head, to aid the one who holds it, while yet another grasps the tail, and two others seize the casting rope. The second step of the operation is to reduce the animal's base of support as much as possible, by bringing the four feet together. To do this, the operator, standing in front of the as- sistants who hold the casting rope, has each hind leg in succession raised sHghtly from the ground and carried forward by the assist- ant having it in charge, a gentle traction being made at the same time upon the casting rope, in order to shorten the length of the chain passing through the hobbles, the assistants at the head meanwhile gently backing the animal still more to reduce his area of support, until the equilibrium is so nearly lost that the animal Fig. 22.— Horse about to be Cast. SECURING S0LIPED8. 35 instinctively abandons the effort to keep his feet, and assumes the recumbent posture in order to avoid the shock of a heavy fall. H. Bouley recommends that the first movement in this final step should be an attempt to back the horse, in order to move the fore legs first, and then to bring the hind legs forward, if the base of support is still too broad. The twitch should now be removed ; in fact, the most prudent plan would be to remove it the moment the hobbles are in place The final step of the act of literal throwing or casting being accompHshed, the last indication remaining to be fulfilled is to seciu-e the patient in the most favorable position for the surgeon to perform the important work of which aU that has been under- taken has been but preliminary. It is properly the permanent (for the time being) adjustment of the body in such a manner as to allow the surgeon the best possible access for all his manipula- tions to the region which is to be the seat of his dissections and other operative movements, without any unsteadiness or opposition. Bouley's dii*ections for this purpose are that the operator, watching for the right moment, as the horse begins to totter, gives orders to the assistants having charge of the ropes acting on the body, the tail and the head, by a prompt and simultaneous action, to pull in the dii-ection of the side on which the animal is to he, and to those at the casting rope to pull firmly but not harshly in the opposite direction, while he himself pushes the body of the animal towards the bed. By this arrangement of opposing tractions the casting is easily efi"ected ; but luiless the assistants act in perfect concert, and especially if the casting rope be drawn too rapidly and suddenly, the animal will be raised from the ground with a sudden lift, to fall so heavily on the bed as to possibly subject him to the risk of sustaining severe injuries. Bouley remarks on this point: "An animal is properly cast only when, bending his knees, he Hes down softly and easily on his side, bringing to the ground successively the shoulder, the ribs and the hind quarters; or again when, the fall beginning from behind, the order is exactly reversed." Once down, the forcible traction upon the chain brings the four legs in close proximity, the spiing hooks or padlock passing through the link nearest to the ring of the hobble through which the chain passes, coming out last. To provide against the possi- 36 MEANS OF KESTKAINT. ble breaking of that portion of the chain which embraces the four hobbles, Peuch & Toussaint advise the passing of the casting rope and chain a second time through the rings of every hobble before it is secured with the spriag hooks. The animal being down, the straps of the Bernardot & Buttel apparatus are buckled, and the head well extended on the neck. The use of this apparatus con- siderably diminishes the difficulties involved in the contention of the head. Before its iatroduction, two assistants were required to keep it in extension and comparatively motionless ; and even then the results were not always easily reached nor accidents avoided, whereas, with this halter and surcingle arrangement a single strong assistant is sufficient to secure control of the head; FlO. 33 —Horse Thrown and Secured by Bernardot & Buttel Apparatus. SECURING SOLIPEDS. 37 and it has the advantage, besides, of " preventing fractures of the vertebral column, rupture of the diaphragm, and rupture of in- ternal viscera." In some exceptional cases the surgeon will be obliged to im- provise his hobbles. This may be done by fastening four ropes of suitable length around the coronets, allowing sufficient room for the passage of the casting rope between the hobbles and the skin, or again placing an iron ring through these loops of rope, which are secured by a knot on the outside of the leg, as suggest- ed by Mr. Dneubourg. The removal of the hobbles and of the other apparatus em- ployed in casting the animal, demands similar care and attention to that which was required to put them on. While the Bernardot & Buttel surcingle is unbuckled, the assistant loosening the Fig. 24.— Improved Hobbles of Dneubourg. straps of the cap, and ready to remove it at a moment's notice, the operator placing himself facing the soles of the feet, in order to be out of danger, cautiously unscrews the screw-jpin which fastens the chain to the principal hobble, and removes it, when all the hobbles becoming loose, are removed, and the animal being freed from all restraint, is allowed to rise. While the animal is rising it will be but prudent in the by- standers to allow him all the scope he may choose. The action is sudden and somewhat violent, and he may move his liind legs 38 MEANS OF KESTEAINT. with a sudden jerk which may throw the hobbles off with force suf- ficient to severely hurt some unguarded spectator upon whose per- son they might infringe. We have been witness to such an oc- currence, when they were thrown a distance of twenty feet, with violence sufficient to inflict, possibly, dangerous injuries. An animal thrown and secured as has been described is in a suitable position for the majority of operations, such as those about the head and neck, of the body, or of the upper part of the legs. But in many cases, it is necessary to fix a leg in a peculiar position either to expose a given region of the body, or when the limb itself becomes the seat of operation. The action of se- curing the animal in the recumbent position is one of great im- portance, and none of its details ought to be overlooked. And there are several points to which we have already referred in our introduction, which may be again noticed with advantage. Bear- ing in mind the accidents which may result from keeping the horse in a state of painful passivity, and his instinctive struggles to free himself, not to mention the painfulness of the constrained posture itself, the inference is palpable that it is incumbent on the surgeon to release the suffering patient from his trying constraint at the earliest moment consistent with the proper comjDletion of the operation. Again, in securing the legs, care must also be taken that, although a given position of a leg may facilitate the movements of the operator, it is not justifiable if there is another mode of securing the same object by means more comfortable and less dangerous to the patient, as well as easier for the surgeon. An experience of many years has taught us that six principal modes of fixing an animal's leg, fulfil all necessary requirements, and that the special purposes and effects of these are such as to forbid their modification. In considering these six specific modes, it will promote facility of description if the reader will follow our references to the dif- ferent legs on a sort of mental diagram which by a mode of ab- breviation by initials will designate — supposing the animal to be thrown on the near side — the near anterior as N.A.; the off anterior as O.A.; the near hind as N.H.; and the off hind as O.H. First position — Exposing the inside of the JV.A. leg. — A loop of the plate-longe is secured on one of the fore legs, above the knee, say the off leg, carried in front of the near leg, under it, back and between the fore legs, always above the knee, to return SECUKING SOLIPEDS. 39 Fig. 25.— 1st Position. Neurotomy. to the starting point, around the off leg again, back to and be- tween the legs, thus forming a complete figure 8. This is re- peated twice or three times, when a turn around all the crossings of the rope between the legs ties up all the twists of the rope and a double slip-knot is made on the forearm of the off fore leg. Both legs thus secured, the near leg is released from the hobble, and carried forward by an assistant pulling on it with a rope tied around the foot. For reasons already stated, we consider this position as the only one justifiable for neurotomy on the inside of the off leg, or for tenotomy. Firing on the inside of the coronet for ringbone, or along the tendons, might also be performed in this position. Second position — Securing the off fore on the off hind leg. — The loop of the plate-longe is placed on the O.A. leg about the middle Pig. 26.-2(1 Position. Ist Step. 40 MEANS OF EESTEAINT. of the cannon region, from there carried backwards over the O.H. leg, above the hock, between both hind legs, and forward, be- tween the fore legs and reflected back over the forearm, about its middle, when it is given to an assistant stationed at the back of the animal. An assistant is placed ia front of the animal, kneeling on the bed, and prevents the rope which passes ia front and over the forearm from sHppiag down too rapidly. The leg being released from the hobble, the operator holding it carries it backward, while the assistant at the back puUs slotoly but steadily on the rope, the action of this lever of the first kind, with its fulcrum on the O.H. leg, the resisting power at the foot of the animal and the moving power at the forearm of the off, moves and draws the leg backward until it reaches the cannon bone of the hind leg. At that moment, steadily holding every- thing in place, the rope that is passing above the hock on the near hind leg is allowed, cautiously, to sHp below the hock, and the near fore leg is then brought to the middle of the near hind cannon bone, where it is secured with a double figure 8. Other sur- geons secure the fore leg above the hock as in the plate we borrow from Peuch and Toussaint (Fig. 27). The danger of injury to the tendo- Achilles has caused us to change that position to the one Fig. 27.— 2d Position. 2cl Step. SECUEING SOLIPEDS. 41 above described. In this position the inside of the N.A. leg is ex- posed, and it can be fired, either for disease of the knee or of the tendons and bursse. All operations upon the foot of the O.A. can be performed except those required on the inside of that foot, such as those for inside quarter-crack, complicated suppurating com or inside cartilaginous quittor. Fig. 28.— 3d Position. Securing Upper Hind to Upper Fore Leg. Third position. — Securing the off Jiind uponthe corresponding fore leg. — In this the rope is first secured in the middle of the off hind cannon region, carried forward and over the forearm, above the knee, in front of the forearm, back between the fore legs, between the hind legs and over the near hind leg, above the hock, to the assistant stationed at the back of the animal. Ke- mo"\ing the leg from the hobble, and pulling on the rope the near hind leg is brought, by the same method, to the middle of the off fore cannon, where it is secured with a figure eight twist of the rope. In this operation the inside of the near hind leg is ex- posed from the hock down, and in that position, operations on the inside of the hock can be performed, such as firing for spavin, thorough-pins, ciu'bs, and cunean tenotomy, as well as firing on the inside of the tendons, or even tenotomy. As far as the off hind leg is concerned, only operations on the foot are justified, with the exception of those on the inside of that part of the leg. Fourth jyosition — Securing the near fore on the off hind leg. — The rope is secured by a loop on the middle of the cannon of the near fore leg, which rests directly on the bed, carried backward over the off hind leg above the hock, back between the hind legs, 42 MEANS OF RESTBAINT. Fig. 29.— 4th Position. Securing Under Fore on Upper Hind Leg. forward under the forearm of the near fore leg, between the fore legs and back to the assistant at the back of the animal. In this action it again becomes a lever of the first kind, with the fulcrums above the hock, the resistance at the lower part of the near fore leg and the moving power at the forearm. The leg is drawn from its deep position to a superficial one, and secured with a figure eight on the middle of the near hind cannon, and not above the hock, for reasons already considered. This posi- tion is only justifiable for operations on the inside of the near fore foot, such as complicated quarter-crack, complicated suppu- rative corns, inside cartilaginous quittor, and the like. The pe- ciiliar awkwardness of this position, in which the leg is carried in excessive adduction subjects the animal to the danger of severe Fig. 30.— 5th Position. Securing Under Hind on Upper Fore Leg. SECURING SOLIPEDS. 43 lesions in the axillary region, and it is justifiable only in the cases specified. Fifth position — Securing the near hind on the cannon of the off fore leg. — The rope is first tied up by a loop on the middle of the near hind cannon bone, forward over the forearm of the off fore leg, between the fox'e legs, and back to under the near hind leg, between the hind legs and to the back of the animal, where it is held by an assistant. The leg is again drawn from under him, is steadily brovight to below the knee of the off forearm and secvu'ed as in the other positions. In this position the only operations to be performed are those on the inside of the digital region, or rather of the foot of that leg. Fig. 31.— 6th Position. Sixth jyosition — Securing the off hind leg near the neck or shoxdder of that side of the body. — The rope is tied ujj by a loop around the coronet of the off hind leg, that is below the fetlock, carried forward toward the superior border of the neck, under the neck and then toward the inferior border of that region, back over the whole length of the animal to the front of the hind legs, between these and over the tibial region of the off" hind leg, where an assistant holds it to the back. Other assistants, pulling on the rope, and making it slide as it passes on the borders of the neck, 44 MEANS OF RESTEAINT. the operator carries the leg forward until it reaches the outside sur- face of the shjoulder, or the lateral j^arts of the neck, where the rope is secured by a double twist and knot around the coronet of the near hind leg displaced. This awkward and painful position is for operations in the inguinal region, including castration, in- guinal hernia, removal of champignon, amputation of the penis, or removal of tumors. When the operations which have necessitated these various positions have been completed, the leg which has been restrained should be returned into its proper hobble, and this should be done slowly and carefully, avoiding any unnecessary motions or noises, and the animal relieved of his means of restraint as in all other operations. Fig. 32.— Side Bar Hobbles. In a few instances, however, aside from these various modes of securing individuals, the surgeon has recourse to the side bar hobbles, which carries a hobble of its own at each end, one hobble being fixed on a fore, the other on a hind leg. Some of the English veterinarians are using the o'oss hobbles, Fig. 33.— Cross Hobbles. which has the advantage of being adapted for use upon legs diametrically opposite, such as the near fore and the ojff hind legs, and vice versa. jB. — Casting with ropes. The hobbles are not the only kind of apparatus devised for throwing horses, nor are they all made according to the English pattern, although the same general principles pre- vail in all. Ropes in the form of side lines, either single or SECURING SOLIPEDS. 45 double, are often substituted for hobbles, and for many varieties of these special claims are made by their inventors, or by those who give them their preference, and use them in then- practice. Without entering into the consideration of the comparative merits of these various methods, which vary, not only in nearly every country of the world, but even in different sections of the same country, there is a mode of their appHcation, upon which we have a word of comment to offer. This is the mode with a single, and that with a double rope. (1st.) With a single rope. — This is the simplest mode of casting, but it is also the least safe. It is the oldest of the methods in use, but has in our days been more or less modified and improved. The method of Rohard seems to be as perfect as any of them. In this, a rope from twenty to twenty-five feet in length is necessary. The horse being placed near the bed where he is to be thrown, is held in the ordinary manner. If he is to lie on the near side, the operator is placed on the right, near the shoulder with the rope, in which is a knot about six feet from its end, which Rohard calls the ring knot («), and immediately below it is another, called the stop2nng knot {h), through which the rope will run. "In this way," says Rohard, "there is a large loop FlQ. 34.— Application of tUe Rohard Method. 46 MEANS OF KESTKAINT. formed, which is thrown over the neck, while both knots made lie a little below the point of the shoulder." Taking with the free portion of the rope, a twist round both forearms, passing behind them first, then forward across the near fore leg, in front of both fore legs, and backward across the off fore leg, over the rope, it is carried across the abdomen, to the near hind coronet, which it surrounds from without inwards, to be brought back to the posterior part of the withers on the near side, where the operator takes hold of it. Then by degree^ slowly pulling on the rope, and making the animal raise his near hind leg by quietly urging him, this leg is carried forward, with a uniform movement, until at one. moment, the animal attempting to resist or struggle, the assistant at the head carries it toward the bed, the operator pressing with his body against that of the animal, until he slowly settles down without injury on his side. To fix the leg definitely, Fig, 35.— Animal Secured by the Rohard Method. one begins by the near hind leg. Making a double twist of the rope around the coronet of that leg, this is carried towards the loop which passes around the neck, and is there secured by a double knot (a), and carried back to the off hind leg, which is then carried far forward and secured to the same collar loop, with a single knot (/>). To release the animal, it is merely necessary to untie the stopping knot, when the rope becomes loosened from the legs. SECUEING SOLIPEDS. 47 (2d. ) With double side lines, or ttco ropes. — This is done by means of a long rope, doubled in its middle, and having a knot made in such a way as to form a loop large enough to be drawn over the head and neck of the animal ; the two ends below the knot are then passed in front of the chest and between the fore legs, carried, one to each hind leg, around the coronet, turning it once around the main rope, and passed on the coUar loop from within outwards, to strong assistants standing on each side of the animal. By steady pulling both hind legs are carried forward, until the animal loses his balance and settles on his haunches, when a strong effort of the assistant at the head brings him down on the bed. The hind legs are secured to the collar loop with the ends of the rope, and the fore to the hind legs in the same manner. The various methods of casting which we have been consider- ing, with hobbles and with ropes are, as we have before said, not the only plans recommended. Almost every country * f Europe, while also using the hobbles, has a fashion of its own in which the ropes are utilized, and as to the fact of their widespread, if not universal use, it would seem that not a few veterinarians of exten- sive practice have originated and employed special methods of their own devising, for which they claim more or less superiority. Among those recommended in this coimtr}^ we may mention the apparatus of Mr. Miles, which he has used for years in his exten- sive practice as castrator. Dr. Wm. Dougherty, of Baltimore, has sent us a set of rope-hobbles and side-line, which upon personally testing we are able to recommend as possessing important points of excellence, especially in casting young colts for castration. For further light and broader information on this subject we must refer our readers to the standard authors by whom it has been discussed in the French, German, Danish and Russian tongues, feeling at the same time quite confident that the general rules which we have suggested and illustrated for the performance of the operation of casting are sufficient to guide any inteUigent operator through all the steps of the proceedings. C. — Casting on the Operating Table. The necessity of employing such a number of assistants in throwing a horse, with the difficulties often encountered in con- ducting all the steps of the operation, and the accidents which 48 MEANS OF KESTKAINT. too often accompany its execution, have led to the invention of other means of accomplishing the object in which the objections to the old method are sought to be obviated. It was with this view that the operating-beds of Lafosse in France and Hart in Wurtem- FiG. 36.— Wall-bed of Fromage de Feugre burg were contrived. The wall-bed of Fromage de Feugre pos- sessed many advantages, but was abandoned on account of its compHcated structure. Of late years, however, several other forms of operating tables have been devised, of which one espe- cially is highly commended by European authors. It is that of Mr. J. Daviau which consists of a broad and heavy table, furnished with pads, surcingles, hobbles, ropes and other necessary appurten- ances for securing the animal, and which is moved by a pecuhar crank arrangement which permits its adjustment in any required position, from the horizontal to the vertical, and by which it may be turned down flat upon an iron frame. The apparatus is placed solidly on the ground, or can be made movable by a set of low wheels attached to the heavy wooden frame upon which the table and the crank are supported. Mr. Daviau claims for his invention: 1st. That it obviates "all the complications " accompanying the ordinary system of throw- ing. 2d. It allows " the easy and comfortable rising of the horse " after the operation, without danger. 3d. It gives entire security to the operator, who can perform his task alone and without the SECUKING SOLIPEDS. 49 60 MEANS OF RESTRAINT. SECURING SOLIPEDa 51 52 MEANS OF EESTEAINT. Fig. 40.— Hodgson & Magee'e Table. Back View ; showing the working of pulley to draw the table down. SECURING SOLIPEDS. 53 need of assistant. 4th. No assistants are needed to be exposed to dangei', and the responsibility of the operator is diminished. 5th. Economy of time. 6th. Economy of material and space for the performance of the ordinary operation of casting. In this country several forms of tables are in use. Those of Dr. Tiffany, Price and others, all of which are constructed somewhat upon the same principles with respect to the action of an iron crank to control the position of the table. Doctors Hodgson & Magee, both veterinarians of New York, have invented a table which for simplicity seems to surpass any one we have yet seen (Fig. 40). Like the others, it has slings, ropes, hobbles, pads, etc., but dif- fers from them in two important particulars. The first is the manner in which the table is lowered and raised ; the second, the manner in which the hobbles are secured and made immovable. In the middle of the superior border of the table, and directly below it on the posterior face, are two solid iron rings. In the ceiling of the operating room, or on the cross-piece of the frame in which it is enclosed, and dii*ectly opposite that in the border of the table there is another. Another is fixed in the floor some dis- tance back of the frame upon which the table rests when in a horizontal position. To these rings two systems of pulleys are attached, one connecting that in the ceiling with that in the bor- der of the table ; the other connecting the ring on the posterior face of the table with that in the floor. Besides this, under the table are two strong iron eyelets through which chains are passed, which at one end are secured to the hobbles by openings through the table, and at the other are secured from slipping through the ring by a wide T arrangement, secui'ed on the last link. These chains measure the distance which exists between the rings on the floor and the table when in a horizontal position. When the horse is brought alongside the table and tied up with the slings, the halters and head-straps securing him, and the hobbles being in place, the rope of the upper pulley is pvdled by an assistant, and the table moved slowly into the proper position. The rope being then fastened to the ring in the floor, the table is immovable. Upon the completion of the operation the rope is gradually slackened, while an assistant pulls on the rope of the base of the table which is thus restored to the vertical position. 64 MEANS OF BESTKAINT. MEANS OF SECUKING OTHER DOI^IESTIC ANIMALS. {a) BoviNES. — With these animals benignant measures are of Httle avail. Kindness may in some possible cases — but they will be rarely met with — succeed to a limited extent, but to trust to the influence of the treatment so often effective with an inteUigent and docile equiue, such as the petting caress, the soothing tone of voice, or the kindly glance of a human eye, with even the placid and mild-eyed milch kine, will be only an act of misplaced con- fidence. To blind them, to induce dizziness by turning them rapidly in a small circle, may at times produce good results, but even then these measures will be more reliable if combined with more palpable agents of restraint. Cattle may be kept quiet in the standing position by raising their heads, by passing the index finger and thumb of one hand into the nostrils, with the arm over the face, and raising the tip of the head upward, while the other hand, grasping one of the horns, moves the top of the head downward, the resistance of the animal being overcome by pinching the nose with the hand which grasps it with more or less force. By this means the head of the animal is fixed, and the operator guarded against injury from the horns, and the movements more or less Hmited. While maintain- ing this position, the cavity of the mouth can be examined and even short and simple operations rapidly performed. Another device for preventing the animal from using his horns as a means Fig. 41.— Securing Cattle. SECTJKING OTHER DOMESTIC ANIMALS. 55 of contention is to tie a long rope around their base, passing it along the neck and the back with one loop around the ribs and another further back around the flanks, and when reaching the tail securing it there by a knot at the base of that member. The head is thus kept elevated, and he is restrained from motion by the pain experienced by the tail when the rope is tightened by his attempt to flex it. This assiu'es his passiveness (Fig. 42). The practice of shielding the sharp points of the horns with smooth, metallic balls is one which tends largely to diminish the power of the animal for doing harm, by obviating to a great ex- tent the danger from punctured wounds to which those who han- dle them are exposed. The best mode, however, of secui'ing cat- tle while standing, is by tying the head up to a post or a tree, or again by yoking an individual with his mate or another animal of the same species. Kicks must also be guarded against. Those by the fore legs are avoided by raising one foot and tying it on the forearm, thus compelling the animal to stand on three legs. But the hind legs of cattle are the most dangerous from their abiUty to kick in so many directions, whether backward, forward or outward. Several methods are recommended by which to guard against this form of danger. Among these may be mentioned the passing of the tan forward between the hind legs and then outward, car- rying it towards the stifle of the leg from which the kick may pro- ceed, and holding it firmly with a backward pull ; thus surround- *^s^-.^:iiSr_^,AV-2^ _J\--:i!i^^^^ Fig. 42.— To Prevent Cattle from Kicking. 56 MEANS OF RESTBAINT. ing or tying the leg with the tail. Again, to pass a twitch round the leg above the hock, and to turn it until the tendo-Achilles pressed upon, is brought in contact with the posterior face of the leg. A loop of rope twisted upon a stick will answer the same purpose. The use of hobbles, single or double, or of the side lines to secure the hind legs, has also been recommended, as with solipeds, with the difference that the horns furnish a strong means of support, which is entirely lacking in the soliped. A method approved by some of controlling the motion of the animal is to pass a rope on one hind leg above the fetlock, and to carry this leg well forward, or even to raise it from the grovmd and to tie it by the rope to the forearm of the same side above the knee or around the horns. The use of a long bar of wood held under the abdomen by two assist- ants in front of the stifles ; keeping the animal pressed against a wall by means of a wooden bar, with which an assistant pushes firmly against the stifle of the side opposite to that upon which the operator stands ; binding the animal against a wall with a rope fixed to a ring in front of the chest and one behind the hind quar- ters — all these are simple means employed to keep cattle quiet in the standing position. Some individuals, however, and especially bulls, are altogether intractable, and require more severe and effectual modes of pun- ishment. These are appHed upon the muzzle of the animal in his nasal septum by nippers or clamps, or with rings. Nippers are of divers forms. One true, single clamp is commonly used in Italy, and has been modified in England ; another is in use in Hol- Fig. 43.— Italian Fig. 44.— Modified FiGS. 45 A and B.— Modified English Nose Clamp. English Nose Clamp Nose Clamps. SECUEING OTHER DOMESTIC ANIMALS. 57 land,, which is a true screw-clamp ; another, which is preferred in France — are a few among the varieties of this single instrument for the application of pressure upon the septum nasi. They are generally secured on the front of the face by ropes or straps. They are effectual appHances, and by their aid the head can be kept up and the animal controlled without difficulty. Among the rings the simplest are most commonly in use. They are made in two parts, articulated at one extremity, and united at the other when in place by a rivet or screw. They vary much both in form and size. Some (though still known as rings) are square ; others 3 Fig. 46.— Square (?) Rings for Cattle, are round and eUiptical. The ling of Rolland, the Alsace ring, and some of simpler construction carry an auxiliary ring at some part of their circumference with which to secure them on the face of the animal by means of ropes or straps. These rings are appHed after the perforation of the nasal septum with a trocar or a punch-nip- pers, making an opening of a size corresponding to that of the ring. Sometimes the perforation is made with a hot iron, the Fro. 47.— Ring of RoUand. anirnal being properly secured and tied to a tree, or placed in a yoke with the head elevated, the operator making a quick punc- ture through the cartilage, and introducing the ring and riveting it. The hemorrhage soon ceases spontaneously. In order to dispense with the punch, trocar, and the puncture with the hot iron, rings of a special construction have been in- vented. These also consist of two parts, and are also articulated, 58 MEANS OF EESTEAINT. Fig. 50.— Puncture of the Septum witli Trocars. i Fig. 51 —Rings with Points. SECURING OTHER DOMESTIC ANIMALS. 59 one of the joints having a sharp point with -which the ring is pushed through the cartilage. A simple form represented in Figure 51 shows the point passing thi'ough an eye at the other extremity of the ring to be bent over it in order to close the in- strument. The ring used in some parts of France is contrived Fig. 53.— French Kings. somewhat on the same plan, but is more compHcated. That of Rueff is a kind of broken circle, which, when closed, forms a per- fect ring in which the branches are kept together by a small screw. Fig. 53.— Ring of Rueff. The rope which is attached to the nasal ring is not always suffi- cient to drive or control bulls, and conductor sticks armed at the end with iron hooks of various shapes are recommended. The apparatus of Vigan is a very simple one, but it fulfils all require- ments and suffices for the restraint of the most vicious animals. It consists of a wooden pole with an iron prolongation having a wide ling by which to hold it, and at a short distance from this a hook to be inserted into the nose ring. Back of this is a strajD to secure around the horns the bar over the top of the head as it passes between the horns. At the other extremity is an iron stifle through which a surcingle is passed to be tied around the body of the animal. Painful, and stni easy to apply, this apparatus is not only a powerful means of restraint, but is siofficient to prevent any motion of the head. 60 MEANS OF RESTRAINT. Fig. 55.— Vigan'B Apparatus. SECURING OTHER DOMESTIC ANIMALS. 61 Fig. 56.— Steer Placed in Stock. The use of stocks for the control of bovines is often also re- quii'ed. These are used principally in shoeing oxen, but are available for some operations which require greater passiveness than can be obtained by the applications of the simpler means above described. It is only in exceptional cases, and when an operation is likely to be unusually painful and prolonged, that the recumbent position is required with bovines. The casting of cattle may be effected with or without hobbles, but in either case special care is necessary to provide a sufficiently thick bed to protect the head, and guard against the possible danger of fracturing the horns. A long board placed transversely across the neck, with an assistant seated on each end, affords an excellent means of controlling his efforts and struggles. When hobbles are used, they must be of smaller size than those used for horses, and should be placed above the fetlocks. To cast bovines without hobbles, either of two methods, one invented by Eueff of Germany, and another described by GweU and Hertwig, will answer the purpose. In the first, the Rueff method, a rope some thirty-six feet long is required, in the middle of which a loop is made and fixed round the base of the horns. The two free ends are then passed between the fore and the hind legs, each being twisted from within outwards, around one of the coronets, and brought back to the loop at the base of the horns, through which they are passed to assistants, one on each side, with directions to pull backwards. The feet are thus brought close together, and the animal seats himself on his hind quarters. 62 MEANS OF EESTEAINT. and finally stretches himself on the bed. If he struggles, the traction on the ropes only expedites the fall. If he pushes for- ward, or attempts to kick or even only moves his feet, the running of the rope is so much more facilitated. In the other mode, a rope about the same length and carrying in one extremity a loop which is thrown over the horns, is passed backwards along the superior border of the neck, as far as about its middle, where a loose loop is made ; then carried backwards at the side of the vertebral column, where another loop is made, be- hind the shoulders, and a third one around the abdomen, on a level with the flank, where an assistant holds it backwards by the side of the sacrum. If the animal is to be thrown on the left side, the rope must pass on the right of the base of the tail, and vice versa. Two assistants pull on the rope, while another holds the head and tries to bring the animal down. The traction on the ropes tight- ens the three loops, and under the effect of this force the animal is made to lie down quietly. It facilitates the operation to lubri- cate the rope with a little grease or soap. In order to avoid compUcations from lacing the ropes too tightly about the body, it is always indicated to subject the pa- tient to a moderate fast previous to casting by this mode. (b) OviNES AND Capkines — Although these animals are timid and comparatively lacking in strength, they are at times capable of struggling violently and becoming dangerous, and they can- not be subjected to surgical treatment without being cast. This is done by grasping both legs of one lateral biped, the right fore and hind legs, for instance, and laying him over on the opposite side, the left, and vice versa. If all the legs are to be secured, those of each lateral biped are first tied, and with the two cords a straight knot is made, binding all together. If the seat of operation is the head, the animal is held by an assistant, who sits with the body of the animal between his legs, with its back close to his own body, holding the fore legs with his hands, and controlling the hind quarters between his legs. In some cases when the operation is light, the oj)erator holds the an- imal himself without help. (c) Swine. — Securing a good hold of this animal is not always an easy task, and it sometimes requires not a little skill and ciui- ning to do so. When seized, two assistants are necessary to cast him, especially if he is of large size, and when down, either a muz- SECURING OTHER DOMESTIC ANIMALS. 63 i Fig. 57.— Twitch for Swine. zle must be put on his snout to prevent Ids biting, or a peculiar twitch placed between his jaws and twisted over the upper one. If an examination or operation is to be made about the mouth, a wooden gag placed between the jaws and held with cords, will be found of great utility. The various operations performed upon c D Fig. 58.— Gag for Swine. the noses of swine, to prevent them from digging the ground, may be considered to some extent as means of restraint. The incision of the snout, which consists in making several transverse cuts through it; the nasal tenotomy, though not so successful; the application of rings through the nose, by the same methods as Fig. 59.— To Prevent Swine from Digging. 64 MEANS OF EESTRAINT. Fig. 59a.— Another Mode. those used in cattle, are simple means which only need mention, be- ing more frequently performed in fact by raisers and breeders of swine, and indeed rather belonging to their special domain than to that of the professional veterinarian. L '^' Fig. 60.— To Prevent Dogs from Biting. (f?) Dogs and Cats. — Dogs can be prevented from biting by muzzling them, or vdth a cord or band wrapped first around the lower jaw, and then around both, and secured over the neck behind the ears. To examine the mouth in the absence of a speculum, as the one represented in Figure 61, the mouth may be held open by cords passed around each jaw behind their tusks, and pulling them apart. If the animal is dangerous or ugly, the collar nippers SECURING OTHER DOMESTIC ANIMALS. 65 Fig. 62.— Keeping the Mouth of a Dog Open, Fig. 63.— Collar Nippers for Dogs. become very handy, in order to hold them by the neck and keep them under control, whether for operation or for administration of medicines. Cats are most difficult to handle. They bite and they scratch, and they are often unconquerable until they are fully subjected to general anesthesia. In many instances, the co-operation of a good assistant, accustomed to handling them, may be found necessary. They may sometimes be made amenable to treatment by grasping them by the neck behind the ears, and close to the head with one hand, and securing the fore paws with the other, while a second assistant holds the hind legs, or it may become necessary to have the four paws tied tightly together, and only the head held by the assistant. We have heard of the utilization of a man's boot as a means of feline restraint, particularly ia the castration of the male, or " Tom," the head and body of the animal being thrust into the leg 66 MEANS OF RESTRAINT. of the garment, leaving only the posterior portions exposed and accessible to the operator. This may not be a scientific device, but its effectiveness can hardly be doubted. SUEGICAL ANESTHESIA. A resort to the various means of restraint, which we have been considering, is sufficient in a majority of cases to bring imder perfect control such animals as require to be subjected to surgi- cal treatment. But there is a class of cases in which they become inadequate to meet the great requirements of inducing in the pa- tient a condition in which a great diminution, or the entire suspension, of sensibility and consciousness, with all power of muscular reaction, is established throughout the organism. This result is obtained through the characteristic action of the special therapeutical compounds, known as anesthesia. It is not merely as a more effectual means of securing control over refractory patients that their administration is justified. It is also prompted by a proper humanitarian feeling in cases in which severe and prolonged suffering accompany the operation. In veterinary surgery, the indication for anesthesia, has not, to the same extent as in human, the avoidance of pain in the patient for its object, and though the duties of the veterinarian include that of avoiding the infliction of unnecessary pain as much as possible, the administration of anesthetic compounds aims prin- cipally to facilitate the performance of the ojjeration for its own sake, by depriving the patient of the power of obstructing, and perhaps even frustrating its execution, to his own detriment, by the violence of his struggles, and the persistency of his resist- ance. To prevent these, with their disastrous consequences, is the prime motive in the induction of the anesthetic state. That it per- fectly succeeds in fixing the patient in the attitude most favor- able for the surgeon in the execution of the various parts of his task, needs no affirmation, nor need we attempt to measure the value of the discovery, which has proved itself to be such a price- less benefaction to the world. There are special cases where anesthesia is more particularly necessary than in others, and where absolute immobility of the patient is essential, and entire muscular relaxation indispensable. Thus it is indicated in the reduction of fractures or dislocations in SUEGICAL ANESTHESIA. 67 the large domestic animals ; in cases of delicate manipvdation and dissection with sharp instruments, as in the operation for strangulated inguinal hernia; in the reduction of other hernial tumors, in the performance of neurotomy; in operations upon the eye, and in the removal of tumors of certain kinds. It is also indicated in certain operations upon the foot, which are always accompanied with great pain, such as that for the extirpation of a portion of the quarter of the foot, in the removal of the cartilage affected with necrosis (quittor); or again, in deep punctured wounds of the sole, where the resection of the plantar aponeurosis becomes necessary, or the bones are scraped with the knife. The anesthetic condition is also very favorable for the reduc- tion of displaced organs, as of a prolapsed rectum, or uterus, or bladder. In operations upon the teeth, in some cases of parturition, in castration, in firing, or even in the application of hobbles, the induction of the anesthetic state has often been of great benefit in quieting nervous animals, and subduing them to a condition of passiveness, which reheved the movements of the surgeon from aU embarrassment and uncertainty. As with human patients, anesthetics are contra-indicated in animals subject to diseases of the heart or of the lungs. A fuU stomach is also always a contra-indication of their administration, especially in soHpeds, which are lacking in the abihty to relieve it of its contents by vomiting. Anesthesia may be either local or general, according to the area of its effects. Local, when apphed to the skin over a Hmited surface, to which its effects are confined ; and general, when ad- ministered by inhalation, and through the respiratory organs in- fluencing the entire economy. In local anesthesia the effects are obtained either by the pulveri- zation of the proper substance upon the region where it is required to take effect, or by the subcutaneous injection of special agents. General anesthesia is usually produced by the inhalation of the vapors of ether or of chloroform. LOCAL ANESTHESIA. The special indications for this are so numerous that they may almost be considered as general, if not universal, and its applica- tion is so simple and easy a process, and its effects usually so cer- 68 MEANS OF RESTRAINT. tain, that it would become the practitioners of our day to utilize it more frequently and extensively than they do. It is available as well as useful in the simplest operations, and may be employed in the opening of abscesses and cysts ; in the puncture of cold abscesses with the hot irons; in the puncture of the cornea; in neu- rotomy ; in simple incisions of the skin ; in the removal of small tumors, etc., etc. We have used it with the best results in ureth- rotomy, in caudal myotomy, in amputation of the tail, and the removal of mammary tumors in dogs, etc. Bouley long ago rec- ommended its application to surgical diagnosis, in cases of doubt- ful lameness, an expedient which has recently been introduced into this country by several veterinarians, for the differential diagnosis of shoulder and foot lameness. We have remarked that the anesthesia can be produced in several ways, though two are principally in use. Among these properly termed minor and secondary expedients, are the applica- tion of cold water or ice, and cooling or freezing mixtures, and pressure upon the blood-vessels and nerves, which have for years been among the adjunct and agencies of surgical practice, but have given place in recent times to methods more potent and more certain in their effects. Notwithstanding this, however, some mention of their nature and qualities, and the methods of utilizing them will not be out of place, if only as a matter of gen- eral reference, and a case might arise in practice when the infor- mation might become practically valuable. 1st. Pulverizatio7i of an Anesthetic Liquid. — The apparatus employed for this process is the invention of Dr. Richardson, and though the spraying tube has been from time to time more or Fig. 64.— Richardflon Atomizer. LOCAL ANESTHESIA. 69 less modified, the mode of its employment continues unchanged ; though any substance susceptible of easy pulverization may be employed. Ether is the agent most frequently chosen. Rigolene has given us great satisfaction in our own practice. In impingiag upon the skin in a state of excessive division, the rapid evaporation of the Hquid lowers the temperature of the surface with which it comes in contact, and it is this process of refrigeration which diminishes the local sensibility, and, as the effect increases, overcomes it entirely for the time being, or so long as the spray continues to be thrown upon the part. Some sHght objections, however, may be alleged against this mode of producing insensibility, arising from the special proper- ties of the fluid employed, and for this reason the mode by sub- cutaneous injection is somewhat to be preferred. 2d. Subcutaneous Injections. — Both ether and chloroform have been recommended, and extensively used, in this manner, but without doubt the salts or compounds of cocaine possess ad- PiG. 65.— Syringe of Pravaz. vantages over either of them. An epidermic syringe, or that of Pravaz, is generally used for the purpose, with a solution of from four to twenty per cent, strength, according to circumstances. If used on a tumor a certain quantity of the solution, perhaps twenty drops, is injected under the skin at two or three points around its circumference, the desired effect following, and the parts being ready for the operation within from eight to ten minutes, more or less, according to the strength of the dose administered. Either of these modes of local anesthesia is harm- less, and may be employed without risk or fear of complications. 70 MEANS OF KESTKAINT. GENEKAL ANESTHESIA. The three principal agents which recommend themselves by the efficiency and certainty of their action in producing general anesthesia, are ether, chloroform and chloral hydrate. Their adaptation varies, however, with the animals subjected to their administration. Chloroform and chloral are chiefly used for the larger animals, principally horses, while chloral and ether are re- served for the smaller kinds, with which chloroform is so generally dangerous, and even so often fatal, that its use with them is almost entirely discarded. Insensibility by Anesthetic Va^yors. — The modes adopted for the inhalation of the vapors of chloroform are numerous, but among them all the merit of simplicity should probably be award- ed to that which is recommended by Bouley. This consists in the introduction into each nostril of a small sponge, or a ball of oakum, saturated with the ether or chloroform, and held in place by the hands of assistants. The inhalation of the vapors, which are thus mixed with air, proceeds rapidly, the sponges being recharged as soon as they become exhausted, and returned to the nostril, rmtil the object in view is accomplished. But while this mode is a very convenient one, we conceive it to be liable to certain objections. First, unless the pouring of the liquid is very carefully per- formed and in such quantity that the sponge is not over-saturated, there is danger that a large portion of it may be wasted, by run- ning off, either on the bed, or possibly, into the nostrils, causing, in the latter case, great irritation of the mucous membrane. And if the anesthesia is to be continued for a considerable length of time, the effect produced upon the delicate membrane of the nose may be sufficiently serious to end in the sloughing of the parts. It must certainly have been with the view of avoiding this complication that Defays invented the inhaler shown in figure 66 with its wide range of appHcation, from the dog to the horse. Many veterinarians have adopted an arrangement consisting of a strong leather muzzle with large openings at its bottom and sides for the free admission of the atmospheric air, the sponge or oakum charged with the chloroform or ether being placed in the bottom of the muzzle, which is fixed upon the animal's head in the GENEKAL ANESTHESIA. 71 Fig. 66.— Apparatus of Defays. ordinary way. This is a very convenient, though quite a simple contrivance, but English veterinarians, and among them Mr. R. Cox, recommend in preference a chloroform-bag, in the form of an ordinary bag, made of strong canvas, both ends of which can be closed by a running string, one being tied around the nose Pig. 67.— Cox's Chloroform Bag in Position. while the bag is secured by cords to the halter or to the straps of the caj). The chloroform is introduced into the bag by means of a thin j^iece of cloth saturated with the liquid. The chloroform nose-cap recommended by Mr. Gresswell also answers a very good piu'pose, and in fact, possesses advantages which render it superior to the apparatus of Mr. Cox. It is not so portable in its form, but is more durable in its construction. In fact, it produces the features of the ordinary stable muzzle which we have already mentioned. The apparatus of Carhsle is also one of English invention, for which great merit is claimed. We have used it, and the trial has shown it to possess many features of marked superiority over the others. The quantity of liquid required to bring a large animal under complete general anesthesia cannot be positively ascertained. 72 MEANS OF RESTRAINT. Fig. 68.— Gresswell's Chloro- form Nose-Bag. Fig. 69.— Carlisle's Chloroform Inhaler. While it has often been induced by the inhalation of a single ounce, there are cases in which two, three, or even more have been necessary. An essential point to consider is that the chloroform should be absolutely pure. Mixtures of two or more drugs have also been employed, usually ether and chloroform, with or without the addition of alcohol, but the result of all ex- perimental tests has been, with us, to establish the conviction, that as yet, chloroform used singly has proved itself to be the most effective and the safest of all. The administration of chloroform of course pre- supposes, besides all the other conditions and preliminaries of an operation, such as previous fasting, the preparation of the bed, and other incidental steps, the act of throwing the patient. When the effects of the inhalations begin to become manifest, the first physiological change noticed is an extreme agitation, accompanied with coughing. The animal struggles more or less violently, the irritation and tickling of the throat produced by the vapors upon the laryngeal mucous membrane, giving rise to a spasmodic motion of the glottis, and whether the patient be a GENERAL ANESTHESIA. 73 large or a small animal, he exerts his strength to rid himself of the apjsaratus and regain his freedom of motion. These manifestations are, however, but of short duration, and are soon followed by a state of passiveness, the respiration be- coming easier, the cough disappearing and his energy subsiding ; and in short, he is subdued. The eye then assumes its character- istic expression, its brilHancy is lost, it is wide open, the pupils slowly dilate, the gaze becomes fixed, the sensibility of the cornea is lost, and the light ceases to effect it. The mouth becomes more or less loaded with saliva ; the pulse, which must be carefully noted by an assistant, becomes slow and weak, the respiration returns to its normal condition ; the state of complete anesthesia has been reached, and the patient, in happy unconsciousness, is ready for the surgeon. The time required to reach this condition varies with the sub- ject, and especially with the quality of the drug administered. The average period is from one to five minutes in small animals, and from ten to fifteen in the large. In some few cases, however, half an hour may elapse before complete insensibility is produced, and again animals are encountered with pecuhar idiosyncrasies, which remain entirely refractory, and successfully resist every attempt to reduce them to insensibility ; a statement equally true when applied to human patients. The duration of the Anesthesia. — Some animals remaining under the influence only for a few minutes, sometimes from fifteen to thii'ty or forty, it becomes necessary to prolong the insensibil- ity by renewing the inhalation, and they must, therefore, be con- tinued until the completion of the operation. Recovery from the anesthetic state does not always take place immediately and per- fectly. As the effect begins to subside, the animal, having parti- ally regained his senses, begins to move his eyes, raises his head, perhaps allows it to fall back slowly on the bed, lying flat on his broadside ; then his legs begin to move, and presently he attempts to spring suddenly to his feet. He may succeed in doing so, but again, his muscles may not have yet recuperated their power of full action, and there may be danger of his experiencing a heavy fall on the bed. His condition is one of drunkenness, and he re- quires to be watched, and, if necessary, aided, in order to prevent him from injuring himself by efforts beyond his strength whUe in a state of weakness of which he is unaware. 74 . MEANS OF RESTRAINT. The symptoms of general anesthesia by chloroform, which we have detailed, are those of ordinary cases. There are, however, other symptoms which the vigilant operator will not fail to look for, which are of great importance as indicative of the dangers, and premonitory of some of the casualties incident to the situ- ation. These we reserve for subsequent consideration. Anesthesia by the Admmistration of Chloral. — While this drug and its compounds, as sometimes used, produces in some cases a condition of insensibihty quite as complete as that ob- tained by chloroform or ether, yet there are cases in which only a less complete degree of success can be secured, though still suffi- cient to be of great assistance to the surgeon as weU as of rehef to the patient. That the intra- venous injection of chloral has been shown to be the best of all modes of obtaining anesthesia, is an admitted truth, but unfortunately it is a method of introducing it into the system which will scarcely ever become sufficiently prac- ticable to be available outside of the laboratory. Efforts to over- come the difficulty referred to have not been wanting, however and Messrs. Cadeac and Mallet have experimented with chloral by combining its action with that of muriate of morphine. By first injecting subcutaneously a certain quantity of a solution of mor- phine, and following it after a few minutes by a rectal injection of a solution of chloral, they have obtained complete anesthesia in a very short time. For a horse they have used eighty centi- grammes to one gramme of the morphine, and from eighty to one hundred grammes of chloral; and, for a dog, ten centigrammes of morphine and twenty grammes of chloral The administration of chloral in the form of balls, as commonly practised by many veterinarians, in doses varying from one to one and a half ounces, given on an empty stomach, and from one to two hours before the operation, is imdoubtedly good practice. We have not personally had the opportunity of testing it in cases of long and tedious dissections, but the benefit we have often de- rived from it in short, though painful operations, justifies us in recommending it, not only for this very object, but in any case, where, from any possible cause, an animal is likely to receive severe injuries during his struggles to liberate himself. ACCIDENTS OF GENERAL ANESTHESIA. 75 ACCIDENTS OF GENEKAL ANESTHESIA. Notwithstanding the caution observed in the use of ether or chloroform, and however pure these articles may be, accidents must be expected during their administration. They are not always of a serious nature, but they may at times have fatal results. Among those of minor importance is the cough which becomes at times quite troublesome, but may be readily subdued by a tem- porary arrest of the iahalation ; vomiting, which often occurs in small animals, but which can be guarded against by causing the patient to fast long enough to insure an empty stomach before being etherized, and spasmodic contractions, of which the exis- tence, when undoubtedly present, is often overlooked. Among those of more serious nature are syncope, either cardiac or res- piratory. Cardiac syncope is a very serious accident, and in a majority of cases proves fatal, especially in large animals. It is sudden in its manifestation, and often unobserved until at too late a period of the oj)eration. It is due to a gradual diminution, followed by an arrest of the muscular contractions of the heart, and as far as oiu* observation extends is always associated with pre-existing heart disease. The apj^Hcation of cold douches, of heart stimu- lants, ammonia given by inhalation or internally, are the first in- dications in these cases. Respiratory syncope, which is far less dangerous, arises from the influence of the laryngeal nerves upon the activity of the res- piratory centers. Its access is sudden, being caused by the arrest of the respiration. There is no convulsion, though the intoxica- tion produced by the anesthetic vapors is sudden in its effects, and is generally detected only by careful watching. The application of electricity, that of the electro-puncture, and especially persevering efforts to effect artificial respiration, may sometimes save the animal, provided the trouble is not connected with the complete arrest of the contractions of the heart. In view of these possible incidental conditions, some general rules suggest themselves tending to their avoidance. Great care and exactness in gauging the doses of the anesthesia, with such caution in their administration as to produce a slow and gradu- ated effect, is one point. Free allowance for the introduction of air with the vapors inhaled ; close attention to the state of the 76 MEANS OF RESTRAINT. circulatory and respiratory apparatuses, and the manner in which their functions are executed, by noticing the heart-beat and watch- ing the pulse and the movements of respiration at the flanks, are other points of importance. Another point is the need of bearing in mind that an animal submitted several days in succession to general anesthesia be- comes more and more susceptible to its effects, and therefore more exposed to the dangers they imply. ACCIDENTS INCIDENTAL TO THE USE OF MEANS OF KESTRAINT. We have already considered some of the accidents which are likely to interfere with the successful application of the means of restraint, and especially with reference to the final act of the pre- liminary series which occur at the moment of throwing the animal and depositing him on his bed, jjarticularly such as may follow the neglect of properly protecting the head with the cap or blinkers, or by an unnecessarily prolonged use of the twitch, or from the sudden and violent movements of the animal himself. These can usually be obviated by proper forethought and watch- fulness. But the most careful attention cannot always assure immunity from miscarriage and casualties. Thus, a common mis- hap, and one which cannot be anticipated nor prevented, is the sudden and heavy faU of the animal just as his equihbrium is lost. The lesions which may follow this casualty may have their seat either in the hard or soft structures, and are of the most serious character, not only including, at times, fractures and dislocations, and lacerations of the soft tissues, including the muscles, but may affect the viscera, and even the blood vessels and the nerves — in this last case involving the parts in all the evils of local paralysis and its disabilities. (a) Feactuees. This form of injury may have its seat in the vertebral column, the ribs, and the bones of the extremities. 1st. Fractures of the Vertebral Column. — In the list of frac- tures, those of this region of the body are the most frequent. The numerous reports of cases which are made public by veterin- ary writers furnish sufficient evidence of the facihty and frequency of their occurrence, even when the most careful attention has been ACCIDENTS DUE TO RESTKAINT. 77 bestowed on all the details of the work of casting. The very peculiar circumstances uuder which these spinal fractures some- times take place, baffling calculation, and occurring when least expected or prepared for, illustrate the responsibility which the veterinarian assumes, and the culpabihty with which he would become chargeable by undertaking the work without due caution and preparation, or without notifjang the owner of the animal of all the hazards and difficulties attending the case in all its steps and stages. As will be seen when we come to the consideration of this special lesion in the chapter on fractures, the symptoms which accompany this accident are distinguished, as to one feat- ure, by the suddenness of their appearance, which takes place at the moment of the infliction of the injury or immediately after. But the most important of the characteristics of the case is the grave fact that the fracture is almost always of the comminuted kind. This is held to be due to the excessively powerful mus- cular contraction, resulting in the over-arching of the vertebral column simultaneously with pressure from the abdominal organs, caused by the sudden extension of the anterior and posterior bipeds, bound together with hobbles, the violence of the struggle so powerfully pressing the vertebrae together as to result in the yielding of their spongy structure ; and the crushing or grinding of the bone is the consequence. This theory of the production of fractures of this character has been adopted by the majority of European veterinarians, es- pecially by those of France, where it is understood as "Bovdey's Classical Theory." In 1889, however, another theory was pro- pounded and defended by Mr. Moussel, of Alfort, differing en- tirely from that of Bouley, in which he claims that the kind of fracture in question is not caused by an over flexion of the spine, but, on the contrary, is the effect of an excessive extension ! result- ing from greater contraction of the ilio-spinalis muscle. According to Dicker hoft, " three factors are active in the cau- sation of these fractures. In the first place, the animal must have some object as 2, point d^ appxd for one hind leg; that point must be connected with either one of the other extremities or directly with the trunk. * * * Secondl}-, the horse must make his vertebral column teiise by the contraction of the spinal extensor muscles * * * Thirdly, the horse must, simultaneously with the extension of the hiad leg and that of the vertebral column, draw its pelvis 78 MEANS OF EESTKAINT. to one side. * * * But no one of tliese three elements, in itself, will produce a fracture; they must all concui-." Whatever may be the value of these theories, the fact that at post-mortem examinations fractiires have been discovered, in some cases in the annular portion, and in others in the body, seems to prove that any one of them is equally applicable with another. To prevent these fractures, therefore, becomes the principal object of the surgeon at the critical moment when the animal is thrown. This involves a strict attention to the rules which we have laid down for his guidance in the various steps of the act of casting; and, moreover, to have recourse, as often as possible and as the indications suggest, to the aid of anesthetic agencies, and by no means to ignore the value or neglect the use of the appa- ratus of Bernardot & Buttel. 2d. Fractures of the Hibs. — These fractures are undoubtedly frequent, as the result of heavy falls upon a badly-made bed — too hard or too thin, or perhaps concealing hard substances, as stones or the like. 3d. Fractures of the Pelvic Bones. — There are but few cases on record of this kind of injury, but they are possible, as the re- sult of carelessness in the preparation of the bed or improper casting, or powerful muscular contraction. 4th. Fractures of the Hones of the Extremities. — Though prob- ably less common than those last referred to, these lesions are not unknown in veterinary practice. They occur principally in the diaphyses of bones, or near to, or at the epiphysis, and are often in- complete in their nature. Delafond describes a case of fracture of the femur taking place during the application of the clamps while undergoing the operation of castration ; and another case is recorded of which the trochanter of the femur was the seat. Rey has reported a case of fracture of the cubitus taking place as the animal, when freed from the hobbles, made a violent effort to spring from the bed uj)on which he had been thrown to be fired for a chronic enlargement. These fractures of the extremities may be avoided by careful attention, not only at the time of throwing the patient, but in placing him in position and in properly securing him, and giving him judicious assistance in regaining his feet. 5th. Dislocations. — These accidents are of very rare occur- rence. One case, however, is recorded of a dislocation backwards of the humerus, complicated with fracture of the cubitus. INJURIES TO SOFT TISSUES. 79 (b) Injuries to Soft Tissues. 1st. Laceratio7is of JIuscles mid their Annexes. — These are the result of the distorted positions into which the extremities are forced wMle undergoing operations. They may be discovered immediately, or may be developed a few days after the operation. Inflammation of the olecranean and pectoral muscles, of those of the croup, and of the anterior part of the shoulder have been re- ported. Bouley has seen a rupture of the aponeurosis of the great and of the small oblique muscle of the abdomen, and one rupture of the flexor metatarsi. A case of laceration of the diaphragm is recorded by Bouley, Jr. In one of our own patients, laceration of the olecranean muscles was followed by such severe compHcations, that it l^came necessary to destroy the patient. 2d. JHuptures of the Viscera. — These are of rare occurrence, being generally prevented by the precaution of refraining from throwing the animal, until assured of an empty digestive canal by previous fasting. Accidents, however, have been witnessed by Gohier, who has noticed their occurrence upon the rectum near the anus. This horse had drunk freely of water before being cast. Bouley, Jr., has seen a case of rupture of the diaphragm. Rey has known one of the heart, Schaak one of laceration of the humeral artery, and even the giving way of the vena cava, in a case of a nervous animal upon which means of restraint were being applied to dress a small wound. The patient suddenly fell, and, struggling violently, died ; and at the post-mortem the abdomen was found full of blood, and the vein torn back of the kidneys 3d. Injuries to JVerves. — These are accompanied with loss of power, usually temporary, but sometimes permanent. The posi- tion in which it is sometimes necessary to fix an animal, as in the diagonal, is that in which they are most likely to occur. The symptoms of paralysis which are then manifested, betray them- selves when the animal has just risen from the bed, when, upon being called upon to move, the leg is discovered to be unable to carry its weight, flexing upon its various bony levers, and render- ing locomotion impossible. Sometimes these symptoms are of but short continuance, and disappear vmder the influence of strong stimulating frictions. The leg was, according to the popular phrase, "asleep," because of a temporary arrest and sluggishness of the circulation. But in other cases, the condition is brought 80 »:eans of eestbaint. on by a true lesion of the nerves, the brachial, the lumbar plexus, or some of their branches having undergone some traumatic hurt which may prove more or less refractory to treatment. 4th. Asphyxia. — According to Peuch and Toussaint, this ac- cident may result from the ignorance of assistants, who, in con- trolling the animal and keeping him down on the bed, have com- pressed the nostrils too tightly ; or again it may be caused by the excessive pressure of the throat straps of the halter, or of the rope which encircles the neck when a horse is placed in position for castration. To explain the causes of this accident should be, with an intelligent operator, sufficiently to hint the means of prevent- ing its occurrence. Conclusions. — A review of the matters we have been considering in this chapter may not be out of place, nor unprofitable even at the risk of being, perhaps, a little repetitious. In view of the oc- currence of these accidents, and appreciating the responsibility assumed by the surgeon when about performing an operation upon a more or less valuable animal, he cannot but be conscious of the obligations which impose themselves upon him to take every precaution to avoid them. He should therefore guard against their eventual contingency, by closely inquiring concerning the condition of his patient, and by satisfying himself that every part of the apparatus of restraint is in good order ; should avoid rough treatment and employ anesthesia when possible, and never put an animal in a constrained position for treatment when an operation can be otherwise performed more advantageously and easily and comfortably to his patient, and he should never allow him to re- main in his restrained and compulsory recumbent position longer than is strictly necessary. And above all, he should never under- take an operation without having fully acquainted the owner of the animal of the possibility of accidents. The fact of thus ex- plaining matters to an owner, and of obtaining his intelligent con- sent does not, of course, relieve the surgeon of his responsibility, but rather, on the contrary, confirms and increases it by thus add- ing a new, though an implied pledge to his employer to devote his most conscientious endeavors and exercise his best skill in the matter, in token of his appreciation of the confidence placed in his skill and faithfulness. CHAPTEE n. SURGICAL DIAGNOSIS. The first query to be settled in examining a diseased animal is whether the ailment with which he is attacked is merely a case of disordered function, requiring only the administration of the proper drugs to restore the usual order of things, or a case de- manding the operative skill £ind expert ministrations of the sur- geon, with bistoury and cautery and suture. The decision of this query involves a thorough knowledge of anatomy, and is compara- tively more diSlcvdt, as well as more important, than the mere medical diagnosis of diseases pertaining to internal pathology. Errors in surgical diagnosis are always both more dangerous and more important than those of a mere medical character, inasmuch as they are likely to be more readily exposed, and to involve a greater amount of responsibihty on the part of the surgeon. To insure the certainty of his diagnosis, the surgeon must call iato exercise all his resources of knowledge and experience, and employ all his faculties of observation and discrimination, with such instinimental aid as may serve to facilitate and confirm his conclusion, as to the nature of the cases before him. He must » especially employ all his organs of sense in the investigation. A single sense is sometimes sufficient to diagnosticate the character of some special lesions, but more commonly each sense is an auxihary of the others, and all are complementary to each. In fact, the surgeon is not justified in reaching a conclusion as to the detection of an affection, which is discovered by the sight, or touch, or smell, or hearing, alone, but to escape the possibility of error, he is bound to confirm his discovery by the corroboration of another, or what is still better, of all the others, if possible. In these cases, as in others, the eye is the most valuable and comprehensible of the organs. 1st. Sight. — Visible changes of contour, or color, or other deviations from the usual appearance of tissues, or of regions, are of co\irse first made known through the sight of the eye. De- formities, unless of very minute dimensions, with abnormal 82 SURGICAL DIAGNOSIS. growths, prominent swellings and changes of direction in the bony levers, belong to the same category, and if these are not suf- ficiently distinct or conspicuous, and seem likely to escape the visual observation of the surgeon, a careful measurement may de- cide the point. The eye must also discern the changes occurring in the various visible membranes, as for example, the heightened redness of a congested membrane, and the paleness of an anaemic subject. Again, if there is abnormal motion in a part, as in fractures and dislocations, it is to the eye that the disclosure is first made. This application and study of the use of his eye wiU be very serviceable to the surgeon in the examination of the external sur- face of the body, but when examinations within the organism, or within its cavity, become necessary, however strong a Hght he may have at his disposal, he will be compelled to have recourse for assistance to the speculum, to hold the parts open. There are many forms of this instrument. The speculum oris, for the mouth, has very numerous shapes, some of them very simple, as in Figures 70 and 71, and some com- FlGS. 70 & 71.— Simple Speculum Oris. Fig. 72.— Brogniez Speculum Oris. plicated, as in Fig. 72, the speculum of Brogniez. Green's spec- ulum is an American invention, simple, safe, comfortable to the patient, and of easy manipulation (Fig. 73). Grange's mouth speculum is rather clumsy and heavy (Fig. 74). These instruments are generally employed for solipeds. Placed between the jaws, they open the mouth forcibly, and keep it so as long as they con- tinue in place. Sometimes, however, the mouths of these animals, as well as those of ruminants, can be held open without them, by putting SIGHT. 83 Fig. 74.— Grange's Speculum. the tongue out of one side of the mouth with one hand, while the cheek is pulled out in the opposite direction with the other. This same manipulation may answer for large ruminants, provid- ing the head is kept elevated by an assistant. In s"^dne, a gag (See fig. 58) made of wood, is often used, and the speculum rep- resented in figure 61 answers well for dogs. At other times, however, with these animals, the mouth is kept open by separat- ing the jaws with tapes passed around each, and pulled apart. 84 SURGICAL DIAGNOSIS. Fig. 75. — Reynal's Mouth Reflector. Reynal is the author of an instrument which facilitates the examination by the eye of some jparts of the mouth. It is polished on both surfaces, and acts as a reflector, and, when in- troduced on the inside of the cheek, will help to detect diseased spots on the teeth, which would otherwise escape discovery. The Fig. 76.— Nose Speculum. speculum to dilate the nostrils and examine the nasal cavities, also acts as a reflector, but fails, we think, to fulfill the object, for lack of sufficient dimensions. It is made somewhat on the principal of the vaginal speculum used in human medicine, and acts in the same manner. Fig. 77.— Eye Speculums SIGHT. 85 Fig. 78.— Ophthalmoscope. The speculum to keep the eyehds apart will be found of great assistance in the examination of that organ, so sensitive to the light when in a state of disease, and so constantly kept closed on that account. It is, in fact, this speculum which renders the use of the ophthalmoscope practicable for the examination of the in- ternal structures of the ocular globe. Some of the various patterns of the speculum used in human Fig. 79.— Examination of Dog's Ear. 86 SURGICAL DIAGNOSIS. surgery for the ear, will be found available in the examination of the external auditory canal, especially in dogs. The dilatation of the vagina and the anus is scarcely ever needed in veterinary surgery, and instruments are there- fore not required j nor is the endo- ••*'CS^"::S^::^-s._ scope, so useful in human sur- gery, of any value in veterinary practice from the impossibility of using it upon animals. To realize the value of these optical aids in the examination of cavities, a strong light is indispensable. Sometimes the ordinary solar rays will be sufficient, but at others reflected and concen- trated artificial light will be necessary, as in the use of the oph- thalmoscope to examine the eye, or to detect the conditions of the deep posterior parts of the nasal cavities. (b.) Touch. — The taxis is the surgical sense ^:)ar excellence, and is probably the more valuable and reUable of all the means of investigation possessed by the surgeon, the sight itself not ex- cepted. Nothing else so accurately detects the changes in the proportions, in the consistency, in the elasticity, or even in the nature of tissues, and its discoveries may be made serviceable at every stage of an operation of importance and delicacy. But to attain a reliable certainty in the exercise of this tactical skill, the finger ends must, equally with the eye, be thoroughly educated to perform their functions with accuracy and discrimination. A change in the aspect, form and contour of a region which easily escapes detection by an ordinary observer, will become instantly evident to the well-drilled digital extremities of the ex- perienced operator. The object requiring examination is not always, however, within reach of any portion of the hand, and resort must be had to instrumental aid in the exploration of parts deeply situated, or of fistulous tracts, and for this purpose the j^robe is brought into requisition. It is usually of metallic material, generally silver, or of lead, or may be made of gutta percha or whalebone, or other TOUCH. 87 Fig. 81.— Straight, cvirved Directory— Silver Probe. suitable, flexible substance, and either straight or curved as the S probe. The dii-ector is also a probe, heavier than the ordinary kind, and having a small groove running its length on one side. It is used as a kind of guide to prevent the deviation of the bis- toury from its proper course, and to conduct it to the bottom of a wound. Exploring needles are used with advantage in the detection of the nature of abnormal growths, the small and narrow wound which they make being sufficient to ascertain the nature of the liquid which may be present, without danger of compHcations. The Dieulafoy aspirator affords another means of exploration and discovery of deep-seated parts, inaccessible in the ordinary way. Fig. 82.— Dieulafoy'8 Aspirator. 88 SUPvGICAL DIAGNOSIS. (c) Hearing. — The indications obtained through the media of the sight and the touch may be usefully supplemented, and are often completed by those which address the sense of hearing. The gurgling soiind iu hquid or gaseous tumors, the peculiar bruit in aneurisms, caused by the current of the blood; the con- tact of a stone ia the bladder when touched by the exploring catheter ; the peculiar glou-glou of the entrance of air into a vein ; the characteristic crepitation of fractures, and the whistling of a roaring horse — these, and other signs, convey their information with unmistakable distinctness to the auricular sense. {d) Smell. — The exercise of the olfactory sense in the formation of a surgical diagnosis is more limited than those just con- sidered, and yet there are conditions in which it may be of great importance. The odor, sui generis, of gangrene and of necrosis are promptly detected, and at once recognized, and the existence of other pathological conditions, as of urinary or stercoral fistulous tracts, and certain affections of the feet, are betrayed by the pungent and aggressive appeal to the olfactory organs. (e) Taste. — As free from anything like fastidiousness ia respect to offensive contacts and surroundings, as the surgeon must imavoidably become, he draws a line ; he insists upon a strict monopoly of his gustatory sense for his own internal uses, and only investigates the domestic animals in an alimentary way, when entirely healthy individuals are reduced to b, post-mortem condition by the butcher, and served in the form of beef, mutton and pork, properly cooked. But if the surgeon should desire much valuable aid from the exercise of the physical senses in form- ing his diagnosis, he will commit a serious error if he allows himself to be entirely and exclusively guided by them. Strictly speaking, a direct diagnosis may sometimes be arrived at by a care- ful collation of the results of his researches, but he will often, also, be obliged to modify or go beyond these conclusions, and make an indirect diagnosis besides. There are two ways of making a positive surgical diagnosis : one which maybe caUed the direct, or diagnosis by confirmation ; another known as indirect, or by exclusion. The former is by ulterior investigations, confirming a previous diagnosis made upon the basis of a single and prominent symptom ; the latter by the elimination of all diseases, which, though they may have some TASTE. 89 resemblance to that whicli has been suspected, yet are excluded by the presence of some specific and incompatible symptoms. It is only by carefiil induction and cautious reasoning, that the surgeon can settle the question of his diagnosis, and insure such a true and tangible conclusion, as can only be reached when there is a perfect correspondence between the suggestions derived from the testimony of the physical organs, and the calm deduc- tions of the logical faculty, aided by a disciplined and well fur- nished memory. CHAPTEE III. SURGICAL THERAPEUTICS. This title refers to one of the most extensive and important departments of surgical practice, upon which, indeed, as to its proper administration, depends in a great measure the success of the operative skill, of which it is the supplement and consummation. It comprehends the bandaging and dressing of traumatic iajuries. DEESSINGS. Gourdon says that " a dressing is a mode of local, periodically repeated, treatment, producing a continued action, following or- dinarily the performance of operations, and consisting in the methodical application upon the surface of wotmds of special apparatuses, which complete the effect of the operation, and co- operate in the recovery." The value of the skni and proficiency to be acquired by dili- gent study and observation in this comprehensive and indispen- sable art, need not be stated ; that it is entitled to be so denomin- ated no one acquainted with the niceties of its details and the judgment and experience entering into their performance, need be told. Nor can the dependence of the surgeon, for the good results which he hopes to secure in his department of duty, upon the faithfulness and intelligence of the nurse, who is to co-operate with him in perfecting the healing process, be easUy overrated. An incompetent or unfaithful nurse, may spoil the best work of a good surgeon. To protect a wound from immediate contact of surrounding bodies, to shield it from injurious atmospheric effects, malarious or otherwise; to keep aloof all putrid and virulent mat- ters ; to secure the absorption and neutralization of their morbid products; to control the cicatrizing process in the ulcerated parts ; to apply topical treatment, according to indications, as the curative processes develop ; to produce a mechanical action, such as dilatation or compression, according to the instructions DRESSINGS. 91 of the surgeon, and the indications of the case. Such is a fair, though brief synopsis of the duties of the nui-se, upon whom it devolves to give effect to the rules of surgical therapeutics. A well-applied dressing may become the first step toward assuring the success of an operation, those following it — even when only methodically executed — being mere continuous degrees of the one well begun action. A well-apphed di-essing may sup- ply the defects and amend the errors of an improperly performed operation; and, on the other hand, a bad dressing may jeopardize the success of a well-executed operation by interfering with the process of cicatrization, and in other ways delay the recovery of the patient, and even prevent it entirely, by causing unfavorable complications. The application of all dressings is subject to certain general rules, from which no deviation is allowable. As in every action in life, the first step should be that of preparing all the necessary means and appHances for the work, and the last, before beginning the actual manipulation, should be to ascertain that nothing more remains to be provided, at the risk of a serious interruption and delay, and loss of time in a search for some missing article of necessity. On such a point the merest hint should be sufficient, and, indeed, even a hint should be unnecessary with a practical and thoughtful person; but, unfortunately, all persons are not practical and thoughtful. The next step for the surgeon is to secure for himself and his patient a favorable arrangement in respect to Ught and room. There must be nothing interposed before the eye, or that can limit the free movement of the hand and the arm — a most obvious sug- gestion. Before applying a dressing, the wound should be thoroughly cleansed and freed from blood, pus, the remains of previous dressings, and, in a word, of any foreign or other substances capable of becoming sources of irritation. This is best done with water alone, but its effect is frequently greatly improved by combining with it some of the compounds, such as carboUc acid, sanitas, creoline, etc , which have proved their value as antiseptic agents. It may be applied by carefiilly passing a fine sponge or a ball of oakum over the surface of the wound, or it may be used more freely in larger ablutions. Crusts or scabs, if any, may be removed with the scissors or scraped away with the sjiatula, but 92 SURGICAL THEEAPEUTICS. _ 1 the finger-nails must by no means be used for such a purpose* for the twofold reason that it is both filthy and dangerous. Handle the wound only as much as is necessary; all needless taxis irritates — the inference is obvious. If the wound is deep, injections can be combined with the lotions in cleansing it. With the first dressing, there is probably only blood to wash away, and that should be done thoroughly, not overlooking any portion that may have dried in the hair and on the skin. The essential condition of cleanliness applies not only to the wound, but also to the material used for the dressing, and soiled cloths or bandages, and dirty tow or oakum must be rigorously rejected. And, while insisting on strict cleanliness in the instruments and dressing material, it will hardly be decorous to the surgeon to omit him from the category, and to remind him of the propriety of looking to his own condition, and especially to that of his hands. In all his manipulations it should be a matter of conscience with the surgeon to treat his patient kindly. Eough handling, loud scolding, threatening or jerking, with a restless animal, to punish him for an instinctive and natural attempt to move under the infliction of pain, will not only be of no service, but, on the contrary, wiU increase his fright and render him all the less docile and willing to submit in quietness. In applying the various parts of the dressings, unnecessary pressure should be avoided, especially on soft tissues ; and when it is indicated, it should be applied by slow degrees, and as uni- formly as possible, packing the wound upon its entire surface, and completed only as the dressing is nearly ended. Assistants should be enjoined to observe the same rules. The dressing should be applied, not hastily, but rapidly; not with the idea of saving time, simply with a view to lose none. The fact of avoid- ing any waste of time, by working without needless pause, has, moreover, the excellent effect of curtailing the sufferings of the patient, and sparing him much needless pain. It is always important to watch the effect of the various arti- cles of dressing as they are appHed, in order to be certain that they cause no pain either at the time, or at a later period by their shape, the roughness of their surface, or their unskillful applica- tion ; and above all, that they cause no interference with any of the essential functions of the economy, as the respiration or cir- DRESSINGS. 93 culation. This last especially may be impeded by excessive pres- sure. To avoid this, bandages applied upon one of the extremities of the body should be so placed as to direct the pressure from the periphery toward the center. If apphed in the opposite direction, more or less strangulation might result, causing considerable swelling below the bandage. In fact, all unnecessary or exag- gerated pressure is liable to cause inflammatory swellings, erysip- elous engorgements, or local gangrenes. The maintenance of an equal and regular pressure will obviate all danger of deformities of parts, and when methodically applied upon irregular wounds, wherever needed, will serve to restore or preserve them in the natural contour of the region. Neatness and finish should be studied as much as possible, but not, of course, at the expense of any of the special and essential objects of the dressing. Besides these general rides there are others relating to minute points and touching the various elements, which, as a combined whole, constitute the completed transaction, such as those relating to the topical treatment, to the material used, to the rollers or bands, and to the bandages proper. The medicinal compounds used for topical treatment are either appHed alone or through the medium of other materials. They are of various natures and con- sistencies, from that of the almost impalpable vapor used for spraying, to the liquid forms in the numerous watery solutions, alcohohc tinctures, and oils or liniments, to the hard and other solid compounds in the various astringent, absorbing, stimul- ating or caustic powders, or the soft pharmaceutical mixtures, the cerates, the pomades, the ointments, the plasters, poul- tices, etc. The appUcation of the material used should receive attention from the surgeon. An invariable rule should be to avoid all ir- regularity, roughness and unevenness, and to be careful that the exterior application rests upon a regular and uniform surface. For this reason it should be the order, in applying this material, always to begin by using the smallest portions, increasing gradu- ally to the largest, thus filling first the small infractuosities and making an even surface, to be covered with larger ones and thin pads, then with thicker ones, and finally with those of the widest dimensions, which should bear a margin extending somewhat be- yond the outlines of the wovmd. The entire dressing is to be 94 STJKGICAL THEKAPEUTICS. maintained in position by means of compresses, rollers or band- ages, as the case may require. Eollers are long bands of muslin, linen, or ticking, or broad tapes, whicli are used principally in dressing wounds of the ex- tremities, or of regions liable to much motion. Their length and width vary, according to the requirements of the case. The sur- geon will do well to assure himself of the dimensions of these, and to ascertain that the rollers are of ample length, with some- thing to spare, which excess in length can be cut off. Deficiency in the length of a roller will interfere with a perfect completion of its application. If too wide, it may prove difficult to apply it neatly, while if too narrow it may have a tendency to act like a ligature, and make even pressiire difficult, besides being more liable to slip and become loosened. Rollers are applied either dry or moist. When moist, they become loose in drying, and their action becomes insufficient. Dry rollers ought, therefore, to be preferred. Bands or rollers are prepared in two ways, either by being rolled on one or on both of their extremities, and are therefore called the single or the double roUer. In applying it, the extrem- FiG. 83.— Single and Double Roller Bandage. ity is first folded tightly to make a small cylinder, which is held by its extremities between the thumb and index finger of the left hand, resting by its width between the same fingers of the right ; and while the fingers of the left hand turn the small central cylin- der, the band is rolled upon it to its end. Rolling on both ends is done in the same manner. When half of it is rolled, a pin will secure it and prevent it from becoming slack until the other half is made ready to be used. In rolhng the bands, slight traction should be made at intervals by the thumb of the right hand, while the fingers of the left keep the central cylinder steady — the object of which is to have the roller firm, hard and solid. In large establishments, or even in private practice where great numbers may be required, the use of the small apj^aratus represented in Figure 85 will be found very advantageous, the DRESSINGS. 95 Fig. 84.— Manner of Koliug a Bandage. band being rolled upon the central rod with facility, and when removed having the necessary qualities of a well-rolled bandage. The general manner of applying a roller bandage is very simple. Placing with one hand the end of a single roller, or the middle of a double one, upon the part to be covered, and keeping it steadily in position, the other hand holding the mass of the bandage with Fig. 85.— Bandage Roller. 96 SURGICAL THERAPEUTICS. the roll turned upward, gently draws on it away from the start- ing point, unrolls it, and with it surrounds the entire region in returning to the starting point. This process is continued until the band is exhausted, when it is secured by j)iiis or by strings. Thus applied, it may be laid in a circular manner, when the turns rest exactly upon each other, or in a spiral manner when they overlap each other in part of their width, or in a crossed or figure of eight manner, when the turns cross each other to meet always at a given point. If they are applied upon cylindrical surfaces, the folds generally He smoothly and evenly upon each other as they are successively formed, but if the region is of conical shape or otherwise irregular in form, one of the borders will adapt itself more readily to the parts than the others. Hence the formation of bulging parts or pockets, which render the smooth and proper application of the bandage very difficult, and may interfere with its sohdity. This is avoided by giving to the roller an obUque half twist, which, while it changes the gaping border in its posi- tion, prevents the slackening of the bandage and removes the pocket. This is principally required in the bandaging of the lower part of an extremity (Fig. 86). The application of bands on double rolls is also subject to the Fig. 86.— How to Apply a Bandage. DBESSINGS. 97 rules we have given. The completion of the process by the appli- cation of the final dressings and proper finishing steps can scarce- ly be subjected to rules which could not well be framed to meet the varieties in the features and circumstances of the diversified cases constantly occurring in practice. The only strictly general rule that can be estabhshed, is, that when a bandage is placed on the outside of a dressing, it must always, first of all, be fixed at the points which are the most essential to secure it and maintain it in its proper place. The proper time for the removal or change of a dressing, is a question which depends for an answer upon the consideration of the nature of the wound, the season of the year, the age and con- dition of the patient ; in fact upon all the various circumstances which in the judgment of the surgeon may influence the progress of the cicatrization. On general principles, the first dressing is not to be removed untn the suppui-ative process is thoroughly established, which is towards the fourth or fifth day. But there are cases where special circumstances indicate an earHer or a later removal. For example, if the dressing has been appHed to control the hemorrhage of a divided blood vessel, from twenty-four to thirty-six hoiu-s are generally svifficient to obtain the obHteration of the vessel. Again, while it is justifiable to leave the dressing of a foot, which has been subjected to an operation, for eight, fifteen, twenty, and even twenty-five days without changitig, and especially in these days of antiseptics when so much is possible in the way of com- bating the suppurative process, there are no doubt cases where it must be looked after earHer, as where there is an exhibition of increased pain, instead of the abatement which might be justifi- ably looked for if the operation and the dressing had been properly executed; the increase of pain indicating some compli- cations which early exposxu'e might easily have controlled. There ai'e, however, conditions where the removal of a dressing is ra- dicated in some more than in others, as, for instance, when sup- puration is abundant. In these cases, to prevent the retention of the pus in the wounds, and to diminish the danger of its pres- ence, or of its absorption, or facilitate its escape, drainage tubes must be used, or the dressing changed. The removal of a first dressing usually involves an attention to minute details not subsequently required, the various parts 98 SURGICAL THEEAPEUTICri. which compose it beiag often impregnated with blood and glued together by concreted pus, causing, if removed carelessly, the laceration of tissues, tearing of granulations, hemorrhages, etc. It must especially be ascertained whether adhesions exist between the material of the dressing, and if they are present they must be thoroughly soaked by means of compresses wet with tepid water, or a warm water bath, if the dressing is upon a region which allows it, as, for instance, one of the extremities. When this is done, the various constituents of the dressings may easily be removed, one by one, but care and dehberation will still be necessary. The smaller particles should be removed vnth the forceps, not the fingers. If the location allows it we even prefer to wash these away by irrigation, with a stream of luke-warm water, or by soaking thoroughly in a foot bath. The wound is to be cleaned out carefully, by soaking or 8ox>ping away the pus with fine sponges, avoiding all rubbing upon the granvdations or caus- ing them to bleed. Then studying all the indications, to be dis- covered in the condition of the wound, and avoiding aU unneces- sary manipulations, and attentively removing all causes likely to interfere with the repairing processes, the dressing is to be re- placed with aU the original precautions. As little time as possi- ble, consistent with thoroughness, should be occupied in this process. The wound should be uncovered only as long as necessity requires, the materials for the dressing being aU easily accessible without delay or hindrance, being prepared in advance and carefully inspected. The effects looked for in the application of dressings can be divided into general and special, these varying in their nature, according to the object which the surgeon has in view. The first and principal object is to protect the wound from exposure to the action of the atmosphere, and also against contact with foreign bodies, thus to relieve the pain, diminish the inflammatory irritation, and accelerate the cicatrization. It also prevents the retention, by their absorption of the suppuration and serosity which form on the surface. They also expedite recovery by maintaining the natural warmth of the body in the region. The special effects of dressing, vary according to the special action produced by their application, and these may be considered under several heads. (a) Retentive dressing. — This is designed to keep parts in their RETENTIVE DRESSING. 99 normal condition and situation, and thus aid in their union or con- sohdation, without deformity. It is principally apphed in cases of fractures or dislocations, but finds also its main indication in maintaining in their proper place the medicinal substances which are the active agencies of cure. (b) Uniting dressing. — That which is made with sutures or adhesive plaster, to hold the parts in their proper position, and maintain their perfect co-aptation. (c) The suspensory dressing, which is a variety of the reten- tive dressing, and serves to support organs of soft texture in some parts of the body, such as the testicles, or the mammae, which by their position are exposed to traumatism by their sit- uation, their weight, and by puUing and bruises. Suspensories, is the name given to these special bandages; they are commonly used in diseases of the testicles, and of the udder. {d) Comjyressive dressings. — These are devised to produce more or less active pressure upon a too active granulating sur- face ; to arrest hemorrhage, to change the vitaUty of some tissues of a morbid nature, or to control the projection of abnormal bony growths. (e) The dividing dressing is the opposite to the uniting. It is of common use in cases where too rapid closing of wounds is to be prevented. It is apphcable in infundibuliform surfaces, in deep fistulous tracts, and in wounds which are the seat of foreign elements, pathological or other. It operates by keeping the superficial opening of the wound dilated, by means of tents, sponges, etc. (/') Expidsive dressing. — The object of this dressing is to assist the exit of pus from the surface of wounds. A simple dress- ing, by its absorbing properties, is somewhat of an expulsive na- ture. The presence of a single tent of an absorbing quahty, as small balls, or padding of absorbent cotton; the application of drainage tubes ; all these faciUtate not only the escape of the secretions, but also the discharge of the morbid products. The drainage is obtained by the introduction into the wound of India rubber tubing, of various dimensions, perforated at intervals upon their length, and kept in position by safety pins inserted through them and the skin, at suitable points. These tubes, when extend- ing through the depth of a wound, embracing its whole length, and projecting through a counter opening, as well as through the 100 SURGICAL THERAPEUTICS. Fig. 87.— Safety Pins. natural ones of the wound, form an excellent means for contin- uous irrigation, in the treatment of fistulous withers, compHca- ted poll evil and other diseases. {g) Antisejytic dressing. — Is intended to prevent the entrance of micro-organism into wounds, to neutralize their morbific ef- fect, to check their development, and thus prevent their septic in- fluences from taking effect. The application of the Lister dress- ings, with the care required ia the preparation and application by the surgeon ; of the instruments and materials included in the arsenal of pharmaceutical resources, comprising the antiseptic sprays; the various acids, boracic, carboHc, and salycilic; the alkahne sulphites and hyposulphites; permanganate of potash; solutions of bichloride of mercury and of creoline; antiseptic gauze and absorbent cotton — all these, and more constitute dress- ings essentially germicide, which caimot be too confidently recommended to the attention and adoption of the veterinary siu'geon. The apphcation of the wadding dressing, so highly recom- mended by some, has given, in our hands very satisfactory results, in many cases. Wadding well prepared and properly applied, forms an almost invincible obstacle to the introduction of micro-organisms, and according to Pasteur, by its direct action upon the pus renders fermentation impossible. The instruments necessary for the adjustment of dressings, are generally speaking, numerous and varied. They consist of forceps of all kinds, the ordinary dissecting, the buU-dog, the straight, and the curved dressing forceps; scissors, directors, ANTISEPTIC DRESSING. 101 Fig. 88.— Dissecting Forceps. Fig. 89.— Bull-Dog Forceps. Fig. 92.— Syringe for Dressing. smtulas the S. probe, and others; syringes, and sometimes liters, and also razors, enter mto the list of those generally "'The materials used to form the base of the dressings va^ : charpie, wadding, wool, moss and sponges, are «*^ . f « costLss as respects their commercial value, is probably he reason why they are not more generally adopted m the prlL ot veterilrians. Oakum is the material, par e^elUnce, 102 SURGICAL THERAPEUTICS. for the apj)licatiou of dressings in veterinary surgery, and is even commonly used in human surgery. We are almost tempted to claim for it the distinction of having been especially created for the benefit of wovmded horses, its various and valuable qualities so obviously fitting it for the uses to which it is appropriated in the equine cHnic. It is excellent as a defense against the contact of external bodies, and in preserving a uniform temperature in the parts covered by it. From the sponginess of its consistency it readily soaks and absorbs the fluids which form upon the surface of a wound, while the tar with which it is more or less impregnated confers upon it slight antiseptic properties, which assist in the stimulation, and are in themselves favorable to all the processes of cicatrization. To be of good quality, it must be clean, soft to the touch, and free from any foreign substance. Sometimes it is cut into small portions for use, but more generally in strips, or in such other special shapes as may be required. It is made into balls by spreading out little masses of the fibres, which after being separated from each other, are rolled between the hands, into the required forms and sizes. They are exceedingly convenient in Fig. 93.— Ball of Oakum. constituting the first steps of this application of a dressing. It is also made into ^x^ds or cushions, by stretching the fibres parallel, into any given width and length, and folding them into the simil- itude of a small mattress. This must be soft, and free from lumps, or fragments of wood, and of an even thickness through- Fig. 94.— Pad of Oakum. out. These are made also of various dimensions, the widest and thickest being used to cover the outside of the wound. It is also shaped into dossils, rolls, and tents, or plugs, the adaptation of which remains yet to be considered. BANDAGES. im BANDAGES The catalogue of means and appliances for dressing is by no means exhausted ia those already mentioned. Among them are the various forms of compresses, the rollers, the splints, the plates and the means of drainage, with the various forms of rolled ban- dages, wide bandages and mechanical bandages. (a) Com2')resses. — These are pads made of linen, of various sizes and shapes, and folded to any degree of thickness required, which are sometimes appHed immediately upon the wovmd, but usually upon the oakum. They are not, however, of frequent use in veterinary surgery, except imder special indications. They may be square, long, triangular, shaped like a neck-tie, or like a Maltese cross, either complete or half, double or treble-tailed, and generally patterned and graduated according to the form required 'fe'l'^g'^'Kil Tl!..':'ll.!.!lil:lini'ilil Fig. 95.— Square Compreds. Fig. 96.— Long Compress. Fig. 97.— Triangular Compress. Fig. 98.— Neck-Tie Compress. Fig. 99.— Maltese Cross Complete. Fig. 100.— Half Maltese Cross Complete. Fig. 101.— Double Compress. Fig. 102.— Treble Compress. 104 SUKGICAL THERAPEUTICS. Fig. 104.— Perforated CompresB. Fig. 103.— Graduated Compress- by the case. They are commonly used in their entire thickness, but are sometimes made with a hole in their center, and then receive the name of perforated or fenestrated. (b) Hollers have already occupied our attention. (c) Splints. — These are long, flat, and more or less rigid strips of wood, or other material, designed to be added to other dress- ings, to give them some peculiar form or position, and to consoli- date and strengthen them by increasing their rigidity. They are usually a]3plied upon the extremities or superior j)arts of the body, and are composed not only of wood, but of hard leather, paste- board, tia, gutta-percha, etc., etc., and maintained in position by bands or adhesive mixtures. They must be carefully and accu- rately appHed in order to avoid chafing or excoriating the skin, and are often padded, and their borders made especially smooth and uniform. (d) Plates. — These are small pieces of metal or wood, ueed pruicij)ally in the surgery of the foot, to keep ia place dressings of the plantar region, which require more or less pressure upon V 7 Fig. 105.— Plates on Shoes. BANDAGES. 105 their surfaces. They consist of separate parts or sections, repre- senting together the entire surface of the sole, one section sliding on each side, between the foot and shoe, and are kept in place by a third and narrower section, introduced transversely between them and the shoe, towards the heel. It is important to ascertain, be- fore applying them, that sufficient room exists between the sole and the shoe, and also that the wall is not in such close contact with the shoe at the heels as to prevent the introduction of the cross pieces. (e) Means of Drainage. — The conduit most commonly used is a vulcanized india-rubber tube, which is introduced into wounds to facilitate the escape of purulent and other discharges, and to keep them in a cleanly state. They are of various dimensions, as to the length and diameter, to accommodate those of the purulent cavity, and are perforated at the side throughout their length, in order to collect and receive all the impurities that may be present. Instead of tubes, long tents of oakum are sometimes introduced into a wound, for the piu-pose of absorbing the impurities, and to serve as a means of di'ainage also. {/) Holler Bandages. — These are the simplest of bandages. They are applied with one or several rollers. We have already mentioned their division into cii'pular, spiral, figure 8, etc. (f/) Wide Bandages are made of broad, thin pieces of linen, ticking or canvas in various forms, to adapt themselves to any part of the body where they may be needed. They are sometimes folded into pads or cushions, and employed as a means of applying moisture. Those invented by Dr. Berns (Fig. 106) for this purpose may be used with advantage. They are kept in place by tapes or ribbons, which must be arranged and fastened about the body according to the judgment and ingenuity of the surgeon. The number of wide bandages is indefinite, and, according to Bourgelat, twenty-seven species can be classified and enumerated. He would prove himself, however, but an indifi'erent practitioner who should find himself unable, upon occasion, to improve the catalogue by adding new devices to meet new i-equii-ements. In examining some of the principal varieties of the wide ban- dage, we shall borrow from the excellent work of Peuch and Toussaint. Our reference will -be to Ist. Simple Frontal. — This is a piece of cloth covering the greater part of the forehead and the summit of the head or poll, 106 SUBGICAL THEKAPEUTICS. Fig 106 -Berns Moistened Pads with a fold superiorly to receive the forelock or toupet, and se- cured by four bands. The lower two have either a small opening or loop, which the upper two pass before extending down below the throat, to cross each other in the form of an X, and drawn upwards in the lateral faces of the head to the poll, where they are held (Figs. 107, 108). 2d. Compound Frontal. — This is shaped like the former, but extends further down on the face. It has six bands, the middle ones having also loops at their free extremity, as in the preceding, the upper ones being also secured in the same manner, the lower ones crossing each other under the jaws, and also carried upward to pass through the loops of the middle bands, to be either tied on the i)oll, or drawn downwards and tied in the maxillary space (Figs. 109, 110). BANDAGES. 107 Fig. 107 —Simple Frontal (full view) Fig. 108.— Simple Frontal (side view). Fig. 109.— Compound Frontal (full view). Fig. 110.— Compound Frontal (side view). 3d. Monocular or Simple Bandage for the Eye. This is an oblong square, notched at the angles, corresponding to the ear of the same side, and provided with two transversal folds, to adapt itself to the convexity of the orbit. It is secured by five bands. The upper three are attached to the throat-strap of the halter or bridle, the lower two to the lower part of the same strap (Figs. Ill, 112). 4th. Binocular or Double Bandage for the Eye. — This is formed of a large piece of cloth, notched on its two superior an- gles to receive the ears, and secured with eight strings or straps. A longitudinal fold in the upper, and another in the lower part 108 SUKGICAL THERAPEUTICS. Fig. 111.— Monocular Band (full view). Pig. 112.— Monocular Band (side view). of the bandage, facilitate its adaptation to the surfaces it is to cover (Figs. 113, 114). 5th. Bandage for the Maxillary Region. — This is of triangular shape, and is formed either of sheepskin or of two layers of cloth, between which a pad of oakum is sewed. It is furnished with four straps. When appHed, the base of the triangle is turned backward, and the apex rests in the angle of the maxillary space. The two upper straps, attached at each angle of the base of the triangle, pass upward at the side of the parotids, and are tied on the summit of the head, the two lower ones attached at the apex of the triangle, passing over the nose to be tied at that point. "We have often obtained a better adaptation of this bandage by utiliz- ing the cheek or the nose-piece of the halter 6th. Ear Bandage (Figs. 115, 116). — This is made of two trian- gular pieces of cloth, united at their base on the summit of the head, each forming a kind of inverted pocket, with which the ears are covered. It is secured by six bands, the two superior having loops through which the middle ones pass, these crossing each other under the throat and extending upward to be tied on the poll. The lower bands cross each other on the forehead and pass under the head, to retiu'n on the lower part of the face where they are secured. Another way to apply a dressing on the ear to envel- ope it properly is to use a thin bandage, which, after it has envel- oped the ear, is passed around the head on each side, and secured under the throat (Figs. 117, 118). When supported by a tightly BANDAGES. 109 FIG. 113.— Binocular Band (full view). Fig. 114. — Binocular Band (side view). Fig. 115.— Ear Bandage (fuU view). Fig. 116.— Ear Bandage (side view). fitting halter this bandage maintains its position in a manner quite satisfactory. To this kind of bandage can be added the one used for dogs imder the name of co^?, which is made of soft cloth or fine cord net. The caps recommended by the Germans answer the purpose also very well (Figs. 120, 121). 7th. Bandage for the Parotids or Throat. — This bandage is long and square, and is notched in the middle of the two borders to secure the inferior border of the neck, and adapt itself to the maxillary space. It covers the parotid, and is secured by four 110 SUKGICAL THERAPEUTICS. Fig. 117.— Bandage for the Ears (side view). Fig. 118.— Bandage for the Ears (full view), PiG. 122 —Parotids Band. bands, two attaclied in front of the forehead, the others on the poll. This bandage is often combined with that of the maxillary region, and made in a single piece (Fig. 122). 8th. bandage for the Su2)erior Border of the Neck. — This bandage is a long piece of cloth placed upon the dorsal border and lateral faces of the neck, with a prolongation in front, passing BANDAGES. Ill Fig. 119.— Bandage for the Ears, A. Bandage for the MammsB, B. Fig. 121. — German Bandage for the Ears. Fig. 131.— Another German Bandage lor the Ears. 112 SUKGICAL THERAPEUTICS. Fig. 123.— Bandage for Superior Border of tbe Neck. between the ears and down to tlie forehead. Eight bands secure it. The two inferior bands (b) have loops through which the bands pass to cross each other under the maxillary bones, and extend upward on each side of the head to be tied over the poll. The bands (d) are fixed on the breast-band of a Dutch collar, and (/) is attached to the surcingle (Fig. 123). 9th. Bandage for the Anterior and Lateral Parts of the Neck. — This bandage is octagonal, with a band at each angle. The anterior are tied on the forehead or on the throat-strap of the Fig. 124.— Bandage for the Anterior and Lateral Parts of the Neck. BANDAGES. 113 halter, the middle ones over the dorsal border of the neck; the posterior cross each other over the withers, and are secured to the surcingle, as are also the two lower (Fig. 124). 10th. Bandage for the Withers. — This is square, truncated at its posterior angles, and having in the middle of its anterior and posterior border a fold to adapt it to the height of the withers. There are five bands. The anterior are secured forward, above Fig. 125.— Bandage for the Withers. the breast, the posterior are passed around the thorax and tied together, the other sewed on the middle of the posterior border extending along the spine and attached to the crupper. Fig. 126.— Bandage for the Back. 114 SURGICAL THERAPEUTICS. llth. Bandage for the Back. — This bandage is composed of a long, square piece, truncated on its two posterior angles, and has six bands, one at each angle. The two in front are tied to- gether after passing around the chest, the middle ones after sur- rounding the abdomen toward the umbilical region and the pos- terior are united after forming a kind of crupper in passing under the tail (Fig. 126). 12th. Bandage for the Loins and Group. — This band- age is of a form similar to the preceding, and of sufficient size to cover the croup posteriorly. It is truncated on both posterior angles, and each border, except the anterior, has folds to allow the bands to adapt itself to the rotundity of the region. At each Fig. 127.— Bandage for the Loins and Croup. angle is a band, the posterior passing around the abdomen, and carried backward and upward to be tied over the loins. The pos- terior then turns from without inwards, over the round of the hip, crossing obHquely the internal face of the thigh forward to the stifle, and passing over the external face of the thigh to the mid- dle bands on a level with the hip-joint, where they are tied. Two extra bands may be attached to the front border and tied to the surcingle, if thought necessary, to prevent the bandage from slip- ping backwards. 13th. Bandage for the Hip (Figs. 128, 129).— This is formed of a piece of cloth the length exceeding the breadth by one-half, or in the proportion of three to two, and so enveloping the hip and part of the croup that the inner border runs along the peri- nseum, and the outer on the external face of the thigh and leg. BANDAGES. 115 —Jl Fig. 128.— Bandage for the Hip. Fig. 129.— The same separate. This border (/, d) forms a fold about four inches wide at its base, and the inferior {d, e, c) has two which, like the first, form an exact adaptation to the parts. Eight bands belong to this band- age — three upon the posterior border (a, a, a) at its superior part, which are fixed to the cnipper, the superior border having one {b) long enough to reach to the sui-cingle, and the inferior border having three {d, e, c). The bands d and e pass around the leg and cross each other at g, the band d being fixed to the crupper, while e extends to the surcingle forward. Band e crosses obliquely to the inner face of the thigh, passes upward along the 116 SURGICAL THEKAPEUTICS. flank, and is tied to the surcingle. The band /is fixed upon e, as seen in the illustration, Fig. 128 at h. l-ith. Bandage for the Inguinal Region and Perinmum. — This is applied to the testicles or to the marnmse. It is a long, triangular bandage, with its base placed forward, and is provided Fig. 130.— Bandage for tho Inguinal Region and Perineum. Pig. 131.— Ths same separate. with four bands, one at each angle of the base. These are passed around the flanks to be fixed on the loins, the two posterior on the apex of the triangle to draw along the perineum, and passed over, and on each side of the tail, crossing each other to join the first one, to which they are tied. 15th. Bandage for the Abdomen. — This should be oblong in shape, its length double its breadth, and having folds on each of its long sides to adapt it to the convexity of the body. The bands are six in number, two of which are fixed on the loins, two on the back, and two over the withers. A seventh is sometimes added, which passes around the base of the neck and prevents the band- age from slipping backwards (Fig. 132). 16th. Bandage for the Chest. — This is square, with a prolon- gation in front to go between the fore legs, and which is notched on the front to adapt itself to the chest behind the elbows. The bands are six, one at each angle, and two on the prolongation in front. These are fixed in pairs, over the back, the loins and the withers (Fig. 133). BANDAGES Fig. 132— Bandage for the Abdomen. Fig. 134 — Bandage for the Breast. 118 SUBGICAL THERAPEUTICS. 17th. Bandage^ for the Breast. — This resembles the preced- ing, except that the narrow prolongation is attached under the chest to the surcingle, or, surrounding the forearm, goes to the withers. The others are tied over the withers and on the sides of the chest to the surcingle (Fig. 134). 18th. Bandage for the Shoidder. — This is cut in the form of a trapezium, to cover the shoulder and the arm. It is applied some- what obHquely, and has on its front borders (Fig. 135) folds to adapt it to the convexity of the anterior part of the arm. Of its Fig. 135.— Bandage for the Shoulder. Fig. 136.— Same, isolated. BANDAGES. 119 seven bands, c, c are fixed on the withers at the origin of the neck, ef, passing first around the forearm and joining c c, as it passes on the opposite side^ and d, g, h are secured to the surcingle. 19th. Bandage for the Shoulder Joint. — This bandage is square and truncated on its superior angle, and is provided with several folds to adapt it to the convexity of the shoulder. The Fig. 137.— Bandage for th" Shoulder JoiBt Proper. bands are six, three anterior and thi-ee posterior. The first two are appHed around the neck, the third on a ring at the surcingle ; the other three also going to the surcingle, either directly or in passing around the inside of the forearm. 20th. Bandage for the JElhov). — This bandage is of an ir- regular shape, with folds on its lateral and lower borders, to adapt Fig. 138.— Bandage for the Elhow. 120 SUKGICAL THEEAPEUTICS. Fig. 139.— Same, isolated. it accurately to the point of the elbow. Five bands serve to con- fine it, / going directly to the withers where it is tied with i, pre- viously passed under and around the thorax on the opposite side, g and h are secured to the breast-band of a Dutch collar, k jjasses around the forearm on the inside, from behind forward, and passes in front of the breast to be also secured to the Dutch coUar. 21st. Bandage for the Forearm. — This is of an irregular tri- angular sharp, with the apex truncated, and the base notched to accommodate itself to the axilla and the fold of the elbow. When applied, the apex of the triangular, which forms a short border, is turned downward and the base upward in the axilla. Two bands sewed to each angle of the base are fixed to the breast-band Fig. 140.— Bandage for the Forearm. BANDAGES. 121 of the Dutch collar, and the borders are secured by little tapes on the outside of the forearm. Sometimes these borders are fastened together by laces inserted obliquely. 22d. Bandage for the Knee. — This is square, notched on its superior border and in the center, both of which are provided with a small piece to form a gusset, in which the bony projections of the knee are secured. A double, ordinary band, or, what is better, an elastic strap attaches it to the breast-band, while smaller tapes serve to tie it to the back of the knee. Fig. 141 — Bandage for the Knee. mm I Fig. 142.— Bandage for the Stifle. 23d. Bandage for the Stifle. — This is of a triangular figure, the base of which should be four times longer than its height. It has three bands, one at each angle. That of the superior angle passes along the flank, and is attached to the crupper strap at the loins ; that of the inferior angle twists forward and inward on the thigh, and connects with the crupjDcr at the base of the tail, while the third band turns around the crupper, crosses the internal face of the thigh from behind forward, j)asses in front of the stifle, and terminates backAvard at the same point with the preceding band, after twisting around that of the superior angle. 122 SURGICAL THERAPEUTICS. 24th. Leg Bandage. — This is the comjDhcated device repre- sented in Figs. 143 and 144. It has four bands on its superior border, (Fig. 144 «, J, c, d) and the lateral borders have five or six tapes. The bandage has three gussets, two of which, c Pig. 143.— for the Leg Applied. and d, are on the superior border, and one, ?*, on the inferior, and the two lateral borders have each one a fold. To put the bandage in place, the band d is passed along the flank upward and tied to the crupper strap, c, passing from within outward on the inside Fig. 144.— The same, isolated. BANDAGES. 123 of the thigh, to be fixed on the round of the crupper. A and b cross each other at the lower part of the leg, a Uttle above the tendo-Achilles, in order to allow a to pass from the inside to the outside of the leg so as to become attached to the surcingle, while b is seciu'ed to the round of the crupper. The small tapes are, of course, tied together in couples. 25th. Bandage for the Hock and Cannon. — This requires a piece of cloth of sufficient dimensions to completely surround the hock and cannon down to the fetlock. Its superior border is Pig. 145.— Bandage for the Hock and Cannon, applied. Fig. 146.— The same, isolated. notched for the fold of the hock, and a gusset is made in its lower extremity for the fetlock. Four straps j)roceed from its superior border to be seciu'ed to the bandage of the leg, and the ends of the small tapes of its lateral borders are tied together in pairs in front of the leg. {g) Mechanical Bandages. — This is the distinctive name of a class of dressings which are not only a passive means of protec- tion to the parts upon which they are apphed, but from which also proceeds a direct or positive action, by co-operating in the recovery of lesions, if indeed it is not the true operating cause which brings it about. Rollers and wide bandages some- 124 STJKGICAL THERAPEUTICS. times act as mechanical bandages. But the name is more par- ticularly appHcable to certain more or less complicated apparatus- es, whose special mechanical action has the effect of producing some defined therapeutical result. The metallic plate used ia the reduction of some forms of hernia ; the metallic spring apparatus used in applying pressure upon special regions, as, in orthopedic surgery, or in the reduction of fractures or dislocations, like those invented by Bourgelat, Brogniez, Defays, and others, are of this class, inasmuch as all of these possess the constituent properties which are understood to characterize the agencies belonging to the category of mechanical bandages. These will be subjects for our consideration when we treat of the various conditions in which they are iudicated. CHAPTER IV. ELEMENTARY OPERATIONS. Under this term are understood those of a simple nature, as perhaps an incision or puncture, or the insertion of sutures, and other impHcated manipulations, but which form the foundation and belong to the operative generalities of the domain of major surgery. They will be treated under the two principal heads of division or dieresis, and reunion or synthesis. DIVISION. This is a very common sui-gical step, of which the object is the separation of tissues from each other. Gourdon has recog- nized six principal modes by which to divide tissues, viz.: by in- cision, dissection, puncture, resection, ligature and cauterization. Varying, somewhat, from this view, and considering resection as an operation specially appropriate to bony structures, and liga- ture as adapted to the cellular tissues, and classifying cauteriza- tion as principally a means of puncture, we prefer, with Peuch and Toussaint, to reduce the consideration of these modes of division to three, viz.: incision, dissection and puncture. A. — Incisions. Any methodic division of soft tissues made with a sharp instrument is an incision. The basis of the majority of surgical operations, their purpose is to allow the escape of the contained fluid from a cavity, to enlarge the size of a wound, to make counter openings, to extract foreign bodies, to remove pathologi- cal growths, to destroy abnormal adhesions, to expose tissues to be operated upon or tumors to be removed, to facilitate the re- duction of displaced organs, etc., etc. The bistoiiry, the scalpel, the sage knife and the scissors are the cutting instruments most commonly used for making incisions. Sometimes, however, the amputation knife, the tenotome, the hemiotome, with lancets, or 126 ELEMENTARY OPERATIONS. even drawing knives, take their place. Drawing knives, however, are better adapted to excise the horny, or other similar hard struc- tures, than to cut upon soft tissues. Fig. 147.— Straight Bistoury. Fig. 148.— Convex Bistoury. Fig. 149.— Concave Bistoury. Fig. 150.— Blunt Bistoury. Fig. 151.— Bistoury Cach6 (Castrating Knife for Females). In form, the bistoury is either straight, convex or concave, and usually is pointed, but the use of blunt or guarded instru- ments is often indicated. The Ustoury cache is also employed in some special operations. A bistoury is generally mounted with a single blade, though sometimes several blades are moimted together on one handle, and can be closed upon it in the manner of an ordinary pocket knife. Bat when strict antiseptic INCISIONS. 127 rules are observed in the operations, the blade is held firmly on the handle, and cannot be closed. Sage knives, which are much used in operations upon the foot, are but convex bistouries, single or double, curved upon their length, and, according to the disposition of the cutting edge, are called right, or left, or double. The blade is generally firmly Fig. 152.— Right, Left and Double Sage Knives. riveted in the handle, to render it more soUd and better adapted to the incision of the comparatively harder tissues . When made to close as an ordinary pocket knife they are less solid, and more difficult to keep in good condition. The scissors vary also in shaj)e, and are sometimes straight, sometimes cui'ved, and with either blunt or pointed ends. Be- sides these cutting instruments, directors are often used as guides to caiTy the knife in the desii'ed direction, and obviate errors and accidents in operating. The bistoury is held in different 128 ELEMENTARY OPERATIONS. Fig. 153.— Various Shapes of Scissors. positions, according to circumstances, as we shall proceed to point out and classify. 1st. Held as a writing pen. — That is, with the handle resting on the back of the hand, the thumb, index and medius finger on each side of the blade, the other two fingers resting on the skin. Figs. 154 and 155.— Bistoury held as a Writing Pen. In this position the edge of the blade may be turned either down- ward or upward. The division mentioned by Gourdon, with the fingers extended or flexed upon the blade is scarcely, and at best but a variety. 2d. The instrument may be held as the hoto of a violin, or the thumb on one side of the articulation of the blade, with the handle and aU the fingers on the opposite side, the index on the back of the blade, the medius on the articulation opposite the thumb and the other two fingers on the side of the handle. None of the fingers must be allowed to divert the instrument from being carried horizontally upon the tissues. In this jDOsition the edge of the blade may be turned either downward or upward. INCISIONS. 129 Figs. 156, 157, 157a.— BiBtoury held as a Bow of a Violin, 3d. The bistoury can be held as a table knife. The thumb and the medius being placed on opposite sides, at the junction of the blade and the handle, the index resting upon the back of the Figs. 158, 159.— Bistoury held as a Tatole Knife. blade, the other fingers holding the handle in the hollow of the hand. As in the preceding positions, the edges of the blade may be either turned downward or upward. Whatever position may be given to the instrument, it is to be held firmly, and with a steady hand. Sage knives are generally held by grasping the handle full in the hand, or, as when holding a bistoury as a table knife, sometimes with one hand only, and at others with both, according to the indications and the amount of firmness and steadiness required. The manner of holding scissors is already known. The only variation likely to be found 130 ELEMENTARY OPERATIONS. Fig. 160.— Sage Knife held with One Hand, Pig. 161.— Sage Knife held with Two Hands. needful, is that in some cases it is handier to grasp them from above and in others from below. There are some general rules which are important to observe in performing the simplest operation. These relate to the condi- tion of the instrument, to the preparation of the parts, and to the direction and dimensions of the incision. The condition of the instrument must be such that the soft tissues may be divided with but little pressure. It must cut and not tear. Therefore, besides their state of thorough cleanliness, they must be very sharp and their edge entirely smooth and free of indentation, which would cause them to act as a saw and pro- duce an irregular and ragged incision, more painful to the patient, and more difficult to heal. It has been recommended to dip them before using in oil or warm water, but these precautions can be dispensed with. The region upon which the incision is to be made must be thoroughly cleaned, the hairs being chpped short, and sometimes even shaved. In these days of antisepsy, it is proper to soak it well, after it is washed, with some antiseptic solution. To make a clean incision, the skin must be well stretched with the hands, the insti-ument firmly held, and the division made by a steady move- INCISIONS. 131 ment, to avoid the possibility of extending the incision beyond the necessary limits. The dii'ection and size of incisions require careful consider- ation. They must run as nearly parallel with the direction of the muscular fibres and the large blood vessels and nerves of the region as the condition of the part vnU. permit. Their direction should also correspond to that of the long axis of the part or tumor undergoing operation, and in such a manner that the retraction of the skin will not tend to separate the borders of the wound. Sometimes, according to the unavoid- able natural motions occurring in a region, the normal folds of the skin should be considered. A vertical incision is always pre- ferable, as more readily allowing the escape of liquids, pus or otherwise, which may have accumulated. As much as possible, and generally, incisions should be made with a single stroke, and of the full length and depth required by the further steps of the operation. Besides diminishing the suf- fering of the animal, such an incision will greatly facilitate all the subsequent manipulations of the operator. Incisions are made by four principal methods : first from without inwards; second, from within outwards; third by sub- cutaneous division; and fourth by the sHcing, scraping or shaving method. In the first two modes the instrument may be turned in five directions. (a) Towards the operator, by beginning at the farthest point aud moving the instrument in the direction of his own person. (b) From the operator, by reversing the former movement. (c) From left to right and transversely, the instrument being held with the right hand. {d) From right to left, or in the opposite direction, with the instrument in the left hand. (e) From above doionwards, in a vertical or slightly obHque direction. Incisions from left to right and from above downwards are the most convenient, and for this reason the surgeon practices them as much as possible. 1st. Iiicisions from without inwards. — These incisions are carried from the siu-face of the skin towards the deep structures underneath. They may be made with any kind of bistoury, but the convex is to be preferred. 132 ELEMENTARY OPEEATIONS. The skin should be well stretched by various movements of the hand, or of the operator, or his assistants, and held tense and smooth, unless it is already sufficiently expanded by the effect of the existiag lesion underneath it. Then the operator, holding the instrument in the first or third position, carries the instrument, with the edges and the point turned down- ward, to the spot on the surface to be divided, and penetrating thi'ough the skin to the depth desired, completes the incision to its proper length. This mode of incising the skin answers for the majority of cases, but there are others when the skin has to be divided care- fully and by layers. Incisions are then made with the convex bistoury, held in either position with its edge downward, carried perpendicularly over the skin and often by repeated light strokes. These two procediu'es answer when the part to be operated upon offers a certain soHdity. Otherwise the incision can be made in a third manner, viz.: by taking hold of a fold of the skin, held at one end by an assistant, at the other by the operator, and completing it by a transverse section through the fold, made from the apex to the base. The objection to this mode of dividing is that the incision can never be thoroughly limited. 2d. Incisions from within outwards. — In contrast with those already considered, these incisions are made from the deep parts toward the superficial, and through the thickness of the skin. The Straight Bistoury is here the preferable instrument, either alone or assisted by a guide or conductor, which may be the grooved probe, the director, or the finger of the surgeon. Either with or without, these incisions can be executed in various ways. Without the Director. — With the bistoury held as a writing jDen, with the blade turned upward, first the point of the instru- ment, and then the entire blade is thrust perpendicularly through the tissues ; then lowering the handle of the instrument untU it forms with the skin an angle of forty-five degrees, the instru- ment is moved in an obHque direction in such a way as to stretch and divide the skin, until at the end of the incision the bistourj' is brought back to a perpendicular direction to complete the incis- ion in a neat manner. This incision can be made toward or from the operator, according to the case. It will facilitate the action of the instrument if the skin back of the hand that holds it is stretched with the free hand of the operator. INCISIONS. 133 Another manner of incision from' within outward is to make a fold of the skin, as ab-eady described, and by pushing the straight bistoury through its base, and turning the edge, completing it by a single stroke upward to the summit. When an incision already existing must be enlarged, the bistoury, held in the second posi- tion, is introduced flatwise under the skin as far as is necessary ; then turned to bring the edge upward and pushing the point through the skin by drawing the instrument outward, the flap of skin between the two openings is divided at one stroke. A fourth procedure is known as the incision with flaps. It is principally used in amputations. With the left hand the surgeon grasps a fold of skin, pushes the bistoury held in the first position, but flatwise, through its base, and in drawing it out obliquely by a sawing motion cuts out a semi-circular flap of the required dimensions. With the Director or Guide. — Incisions in this mode are made to remove compressions caused by strictures, or to establish a free exist to jDus by a counter opening. Either the finger or the grooved probe or the director may be used as a guide to the in- strument. In all cases there must already exist a natiu-al or acci- dental oj)ening to allow the introduction of the dii*ector. Several modes of procedure are employed according to conditions and ob- jects in view. In one, the director being introduced into the tract to be enlarged, as far as the point where the incision must end, the bistoury, held in the first or second position, mth the edge turned upward, is made to slide into the groove of the director, forming with it an acute angle, and pushed in its whole length, di\'iding the tissues until it reaches the end of the groove, when it is withdrawn in the perpendicular position. A second mode is to carry the bistoury flatwise alongside the director, and when reaching its end to turn the instrument with the edge upward, first thrusting the point through the tissues and tegument, and completing the incision by withdrawing the bistoury outward and toward the operator. In a third procedure, which is that of mak- ing counter openings, the probe or director is introduced into the wound, and at its deep end, to push toward the skin until it raises it from the inside or can be felt through it ; an incision from with- out inward is then made at that point, and the director being ex- posed, the bistoury is engaged in its groove and pushed alongside, dividing the tissues at will in length and in depth, and establishing 134 ELEMENTAEY OPEKATION8. a broad communication between the original opening and the one just formed. By using the sharp end of an S probe, passing it alongside the director previously engaged, and pushing it through the side, the making of the incision from without inward may be avoided, as described above, and the groove of the S probe may be used as that of an ordinary director. Sometimes, however, when the original opening allows it, the finser is introduced into it and used as a conductor. In this case, a blunt bistoury is preferable, as less dangerous to the operator than the straight instrument, or the curved form may be used. This may be made to slide with the back of its blade, or again flatwise, along the palmar face of the finger untH the bottom of the wound has been reached, and then turning the knife, the tis- sues are divided by carrying the bistoury either toward or from Fig. 162.— Using the Finger as a Director. the operator. This procedure is more appHcable when the fistu- lous head is not deep, but it is preferable to the use of the ordin- ary du-ector as being a much better instrument of diagnosis, and safer as a director of the bistoury. 3d. Subcutaneous Incisions. — The usefulness of this mode of dividing tissues is best demonstrated by its apj)lication to cases of tenotomy and myotomy, or the puncture preceding the injec- tion of tincture of iodine according to some methods. It requires special instruments, made with narrow blades or with fine trocars, which, when introduced through the skin, leave a very small open- ing, the division being made under the ligaments, with special care to avoid its division beyond the point where the instrument has been introduced. Suppuration seldom follows this operation if it has been properly performed, and, accordingly, the cicatrization is very rapid ; the great advantage obtained by this mode of incision cannot be overlooked. INCISIONS. 135 4tli. Incisions by Slices — Scraping or Shaving Incisions. — These incisions are made by di^dding the tissues in successive lay- ers. Three varieties of operation are practiced, differing accord- ing to the density of the tissues acted upon. In the first, which is apphcable to hard structures, the bistoury, or, preferably, the sage knife is required. The instrument is held full in the hand, as a table knife, or, again, as the bow of a violin, and is passed flatwise over the siu*face of the tissues, and layers of various thicknesses removed from it ; and sometimes the tissues are sufficiently hard to require the strength of both hands for the management of the instrument. Fig. 163.— Sharp Tenaculum. In a second mode, apphcable to soft tissues, a convex bistoury and a pair of forceps or a sharp tenaculum are necessary. Rais- ing with either of these a thin layer of the tissue to be divided, the bistoury is carried sHghtly flatwise over the surface and a piece of it is cut, scraped, or shaved off, the operation being repeated untn the desired depth has been reached. A third mode is applied in cases of growths which are to be cut oflf at their base. To do this, the growth is raised as much as possible, by means of the forceps or tenaculum, and the amputation is accomphshed with a few sawing movements of the instrument. The forms which incisions may receive are of two principal kinds — the simple and the compound. Simple incisions are those which are generally made with one stroke of the bistoury, and generally from without inward, and are either straight or curved. The straight, or simple, are indicated for the exposure of regions, the opening of abscesses, etc., etc. They are not as apphcable to the removal of tumors, especially of those which have large bases. The curved incisions vary in their circular shape, and differ also from the straight in the modus operandi, as they require a stretching of the skin to be made in various directions, as that of the bistoury is changed over the cutaneous surface. Compound incisions are formed by the union of several simple incisions, their number varying much, but they may be reduced 136 ELEMENTAEY OPERATIONS. to the following kinds: the T and V shaped, the crucial, the eUiptic, and the semi-lunar. The branches of these compound in- cisions are made in the same manner as for the simple kind ; when two incisions are to meet at a given point, the second one must be made, not to begin, but to terminate at that point ; when two incisions are to unite, one above the other, the lower one is to be made first, to avoid the flow of blood from the upper, which would cover and conceal it ; and when two incisions are to meet at their extremities, it is proper that the ends of the second incision should start a short distance beyond the commencing point of the first, and terminate with a similar space from the end of the first in- cision. In other words, the junction of the extremities of the two incisions must never be by a perfect acute angle. The angle must always have a shght prolongation formed at one extremity, by the extension of one, and at the other by that of the other incision. These rules are not absolute, but may be changed as circumstances may require. In the T-shaped incision, a straight cut is carried perpendicu- larly upon the middle of another. In the V-shaped, there are two straight incisions meeting at an acute angle by one of their extremities, this angle, as we have just said, having a small pro- longation on one of its lines at their junction. The V-shaped in- cision may open in every direction. Sometimes the two incisions are made to meet at a right angle, to form the L-shaped incision. In the crucial incision, two straight cuts are made to meet at their middle, usually at a right, sometimes at an acute angle, forming an X-shaped incision. This is made in three steps, first, a simj)le straight cut ; second, the first part of the second incision as in the T-shaped form, and third, the second part of the second incision ending, not beginning, at the point of junction of the in- cision made in the first two steps, and in such a manner as to be the continuation of the incision made on the second step. This incision may also be made in two cuts, when the skin is hard and adherent to the deeper tissues, by making the second incision with one stroke of the knife, passing at the middle of the first. The elliptic incision is made with two curved cuts, so united at their extremities as to leave between them an elliptical space. The semi lunar or crescentic incision is formed by two curved ones, the circumferences of which are turned in the same direction, leaving between them a form like that of the new moon. INCISIONS. 137 Fig. 164.— T-shape Incision. Fig. 165.— V-Bhape Incision. Fig. 166.— Crucial Incision. Fig. 167.— Semi-Lunar Incision. Fig. 168.— ]j-shape Incision. Fig. 169.— X-shape Incision. Fig. 170.— Elliptic Incision. B. — Dissections. Dissection is the separation of the cellular tissue from the various parts to which it is united. The scalpel, the bistoury and the scissors are among the necessary instruments, sometimes replaced or assisted by the fingers or a strong director. With the scalpel, or the bistoury, the handle is also utilized, and frequently the blunt extremity of the scissors, while again in some cases the cellular connections are separated with the fingers or the blunt end of a director. To these instruments are added forceps, either the common dissecting, or the bull-dog form. Three procedures are involved, viz.: the free dissection, the limited, and the dissee tion by slices or shavings. 138 ELEMENTAKY OPEKATIONS. Fig. 171.— Dissecting Forceps. Fig. 172.— Bull-Dog Forceps. (a) Free dissection is that of a flap of skin from the tissues beneath, to which it is only sUghtly adherent. Holding the skin with the fingers, or the forceps, with one hand, and having the bistoury or scalpel in the other, the skin is raised as much as possible and separated from the other tissues with a single stroke of the bistoury, held as a pen or as a violin bow, the operator di-awing it towards him as much as possible. In the dissections of flaps of skin, as those in theV, the T, the crucial, and the cres- centic incisions, the strokes of the bistoviry extend in length as they approach the base, or the adherent portion of the cutaneous flap. In the straight or elHptic incisions, on the contrary, the strokes are longer at the beginning. When the cellular tissue is very loose, its separation from the skin is made with the fingers or the blunt end of the scissors. This mode, called enucleation, is often employed for some special forms of tumors, as the fibroid, or fatty. (J) Limited Dissection. — The steps of this process are the same as those of the preceding, excepting that the surgeon proceeds by small strokes in order to avoid going too deeply into the tissues, and leave the skin of a sufficient thickness. (c) Dissection by Slices or Shavings. — The skin being divided, and the subcutaneous tissues raised with the forceps, the bistoury, held flatwise, excises horizontally each layer of the structure by a sawing movement. C. PUNCTUBE. Properly speaking, this is a simple, special operation, designed to penetrate into hollow parts, to explore the nature of tumors, to DISSECTIONS. 139 examine the contents of natural cavities, or to provide for the escajoe of gases or flviids. It is, therefore, a solution of continuity of small dimensions, constituting often the first steps of an incision, but which forms also an essential operation. It can be performed with various instruments, as the lancet, the straight bistoury, the trocar, the exploring needle and their adjuncts, the aspirator, and the actual cautery. ■ Fig. 173.— Various Shapes of Lancets. Puncture with the Lancet. — In form and shape the lancet greatly varies, but in general it may be considered as a compound bistovuy, with a pointed and two-edged blade. The point may be either quite wide, or very acute, and is sometimes curved, with one edge convex and the other concave. To use the lancet, the blade, open at a right angle with its handle, is held between the thumb and index finger, while the Fig. 174.— Manner of holding a Lancet. 140 ELEMENTARY OPERATIONS. handle rests on the back of the hand, with the fingers shghtly flexed. The joint, brought close to the skin, and perpendicular to it, is thrust by the extension of the fingers through the tegument and tissues underneath and then drawn out perpendiciilarly, un- less it is desirable to increase the size of the incision, when the division is made by extending the incision from within outward. Puncture with the Straight Bistoury. — The bistoury, for this purpose, must be finely pointed and sharp. Held as a writing pen, with its edge upward or downward, or as a table-knife, accord- ing to the thickness of the tissues, and its action limited by having the fingers at a given distance from the point, it is pushed per- pendicvdarly and more or less raj)idly at once to the necessary depth. It is then drawn out, unless the incision is to be enlarged, which is done by a motion from within outward by the blade. Sometimes the instrument is pushed into the tissues in an oblique, instead of a perpendicular direction, when it is not desirable to have communication between the opening of the skin and the one directly beneath it. This constitutes the first step of the subcutaneous incision. Fig. 175.— Trocar and Canula. Puncture with the Trocar. — This instrument is composed of two parts. A rod, secured to a firm handle at one extremity and terminating at the other in a tri-f aced point, is one ; this rod fits into a canula, blunt at one end and having at the other a cup- shaped flange, which is the other part. The canula is long enough to receive the entire length of the rod, except the tri-faced point, which projects beyond it. The two parts are fitted closely together. Trocars are of various size and form, being both straight and curved. That which is used for hyovertebrotomy is the longest of all ; those used for rumenotomy are quite large in diameter ; the enterotome is, on the contrary, quite small. DISSECTIONS. 141 Fig. 176. — Various FormB of Trocare. To puncture with the trocar, the operator will assure himself that it is in good condition, and that the rod can readily be with- drawn from the canula when necessary. Holding the instrument in such a manner that the handle, grasped by the three fingers, rests in the palm of the hand, the thumb is apphed on the canula near its point of union mth the handle, and the index extended on the outside of it, to limit the play of the instrument ; the trocar is pushed through the tissues in a perpendicular direction, and until a sensation of resistance is no longer felt. When introduced, the canula is held in place with one hand, while with the other the rod is slowly drawn straight out, or by a sHght rotary motion. If the design of the operation has been the evacuation of the liquid contents of a tumor, as the fluid escapes the growth dimin- ishes, and it becomes necessary to insert the caniila fiirther in the cavity or turn it in different directions, to ensure the removal of the entire contents. Yet it is necessary to be careful not to press the orifice of the canula against the walls of the sac, a condition likely to prevent the escape of the fluid. To remove the canula, moderate pressure is ajDplied with one hand on the skin around the seat of the puncture, while the other 142 ELEMENTARY OPERATIONS. withdraws the instrument by its pavilion, drawing it in a line parallel to the division in which it was introduced. Exploring needles, or trocars, which are but smaU directors with a lanceolate blade at one end, and a small groove on one side, are also used for making punctures, and their adaptation as Fig. 177.— Exploring Needles. very small trocars, with aspirators (principally that of Dieulafoy) find frequent use in our surgery. These instruments have akeady been considered in the chapter upon surgical diagnosis. The Puncture with the Actual Cautery. — The conical cautery is the one used in this mode of operation. It varies in diameter and in length. The instrument is heated to a white heat, applied perpendicularly upon the sldn and pushed in until the sense of resistance is no longer felt, when it is withdrawn. The condition of white heat of the instrument is of great importance. Though apparently an act of great severity, the operation finds numerous appHcations in our surgical practice, principally for the punctiu'e of deep-seated cold abscesses. It has great advantages over the puncture with the bistoury, inasmuch as there is no hemorrhage to fear from its use ; because the opening made by the cautery remains unclosed a longer time, and because the inflammation is modified in its nature, and the process of resolution thus assisted by the caloric thrown in. The use of local anesthesia, by the injections of cocaine, will remove from this mode of puncture the rough side of its applica- tion by rendering the operation entirely painless. KEUNION. This term signifies the readjustment and consoUdation of tis- sues which had been disintegrated and divided — otherwise, simply the reuniting of separated parts, and their restoration to a nor- mal condition. This process is otherwise referred to as that of cicatrization, a natural property of organic tissues, which, though it may be aided and guided by the surgeon, can be controlled by REUNION. 143 him only to the extent of preventing accidents and maintaining natural conditions. The processes, the order, and the rapidity of the formation of cicatrization are not the same with different tis- sues, and certain distinctive terms have therefore been adopted by which to denote the modified ways by which the purpose of nature is effected. Thus we have immediate reunion or adhesive inflammation or union by the first intention, by which separated parts soUdify upon simple contact, as varying from union by the second intention, or by granulation and suppuration ; followed by union by the third intention, when, together with the processes of the second intention, there is added one of mortification and the elimination of dead structure. This subdivision accords strictly with the order of nature, as it may be constantly observed, the phenomena of separation involving a regular gradation of de- tail in the active forces employed in the recuperative effort, from the simplest and most efl&cient in the union by first intention to that which is, in fact, a struggle between the elements of growth and preservation and the tendency to dissolution and death, as ex- hibited in the third degree. Before proceeding to the direct discussion of the means used to assist the vis conservatrix in the reunion of di\aded parts, there are some general considerations of which the surgeon must never lose sight. They are not of the less importance because they are matters of an obvious and secondary character, and refer mainly to what may be termed matters of minor detail. Where immediate reunion is looked for, the wound must be fresh and clean, and entirely free from clots of blood or foreign substances. The edges must be smooth and even, and if there are any ragged portions they must be carefully excised. In addition to this, where there is a granulating sui-face the gran^dations must be carefully inspect- ed and their healthiness assured, and the surgeon must search care- fully to ascertain that there are no fistulous tracts present. In any case the hair must be clipped short around the edges, the skin thor- oughly washed, and, what is a point of primary importance, the exact coaptation of the opposite edges carefully ascertained and secured. The means employed to maintain the contact of the edges of a wound, and assist in its closure are, according to Gourdon, of four kinds — jyosition, uniting bandages, adhesive plasters and sutures. 144 ELEMENTARY OPERATIONS. A. — Position. This is more a preparatory step toward obtaining reunion than a true means of securing it, and to have its full effect and assure all its benefits, must be accompanied by the judicious appHcation of plasters or bandages. By position is understood such an atti- tude of the patient as will tend to keep in coaptation the sides of the wound, as opposed to a posture which would, if left unguard- ed, disturb the immobihty which is indispensable to the comple- tion of a symmetrical union. The natural restlessness of the pa- tient under the cii'cumstances, even irrespective of the ordinary UabiUty to the sHghter causes which divert his attention and ren- der immobility impossible, forbid the idea of entire passivity. And yet there are some cases where it is possible, or at least must be attempted. This may be illustrated by the hypothetical case of a lacerated wound, forming a V shaj)ed flap of skin, with its base turned upward. By taking advantage of this condition, and keeping the apex of the V downward, the position of the flap will itself assist in closing the wound, the edges having a natural ten- dency, from the contractive character of the fibres, to form, and to maintain the desirable contact. But if, on the contrary, the flap has its base turned downward, the difficulty of keeping it in its proper position will be greater, proportionately to the tendency of the edges of the flap to drop away from those of the skin. Taking advantage of the position of this peculiar wound, and assisting it by the apj)lication of bandages or other means, will materially facilitate the closure of the wound. B. — Uniting Bandages. Though these are not so frequently required in veterinary as in human surgery, they are very effective in bringing together and retaining the edges of wounds, especially in the extremities, where in both transverse and longitudinal wounds they fulfil their pur- pose very satisfactorily, especially where only the skin is involved. If the injury extends to the muscular substance, however, they are both more difficult to apply, and less serviceable in their ef- fects. In wounds of a transverse character, two bandages of a length equal to that of the injured leg, and as wide as the great axis of the wound, are required. One of these is divided into UNITING BANDAGES. 145 Fig. 178.— Bandage for Transversal Wound. three or four strips in one-half of its length, the other having in its middle an equal number of longitudinal shts, smaller than those of the first, these two being fixed parallel to the axis of the leg, one above the other below the wound, by several turns of roUers, and by passing the strips of one through the correspond- ing shts of the other, the edges of the wound will, by opposite traction upon the bandages, be necessarily brought together and supported in that position (Fig. 178.) The same method answers for longitudinal wounds, though simpler in structure ; this bandage, consisting of a single band of a width equal to the length of the wound, and prepared with strips and corresponding shts, as just described, at a distance of about three-quarters of the circumference of the leg. Thus prepared, and compressive pads placed on each side of the wound, the bandage is manipulated as in the other cases, and when it is all properly adjusted, is further secured by roUing it around the leg over the strips (Fig. 179.) C. — Adhesive Sticking or Agglutinating Plasters. These descriptive terms refer either to certain special mixtures which are applied either directly, and alone upon the solutions of continuity, or spread upon hnen, in the form of the ordinary 146 ELEMENTARY OPERATIONS. Fig. 179. — Bandage for Longitudinal Wounds. surgeon's plasters. They are better adapted for use, with the smaller, than with the larger animals, answering all the require- ments with the former class. They are composed of various in- ingredients, differently combined, such as black pitch, with resin, Venice turpentine, etc., and oils, to improve their flexibihty, and aid their curative qualities. Venice turpentine, alone, is sometimes spread over the bandages, also a mixture of tar and Burgundy pitch. Pitch, alone, when melted and mixed with cut oakum or tow, forms a good adhesive mixture. The ordinary adhesive, or diachyton, or lead plaster, used in human medicine, is of great value in the surgery of small animals, and we have used it with great satisfaction with both large and small patients, applying it in long strips, roUing them around the affected region in two or three thicknesses. Collodion has also been highly recommended. Either alone, or applied with thin Unen, or what is better, with wadding, it forms over the sur- face of a wound, not only an adhesive plaster, but also a jprotec- tive dressing. Plasters are, in some cases, used alone as means of reunion, and in the treatment of fractures, they form a jDOwerful adjunct in controlling the displacements of fragments of bone. They are, however, also frequently used to reinforce other means of reunion, and especially deep sutures. D. — Sutures. In all the category of surgical detail, there is nothing so effec- tive, or indeed iudispensable, as the suture, properly applied, for SUTURES. 147 the retention of breaches of continuity, whether the sewing be done by means of Hnen or silk thread, animal fibre, metallic wire, needles, pins or other instruments. By no other means can the parts be held in the necessary coaptation to insure a perfect reunion. The suture is available for various purposes. Besides contributing materially to the coaptation of the edges of a wound, and thus aiding to secure a cicatrization by first intention, it pre- vents the contact and introduction of air into a wound, arrests and prevents hemorrhage, keeps in place lacerated fragments of deep wounds which could not be controlled by bandages alone, assists in the closure of artificial openings, such as may take place in the walls of the abdominal cavity, and prevents the escape of any portion of its contents, and assists in the closing of natural openings. But, though principally useful in efi'ecting the objects enumerated, the essential indication of the suture appears in the re- union of solutions of continviity, and, particvilarly, in regions where the natural movements of the parts tend necessarily to prevent the borders of the wound from remaining in undisturbed contact, for a period sufficient to obviate the danger of serious blemishes of cicatrization. But while the suture is of no less advantage in fresh injuries, it is also indicated as well in suppurating wounds, with the precaution of leaving room for the free escape of patho- logical secretions. Sutui-es are contra-indicated, when a wound becomes the seat of extensive inflammation, or occupies a broad surface, or is ir- regular, or accompanied by loss of tissue ; or when the parts are the seat of severe contusion, or contain foreign bodies or mortified tissues in their depths. There are other cases also, where their emplo}Tnent is contra-indicated, as when their object is likely to be defeated by the uncontrollable movements of the patient. Causes of failure may also sometimes be found in the irritation arising from the material of which the suture is formed, cutting its way loose. By this accident, a wound which, if not interfered with, would have left but little if any cicatrix, and would have required but a short time to heal, becomes transformed into a large, ugly, granulating surface, that is likely to leave a compara- tively bad looking cicatrix in the end. The appHcation of these retentive stitches falls under the general rules relating to the disjyosUion of the edges of the too und, and the special placing of sutures. In reference to the first point, 148 ELEMENTARY 0PEKATIC3. the first consideration to be noted is, that the vvoand must, of course, be thoroughly cleaned, and free from blood or foreign bodies. Then the borders of the wound must be fresh, or, if old, blackish, or beginning to granulate, must be slightly excised by thin scraping, and the edges brought as closely in contact as posaible. To apply the suture, the needle is to be held and used precisely like an ordinary eewing needle. If the skin is thick enough to require it, a thimble can be used. Sometimes special needles with handles are made, and sometimes forceps may be needed to grasp the needle, and push or pull it through the integument. The needle should pass through the skin as nearly perpendicularly as possible, since, if introduced too obliquely, the tractions upon the skin may be sufi&ciently uneven to involve the possibihty of tearing out the stitch. In placing the suture, nerves, tendons and blood vessels must, of course, be avoided. The suture should embrace a good hold of the skin to secure a greater traction and better approxi- mation of the parts ; the distance between the stitches must be such that no gaping can take place ; they must be disposed at regular distances apart. When the needle is introduced from without inward, the skin is raised with the fingers of the left hand, or, better, with a forceps ; if introduced from within out- ward, pressure is to be made upon the skin with the fingers or the blunt blade of a pair of scissors, near the point of exit of the needle. Generally, the suture is begun at the middle of the wound, in which case the edges are made to meet more accurately and regu larly. This rule, however, will find numerous exceptions. All the stitches should be placed before any are tied, and they must be tied only sufficiently tight to keep the edges together; other- wise they may cut through the skin. If not sufficiently tight the wound will be left gaj)ing and cicatrization will be interfered with. The knots ought to be placed as much as j)Ossible on one side of the wound and towards the most dependent part, to avoid their being soiled by the suppuration. The material used for sutures varies much. Strong Hnen thread, sUk, metallic wires of silver, lead or tin, and in some cases narrow and thin elastic cords or bands are used, according to the circumstances. MetaUic wires have the advantage of being less irritating, and can remain in the thickness of tissues without giv- SUTURES. 149 ing rise to excessive inflammation or ulceration if the swelling should be extreme. Elastic cords or bands have an important advantage in their property of yielding to the inflammatory swell- ing, as it develops itself while avoiding dangerous or unnecessary traction. Fig. IbO.— Various Sutured Needles. Suture needles are made in countless forms and numbers, straight and curved, and of different lengths and dimensions, but having, all of them, flat points. When metallic sutvires are used, their extremity is grooved to receive the wu'e in such a manner that its double thickness will not interfere with its passage through the skin. 150 ELEMENTARY OPERATIONS. Some needles are armed and protected with handles, as those of Trelat, of Riverdin, and of Simpson. Sometimes their lanceo- lated part has the eye pierced in its center ; in others, the eye is merely a notch, closed by a repulsor, moved by sHding through the handle. Generally, the hand is sufficient to push the needle through the skin, but at times, as has been mentioned, forceps or needle-holders are necessary, such as the needle-holder of Mat- thieu, an ordinary forceps or an ordinary pin-holder. The com- mon wire dressing pin is also included among suture implements. SIMPLE OR INTERRUPTED SUTURE. 151 Fig. 186- - Suture Forcops. Fig. 187.— Needle or Pin Holder. but is not always efficient from lack of rigidity, when a stronger and less flexible implement becomes necessary. Sutures are of many kinds, some being superficial, others deep, and otherwise classified, according to the requirements of their application, into single, as when the thread or wire alone main- tains the reunion, or compound^ when it requires other and acces- sory means, such as needles, pins, quills, etc., etc. 1. The simple or interrupted suture (Fig. 188) is formed of dis- tinct stitches between the borders of the wound, each being tied 152 ELEMENTABY OPEEATIONS. Fig. 188.— Simple or Interrupted Suture. Fig. 189.— Looped Suture. separately. It is made in two ways. By a first procedure, with a needle holding a long thread, the surgeon holding both edges of the wound, passes it through both at once, cutting the thread and making each stitch entirely distinct, and tying then only when they are all in place. He begins with the center stitch. In the second procedure, a separate thread is prepared for each stitch, having a needle at each end, which is passed through the skin from within outward, and, as before, each stitch is tied independently of the others. Often, only a single needle is used, making the first half of the stitch from without inward, and the second half from within outward. This suture is used for recent wounds, and those in which there is extensive laceration of the integument. 2. Looped Suture (Fig. 189). — This is an interruj)ted suture, in which the threads, instead of being tied up separately over the wound, are twisted together on each side, without being tied, in order that each thread may be removed independently of the others, if necessary. The cords are then twisted together, and sometunes tied and sometimes not. It was formerly recommended for intestinal wounds, and is but Httle used at the present time. 3. Uninterrupted oi' Glover's Suture (Fig. 190). — This is a con- tinuous suture, of which the stitches successively cross the wound from both within and without. In making it, the thread is knot- ted at the end, and the needle pushed through the skin at one ex- tremity of one of the borders of the wound, from without inward, and then directly opposite it through the other edge, brought to DOSSILED SUTURE. 153 the first in crossing the wounds obliquely, and this is repeated until the lower end of the edge, opposite to that at Avhich the suture was begun, is reached, when the thread is stopped by a knot. Before securing the last stitch, care must be taken to re- move any possible wrinkles between the stitches. Fig. 190.— Glover's Suture. Fig. 191.— Dossiled Suture. 4. Dossiled Suture (Fig. 191). — This is a variety of interrupted sutiure, in which the thread is doubled, and at one end carries a httle ball or dossil of hut or oakum. Passed through one edge of the wound from without inward, it is brought outside of the wound, and cut the necessary length. Another similar thread is passed through the other border in a similar way, and, when cut, both threads are tied together in the center of the wound. This suture is often used for the pui-jDose of holding in place the substances (wadding, oakum, etc.) that may be placed in the wound, or to prevent the return of a hemorrhage. It is a strong adjuvant of other hemostatic measures. 5. Quilled Suture (Fig. 192). — This is formed by a series of in- terrupted stitches, supported on each side by a short piece of quill or wood, or metaUic jDin, which must be longer than the great axis Fig. 192 QuillPd Suture. Fig. 193.— Suture with Adhesive Bandage. 154 ELEMENTAKY OPEKATIONS. of the wound. To apj)ly it, a double thread, with the ends knot- ted, is passed through the edges of the wound, and several stitches made in succession, as in the regular simple interrupted Buture. When these are in place, the support (quill, pencil or otherwise) is passed through the lap of each double thread on one side of the wound. Drawing this first quill close to the skin, the threads are separated, and, between them, a second quill apphed on the other border of the wound, and secured in place by a knot. This suture is recommended for wounds of the abdomen. Peuch and Toussaint recommend it after the removal of mammary tumors in bitches. Sometimes elastic cords are used, in preference to or- dinary threads, as being less putrescible, and yielding better to the inflammatory swelling, etc. Director Degive frequently employs the elastic suture toitH ad- hesive bandages (Fig. 193). Two adhesive bandages, of dimensions proportionate to that of the wound, are glued on each side of it. These carry near the border, in the neighborhood of the edges of the wound, small holes, through which elastic rings are passed. These rings repre- sent the threads used in the other mode of procedure, and through these rings the quills or pins are placed, which will rest on the outside of the bandages and keep them in j)lace. 6. The single pin suture is a simple opera- tion for small wounds, commonly used as the last step of the operation of bleeding, and by which both edges of the wound are brought riG. 194.— Single Pin together with a pin, and secured by a special Suture. double loop or hitch called the bleeding knot. 7. Twisted Suture (Figs. 195, 196). — This is frequently used for wounds of the eyelids or of the nostrils. It consists in placing through the borders of the wound as many pins as may be neces- sary, and holding them by twists of thread. Ordinary pins are generally used in veterinary surgery. The pins are secured in difi"erent ways. In one case, the tvsdsts are so made as to form a series of figure 8s, placing them two or three times successively, first around the pin at one extremity of the wound and repeating the movement with each pin. In an- other way, instead of making a figure 8, the threads are turned around the pins at each stitch, surrounding all with a circular thread. ZIGZAG SUTUEE. 155 Fig. 195.— Twisted Suture. Fig. 196.— Another. Some veterinarians, in making this compound pin suture, prefer tlie use of elastic rings to that of the circular or figure 8 threads. We have personally used these rings with very satisfactory results. 8. Zigzag Suture (Fig. 197). — This is a continued suture in which the thread is made to cross and re-cross from one border of the wound to the other. The procedure is as follows: a needle carrjdng a long thread is passed through one edge of the wound from without inward, and thi'ough the other in a straight dii'ec- tion from within outward. Starting with the same thread, a sec- ond stitch is taken at some distance from the first, and on the same side of the wound on which the first was ended, a second stitch is made by passing the needle from without inward, and back from within outward, to reach the side of the wound where the first stitch was started at an equal distance from it. The re- maining stitches are, of covu'se, made in the same manner. This suture has been recommended for the treatment of um- bnical hernia in soHpeds. 9. Suture of the Furrier. — This is performed with a needle and a long thread, which is alternately passed through the edges of the wound from without and from within. It is also a continuous Fig. 197.— Zigzag Suture. Fig. 198.— Suture of ttie Furrier. 156 ELEMENTARY OPERATIONS. Fig. 199.— T Suture. Fig. 200.— X Suture. suture, in wliich the coaptation of the borders of the wound is regular and exact. It is principally applicable when the borders of the wound have a tendency to overlap each other. 10. T Suture (Fig. 199). — This is the peculiar stitch used to bring together the borders of a T or crucial incision. A thread is used with a needle at each end, each of which is passed through from without inward, in one of the angles of the T, and brought from within outward beyond the transverse incision of the T when being unthreaded and laid aside. The suture is completed by tying the two ends of the thread together. The same suture could be made with a single needle. The same procedure is required for the crucial incisions. 11th. X Suture (Fig. 200). — This suture, which is recommend- ed after spaying sows, is made by taking a stitch through both edges at once, and carrying the thread obliquely across the wound, starting the second stitch on the same border of the wound as the first, and finishing in the same manner; the thread is then again passed across the wound, and the ends tied together. 12th. Metallic Sutures. — These do not difier from the sutui'es which we have considered, excejDting that metals are used instead of thread or silk. They are applied like the others, and secured in the same manner, by knots or by twisting their ends together. The period for the removal of sutiu^es dejoends upon many circumstances, and varies according to the nature of the tissues involved, their thickness, and the species of the animals operated on. In horses and in dogs, suppuration occurs more raj)idly than in ruminants or swine, and on that account the sutiu'es cannot be allowed to remain as long, without giving rise to the formation of pus. Moreover, in regions where cellular tissues and blood vessels are abundant, the pus is usually formed more rapidly than in those REMOVAL OF SUTURES. 157 of the opjDOsite formation, and consequently sutures must be re- moved earlier. On general principles they should be taken out by the foiu'th or fifth day, or even sooner, if indications of complica- tion due to their presence are manifested. In removing sutures, it is necessary to proceed cautiously, in order to avoid breaking any adhesions that may have been formed. As a general rule, but one shoidd be detached at a time, be- ginning at the least important point. The threads and needles should be cut close to the side opposite to that on which they are to be extracted ; they must be carefully cleaned of crusts or dried pus and any roughness whatever, and the skin should be carefully held down as they are slowly drawn out. If the adhesion seems at any points to be too Ught, the sutures must be left in a few days longer. The appUcation of adhesive mixtures, or of collodion, will strengthen a weak cicatricial tissue. When a suture has been applied, as well as when it has just been removed, it is sometimes necessary, in order to prevent the animal from biting or rubbing the cicatrix, to bring the cradle or the side bar into requisition. CHAPTER V. OPERATIONS ON THE SKIN AND CELLULAR TISSUE. CAUTERIZATION. The theory of the cautery is the irritation and disorganization of living tissues, either by the immediate contact of heat or of chemical substances, producing an analagous effect on the organ- ism. Cauterization is thus of two kinds, the actual and the poten- tial^ according to the agent employed in its production. Potential cauterization, by reason of the nature of the agents employed, as well as of the method of employing them, belongs properly to the domain of therapeutics, and we shall therefore pass the subject by with a simj)le mention, to give our attention to what falls more particularly under the head of operative surgery, the actual cautery. ACTUAL CAUTERIZATION OR FIRING. Firing is one of the most valuable of therapeutic agencies. It is also one of the oldest and best known among methods of surgi- cal treatment, in both human and veterinary medicine. It was practiced and recommended as far back as the times of ColumeUe, Absyrtus and Vegetius, when it was in high repute as a remedy for articular diseases, sprains and weakness of the loins ; but to- wards the 15th century, its popularity waned somewhat, and it seemed to have partially lost favor, until the days of Markam and Gray in England, and SoUeysel in France, where it regained by degrees its former repute. It now holds an established place among regular and methodical operations, and is one of the most important among our surgical resources, applicable in many pathological conditions, and efficacious in most. The following long list of ailments and lesions in which it may be indicated is given by Bouley. ACTUAL CAUTEKIZATION OR FIRING. 159 (a) Diseases of Joints. — Exostoses around the borders of articiilar surfaces ; sprains of ligaments ; dilatations of syno^ial bui'sse and indurations of their walls ; dislocations ; true or false anchylosis ; deformities of the extremities from excess of work ; congenital general weakness, etc. (b) Diseases of Hones. — Exostoses; periostosis; callus of complete or incomplete fractures ; caries ; necrosis. (c) Diseases of Tendons. — Pai'tial lacerations ; chronic swelling after tenotomy. {d) Diseases of Tendinous Sheaths. — Dilatation ; lacerations ; changes ia the structui'e of their walls. ((?) Diseases of 3Iuseles. — Atrophy; induration; pathological changes of structure. (/') Diseases of the Cellular Tissues. — Chronic oedematous swellings; induration; abscesses; cysts. {g) Diseases of the JSTervous Apparatus. — Paralysis; occult pains without visible lesions. {h) Diseases of the Lymphatic System — Chronic lymphangitis ; farcinous cords; pustules or tumors. {i) Diseases of Veins. — Chronic phlebitis. (J) Diseases of Arteries. — Hemorrhages. {k) S2)ecial Diseases. — Carbuncular tumors ; gangrene ; ulcers ; fistulas, etc. To epitomise and simplify this long recapitulation, we may say with Gourdon, that the use of the actual cautery is indicated when its characteristic effect as an excitant and tonic is sought for in atrophy, or in diseases of joints ; or again, as a modifying factor in chronic inflammation ; as a derivative, and as a physical or a preventive agent. It is contra-indicated in cases where there exists an excess of vital irritation, or of inflammatory tendency, until the symptoms which attend such a state of the system have more or less sub- sided. Actual cauterization is divided into the superficial and the deep., the former being again subdivided into the mediate and the immediate. In the immediate the iron is applied directly to the skin, while in the mediate the action is supposed to be modified by the interposition of some kind of medium. The various modes of actual cauterization, according to Bouley, are systematically exliibited in the following table : 160 OPEBATIONS ON THE SKIN AND CELLULAR TISSUE. SUPEEFICIAL. . Immediate . Mediate . Penetrating . . Subcutaneous. Transcurrent, in lines. On surface, a la Gaulet. In points or dots. By ignited bodies. By heated liquids. By radiation or objective. By the interposition of kid sldn or of a layer of lard. r Kapid. [ Inherent or disorganizing. Peuch and Toussaint have added the needle cauterization, and firing with the thermo-cautery. Overlooking several of these specifications, which are of little or no utility, such as the firing with the inter-position of ignited bodies, of heated liquids, kid skin, etc., we proceed to consider the various prevalent and established modes in daily practice and of general utiUty. Transcurrent, or Firing in Lines. The Cautery. — The instrument used in all these operations, while formerly made of difi"erent metals, is now made exclusively of iron, for which there are various reasons. It is not only because of its cheapness and excellence and the general quahties which give it universal precedence in the arts, but for some reasons pe- cuUar to the case. Thus, its changes of color when heated, render it easy to gauge, proximately, the degree of heat, and it also possesses the property of retaining heat longer than many other substances. The form of the cautery varies greatly. The style most com- monly in use resembles a small hatchet, of triangular, prismatic shape, thick at its base and with a thin border or edge, sometimes convex, sometimes straight, and more or less sharp, according to the indication. The handle is, of course, of wood or other non- conducting material, and in respect to the weight, reference must be had to facility of handling and power of retaining heat. The THE CAUTERY. 161 Fig. 201.— Various Cauteries. lighter ones are usually preferred, not only on account of this facility, but as being less liable to produce too pronounced an effect. Heavy instruments, in consequence of the degree of heat they radiate, and their contact with a broader surface of skin, are liable to transf orra the firing into the condition of a mere burn. The size of the cautery will necessarily be regulated by the ex- tent of the region to be treated. The cautery must be perfectly smooth, on its surface as well as on its thin edge, and to ascertain that this is the case, before they are heated a file should be passed over both surfaces, and before being apphed to the skin they should be again inspected by the surgeon or an assistant, to be assured that the edge is clear and clean, and there is no roughness to cause a ragged and uneven line on the skin. In heating the cautery, a charcoal fire is much to be preferred to that from the blacksmith's forge. The latter soon soils and blackens the instrument, while the former is smokeless and every way cleaner, besides being portable and always convenient. There is no uniform rule to govern the position in which the animal must be secured. Wlule there are occasions when he can be treated while standing, and kept under control by the simple means of restraint, in many, and indeed in a majority of cases, 162 OPERATIONS ON THE SKIN AND CELLULAR TISSUE. it will be every way advantageous to have tlie patient thrown down and secured, in order that the region to be fired may be exposed as freely as possible — a point which has already been considered. The parts upon which the firing is to be made must be thor- oughly cleaned and especially free from scabs or greasy sub- stances. The hair is to be chpped short whenever its length and thickness are likely to interfere with the action of the instrument ; yet the skin must not be shaved, inasmuch as a thin coat of hair will always prove rather an assistance than otherwise, in drawing the first hnes, by preventing the instrument from sUpping. There was a period when animals were fired with a view to their alleged ornamentation, without any pretext of necessity aris- ing from disease, but simply in conformity to the behest of fash- ion (and possibly as a means of the identification of property), but this artistic firing for fashion's sake is now altogether discarded, and the burned-in shapes of fern leaves, stars, crosses, harps, etc., 1 ^S\ ^ — - - ~ _ --, L Fig. 202.— Old-fashioned Drawings. etc., have made room for firings inflicted for better reasons and with more beneficient and valuable results. And while the results of these aesthetic and artistic firings made for purposes of embellishment were usually ugly, un- sightly cicatrices, thickened and hairless, the operations of the present time leave as their sequelae but slight and superficial marks, which are hardly entitled to rank as blemishes, though in this connection must not be included the Prange firing (Fig. 203), which, with its pecuHarity, is applied as the ordinary line firing, except that the lines are divided in small sections. Firing in Hnes must be applied not only upon the diseased part, but must extend somewhat beyond it, and the lines must be made as nearly as possible parallel with the direction of the hair. FIRING IN LINES. 163 FIG 204.-VariouB Forms ol Drawing in Firing.' -T;;e.ringontUeioin..e tuin. oug.t to.e paraUel to me median Une iasteaa of oblique. 164 OPERATIONS ON THE SKIN AND CELLULAR TISSUE. This rule we consider a very important one, althougii it is known that European veterinarians, when operating in some special re- gions, entirely disregard it, firing in lines running at right angles with the direction of the hair, though it is quite obvious that the result must be an irregularity in the growth of the hair and a wavy appearance, which can be entirely avoided by observing the rule we have referred to. A glance at Fig. 204 wUl give the reader an idea of the proper form for making the drawings and the directions of the lines. Not only should the Hnes run parallel with the direction of the hair, but it is equally important that there should be no deviation in the width of the intervals between the lines. It would be im- possible to give exactly the distance which must separate them, as this depends upon the thickness of the skin, the condition of the patient and the effects to be produced. In drawing the lines it must be remembered that they ought to be of an even depth their entu^e length, but we do not think that this can be easily accomphshed with the instrument having the convex edge, while there should be no considerable difficulty in effecting it by a steady and uniform manipulation with the straight edged iron, and by merely raising the hand at the begin- ning of the line and depressing it sUghtly at the end. The cautery must never be passed in one hne against the growth of the hair, and by always drawing it toward himself the operator will avoid injuring the bulbs, and escape the danger of causing a subsequent abnormal growth of hair. Nor should the cautery be passed twice in succession in the same line. If the in- strument should slip out of its track before reaching half its length, the line should be abandoned and the next one proceeded with. To determine the Hnes correctly, and follow them accu- rately by the eye alone, requires a natural aptitude which all do not possess. It is an art, however, which, if possible, should be ac- qmred, and as weU as when existing naturally, cultivated and im- proved, by study and practice. But in the absence of the natural faculty, which it is so desirable for the surgeon to possess, resort must be had to the obviously reliable expedient of previous mark- ing, by which a charcoal mark upon a light-haired, or a chalk mark upon a dark animal will obviate all risk of lack of symmetry and want of regularity. The degree to which the cautery should be heated, as well as KULES FOR APPLYING THE CAUTERY. 165 the manner in which it must be moved on the skin, is to be deter- mined by the steps of the operation. In beginning- the markings of the firing or the initial dravying, the iron must be of a dark red color, just hot enough to burn the thin coat of hair left on the skin. By this method, any irregrdarity in the drawing can be re- moved and corrected by the passing of a second instrument. When the entii'e sui'face has been covered with the initial draw- ings, and everything is correct, the heat of the cautery can be shghtly and i^rogressively increased as the oj)eration approaches the end. The rapidity with which the instrument is moved over a line should var}^ inversely to the degree to which it is heated, the thickness of the skin, the consistency of the subcutaneous tissues, and also the stage of the operation. Generally, the movement of the cautery should be accelerated when the heat is greatest, when the skin is thin, v/hen the tissues underneath are hard, and when the operation is nearly completed. Another important rule is not to apply too heavy a pressure upon the cautery when moving it over the skin. A sHght pressure with a slow movemeat is harmless and even advantageous at the beginning of the operation, or when the skin is thick, but it be- comes dangerous under the opposite conditions when the heat of the cautery is extreme. In such a case a true incision of the skin may be the result. Firing is essentially a bloodless operation even when severely appHed, but it is only by the carefid observ- ance of the above rules that hemorrhage dui'ing actual cauteriza- tion can be avoided. Its appearance during the operation is, we beUeve, the result of inattention, and caused by too hastily raising the heat of the instrument, or more often by excessive pressure upon it. The observance or neglect of these rules will demonstrate the difference between scientific and unscientific firing, and show that while one is true sclentijic surgery, the other is simply burning the skin. The first is applied by one who appreciates the value of the results he hopes to realize, while the other merely places a hot iron in contact with the skin, quite ignorant of the good or evil results which may f oUow the act. As the operation progresses, changes take place upon the lines, which give an indication of the strength of the firing. These objective changes consist in a change of color in the lines, and an accompanying exudation from the skin. In the first degree, or light firing, the Hues are not deep, and 166 OPERATIONS ON THE SKIN AND CELLULAR TISSUE. are of a golden yellow tint, having only a few isolated drops of serosity at their sides, the dermis not being extensible, and the skin between the Hnes free from infiltration, the epidermis can- not yet be scraped with the finger nail. In the second degree or ordinary firing, the lines are of a lighter color, or bright yellow, the drops of serosity are more abundant, the dermis is more ex- tensible, the skin between the lines is thickened with infiltration, and the epidermis is easily scraped off. In the third degree, or strong firing, the lines have a light yellow color, the dermis is so thinned that the slightest traction of the portions between the lines, which then become wider, stretches it, the serosity is abund- ant and overruns the edges of the lines, and the skin between them is infiltrated and possibly covered with small phlyctenases or bUsters. To proceed fiirther will be to produce a deep burn, which may be followed with serious complications, or at the least, leave large, unsightly cicatrices. The length of time required to produce these effects, and the frequency of the applications upon a given region, are points by no means easily determined. They are affected by many contin- gencies, which cannot be anticipated. According to Fromage de Feugrd, a cautery heated to a cherry color must be used in each Hne from ten to twelve times for a light firing, and from fifteen to twenty for more serious cases ; but Gourdon considers these fig- ures too high, and says that from five to six strokes will be suffi- cient for a firing of the first degree, from eight to nine for one of the second, and from twelve to fifteen for the third, or strong fir- ing. But these figures have no absolute value. The number of strokes will depend upon many conditions, such as the heat of the instrument, the state of the parts and the dexterity of the operator. The effects resulting from actual transcurrent cauterization may be divided into primitive and secondarg. (a) Primitive effects. — The inflammation which follows the burning manifests itself by the appearance of a serous exudation, the serosity being in the form of small di-ops, in greater or less abundance, according to the degree of the cauterization. This serosity collects between and at the bottom of the lines, and con- tinues to flow for from twenty-four to forty hours, when it is re- placed by the formation of crusts or scabs, dry, yellowish, and ir- regular, and if the firing has been light, attached to the bottom or the borders of the lines ; but covering the entire cauterized sur- PRIMITIVE EFFECTS. 167 face between tlie lines, as well as at the bottom, if the firing has been stronger. These crusts of dry serosity remain adherent for a few days only, and from the sixth day to the eighth they begin to separate, but the di-opping off of the cauterized j)ortions of the skin requires a longer time, varying according to the degree of the firing. In the first degree they are ehminated by the formation of a new layer of epidermis. It is a process of dry desquamation by which they are exfoHated, and requires from two to three weeks for its accompHshment. In the second degi-ee, when the thickness of the cauterized tissue is greater, the scabs 23i'oper are more adherent, and it requii-es a process nearly aUied to one of suppurative expulsion, which may consume a month before the final sloughing is accomphshed. In the third degree, a regular process of suppuration is necessary for the removal of the scabs, and its completion will requu-e a period of not less than five or six weeks. After light firing, the marks left are scarcely detectable ; after the second degree, the hair grows over the hues, but in an irregu- lar way, giving a somewhat roughened appearance to the part, while the strong firing leaves a thick and callous epidermis, and therefore a serious cicatrix. Besides these first and dii-ect effects of the cautery, there are others which ought not to be overlooked. About the parts where the firing has been applied, the skin and the subcutaneous tissues become the seat of extensive inflamma- tion, accompanied with pain and sweUing, and in some animals this may assume a severe aspect. The swelling may extend until it involves the entire extremity, and this may seriously interfere with the act of locomotion. It, however, subsides and disappears as the process of the removal of the scabs advances, and when this has been accomphshed, the swelhng and pain will also have disappeared. (b) Secondary effects. These are slow in their development, and cannot be easily or weU described, and they vary widely ac- cording to the objects for which the firing has been appUed. It may be said, however, on general prmciples, that the development of secondary effects cannot be expected except after a consider- able lapse of time, allowing at least several months, and in any case, only long after the objective effects have entirely disappeared. The treatment following the operation, is of a very simple character. For a few days, and until the secretion upon the 168 OPERATIONS OK THE SKIN AND CELLULAR TISSUE. cauterized parts has dried and the scabs have begun to slough, the animal must be restrained from lying down, and biting or rubbing himself, nor must this vigilance be relaxed, until the danger of breaking up the surface of the wound has ceased, with the temptation which was kept up by the continuation of the irri- tation, with the dropping off of the scabs and of the cicatrization. There is no necessity for interference with the sloughing of the scabs, or occasion for impatience to see them removed. After a period of time, which varies according to the severity of the op- eration, they will separate spontaneously, or with a little friction of the parts, or washing with tepid water and soap. A question of some importance in connection with this oper- ation, is that which refers to the use of oily or greasy substances in the treatment of the cauterized surface. In times past this was accounted to be good practice, and soothing embrocations were recommended and freely employed, but this treatment has become nearly, if not wholly, obsolete. At the most, vesicating prepara- tions are considered allowable, but even these only under special conditions, as when the cauterization has not been sufficiently strong. This practice is specially prevalent in the United States, where the operations of firing and blistering are almost always as- sociated. This combination has nothing objectionable, and in fact is justified by the apprehensions and opposition existing among Americans. Yet practitioners must always remember, that if many cases where firing is indicated terminate unsatisfactorily, after both firing and blistering, it is because the true and local effects of the cauterization, by ordinary or strong firing, have not been produced, when they were necessary to obtain good results. The possibility of ugly cicatrices cannot be well avoided if proper firing is to be depended upon. In view of the fact that the effects of firing are not limited to those which visibly and immediately appear on the surface of the skin, but that others of importance are also to be anticipated, after a certain time, the question of the duration of the rest necessary for the patient after the firing, be- comes one of some importance. All written authorities on the subject agree in saying, that this rest must be a long one, reckoning it by months, though in some instances hght exercise, or even light work, may be allowed sooner. Generally speaking, however, the surgeon will be guided by the nature and history of his case, and especially by the extent SECONDAKY EFFECTS. 169 of the cauterization. The patient will of course require perma- nent and absolute rest for a few days, or until the serosity and the scabs have dried, but after that he may be allowed the Uberty of a box-stall, or of the pasture, without interfering with the necessary oversight of his condition and progress. There are cases where moderate walking exercise coiold not be otherwise than beneficial in its effect upon the final result. Though, as we have said, the aj)j)lication of greasy medica- ments may not be recormnended, yet, as a substitute or alterna- tive, bhstering ointments may be used to supplement too Hght a firing. It is, in fact, not rare to find it necessary to follow the firing with a severe bhstering after the scabs of the first operation have fallen off. If this is done, however, it must not be until the more active effects have diminished, and the inflammation has subsided. It may sometimes become necessary to solve the problem of the duty of the veterinarian in cases where an animal requires the treatment of the cautery on two places on one leg, or on two legs, or perhaps on the entire four. Humane feeUng alone ought to furnish a sufficient guide in this matter. "When the operation is not only in itself so excep- tionally painftd during its performance, but is followed by further suffering arising from the necessity of protecting the animal against himself, it should be considered sufficient to inflict the firings singly, and after the first infliction to repeat the torture only after a respite of several days. On this point we differ from the opinion expressed by some European writers, and cannot dis- cover the alleged benefit to be derived from any extra dispatch, in the absence of any ui'gent reason for considering it to be im- perative. Our conviction is strong that one firing ought not to foUow another until the immediate effects of the first have sub- sided, and the animal has had several days to recuperate from the great strain he has been compelled to endure. The application of transcurrent cauterization is very often in- dicated in sohpeds, and we borrow from Bouley a hst of the ordin- ary lesions for which it is most frequently emjDloyed. A. — Regions of the Extremities. Coronet. — Indicated against ringbones, circular periostitis following phalangeal arthritis, or deep penetrating wound of the foot ; exostosis following fractures. AppUed in hues, parallel to the axis of the bone ; not too near to- 170 OPEKATIONS ON THE SKIN AND CELLULAR TISSUE. gether, to avoid sloughing of the skin; never fire beyond the second degree ; avoid burning the coronary band. Eesults : gen- erally efficacious, but necessary to repeat it. Fetlock. — Articular or tendinous windgaUs ; exostosis ; perios- titis after sprains or arthritis ; induration of tendons ; cold infil- trations and indm-ation of cellular tissue; knuckhng. AppUed in parallel lines, vertical in front and shghtly obhque behind. Re- sults : not so satisfactory, though in many cases favorable. Cannon. — Splints ; callous and thick tendons ; cold infiltra- tion and induration of ceUular tissue. Applied as in the fetlock. Results : generally very satisfactory ; second firing is often re- quired. Knee. — Articular and tendinous synovial dilatations at any part of the joint ; hygroma; bony deposits. Applied in parallel Hues, vertical in front or oblique on the lateral faces. Very ad- vantageous for synovial dilatations and hygroma ; less so in exos- tosis. Forearm. — Bony growths of any kind ; muscular weakness, manifested by sprang knee. Lines parallel to the axis of the re- gion. Beneficial for exostosis ; doubtful in the other cases. Elhow-joint. — Bony deposits; dilatation of articular synovial sac. In parallel lines. Results very satisfactory. Arm. — Weakness of olecranon muscles. In lines parallel to the hairs. Results very doubtful. Shoulder. — Muscular atrophy ; paralysis ; diseases of the artic- ulation, dilatation of the coraco-radialis bursae; lameness of un- known nature, and located in that region, may involve the en- tire region, or it may only cover the scapulo-humeral angle. In the first case, appHed in lines parallel to the direction of the hair, extending from the upper to the lower end of the scapula, the firing has an oval shape ; in the second case, the firing is circular, and forms parts of two parallel Hues, slightly oblique to each other. Generally advantageous in atrophy and occult lame- ness, doubtful in paralysis, not so much in articular or tendinous diseases. Hock. — Articular or tendinous tumors, hygroma, dilatation of the bursse of the extensors of the cannon and flexors of the foot, bony growths, peripheric periostitis, cold infiltrations, and indura- tions of cellular tissue. Drawings of the firing at the hock vary, according as it may be desired to fire the entire joint or only j)art. KEGIONS OF THE BODY. 171 In this latter case it is applied in vertical or oblique lines, form- ing a drawing as regular as possible. In the former case two ways are recommended ; in one the siu'face of the hock is divided into halves by a line drawn parallel with the tendo- Achilles ; all lines back of this one are parallel with it, and all those in front of it are parallel with the front of the hock, and therefore slightly oblique to the others. In the other method, a line is drawn from the point of origin of the tendo-Achilles vertically downward to the cannon bone, and upon this, oblique, feather-shaped lines are drawn on each side. Results, generally rather favorable in all the diseases of the hock. Leg. — Bony deposits, rupture of the cord of the flexor meta- tarsi; chronic swelling applied in lines parallel to the region. Results, very advantageous. Stifle. — Dilatation of femoro-patellar bursas, exostosis of the patella, luxation, pain remaining after bruises or wounds, liga- mentous fistulas of old standing. Applied in several parallel ver- tical lines in front, and on each side oblique to them. Results, almost always successfiil. Thigh and Goxo- femoral Joint. — For similar lesions to those of the shoulder, atrophy, paralysis, occult lameness ; same appli- cations. Results about the same. B. — Regions of the Body. Loins. — Weakness of vertebral column due to paralysis ; sprain of the vertebral column, vertebral periostitis, occult pains. Applied in lines parallel or oblique to the median line of the body. Results generally doubtful. 'Withers. — Chronic cysts, indurations following fistulous withers, old fistulas. A few lines parallel with the vertebral col- umn, the others oblique. Results almost always beneficial. Rihs. — Acute or chronic pleuresy and pneumonia. In lines parallel with the long axis of the ribs ; seldom used, the results are difficult to appreciate. Principally used by Nicholson and Maclean against contagious pleuro-pneumonia. Firing on the Surface, or a la Gaulet. This is so named after its inventor. The mode of operation is with cauteries which have their border, or the part which is apphed to the skin made to form a flat or slightly convex sur- face (instead of being thin and sharj)), in order to remedy one of the principal objections to ordinary firing, that of lea^4ng 172 OPEKATIONS ON THE SKIN AND CELLULAR TISSUE. permanent marks. It proposes to effect this by throwing upon the surface of the skin an even radiation of heat. The descrip- tion given by Mr. Gaulet is this: "The iron being heated to nearly a cherry color, a straight line is made in the principal direction of the region to be fired, and immediately alongside of it another, and so successively until the entire surface is covered. The first hues are then crossed, transversely or obliquely, by others, which perhaps also touch each other, and at last, in order to have the entire surface evenly cauterized, the parts which have not been touched in tracing the original lines are also touched with the iron which then retains but one-half of the heat it pos- sessed at first." * * * " After twenty-four hours, or perhaps less, an inflamma- tory swelling takes place, and the skin is covered with small blisters of serosity ; three weeks after, the crusts which have fol- lowed begin to drop off, and the hair is seen growing underneath them." According to Bouley, this method cannot be substituted for the ordinary cauterization. If applied lightly, its effects are not more severe than those of an ordinary blister ; but if applied in a severe form, it is Uable to be followed by the sloughing of large portions of skin, and to leave behind cicatrices of the very worst description. It has, however, in the hands of Mr. Paul Boviley, given satisfactory results in its application upon the stifle, the point of the shoulder, and the cyst of the withers, and with Mr. Naudin, in the treatment of chronic swellings of the extremities. Firing in Superficial Points. This form of cauterization is performed with instruments of conical or olivar forms (see Fig. 201), having the point blunt and rounded, in order to rest on the skin without incising or penetrating it. The point must not be so long as to cool off too rapidly, nor so short as to be incapable of retaining a sufficient amount of heat. In this mode of firing, the points or dots are arranged in quintu- ples, a first series of points being marked in either a vertical, obhque or horizontal Hne, equidistant from each other, and more or less close according to the indications ; a second series is marked on a parallel Hne, at a distance equal to that which sepa- rates the dots of the first series, and placing the first point on a line with the middle of the space separating the dots of the first FIEING IN SUPERFICIAL POINTS. 173 series, thus alternating the appUcation of the points in a third and fourth series, until the whole surface is covered. This makes a regular drawing, and leaves but httle blemish afterward. The rules pertaining to the appHcation of firing in straight lines are the same as in the cauterization in superficial points, and they apply to this also, but we beheve this is to be better indicated ia the firing of small surfaces, for bony deposits, ringbones, splints, spavins and side-bones, or generally in the treatment of circumscribed diseases. Fig. 205.— Firing in Dots and Points. Firing in poiiits is always more eJBfectual than that in straight lines, and being exempt from the danger of skin sloughs, it always leaves fewer blemishes. Moreover, ia a majority of cases, it can be appUed without casting the patient. These are points which should count largely in its favor. The principal objection to be urged against it is the greater length of time required to realize the full measure of its effects. Mr. Prange has invented a mode of cauterization, which is very similar to that in superficial points, but differing from it in the fact that instead of points, the ordinary flat iron is used. It is cauterization in Hues, but instead of being long and made with one stroke of the cautery, they are divided into short lines (see Fig. 203), also arranged in quiatuple, like the dots of the poiat firing. This method has not found favor with those who have experimented with it. 174 operations on the skin and cellular tissue. Objective Firing, In this mode of cauterization, the heat is transmitted, not by contact, but by radiation. It is a process rarely resorted to, and when it is used it is more as an adjiuict to transcurrent firing, or as a simple mode of revulsion. It consists simply in bringing the heated iron in close proximity with the surface to be cauterized. Gaulet is reported to have obtained good results from it in the treatment of ulcers, grease and ophthalmia ; Leblanc in chronic diseases of the eye, and Laux in the treatment of chronic lameness of the thigh. According to Gourdon, it is indicated for the arrest of some internal hemorrhage of mucous membranes ; for the re- duction of prolapsus of the rectum and of the uterus ; in hernias ; to stimulate the cicatrization of ulcers, and against some chronic inflammation of mucous membranes, of the conjunctiva, the pituit- ary membrane, etc. The cautery used by Mercier is square, oval or circular, with the surface, which is to face the skin, unpoHshed, while the other is smooth and poHshed, a disposition designed to graduate the firing by facilitating the radiation of the heat with the first, and diminishing it with the second. The special aim in this plan is to avoid the formation of a slough, and to attain it as perfectly as possible, the firing ought to be so managed, as to approximate the point of disorganization as nearly as possible without reaching it. In operating, the surgeon, after satisfying himself of the con- dition of the skin and its subjacent connections, moves the instru- ment to and fro over the part, carefully avoiding contact with the tegument. If the hair burns too quickly, it indicates an excess of heat, or that the instrument is too near the surface. The heat should be gradually increased from a brown to a cherry red color. The duration of the operation depends on the condition of the skin. When the epidermis can be easily scraped with the finger- nail, or is raised by the formation of small bhsters, and the fired surface becomes moist, and shows little drops of serosity, and the skin becomes thicker, denser, and more adherent to the subjacent tissues, the evidence is present that the proper degree of firing has been reached. The serosity increases immediately after the operation, and for some time continues to flow, until the surface is covered with OBJECTIVE FIRING. 176 its dried pellicles or crusts. On the second or third day an in- liaimnatory swelling is developed, and all the symptoms of ordin- ary lii-ing are manifested, and after three or four weeks the reso- lution is complete. If the firing has been too severe, the serous secretion becomes very abundant, and the inflammatory sweUing increases rapidly and becomes warm and painful. Towards the fifth or sixth day the skin becomes black, dries up, shrinks, is raised in large patches, and sloughs off, leaving a broad sm^face, covered with large granu- lations, very slow to cicatrize. One great advantage which objec- tive cauterization can claim o\'er ordinary firing is, that when prop- erly performed, it leaves no blemish whatsoever. Deep Cauterization. The cauterization which is carried beyond the thickness of the skin and penetrates the subcutaneous structures, receives this designation. The manner in which the cautery is inserted into the tissues, and the length of time it is allowed to remain in contact with them, have justified the division of this kind of cauterization into rapid deep^ and inherent, or disorganizing cauterization. Rapid Deep Cauterization. This is the comparatively recent mode known as needle firing, inasmuch as it consists in the insertion of elongated sharp, needle shaped cauteries, heated to a Hght red, Urbain Leblanc is credited with the introduction of this species of instrument and is the FiC. 206.— Abadie Cautery. 176 OPERATIONS ON THE SKIN AND CELLULAR TISSUE. author of the first report of its results. The first cautery used by Abadie resembled the one shown in Fig. 206. In using it, the animal is generally secured in the standing position. It is applied at a Hght red heat and made to penetrate through all the tissues down to the subcutaneous cellular structure, and even through the synovial sheaths. Leblanc's advice is to make the puncture by passing the iron three or four times in succession in the same spot, but Abadie completes it at a single stroke. This firing is followed by severe inflammation of the parts, great pain, swelling, abundant serous secretion, and the escape of synovial fluid. It has, therefore, powerful revulsive effects, which, how- ever, leave scarcely any marks, provided only the finest parts of the cautery have penetrated the tissues. Otherwise extensive and fatal suppurative arthritis may be looked for. This cauterization is indicated in cases of exostosis, tendinous swellings, articular and tendinous synovial dilatations, splints, riagbones, spavin, side- bones, thick tendons, articular and tendinous windgalls, thorough pins, blood spavins, etc. In the true needle cauterization or ignipuncture, the form of the cautery is changed, but in all other respects there is no difference. The forms of the needle instruments are numerous, and of course each one claims some special merit. The cautery of Bianchi and that of Foucher were first used, and these were fol- lowed by the instruments in which the point or needle of platinum could be changed. There were others of more complicated make, as those of Bourguet, Salles, Lagarrigue, VasseUn and others, or Fig. so?.— Bianchi Cautery, RAPID DEEP CAUTERIZATION. 177 Fig. 208.— Foucher Cautery. of more recent invention the autothermic cautery of Mr. Ehret (Fig. 211). In using these instruments, whatever may be the position of the animal, the perforation is made vsdth a single stroke only, the points being from three-fourths of an inch to an inch apart. When operating on a synovial bursa, the needle is applied but once ; but if the skin is thick and indurated, two or even three times may be necessary. The subsequent application of a stiff blister is recom- mended by some, immediately after the operation, but by others after an interval of a few days. This firing is always accompanied by severe inflammation and its usual phenomena, but it generally subsides after a few days. 178 OPEBATIONS ON THE SKIN AND CELLULAR TISSUE. Fig. 209.— Cautery with Changing Points. No severe accidents are likely to accompany needle firing. Small hemorrhages may occur, but they usually cease spontane- ously, though it must be admitted that fatal cases of arthritis have been recorded, which, however, are avoidable by the use of proper precautions. The attention required by the patient after these operations do not vary from those required in ordinary cau- terization, although the duration of the period of rest, always necessary, may be less prolonged. Inhekent Firing. This differs from other kinds, in beiug performed with the cautery heated to a white heat, with a view to produce more or less deep disorganization, according to the needs of the case. Sometimes the appUcation is made upon the surface only, but at others at a required depth upon the deeper tissues. INHERENT FIRING. 179 Fig. 2:0.-Bourguet Cautery. Fig. 2n.-Autothermic Cautery. 180 OPERATIONS ON THE SKIN AND CELLULAR TISSUE. In the first instance, it is indicated in superficial cutaneous ulcers, in wounds indisposed to cicatrize ; in those following warts, in fun- goid growths, in cancerous, melanotic or fibrous tumors, in gan- grenous wounds and those following the opening of a cold abscess ; in fistula due to caries or necrosis of bones, tendons or ligaments, etc. The instruments used are of various shapes : round, olivary, annular or cultellar. They are applied firmly upon the tissues, and held in place for a few seconds, according to the density of the parts If the surface is wider than the instruments, the firing must be done by sections, applying the iron in detail upon spots, until the entire surface has been touched. This is a better method than that of rubbing the instrument over the surface, and renders the effect more regular and uniform. In the second degree, or the cauterization into the depth of the tissues, a conical instrument is used and held in its place of insertion until it has lost most of its heat, thus reaching whatever depth may be neces- sary. This cauterization is indicated against anthracoid, gangrenous, farcinous and cancerous tumors ; in wounds of a virulent or veno- mous nature; in purulent infiltrations of the skin or of the cellular tissue ; in caries of bones, tendons, cartilages and liga- ments, in dental caries, in indurated tumors, in fimgoid growths, polypoid granulations, etc. Renault has recommended them in the treatment of the large sores so often occurring in granular dermatitis. Subcutaneous Cauteeization, Otherwise known as Neapolitan cauterization, or " a la Nan- zio," consists in the appUcation of the cautery in points directly upon the muscular structure, exposed by an incision made through the skin. The method was known and had been mentioned by Ruini, SoUeysel, Bourgelat, Reynal and others in more or less modified and varying terms, before Mr. de Nanzio called the at- tention of the profession to the good results he had obtained by it. Its application is principally efficacious in the treatment of chronic lameness of the shoulder or of the coxo-femoral joint. The instruments required are two bistouries, one curved and one straight, two flat tenaculums, a buU-dog forceps, scissors and an ordinary oHvary cautery. De Nanzio thus describes the oj^era- SUBCUTANEOUS CAUTERIZATION. 181 Fig. 212. — Cauteries of Nancio. tioj : " My method consists in making an incision from above downward to the skin covering the articulation, the location of which has been first carefully determined. The skin is then dis- sected from the cellular tissue, and the flaps enveloped with folds of wet cloth. The flat tenaculum placed on each border of the incision keeps it open, and mth a blunt cautery, not too red, three Fig. 213.— Firing b. la Nancio. 182 OPERATIONS ON THE SKIN AND CELLULAR TISSUE. or four points are applied upon the seat of the articulation, carefully ascertaining with the finger the point which the cau- terization has reached, and carefully avoiding the opening of the joint." The subsequent treatment is simple, and consists in cleanli- ness, lotions of clear or slightly astringent water, and the protec- tion of the wotmd by small threads of oakum. The suppuration is abundant and the wound ugly, but these effects are soon modi- fied, and healing is followed by only a simple linear cicatrix. Se- vere compHcations have been recorded as sequelae of this operation, but, on the other hand, several authors have spoken of it in very favorable terms. Our own experience with it has not been suffi- cient to warrant the expression of a confident opinion. Cauterization with the Thermo-Cautery. This valuable instrument, the invention of Doctor Paquelin, has only within a comparatively recent period been added defi- nitely to the armament of the veterinarian. The original instru- ment, as used in human surgery, has been modified by the inven- tor, and as now sold by our instrument makers, is fully adapted Fig. 214.— Paquelin Cautery. CAUTERIZATION WITH THE THERMO CAUTERY. 183 Fig. 215.— Paquelin and de Place Cautery. to veterinary practice, and possesses points of superiority over all the rest. It is used in the same manner and under the same rules as other modes of firing already considered, but w^hile its application is followed by similar results, it possesses also many other attendant advantages, which render it a valuable addition to our operative means. The veterinary cautery of Paquelin and de Place is a modifica- tion which has recently been introduced, and which is considered superior to the original instrument by those who have used it, principally on account of the facility with which an even degree of temperature is kept during the entire length of the operation. The low price of the instrument is also an important item for vet- erinary practice. Cauterization in Other Animals. Firing in Large Ruminants. — If firing is not as commonly used with these animals as with solipeds, it is not because its ne- cessities are less frequent, but rather from economic considera- 184 OPERATIONS ON THE SKIN AND CELLULAR TISSUE. tions, and because when they become seriously disabled, instead of subjecting them to expensive surgical treatment, a wise pecu- niary policy consigns them to the shambles where they may still claim an unimpaired market value ; while a dead horse is (in popular estimation, at least) held to be of no particular worth in theory, that is, whatever may be the unconscious practice of un- inquiring eaters of "beef." It has been apphed, however, in very numerous instances, by Cruzel, Roche, Lubin, Festal, and especially by Lafosse, who rec- ommended its apphcation in articular, muscular and tendinous lameness ; for synovial dilatations, bony growths, anchylosis and luxations, and also in nervous affections, epilepsy, paraplegia, va- rious paralytic cases and amaurosis. The modus operandi is the same as that already described for solipeds, although allowance must be made for the thickness of the skin, which requires a deeper application, and necessitates the repetition of the firing from twelve to fifteen times in the same line, in order to obtain an ordinary effect. The scabs of the firing generally separate in from fifteen to twenty days, and leave pale rose wounds, followed by cicatrizations with a smooth sur- face. The swelling of the parts, and the reactive fever following the operation, is more severe, but subsides quite readily. The animal must be prevented from rubbing or hcking himself in order to obviate the danger of secondary wounds with their trou- blesome comphcations, as with soHpeds. In smaller anim,als cauterization is seldom resorted to. In dogs, however, its apphcation is sometimes indicated in lameness of the elbow, the stifle, and even the hip joints. Superficial firing by points has been advantageously apphed, and is recommended by Peuch and Toussaint. Accidents of Actual Cauterization. To a great extent, the accidents and failures following the use of the cautery result from the non-observance of the rules estab- lished for the regulation of the operation, and subsequent care- less and incompetent nursing. The remedy for these is too obvi- ous to need mention. («) Section of the Skin. — This is a very common accident, usu- ally chargeable to the carelessness or incompetence of the sm*- ACCIDENTS OF ACTUAL CAUTERIZATION. 185 geon, or it may be caused by the use of too heavy or too sharp an instrument, or to an excess of heat or of pressure. It is recog- nized by the separation of the edges of the wound, and the ap- pearance at the bottom of the Hues of a white nacreous stria, shown by the subcutaneous tissue. There is no remedy for this accident, and though it is not a very severe lesion, it is likely to be followed by rough and irregular cicatrices. {b) Hemorrhage. — We have said that firing is an essentially bloodless operation if properly performed. The appearance, there- fore, of drops, or perhaps of a small stream of blood, at the bot- tom of the lines or points, and perhaps running over the surface of the skin, though unattended with danger and not likely to be injurious, is, at the least, evidence of some miscarriage of skill. If it arises from the use of a rough or too sharp an instiniment, it can be readily suppressed by searing the part, or applying uj)on bleeding vessels another cautery, heated a little in excess of the first. Sometimes the burning of a smaU quantity of pulverized resin, or of a small lock of hau- in the bleeding cavity, will have a sufficient hemostatic effect, and simple pressure will seldom, if ever, fail. (c) Tearing off Scabs. — This is the result of careless and in- secure dressing, and in omitting to provide effective safeguards for preventing the patient from reaching the wound with his own teeth, or rubbing it against some hard object. Suppurating wounds of various dimensions are often the result of this inad- vertency, requu'ing careful treatment, and sometimes leaving bad blemishes to be regretted. (d ) JSloughing of the Skin and Subcutaneous Tissues. — This accident is not uncommon, and like that just mentioned, is the effect of the improper application of the cautery, though less the effect of the firing than of burning the parts, and it is character- ized by all the conditions of ordinary bum wounds. Among specific causes, however, may be mentioned too strong a firing, or firing with lines too near together, or touching each other at some angle, or in crossing, or when too large an iron is used, or one brought to a radiating heat, or too high a temperature; or when greasy substances have been applied in the lines, or the skin submitted to long frictions. All these causes tend to the disorgan- ization of the skin, with mortification and sloughing, and its sej^ara- tion in large patches, leaving after healing, broad, ugly blemishes. 186 OPEEATIONS ON- THE SKIN AND CELLULAR TISSUE. (e) Bad cicatrices. — Though firing, however carefully applied, will always be followed by legible marks, there are cases in which bad, callous cicatrices form a positive and repulsive life-long dis- figurement of the animal. In the most aggravated forms of the ac- cidents enumerated, there are circumstances which particularly favor their occurrence. Among these may be regarded the thin- ness and sensitiveness of the skin, the interference of the animal himself, by rubbing and biting, and an excessive suppurative action accompanying the falling off of the scabs. No treatment is known that can be made effective against these lesions, but it is satisfactory to know that they do not inhere in the operation, and are preventable in the exercise of projDer skill by the operator, and attention by the nurse. EXUTORIES. An executory is any therapeutic agency or means the efi'ect of which is to promote the formation of purulent matter, and to sustain the suppurative process after it has been established. Some exutories have no special intrinsic quahties, and simply take effect in the manner characteristic of foreign bodies when lodged in any portion of the system ; while, on the other hand, some of them possess specific properties by which a special irrita- tion is produced in the tissues with which they come in contact. The various forms of seton are included in the first class; the trochiscus, bhsters, however composed, the moxa, and the actual cautery belong to the second. But while the fact of the utilization of the operation is as old as the practice of medicine itself, the modes of application and the materials used have varied considerably during various epochs. The use of the root of black hellebore was recommended for diseases of the ears in large ruminants, and also in the treatment of diseases of the chest, or in oedematous swellings of the abdomen. At a later period, the actual cautery found its advocates in the treatment of tetanus. The introduction of feathers, or long quills under the skin, in the treatment of old shoulder lameness, followed, and in some parts of the world this practice has not yet been wholly abandoned. Sometimes the feathers were used alone, and in other cases air was blown into the cellular tissue under the skin, in the parts where they were to be placed. The EXTJTORIES. 187 first description of the seton and its effects was given by Markam, in 1556. But even after that date we read of the use of irri- tating soft pencils, or candles composed of various ointments, melted or mixed together, and introduced under the skin, incised for the purpose, and more or less massed or bruised with some hard substance. But the accidents which were apt to accompany some of these energetic forms of treatment were of so serious a nature that they gradually fell into disuse, and to-day this class of principal exutories includes only the seton in its various forms, the trochiscus and the vesicating preparations. Exutories act as counter irritants, resolvents, and alteratives. The irritation which follows their contact with the living tissues excites the purulent secretions, and the activity in the process of interstitial resorption, which they stimulate, render theii' adoption and frequent use a source of much benefit and great satisfaction to the veterinary practitioner. The list of ailments in which their value is manifest and unquestioned is a long one, and com- prehends affections of the chest, catarrhal inflammation of the air passages,' and affections of the abdominal organs, with those of the eye, and in dogs of the ear. They stimulate the resolution of local affections having a tendency to chronicity, for example, oedematous swellings of the extremities, and they are frequently indicated in diseases of the locomotory apparatus, in certain af- fections of joints, and in rheumatic lameness, and also to excite the resolution of soft tumors, especially those of the synovial structures. The most ehgible of the forms in which exutories are prepared, especially when they are designed to act as a means of drainage, or to prevent the accumulation of pus in anfractuous cavities, is the seton. It is recommended in nervous affections and in paralysis, and also for the relief of atrophied regions, and, according to Bouley, it may often become a means of diagnosis, as well as of prognosis. In an acute disease having a tendency towards recovery, a seton wiU have an irritating effect, and give rise to a phlegmons sweUing about its tract, while in the same disease, if the tendency be toward a fatal termination, the artificial suppuration which it causes will soon cease to flow, and the tract will remain compara- tively dry. There have been those who have made the seton a prophylac- tic agent, or insurance institution, to be made use of at certain 188 OPERATIONS ON THE SKIN AND CELLULAR TISSUE. special periods or seasons of the year, and have thus invented the seton of prevention or of precaxdion, but without satisfactorily demonstrating what is to be prevented, or what anticipated. The theory, if any, in which such an assumption originates cannot be certified, and honest veterinarians cannot themselves identify it with such a practice or pretext. If exutories are a frequent resort, and are highly appreciated in veterinary surgery, and their general use is commonly unat- tended with danger, yet they are not always so absolutely harm- less that they may be trifled with, and prescribed without due consideration of the peculiar conditions under which their use is contra-indicated. It cannot be rationally supposed that the potency to which they owe their beneficial effect when rightly directed is to vanish when it is erroneously applied, and that it can be made innocuous by misdirecting it. Animals debilitated by heavy work or by disease ; those affected with cdironic organic ailments; those threatened with eruptive diseases, or suffering with septic complaints; none of these are fit subjects for the application of exutories. SETONS. A seton is a form of exutory which consists in the introduction of a foreign substance under the skin, ordinarily a band of linen tape, or a leather ring. The former is known as the tape seton, while the second is more appropriately termed a rowel. Tape Seton. This is usually merely a piece of clean, white tape, of suitable width and length as required by the case. In some circumstances, however, cords or braids of lint or horse-hair are substituted. The seton may either be introduced under the skin alone and dry, or it may be saturated with some irritating fluid, or covered with a stimulating ointment, to increase its effect and promote the purulent secretion. The operator must not fail to allow a suffi- cient length to securely tie the ends which pass out at the two openings of the tract through which it is drawn. Yet they are not always secured by an ordinary knot, but are quite generally united by a species of twist upon their extremities, which can be readily loosened when it becomes necessary. This knot must be sufficiently wide and strong to prevent it from slipping through SETON NEEDLES. 189 Fig. 216.— Seton Knots. the incision. In some cases, instead of making a knot on the tape, small wooden pins are secured at the extremities, and answer the same purpose. The essential instrument required to apply a seton is the peculiar needle known as the seton needle. It is, of coiu'se, made various lengths, some consisting of but a single piece (Fig. 218); Fig. 218. Fig. 219. Fig. 220. SETON NEEDLES. Fig. 221. 190 OPEBATIONS ON THE SKIN AND CELLULAR TISSUE. while others are in two or three sections, connected by screw joints (Figs. 219, 220, 221), and in some few instances fitted to handles (Fig. 217). But however they may otherwise vary, they are in the general form of a stiff, iron rod, with one lanceolated extrem- ity, both edges sharp, and a large eye at the blunt end to receive the tape. The lanceolated portion is slightly curved on the flat side. There are also other forms designed for special objects, among which may be mentioned one which is used for passing a seton through the frog of the foot, and is therefore known as the frog seton-needle. ' Fig. 222.— Frog Seton Needle. For small animals, such as the dog, the smaller sized straight needles are often suitable, and the one which is used for making the quiU-suture is very convenient. Besides the seton needle proper, in its authorized and usual patterns, occasions sometimes occur when to meet special requii'e- ments, a straight, pointed bistoury and a pair of scissors are re- quired as adjuncts. Fig. 223.— Quill Suture Needle. The operation of setoning is comparatively a bloodless one, and the division of the cellular tissues through which the needle passes is very often made without any hemorrhage. Yet there are regions where more or less blood may subsequently escape. A region, therefore, where the cellular tissue is abundant and loose, is that which is most favorable for the introduction of setons. The modus operandi is simple. The hair must be closely clipped from about the points selected for the two preUminary punctures, one for the entrance and one for the exit of the needle, SETON NEEDLES. 191 and the patient must be properly secured. Certain nervous ani- mals may oblige the siu'geon to place them in the recumbent posi- tion, but our experience has taught us that the cases in which this is necessary are very exceptional, and that in the great majority of operations, the simplest means of restraint, a twitch, with the raising and securing of one or two of the extremities, is all that is requii-ed. The application of local anesthesia, so far as it may be practi- cable, is also a measui'e which is in all respects judicious and com- mendable. With the spraying apparatus, any part of the body can be reached with great facility. In introducing the needle, many veterinarians pass it dii'ectly thi'ough the skin, which is raised in a fold, and drawn away as far as possible from the deeper tissues. This maybe readily practica- ble in regions where the cellular tissue is very loose and abundant, as under the chest ; but it is much less so, and more dangerous where the skin is thick, and the subjacent connective tissue is de- ficient or scant, and especially if the edges and point of the needle are not perfectly sharp. For this reason the method preferred by many is more judi- cious, of making an incision with the straight bistoury through the skin at each of the two extremities of the proposed tract through which it is intended to pass the seton. The manij)ulation is sufficiently easy and simple, the operator holding the skin in a fold with one hand, while with the other he guides the needle under the skin and parallel with it, through the cellular tissue, entering through one of the punctui'es made with the bistoury, and emerging through the other. The point most important to observe here is that of so guiding the needle in its motion that it shall neither plunge into the deeper tissues nor emerge outwardly at the wrong place. At this point the scissors may be utilized by laying blades .flatwise over the place of exit, and pressing down the surface. Directions are sometimes given, as the next step, to insert the tape into the eye of the needle, but it would seem that the safer plan would be to have the tape akeady in place when the needle is introduced. After the tape has been drawn through, and the needle disengaged, the next and final step is either to unite the ends of the seton by a knot, or, without tying, to secure them separately by the twisting or plaiting already described, and leave them free. 192 OPERATIONS ON THE SKIN AND CELLULAR TISSUE. The first effects following the application of a seton are those met with in a majority of ordinary wounds ; more or less swelling and inflammation, followed by an access of the suppurative pro- cess. At the points of insertion and exit of the needle, a certain amount of hemorrhage takes place, generally of no importance, and subsiding without interference, and this is succeeded by a swelling along the braid of the seton, at first more or less diffusi- ble, with a tendency to increase during the first forty-eight hours but then becoming more defined. In the beginning, and for the first two days, there is a flow of a thin serosity from the opening of the seton, which gradually assumes the character of suppura- tion of good quality in the shape of creamy, laudable pus. Up to this period the seton needs no attention, and should be left with- out interference, to exhibit the natural traumatic effect of its presence. Although it is desirable to have the suppuration weU established and flowing freely, it must not be permitted to accumu- late in the tract, and should be subjected once or twice a day to gentle pressure along the entire length of the seton, to expel the least portion of purulent matter present. At the same time, such a pressure as would be Hkely to crush the granulations of the wound and thus excite small hemorrhages, must be avoided. The cleaning and washing of the openings of the seton, and of the tape itself, must be carefully and strictly performed as often as the abundance of the discharge requires it. It should be sys- tematically attended to, not less than once or twice daily, at the least. Precautions must be taken to prevent the animal from biting and pulling off the seton, and yet this accident is very possible, and it may frequently become necessary to replace it. In that case the needle should be introduced by its blunt end, with the new tape previously inserted in the eye. At times it becomes necessary for other reasons to renew the seton. A feasible way to effect this will be to attach the old tape to the new, and draw out the former by means of the latter. The length of time a seton ought to be allowed to remain in place varies according to circumstances, extending to a period of from three to four weeks, or even longer. When the time has arrived for the discontinuance of a seton, if more than one have accomplished their purpose and had the desired effect, they ought not to be all removed at the same time, but singly, and with an interval between them. Nor must the APPLICATION OF TAPE SETONS. 193 wound be neglected because the seton lias been removed, but it must receive needed attention for several days. Tlie openings of the tract will still require cleaning, and the residue of the pus will still require the aid of pressure to effect the final emptying of the wound. Tape setons are applied upon all parts of the body, but more frequently, of course, in regions where their therapeutic effects are most needed, for which reason they will be most commonly fovmd on the breast, the ribs, the shoulder, the hip, the thigh, the stifle, the abdomen, the neck, the cheeks and the foot. («) The Breast. — This is a very common location for the setons. In inserting it the animal is secured in the usual way, but to pre- vent his striking the operator with his fore feet it will be necessary to have one of his hind legs raised and firmly held. If there is but one seton it must be introduced on the median line ; if two, one on each side of it. The position assumed by the operator varies, according to the abiUty he possesses, and the hand with which he operates. If ambidexter, and but a single seton is to be introduced, he can operate from either side of the animal, and if two are to be insert- ed, he can change the needle from one hand to the other, to suit his convenience, without change of position. This seton is to extend from the anterior extremity of the sternum downward and backward, vmder the chest, or between the fore legs, backward beyond the elbow. When the incision of exit has been made, and the tape introduced into the eye of the needle, the instrument must be drawn away in the direction op- posite to that in which it was introduced, to avoid the possibility of doing injury with the point or the edges. (J)) 0)1 the Hibs or the Chest. — Setons are used in these regions for the treatment of diseases of the thoracic organs. Sometimes as many as three are applied, either on one or both sides of the chest. They should be placed in a slightly oblique direction from before backward and from above downward, beginning about the middle of the side of the thorax, and ex- tending as far as the lower border of the chest, occupying, there- fore, the lower half of the thoracic cavity. The manner of insert- ing the seton in the tract made by an incision with a bistoury through a fold of the skin has been already described, and a repetition in minute detail becomes unnecessary. 194 OPERATIONS ON THE SKIN AND CELLULAR TISSUE. Care must be taken while operating in this region to avoid wounding the spur vein, which can be done by raising the skin well from it when the point of the instrument has reached its course, by which movement the needle passes outside of the vein and can be brought outside on the inferior border of the thorax. The tape is thfen placed in the eye of either the needle or the blade as already frequently described. Our own practice is to secure the tape through the eye of the blade, and draw the tape into position by removing the needle from below upward, considering this plan to be both more convenient and less dan- gerous. (c) At the Shoulder. — Setons are often applied in this region against lameness of old standing ; at times only one, at others two, or even more, according to the extent and location of the dis- eased region. When applying more than one, they are commonly placed parallel with each other. Many practitioners place them crossing each other, meeting in the middle of their length, with their point of meeting on a level with the center of the scapulo- humeral joint. In placing them, the compound, or three-jointed needle, somewhat flexible (already described), will be necessary, as beiag capable of adapting itself as much as possible to the convexity of the joint. Some care is required in the selection of a proper place for the puncture, and the animal must be kept in the standing position as much under restraint as possible. There is probably no special rule for the location and direction in which setons should be apphed, the discretion of the operator, in many cases, furnishiag the only guide. This is well illustrated in the application of the monstrous "seton a la G-aulet^'' so called from its inventor, and which consisted in surrounding the entire scapular surface with one immense seton, beginning at the cervical angle of the scapula, running along its anterior border to a point below the shoulder, passing in front of the breast to the axilla, through that region, horizontally back on a level with the elbow, to return outward and then upward to the dorsal angle of the scapula, where it ended. This form of exutory is no longer toler- ated, the dangers attending it, from the severe and exhausting drainage of the organism having brought it into discredit, with the result of its dismissal from general practice. A seton at the shoulder requires special protection from the animal, by means of the cradle or the side bars, its location APPLICATION OF TAPE SETONS. 195 makiag it too easily accessible to his teeth to be suffered to re- main long in place without such a defence. {d) Seton at the Hip-Joint. — Lameness of this region is fre- quently treated by the tape seton, the conditions of their appUca- tion being nearly identical with those required when the shoulder is the region involved. They are placed, whether single or dou- ble, directly over the articulation, or crossing each other in the X form, and also over the center of the joint ; and care must be taken that they are not inserted so obliquely as to interfere with the free flow of the pus. A needle similar to that used with the shoulder will be found convenient, and for a similar reason, the thickness of the skin, and the closeness of its connection with the sub-tissues, will render necessary the preliminary incisions with the bistoury to facilitate the entrance of the needle ; and the con- trol of the animal, as he is to be treated on his feet, should be secured by supplementing the restraint of the twitch with that of the side Hues, and raising one of the hind legs. (e) Setons at the Thigh. — These are prescribed in chronic swelling of the hind legs. The region they should cover extends from a level with a point a little below the inside of the ischial tuberosity to the superior third of the shank, and they should be placed in a slightly obHque direction from without inward. It is necessary while operating here, as in the hip-joint, to have the animal well secured, and not only the twitch and the side-lines, but sometimes the raising of one of the fore foot will be required ; as of all setons, this is probably the most painful to insert, in con- sequence of the division of branches of the sciatic nerves, which lie in the course of the needle. The steps of the operation do not in any way vary from those in other regions, and therefore do not call for a redescription excepting perhaps to specify that in placing the tape the convexity of the blade must be turned in- wardly, and an assistant will be needed to hold the tail aside. The tying of the tail to the surcingle on the opposite side of the body will prevent its becoming soiled with the discharge of the seton, and render the subsequent care of the patient easier. {f) Setons at the Stifle. — This seton is recommended by Peuch and Toussaint in lameness of that region which has resisted vesi- cating liniments and blistering applications. They recommend the recumbent position for the safety of the operator. A convex bistoury and the ordinary seton-needle are required. The animal 196 OPEBATIONS ON THE SKIN AND CELLULAR TISSUE. while lying down has his hind leg extended by the traction made upon it by assistants with a rope. An incision is made above with the bistoury, and the needle introduced through it, it is pushed downward in front of the joint, carefully raising the skin as it progresses, to avoid injury of the femoro-patellar articulation. {g) Seton on the Abdomen. — This seton is both difficult and dangerous to apply in the standing position, and, therefore, unless the animal is very carefully secured, and the operator unusually dexterous, it is better to have the animal cast. The seton placed on the median line, under the abdomen, extends from about the xyphoid cartilage back to near the sheath or other mammae. In applying it, care must be taken to avoid injury to the tunica abdom- inahs and the abdominal muscles, or making a deep wound of the abdomen. Caution must also be exercised against the possi- bility of the animal kicking against the needle at the moment of its passage through the skin at the opening of exit The tape when introduced in the eye of the instrument is to be drawn into the tract by puUing the needle away from behind forward. (A) Setons to the Neck. — These are recommended against im- mobihty and periodic ophthalmia. They are placed in an obhque direction, one or two, on one or both sides of the neck. The hori- zontal direction sometimes recommended is certainly quite un- likely to facilitate the free escape of pus. In introducing the needle it is better to direct it from below upward, starting at about the level of the convexity of the mastoido-humeralis muscle. (^■) Setons on the Cheeks. — These have been more or less ad- vised in the treatment of diseases of the eyes, and principally of periodic ophthalmia. They are placed a little below the zygomat- ic spine, below and in front of the temi^oro-maxHlary articulation, and extend downward some distance in front of the zygomatic crest. The blood vessels of that region, and principally the large nerves which cover the masseter muscles, must be carefuUy avoid- ed, to guard against paralysis of the lip. {j) Setons in the Foot. — The insertion of a seton in the foot, or i\ie frog-seton, as it is also called, has been principally recom- mended in the treatment of navicular disease, though it is con- sidered by many as of very doubtful utility. A special curved needle (see Fig. 222) is used for the purpose. The horse is in some instances kept in the standing position, while in some special cases it is better to have him thrown. KOWEL SETON. 197 The shoe being removed, and the sole and frog pared down and made as thin as possible, either an incision may be made in the hollow of the heels, or the needle inserted without it through the skin, in such a direction as to have its point emerge at about the front part of the middle commissure of the frog. The tape is drawn into position by pulling the instrument straight away through the opening of exit. The seton is to be secured by tying ends together. When the operation is performed while the animal is standing, a strong assistant must hold the foot, and the needle pushed and passed through the frog rapidly, as by possible struggles, severe injuries of the tissues of the posterior part of the foot might result. KowEL Seton. This form of exutory is of earher origin than the ordinary tape seton, and consists in a round piece of leather, felt or pasteboard , sometimes perforated in its center, which is deposited in a pouch Fig. 224.— Rowel Seton. made under the skin, either simple, or sometimes surrounded with a band of tape to prolong its continuance. It is piincipaUy used when the disposition of the parts renders the introduction of a tape seton diflficult, or when it is for any reason contra-indicated, and especially when the exutory being indispensable to the well being of the patient, it is at the same time imperatively required that the animal shall be preserved free from any blemish or dis- figurement. It is also to be preferred with animals which cannot be prevented from tearing out the ordinary tape seton with their teeth. A pau' of scissors and a straight bistoury are required for its insertion. A simple incision is made with the bistoury, long enough 198 OPEBATIONS ON THE SKIN AND CELLULAR TISSUE. to allow the introduction of the rowel, rolled or doubled on itself ; then, with the scissors passed flatwise under the skin, a pouch is made, by dividing the cellular tissues, of sufficient dimensions to secure the rowel, which is to be opened or unrolled and flattened in the pouch in such a manner as to bring its central opening in correspondence with the incision in the skin. This form of seton can remain for a period of from fifteen to twenty days, and there are cases where it has been kept in place as long as six weeks. It can easily be removed with the forceps or a pointed tenaculum. Trochiscus. This is an exutory formed of some mineral or vegetable sub- stance, sometimes termed an issue pea, possessed of irritating or even caustic properties, which are introduced imder the skin in the same manner as the rowel. They differ from the other exutories by causing a greater amount of irritation, a higher degree of in- flammation, and for that reason are left in place for a shorter period, and are removed as soon as inflammatory symptoms are well estabUshed. They are less frequently used in solipeds, but are of more common employment in cattle. In the former, how- ever, lameness of long standing in the upper segments of the legs has been successfully relieved by them. In cattle they are often inserted in the dewlap. They can be introduced directly under the skin, either through an incision made alone, or attached to a seton, which may continue longer in place after the removal of the trochiscus. Accidents, Sequels of Setons. The accidents which sometimes follow the application of setons are: hemorrhage, gangrenous swellings, abscesses, excessive granulations or fungosities, and indurations. (a) Hemorrhage. — In ordinary circumstances, their introduc- tion is accompanied by the escape of only a few drops of blood, but there are cases where abundant hemorrhages occur, either resulting from an injury to some blood vessels, or because of a special hemorrhagic predisposition in the animal, as when it is in a debihtated or anaemic state. When there is hemorrhage, it usually shows itself at the con- clusion of the operation, the blood oozing in drops from the open- ACCIDENTS, SEQUELiE OF SETONS. 199 ings of the seton, or causing a swelling, if it accumulates in the tract. The ordinary means of hemostasis must be employed, as cold douches, iced lotions, etc., and if these fail, the seton must be removed, and the openings plugged with oakum, moistened with hemostatic liquids, or with absorbent cotton ; or it may even be necessary to close the openings with sutures, or resort to the the appUcation of pressure. Bouley recommended the introduc- tion of a thick tent of oakum through the entii'e length of the tract. {b) Gangrenous Swellings. — These are among the most common and dangerous of accidents accompanying setons, and occur prin- cipally during warm weather, in debilitated animals, or such as are exposed to bad hygienic conditions or affected with some special diseases. The gangrene manifests itself by the appearance of a warm and painful swelliag, oedematous and diffused, spreading rapidly, but in the central portion cold and painless, and a general reaction soon becomes manifest. The animal becomes dull ; the pulse is accelerated and small, and the temperature heightened, the dis- charge of the setons has changed its character to that of a thin, sanious, and very foetid suppuration. All these symptoms become rapidly exaggerated, and soon threaten the life of the patient, unless heroic measures are at once resorted to. "When the tract assumes this gangrenous aspect the tape must be immediately removed, and the tract thoroughly emptied and cleansed, by injections of antiseptic liquids such as solutions of phenic or salicylic acid, followed by cauterization with the red iron in the tract, and through the oedematous swelliag, accom- panied by the free administration of tonics and antiseptics inter- nally. No means should be neglected likely to overcome the threatening septicaemia, which, if not controlled, wiQ certainly have a fatal termination. (c) Abscesses. — When the seton has been left in place too long, or there has been neglect ia respect to the care and cleanliness of the tract, or when the tape has been removed, numerous abscesses will sometimes be found along the course of the seton. They have the character of phlegmonous swellings, and soon become fluctuating. While they remain superficial, no serious results need be appre- hended, and all they require is to be opened to allow the escaj^e 200 OPEBATIONS ON THE SKIN AND CELLULAE TISSUE. of the pus, and to be treated generally after the manner of similar tumors in other parts of the body. But occasionally a filtration of the pus takes place between the different layers of tissues, and the abscesses become troublesome. To avoid their formation there must be a complete and regular evacuation of the tract by pressing out the contents once a day or oftener, according as the discharge requires it. To avoid the possibihty of the migra- tion of the pus and the formation of a deep abscess, the operator must be careful not to make a false tract with the needle during its passage under the skin. (d) Excessive Granulations or Jningosities. — These often occur at the openings of the tract, when the tape has been left in place a long time. They are not of a serious character, and can be re- moved by excision or cauterization. (e) Jncluratio7is. — These are also among the sequelae of setons left in position too long, or when, after the removal of the tape, care has not been taken to press out and thoroughly empty the tract of any remaining portion of the discharge. These indurations appear in the form of long, hardened cords, extending more or less in the original length of the setons. They often disappear spontaneously, by a slow process of resorption, but in many cases it becomes necessary to have recourse to friction with alterative ointments composed of preparations of mercury or iodine. Deep pointed cauterization, or their entire removal by dissection are also recommended. ABLATION OF TUMOES. Under this heading are included the various modes of the divi- sion of tissues involved in the removal of tumors — a tumor being, as technically defined, a non-inflammatory mass, constituted by tissues of new formation, and having a tendency to persistency and possible growth. The term ablation, of which the common definition is simply taking away, is in surgery employed to denote the excision or re- moval of tumors — a tumor being, in a surgical sense, any morbid, circumscribed enlargement affecting any of the structures or organs of the body, sometimes harmless, and sometimes malignant and fatal in their character and termination. The surgical means at the disposal of the veterinarian, by which this operation is accomplished, are not so numerous as ABLATION OF TUMOKS. 201 those employed in human surgery, and can be comprehended in the four principal processes of excision, ligature, tearing and puncture. They are about equally employed, according to the cu'cumstances and nature of the case, and the discretion of the operator. 1st. — Excision. This mode of ablation can be performed in four ways, with the scissors, the bistoury, the ecraseur or the thermo-cautery. (a) With the Scissors. — This is the simplest process, but is apphcable only to tumors of dimiautive size, such as warts, con- dyloma, and in general, to growths having a small and narrow peduncle. Curved scissors are generally used. The tumor is raised from the skin and secured with a pair of bull-dog forceps before the scissors are applied. The hemorrhage which may foUow is not usually serious, and ordinarily requires no interfer- ence, and when necessary, can be readily controlled by means of cooHng apphcations, pressure or cauterization. (b) With the Bistoury. — When the tumor is comparatively small, with a narrow peduncle, its removal is effected in the same manner as with the scissors, the only change being in the stroke of the instrument. Usually a single stroke of the bistoury is suf- ficient. But if the tumor is of large dimensions and covered by the skin, the operation becomes more compHcated and requires more time and care. It is ordinarily divided into three steps, viz. : the incision of the skin, the dissection of the tumor, and its extir- pation. The form and size of the incision must of course correspond to those of the tumor, which must be considered in reference to its basis, connections, adhesions and surrounding tissues, as weU as the healthy or morbid condition of the teguments. The straight incision is applicable to subcutaneous tumors, free from adhesions or comparatively loose and susceptible of enucleation, while that made thi-ough a fold of the skin is better adapted to encysted growths, which it would be dangerous to open. The elliptic incision is used when a portion of the skin is to be removed, because of its being diseased or too thin, and its closing up would be too difficult; or when the extent of the skin exceeds that of the wound it covers. Crucial incisions, or those of the T or Y shape, are indicated when a tumor of large size is to be exposed, 202 OPEKATIONS ON THE SKIN AND CELLULAB TISSUE. while it is necessary to preserve the skin which covers it. What- ever form of incision may be used, it must always extend beyond the base of the tumor to allow a free dissection and an easy removal of aU the diseased tissues. The convex bistoury is preferred in this step of an operation and must be applied with light pressure, and a very guarded motion, to avoid any subcutaneous blood ves- sels that may run over the surface of the growth, and which may be of large size. The incision is followed by the dissection, which is done with the scalpel or the bistoury, by separating the tumor from the teg- uments, carefully avoiding siirrounding structures, which should be held aside with the forceps or tenaculum, in order to keep the wound open and accessible. Instead of the scalpel or bis- toury, the blunt end of the scissors sometimes becomes the in- strument by which the adhesions of the cellular tissue covering the tumor are most easily destroyed. In the third step, or the extirpation of the tumor, either the bistoury, the scalpel or the sage knife may be the most eligible in- strument, according to the consistency of the tumor, whether hard, cartilaginous or bony If it is of sufficiently small size, by steady- ing it with the forceps or tenaculum, it may be excised with a single stroke of the instrument. If too large for this, it may be controlled by passing a loop of ribbon or taj)e through it, by which its position can be changed at pleasure, to facilitate its complete dissection. The hemorrhage following may be arrested by any of the usual hemostatic measures. When the tumor is of large di- mensions this last step of the operation will require great care in the execution, and the blood vessels which may run through its base must be securely ligated before the tumor is entirely excised. Fig. 225. — Ecraseur of C'hassaignac. ABLATIOX OF TUMORS. 203 (c) Wtth the Ecraseur. — The instrunaent used in this method has received its name from the fact of its crushing action upon the tissues upon which it is appHed and for which it was invented by Chassaignac. The original form of the instrument of Chassaig- nac has been subjected to various modifications, some being made to use with a chain alone, others to carry a wire, and others again to carry a chain or a wire alternately. Others like that of Keynal, of Miles, of Smith, and many others, vary also in shape or in size, but without differing in their general principles, and whether employed for the removal of tumors, or in special operations, as Fig. 287.— Ecraseur with Wire. Fig. 338.— Ecraseur with Chain or Wire. those of castrations in males, or spaying in females, the modus operandi remains the same. This consists in enclosing the base or pediincle of the tumor with the chain or wire of the instru- ment, and tightening it more or less rapidly at the discretion of the operator, by means of the screw in the handle until it is com- pressed, strangulated and crushed, and at last entirely separated. The action should be more or less gradual, according to the size of the parts and the consistency and vascularity of the tissues. A 204 OPERATIONS ON THE SKIN AND CELLULAR TISSUE. Fig. 229.— Ecraseur of Reynal. Pig. 289a.— Haussman Ecraseur. slow movement of the ecraseur is essential to avoid hemorrhage, but although this rule is recommended by European authors, it does not seem to be as important as it is reported to be, if we may judge by the results obtained by American practitioners, in view of the manner in which they use this instrument in the operations of castration. Our experience, however, justifies a slow and careful application of the crushing process, especially in the removal of tumors where blood vessels of large size or in a state of disease may be known to ramify, and particularly in the ablations of the champignon of castration. ABLATION OF TUMOKS. 205 {d) With the Thermo- Cautery. — The ablation of tumors can also be performed with the flat platinum cautery of Paquelin, well heated, by following the same rules as with the bistoury, both when either the growths are small, or the incision of the skin and dissections of the tumor have been previously performed. The advantages gained by the use of the red-heated cautery in controlling the hemorrhage while the incision goes on, is too ob- vious and important to be ignored or depreciated. 2d. — Ligature. The Hgature operates on the tumor in its own peculiar and effective way, by circumscribing the base and depriving it of its nutriment by occluding the circulation and leaving it to undergo the process of gangrenous dissolution and sloughing, with the ad ■ vantage of obviating any apprehended danger of subsequent hem- orrhage. The kind of Hgatures used for this purpose will vary with the choice of the practitioner. In veterinary surgery, the material is variously flax, hemp, silk, catgut, india rubber cords, or metaUic wire. WhijDcord or fishing line is often used, when a powerful constriction is to be apphed, and their efficiency is in- creased by being waxed or soaped. There are various ways of applying a Hgature, but they are all subject to the following rules : the size of the ligature must be proportioned to that of the parts to be ligated, and to their resistance ; it ought to be applied only upon a limited portion of the tissues, and the skin ought never to be included, except when the peduncle is very narrow, or the skin already ulcerated. First Method, Simple Ligature. — A cord or band is affixed around the base of the tumor, and tightly tied by a single knot. Sometimes the bleeding knot or double clove-hitch is preferred, drawn tightly and secured by a simple knot. The mortification of the growth may be accelerated, if thought proper, by covering the ligature with some caustic preparation, such as an ointment of sulphide of arsenic, or also by adding to the effect of the hgature that of the actual cautery. Second Method, Double Ligature. — This is brought into requisition when the peduncle of the tumor is too large to be easily embraced by a sin- gle Hgature. It is made by piercing the base of the j^j^ sso—Tapestry growth through the centre, by means of a straight Ligature. 206 OPERATIONS ON THE SKIN AND CELLULAE TISSUE. needle with a double thread or cord, thus dividing the growth into separate halves, each having its own distinct hgature, tied on opposite sides of the peduncle. Third Method^ Multiple Ligature. — At times, the tumor may have a sufficiently wide base to require the addition of a third ligature in order to secure a sufficient amount of constriction to slough the entire mass, in which case special needles become necessary. These are longer than the ordinary ones, though more or less flexible, and with an eye in the centre, additional to that at the extremity, according to indications. When the tumor is to be divided into three portions two needles are necessary, and a correspondingly long thread. The needles being passed together through the base of the tumor, with sufficient intervals between to divide it into three nearly equal Fig. 231.— Treble Ligature. parts, leave, when drawn through, three Hgatures with which to enclose separately the central and two lateral portions of the peduncle. If it becomes necessary to apply four ligatures, two different needles are necessary, one (female) long, having an eye in the Fig. 232.— Female Needle. Fig. 238.— Male Needle. centre, and another (male) of the ordinary form, with the eye at its extremity, but of a size which will permit its passage with a double thread through the central eye of the other. This male needle is to carry a long, double thread. The manipulation is very obvious. The first needle is inserted far enough to bring the central eye half way through the growth, and the second needle is passed through it, and out at the other side ; then, draw- ing out the first, two double ligatures are left, or one for each quarter of the tumor. All that then remains is the tying of the four knots. To describe it more in detail, the female needle is inserted in ABLATION OF TUMORS. 207 Fig. 234.— let Step of the Ligature by Four. Fig. 235.— Sd Step of the Ligature by Four. the growth until the eye reaches the centre, when the male needle is introduced at a right angle with it, and passed through the eye, as in Fig. 234, to be drawn out on the opposite side of the tumor carrying the ligatures with it (Fig. 235). In the second step of the operation, the passage of the male needle through the tumor with the double ligature is completed, and by the sej)aration of the needle from one of the threads, two threads are left loose. The female needle is then pushed through the ttunor, when one of the threads is cut off (Fig. 236) ; the fourth step being completed by having the female needle drawn back Fig. 336.-3(1 Step of the Ligature by Four. Fig. 23r.^th step of the Ligature by Four. through its original tract with the last threads or loop (Fig. 237), and when the needle is finally separated, it leaves the tumor divided into four segments by four threads, whose extremities are drawn and tightly secured by a single knot (Figs. 238, 239). 208 OPERATIONS ON THE SKIN AND CELLULAR TISSUE. Pig. 239 —The Liga- tures Secured. Fig. 238.— The Tumor divided in Four. Fourth Method, Subcutaneous Ligature. — This method is sel- dom practiced, as there are always objections to leaving under the skin the mortified structures divided by the constriction of the cord. But as there may be circumstances under which the growth cannot be immediately uncovered, its application becomes a ques- tion of necessity. Three needles are required: one, A, straight and sharp; the second, B, straight and pointed; the third, C, curved and also pointed. These are placed upon a single long thread. Fig. 240.— Tliread and Needles for Subcutaneous Ligatures. FiG. 241.— 1st Step. The growth A being subcutaneous, and spherical in shape, a vertical cutaneous fold is raised above its superior thu'd, through the base of which the needle A is introduced. Leaving the fold loose, and the skin resuming its position, a first portion of hga- ture is fovmd in place, under the teguments, surrounding one- third of the circumference at C (Fig. 241). The curved needle, C, is then passed through the tumor, entering at C, and coming out at B, with the loop D, and at B the needle is removed (Fig. 242). By these first steps of the operation, the superior third of the growth is surrounded by the loop of thread B, C, D, both of whose ABLATION OF TUMOKS. 209 Fig. 242.— 2d Step. Fig. 243.— 3d Step. extremities come out by the same opening (Fig.. 243), while a sec- ond thread, f f, is free between the superior and the two lower thii'ds of the tiimor (Fig. 244). The manipulations for the superior third of the growth are repeated for the lower third, with another thread, and the middle thkd is then surrounded by two parallel threads A, B and C, D (Fig. 245). Fig. 244.— 4th Step. Fig. 245.— 5tli Step. Both of these two threads are passed into the curved needle, and it then becomes easy to carry vmder the skin the extremity of the thread B to the opening D, and the thread A to the opening C, where it will be tied to thread B. All the threads A, B, C, D will thus form a loop embracing the middle third of the growth, as the other threads will siuTound the upper and the lower thirds. All the ligatures can be then tied to the required degree and the operation is completed (Figs. 246, 247). Fig. 246.- The Ligatures in Position. Fig. 247.— The Ligature Secured. When the Hgature that is to apply the necessary constriction upon the base of the tumor is in place, it must be tied more or 210 OPERATIONS ON THE SKIN AND CELLULAR TISSUE. less suddenly and firmly, but never with sufficient force to pro- duce an immediate section, an operation whicli could have been more easily performed, and with less pain, with the bistoury. To avoid this section, apply the constriction slowly, and in accordance with the effects produced, and the resistance encountered by the ligature. If the tissues are soft and frangible, it would be unsafe to com]3lete the constriction at once, and it should be deferred to a later period ; if, on the contrary, it is hard and resisting, the ligature may be drawn tightly, and firmly tied at once. Ordinary traction on the ligature may be made with the hands only, but when extra strong and steady traction is required, wooden holders will prove of great assistance. These means of securing the Uga- ture on the tumor are successful so long as it is comparatively superficial, but if it is situated at a certaia depth, special instru- ments are required. Among these is one particularly adapted to the removal of growths from the natural cavities, such as the nasal, rectal, vaginal or inguinal regions. It consists of a wooden or metallic tube, of variable length, through which the loop of a double, strong, waxed Hgature can be introduced into the cavity Fig. 248.— Ligature Carrier. and adjusted around the base of the tumor, and when in position, tightened by traction on the thread at the mouth of the tube, and so secured that the constriction can be maintained at any degree of tightness, and increased or relaxed at pleasure. 3d. — Elastic Ligature. This is but a variation from the ordinary Hgature, in which an india-rubber cord or tubing of suitable diameter is substi- tuted for the other means of constriction. It is applied like the others at the base of the tumor, and secured in the same manner. The pecuHarity of its action arises, of course, from its elasticity, the result of which is a constant unrelaxing, self-regulating con- striction, which continues automatically untO. the ablation is effected. The growth upon which the elastic ligature is aj^plied soon begins to undergo changes, which may be at first unnoticeable. ABLATION OF TUMORS. 211 But presently it becomes cooler, the skiu becomes soft, flabby, and of a dark brownish color ; the mass becomes dry and con- tracted, and in from fifteen to twenty days it drops off, leaving a wovmd which heals in the usual manner. The use of this Hgature is, we beheve, principally advantage- ous for small growths, and we have obtained good results from it in the castration of medium or small-sized animals, as well as in the treatment of small and superficial tumors, as warts, and the like. But in respect to large growths, such as the fibromas of the elbow joint, from the enormous size of the wound which follows, and the excessive length of time this requires to heal, we cannot feel justified in recommending it in similar cases. 4th. — Removal by Tearing. This is a method of extirpating tumors by mere force, grasp- ing them with one hand or with the forceps, and with the other they are simply — with a twisting motion — torn from their connec- tion. Of course it can only be practiced on small growths, but it has the advantage of preventing hemorrhage, and can be performed with the hands alone, or with the assistance of special forceps or nippers. The principal objection is that it sometimes fails to remove the fundamental element of the growth, and a renewal of the trouble may be looked for. 5th. — Puncture. This subject has already been partially considered. It is per- formed with either the bistoury, the lancet, or the trocar, but it is principally applicable to soft tumors only, and as by its un- aided action it is ordinarily insufficient to effect their complete disappearance, it becomes necessary to resort to instrumental help, in which cauterization with the pointed red iron, bhstering appHca- tions, or the injection of irritating or modifying compounds, as solution of tincture of iodine, become the ef&eient adjuncts, if not in truth the actual curatives. CHAPTER VI. OPERATIONS ON BONES. FRACTURES. In technical language a fracture is a " solution of continuity in the structure or substance of a bone," and it ranks among the most serious of the lesions to which the horse — or any animal — can be subject. It is a subject of special interest to veterinarians, and to horse owners as well, in view of the variety of forms in which it may occur, as well as of the loss of time to which it sub- jects the patient, and the consequent suspension of his earning capacity. Though of less serious consequence in the horse than in man, it is always a matter of grave import. It is always slow and tedious in healing, and is fre- quently of doubtful and unsatisfactory result. This solution of continuity may take place in two principal ways. In the most numerous in- stances it includes the total thickness of the bone and is a complete fracture. In other cases it in volves a portion only of the thickness of the bone, and for that reason is described as incomplete (Fig. 250) If the bone is divided into two separate portions, and the soft parts have received no injury, the fracture is a simple one ; or it becomes compound if the soft parts have suffered laceration, and comminuted if the bones have been crushed or ground into fragments, many or few. The direction of the break also determines its further classification. Broken at a right an- gle, it is transverse (Fig. 251) ; at a Fig. 249.-Complete »' "^ *= \ Fracture different angle it becomes oolique FRACTURES. 213 (Fig. 252), and it may be longitudinal or lengthwise. In a com- plete fracture, especially of the oblique kind, there is a condition of great importance in respect to its effect upon the ultimate re- sult of the treatment, in the fact that from various causes, such as muscular contractions or excessive motion, the bony fragments do not maintain their mutual coaptation, but become separated at the ends, and this fact has made it necessary to add another descrip- tive term in the words — loith displacement. And this term again suggests its negative, and introduces the fracture without disjjlace- PlG. 251.— Transverse Fracture of the Radius. Fig. 252.— Oblique Frac- ture of the Femur. 214 OPEEATIONS ON BONES. merit, when the facts justify this description. Again, a fracture may be intra-articular or extra-articular, as it extends within a joint or otherwise, and once more, intra-periosteal, when the peri- osteum remains intact. And, finally, there is no absolute limit to the use of descriptive terminology in the case. The condition of displacement is largely influential in deter- mining the question of treatment, and as affecting the final result of a case of fracture. This, however, is dependent npon its loca- tion or whether its seat be in one or more of the axes of the bone, in its length, its breadth, its thicknsss, or its circumference. An incomplete fracture may also be either simple or comminuted, the periostevim, in the latter case when it is intact, keeping the frag- ments together, the fracture in that case belonging to the intra,- periosteal class. At times there is only a simple fissure or split in the bone, making a condition of much difficulty of diagnosis. Two varieties of originating cause may be recognized in cases of fracture. They are the predisposing and the occasional. As to the first, diflerent species of animals difi'er in the degree of their liabihty. That of the dog is greater than that of the horse, and, in horses, the various questions of age, the mode of labor, the season of the year, the portion of the bodj^ most exposed, and the existence of ailments, local and general, are all to be taken into account. Among horses, those employed in heavy draught work or that are driven over bad roads, are more exposed than light-draught or saddle horses, and animals of different ages are not equally liable. Dogs and young horses, with those which have become sufficiently aged for their bones to have acquired an enhanced degree of frangibUity, are more hable than those which have not exceeded the time of their adult prime. The season of the year is undoubtedly, though in an incidental way, an imjDortant factor in the problem of the etiology of these accidents, for though they may be observed at all times, it is during the months when the slippery condition of the icy roads renders it difficult for both men and beasts to keep their feet, that they occur most frequently. The long bones, those especially which belong to the extremities, are most frequently the seat of fractures, from the circumstance of their superficial position ; their exposure to contact and collision, and the violent muscular efforts involved both in their constant rapid movement and their labor in the shafts or at the pole of heavy and heavily laden carriages. FKACTUKES. 215 The relation between sundiy idiosyncrasies and diatheses and a liability to fractures is too constant and well established a path- ological fact to need more than a passing reference. The history of rachitis, of melanosis, and of osteo-porosis, as related to an abnormal frangibihty of the bones, is a part of our common medi- cal kaowledge. There are few persons who have not known of cases among their friends of frequent and almost spontaneous fractures, or at least of such as seem to be produced by the sHghtest and most inadequate violence, and there is no tangible reason for doubting an analogous condition in individuals of the equine constitution. Among local predisposing affections, mention must not be omitted of such bony diseases as caries, tuberculosis, and others of the same class. Occasional or "efficient" causes of fracture are in most instances external tra.umatisms, as violent contacts, collisions, falls, etc., or sudden muscular contractions. These external acci- dents are various in their character, and are usually associated with quick muscular exertion. A violent, ineffectual effort to move too heavy a load ; semi-spasmodic bracing of the frame to avoid a fall or resist a pressure; a quick jump to escaj)e a blow; stopping too suddenly after speeding; struggling to liberate a foot from a rail — perhaps to be thrown in the effort — all these are familiar and easy examples of accidents happening hourly, by which our equine servants become sufferers. We may add to these the fracture of the bones of the vertebrae, occurring when a patient is cast for the purpose of undergoing a siu'gical opera- tion, quite as much the result of muscular contraction as of a pre- existing diseased condition of the bones. A fracture occurring under these circumstances may be called with propriety indirect, while one which has resulted from a blow or a fall differently caused is of the direct kind. The symptoms belonging to the existence of fracture vary ac- cording to the site of the lesion. In case of its being on a bone of the extremity there is irregularity in the jDcrformance of the functions of the apparatus to which the fractured bone belongs, and as a necessary consequence of the existing lesion, lameness more or less marked. If the broken bone belongs to one of the extremities, the impossibility of the performance of its natural function, in sustaining the weight of the body and contributing to the act of locomotion, is usually complete, though the degree of 216 OPEBATIONS ON BONES. poweiiessness will vary according to the kind of fracture and the bone which is injured. For example, a fracture of the cannon bone without displacement, or of one of the phalanges which are surrounded and sustained by a complex fibrous structure, is, in a certain degree, not incompatible with some amount of resting of the foot. But, on the contrary, if the shank bone, or that of the forearm be the impHcated member, it woiild be very difficult for the leg to exercise any agency whatever in the support of the body. And in a fractvire of the lower jaw, it would be obviously futile to expect it to contribute materially to the mastication of food. A fracture seldom occurs which is not accompanied with a degree of deformity, greater or less, of the region or the leg affected. This is due to the exudation of the blood into the meshes of the surrounding tissues and to the displacement which occairs between the fragments of the bones, with subsequently the swelling which follows the inflammation of the surrounding tissues. The character of the deformity will mainly depend upon the manner in which the displacement occurs. In a normal state of things the legs perform their movements with the joints as their only centres or bases of action, with no participation of intermediate points, while with a fracture the flexibility and motion which will be observed at unnatural points are among the most strongly characteristic signs of the lesion. No one need be told that when the shaft of a limb is seen to bend midway between the joints, with the lower portion swinging freely, that the leg is broken. But there are still some conditions where the excessive mobility is not easy to detect with certainty. Such are the cases where the fracture exists in a short bone, near a movable joint, or in a bone of a region where several short and small bones are united in a group, or even in a long bone where its situation is such that the muscular covering prevents the visible manifestation of the symptom. If the situation of a fracture precludes its discovery by means of this abnormal flexibihty, other detective methods remain. And after all there is one decisive sign which, though it may not avail in every case, as it does not, is in cases where its testimony can be secured absolute and positive beyond question. This is cre^)- itation, or the pecvdiar effect which is produced by the friction of the fractured surfaces one against another. Though discerned FRACTUKES. 217 by the organ of hearing, it can scarcely be called a sound, for the grating of the parts, as the rubbing takes place, is often more felt than heard, but there is no mistaking its import in cases favorable for the aj)pHcation of the test. The conditions in which it is not available are those of incomplete fracture, in which the mobility of the parts is lacking ; and those in which the whole array of phenomena are usually obscure. To obtain the benefit of this pathognomonic sign requires deliberate, careful, and gentle man- ipulation. Sometimes the sHghtest movements will be sufficient for its development, after much rougher handling has failed to discover it. Perhaps the failure in the latter case is due to a sort of defensive spasmodic rigidity caused by the pain resulting from the rude interference. More or less reactive fever is a usual accompaniment of a frac- ture, and an ecchymosis of the joarts is but a natural occurrence, more easily discovered in animals possessing a light-colored and deHcate skin than in those of the opposite character. There are difficulties in the way of the diagnosis of an incom- plete fracture, even sometimes when there is a degree of impair- ment in the function of locomotion, Avith evidences of pain and swelling at the seat of lesion. There should then be a careful examination for the evidences of a blow or other violence sufficient to account for the fracture, though very often a suspicion of its existence can only be converted into a certainty by a minute his- tory of the patient if it can be obtained up to the moment of the occurrence of the injury. A diagnosis ought not to be hastily pronounced, and where good ground for suspicion exists it ought not to be rejected upon any evidence less than the best. Serious and fatal comphcations are too often recorded of the results fol- lowing careless conclusions in similar cases, among which we may refer to one instance of a complete fracture manifesting itself in an animal during the act of rising up in his stall after a decision had been pronounced that he had no fracture at all. Fractures are of course liable to comphcations, those especial- ly, from the natui'e of the case, which are of a traumatic character, such as extensive lacerations, tearing of tissues, punc- tures, contusions, etc. But unless these are in communication with the fracture itself, the indication is to treat them simply as independent lesions upon the other parts of the body. A traumatic emphysema will at times cause trouble, and abscesses, 218 OPERATIONS ON BONES. more or less deep and diffused, may follow. In some cases small bony fragments from a comminuted fracture, becoming loose and acting as foreign bodies, may give rise to troublesome fistulous tracts. A frequent complication is hemorrhage, which often be- comes of serious consequence. A fracture in close proximity to a joint may be accomjianied by dangerous inflammations of im- portant organs, and may induce an attack of pneumonia, pleurisy, arthritis, etc., as well as luxations or dislocations, and the more so if situated near the chest. Ga7igrene, as a consequence of contusions or of hemorrhage or of an impediment to the circula- tion, caused by unskill fully applied apparatus, must not be over- looked among the occasional incidents ; nor must lockjav:i, which is not an uncommon occurrence. Even laminitis has been met with as the result of forced and long-continued immobility of the feet in the standing postiire, as one of the involvements of una- voidably protracted treatment. AVhen a simple fracture has been properly treated, and the broken ends of the bone have been securely held in coaptation, one of two things will occur. Either — and this is the more common event — there will be a union of the two ends by a solid cicatrix, the callus, or the ends will continue separated or become only partially united by an intermediate fibrous structure. In the first instance the fracture is consohdated, or united, in the second there is a false articulation, ox pseiido-arthrosis. The time required for a firm union or true consoHdation of a fracture will vary with the character of the bone affected, the age and constitution of the patient, and the general condition of the case. The union will be perfected earlier in a young than in an adult animal, and sooner in the latter than in the aged, and a general healthy condition is of course, in every respect, an advantage. The mode of cicatrization, or method of repair in lesions of the bones, has been a subject of much study among investigators in pathology, and has ehcited various expressions of opinion from those high in authority. But the weight of evidence and pre- ponderance of opinion are about settled in favor of the theory that the law of reparation is the same for both the hard and the soft tissues. In one case a simj^le exudation of material, with the proper organization of newly formed tissue, will bring about a union by the first intention, and in another the woi'k will be ac- FRACTURES. 219 companied by suppuration, or the \inion by the second intention, a process so familiar in the repair of the soft structures by granulation. Considering the process in its simplest form, in a case in which it advances without interruption or complication to a favorable result, it may probably be correctly described in this wise : On the occurrence of the injtiry an effusion of blood takes place between the ends of the bone. The coagulation of the fluid soon foUows, and this, after a few days, undergoes absorj)tion. There is then an excess of inflammation ia the surrounding structure, which soon spreads to the bony tissue, when a true ostitis is established, and the compact tissvie of the bone becomes the seat of a new vascular organization, and of a certain exudation of plastic lymph, Fig. 253.— Fracture of the Common Bone, with Callus. 220 OPERATIONS ON BONES. appearing between the periosteum and the external surface of the bone, as well as on the inner side of the medullary cavity. After a few days the ends of the bone thus surrounded by this exudate become involved in it, and the lymph, becoming vascular, is soon transformed into cartilaginous, and in due time into bony tissue. Thus the time required for the consolidation of the fractured segments is divisible into two distinct periods. In the first they are surrounded by an external bony ring, and the medullary cavity is closed by a bony plug or stopper, constituting the period of the provisional callus. This is followed by the period of permanent callus, during which the process is going forward of converting the cartilaginous into the osseous form. The restorative process is sooner completed in the carnivorous than in the herbivorous tribes. In the former the temporary callus may attain sufiicient firmness or consistency for the careful use of the limb within four weeks, but with the latter a period of from six weeks to two months is not too long to allow before removing the supporting apparatus from the Hmb. This in general terms represents the fact when the resources of nature have not been thwarted by untoward accidents, such as a want of vigor in the constitution of the patient or a lack of skill on the part of the practitioner, and especially when, from any cause, the bony fragments have not been kept in a state of perfect immobility and the constant friction has prevented the osseous union of the two portions. Failures and misfortunes are always more than possible, and instead of a solid and practicable bony union the sequel of the accident is sometimes a false joint, com- posed of mere flexible cartilage, a poor pseudo-arthrosis. The ex- planation of this appears to be that, first, the sharp edges of the ends of the bone disappear by becoming rounded at their extrem- ities, by friction and polishing against each other. Then follows an exudation of a plastic nature, which becomes transformed into a cartilaginous layer of a rough articular aspect. In this, bony nuclei soon appear, and the lymph secreted between the segments thus transformed, instead of becoming truly ossified, is changed into a sort of fibro-cartilaginous pouch or capsular sac, in which a somewhat albuminous secretion, or pseudo-synovia, permits the movement to take place. Most commonly, however, in our animals, the union of the bony fragments is obtained wholly through the medium of a layer of fibrous tissue, and it is because FRACTUEES. 221 the union lias been accomplished by a ligamentous formation only, that motion becomes jjracticable. The prognosis in a case of fracture in an animal is one of the gravest vital import to the patient, and therefore of serious pecu- niary concern to his owner. The period has not long elapsed when to have received such a hurt was quite equivalent to under- going a sentence of death for the suffering animal, and perhaps to-day a similar verdict is pronounced in many cases in which the exercise of a httle mechanical ingenuity, with a due amount of careful nursing, might secure a contrary result and insvu-e the re- turn of the patient to his former condition of soundness and use- fulness. Considered per se, a fracture in an animal is in fact no less amenable to treatment than the same description of injury in any other hving being. But the question of the propriety and expediency of treatment is dependent upon certain specific points of collateral consideration. First. The nature of the lesion itseK is a point of paramount importance. A simple fracture occurring in a bone where the ends can be firmly secured in coaptation, presents the most favor- able conditions for successful treatment. If it be that of a long bone it will be the less serious if situated at or near the middle of its length than if it were in close proximity to a joint, from the fact that perfect immobility can rarely, in the latter case, be secured without incurring the risk of subsequent rigidity of the joint. A simple is always less serious than a compound fracture. A comminuted is always more dangerous than a simple, and a trans- verse break is easier to treat than one which is oblique. The most serious are those which are situated on parts of the body in which it is difficult to secure perfect immobility, and especially those w^hich are accompanied by severe contusions and lacerations in the soft parts ; the protrusion of fragments through the skin ; the division of blood vessels by the broken ends of the bone ; the existence of an articulation near the point to which inflammation is likely to extend ; the luxation of a fragment of the bone ; lacer- ation of the periosteum ; the presence of a large number of bony particles, the result of the crushing of the bone — all these are cir- cumstances which discourage a favorable prognosis, and weigh against the hope of saving the patient for future usefulness. Fractures which may be accounted curable are those which are 222 OPERATIONS ON BONES. not conspicuously visible, as those of the ribs, where displace- ments are either very limited or do not occur, the j)arts being kept in situ by the nature of their position, the shape of the bones, the articulations they form with the vertebrae, the sternum, or their cartilages of prolongation ; those of transverse processes of the lumbar vertebrae ; those of the bones of the face ; those of the ili- um, and that of the cof&n bones. To continue the category, they are evidently curable when their position and the character of the patient contribute to aid the treatment. Those of the cranium, in the absence of cerebral lesions ; those of the jaws, of the ribs, with disjDlacement, of the hij), and those of the bone of the leg in movable regions, but where their vertical position admits of per- fect coaptation. On the contrary, a compound, complicated, or comminuted fracture, in whatever region it may be situated, may be accounted incurable. In treating fractures, time is an important element and " de- lays are dangerous." Those of recent occurrence unite more easi- ly and more regularly than older ones. /Second. As a general rule, fractures are less seriovis in animals of the smaller species than in those of more bulky dimensions. This influence of species will be readily appreciated when we real- ize that the difficulties involved in the treatment of the latter class have hardly any existence in connection with the former. The difference in weight and size, and consequent facility in handling, and making the necessary applications of dressings and other ajD- pliances for the purpose of securing the indispensable immobility of the parts, and usually a less degree of uneasiness in the de- portment of the patients are considerations in this connection of great weight. Third. In respect to the utilization of the animal, the most obvious point in estimating the gravity of the case in a fracture accident is the certainty of the total loss of the services of the pa- tient during treatment — certainly for a considerable period of time, perhaps permanently. For example, the fracture of the jaw of a steer just fattening for the shambles will involve a heavier loss than a similar accident to a horse. Usually the fracture of the bones of the extremities in a horse is a very serious casualty, the more so proportionately as the higher region of the limb is affected. In working animals it is exceedingly difficult to treat a FRACTURES. 223 fracture in such a manner as to restore a limb to its original per- fection of movement. A fracture of a single bone of an extremity in a breeding stallion or mare will not necessarily impair their value as breeders. Other specifications under this head, though pertinent and more or less interesting, may be omitted. Fourth. Age and temper are important factors of cuu*e. A young, growing, robust patient, whose tns vitce is active, is amen- able to treatment which one with a waning constitution and past mature energies would be unable to endure, and a docile, quiet disposition will act co-operatively with remedial measures which would be neutralized by the fractious opposition of a peevish and intractable siifferer. The fulfillment of three indications is indispensable in all frac- tures. The first is the reduction, or the replacement of the parts as nearly as possible in their normal position. The second is their retention in that position for a period sufficient for the formation of the provisional callus, and the third, which in fact is but an in- cident of the second, the careful avoidance of any accidents or causes of miscarriage which might disturb the curative process. In reference to the first consideration, it must be remembered that the accident may befall the patient at a distance from his home, and his removal becomes the first duty to be attended to. Of course this must be done as carefully as possible. If he can be treated on the spot so much the better, though this is seldom practicable, and the method of removal becomes the question call- ing for settlement. But two ways present themselves — he must either walk or be carried. If the first, it is needless to say that evei'y caution must be observed in order to obviate any additional pain for the suffering animal, and to avoid any aggravation of the injury. Led slowly, and with partial support if practicable, the journey will not always involve untoward residts. If he is carried it must be by means of a wagon, a truck, or an ambulance ; the latter being designed and adapted to the purpose, would, of course, be the preferable vehicle. As a precaution which should never be overlooked, a temporary dressing should first be jq^phed. This may be so done as for the time to answer all the j)urpose of the permanent adjustment and bandaging. Without thus secur- ing the patient, a fracture of an inferior degree may be trans- formed to one of the severest kind, and, indeed, a curable changed to an incurable injury. We recall a case in which a fast trotting 224 OPEKATIONS ON BONES. horse, after running away in a fright caused by the whistle of a locomotive, was found on the road limping with excessive lame- ness in the off fore leg, and walked with comparative ease some two miles to a stable before being seen by a surgeon. His imme- diate removal in an ambulance was advised, but before that vehi- cle could be procured the horse laid down, and upon being made to get upon his feet was found with a weU-marked comminuted fracture of the os suffraginis, with considerable displacement. The patient, however, after long treatment, made a comparatively good recovery, and though with a large bony deposit, a ringbone, was able to trot among the forties. The two obvious indications in cases of fracture are reditction, or replacement and retention. In an incomplete fracture, where there is no displacement, the necessity of reduction does not exist. With the bone kept in place by an intact periosteum, and the fragments seciired by the uninjured fibrous and ligamentous structure which surrounds them, there is no dislocation to correct. It is also at times ren- dered impossible by the seat of the fracture itself, by its dimensions alone, or by the resistance arising from the muscular contraction excited by the surgical manipulation. This is illustrated even in small animals, as in dogs, by the exceeding difficulty encountered in bringing the ends of a broken femur or humerus together, the muscular contraction being even in these animals sufficiently for- cible to renew the displacement. It is generally, therefore, only fractures of the long bones, and then at points not in close proximity to the trunk, that may be con- sidered to be amenable to reduction. It is true that some of the more superficial bones, as those of the head, of the pelvis, and of the thoracic walls may in some cases require special manipulations and appliances for their retention in their normal positions, but the treatment of these and of a fractured leg cannot be the same. The methods of accomplishing reduction vary with the features of each case, the manipulations being necessarily modified to meet changing circumstances. If the displacement is in the thickness of the bone, as in transverse fracture, the manipulation of reduc- tion consists in applying a steady pressure upon one of the frag- ments, while the other is kept steady in its place, the object of the pressure being the re-establishment of the exact coincidence of the two bony surfaces. If the displacement has taken place at an FEACTUKES. 225 angle it will be sufficient in order to efiect the reduction to press upon the summit or apex of the angle until its disappearance in- dicates that the parts have been brought into coaptation. This method is often practiced in the treatment of a fractured rib. In a longitudinal fracture, or when the fragments are pressed together by the contraction of the muscles to which they give insertion until they so overlap as to correspond by certain points of their cii'cumference, the reduction is to be accomplished by effecting the movements of extension, counter-extension, and coax)tation. Extension is accomphshed by making traction upon the lower por- tion of the limb. Counter-extension consists in firmly holding or confining the upper or body portion in such a manner that it shall not be affected by the traction applied to the lower ; in sim- pler language, holding it motionless against the force exercised in the extension. In other words, the operator, grasping the limb below the fracture, draws it down or away from the trunk, while he seeks, not to draw away, but simply to hold still the upper por- tion until the broken ends of bone are brought to theix- natural relative positions when the coaptation, which is thus affected, has only to be made permanent by the proper dressings to perfect the reduction. In treating fractures in smaU animals the strength of the hand is usually sufficient for the requii-ed manipulations. In the fracture of a forearm of a dog, for example, while the upper segment is firmly held by one hand, the lower may be grasped by the other and the bone itself made to serve the purpose of a lever to bring about the desu-ed coaptation. In such a case that is sufficient to overcome the muscular contraction and correct the overlaj)ping or other malposition of the bones. If, however, the resistance can not be overcome in this mode, the upper segment may be committed to an assistant for the management of the counter extension, leaving to the operator the free use of both hands for the further manij^vdation of the case. But if the reduction of fractures in small animals is an easy task it is far from being so when a large animal is the patient, whose muscular force is largely greater than that of several men combined. In such a case resort must be had not only to superior numbers for the necessary force, but in many cases to mechanical aids. A reference to the mode of proceeding in a case of fractm-e with displacement of the forearm of a horse will illustrate the 226 OPERATIONS ON BONES. matter. The patient is first to be carefully cast, on the uninjured side, with ropes, or a broad leather strap about 18 feet long, j)assed under and around his body and under the axilla of the fractured limb and secured at a point opposite to the animal and toward his back. This will form the mechanical means of counter extension. Another rope will then be placed around the inferior part of the leg below the point of fracture, with which to produce extension, and this will sometimes be furnished with a block or pulleys, in order to augment the power when necessary ; and there is, in fact, always an advantage in their use, on the side of steadiness and uniformity, as well as of increased power. It is secured around the fetlock or the coronet, or, what is better, above the knee and nearer the point of fracture, and is committed to assistants. The traction on this should be firm, uniform, and slow, without relaxing or jerking, while the operator carefully watches the process. If the bone is superficially situated he is able to judge, by the eye, of any changes that may occiir in the form or length of the parts under traction, and discovering at the moment of its happening the restoration of symmetry in the disturbed region, he gently but firmly manipvdates the place until all appearance of severed con- tinuity have vanished. Sometimes the fact and the instant of res- toration are indicated by a pecuhar sound, or "click," as the ends of the bone sHp into contact, to await the next step of the restora- tive procedure. The process is the same when the bones are covered with thick muscular masses, excepting that it is attended with greater diffi- culties, from the fact that the finger must be substituted for the eye, and the taxis must take the place of the sight, and the result naturally becomes more uncertain. It frequently happens that perfect coaptation is prevented by the interposition between the bony surfaces of substances, such as a small fragment of detached bone or a clot of blood, and some- times the extreme obhquity of the fracture is the opposing cause, by permitting the bones to slip out of place. These are difficulties which can not always be overcome, even in smaU-sized animals, and still it is only when they are mastered that a correct consoli- dation can be looked for. Yet without it the continuity between the fragments will be by a deformed callus, the union will leave a shortened, crooked or angular Hmb, and a disabled animal. If timely assistance can be obtained, and the reduction ac- FRACTURES. 227 complished immediately after the occurrence of the accident, that is the best time for it. But if it cannot be attended to until in- flammation has become established and the parts have become swollen and painful, time must be allowed for the subsidence of these symptoms before attempting the operation. A spasmodic musciolar contraction, which sometimes interposes a difficulty, may be easily overcome by subjecting the patient to general anesthesia, and need not, therefore, cause any loss of time. A tendency to this may also be overcome by the use of sedatives and anti-phlo- gistic remedies. The reduction of the fracture having been accomplished, the problem which follows is that of retention. The parts which have been restored to their natural position must be kept there, with- out disturbance or agitation, until the perfect formation of a caUus, and it is here that ample latitude exists for the exercise of ingen- uity and skOl by the surgeon in the contrivance of the necessary apj)aratus. One of the most important of the conditions Avhich are available by the surgeon in treating human patients is denied the veterinarian in the management of those which belong to the animal tribes. This is position. The intelligence of the human j)atient co-operates with the instructions of the surgeon, but with the animal sufferer there is a contiaual antagonism between the parties, and the forced extension and fatiguing posi- tion which must for a considerable period be maintained as a con- dition of restoration require special and effective appliances to insiure successful results. To obtain complete immobility is scarcely possible, and the surgeon must be content to reach a point as near as possible to that which is unattainable. For this reason, as will subsequently be seen, the use of sUngs and the re- straint of patients in very narrow stalls is much to be preferred to the practice sometimes recommended, of allowing entire freedom of motion by turning them loose in box stalls. Temporary and mova- ble apparatus are not usually of difficult use in veterinary practice, but the restlessness of the patients and their unwillingness to submit quietly to the changing of the dressings render it obliga- tory to have recourse to permanent and immovable bandages, which should be retained without disturbance until the process of consolidation is comjolete. The materials composing the retaining apparatus consist of oakum, bandages and splints, with an agglutinating compound 228 OPEKATIONS ON BONES. which forms a species of cement by which the different constit- uents are blended iato a consistent mass to be spread upon the surface covering the locahty of the fracture. Its components are black pitch, resia, and Venice turpentine, blended by heat. The dressing may be applied directly to the skin, or a covering of thin hnen may be interposed. A putty made with powdered chalk and the white of an egg is recommended for small animals, though a mixture of sugar of lead and burnt alum with the albumen is preferred by others. Another formula is spirits of camphor, Goulard's extract and albumen. Another recommendation is to saturate the oakum and bandages with an adhesive solution formed with gum arabic, dextrine, flour paste, or starch. This is advised particularly for small animals. Dextrine mixed, while warm, with burnt alum and alcohol cools and soUdifies into a stony consistency, and is preferable to plaster of Paris, which is less friable and has less soHdity, besides being heavier and requiring constant additions as it becomes older. Starch and plaster of Paris form another good compound. In applying the dressing the leg is usually padded with a cushion of oakum, thick and soft enough to equalize the irregu- larities of the surface and to form a bedding for the protection of the skin from chafing. Over this the splints are placed. The material for these is, variously, pasteboard, thin wood, bark, laths, gutta percha, strips of thin metal, as tin or perhaps sheet iron. These should be of sufficient length not only to cover the region of the fracture, but to extend sufficiently above and below to render the immobihty more complete than in the svu-rounding joints. The splints again, are covered with cloth bandages, linen preferably, soaked in a glutinous moisture. These bandages are to be carefully applied, with a perfect condition of lightness. They are usually made to embrace the entire length of the leg, in order to avoid the possibHity of interference with the circulation of the extremity, as well as for the prevention of chafing. They should be rolled from the lower part of the leg upward, and carefully secured against loosening. In some instances suspen- sory bandages are recommended, but excepting for small animals our experience does not justify a concurrence in the recommen- dation. These permanent dressings always need careful watching in reference to their immediate effect upon the region they cover, FKACTURES. 229 especially during the first days succeeding that of their applica- tion. Any manifestation of pain, or any appearance of swelling- above or below, or any odor suggestive of suppuration should excite suspicion, and a thorough investigation should follow with- out delay. The removal of the dressing should be performed with great care, and especially so if time enough has elapsed since its appUcation to allow of a probabiUty of a commencement of the healing process or the existence of any points of consolidation. With the original dressing properly applied in its entirety in the first instance, the entii'e extremity will have lost all chance of mobility, and the repairing process may be permitted to proceed without interference. There will be no necessity and there need be no haste for removal or change except under such special con- ditions as have just been mentioned, or when there is reason to judge that soHdification has become perfect, or for the comfort of the animal, or for its readaptation in consequence of the atrophy of the limb from want of use. Owners of animals are often temj)ted to remove a splint or bandage prematurely at the risk of producing a second fracture in consequence of the failure of the callus properly to consolidate. The method of applj-ing the splints which we have described refers to the simple variety only. In a compound case the same rules must be observed, with the modification of leaving openings through the thickness of the dressing, opposite the wovmd, in order to permit the escape of pus and to secure access to the points requiring the application of treatment. Feactuee of diffeeent Bones, Of the Cranial Bones. — Fractures of this variety in large animals are comparatively rare, though the records are not desti- tute of cases. ^\Tien they occur, it is as the result of external violence, the sufferers being usually runaways which have come in coUision with a wall or tree, or other obstruction ; or it may occur in those which in pulling upon the halter have broken it with a jerk and been thrown backward, as might occur in rearing too riolently. Under these conditions we have witnessed fractiires of the parietal, of the frontal, and of the sphenoid bones. These fractures may be of the complete or incomplete kind, which in- deed is usually the case with those of the flat bones, and they are liable to be complicated with lacerations of the skin, in conse- 230 OPEKATIONS ON BONES. quence of which they are easily brought under observation. But when the fact is otherwise and the skin is intact, the diagnosis becomes difficult. The incomplete variety may be unaccompanied by any special symptoms, but in the complete kind one of the bony plates may be so far detached as to press upon the cerebral substance with sufficient force to produce serious nervous com- pHcations. ^\Tien the injury occurs at the base of the cranium, hemorrhage may be looked for, with paralytic symptoms, and when these are present the usual ter- mination is death. It may still happen, however, that the symptoms of an appa- rently very severe concussion may dis- appear, with the result of an early and complete recovery, and the surgeon will do well to avoid undue precipitation in venturing upon a prognosis. In frac- tures of the orbital or the zygomatic bones the danger is less pressing than with injuries otherwise located about the head. The treatment of cranial fractures is simple, though involving the best skill of the experienced surgeon. When in- complete, hardly any interference is need- ed; even plain bandaging may usually be dispensed with. In the complete va^ riety the danger to be combated is com- pression of the brain, and attention to this indication must not be delayed. The means to be employed are the trephining of the skull over the seat of the fracture, and the elevation of the depressed bone or the removal of the por- tion which is causing the trouble. Fragments of bone in commin- uted cases, exfoliations, collections of fluid, or even protruding portions of the brain substance must be cleansed away, and a simple bandage so apphed as to facilitate the application of sub- sequent dressings. Fractures of the Bones of the Face. — In respect to their origin — usually traumatic — these injuries rank with the preceding, and are commonly of the incomplete variety. They may easily be over- FiG. 254.— Apparatus for Frac- ture of the Nasal Bone. FRACTURES. 231 looked and may even sometimes escape recognition until the rep- arative process has been well established and the discovery of the wound becomes due to the prominence caused by the presence of the provisional callus which marks its cure. When the fracture is complete it ^viLl be marked by local deformity, mobility of the fragments, and crepitation. Nasal hemorrhage, roaring, frequent sneezing, loosening or loss of teeth, difficulty of mastication, and inflammation of the cavities of the sinuses are varying complica- tions of these accidents. The object of the treatment should be the restoration of the depressed bones as nearly as possible to their normal position, and their retention in place by protecting splints, which should cover the entire facial region (Figs. 254, 255), Fig, 256.— Apparatus for Fracture of the Bones of the Face Applied. and special precautions should be observed to prevent the patient from disturbing the dressing by rubbing his head against sur- rounding objects, such as the stall, the manger, the rack, etc. Clots of blood in the nasal passages must be washed out, collec- tions of pus must be removed from the sinuses, and if the teeth ai'e loosened and likely to fall out, they should be removed. If roaring is threatened, tracheotomy is indicated. Fractures of the Pre-Maxillary Bone. — These are mentioned by continental authors. They are usually encountered in connec- tion with fractiu'es of the nasal bone, and may take place either in the width or length of the bone. The deformity of the upper lip, which is drawn sideways in 232 OPEBATIONS ON BONES. this lesion, renders it easy of diagnosis. The abnormal mobihty and the crepitation, with the pain manifested by the patient when undergoing examination, are concurrent symptoms. Looseness of the teeth, abundant saHvation, and entire inability to grasp the food complete the symptomatology of these accidents. In the Fig. 256.— Fracture of the Lower Jaw. treatment, splints of gutta percha or leather are sometimes used, but they are of difficult application. Our own judgment and practice are in favor of the union of the bones by means of metalhc sutures. The Zioioer Jaw. — A fracture here is not an injury of infrequent occurrence. It involves the body of the bone, at its symphysis, or back of it, and includes one or both of its branches, either more or less forward, or at the posterior part, near the temporo-max- illary articulation, at the coronoid process. Falls, blows, or other external violence, or powerful muscular contractions dur-ing the use of the speculum, may be mentioned among the causes of this lesion. The fracture of the neck and of the branches in front of the cheeks cause the lower jaw, the true dental arch, to drop without the ability to raise it again to the upper, and the result is a pecuHar and characteristic physiognomy (Fig. 256.) The prehension and mastication of food become im- possible; there is an abundant escape of fetid and sometimes bloody saliva, especially if the gums have been wounded ; there is excessive mobility of the lower end of the jawbone ; and there is FEACTUi.ES. 233 Fig. 257.— Splint for Fracture of the Lower Maxillary. crepitation, and frequently paralysis of the under lip. But al- though the aspect of an animal suffering with a complete and often compound and comminuted fracture of the submaxilla pre- sents at times a frightful spectacle, the prognosis of the case is comparatively simple, and recovery usually only a question of time. The severity of the lesion corresponds in degree vdth that of the violence to which it is due, the degree of simphcity or the amount of compHcation, and with the situation of the wound. It is simple when at the symphysis, but becomes more serious when it affects one of the branches, to be again aggravated when both are involved. Fracture of the coronoid process becomes import- ant principally as an evidence of the existence of a morbid diathe- sis, such as osteoporosis, or the like. The particular seat of the injury, with its special features, will of course determine the treatment. For a simple fracture without displacement, provided there is no laceration of the periosteum, an ordinary supporting bandage will usually be sufficient. But when there is displacement the reduction of the fracture must first be accompHshed, and for this special splints are necessary. In a fracture of the symphysis or of the branches the adjustment of the fragments by securing them with metallic sutures is the first step necessary, to be f oUowed by the application of supports, consisting of splints of leather or sheets of metal (Fig. 258 and 259), the entire 234 OPERATIONS ON BONES. Fig. 25S.— Splint, for Fracture of the Branches. front of tlie head being then covered with bandages prepared with adhesive mixtures. During the entire course of treatment a special method of feeding becomes necessary. The inability of the patient to appreciate the situation of course necessitates a resort to an artificial mode of introducing the necessary food into his stom- ach, and it is accomplished by forcing between the commissures of the lips, in a liquid form, by means of a syringe, the milk or Fig. 259.— Another Splint for Fracture of the Maxillary. FKACTUEES. 235 nutritive gruels selected for his sustenance, until the consoUdation is sufficiently advanced to jjermit the ingestion of food of a more soUd consistency. The callus will usually be sufficiently hardened in two or three weeks to allow of a change of diet to mashes of cut hay and scalded grain, until the removal of the dressing re- stores him to his old habit of mastication. Fractures of vertehrce. — These are not very common, but when they do occur the bones most frequently injured are those of the back and loins. The ordinary causes of fractui'e are responsible here as elsewhere, such as heavy blows on the sj^inal column, severe falls while conveyiag heavy loads, and especially violent efforts in resisting the process of casting. Although occurring more or less frequently under the latter cii'cumstances, the accident is not always attributable to carelessness or error in the management. It may, of coiu'se, sometimes result from such a cause as a badly iDrejjared bed, or the accidental presence of a hard body concealed in the straw, or to a heavy fall when the movements of the patient have not been sufficiently controlled by an effective apparatus and its skillful adaptation, but it is quite as likely to be caused by the violent resistance and the consequent jjowerful muscular contrac- tion by the frightened jjatient. The sim- ple fact of the overarching of the vertebral column, with excessive pressure against it from the intestinal mass, owing to the spasmodic action of the abdominal mus- cles, may account for it, and so also may the struggles of the animal to escape from the restraint of the hobbles while frantic under the pain of an operation without anaesthesia. In these cases the fracture usually occm-s ia the body or the annular part, or both, of the posterior dorsal or FiG.360.— Fracture of the Body the anterior lumbar vertebra. When the of a Dorsal Vertebra. tranversc processes of the last-named bones are injured, it is j)robably in consequence of heavy concus- sion incident to striking the ground when cast. Diagnosis of a fracture of the body of a vertebra is not always easy, especially when quite recent, and more especially when there is no accom- panying displacement. There are certain peculiar signs accom- panying the occurrence of the accident while an operation is in 236 OPEEATIONS ON BONES. Fig. 261a.— Comminuted Fracture of a Dor- sal Vertetorae at the Annular Portion. Fig. 261.— United Fracture of the Spi- nous Processes of Dorsal Vertebrae. progress which should at once excite the suspicion of the surgeon. In the midst of a violent struggle the patient becomes suddenly quiet ; the movement of a sharp instrument which at first excited his resistance fails to give rise to any further evidence of sensation ; perhaps a general trembling, lasting for a few minutes, will f oUow, succeeded by a cold, profuse perspiration, particularly between the hind legs, and frequently there will be micturition and defe- cation. Careful examination of the vertebral column may then detect a slight depression or irregularity in the direction of the spine, and there may be a diminution or loss of sensation in the j)osterior part of the trunk while the anterior portion continues to be as sensitive as before. In making an attempt to get ujDon his feet, however, upon the removal of the hobbles, only the fore part of the body will respond to the effort, a degree of paraplegia being present, and while the head, neck, and fore part of the body wiU be raised, the hiad quarters and hind legs will remain inert. The animal may perhaps succeed in rising and probably may be re- FRACTURES. 237 Fig. 262. — Fracture of the Axis in an Animal Suffering with OBteo-Porosis. moved to his stall, but the displacement of the bone will follow, converting the fracture into one of the complete kind, either thi'ough the exertion of walking or by a renewed attemj^t to rise after another fall, before reaching his stall. By this time the paralysis is complete, and the extension of the meningitis which has become estabUshed is a consummation soon reached. To say that the prognosis of fracture of the body of the vertebrae is always serious is to speak very mildly. It were better, perhaps, to say that occasionally a case may recover. Fractures of the transverse processes are less serious. Instead of stating the indication in this class of cases, as if assuming them to be medicable, the question naturally becomes rather a queiy : " Can any treatment be recommended in a fracture of the body of a vertebra?" The only indication in such a case, in our opinion, is to reach the true diagnosis in the shortest pos- sible time and to act accordingly. If there is displacement, and the existence of serious lesions may be inferred from the nervous symptoms, the destruction of the suffering animal appears to sug- gest itself as the one conclusion in which considerations of policy, humanity, and science at once unite. If, however, it is fairly evident that no displacement exists; that pressure upon the spinal cord is not yet present ; that the animal with a little assistance is able to rise ujaon his feet and to walk a short distance, it may be well to_ experiment upon the case to the extent of placing the j^atient in the most favorable circum- stances for recovery, and allow nature to operate without further interference. This may be accomplished by securing immobility 238 OPERATIONS ON BONES. of the whole body as much as possible, and especially of the sus- pected region, by placing the patient in slings, in a stall sufficiently narrow to preclude lateral motion, and covering the loins with a thick coat of agglutinative mixture, and wait for developments. Fracture of the Ribs. — The different regions of the chest are not equally exposed to the violence to which fractiu'es of the ribs are due, and they are therefore either more common or more easily discovered during life at some points than at others. The more exposed regions are the middle and the posterior, while the front is largely covered and defended by the shoulder. A single rib may be the seat of fracture, or a number may be involved, and there may be injuries on both sides of the chest at the same time. It may take place lengthwise, in any part of the bone, though the middle, being the most exposed, is the most frequently hui-t. In- complete fractures are usually lengthwise, involving a portion only of the thickness, or one or other of the surfaces. The complete kind may be either transverse or obhque, and are most commonly Fig. 263.— United Transversal and Longitudinal Fractures of the Ribs. denticulated. The fracture may be comminuted, and a single bone may show one of the complete and one of the incomplete kind at different points. The extent of surface presented by the thoracic region, with its complete exposure at all points, explains the liabihty of the ribs to suffer from all forms of external vio- lence. In many instances fractures of these bones continue undiscov- ered, especially the incomplete variety, without displacement, though the evidences of local pain, a certain amount of swelling and a degree of disturbance of the respiration, if noticed during the examination of a patient, may suggest a suspicion of their ex- istence. Abnormal mobility and crepitation are difficult of de- tection, even when j)i"esentj and they are not always present. FKACTURES. 239 Wlien there is displacement the deformity which it occasions "will betray the fact, and when such an injury exists the surgeon will, of course, become vigilant in view of possible and probable com- pHcations of thoracic trouble, and prepare himself for an encoun- ter with a case of traumatic pleuritis or pneumonia. Fatal injur- ies of the heart are recorded. Subcutaneous emphysema is a common accompaniment of broken ribs, and we recall the death from this cause of a patient of our own, which had suffered a frac- ture of two ribs in the region of the withers under the cartilages of the shoulder, and of which the diagnosis was made only after the fatal ending of the case. These hui'ts are not often of a very serious character, though the union is never as solid and complete as in other fractures, the callus being usually imperfect and of a fibrous character, with an amphiai'thi'osis formation. Still, compHcations occur which may impart gravity to the prognosis. Fractures with but a sHght or no displacement need no reduc- tion. All that is necessary is a simple apj)lication of a bHstering nature as a preventive of inflammation or for its subjugation when present, and in order to excite an exudation which will tend to aid in the support and immobilization of the parts. At times, however, a better effect is obtained by the appHcation of a band- age placed firmly around the chest, although, while this limits the motion of the ribs, it is aj)t to render the respiration more labored. If there is displacement with much accompanying pain and e\ddent irritation of the lungs, the fracture must be reduced with- out delay. The means of effecting this vary according to whether the displacement is outward or inward. In the first case the bone may be straightened by pressure from without, while in the second the end of the bone must be raised by a lever, for the in- troduction of which a smaU. incision through the skin and inter- costal spaces wiU be necessary. "When coaptation has been af- fected it must be retained by the external appUcation of adhesive mixture, with spHnts and bandages around the chest. Fractures of the bones of the 2^elvis will be considered under their separate denominations, as those of the sacrum and the os innominata, or the hip, which includes the subdivision of the ihum, the pubes, and the ischium. The Sacrum. — Fractures of this bone are rarely met with among solipeds. Among cattle, however, it is of common occur- 240 OPERATIONS ON BONES. rence, being attributed not only to the usual varieties of violence, as blows and other external hurts, but to the act of coition, and to violent efforts in parturition. It is generally of the transverse kind, and may be recognized by the deformity which it occasions. This is due to the dropping of the bone, with a change in its di- rection and a lower attachment of the tail, which also becomes more or less paralyzed. The natural and spontaneous relief which usually interposes in these cases has doubtless been observed by the extensive cattle breeders of the West, and their practice and example fully establishes the inutility of interference. Still, cases may occur in which reduction may be indicated, and it then be- comes a matter of no difficulty. It is effected by the introduction of a round, smooth piece of wood into the rectum as far as the frag- ment of the bone, and using it as a lever, resting it upon another as a fulcrum placed under it outside. The bone having been thus returned maybe kept in place by the ordinary external means in use. The Os Iniiominata. — Fractures of the ilium maybe observed either at the angle of the hip or at the neck of the bone ; those of the pubes may take place at the symphysis, or in the body of the bone ; those of the ischium on the floor of the bone, or at its pos- terior external angle. Or, again, the fracture may involve all three of these constituent parts of the hip bone by having its situ- ation in the articular cavity — the acetabulum by which it joins the femur or thigh bone. Some of these fractures are easily recognized, while others are difficult to identify. The ordinary deformity which characterizes a fracture of the external angle of the ihum, its dropping and the diminution of that side of the hip in width, unite in indicating the existence of the condition expressed by the term "hipped." But an incomplete fracture, or one that is complete without displace- ment, or even one with displacement, often demands the closest scrutiny for its discovery. The lameness may be well marked, and an animal may show but little appearance of it while walking, but upon being urged into a trot will manifest it more and more, until presently he will cease to use the crippled limb altogether, and perform his traveling entirely on three legs. The acute character of the lameness will vary in degree as the seat of the lesion ap- proximates the acetabulum. In walking, the motion at the hip is very limited, and the leg is dragged, while at rest it is reUeved from bearing its share in sustaining the body. An intelligent 241 Fig. S64.— Fractures of the Ossa Innominata : 1, at the external angle; 2, at the internal angle; 3, at the neck of the ilium; 4, at the body of the pubis; 4o, at the antero-external angle of the ischium ; 5, at the cotyloid cavity ; 6, at the postero-exter- nal angle of the ischium ; 7, at the symphysis pubis. oj)inion and correct conclusion will depend largely upon a knowl- edge of the history of the case, and while in some instances that will be but a report of the common etiology of fractvires, such as blows, hurts, and other external violence, the simple fact of a fall may fui-nish a satisfactory solution of the whole matter. With the exception of the deformity of the ilium in a fractiu-e of its external angle, and unless there has been a serious laceration of tissues and infiltration of blood, or excessive disj)lacement, there are no very definite external symptoms in a case of a fractui*e of the hip bone. There is one, however, which, in a majority of cases, will not fail — it is crepitation. This evidence is attainable by both external and internal examination — by manipulation of the gluteal surface and by rectal taxis. Very often a lateral motion, or bal- ancing of the hinder parts by pressing the body from one side to the other, will be sufficient to render the crepitation more distinct — a slight sensation of grating, which may be perceived even through the thick coating of muscle which covers the bone — and the sensa- tion may not only be felt, but to the ear of the expert may even become audible. This external manifestation is, however, not always sufficient in itself, and should always be associated with the rectal taxis for coiToboration. It is true that this may fail to add to the evidence of fracture, but till then the simple testimony aJOforded 242 OPEEATIONS ON BONES. by the detection of crepitation from the surface, though a strong confirmatory point, is scarcely sufficiently absolute to estabhsh more than a reasonable probability or strong suspicion in the case. In addition to the fact that the rectal examination brings the exjjloring hand of the surgeon into near proximity to the desu-ed point of search, and to an accurate knowledge of the situation of parts, both pro and con as respects his own views, there is another advantage attendant upon it which is well entitled to appreciation. This is the facility with which he can avail himself of the co-opera- tion of an assistant, who can aid him by manipulating the implicated limb and placing it in various positions, so far as the patient will permit, while the surgeon himself is making explorations and study- ing the effect from within. By this method he can hardly fail to ascertain the character of the fracture and the condition of the bony ends. By the rectal taxis, as if with eyes in the finger ends, he will " see " what is the extent of the fracture of the ilium or of the neck of that bone ; to what part of the central portion of the bone (the acetabulum) it reaches ; whether this is free from disease or not, and in what location on the floor of the pelvis the lesion is situated. We have frequently, by this method, been able to detect a fracture at the symphysis, which from its history and symptoms and an external examination, could only have been guessed at. Yet, with all its advantages, the rectal examination is not alwaj's necessary, as, for example, when the fracture is at the posterior and external angle of the ischium, when by friction of the bony ends the surgeon may discern the crepitation without it. Every variety of complication, including muscular lacerations with the formation of deep abscesses and injuries to the organs of the pelvic cavity, the bladder, the rectum, and the uterus, may be associated with fractures of the hip bone. The prognosis of these lesions will necessarily vary considerably. A fracture of the most siiperficial part of the bone of the ilium or of the ischium, especially where there is Httle displacement, will unite rapidly, leaving a comparatively sound animal often quite free from subsequent lameness. But if there is much disjDlacement, only a ligamentous union will take place, with much deformity and more or less irregularity in the gait. Other fractures may be fol- lowed by complete disability of the patient, as, for example, when the cotyloid cavity is involved, or when the reparatory process has left bony deposits in the pelvic cavity at the seat of the union. FEACTUEES. 243 whicli may, with the female, interfere with the steps of parturition, or induce some local paralysis by pressure upon the nerves which govern the muscles of the hind legs. This is a condition not in- frequently observed when the callus has been formed on the floor of the pelvis near the obturator foramen, pressing upon the course or involving the obturator nerve. The treatment of all fractiu-es of the hip bone should, in our estimation, be of the simplest kind. Rendered comparatively im- movable by the thickness of the muscles by which the region is enveloped, one essential indication suggests itself, and that is, to place the animal in a position which, as far as possible, will be fixed and permanent. For the accompHshment of this purpose the best measure, as we consider it, is to place him in a stall of just suffi- cient width to admit him, and to apply a set of slings snugly, but comfortably. This will fulfill the essential conditions of recovery, rest, and immobihty. Bhstering applications would be injurious, though the adhesive mixture might j)rove in some degree beneficial. The minimum period allowable for solid union in a fractured hip is, in our judgment, two months, and we have known cases in which that was too short a time. As we have before said, there may be cases in which the treatment for fractau'e at the floor of the pelvis has been followed by symptoms of partial paralysis, the animal, when lying down, being unable to regain his feet, but moving freely when placed in an upright position. This condition is due to the interference of the caUus with the functions of the obturator nerve, which it presses upon or surrounds. We feel warranted by our experience in similar cases in cautioning owners of horses in this condition to exercise due patience, and to avoid a premature sentence of condemnation against their invalid servants ; they are not all irre- coverably paralytic. With alternations of moderate exercise, rest in the slings, and the effect of time while the natural process of ab- sorption is taking effect upon the callus, with other elements of change that may be so operating, the horse may in due time be- come able to once more earn his subsistence and serve his master. Fracture of the Scapula. — This bone is seldom fractured, its comparative exemption being due to its free mobHity and the pro- tection it receives from the superimposed soft tissues. Only direct and powerful causes are sufficient to effect the injury, and when it occurs the large rather than the smaller animals are the 244 OPEBATIONS ON BONES. Fig. 265.— Transverse Fracture of the Scapula. subjects. The causes are heavy blows or kicks, and violent collisions with unyielding objects. Those which are occasioned by faUs are generally at the neck of the bone, and of the trans- verse and comminuted varieties. The diagnosis is not always easy. The symptoms are inability to rest the leg on the ground and to carry weights, and they are present in various degrees from slight to severe. The leg rests upon the toe and seems shortened, locomotion is performed by jumps. Moving the leg while examining it and raising the foot for inspection seem to produce much pain and cause the animal to rear. Crepitation is readily felt with the hand upon the shoulder when the leg is moved. If the fracture occurs in the upper part of the bone, overlapping of the fragments and dis- placement will be considerable. The fracture of this bone is usually classed among the more serious accidents, though cases may occur which are foUowed by recovery without very serious ultimate results, especially when the seat of the injury is at some of the upper angles of the bone, or about the acromion crest. But if the neck and the joint are FRACTUKES. 245 Pig. 266.— Bourgelat Apparatus for Fracture and Dislocation of the Shoulder Joint. FIG. S67.— The same in place. 246 OPEKATIONS ON BONES. the parts involved, complications are apt to be present which are likely to disable the animal for life. If there is no displacement a simple adhesive dressing, to strengthen and immobilize the parts, wiU be sufficient. A coat of black pitch dissolved with wax and Venice turpentine, kept in place over the region with oakum or Hnen bands, will be all the treat- ment required, especially if the animal is kept quiet in the shngs. Displacement cannot be remedied, and reduction is next to impossible. Sometimes an iron plate is applied over the parts and retained by bandages, as in the dressing of Bourgelat (Figs. 266, 267) ; and this may be advantageously replaced by a pad of thick leather. In smaller animals, and also in larger ones, the parts are retained by figure-8 bandages, embracing both the nor- mal and the diseased shoulders, crossing each other in the axilla and covered with a coatinsr of adhesive mixture. Fig. 268.— Delwart's Bandage for Fracture of the Scapula. Fig. 269.— Another Bandage, with Iron Splints. Fractures of the Humerus. — These are more common in small than in large animals, and are always the result of external trau- matism. They are generally very oblique, are often comminuted, and though more usually involving the shaft of the bone will in some cases extend to the upper end and into the articular head. There is ordinarily considerable displacement in consequence of FEACTURES. 247 the overlapping of the broken ends of the bone, and this, of course, causes more or less shortening of the hmb. There will also be swelling, with difficulty of locomotion, and crepitation will be easy of detection. This fracture is always a serious damage to the patient, leaving him with a permanently shortened limb and a remediless, lifelong lameness. If treatment is determined upon, it will consist in the reduction of the fracture by means of extension and counter extension, and in order to accomplish this the animal must be thrown. If suc- cessful in the reduction, then follows the application and adjust- FlG. 270.— Commlnutd Frac- ture of theHumerus. Fig. 271.— Oblique Fracture of the Humerus with Displacement and Partial Union. ment of the apparatus of retention, which must needs be of the most perfect and efficient kind. And finally, this, however skill- fully contrived and carefully adapted, will often fail to effect any good purpose whatever. Fracture of the Forearm. — A fracture in this region may also involve the radius or the cubitus, the first being broken at times in its upper portion above the radio-cubital arch at the olecranon. If the fracture occurs at any part of the forearm from the radio- 248 OPERATIONS ON BONES. cubital arch down to the knee, it may involve either the radius alone or the radius and the cubitus, which there intimately imite. Besides having the same etiology with most of the fractures, those of the forearm are, nevertheless, more commonly due to kicks from other animals, especially when crowded together in large numbers in insufficient space. It is a matter of observation that, under these circumstances, fractures of the incomplete kind Pig, 271a.— Consolidated Frac- of the Body of the Humerus. Pig. 272. Fractures of the Radius. are those which occur on the inside of the leg, the bone being in that region almost entirely subcutaneous, while those of the com- plete class are either oblique or transverse. The least common are the longitudinal, in the long axis of the bone. This variety of fracture is easily recognized by the appearance of the leg and the different changes it undergoes. There is inability to use the limb; impossibihty of locomotion; mobility FRACTURES. 249 Fig. 273.— Fracture of the Ulna. below tlie injury ; the ready detection of crepitation — in a word, tlie assemblage of all the signs and symptoms which have been already considered as associated with the history of broken bones. The fracture of the cubitus alone, princiiially above the radio- cubital ai'ch, may be ascertained by the aggravated lameness, the excessive soreness on pressvire, and perhaps a certain increase of motion, with a very slight crepitation if tested for in the usual way. Displacement is not likely to take place except when it is well up towards the olecranon or its tuberosity, the upper seg- ment of the bone being in that case likely to be drawn upward. For a simple fracture of this region there exists a fair chance of recovery, but in a case of the compound and comminuted class there is less ground for a favorable prognosis, especially if the elbow joiat has suffered injury. A fracture of the cubitus alone is not of serious importance, except when the same conditions prevail. A fracture of the olecranon is less amenable to treat- ment, and promises little better than a ligamentous union. Considering all the various conditions iavolving the nature and extent of these lesions, the position and direction of tlie bones of the forearm are such as to render the chances for recovery from fracture as among the best. The reduction, by extension and 250 OPERATIONS ON BONES. counter-extension; the maintenance of the coaptation of the seg- ments; the adaptation of the dressing by splints, oakum, and agglutinative mixtures ; in a word, all the details of treatment may be here fulfilled with a degree of facility and precision not attain- able in any other part of the organism. An important if not an essential point, however, must be emphasized in regard to the splints. ^Vhether these are of metal, wood, or other material, they should reach from the elbow joint to the groxind, and should be placed on the posterior face and on both sides of the leg. This is then to be so confined in a properly construct- ed box as to preclude all possibility of motion, while yet it must sustain a certain portion of the weight of the body. The iron spHnt rec- ommended by Bourgelat is designed for frac- tures of the forearm, of the knee, and of the cannon bone, and wall prove to be an appliance of great value. For small animals our prefer- ence is for an external covering of gutta per- cha, embracing the entire leg. A sheet of this substance of suitable thickness, according to the size of the animal, softened in lukewarm water, is, when sufficiently pliable, molded on the outside of the leg, and when suddenly hardened by the application of cold water forms a complete casing sufficiently rigid to resist all motion. Patients treated in this manner have been able to use the limb freely, without pain, immediately after the application iron Spiint for Fracture of the dressing. The removal of the splint is ^""^ Lugation of the Forearm. easily effected by cutting it away, either wholly or in sections, after softening it by immersing the leg in a warm bath. Fracture of the Knee. — This accident, happily, is of rare occur- rence, but when it takes place is of a severe character, being of the comminuted kind, and always accompanied by synovitis, with dis- ease of the joint, requiring for treatment therefor, besides the in- dication of perfect immobihty of the joint, that of open joints, synovitis, and arthritis. Fracture of the Femur. — The protection which this bone re- ceives from the large mass of muscles in which it is enveloped does Fig. 274. — Bourgelat'B FRACTURES. 251 not suffice to invest it with immunity in regard to fractures. It contributes its share to the hst of accidents of this description, sometimes in consequence of external violence and sometimes as the result of muscular contraction ; sometimes it takes place at the upper extremity of the boue; sometimes at the lower; some- times at the head, when the condyles become implicated; but it is principally found in the body or diaphysis. The fractiu-e may be of any of the ordinary forms, simple or compound, complete or in- complete, transverse or oblique, etc. A case of the comminuted variety is recorded in which eighty-five fragments of bone were counted and removed. The thickness of the muscular covering sometimes renders the diagnosis difficult by interfering with the manipulation, but the crepitation test is readily available even when the swelhng is con- siderable and which is likely to be the case as the result of the in- FlG. 275.— Fracture of the Femiir. Fig. 276.— Fracture, with Shortening. 252 OPERATIONS ON BONES. terstitial hemorrhage which naturally follows the laceration of the blood vessels of the region involved. If the f ractm-e is at the neck of the bone the muscles of that region (the gluteal) are firmly con- tracted and the leg seems to be shortened in consequence. Loco- motion is impossible. Crepitation may in some cases be discerned by rectal examination, with one hand resting over the coxo femoral articulation. Fractures of the tuberosities of the upper end of the bone, the great trochanter, may be identified by the deform- ity, the swelling, the impossibiUty of rotation, and the dragging of the leg in walking. Fracture of the body is always accompanied by displacement, and as a consequence a shortening of the leg, which is carried forward. The lameness is excessive, the foot being moved, both when raising it from the ground and when setting it down, very timidly and cautiously. " The manipulations for the discovery of crepitation always cause much pain. Lesions of the lower end of the bone are more difficult to diagnosticate with certainty, though the manifestation of pain while making heavy pressure upon the condyles will be so marked that only crepitation will be needed to turn a suspicion into a certainty. The question as to treatment in fractures of this description resolves itself into the query whether any treatment can be sug- gested that can avail anything practically as a curative measure, whether, upon the hypothesis of reduction as an accomplished fact, any permanent or efficient device as a means of retention is within the scope of human ingenuity. If the reduction were successfully performed would it be possible to keep the parts in place by any known means at our disposal? At the best the most favorable result that could be anticipated would be a reunion of the fragments, with a considerable shortening of the bone, and a helpless, limp- ing, crippled animal to remind us that for human achievement there is a "thus far, and no farther." In small animals, however, attempts at treatment are justifiable, and we are convinced that in many cases of difficulty in the appli- cation of splints and bandages a patient may be placed in a con- dition of undisturbed quiet and left to the processes of nature for "treatment " as safely and with as good an assurance of a favorable result as if he had been subjected to the most heroic secundum artem doctoring known to science. As a case in point, we may mention the case of a pregnant bitch which sufi'ered a fracture of the upper end of the femur by being run over by a light wagon. FRACTURES. 253 Her " treatment " consisted in being tied up in a large box and let alone. In due time she was delivered of a family of puppies, and in three weeks she was ronning in the streets, Umping very sHghtly, and nothing the worse for her accident. Fracture of the Patella. — This, fortunately, is a rare accident and can only result from direct violence, as a kick or other blow. The lameness which follows it is accompanied with enormous tumefaction of the joint and disease of the articulation. The prog- nosis is unavoidably adverse, destruction being the only termi- nation of an incurable and very painful injury. Fractures of the Tibia are probably more frequently encoun- tered than any others among the class of accidents we are consid- ering. As with injuries of the forearm of a Uke character, they may be complete or incomplete; the former when the bone is broken in the middle or at the extremities, and transverse, oblique, or longitudinal. The incomplete kind are more common in this bone than in any other. Complete fractures are easy to recognize, either with or -without displacement. The animal is very lame, and the leg is either dragged or held up clear from the ground by flexion at the stifle, while the lower part hangs down. Carrying weight or moving backward is impossible. There is excessive mobility below the fracture and well-marked crepitation. If there is much displace- ment, as in an oblique fracture, there will be considerable short- ening of the leg. While incomplete fractures cannot be recognized in the tibia with any greater degree of certauity than in any other bone, there are some facts associated with them by which a diagnosis may be justified. The hypothetical history of a case may serve as an illustration : An animal has received an injui-y by a blow or a kick on the inside of the bone, perhaps without showing any mark. Becoming very lame immediately afterwards, he is allowed a few days' rest. Being then taken out again, he seems to have recovered his sound- ness, but within a day or two, or even in a shorter time, he be- trays a little soreness, and this increasLag he becomes very lame again, to be furloughed once more, with the result of a temporary improvement, and again a return to labor and again a relapse of the lameness ; and this alternation seems to be the rule. The leg being now carefuUy examined, a local periostitis is readily discov- 254 OPEKATIONS ON BONES. Fig. 2' , — Fracture of the Tibia. Fig. 278.— Bourgelat'B Iron Splint for Fractured Tibia. ered at the jjoint of the injury, the part being warm, swollen, and painful. What further proof is necessary ? Is it not evident that a fracture has occurred, first superficial — a mere split in the bony structure which, fortunately, has been discovered before some extra exertion or a casual misstep had developed it into one of the complete kind, possibly with complications? What other infer- ence can such a series of symptoms thus repeated establish? The prognosis of fracture of the tibia must, as a rule, be un- favorable. The difficulty of obtaining a union without shortening and consequently without lameness, is proof of the futility of or- dinary attempts at treatment. But though this may be true in respect to fractures of the complete kind, it is not necessarily so with the incomplete variety, and with this class the simple treat- ment of the slings is all that is necessary to secure consolidation. A few weeks of this confinement wiU be sufficient. With dogs and other small animals, there are cases which may be successfully treated. If the necessary dressings can be success- fully applied and retained, a recovery will follow. FRACTUKES. 255 Fractures of the Hock. — Injuries of the astragalus have been recorded which had a fatal termination. Fractures of the os calcis have also been observed, but never with a favorable prognosis, and attempts to induce recovery have, as might have been anticipated, proved futile. Fractures of the Cannon Bones. — "Whether these occur in the fore or hind legs they appear either in the body or near their ex- tremities. If in the body, as a rule the three metacarpal or meta- tarsal are also affected, and the fracture is generally transverse and oblique, and often compound, one of the segments protruding sharply through the skin. Having only the skin for a covering the diagnosis is easy. There is no displacement, but excessive mo- PiG. 279.— Splint and Dressing for Fractured Cannon Bone. 256 OPERATIONS ON BONES. bility, crepitation, inability to sustain weiglit, and the leg is kept off the ground by the flexion of the upper joint. No region of the body affords better f acihties for the appHcation of treatment, and the prognosis is, on this account, usually favor- able. We recall a case, however, which proved fatal, though under exceptional circumstances. The patient was a valuable staUion of highly nervous organization, with a compound fracture of one of the cannon bones, and his unconquerable resistance to treatment, excited by the intense pain of the wound, precluded aU chance of recovery, and ultimately caused his death from nervous fever. The general form of treatment for these lesions will not differ from that which has been already indicated for other fractures. Reduction, sometimes necessitating the casting of the patient; coaptation, comparatively easy by reason of the subcutaneous sit- uation of the bone ; retention, by means of splints and bandages — apphed on both sides of the region, and reaching to the ground as in fractures of the forearm — these are always indicated. We have obtained excellent results by the use of a mold of thick gutta percha, composed of two sections and made to surround the entire lower part of the leg as in an inflexible case. Fracture of the first Phalanx. — The hinder extremity is more liable than the fore to this injury. It is usually the result of a Fig. 280 Splint and Dressing on Lower Part of Fore Leg. Fig. 281.— Bourgelat's Splint for Frac- ture of the Cannon and Phalanges. FRACTURES. 257 Fig. 282 Longitudinal Fractures of the Os Suffraginis. Fig. 283. Comminuted Fracture of the Oa Suffraginis. violent effort, or of a sudden misstep or twisting of tte leg, and may be transverse, or, as has usually been the case in our experi- ence, longitudinal (Fig. 282), extending from the upper articular surface down to the centre of the bone and generally obhque and often comminuted (Fig. 283). The symptoms are the swelling and tenderness of the region, possibly crepitation; a certain ab- normal mobihty; an excessive degree of lameness, and in some instances a dropping back of the fetlock, with perhaps a straight- ened or upright condition of the pastern. The difficulty of reduction and coaptation in this accident, and the probability of bony deposits, as of ringbones, resulting in lameness, are circumstances which tend to discourage a favorable prognosis. The treatment is that which has been recommended for all fractures, as far as it can be applied. The iron splint of figure 281 gives excellent results in many instances, but if the fracture is incomplete and without displacement a form of treatment less energetic and severe should be attempted. One case is within our knowledge in which the owner of an injured horse lost his property by his refusal to subject the animal to treatment, the post mortem revealing only a simple fracture with very slight dis- placement. 258 OPEKATIONS ON BONES. Fractures of the Coronet. — Though these are generally of the comminuted kind, there are often conditions associated with them which justify the surgeon in attempting their treatment. Though crepitation is not always easy to detect, the excessive lameness, the soreness on pressure, the inability to carry weight, the difficulty experienced in raising the foot, all these suggest, as the solution of the question of diagnosis, the fracture of the coronet, with the accompanying realization of the fact that there is yet, by reason of the situation of the member, immobilized as it is by its structure and its surroundings, room left for a not un- favorable prognosis. Only a slight manipulation will be needed in the treatment of this lesion. To render the immobility of the Fig. 284. -Animal with Fracture below the knee with Spinte and Support, Resting in Slings. FBACTURES. 259 region more fixed, to support the bones in their position by band- aging, and to estabHsh forced immobiLity of the entire body with the sUngs is usually all that is required. Ringbone, being a common sequela of the reparative process, must receive due at- tention subsequently. One of the severest complications likely to be encountered is anchylosis. Fractures of the Os pedis. — Though these lesions are not of very rare occurrence their recognition is not easy, and there is more of speculation than of certainty pertaining to their diagnosis. The animal is very lame, and, as much as possible, spares the in- jured foot, sometimes resting it upon the toe alone and sometimes not at all. The foot is very tender, and the exploring pincers of the examining sui'geon causes much pain. There is nothing to encourage a favorable prognosis, and a not unusual termination is an anchylosis with either the navicular bone or the coronet. No method of treatment needs to be suggested here, the hoof performing the office of retention unaided. Local treatment by baths and fomentations will do the rest. It may be months before there is any mitigation of the lameness. Fracture of the Sesamoid Bones. — This lesion has been con- sidered by veterinarians, erroneously, we think, one of rare oc- currence. We believe it to be more frequent than has been sup- posed. Many observations and careful dissections have convinced us that fractures of these little bones have often been mistaken for specific lesions of the numerous ligaments that are implanted upon their superior and inferior parts, and which have been de- scribed as a "giving way" or "breaking down" of these Hga- ments. In our ji^osi mortem examinations we have always noted the fact that when the attachments of the ligaments were torn from then- bony connections minute fragments of bony structure were also separated, though we have failed to detect any diseased process of the fibrous tissue composing the Ugamentous substance. From whatever cause this lesion may arise, it can hardly be considered as of a traumatic natvire, no external violence having any apparent agency in producing it, and it is our belief that it is due to a peculiar degeneration or softening of the bones them- selves, a theory which acquires plausibility from the consideration of the spongy consistency of the sesamoids. The disease is a pecuHar one, and the suddenness with which difi'erent feet are successively attacked, at short intervals and without any obvious 260 . OPERATIONS ON BONES. cause, seems to prove the existence of some latent morbid cause whicli has been unsusi^ectedly incubating. It is not peculiar to any particular class of horses, nor to any special season of the year, having fallen under our observation in each of the four seasons. The general fact is reported in the history of a majority of cases that it makes its appearance without premonition in animals which, after enjoying a considerable period of rest, are first exercised or put to work, though in point of fact it may manifest itself while the horse is still idle in his stable. A hyj)othetical case, in illustration, will explain our theory. An animal which has been at rest in his stable is taken out to work and it will be presently noticed that there is something un- FlG. 285.— Fracture of Os Sesamoids. usual in his movement. His gait is changed, and he travels with short, mincing steps, without any of his accustomed ease and free- dom. This may continue until his return to the stable, and then, after being placed in his stall, he will be noticed shifting his weight from side to side and from one leg to another, continuing the movement until rupture of the bony structure takes place. But it may happen that the lameness in one or more of the ex- tremities, anterior or posterior, suddenly increases, and it be- comes evident that the rupture has taken place in consequence of a misstep or a stumble while the horse was at work. Then, upon coming to a standstill, he vsdll be found with one or more of his FRACTURES. 261 toes turned up — he is unable to place tlie affected foot flat on the ground. The fetlock has dropped and the leg rests upon this part, the skin of which may have remained intact or may have been more or less extensively lacerated. It seldom happens that more than one toe at a time wUl turn up, yet stUl the lesion in one will be followed by its occurrence in another. Commonly two feet of a biped, the anterior or posterior, are affected, and we re- call one case in which the two fore and one of the hind legs were included at the same time. The accident, however, is quite as likely to happen while the horse is at rest in his stall, and he may be found in the morning standing on his fetlocks. One of the earhest of the cases occurring in oiu' own experience had been under oui- care for several weeks for suspected disease of the fet- locks, the nature of which had not been made out, when, appar- ently improved by the treatment which he had undergone, the patient was taken out of the stable to be walked a short distance into the country, but had little more than started when he was called to a halt by the fracture of the sesamoids of both fore legs. While there are no positive premonitory symptoms known of these fractures we believe that there are signs and symptoms which come but little short of being so, and the appearance of which will always justify a strong suspicion of the truth of the case. These have been indicated when referring to the soreness in standing, the short "mincing" gait, and the tenderness be- trayed when pressure is made over the sesamoids on the sides of the fetlock, with others less tangible and definable. These injuries can never be accounted less than serious, and in our judgment will never be other than fatal. If oiu' theory of their pathology is the correct one, and the cause of the lesions is truly the softening of the sesamoidal bony structure and inde- pendent of any changes in the ligamentous fibers, the possibihty of a solid osseous union can hardly be considered admissible. In respect to the treatment to be recommended and instituted it can only be employed with any rational hope of benefit during the incubation, and with the anticipatory pvirpose of prevention. It must be suggested by a suspicion of the verities of the case, and applied before any rupture has taken place. To prevent this and to antagonize the causes which might precipitate the final catastrophe — the elevation of the toes — resort must be had to the slings and to the application of firm bandages or splints, perhaps 262 OPERATIONS ON BONES. of plaster of Paris, with a liigh shoe, as about the only indications which science and nature are able to offer. When the fracture is an occurred event, and the toes, one or more, are turned up, any further resort to treatment will be futile. DISLOCATIONS. Strength and soUdity are so combined in the formation of the joints of our large animals that dislocations or luxations are inju- ries which are but rarely encountered. They are met with but seldom in cattle and less so in horses, while dogs and smaller animals are more often the sufferers. The accident of a luxation or (its synonym) dislocation (dis- placement) is less often encountered in the animal races than in man. This is not because the former are less subject to oc- casional violence involving powerful muscular contractions, or are less often exposed to casualties similar to those which result in luxations in the human skeleton, but because it requires the co- operation of conditions, anatomical, physiological, and perhaps mechanical, present in one of the races and lacking in the other, but which can not in every case be clearly defined. Perhaps the greater relative length of the bony levers in the human formation may constitute a cause of the difference. Among the predisposing causes in animals, caries of articular surfaces, articular abscesses, excessive dropsical conditions, de- generative softening of the ligaments, and any excessive laxity of the soft structures, may be enumerated. The symptoms of fractures and of dislocations are not always so variant as to preclude the possibility of error in determining a case without a thorough examination, but the essential difference, as it must always exist, must always be discoverable. In a dislocation there is one very pecuhar and characteristic feature in the impossibility of motion associated with an excessive liberty of movement — the impossibiUty of active or controlled motion, and a facility of passive movement (or movableness) at either the affected joint or at another of the same leg near to it. In a dislocation of the scapulo-humeral (or shoulder) joint the animal possesses no power of motion over the limb — no muscular contraction can avail to cause it to perform its various functions —but in the hands of the surgeon it may be made to describe a DISLOCATIONS. 263 series of movements which would be simply impossible with the joint in a state of integrity. Both fractures and luxations are marked by deformity, but while in a fracture with displacement there will usually be a shortening of the leg, a dislocation may be accompanied by either a shortening or a lengthening. Swelling of the parts is usually a well-defined feature of these injuries. With all this similarity in the symptomatology of luxations and fractures, there is one sign which either by its presence or its absence will greatly assist in settling a case of differential diag- nosis, and this is the existence or lack of crepitation. It has no place or cause in a mere dislocation ; it belongs to a fracture, if it is a complete one. If there is crepitation with a dislocation then it proves that there is a fracture also. The prognosis of a luxation is comparatively less serious than that of a fracture, though at times the indications of treatment may prove to be so difficult to apply that compHcations may ax'ise of a very severe character. The treatment of luxations must of course be similar to that of fractures. Eeduction, naturally, will be the first indication in both cases, and the retention of the replaced parts must follow. The reduction involves the same steps of extension and counter- extension performed in the same manner, with the patient subdued by anesthetics. The difference between the reduction of a dislocation and that of a fracture consists in the fact that in the former the object is simply to restore the bones to their true normal position, with each articular surface in exact contact with its companion surface, the apparatus necessary afterwards to keep them in situ being similar to that which is employed in fracture cases, and which will usually require to be retained for a period of from forty to fifty days, if not longer, before the ruptured retaining hgaments ai'e suffi- ciently firm to be trusted to perform their office unassisted. A vari- ety of manipulations are to be employed by the surgeon, consisting in pushing, pulling, pressing, rotating, and indeed whatever move- ment may be necessary, until the bones are forced into such rela- tive positions that the muscular contraction, operating in just the right directions, puUs the opposite matched ends together in true coaptation, a head into a cavity, an articular eminence into a trochlea, as the case may be. The " setting " is accompanied by a 264 OPERATIONS ON BONES. peculiar snapping sound, audible and significant, as well as a \dsible return of the surface to its normal symmetry. Special Dislocations. — While all the articulations of the body are liable to this form of injury, there are three in the large animals which may claim a special consideration, viz: 2'he Shoulder Joint. — We mention this displacement without intending to imply the practicability of any ordinary attempt at treatment, which is usually unsuccessful, the animal whose mishap it has been to become a victim to it being disabled for life. The superior head of the arm bone, as it is received into the lower cavity of the shoulder blade, is so situated as to be liable to be forced out of place in four directions. It may escape from its socket, according to the manner in which the violence affects it, outward, inward, backward, or forward, and the deformity which results and the effects which follow wiU correspondingly differ. We have said that treatment is generally unsuccessful. It may be added that the difficulties which interpose in the way of reduction are nearly insurmountable, and that the appHcation of means for the retention of the parts after reduction would be next to impossible. The prognosis is sufficiently grave from any point of view for the luckless animal with a dislocated shoulder. The Hip Joint. — This joint partakes very much of the char- acteristics of the scapulo-humeral articulation, but is more strongly built. The head of the thigh bone is more separated, or promi- nent and rounder in form, and the cup-like cavity or socket into which it fits is much deeper, forming together a deej), true ball- and-socket joint, which is, moreover, re-enforced by two strong cords of funicular Ugaments, which unite them together. It will be easily comprehended, from this hint of the anatomy of the re- gion, that a luxation of the hip joint must be an accident of com- paratively rare occurrence. And yet cases are recorded in which the head of the bone has been affirmed to slip out of its cavity and assume various positions, inward, outward, forward, and back- ward. The indications of treatment are those of all cases of dislocation. When the reduction is accomphshed the surgeon will be apprised of the fact by the peculiar snapping sound usually heard on such occasions. Pseudo luxations of the Patella. — This is not a true disloca- tion. The stifle bone is so peculiarly articulated with the thigh DISLOCATIONS. 265 bone that the means of union are of sufficient sti-ength to resist the causes which usually give rise to luxations. Yet there is some- times discovered a peculiar pathological state in the hind legs of animals, the effect of which is closely to simulate the manifestation of many of the general symptoms of dislocations. The peculiar pathological condition originates in muscular cramps, the action of which is seen in a certain change in the coaptation of the artic- ular surfaces of the stifle and thigh bone, resulting in the exhibi- tion of a sudden and alarming series of symptoms which have suggested the phrase of "stifle out" as a descriptive term. The animal so affected stands quietly and firmly in his stall, or per- haps with one of his hind legs extended backward, and resists every attempt to move him backward, and if urged to move for- ward he will either refuse, or comply with a jump, with the toe of the disabled leg di-agging on the ground and brought forward by a second effort. There is no flexion at the hock and no motion at the stifle, while the circular motion of the hip is quite free. The leg appears to be much longer than the other, owing to the straight- ened position of the thigh bone, which forms almost a straight line with the tibia from the hip joint down. The stifle joint is motionless, and the motions of all the joints below it are more or less interfered with. External examination of the muscles of the hip and thigh discovers a certain amount of rigidity, with perhaps some soreness, and the stifle bone may be seen projecting more or less on the outside and upper part of the joint. This state of things may continue for some length of time and untn treatment is applied, or it may spontaneously and suddenly terminate, leaving everything in its normal condition, but j)erhaps to return again. Pseudo-dislocation of the patella is likely to occur under many of the conditions which cause actual dislocation, and yet it may often occur in animals which have not been exposed to the or- dinary causes, but which have remained at rest in their stables. Sometimes these cases are referred to falls in a slippery stall, or perhaps slipping when endeavoring to rise ; sometimes to weakness in convalescing patients ; sometimes to lack of tonicity of structure and general debility; sometimes to relaxation of tissues from want of exercise or use. The reduction of these displacements of the patella is not usually attended with difficulty. A sudden jerk or spasmodic 266 OPEKATIONS ON BONES. action will often be aU that is required to spring the patella into place, when the flexion of the leg at the hock ends the trouble for the time. But this is not always sufficient, and a true reduction may still be indicated. To effect this the leg must be drawn well forward by a rope attached to the lower end, and the patella, grasped with the hand, forcibly pushed forward and inward and made to slip over the outside border of the trochlea of the femur. The bone suddenly slips into position, the excessive rigor of the leg ceases with a spasmodic jerk, and the animal may walk or trot away without suspicion of lameness. But though this may end the trouble for the time, and the restoration seem to be perfect and permanent, a repetition of the entire transaction may subse- quently take place, and perhaps from the loss of some portion of tensile power which would naturally follow the original attack in the muscles involved, the lesion might become a habitual weakness- Warm fomentations and douches with cold water will often promote permanent recovery, and Hberty in a box-stall or in the field will in many cases insure constant relief. The use of a high- heeled shoe is recommended by European veterinarians. The use of stimulating liniments, with frictions, charges or even severe blisters, may be resorted to in order to prevent the repetition of the difficulty by strengthening and toning up the parts. AMPUTATIONS. To amputate is simply to cxtt off. In veterinary surgery it comprehends the removal from the body of an animal of one or more of its projecting parts, as a portion of a leg, or an entire ex- tremity; the horns, the ears, the penis, the tail, etc. From the nature of the case it involves a degree of deformity, greater or less, with a loss of the function of the severed member. The difference between amputation and extirj)ation has respect only to the organs or members which become subject to the opera- tion. The parts already referred to are amputated ; the organs or members liable to extirpation have their seat in the interior regions, as the testicles, the ovaries, and even the uterus, in females, and any other non-vital organs or morbid growths, including some of the glandular structures, more particularly the lymphatic. Amputations in domestic animals are of two classes : In one case they are performed at the dictate of a capricious fashion, for AMPUTATIONS. 267 the alleged purpose of improving the appearance of the animal, and are performed upon parts of only secondary and accessory functional importance, and which may be removed almost with im- punity, as the ears, the tail or the horns. In the second class, the subject is brought under the general laws governing diseases and remedies, and they are practiced only as it becomes necessary by the existence of diseased conditions in important organs, such as the penis, the tongue and the locomotory organs. In this class the serious nature of the operation must be measured by the importance of the function fulfilled by the organ impUcated. The instruments necessary for the operation are amputating knives, similar to those used in human surgery, or more commonly those belonging to our veterinary work, a strong, convex bistoury, Figs. 286, 287.— Amputating Knives. Fig. 288.— Amputating Saw. which is generally sufficient, an amputating saw, means of tem- porary hemostasis, cord, an elastic band or ligature, needles, sutures and artery and dissecting forceps. For dressings, balls and pads of oakum of various sizes, com- presses and antiseptic washes are needed. In the present chapter we shall limit our consideration to the amputation of the legs, the horns and the ears. 268 operations on bones. Amputation of Members or Limbs. The amputation of the Hmbs of animals is a matter of much less importance than a similar mutilation would be in human sur- gery, and its occurrence is relatively much less frequent, being necessarily limited by the exclusion of that large class of subjects whose usefulness would necessarily be lost by the total impairment of their organs of locomotion, thus rendered unfit for their work, and even when it is indicated for animals designed for food con- sumption, the question becoming pertinent whether it would not be wiser and more profitable, in a large majority of cases, as it would unquestionably be more humane, to dehver them at once to the butcher, before subjecting them to a painful mutilation which must necessarily more or less impair their condition, and therefore materially diminish their market value. As a matter of fact, it is principally upon dogs that, in ordinary circumstances, the veterinarian is called to operate in this manner, as even in his mutilated condition, he may continue to be able to fulfil many of his duties as one of the domestic animals. But stiU there are circumstances in respect to animals other than the dog, under which the operation may be indicated and rationally prac- ticed, as when the life of a valuable animal is to be saved on account of his desu-able qualities as a breeder, and which may not be dis- abled from his special function by the lack of a limb. A valuable ram or bull, a high-bred ewe or cow, or perhaps also a mare or a stalHon, may, for such a reason, become proper subjects for an amputation. But even under these conditions, other considerations of impor- tance must not be overlooked, and whether it is a fore or a hind leg which must be sacrificed, will be a point of great weight to be considered in deciding for or against the operation. A female with only three legs may yet carry a foetus to term, and be fat- tened and put in good condition before being sold for meat, or may possibly be covered by a male ; but it would be impossible for the stalhon or the bull, deprived of one of his hind quarters, to mount and keep the raised position a sufficient time to complete the act of copulation. Animals of small size and weight, being more supple and active in their movements, suffer least from the loss of one of their limbs. The distance from the mass of the body to the seat of the ampu- AMPUTATIONS. 269 tation is also a consideration of moment. A reference to all the reasons will necessarily prove that of all domesticated animals, the horse is probably the one upon which the operation is least justifiable. If ever to be performed upon him, it can only be upon the lower regions of the leg close to the ground, inasmuch as the shortened leg can still be made useful as an apparatus of support, either directly or indii'ectly, by artificial means. The sum of the matter seems to be embodied in the following general considerations pertaining to the question of the amputa- tion of the limbs of our domestic animals : 1st. In Dogs it is indicated in diseases of both bones and soft parts, as in comminuted fractures, comphcated with contused wounds of the skin or other soft strictures ; in old caries, com- phcated with suppurative arthritis ; in osteo-sarcoma ; in the crushing of muscular tissues around bones and then- complete separation ; in extensive gangrene, as that resulting from the ap- pUcation of too tight a bandage ; in chronic suppurative articular disease ; in sloughs of soft tissues surrounding the exposed bones ; and in deep cancerous affections. 2d. In O vines. — Indications are offered, as in dogs, in com- minuted fractures, with lacerations of soft tissues, and more com- monly in comphcated phalangeal arthritis. 3d. In Bovines. — The same conditions exist as in the smaller ruminants. 4th. In Equines. — Amputation is indicated as a means of sa\ing an animal for breeding purposes ; in comphcated fractures of the cannon bone, or of the phalanges ; in gangrene of the digital organs; extensive abscesses of the same region, with softening of tendons, and in suppurative arthritis. It is also sometimes per- formed for the removal of a supplementary limb. 5th. In Birds. — The amputation of a wing or even of a leg can be performed, either to prevent flight, or to reHeve a diseased process of the limb. But in all cases it should be performed upon healthy tissues, above the seat of the disease, and at the greatest, possible distance from the trunk. The number of cases on record is not large, and they are prin- cipally reported in European veterinary journals. In these we find a case of amputation at the hock in a ewe, by Chabert ; in a cow at the knee, by Chaumontel; in an ox of one of the toes, by 270 OPERATIONS ON BONES. Durant ; in a dog at the arm, by Fromage de Feugre ; in a sheep, in a case of foot rot, by Lecoq; in a mare at the fetlock, by Maurette ; in a stallion, on the third phalanx, by Bouley ; and in English journals: in a cow in the metacarjDal region, by Laing; a cow on the hind cannon, by Shield ; and on a mare in this coimtiy, by Huidekoper. Others are reported, which were attended by vari- ous degrees of success, many of them, however, terminating fatally. The proper mode of performing the operation is to secure the animal in the decubital position, and to place him under the influ- ence of general anesthesia, securing temporary hemostasis, by the application of the circular Ugature, or a bandage tightly placed above the point of amputation, or, preferably, by using the process of Esmarch, which secures a more perfect removal of the blood, and enables the operator to perform a thoroughly bloodless opera- tion. Digital pressure, sometimes recommended for the smaller animals, will not, however, secure as good a result as that obtained by the ch'cular ligature. The operation is made in two ways : first, in the continuity of the bones, or by the division of the substance of the bone itself ; and second, in their contiguity, or at the nearest sound articula- tion. This last is also called disarticulation. All amputations consist of three steps : The division of the soft tissues, that of the bones, and the arrest or prevention of hemorrhage. 7'Ae First Step, the Division of the Soft Tissues, may be prac- ticed several ways, among which the jDrincipal are the circular, elliptic and the ovalar methods, and that by flaps ; all of which have the common object in view, of leaving a flap of proper form and sufficient dimensions to cover the stump of the bone, and prevent its projection beyond the surface of the wound. The circular method, which is the oldest, consists in incising the skin in a circular manner, stretched over the surface of the region with the left hand of the operator, or with that of an assist- ant. This must be done with rapidity, made by one stroke of the knife, applied as perpendicularly over the skin as possible. If the amputation is to be made in the continuity of the bones, the skin being divided while stretched by the assistant, is sepa- rated from its adhesions underneath, and reversed upward ; when close to the line where it is yet adherent, the muscles are divided circularly, by one stroke of the knife, drawn to the bone. These AMPUTATIONS 271 muscles spontaneously retreat, and the superior stump is drawn upward beyond the cutaneous incision. This action may be facil- itated bj' separating from the bone whatever attachments may exist between them. The periosteum is thus divided, on a level with the retracted muscles. The amputation in the contiguity of the bones, differs from that in the continuity only in the fact that when the section of the muscles is made, there is no division of the periosteum necessary, and the disarticulation is completed with either the bistoui-y or amputating knife, or, in preference, with the sage knife. The method hy flaps consists in making on one or both sides of the bones, one or two flaps of skin which are afterwards united to cover the stump, and form the new surface. In amputation by the contiguity of the bone, the method to be preferred, and which may be practiced both from within, out- ward and contrarywise, is this : In the first instance, the knife is passed through the soft tissues at the point where the bone is to be separated, and the entire mass divided by drawing the instru- ment toward the operator in a somewhat obHque direction. In the second way, or from without inward, the flap is first drawn with the point of the knife, and then dissected from without, or, otherwise, made at once in the same direction, by one stroke of the instrument. The flaps must be rounded, not angular, at their line of meeting, and in such a way that the amputated wound will represent an elliptic inf undibulum, whose center is occupied by the stump of the bone, surrounded by whatever projecting fleshy structures may be brought over it to form a protective cushion. The second step of the operation is that of the section of the bone, or of the articular attachments. In sawing the bone in its continuity, the periosteum being divided, and the soft tissues protected by compresses, some little art is necessary. The saw applied perpendicularly to the axis of the bone, should be worked slowly at first, until a track is formed, after which the movement may be more rapid. PressiU'e upon the instrument is unnecessary, if it has been properly set. Special caution shoiild be observed in finishing, in order to avoid leaving rough edges to be cut off vrith the bone forceps. The saw must be propelled wholly by the action of the arm of the surgeon, his body remaining completely motionless. "When the amputation is made upon the segment of a leg 272 OPERATIONS ON BONES. which has two bones, though they may be divided separately, it will be preferable, if they can be held together with sufficient firmness, to act upon them jointly, but finishing the smaller bone first. The actual disarticulation, or second step of the amputation, is performed by diA^ding the ligaments or other structures which surround the joint, from without inward. Beginning with the strongest and most external ligament by giving a movement of semi-flexion to the articulation, not necessarily cutting them in their middle, the joint is penetrated by inserting the knife be- tween the articular surfaces. The double sage knife, according to Bouley, is the most convenient. In articulations composed of ir- regular surfaces, united by inter-articular ligaments, care must be taken to avoid injuring the bones, and to divide the fibrous cords only, as most of the synovial capsules must be removed, in order to avoid fistulous complications. In some disarticulations, according to Bouley, it is necessary to use the saw to remove diarthodial projections on the surface of the amputated bone, which if left in place would prove a serious obstruction to the cicatrization of the stump The last step of the operation is the arrest, or, what is better, the preve7ition of the hemorrhage. It consists simply in twisting or ligating the arterial vessels which have been divided. If the means used for the temporary hemostasis prevent the operator from discovering its source, the ligatures can be slightly relaxed until it is betrayed by the oozing of the blood. The various methods of permanent hemostasis have already been considered, and need no further description. In the application of a dressing to the wound of amputation, the requirements are few, but they are imperative, and they are sufficient, assuring the best results by their simphcity and solid- ity. The soft tissues and the skin must be brought together, over the extremity of the bone, and kept together by the apphca- tion of a continued suture, leaving a place of drainage for the suppuration and the sloughing of the ligatures which occlude the blood vessels, and the extremities of these must be gathered to- gether at the most dependent part of the wound. This is com- pleted and protected by the appHcation of an antiseptic dressing consisting of pads of oakum, absorbent cotton, or threads of toiirbe, kept in place by rollers, and supported by an outside AMPUTATIONS. 273 envelope of coarse cloth. The wound may cicatrize by first or by second intention, according to the severity of the original injury, as well as to the amount of attention bestowed upon the antisep- tic applications which may have been employed. Fig. 289.— Wooden Leg after Amputation. Complications are not uncommon after amputations, though they do not materially differ from those which are encountered in other serious operations. Among those which may be mentioned are: Ist. Secondary hemorrhage, as the result of carelessness in the application of the ligatures, which can be overcome, however, by immediate or lateral compression, or by the renewal of the lig- ature. 2d. Abscesses, of various dimensions, resulting from the presence of the hgatures into the wound, or possibly of necrosis of the bone. These collections are to be treated in the usual way, as are alsa undermining of the ski7i by suppurative collections, phlebitis, purulent infection and gangrene, all of these being con- ditions having the same indications as in other forms of traumatic lesions. There are, however, some complications which belong specially to the sequelae of this operation, such as may result from an im- proper section of the bone, which might end in the formation of a conical stump, a condition which, like that of strangidation of the stump, can only be relieved by a new amputation, with a bet- 274 OPEKATIONS ON BONES. ter section of the bone, and more careful attention to the subse- quent dressing. JV^ecrosis of the amputated bone may also com- plicate the process of cicatrization, accompanied by more or less pain and difiused suppuration, which cannot be relieved until the necrotic bone has sloughed away. Amputations in the contiguity of the bones are, besides, likely to be complicated with sipiovial ^fistulas, which may be of an ar- ticular or tendinous nature. The ordinary forms of treatment in similar cases will be sufficient for these. These general rules regulate amputations of every kind, though the various steps of the operation may have somewhat varied, ac- cording to circumstances. But whether it be ux the continuity or contiguity of a bone, or whatever may be the bone involved ; whether the scapulo-humeral joint, the fetlock or the digital re- gion ; or even to remove supplementary digits ; they are of equal applicability, and the general modus operandi remains the same. Even in the operation of amputation of the wings we find but Httle room for modification or change. In operating upon the wings of birds, with the principal object of destroying their power of flight, it may frequently be accom- plished by simply cutting off the extremity of the wing, at the carpal articulation, with the scissors, and cauterizing the wound with perchloride of iron or nitrate of silver. Another method is to pull out the feathers from the inner side of the wing, as far as the elbow joint, the skin being then incised with a bistoury somewhat below the joint, and dissected and reversed upward, the bones being then divided with the bone forceps. The wound should be carefully washed or sponged with cold water, to check the bleeding, and the skin drawn over the stump, secured by interrupted sutures. The bird requires no special attention, and the wound heals in a few days. Amputation of Hokns. The amputation of horns is an operation the description of which dates back to 1790. It is indicated in cases of fractm-es, or of vicious growths which might embarrass the motions and prevent the usefuhiess of the animal, and also to j^rovide against the mu- tual injuries which cattle are hable to inflict upon one another. It is also indicated in cases of suppurative collections in the si- nuses, and for the removal of parasites from those cavities. It has AMPUTATIONS. 275 of late not only assumed a j)lace among the operations of fashion, but has found favor from its alleged tendency to improve the quantity and quality of milk, and of the flesh yielded by animals subjected to it. It is in relation to this hypothesis that Gourdon considers it as "a great progress in the raising of horned cattle, and which, on account of the benefits that may be derived from it, is perfectly justifiable." The operation is comparatively a sim- ple one, but nevertheless involves special considerations, varying according to the species of the animal. 1st. In Bovines. — If only the free extremity of the organ is to be cut off, it is done with the saw carried rapidly through the horny structure, the animal, of course, being properly secured. But occasionally, especially in cases of fracture, the section is to be made near the base, or the middle of the horn, and soft and sensitive tissues are also involved. The amputation must then be made below the fracture with a sharp saw, apphed perpendicularly to the long axis of the horn, and completed as rapidly as possible. The operation will be accompanied by some hemorrhage, but not svifficient, usually, to require the apphcation of severe hemo- statics. The wound is dressed with pads of absorbent cotton, or of carboHzed or antiseptic oakum, retained by compresses or the Maltese cross bandage. Possible collections of pus must be watched for, and the sinuses shovdd be carefully cleaned by injec- tions. The dressings are renewed as often as the indications require, and continued until the granulations have closed the ca\ities of the sinuses, and the suppuration has almost entirely subsided. The application of a permanent dressing in the form of a pitch plaster is recommended by Gourdon. It need not be i-emoved, like the ordinary dressing, and under some circumstances is of great advantage. Among the probable accidents attendant upon this operation, there are four which require mention : (a) Hemorrhages, more or less serious, always occur after the section of the horn, and of its bony support. Usually, it is sufficiently arrested by the dressing alone, but there are times when the application of the actual cautery becomes necessary to subdue it. (b) Inflammation of the mtieous membrane of the sinuses may also foUow. In its ordinary manifestation it is not serious, and is 276 OPERATIONS ON BONES. likely to terminate either by resolution or even suppuration, though in a few cases it may be followed by gangrene. (c) Gangrene, which generally manifests itself toward the eighth or tenth day, ordinarily ends in death, and is often accom- panied by an attack of ophthalmia more or less violent. (d) Incomplete cicatrization of the stump, occurring principally in cases in which the wound has been neglected, and suffered to remain too long unprotected by a dressing, and when the mucous membrane of the horn has become the seat of chronic inflamma- tion. A central fistula usually results, accompanied by an abun- dant suppuration, which is apt to prove exceedingly intractable to treatment. 2d. In many young rmninants this operation is performed on calves two or three months old, and consists in removing the rudi- mentary horns. For this Charlier has invented a peculiar tre- phine kind of circular gouge, which is used as follows : The ani- FiG. 290.— Charlier'B Method of Amputation of Horns in a Calf. Ist Step. mal being thrown and held by two assistants, the hair is cut short around the base of the horns, and the trephine appHed over the horns in such a manner as to divide the skin and subjacent tissues down to the frontal bone where they are isolated by a circular in- cision. Then by a downward and horizontal twist of the trephine the divided structures are gouged out and the secreting matrix of AMPUTATIONS. 277 Fig. 291.— Charlier'8 Method of Amputation of Horns in a Calf. 2d Step. the horn removed. The hemorrhage is controlled with a com- pressive bandage or other hemostatic, and antisejDtic dressing- applied. The wound generally heals rapidly and without compli- cations. Amputation of the Tail. For some unexplainable reason the term " docking " has been appUed to this operation, which is simply the removal of some of the vertebrae composing the caudal appendix. It is one of the most peculiar among the operations of fashion, although, of course, under some sj^ecial conditions incident to all animals, it is also sometimes perfoi-med as an operation of genuine beneficent sui'gery. This may be the case, for example, when the tail is abnor- mally so long and heavy as to interfere with the usefulness and comfort of the animal, or when it becomes the seat of disease and becomes affected with caries or necrosis, or fistulous tracts, or af- fections of the skin. In some instances, also, this curtailing oper- ation does constitute a true siu'gico-therapeutical means of obtain- ing a local bleeding. Docking, which is of Enghsh origin, is now performed all over the world, and has given rise to a great deal of controversy upon the question of its propriety. Whether it is an act of inexcusable cruelty or not, it is not at present our province to decide, but from a surgical point of view we feel that it is due to truth to say that we are satisfied that a great deal of what has been said in opposition to the operation results, from the various and, too often, bungling 278 OPERATIONS ON BONES. and cruel methods which have characterized the details of the amputation. We believe that some of these methods may be so modij&ed as to reheve the operation of its apparent character of cruelty. We refer now especially to the means which have been and are employed for the arrest of the hemorrhage which is likely to follow the section of the blood vessels of the region. The tail has for its bony support a series of the caudal verte- brae — from fifteen to eighteen — varying in number and diminish- ing in size from the sacrum to the end of the organ, and united by a thick inter-vertebral ligament, and attached to them are the caudal muscles in pairs, three on each side, the stqMriors or ele- vators, the inferiors or dep7-essors, and the laterals or inclinators. Beside these, there is also the ischio-caudal muscle, which extends from the ischiatic ligament upward and backward to terminate on the sides of the first caudal vertebrae. Between each of the lateral and inferior caudal muscles runs the lateral caudal, and on the median line between the inferior muscles the median caudal ar- tery, all running to the end of the tail, and hkely, when divided, to cause a more or less troublesome hemorrhage. All these or- gans are sui-rounded by the caudal aponeurosis, from the deep surface of which proceed bands which form a sj)ecial sheath for each muscle, and is ultimately united by its external face to the thick skin which surrounds the region. This skin on the upper and on each lateral face of the tail is covered with long, thick, coarse hair, while the inferior face is hairless, smooth and com- paratively thin. Fig. 292.— Tail Cutters. AMPUTATIONS. 279 Dockiiig properly includes three steps : 1st, the preparation of the tail ; 2d, the amputation ; and 3d, the arrest of the hemor- rhage. (There is, however, a mode of operation in which the last two steps can be merged into one.) The animal is kept in the upright position, and well secured. 1st Step. Preparation of the Tail. — This is first well washed and combed, and ought to be cleaned with an antiseptic solution. The place where the amputation is to be performed should be marked by clipping the hail' from it in a circle, and above this the hair should be secured either by being braided, or simply tied tightly in a mass with a string aroiind the tail. Some practition- ers apply a cord hgatiore or an elastic bandage above the place to prevent the hemorrhage. 2d Step. The Amj^utation. — This is accompUshed by several methods. The oldest mode was by using a simple hatchet as the instrument with which the tail, properly prepared and laid over a wooden block, was severed by a heavy blow on the "instrument." (Fig. 292). Fig. 293. Tail Cutters. Fig. 294. 280 OPERATIONS ON BONES. At a later period, special knives called tail cutters, were in- troduced. These were peculiar large shears, differiag more or less in general form and in that of their cutting edges, but which were used in the same manner, and are stUl in common use by many- practitioners. The manner of using them is very simple. The tail, prepared as before mentioned, and held horizontally by an assist- ant, is so placed in a hollow formed in the edge of the shears as to insure a perpendicular stroke, and the division is made by closing the blades with a single quick and forcible motion. Other instru- ments were invented to work by springs. Fig. 296.— Spring Tail Cutter. Some practitioners, instead of dividing the entire thickness of the organ, prefer to do so by disarticulating the vertebrse with a bistoury, first making flaps on each side of the skin in order to find the joint. 3d Step. — To stop the Hemorrhage. — The moment the tail is amputated three streams of blood spring from the stump, with more or less force, according to the position of the member, unless a ligature or an elastic bandage has been previously appHed. In AMPUTATIONS. 281 either case attempts may be made to ligate or to employ torsion of the arteries, but the hemostatic generally emj)loyed is the actual cautery. The tail-cauterj^, heated to nearly a white heat, is firmly held upon the truncated tail for a few seconds until it has stopped the hemorrhage. To assist this process and obtain the formation of a thicker scab, certain com- bustible substances are some- times placed upon the wound before the cautery is apphed, to Fig. 297.— Tail Cautery, . i.i_ i„ i. i j.i, • • • mcrease the heat by their igni- tion. A ring of hair or a little pulverized resin may be employed for this purpose. We have before noted that in this measure of hemostasia there is much that is repulsive and coarse, and that it is not at all in har- mony with the spirit of modern scientific surgery, and we have long felt a conviction that a great improvement is possible in the manipulation of such a case. "VVe have, therefore, made the matter one of careful experimentation, and the conclusion we have reached is that the following course of procedure will meet all the indica- tions and fulfil all the purposes contemplated, and at the same time avoid the compUcations likely to occur, and obviate the objections of the sensitive and the timid, besides securing results entirely satisfactory to all the parties concerned. First, to render the operation painless, we inject cocaine at two or three points in the circumference of the tail skin. Then, around the tail, and above the ring made by clipping the hair, as before mentioned, to mark the place of amputation, we place a narrow elastic band at a tension merely svifiicient to stoj) the hemorrhage. Having waited for the full efi"ect of the anesthetic, and accurately identified the center of the articulation between two of the vertebrae through which we intend to amputate, with a strong and sharp bistoury we make rapidly a circular incision of the skin entu'ely around the tail, and, if possible, divide the muscle with a single stroke through the intervertebral Kgament. With a little care and practice the amputation may be completed in a few seconds, and there remains at the end of the tail but a smooth, perfectly blood- less stump. We cover the fresh surface with a dressing powder, antiseptic, caustic or astringent as indicated, and leave the patient eating his oats as he had been doing during the operation, unaware 282 OPEEATIONS ON BONES. of the mutilation to which he has been subjected. We leave the elastic band in place for from twenty-four to thirty-six hours, pos- sibly loosening it once during that time, or tightening it, if any oozing of blood is discovered, and removing it entirely as soon as it becomes safe to do so. The stump generally needs no special care, except in cases of possible complications which may follow the operation. The am- putation of the tail by flaps is also jaerf ormed by some veterinarians with great siiccess, this mode leaving a wound which generally heals very rapidly and without the ordinary possibility of complication. Among these are, first, hemorrhage. The occurrence of this is an evidence that the hemostasia has been imperfect, proba- bly the cauterization has not been sufficiently thorough; or the torsion of the arteries has been insufficient; or the hgature has been loosely tied. This accident requires a repetition of the man- ipulation, and perhaps another cauterization or torsion or ligature. With the apphcation of our elastic band this can scarcely ever oc- cur. If it does, another turn of the band will complete the work. Bad aspect of the Stump. — The amputation of the tail by sec- tion through the continuity of the bone, as commonly happens when the tail-cutters have been used, leaves in the center of the wound a projecting portion of a vertebrae, which is usually burnt by the cautery, when this has been used. As the result of this, and surrounding the mortified bone, large granulations rapidly appear, overlapping the circular edges of the wound, and char- acterized by an abundant discharge. The necrotic bone must then be amputated and the granulations heavily cauterized with caustics of the potential kind ; the saturated solution of chloride of zinc making an excellent prescription for the purpose required. To obviate this complication the operator will do well, when any portions of vertebrae have been left in the stump, to remove the fragments with the bone forceps rather than to wait for their re- moval by the natural process of necrosis. We have never encoun- tered these comphcations when using the elastic band, being careful to amputate at the articulation of the vertabrae. The powdered dressings we have used have always kept the granulations under control. Multiple Abscesses. — We have met these once, as the result of the presence of a very thick scab, which prevented the escape of the underlying suppuration. TREPHINING. 283 Gangrene and Tetanus have also been recorded as sequelae of this operation. The rules we have given apply without change to the amputa- tion of the tail in smaller animals, as sheep, dogs and cats. TREPHINING. The operation of trephining or trepanning consists in boring into or through a bony or other hard structure, in order to form an aperture for surgical purposes. Although the cranium is usually the seat of the opening, it may be made in any part of the body where the indications demand it. The apphcation of the trephine or of terebration, as it is called when it is performed at the base of the horns of cattle, dates back to antiquity, having a record antedating the time of Hippocrates, and yet it was not until toward the year 1749 that it in fact entered the domain of veterinary siu'gery. About that time Lafosse, Sr., performed it to open the frontal and maxillary sinuses in the treatment of glanders and other diseases mistaken for it. It was afterwards recommended by Greave and Haubner as the proper treatment for the rehef of purulent collections in the sinuses of the head, and it has been recommended by many others for parasitic affections of the cranial cavity, as cases of coenurus cerebralis. Trephining is undoubtedly indicated in many pathological conditions, and in fact ought to be more frequently practiced by the veterinarian of to-day. Much has been lost, no doubt, by its neglect and disuse. Its value is most fully demonstrated in cases where it becomes necessary to remedy the effects of mechan- ical lesions taking the form of bloody or purulent gatherings within the cranium, like those which may result from the pressure of fragments of fractured bones upon the brain. Fractures of the cranial bones resulting in this manner are not common with our domestic animals, but when they do occur they are always of a serious nature, and too often are beyond remedy. In a case of remediable character the removal of the pressure ujDon the men- inges by trephining and cleansing the wound from the matters which produce and continue it, whether bony fragments or bloody extravasations, is the treatment indicated before any other. Yet as experience has many times proved that the brain is able to sus- tain a very considerable amount of pressure without betraying 284 OPEEATIONS ON BONES. any signs of inconvenience, the indication of trephining only becomes absolute when serious nervous manifestations are ex- hibited. In simple contusions, or even with complete fracture of the bone, trephining is not indicated unless brain lesions are unmistakably present. It is indicated in solipeds in cases of chronic discharges pro- ceeding from suppTirative collection in the sinuses, characterized by a yellowish, grumous, and often offensive, running at the nose, usually from but one side, and not uncommonly accompanied by a deformity of the face, caused by a bulging of the bones, and associated with it a dullness on percussion over their surface. Jessen & Unterburger have also recommended it in cases of suppuration in the cavities of the nasal turbinated bones. In the treatment of chronic catarrhal inflammation of the horns or of the portions of the frontal sinuses which extend into the apjDendix of the head, in ruminants, it has given excellent results. It is also indicated for the removal of foreign bodies, either of a pathological nature or the product of wounds, entering the cranium from the outside. It is available for the removal of polypi or any kind of neoplasm, of migrating dental cysts, of odontomse, or as one of the first steps in the operation for the removal of diseased teeth from their alveolar cavity; in all these cases it is the first indication. It is also of common application in extracting parasites, the coenurus especially, from the cranial cav- ity of small ruminants, when their location has been first positively ascertained. In some severe cases of diseased withers accom- panied with abundant suppuration, which may filtrate under the internal surface of the scapulae, and accumulate between that bone and the thorax, it has been claimed that, performed upon the scapula, it would furnish an eligible means of reaching the bottom of the collection, and providing suitable drainage and consequent relief. Trephining the wall of the foot in special cases of laminitis, to assist the escape of the effused blood from between the laminoe has also been tried, but with what results we are not informed. It has even been performed in the treatment of immo- bility, but so far as we have learned, has never been followed by satisfactory results. It is also referred to in connection with the cranial inoculation of rabies, as performed by Pasteur. The special instrument employed in the operation is the TREPHINING. 285 trephine, or trepan, in various modified forms. There are also others which may be considered as accessory, viz., scissors, bis- touries, forcej)S, bone-scrapers and elevators. The brace and bit trephine is the original instrument which has been more or less modified, and which, while it is capable of more rapid execution, is probably less controllable than the ordin- FiG. 299.— Bichafs Trephine. Fig. 298.— Old-Fashioned Trephine. Fig. 300.— Single-Handed Trephine. 286 OPERATIONS ON BONES. Fig. 301.— Operation of Trephining. Modus Operandi. ary trephine (Fig. 300), and therefore not so safe. The single- handed trephine is also to be preferred from the fact that the former requires both hands to manage it, while the latter can be manipulated with a single hand. They are both what might be properly denominated true circular saws, if judged by the result of their appHcation, which is the removal of a circular portion of the bony structure, and a corresponding round opening, through which other surgical indications can be fulfilled. A simple gimlet has often taken the place of the regular instru- ment, but such an appUance can be considered as possessing little more than the character of a mere exploring needle, from the impossibility of making an opening with it of sufficient dimen- sions to be available for any other practical use. TREPHINING. 287 The hone-scrapers^ or elevators, which are sometimes employed as accessory, are used for preserving the periosteal covering of the bones; for removing the rough edges of the opening; or in Fig. 302.— Bone Scrapers and Elevators. raising the bony fragments which have been crushed in, or may be pressing against the cerebral substances. An important step before entering ujDon the operation, is to determine the points which are to be avoided. Generally speak- ing, any part of the head or of the body can be operated upon, so long as there is a bony surface that can be readily exposed without danger of injimng other important organs. But, upon the head, the angles of bones and the tracts of the cranial sutures ought to be avoided. In the more common apphcations of the operation upon the head (Figs. 303, 304), one of four principal points is gen- erally selected, b}' which to effect an entrance into the cavities of the sinuses. The points marked h, near the lower borders of the frontal bone, will open the frontal sinuses : the point c, upon the surface of the nasal bones, communicate with the superior part of the nasal ca\-ities in the upper portion of the turbinated bone; the points e, upon the zygomatic bone, will enter the superior, and f, upon the great maxillary bone, will penetrate the lower maxillary sinus. Besides these specific regions upon which to apply the 288 OPEBATIONS ON BONES. Fig. 303. Fig. 304. Parts of the Head where Trephining is Performed. instrument, there are conditions where, the bone being less sub- cutaneous, the operation is less easily performed. Such is the case as to the lateral faces of the parietal bone, where it will be necessary to penetrate through where the crotaphite muscle is. This, however, makes a compHcation of little importance. Again, there are indications, such as in cases of chronic coryza, with sup- puration of the sinuses, where a double trephining becomes neces- sary, one to enter the frontal, and the other the superior maxillary sinus. Figure 305, which is borrowed from Peuch & Toussaint, shows the exact location where the trephining can be made. A, entering into the frontal; B, the upper, and C, the lower max- illary sinuses. The modus operandi of this operation is very simple. Unless the animal is very restless, and cannot be controlled by the ordi- nary means of restraint, or by local anesthesia, and must there- fore be cast, or unless the trephining is merely the first step of an operation to remove foreign bodies or growths from the sinuses, or to apply special action upon a displaced bone, as in a fracture, we prefer to operate in the standing posture, and in such cases have found the use of cocaine of great advantage. In any case the skin is first divided by either a V, or a T, or a I TKEPHINING. 289 Fig. 305.— Common Points of Selection for Trephining. semi-lunar incision. We prefer tlie first as being least liable to be followed by a blemish. The periosteum is divided in the same form, if its division has not already followed that of the skin. The flap thus formed in two structures is then carefully raised from the attachment to the external surface of the bone, and held aside by an assistant, vnth. either a blunt tenaculum or forceps. The instrument is then implanted ujpon the centre of the exposed bony surface, and by the rotatory or semi-rotatory motion imparted to it, gradually separates a circular disk of the bone. The pressure necessary to make the instrument seize or bite on the bone may at first be considerable, but as the trephine penetrates, the force must be carefully relaxed in order to avoid the hazard of injuring the parts beneath by the sudden yielding of the bone and plunging of the instrument into the parts beneath, accompanied by the bony disk, as it separates from its last attach- ments, perhaps passing beyond reach, and costing no little touble and danger before it can be discovered and removed. It is not judicious to penetrate through the bone at once. As the operator feels that he has nearly reached the last turn, the 290 OPERATIONS ON BONES. safe plan will be to partly separate the disk with a partial, oblique turn of the trephine, and to complete the separation with the elevator. Sometimes this segment will be retained in the crown of the instrument, or, again, it will be only partially loosened. In that case, securing it with a pair of bull-dog forceps, its excision can be made complete with the bistoury, by dividing the mucous membrane of the sinus which may hold it. If the edges of the opening in the bone are not perfectly smooth, their asperities should be removed with the bone scrapers or bone knives. The indications following the perforation of the bone vary according to the case. If it is a fracture, with pushing in of the bone, the fragments, or the bone debris, must be removed by being raised with the bone elevator, cutting from within outward. If a removal of a parasite of the cranial cavity is to be effected, its membranous envelopes may be carefully twisted around the jaws of the forceps, and thus removed in a single mass. In cleansing out a purulent collection in the sinus, it must be injected and washed with the proper medicated solution. If, on the contrary, the removal of a foreign body is necessary, as a polypus, or an odontoma, or the extraction of a molar tooth by gouging, it may become necessary to enlarge the opening. This is done either by chipping off the edges with the bone forceps, or by making another opening with the trephine, adjoining the first, and merging them together by properly trimming and shaping them. The dressings required after trephining vary according to cir- cumstances. If the trephining has been but a preliminary step to a subsequent manipulation, such as the raising of a fragment of fractured bone, or for the removal of foreign bodies, the woimd, after being thoroughly and antisepticaUy washed, can be closed by bringing the edges of the integument together by sutures, and covering the surface with a pad of oakum, kept in place by a fig- ure 8 roller, around the head, or by one of the frontal, single or double, already described. If, however, the operation has been performed in a locahty where there would be difficulty in retain- ing such a dressing, the application of agglutinating preparations or plasters wiU effect the object. When the frontal and maxillary sinuses have been opened, and it becomes necessary to wash out their cavities by injections thrown into them, the trephined opening must be prevented from closing by the introduction of a tent of oakum and a kind of soft cork, PEKIOSTOTOMY. 291. which may be kept in place by securing it to the halter of the patient, to prevent it from falling into the sinus. The cicatrization of the wound made by the trephining in- strument springs from the rapid development of granualations which soon fill up the opening. These granulations soon undergo the various changes which take place in the process of calcification and ossification, and the loss of bony substance is soon completely repaired. In a few instances, however, the seat of the operation, after a few days, assmnes a most unfavorable aspect, becoming swollen and offensive, and betraying the characteristic necrotic odor. In many instances the seat of the necrosis is found to be the edge of the opening, and is due to the imperfect apphcation of the tre- phine, and the destruction of the periosteum. Care must then be taken to remove all the loose necrotic fragments. To allow them to remain imbedded in the granulations and under the skin, will be to incur the certain hazard of the development of abscesses and the formation of fistulous tracts, which wiU refuse to heal until the last particle of diseased bone has been exfoliated and removed. PEKIOSTOTOIHY. Periostotomy is an operation which consists in the subcutaneous division of the periosteum, on the surface of bony growths. It may be for the purpose of stimulating their resolution, or it may be to relieve the pain arising from the tension of the inelastic membrane as it is pressed upon by a tumor of the bone growing under it. The operation was originally performed by Professor Sewell of the Koyal Veterinary College in 1846, and was at first considered to be one of the neatest and most scientific among the methods practiced for the rehef of the lameness due to exostoses. It was considered by SeweU himself to be far superior to any other means then in use, counter irritations, firing, and the rest. But although earnestly supported by the authority of its inventor, periostotomy has not sustained its claims by exhibiting all the results which were promised for it, and experience has shown that it is in many instances not only a useless, but even a dangerous operation. Several special instruments are necessary iu its per- formance. These are a peculiar roioel scissors (Fig. 306) to incise the skin, for which, however, a special bistoury (Fig. 307) is 292 OPERATIONS ON BONES. Fig. 306.— Scissors. 307.— Bistoury, 308.— Periostome. 309.— Seton Needles. sometimes substituted ; a periostome (Fig. 308), a kind of blunt bistoury, narrow and curved; and two flat needles (Fig. 309), short and curved flatwise, one of which is blunt, and used to di- vide the connective tissue, the other being sharp and to be used as a seton needle to pass a tape into the subcutaneous incision, if it is judged necessary. These needles may either be inserted into a handle, or used free. The operation is a simple one to perform. The animal being cast and properly secured, an incision is made with the rowell scissors or the bistoury, at the most dependent parts of the bony growth, large enough to aUow the introduction of the blunt curved needle. This being pushed slowly under the skin, separates it from its attachments, and upon being gradually withdrawn, the periostome is passed into the tract thus formed, directly over the bony tumor. Turning the sharp edge of the periostome on the exostosis, and pressing it over the periosteum, this is divided by subcutaneous strokes down to the most superficial layer of the exostosis, which may be incised by the instrument. When the tumor is of long standing, a seton may be intro- duced by pushing into the tract, from which the periostome has been removed, the curved needle which carries the tape, and it is brought out by an opening made at the highest part of the tumor. Sewell claims that after twenty-four hours the parts become the seat of a large swelling, and more or less inflammation may take place, but after twelve days the animal is ready to resume his work, the swelling having gradually subsided, and the lameness RESECTION OF BONES. 293 passing oflf, sometimes the enlargement haying disappeared. Our own observation, however, differs from that of Sewell and agrees with that of Keynal, as we have seen cases where excessive inflam- mation has followed the operation, accompanied by the persistent development of large indurated swellings, intractable to any other form of treatment, and giving rise to permanent lameness. This operation, although highly recommended by English practitioners, especially in the treatment of splints, is not, however, held in the same estimation by Continental veterinarians. RESECTION OF BONES. The resection of a bone is the removal of a portion of its sub- stance, for the connection of a deviation from its normal position, or other deformity, or in cases of fracture, or necrosis, or other incurable disease. It is to a bone what excision is to the soft tissues. It has been known for a long time, but it is within only a comparatively recent period that it has found admission into veterinary surgery, and even now it is but seldon practiced. It is practicable on all parts of the skeleton, but there are some special conditions in which it is more evidently indicated than in others, such as cases of necrosis in the vertebrae, gi-^dng rise to obstinate fistulous withers, and in the treatment of some exostoses ; or again in that of the complicated wounds accompanying frac- tures. '--Hi Fig. 310.— Various Forms of Saws. 294 OPERATIONS ON BONES. Fig. 311.— Chain Saw. Fig. 313.— Bone Forceps. I Fig. 313.— Gouge. Fig. 313a.— Chisel. Fig. 313&.— Mallet. The instruments necessarj"^ are quite numerous. Saws of different forms, including the chain saw, the bone forceps, or shears, the gouge, the chisels, and the mallets are all brought into requisition at times. Before making a resection the diseased bone must be thoroughly exposed by a free and long incision, giving ample room to the surgeon for the free use of the instru- ments. If the bone is already exposed, great care should be taken to protect the soft tissues, the muscles, the blood vessels and the nerves, from being accidentally wounded, by covering them with compresses, cloths, or other substances. RESECTION OF BOXES. 295 The manipulations will of course vary, according to the bone which is to be incised. When one of the long bones is to be re- sected in its long axis, either in part or in whole, the periosteum must be kept as nearly intact as possible ; as the principle regen- erator of the osseous tissue, its removal would necessarily interfere with the cicatiizing process. It must be very carefully separated from the bone, and isolated, to the whole extent of the segment to be removed. This done, the bone can be readUy cut off, with either the chain saw or the plain instrument. The resection of bones in their articular extremities seldom occurs in ovu: practice ; it sometimes becomes necessary in diseases of the vertebrae, in fis- tulous -nithers, and occasionally in caries of the ribs. In the first case, that of the diseased vertebrse, the excision is commonly made with the bone forceps and chisels, or even with the gouge. The principal point to observe in these instances is to avoid injury of the ligamentum nuchoe as much as possible, and to save aU the periosteum that can be preserved. The resection of ribs is accomplished with difficulty, on account of the proximity of the pleura which lines their internal surface. To avoid woimding this important organ the rib is exposed by a longitudinal or crucial incision, and after isolating the intercostal muscles from their attachments, the pleura can be pushed away from the bone with the blunt end of a scalpel, and with the chain saw introduced carefully between the bone and the pleui'a, the resection can be accompHshed by dividing the bone from Avithin outwards. The hemorrhage which arises from the intercostal arteiy can be stopped by plugging. The wound is dressed by a protective antiseptic bandage applied round the chest. The general indications, after the resection of bones, are to care- fully watch the progress of the wound and watch for the possibility of the formation of fistulous tracts, which may result from the extension of the necrosis, which may not have been entu'ely re- moved, or may result from the removal of the periosteum. These, however, may often be prevented by so regulating the process of granulation, as to prevent the accumulation of pus in the wounds, and if necessary, by applying caustics or resorting to any other of the means recommended to fulfil the existinof indications. CHAPTER VII. OPERATIONS ON MUSCLES AND THEIR ANNEXES. CAUDAL MYOTOMY. This operation, more commonly known under the name of pricking, is exclusively performed on equines, and is designed to diminish the power of contraction of certain of the muscles of the tail. However it originated, it has been perpetuated by a class of horse fanciers who have, to a certain extent, made it a dictum of fashion, and by whom it has been supposed to improve the symmetry of the animals upon which it is inflicted But it has lost, in our day, much of the estimation in which it was once held, and while at first, before its prestige had been weakened, all kinds of horses, indifferently, became victims to the bad taste and thoughtless cruelty of the custom, either the external form of our horses and the mode of attachment of their tails have been improved by more skillful methods of breeding, or they have in- stinctively learned the regulation style of carrying their caudal extremities. Whatever may be the cause, the fact is beyond dispute that the indications for the operation have considerably diminished. But though the effect of the division of the inferior caudal muscles is in fact, with some animals, to cause them to carry their tails in lines more graceful and more horizontal than before, it is stni necessary, in order to accomplish a successful result, that the tail should be properly attached to the body as a con- genital arrangement, or well set up on the sacrum. A horse with an oblique sacrum, with the tail set low and close to the ischial tuberosities, can never be a good subject for the operation, or made to serve as a favorable example of the beautifying effect of pricking. But with aU this, there is sometimes a condition which (look- ing not to the welfare of the horse, but solely to the conveniences CAUDAL MYOTOMY. 297 of his master), renders caudal myotomy an operation of necessity. This occurs with those animals which have contracted the annoy- ing habit, when driven in harness, of switching their tails over the reins and, in effect, grasping and holding them so tightly that it is only with difficulty that they can be extricated — often placing the driver in a position of imminent peril by making it impossible to control their movements at a moment when perhaps a disas- trous collision or other dangerous encounter may impend. There is also another condition which relieves caudal myotomy from the imputation of relying for its justification exclusively on the plea of being in the fashion, though it involves only the sordid argument of a money consideration. This condition is found in the case of the animal which carries its tail sidewise or with a lateral curvatiu'e — a deformity which may in many instances considerably diminish his market value. In other words, if the contra-indication of the operation is the fact of bad conformation of the animal and a low insertion of the tail, the indications, leav- ing aside the question of good appearance, no matter if the tail is attached low or high, are when the horse has the habit of taking hold of the reins by switching it over them, and again when the tail is carried crookedly sideways. We proceed to consider the operation under all the requirements. Caudal Myotomy Proper, or Pricking, means the division of the two inferior sacro-caudal muscles, for the purpose of dimin- ishing their contractile power. It is performed in several ways, most of which consist not only in the division of the muscles, but in the removal of a portion of the muscular substance. There is, however, one method of which we have failed to dis- cover any mention by European authors, and which' we have for years practiced in the United States, where it has been in vogue for a period of more than forty years. This mode of operation we shall consider in another place as the " American method.'''' A glance at plate 314 will show the peculiar anatomical position of the muscles, blood vessels, and nerves of the region to be oper- ated upon. Peuch and Toussaint refer to six modes of operations, but we think the matter can be judiciously simplified by reducing the number by at least one-half. We shall therefore adopt a sim- pler classification, and describe the operation as it is performed by, first, the transversal incision ; second, the longitudinal ; and third, the transversal and longitudinal in combination. 298 OPEBAXXOKS O. MUSCBS ... ,hkzk .'..™. !?;. ^--SuBpeneory 1Wamlnr.n;^° coccygeal m^uS! T/!^?f: ^—Portion of th« o^ "^^ ^'^"tiai -Kegions. -One of the snn«lfi?:,-„,^i:rJ^.'»Pbatic glands, ii. io^_'^c^?i55i^'lal arteries artery. 3010 — Inferior oaiidni ,. ""® ^* *^e median aru,^ A'~if'^^^^^ caudal 8 muscle. 17 1?" Sf.^'^ranosus muscle, i.^ -i-s.^,?:-?^^*'^'!. of the perinea CAUDAL MYOTOMY. 299 The patient must be kept, as much as possible, iu the standing position, with a twitch on his nose, and his hind legs hobbled, or seciu'ed with the hippo-lasso ; or if he is of a very excitable and restless disposition, the stocks should be brought into requisition. The decubital position is, in our opinion, unnecessary, and un- doubtedly a very inconvenient one for the svu-geon, and not at all contributive to the performance of a neat operation. "We have often used cocaine when pricking horses, and it has in many in- stances j)roduced all the excellent effects of general anesthesia; and we prefer it, therefore, to the inhalations of chloroform which some recommend. 1st. Operation by Transverse Incisions. — The instruments required in this mode are a bistouri a serpette, an instrument re- sembling that known as bistouri cache of owe obstetric cases; FxG. 315.— Bistoury for Caudal Myotomy. a sharp convex bistoury, and a bull-dog forceps, or a pointed tenaculum. The animal being secured in position, an assistant, placed on one side of the croup of the patient and facing the operator, raises the taU perpendicularly and well on the middle of the back of the patient, in order to render the mus- cles tense and cause them to project well under the fine, soft skin which covers that region. The operator, dii-ectly facing the posterior parts of the animal, then firmly grasps the tail with his left hand and steadies it, while holding the blade of the bistouri a serpette between the right thumb and index finger, close to its sharp part, and plunges the instrument through the skia and the entire thickness of the muscle, beginning on its inside border, or slightly on one side of the median line, and carrying Fig. 315a.— How to Hold the Bistoury and Make the Incision. 300 OPERATIONS ON MUSCLES AND THEIR ANNEXES. These operation. the incision outward, right across the entire width of the muscle. The incision must run through the entire thickness of the organ and ought to be made by a single stroke of the instrument. The first incision is to be made about three fingers width from the base of the tail ; the second from one inch and a half to two inches back of it, and the third, if not considered unnecessary, at the same distance from the second. Owing to the tapering form of the tan, the incisions should become shorter as they approach the end of that member. When all the incisions are made on the right side, the ojjerator, if ambidexter, changes hands and re- verses his mode of manipulation, j^roceeding otherwise in the same manner as before, being careful that all the incisions are made directly in line with one another, entirely across the muscle. first three incisions constitute the first step of the If the division of the muscle has been made through its entire thickness, the portions of tissue be- tween the incisions will slightly protrude, and these are to be seized with the bull-dog forceps, and drawn over to one side, while they are care- fully dissected away with the convex bistoury, placed flatwise, under the muscle, with the sharp edge turned up- ward, and separating entirely the two portions of muscles included between the incisions. The amount of muscular tissue thus removed will measure from three to four inches in length. The number of the incisions varies. At first one was considered sufficient, but the number was gradually increased to five, while at present com- mon agreement has fixed the rule at three. 2. The Operation by Longitudinal Incisions. — This is comparatively an old mode of operating, which, having been once abandoned, was revived by Delafond, in 1833, when it was again reinstated in general practice. It requires for its perform, pig. giea.— Cau- ance only a stronsr, convex bistoury. The animal ^^^ Myotomy by •' °' , •' Longitudinal In- bemg secured in the usual position, and the tail cisions. Fig. 316. — Trans- versal Incisions in Caudal Myotomy. CAUDAL MYOTOMY. 301 kept as in the other methods, the operator makes on the middle of one of the projecting muscles a longitudinal incision, three or four inches long, di^^.ding at one stroke the skin and the fascia underneath. From the muscle thus exposed, a portion is dissect- ed, and by passing the bistoury under it, close to the vertebrae, it is removed by cutting it transversely at both extremities of the cutaneous incision. The removal of the muscle is made first on one, then on the other side of the median line. 3d. Operations by Mixed Tncisiojis. — This was demised by Vatel, who made two transversal incisions on each side of the tail, from thi'ee to four inches apart, and uniting those of the same side by a longitudinal incision, made in the direction of each in- ferior caudal muscle, and then dissecting a portion of each organ with the aid of a bistoiuy, or a pair of scissors, securing a hold at one end with a pair of forcej)s, or a j^ointed tenaculum. The method patronized by Brog- niez, and recommended by Belgian veterinarians, requires two special in- stz'uments: the caudal dermatome, which is used for the division of the skin, and the caudal myotome for that of the muscles. The operation is minutely described by Director Degives, and includes the following steps: Two or thi'ee incisions are made on the prominent part of the muscle, parallel to its long axis, the first about two fingers' width from the base of the tail, a space of about half an inch being left between each in- cision. These incisions are made with the dermatome, pressed perpendicularly over the tissues to be di^sided. The two lower incisions are first made, then the two middle ones, and the two upper ones last. By this process the skin and subcutaneous fascia are divided. The myotome is then introduced under the muscle, from within outward, and after twisting it around the organ, di- vides it by turning the instrument so as to bring its sharp edge against the muscular tissue. Thus divided, the muscles protrude through the incision, and are then excised in the usual way. Fig. 317 — Operation by Mixed In- cisions (Vatel's method) 302 OPEEATIONS ON MUSCLES AND THEIR ANNEXES. Fig. 318.— Caudal Der- matome. Fig. 319.— Cau- dal Myotome. Fig. 330.— Brogniez's Mode of Operation. The American, or Subcutmieous Method. — This requires but a single instrument, viz.: a strong, straight tenotomy knife. The operator, having the animal in the usual position, with the tail under proper control, and holding his knife flat full in the hand, plunges it flatwise through the skin, with the sharp edge turned downward, from without inward, measuring carefully to intro- duce it at about the separation of the lateral and inferior caudal muscles, and pushing it as nearly as possible between the mass of the muscle and the vertebrae. When the instrument has pene- trated to near the median line, the sharp edge of the instrument is, by a twist of the hand, turned perpendicularly in the direction of the muscle, and by a careful sawing motion, the division of its fibers is accomplished. This is easily detected by a peculiar crack- ing sound, which ceases as soon as the entu^e thickness of the muscle is divided. The edge of the instrument can then readily be felt under the skin. The cutting must be carefully done in order to avoid the division of the entire thickness of the skin. A second and third division must follow, the number being equal on each side. There is also another subcutaneous mode, practiced by Ger- CAUDAL MYOTOMY. 303 man veterinarians, but which is claimed by Hering to be uncertain as to its results. In this operation both a straight and a curved myotome are used. With the straight knife a small incision is made, parallel to the axis of the tail and close to the hair, and the curved myotome is then introduced between the skin and the muscle. A turn of the instrument brings its edge against the muscle, and by the usual sawing motion, the organ is divided from within outward, the blunt end of the myotome sliding upon the vertebrae. Neither of these subcutaneous methods include the removal of any portion of muscle. When the operation is finished, the animal may be relieved and the tail released without any apprehension of serious hemorrhage, although by reason of the unavoidable division of the lateral caudal arteries, a certain amount will necessarily take place. But this is not of a serious nature, and, as a rule, needs no special attention ; we have seen the blood which had flowed quite freely while the tail was hanging pendant, cease almost immediately when the animal was returned to his stall, and the tail placed in the position to be described on another page. But in case of an unusually abvmdant hemorrhage, a simple compressible bandage may be applied, to be left on until the bleeding is controlled. The treatment appropriate for wounds resulting from incision and removal of portions of muscular substance, is that which is common to all suppxu'ating wounds, cleanliness being the most important item. AVhile such attentions are naturally re quired for animals subjected to any of the various methods of operation, the subcutaneous mode can claim an important advantage in the fact that the heahng process is almost always by first intention, and the tail demands no subsequent nursing. Whatever may have been the method of operation which the animal has undergone, it will be subsequently necessary to place the tail in some given elevated position, and retain it in position for a term ranging from two to possibly foiu- weeks, or until the wounds are cicatrized. Various devices are in use for keeping the tail in an elevated position, the simplest and probably the best of which is that of the pulleys. The proof is simple ; either a single pulley is placed in the middle of the ceiling, or two are used, one on each side of the stall, and in either case about on a level with the loins of the animal. The tail is kept in the perpendicular 304 OPERATIONS ON MUSCLES AND THEIE ANNEXES. Fig. 331. —Simple Method to Keep the Tail Elevated. position by a cord passing through the pulley, one end being se- cured to the tail and the other to a weight sufficiently heavy to effect the purpose (Fig. 323). A httle art is necessary in attaching the cord to the tail. The hair should be nicely braided and a loop formed, and then a small wooden pin run through the braid will effectually prevent the cord from becoming detached. This plan Fio. 323.— Brogniez's Apparatus to Elevate the TaiL CAUDAL MYOTOMY. 305 Fig. 323.— Elevating the Tail with Pulleys. also has the advantage of equalizing the strain on the hair. In respect to the amount of weight to be employed in this process, much caution must be exercised in order to avoid excess. An error here might cause the loosening and loss of the hair, with the troublesome consequences of greatly interfering with the final result at the cost also of much suffering to the horse. The cord should run freely through the pulley and be of sufficient strength to allow the animal to He down if disposed to do so. It will be a prudent precaution to accustom the animal to the use of the pul- leys by placing them on him for a few hours daily for a short pe- riod in anticipation of the operation. It will be necessary — as we before remarked — for the horse, after that, to remain in the pul- leys not less than two, and possibly three or four weeks, although after a short time he may be relieved for the purpose of taking proper exercise. The Bartlet's apparatus recommended by G. Fleming may also give very good results (Fig. 324). Caudal myotomy is an operation, which, though simple in it- self, may be followed by numerous and, at times, severe compli- cations. Out of one hundred and forty-one animals operated upon by Hering, four died from either gangrene, severe petechial fever or suppurative infection. Among the most common acci- dents met with are the following : 306 OPERATIONS ON MUSCLES AND THEIR ANNEXES. Fig. 834.— Bartlet's Apparatus, Separate and in Position. 1st. Hetnorrhage, which is not generally serious, taking place mostly when the tail is loosened and allowed to hang down, and ceasing as soon as it is again placed in an elevated position. It is but seldom that it becomes necessary to interfere for the pur- pose of arresting it, which is easily effected by the ordinary means, as pressure or the application of hemostatics. 2d. Gangrene is one of the most dangerous sequelae of the operation, whether resulting from excessive traction on the tail by the heavy weights, a dressing too tightly appHed, or excessive inflammation, or, according to Hering, to the completed* section of all the arteries supplying the tail. When becoming gangren- ous, the wounds assume a brown or blackish appearance, the sup- puration becomes sanious, with a repulsive, sui generis odor, the tail is swollen and flabby, and the oedema surrounding is cold and puffy. The gangrenous process generally begins toward the end of the tail and progresses rapidly, endangering in time the hfe of the j)atient. It is often only by the most energetic measures that it can be controlled, such as the free use of antiseptics, scarifica- tion, cauterization, or even amputation. 3d. 'Wounds of the Vertehrve and of their Ligaments. — These injuries, not so serious in their character, are usually produced by the contact of the knife during the operation, causing a scraping of the bone and wounding of the jaeriosteum or the ligaments which unite the vertebrae. Another injury is a re- sulting necrosis caused by the formation of a fistula, from which a thin sanious pus is discharged, and which forms a wound which refuses to cicatrize. Though Zundel affirms that this complica- tion is most common after the subcutaneous operation, long experience with this process fails to justify our agreement with CAUDAL MYOTOMY. 307 this assertion. Wheu disease of the bones exists, the indication is to promote the exfoHation of the necrosed parts by free open- ings, antiseptic dressings, and, if necessary, caustic injections. Anchylosis of the vertebrse is a common sequel of this complica- tion. 4th. Abscesses. — These suppuratire collections are not uncom- mon, especially in animals having pecuUar idiosyncrasies, as in cases of strangles. They may extend to the root of the tail, around the anus, or any part of the hind legs even to the rectal region. They require treatment similar to that of all analgous gatherings. 5th. Anal Fistulce. -This accident occurs when the first in- cision is made so near to the anus that it enables the pus, when it forms, to filtrate between the skin and the rectum into the pel- vic cavity, and is a condition which can be reheved only by giving free exit to the collected suppuration. 6th. Tetanus. — This termination can, in many instances, be avoided by antiseptic measures during and after the operation. 7th. The introduction of air into the veins is also mentioned by Loiset and Brogniez, but in our opinion there is no moi'e reason to expect its occiu-rence in this than in any other operation. 8th. Exaggerated Elevation of the Tail. — This is one of the most common of all the sequelae met with. In this case the tail, instead of being carried horizontally and hanging gracefully, is, on the contrary, either elevated vertically, or even laid back on the croup. This is not precisely due to improper manipulations during the operation, but is rather the result of the apphcation of too heav;y' a weight and an excessive amount of traction while the animal is in jJuUeys. The most effectual way of avoiding this un- pleasant incident is to watch closely the progress of the cicatri- zation by taking the patient out for exercise and watching the manner in which he carries his tail, and then increasing or di- minishing the weight on the pulley, and shortening or lengthen- ing the period of its use. Operation for Abnormal Deviation of the Tail. — This is in- dicated where there is a lateral curvature of the tail, and the animal carries it sidewise, whether it be a congenital habit or occvQ's as one of the complications of pricking ; and also when he carries it in an excessively elevated position. In these cases myotomy is performed, according to the requirements, either on 308 OPERATIONS ON MUSCLES AND THEIR ANNEXES. the lateral caudal muscle on the side to which the tail is carried, or upon one or both of the superior sacro-caudal muscles, the elevators of the tail. As a rule, one incision only is necessary, and it must be done subcutaneously, and in the subsequent treat- ment, instead cf placing the animal in pulleys, the tail must be tied up to the siircingie on the side opposite to that of the opera- tion ; or it may be allowed to hang down free. An experience on our part of many years, has rendered us skeptical as to the success of lateral caudal myotomy, a careful dissection of the tails of animals affected with this deformity having proved the existence of an abnormality in the formation and development of the caudal vertebrae which has been either the cause or effect of the trouble. Operations performed ujDon animals of this class have not been usually followed by a satisfactory result. CRURAL MYOTASE— CRURAL MYOTOMY. This affection is peculiar to bovines, and is a species of dis- location, or displacement of the long vastus muscle — the external ischio-tihial. It is a lesion which forms a very serious impediment to the act of locomotion, by its disabling effect upon the movements of the hind leg. The nature of crural myotase will be understood by those who are familiar with the anatomy of the region in cattle. With them, the biceps femoris covers, in its normal position, the whole of the coxo-femoral joint, in such a manner that its anterior border {a b), Fig. 325, is situated in front of the joint. This border, from the articulation to its lower end, forms a kind of tendon, (c) closely connected with the aponeurosis of the fascia lata, (f) whose divided layers surround the muscle, adhering intimately to its two faces, the deep and the superficial. Passing over the trochanter of the femur, with the assistance of a large mucous bursa, the biceps is quite thin, and is kept in position by an aponeurosis (c) which partially covers the gluteus externus, and is united to the fascia lata. When this aponeurosis is lacerated at a point on a level with the hip joint, while the leg is carried backward, in excessive ex- tension, it is possible that the trochanter, thus carried forward, may become engaged in the laceration, the biceps itself being hooked, as it were, behind the trochanter, and prevented from re- CEUKAL MYOTOMY. 309 Fig. 325.— The Biceps Femoris in Cattle. Normal Position. Fig. 326.— The same over the Trochanter. turning in its normal direction. This accident has been noticed and mentioned in the remotest ages. It may result from both jn'edisposing and occasional causes. Among the former may be reckoned the conformation of the animal, as when, for examj^le, the croup is short, flat and narrow, the hip joint not prominent, and the trochanter high. Among the predisposing causes may also be included that of leanness, as when the animal is thin and in poor condition, and the cellular tissue deficient. The combina- tion of these causes renders it easy for the muscle to slip over the trochanter, now relatively prominent, and it is thus that the dis- location occurs. Occasional causes also call for mention. These include all mischances likely to bring about the excessive extension of the leg, such as faUs, missteps, shpping, jumping, kicking, blows, etc., any of which may thus affect the limb and produce the lesion under consideration. And withal, it may take place vnthout any visible, direct and efficient agency beyond the circumstance of the excessively lean condition of the animal, and even if the difficulty is remedied, and the displacement is reduced, while the same state of things continues, there is a constant liabihty to a return of the difficultv. 310 OPERATIONS ON MUSCLES AND THEIR ANNEXES. The symptoms characteristic of this lesion are readily identi- fied. Principally, there is great diflficiilty in flexing the hip joint. The diseased leg is dragged on the ground, carried outward and backward and the animal resting it on the ground by the point of the hoof only. It very much resembles the position of a hmb of a horse suffering with a dislocated patella. The anterior border of the muscle, hooked by the trochanter, forms a longitudinal projection, resembling a stretched cord, which becomes more and more marked when examined nearer the coxo-femoral joint. It can be made more prominent by raising the opposite leg, when it will be found extending obliquely downward from the joint to the patella. As the trochanter is no longer covered by the muscle, this bony eminence becomes directly subcutaneous, and may be readily recognized, holding posteriorly the displaced muscle, which forms a kind of tumor behind it. These symptoms, being rarely associated with inflammatory phenomena, are not always easy to detect. There are cases where the lameness, and the carrjT^ng of the leg outward and backward, are the only apparent symptoms. The lameness, however, is characteristic, and may be temj^orary or intermittent, being more severe when the animal is traveling up-hill than when descending, but remaining the same on both soft or hard ground ; and it sometimes happens that while the animal is in the act of descend- ing, the muscle will suddenly return to its place with a clapping sound, and the lameness subside, though only to return again as soon as the slightest effort is required of the animal, and his hind leg is again carried backward more forcibly than usual. This peculiar intermittent character is sometimes the cause of an error of diagnosis which confounds this affection with the dislocation of the patella, but the exploration of the stifle will always serve to establish the differential diagnosis. This accident is more or less serious in its consequences, and is particularly detrimental to the usefulness of working animals. It may sometimes, however, subside spontaneously or by simple rest, and especially if the condition of the animal is improved by good feeding with fat-producing fodder. Sometimes the displace- ment is comjDhcated by a laceration of the mucous bursa with the formation of a hygroma of warm, painful, oedematous swellings, indicating the rupture of the aponeurosis or the inflammation of the cellular tissue. CEUEAL MYOTOMY. 311 Generally the dislocation is unilateral, but in other cases it may- occur in both legs. This last condition is always of a serious nature, and seldom responsive to treatment. The displacement of the biceps femoris seldom recovers naturally, although where in- complete and intermittent, it may be benefitted by long rest, or when, as we have before remarked, it is due to the excessive lean- ness of the patient, in which case a hberal fattening diet will prove the best remedy, by removing the cause of its appearance. Local, external topical treatment by bUsters, plasters, setons, etc., are of no avail. The section of the muscle or the operation of crural myotomy, is the indication. The modus operandi is not uniform, although the final object is the same in all. Our opinion in respect to the best way of operating is in favor of that by the subcutaneous section. This is performed below the trochanter, and yet as near to it as possible, where the excessive tension of the hooked muscle can readily be felt. This consists simply in making a small incision through the skin, by which to introduce a blunt bistoury, which is inserted under the muscle, with a director or a finger for a guide, and when at a proper depth turned to bring the sharp edge towards the aponeurosis, and cutting it from within outward, carefully avoiding the section of the skin. Fig. 327.— Gouze's Bistoury. The bistoury invented by N. Gouze answers the purjjose very well. There is no after-treatment required beyond the ordinarj^ care re- quired for all wounds. Simple as the operation of crural myotomy is, some compHca- tions may accompany it. Hemorrhage is not uncommon, usually subsiding without inter- ference, but sometimes requiring the appHcation of hemostatics. Inter-3Iuscnlar Abscesses. — Diffused Suppuration. — These are the result of improper manipulations during the operation, such as lacerations of the cellular tissue by introducing the fingers too frequently into the wound, or dividing the muscle in several places. Gangrene. — Though but rarely met with, this should be re- membered among the possible contingencies. It may occur as the 312 OPEKATIONS ON MUSCLES AND THEIR ANNEXES. result of the presence of clots of blood or other mortified tissues in the wound, and is indicated by the bad appearance of the parts, the pecuhar oedematous swelling, first warm and painful, but sub- sequently becoming cool and painless. This condition requires prompt and efficient treatment, both external and internal. In Sollpeds. — We once had occasion to resort to crural myotomy for the rehef of a case of pseudo-dislocation of the patella of several months' standing. The division was made towards the lower por- tion of the muscle, and was followed by satisfactory results, though not immediately. OPERATIONS UPON FIBROUS TISSUES. Tenotomy. In the terminology of surgery, tenotomy means the section of tendons — an operation which contemplates the correction of de- formities, from whatever cause they may proceed; the relief of pressure upon exostoses, and the prevention of the complete execu- tion of a normal function, as that of flying in birds. Our atten- tion wiU, accordingly, be directed to the study of the five varieties of plantar, carpal, antibrachial and tarsal tenotomy, with that of the wings of birds. Plantab Tenotomy. This operation is the proper remedy for the deformity known as knuckling, or the malposition which arises from the exaggerated flexion of the fetlock joint, and consists in the subcutaneous section of the tendons of the flexor of the phalanges. In this affection of knuckling, which is mostly pecuhar to soHpeds, there is lameness more or less marked, with a hard and painful enlargement of the tendons, and a consequent interference with the act of locomotion, caused by an incomplete flexion of the articulations. The fetlock is carried forward, and contact with the ground is effected with the toe alone. Instances of spontaneous cure or abatement are exceedingly rare. On the contrary, it has a tendency to aggravation, the swell- ing increasing, and the deformity becoming by degrees more and more developed, until at length the anterior face of the wall of the foot rests on the ground, and the case assumes all the weU estab- OPERATIONS UPON FIBKOUS TISSUES. 313 lished characters of a recognized club-foot. In a majority of cases the disease is locahzed in the tendon of the deep flexor of the phalanges, but it often extends to the superficial tendon as well, or may involve the tarsal or carpal band, or the suspensory ligament. This deformity of knuckhng may exist in three different degrees : either the cannon bone and the phalanges meet in an almost ver- tical hne, as in the case of the animal straight or upright on his pasterns, which is the first degree ; or the bones meet to form an angle opening backward, the phalanges being somewhat oblique in that direction, instead of forward, as in the normal state, and the animal still resting on the entire plantar surface of the foot, which is the second degree ; while in the third degree these conditions are still more exaggerated, the animal traveling altogether on his toe and exhibiting a case of the perfect talipes. This last conformation, which exists principally in the hind legs, is specially due to the retraction of the deep flexor, while in the other degrees it is the superficial flexor which is diseased. Lesion of the suspensory ligament may coexist in either case. The condition of the tendons, from which this deformity arises, is not the only question to take into consideration when the j)i"0- priety of the oj)eration is to be determined. The causes which have produced it must not be overlooked. For example, while in the hind legs the accident has usually a traumatic cause, such as a sprain, violent over-exertion, lacerations, or contusion of tendons ; when the fore legs are affected it is most commonly as the accom- paniment of some lesion in other parts of the leg, as of the foot or the digital region proper, such as bad feet, navicular disease, contraction of the heels, corns, quarter and toe-cracks, quittors, deep punctured wounds, and very commonly ringbones, or other exostoses. Taking all these various causes into consideration, with their specific natiu'es, and the extent of the lesions which accompany them, we are justified in believing with Gourdon, that plantar tenotomy is indicated with fair chance of success, when the knuck- hng results from traumatism, and the perforans tendon is alone diseased ; and even when both tendons are affected, good results are still not improbable ; but that it is contra-indicated whenever complications exist which are likely to prevent the leg from re- turning to its natural position, as when the disease is of long standing ; when there are alterations of the articular surfaces ; 314 OPEEATIONS ON MUSCLES AND THEIR ANNEXES. anchylosis of the fetlock ; exostoses ; adhesions between the ten- dons and the bones ; large engorgements of the tendinous struc- ture ; or chronic dilatation of the synovial btirsse surrounding the region of the fetlock. Remediable cases would seem, from this, to constitute rather a small minority of the whole number. The fibrous tissues acted upon in plantar tenotomy, are the tendons of the flexors of the phalanges, in that part of their length which is situated back of the cannon bone, between the carpal or tarsal sheath and the fetlock. The superficial tendon reaching the fetlock forms a ring through which the deep flexor passes, a cir- cumstance from which has been devised the manner of perforatus and perforans, by which they are known. Fig. 328.— Median section at the infe- rior row of the carpus — of the metacar- pus and suspensory ligament. 1. Os magnum. 2. Posterior common ligament of the carpus. 3. Band to the perforans. 4. Suspensory ligament. 5. Its superficial layer. 6. The deep. 7. Principal metacarpal bone. The superficial tendon is covered by the fibrous expansion of the two cai-pal and metacarpo-phalangeal sheaths in the fore, and by the tarsal and metatarso-phalangeal in the hind leg. The deep flexor toward the middle of the cannon receives a strong, fibrous band coming from the posterior Ugament of the carpus or tarsus. Below and between the two small metacarpal or metatarsal bones is the suspensory ligament, a strong band, thin superiorly at its origin, and bifid inf eriorly. Between the suspensory ligament and the cannon bone, there is an interosseous vein and the two inter- osseous arteries ; on the side of the tendons, the internal and ex- ternal collateral veins, with, in the fore leg, the principal artery I OPERATIONS UPON FIBROUS TISSUES. 315 collateral of the cannon., and the internal plantar nerve as its satellite on the inside, and the external plantar nerve on the out- side of the leg; whUe on the posterior leg the iirincipal artery of the cannon, which is the collateral metatarsal, is situated on the outside of the bone, and comes in relation with the tendons only in the lower part of the metatarsus. In the anterior legs, the carpal bursa, lined with its synovial sac, extends downward on the flexor tendons as far as below the superior third of the metacarpal region ; the synovial vaginal sac of the sesamoid sheath runs upward along the tendons, as far as the lower extremities of the small metacarpal bones. It is at about the center of the middle third of the cannon that the operation can be performed without fear of injuring either of these synovial sacs. In the hind legs the tarsal sheath extends as far as the upper part of the middle thuxl of the metatarsal region, and the sesamoid sac being the same as in the anterior leg, a little larger space is left for the operation. Modus Operandi. — To perform plantar tenotomy, the animal must be thrown. Some practitioners operate with the horse on his feet, but this position is dangerous, although by the use of cocaine, much of the risk attending it may be obviated. The animal is thi'own on either side, according to the leg upon which the operation is to be performed. If on the fore leg, it must be on the side of the leg to be operated on in order to expose the inside of the Hmb ; if on the hind leg, the animal should be thrown in such a manner as to make the leg upon which the operation is to take place the upper one. The arrangement, according to Gourdon, makes the operation feasible both on the inside of the fore, and the outside of the hind leg. Several modes of proceeding have been practiced. The old method is by a large lateral incision, in which the tendon is ex- posed, divided either with a bistoury, or by being raised from the wound and then di\ided. But this style of procedure necessitates the formation of large wounds, and is liable to severe and trouble- some comj^lications, which the modern or subcuta?ieoi(s method obviates. In performing the subcutaneous division, two instruments are necessary. These are the straight and curved tenotomes. The blade of the former is narrow, straight, thin and pointed ; that of 316 OPERATIONS ON MUSCLES AND THEIR ANNEXES. Fig. 329. Straight Tenotomy Knife. Fig. 330.— Curved Tenotomy Knife. the latter narrow, curved and blunt, and sharp on its concave edge. The animal being prepared, a puncture of the skin is made over the tendinous region (carefully avoiding the synovial sacs, as men- tioned above), by introducing the straight tenotome perpendicu- larly between the tendons, until the point of the instrument is felt on the opposite side of the leg. A slight sawing motion of the instrument then cuts through the connective tissue which unites them, and permits the introduction of the curved tenotome into the tract made by the straight instrument, and the latter is slowly withdrawn. At this point the leg is carried into excessive exten- sion by the assistants, by means of ropes secured respectively, one about the knee, and one about the foot, and pulling that of the knee backward and that of the foot forward. The fetlock being thus stretched to its utmost, the operator, with the edge of the curved tenotome turned toward the deep flexor, makes a slight sawing motion with the instrument, and cuts through the fibrous structure from behind and forward, a peculiar crackling sound in- dicating when the section is accomplished. The retracted extrem- ities of the tendons can now be felt with a wide interval between them, and the straightening, more or less, of the fetlock gives fur- ther proof that the operation is completed. This is the method in simple tenotomy. Some operators have suggested the introduction of the instrument between the sus- pensory ligaments and the perf orans in preference to the mode we have described, in which case the section of the tendon must be made from before backward. It is, however, a complicated pro- cess, and one which is not without danger of injuring tissues which ought to be left intact. The mode of operating known as the Bernard method is based on this principle. The double tenotomy, though considered at first as a severe OPERATIONS UPON FIBROUS TISSUES. 317 operation, does not involve as many objections as at first thought, but, on the contrary, has often been followed by very satisfactory results. It is, therefore, a justifiable operation when the defor- mity of the fetlock is quite extensive. In fact, it is unavoidable when both tendons are united, or when the deviation in the di- rection of the bony levers is caused equally by the common con- traction of both. In performing this double tenotomy, the divis ion of the deep flexor being made by the manipulations already described, the curved tenotome being still retained in the wound between the tendons, the operator simply reverses its position in order to bring the cutting edge in contact with the superficial tendon, and completes the operation precisely as ah'eady described. In this division of the tendon great caution must be observed, in order to avoid making a complete transverse section of the skin. Double tenotomy is also performed in some cases by introducing the tenotome between the suspensory ligament and the tendons, and dividing them by a section made at once through both from before backward. In some peculiar cases, besides the division of the two tendons, that of the suspensory ligament has also been included, sometimes in connection with the tenotomy, and sometimes independently. In this case, the place selected differs from that which is indicated for the simple or double operation. It is, indeed, toward the lower extremity near the bifiu'cation, and toward the lower third of the cannon, where it is more readily reached. The straight tenotome is first introduced, flatwise on either the internal or external face of the leg, between the ligament and the deep flexor of the pha- langes, carefully avoiding the blood vessels and nerves, and the curved instrument is inserted with its cutting edge toward the ligament, the section being made by cutting from behind forward. The instrument must not be introduced between the bone and the ligament, nor must the section be made from before back- ward ; such a course not only endangering the nerves and blood vessels, but also involving the risk of breaking the blade of the tenotome at the bottom of the wound. Whatever mode may have been followed, and however many tendons may have been divided, or whatever force may have been apphed to the rope by the assistants who made the traction, it is an exceedingly rare result to obtain a perfect straightening of the leg, most especially when the disease has been of long continu- 318 OPERATIONS ON MUSCLES AND THEIR ANNEXES. ance, and chronic adhesions may exist. A short walking exercise following the operation may facilitate the straightening of the leg, and in any event can have no injurious effect. But even with this, it is sometimes several days before any well-marked improvement can be discerned. There are cases, indeed, when ten or fifteen days may pass without noticeable change, but if it fails to appear after such a lapse of time, the case may be considered hopeless. There are practitioners, however, among whom are Didot, Delward and Hering, who object to this exercise, and hold that the natural and spontaneous straightening of the fetlock can be greatly assisted by proper shoeing, as, for exam- Fig. 332.— Mov- 11 • 1 .11 able Toe-Cork. pie, by weanng a shoe with a long toe, such as are used in cases of club- foot, or again, by having pecuHar movable toe-corks by which the effect of the bearing of the shoe is in- creased. The ordinary long-toed shoe represented in Fig. 333 is often worn with advantage. Fig. 331. — Shoe with Pro longed Toe, for Cluh-Foot. Fig. 333.— Long-Toe Shoe. Complete rest after the operation will benefit the patient in the most essential manner by diminishing the causes of pain and f avoi*- ing the cicatrization, and possibly preventing an exaggerated ex- tension at the fetlock. It is only after from twenty to twenty-five days that moderate exercise may be allowed, and not less than six OPERATIONS UPON FIBROUS TISSUES. 319 weeks should elapse before the ordinary labor of the patient can be resumed. The resulting wound needs no special dressing, and by being thoroughly sterilized by antiseptic manipulations, the parts will heal without trouble. The suggestions of poultices, fomentations, counter irritation, blisters and firing of old-time surgery must be strictly ignored. If, however, all the measures recommended for the straighten- ing of the leg should fail, and, on the contrary, a tendency to an Fig. 334. FiO. 335. Figs. 331, 335, 336.— Various Apparatus Recommended after Tenotomy. excessive extension of the fetlock should be manifested, the appli- cation of some of the various kinds of apparatus designed for the correction of these defects may be experimentally tried, with a 320 OPERATIONS ON MUSCLES AND THEIR ANNEXES. Fig. 336. possibility of good results. According to their peculiar working arrangements, slowly increased extension might be maintained? or the leg might be steadily retained in a given position, or with the power of regu- lated motion, the result being an important and permanent improvement in the value and comfort of the animal. The accidents which may be apprehend- ed in connection with plantar tenotomy are he^norrhage and wounds of nerves, or of the skin, or of the synovial sacs / an exag- geration of the extension, and a return of the original deformity. To these Peuch and Toussaint add gangrene. {a) Hemorrhage, both arterial or vein- ous. But this may be avoided by careful attention to the rules laid down for the operation, and if it should occur, hemostatis by pressure must be resorted to, and the band- age can be safely removed, or at least the pressure diminished, in from twelve to twenty-four hours. {h) Wounds of Nerves. — These cannot very well be avoided, and while they are manifested by severe struggles of the animal at the moment of their occurrence, they involve no danger other than those pertaining to similar injuries in other regions, viz.: the temporary suspension of the sensorial functions. (c) Wounds of the Skin. — These are among the comparatively severe compHcations, and when they occur, they destroy aU the advantages which properly accompany the operation as a subcu- taneous process. They are likely to compHcate the operation with fungoid growths upon the stumps of the tendons, abundant sup- puration, ugly cicatrices, etc., and should therefore be specially guarded against. {d) Wounds of the Tendinous JBursoe. — These may be attrib- uted to an improper selection of the place where the puncture should be made, and may be recognized by the flow of synovial fluid from the wound. Suppurative synovitis may then complicate the case with fatal effect. The treatment they require is that directed for open synovial tumors. Local appUcations, rest, pres sure, counter irritation, bhsters and firing are the indications. OPERATIONS UPON FIBROUS TISSUES. 321 (e) Exaggeration of the Extension. — This may take place when artificial means to produce sudden extension are too power- ful, or when the violent efforts of the animal have caused a ten- dency in the j)arts to give way suddenly. The apparatus before referred to must be here brought into requisition. (/) Return of the Original Deformity. — This results from the retraction of the new tissue formed between the stumps of the divided tendon. It occurs as a consequence of returning the animal to his work at too early a date, and when the newly formed tissue has not yet become sufficiently matured and solidified to sustain the strain to which it had been subjected. Rest, cold water bathing in a running stream, vesicating applications and firing have been recommended as remedies, and even a second section of the tendon may be suggested, though with but a doubt- ful prospect of good results. Carpal Tenotomy. This defines the section of the tendons of the external and oblique flexor muscles of the metacarpus. They are inserted on the trapezium bone of the carjDus, and their retraction occasions the deformity known as sprung knees, a condition brought on by excessive and exhaustive labor, though there is a class of pa- tients in which the lesion may be ascribed to a congenital taint, and it is principally for the benefit of this class of patients that the operation is indicated and usually perfonned. It is principally favored and utilized in Germany, where it was originated by Dieterichs, though afterwards adopted and practiced by Prud- homme, Lafosse, Miguel, Brogniez, Hering, Gourdon and others. The operation can be performed on either tendon singly, or on both ; but according to Hering, the division of the external mus- cle is generally sufficient. The anatomy of the region should be described before passing to a detail of the steps by which the section of the tendon is ef- fected. The external flexor is situated on the posterior external part of the forearm, and terminates by the branches, one of which, the funicular, is anterior, and passing in the groove of the external face of the trapezium, becomes attached to the hand of the exter- nal rudimentary metacarpal bone ; while the other posterior, wide and short, goes to the supero and posterior circumference of the same bone, in connection with the middle flexor, to which it is 322 OPEBATIONS ON MUSCLES AND THEIR ANNEXES. united. The section must be made above the bifurcation of the tendon, to avoid the artery which passes under it, though it is quite deeply situated, and besides, there is no danger of injuring the synovial sac of the carpal arch. The obhque flexor is situated back and inside of this, and has its tendon single, terminated on the trapezium, with the posterior tendon of the external flexor. The section must be made before the union of the two tendons, in order to avoid injury to the carpal arch. The animal is thrown, and the knee extended with two ropes, one above and one below the knee, and drawn in opposite direc- tions. The same instruments are used for carpal as for plantar tenotomy. The incision of the skin is made about two inches above the knee with the straight tenotome, immediately in front of the tendon, which is easily felt under the skin, and is raised with the fingers ; the curved tenotome is inserted between the skin and the tendon, from before backward, and the section made as in the plantar operation. Gourdon suggests the introduction of the knives under the tendon instead of between that and the skin. By this mode the division is made from within outward, while in the other way it is made from without inward. The external flexor being thus divided, the section of the middle flexor is made a httle below ; the puncture of the straight tenotome is made between the two tendons, and the curved tenotome inserted as before, between the skin and the tendon from before backward, or preferably, from without inward, and when its blunt end is felt on the posterior border of the muscle, the section is made from without inward, with the usual motion of the knife. Only a simple dressing is required, but the animal must be kept at rest for at least a month. The modus ojyerandi to which we give the preference over that which we have just narrated, and which we have described in our work on lameness, is very simple. The animal being thrown, on the side opposite to that of the operation, and the knee extended as usual, the operator, who is in front of the knee, feels for the space between the two muscles, where they are about to unite, and this being found, a straight tenotome is introduced through the skin from before backward, about two inches above the super- ior border of the trapezium, and under the thickness of the middle flexor, and when the point of the instrument is felt on the OPEKATIONS UPON FIBROUS TISSUES. 323 other border of the muscle, in front, the curved tenotome is in- serted and the straight one withdrawn, and the tendon di-vided from within outward ; the straight tenotome is then re-introduced through the same opening, between the muscles, and carried from behind forward on the posterior border of the external flexor, under its thickness, until the point of the instrument is felt on the anterior border, when the curved tenotome is again re-insert- ed, and the division of the tendons performed as before. The wound of this operation is simple, heals readily, and is Hable to no complications or accidents. Of course the operator must ex- ercise due caution, when dividing the tendons from within out- ward, to avoid making a complete section through the skin. Anti-Bra.chial Tenotomy. This operation has been recommended for the relief respec- tively of sprung knees and knuckled fetlocks, but by reason of the numerous and almost constant failures by which it was character- ized, has been discredited, and banished from the domain of our surgery. It consisted in the section of the tendinous band which from the lower extremity of the coraco-radialis extends downward to mingle with the fibres of the anti-brachial aponeurosis, in pass- ing a little below and in front of the elbow joint. Brogniez, who recommended the operation, performed it by making a longitudinal incision of the skin over the course of the tendon, which is readily felt under the skin, and passing the point of a convex bistoury over the aponeurosis and the band, dividing it from without inward. Taesal Tenotomies. Two modes of operation are practised upon some of the tendons sm-rounding the hock joints, one upon the cunean branch of the flexor metatarsi muscle, the other upon the tendons of the lateral extensor of the phalanges. They are known distinctively as the cunean and the peroneo-phalangeal tenotomy. {a.) Cunean Tenotomy. — The flexor metatarsi, one of the muscles of the anterior tibial region, is composed of two por- tions, one muscular, the other tendinous. The tendinous portion is situated between the muscular portion and the anterior extensor of the phalanges, and is attached above to the inferior extremity of the femur, between the external condyle and the external 324 OPERATIONS ON MUSCLES AND THEIK ANNEXES. border of the trochlea of that bone, and passes in the groove situated between the anterior and external tuberosity of the superior extremity of the tibia, downward to the hock, where it rests on the anterior face of that joint and is attached by two branches, one to the cuboid, on the outside of the hock, the other to the superior extremity of the principal metatarsal bone. The muscular portion, which rests on the external face of the tibia, from the upper part of which it takes its origin, terminates in- f eriorly by a tendon which passes through a ring of the tendinous portion, and becomes more superficial, and then divides into two branches, a large one, which goes to the superior part of the principal metatarsal bone, in uniting with that of the tendinous portion, and another, smaller, which bends inward, to terminate at the small cuneiform bone. This branch is chosen as the seat of operation. The operation recommended by Abildgaard and Viborg, was indicated by Hertwig, and at a later period performed by Lafosse, Hering, Mantel, Grad, Bugniet and Dieckerhoff. It is very com- \ monly performed on this continent, and, like many other operations at the time of their first introduction, has been both used and probably abused to such an ex- tent that it has not yet received the credit to which it is fairly entitled. It is indicated for the relief of the pres- sure which this branch makes upon the distended periosteum of the enlarged tar- sal exostoses known as spavins, and when the exostosis is, strictly speaking, the only lesion in the hock, it will prove essen- tially beneficial. But if, with the new growth of bony deposits, the joint itself Fig. 337.— Cunean Brancb of the should be involved, and some of the ar- piexor Metatarsi. ticular diseases should be present, the result, so far as the removal of pain and lameness is concerned, is not always certain. Although more or less satisfactory at times, in many instances it entirely fails. The difficulty of positively diagnosing the condition of the articular surfaces justifies the surgeon in operating, when the tense condition of the tendon, its pressure upon the exostosis, and the irritation of the synovial sac OPERATIONS UPON FIBROUS TISSUES. 325 whicli aids its movements, which it produces, point with certainty to the cause of the lameness. The instruments necessary are scissors, a straight and a con- vex bistoury, a dissecting forceps, a curved director, and perhaps a curved tenotomy knife. The animal is cast on the side of the leg to be operated upon, the upper leg carried forward and secured on the upper forearm, and the hair cHpped over the tract of the tendon, which can be readily identified by an oblique groove generally found running on the upper portion of the bony enlargement. An incision about two and a half inches long is made with the convex bis- toury, either parallel to the tendon, or slightly obhque, and right Fig. 338.— Tarsal Tenotomy. Cunean Tendon Exposed. Fig. 339.— Tarsal Tenotomy. The Tendon Raised, across its direction. This incision is generally accompanied by a somewhat troublesome capillary hemorrhage, which ought to be controlled before proceeding further. The tendon may then be felt through its bursa, which is raised with the dissecting forceps and opened, when the tendon is readily exposed. The curved director is then inserted under the tendon, which is easily raised from its tract, and by guiding the tenotome along its groove the section is made by a single stroke. Some practitioners complete the operation by amputating a portion of the tendon. This is unnecessary, and complicates the operation by subjecting the parts to the necessity of a repairing 326 OPERATIONS ON MUSCLES AND THEIE ANNEXES. process, wliich is not needed for the result of the operation, and exposes the animal to a complication of inflammation of the synovial bursse which ought to be avoided. To obviate these dangers, Dieckerhoff is of the opinion that the division of the bursa is all that is required, and states that he has often secured good results, from that alone, without the section of the tendon. Besides this mode of operating, which may be called the open incision, there is another procedure by subcutaneous division, which is also recommended by some, but the difficulty of discover- ing the tendon in its bony groove, and in reaching it properly, and the possible compUcation of subsequent inflammation of the bursse, will probably secure the preference for the method by open incis- ion. The operation is completed by closing the wound with a stitch of suture, and protecting it with antiseptic dressings. The results of the operation are sometimes immediate, though in some cases not apparent for a few days, but if after the lapse of two or three weeks the lameness has not either disappeared or greatly abated, it may be safely concluded that it is attributable to some cause other than the pressure of the tendon. ( 5. ) Peroneo - Phalangeal Teiiototny. — Though the true pathology of the peculiar affection of the hock joint known as springhalt, and the cause that excites the spasmodic action characterizing it, are far from being satisfactorily known, it has been observed that in animals thus affected the tendons of the ex- tensors of the foot in front of the hock have a tense or rigid character, which renders them unusually prominent ; and it is this symptom which suggested to Brocar, a Belgian veterinarian, the division of the tendon of the lateral extensor of the phalanges, or peroneo-phalangeal muscle, as a means of cure Brocar, Brogniez, and Delwart performed it, and have recorded their success in numerous cases. The lateral extensor of the phalanges terminates inferiorly by a round tendon, which passes into the groove situated on the out- side of the lower extremity of the tibia, in a sheath formed at the expense of the superficial external ligament of the tibio- tarsal joint. In this sheath it bends forward and downward to join the tendon of the anterior extensor toward the middle of the metatar- sus, which it crosses downward, forward and inward. The operation is of the simplest nature, and may be performed with great facility. The animal being cast, and the section com- OPEKATIONS UPON FIBROUS TISSUES. 327 pleted through a small incision made over the tendon, a little be- low the hock, and near its junction with the principal extensor, about one inch of the tendon is removed. Sometimes the action of springhalt ceases at once, when the animal is allowed to rise to his feet. Other cases require a few days for the completion of the cure. The simple operation has proved satisfactory in our hands in two cases. Tenotomy in Birds. The operation is performed in this instance with the object of preventing the animals from flying, and consists in the section of the tendons of the extensor muscles of the carpus and phalanges. The bird is held by an assistant, with its wing extended, and a few feathers are pulled out from each side of the carpal joint, as well as in front of the radius, to expose the skin, through which the extensor tendons, two in number, are readily seen. A small incision being made through the skin, the tendon is raised with forceps, and a portion of it amputated, the operation being re- peated on the other side of the wing upon the extensor tendons of the digits, between the radius and the cubitus. The treatment is appHed to both wings ; it is without hemorrhage, and the wounds heal in two or three days. CHAPTEK VIII. OPERATIONS ON THE DIGESTIVE APPARATUS. ON THE TEETH. The office fulfilled by the dental system in the preliminary preparation of the iagesta, and the first step in the process of di- gestion, is necessarily one of the utmost imjjortance. Of course, therefore, any diseased conditions which may interfere with its efficient action, especially with the herbivorous animals, become matters of deep interest to the veterinary practitioner. All facts and circumstances concur to establish and substantiate the claims of that branch of veterinary science which refers to the care of the teeth as a very important specialty, and we shall, there- fore, so estimate and so elucidate the subject of veterinary dentis- try, so successfully studied and so largely developed in recent years by American veterinarians. The diseases of the teeth to which our domestic animals are subject may be due to various pathological conditions. The den- tal arches formed by their arrangement ia the jaw may be the seat of congenital deformity; the teeth may possess abnormal quahties in respect to their number, their shape and their direc- tion ; or, again, in the condition of their grinding surfaces, and there may also be special diseases of the elementary substances of the tooth itself.* The abnormality which exists in relation to the number of the teeth is of not iincommon occurrence in horses, in which animal we sometimes discover the presence of supplementary molars, resulting either from the persistence of a temporary tooth which has failed to be shed at the proper time, or may be due to an excess of de- velopment in the evolution of a dental foUicle, as we may observe in the formation of the wolf tooth. In relation to the shape of the dental arches, there are cases * We take pleasure in recommending, in connection with this subject, the excellent little work on Horses' Teeth, written by Mr. William H. Clarke. OPERATIONS ON THE TEETH. 329 where, instead of presenting the regular and correct natiu-al lines, the upper and lower molar arches so far disagree as to render their perfect coaptation impossible, and render the execution of their function to a great extent impracticable. The direction or implantation of the teeth is, at times, so far irregular and abnor- mal as to change the frictional surfaces in such a manner as to remove the wear and abrasion from the crown to the surface of the organ. In relation to the disposition of their rubbing sur- faces, it is well known that on account of the difference existing in the consistency and power of resistance, two of their elements, the enamel and the dentine, their frictional surfaces become rough, irregular and sharp; and, as they sometimes assume excessive dimensions, they may give rise to serious phenomena, especially when they have theu- seat in a part of the dental arch where no resistance can be offered to their development, as when the cor- responding tooth of the opposite jaws becomes diseased or absent. The special diseases of the elementary constituents of the teeth exist in the depth of their substance, and consist in caries or ul aeration of the tooth, the affection involving the dental pulp itself, with other diseases pertaining to the alveolo-dental membrane, all of them being accompanied by a series of well understood symp- toms, severely distinctive in their character, and which in the ma- jority of cases call for the assistance of the veterinary dentist in order to relieve the suffering animal from the distress in which his human master knows but too well how to sympathize. The symptoms pertaining to the various conditions above al- luded to may be either common, or general, or special. Among the general symptoms, the first to be observed is a change in the style of performing the function of mastication, proportional to the sensitiveness occasioned by the dental lesion. Thus it is ob- served that although the animal seizes his food with the same avidity as if his teeth were in good order, the motion of his jaws, the chewing of the food, are slowly and carefuUy performed, the lateral movements of the lower jaw occurring in a hesitating man- ner, and often made on one side of the mouth only. In eating hay, the mouthful of the food is never triturated as it ought to be, and before the process of mastication is completed the animal drops it out of its mouth in the shape of a flattened bolus, satu- rated with saliva, to seize it again and make a new attempt at mastication, perhaps twisting his jaw in different directions in his 330 OPEEATIONS ON THE DIGESTIVE APPARATUS. endeavor to accomplish tlie act without pain. The attempt seems, however, to be vain ; again the mouth is opened and the same flattened bolus is dropped in the manger, and this continues until the poor animal, suffering and hungry, is seen standing before a rack full of hay for which he both longs and fears to touch. The suffering horse will sometimes swallow his oats imperfectly mas- ticated, but the partial chewing is performed slowly and with dif- ficulty, his manner indicating the pain it costs him ; dipping his nose in the manger, chewing on the grain for a long time, and impregnating it with saUva before he swallows it. Soft food, bran and mashes, cooked roots, scalded grains, and the like, are the only aliments that can, without difficulty with this imperfect de- gree of mastication, enter into the pharynx. Animals suffering with diseases of the dental apparatus are often affected with coHcs. At first they may be slight and inter- mittent, but they soon become more severe and more frequent. They may last for several days, and may be marked by the pecu- liarity^ that during their continuance defecation may still continue, though irregular as to time, and the movements scanty in amount, the foeces besides being in small and adherent lumps, and more or less coated. In other cases they are soft, and the animal has a tendency to be washy, and more or less to scour, but in either case the droppings are more or less loaded with unmasticated food. All these symptoms are manifestations resulting from an imperfect digestion. It is easy to understand that if this condition continues for any length of time the entire economy will suffer from it. The animal looses flesh ; his coat becomes dull, dry and staring ; his force and ardor diminish ; he sweats easily, and aU his other func- tions exhibit evidences of the weak condition of an organism de- prived of the nutrition and strength which follow the ingestion of food thoroughly masticated and well digested. Having recognized these symptoms, which, if not seen by the surgeon, should be brought to his attention through the history of the patient; when intelligently stated, the diagnosis may be considered established. But it becomes positive only after an examination of the mouth, by which the special symptoms per- taining to each alteration are elicited. The inspection of the moath, which may be kept open by the use of the various speculums, or by merely pulling the tongue OPERATIONS ON THE TEETH. 331 sidewise out of the way, will, in a gi-eat majority of cases, easily lead to the detection of the cause which interferes with masti- cation. First of all, when the mouth is opened, a peculiar symptom will be observed, consisting in a change in the salivary secretion. This will be increased more or less, and as the saliva will escape freely, a pecuHar acid odor will be noticed proceeding from it, and on looking for the cause of this trouble, if it be one or other of the irregularities already mentioned, such as the projection of one of the teeth, the vicious inclination of their crowns, the sharp edges, etc., critical inspection wiU soon reveal them. The teeth will be found to be soiled with greenish food-detritus on the side where the difficulty exists, and on that same side the animal will be found to have stored the surplus food which he has accumu- lated between his teeth and the cheek. If, however, in consequence of being situated so far back in the mouth that the eye fails to detect the condition of the part, he can complete his examination with his hands. With due prac- tice in this mode of investigation, one may become sufficiently expert in the manipulation of the mouth to dispense entirely with the aid of the speculum ; though of course there will be cases when in order to establish a thorough diagnosis of the exact and positive condition of the part, this instrument cannot be dispensed with. There are also conditions where the examination cannot be carried out in the standing position, even with the assistance of means of restraint, and the animal must be thrown down, and even, says Bouley, " placed under the eflects of ether. In this condi- tion, the jaws are readily kept open and immobile, the tongue is free from contraction, and the hands and fingers can be carried over the entire length of the dental arches without the slighest danger to the operator." Manual exploration removes all doubt about the diagnosis, since the surgeon may, by skillfully practicing the taxis, recognize all the irregularities present, whether the vicious direction of the dental surfaces, the uneven wearing of the teeth, the cavities which may exist in their thickness, or the condition of their im- plantation with that of the alveolar cavity, etc. When the mucous membrane has been excoriated by the sharp projections of the teeth, when the gums are highly inflamed, and the jawbones have been bruised, and are necrosed and suppurating; 332 OPERATIONS ON THE DIGESTIVE APPARATUS. when tlie saliva which flows from the mouth is abundant, gluey and foetid in odor ; when the mouth is hot, the mucous membrane injected, and in the regions where this di£fused inflammation has started, lesions are apparent corresponding to the cause that pro- duced them, such as deep cuts on the internal face of the cheeks, which have been torn by the asperities of the teeth ; when there is swelling and redness of the gum at the point where it is inflamed ; when there is enlargement of the bone, with a grayish hue at the point where it is exposed and in process of sloughing ; or again if these fistulas penetrating the spongy tissues of the maxillary bone — all this becomes evident under the careful and accurate manip- ulation of the instructed fingers. Besides the exhibition of the general symptoms belonging to all diseases of the dental apjoaratus, caries of these organs is characterized by some special characters belonging to them ex- clusively. Principal among these is the peculiar foetor of the in- terior of the mouth and of the saHva flowing from it, which is sui generis. There is also the escape from the mouth of this saliva in excessive quantity and in long, slobbering masses. Then there is the existence on one of the faces of the carious tooth, and principally on the crown, of a blackish spot, or of a hole, or of a large excavation, penetrating the substance of the tooth at a vary- ing depth, according to the extent of the disease and the duration of its existence — the violent pain experienced by the animal when the percussion is applied on the tooth, or its cavity explored with the instrument — the swollen condition of the gum surrounding the diseased tooth ; its red color ; its want of adherence in some places, and the hemorrhage with the oozing of pus when pressure is ap- pHed directly over those same places; the soiled appearance of the dental surfaces on the side of the diseased tooth, caused by particles of food remaining adherent to their anfractuosities, and filling up the cavity of the carious tooth, or forcing themselves between the tooth and the gum, and spreading, diffusing the most repulsive odor — these all belong to a carious condition of one or more of the teeth. But if in addition to this the caries is of long standing, and has advanced towards the root of the tooth, the or- dinary complications pertaining to its development in the maxil- lary bone at the alveola take place, and that point becomes the seat of an inflammatory swelling, manifested externally by a pain- ful enlargement, hot and oedematous, which gradually increases, OPERATIONS ON THE TEETH. 333 though at a given time it may remain stationary, hard and resist- ing. Again, as the progress of the disease continues, the hy^jer- trophied dental root, by its continued pressure outward, may destroy the external surface of the bone, and form a communica- tion between the bottom of the diseased alveola and the external plate of the maxillary. In these cases pus, saliva and putrefied food collect or filtrate into the subcutaneous cellular tissue, and an abscess is formed which soon ulcerates and empties itself on the surface of the cheek. Once open, this abscess has no tendency to heal, but, on the contrary, maintains its fistulous form, and dis- charges through its opening a mixture of pus, saliva and food, having the very repulsive and characteristic odor already men- tioned. Exploration of this fistula with the probe will give different results according as the fistulous tract is straight or irregular. In the first instance, the probe will penetrate directly into the mouth, opening on one of the faces of the diseased tooth, or even passing into the center of its carious crown; while in the other case it is arrested by the spongy substance of the ulcerated max- illary; or it may strike against the root of the diseased molar. At this point, changes will have taken place in the mouth, upon the svirface of the teeth, on the side of the jaw where the disease exists. These changes vary, and consist either in a great obhqmty of the tables of the teeth, the crowns or rubbing sur- faces being beveled in very obUque and opposite directions, or in the well marked elevation or projection of the molars correspond- ing to the diseased grinders, in the healthy jaw; a projection which is in proportion to the diminished size of the opposite carious tooth which stands much lower. The first condition is observed when the pain caused by the caries has entirely prevent- ed mastication on the diseased side, and the second, when, not- withstanding the caries, the performance of mastication has still contiaued. The condition then presented by the carious tooth may also vary. In some cases it may still be complete in its alveolar con- nection, though otherwise partly destroyed, and yet firmly ad- herent by its root. In others it may be broken, entirely or in fragments, merely parts of the outer surface being present; while again, some broken fragments, more or less detached, may remain in the alveolar cavities. Caries of the first and second superior molars may become 334 OPEEATIONS ON THE DIGESTIVE APPARATUS. complicated with lesions of the nasal cavities, when the ulcerating process has been followed by a perforation between one or other of these cavities and the mouth. This lesion is accompanied by a discharge taking place on the side of the nose corresponding to that of the diseased tooth. This discharge is of a muco- purulent character, and mixed with saliva and food, which gives it the usual foetid odor as weU as a peculiar green appearance. It is very different from that belonging to glanders, and is too charac- teristic to justify by its presence an error in diagnosis in that direction. If, however, the same compUcations take place in the molars, whose roots rest on the sinuses of the head, the symp- toms which are manifested are often so nearly similar in aspect to those of chronic glanders, that the commission of an error should not be considered whoUy inexcusable. Careful examina- tion win readily bring out the differential diagnosis between the two diseases, though so different in their ensernble. "When the caries of one of these last molars exists to such an extent as to transform the mucous membrane of the sinuses into a sup- purative surface, and to cause the development of granulations upon its surface ; or to allow the collection of pus in the cavity of the sinuses, a discharge becomes estabHshed through the nostril of the side of the diseased tooth and affected sinus. This dis- charge is white, grumous, very abundant, and keeps increasing, and has also an extremely foetid odor, identical with that of dental caries. The lymphatic glands of the maxUlary space then become swollen, hard, though painless, and loose under the fingers. The plates of the zygomatic, of the superior maxillary and of the nasal become swollen, and give a dull sound on percussion. Sometimes their surfaces are so thinned out that it flexes under the pressure of the fingers, and they are then surrounded by an oedematous infiltration of subcutaneous cellular tissue. The long and minute consideration which we have thus given to the diseases of the dental apparatus has been principally devoted to the molar teeth of herbivorous animals, although many of the conditions observed in the grinders may also be found belonging to the incisors. Indeed, incisor arches may also offer abnormali- ties in the number of teeth, in their position, and in the direction or the length of these organs, and they may also become the seat of accidental lesions, such as fractures, luxations, or the too OPEBATIONS ON THE TEETH. 335 rapid wearing of various parts of their surfaces, though it seldom reaches the point of caries. The different indications which the majority of these patho- logical conditions may impose resemble so nearly those required under similar circumstances for the grinders, that it becomes un- necessary to appropriate a special chapter to their discussion, and we therefore proceed to the consideration of the general opera- tions performed upon the teeth, according to the indications which may be from time to time presented. Opekative Dental Stjkgeey. Two principal indications present themselves under this head- ing. J^irst, the leveling of the frictional dental surfaces, for the removal of any existing asperities or sharp projections, in order to establish a perfect coaptation, as weU as the free movement necessary for the execution of their function of attrition. Second, the extract 1071 of the teeth which have undergone such important alterations in their structure, that their conservation becomes in- compatible with the regular execution of mastication, or because of the serious compHcations they may involve. Leveling of the Dental Arches — The original mode of operat- ing to level the molar teeth consisted in making the animal chew on the blacksmith's rasp. It is a simj)le process, easy to jjerform, without danger to the animal, and so well answering the purpose that even to-day the process is still in extensive use. But this modus o^yerandi is not without its inconveniences, among other objectionable points, requiring to be repeated for several days until perhaps the teeth have become smooth by rubbing against the rough surface of the rasp — a result not always as satisfactory as it might be. More appropriate instruments have therefore been invented, though, in point of fact, none of them are other than more or less modified rasps or files, as they are truly called. Their number and variety are to-day very great, and theii" quali- ties vary veiy much, according to the taste, the ideas, and often the dexterity of those who use them. Samples of these files are represented in Fig. 340, and according to their general construc- tion may be classified as rough and fine rasps, flat and angular, guarded, double and single on one or other of their edges. Some are simple, and formed of a single piece, while others are jointed and compound, and may be screwed or unscrewed with facility 336 OPERATIONS ON THE DIGESTIVE APPAKATUS. Fig. 340.— Samples of Tooth Rasps. for use and transportation ; some have the rasp fixed to a solid handle, and again, the handle in others is moveable, and may be changed as indications may present themselves. Their number in this country is about incomputable, and while many which we find registered in the patent ofiice are of real value, many others have no reason for being beyond their maker's whim. As we have said, the advantages which any of them may possess depend more on special conditions than on the resvilt to be obtained, in the removal of the small, sharp edges of the external surface of the tooth, or its lateral faces, resulting from an excessive develop- ment in the enamel. Whatever may be the file which the veterinary dentist may see fit to use, the manipulations required in its handling will be in all cases the same. In referring to this, the first question which offers is, whether the use of the speculum is necessary to enable the surgeon to file a horse's teeth? There is no doubt that in many instances it will be difficult, and even perhaps impossible, to compel the patient to keep his mouth sufficiently open to per- mit the use of the rasp with the necessary delicacy and freedom, or prevent him from constantly biting it, or keeping his jaws closed during the operation. In every instance, the play of the instru- ment will be sure to be interfered with by the excited patient. We believe that American practitioners were the first to dis- pense with the speculum in these cases ; and that to Mr. House, a celebrated veterinary dentist, who died not many years ago, is due, in fact, the paternity of this specialty in veterinary surgery. Whether the mouth of the animal is held open with a sjdccu- OPEKATIONS ON THE TEETH. 337 lum, and the tongue drawn out and held on one side by an assist- ant, or whether the operator himself controls the tongue with one hand while working the instrument with the other, the manipula- tions must be the same, viz. : the passage to and fro of the file over the siu-faces requuing to be corrected, wherever they are rough and sharp ; filing them just as the smith files the iron he is shap- ing as he holds it in the vise. We beheve, however, that the rasping out ought to be done slowly, softly and without giving the animal any cause for fright or excitement. The method sometimes practiced of using the rasp with a succession of rapid movements over the dental arches is certainly dangerous and hable to be ac- companied with accident to the patient. An ii-ritable, struggling animal, by violent movements of the head, or in his attempts to chew on the rasp, may easUy receive injuries from the rough con- tact of the instrument with the delicate structures of the mouth. After such a passage of the rasp a number of times over the teeth, the hand introduced in the mouth will at once detect the effect upon the patient. Although the use of the speculum may be advantageous in many instances, there is certainly a risk attending its use, in the possibility of bruises and lacerations which may occiu- at the bars when the animal, annoyed by its ajDpHcation, chews upon it in his endeavors to close his mouth. The work of filing when the teeth are sharp is of common in- dication, and finds its direct appHcation under the special condi- tion that the edges or asperities which are treated should not be too large or too prominent. If this should be the case, and the inefficiency of the file or rasp, however, become evident in the trial, other means remain for accomplishing the desired pm-pose. Such a contingency was not lost sight of in former years, and chisels and gouges were then emplojised to reduce the excessively devel- oped projections of enamel. With these instruments the patient was either thrown or treat- ed on his feet, his mouth being opened with a speculum, with his tongue drawn out and held on one side. The chisel was then laid against the dental projection, and an assistant striking it with a hammer, the excess of tooth was knocked oi9f. Bouley considered this mode of operation dangerous. " The chisel might, under the imjDulse received by the hammer, slide in the mouth and severely injure the tongue, the cheeks, and the soft or the hard palate ; or 338 OPERATIONS ON THE DIGESTIVE APPARATUS. in animals advanced in age, the tooth, might be fractured or dis- located; or again, the operator himself might be injured by the instrument, vrhen, suddenly displaced by a movement of the ani- mal, the assistant knocks against it." It was to remedy this objection that Brogniez invented his odontritor (Fig. 341), an instrument which carries on one end a blade sharpened on both edges, and on the other is hollowed out, in order to allow the play of a rod through one-half of the length of the instrument. This rod is provided with a transversal handle, which also acts as a hammer, by which the blow is carried against the sharp edges of the tooth. When the odontritor is used, it is not necessary to use a spec- ulum to open the mouth, the holding of the tongue out of the mouth being sufficient. The operator, holding the instrument with the left hand, places the anterior sharp edge against the j)ro- jecting portion of the tooth, and holding the rod by the handle full in his right hand, moves it to and fro, striking at the proper points as he moves it. This operation is repeated on both jaws until all the sharper edges of the teeth have been cut off, and is completed by passing the rasp over the dental plates, as is done when the teeth are not too sharp. Several modifications have been made in the conformation of the odontritor, but that of Prang d is probably the best (Fig. 342) It consists in having three blades, which may be changed at will and which vary in the form and disposition of their cutting edges. This instrument is considered superior to that of Brogniez, and is thought to work to better advantage when the elevation of the tooth is well marked. The odontritor answers perfectly for leveling the molars when the projections are not excessively developed, or do not offer too great resistance to the action of the blade. But when an entire tooth projects above the general level, the odontritor ceases to be of any advantage, and it becomes necessary to perform the resec- tion of the tooth, consisting in the removal of all that portion of it which rises above the level of the general dental surface. To Brogniez is due again the first instrument invented for the performance of this operation in the chisel odontritor (Fig. 343). This is composed of two rods, one of them having at one end, like the ordinary odontritor, a frame of sufficient dimensions to allow the entire molar to pass through it, and on the anterior border of OPEEATIONS ON THE TEETH. 339 Fig. 341.— Brognlez'B Odontritor. Fig. 342.— Prang6's Odontritor. 340 OPERATIONS ON THE DIGESTIVE APPARATUS. this frame a solid blade with a sharp con- cave edge tvirned backward. The other extremity of this rod carries a transverse prolongation, which serves to change the y j position of the blade when necessary, and which has on its shorter portion a hole through which the other rod is allowed to slide. This second rod has on one end a sharp blade which slides into suitable grooves made in the frame of the first, and is curved forward on its front edge. On the other extremity it carries a metal- lic mass which is used as a hammer. In using this instrument, the tooth being enclosed in the frame between the two blades, the movable rod, with its sharp edge, is pushed against the blade of the frame, and a strong blow of the hammer cuts off the tooth smoothly and evenly. The chisel invented by Gowing (Fig. 344), works somewhat on the same princi- ple as that of Brogniez. Resection of the teeth has also been per- formed with the instruments used for the same operation on bones. Saws of various form and design are also recommended, the chain saw, which we have often used, beinff one of these. But there are serious Fig-344— Gow- <=• ing's Chisel. objections to this latter mstrument, among which is its liability to become heated while in use, when it becomes unable to " bite " upon the hard dental substance, and may, moreover, break or slide. The only method of overcoming these objections, which, in fact, may occur in using any kind of saw, is by hold- ing a wet sponge against the tooth to which the instrument is applied — a precaution which is not always of easy adoption, and which can scarcely be effected without more or less danger of wovmding the hand which holds Pig. 343.— Brogniez's Tooth Chisel. OPEKATIOKS ON THE TEETH. Fig. 3J5. 341 Liautard's Cutter. Scheffler-8 Extractor and Molar Cutter. 342 OPERATIONS ON THE DIGESTIVE APPARATUS. Fig. 345a.— Hamlin's Molar Cutter. the sponge. But when none of these modes of operation can be readily applied, the use of the tooth-chisel becomes the order. Its application is simple, and with a weU-made instrument in the hands of an expert operator, quick and strong, the resection can be readily performed. The array of tooth-chisels or resectors is beyond compute in variety and number, and especially in this coimtry where the in- stinct of mechanical invention is so universal, and the specialty of veterinary dentistry is so extensively practiced, and many different kinds can be inspected among the samples of workmanship which decorate the show-cases of our instrument makers. Among the principal forms, we may, however, mention those which recall the names of Lafosse, Moller, Scheffers, Gowing in Europe, and of Clarke, House, Liautard and Hamlin in this country (Figs. 345, 345a). Some of these instruments have their jaws closed, others have them open. Some work by a peculiar thread-screw arrange- ment, others by the manual power of the operators ; and again, the blades of some are straight and others curved, and still others are sharp like a concave saw. In theii- ajDplication they all work upon about the same principle, and are used in the same man- ner. The mouth being opened, the tooth is seized between the jaws of the forceps, and by the pressure of the screw with which some of them are armed, or by the unaided strength of the operator, the tooth is squeezed and cut off with a sudden snap, followed by the dropping out of the mouth of the amputated portion. As a rule, the surface left on the tooth shows but a slight roughness, which can be smoothed off with the rasp. OPERATIONS ON THE TEETH. 343 Extraction of Teeth. The extraction or removal of teeth is indicated for the reduc- tion of any excess in their number, which may interfere with mas- tication ; or when these organs are abnormal in form or direction, and obstruct the growth or usurp the place of a permanent tooth ; or when they are diseased with caries, or affected with any of the pathological conditions which we have before considered ; or when they become the cause of a dental fistula. To extract the incisors of any of our domestic animals, the molars of dogs, or the caduc molars of large herbivorous animals, some of the various forms of tooth forceps that are used in human Fig. 346.— Samples of Tooth Forceps. dentistry or the different shapes of the key of Garangeot or special larger forceps, such as that of Lecellier (Fig. 848) or the enlarged Garangeot's key, as modified by Delamarre (Fig. 349), wall be necessary. The modus operandi is generally simple ; the tooth, still firmly attached to its alveola, or perhaps loose and more or zu OPERATIONS ON THE DIGESTIVE APPARATUS. 1 Fig. 347.— Garangeot's Keys. less pushed out of its place by a succeeding growth, is seized be- tween the jaws of the forceps, or of the Garangeot's keys, and is easily wrenched from its position by a strong pull or with a sHght twisting motion sufficient to lacerate its last adhesions. The extraction of the permanent molars of a horse is a diffi- cult and, under some circumstances, a serious operation. Their mode of implantation and insertion in the alveolar cavities ; the great length of their roots as compared to the small dimensions of their free portion; the narrow connections which exist be- tween them, and withal, the solidity of the dental arch — aU these conditions are sufficient to explain the serious character of the prognosis of this operation, and the difficulties which are often encountered when the organ to be removed is the molar tooth of a horse. These difficulties, however, vary considerably under pe- culiar conditions, such, according to Peuch & Toussaint, as " the age of the subject, the position of the tooth on one or the other jaw, and the degree of alteration of the tooth to extract." For example, the operation is more difficult in young animals than in adult, or older subjects, the latter requiring less effort, the root of the tooth being shorter and the adhesion to the alveola less solid. The upper are less firmly attached than the lower OPERATIONS ON THE TEETH. 345 Fig. 348.— Lecellier's Tooth Forceps for Molar. Fig. 349.— Garangpot's Keys, Modi- fied by Delaiuarre. molars, the presence of the cavities of the sinuses, and the diminished thickness of the walls of their alveola rendering their 346 OPERATIONS ON THE DIGESTIVE APPARATUS. insertion and implantation less tenacious than in the lower. The extraction of the front is less difficult than that of the posterior molars. At times, as when the teeth are partly destroyed by caries, a single effort wiU be suffi- cient to extract them ; but in other cases, as when the periosteum is dis- eased, and the roots adhere more intimately to the alveola, the extrac- tion becomes very difficult. And again, if the tooth having a hyper- trophied root, resists the action of the instruments through the op- position of those immediately sur- rounding it, which, though healthy, are less firmly fixed in their alveola, which are mechanically dilated by the outward pressure made upon the plates of the maxillary bone, is easy to loosen and dislocate them ; and this is a circumstance which must not be overlooked during the manipulation required for the ex- traction, in order to avoid serious disturbances of the dental appa- ratus. In the extraction of a molar, the patient must be thrown, and the head well elevated, the mouth being kept well open by means of a per- fectly safe speculum, such as that of Lecellier (Fig. 350), but we think it rather clumsy to handle. Bouley recommends the etherization of the patient. The mouth is to be thor- oughly cleansed. There are circum- stances, however, in which the op- eration of casting is unnecessary, and, in fact, our own personal ex- perience has raised doubts in our PIG. 350.-Spectiium of Lecellier. mind as to the necessity at any OPERATIONS ON THE TEETH. 347 Fig. 351.-PIas8e Molar Extractor (full view). Fig. 353. _- The same (side view). 348 OPEKATIONS ON THE DIGESTIVE APPARATUS. time of exposing the animal to the possible accidents which may- attend this mode of restraint. We hold strongly to the expedi- ency of performing the operation in the standing position. There will necessarily be cases in which to attempt to remove a tooth with the animal standing would be simple folly and time lost, but with many operators in this country, we have in several instances succeeded in extracting a condemned molar without any other means of restraint than a twitch on the patient's lower lip or on his ear. The removal of molars is effected in two ways — ^by pul- ling, or by repulsion or gouging out. The method by extraction or evulsion, is preferable whenever it is practicable, having the advantage of causing less injury to the surrounding structures, and is objectionable, princij)ally for the posterior teeth, which always oppose great difficulties to the operation. The oldest instrument used in this operation is the enlarged key of Garangeot, as modified by Delamarre. lis ajDpli- cation has always seemed to us difficult, if not dangerous, and we think that it involves more or less risk of fracture of the plates of the maxillary bone, on which account we prefar the large tooth forceps, which may be found under many forms and designs. The forceps of Plasse (Fig. 351), of Wendenburg (Fig. 353), of Pill- wax (Fig. 354), of Gowing (Fig. 355), of the same inventor, as modified by Bouley (Fig. 356), those of Gunther (Fig. 358), the key-forceps of Bouley (Fig. 357), those of House, of Walters, and many others will furnish the operator a large collection from which to select. Many of these instruments are very complicated (as that of Scheffer) ; some are clumsy and difficult to handle ; have levers, like those of Wendenburg and Pillwax; many work by merely grasping the tooth and holding it by a peculiar arrangement of spring, or of thread-screw, and thus to the end of the chapter. We have for many years given the preference to the simple forceps of Gowing, leaving off the little rod which is connected with the cross-piece which carries the thread, and which is to be screwed on the handles of the instrument to hold them firmly to- gether. What we think most essential in the instrument is that its arms should be firm and so solid as not to bend or yield when the screw is applied on them, and that the jaws of the forceps should not be too narrow nor too curved, and above all, that the instrument should not be made unnecessarily heavy, a fault which we have too often observed in some of the continental patterns. OPEKATIONS ON THE TEETH. 349 (D Fig 353.— Wendenburg Forceps. Fig. 354.— Pillwax'a Forceps. Fig. 355.— Gowing's ForeepB. Besides the forceps which we have named there are many others, but whatever may be their plan or shape, the manner of using them includes nearly the same manipulations for all. These, in their various steps, are done about as follows : the animal be- ing properly secured, with his mouth open, and his tongue drawn 350 OPEEATIONS ON THR DIGESTIVE APPARATUS. Fig. 356.— Gowing'ti Forceps, Modified by Bouley. out on one side, an assistant inserts the forceps into the mouth, adjusting it to the tooth to be extracted, and notifies the op- erator of the moment when he can close the jaws of the instru- ment together, which is done in various ways according to the kind of instrument in use. When the tooth is properly seized and firmly held by the forceps, the operator, using all his force, carefully and slowly oscillates the instrument from left to right, and from right to left, in order to produce the gradual dislocation of the organ, and when it is loosened from its attachments it is drawn vertically out of its canity by a final movement of evulsion. There are instruments possessing a lever attachment close to the OPERATIONS ON THE TEETH. 351 Fig. 357.— Bouley's Tooth Keys. jaws by which the extraction of the tooth is considerably facilitat- ed. If the animal has not been put tinder general anesthesia the dislocation of the tooth is very painful, and often accompanied by 352 OPEEATIONS ON THE DIGESTIVE APPARATUS. A B C Fig. 358.— Guather'8 Forceps. violent struggles, at the critical moment; and if the tooth is not very strongly held by the forceps, it is possible that it may shp out of the jaws of the instrument and di'op into the mouth. To avoid the possibihty of its passing into the phaiynx, we think it would be but a prudential measure to have an assistant keep his hand in the animal's mouth ready to secure the tooth, if necessary, before it passes beyond the soft palate. OPEEATIONS ON THE TEETH. 353 The second mode of extracting molars, or that by repulsion or gouging, is the only one possible under aU. the circvimstances, when the prehension of a carious or diseased tooth cannot be effected by the instrument used in the first method, as, for in- stance, in cases of disease of the posterior molars when the carious tooth is so far diseased or destroyed that not enough of its sub- stance remains above the root to be reached by the forceps ; or again, when the exostosis of the root has reached such dimensions that it will not aUow its exit from the alveolar cavity, whatsoever efforts may be made to overcome its resistance. This operation was first recommended by H. d'Arboval, and although it has been condemmed by some practitioners, is certainly indicated for all operations upon the molars. All the superior molars, together with the three anterior inferiors, are readily reached by their roots, in trephining the external plate of the bones in which they are implanted. The posterior inferiors are the only ones that present any serious objections, and the trouble is truly a tangible one, being nothing less than the necessity of passing through the entire thickness of the masseter muscle. The tooth demanding removal being surely identified, and the impossibility of removing it by the mouth well estabhshed, the animal is thrown on the side opposite to that which is occupied by the diseased organ, and placed under complete anesthesia. The location of the alveolar walls, upon which the operation is to be made in order to reach the root of the tooth, must be first well determined. If it is one of the last three upper molars, it will corres- pond to the sinuses. But the operator must not allow himself to be deceived by the presence of a fistulous opening, which, by ap- pearing on the surface of the skin to indicate the point of attack, may in fact mislead him by conducting him to a point consider- ably remote from the diseased tooth. A positive and satisfactory diagnosis being settled, and the hair being clipped, a large V or cross-shaped incision is made over the spot selected for the tre- phine, and carefully avoiding the infliction of any injury to the muscles of the region, the sinuses are opened by removing two or three circular portions, at a tangent to each other, to effect the removal of a fair-sized piece of the bone. The edges or prolonga- tions which remain are levelled off with the bone forceps, which is certainly preferable to any other means ; or if the opening made in the bone is too small, it can also be enlarged by using the same 354 OPERATIONS ON THE DIGESTIVE APPAEATUS. bone forceps, by nipping o& fragments from the edges and making entrance into the sinuses of the proper dimensions. The wound and the sinuses are then thoroughly cleaned out, and the blood and the pultaceous purulent collection found in their bottom thoroughly removed. This exposes the root of the tooth, in the form of a hard, dry, greyish mass, analagous to a piece of necrosed bone. The operator, then holding the blunt gouge, or rejyoussoir in his left hand, apphes it through the sinuses against the middle of the dental root, and with a strong mallet held in his right, strikes upon it with firm and steady blows. The mouth of the animal being held open by the speculum, an assistant with his hand upon the crown of the tooth studies the effect of each blow, and notes as it yields to the percussion, and moves and loosens until it becomes detached, and faUs, liberated into his hand, secured by his continuous grasp from any possible danger of being swal- lowed. As a rule the tooth is pushed out of its cavity by the first blows, either entire or in as many portions as it may have been divided into by the carious process. But at times it becomes necessary to repeat the percussion and to use considerable force to compel it to leave the jaw. The modus operandi is about the same for any of the molars, though for the lower teeth greater force in the blows of the mal- let is generally required, in consequence of the greater thickness of the walls of the alveolar cavities in the lower maxillary bone. If it is one of the posterior lower molars which is the subject of the operation, the masseter muscle must be cut through, but the general manipulations are otherwise the same, care being required, however, to avoid injury to the glosso-facial artery, or the duct of Steno, Though apparently a severe operation, this is not a dangerous one, the wounds which it involves healing rapidly, and the great advantages which are realized by it, among which may be included the cleansing of the sinuses, and the removal of their suppurative collection, which could not be otherwise secured, amply compen- sating for the severity of the process. After the operation the wound is, of course, to be thoroughly cleansed, fragments of bone to be removed, and acidulated gargles used to wash the mouth and the cavity of the alveola of its blood. The cicatrization of the external wound generally gives no trouble to the surgeon, and requires no particular methods be- OPERATIONS ON THE TEETH. 355 yond those of ordinary cleanliness and proper attention to the granulating process. It is the cicatrization of the internal wound which requii'es attention, and in some cases a great deal of it. This is in order to guard against the collecting and the packing of the food in the cavity of the alveola, and thus interfering with its closing up by proper granulations. The diet of animals thus operated on must, of course, consist almost entirely of liquid food, as mashes of bran or of oatmeal ; hay teas, flour water, milk, etc., or of cooked roots, scalded grains and the like. According to some authors, fibrinous food is dangerous only diuing the early days immediately following the operation, but our experience has taught us that neither solid nor semi-solid food is to be allowed to an animal which has lost a molar tooth, for a period of from three to four weeks, and during that time the alveolai' cavity ought to be thoroughly cleansed out after every meal, until all possibility of danger has subsided. The vacuum left in the dental arch after the removal of a tooth is never entirely filled up, but it gradually diminishes, in conse- quence of the oblique direction which the teeth in front and behind are disposed to assume, and which, though it brings them closer to each other, never brings them into actual contact. It may hap- pen that by reason of this vacant space the tooth on the opposite side of the jaw may acquire a tendency to grow to excess, and from want of wear, ultimately project above the level of the other teeth. In reference to this it will be but prudent to watch the condition of that particular tooth, and to be prepared to reduce it to its proper level, if that should become necessary. In reference to accidents that may occur during operations upon the teeth, we have already mentioned the jjossibihty of deg- lutition of the tooth as it is drawn from its socket. In some cases reported by Kenault and Bouley fatal results have followed, caused by violent colics thus induced. Strong cathartics have been rec- ommended in these cases for the removal of the foreign body, but the precaution which we have already mentioned will effectually prevent the possibiHty of this accident. Bruises and excoriations of the bars, with the speculum, and hemorrhage, are accidents which also sometimes accompany these operations of extraction. The first is not usually a matter of any importance, unless necro- sis of the jaw should follow ; and as for the hemorrhage, unless it results from direct injury to the palatine artery, it is easily con- 356 OPERATIONS ON THE DIGESTIVE APPABATUS. trolled by pressure and packiiig with oakum or compressed sponges. Fractures of tlie alveola, or of the lower maxillary bone, are of a more serious character than any of the preceding injuries, the last, mentioned iu a case recorded by Koerter, having necessitated the destruction of the animal. Filing Teeth. This operation has not, we beUeve, as yet entered into the general practice of veterinary surgery, and, with the exception of a few veterinarians on this continent who have attempted it, we think that in the presence of the many difficulties which exist in reahz- ing a perfect result, similar to those obtained with the thorough work of human dentistry, it will be some time before this branch of veterinary dentistry can be practiced with any great prospect of good and permanent results. Our experience in fiUng the teeth of our domestic animals is very Hmited, and on that account we will refrain from saying more about it, referring our readers to the work of Dr. Hinebauch on "Veterinary Dental Surgery," where the subject is treated rather extensively. Canine Dentistry. Operations on the teeth of the dog are sometimes indicated under some peculiar and abnormal conditions, such as irregu- larity in number or in direction, or in cases of traumatism, such as fractui-es or dislocations. Their extraction is performed ynth. tooth forceps, as we have already had occasion to remark. Their resection has been recommended by a French veterinarian, Mr. Bourrel, as a means of preventing rabid inoculation (Fig. 359). The operation is a very simple one, and consists in smoothing over the sharp points of the teeth with a file, though sometimes sharp nippers are used in preference. But an operation which is of daily necessity is that of clean- ing the teeth by removal of the accumulation of cement or tartar, which gathers on the external surface of the tooth, at its insertion in the alveolar cavity, where it forms a thick crust, of greenish gray color, composed of microscopic fungi. In neglected cases, the gums become irritated and ulcerated, and the tooth, partially denuded of its gum, exposes not only its free portion, but por- tions of the root also, sometimes even becoming loose and drop- ping out of the jaw. There is in these cases a free and abundant OPERATIONS ON THE TEETH. a 357 Fig. 359.— Bourrel's Mode of Piling Dog's Teeth. flow of saliva, of a characteristic and putrid smell ; mastication becomes impossible, and the animal becomes a regular martyr to the lack of attention of his dental apparatus. The formation of these concretions can be prevented in animals in the same way and with the same care that is exercised in respect to the human when teeth- washing, brushing, etc., with some of the properly com- pounded tooth powders, will remove a slight coat of the offensive deposit, but if the accumulation is quite large, it must be scraped off with proper instruments (Fig. 360), carefully avoiding, if prac- ticable, any injury to the gums, or the loosening of the teeth. Fig. 360.— Tooth Scrapers. X 358 OPEKATIONS ON THE DIGESTIVE APPARATUS. If several teeth are loose, and their loss is threatened, the bet- ter course in regard to their extraction wiH be to remove them singly, and not all at the same time, lest a serious hemorrhage might supervene, which might even endanger the animal's hfe. OPERATIONS ON THE TONGUE. The pathological lesions to which this member of the digestive apparatus is subject, and which may require surgical interference, are princij^ally wounds and tumors, the former demanding either sutures or amputations of the organ, partial or complete. The latter, however, present a greater variety of indications, according to the nature of the neoplasm with which the organ may be af- fected. Wounds of the tongue are quite frequent, but the most common are probably those of the lacerated kind, though again, they may be the result of contusion, incision, or may even be caused by burns. Produced generally by self-inflicted bites, caused by falling, or during epileptic seizures, they are usually made by the incisors. A badly made bit, or a halter or rope tightly binding the mouth and pressing down the tongue, may also produce a bruise, or even a complete laceration of the organ. They are also not uncom- monly seen as the result of bites inflicted by one animal upon an- other, placed in an adjoining stall, when the separation between them has been insufficient. In these cases, not only a portion of the tongue, but often also the fraenum may be more or less lacer- ated — a condition which may also take place when the tongue has been pulled out by an assistant, a groom or other person, and the horse rebelling, pulls back violently and suddenly. Against such opposite forces the soft structure of the frsenum readily gives away. The burnt wound, or scalding of the tongue, may arise from the administration of a drench not sufficiently cooled, or of too irritating a nature. The common way of steaming horses with bran heated with boiling water, is also an occasional cause. Injuries such as these are generally easily detected, present- ing, as they do, a series of symptoms which may properly be called general. Difficulty in eating, and a more or less abun- dant flow of stringy saliva, which also may be mixed with blood, is apt to be among the signs. In relation to the special char- acters, noticeably, there may be in one case a protrusion of the OPERATIONS ON THE TONGUE. 359 tongue out of the mouth, with perhaps a drawing of the organ to one side, or it may be pressed. between the incisors and hanging- more or less outside of the buccal cavity. In opening this cavity, the tongue may then be seen to be lacerated at its free portion, the laceration being transversal or longitudinal, complete or incomplete, and varying in dimensions, from a small portion of the organ nipped from the main body, to nearly the entii'e portion in front of the frsenum. If the anterior portion is missing, the frsenum may be seen in its normal condition, or again may be exten- sively torn, in. which case the tongue is commonly hanging out of the mouth. If the laceration is complete, the part in front of the cut may have dropped outside and fallen into the bedding of the animal, or of the one next to him, both stalls being more or less spattered with blood from the hemorrhage which has accom- panied the injury. In cases of burns, the tongue presents all the symptoms of glossitis, it is swollen, its epithelium readily peels off, the saliva- tion is abundant, and the mouth heated and sore. Considered from one point of view, the prognosis of lacerated wounds of the tongue is not serious, there being but few forms of that injury which are not more or less amenable to treatment. The nature of the prognosis varies, of course, with the extent of the wound, the depth of the tissue which it involves, and the amount of substance already lost or requiring removal. A complete section is always a serious matter, especially in herbivorous animals, by which the tongue is so largely employed, and so ef- ficient, as an instrument for the prehension of food, as well as for aiding in its mastication, by keeping it in contact with the grind- ers during the process of chewing. In carnivorous animals, as in dogs, we have seen the complete sloughing of the free portion attended with such difficidty in eat- ing, that the destruction of the patient became necessary in order to avert his death by starvation. In almost all conditions of laceration of the free portion of the tongue, there is an indication of an attempt to effect the union of the di%'ided parts, and our experience has led us to the conclusion that no one is justified in refusing to treat a wound of the tongue or abandoning such a case without at least an effort to save it, even, as in some cases, where the divided parts are held together by the smallest portion of substance. 360 OPEKATIONS ON THE DIGESTIVE APPARATUS. SUTUEE. It is only by suture that the attempt can be successfully made. Peuch, Toussaint and Zundel advise the throwing of the horse, but we prefer the standing position for the operation. The instruments necessary are strong needles for metallic sutures, and soft, pHable lead wire. We prefer this kind of suture as being less liable to cut through the muscular structure of the organ and having less tendency to give way. Having carefully washed the surfaces of the lingual wound, we apply an inteirupted suture, varying the number of stitches, according to the extent of the laceration, and prefer the interrupted to the continued suture for the reason that if one stitch fails to hold, it can be easily re- placed by another. The important point is to secure a thorough hold for each stitch, or in other words, to involve a good portion of the tongue in the stitch on each edge of the wound. Wounds of the frsenum need no special treatment, but there is an indication which by its application greatly facilitates, though indirectly, the cicatrizing process of the two parts. It consists in placing the tongue in a muslin suspensory, having the shape of the free portion of the tongue, and sewed together on a part of their circumference, leav- ing an opening for the organ to enter. This suspensory is kept in place by two strings attached to the halter on Pig. 361.— Tongue Suspensory. each side of the cheeks. The use of this easily made appliance has given us great satisfaction, not only in keeping the tongue in the mouth, but also in hmiting the movements of the organ, and preventing the giving way of stitches. The suspensory is to be taken off two or three times a day, and washed, or changed for another, but niust be kept in place as long as this condition of the patient requires it. The mouth is to be kept clean by antiseptic astrin- gents and cooling gargles, by means of a syringe or an irrigator. The use of peroxide of hydrogen has given us excellent results in these cases. Nocard recommends the application of a muzzle upon the patient's nose, to prevent the prehension of fibrous food, keeping the mouth closed, and restricting the movements of OPERATIONS ON THE TONGUE. 361 the jaws. Dui'ing the treatment the animal is to be fed with liquid or semi-Hquid food, as mashes and gruels of all kinds, with teas, milk, etc. It is only when the stitches are all united that the animal can be brought by degrees to its ordinary diet. After several days the sutures can be removed. Amputation, or Glossotomy. "When the sutures have failed, or when the peduncle which holds the divided portions of the tongue together is too small to permit the processes of circulation and nutrition to go on, the in- dications are to amputate the part of the tongue below it. This is done with the scissors ; the hemorrhage that may follow is sel- dom serious, and soon ceases spontaneously, or yields to the use of hemostatics. Sometimes, instead of direct amputation, or in order to avoid the hemorrhage, the removal of the divided portion is effected with an elastic hgatui'e — a mode of treatment also com- monly used for the removal of lingual tumors. The ecraseur has also been recommended, on account of the absence of hemorrhage attending its use. The animal whose tongue has been amj)utated eats slowly and with difficiilty. His prehension of liquids is also necessarily interfered with. It requires time and practice for him to acquire facility in performing the old functions with curtailed means. Adenotomy. This operation consists in the dissection and removal of such of the glands as are accessible and amenable to that method of treatment, including the lymphatic and sahvary, and is described as parotidian or maxillary, as one gland or the other becomes the subject of operation. The extirpation of these organs is indica- ted by pathological changes occurring in their structure, as in cases of chronic infiltration following a suppurative process, as seen in the lymphatic glands of the inter-maxillary space after strangles, and again when they become the seat of scirrous de- generation, or of melanotic deposits, or in cases of salivary fistula compHcated with loss of substance of the excretory ducts. Parotidian adenotomy is a very delicate operation, and has, therefore, been but seldom attempted. To Leblanc, in 1822, is due the record of its first performance, and of the advantages attending it. A reference to Figures 396 and 397, which show 362 OPEKATIONS ON THE DIGESTIVE APPARATUS. both the superficial and the deep anatomical stnictm-es of that region, will at once suggest the difficulties to be encountered in the numerous and important blood vessels, which must be either avoided or ligatui-ed, and the important nerves which must be saved According to Brogniez, the operation is fully justified by its results, and jDossesses an undeniable claim to admission into the domain of authorized veterinary surgery. After Leblanc, it was performed by Brogniez, Vanhaelst, Delwart, Barlow and Per- civall. The Traite de Chirurgie Veterinaire furnishes the following description of the manual execution of parotid adenotomy : " The animal, being well prepared, is thrown, with the parotid region of the side on which he hes resting on a small bundle of straw, in order to render the gland, which is to be operated upon, more prominent, and the hair being clipped, a long incision is made in the direction of the organ, viz., from the anterior part of the base of the ear down to below the glosso-facial branch of the jugular vein. This first incision, it may be remarked, must be made more to the anterior border of the gland, which is strongly adherent to the maxillary bone, as well as to the blood vessels and nerves passing that jjoint, and, if necessary, a second incision can be made be- hind the first and perpendicular to its lower extremity. The skin being dissected from the whole extent of the gland, the beginning of the separation of the organ is made near the facial nerve, from thence gradually working downward. The lower extremity of the gland is isolated, and after it the posterior border, to terminate by the superior extremity, which surrounds the concha — in other words, without reference to the muscular layer that covers it, or to some little glandular masses which are isolated from the prin- cipal mass, nor even to its central portion situated under the fa- cial branch of the jugular vein ; the gland being thus separated is removed in its whole circumference. After ligating the blood vessels which may have been opened, the wound is dressed and closed with quill sutures. Suppuration is soon established, the granulations rapidly develop themselves, and the cicatrization is soon accomplished." The most serious compHcation usually met with is the section of the facial and sub-zygomatic nerves, which is followed by par- alysis of the face and lips on that side. Director Degives divides the operation into three steps. The first includes the incision OPERATIONS ON THE TONGUE. 363 and dissection of the skin. The incision is made lengthwise, from the base of the ear down to the middle of the external face of the gland, that is, as far as below the glosso-facial vein, and involving the sMn and the parotido-auricularis muscle, the dissection of the skin being made a little beyond the borders and extremities of the skin. The dissection of the gland forms the second step, and must be as complete as possible. There are some parts where the gland is difficvdt to isolate, especially at the base of the ear, at its masseterine adhesions near the sub-zygomatic blood vessels and nerves, but at these points some Httle glandular granulations may be left. In this dissection the use of the fingers or of the dull end of the handle of a dissecting scalpel is recommended in order to avoid the blood vessels and nerves which are so intimately connected with the organ. Beginning with the ligation and section of the posterior auric- ular vein, the anterior border of the gland is isolated from above downward, carefully avoiding the sub-zygomatic blood vessels and nerves, after which the jugular vein is isolated in the whole extent of its parotid course, and the gland divided into two por- tions, one above, the other below the vein. The dissection of the upper portion is made from below upward, avoiding first, four ar- terial divisions, including the external carotid, the temporal trunk, the internal maxillary, and the posterior auricular ; secoiid, the superficial temporal and the facial nerves ; and third, the guttural pouch, which is intimately adherent to the internal face of the gland above. The smaller arterial branches that are divided are hgated or twisted. The lower portion is then carefully dissected from above downward. The dressing of the tcoitnd, which is the third step, is performed according to the process of Brogniez. Maxillary Adenotomy. We find but a single description of this operation, which is by Director Degives in his Manuel de Medecine Oj^eratoire Veteri- naire. Kecommending it only as the last treatment in the re- fractory fistula of Warthon's duct, he first divides the skin and the cutaneous muscle against the inferior border of the gland, parallel to the glosso-facial vein, and makes an incision about four inches long, which brings him to the loose and abundant cellular tissue which surrounds the gland. The dissection is made with 364 OPERATIONS ON THE DIGESTIVE APPARATUS. the fingers by tearing the connective tissue in the middle part of the gland ; when taking hold of it at that place it can be care- fully pulled out, the division of the cellular tissue which holds it being easily detached with the fingers or a blunt instrument. The position of the wound is such that no special dressing is indicated, suppuration having a free exit. OPEKATIONS ON THE CESOPHAGUS. The surgical affections which require interference with the oesophagus and adjacent regions are classified as foUows: Bruises, wounds, lacerations, ruptures, tumors, jabot, obstructijon by for- eign bodies or alimentary masses, and strictures. The various operations of direct apj)lication which are indicated in connection with these casualties are: Catheterism of the oesophagus, the taxis, the crushing of the foreign bodies, and oesophagotomy. This classification, arranged by Peuch and Toussaint, meets with our acceptance, including the operations enumerated, and in our con- sideration of the subject we shall, for the jDresent, refer our readers for descriptions of the various forms of disease to the standard authorities upon veterinary medicine, especially includ- ing in the list the excellent work of Professor Williams. Before entering upon a description of these operations, a re- view of the surgical anatomy of that organ will be in place. The oesophagus is a long musculo-mucous canal, which at the third step of deglutition carries the food, both liquid and solid, from the pharynx to the stomach. Stretched between these two or- gans, it successively occupies the neck down its inferior region, the entire length of the thorax, and a small portion of the abdomen. At its origin (Fig. 362), situated on the median line, it communi- cates with the pharynx by an opening above the glottis; from thence it runs obliquely downward, from before backward, be- hind the trachea, until about the middle of the neck, where it begins to deviate to the left, resting from thence on that side of the trachea. In this situation it enters the thorax, to resume its former position on the trachea; passes above its bifurcation and the base of the heart, running through the layers of the posterior mediastinum, which covers it, reaches the right pillar of the dia- phragm, and passes through it, and entering the abdomen, has its termination on the left side of the small curvature of the stomach. OPEKATIONS ON THE (ESOPHAGUS. 365 Fig. 362.— Anatomy of the CEsophagus and Jugular Vein of the Horse. J J, Jugular vein; C, carotid artery; O 11, sub-scapulo hyoideus muscle ; D, oesophagus; S, sterno- maxillaris muscle ; M, mastoido-humeralis muscle. The relations of the oesophagus must then be considered accord- ing to its divisions of the cervical, thoracic and abdominal portion. At its point of origin, at the pharynx, it is situated between the larynx and the guttural pouches. In the upper half of the neck it is in relation, in front, with the trachea; behind, with the long muscle of the neck; and on the side with the car tid and its sateUite nerves. Below this point, and as it deviates to the left, it is related to the left side of the trachea, upon which it rests, and on its outside, with the scalenus muscle, the carotid artery and the jugular vein. In a very few instances, instead of passing to the left of the trachea, it deviates to the right, but otherwise holds the same relations as when in its normal position. At its entrance into the thorax, the oesophagus, still on the side of the trachea, corresponds outwardly with the inferior cervical ganghon and its branches, and to the vertebral, superior cervical and dorsal arteries 366 OPERATIONS ON THE DIGESTIVE APPARATUS. and veins, which cross its course and further back, returning be- tween the trachea and the longus colli, it passes over the left bron- chia and to the right of the thoracic aorta. Beyond this, placed between the folds of the posterior mediastinum, it is received into the groove of the internal face of the lungs, with the oesoph- ageal arteries and nerves. Passing through the opening of the right pillar of the diaphragm, we find it in its abdominal portion related on the right to a notch of the superior border of the hver, and ending at the cardiac. The structure of the oesophagus is formed of two coats ; one of external and muscular, the other of internal and mucous membrane. The external is composed of muscular fibers, spiral, red and longitudinal, striated in its anterior three quarters, and white in the posterior quarter. Anteriorly, the crico-pharyngeus furnishes it with a sort of circu- lar necktie. Towards its posterior portion, the muscular coat is much thicker than in the other parts, and as it passes through the pillars of the diaphragm, it is more or less pressed upon. These three points must be remembered, inasmuch as they serve to ex- plain the resistance which is encountered by instruments, such as the catheter, or the probang, when introduced into its cavity. The internal coat or mucous membrane is whitish, with longi- tudinal folds, which are so developed at the cardia that they may resist the passage of the probang into the stomach. (Esophageal Catheterism is an operation consisting in the introduction of a special instru- ment, solid or hollow, but always flexible, into the cavity of the oesophagus, either to remove bodies that obstruct it, or to aid the exit of gases which have accumulated in the stomach. It is therefore indicated in three principal conditions, viz.: first, tympanitis in ruminants ; second, in cases of oesophageal dilatation, ov jabot ; and third, to dislodge foreign bodies arrested in its canal. In cases of tympanitis^ it is of advantage if the trouble is not too far developed, and danger of suffocation not too imminent. In cases of oesophageal jabot, due to a more or less extensive dilatation of the organ, in consequence of the lodgment and packing of food, it is in many instances of but very little benefit. When foreign bodies are lodged in the oesophagus, an accident to which horses are liable, and which is very common in cattle OPERATIONS ON THE CESOPHAGUS. 367 and in clogs, it is often of great advantage. The operation would naturally depend very lai-gely for its success upon the size of the foreign body, which of course is a variable circumstance, and also on the condition of its external sur- face, whether rough or smooth, or having projecting points ; depend- ing much likewise on the situation in the length of the canal, and whether it has become engaged in the cervical or the thoracic portion of the passage. Probangs for the throat and a speculum for the mouth are instru- ments necessary for this operation. There are various forms of pro- bangs, the designs of different in- ventors. The first, which, accord- ing to Brogniez, was invented by Mom-o of Edinbm-gh, has been more or less perfected. The pro- bang of Baujin (Figure 3G3) is re- versible, and may be so adjusted as to either push down or extract the offending substance from its place of lodgment. The instru- ment in ordinajry use is designed essentially to push the obstruction through the passage. It is found in all oiu' surgical instrument ma- kers' shops, and is made of whalebone or of rubber, separable in two parts, connected by a screw. One end (Fig. 364) has a bulb- ous enlargement, the other a blunt mass or head, made concave Fig. 363.— Baujin's Probang. Fig. 364.— Ordinary Whalebone Probang. 368 OPERATIONS ON THE DIGESTIVE APPARATUS. on its free end, the better to act without slipping against the ob- ject with which it is to come in contact. The probang of the stomach pump forms an excellent instrument for that purpose. Dr. Peabody has constructed a simple implement of strong, thick wire, twisted together and forming a rod of sufficient length, protected by a tube of India rubber, and having one end formed into a ring or loop, to serve as a handle, while at the other ex- tremity a sponge of suitable size is secured and formed into a bulb resembling that of the ordinary probang. Degives recom- mends for use in cases of emergency an extemporized instrument, formed of a whip handle or a branch of a tree, of sufficient length, of the size of the little finger, with a bulb composed of a ball of oakum covered with cloth. This bulb is attached to the end with strong twine, of which a free end is left of equal length with the instrument, in order to draw out the broken fragments in case of fracture of the probang. Whatever form of probang may be used, it is always neces- sary to associate with it a speculum to keep the mouth sufficiently open and immobile. Those which are recommended and em- FiG. 365.— Brognlez's Gag. ployed in the exploration of the mouth are available for this pur- pose. But as these are not always obtainable, some iagenious and simple apparatus can be made at a moment's notice like that illus- trated in Figure 365, which, or something equivalent, ought to be within the scope of the inventive and constructive capacity of any well equipped surgeon. OPERATIONS ON THE CESOPHAGTJS. 369 In ruminants the operation is performed in the standing posi- tion, mth the head extended and elevated on the neck. In soli- peds it cannot be performed except while the animal is down, and when the head can be placed in the proper position of extension to allow the instrument to pass beyond the elbow formed by the pharynx and the oesophagus. The animal being in position, and the speculum adjusted, an assistant draws the tongue out of the mouth, and the operator, placed in front of his patient, passes the probang through the opening of the speculum, and rapidly pushes it into the mouth, resting it upon the hard palate, in order to pre- vent its being displaced laterally by the motion of the tongue. At the bottom of the mouth the probang meets with some Httle re- sistance at the soft palate, but the instrument soon reaches the fauces, in the pharynx, and penetrates the oesophagus. At this moment possibly some resistance may be encountered, owing to the contraction of the crico-pharyngeus miiscle, but once engaged in the oesophagus the instrument readily passes the proj^er dis- tance downwards, according to the requirements of the case. If the object in \iew is to relieve tympanitis, and a true catheter, tube, or stomach pump or hoUow probang has been used, the gases will find a means of exit as soon as the instrument has penetrated the stomach. If the catheterism has been performed for the displacement of foreign bodies, the resistance they offer to the pressui-e of the probang must be overcome by a steady, and, at times, quite a powerfiil pressure of the instrument, caution being always neces- sary to avoid causing laceration of the wall of the passage. When the obstruction is even but sHghtly loosened, its complete dis- lodgment often follows from the mere unassisted contraction of the oesophageal muscles. Caution and gentleness must not be overlooked even in the mere withdrawal of the probang. It should be practiced as a maxim, indeed, that whatever instrimient may be, for any pvirpose, made use of, not alone in the propulsion of the intruding body in these cases, the operator must never re- mit his caution and gentleness, nor lose sight of the fact of the natural Hability to accident always accompanying svii*gical in- terference with the organs and tissues having their place in the interior regions of the animal organism, and not cognizable by the eye. Serious accidents have been recorded as resulting from a lack of care and attention in the manner of withdrawing the in- 370 OPERATIONS ON THE DIGESTIVE APPARATUS. strument. Lacerations of the oesophageal walls, rupture of blood vessels, jierforation of the trachea, abscesses of the mediastines, pleurisy and pericarditis belong to the list of recorded casualties in this connection. To facilitate the working of the probang, in these cases, certain practitioners have recommended the adminis- tration of oil or mucilaginous drenches. The Taxis. The oesophageal catheterism which we have just considered is principally applicable to cases where the obstruction is in the thoracic portion of the passage. When it is in the cervical por- tion, instead oi jyrojyulsioyi or intrapulsion, it is by extrajyulsion, or by the course of the natural passages that the foreign body is to be removed. In this case the taxis is made to take the place of the ordinary artificial appliances, and the hands become the in- struments with which the surgeon seeks, by making forcible and methodical pressure, to move the impacted object back into the mouth. In 1820, Delafoy recommended a process which is to-day ad- mitted to be one of the best modes of relieving cattle when suf- fering with this difficulty, and many other methods have since then been devised, but most of them are merely modified plans of Delafoy's method. We shall consider them as briefly as possible. In, order to raise the itnpact (as we shall for convenience call it) back into the pharynx, Delafoy has the animal thrown, on the right side, and administers a glass of sweet olive oil, and while an assistant steadies the oesophagus, applies with his fingers upon the impact, a retrograde motion which carries it upward, back and to the pharynx. When it reaches that cavity, the head is raised, the jaws are opened with a speculum, and the operator, passing his hand through that instrument into the back of the mouth, seizes the impact and brings it away. Lindenberg keeps the patient on his feet instead of casting him, but otherwise ob- serves the same modus operandi. Denenbourg operates with his patient in a standing position. While an assistant holds the head, well extended, and elevated on the neck, he places himself on the right side of the animal, and with the fingers pressing be- low the impact (like Delafoy), displaces it and gives it the as- cending motion which transfers it to the pharynx, and keeps it there by pressing hard below it. Then putting an assistant in his OPERATIONS ON THE (ESOPHAGUS. 371 place he proceeds like the others to remove the impact with the hand passed through the speculum. Schaack operates also in the standing position, the hind legs being hobbled above the hocks, the head is kept, as much as pos- sible, in a horizontal position, and a speculum placed in the mouth. The oj)erator takes his place on the left side, in front of the shoulder, the right hand on one side of the neck, the left on the other. If the impact is rather low down, or near the chest, the extremities of the fingers are brought together and employed to push it upward, with careful manipulations. If it is situated higher up, near the oesophagus where it is less surrounded by muscles, the pressure is made with the fingers closed. In either case, however, when it has reached the throat, Schaack holds it there, while an assistant with his hand boldly introduced into the mouth, seizes it and di'aws it out of the pharynx. According to Peuch and Toussaint, Mr. G. Tisserand, in cases of jabot, operates as follows : Making a point of support on the neck vnth. the right hand, with the left he violently shakes the part where the projection of the jabot is most prominent, and then apphes alternate movements, up and down, with a lateral shaking of the enlargement until the patient voliuitarily lowers his head, and as he snufiles throws out through the nostrils and the mouth, abundant mucosities, mixed with alimentary detritus. If the first manipulations fail, Tisserand advises the occasional ad- ministration of mucilaginous decoctions, or oil, or even plain water. The method of Martin is one which is also held in high esteem, and at the hazard of needless repetition and unnecessary minutiae we give it in detail. Instead of extending the head, which has a tendency to stretch the oesophagus and diminish its diameter, he keeps the head of the patient low down, at about a foot from the ground, and placing himself on the left side of the neck, he passes his right arm over the neck, in such a manner that envelop- ing the neck between both arms, his hands can join on the lower border of the neck, and both thumbs jjressed in the jugular grooves, one on the right, the other on the left. It is by succes- sive pressures from behind forward, that he succeeds in pushing the impact in the pharynx. Then comes a peculiar step of the operation : As by its presence the soft palate closes somewhat the posterior opening of the mouth, the impact cannot re-enter this cavity, and thus, while the mass is in the pharynx and resting on 372 OPERATIONS ON THE DIGESTIVE APPARATUS. the posterior face of the velum palati, with both thumbs he pushes it from above downward and from behind forward; the effect of this is to depress the base of the tongue, and to enlarge the isthmus of the throat sufficiently for the impact to pass through it, back in the mouth, and drop it to the ground. If, however, the pressure required in this step of the operation could not, for one reason or another, such as excessive thickness of the lower border of the neck, for instance, be maintained, then the impact is ex- tracted with the hand. Courioux has advised the application of a cord around the neck, below the impact to be moved upwards with it, as the dis- placement is accomplished. The object of this is to retain what- ever progress may be gained by preventing the mass from re- ceding again. It forms a substitute for the fingers in holding it in position. The extraction by the mouth of many substances arrested in the oesophagus has also been effected with instruments. Forceps long and curved, hooks and hollow sounds, having metal- lic nippers or jaws, like that of Baujin, have been recommended. That of Wegerer is probably entitled to the highest commenda- tion of all. But with all then- ingenuity and perfection their use is not without danger of causing lacerations of the oesophageal walls, and they are constantly liable to get out of order. Crushing the Foreign Body. At times the obstruction takes place in the cervical portion of the oesophagus, and attempts to displace it, either toward the mouth or the stomach, have failed. To meet this emergency various means have been sought for, either to crush the impact, or cut it in small pieces. One suggestion for the first object is to break it with blows of a mallet, a piece of wood, or other object held by an assistant, furnishing the point of resistance. But this is obviously a dangerous process, nearly certain to produce bruises and lacerations of the soft structures, with probably sub- sequent gangrene. At best it can be available only when the im- pact is in the form of a comparatively soft mass, such as ripe fruit or the like. Professor Lafosse had in 1846 suggested subcutaneous incis- ion, and this was put in practice in 1855 by Chapard for the relief of a cow choked by a piece of a beet. A simple puncture of the OPERATIONS ON THE (ESOPHAGUS. 373 oesophagus was first made, with a straight tenotome, below the obstruction, then a curved tenotome was introduced through the wound, and by careful movements in the mass of impact, it was sufiiciently divided to enable it to resume its usual course down- ward into the rumen. Though this mode of operation has not become established in general practice, the application of its prin- ciple has not been overlooked, and has not been without its influ- ence in simplifying the performance of the operation of oesopha- gotomy. CESOPHAGOTOMY. When the obstruction is in the cervical portion of the oesopha- gus, and, either because of its nature or of its form, cannot be displaced by any of the means we have discussed, the division of the organ itself furnishes the only escajoe from the consequences of the difficulty. The operation of cesophagotomy consists in the exposure of the oesophagus and the incision of its walls. While it is usually performed for the removal of obstructing bodies, it is also indicated in some cases as a mode of facilitating the adminis- tration of drugs, or, under special circumstances, of food and drinks. It is of French origin, and its adoption in veterinary surgery seems to have occurred in 1782, when it was performed by Lom- pagieu Lapole to remove an orange, arrested in the inferior region of the neck. Since that epoch it has been performed on horses, cattle, dogs, and even on swine. Damoiseau, Fehx, Michel and others have performed it on cattle ; Thissine, H. Bouley, Reynal, Rey, Marrel, Mauri on th6 horse ; Peuch, MacgiUivray, WOHams, on dogs, and Lagrange on pigs. H. Bouley performed it to re- move a piece of corncob and a large molar tooth which, after ex- traction, had sHpped into the oesophagus; Baldwin extracted a large piece of a root; Rey removed a cork; Peuch took away pieces of bone from a dog. In fact, the operation has generally, if not exclusively, as is but natural, been appropriated to the relief of patients laboring under the difficulty we have been discussing. A claim has been made in its behalf as a means of relief in lock- jaw, by facilitating the artificial feeding of the sufferer. But such a claim, as to any practical value which may be supposed to attach to it, cannot in anywise possess any validity, nor be to any extent sustained when we take into consideration the history and the 374 OPERATIONS ON THE DIGESTIVE APPARATUS. nature of tetanus and its origin, with the complications and con- sequences likely to accompany and to follow it. Marrel has rec- ommended it in cases of fractures of the jaws ; but such practice would truly furnish an example of the proverbial case in which the remedy is worse than the disease. It has also been recom- mended for the rehef of jabot, and has been, in some cases, fol- lowed by favorable results. The instruments necessary for this operation are a convex and a straight bistour}^ a pair of dissecting forceps, a director, a needle and strong thread ; to these may be added a pair of scissors and two blunt tenaculums, with also large forceps to grasp the impact and extract it, close at hand. The animal must be kept in the standing position, and held under thorough control by an assist- ant, with a twitch on the lower lip or on the ear, and either fore foot raised or both fore legs hobbled. It must be taken into consideration that the cervical portion of the oesojjhagus is situated immediately behind the trachea, con- tinuing thence as far as the middle of the neck, when it deviates to the left, where it occupies the lower third of the neck ; and again, that this cervical region is surrounded by an abundance of loose connective tissue, having on each side the carotid and its nerves. It will also be observed that the lower third of the neck forms a triangular space, with above it the inferior border of the sub-scapulo-hyoideus muscle, and on the sides the sterno-maxil- laris, levator-humeri and scalenus. In this space it is in connec- tion on the inside vnth the trachea, upon which it rests ; and on the outside with the scalenus, the carotid, the jugular and the nerves of that region — organs which are all covered by the cuta- neous colli and the skin. The point of separation of the middle and lower third of the neck, in the left jugular groove, is the place of election or of ne- cessity for the operation, or where the incision of the skin must begin, a little above and behind the jugular. If the obstruction is considerably prominent, this incision must be made directly over it. Peuch and Toussaint, in their excellent work, divide the oper- ation into three steps, which they thus describe : — 1st. Step. Incision of the skin and dissection of the subja- cent tissues. — Standing on the left side, the operator first deter- mining the situation of the jugular vein, cHps the hair from over OPEKATIONS ON THE OESOPHAGUS. 375 the tumor, stretches the skin with the left thumb and index finger, and with the convex bistoury, extends the incision from the initial point, about four fingers' breadth down, parallel with the blood vessels. The incision divides the skin, and the cuta- neous muscle, and exposes the jugular and carotid and their nerves. The thumb of the left hand is then introduced into the incision and depresses forward the blood vessels and nerves, while the other fingers of the same hand are embracing the tracheal border of the neck. The oesophagus is thus exposed on the lateral border of the trachea, and the cellular tissue which covers the organ is then divided. By raising the upper lip of the incision with a blunt tenaculum the oesophagnis may be still more exposed. 2d Step. Loosening or isolation of the oesophagus — Cutting away part of the cellular tissue, the oesophagus is seized with the thumb and index of the right hand and drawn outward. The vascvilo-nervous fasciculus are then let loose, the oesophagus is Fig. 366.-1116 (Esophagus Drawn Outward and Raised with the Scissors. 376 OPEBATIONS ON THE DIGESTIVE APPARATUS. drawB out with the left hand, the right holding the curved scis- sors, which being passed from above downward, and separating the remaining portion of cellular tissue, holds the organ resting upon its blades, in readiness for the thh-d step (Fig. 366). 3d Step, or Incision of the msophagus. — The operator then, supporting the scissors with the oesophagus resting upon them, in the left hand, with a straight bistoury with the edge turned upward, in the right, makes a large puncture in the oesophageal walls, passing through their entire thickness, and afterwards en- larging it with the aid of a director. At this point of the operation, and at each deglutition, there is usually an escape of mucosities mingled with food. When the impact forms a decided projection, the incision should be made directly over the promiaence. Professor Nocard has modified the operation in cases where the obstruction can be divided in small j)ieces, by making only a coiTespondingly small incision. He uses both a straight and a curved tenotome, and performs the first and second stejDs as in the preceding methods, the third one being made as follows: "The oesophagus being exposed, isolated and placed over the scissors, the operator introduces the sti-aight tenotome through the oesophageal membranes, the blade running parallel with the muscular fibers, into the thickness of the impact (apple, potatoe, pieces of beet, etc.,) avoiding injury to the opposite surface of the canal; then sliding the curved tenotome against the straight one, and pushing it through the entire mass until it touches the op- posite wall of the oesophagus, he withdraws the straight instru- ment, and divides the impact by movements of the curved instru- ment, analogous to those made in the division of the tendons in the operation of plantar tenotomy. The blunt end of the curved tenotome jjrotects the oesophagus from any enlargement of the original wound." Cagny, after exposing the oesophagus, as already described, crushes the obstruction by repeated gentle blows of a small mallet, as before described. He prefers this mode to that of in- cision if the impact, though hard and flat, possesses but little force of adhesion. When the objects of the cesophagotomy have been reahzed, there is no necessity for further interference, the appli- cation of sutures being generally considered rather injurious than otherwise, and though the resulting wound is of a somewhat com- plicated nature, its perfect cicatrization in a comparatively short GASTKOTOMY. 377 time is the general rule. The principal indication is cleanliness in the removal of the discharges, and of any mucosities or food that may escape over its surfaces. H. Boviley has experimentally proved that to obtain the cicatrization of oesophageal wounds it is essential '■Ho feed the animals loith food of fibrous texture, and nothing but pure water to drink."' By respecting this indication all danger of comphcations is avoided. The possible accidents and complications are : wounds of the blood vessels during the first steps of the operation, but the hemorrhage that follows may be stopped by pressure or ligature ; (edematous swelling of the wound, suggesting the infiltration of food or pus in the surrounding cellular tissue. It may terminate in a simple abscess, or it may be the precursor of a fatal gangrenous complication: purulent infection, septiccemia, tetanus, are also possible sequelae of oesophagotomy, but a faithfvd and judicious appHcation of antiseptic means in dressing and nursing the patients will usually baffle the possible evil. GASTROTOMY— RUMENOTOMY. This title, in our opinion, ought to include the puncture or in- cision of the rumen, when designed to Hberate confined gases or to remove the solid contents which may have accumulated in that viscerse. In the first case it is indicated when the tympanitic condition of the first compartment of the stomach exhibits alarming s^inptoms and resists all ordinary remedial indications ; and in the second, when the gases of the rumen are mixed with the aUmentary mass contained in that organ and a larger opening than that made by the trocar becomes necessary, for their re- moval. In either case the left flank must be the seat of election for the operation, the rumen occupying that side of the abdomen, and situated at a point equally distant from the last rib, the angle of the ilium and the transverse process of the lumbar vertebrae. Tabourin suggests the last intercostal space as the proper place for the operation. The instruments necessary are a large trocar (Fig. 367) with a straight and a curved bistoury. The gastrotomes invented by Brogniez (Fig. 368) and Sajoux are too comphcated. The animal must be in the standing position. Puncture of the rumen. — The operator, facing the left flank, makes an incision through the skin, about an inch and a half long, 378 OPEEATIONS ON THE DIGESTIVE APPARATUS. Fig. 367.— Large Trocars. with the bistoury, or with the blade of a lancet. Then placing the trocar perpendicularly upon the flank and into the cutaneous incision, jjresses it against the muscles, and with his right hand strikes a heavy blow on the handle of the instrument and forces it into the cavity of the rumen, provided the blow has been suffi- ciently heavy. The blade of the trocar is then withdrawn, the canula being left in j)lace, and the gases allowed to escape, as in the operation of enterotomy. Incision of the rumen. — The operator, using a convex bistoury, makes an incision in the middle of the left flank, beginning a little below the point selected for the puncture of the rumen, and measuring a length of from three to four inches, cuts through and divides the entu-e thickness of the skin, and the walls of the rumen. The hand is then introduced and employed for the re- moval of the food contained in the cavity. The further cleaning- out of the rumen may be done vdth a large spoon. Schaack recommends the removal of only a limited portion of the ferment- ing mass, and that the walls of the organ should not be scraped. While the puncture of the rumen does not require to be fol- lowed by any special subsequent treatment, the wound of the in- cision needs to be closed immediately after the removal of the contents of the organ. This must be attended with every anti- septic precaution, and the closing be done by means of the inter- rupted suture. The parts should be thoroughly cleansed. Adhe- sion may be promoted by the application of a wide band of ad- hesive plaster placed all round the animal, as recommended by Professor Brush of the American Veterinary College. The wound of the puncture heals rapidly, while that of the incision requires from a week to ten days, and if proj)erly treated, unites by the first intention, without suppuration. The accidents which are GASTKOTOMY. 379 Fig. 368.— Brogniez's Qastrotome. likely to follow these operations are subcutaneous emphysema, abscess, or peritonitis. The first of these is not uncommon, or dangerous; the abscesses are comparatively rarer ; the peritonitis generally proves fatal. 380 OPERATIONS ON THE DIGESTIVE APPARATUS. ENTEROTOMY. The division or puncture of the intestines, or enterotomy, is an operation the object of which is to facilitate the exit of gases contained ia these organs, to prevent their excessive dilatation, and to obviate certain too commonly fatal compHcations. It was mentioned at an early day by Vegetius, especially in connection with the treatment of wind colics, but not again spoken of until 1776, when Roem, Bomvinghausen, and at a later date, Barrier and Herouard obtained good results from it. Bourgelat and Chabert recommended it in the early stages of the disease, but, notwithstanding the favorable dicta of all these authorities, the operation was not fully admitted to a place in the domain of veterinary surgery until Bernard, Dieterichs, Falke, Rey, Schaack, Hayne, Eckel, Blendeiss, Charlier and others, had proved by nu- merous facts that when j)erformed under favorable circumstances it is not only harmless, but is capable of insuring results of the most beneficial character. Intestinal puncture is radicated in cases of tympanitis or flat- ulent coHc, due to indigestion, or to an intestinal obstruction, and must be performed whenever the accumulation of gases has resisted ordinary forms of treatment. The indication, in our opin- ion, is to operate early in the disease, as an almost positive means of avoiding the complications, or rupture of the stomach or lacera- tion of the intestines, which, if unchecked, may accompany the flatu- lent accumulation. Enterotomy is also recommended in cases of strangulated hernia, when the gases which are imprisoned in the hernial intestines prevent its reduction. Imbert used it with ad- vantage in reducing a strangulated ventral hernia. In former days Chabert performed the operation through the rectum, and Abadie, in 1875, reported a case in which he reached the intes- tines through the vagina. But while it may be possible to ob- tain access to the dilated iatestines through these channels, it is evident that it is a method which must oppose more difficul- ties and involve more compHcations than the pvmcture through the flank. The point of selection for the operation is about the center of the space formed forward by the border of the last rib, behind by the external angle of the ilium, and above by the extremity of the ENTEKOTOMY. 381 Fig. 369.— Trocars for the Coecum. Fig. 370.— Brogniez's Enterotome. transverse processes of the lumbar vertebrae, on the right flank — since it is there that the dilatation of the intestines is most prom- inent. The puncture, if made at this stated point, penetrates the second portion of the large colon ; if it is made nearer the lumbar vertebrae, it enters the arch of the coecum. The only instrument necessary to perform enterotomy is a trocar. The instrument used in cattle for puncture of the rumen 382 OPEKATIONS ON THE DIGESTIVE APPAKATUS. was formerly employed, but it is quite unnecessary and of no ad- vantage to use a canula of such dimensions merely to allow the escape of the gases. A small, round trocar is now in general use, and is in our estimation to be preferred to the ordinary flattened form of instrument (Fig. 369). The enterotome of Brogniez (Fig. 370) is too large an instrument, and its use endangers the walls of the intestines and the surrounding blood vessels. Brogniez reports a case of injury to one of the ccecal arteries by the point of this instrument. We have frequently had re- course to the trocar of the epidermic syringe used for horses, when no other instrument was conveniently at hand. The animal suffering with flatulent colics is treated while on its feet, and the pain it endures is usually of so intense a kind that no means of restraint are necessary, and it remains per- fectly indifferent to the insignificant and minor pang of the oper- ation. The principal caution to be observed, is to be on guard against the patient's suddenly falling, but if this should occur it need not interrupt the operation, which may be continued with- out forcing it to rise. The modus operandi is very simple. The spot being acurately determined, the point of the instrument is pressed perpendicu- larly upon the skin with one hand, and driven by a strong, quick blow with the other upon the handle, through the skin and the in- testinal coats into the visceral cavity. The withdrawal of the rod, leaving the canula in place, completes the process, by giving vent to the gases. These escape with more or less force, as announced by a whistling sound as they pass out of the tube. The intestines must then be entered from above downward, and not as recom- mended by Hertwig, who punctures the most dependent part of the abdomen, and thus exposes his patient to serious subcutaneous infiltrations. Peuch and Toussaint suggest the propriety of making a smaU preparatory incision through the skin with a bistoury, pre- vious to the main puncture with the trocar. The escape of the gases continues for a varying time, according to the amount of the accumulation. The instrument should continue in the wound while the escape continues, and until the tympanitic con- dition of the intestines disappears. If the escape of gas should suddenly cease, it will be because the canula is filled with foecal or other matters, and the trocar must be re-inserted into its PARACENTESIS. 383 canula until the renewed escape of the gas proves that the ob- struction has been removed. If, however, they still fail to find an exit through the canula, a second puncture must be made at a short distance from the first. The wound of the puncture re- quires no treatment. According to Zundel, enterotomy is comparatively — in ordin- ary cases — harmless; still, however, complications more or less severe are possible, and have been observed. Hemorrhages, though of no alarming nature, have been noticed, and several cases of abscess have been recorded, either at the seat of the operation, or at the wound of the flank, and even in the groin. Peritonitis has also been encountered. Subcutaneous emphysema has been mentioned by Bouley ; but in an experience of many years, we have never seen it. Laceration of the floating colon has been reported by Schaack. As a means of prevention against these accidents we would recommend great care in the introduc- tion of the trocar through the abdominal walls, and especially a condition of thorough cleanliness, with a careful disinfection, of the instrument. PAEACENTESIS. This term, with its synonyms of puncture and tapping^ is at the present time appHed exclusively to the operation performed upon the abdominal walls for the purpose of evacuating the seros- ity collected in the peritoneal cavity, as the result of dropsical ef- fusion. It consists in puncturing the abdominal walls in the man- ner practiced in enterotomy and gastrotomy. The operations are similar, while the purpose varies materially in the several cases. This operation had already been recommended by Vegetius — afterward employed by Vitet, as a last resort in ascitis. Lafosse, Jr., also speaks of it, and in more modern times we find it advo- cated by St. Cyr, Lafosse, Forster and others. Though in the majority of cases forming only a palliative treatment, it is never- theless indicated in chi'onic dropsy of the abdomen, when all other forms of treatment have failed to produce the resorption of the fluid, especially when its accumulation interferes with the ab- dominal and thoracic functions. In these cases of ascites it has been performed upon horses, cattle and dogs. The injection of tincture of iodine into the j)ei"itoneal cavity, after the removal of 384 OPEKATIONS ON THE DIGESTIVE APPARATUS. the e£fusion, has been successfully added as a means of preventing the return of the fluid. In selecting the place where the operation is to be performed, Brogniez, Degives, Peuch and Toussaint advised the middle of the linea alba, at an equal distance from the xiphoid cartilage of the sternum and the anterior border of the pubis ; Zundel, on the contrary, recommends " a punctxire on the right side in ruminants, on the left in horses, on a point at an equal distance between the umbiHcus and the external angle of the ilium, about on a line run- ning from the stifle towards the cartilage of the last rib." He adds, however, "to select the point where the hquid is most de- tectable and fluctuation better felt." A trocar of the size of a quill for large animals, and an aspirator for the small, are the only instruments required. In operating on large animals, they are kept standing, while small animals are laid upon a table and placed slightly on their backs. Placing himself on the left side of the animal, after having selected the place where the puncture is to be made, the operator, holding the trocar Fig. 371.— Holding the Trocar in Paracenthesls. full in his hand and hmiting its action by keeping his fingers a short distance from the point of the instrument, pushes it by a rapid and firm pressure through the thickness of the abdominal walls, until he feels that he has overcome their resistance, and that the instrument has passed into the cavity. The trocar is then withdrawn from its canula and the fluid escapes through the tube. Director Degives describes another modus operandi, which he calls subcutaneous, in which the opening of the skin does not cor- respond with the division of the deeper muscular layers, and by which the opening becomes covered by the skin. To effect this the skin is drawn a little aside, then punctured, or a large fold of the tegument is taken hold of, and the puncture made at its base. In either case, when the skin is loosened, its retraction completely closes the abdominal opening. HERNIA. 385 If the escape of the fluid should stop or diminish, a blunt stylet can be introduced into the canula to clean it of any albu- minous or epiploic mass which may obstruct it. The operation in small animals is performed in the same manner. As the removal of the entire accumtdation of the fluid is dan- gerous, though less so than ia thoracentesis, it is better to permit a portion of it to remain. The quantity is sometimes enormous, ranging between thirty-five and ninety-six quarts. After the quantity desired has been obtained, the canula of the trocar is carefully withdrawn, and a bandage or roller of adhesive plaster placed around the body of the animal. Among accidents possible in this operation, wounds of blood- vessels or of the intestines, and fatal peritonitis may be men- tioned. HEENIA. General View. In a general sense, any tumor formed by the entire or partial escape and protrusion of an organ, either wholly or in part, from the restraining tension of the integuments, or from the cavity which forms its normal location, is a hernia, or in popular phrase, a rupture. The more special appUcation of the term is to the dis- placement of the abdominal viscera, but it is also employed to describe the encephalocele, or protrusion of the braia through the cranium; the projection of the iris and the ^'aJoi, or protrusion of the oesophagal mucous membrane, through its muscular coverings. And again the prominence of a synovial membrane beyond its ordinary bounderies: that of a muscle through its aponeurotic envelope ; the prolapsus of the rectum ; of the vagina ; of the uterus, etc., etc., — these also receive the same designation and are recognized members of the hernia family. We shall, in the pres- ent chapter, mainly limit our consideration to the displacements of the abdominal digestive organs. The rationale of the formation of a hernia becomes a matter of easy comprehension, when we take into consideration the gen- eral anatomy of the abdomen, and especially the structure of its inferior wall. The muscvdar layers which form the exterior wall of this large splanchnic cavity are not of equal density through their whole extent, and consequently do not offer in every part an equal amount of resistance to the outward pressure of the interior 386 OPERATIONS ON THE DIGESTIVE APPAEATUS. contents. In one place musciilo-cartilaginous, or bony, it is in another, musculo-aponeurotic. In some parts jorotected by only a single layer of muscle, as in its anterior wall ; in others the layers of muscular aponeurotic structure, or of fibrous bandages, are re- inforced by a powerful elastic band, as in the inferior portion, by the tunica abdominahs. But besides this variety in the elements Fig. 372.— Muscles of the Inferior Abdominal Region. 1, aponeurosis of the great ohlique; 2, fleshy portion ol the small ohlique; 3, straight of the abdomen; 3 ', transverse of the abdomen; 4, pre-pubic tendon; 5, inguinal ring; 6, its anterior border ; 7, the posterior ; 8, external commissure ; 9, internal commissure ; 10, posterior border of the aponeurosis of the great oblique ; 11, internal crural aponeu- rosis; 12, flap of the aponeurosis of the great oblique, drawn downward to show the origin of the reflex portion which forms the crural arch ; 14, remains of the umbilicus. forming the walls of the cavity, there is also to be taken into con- sideration the fact that, at certain points in the walls, natural openings exist, and that the abdominal cavity is therefore not strictly a close cavity. These passages consist of the inguino-cru- ral openings, the umbilicus and those found in the diaphragm for HERNIA. 387 the egress of certain organs out of the abdomen, either during foetal hfe or after birth. The hernia, when not arising from a traumatic cause, is the result of some violent muscular effort on the part of the animal, in the coui'se of which the viscera are made to exert a violent out- ward pressure upon the walls of the abdomen. If the pressure bears against any of the more soHd portions of the wall, there will be no yielding, and the parts will remain iininjured and intact. But if the pressm'e becomes unduly violent, and the attack is di- rected against some one of the weaker supports, there must be a jdelding, and the intestine or omentum, as the case may be, will be forced through the opening which falls most nearly in hne with the direction of the violence. The resistance fails, the viscera passes through the aperture, and there is a protrusion, a rup- tui'e, a hernia. Two elements must enter into the composition of all hernias, with the exception of eventrations. They are the sac, and the displaced organs which form its contents, and the mode of its formation may be readily comprehended by a consideration of the figures 373, 374, 375, which show the progressive displacement of the peritoneum, as it is pushed through the opening of the ab- dominal waUs, by pressure of the intestines, which are also gradu- ally passing through the same opening. The figures show in what manner the hernial or 2^eritoneal sac is formed. The sac is thus shown to be the j)i'olongation of the perito- neum, which is displaced, moved and distended, or may have sus- tained partial laceration of its fibres. It may even happen that the rupture of that serous membrane is complete, and that it has become lodged in the cellular tissue. In such a case the lacerated peritoneum soon throws out a provisional reparatory sheath, which becomes continuous with the natural serous membrane. Whether formed by the peritoneum itself, or by a membrane of secondary formation, the sac is always composed of a middle por- tion, or body, and an opening, or ring, which constitutes a means of communication with the abdominal cavity, with a neck or canal, a narrowed portion, uniting together the body and the opening of the tumor. But Uttle uniformity exists in the formation of the ring or opening of a hernia. In some instances it is rovmd or oblong, in others it is a narrow slit, and again it exhibits a triangular outline. 388 OPERATIONS ON THE DIGESTIVE APPARATUS. Fig. 373. EXPLAKATION.— In these three flgures an idea of the mode of formation of hernias is given: aa aa aa, represent a section of the abdominal wall; o o o, the aponeurotic opening through which the peritoneum, pppppp, is engaged to form the hernial sac, s; the intestine, ii ii it, is shown entering the hernial sac gradually. Fig. 374. Fig. 375. In the ventral kind the aperture is wide and of varying dimen- sions, and it may, moreover, be quite wanting, or again, it may be long and cylindrical, as in inguinal rupture; while in the um bilical variety it is very short, and represented merely by the thickness of the edges of the hernial ring. The body or middle portion of the intestines, or that which becomes lodged in the cavity of the sac, also varies in size, direction and form, and may be considered imder the four principal heads of the cylindrical. HEKNIA. 389 Fig. 376.— Cylindrical Hernial Sac. Fig. 377.— Spheroidal Hernial Sac. Fig. 378.— Conical Hernial Sac. Fig. 379.— Pyriform Fig. 380. -Hernial Sac Hernial Sac. in Clusters, or having three contractions— /, d, b. Figs. 381, 382 — Multilobular Hernial Sacs. 390 OPERATIONS ON THE DIGESTIVE APPARATUS. the spheroidal, the convex^ the pyriform, to which Zundel adds the clustered and the vnxdtilohular . The relation as to dimensions between the body of the hernia and the measurement of the ring is a point of importance in re- lation to estimating the more or less serious nature of a case. It will readily be inferred that with a narrow and contracted open- ing, an obstruction may easily take place, and at an early date, and that in due time the result will be manifested in the legitimate form of a strangidation, an accident which will be accompanied with various phenomena, according to the degree of pressure and the duration of the period of formation, and all of them attended with trouble and danger. At first, as the capillary circulation becomes retarded and diffi- cult, the intestines assume a red color, which passes successively through many shades, from deep red to brown or a blue-black, indicating the arrest of the blood, of which the dreaded sequel may be looked for in the appearance, a httle later, of signs of mor- tification of the parts involved. The blood then transudes through the walls of its vessels, and filtrates into the sub-serous and sub-mucous cellular tissue, thus increasing the bulk of the contents of the sac. At the same time the external surface of the protruding intestines becomes the seat of what is at first a yellowish exudation, but which becomes a bloody deposit, ready for organization if the patient lives long enough to survive the pains of the strangulation. By the eight- eenth or towards the twenty-fourth hour, however, signs of total gangrene make their appearance and the hernial portion becomes flabby, cool, and insensible; the odor becomes very offensive, and the tissues easily lacerated or torn. The fatal end is then near, being rarely deferred beyond the twenty-fourth hour, unless im- mediate relief has been interposed. But, of course, every case does not observe this regvilar succes- sion of symptoms, nor reach the same final termination, and in the instances in which the interference with the circulation is less pronounced and the degree of pressure upon the protruding organ is lighter, probably not more than sufficient to interfere moderately with the movement of the intestinal contents, we have a modified evil to contend with in the obstruction or engorgement of the hernia, with consequences in view less discouraging to con- template The exudation upon the surface of the contents of the HEENIA. p/'f fi/////r////W /// Ilium 391 Fig. 383.— Strangulated Inguinal Hernia. A, intestinal circumvolution. B, herniated portion of the intestine. D D, neck of the vaginal sac compressing the intestines. E, internal wall of the vaginal sac. T, tes- ticle in the fundus of the vaginal sac. sac has resiilted in an adhesion with the internal surface, and the hernia has taken its place in the class of the irreducible. Hernias of long standing-, which have, at intervals, shown indications of obstructions, are, in the greater number of instances, in fact, ir- reducible There are still, however, cases of simpler condition in which the viscera continue to be movable in the sac, in which fact they are due to the lubricating effect of a free serous exudation. 392 OPEKATIONS ON THE DIGESTIVE APPAKATUS. Aside from other distinguisliing characteristics, all hernias are divisible iato two classes — internal and external. Of the latter, some, as the eventration, have no containing sac, while the others, which have a serous covering, are in reahty alone entitled to be considered as the true hernias. These, usually occurring through one of the natural openings, are called natural, in opposition to the accidental, which, like the ventral hernias and the eventration, occur through accidental and artificial openings. Any of the ab- dominal viscera, with the exception of the pancreas and the kid- neys, may enter into the formation of a hernia, and as each is known by the name of the displaced organ, we are given the designations of enterocele for a hernia of the small intestines ; epi- plocele, for that of the omentum, and enter o-epiplocele of both the intestines and omentum. • The name of gastro-ventral is given to the ventral hernia which involves with it the stomach ; cystocele, when it is the bladder which is affected, and hysterocele when the uterus is concerned. Hernias can be, moreover, congenital or oc- casional — that is, they may exist at birth or previous to it, and also when making their appearance under special causes after birth. They may be also considered as acute when recent, or chronic, when of long standing. Their originating causes are numerous, and may be said to comprehend any which may predispose an animal to such a lesion by contributing to an increase of the pressure which the organs contained in the abdominal cavity bring to bear upon its walls, or any weakness in the walls, which may diminish their power of re- sistance to the pressure, as, for example, a condition of leanness arising from a sudden or recent change from a state of obesity ; blows upon the abdomen ; wounds and cicatrices of the abdomi- nal walls ; violent, jerking efforts, such as those required in com- pulsory jumping or hauling, or in any other of the struggles to which they are too often forced, and even when under the sur- geon's hands, when, as a patient, the animal is cast and secured for an operation; the rapid relaxation after contraction of the natural openings, repeated pressure, or excessive dilatation, as with stallions used for covering mares, may be placed among the predisposing causes. They have also been observed in mares, after violent efforts during parturition ; also during colics and other tympanitis. To recapitulate and partly to repeat The general symptoms characteristic of hernias, are compar- HERNIA. 393 atively easy to recognize, and can be reduced to two principal points, to wit — the discovery of a tumor, and appearance of an opening coexisting in the abdominal waUs. These tumors and openings offer many varieties of form and character. The tumor located opposite to a natural opening, or under a breach or separ- ration in the structiu'e of the abdominal walls, or under a cicatrix, forms a mass, indolent, elastic, remittent, of varying size, but di- minishing or increasing under peculiar conditions, such as rest or pressure, and the standing, or the lateral or recumbent position, etc., and having different forms, being located in various places. It has also, in many instances, the quality of being reducible, that is, it may be made to disappear by means of certain manipu- lations and appropriate treatment, and arrangements of position, to return to their previous status when these agencies are sus- pended ; or again, they wiU. become permanently irreducible under special pathological changes already alluded to. The presence of borborygmus is also an important item among the means of form- ing a physical diagnosis of these tumors. This is detected more or less readily when the displaced organ is a portion of the in- testines. They are, however, missing when the hernia is formed by other organs, as, for instance, in case of epiplocele. Other points connected with this subject remain to be mentioned. Among these are the final symptoms, and more or less remote re- sidts, which may follow the presence and working of the lesion upon the general economy and the physiological functions at large, when the acute action has passed away. The constitutional symptoms, or what may be so denominated, will vary, in their nature and their intensity, correspondingly with the condition of the hernia and the comphcations which may ac- company each case. Among these comphcations, four principal ones may be mentioned as taking precedence : 1st. Irreducibility. — This is more frequent in old cases than in new, and is probably due to the increase in size of the dis- placed organ to the degeneration of the tissues, or to old adhe- sions between the organ and its covering, the sac. These cases, which may be considered rather permanent than merely chronic, maintain their status, either completely or partially, unchanged. Yet they cannot, naturally or rationally, be held to be compatible with a sound constitution or unimpaired stamina in the animals so conditioned, and their Habihty to contract indispositions easily 394 OPERATIONS ON THE DIGESTIVE APPARATUS. has frequently been remarked. Difficulty in the performance of movements requiring effort has also been noticed, with conse- quently a liability to suffer traumatic injuries from external vio- lence. To this must be added a facihty in contracting: 2d. Injimn'tnation. — Generally this occurs as the I'esult of external injuries, but it may also occur without any apparent cause. Its seat is the sac or its contents, and it affects the serous structures alone, or assumes a phlegmonous aspect. The inflam- mation of the serous tissue is often overlooked, while that of the phlegmonous cannot pass unobserved. It may sometimes assume a very serious character, and become even more dangerous than the true strangulation. 3d. Ohstructions or engorgements, common in intestinal her- nias, are due to the accumulation of alimentary or stercoraceous masses in the displaced intestines, or to gases which interfere with the reduction of the hernia. This is often complicated with strangulation, but is not in itself of a very dangerous nature. 4th. Sitr angulation. — This condition has been already consid- ered. It is the result of excessive pressure upon the blood vessels of the displaced organ, and while under its three periods or degrees of congestion, inflammation, and gangrene, has usually a fatal termination. The general treatment of hernia has the two objects in view of the destruction or obliteration of the sac, and the reduction or closing of the ring. If the first is not always easy to accompHsh the reduction of the diameter of the ring often is so. Each form of hernia demands some special directions for the reahzation of these two objects, and these will each receive its own share of attention as they may in turn come under our notice in further treating the various forms of hernia. Inguinal Hernia. Inguinal hernia results from the passage or presence of a portion of the intestines, or of the omentum, or of both together, in the testicular or vaginal cavity whose opening of communica- tion with the peritoneum or inguinal ring continues in its normal condition, having never closed. A brief survey of the general anatomy of the region involved will be a necessary preliminary to our discussion of the subject, which is one of interest and im- portance. 395 OK O K o \] II fit "I' fif iJii'ih Jii ii\ Fig 38 1.— Anatomical Disposition of the Inferior Inguinal Ring and Testicular Sac. Explanation of Fig. 384.— A C, testicular sac, in which are shown— list, the neck situated above- the letter A, and concealed in the inguinal canal; 2d, a middle portion extending from A to E ; 3d, a fundus, B C, where the testicle is. D D, division of the scrotal artery. F G, inferior inguinal ring, whoso internal commissure Is rounded and formed of white fibres crossing each other and attached to the prepubic tendon. H H, fleshy portion, from the small oblique, and forming the anterior and internal lip of the inguinal ring. K K, postero internal edge of the inguinal ring, formed princi- pally by an aponeurotic portion of the great oblique. L, scrotal artery. M, veins of the scrotum and of the penis. N, part of the penis thrown backward, o o o, tunica abdominalis. P, muscles of the flat of the thigh, short adductor of the thigh. The inguinal canal is an infundibuliform cavity, flattened from one side to the other. It is situated in the groin, and 396 OPERATIONS ON THE DIGESTITE APPARATUS. through it pass the testicular cord and the testicvilar blood ves- sels, in the male, and the blood vessels of the mammae in the female, as they emerge from the abdominal cavity. Situated on one side of the prepubic region, it observes an oblique dii'ection, downward, backward, and from without inward, being formed posteriorly by the crural arch, and anteriorly by the fleshy portion of the smaU oblique muscle of the abdomen. Inferiorly it has an opening called the inferior inguinal ring, which is made through the aponeurosis of the great obUque, oval in shape, and possessing two lips, edges or pillars, united together by two commissures. The lips, divided into anterior and posterior, are formed by the fibres of the aponeurosis of the great oblique muscle of the abdomen, and a few of the muscular fibres of the small oblique, reinforced by some bands of the tunica abdominalis. The commissures, divided into external and internal, result from the union of the extremities of the two pillars. The superior opening of the inguinal canal is known also as the peritoneal or superior inguinal ring, and is situated in front of and directly opposite the crural ring. It represents a single slit, subject to dilatation, placed also between the crural arch and the small oblique of the abdomen, and allowing on its inner border the pas- sage of the anterior pudic or posterior abdominal artery, it sur- rounds the neck, and forms the entrance of the vaginal sheath. It is open in horses, and often in bovines also, and it allows a direct communication between the cavity of the vaginal sac and that of the peritoneum — undoubtedly a predisposing condition to hernias, not to be overlooked. The testicular sac off'ers to our attention, from the point of view from which we now consider it, an entrance, or true infundibulum, overlapping the internal opening of the inguinal ring or canal; a neck situated just below that ring, a continuation of the infimdibulum or entrance, and which at a short distance from its origin offers a well marked contraction in its diameter — this being the point where strangulation takes place — a tnicldle part, containing the spermatic cord; and a bottom, or true cvd-de-sac, where the testicles and the epididjTuis are lodged. The special signification of the terms which have been else- where and already employed to designate and classify the varie- ties of form and manifestation characterizing difi'erent varieties of hernia are of interest, and should not be lost sight of. They are HERNIA. 397 divided principally into recent or acute, and old or chronic, and we find them considered as enter ocele, epiplocele, and enter o- eplplocele, according to their contents. The name of vaginal hernia has been used to denote a case in -which the intestine is directly engaged in the inguinal canal; and hernia of the ring, or hernia in the canal, describes that in which the viscera have en- tered but a short distance into the sheath. Bubonocele signifies that the intestine has entered but a very slight distance into the inguinal sheath, in opposition to the oscheocele or scrotal hernia, when the intestine falls quite down into the sac, and with the testicles themselves, occupies the bottom of the scrotum. Inguinal hernias are generally accidental, but, as some authors hold, are also sometimes congenital, having been found existing at birth ; and in many instances they become permanent, the in- testines occupying the vaginal sac without change, as a fixity. Then, again, they may be intermittent, disappearing more or less completely, under peculiar conditions, only to reappear imder the stress of new influential causes. Of coiu'se the classification of re- ducible and irreducible, always holds. The classification of the hernia of castration, which takes place during or after that operar- tion, is considered by some to be properly one of the forms of eventration. A consideration of the anatomical disposition of the vaginal canal, and especially of its upper ring, which presents an opening communicating with the peritoneal cavity, will explain the reason why inguinal hernias of the horse are more common in the stallion than in the gelding. It is rare in bovines, but Lafosse has seen it in sheep and in rams and although the anatomical disposition of the canal in the dog render its occurrence difficult, Wolstein has observed it in that animal. Cases are rare in females, but Girard, Jr., has seen it in mares, Rychner in cows, and Hering, Hertwig and Goubaux in bitches. Recent Ingtjinal Hernia. ^Tien the hernia appears suddenly, in a subject not j^redis- posed to it, the first symptoms are those of abdominal j)ain, ap- pearing suddenly and without warning, and quite inconsistent with the general perfect health of the animal. These symptoms are at first vague in their significance, and definable merely as ex- hibitions of simple pain in the abdomen. 398 OPERATIONS ON THE DIGESTIVE APPARATUS. If in the stable, the animal becomes restless, paws with his fore feet, gazes earnestly toward his flanks, and flexes his legs, as if to he down, and perhaps accomplishes that movement, but only to resume the standing position. The skin is moist, the per- spiration appearing on the face, around the ears, behind the shoulders and in the groins. If he is in harness, his action is changed, he shortens his steps, stops pulling, wants to stand still, and becomes covered with abundant perspiration running over him and drijDjDing from his belly. These first symptoms excite suspicion as to the real cause of the trouble, but they soon assume a character which changes the suspicion into certainty. They rap- idly assume greater severity, increasing in the ratio of the suffer- ings of the animal, which then has no more rest or intermission, and gives evidence of the most intense abdominal pain. He paws and stamps upon the floor more and more violently, sometimes kicking his abdomen; gazes anxiously toward his flanks; lies carefully down and rolls to and fro on his back, sometimes keeping the dorsal position for a few moments, as if he could only thus find relief; then suddenly rises to his feet and rej)eats the movements, which give evidence of the torture he suifers, but more forcibly and rapidly than before. The expression of his face soon becomes characteristic. The lips are contracted, the nostrils are retracted and dilated, and the widely opened eyes ap- pear unnatiu'ally large and prominent, rendering their agonized expression more and more striking. The respiration becomes ac- celerated and the pulse more rapid; the perspiration streams more copiously from his body and the poor animal groans under the weight of his trouble. After a lapse of some hours, the time arrives for the occurrence of strangulation, which may be pronounced the crisis or fatal event of inguinal hernia. It is characterized by a peculiar mo- tion of the head, which is thrown up and down repeatedly (and which the French have designated by the word " encensd.'') This motion, which is sometimes habitual with horses while in harness, has a pecuHar meaning when it becomes the expression of the coHc of hernia. It is then performed slowly, the head being ele- vated gradually and extended upon the neck, to be suddenly dropped again as if from weakness, to be again raised and dropped during the few and brief intervals of remission of the pains, while the animal possesses the ability to keep on his feet. HERNIA. 399 In fact, when the hernia is completed, the coHcs are so violent that the animal no longer lies down, but literally throws himself with violence upon the ground, having become forgetfvd of the natural instinct of conservation, and now rendered indifferent to all other pain by the overpowering force of the hernial torture. With his body covered with bruises, and bleeding from numerous superfi- cial wounds, he now becomes a pitiable object. There are animals of particularly sensitive temperament which will even, Hke those in a rabid f m-or, bite themselves on their flanks and forearms in their delirious desperation. Diiring these excessive sufferings there seem to be just two positions in which the animal can experience a comparative de- gree of comfort. They are, lying on his back, or maintaining the dog-sitting posture, on his haunches. But these movements of reprieve are of but short duration, and the pains may continue to be manifested without cessation, by tumultuous, violent, imequal struggles, which may continue twelve or fifteen hours, or even more. At last, toward from the fifteenth to the twentieth hour, all the signs of pain subside, and a great calm succeeds to the previous violent agitation. This, however, is far from being a good sign, or an indication of the termination of the disease. It is, on the contrary, a sure token that a fatal termination is close at hand, and if the patient has ceased to suffer, it is because the anesthesia of death has fallen upon the organ in which his pains originated. The parts which were so recently altogether too much alive, have died. Gangrene has attacked the imprisoned intestine, and with its apjDearance, loss of feeling has also come — and death — for death is the loss of feeling. The animal is now in a con- dition of extreme prostration. The temperature is diminished; the perspiration is cold, the pulse is imperceptible, his face is without expression, the poor brute can scarcely maintain a stand- ing posture or move his legs when urged to stir, and when the last remnant of his strength is exhausted, after a few hours, he drops upon the earth and dies without a struggle. Death rarely delays beyond twenty-four hours following the strangulation. This is the extreme limit, and in the greatest number of cases it takes place within a shorter period. These manifestations (the description of which we borrow from H Bouley), constitute the series of general symptoms of hernia, but, at the same time, they do not belong exclusively to that kind 400 OPERATIONS ON THE DIGESTIVE APPARATUS. of injury. They are those of any violent abdominal pain spring- ing from any cause, and may be met with in invaginations, volvulus, intestinal obstruction, etc. But if not possessing any positive and intrinsic significance in themselves, they assume great value in the diagnosis, when added to the series of local, or pathognomic symp- toms which have their origin and limit in the inguinal region. Two methods are available for the location of the seat of the lesion, one being the external exploration of the inguino- scrotal parts, the other consisting in the internal rectal examin- ation of the pubic region. In a horse, and especially a stallion, suffering from colics, the indication to a general and immediate examination of the inguinal region, for abnormal appearances, is always present, and it will not be safe to be too easily satisfied with visual examination exclusively, to become certain that no part of the intestines is engaged in the vaginal sac. The eye may be deceived; it is the touch alone which will prevent all possibility of error. The sensation imparted to the touch at the beginning of a recent inguinal hernia is that of a thickened testi- cular cord which has lost its usual suppleness, and whose con- stituents can no longer be determined under the pressure of the fingers. Thus thickened, the cord gives a sensation of resistency, increasing as the exploration is carried further up in the groin, while toward the bottom of the sac, the scrotal mass feels fuller than usual, the testicle becoming less movable, giving the sensa- tion of a slightly puffy tumor. After several hours duration of the disease, the characters become better marked, in consequence of the increase in the size of the intestine, and the amount of exu- dation, and there is also a formation of gases above the neck of the sac, which also contributes to its increase in size. The hernial tumor has thus become changed from its original appearance, by its enlarged size, and is easily detected by the great general tension caused by the presence of the accumulating gases ; the cord is found to be tumefied in its whole length, while its renitentcy increases as it extends upward into the canal. Direct pressure with the fingers upon the tumor does not seem to cause great pain, probably because this local sensation is dulled by the extension of the excessive pains which radiate from the hernia throughout the entire abdominal system. The external characters of the inguinal tumor become more noticeable when both sides of the testicular regions are compared, the difference between the HEKNIA. 401 healthy and the diseased regions being then easily ascertained. Continued spasmodic movements of the healthy testicles have been observed. In the rectal examination of the horse, the hand may be easily carried beyond the anterior border of the pubis, and the condition of the superior ojDening of the inguinal canal, and the state of the organs engaged in it thus ascertained. In the normal condition, the anterior pillar of the superior opening of the canal is easy of identification. It is in front and on each side of the pubic region, and by reason of the extensi- bility of its muscular structure, requires no greater force for its separation from the posterior pillar than the introduction of two fingers into the ring. When the intestine is in the vaginal canal, after having passed through the superior opening, it can be felt with the hand through the walls of the rectum, its situation being generally on the inner side ; and being thus recognized, it can be raised, pulled upon, and sometimes even extracted from the open- ing through which it had passed. But to be able to judge accu- rately the nature of the object which has been felt, requii'es in the siirgeon an amount of experience in the taxis not always pos- sessed, while its absence may at times betray the explorer into serious error. Moreover, the sensations transmitted through the rectum cannot in every case be triily interpreted, and it sometimes becomes necessaiy to combine the two modes of examination em- ployed simvdtaneously — the rectal investigation and the external, manual, testicular exploration. Thus, when with one hand in the rectum, pressing on the in- ternal ring, and the other pushed well into the depths of the in- guinal region, both are brought in contact, and it is discovered by the actual touch that the inguinal canal is cleai*, the hypothesis of strangulated hernia is at once negatived. On the other hand, if there is hernia, and the imprisoned intes- tine is encountered, the fingers of the two hands cannot possibly come in contact, and the next question will be one of indication, if not of prognosis. As a rule, the prognosis of recent inguinal hernia is always seri- ous. If developed without organic predisposition it is necessarily a serious lesion by reason of its tendency to spontaneous strangu- lation,, which when unreHeved means death by torture, unless the fatal event should be humanely anticipated and prevented by the 402 OPERATIONS ON THE DIGESTIVE APPARATUS. fiat of a compassionate master. But a fatal prognosis need not be unnecessarily volunteered. Timely and vigorous measures, es- pecially emphasizing the "timely," may still prevent the strangu- lation and defer the sentence of mortality, and the sooner, there- fore, the means of reHef are applied, the more certain will be their effect. Every minute's delay increases the force of the disease and lessens the chances of success. It is rarely the case that the lapse of fifteen hours leaves any room for confidence, though it is not yet time to abandon hope. Within that period there are many chances for saving the patient, but after the earlier periods of the attack a single hour's neglect may be fatal — that hour may prove to be the turning-point of the conflict. The treatment of recent inguinal hernia assumes two forms, consisting of the taxis, and the oj)eration of herniotomy, or the en- largement of the neck of the vaginal sheath with a cutting instru- ment. The first mode is indicated at once, or as soon as the her- nia is recognized. The reduction must be accomplished in the shortest time possible, the danger of strangulation becoming more imminent and threatening with the lapse of every moment. The taxis may give immediate relief, and may be materially assisted by douches of cold water. In this case the taxis consists in the manipulation of the part with the hands, by pressure and otherwise, for the purpose of re- placing the protruding intestine in its proper cavity ; technically, the reduction of the hernia. This manipulation is appHed either by simple pressure over the external surface of the diseased part, or, if practicable and necessary, by supplementing it with a proper traction appHed upon the intestine from within through the rectal walls. This manipulation may be applied by two processes, first the subcutaneous, medial or indirect^ and second, the direct taxis. 1st. The Indirect Taxis. — In the first or indirect method, the animal is placed in a standing position, with the hind legs secured. Then the hand and arm of the operator, well oiled, are introduced into the rectum, using the right, if he is to operate on the left side, and vice versa. "When in the rectal cavity, the hand is carried to the anterior border of the pubis, while with the other, passed in front of the patella, pressure is applied upon the scrotal sac, and the intestine pushed toward the superior opening. The hand in the rectum then grasps the loops of the hernia, through the rectal walls, and at the same time pulls them ujDward. Through these HERNIA. 403 manipulations the surgeon may succeed in removing the difficulty, if by that time the testiciilar sheath continues to be free from con- gestion. But if this akeady exists, and the coUcs are increasing in severity, the taxis in the standing position becomes impossible and it wiU. be necessary to throw the animal. This done, he must be placed in the dorsal position, with his hind legs kept apart and his haunches raised as much as possible by bimches of straw. In this position, the operator must proceed to practice what must be described as an exceedingly dehcate massage or taxis uj)on the scrotal sac, both hands being used, in such a manner as to crowd or press the intestinal mass toward the superior opening of the canal. The design of this is to stimulate the circulation through the capillaries, and also to free the cavity of the intestine from the semi-fluid and gaseous contents which ma}' be present, by this means diminishing its volume and facilitating its reduction. That this must be done with the utmost caution and jDatience, needs hardly to be urged. And it should be persevered in for at least a period of thirty seconds before advancing to the other step, which consists in gradually pushing the intestine toward the opening. If the protrvidmg loop is not too long, and the massage has succeeded in its design, and the bulk of the tumor has been sufi&cieutly diminished, and, above all, if the hernia has had but a short existence, it may be within the probabihties that this external taxis alone will be sufficient to reduce it. But such a result cannot be counted on with any degree of certainty, and it is then the simple dictate of wisdom to make assurance sure, if possible, by having recourse to double taxis, and attacking the danger at both its internal and external accessible points. For a single operator to undertake the performance of both branches of this compound manipulation can hardly be advised. Few men possess the necessary powers of endurance, and an acci- dent might easily compromise the very life of both surgeon and patient. At the least, it involves quite an unnecessary amount of effort and fatigue. All the reasons are in favor of a di\dsion of the work, by which a competent assistant will be put in charge of the rectal taxis portion of the labor, while the practitioner in chief will direct and execute all the other steps of the treatment. The successful result of the operation will be known at once by the diminution of the tumor, the disappearance of its puffy and tense condition, by the sudden sensation of yielding, felt by 404 OPERATIONS ON THE DIGESTIVE APPARATUS. the hand working in the rectum, and also by the facility with which the fingers of that hand can be introduced into the now liberated superior ring. Anesthetics have been recommended as powerful adjuncts in the application of the taxis, in this class of cases. Bouley recommended their use, and Bagge, a Russian veterinarian, agrees with Bouley, in advising their administration. His pro- ceeding is thus described : The rectum being emptied, a solution of two to four grammes of chloral and sixty or seventy centi- grammes of acetate of morjjhia are thrown into it, while at the same time compresses of chloroform are laid on the diseased side of the inguinal region. In the course of ten minutes there is such a relaxation of all the tissues that the reduction by rectal taxis is quite easy. The spermatic cords are then surrounded by rolls of bandages moderately tight, in order to prevent the return of the hernia. These bandages are left on for eight or ten hours. The danger of strangulation upon the testicular cords is an im- portant objection to the adoption of this process. Severe appli- cations of douches of cold water applied for one or two hours previous to the taxis have been successfully employed by Steff and Lacassin. A process known as that of Patey, from its discoverer, con- sists in the injection of oil of belladonna into the hernial sac, the action of the oil, it is claimed, producing the dilation of the pseudo-sphincter, which prevents the reduction. It causes a cer- tain flaccidity of the parts, renders the taxis much easier, and con siderably facilitates the reduction. 2d. The Direct Taxis. — This procedure is of too dangerous a character to mamtain a place in the domain of veterinary surgery, except under very exceptional conditions. It consists in apply- ing the manipulations of the taxis directly upon the intestine, previously exposed by the dissection of the testicular envelopes. These manipulations, which are dangerous when the intestine is distended by gases or fluids, may, however, be rendered easier by relieving the intestinal loop, through the use of a fine needle- trocar or aspirator, of the cause of its abnormal dilatation. The method of Renault, mentioned by Zundel, is also a form of direct taxis which, though it may be employed in cattle, involves a subsequent fatal peritonitis in the horse. The operation con- sists in the opening of the flank and the performance of the re- HEKNIA. 405 duction by dii'ect traction with the hand thus introduced into the abdomen. The operation of herniotomy is that which consists in the section of the neck of the vaginal canity. It is the proper opera- tion ioY strangulated hernia. Bouley has said: "This operation is not, as one may be inclined to think, a last resource, which is not to be used except after the taxis, under its various forms, has been appHed and failed. Far from it. We beUeve, on the con- traiy, that in the horse, the taxis is a means of treatment which is trvdy indicated only in the first five or six hours of the descent of the intestine ; that even, in this first period of time, one must not use it too much nor too long, from fear of the compHcatious which might arise through the rectal manipulations, and that after this Hmit of a few hours has elapsed, it is better to have re- course immediately to the operation, without trusting to vain hopes from the use of the taxis." The operation is comparative- ly a simple one, the dangers which were formerly apprehended having been greatly reduced by a better knowledge of the seat of the strangulation, and of the parts to be divided, and the ratio of mortahty is now so small — forty-two recoveries out of fifty-two operations — that hesitation is no longer justifiable. The instruments requu'ed for this operation are straight and curved bistouries, scissors, an ordinary director, a herniotome (Figs. 3846i!, 385), or blunt, straight bistoury, and a pair of curved clamps with strong cords to secure their branches. The hernio- tome is a histoury-cacJu, which, however, since the use of general anesthesia, has been replaced by the blunt, straight bistoury, en- ables the operator to diride the neck of the vaginal sheat*h in the right place with more certainty than heretofore, and to regulate more accurately the dimensions necessary to relieve the strangu- lation. The director which is best adapted for use in herniotomy is one which has a flat, lanceolated, grooved surface at one end, and which, while it guides the blade of the bistom-y, contributes likewise to the protection of the intestine against the possibility of injury by the shai-p edges of the bistoury. The patient to be operated on is laid upon a soft bed, anes- thised as completely as possible, and placed ujDon his back. The hind leg corresponding to the side where the hernia is located is freed from the hobble, secured with a rope, and carried outward in abduction, with the rope made fast to a fixed point near by — 406 OPEBATIONS ON THE DIGESTIVE APPARATUS. Fig. 384a. Herniotome. Fig. 385. HerniotomeB of Colin, as a ring in the wall, a post, a tree, or other immovable object. If the oi:)era- tion is to be performed at night, which is too often necessarily the case, the presence of additional assistants will probably be required, in order to insure an abundant amount and proper man. agement of light, which is indispensable in so delicate a dissection. In operating, the surgeon kneels be- hind the patient and with a curved bis- toury begins by making a long incision upon the tumor, parallel with the long axis of the testicle. This incision is similar to that which is made in castration with covered testi- cles, and must involve onl}- the scrotum, the dartos, and the first layers of the lamellated cellular tissue which unite this last to the tunica erythroidea. The remaining portion of this lamellae is then carefully incised, until the fibrous coat is exposed, and the tumor is entirely enuclea- ted from its envelope of cellular tissue. This done, the fibres of the tunica erythroidea are scraped apart with the point of the straight bistoury, until the vaginal sac has been open- ed, which the operator dis- covers by the appearance of a stream of liquid pass- ing through. The canula- ted director is then intro- duced into the opening and HERNIA. 407 guides the bistoury, with which the hernial sac is now freely opened, in front and behind. This free cutting allows the escape of all the serous or sero-sanguineous fluid contained in the sac, varying in quantity according to the duration of the hernia. The contents of the hernial sac are now exposed. They consist of the testicle, pushed outward, against the commissure of the ring ; the loop of the intestine, placed on the inner side of the spermatic cord, rarely extending as far down as the testicle, but usually reaching to the level of epididymis, and again, not un- commonly remaining in the condition of a bubonoale. But what- ever may be the dimensions of the protruding loop, the intestine is always easily recognized by the roundness of its form, the smooth- ness of its sui'face and its color, which may range from various shades of red to bluish black. It is also recognized by the changes which have taken place in its consistency, resulting from the bloody and serous infiltration which has taken place in its structure. The intestine should now be carefully wiped off with a soft, fine sponge, or washed with lukewarm water, in order to free it from any de- posits or adhesions of serous or bloody matter that may be present. The opening of the hernial sac should be immediately followed by the exploration of the neck with the index finger, with a view to the determination of the exact point where the strangulation exists, and to judge of its degree of tightness. This will not be found upon the superior opening of the inguinal canal, as thought by Gu-ard, D'Arboval, Hertwig, Hering, Laf osse, Rey, Verrier and others, but should be looked for two or three centimetres below that opening, as demonstrated by Bouley ; that is, where the neck of the vaginal sac is situated. This point made out, if the hernia is very recent, and the intestine has not yet become the seat of thick- ening, a few tactical manipulations can be apphed, the internal face of the vaginal sac having first been lubricated with sweet oil, or some mucilaginous substance, or even oO. of belladonna ; and even cool irrigation has been of service. In the performance of this taxis the first step is committed to the assistant, who stretches both borders of the sheath in order to separate them in the form of a funnel, the testicle being di'awn outward, in order to stretch the cord also. The operator then applies both hands upon the loop of the intestine, and with moderate and gradual pressure endeavors to push it through the neck of the vaginal sac. Eectal taxis applied at the same moment may also be of great assistance. But these 408 OPERATIONS ON THE DIGESTIVE APPARATUS. efforts must not be persevered in too long. If not successful al- most immediately, it is better to have recourse at once to the in- cision of the neck of the sac than to expose the intestine to the subsequent effect of j^i'essures or tractions of vs^hich the termina- tion may be a fatal gangrene. The following steps are recom- mended by Bouley in making this incision. Says this author : " One assistant takes hold, with both hands, of the edges of the incision made through the vaginal sac, stretching them into a funnel shape ; another draws the testicle outward and backward, to stretch the cord. Then the operator having explored with his finger the con- dition of the neck, introduces the blunt bistoury or the herniotome (Fig. 386) as far as the neck of the sac, taking for his guide the index finger of his right hand (Fig. 388), introduced into the neck or canulated director, and holding the instrument in such a manner that its back rests against the pulp of the fin- ger which supports it, and its sharp edge turned outward, corresponds to the stiffened band of the neck, to- wards the internal face of the thigh. This band will thus become stretched over the knife in such a manner that it divides itself upon the sharp edge of the instrument, with the aid per- haps of the slightest pressure made by the finger which supports it. The important point is to make a very lim- ited incision, dividing only the thick- ness of the vaginal sac and its fibrous covering, and avoiding the wounding of the cremaster, that being one of the conditions of the closing of the sheath. The division once made, the degree of dilatation of the neck is readily made out, and if the finger can be easily in- troduced into it, the reduction of the hernia becomes then an easy task. The modus operandi by the use of the herniotome differs but little from the preceding. When this instrument -J c HERNIA. 409 Fig. 388. — Holding the Bistoury upon the Grooved Director. is to be used, a careful measurement of the amount of opening to be allowed to the blade must first be made. Then, guided by the side of the index finger, and with its blade turned outward, the instrument is introduced into the sac. "When it has reached the proper point where the division is to be made, the blade is brought out by pressing upon the peculiarly-contrived handle of the instru- ment, and the division of the band of the neck is completed. After the division at the point of strangulation, the taxis is to be used, both externally and by the rectum, carefully taking into consideration the condition of the intestines in the application of the various manipulations required. Upon reduction of the hernia, obUteration of the sac is secured by the application of a clamj), curved or straight, upon its parietal layers, embracing between them the spermatic cord. In short, the final steps of the operation will be precisely those by which the operation of castration with covered testicles is completed. This methed of closing the vaginal sac is the best, the simplest and the most certain in its results. It is true that the objection that it impUes castration is a weighty one, but the mutilation which it involves is a condition of radical recovery which cannot be obtained by any other means. The attempts which are made to save the testicles, which are justifiable only in the case of very valuable animals used for breeding purposes, are nearly always followed by fatal results. Among these may be mentioned the process by which, in- stead of leaving the testicle to drop under the effect of the pressure of the clamp, it is left inclosed in the vaginal sac, whose divided edges are brought together by sutures. Schmidt has attempted to push it back into the abdomen ; but such methods have been followed by fatal peritonitis. Bouley has 410 OPERATIONS ON THE DIGESTIVE APPAEATUS. also advised a subcutaneous herniotomy, whicli was put into prac- tice afterwards by Siegen & Verrier, in which the careful punctiu'e of the sac was made at the origin, or, preferably, at the flabelH- form insertion of the cremaster. After enlarging the opening, the index finger is introduced into the neck, carrying with it the blunt bistoury with which the structure is divided, and the reduction is completed by the taxis, the wound being closed by several points of suture. The use of antiseptics in our day obviates a large portion of the danger arising from the comphcations which may follow these modes of operation. The operation for strangulated hernia in the gelding does not differ much from that indicated for stallions, excej)t in the man- ner of closing the wounds, the clamp, in this class of patients, being applied upon the hernial sac, involving the skin, as is done in some cases of treatment for umbilical hernia. The treatment of the patient subsequently to the operation is generally a simple matter, the violent colics, with other manifesta- tions of the hernia, having suddenly subsided, and the patient being comparatively free from pain. He will probably give evi- dence of some slight abdominal uneasiness, which will probably be due to the pressure of the clamp upon the testicular cord, but this will not be of long duration, probably requiring no other at- tention than a moderate walking exercise. The animal is then turned loose in a box stall and placed upon a diet suited to his case, and watched for future developments. The wound requires no special attention but cleanhness, and towards the fifth or sixth day, when the suppuration is estab- lished, the clamp can be removed. It is about this time that comphcations may be looked for. A fatal peritonitis, for example, may appear between the fifth and tenth day, when everything has seemed to be progressing favor- ably, and bid defiance to treatment, esjoecially if the intestines were already in a gangrenous condition when the reduction was made. After ten days there need be no more fear of comj)lica- tions, so far as the hernia is concerned, but it is not yet too late for those of castration, which may still occur. The duration of convalescence will average from twenty to twenty-five days, after which the animal can resume his work. A return of the hernia, recidive, is a rare and almost impossible event when the reduction has been completed by castration. HERNIA. 411 During the operation certain accidents may occur, including eventration, an extra vaginal hernia and injuries to the intestines. At the present time, eventrations are rare, by reason of the fact that the division of the superior ring itself is no longer per- formed. Yet they may occur through an accidental slip of the knife, or a tearing of the walls of the vaginal sheath during ma- nipulation for the reduction, and the accident is usually a fatal one. Of extra vaginal hernia, Bouley says: "While making the in- cision of the neck, sometimes the cremaster muscle is divided in the direction of its length ; an accident possible, especially when one uses the concealed herniotome, and when too much freedom is allowed to its blade. It is then possible that the intestines may become engaged through this incision, and appear outside of the vaginal sac, above the inguinal ring. If at this moment, by mis- applied taxis, the intestines should fail to re-enter the cavity of the sac, eventration may take place. But if, on the contrary, the intestine is first carefully returned into the vaginal cavity, and then into the peritoneum, the edges of the peritoneal opening of the canal being intact, the intestines will then be prevented from making another exit." Woicnds of the intestines may take place either through a misdirection of the bistoury during the struggles of the animal, or possibly from the nails of the operator or his assistants, and the fact of their possibility suggests a sufficient hint touching the obvious means of obviating their occurrence. The gravity of these injvmes will be measured by their extent. Old iNGTJiNAii Heenia. Old, or chronic inguinal hernias, are those of which the charac- teristic condition is that owing to the state of dilatation of the vag- inal sheath, the intestine contained in it is enabled, without jeop- ardy to the life of the patient, to continue its function in the same manner as if it had remained in the open cavity of the abdomen. The vaginal sac has in this case become a kind of large diverticu- lum of such dimensions as to allow, without interference, the work and motion of the intestinal tract, lodged within it, to go on in a natural way. These hernias are divided into continued, or ^)er?>i«- nent and intermittent — a division elsewhere alluded to — but they may also be distinguished as simple and complicated. 412 OPEEATIONS ON THE DIGESTIVE APPAKATUS. Among the varieties belonging to the latter category may be named: the laceration of the superior opening of the testicular sheath; the collection of serosity in the sac (hydrocele); the sar- comatous transformation of the testicle where the hernia exists (sarcocele); the adhesion of the intestines to the walls of the sac (irreducible hernia) ; with obstruction and strangulation. Although their causes belong to the list which we have already considered, there is still a sort of latent difference observable in the effects to which they severally give rise, as evidenced by the slowness and tardiness of their maturity. They often appear, also, as a sort of relapse or reactionary sequelae (recidive of the French) of acute hernia improperly reduced, or as a consequence of the ab- normally dilated condition of the upper ring, while this constitutes a predisposing cause. But this same condition of dilatation may be congenital, and in animals with a predisposing conformation chronic hernia of the intermittent kind is of easy occurrence. Whatever may be their mode of formation, however, they are gen- erally of long standing, and readily diagnosticated by their positive and familiar characters. Chronic hernias are generally of larger dimensions than the acute, and when exclusively vaginal, filling the cavity of the scro- tum and forming a true oscheocele. If the laceration of the supe- rior opening of the canal has allowed the formation of a sac and of an adjunct tumor, in front and outside of the cord, the hernial tu- mor will then consist of two lobes, the smaller situated in the depth of the groin, under the ventral walls, and the larger occupying the scrotal sac. These hernial tumors are usually formed by the small intestines and the floating colon, in exceptional cases, by the pelvic curva- ture of the colon as well. They vary also in volume as well as in consistency, from an obvious cause ; enlarging after meals, to con- tract again when the abdomen is empty ; and again, giving various impressions under the hand, according as their contents are gas- eous, liquid or sohd. In the first condition, when the intestines are empty and the animal is at rest, the tumor is soft, supple, elas- tic and more or less reducible, but when the animal is in action it increases in bulk, and becomes more tense and elastic, and less easy of reduction. There is therefore a condition of intei-mittency in their character, which is due to the pecuUar conditions in which the animal may be placed. The form of these tumors corresponds HERNIA. 413 to that of the testicvJar sac in which they are contained, the in- guinal oscheocele being j)yriform, with its contracted portion resting in the groin. Vermicular movements of the intestines and borborygmus are symptoms easily detected in large hernias. The tumor of a chronic hernia is painless, or nearly so. Rectal examination furnishes evident indications of the jDOSsibility, and of the presence of the hernia by the degree of the dilatation of the ring and the size of the organ engaged in it. In such a case, the dila- tation may be so great, even notwithstanding the presence of the intestines, that the hands, placed respectively, one in the rectum and the other in the inguinal region, can be brought in such near proximity as to touch each other. All these symptoms, taken to- gether, or even isolated, are sufficiently characteristic to establish a positive diagnosis of simple chronic hernia. The serous exudation which necessarily exists in chronic hernia, may, when it is excessive, render the natvu-e of a hernial tumor more obscure, and give it the appearance of a case of true hydrocele, the serous sac in these cases being so full as to render it impossible to discover, either by sight or feeling, the presence of the intestines contained in it, even the elastic resistance of its walls being undetectable. But here a rectal exploration will help to solve the question ; and, again, by placing the animal in the dorsal position, the gravitation of the hquid into the abdomen will readily reveal the truth by leaving the intestine alone in the sac. Great caution is necessary in these doubtful cases, in which a misdirected stroke of the bistoury, thoughtlessly or accidently made, might prove certainly fatal, by incising the intestinal knuckle, which it really is, instead of simply opening the mere serous sac which it was supposed to be. The formation of a sarcocele may also render the diagnosis difficult. In these cases the testicle, considerably tumefied, rough on its siu'face, and hard and painful, is felt at the bottom of the sac, and thus conceals the character of the hernia. Still, with sarcocele hernia coexistent, the scrotal tumor acqviii'es an appearance and proportions differ- ent from those of its uncomi^licated state. In this last case, the testicle constitutes the principal mass, and the elongated cord, stretched by the weight of the organ, can be easily traced with the fingers quite up into the groin. If, on the contrary, both hernia 414 OPERATIONS ON THE DIGESTIVE APPARATUS. and sarcocele are present, the testicle is bosselated and hyper- tropbied, and the cord which sui)i:)orts it is surrounded by the protruding intestines, which form on the outside an elongated mass, of a consistency either puffy or perfectly elastic, according to the period of digestion. Intelligent rectal exploration will always reveal the presence of the intestine through the ring. When chronic inguinal hernia becomes complicated with acute inflammation of the displaced organ, the scrotal tumor becomes warm, painful, evenly tense and remittent, and assumes nearl}' all the characters of a phlegmonous tumor, that a strong tempta- tion is oflfered to open it with the bistouiy. But, if this is con- templated, it should be preceded by a rectal examination, carefiilly made, as the only means of avoiding a possible error of diagnosis whose consequences would be fatal. If the inflammation con- tinues to be localized, the intestine contracts adhesions with the walls of the sac, and the hernia becomes irreducible; but if, on the contrary, the phenomena of inflammation extend to the peri- toneum, an acute peritonitis is established, and the patient suc- cumbs in a few days. The obstruction or engorgement^ which is a possible complica- tion of chronic inguinal hernias, consists in the distension of the intestinal loop by the lodgment of alimentary masses of varying bulk which accumulate, and for the time being, occlude the intes- tinal tract. This complication may be recognized by the in- creased volume of the tumor, its greater weight, and the sensa- tion of a softish and puffy mass contained in it. It is often, how- ever, but a temporary trouble, the colics which attend it yielding easily to appropriate treatment, and the removal of fseces from the rectum by back-raking being often sufficient in itself to afford relief. But in exceptional cases, treatment fails ; the obstruction becomes persistent ; the faeces accumulate in the protruding in- testines ; the tumor is increased in bulk, and at length a period arrives when such a disproportion between the volume of the dis- tended intestine and the capacity of the opening through which it has passed is established, that all the conditions necessary for strangulation are fulfilled. This soon takes place and becomes evident by the exhibition of symptoms akin to those pertaining to its analogue of the recent or acute variety. There is, how- ever, a difference between the two forms in respect to the impor- tant matter of their comparative amenability to treatment, inas- HEKNIA. 415 mucli as while strangulation in the acute cases is only relieved with great difficulty, withou.t resorting to the operation of herni- otomy, it is not uncommon in those of a chronic character, also strangulated, to succeed by a careful exercise of the taxis, in dis- placing the alimentary mass which causes the obstruction, and thus forms one of the contributing conditions of the strangula- tion. It is only in case of failure in this endeavor that herniot- omy becomes admissible. A chronic inguinal hernia is always a serious ailment, though not necessarily incompatible with the Ufe and health, and even partial usefulness of the horse. It must, however, constitute a blemish which cannot fail largely to depreciate his commercial value, since it must always be liable to interfere with the efficient performance of his accustomed labor, besides keeping him in a state of greater or less exposure to complications and tendencies which are a constant soiu'ce and menace of danger to the valetu- dinarian animal. Operations for the relief of hernia are always attended with a certain gTa\'ity, even when they are of the simplest character of which they are capable, and if compUcations exist the danger must necessaiily be intensified and aggravated, even to the ex- tent of jeopardizing the hfe of the patient. In the excellent work of Peuch & Toussaint, speaking of the applications of treat- ment, they remark : "In animals less than fifteen months of age suflering with hernia, the expectant method is the proper indica- tion, since the lesion may disappear as the animal gets older and develops. Inguinal hernias of smaU size must be left alone, not interfering, while in that condition, with the work of the animal. The operation in chronic inguinal hernias, complicated with lacer- ation of the superior opening of the inguinal canal, and conse- quently with ventral hernia, is contra-indicated by the imminent danger of the occurrence of eventration during the operation, or when the clamj) is removed. When, however, the hernial tumor has assumed such enormous dimensions, that, like the udder of a cow, it hangs down to the hocks, there is no more contra-indica- tion, the animal being then useless - and yet some slight chances of success still remain. Hernias complicated with hydrocele, sar- eocele or obstruction, are cases calling for operation, and when the point of strangulation has been reached, the indication of immediate and urgent interference is imperative." 416 OPEKATIONS ON THE DIGESTIVE APPARATUS. To this we may add, with Bouley, that the operation is also indicated when the hernia is exclusively vaginal and of sufficient proportion to interfere with the locomotion of the patient. It is also indicated as a means of preventing its further development. The operation for chronic inguinal hernia identifies itself with that of castration with the use of the clamp, and by the process known as covered testicles, as it is by this alone that the accom- plishment of the ultimate purpose in the reduction of the hernia and release of the strangulation can be obtained. The instru- ments required are those needed in castration. The clamp, how- ever, requires to be of increased length and dimensions, and Fig. 389.— Straight and Curved Clamp, curved, in order to adapt itself to the parts. A broad cloth, such as a bed sheet, may prove useftil to receive and protect the intes- tines in case they should protrude too extensively. The animal is placed in the decubital position on his back, with the leg of the affected side maintained in abduction. Anes- thetics are generally used, especially when there are fears of com- plications, while, in fact, they ought never to be omitted. The operator then, with the convex bistoury, makes carefully, on the inferior border of the hernial sac, an antero-posterior incision, parallel to the median raphe of the scrotal region, cutting through the skin, the dartos and the first layer of the cellular tissue under- neath. He then with his hands tears the adhesions which exist between the dartos and the tunica erythroidea, in order to enucle- ate the hernial tumor in its entirety. This step is easily effected when the cellular tissue, which covers the fibrous coat, is not in- durated, but if that should be the case when adhesions exist, the HERNIA. 417 dissection should be carefully made with the knife until the ad- hesions are completely divided and the fibrous coat fully exposed. The reduction must then be attempted without opening the sac, and in the absence of any adhesions this is effected without diffi- culty, the inguinal opening being so large that, through the force of mere gravitation, the dorsal position in which the animal is placed is often sufficient in itself to cause the return of the intes- tines into the abdominal cavity, even the testicle and the hernial sac often following it in its inward movement. If the reduction does not take place in this manner, or in con- sequence of the position of the animal, the taxis, both scrotal and rectal, is then indicated to be performed in the same manner as for acute hernia. Difficulties in effecting this reduction may arise from three causes — either, first, the bulk of the mass repre- sented by the protruding intestines ; or second, its obstruction ; or third, the adhesions which it may have contracted with the walls of the sac or with the spermatic cord. To obviate the first difficulty, while the manipulations of the taxis, scrotal and rectal are simultaneously continued, it will be well to relieve the jDOsition of the animal, and instead of keep- ing him lying absolutely on his back, to allow him to turn shghtly, and to rest on the side opposite the hernia. In this way the mass wUl not be so heavy to manipulate, and will be in a better position to foUow the dependent dii-ection in which it must be pushed by the scrotal taxis, while at the same time, by the rectal manipulation, it can be more easily unfolded and drawn from the cavity in which it was imprisoned. But if, notwithstand- ing all these precautions, this difficulty in the reduction cannot be overcome, the indication of opening the sac still remains. The incision of the sac is performed as in cases of recent hernia, the bed-sheet already mentioned being held in readiness to receive the intestinal mass as it vvill be exposed. Then the animal being completely under the influence of ether, and in the dorsal position, an assistant grasps the edges of the sac and stretches them apart, funnel-wise, using both hands alternately, gradually pushes the intestines towards the hernial opening, an assistant at the same time slowly unfolding the mass and permit- ting it to sUde into the abdominal cavity. Rectal taxis may largely assist in this step of the operation. If the reduction is rendered impossible by the interposition of 418 OPERATIONS ON THE DIGESTIVE APPARATUS. obstructions, the first indication will be to evacuate the intestines by a methodical pressure which will displace the alimentary mass and return it toward the abdomen. The puncture made with the aspirator has proved very beneficial in these comphcations. The adhesions require the most careful dissection, especially when they are short, and when both the visceral and parietal layers of peritoneum are closely tmited. The separation must be done by a succession of short, limited incisions, at the expense of the thickness of the parietal layer. When strangulation of chronic hernia occurs, it is due not to want of room at the hernial ring, but to the enlarged bulk of the protruding organ, which constitutes the obstruction Conse- quently the indication for herniotomy is not present. On the contrary, as serious eventration is always to be feared, the only indication is the removal of the obstruction as already indicated. "When the reduction has been completed, the occlusion of the vaginal sac is to be obtained by the application of the clamp, applied as high up as possible, as in cases of strangulated acute hernia. In cases of inguinal, complicated with ventral hernia, attempts at reduction may be made by placing a long clamp over the cov- erings of the latter, involving with them the hernial sac and its cutaneous envelope, as practiced in some cases of the umbiHcal form. We need but briefiy to refer to certain different modes of treat- ment of the various forms of hernia by the use of bandages, rec- ommended by Petard, Grau, Klinger and Marlot, together with the application of sutures upon the edges of the inguinal canal, patronized by Hertwig and Dieterichs, to say that none of these, any more than some others, borrowed from human surgery, can give more satisfactory results, or be employed with greater safety, and effect a radical cure better than the use of the clamp and the castration by the process of the covered testicle. Inguinal Hernia in Geldings. Although inguinal hernia in the gelding is certainly less com- mon than in the stallion, it is not, therefore, of impossible occur- rence. But from the fact of its rare appearance it is far more likely to be overlooked, and therefore neglected, with similar fatal HERNIA. 419 results to those in tlie stallion, when it reaches the stage of sti'angulation. From the fact that, as the result of castration, the superior opening of the testicular sheath is more or less closed, it becomes a matter of rational inference, that hernia in a gelding is not of posterior occurrence to castration, but that its existence is due to a congenital disposition, and that by the operation of gelding they have been reduced to their smallest proportions, in relation to the dimensions of the intra- vaginal sac, to the dimensions, in fact, of a bubonocele, which continues unobserved in consequence of the smallness of its size, and the depth of its location. These hernias are detected outwardly by a physical symj)tom, to wit, the existence in the inguinal region, on either side of the penis, and above the cicatrix of castration, of a ttmior about the size of an egg, soft, depressible, altogether painless, sometimes elastic and at times puffy. It varies much in size, diminishing with rest and quiet, and increasing with effort and active move- ment. It may, in fact, under the first condition, entirely disap- pear, to return as soon as the animal is put to work. In a word, it has the true character of being intei*mittent. Aside from these symptoms, rectal exploration furnishes positive data of its exist- ence, by the abnormal dilatation of the ring, easily detected, and by the pressure of the intestines lodged in it. This hernia is also susceptible of strangulation, and is then ac- companied by violent abdominal pains, which must not be ignored as to theu' possible diagnosis and significance. The indication for careful examination in that direction must, indeed, never be overlooked in cases of violent coHcs in geldings. If these colics are due to strangulated hernias, the presence of a round, tense, resistant and painfull tumor will be detected in either of the in- guinal regions, and, according to Bouley, more commonly on the left than on the right side. The strangulation in this class of hernia is generally irreducible, and becomes rapidly fatal ; if not reheved immediately, it is not reheved at aU. The first indication of treatment is the reduction of the hernia by simple, external taxis, or by combining with it the rectal taxis. The reduction will be followed by the disappearance of all the symptoms, and the animal will be apparently well, until a second attack takes place. After the reduction, steps must be taken to prevent its return, by an operation similar to one of those used ia 420 OPERATIONS ON THE DIGESTIVE APPARATUS. umbilical hernia, to obtain tbe reduction and retention of tiie in- testine, by the application of a proper clamp upon the sac cov- ered by the scrotal skin. The treatment of the gelding for strangulated hernia does not differ from that of the staUion. Ordinarily, the taxis is sufficient to reduce such compHcated hernia, but in case of failure in obtain- ing rapid success one must be careful not to carry on the manipu- lations so long as to encounter the risk of lacerating or tearing the tissues. The wiser and safer plan will then be to have recourse to the operation of herniotomy, an operation which should be performed with the greatest care in separating and dividing the existing cicatricial adhesions of castration. The clamp is after- wards placed upon the hernial sac, with its cutaneous covering, requiring a longer time to slough, and constituting a means of retention most favorable to the success of the operation. Crural Hernia, or merocele, is that form of rupture in which the abdominal organs make their escape through the crural ring. It is a rare affection among our domestic animals, but has been seen by La- fosse, Jr., in the horse, by Girard, Jr., in the dog, by Dandrieu in cows, and by Hertwig in horses, donkeys and dogs. It is said to be more frequent in males than females. It results from violent muscular efforts, and especially from the slipping apart of the legs when already separated or straddling in abduction. It is char- acterized by a somewhat well defined tumor, of moderate size, situated behind the inguinal ring, towards the middle of the flat part of the thigh. When the rupture is recent, the animal is some- what stiff in his gait, especially on the affected side, and carries his leg in abduction. There is also a degree of lameness. Accord- ing to Hertwig, the tumor is easily reduced, and not very painful. In a few cases it may be complicated with strangulation. The organs which have been found in the sac have been portions of the small intestines ; the omentum, as reported by Hertwig, and the bladder, in one cow, according to Dandrieu. The prognosis in cases which receive early attention, is not serious. The treatment consists in reducing the rupture, and afterwards closing the passage through which it occurred. This is effected by making an incision through the skin over the tumor, and closing HERNIA. 421 the ring with a few stitches upon Poupart's ligament and the small adductor of the leg. A good bHster rubbed over the enlargement completes the treatment. According to Zundel, three weeks of subsequent rest are required to assure recovery. Perineal Hernia. This is a very rare lesion and, as Zundel describes it, is the pas- sage of the peritoneum and viscera through the vasculo-aponeur- otic floor of the bottom of the pelvis. It is, however, reported to be common in dogs, in which animal it is situated between the ischium, the sacrum, the anus and the lu-ethra, and is often mistaken for an abscess. It is more frequently formed by the bladder than by the intestines. Pancreatic Hernia. This hernia was first observed by Prinz, and afterwards noticed by Husson, Eoell, and others. It is caused by the strangulation of the jejunum and the anterior part of the ileum through the hiatus of Winslow, the orifice above the right angle of the pan- creas, and of the vena cava, in front of the right kidney. It is accompanied by symptoms of intestinal congestion, and cannot be reached by any form of treatment, if indeed it can be accurately diagnosed during life. Pelvic, or Internal Hernia of Oxen. This form of hernia is principally described by Zundel, from whom we extract the following : " It is the strangulation of a loop of intestines, which has pushed through the ruptured peritoneum, from before backward, between the testicular cord and the lateral wall of the pelvis, the rupture of the peritoneum having resolved during some of the manipulations of castration from excessive stretching of the cord, as in the operation by tearing. It is, there- fore, exclusively a lesion of the ox, and cannot affect the biiU. It is quite common in Germany, and has been met with in England, Mecklenburg and Alsace. It was first described by Oesterten, in 1811, followed by Anker in 1824, and later by Zundel, Ostertag and Tues. It is comparatively often seen, and in many cases over- looked. The first intimation of the presence of the disease appears in the onset of symptoms of a violent attack of coUc. The animal becomes anxious and restless, lies down hastily and rises again 422 OPEEATIONS ON THE DIGESTIVE APPARATUS. suddenly ; turns about, moves to and fro, lashes with his tail, and, in'a word, betrays all the usual signs of intense suffering, and it becomes difficult, if not dangerous, to approach him in order to make a proper examination. The temperature of the body is ele- vated, there is some perspiration, the nose is hot, though still moist ; both respiration and circulation are accelerated. The ani- mal refuses food or drink, rumination is suspended, and though defecation has not ceased, the fseces are hard, blackish and coated. In from six to twelve hours, this state of febrile excitement subsides, and the animal becomes dull and quiet, gazing towards its flanks, the ears dropping, the hind leg coiTesponding to the side of the hernia is extended backward, and at the same time the lumbar region is relaxed downward. If the animal is lying down he may remain quiet for a while, with his hind leg stiU extended, but will presently spring to his feet with his back arched as before, at the lumbar region, but which drops agaia and straightens im- mediately. When he walks it is with a stiff action, principally towards the diseased side ; the extremities are cool, the pulse is small and insensible, respiration is accelerated ; constij)ation at length becomes complete with mucous and bloody passages, jDer- haps accompanied with flatulence, but micturition is still easy. Two or three days later there are other changes. The period of calm terminates, and is succeeded by a season of alternating agitation and repose — action and reaction of the fluctuating in- flammatory process. The animal now and then utters grunts of pain, his pulse be- comes smaller, and is at length imj)erceptible, and all the un- favorable manifestations are exaggerated. Either gangrene has supei'vened, or, as some would judge, enteritis, and all the symp- toms point towards the more fatal termination. It is only by rectal examination that the diagnosis can be j)osi- tively established, and when this has been carefully and success- fully made, he will have discovered what may be thus described : a puffy mass, indefinite as to size, situated usually nearer the sacrum than the pubis, on the side of which, generally the right, a portion of the intestines has sHpped under the testicular cord — this being the definition of a crural hernia. It may be a simple protrusion of the intestine, and again, this maybe twisted around the spermatic cord, a condition particularly likely to terminate in strangulation. HERNIA. 423 This lesion may continue as long as nine days, four to five being the average duration, and it may terminate by spontaneous reduction, but the trustful surgeon vyho too confidently and too often expects to find that Nature has dispensed with his aid in this kindly way, is doomed to encounter many disappointments. Or it may end in gangrene or enteritis. The fact that the disease, if not interfered with, may terminate fatally in so brief a period as five days, of course renders the prognosis quite a serious one, unless the nature of the ailment has had an early identification and measures have been taken to avert the danger. The gravity of the prospect is, of course, in- creased when the compUcation with strangulation or enteritis, as before mentioned, enters into the case. The treatment, as in other cases, consists in the reduction of the hernia. With a small proportion of patients this may be efiected by the simple act of causing the animal to walk down a steep declivity — a sort of spontaneous, or semi-spontaneous cure, from which, although founded on anatomical principles, too much must not be confidently expected. We coj^y from Zundel his de- scription of other and more scientific methods : {a) Reduction by Simple Taxis. — The animal is placed on an incHned plane, with his hind-quarters raised, and an assistant on one side of him ready, at a given moment, to press on the loins. The operator, with his hand in the rectum, searches for the in- testinal loop, and when he has found it, holding it in the bottom of his hand, he feels for the opening under the spermatic cord, which he dilates with his fingers, and now, while the assistant presses hard on the loins, as just mentioned, the intestine may be readily felt moving downward and forward under the cord, to resume its normal position. Although simple, and, in the ma- jority of cases, successful, this mode has the defect of leaving the animal exposed to a return of the hernia. {b) Reduction by Laceration of the Cord through the Rectum. : — This method is recommended by Metzger, Eisele, Schenck, Gierer and Ostertag. It consists in tearing away the adhesions formed by the stump of the cord after castration, and loosening it from the inguinal ring. It is, however, difficult to do, and not without danger. The hand being introduced into the rectum, and the opening found, the fingers are closed in the form of a wedge, and with a slight movement of rotation pushed through 424 OPEEATIONS ON THE DIGESTIVE APPAKATUS. the opening, and tlie cord thus separated from its adhesions. After a while, the pressure, which was quite firm at first, dimin- ishes, and the intestine gradually returns to its position. This mode is slow in its steps, but it is successful in its results, even in cases of obstruction and of strangulation. When it fails, it is because of the strength of the adhesions between the cord and the abdominal walls, or the inguinal canal. (c) Division of the Stricture through the Rectum. — To per- form this operation, invented by Schmidt, a trocar about sixty- five centimeters (some thirty-five inches) long is necessary. This trocar has its point attached with a screw, in order to permit its removal and the substitution of a blunt bistoury. "With the left hand in the rectum, a fold of that intestine is secured a little be- hind the point of stricture, and the trocar pushed through it. The stylet of the instrument being then withdrawn, leaving the canula in place, the point of the trocar for the bistoury is then inserted, while the hand, still in the rectum, leaves the rectal fold loose, feels for the spermatic cord, raises it and guides the bis- toury against it, which with comparative ease completes the di- vision of the stricture. {d) Division of the Stricture after Incision of the Flank. — Through an incision made in the middle of the right flank, the hand is introduced and grasps the spermatic cord, which is then divided with a bistoury cache, or, which is better, mth the inside edge of a hook kept sharp, similar to the hook used in some cases Fig. 390.— Sharp Hook for the Section of the Testicular Cord. of distokia. The hernia being reduced, and the wound in the flank brought together with sutures, a circular bandage is apphed around the abdomen. With the reduction of the hernia, what- ever may have been the means of accompUshing it, the symptoms subside, and the treatment is completed by the administration of laxatives or sedatives, rectal injections, etc., as tke indications may require. 425 Umbilical Hernia. Umbilical hernia is the protrusion through the non-obhter- ated umbilical ring of either the omentum or the small intestine, or both. It is also known as an exomphalus or omphalocele. It receives the name of enter omphalus or epiplomphalus when formed by the displacement of the intestines, or that of the omentum separately, and when both of those organs are implicated it be- comes an entero-epiploniphalus. UmbiUcal hernia is quite com- mon in horses and dogs, not less so in bovines, and has been no- ticed in swine and sheep. It is most common in young animals, especially soon after birth, is at times congenital, and may be long continued, even to adult age, or for eight, ten or twelve years. Umbilical hernias are either congenital or accidental. The former are formed during foetal life and continue at birth, al- though, according to some authors, they are, strictly, not so much congenital as accidental, and are, in fact, the result of the pulling and stretching of the umbilical cord during the act of de- livery. However this may be, they do usually, in fact, make their appearance during the second and third months following birth, when through the persistency of the opening, and the imperfec- tion of the umbiHcal cicatrix, the intestines are enabled to pro- trude through the ring, and subsequently to prevent its closing by their presence. But again, while the cicatrix is weak, the ac- tive exercise and forcible movements of the young animal while at play may cause the rupture ; and still, again, the protrusion may be caused by intestinal derangements. Indeed, all traumatic causes, such as contusions, blows, and any violent efforts taking place diu:ing the period of consolidation of the closing cicatricial tissue, may become an originating cause of this lesion. Animals of low and lymphatic constitution are much predisposed to this. trouble, especially such as feeble colts, born of mares badly cared for and insufficiently fed during gestation. Heredity fills a large place among the predisposing causes in low-conditioned mares with feeble organizations, and suffering with similar trouble when young, dams of this class naturally bringing forth foals of defective stam- ina, liable to perpetuate the same constitutional tendencies. The symptoms of umbilical hernia are generally exclusively local. It is characterized by a semi-globular or pyriform tumor situated on the median Hne of the abdomen at the umbilical ring, 426 OPERATIONS ON THE DIGESTIVE APPARATUS. and varying in dimensions from the size of a lien's egg to that of a child's head — dimensions which may vary according to the con- dition of vacuity or fullness of the intestine ; the position of the animal, whether standing or lying, or according to the length of time it may have existed. The consistency of the tumor is very variable. It may be soft, easily dejjressed by the finger ; elastic, when distended with gases ; or soft and puffy when containing alimentary matter — these changes being accounted for by the na- ture of the organ. An enteromphalus will give the sensation of an elastic mass, while the epiplomphalus will form a puffy swell- ing. This species of hernia is almost always painless, and exhib- its as one of its peculiar and constant symptoms the character of being reducible. In the generality of cases, it can be made to disappear temporarily by the taxis and by forcing the protruding portion back into the abdomen, but only to reappear at once as soon as the pressure is withdrawn, especially if the animal is on his feet. On being thus reduced, the oj^ening of the ring can readily be detected, and the fingers may be freely introduced through its diameter and its form and dimensions ascertained shewing it to be sometimes eUiptic, sometimes circular, and some- times irregular, the originating cause of the hernia itself deter- mining the difference. Besides these more common symptoms of umbihcal hernia, there are others which can be detected by more careful examina- tion. For instance, on applying the hand over the tumor, the ver- micular motions of the intestines may be recognized, and by feel- ing in the hernial sac, the presence of fpecal masses may be discov- ered ; and it may be possible by auscultation even to detect the presence of borborygmus through the displaced intestines, and even to observe its true nature, by reason of the transparency of ■ the sac and its envelopes. These are the most ordinary symp- toms of an exomphalus, although it is subject to complications, and the sjonptomology will vary accordingly. There are cases, but they are rare, in which the hernia be- comes irreducible. The most serious of these are such as are found to have become so in consequence of the formation of ad- hesions between the protruding organ and the hernial sac — a very infrequent occurrence. The most common cause will be the pres- ence of undigested masses of food accumulated in the intestines, such as hard balls of faeces or sand. HERNIA. 427 Inflammation of umbilical hernia may follow blows or bruises, though such a result from these accidents is not a common one, and its occiu'rence will naturally be accompanied with changes in the appearance of the tumor, such as the usual phenomena attending inflammatory action, as increase of temperature, ten- derness or pain, oedema, etc., which may even at times so com- bine theu' effects as to render the hernia irreducible. Engorge- ments and strangulations, however, are very rare comphcations of this form of hernia, a fact easily understood when it is con- sidered that the neck of the hernial sac is formed by the umbiHcal ring itself. An exomphalus is usually an affection of Httle gravity, and often disappears spontaneously, or if it joersists after the period of weaning, is easily radically cured when the animal grows and develops. Yet even if undisturbed and unchanged, they persist in remaining, their existence is not incompatible with perfect health and full ability to labor, however they may reduce the com- mercial value of the animal. They are less injurious to young animals than to adults, and less dangerous when small than when assuming large dimensions. When simple, they are easily amen- able to treatment, but if compHcated they become dangerous, es- pecially so when the capacity of the ring is so disproportioned to the dimensions of the protruding intestines that strangulation be- comes an accident of easy occurrence Reducible hernia is at- tended with but little hazard, while the danger arising from the possible formation of adhesions in cases which have passed into the irreducible class becomes a matter of very serious import. If it is an admitted fact that animals suffering with umbilical hernia do often recover spontaneously, the recovery being a normal incident of the natural development of the animal, due to changes of position in the abdominal contents, not to specify other effi- cient causes ; then the question of immediate or early interfer- ence undoubtedly receives and justifies a negative answer. Our own testimony is that we know of cases where patient waiting, even for a period of twelve months, has been rewarded by the radical disappearance of the hernia. But the objections to such long waiting are of a tangible and serious nature, and siu'gical interference becomes imperative and indispensable. The persons are few who are able or wiUing to nurse an idle horse for a year for the sake of saving him from the pain of an operation. 428 OPERATIONS ON THE DIGESTIVE APPARATUS. The object of all treatment is, of course, the reduction and re- tention of the hernia, but the means of doing so are various. They are mainly included under four heads. The first method is by bandages ; the second, by external or topical ajypUcations / the third, by surgical operatio?is for the cotistriction of the tumor ; and the fourth, such special treatment as may be required to meet comjMcations. 1st. Bandages. — The bandage of retention is essentially a belt buckled around the body, by which a pad is kept over the open- ing of the umbilicus to prevent the escape of the abdominal con- tents, and temporarily perform their office in the subcutaneous hernial sac. It is designed to aid in the mechanical closing of the umbilical opening until that takes place by the process of physio- logical change in the sac and its borders. The forms of bandage in use are many and various, among which Peuch and Toussaint name four principal kinds. A most import- ant requisite in all of them is that while they possess the solidity and fixity necessary to retain the reduced hernia in place, they shall cause the minimum amount of discomfort to the patient. The bandage of Marlot, according to Zundel, is the one which best fulfills the three conditions of solidity, fixity and elasticity. It consists of a kind of padded saddle, with strajps at its four corners, buckling on two belts, the anterior or pectoral., which sur- rounds the chest like a girth, and the posterior or ventral., which presses the retaining pad against the umbilicy. This pad is a wide hair cushion of a moderate thickness, kept in place and pre- vented from sHpping back by a longitudinal girth connecting the pectoral and the ventral belts. The bandage of Massicra is much recommended in Italy. This also is a small saddle with two wide girths passing under the thorax, and pressing against the sternum and the epigastric re- gion, with a steel band corresponding at its posterior extremity with the umbilical ring, forming a plate padded with a hair cushion. The apparatus of Strauss, used in Germany, is made somewhat on the same principle, but is reinforced by a kind of breeches which prevents it from slipping backward. The length of time necessary for a patient to wear a bandage will vary with the dimensions of the hernia — from one to three months, according to Lafosse, being required to obtain a radical cure. Marlot claims that an average of thirty-two "days is all that HERNIA. 429 is necessary. The bandages must be apj)lied only after the perfect reduction of the hernia, and the most acciu'ate adaptation of the pad to the umbihcal opening. These appHances are of difiiciilt adjustment and are unavoidably uncomfortable to the animal from their liability to chafe and excoriate the skin. They, therefore, constitute a mode of treatment which must necessarily be attended with uncertainty, and, therefore, as justifying only a careful and modified recommendation. Still, it has in the hands of many prac- titioners given very satisfactory results. 2d. Local Applications. — The treatment by irritating local med- ication aims to produce in the tissues surrounding the hernial sac an inflammation which will end in a serous infiltration which wiU crowd away the protruding organ, prevent its return into the open- ing, and subsequently facihtate the obhteration of both the sac and the ring. This result is obtained by the use of certain chem- ical agents, which applied on the hernial tumor tend to produce various degrees of inflammation, from simple rubefaction to com- plete escharification of tissues. In former times sulphuric acid was recommended, and as late as 1833, Hertwig employed it in appli- cations made during two or three days. BHsters and their con- geners have had their day. Astringents have also been recom- mended, as also caustics, principally in the form of ointments, as that of chromate of potash, in the proportion of one part in eight, as recommended by Foelen — these also have had then- advocates. But of all these, nitric acid, applied externally, is the one which has proved most satisfactory and least dangerous. The treatment consists in applying acid upon the tumor of the exomphalus, in sufiicient quantity to produce an escharotic effect, and afterwards promote the sloughing of the cutaneous sac. The mode is thus described : After positive diagnosis of the nature and character of the tumor, the animal being kept in the standing posture, the hairs cut short, the acid is appHed over the entire sur- face of the sac, by rubbing it in with a brush, or a small ball of oakum secured at the end of a stick, and dipped into the acid — which should register 34" to 36° Baume — first passing it circularly over the base of the examphalus to define the place where its action is requii-ed, and then including the entire surface. A sufficient quantity of the caustic must be applied, and with enough energy to produce the disorganization of the skin in its entire thickness, and positively produce its mortification. Experience has proved 430 OPERATIONS ON THE DIGESTIVE APPAEATUS. that the deeper the action of the caustic, the more successful the operation is likely to be. It is said that nearly one ounce of the acid is required for a tumor as large as a man's fist, and that the friction should be continued from three to five minutes. The duration of the friction and the quantity of the acid to be used must, however, be guaged by the dimensions of the tumor, and also with careful consideration of the thickness of the skin, Dayot, to whom is due the positive and practical introduction of this mode of treatment, proposes to apply the acid in instalments, and recom- mends that the apphcation be repeated once or twice an hour, according to the thickness of the skin, until the desired effect is assured. The result of our own experience is a conviction that as a rule only a single apphcation is necessary. Nitric cauterization produces a yellow eschar, which ordinarily remains for a long time, soft, supple, and unctuous to the touch, but the epidermis of which is easily lacerated. In some cases the formation of the eschar is followed by a large swelling of the cauterized parts and the sur- rounding tissues. Sometimes it makes its appearance immediately following the operation, but more commonly it appears at a later period, gradually increasing during the first hours following the cautery, although again, in other cases, this swelling is altogether absent The oedema is the direct effect of the action of the caustic upon the subcutaneous cellular tissue, which becomes infiltrated ; and in this condition apphes a uniform pressure in all directions upon the peritoneal hernial sac, crowding back into the abdominal cavity the displaced intestines and preventing their return by the kind of retentive bandage which is formed by the engorgement which takes place around the sac. In the days following, after reaching the maximum develop- ment, the oedema gradually diminishes by resorption, becoming at the same time somewhat harder, the portions of cauterized skin which is in its center meanwhile gradually drying, and becoming transformed into a dry, hard plate. In place of the hernia there now remains a fibrous mass of new formation, which gradually diminishes and is soon more or less resorbed. In the meantime, while these phenomena are taking place, the process of the separation of the eschar has begun and progressed, and on the eighth day, on the boundary between the dead and the living structures, a fissure shows itself, and minute granulations appear. The separation goes on slowly, from the HERNIA. 431 circumference to the center, leaving, when complete, a rose siu'f ace, granulating evenly, small fibrous formations sometimes appearing in its center. This wound heals rapidly, lea'sang a contracted cicatrix, which assists in keeping the hernia in its place, while the indurated skin, which for some time remains adherent to the still fibrous, abdominal, subcutaneous tissue, contributes to the com- plete obHteration of the ring. After a month the cure is radical, and in place of the hernia, there remains only a hairless cicatrix, often without pigment. Though this treatment is simple, and has, by the resiilts it has shown, justified the credit it enjoys among those who have had experience and knowledge of its working, it must not be at once accepted as infallible, or unattended with danger. Cases are on record which negative such a claim. For instance, too severe a cauterization may be followed by the entire sloughing of some portion of the abdominal walls, followed by a large eventration ; and peritonitis, tetanus and intestinal fistulse are comphcations which have sometimes disappointed hopes which seemed to be well founded. Animals to which this treatment has been applied must be carefuUy watched for some time during the period following the cauterization. They must be especially prevented from indulging the tendency they often betray — to bite, or scratch vrith their feet or legs, the irritated, cauterized surface. A cradle or aprons hanging in front of their hind legs, or even bandages may prove effectual to prevent this suicidal habit. The topical remedies we have mentioned before, might in strictness be considered as coming under the head of external treatment, since they have all been appHed to the surface of the skin. There is, howevor another mode of application which is subcutaneous, and which is represented by the method of Dr. Luton, and employed in the treatment of the same ailment in childi-en. It consists in injecting subcutaneously, at each cardinal points of the hernial sac, a few drops of a saturated solution of chlorides of sodium (kitchen salt). We have had but one oppor- tunity to try the value of this treatment, which we improved by injecting ten drops of this solution at each point of a hernial tumor. We produced an enormous swelling, followed after several weeks by resorption and complete disappearance of the hernia. According to Peuch and Toussaint, our friend M. Cagny has 432 OPERATIONS ON THE DIGESTIVE APPARATUS. made the same experiment, but failed to obtain a successful result. 3d. Surgical Operations for the Constriction of the Tumor. — Modes of surgical treatment are numerous, usually having in view the destruction of the hernial sac, by the process of mortification, so controlled and directed as to bring about the necessary work of adhesion between the walls of the sac, above the line where the mortification begins, with the formation of a secondary cicatriza- tion between the edges of the skin, where the mortified sac has dropped off. Before casting the animal, without which the operation cannot be performed, the surgeon must satisfy himself that the hernia is reducible, and that there is no adhesion, and should carefully measure the dimensions of the sac in order to know accurately where the constriction must be applied. The animal must be placed well on his back, with his hind quarters elevated — a posi- tion which is sometimes sufficient alone to enable the hernia to reduce itself. If that fails to occur, the sac can be evacuated by the taxis. It is then to be weU stretched, and the application of the means of constriction proceeded with. These means are many, but may be considered under the three heads of the ligature, the clamp and the suture — all of which are occasionally combined in use, as the Hgature with the suture, or the suture with the clamp. (a) The Ligature. — This old mode of operation consists in the application — the hernia having been reduced — of a strong cord, firmly tied at the base of the hernial pouch. The modus operandi is very simple. The hernia being already reduced, either by the taxis or by the j)ower of gravitation, as before mentioned, and the horse in the right position, on his back, the sac is raised from the abdomen, and a strong ligature, firmly tightened, is apphed at its base, a strong fishing Hne forming the best of ligature for this purpose. The degree of tightness of the ligature must be such that the mortification of the sac will be a gradual process, and that it does not slip from the walls of the sac, on account of the progress of the inflammatory swelling. Still this constriction must not be permitted to become so ex- treme as to produce too rapid a sloughing of the skin, with the possible result of a calamitous eventration. In order to prevent the displacement of the ligature, some HEBNIA. 433 practitioners recommend the introduction of two small wooden pins just under it, either parallel or crossing each other, through the base of the sac. If the hernia is very large, instead of employing this mode of simple Ugature, en masse, the operator may use two ligatures. By pushing through the middle of the sac, close to the abdomen, a dog seton-needle, carrying a doubled cord, and converting it into two parts in cutting it from the needle, each length will serve to embrace half of the tumor, in the manner practiced in the pro- cess of removing large, hard tumors by ligature. Legoff has rec- ommended the use of several ligatures dipped into ammonia, placed one above the other upon the whole length of the sac, from its bottom to its base, tightening them more and more as they ap- proach the abdomen. By this process he combined constriction with cauterization. This mode of treating umbilical hernia is a simple and easy one, but yet it is not very frequently practiced. The uncertainty of its results, the possibility of the sloughing of the skin at too early a period, with the danger of eventration, as well as that of injuring the intestines with the wooden pins or the needle, have all combined to impair its credit and discourage its use among care- ful operators. (b) Clamp. — In this process, which dispenses with the caustic, after the reduction of the hernia, the skin is stretched and pressed between the branches of a wooden clamp or of a specially adapted forceps. The clamp is a simple implement, and may be made with a CTirve, in which case its convexity is made to adapt itself to that of the abdomen. When appUed, it is pressed close to the abdom- inal walls, and its branches brought together with nippers adhoc, and secured with a strong cord, as in the process of castration. The clamp is left on from nine to fifteen days. In many cases, the displacement of the instrument is prevented by using the wooden or metaUic pins passed through the skin below it, the ends of the latter being bent over to keep them in place. This operation possesses some great advantages, but offers also some special dangers, among which is the instinctive tendency of the patient to get rid of the irritating appliance by tearing it off. Another objection to the clamp is found in the danger of caus- ing troublesome excoriations of the sheath by the friction which it necessarily occasions. Benkert and Brogniez have advocated 434 OPEEATIOKS OX THE DIGESTIVE APPAKATUS. the use of metallic clamps, but an important objection is found in their weight. Borhauer had the branches of the wooden clamp perforated in several places for the introduction of the pins which held it in place. Bordonnat has invented a special form of me- tallic clamp- or rather forceps, with sharp points on the inner bor- FiG. 391.— Clamp of Bordonnat. der of one of its branches about one-half or three-quarters of an inch apart, and in the other a corresponding number of holes into which the points are designed to fit when the instrument is closed. Each branch has a prolongation at each end, which on one carries a vertical projection cut with a screw-thread, while in the other there are holes corresponding with the projections, and there are nuts to fit the screws. When the instrument is apphed, and the projections passed through the holes, the nuts not only hold it in place, but are adapted to fix the pressure at any desired point, or change it at pleasure. The umbilical forceps of Marlot is made of two small wooden plates, slightly curved lengthwise, and brought together by means of gooves in their dove-tailed extremi- ties, through which screws are fastened. This instrument, like the metallic clamps, is objectionable principally on account of its weight, and is generally less practical than the ordinary clamp. (c) Sutures. — These are of various kinds, aU agreeing, how- ever, that the stitches upon which they rely shall be so close and tight that the circulation will be so effectually cut off in every part of the hernial sac that mortification cannot fail to follow. The Quilled Suture. — This consists in placing the sac between two small rods of hard wood or metal, and tying them before and behind with strong cord tvnsted and rolled around their extremi- ties, and also by passing here and there in their length sutures of double the strength of those which are apphed in cases of ordi- nary quiUed suture. Acting somewhat by pressure, this mode much resembles the treatment by the clamp, but is Httle used at present, notwithstanding some small advantages which it may be thought to possess. HEKNIA. 435 Twisted Sutures. — This consists in applying upon the hernial sac several stitches of strong cord in order to keep the reduced hernia in statu quo. It is sometimes used in dogs, but is uncer- tain and dangerous. Suture of Delavigne. — This is another dangerous mode of operation, no longer in practice because of the hazard of injury to the intestines. It consists in applying a strong double suture at the base of the sac in the following manner : With a small needle, like that used by harness makers in sewing leather, a thread is passed through and through on both sides of the flat, cutaneous surface from right to left, or vice versa, then carried back the re- verse way at a small distance from the first puncture, and the sutures firmly tied. This is repeated until the entire sac is in- cluded and the sutures have gone beyond the umbilicus. From fifteen to twenty days are said to be sufficient to effect a radical cure. Method of Mangot. — To make a closing suture on the hernial sac, without danger to the intestine, Mangot has recommended the use of a perforated plate of lead, by which to aid in the reten- tion of the intestines in place and accurately define the line upon which the sutures are to be applied. The plate is made to cor- respond in dimensions with the opening of the umbilical ring, but somewhat longer and wider. Besides the longitudinal slit in its center, it also has an eye at each corner for the attachment of strings to secure it in place by tying them over the back. The hernia being reduced, and the plate put in place by pushing the skin of the sac through its longitudinal opening, the operator ap- plies a continued suture over and on the outside of the plate to keep it in position, with the flap of sewed skin hanging below it, the entire apparatus being securely attached to the abdominal walls by two pins running through the sac at the extremities of the suture. During the first days there is much inflammation. About the third or fifth day the pins are removed and the skin below the su- ture excised, leaving the plate to be retained only by the strings which pass over the back. These are sufficient, however, to keep it in place, and its removal will not be necessary until inflamma- tion is well estabhshed all around them. A simple dressing, held in place by a bandage, will help the cicatrization, which is said to take place in from seven to eight days. 43G OPERATIONS ON THE DIGESTIVE APPARATUS. Method of Ilannon. — The modus operandi here indicated does not vary from that of Mangot, except in being modified by the use of the quilled su- ture, as before described, instead of employing the transversal pins of Man- got. Method of Mignon. — This is a com- plex mode, consisting of a combination of the ligature, the clamp and the suture. Like Mangot, he passes the skin through a plate of lead, attaches perforated clamps on the protruding sac below it, and pass- es the stitches or sutures through the perforations in the clamps. Method of Benard. — This is strictly speaking, the application of the crossed suture, a stitch exactly resembling that of harness and shoemakers in their re- spective trades. In making it, a peculiar forceps is used, which is apphed like a clamp, and serves not only to keep the sac closed and secured, but also to pre- vent the return of the intestines into its cavity, and to assist in guiding the two needles with which the suture is made. Its branches are at one end articulated together, and also at the other in order to fit into handles. It is twenty-two cen- timeters in length, without including the handles ; two centimeters in height, and one and a half in thickness. The branch- es are brought together tightly by a spe- cial screw arrangement near the handles, and each has a number of holes, placed regularly, one centimeter apart, and uni- ted by a groove. Two strong straight needles and strong waxed thread are re- quired. In operating, the hernia being first reduced, the skin is well stretched fig. 392. -Nippers of Benard 487 between the brandies of the forceps, then these are tightened by the screw management of the handles, and next the instrument is committed to the care of an assistant. The crossed suture is then made by the simultaneous passage of the needles through the holes in the branches of the instrument. The directions to insert the needles simultaneously must not be overlooked. If disregarded, the penalty hable to follow will be the tearing of the waxed thread with the points of the instrument, and also a tang- ling of the thread. This method gives a stronger Hgature than Mangot's, but it lacks the support furnished by the metaUic plate. Method of Marlot. — The methods of Benard and Mangot are here combined. A pecuhar thin forceps is used having dotted grooves on its outer siu-face to indicate where the stitches are to Pig. 393.— Plate and Nippers of Marlow. be placed. When the suture is finished and the forceps removed a plate of zinc like that of Mangot is appUed, as a means of reten- tion, the zinc plate being thought to be an improvement upon that of lead, on account of its adapting itself better to the parts. Method of Chedhomme. — The animal in this method is kept on his feet, jproperly secured, and a plate of lead applied, as in the process of Mangot. The hernial sac, folded in two on its longitu- dinal axis is then passed through the opening of the plate, the operator making the least possible traction until the remaining por- tion of the umbiHcal cord, which is still quite large, is firmly held between the thumb and the index finger of the right hand. Then a stronger traction is made uj)on the sac, at the same time moving it in various directions, while w^th the left hand the plate is strongly pressed towards the abdominal walls. Then with the intestines entirely replaced, the operator grasps the sac with the 438 OPERATIONS ON THE DIGESTIVE APPARATUS. left hand, and with the right, introduces a strong needle which is pushed through and through at each extremity of the sac, and an elastic Hgature passed three or four times around its base. Towards the tenth day the slough is completed, and only a small wound remains, which cicatrizes rapidly. Direct Suture of the umbilical ring. — Director Degive recom- mends for the treatment of umbilical hernia in young dogs, the direct interrupted sutures of the ring, the number of stitches varying with its dimensions. After bringing the threads together the wound is left open until they have safely eliminated themselves. We have employed this mode of operation for many years in the hospital of the American Veterinary College, using antiseptic pre- cautions, and with the best results. Making a longitudinal line on the median line of the sac, and having carefully pushed back the intestines, the edges of the ring are sewed together with two or three stitches of cat gut ligature. The parts were then thor- oughly washed with a solution of bichloride of mercury, and the edges of the skin brought together with silk sutures and a com- pressing bandage appHed for the protection of the wound from the patient's own teeth. Complete cicatrization follows in a few days. Whatever may be the original mode of treatment the secondary effects are about the same in each case. They consist of irritation of the parts, more or less marked, and betrayed by the patients by varying degrees of restlessness, and jjossibly, in some cases, by abdominal pain or cohcs. After a few hours the swelling of the part begins. A diffused oedema takes place above the point of compression, and the hernial sac is sUghtly swollen and warm and becomes covered with Uttle phlyctenoids, indicating a commencing necrosis. Perhaps a little fever is manifested and there is great thirst. By the third day the swelhng is quite large, and in males it may involve the sheath. The sac then becomes cooler, the fever subsides, the appetite re- turns, and the animal which has instinctively kept his feet, rests himself by lying down. On the fourth or fifth day the skin of the sac is insensible, cold and flabby, and the sloughing process between the Hving and the dead skin has begun. Little by Httle this pro- cess becomes more active, and the separation becomes more and more marked, the secretion around its opening a purulent character, and from the sixth to the tenth day the complete sloughing will have taken place. The wound that remains is now granulating. HERNIA. 439 Its length exceeds its width, and it is somewhat depressed in its center It progresses rapidly towards cicatrization, only a small scar remaining, and this is readily concealed by the growth of the surrounding hair. {d) Operation in Cases of Complications. — If the hernia is irreducible and there is strangulation, the enlargement of the ring must be carefully made with a curved, blunt bistoury, having a short, guarded sharp edge. When the reduction is prevented by adhesions, the operation necessary for their division will demand the exercise of the utmost skill and caution to avoid injury of the peritoneum, and there should especially be no neglect or parsi- mony in respect to the employment of antiseptic precautions. In fact, it would in many instances be wiser to leave the animal to the resources of nature than to undertake an operation of so much delicacy and importance, and which involves so many serious con- sequences, without amply providing every resource of skill and knowledge, and anticipating every contingency of accident or dan- ger. In some cases, when the strangulation has been due to the formation of gases in the protruding intestine, we have used the aspirator for their removal, and then have met with no difficulty in reducing them by the taxis. This is a means, however, which is also recommended in the treatment of strangulated ingiiinal hernia, and is discussed in the chapter appropriated to operations in that region. Diaphragmatic Hernia . A diaphragmatic hernia, or diaphragmatocele., is formed by the displacement of one of the abdominal organs, and its intrusion into the pleural cavities, through a laceration of the diaphragm. It is necessarily an accidental opening, through which such a dis- placement takes place. One case is on record, and only one, where the hernia passed through a normal opening, viz., the oeso- phageal. The causes which give rise to ruptures of this kind may be classiiied under three heads : first, external violence ; second, pow- erful contraction of the expiratory muscles while making a violent effort ; and third, the exertion of force and pressure upon the dia- phragm by the organs, situated on its posterior face. (a) External Violence. — Foremost in this category are blows or contusions on the posterior costal region, such as may be made 440 OPEBATIONS ON THE DIGESTIVE APPAKATUS. by tbe shafts of vehicles with either the blunt or broken ends. The laceration of the diaphragm may occur either with or without involving the fracture of the ribs. Several cases of this kind have been seen and recorded by Professor Barrier. (b) The Powerful Contractions of the Expiratory Muscles during Violent Muscular Efforts. — It may result from the vio- lent and concentrated action of the abdominal muscles, compress- ing powerfully the intestinal mass, and crowding it against the diaphragm, until it destroys its continuity at one or more points, sufficiently to admit of the passage of the abdominal organ into the thoracic cavity. Durand has seen it in a six-months-old colt ; Didry and Fabey have reported cases where the hernia took place during violent efforts in hauhng a load, and Franconi met with a case of a similar character to the one referred to in which the rup- ture opened into the oesophagus. Schild has seen it associated with the efforts of parturition. (c) Violent Action and Pressure upon the Diaphragm by the Organs Situated on its Poslerior Face. — The obhquity, forward and downward, of the inferior plane of the abdomen, is shared forward upon the posterior face of the diaphragm by the organs related to it, as the liver, the stomach and the anterior curvatures of the large colon. These are bulky organs, and their united weight being very considerable, the pressure it exerts upon the diaphragm, under any extra impulse would tend directly and nat- urally to the disruption of the weaker muscular fibres of the midriff, and these yielding, the hernia would immediately become developed, and thus we have the generation of this kind of hernia. A sudden fall might easily bring this to pass, in a second or two of time. Bouley has recorded a case in which this accident oc- cured in an animal cast for a surgical operation. Pilton has seen it take place in an animal falling down while butting against a slope of ground. Diaphragmatic hernias, like others, are either acute or chronic ; or convertibly, recent and free, or of old standing, with adhesions. The distinctions of hepatocele, splenocele, stomachocele and entero- cele are of but httle importance, none of these differences being discoverable in the living animal. The symptoms of acute hernia of the diaphragm differ, accord- ing to the extent of the laceration of the muscle, and the size of the displaced abdominal mass. There are cases in which the in- HEENIA. 441 jury is of so aggravated a character from the first, that a fatal result immediately follows the formation of the hernia, the only characteristic symptoms present being those of rapid asphyxia. In other cases, though death must inevitably follow, the life of the animal may be prolonged for several hours, or even several days. And again, there are recent hernias which have been formed under such conditions that they are still compatible with the sur- vival of the animal. These assume the chronic character, and not infrequently escape discovery. The horse affected with diaphragmatic hernia becomes dull, anxious and uneasy, avoiding his manger and avoiding his food. He paws in the stall, giving evidence of suffering from abdominal pains, but which betray no pecuHar characteristics, and possess no special or positive significance. Very often coUcs precede the hernia, and its formation compHcating the case, the coHcs be- come more violent. During these coHcs the animal hesitatingly and carefully lies down, rolls much, and assumes various attitudes of no special significance, though the dog-sitting posture is some- times held to be characteristic. During these colics, which are more persistent than those due to intestinal indigestion, the pulse remain strong and quite regular, and respiration is not only ac- celerated, but difficult — the physiognomy is anxious, with an ex- pression of apprehended suffocation, the nostrils are tetanically dilated, inspiratory movements are performed with effort, and expiration is of twice or three times its normal frequency. The coexistence of this condition of the respiration with the colics is a sign of great importance as an element of the diagnosis. At times auscultation furnishes valuable data. Borborygmus may be detected in the thorax, where the respiratory murmur ought to be heard, and dullness on percussion takes the place of the nor- mal resonance, where the respiratory murmur has disappeared. Bouley, though he recommends this means of diagnosticating, considers it to be applicable only for hernias of large size, in which, according to Lafosse, an increase in the size of the thorax, a well marked projection of the cai'tilaginous circle of the ribs, and to- gether with these, a reduction in the size of the abdomen wovild be noticed. When the hernia is small, the respiratory function is imaltered. Acute diaphragmatic hernias, not necessarily of fatal tendency, are more difficiilt to detect. Probably from their rareness they 442 OPERATIONS ON THE DIGESTIA'E APPARATUS. often escape discovery, notwithstanding a somewhat positive exhi- bition of abdonunal and thoracic symptoms. And if this is so with the acute form, it must necessarily more frequently occur with chronic cases, which not only do not jeopardise life, but even fail to interfere with the usefulness of the animal. The horse thus affected not only has the double expiration of his emphysematous lungs, but he continues to be subject to intermittent cohcs, and especially if the hernia is formed by the intestines, and they con- tinue to suffer from occasional obstructions. To this complication of occasional actual obstruction must be added a perpetual Hability to become strangulated, with a certainty of speedy death following that accident. The lesions found at the post-mortem examinations of ani- mals which have died with this description of hernia varies. The accidental diaphragmatic openings may exist in different parts of the central aponeurotic portion or in the peripherical muscular zone, and may assume various forms, being at one time round, at another eliptic or triangular, or indefinite and irregular, at times very narrow, at others so extensive that the abdominal and thoracic cavities are no longer distinct. Between these two extremes there are many degrees and ample scope for the formation of chronic hernias of a non-malignant character. When the hernia is recent and has existed before death, the borders of the laceration whether muscular or aponeurotic, are irregular, thready, infiltrated and bloody, with small blackish clots adhering to the extremities of the red muscular fibres. But when the rupture is of post-mortem formation, resulting from excessive meteorism, there is no trace of capillary hemorrhage upon the lacerated edges of the aperture. With a chronic hernia these edges have various aspects; at times thin, at others in thick cords ; now torn in scallops, and again with a regular edge, they are always smooth, hard, of fibrous consistency, and even presenting a cartilaginous aspect. There is never any formation of a special serous sac for these hernias, even for those which take place through the normal openings. The organs most commonly met in these diaphragmatoceles are the omentum, the small intestines, the anterior curvature of the large colon, and more rarely, the spleen and the stomach. If not con- gested by pressure in passing through the opening, they continue to perform their functions. In these injuries the prognosis can never be confidently favor- HERNIA. 443 able. It is always serious. Some kill immediately, while with others there may be a respite of several hours or days, and with those which are chronic, there may be no apparent impairment of life or health. But whatever may be the character or the aspect of a given case, and however the prognosis may vary, it must never be forgotten that diaphragmatic hernia has this invariable character, that its effect is always to interfere with the respiration ; that the horse is at the best permanently affected with heaves, is unable to perform any active or laborious service where strong lungs are needed, and is always more or less liable to engorgement and strangulation. Diaphragmatic hernias are incurable, their sit- uation, in the deepest interior of the anatomy, rendering it impos- sible to apply any means of direct therapeutic treatment. They cannot be reduced, and even if that were practicable, they could not be secured and retained in situ. Attempts have been recom- mended by Bouley to reduce them by making an incision through the flank and replacing the protruding organ in its proper posi- tion by the taxis with the hand in the abdominal cavity. Whether in our days of perfect antiseptics such an operation could be suc- cessfully performed on the horse is a question not yet solved. The experiment might be attempted with better chances of success in cattle. In any case the operation will be justifiable only as a last resource, and when the life of the suffering animal is abso- lutely in jeopardy, in fact, as a final alternative, a dernier resort. Ventral Hernia. This term includes all hernial tumors produced by the pro- trusion of one or several of the abdominal organs through an ac- cidental opening in the muscular and fibrous walls of the abdomen, under the skin, which remains intact. The opening through which this kind of rupture takes place is always accidental, unlike those which pass through the natural channels, as the umbiHcal or in- guinal, but still, in common with them, has a peritoneal lining. Ventral hernias are of quite common occurrence, principally however, in large animals, while in small quadrupeds they occur less frequently, and they may take place in any part of the abdo- men. They are known by distinctive names, corresponding with those of the protruding organ, as gastrocele, hepatocele, enterocele and epiploocele, etc. They usually originate as direct causes in blows or contusion 444 OPERATIONS ON THE DIGESTIVE APPARATUS. Fig. 394.— Ventral Hernia. upon the abdominal walls, made by blunt bodies, vehicli, lacking force to pierce throug-h. the elastic skin, are yet sufficient to lace- rate the interior abdominal walls. An example of this occurs in a thrust from the shaft of a vehicle, or its broken end, in case of a faU, or of kicks or horning among cattle in the field. In colts they are more commonly found in the lower wall of the abdomen, the animal frequently inflicting them upon itself by attempting too high a jump over a picket fence, and failing to clear it properly. Serres says that in cattle they may follow a severe distension of the abdomen under the influence of tympanitis, abdominal dropsy, or gestation. The character of a case of ventral hernia will vary in respect to its being acute and recent, or chronic and old. Indeed, the lapse of but a few hours will materially change its character from one to the other. If seen immediately after the infliction of the HERNIA. 445 injury, it is in the form of a round, soft, elastic tumor, well- defined in its outlines, and easily reducible. But if not examined until after a season of delay, the definite configuration disappears, and it is changed into an inflammatory swelHng, oedematous, warm and painful to pressure — in fact having the aspect of a warm ab- scess. In the recent cases, the edges of the torn abdominal walls may be identified through the thickness of the skin, but the sur- geon will vainly try to make out this condition if the inflamma- tory process following the lesion has become established, and the serosity and the blood have become sufficiently infiltrated into the cellular tissue to make the change described. After a few days, if the hernia is not situated too low in the abdomen, the swelling moves downward toward a more dependent spot, and gradually abating disappears in about two weeks. Upon reaching this point, the hernial tumor is once more recognized, constituting, as it does, the exclusive manifestation of the displacement of the in- testinal mass, and its presence outside of its natural cavity. It is recognized by its changing conditions — elastic when the intestine is empty ; soft and puffy during digestion ; by its state of tension, increasing with effort, and by being painless, depressible and re- ducible. T\Tien reduced, the edges of the opening are easily made out, but it is not uncommonly found, upon the subsidence of the inflammatory process, that, during the continuance of that state, adhesions of the protruding organ with the walls of the sac have formed, and the hernia has become irreducible. In their dimensions, ventral hernias vary considerably. They may measure from the size of a large nut to that of a man's head, or even exceed that. Zundel reports a case where the rumen had penetrated into the sac, which hung almost to the ground, and had produced a dis- placement of the mammffi, crowding them in a mass toward the right side of the abdomen. Although the diagnosis of ventral hernia is not difficult, it is still not impossible to mistake a recent case for certain other affec- tions of the abdominal walls, such as tumors of bacterian anthrax, or those of a bloody nature, or with phlegmonous or oedematous growths. The reducibility and elasticity of the tumor, the bor- borygmus, and the presence of the opening through the abdomi- nal walls, are intelligible signs by which to recognize the ventral hernia. Aspiration of the tumor may sometimes be performed, and rectal examination will also be of great assistance provided 446 OPERATIONS ON THE DIGESTIVE APPARATUS. the iBJury is not beyond the reach of exploration with the hand. Certain complications are not uncommon in ventral hernia. Besides irreducihility already mentioned, excessive inflammation has sometimes been followed by traumatic peritonitis. Lacera- tions of the displaced organs have proved fatal. Internal hemor- rhages, fistulas and consecutive eventration have also been record- ed. Strangulation is not unknown, though it is comparatively rare. But with all these possibilities, it is not a rare circumstance to meet with animals affected with ventral hernia, even of large di- mensions, which have reached a good age with all the appearance of perfect health. From data like these upon which to found a judgment, it ought not to be difficult to deduce a prognosis which should never be far wrong. But, although compatible with the life, health and utilization of the animal, such a lesion must neces- sarily detract more or less from its commercial value. Under any circumstances, it is a blemish. The least dangerous of this class of ruptures are those which are situated on an elevated point of the abdomen. Recent and uncompHcated, they are amenable to treatment more or less, according to their extent ; if old or chronic, the chances of success are reduced ; if strangulated, they are generally fatal. Usually, a ventral hernia, to be curable, must be treated when it is recent, and before sufficient time has elapsed for the intestines to become, as it were, accommodated to their new position, and especially before the cicatrization of the borders of the lacerated openings has taken place. Recent and free from complications, all that is required is their reduction and retention in their proper place. When reduced, whether by rectal taxis or by external pres- sure, the parts are covered with a mixture of pitch and Venice turpentine melted together, upon which is spread oakum cut in small, short threads, which is to be covered with a second appli- cation of the pitch, after which a sheet of pasteboard, itself also impregnated with the pitch mixture, is placed over the opening. The whole is then covered and held in place by a broad bandage carefully rolled around the abdomen. Leather is sometimes used in Heu of the pasteboard. This bandage, when applied upon male bovines, requires to be carefully adapted in order to avoid any possible interference with the penis, and its freedom of motion in the act of micturition. The complications of swelling or bloody HERNIA. 447 extravasations must not prevent the immediate application of the bandage. In cases of chronic hernia, compression is no longer sufficient. Jannet recommends the use of clamps as in umbihcal hernia, and reports having reUeved a case where the tumor was as large as a child's head. Leblanc advises the quiUed suture, and Schwane- feld cured by this mode a hernia twice as large as the head of a man. Hertwig speaks favorably of the application of Delavigne's method in exomphalus. Going, Lafosse and Hertwig have ob- tained success with nitric acid injections, and Krantz and Schutt with blisters. Peyon, Dandrieu, Terrien and Obich have had good results with the direct suture of the ventral waUs in bovines, and even solipeds. Bouley objects to the suture of the edges of the opening, and also to injections into the evacuated sac of irri- tating substances, to excite inflammation and produce the adhe- sion of its walls. We have ourselves experimented several times with the subcutaneous injections, but every attempt has resulted in failure. According to Peuch & Toussaint, if old ventral her- nias are to be treated, the best plan is to have recourse to bandag- ing, as employed in the treatment of exomphalus. EVENTRATIONS. An eventration may be defined as a compound hernia, and it constitutes an accident of the first degree of severity, consisting in the formation of a hernia, of indefinite dimensions, taking place through an opening involving the entire thickness of the abdomi- nal walls, the skin included, in such a manner that some portion of the abdominal viscera, but most commonly the intestines or the omentum, become directly exposed. Ordinarily they are due to some traumatic lesion, such as a thrust from or a fall upon a sharp body, or they may be produced by stab wounds, or pvmctures with a fork or a knife ; or again, by kicks inflicted by other animals, or horn-blows, when cattle are crowded into too contracted a space and struggle for more room, or quarrel when herded in pastures. And they quite commonly end the career of the wretched victims of barbarity which are compelled to assist in the bloody and cruel sport of the Spanish buU. fight. They are also observed at times following severe surgical manipulations, as in castration, during the operation for strangulated inguinal hernia, after the efforts of 448 OPERATIONS ON THE DIGESTIVE APPARATUS. distokia. They may also form one of the complications of some of the forms of the treatment of umbHical hernia. In the smaller animals, such as dogs, they may be produced by a severe bite by a larger animal. The pathognomonic symptom of an eventration may be con- sidered the protrusion of a portion of the abdominal contents through its lacerated walls. If the opening through which this takes place is small, the viscera will appear as a small round tumor, which presently becomes transformed into a large mass of intes- tinal circumvolution, which itself varies in dimensions, according to the extent of the laceration. As the exposed intestines begin to protrude, they for a period retain their physiological appear- ance and normal color, but they undergo rapid changes, becoming progressively darker, blueish and then black, and grow cool to the touch. The viscera as they protrude from the abdomen may be quite intact, but they often are injured, bruised or torn, the con- ditions varying according to the peculiar circumstances attending the accident. And not only is this so, but the sequel of the case must be especially considered, since an eventration which possibly might be susceptible of cure, if carefuUy tended from the first, may become so aggravated and exaggerated as to preclude aU possibility of remedy, as when the wounded creatiire, frantic with pain, from colics and otherwise, in rearing and struggling, forces his entrails more and more out of their place, and tears and tram- ples them upon the earth until they become a mere mass of crushed and bruised viscera, ground into the earth. And yet, colics are not always present in eventrations, even in horses whose irritable temper, combined with the condition of the injured j)arts, would naturally tend to render their occurrence quite inevitable. The prognosis of their injuries varies according to the species of the animal, and also under the special condition and circum- stances of each case, as judged by itself. In horses, it is, in the majority of cases, a fatal accident. The sensitiveness of the animal to impressions upon the nerves, and the delicate susceptibihty of the peritoneum account for this. In ruminants they are less serious, and certainly still less so in carnivorous animals, where sometimes the whole intestinal mass may be seen hanging through the laceration, and with extensive co-existing inflammation, with- out the occurrence of a fatal termination. Swine are also very sensitive to this kind of injury, though the EVENTEATIONS. 449 prognosis may vary with them, according to the condition of the lesion, being more or less favorable according as the bulk of the proti'uding viscera is less or greater. The chances of recovery will also vary in the ratio of the degree of the exposui'e of the vis- ceral organs to the atmospheric aii', or to the severity of any traumatic accidents they may have encountered. The indications of treatment suggested in these cases is obvious. The first is always, when practicable, reduction. To return the intestine to the situation designed by nature for its occupancy is the first step to take. If it has not been seriously wounded, and is in a state of cleanliness, and has escaped contact with the earth and other soils and stains, simple washing may be attended to at once. But if, on the contrary, it is bruised, soiled and inflamed, it must be carefully cleansed with warm water, before being re- turned to its position. This reduction must be carefully per- formed by the taxis, and if the opening of the abdomen is too small to allow this to be accomplished with facility, it will be good prac- tice to enlarge the opening with the knife, rather than to hazard the too free manipulation of the tender parts which will form the dangerous alternative which may become the exciting causes of consecutive inflammatory, and perhaps gangrenous sequelae. If instead of the intestines the eventration allows the exit of the omentum, this also must be cleaned and washed, if necessary, and returned, though in some instances it may be torn or cut off after ligating its large blood vessels, or better yet, Hgating the whole mass with animal ligature. The second step of the operation con- sists in applying means of restraint to retain the retiu-ned organ and prevent a second exit. The quilled suture is at this jnnctui'e the means which always first suggests itself to the surgeon's mind. The clamps have their advocates, but Zundel prefers the metaUic interrupted sutures. The entire application is to be supported, reenforced and j)rotected by a wide bandage, similar to some of those recommended in umbilical hernia. LAPAROTOMY. This operation, which consists in the opening of the abdominal cavity thi-ough the loins or flanks, is one which, considering the general indication for which it is performed in human surgery, has found but little appUcation and occupies but a smaU place in 450 OPEEATIONS ON THE DIGESTIVE APPAKATUS. veterinary practice. According to Director Degives, who furnishes the only description of the operation to which we have been able to obtain access, the indication for laparotomy occurs in cases of intestinal invagination, internal hernia and intestinal strangulation and for the removal of foreign bodies from the abdominal cavity or the intestinal tract. Once a celebrated surgeon of New York had decided to prac- tice it upon one of his valuable dogs, which was suffering with impaction caused by the lodgement of a mass of hair in the intes- tines, which we fortunately succeeded in softening and removing by internal treatment. The indications for the operation are im- perative as soon as a fatal result becomes imminent and certain. The instruments necessary are a convex bistoury and suture needles. Dr. Degives briefly describes the operation as follows : " I*osi- tion and Restraint of the animal standing up, or in stocks, or resting against a wall or its equivalent. If the animal is restless let him be thrown down on the side opposite to that of the opera- tion, which is divided into three steps. First Step, opening of the fianh. — The abdominal opening must be in the ujjper part of the flank, upon a line between the hip and the last rib. This opening may be made in two ways : 1st, or Simple Method. — It consists in making an incision through the various anatomical layers, in the same direction, in order to form a simple vertical wound, large enough to admit the hand. The parts having been shaved, the division of the skin, the abdominal muscles and the peritoneum is made successively with the convex bistoury. The incision of the deep layers alone pre- sents any difficulty, and this requires some attention, the hemor- rhage being sometimes troublesome ; but when the peritoneum is exposed, the incision is increased, from without inward, with either a blunt bistoury or the straight bistoury controlled by a grooved director, an assistant protecting the intestines from the contact of the instrument. 2d, or JSfew Method, by Complex Incision. — In this each mus- cle is divided in the direction of its own proper fibres. Thus, the first is a transverse, cutaneous incision ; second, three muscu- lar divisions, running in directions more or less opposed to each other ; the first, obliquely downward and backward ; the second, obliquely forward and downward, and the third transversal and parallel to that of the skin. These incisions are very easily made, LAPAROTOMY. 451 little more being necessary than a simple laceration of the intesti- nal tissue with the fingers — there is Httle or no hemorrhage. The opening thus made admits the hand into the abdomen, and when it is removed the fibres of each muscle having a tendency to come together spontaneously, the opening is more or less eff"ectually closed. Second step. — This varies, to correspond with the object of the operation ; 1st, whether the extraction of a foreign body in the abdomen or intestines, or 2d, the reduction of an invagination or of an internal hernia (diaphragmatic, mesentoric, epiploic, or pan- creatic), and, 3d, the displacement or removal of a tumor involving the intestines. In the reduction of an internal hernia, it may be necessary either to pull or to push upon the displaced organ. In some cases the hernial ring must be enlarged, and if that cannot be done with the fingers, the bistoury must be used. The reduction of an intes- tinal invagination is obtained by the combined action of a slight traction on the invaginated part and a steady external pressiu-e upon the enlargement formed by it in the portion of the intestines in which it is enfolded. When the sweUing of the organs or the presence of abnormal adhesions prevent the reduction, the traction must be increased and in opposite directions — the invaginated por- tion in one, the enfolded portion in the opposite. If a stone, a calcvdus, or any foreign body is to be extracted, the intestine is to be incised at some distance from the insertion of the mesentery, on its lateral face, between the two curvatiu'es. On the removal of the body the intestinal suture is to be appHed. Third step, Closing the Parietal Wound. — "When the complex incision has been made, a strong cutaneous suture is all that is re- quired. When the di\ision has been a simple one, the edges of the muscular wound are brought together by ordinary interrupted sutures, and the skin is afterward sewed up. The drainage at the lower part of the wound is always advantageous." As enteritis and peritonitis are common sequelae of this opera- tion much care and watchfulness devolve on the surgeon in direct- ing the regimen and nursing of the patient in order to prevent the possibility of their access from becoming a certainty. CHAPTER IX. OPERATIONS ON THE RESPIRATORY APPARATUS. ON THE GUTTUEAL POUCHES— HYOVERTEBROTOMY. TMs term fails to meet the approval of Zundel, who has pro- posed that of Hyospondylotomy as a substitute, in order the better to indicate the puncture of the sac of the guttural pouches which it signifies. The former name, however, has been generally ac- cepted, and while its etymology would point to the operation by which the puncture referred to is made between the hyoid bone and the atlas, it is stiU used to mean generally, the puncture of the pouches, at whatever point it may be made. These guttural pouches, which exist exclusively in the sohpeds, and are two in number, are situated between the cranium, the pharynx and the atlas, resting upon each other on the median line, each one, by an expansion of the mucous membrane of the Eustachian tubes, forming a sac and fiUing the triangular space situated posterior to the pharynx and extending to the larynx. The mucous membrane which forms them is easily stretched, and the cavity may thus become greatly distended by the accumulation of pus, and when this is the case, the pouch extends below the larynx and the lower extremity of that organ. Thus situated in the parotid region, these two sacs sustain important relations to other points, varying according to the position, whether of extension or flexion, of the head ujjon the neck, and are covered by seven separate tissues, as represented in their order from without inward, by 1st, the skin ; 2d, a layer of subcutaneous connective tissue, more or less abundant ; 3d, a thin expansion of cutaneous muscle with the parotido-auricularis muscle ; 4th, the parotid gland, whose internal face is moulded upon the muscles and blood vessels un- derneath ; 5th, the following muscles in the order as named from above downward, viz., the small obHque of the head — the stylo- hyoideus, which fills the space left between the anterior border of HYOVEKTEBKOTOMY. 453 Fig. 395.— Antero-PoBterior Section of the Head, showing the Mouth, Fances, and Nasal Cavities. 1, genio-glossus mascle; 2, genio-hyoideus muscle; 3, the velum palati; 4, pharyn- geal cavity; 5, oesophagus; 6, guttural pouches; 7, pharyngeal opening of the Eustach- ian tube; 8, laryngeal cavity; 9, lateral ventricle of the larynx; 10, trachea; 11, ethmoi- dal turbinated; 12, maxillary turbinated; 13, ethmoidal volutes; 14, cerebral compart- ment of the cranian cavity; 15, cerebellar compartment of the same; 16, falx cerebri; 17, tentorium cerebelli; 18, superior lip; 19, Inferior lip. the styloid process of the occipital bone and the superior border of the long branch of the hyoid, through which the puncture is made in order to enter the guttural pouches, and back of this the stylo-hyoideus and the superior border of the digastricus ; then, 6th, on the deejDest layer, the guttural pouches are found supe- riorly, resting intimately on the internal face of the stylo-hyoideus muscle, inferiorly closely cemented with the posterior face of the pharynx and posteriorly with the superior extremity of the long muscle of the neck ; and 7th, the numerous and important blood vessels and nerves belonging to the parotid region. 454 OPEKATIONS ON THE KESPIKATORY APPARATUS. Pig. 397.— Parotid Region— Superficial Layer. PP, parotid gland; Mpa, parotldo-auricular muscle; 3, transveral artery of the face; 4, maxillo-muscular vein ; 7, jugular vein ; 8, glosso-f aclal vein ; 9, transversal vein of the face; 10, maxillo-muscular vein; 12, posterior auricular vein; 13, facial nerve; 15, auricular branch of the 2d cervical pair. The arteries are the three divisions of the primitive carotid ; 1st, the occipital, which, by its mastoid branch, runs over the ex- ternal surface of the styloid process of the occipital bone ; 2d, the internal carotid, which runs upward through the thickness of the fold of the mucous membrane which forms the guttural sacs ; 3d, the external carotid, with its parotid branches, the maxillo-mus- cular, the posterior auricular, the superficial temporal trunk and the internal maxillary. The veins, which are numerous, empty HYOVEKTEBKOTOMY. 455 Fig. 397.— Parotid Region— Middle Layer. P, parotid gland; D, digastricus muscle; Sh, occipito, or stylo-hyoideus, muscle ; Sm, sterno-maxillaris muscle; P, thyroid gland; H, posterior border of the great branch of the hyoid bone; 1, primitive carotid artery; 2, external carotid artery; 3, transversal artery of the face; 4, maxillo-muscular artery; 5, posterior auricular artery; 6, thyro-laryngeal artery; 7, jugular vein ; 8, glosso-facial vein ; 9, transversal vein of the face; 10, maxillo-muscular vein; 11, anterior auricular vein ; 12, posterior auricular vein; 13, facial nerves ; 14, anterior auricular nerve. into the jugular or its different branclies. The principal nerves of the parotid region are the facial, the pneumogastric, the spinal, the superior cervical ganglion of the sympathetic, the great hypo- glossus and the glosso-pharyngeal. These nerves, with the exception of the facial, are situated on the external face of the pouches below the long branch of the hyoid bone and the stylo-hyoideus. 456 OPERATIONS ON THE RESPIRATORY APPARATUS. This rapid smnmary of the anatomy of the parotid region will sufficiently indicate the dangers which the surgeon is likely to encounter at successive steps of the operation, and especially if he duly considers the location of the occipito-hyoideus, which must be reached before the puncture can be made, and again, the pecu- liar course followed by the posterior auricular artery as it emerges from the parotid to reach its destination. Hyovertebrotomy is indicated in all cases of repletion of the guttural pouches resulting from a purulent collection and main- tained by a process of chronic inflammation. It is principally when horses have become liable to be attacked with strangles that these purulent collections are formed. They are marked by an increase of size in the pouches, gradually augmenting with the continued formation of the pus, and interfering more and more with deglutition and respiration, sometimes assuming such pro- porfei^as as even to threaten suffocation. Attacks of pharyngitis or laryngitis, or catarrh of the anterior chambers of the respira- tory apparatus and nasal cavities, or sinuses, are at times noticed in connection with this affection. To revert to the anatomical arrangement of the parts : The guttural pouches, opening into the cavity of the pharynx by a narrow sHt, are situated on the lateral surface, and thus allow any collection of pus they may contain to flow without interruption into the pharynx, and hence into the other nasal cavities. We have here an explanation of the fact that a discharge from the nose in any one of a variety of affections, such as suppuration of the guttural pouches, pharyngitis, laryngitis, catarrh, and also the dis- charo-e of glanders, may all possess different characteristics, and each exhibit a different aspect, and therefore demand a different diagnosis and require different treatment. The discharge from the guttural pouches is whitish, glairy, more or less mixed with mucosities, inodorous, non-adhesive to the wing of the nose, and intermittent, being marked during mastication or deglutition, and especially while swallowing liquids — in all form- ing an assemblage of characteristics which should be sufficient to distinguish the affection from all others. There is, besides this, a negative point, in the absence of chancres, which with the distinct nature and pecuharity of the discharge, and the characters so typical of the maxillary lymphatic glands in that disease, will largely aid in determining the difference between the two affections. HYOVEETEBEOTOMY. 457 In respect to glanders, moreover, the bad odor, the thick, gru- mous nasal discharge, and the soreness and dullness on percussion of certain parts of the face, will in many cases serve to identify and distinguish a pathological condition of the sinuses ver}'^ dif- ferent from that of the disease we are considering. Gohier and Vatel also refer to guttural tympanitis, or dilatation of the pouches by air, as a feature of their disordered condition. The amount of pus collected in the pouches varies in different cases to such an extent that from only a trifling degree of dilatation it may be suf- ficiently extensive to produce a sensible projection of the sac below the parotid. This dilation furnishes a guide for the determination of the proper point at which to make the puncture, whether in the upper, in the middle, or in the lower part of the pouches. The upper operation is hyovertebrotomy proper. Besides these three modes of operation, Gunther has proposed a fourth method which consists in penetrating the pouches through the nasal cavities. Upiyer operation — Hyovertebrotomy proper. — As described by Chabert and Fromage de Feugre, this is one of the finest and most dehcate operations of veterinary svirgery. Extremely so when per- foi'med on horses whose pouches are healthy and normal in size, it loses a great deal of its apparent difficulty when these are full of pus with prominent and well developed walls. The nerves and blood vessels which surround them are then easily pushed aside from theu' position, and the lobules of the parotid are more or less separated. The instruments required for this operation are: a pair of scissors, a convex and a straight bistoury, a dissecting forceps, an Fig. 398.— Curved Trocar, or Hyovertebrotome. S probe, or preferably, the curved trocar, the hyovertebrotome (Fig. 398), and a piece of tape. Artery forceps and ligatures ought to be always within reach. BoTiley, Zundel and others recommend that the animal should be kept in the standing position with simply a twitch on the lip, 458 OPEKATIONS ON THE EESPIRATOKY APPARATUS. but our experience lias tauglit us that the recumbent position is the safest, especially if there are plenty of assistants at hand, with instructions to keep the head of the animal steady, and in a mode- rate state of extension on the neck. The operation is divided into three steps; 1st, The incision of the skin and dissection of the parotid ; 2d, The puncture of the pouch through the occipito-hyoideus muscle ; and 3d, The estab- lishment of the counter-opening. Before considering these three steps, it will be well to answer sundry important questions put by Lecoq in the first good de- scription of the operation, made in 1841. IVhere shall the p>uncture he made? The anatomical disposition, which we have already examined, suggests as an answer to this query, that the occipito-hyoideus muscle is the proper place for the puncture. Its inner side is lined with the mucous membrane of the pouches, and as has al- ready been remarked, when this is distended by fluid and becomes tense and resisting, it is in a much better condition for the pass- age of the knife through its thickness than when flabby and soft, and therefore movable and shifting, as if endeavoring to evade the knife. At any other point the pouches are so surrounded by im- portant blood vessels and nerves that the operation is precluded by the danger which would be incurred by attempting it. Where must the first incision he m,ade to reach the occipito- hyoideus muscle? It would be easy to reach the muscle by a division of the paro- tid gland, but this would involve the formation of a fistula, and a wound difficult to heal, to avoid which the gland must be raised out of the way. This should be done by raising the posterior bor- der, where it is loose and free from blood vessels or nerves of importance, in preference to doing so by disturbing the anterior border or superior extremity, where the posterior auricular artery, the facial nerve and the sub-zygomatic artery are situated. The superior extremity of the incision must begin near the inferior border of the tendon common to the splenius and small com- plexus muscles, a little in front of the transverse border of the atlas, and extend downward for a space of two or three inches. Upon v^hat point of the muscle must the puncture he made? The answer to this is — upon the central portion of the muscle. The introduction of the bistoury into the superior part of the HYOVERTEBKOTOMY. 459 muscle will involve possible danger to the posterior auricular ar- tery, and the risk of the di\ision of the facial nerve. In what direction must the sharp edge of the bistoury he turned? The reply to this is the point of minimimi danger from irregu- lar motions of the instrument, caused by the struggling of the patient ; and this result is most likely to be accomplished by carry- ing the bistoury towards the tuberosity of the hyoid bone, and consequently in the direction of the patient's nose. With the instrument turned towards the ear, there would be possible dan- ger of dividing the posterior auricular artery, the facial nerve or, perhaps, the internal carotid. In carrjdng it toward the atlas, the internal carotid, and the nerves surrounding it, would be the endangered parts, if any. If directed downward, toward the larjoix, a division of the great hy- poglossus, and possibly of the external carotid, might be possible. "What must he the direction of the instrument? If the bistoury is pushed through the occipito-hyoideus muscle, and in a direction perpendicular to it, there will be great danger, at a certain depth, of reaching and penetrating through the in- ternal carotid artery ; but if an obHque direction be given to the instrument, not only is this danger avoided, but no accident be- yond some slight muscular injury, of no importance, need be ap- prehended. Where is the counter-opening to be made ? The right place wiU be the most dependent parr of the pouches, and the instrument used must be either the S probe or the trocai*, as wiU be hereafter described. These preliminary points being understood, we shall the more inteUigently foUow the description of the three steps of the opera- tion, which we now proceed to give. 1st. The Incision of the Skin and Dissection of the Posterior Border of the Parotid. — This incision is made a little in front of the transverse process of the atlas. It includes the skin and some subcutaneous aponeiu'otic fibres, and extends to the posterior bor- der of the parotid, which is at this point exposed. "With the straight bistoiiry and dissecting forceps, the jDarotid border is dissected, and under it the aponeurosis of the levator-humeri is divided. The finger is then pushed between the aponeurosis and the small obhque muscle of the head, in order to reach the occipito- 460 OPERATIONS ON THE RESPIRATORY APPARATUS. hyoideus, whicli is readily identified by feeling for tlie styloid pro- cess of the occipital bone and the superior border of the long branch of the hyoid. Some little hemorrhage and some strug- gling of the patient may follow this incision, caused by the divis- ion of the auricular vein and nerve, but the consequences will not be serious. 2d. Puncture of the Poxich through the Muscle. — The central point of the muscle being identified, the operator, with a straight bistoury held in the manner of a writing-pen, introduces it under the parotid, obliquely, from above downward, and from behind forward, and thus divides the muscle through and through, and penetrates the pouch. If the puncture proves to be sufficiently large, the index finger is introduced into the opening for explora- tion, and, if necessary, for its fiu-ther dilatation. If the collection of pus is not very abvindant, and the mucous membrane lining the sac not greatly distended, it will be important to have a very sharp-pointed instrument, which will make its work of incision sure, instead of merely pushing the membrane away from the internal face of the muscle — an accident which might lead to serious results. But again, when the collection is abundant and the pouches much distended, the use of the bistoury may prove unnecessary, the puncture being then readily made by pushing the index finger through both the muscle and the mucous membrane of the pouch. 3d. Making a Counter-Opening. — The S probe, or curved tro- car (Fig. 398), is introduced through the opening made, and is pushed down to the bottom of the pouch, where the mucous mem- brane is easily torn ; it is then carefully directed toward a point a little below the giosso-facial branch of the jugular, back of the thick border of the maxillary bone, and pushing against it with sufficient force, the instrument forms a prominent point under the skin. If the S probe is used, an incision is made with the bistoury through the skin, and the instrument is exposed. If the curved trocar, it is by a strong pushing movement passed through the skin and brought outside. Whatever instrument may be used, a piece of tape or kind of seton is introduced from the lower through the upper opening, and the continued escape of pus thus facilitated and ensured. The extremities of this piece of tape are secured together by tying them with the knot used with the or- dinary seton. HYOVERTEBROTOMY. 461 The attention required by the patients after the operation is of the simplest kind, consisting in keeping the wounded surface thoroughly clean and keeping up the flow of the pus This will at first make its escape through the upper opening, but will soon find its way through the lower one, and so long as it is discharg- ing the opening must not be allowed to close, nor must the seton be moved. Puncture in the Middle and the Lower Regions of the Parotid. — These modes of operation are so nearly identical that, with H. Bouley, we think they may with prox^iiety be jointly con- sidered. In these cases but little attention to the anatomy of the part is requii-ed. The growth of the purulent collection distends the pouches, displaces the blood vessels and nerves, separates them more or less from the parotid, and becomes more superficial, and, in fact, may ulcerate through the skin and empty itself spontane- ously. But this process is a very slow, tedious and painful one, and subjects the patient to such a degree of suffering, that it be- comes a duty imj)erative to interpose the resources of sui'gery for its relief. The puncture in this case should be made as early as possible, and at the fluctuating point, as with an ordinary abscess. It is made with the bistoiuy, or, what would be better, with the olivary actual cautery, by which the prevention of hemorrhage will be as- sured. The opening thus made and cauterized, will, moreover, have less tendency to close too rapidly, besides which the modify- ing effects of the cauterization will have a highly advantageous in- fluence upon the healing jjrocess. The opening of the pouch at its lower extremity has been recommended when the purulent collection is small, or when con- cretions of inspissated pus are supposed to exist in the cavities. It is done by first dissecting the wide and thin lower portion of the parotido-auricularis, then of the base of the parotid, under which the distended pouch is seen and punctured. We remember a case where the collection in both cavities was such that we had no difficulty in opening them on each side of the neck, about on a level with the thyroid glands, the lower operation with emphasis ! Puncture Through the Eustachian Tubes. — Gunther has in- vented a tube, rounded at one extremity, a sort of hollow bougie, 462 OPEEATIONS ON THE RESPIRATORY APPARATUS. which he introduces into the guttural pouches by passing it through the 'nasal cavities and the Eustachian tubes. Although in performing this operation the animal is thrown down, it is veiy difficult to accomplish, and requires to be preceded by the operation of tracheotomy. It also requires to be repeated several times, by reason of the liability of the collection to return. The mode of operation is a matter of no importance, since the solutions of continuity resulting from it seldom assumes a form more serious than that of an ordinary simple wound, and requir- ing no special directions as to treatment. Even ordinary de- tergent washes are scarcely necessary. LAEYNGOTOMY— AEYTENECTOMY. The history of surgical interference at the larynx, to relieve the peculiar difficulty of respiration known as roaring, depending upon paralysis of the laryngeal muscles, dates as far back as 1845, when Professor Gunther, of Hanover, attemj)ted, in succession, the resection of the vocal cords, the removal of the vocal cord of the paralyzed side of the larynx, the partial excision of the arytenoid cartilage, the entire extirpation of that cartilage, the removal of the vocal cord and of the corresponding laryngeal vetitricule, and finally the fixation of the arytenoid, by an anchylosis at its artic- ulation vnth the thyroid cartilage. The results obtained by Gun- ther were more or less successful. These experiments were repeated by Gerlach, H. Bouley, Stockfelth and Bassi, but subsequently repudiated and ignored. But in later years Professor MoUer, of Berlin, and George Flem- ing, of London, have turned their attention to the subject, with the suggestion of various new modes of operating, which have yielded results more or less encouraging. The matter has been followed up by other veterinarians in various parts of the world, and re- cently especially by Professor Cadiot, and the successes which have been recorded, though not always perfect, seem to justify the prosecution of further inquiries and new trials for the rehef of a disease which has thus far baffled the skill of veterinarians, and consigned many a valuable animal to the hands of the knacker. The operation of Professor Moller, also recommended by Pro- fessor Cadiot, as at present practiced, is the excision of the para- lyzed cartilage. That of George Fleming is the removal of the LARYNGOTOMY ARYTENECTOMY. 463 cartilage and the vocal cord. We shall describe the Fleming and Cadiot modes as we find them recorded in their own works, " Koaring in Horses," by the former, and " The Surgical Treat- ment of Chronic Roaring," by the latter. The Flemhig Method. — The special instruments necessary are small ordinary forceps ; scalpels ; bull-dog forceps ; tracheal Fig. 399 —Tracheal Tampon Canula. tampon ; a canula, formed of a long tracheotomy tube, with an india rubber bag surrounding its middle. This bag is inflated by means of an india-rubber air-pump, after the insertion of the tube into the trachea, and is useful in preventing the flow of blood into the bronchii during the horse's getting up after the operation, and for half an hour subsequently. Other instruments required are a razor-shaped knife, with which to excise the cartilage ; a bent knife with which to remove the muscles from the outside of the arytenoid cartilage ; a hook to seize and raise the lower end of Fig. 400.— Razor-shaped Knife. Fig. 401.— Bent Knife. Fig. 402.— Hook to Secure the Cartilage. 464 OPEEATIONS ON THE KESPIRATOKY APPARATUS. Fig. 404.— Curved Scissors. Fig. 406.— Electric Lamp. the cartilage ; a special forceps with toothed ends, to seize the body of the cartilage ; curved scissors to cut through the mucous membrane ; two retractors to keep the trachea opened during the operation ; and an electric lamp to illuminate the interior of the larynx. Fleming describes the operation as follows: "The horse should be well fed for a day or two preceding the operation, but have little or no food or drink for some hours before its actual performance. In the case of thoroughbred horses, a dose of four ounces of tincture of opium in a pint of water, half an hour be- fore operating, is advisable. The hair must be removed closely from around the upper part of the trachea and larynx, before the LARYNGOTOMY ARYTENECTOMY. 465 animal is cast, and he is thrown in the usual manner, on a good bed of straw or moss or litter. The chloroform bag is put on, and when the required state of narcosis is induced, the animal is placed on his back, and maintained there by sacks filled with straw, placed close under each side of the body. The neck and head are ex tended in a line with the body, the head placed on the vertex and kept steady by an assistant. The operator places himself in a kneeling position, on the off, or right side of the body, if right handed, beside the neck, with his back to the shoulder and face toward the head." The operation is divided into three stages : First Stage. — " With a scalpel, an incision of from four to six inches in length is made through the skin, the middle Une of the larjTix and trachea, opposite the posterior border of the lower jaw, extending from the body of the thjToid cartilage to the second or third tracheal ring. This exposes the subscapulo-hyoid, sterno- hyoid and sterno-thyroid muscles, which are incised to the same extent, and as close as possible to their line of junction {raphe) in the middle, the section being then carried through to the larynx and trachea. There is a variable amount of hemorrhage now to contend with, which, if only oozing, may be checked by sponging it dry until the blood has ceased to flow ; and if it comes from twigs of arteries or veins, they may be seized, and twisted, or ligated." Second Stage. — "The middle crico-thyroid ligament, cricoid car- tilage, and one, two or three tracheal rings are cut through, in a straight line, exposing the interior of the larjoix and trachea. If blood vessels are cut, they should be taken up. A retractor is applied to the sides, and these being pulled gently apart by an assistant, there is ample space in which to manipulate. The con- vex lower border of the arytenoid on each side can now be seen, and if the respiration is deep, that which is next the operator (the right), will be observed to move actively from the side toward the middle ; jv^hile if the roaring is due to paralysis of the left dilator muscle, there is no movement in the opposite cartilage. When the breathing is very tranquil, which is often the case, the right carti- lage moves almost imperceptibly, and it becomes necessary to as- certain whether the left one is really immovable. This can be done by passing the finger, or a long probe, up toward the epi- glottis, when the act of swallowing will be excited, during which 4.66 OPERATIONS ON THE RESPIRATORY APPARATUS. the right arytenoid cartilage is energetically jerked into the mid- dle of the cavity; but the left one is either motionless or only feebly stirs, depending upon the degree of the wasting of the con- strictor muscles on that side. " If any blood lodges in the trachea, it can be removed by large or small (handled) sponges, which may be passed to the operator by an assistant who receives and washes them. As the horse is now breathing through the wound, the chloroform bag may be removed. "It is always advisable to examine the interior of the larynx carefully, in order to ascertain its exact condition, as there may be something more in the case than an immovable cartilage. For this purpose the electric lamp is invaluable. Fig. 407.— Left Side Section of Larynx, showing the Parts excised in the Operation for Roaring. " The left arj^enoid cartilage may be excised by commencing at the lower convex border, or at the upper part, where it meets the right cartilage (Fig. 407). If the latter method is selected, then a cut with a razor-shaped knife is made through the mucous LARTNGOTOMY AEYTENECTOMT. 467 membrane, into the arytenoid ligament and arytenoid muscle, as close to the margin of the cartilage as possible, beginning between the cartilage of Santorini, downward and then upward and the vocal process at the insertion of the vocal cord (Fig. 407). The hook is inserted in the vocal process, which is raised, and the vocal cord is separated from the cartilage by the scissors ; then the muscles on the outside of the cartilage are cut with the bent knife, or, what is better, pushed from its surface as close as possi- ble. The hook is removed, and the body of the cartilage seized with the rachet forceps. The mucous membrane connecting the cartilage with the vocal pouch is divided, with the curved scissors, cutting as close to the cartilage as possible, to save the membrane. "The arytenoid cartilage is now free, except at its articula- tion with the cricoid, and it may either be disarticulated or cut through with the scalpel at this point, care being taken to leave no loose portions or shreds. The cartilage being now only retained by the soft parts at the upper portion (or base of the arytenoid cartilage), these are cut through, close to it, with the scissors, when it is altogether detached. " Care must be taken to avoid wounding the other cartilages, or the pharyngeal mucous membrane, and to spare that membrane in proximity to the arytenoid cartilage as much as possible, remov- ing only that which covers its surface and the cartilage of Santorini. " The vocal cord is now removed close to its attachment to the thyi'oid cartilage, in front and at its fixed border (Fig. 407). This can be done with the scissors, a finger being passed to the bottom of the ventricle to facilitate the excision ; or the cord may be drawn from the side by inserting a hook iu it, to allow plenty of room for the scissors. " If the hemorrhage is troublesome, which it seldom is, the blood can be mopped out of the trachea with the sponges. It cannot pass down that tube, owing to the position of the neck. If necessary, the electric lamp may be employed to ascertain how the operation has been performed, or even during it performance ; but after a little experience this is unnecessary." Third Stage. — "The trachea being completely freed from blood, and the tampon canula introduced, the bag being inflated after it has been properly placed into the trachea by means of the air-pump, the canula is secured in position by a tape around the 468 OPERATIONS ON THE RESPIRATORY APPARATUS. neck. It is only required for about half an hour, luitil the hemor- rhage has ceased, as it will prevent the entrance of blood into the lungs while the horse is getting up, and for a short time after- ward respiration being carried on through the tube. It ought not to be left any longer, being liable to injure the interior of the trachea. The blood being again removed from the larynx, one or two syringe-fulls of the common salt or borax solution are inject^ ed into it and the pharynx. This washes out these cavities and the sinuses of the head, a necessary precaution, as putrefying blood in them sometimes gives rise to troublesome consequences. Swallowing should be induced by touching the epiglottis, and then the horse may be turned on his side, the lower margin of the wound being depressed, to allow the remaining blood and water to flow out. This completes the operation. " The horse is now allowed to recover from the chloroform? and when ready he may be assisted to get upon his feet, care being taken that the canula is not displaced while doing so. The wound is kept open with the finger for a short time, to allow any remaining blood to escape, and it is afterward cleansed away from around the wound, the face and nostrils sponged to refresh the patient, and if the weather is cold, the body clothed and the legs bandaged." Method of Gadiot. — The special instruments required are a Pig. 408.— Blunt Bistoury. Fig. 409.— Curved Scissors. Fig. 410.— Spring Tenaculum, or Dilator, blunt bistoury, curved scissors, whose blades are nearly perpen- dicular to the branches, a spring tenaculum, a hooked or long bull-dog forceps, a canula tampon, like that used by Fleming, a LAKYNGOTOMY ARYTENECTOMY. 469 Fig. 411.— Hooked Forceps. peculiar curved needle, shown in Figure 418, straight, long and ordinary curved scissors, bistouries, dissecting forceps, artery nip- pers, loose and fixed sponges, thread, cotton, pheniated or iodo- formed gauze, and antiseptic solutions. The preparation of the animal is similar to that in Fleming's method. First Stage. — Incision of the SMn and Muscles covering the Larynx. — The incision must be made on the median Hne, and ex- tend from the body of the thjToid to the second or third tracheal ring. This is done with the convex bistoury, first dividing the skin in its whole length, when the edges separating show the raphe of the sterno-hyoid and omojDlat-hyoideus muscles. The muscular layer can then be divided exactly upon the median line. The division of the prelaryngeal connective tissue closes the first stage. The hemorrhage is always light and easily controlled. Second Stage. — Incision of the Larnyx and of the First Two Rings of the Trachea, Introduction and Fixation of the Can- ula. — The incision may be made by a single stroke of the knife, dividing the crico-thyroid, and with it, successively, the cricoid and the crico-tracheal ligaments, and the first rings of the trachea. But by this mode of operation, the vocal cords may be injured, and to avoid this, the bistoury held perfectly vertical, with the edge turned backward, is inserted through the crico-thy- roid Hgament, immediately in front of the cricoid cartilage, and this is divided with the crico-tracheal ligament, as well as the first ring of the trachea. The edges of the laryngo-tracheal incision are then opened with the spreaders, or the spring tenaculum, and the division of the thyro-cricoid ligament is completed, from be- hind forward, and from within outward. As by the act of inspi- ration the vocal cords move more or less outward, this movement should be carefully watched while making the incision of the crico-thyroid membranes to save them from injury. The canula- tampon is then introduced, and when in place, is moderately in- flated by an assistant, the operator measuring the degree of dila- 470 OPEBATIONS ON THE KESPIRATORY APPARATUS. tation with his fingers in the superior part of the trachea. When it is sufficiently expanded, a ligature is applied upon the India rubber tube, and this is cut off. Though the tampon is inflated, Fig. 412.— Arytenectomy. The second stej) is over. The crico- thyroid ligament, cri- coid cartilage, crico-tracheal ligament and the two first tracheal rings are divided. The canula and the tenaculum are in place— ,'L''' ^^^^^^ 7 7.-Lateral caudal artery lo lO.-Inferior caudaf nei v " i, ^1,^'l'^'f'' ^'"'^''T'- 9— Median caudal caudal veins. 12'.-One of the «,7t?«,X!;- , ^^•~,^™P.'^*tic glands. 12 12.-Superflcial aponeurosis. 14 14.-b°miUeXanosi8 muscle ^T% 'h~^or'''''' «* the Set^ cavernous muscle 17 17 —VinihX^^ muscle. 15.— Sphincter ani 16 16 — Ischln t^« P--- ^9J«--BulbLs''o"r'nt?r;rprbi?'artries'' ^.V 't"^?«-'^^°'^ Kentf ^ canal for urethrotomy, gi.— Anus. ^^- 80. -Incision of the urethral 560 OPERATIONS ON THE GENITO-URINARY APPARATUS. below the anus, but downward and on the sides, is is covered with short hair. Below the skin are found the two principal layers of aponeurotic covering, divided into the superficial and the deep. The former, of fibro-elastic texture, is the continuation of the dar- tos, and covers the perineal region, thinning down as it nears the anus, to disappear at the sphincter ani. Its most superficial fibres give attachment to a subcutaneous muscular fasiculus, which from the splineter ani runs downward to lose itself about three inches below. The latter plane, or deep aponeurosis is formed of white inextensible fibrous tissues. Intimately adherent by its external face to the superficial layer, it covers and unites with the accelerator urinse, and the ischio-cavemous muscles, as well as with the suspensor and retractor Hgaments of the penis. It then passes between the ischio-cavernous and the semi-membranosus, to attach itself above on the ischial tuberosity and become lost downward on the thighs. Some of its fibres directly surround the fixed portion of penis, and join the aponeurosis common to all the muscles of the flat of the thigh. The suspensor and retractor of the penis form, in the upper perineal region, that is, from the anus to the ischial arch, an ex- pansion of sufficient width to form a true anatomical layer. Below this they represent bands about half an inch wide, situated on the median line, and covering the accelerator muscle. They are formed of white muscular fibres. The blood-vessels and nerves of this region, with the other parts pertaining to the anatomy of the urethra, have already been considered. The peculiarity that belongs to the penis of ruminants must not be overlooked, when the question of urethrotomy in these animals is under discussion. Their penis is very long and thin, and is surrounded in the perineal region by a complete aponeurotic sheath, and on a level with the pubis it has two ciirvatures, which give to the organ the form of an S. On a level with the second curvature it gives attachment to the suspensory ligaments. The free portion of the organ is elongated, strongly filiform, and covered by a fine, rosy mucous- membrane. The pecuUarities possessed by the penis of the horse do not exist in cattle. The operation of urethrotomy is classified and designated with reference to the part of the urethra, which is to be divided, and this is of cotirse determined by the location of the body to be re- moved, making the designations principally regional; and it is UKETHROTOMY. 561 therefore said that tlie operation can be performed in three ways, though three jplaces would be the more accurate phrase. Thus we have first, the incision at the point of the penis, or 'preputial urethrotomy ; second, the division in the scrotal region, or scrotal urethrotomy ; and third, the incision below the anus, or ischial urethrotomy. Preputial Ueethkotomy. In horses and dogs the urethra becomes more or less con- tracted toward the full extremity of the penis, and calculi are therefore apt to become arrested in that locality ; in other cases, masses of sebaceous matter will collect in the navicular fossa. In sheep, saline concretions are found, either in the prepuce or in the urethra. All these conditions involve a contingency of surgical interference. To remove them in the horse and in dogs, a trans- verse incision is made with a bistoury over the spot where the presence of the foreign body is detected, and it is readily disposed of. If the erratic substance is in the urethra, an incision is made through its membranes and it is removed in entirety, or sometimes after having been reduced to fragments by means of a probe or of a curator. In sheep, the simple amputation is recommended by some. The wound made in these cases heals without trouble. Scrotal Urethrotomy, Scrotal urethrotomy ean be performed either on the front or behind the testicles. In cattle it is ordinarily posteriorly that the calculus is lodged, more commonly in the second than in the first curvature, and hence the indication for selecting this place for the operation. Yet there are practitioners who prefer the anterior sec- tion, because the penis being more superficial at that place, there is less cellular and adipose tissue to be divided before exposing it. In either case, the animal is thrown, with the hind leg carried forward and secured as for castration. If the operation is to be performed behind the testicular mass, an incision is made on the median Hne, measuring about three inches in length, the cellular tissue divided with the knife or the finger and the penis drawn out through the incision. The calculus is extracted through a longitudinal incision. The canal should then be examined with a probe or bougie, to ascertain whether any more offending bodies are present, and if so, they are of course also removed. The 562 OPEKATIONS ON THE GENITO-URINAKY APPARATUS. wound may be either closed by sutures, or, preferably, left without interference, to obviate the possible danger of the formation of future scrotal abscesses. In the pre-scrotal operation, the hair is first cHpped short, and an incision made through a transverse fold of the skin, to expose the penis. The concluding steps are the same as those in the former case. It is, however, always advisable, when the animal is secured, and before dividing the tissues, to insert the hand into the pre- puce to draw out the organ. By thus straightening it and remov- ing the S curvature, it is possible, and sometimes occurs, that calculi are displaced and extracted without the necessity of resort- ing to the knife. The urinary fistulas which are among the sequelse of scrotal urethrotomy, are of two or three weeks' duration, seldom continu- ing longer. Care must be taken to protect the skin from the irritation produced by the dripping of the urine through the wound. Ischial Ueethrotomt. This is the most common of the three operations, and is apph- cable to all males. It is performed vsdthout casting, with the animal hobbled on both hind legs and a twitch on his lip. (Fig. 470.) The decubi- tal position is seldom required. The free use of cocaine has enabled us to operate without any means of restraint, not only in horses, but in camels, which are very awkward and uneasy animals at the best, and esj)ecially when in the hands and under the knife of the surgeon. The insertion of a catheter has been recom- mended by many, to serve as a guide to the dissection of the urethra, while others prefer the artificial dilatation of the canal by the injection of water. In some cases, however, neither of these expedients is necessary. The presence of the calculus and the dilatation of the urethra above it, by the confined urine, greatly assists in the location and puncture of the canal. The incision must be made on the main line, on a level with the ischiatic arch. The structures to be divided are first, the skin, then the subcutaneous cellular tissue, the aponeurotic layers, and the accelator urinae; which being completed, a straight puncture can be made in the urethra between the two suspen- sory ligaments. The incision is then extended upward or down- URETHEOTOMY. 563 Fig. 470.— Secure for Ischial Urethrotomy. ward, as may be required, with the bistoury, guided by the grooved director, a blunt bistoury being sometimes chosen from the motive of prudence, in order to avoid possible injury to the surrounding blood vessels. In our experience we have secured very satisfactory results by adopting the method recommended by Bouley, of making one comprehensive pimctiu'e, which penetrates the canal without any preliminary dissection of the incumbent parts, esjoecially when a catheter has been placed in the urethra for the guidance of the knife. The hemorrhage, which generally accompanies this mode of operation is of no great importance, often subsiding of itself, and seldom requiring external hemostatic applications. We beUeve it to be the better course, when the object in view has been realized, to leave the wound to itself, without interfering with the healing process by seeking to facHitate it by the appHca- tion of sutures. It gradually granulates and closes without any special care beyond the observance of cleanliness and the neces- sary measures to prevent irritation of the skin from the contact of the urine as it "leaks " through the wound. When the urethra has been opened, in whatever region of the penis the offending foreign body may be lodged, it is readily 564 OPEKATIONS ON THE GENITO-UKINAKY APPARATUS. Straight. Curved. Figs. 471, 472.— Forceps to remove Foreign Bodies from the Bladder. extracted witli straight or curve forceps. These can also be em- ployed to secure those of comparatively small size that may be found in the bladder, and answer very well likewise for those masses of a sedimentary nature that are commonly seen in mares. There may sometime be some peculiar pathological conditions which render it necessary to prevent the closing of the wound in cases of ischial urethrotomy, and when the formation of a perma- nent artifical opening should, perhap, be attempted. The entire closing of the urethra, in its anterior portion, re- UEETHKOTOMY. 565 suiting from some special trauma- tism would be such a case ; or again, when the formation of calculi has become an estabhshed constitutional habit, and the results of this perver- sion of the nutritive and assimilative function are always present and con- tinually renewed. In view of this imfortunate state of things, and to prevent the closing of the wound, Troeber recommends the use of a pecuhar tube, which, when intro- duced into the urethra can be per- manently retained in place for an indefinite length of time (Fig. 473). We have attempted the formation of an artificial urethral opening, by sewing together the mucous mem- brane of the canal and the skin, but the results of the experiment were of the most transient character. Fig. 473.— Tube of Troeber, for Isclual Uretbrotomy in Bovines. CYSTOTOMY. Improperly known also as lithotomy, is an operation which consists in the incision of the neck of the bladder to remove cal- culi of dimensions too great for removal intact through the urethra. This operation has no longer a place in our surgery, and, in fact, there is no existing reason for its performance. If a calculus is of small or of medium size the neck of the bladder can always be sufficiently dilated to permit its passage, and if it should be of greater dimensions, and rendered impossible of ex- traction by its size, the operation of Hthotrity is always available, and in experienced hands as nearly certain and safe as can reason- ably be expected. LITHOTKITY. This term designates the operation of crushing, or piercing, or drilling stones in the bladder, in order to reduce them to frag- ments, preparatory to their removal by means of forceps or ciu'- ates, or by washing them out of the bladder with water. It mostly corresponds with, or rather, includes the lithotomy of 566 OPEBATIONS ON THE GENITO-URINAEY APPARATUS. Fig. 474.— Lithotritor of Guillon. human surgery. It was per- formed for the first time by H. Bouley in 1858, with the assistance of a practitioner of human surgery, Dr. Guil- lon. Horses are more specially the subjects of this opera- tion in cases when the cal- culi are too bulky and too hard to be broken and re- moved with the forceps alone. In ruminants, on the contrary, vesical calculi, though more common, and more numerous in single animals, are generally of sufficiently small size to permit the relief of the pa- tient by the simple opera- tion of urethrotomy. The instruments neces- sary for this oj)eration are the lithotritor, or lithon- triptor, with also the crusJi- ing forceps. The lithotri- tor of GuiUon (Fig. 474), or the crushing forceps of Bouley (Fig. 475), are those generally used. We are con- vinced by our experience of these instruments that the -. principal, and probably the only objection that applies to them lies against their mechanical construction. "We consider them to be too clumsy, too large and too heavy; objections, however, which are very easily obvi- LITHOTEITY. 567 ated by any competent instru- ment-maker. WMle they must necessa- rily possess sufficient power to crush the calcuU, we fail to see that a proper attention to the featiu-es of symmetry, finish, and convenience of manipula- tion can involve any sacrifice of efficiency. The instrument can be made to possess ample strength, while still more easy to handle when introduced in- to the bladder through the com- paratively small opening of is- chial urethrotomy. A bivalve speculum (Fig. 476) to dilate the wound of the urethra is sometimes of great value. A large syringe, and plenty of water, or what is better, an irrigator for douches to wash out the bladder, will complete the series of neces- sary instruments. The opera- tion is performed with the ani- mal in the standing position, secured as for urethrotomy, or cast if the operator so prefer it, and placed under the influ- ence of general anesthesia. "We borrow from H. Bou- ^^^- 475.— Crushing Forceps of Bouley. ley, the father of the operation, his own description of the modus operandi : Access to the bladder having been obtained by the process already described, the essential operation is divided into three principal steps : 1st. The introduction of the lithotritor, and searching for and grasping the stone ; 2d, crushing of the calculus ; 3d, removal of the fragments. 568 0PEKATI0N8 ON THE GENITO-URINAKY APPAEATUS. Fig 476.— Bivalve Speculum. 1st. Introduction of the instrument for searching and grasp- ing the stone. — This step varies with, the instrument, as to whether the lithotritor or the crushing forceps is used. If the first, the instrument, well greased and kept closed, is inserted through the urethral incision, with its concavity resting on the convexity of the ischial arch, and is pushed obliquely forward and downward through the pelvic portion of the urethra and the neck of the bladder. "When in this cavity the branches of the instrument are opened, and by a shght and slow movement made to traverse the cystic space until it comes in contact with the calculus, which then drops into the hollow of the branch adopted by its shallow form to receive it. The jaws of the instrument are then brought to- gether and the stone firmly secured. The same description, in every particular, applies to the ma- nipulation of the crushing forceps. In some cases, however, it is necessary to disarticulate the in- struments, and to introduce the branches sej)arately, unitiag them when both have been inserted. It is important, in every case, to leave a small portion of urine in the bladder to facilitate the movement of the stone and aid in its seizure without grasping and pinching the lining membrane of the organ. If the bladder is empty a portion of water might be injected. 2d. Crushing of the Stone. — This is done by slowly approxi- mating the jaws of the instrument. It is not necessary to reduce the stone to very minute particles. It will be sufficient if their dimensions are not too great to permit their free escape through the urethral passage. In removing the instrument after accomphshing the crushing, a great deal of the comminuted calculus is extracted between its jaws. 3d. JRetnoval of the Fragments. — Dilating the urethral wound LITHOTKITY. )69 with the bivalve speculum, a stream of water is then thrown into the bladder, either with the syringe or the tube of the irrigator. The water ought to be tepid and antisejptic ; and a hand intro- duced into the rectum and manipulating the bladder, will facih- tate the repulsion of the larger fragments, and the washing out of the smaller. The general attention required in all cases of serious operations will be necessary after the performance of lithotrity. In respect to any special dressing, they are the same as those in- dicated in simple urethrotomy. Serious, however, as this operation is, it is comparatively free from dangerous sequelae. Hemorrhages of easy control have been met, luinary abscesses, with infiltration, have occurred, serious wounds of the urethra, of the rectum and of the bladder may also happen, but they are of rare occurrence, and can be avoided by careful manipulation through all the steps of the operation. AMPUTATION OF THE PENIS. This operation is indicated in the horse when the penis becomes the seat of warty growths ; of epithelial, ^papillomatous, or can- cerous degenerations ; of fracture ; of paraphymosis, or of paraly- sis. Warty growths are usually found covering more or less the free part of the penis; or its free extremity; or the glans penis; and are also sometimes met with on the inside of the sheath, their presence being accompanied with an offensive and very irritating sebaceous discharge, becoming at times so painful as to interfere with mictiu'ition. They resist the severest forms of treatment, and it is not unusvial for them to develojD into forms of a more alarming natiu'e, notably those of chancroid degeneration, of which, in fact, these epithilial growths are but the seminal origin. In other cases the erectile tissue of the glans penis becomes the seat of ulceration, extending in depth, spreading in such a manner over the penis that the free portion of the organ becomes a mere mass of bleeding surface, of m-egular aspect, macerating in the pus which abundantly forms, and which escapes with its peculiarity of bloody saniousity, with the most repulsive odor and irritating effect, rendering the act of micturition most painful and difficult. In many instances the animal so dreads to bring his penis out of the sheath that he urinates within the cavity formed by the folds of the skin, adding another source of irritation to that already 570 OPERATIONS OX THE GENITO -URINARY APPARATUS. existing. And if the penis is still allowed to pass out of the sheath, the micturition is made with a crooked stream, which in- stead of escaping forward is, on the contrary, discharged back- ward. In such a case no treatment will reheve the difficulty but the removal of the entire diseased structure. In fractures of the penis ; in many conditions of paraphymosis ; or in those of paralysis, the organ hangs suspended outside of the sheath, and cannot be restored to its cavity. If pushed back it soon returns to its abnormal condition, and even if retained by artificial means, wiU continue in place only while the means are continued to enforce it, becoming displaced agaia whenever the restraining agency ceases to operate. This serves to render the animal useless, in consequence of its appearance being so repul- sive as to preclude his employment in public view. Of course the only radical cure for such an ailment is the knife or its equivalent. The operation usually consists in the removal of the free por- tion of the penis, the necessity for going beyond this seldom occurring, yet in order to reach the diseased part it is sometimes necessary to divide the sheath along the median line. The general anatomy of the organ, as far as it relates to the operation, is very simple. The penis it formed by the corpus Fig. 477. — Penis in Normal Condition. cavernosum, a long, erectile structure, flattened from side to side, and grooved on its inferior border for the reception of the corpus spongiosum urethrse. Terminated inferiorly by a blunt point, this corpus cavernosum dips into the erectUe tissue of the urethra. After passing out of the pelvic cavity, by the ischial arch, the spongious portion of this canal, is received into the groove of the corpus cavernosum, at the anterior part, and also extends beyond it. The mucous membrane is covered externally by the tissue AMPUTATION OF THE PENIS. 571 which gives to this part of the urethra its name, and this erectile tissue terminates anteriorly in an enlargement, more or less developed, forming the head of the penis, or the glans penis. The urethra proper protrudes a Httle below the center of the head of the penis, and shows in a cavity underneath, the urethral fossa, more or less filled with a sebaceous secretion. The blood vessels which ramify in these erectile structiu'es are the two dor- sal arteries of the penis, anterior and posterior, and the veins, which form large branches, running also upon the dorsal border of the organ. Zundel very wisely insists upon two principal conditions (to which we shall again refer) to realize in the operation, first to manage to leave a free means of exit for the urine, by cutting away less of the urethra than that of the cavernous body, and second, to avoid the hemorrhage, which is especially liable to take place in horses, on account of the abundant circulation in the erectile tissues. The animal if to be placed in the recumbent position, as in the operation for castration, that is, on the left side ; or it may prove advantageous to place him on his back. Five modes of operation are described by different writers on the subject — 1st, the ligature; 2d, cauterization; 3d, excision; 4th, by scraping; and 5th, by cnishing. As an adjunct to the various instruments which these different operations may require, metallic catheters are also necessary. The Ligature. — The catheter being introduced into the urethra, beyond the point where the amputation is to be made, a strong ligature is applied at that point and tightened sufficiently, if pos- sible, to strangulate the portion of the penis which is to be removed. After from twenty-four to forty-eight hours, the external layers of the tissues will have become mortified, even to a certain depth in the penis, and a new ligature is then applied, and strongly tied like the first one. The deeper layers of the penis are also, after a day or two longer, so mortified that they continue attached to the tissues above the Hgature only by a small particle, which can be divided with the knife. The catheter may then be removed or it may be allowed to remain in place a few days longer. No special subsequent treatment is required. If, after a few days, micturation seems to become difficult, the urethral opening may be enlarged by the introduction of a bougie 572 OPERATIONS ON THE GENITO-URINAEY APPARATUS. or a catheter, or again enlarged by an incision with the bistourj'. Instead of the ordinary string, an elastic ligature may be sub- stituted with the advantage of maintaining an uninterrupted pres- sure upon the tissues up to the moment when mortification is established in the part to be amputated. Cauterization. — No catheter is required with this plan. Two ligatures are apj)lied, one anterior, by which the penis is kept out of its sheath, and one posterior, acting as a hemostatic, placed above the point where the division is to be made. The operator then with a flat and sharp cautery, heated to white heat, makes a complete section of the penis. But, says Zundel, " as the urethra is especially dehcate and sensitive, it is better, in order to avoid its retraction, to separate it from the cavernous body about half an inch in front of the place where the section is made." A hollow bougie of india rubber inserted into the urethra will also prevent its contraction. Professor Nocard has recommended the use of the galvano- cautery, to obtain an easier division of the tissues, a more perfect hemostatis and to shorten the duration of the operation. Excision. — After introducing a metallic catheter, a rapid sec- tion of the organ is made by a single stroke of the knife. Again, says Zundel, " when the urethra is reached, it must be dissected a little forward, toward the glans penis, and caused to protrude about half an inch beyond the point cauterized." Scraping of the penis. — This method, which was put in prac- tice in 1829 by Moiroud and Delafond, consists in scraping the penis with a bistoury, in such a way that the remaining portion of the organ forms a cone, with its apex formed by the urethra. A catheter may be introduced into the canal previous to the opera- tion and left in place for awhile ; or again, it may, if thought proper, be entirely dispensed with. This mode precludes the danger of hemorrhage. Crushing. — By operating with the ecraseur, the amputation is perfected without danger of hemorrhage. The chain of the instrument is applied at the point of amputation, and by slow and gradual action, cuts through the tissues until the diseased part drops off. The danger attending this method is that the chain may break during the |)rocess, in consequence of the resistance of the cavernous tissue. This accident has certainly been encoun- tered by many practitioners, and we have ourselves witnessed it AMPUTATION OF THE PENIS.. 573 in two instances. On one occasion it was found necessai'y to re- place the chain twice, and to complete the amputation with the knife. Reynal has modified the crushing operation by making the action of the ecraseur slower. He has invented a small instru- ment (ecraseur) which is left in place for two or three days, being tightened every day, or several times a day, until the mortification is complete, and the diseased penis sloughs off. In this method, a metallic catheter is placed in the urethra ; in the other the catheter is not required. In reflecting upon the various modes of operation we have thus described, and noting especially the two very important, and indeed, essential requirements referred to by Zundel, in respect to the matters of micturition and hemorrhage, we are struck with the fact that in none of those methods are these obvious require- ments complied with, or if they are, it is in a manner so faintly imphed, and so indefinite and unsatisfactory as to be scarcely intelligible, and certainly to leave no distinct impression on the mind, of the importance of the points referred to. In every case the danger of possible subsequent interference with micturition is threatened, whether the catheter is used during or after the operation, or even, we fear, if left in the passage " at least two months," as recommended by Peuch and Toussaint. We can remember cases of our own which, with even a longer retention of the catheter, were followed by failure. We have attempted the formation of an artificial urethral opening below the ischial arch, and with no better result. We are tempted to believe that the hemorrhage is less danger- ous than many think, and we believe it could be controlled by ordinary pressure, or by plugging the sheath afterward, or by still other means of hemostasia. Taking all this into consideration, we cannot but think strange of it, that the process used in human surgery, which we find merely mentioned in some European woi'ks, but which we believe has been performed by Gerlach, and which we ourselves adopted more than fifteen years ago, should be practically ignored or rejected by writers as well as practitioners. We have practiced it during the period mentioned without having encountered the slightest comphcation or troublesome sequelse. We refer to it as the only safe, and as, therefore, the best mode 574 OPERATIONS ON THE GENITO-URINARY APPARATUS. of operation for the amputation of the penis. It differs from any that have been previously recommended, and is as follows : The animal being prepared for the operation in the ordinary way, the penis is secured with a ligature at its end and drawn out of the sheath, and another ligature tightly applied on the upj)er part of the organ. An incision of the skin covering the penis is made entirely around the organ and down to the cavern- ous body, with the precaution of drawing the skin slightly back- ward, so that when the amputation is completed, and the skin allowed to return to its position, it will sHghtly overlap the stump of the penis. We divide the cavernous body, carefully avoiding injury to the urethra, and when this organ is reached it is dissected from its groove forward into the cavernous body (Figure 477a) for a Fig. 477a. —Amputated Penis, with the Urethra Protruding. length extending between one and one-half to two inches, when the division across the urethral canal completes the amputation. The removal of the diseased tissue being thus made, we have before us the stump of the cavernous body, almost dry, the hemorrhage being prevented by the upper ligature, which moreover, seciu-es a good hold and good view of the mutilated organ. The urethra is then slit on its inferior border on the median raphe and both flaps turned upward and brought in contact by interrupted sutures with the skin which has been so divided as to overlap the stump (Fig. 4775). These sutures are made close to each other, of strong s ilk or catgut. The res'ult is that the stump of the penis carries at its lower margin a sht of from one to one and one-half inches in length, which, after allowing for all shrinkage of cicatricial tissue, will always be sufficient to permit thorough micturition. AMPUTATION OF THE PENIS. 575 Pig. 4776,— Stump of Amputated Penis, with Stitches uniting Urethra and Skin. The sewing done and tlie upper ligature removed, the penis re- tracts within the sheath, and the animal is allowed to rise. We have been performing this operation for fifteen years, and have never yet met with the slightest compHcation or disappoint- ment. In dogs the amputation of the penis is indicated for about the same diseased processes as in the horse. The amputation, however, does not include only the soft tissues, but also the bone of the penis, which is divided with nippers or a saw. The division of the cav- ernous body is done with the ligature or the ecraseur. Strictures of the urethra are of common occurrence after this operation, and can be overcome only by the repeated introduction of the catheter, or the enlargement of the urethral opening with the knife. CHAPTEK Xni. OPERATIONS ON THE FOOT. ANATOMY. In our domestic animals we call the foot the extremity of the leg, and even only the extremity of the digit, for, considered in a zoological point of view, the foot extends from the carpus or tar- sus to the last phalanx, inclusive. The foot of the horse forms an extremely important study on account of the numerous diseases to which that member is sub- ject, and also of the value of the motor powers required from the horse ; the old horsemen expressed this importance by the aphor- ism, "no foot, no horse." This truth finds daily its sad applications in the prematiire ruin of large numbers of horses rendered useless because of the defects in their feet. All the quahties of a horse are, indeed, considerably diminished and can even be entirely destroyed, by the bad conformation or accidental alterations of these essential organs. The study of the foot of the horse has been the object of many voluminous works, such as those of Gir- ard, Bouley, Bracy, Clark, Anker, Leisering & Hartman, Lafosse, Gourdon, Reynal, Defays, and many others, to which we refer for the more complete description of the organization of the foot. The organ is composed of two orders of parts, some internal, organized and sensitive ; the other external, formed of a horny, organic substance, the hoof, but entirely void of the property of ^atal sensitiveness. The internal parts are bones, three in number, the second and third phalanges, and the small sesamoid, which form by their reunion the articulation of the foot ; special liga- ments, which maintain the connections of these bones ; tendons, which fill the triple office of agents of transmission of motion, articular ligaments and organs of support of the weight of the body; a fibro-cartilaginous apparatus, superadded to the third phalanx, and which completes, so to speak, posteriorly, and increases the surface by which it rests on the hoof and transmits ANATOMY OF THE FOOT. 577 Fia. 478.— Longitudinal Section of tlie Digital Region. A.— Lower part of the plantar cushion. B.— Ligamentous bands of the fibrous layers of the plantar cushion. C— Fibrous membrane of the plantar cushion. D.— In- sertion of the plantar cushion to the inferior face of the os pedis. E.— Spongy tissue of 08 coronse. F. — Articulation of first and second phalanx. H. — Perforatus tendon at- tached to the OS coronae. I. —Insertion of plantar aponeurosis to the semi-lunar crest. K.— Spongy structure of os'suffraginis. L. — Section of perforatus tendon. M.— Yellow fibrous band uniting the anterior face of the perforans tendon to the posterior face of the 03 coronsB. N. — Synovial sac of the sesamoido-pedal articular. O. — Tendinous sesa.- moid sheath. P. — Synovial capsula of the articulation of- the foot. T. — Perforans ten- don. Y.— Metacarpo-phalangeal joint. to the ground the pressure which it receives. These are the lat- eral cartilages and the plantar cushion ; arteries, veins, lymphatics and nerves, remarkable for their number, development and dispo- sition; and at last, a ligamentous, sub-horny membrane, or kera- 578 OPERATIONS ON THE FOOT. Fig. 479.— Plantar Nerves in Digital Region. P.— Plantar nerve. A.— Origin of the digital nerves. BB.— Cartilaginous branch. C C— Cutaneous branch. D —Digital artery. G.— Transverse branches back of the fet- lock joint. I. — Nerve of the plantar cushion. L. — Lateral band of the plantar cushion. v.— Digital vein. togenous apparatus, forming a continuation of the skin, whicli surrounds the parts of the foot like a stocking, and upon which the foot rests, as a shoe on the human foot. In this ajsparatus are found : 1st, the coronary band, which forms a rounded projection at the separation of the skin and hoof, and which serves as a matrix to the periople and the wall ; at its surface are seen numer- ous villosities or papillae ; 2d, the podophyllous or laminated tissue which is spread upon the anterior face of the third phalanx, and is remarkable by the sheet of jjarallel laminge which it presents at its svirface, separated by deep furrows in which are received the analogous laminae of the internal face of the wall (Figure 481) ; ANATOMY OF THE FOOT. 579 Fig. 480.— Arteries of the Digital Region. AAA.— Digital artery. B.— Transversal branch in front of fetlock joint C— Per- pendicular artery of Percival. D.— Its ascending branch. E.— The descending branch. F.— Branch to form the superficial coronary circle. G.— Posterior transverse branches. K.— Artery of the plantar cushion. P.— Circumflex artery, C C— Ascending terminal branches of the digital artery. 3d, the velvety tissue or villous tunic which covers the plantar cushion at the interior face of the foot, and is the secreting organ of the sole and frog, its surface covered with villosities similar to those of the coronary band, and like them, of various sizes, are lodged in the porosities of the internal face of the sole and frog. The external parts of the foot are four in number : the wall. 580 OPEBATIONS ON THE FOOT. I /„ I Fig. 481.— Portion of the Keratogenous Apparatus. A.— The skiu. B B.— Coronary band. R.— Its villosities. P.— Podopbyllous tissue. 6f 7 Fig. 482.— Section of the Hoof. l._Periople. 2.— Cutigeral cavity. 3.— Keraphillous tissue. 4.— Wall. 5.— Contin- uation of the periople with the frog. 6.— The sole. 7.— Union of the sole and wall. &— Frog stay. the sole, the frog and the periople (Fig. 482). These form, together, a horny box, the nail, or hoof, which is adapted exactly by its internal cavity to the external contour of the sub-horny membrane, contracting with it an intimate union by a reciprocal reception, and thus completing the structure of the foot, furnish- ing to the sensitive parts an apparatus, thick, hard, resisting and at the same time elastic, which makes one with them, and protects them against violence from the substances with which the foot, from the nature of its function, must necessarily come in contact. ANATOMY OF THE FOOT. 581 The homy substance which constitutes the hoof has a fibrous aspect ; it is hollowed all over by cylindrical canals, whose superior extremities, widened into a funnel shape, cover the papUlse of the matrix of the hoof, either at the coronary band or velvety tissue, while the inferior open in the wall upon the plantar border, in the sole and frog, at the external or inferior face. These canals are rectilinear, except those of the frog, which are flexuous ; their diameter varies from 0, 02 to 0, 2 or O^"-"- These tubes are not only hollowed in the horny substance ; they have also proper waUs, of very great thickness, formed of numerous concentrical layers, received into each other. These are lamellae of pavimentous epithelium, which constitute the horny tissue ; in the walls of the horny tubes, they are grouped flatwise around theii* inferior canals, and stratified from within outward, so as to form successive and concentrical layers; in the intertubular horn, these lamellae are not stratified in a direction parallel to that of the tubes, but at right angles with it. Ai'ound the tubes, the lamellae have an oblique intermediate dii'ection. A granular opaque substance fills up the space lying between the horny tubes and the papillae. The hoof, which is a part of the epidermis, develops similarly, that is, by the constant formation of cells in the layer which cor- responds to the mucous malpighian body, at the expense of the plasma thrown off by the numerous blood-vessels of the keratoge- nous membrane. The velvety tissue is the starting point of the elements of the sole and frog ; the periophc band is the organ secreting the periople ; and the coronary band proper, the matrix of the wall. Upon these different parts, the epithehal ceUs multi- ply and flatten into lamellae, in the direction of the surface of the keratogenous membrane, as they spread from it. The wall then grows from its superior to the inferior border, and the other parts of the wall from their internal to their external face. The villosi- ties of the coronaiy band and of the velvety tissue are the organs around which accumulate the epithelial cells ; their presence defines, consequently, the tubular structure of the horn. The laminae, in the physiological state, do not co-operate in a sensible manner with the formation of the wall ; the keraphyllous laminae form themselves at the coronary band, at the origin of the podophyUous ; they descend with the wall, gUding at the surface of the layer of cells which separates them from the laminated tissue, a movement of descent which is f acihtated, however, by the 582 OPERATIONS ON THE FOOT. mviltiplication in the same direction of the said cells. When the podophyllous tissue is inflamed, whether exposed or not, its latent activity soon manifests itself. It gives rise to a great quantity of hard horn, hollowed, as seen by Gourdon, with tubes, and oblique in a direction backward. These tubes, more irregular than those of the normal wall, are disposed in a parallel series ; they are in form round, villo-papillae, which have developed on the face border of the laminae. In these cases of production of horn by the action of the podophyllous tissue alone, one never sees, between the sensitive laminse, distinctly formed horny laminae in the middle of the other cells, as it is observed in the wall proceeding from the coronary band. The horn which rises on the surface of the podophyllous, immediately after the removal of the piece of the wall, is not a permanent one ; it must be replaced by the horn of the coronary band. -This change is complete, microscopical examination proving that the wall which descends from the coronary band, provided with keraphyllous laminae, engages itself under the temporary wall, and slides by the action already described over the surface of the soft cells of the laminated tissue. As soon as this tissue, modified by inflammation, is covered over by the permanent wall, its papillae become atrophied, and its action returns to the limited boundaries of physiological condition. — {Chauveau.) The foot is an organ of support and an apparatus of elasticity; it is through it that the whole animal machine maintains its rela- tions with the ground, and that it adapts itself in its various move- ments, so to speak, to its roughness. It is this that, as a last spring, distributes and modifies the force of aU the movements of the horny mass of the body, whose columns, the legs, may be considered as the resultant. Intermediate with the body and the ground, the foot transmits aU the actions of weight reaching it, and also between the. body and the sensorium, toward which all sensations resulting from its contact with surroimding external substance return, the foot then becoming at the same time an organ of feeling. To adapt it to this triple formation, nature has given to it three properties, in appearance incompatible with each other, which has, however, harmonized, viz.: first, a very great external hardness, due to its horny envelope ; second, a certain amount of flexibility, the combined result of the physical properties of its cortical envelope and of its mechanical disposition of its different ANATOMY OF THE FOOT. 583 parts, and thirdly, a highly developed sensibility resulting from the high organization of its tegumentary membrane. — Bouley. DISEASES AND DEFECTUOSITIES OF THE FOOT IN SOLIPEDS. Of all the domestic quadrupeds, the horse is the most exposed to diseases of the foot, which are more or less frequent in him according to the work he is subjected to, the places he Hves in, and the nature of the ground upon which he travels. As rare as are those accidents in farm horses, so common are they among horses in cities, of heavy draught, and also army horses ; in aU, in fact which travel continually on hard, paved and stony roads, and especially in large cities, where all those injuries can but be the result of their constant work on stone pavements, always so rough and sHppery. If to these conditions are added the very numerous accidents resulting from bad shoeing, so badly carried on, one will be less surprised to see the foot becoming deformed and altered in different ways, deteriorated, and preserving with difficulty, and for a short time, its state of integrity, and becoming the seat of numerous affections. We shall distinguish the diseases proper and the vices of conformation of the foot. The former are generally sufficiently serious to merit special description. Among them some are su- perficial, as the false quarters, uncomplicated cracks, or solution of continuity, thrushes, canker; others of deeper interest, specially those of the keratogenous apparatus, such as laminitis, with its complications and sequelae, keraphylocele, seedy toe, and separation of the wall, which may extend as far as entii'e sloughing of the hoof ; accidents then due to the suppuration accomj)anying several diseases of the foot. Some maladies are specially the effects of wounds, of contusions such as overreaching, quittor, bruised sole, bruised heels, corns, pxmctured v)0U7ids; others are results of shoeing, pricked, tight shoe, burned sole; others are deep alto- gether, such as bionions, navicidar disease, and, lastly, fracture of the OS pedis, or of the navicular bone. VICES OF CONFORMATION. Among the vices of conformation some are serious, as contrac- tion of the heels, flat foot, pumiced foot, club foot, crooked foot, rammy foot, and, lastly, the foot xoith bad horn. 584 OPERATIONS ON THE FOOT. (a) Flat foot (Germ. Platfuss). — By this is understood the foot in which the sole, instead of having the natural concavity, is, on the contrary, flat, and by its whole svirface about on a level with the border of the wall and the base of the frog ; ordinarily this is accompanied with low heels, more or less contraction, and a well-marked oblique direction of the wall. Flat foot is generally observed only on front feet, and is very common in lymphatic animals or of low breed, raised in low and damp soils ; it may be congenital. Large feet, badly shod or used up by very heavy work, are predisposed to it. It is claimed that the weakening of the sole by too repeated and deep paring of the sole wiU ultimately bring it on ; it is said that abuse of poultices may produce it ; it follows excess of the hollowing of the shoe by the upj)er surface, which, pushing the wall outward, obliges the sole to drop lower than its normal level. The horse with flat foot rests on all parts of the sole at once ; there is no elasticity of the arch of the sole, and percussions take place on it entirely. The actions of the animal are heavy, espe- cially as it is commonly seen when the feet are large. When the foot is somewhat tender, the animal lames easily, especially if the shoeing is bad, or if the animal rests on the sole or is obliged to trot on rough or stony roads, which render the percussion very painful. There arises some irritation, which keeps on increasing, and produces several accidents, such as bruised sole, corns, pumiced feet. The horse which has flat feet often has weak walls, and as the nails of the shoe become loose, this is often cast. By shoeing one may remedy this bad condition of the foot. For this, the foot must be pared flatways, the sole spared, the wall relieved only of what is broken off; the frog must be left alone, the heels also ; a shoe somewhat wide in the web, protecting, therefore, the sole more than an ordinary shoe does. It will be adjusted so as to rest on the border of the wall only, and not on the sole ; stOl, care will be taken not to hollow it too much or to excess. Sometimes a thick shoe only is necessary, without in- creased width. Soles of gutta-percha or felt are also used, as we will see when speaking of the pumiced foot. (b) Pumiced foot (Germ. Vollfuss). — Thus is called the foot whose sole projects beyond the level of the wall, and presents a convex surface, extending beyond the plantar border, upon which ANATOMY OF THE FOOT. 585 the horse rests. It is the exaggeration of the flat foot. In the pumiced foot the wall has a great obliquity, sometimes even assuming a nearly horizontal direction. The horse is never born with such feet ; this is a malformation, accidental, or resulting from various causes. One of the most common is lack of care of the foot, of necessary caution, for instance, ia paring, or shoeing in such a way as to bring the rest of the foot on the circumference of the under part in such a way that the sole does not touch the ground, and ceases to be pressed by it. Too much concavity of the shoe may bring on this result, by resting only on a too narrow part of the inferior border of the foot ; and by opposition, not enough concavity will compress the tissues, irritate them, and produce the same alteration. Feet become pumiced by laminitis, but this is complicated with seedy toe. Never, then, is the foot pumiced ia its whole extent ; its deformity stops always at the limit of the inferior border of the bars ; beyond them, behind, on each side are seen the excavations of the lateral lacunae of the frog, so much deeper that heels are higher. The hoof does not preserve its circular shape. It atro- phies on the side, and presents at the toe an excess of thickness in the wall; the heels assume a greater development. This deformity is very serious, and disables the horse easily ; rest takes place only upon the sole and frog ; after laminitis, upon the sole and heels ; it is always very painful. "Work upon hard ground and pavement is next to impossible. After laminitis, one sees, during walking, that the foot rests upon the heels, and then by a motion from backward to forward. An animal with pum- iced feet has a tendency to forge and interfere; the slightest bruise of the sole gives rise to serious complications. One often observes wounds, suppurations, etc. The indications are analogous to those of the flat foot ; the sole ought to be spared as well as the frog, the walls only ought to be slightly trimmed ; the shoe must be made so as to carry the rest upon the border of the wall and protect the sole. A\Tien the foot is not pumiced to excess, one must use a broad web shoe, sufficiently concave to allow the sole to rest in it ; but it must not be too excessive, as then the base of the rest would not be very firm. A sheet of gutta-percha, or felt, with tar and oakum, may be placed between the shoe and the foot. (c) Clubfoot (Germ. Bockhuf). — This is the foot in which the 586 OPEKATIONS ON THE FOOT. wall is straightened more or less perpendicularly, or even obliquely backward, so that the superior border of the wall is more forward than the inferior. The superior levers participate always in this vicious direction, which constantly brings back the rest of the foot toward the anterior part of the wall, and, according to its degree, makes the animal walk more or less on the toe, even some- time obliging him to rest on the anterior face of the hoof ; the heels are raised from the ground, and the fetlock, instead of being open forward, seems to be turned backward. This deformity, which exists especially in the hind legs, is very common, and is even natural in mules, and supposes, with its presence, high heels, which throw the rest on the toe, which is always very thick. It may also exist with low heels, especially when due to overwork or other accidental cause. Horses which, like mules, are club-footed only by a peculiar condition of the parts, walk with firmness, and even pull better and work better in hilly countries. If they are unfit for the saddle, it is because their reactions are hard, and that they tire the rider. It is not so with those which are club-footed from hard work ; they continually stumble, are subject to knuck- ling, to interfering, or even to falling ; and for these reasons do they always require a mode of shoeing which would give them the missing solidity, and render their walk more steady. This cir- cumstance indicates the necessity of sparing the toe, and throwing the weight back on the heels, which, however, must not be pared off too much. The best shoe for such feet must be short, thin at the heels, with a thick toe, slightly raised upward, and prolonged beyond the level of the border of the wall ; small heels to the shoe are often advantageous, as giving an opportunity for rest and relief. The shoe with truncated branches of Lafosse (slipper), which is a short shoe, not extending beyond the quarters, and leaving the heels free, is sometimes used. This shoe is very thick at the toe, and very thin at the heels. It is unnecessary to say that club foot is often cured by tenotomy, or by treatment of the tendinous retraction. (d) Crooked foot. — ^We call by this name the foot whose sides are not of the same height ; it may be crooked outward or inward. This deformity may result from a vice of direction of the regions above ; ordinarily, however, only from a deviation of the phalan- geal one. Sometimes it is due to bad shoeing, to bad paring of the feet ; sometimes it follows unequal wearing of the foot, it being ANATOMY OF THE FOOT. 587 without shoe. Colts which have never been shod, and are walking for a long time on hard and rough ground, often present this con- dition. The horse with crooked feet inward, specially if the deviation is much marked at the toe, is exposed to cut himself with the internal heel of the shoe — to bruise himself ; the horse with crooked feet outward cuts himself with the inner toe. Besides these, lameness, from lacerations of articular ligaments, may often follow. This is relieved, especially in young animals, by lowering the side of the wall which is the highest, and sparing the other ; the proper shoe for this condition must be thicker in the branch cor- responding to the lower side of the foot. The shoe ought to be changed quite often, in proportion to the existing difference in the height. If the foot is very crooked, it is difficult to straighten it by having a greater thickness of the shoe ; it would make this too heavy. Sometimes it is better to use nails with large-sized heads on the lower side of the hoof ; and in these cases one might put on corks at the heels, external or internal, as required. (e) Mammy foot. — This is a defectuosity of the foot, always accidental, in which the surface of the waU offers more or less numerous circles, above each other and running from one quarter or heel to that of the other side. These roughnesses, arrranged in rows, rise always from the coronary band, and form as many elevations gradually descending and disappearing toward the in- ferior border of the wall. They are so much more serious that they are deep, and sometimes are accompanied with lameness, especially when in great number, close to each othei-, and when the foot is narrow and long. These circles are sometimes seque- lae of laminitis, and accompany seedy toe ; the rings are then in the middle of the toe, which is more or less roughened, Hke an oyster shell, and they disappear only when the primitive alteration is removed. When they are smaU, not numerous, and grow down without being replaced by new ones, this favorable disposition of the wall must by stimulated by all the means which may stimulate and keep up the suppleness, by light bUsters over the coronet. A light shoeing, often changed, is the best in those cases. Circles which reappear continually are due to an intimate and continued alteration, and are in company with other defectuosities, such as contraction, pumiced foot, etc. (/■) Foot with bad hoof. — A hoof may be too soft or too dry. .'v88 OPERATIONS ON THE FOOT, When too soft, too greasy, it contains too much dampness and is lacking resistance. Horses which have this weak hoof, as said Laf osse, have the foot tender and unfit for long walks on hard and stony ground ; they are, besides, much exposed to lose their shoes, because the hoof breaks up at the nail-holes. This fault is quite common in large feet, frequently seen in Northern lymphatic ani- mals, especially in those which come from marshy districts ; if, then, those horses are submitted to stabulation, their hoof becomes dry to excess, which gives rise to narrow and contracted feet. The lower part of the foot must be pared with care, as it has but little thickness ; the appHcation of the warm shoe while fitting must be as short as possible. An ordinary thin and light shoe must be used ; the nails will be as Hght and thin as possible, and ham- mered in carefully. Too dry hoof is liable to break, because it has lost its physio- logical suj)pleness ; this brittleness is often met ia animals whose feet have been much in water and afterward are placed on dry ground ; it seems as if the water had dissolved the adhesion of the horny cells. The same condition follows the excessive use of poultices and also of strong grease in shape of ointments. It is wise to grease, but previously the old crust must be removed. Hoof ointments of wax, turpentine or tar are better. The foot is called derohe (broken) when by the use of a thick nail it is more or less broken at the edges of the wall. These feet lose the shoe easily ; animals then go on bare feet, and then it becoraes very difiicult to put other shoes on. It is necessary in these cases to punch nail holes on the shoe corresponding with parts where the hoof is sound. In paring, all the pieces of broken horn are removed, or at least as much as can safely be done. Nails are secured as high as possible ; shoes must be changed as often as possible, and the hoof is to be kept supple by unctuous applica- tions. When the breaks of the horn are too large, softened gutta- percha, or a mixture of gutta-percha three parts, with one of gum ammoniac, melted together, can be used to fill the anfractuosities, all grease having been first removed by a wash with ether ; the putty hardens, and the shoe can be tacked on solidly. Nails can even be punched through the gutta-percha. ANATOMY OF THE FOOT. 589 Instruments. The surgery of the foot requires siDecial instruments for the operations which influence aetion upon the hoof, as also for those which are to be performed upon the tissues of the foot proper. Besides those which are commonly required in ordinary sur- gery, such as curved scissors, probes, bistom'ies and forceps, others are needed of special forms and for special purposes; among those most commonly used are the different sage knives and drawing knives. Sage knives are lanceolated blades secured to handles, and are either double or right or left. The blade, which is curved upon its long axis, may be sharp on both edges, as in the double, Fig. 485. Fui. 484. SAGE KNIVES. Fig. 483. (Fig. 483) or on only one or other edge, when it is known as a right (Fig. 484) or left (Fig. 485) sage knife, being thus adapted to use by either the right or the left hand. Drawing knives, which are made somewhat like those used by blacksmiths in the ordinary method of paiing the foot, yet differ from those in being straighter in their attachment 'to the handle, and also on being curved on their long axis, being also sharp on both edges. The groove of the instrument is made to vary in 590 OPERATIONS ON THE FOOT. width, and thus can be used as the different steps of the operation may require (Fig. 486). Sometimes the drawing knife resembles more that of the blacksmith, as being sharp on one edge only (Fig. 487), and in this case the groove of tTie blade is generally much narrower than in the others. Some special operations require peculiar forms of drawing knives ; for instance, those which are Pig. 487. Figs. 486. DRAWING KNIVES. Fig. 488. made with a blade perfectly straight and narrow, very slightly sharp on the edges, but having a very narrow groove at the ex- tremity (Fig. 488). These are used principally in the scraping of diseased bone-structure, in deep punctured wounds of the foot, and in cartilaginous quittor, when small sections of cartilage are to be removed from the lateral border of the os pedis, which could not othewise be accomplished. Other instruments are also required, the description of which will be given as we refer to the different diseases where they find their applications. Genekal Operations. Removal of the sole (Germ. Absohlen). — This is an operation by which the sole of the foot is removed by severing it from the living tissues underneath. In times gone by this operation was extensively performed, being considered indispensable as soon as the slightest lesion under the sole existed. It was alleged that ANATOMY OF THE FOOT. 591 vmless this was done the suppuration would be likely to spread underneath the horn. In our days it is rarely performed, as it is considered that it presents but Uttle advantage, so far, at least, as it involves the removal of the entii-e organ. Sometimes, however, poi-tions of it have to be taken off, as in some special diseased con- dition of the foot, such as in punctiu-ed woimd, pricking by the blacksmith, burnt sole, etc., the modus operandi of which will be considered when treating of these diseases. Itemoval of portion of the locdl. — A few morbid conditions of some parts of the foot require ia their treatment the removal of a portion of the wall, in order that the escape of pus, the removal of diseased tissue, or the sloughing of necrossed cartiliginous or bony structure, as in complicated cases of suppurative corns, of quarter-crack or in cartilaginous quittor. A similar operation is sometimes requu-ed in cases of toe-crack, complicated with disease of the OS pedis. These will be further considered when treating of these special subjects. Dressings. As nearly every operation of the foot requires a mode of dress- ing pecuhar to the manipulations which have been necessary, we shall, when speaking of the different diseases, where parts of the walls have been removed, iuclude also a description of the peculiar dressing they require. There is one, however, which is thought much of in veterinary surgery, and of which we will have to say more when speaking of punctui-ed wounds of the foot. This is the dressing with plates, which serve to retain the plantar surface, the balls and pads of oakum, which are placed to protect the wound. The application of these plates is far superior to the leather sole, because of its easy removal when the parts are being examined, and of their easy replacement ; thus allowing the surgeon to change the dressing whenever he sees fit, without being obliged to remove the shoe. DISEASES. Canker of the Foot. (Germ., Strahlkrebs, Hufkrebs). — Under this somewhat un- scientific,* though accepted name, is designated a pecuhar disease * Crwpaud of the French. 592 OPERATIONS ON THE FOOT. of the feet of solipeds, seated in the secreting tissues of the horny box, always beginning at the frog, and characterized by alteration of the homy secretion. Names of a more scientific meaning have frequently been proposed, such as gnaioing ulcer (Bourgelat), schirrus or cancerous carcinoma of the frog, carcinoma of the reticular tissue of the foot (Vatel), darter of the plantar cushion, chronic podoparenchydermitis (Mercier), and epithelioma of the frog (Fuchs). None of these has ever been accepted, and the old hippiatric name has been retained. History. — It is conceded that the old veterinarians were ac- quainted with canker, and Vegetius evidently speaks of it, but not until the time of Solleysel do we find a description somewhat complete of the disease and its treatment ; Garsault, La Gueri- niere, Weyrother and others spoke of it, and have expressed various opinions as to its etiology, and especially as to its treat- ment. So little progress was discernible in the writings of Bour- gelat, Chabert, Huzard and Girard, on that very question, and so many false ideas were admitted, that Chabert in despair has called canker the opprobrium of veterinary medicine. It is but recently that serious research as to the nature of the disease have thrown some hght on the question, and estab- lished the important fact that its seat is not in the disorganized horn, but in the secreting organs, and that there is an alteration in the products of this secretion ; that it is consequently to these that remedies must be applied. We might refer to the writings of Jeannie, Crepin, Hurtrel d'Arboval, Prevost, Mercier, Plasse, Percivall, Dietrichs, Eichbaum, Wells, H. Bouley, Reynal, Haubner, Fuchs, Rey, Megnin, etc., each of whom has furnished his contingent, while stiU. the inti- mate nature of the disease remains but imperfectly known, and there is but little certainty either in the treatment or its results. Let us observe, however, that in our day canker has become comparatively a rare disease, especially in cities, which, doubtless, is because of the cleanliness of the streets. In the beginning of this century, canker and grease — closely related diseases — were frequent in Paris; then horses were obliged to travel through deep gutters of mud, while to-day these affections are exceptional occurrences (H. Bouley). The same thing has been observed by Percival in England. "When hygienic precautions were not as well understood as they are to-day, in establishments employ- DISEASES. 593 ing large numbers of horses, when the stables of mail and stage coaches, and even those of mihtaiy garrisons, were small, ill- venti- lated and dirty, among horses standing in filth and soiled manure, these affections were relatively common ; with hygienic improve- ments, they have almost disappeared. In the army, canker was the cause of considerable annual loss, almost as serious as those from glanders ; to-day it is rare and almost unknown. Improvements in the different breeds of horses, either by bet- ter choice of reproducers, or by changes in the mode of feeding, resulting from the progress of agricultural processes, the suppres- sion of common pastures, etc , have contributed to render the disease less common. Symptoms. — It is seldom that the symptoms of canker can be observed from the start ; slow in its progress, and not surexciting the sensibihty of the parts, the disease may progress without manifesting any ill effects, and consequently escape notice by the owner or groom, nothing appearing to call his attention to the affected foot. Thus, in a majority of cases canker is only dis- covered after it has been in existence for a considerable period, and when serious alterations have already taken place. It is often at the shoeing shop, when the shoes are changed, that in the laminae is observed a moistiu*e more or less abundant, giving rise to softening and raising of the hoof. The disease sometimes attacks only one foot, often several feet at a time ; at times when one foot is cured, another becomes affected, and the disease thus appears traveling alternately from one foot to another. Usually the disease begins with the inflamation of the kerato- genous membrane which covers the median lacunae of the plantar cushion ; the hoof covering this is softened, raised by a serous moisture, and once loose, is not renewed, the tissue producing it ha\Tag lost its function of secreting the horny substance, and now secreting a serous element, which becomes the caseous matter of which we shall speak hereafter. Sometimes the disease begins by moisture in the hollow of the coronet, by a kind of grease, a disease which we shall see to be of the same nature as canker. The is an cedematous swelling, warm, somewhat painfvd, of the phalangeal region, first serous, then be- coming opalescent, which seems to filtrate through the softened, but not yet raised, epidermis. This inflammation, spreading Httle by little toward the hoof, extends to the plantar keratogenous 594 OPEKATIONS ON THE FOOT. membrane, and gives rise to an exhalation of the same nature as that of the skin which produces the separation of the hoof, and the first marks of canker. Sometimes one may observe at once, a fungoid growth of ficus, formed by an hypertrophy of the tissues underneath ; this growth is more or less moist and offensive, bleeding easily, having the aspect of caidiflowers, and protruding through a break of the softened hoof, and forming a thready detritus to be subsequently studied. Commonly, the hoof is more or less loose, and under it is a caseous matter, greasy, ordinarily of a foetid odor, easily re- moved by scraping, being non-adherent to the tissue which secretes it. If the parts are well cleaned from this, the velvety tissue of the pyramidal body of the frog, appears to be covered with a smooth membrane of a slight whitish color ; the external layer then appears formed by a pellucid epidermic covering, show- ing through its transparency the purplish color of the capillaries underneath. The velvety tissue is diseased, but still retains its functions, which, on the contrary, are increased but perverted, and instead of secreting a horny substance which adheres to the surface of tbe keratogenous membrane, produces the caseous mat- ter already referred to. The break in the hoof frequently seems small in size. Nevertheless, the alteration of the keratogenous tissues, viz : the substitution for its normal, of a pathological se- cretion, whose product is this loose caseous matter, is far ad- vanced. There is then an extensive, though a concealed separa- tion of the hoof. One then must not allow himself to be deceived into supposing it to be a limited diseased process, by the apparent external integrity of the horny box. The characteristic of canker is its tendency to spread, like can- cerous affections. Once manifested in any part of the sub-horny tissues, the special changes which characterize the disease seldom remain circumscribed; on the contrary, they generally extend from that part as a centre, throughout the whole circumference, and little by little, attack slowly but continuously the whole ex- tent of the secreting apparatus, and thus loosen the entire horny box — starting from the median lacunae, or the glomes of the frog, it extends to the branches and the body of the plantar cushion ; then spreads at the side, in the lateral laminae, from there all round on the velvety tissue, then by degrees reaches the inferior ex- tremity of the podophyllous laminae and going upward, reaches DISEASES. 595 the coronary band, the last point, where, in extreme cases, the hoof preserves its adhesions with the tissues which form it. In this condition the disease process progresses more slowly than be- tween the sole and the velvety tissue, and then it seems to remain stationary ; otherwise the dropping of the hoof would be possible. We have seen that often at the beginning, but especially as the disease progresses, there are growths called fici, found principally round the laminse, the frog and the sole. These are of whitish color, opal, varying in size and in shape ; they constitute an irregular mass, formed of those fici pressed together ; some of these growths have a wide basis, others are somewhat peduncu- lated ; sometimes they are single, tubercular, slightly elevated ; at other times elongated bodies, true fibrous bundles. The fici are nothing more than the normal villosities of the keratogenous tissue which have become tumefied and hj^^ertrophied, and are found principally where, in the normal state, the villosities of the velvety tissue are themselves more numerous and more developed. Where these vegetations are confluent, as upon the sharp edge of the bone, they are separated from each other by a kind of deep sinu- ous grooves, filled with the caseous matter secreted by the diseased keratogenous structui-e. These growths bleed easily and grow rapidly again when excised. Those most developed, and which seemed to form a homogeneous mass, constitute, however, an aggregate of smaller vegetations united in a certain part of their extent, and continued at their bases. Besides the vegetation of the living tissues, the plantar sur- face of the foot presents, in old cankers, isolated fasciculi of solid homy substance, of thready appearance, soft, analogous in their form to coarse brushes whose hairs are glued together. These isolated, still adherent, brushes are seen spreading toward the sole ; they correspond with parts of the velvety tissue which have maintained their soundness in the midst of the diseased surface, and there continue to secrete healthy hoof. These homy growths are ordinarily multiple, and are of various shapes, often twisted, and give to the plantar surface a pecuHar aspect, so much so, that their brushy masses sometimes retain the mud of the streets and are filled at their bases with a black and foetid substance of an ugly appearance. When canker has arrived at a very advanced period, it is char- acterized by the deformity of the whole horny box, whose length 596 OPERATIONS ON THE FOOT. and width is considerably increased. The last of these conditions is a sure sign that the disease has spread under the wall of the quarters and of the heels, and has produced the complete separa- tion of the bars from above and below, "When percussed, the hoof at the heels gives a dull sound. The excessive length is only an indirect consequence of the disease, and is due to the fact that, so as to keep the animal at work, the walls are spared as much as possible by the blacksmith, so as to avoid the contact of the protruding parts with the ground. Physiological signs are almost entirely absent in canker. It is a curious fact that the sensibihty which is generally highly in- creased in all affections of the foot, even in chronic diseases, re- mains always so obscure in canker that animals may be used for a long time without lameness, though the sub-homy tissues have become quite unprotected over a large surface. Complications. — Yery frequently, canker is complicated by a disease of the skin, analogous to it, known as grease ; a disease which, if not entirely of the same nature, as admitted by Plasse, Megnin, etc., is closely related to it. It is often through this that canker begins, and very often the two diseases exist together in the same animal, one sometimes following the other, just as canker of one foot follows that of another. Among the complications of canker, as generally admitted, are some injuries of the plantar cushion : inflammation and necrosis of cartneges, ligaments or tendons, and even caries of the os pedis and anchylosis, which are sometimes observed ; however, a close examination of the facts allows us to say that these accidents do not arise under the simple influence of the disease alone, but that they are due to the improper use of sharp instruments, of the actual cautery, and especially of potential caustics. As La Gueri- niere said, the deep lesions of tendons and of the os pedis, which are observed in severe cankers, have no other cause than the action of too powerful dessicatives. Duration, march, termination. — Canker is an essentially chronic disease, and may be of long continuance, even lasting for years. Still, under this heading there are many variations, whose cause it is difficult to find. There are horses whose disorganization of the hoof is complete after two or three months. There are others where the disease remains stationary for more than a year. We have seen it remaining limited to one lacuna for months, and all DISEASES. 597 at once assume a rapid evolution of disorganization. "We have noticed this principally after the use of sharp instruments. Generally, animals affected with canker feed well, and for a long time retain a good condition ; toward the end, however, they lose flesh and exhibit symptoms of septicohemia, especially if affected with grease. We do not admit that, as advanced by some, canker can give rise to such virulent diseases as glanders and farcy. Diagnosis. — At the beginning, canker may be confoiinded with thrushes, and many veterinarians have considered this as the first stage of canker. There is, however, a great difference be- tween the two : first, as to the anatomo-pathological point of view, inasmuch as the pultaceous, foetid secretion is less abund- ant ; that the loosening of the hoof is less, and that there are no fici; and again, especially in the point of view of the treatment, where single cases of cleansing, with or without dessicatives, easily control it, while canker remains rebellious to them. Prognosis. — The prognosis varies. Where the animal is young, well fed, and the disease is not too old, it is favorable. Yet it remains uncertain, as often the most benign form may last long and remain rebellious to all treatment. The severity and the extent of the internal lesions cannot be estimated by the altera- tions or deformities of the hoof, as these appearances are often decejDtive. Canker, though considered incurable for a long time, is not absolutely so — far from it ; with rational treatment, projD- erly carried on, it is curable in the majority of cases. There are cases, however, not very rare, where relapses and useless attempts have discouraged the owner as well as the veterinarian, and where it has been more advantageous to destroy the animal rather than to submit him to a long, tiresome, and always expensive treat- ment. Pathological Anatomy and Nature of the Disease. — It has always been considered that a morbid condition susceptible of producing disorders so severe as those produced by canker, must necessarily be a deep affection, essential and important to the organic structure, and depending on a complete transformation in its textm-e. And, indeed, it is the impression which predominated from the time of Solleysel down to the foundation of veterinary schools and which still exists with Girard, who considers canker as a gnawing ulcer which changes and alters the tissues it invades. 598 OPEKATIONS ON THE FOOT. and even witli Vatel and Hurtrel d'Arboval, who looks upon canker as the carcinoma of the reticular structure of the foot. It is but recently that these ideas have been abandoned. Du- puy, in 1827, considered canker as a hypertrophy of the fibres of the hoof, admitting at the same time the disintegrations and softening of those same fibres occasioned by an ammoniacal sap- onization produced by an altered secretion. In 1841, Mercier expressed the opinion that canker is nothing more than a chronic inflammation of the reticular tissue of the foot, characterized by diseased secretions of this apparatus. It is now known that there is in canker no essential alterations of the sub-horny tissues ; no radical change of their substance, and no deposit of heteromorphous molecules in their structure. This last mentioned fact was well observed by Robin, who in his microscopical remarks constantly observed the absence of the characterizing elements of canker. Hertwig and Haubner, who have made researches in the same direction, arrived at the same result and have noticed the absence of any cancerous cells in canker. This opinion is, however, doubted by Glisberg and Fuchs, who look upon canker as an epithelioma, though they bring no sufficient evidence to establish it. Except vegetal parasitism, of which we will speak hereafter, and which makes of canker a true dartre, an herpetic disease, as demonstrated by Megnin, there is only in canker a chronic in- flammatory condition of the sub-horny tissues which is mani- fested by a perversion in theu' secretion, and is complicated by a morbid hypertroj)hy of the villous processes by which their sur- face is normally covered. Robin has seen in the fici, papillae made thicker and more brittle by the plastic infiltration which moistens them; he has observed besides, that at the points where the secre- tion is good, it is so active, that instead of drying in sheaths, to scale off afterward in transverse pieces, as normally occurs in the frog and sole, the epithelial cells grow lengthwise, as those which form the walls of the foot. Hence these long, horned, twisted threads (epithelioma?) which are seen rising from the sole of long affected cankerous feet. It has sometimes been admitted that fici had deep roots in the tissues, and even in the plantar aponeurosis, which is an error ; injections and macerations having shown that there are no essen- tial changes in the anatomical structures of these parts, and that DISEASES. 599 what have been considered as the roots of fici were only cellular tissues, which has become indurated under chronic inflammation (Bouley). Fici are only fasciculi of villosities whose vascular net- work is no longer retained by the thick horny box which encloses them and which is infiltrated with plastic material. Bouley has already admitted that canker could not be better classified than among skin diseases, with and after dartroid afi"ec- tions, and thus gave reason to Huzard senior ; Plass also f ovmd that canker had the greatest analogy with grease, and that in it the nutrition of the horn iinderwent the same alteration with nu- trition of hairs in the second affection. Megnin, in 1864, observed, in operating upon fresh pieces taken from the living animal, and from one which had not received any treatment, that in canker there is constantly a cryptogam, as in favus, and that canker is a parasitic affection. Examining the caseous product of the abnormal secretion which charactemes canker, Megnin found in it a large quantity of very animated vibrios, swimming in a liquid having in suspension nu- merous epidermic cells more or less advanced in dissolution ; he found besides rounded corpuscles, which he recognized as the spores of the cryptogam, and from which the vibrios escaped at the maturity of the granulations there contained. In examining the fici, he has recognized them to be an aggregate of hypertrophied villosites, at the base of which were found in the mass obtained by a slight scraping epidermic cells or parts of cells enclosed in a net-work of inter-crossed, ramified threads, appearing to rise from certain centers marked by an agglomeration of spores, forming in their whole a yellow spot. In the water of the microscopic prep- arations, one finds also several of these isolated threads, epithelial cells, globules of lymph, of blood and finally spores ; very rarely vibrios ; oftener micrococci. These threads are nothing more than the parasites, the myceUum product of the vegetation of the spores ; those contained in the serosity, swell, break up, and the granulations which escape from them become for some time the vibrios, or as we prefer to call them, pseudo-vibrios ; as soon as the brownian motion, which for some time animates the granula- tions, ceases, the cells which have proceeded from them (the micro- cooci) gather together in chains and form the characteristic threads of the mycehum. This parasite of canker has been named by Megnin the kera- 600 OPEKATIONS ON THE FOOT. phyton or parasitic plant of the horn, by analogy with the tricho- phyton, the parasite of the hair. We consider this name very appropriate and prefer it to the name of odium batracosis, parasite of the canker, which Mr. Megnin has also proposed. Etiology. — The causes of canker are yet but little known; there is one, however, which cannot be ignored, and which, if it does not produce the disease, assists materially in its develop- ment and is indispensable to its existence. We refer to the con- dition of dampness. It is that influence of dampness which explains why the disease is so very common in the marshy lands of Poitou ; in the pastures of Holland, and in general in low grounds ; and why it is more frequent in northern than in southern coun- tries. Canker is incomparably more frequent in rainy seasons than in those where dryness predominates. We have already seen in the history of the disease that it is since the streets and the stables of admiaistration are kept more free from dampness that canker has become less common. Sometimes the action of direct irritating causes has been admitted, and then the canker has been attributed to irritating muds and the excrementitial liquids of stables ; their contact often giving rise upon the skin, ujDon the glomes of the frog, to an ery- thematous inflammation, soon followed by a serous flow, which ex- tends to the sub-horny structures and gives rise to an exudation in the laminae of the frog. This cause produces the rotten frog (thrushes) but not canker. We beheve that this cause has princi- pally been admitted by veterinarians who look upon thrushes as the first stages of canker, but this is not so, and for canker to develop itself under similar conditions, others are necessary, which are as yet unknown. Canker has also been attributed to narrow and contracted feet, so common in horses of meridional climates, and in which the sole is very concave, with the frog and pyramidal body shrunk in. Often in the laminae of these feet a sero-purulent moisture is dis- covered, more or less offensive, which is a rotten frog, but not canker, and but seldom followed by it. To produce canker a simple irritation of the sub-homy struct- ure is not sufficient. There must be a special cause, proper to canker, stimulating alone the characteristic changes of the cause. This cause we find in the cryptogam which characterizes canker, propagates it, and which has no power of spontaneous existence. DISEASES. 601 As with other parasitic diseases, canker is communicable by- contagion ; although the examples are quite rare they cannot be doubted. Hutrel, d'Arboval, Plass, Blind and Megnin have ob- served them, and in all the cases dampness has contributed to the propogation of the cryptogam. The lymphatic constitution in an animal is eminently propi- tious to the development of canker, as it is observed to be, in fact, for all parasitic diseases. It is known by daily observation of facts that horses whose skin is thick, with the hairy system well developed, the feet flat, with thick frogs, are more often affected with canker than animals of a nervous constitution. It is more particularly observed in horses with much white at theii* extremities, with stockings and white feet, and in those where there is a tendency to albinism. An unknown diathesis has also been considered as causing a predisposing constitutional organic condition, but this has not been justified by observation. It may happen that canker cured or dried on one foot, may attack another foot, perhaps a third, and then a fourth, to re-appear in the first ; this character of the disease has often been mentioned as proof of this diathesic condi- tion ; but it may also be explained by its contagious character. The disease remains too much localized to be constitutional, as generally in diathesic diseases we have critical eruptions upon different organs or different tissues. Treatment. — From the preceding remarks, it is evident that in feet affected with canker, the keratogenous apparatus of the foot has undergone no essential alteration in its structure, that its thickness and density have only increased by consequence of the infiltration and organization in its net- work of the plastic products of inflammation. And, again, the secreting function of this appa- ratus, far from being arrested, is on the contrary, more active ; but the products it gives instead of being concrescible, remain difflu- ent ; hence the impossibiUty for the hoof to be restored in the regions where this alteration of secretion exists and remains. These important facts, says M. Bouley, must take the lead in the chapter of the therapeutics of canker, because they teach the practitioner that the object to effect, in the treatment of this dis- ease, is not to radically destroy the diseased tissues, as has been too often done and recommended, but to return to them their physical and physiological properties by the application on their 602 OPERA.TIONS ON THE FOOT. surface, of modifying agents which influence the nutritive and secreting functions of their tissues without interfering with their structure. To reach this point, the most varied pharmaceutical agents have been recommended, the most successful being those which at the same time had parasiticide properties. We, however, find it difficult to give the preference to any of them ; and we have now more faith in the modus faciendi, to the skiU of the operator, to the continued use of dressings properly applied, than to such or such agent; all of those which have been recommended if methodically appHed, can cure canker, and it will be wise to em- ploy them alternatively ; when one fails at first it is prudent to try another ; canker is a disease so often rebellious to treatment, especially when confined to the lacunae of the frog, that too many remedies cannot be used. The first indication is to remove the excess of the horn of the wall, the length of which, we have said, is often very great ; then prepare a convenient shoe for the dressings. This shoe nec- essarily varies, as canker is exclusively localized to the plantar surface of the foot or extends to the podophyllous laminae. Gen- erally an ordinary shoe is used, more or less covered (wide) and so hoUowed as to allow the free appUcation of plates by which the dressing is kept in place. When the condition of the disease requires the removal of large pieces of horn, a truncated slipper is used, proportioned in cutting to the extent of the parts of the wall upon which it is to be appHed. There are circumstances even when shoes cannot be used, so much does the disease extend under the wall. It is then necessary to use a shoe without nails, or boots, secured to the coronet by means of straps. In all cases the rule is to take care that the dressings remain fixed in the most exact manner, and that through them a methodic, steady, but not excessive pressure is constantly appHed over the diseased parts. The first step of the operation passed, the next consists in the removal with proper instruments of aU the loose portions of the horn, either at the plantar surface, at the quarter, or at the heels. One must avoid, in this operation, the excision of soft parts ; but the important indication is to follow the disease where- ever it exists, and to leave no part of the horn which may have been detached by morbid exudations. Better cut the healthy structures, and have them bleed, than to neglect to completely expose a diseased part. This done, the horn is to be thinned as DISEASES. 603 much as possible, upon the circumference of the diseased spots, in order to give a suppleness which would ease the swelling of the uncovered parts. Upon the exposure of the disease where it exists, the fici exist- ing on the surface and edges of the velvety tissues are to be removed with the scissors or sharp sage knife ; at the same time the parts of horn which may have remained are to be cut off, avoiding, however, the healthy tissue beneath, which still retains its normal character. When the canker is very extensive, so that the wall is loose on each quarter, or on all its circumference, it is of advantage to pro- ceed in the requu-ed operations at different times. This done, the shoe can be put on ; after which the diseased surface and surrounding horn are to be covered with a thick layer of the medicamentous preparation. If this is in form of a paste, as is often the case, it is spread over with a spatula. If in powder, it is thrown over it carefully. If liquid, balls of oakum are soaked with it and placed on, the whole being then kept in place by pads and plates. The important point is that the dressing should be so appHed as to be easily changed, that an exact, regular and sufficiently strong pressure be kept on. No better means can be used for this than the di\dded plates already referred to. In canker the dressing must be renewed every day, and even twice daily at the beginning of the treatment. This is an essential condition of success, whatever may be the therapeutical agent employed ; and this is not a simple difficulty in practice where the patient is not always of easy access. Moreover, this dressing is somewhat comphcated, and can only be skillfully made by the vet- erinarian himself. It often occurs that upon the removal of the first dressing, (the second day) one finds the tissues already covered by a layer of hardened horn, adherent to the surfaces. One must then, with the finger, a spatula, or a dry pad of oakum, rub it off where it is found loose and movable and, if necessary, renew the apphcation of the dressing. The same must be done at the other dressings, carefully watching if this new horn thus formed by the influence of the medication, is not separable from the parts underneath by the different morbid secretions of the disease. One must then carefully scrape off all that is not adherent, and thin the edges, and the projections of all the horn which retains its soundness ; 604 OPERATIONS ON THE FOOT. the caseous substance being also removed ; the same compressive dressing to be put on again. The modification in the homy secretion, and the formation of a layer of hardened and adherent horn, are especially great in the parts where podophyllous and velvety tissues exist ; but are very slow, and surrounded with difficulties in the median and lateral lacunse of the frog. After ten days of treatment, one may have brought about a normal secretion on the whole circumference of the sole, on the inferior face of the os pedis, and on the prominent parts of the pyramidal body. But in the lacunse the alteration remains isolated, and resists treatment ; and it often happens that, if neglected, it may again spread and the disease reach its former extent. It is then the case, when the disease is limited to the lacunse, to add to the ingredient already in use and which is kept applied upon the restored parts, another stronger and more active agent, sometimes simply absorbent ; here again it becomes diffi- cult for us to advise the practitioner, the number of recommended drugs being very large and the result depending less on their nature than in the intelligent and persisting manner with which it is apphed. When caustics are used, it must be done with great care, to limit their action only to the thickness of the keratogen- ous tissue, and not to carry it to the destruction of the bone, or still worse, of the plantar aponeurosis. Let us glance at the drugs which have proved most successful in the treatment of canker : First we have the different pyrogen- ous preparations, especially wood tar, recommended by Bracy, Clark, Eeyual and Bouley, and which give astonishing results. Gas tar, oil of cade, petroleum and soot have also been used, but with less advantage ; creosote and phenic acid have often shown them- selves very useful, by penetrating easier to the base of the vHlosities where the parasite resides and thus acting more regularly ; phenic acid proved very useful with Krause, Gerlach and Zundel. After these the best recommended preparations are the salts of iron. Hertwig seems to be well pleased with the powder of sul- phate, and Arnold recommends the jDyrolignite of the same metal ; Megnin advises specially the perchloride, which, like phenic acid, is rather a powerful astringent than a true caustic. The prepar- ations of copper have also had their time, and especially the aceta- tes, such as the CBgyptiacum ointment (Girard, Schaack, Kainard and Key) ; the baths of sulphate of copper were employed by DISEASES. 605 Verrier, Jr., of Rouen; a solution of sulphate of copper and of zinc in water or vinegar were recommended by Delaval and Haub- ner ; SoUeysel employed the prej)arations of copper, but added to them arsenic and other drugs ; Eichbaum preferred the powder of chloride of lime, and Rauch ordinary Hme, while Aubry employed a mixture of lime and caustic potash. Caustics were well recommended by other practitioners, but their prescriptions seem to be contrary to the rule we have laid down in the beginning. However, one must not forget that the tissues of the foot, especially when diseased, offer an extraordinary resistance to the action of caustics ; they are, so to speak, impene- trable, and the irritation they produce remains superficial, while where those tissues are healthy such agents produce a deep cau- terization. Again, this resisting force of the indurated tissues against the actions of caustics is limited, and it is possible that one, two or three applications may apparently remain inefficacious, where a fourth or a fifth will give rise to extensive cauterization. The result is explained by the repeated irritating influence of the caustic agent, which, by gradually increasing the vascularity of the parts it touches, increases also the means of their absorption and imbibition. These facts must also be present to the practitioners mind, and it is by them that he will be guided in their use, rendering them at wni, simply modifying, catheretic, or deep caustics. Nitric acid was used by Percivall and Delorme, the latter con- sidering it the best means in use. Sulphuric acid has also been employed, seldom alone, but mixed with agents likely to reduce its effects and render its applications more convenient. Collignon and Renault recommend its reduction with alcohol ; Mercier mixed it with four parts of oil of turpentine ; Prange with equal parts of tar, and Plass made a paste of it with burnt alum. This last remedy, very simple in its formtda, was applied without any dressing ; it has proved most excellent in a great number of cases, but may give rise to too deep cauterization (Bouley, Mendel). Arsenious acid was much used by old horsemen, combined with oegyptiacum, turpentine and other ingredients. Hoffmann prefers . the arsenite of soda in solution ; he sold his secret to the Austrian government for a high price. Butter of antimony was recom- mended by Huzard Sr., Prevost, and especially Huzard ; chloride of zinc was preferred at the Lyons school. The treatment of canker by actual cauterization was indicated 606 OPERATIONS ON THE FOOT. by SoUeysel, but soon abandoned by him. In applying- the cau- tery upon the uncovered tissues of the hoof, we encounter the chance of jDroducing a very severe inflammation, which spreads by degrees and gives rise to extensive slough of the hoof, as a con- sequence of the serious exudation which takes place ; the action of the cautery may then become either too mild or too vigorous. Still, it has been recommended by Prevost, of Geneva. Hurtrel d'Arboval, who also employed it, used it in the following manner: the parts being covered with a mixture of gunpowder and sulphur, a red-hot iron was applied to the spot, the powder burning sud- denly and the sulphur slowly. If the combustion was too slow, he increased it and kept it up by the same means. When the operation is concluded the parts are transformed into a black scar, which can be easily removed by scraping, and the application and cauterization may be repeated, and so on until it appears that a sufficient amount of heat has penetrated the tissues to destroy the material by which canker may be regenerated. The cauterization being once properly effected, then in order to sustain irritation, the foot is covered with Burgundy pitch, or resin, melted and warm, which is allowed to cool off on the foot, when a dressing of oakum and the shoe are put on. The dressing is changed as soon as suppuration shows itself and renewed with the same ingredients in the same manner until the wound becomes healthy and granu- lating. It is only for the sake of the record that we refer to the ex- clusively surgical treatment, based upon the erroneous idea that the fici of canker are abnormal products, deejDly implanted in the tissues beneath, and where it was advised to look for the imagin- ary roots of these fici at their extreme limits. In this treatment, not only the diseased horn was removed, but the entire sole, the plantar cushion and often the plantar aponeurosis was excised. This practice, advised by Lafosse junior, was also recommended in the veterinary schools by Chabert in France, and Dieterichs in Germany. It prevailed for a long time, though experience showed .that the wound resulting from such an operation was of very slow recovery, that the frog especially could not be regenerated, that there remained a central ulcer, and that it gave rise to such a mal- formation of the foot that the animal remained lame for a long time, sometimes for life. Notwithstanding these objections, ob- served by Jeaune, Girard and Eichbaum, this treatment is still DISEASES. 607 followed by a few who prefer it to the simple operations of SoUey- sel, which consists in the division of the loose pieces of horn and the excision of the fungoid projections. We have thus far only spoken of the local, without referring to the internal or constitutional treatment of canker, recommended by those who look upon the disease as constitutional. Without beUeving that it can have any real curative effect, we, however, admit its usefulness, when the disease is of old standing, and that the animal has suffered much by it. Ferruginous preparations are specially advisable^ and we prefer the carbonates that are used by Delwart to the sulphates recommended by Prevost, Delaval and Hertwig, and it is well to unite them with bitters and tonic powders. Arsenious acid is prescribed internally by Delaval, Feuillette, Niederberger, Obich ; and other alteratives, such as mercury, which we would not advise. Nor can we understand how any benefit is to be derived from diuretics and purgatives, and especially from the use of external emunctories, such as setons. Corns. Under this name is understood an alteration of the tissues underneath the hoof ; of the heels of the horse's foot by lesions of the hving parts in the movements of expansion of the hoof ; by bruises, compressions or contusions. There is then a capillaiy hemorrhage which extends in ecchymosis in the hoof. A corn, then, is a bruise of the Hving horn at the extreme end of the branches of the sole, and especially in the laminated tissue of the folds of the bars. It is a very common disease, and one to which all horses are exposed. Some have them constantly. Corns are seen mostly on the fore feet, and on the inside more commonly than on the external side. They are rare on the hind feet,. because in the various gaits the weight of the body is carried more on the front legs and on the posterior part of the foot, while in the hind legs it is the front part which principally receives it. I. Divisions. — Lafosse Sr., has distinguished them into natural and accidental, while Girard considers them all as accidental. H. Bouley designates as essential those which come from other than external causes. We believe that it wovild be better to estabUsh the divisions on pathological and anatomical bases, and admit a 608 OPERATIONS ON THE FOOT. corn of the wall, or laminated, that which has its seat in the laminae which unites the wall to the tissues underneath, viz., in the keraphyllous and podophyllous tissues of the heels and bars, and a corn of the sole, or velvety, that which has its seat in the velvety tissue which unites the sole to the fleshy parts. The laminated corn corresponds exactly to the " natural " of Lafosse and to the " essential" of Bouley. It is due to lacerations in the movements of expansion of a badly-made foot. The other is due ■ to contusions. \\Tiatever may be the adopted divisions, we, with Girard, and as admitted in practice, recognize in each category, the dry, the moist and the suppurated corn. n. Etiology. — All feet are exposed, but not all predisposed to corns. They are more frequent in heavy feet, with those where the heels are high or contracted in which there is a motion of re- traction of the hoof which interferes with the displacement back- ward of the third phalanx at the time of rest, and hence the lacera- tions are easy ; besides, there is a continual pressure upon the living parts of the posterior region of the nail. Corns are fre- quently observed in excessively long feet where the hoof does not receive the moisture necessary to its elasticity ; it then losses its suppleness and fails to assist the internal motions of the parts contained within. It is seen whenever the hoof is too dry, the posterior diameter of the feet being then diminished. Corns are seen on weak feet, on which the hoof is too thin to resist the dilating effect of the internal structure, and spreads excessively. "Wide and flat feet, with low heels, in which the interior surface of the branches of the sole is on a level with the plantar border of the quarters and bars, are very often affected with corns. The pres- sure of the shoe or the roughness of the ground produce these bruises through the sole. Here the conditions are unfavorable to the normal dilatations of the hoof ; the ungeal phalanx, being unsupported by the convexity of the sole, has a tendency to drop down lower, the tissues are easily lacerated and bruised in its dis- placement at the time the foot rests on the ground. The most serious causes of corns arise from the shoeing, which not only sometimes gives to the hoof a shape predisposing to that disease, but also very often is a determining cause itself of these injuries. " As long," says Hartmann, " as horses will have corns, horse-shoeing cannot pass as an art, and their too frequent pres- ence is an evident proof of our imperfect means of protection to DISEASES. 609 the hoof." Without shoeing there would be no corns, and it is in its irrational methods that the true causes of thfese accidents originate. It is by the greater or less frequency of corns that one may judge of the state of that art in a country. The faults are found, 1st, in the manner in which the foot is pared, or in the shape which it receives ; 2d, in the fitting of the shoe ; 3d, in its application. In paring the foot, the sole is often weakened and thinned too much ; it does not resist the pressure, and, at the time of resting the foot, all the weight of the body is thrown upon the point of union of the sole with the wall. Ordi- narily too much has been cut away from the frog, and this not resting any more on the grovmd, no longer resists the pressure, and the lowering of the branches of the sole is then extreme, as proved by the experiments of Leisering. The custom of cutting the corns, and of cutting the hoof at the heels, acts in a similar manner ; the posterior half of the foot is weakened, and that is the part which must carry the greatest part of the weight. One needs only to compare a foot from which the shoer has removed much horn at the sole, frog and bars, with one in which the hoof has been left alone for a long time. In making a vertical and tranverse section of the two in the middle of the frog, a little in front of the angles of the sole, he wUl see at once how weak the point of reunion of the sole with the waU has become, the means of resistance to the pressure of the weight of the body through the third phalanx being thus diminished, and consequently a pre- disposition to bruises created. The shape of the shoe also contributes to corns ; an excess of concavity ; a shoe which from the last nail-hole is not flat to the heels, whose branches are too much inclined, contributes to the lateral contraction of the foot and gives rise to corns. In this case the shoe resists the play of the horny box, and by itself, through the sole, exercises a great pressure upon the tissues underneath. Too high caulks, in preventing the resting on the frog, cause an excessive pressure on the inside of the foot, and compel it to rest on the heels and the branches of the sole, which are too much lowered; The opposite excess, when the shoe is thin at the heels, as in the Coleman shoe — which is thick at the toe and thin at the heels — produces a similar result, because in increasing the pres- sure on the heels, it gives rise to bruises of the tissues through the retrossal processes, which comes down too heavily. A very 610 OPEKATIONS ON THE FOOT. wide shoe, too thin, may also contribute to the genesis of corns, because, then, the shoe helping, with the intensity of the reactions on the pavement or on too hard and stony roads, the shoe soon gives under the foot, and compresses the sole and tissues beneath. The manner in which the shoe is put on may also be a cause of corns ; the shoe ought to rest exclusively on the inferior border of the wall, and not touch the sole ; when it is too narrow it may be a cause of contusion or of contraction ; if too wide it prevents the natural expansion. It is upon horses long shod that the wrong apphcation of the shoe as a cause of corns is observed. As a con- sequence of the growth of the hoof, the shoe no longer sufficiently protects the plantar border of the foot, the heels of the shoe being inward and pressing on the branches of the sole ; this is especially the case when the shoe is thinned by wearing ; it yields, and easily bruises the parts of the sole on which it rests ; high caulks, on a branch already too ghort, or too thin, act the more injuriously be- cause, not being concentrated on the projection of the caulk, the branch gives away sooner, and presses still more on the heels. The shoe becomes an indirect cause of corns, when hard sub- stances, as stones or dry earth, are found between its superior and inferior face on the sole, or between the frog and the internal bor- der of the branches of the shoe ; this is a secondary cause, which was formerly considered of great importance. The work of horses has a great influence, corns being very fre- quent in horses which work on pavements and stony and hard roads. They are rare in country horses, but common in those of great cities ; a rapid gait contributes to their development on account of the great pressure on the ground. The seasons have also an influence, dry and warm weather depriving the hoof of its moisture, and by preventing its elasticity of motion, increasing the effect of pressure upon the tissues. Emigration has been considered a cause of corns. Horses coming from the north of Germany are mentioned as having been rapidly affected by them after being in large cities. But if the change too suddenly made from soft to dry bedding is an effective cause, the mode of shoeing can also be considered as a stimulating cause. The same is true with respect to the African horses, which are generally free from the disease in their native coimtry, but frequently suffer .with them when brought to France, and submitted to a mode of shoeing so different from that of the Arabs. DISEASES. 611 m. Symptoms. — The ordinary symptoms of corns are noticed in the abnormal position of the leg at rest, in the lameness and the sensibihty of the region. When lame with a corn the horse carries the leg forward of the plumb Hne, and keeps it semi-flexed at the fetlock; he tries to reUeve the painful region by resting ; sometimes he manifests his pain by pawing and moving his feet from forward backward, pushing his bed under him. The lameness is not characteristic ; it varies greatly in intensity, from a slight soreness to lameness on three legs. It is generally proportioned to the intensity of the disease. However, there are horses so accustomed to their corns that they do not go lame, while others are very much so for a trifling injury. Sometimes it is intermittent, and diminishes when the suppuration has made its way between hair and hoof. The sensibility of the heel — seat of a corn — is discovered by an explo- ration with the blacksmith's nippers. Sometimes it is made known by pressure of the fingers, the cases varying, of course, according to the severity of the disease. There is often heat, especially at the coronet, which may be tumified, particularly so when the corn is of a comphcated suppurative character. To obtain an accurate view of the disease the foot should be well pared, and this opera- tion may be greatly facilitated by the application of poultices for twenty-four or forty-eight hours previously. It is only by the objective examination and the pathological anatomy, so to speak, of the com that the moist or suppurative variety can be distinguished from the di-y, and we shall find either a simple ecchymotic spot, or a complete disintegration of tissues. rV. Pathological Anatomy. — The lesions vary according to the severity of the disease. In dry corn, we find an infiltration of blood in the homy structure. This is blood which has transu- dated through the laminated or irritated velvety tissue from the injured blood vessels. This blood gives to the hoof various tints, more or less pronounced, not unfrequently yellowish, according to the intensity and duration of the disease. The hoof sometimes loses consistency and becomes brittle ; at others, it is hard and dry, and then resembles healthy hoof minus its coloration. If the ecchymotic spot involves the whole thickness of the horn, from its surface to its depth, it is an evidence of the continued activity of the cause. A deep mark indicates a recent injury ; a superficial one is an evidence of an older corn, which disappears, 612 OPERATIONS ON THE FOOT. and then it seldom produces lameness. Sometimes the marks are arranged in layers, the healthy horn being alternated with others which are infiltrated with blood. This is a proof of the intermit- tent character of the acting cause which has originally produced the corn. The ecchymosis, however, is not the actual seat of the corn, which is more in the velvety and especially in the laminated tissues, which are torn or bruised, the blood escaping through the sole simply by the action of the laws of gravitation. It is rarely that this lesion is looked for in the case of dry com, and it is usually ignored ; but in the confirmed com, a true alteration of the laminae of the keraphyllous tissue is observed. This is re- placed by a homy tumor, a kind of keraphyllocele, analogous to that of chronic laminitis, due to a union of the laminae under the influence of the fibro-plastic exudation resulting from the inflam- mation, which is of varying size, and presses more or less on the sub-horny tissues. In some cases, this horn breaks up Httle by little, and gives rise to quarter crack. The ecchymotic spots of the dry corn may vary in size ; they may range from the size of a pea to that of a ten-cent coin. At other times they may occupy the entire space between the bars and the walls of the foot. In moist corn, there is not only hemorrhage, but also inflam- mation proper, with serous exudation. The hoof is colored, as in dry com, of a brownish tint, due to the infiltration of blood which occured at the start ; on searching deeper, one will discover be- tween the hoof and the living tissues beneath a separation of varying dimensions, filled by citrine serosity. Most frequently this separation takes place at the line of the sole with the wall, and extends under both. The horny substance is then more or less impregnated with this serosity, and then has a charcteristic yellow appearance and a waxy consistency. In siqjpurative corn, or more properly, suppurating, the in- flammation ends in suppuration. The pus is secreted by the vel- vety and laminated tissues. It makes room for itself by gradually separating the hoof as its formation progresses. Before long it passes between the podophyUous grooves of the bars and of the quarters, the horny are lossened from the fleshy laminae, and in its ascending progress the pus soon makes its appearance between hairs and hoof at the quarter, at the heels, or at the glomes of the frog. It is not common for the pus to make its way through a hoof of too thick or resisting a nature, unless it has first been DISEASES. 613 sufficiently softened by poultices and thinned down with the knife. This suj^puration, in the generality of cases, brings on serious compHcation, by the excessive pressure to which the sub-horny tissues are then subjected. Gangrene of the velvety tissue near the branches of the sole and of the podophyllous grooves which have been lacerated in the suppuration, are very common compli- cations. If the pus remains long in the hoof its gangrenous re- sults may extend to the os pedis, the latemal cartilage, the plantar cushion, and even to the plantar aponeurosis, and give rise to necrosis or caries of the bones, or to quittor, to a more or less variable extent. This sub-horny suppuration, which may some- times be considerable, as well as the compUcations accompanying it, are detected with the probe. V. Termination and Prognosis. — Resolution is a common termination of corns. But their relapse is common also, especially in feet predisposed to them by bad conformation. A kind of chronic condition of the disease, and one which is more liable to become serious than the accidental variety, is the ordinaiy ter- mination in this case. The mere extent of the disease is of less importance in the diagnosis than the predisposing conditions. Generally the dry corn is less serious than the moist one, and especially less than the suppurative. Comphcated corns, princi- pally in flat, wide feet, with low heels, by reason of iincertain, protracted and expensive treatment, are in general fatal, and necessitate the destruction of the patient. VI. Treatment. — The largeness of the space we have consumed in considering the etiology of corns will compel us to be brief in our remai'ks upon the ^^reye;iif?ea^ syno^>^7^s (synovite podosesamoidienne) ; by Braull, chronic podotrochlitis, is an inflammation of the sesamoid sheath of the horse, that Turner and some other English veterin- arians were the first to describe, and which is mostly observed in thoroughbreds. DISEASES. 695 The disease is principally seen in the fore feet, and more com- monly in one foot alone ; sometimes, however, both legs are affected, one first, and the other following. Navicular disease of the hind feet is seldom observed. It is accompanied with lameness and deformity of the foot, and often proves rebellious to treatment. It is followed by con- traction of the heels {encastelure) which is itself often mistaken for navicular disease. At any rate, the affections are nearly re- lated, whether the disease of the sesamoid sheath, first occurring, is followed by the contraction, or that the hoof, origiaally con- tracted, gives rise to the subsequent alterations of structure which constitute navicularthritis. At present we shall only con- sider the deep inflammation of the podosesamoideal articulation, occurring without primitive alteration in the form of the foot. I. /Symptoms. — These are at first obsciu'e. The lesion is deeply situated, and is, so to speak, concealed in the hoof, which itself, is generally at first of very limited extent. The first symp- tom which attracts attention is the lameness, which sometimes, indeed, seems to be merely a certain weakness of the affected leg. This lameness is at first intermittent and slight, but gradually in- creases. WTien in the stable, the animal '' j)oiats," that is, the dis- eased foot is carried forward of a vertical Hne, and assumes a state of general relaxation of the muscles, with the coronet straightened and the foot mostly resting on the toe. This in- complete rest of the leg, which is sometimes kept in motion for- ward and backward, becomes especially apjjarent if the animal is moved backward in his stall. He then sets down his foot with much hesitation, and for a short time ; the same thing also occurs when, in order to relieve the opposite leg, the animal puts all his weight on the diseased one. Still, a close examination of the foot fails to reveal any marked lesion ; no change of form appearing, no wain at the coronary band ; merely a little heat toward the heels, or on the frog, where there can also be found a certain amount of low and deep sensibility, made apparent only by per- cussion of the hammer upon the foot, or by the pressure with the blacksmith's nippers, principally toward the heels and the frog. According to Laf osse, the frog is often found indurated, atrophied and thrushy. If exercised, the horse frequently stumbles, and sometimes falls on his knees; he fears the pain of resting the heels on the ground, and is limited in the movements of his knee 696 OPERATIONS ON THE FOOT. and fetlock. If the heels are pared off, in such a manner that the frog is well prominent, and the horse becomes much heated, the lameness is increased, although at first it may have been very slight. Blacksmiths may frequently obtain the same result by i^lacing under the foot a bar shoe, which, then resting on the frog, and not the heels, greatly aggravates the lameness until it be- comes excessive. This mode of diagnosis was originally indicated by Brauell : When, after more or less exercise, the animal is left to cool off, he at once points, straightens his fetlock, and slightly flexes the knee ; the leg has a trembling motion, and no rest is taken upon the heels. There are, however, according to Hertwig, cases where navicu- lar disease suddenly reaches a period where, in the stable, the animal avoids all resting on the heel ; points constantly, and hes- itates to put his foot on the ground when made to walk. It al- ways seems that there must be some traumatic lesion in the foot, as a punctured wound or a suppurating corn ; and still there is no increased heat m the hoof, and no extraordinary pulsation of the arteries of the foot. The disease has a tendency to increase, and the animal soon becomes very lame upon being put to work, especially on a hard road or rough ground. The heat of the foot is increased princi- pally after work, though not in proportion to the lameness. The sensibility of the foot is also more manifest under the exploring pressure of the nippers. In the stable the pointing is well marked, and the trembling of the leg gives signs of deep and per- sistent pain. It is only after several months of this suffering that the foot begins gradually to show a change of shape. It then be- comes visibly narrowed and elongated, in a manner which can readily be detected both by sight and management. There is a general atrophy of the hoof; the periople has disappeared, or scales off; the foot becomes covered with ridges, more or less marked, but better developed toward the heels ; the frog has be- become sunken and atrophied; the sole is ecchymosed, present- ing evidences of corns ; and the leg is atrophied, especially about the muscles of the shoulder. In cases where both fore feet are affected, the animal points with either foot alternately, while seeking the desired relief for each, but the rest on either is very short. The hiad legs are brought under the centre of gravity, the back is arched, and the DISEASES. 697 decubitus prolonged. In stepping out of the stable, both fore feet are held stiffly, and kept close to the ground, the animal stumbles on his fetlocks, and often falls, and one might suspect him of being weak. In walking, his shoulders seem to be rigidly attached to his body, but as he warms up the legs move more freely and his actions become less limited ; but immediately on cooling off, and especially the day following one of hard work, all the symptoms reappear, with even aggravated intensity. The disease increases steadily with the lapse of time. When one, or what is more rarely the case, both hind feet are affected (Loiset has seen it occur), the animal is stiff behind; he is lame on one or both feet; he puts his foot on the toe only; knuckles at the fet- lock; and presently an atrophy of the muscles of the superior regions takes place. II. Progress, Duration, Termination. — The disease gener- ally maintains a steady progress ; nevertheless it very often un- dergoes a remission, due to the hygienic conditions in which the animal is placed ; to the seasons ; to the state of the atmosphere, and to other causes. It may diminish in severity, and its symp- toms disappear, while in its first period, if the animals are left at rest — without shoes if possible — loose in a box, with damp bed- ding, or in a marshy field ; or in winter, during the rainy season, while the atmosphere continues in a moist condition for a long period. It is, under these circumstances, not uncommon to see feet which had become contracted quite recover their natural di- mensions. Aside from these exceptional cases of recovery, the lesion keeps on slowly destroying the tissues where it exists ; the lameness remains constant, or becomes intermittent for years, sometimes after the animals have become entirely unfit for work. There are frequent complications involving the surrounding parts ; sometimes a true arthritis, and besides the complete atro- phy of the muscles of the shoulder, the carpal ligament becomes thickened, the tendon of the perforans undergoes the same alter- ation, and ring-bones and side-bones may follow. Again, how- ever, the animal may become knuckled to such a degree that he can scarcely rest his foot on the ground at all. III. Pathological Anatomy. — As we have said, the disease has its seat in the synovial capsule, formed by the small sesamoid sheath between the navicular bone and the perforans tendon, slid- ing upon it. At first may be observed a certain injection of the 698 OPERATIONS ON THE FOOT. synovia, and a darker hue in the coloration of the trochlear carti- lage with the corresponding face of the tendon, the synovia be- coming reddish and thick, the surrounding cellular tissue becom- ing, also, inflamed and infiltrated. At a later period, when the disease has somewhat progressed, there is a thickening of the walls of the capsule, which is then filled with a clear citrine ser- osity. There is then, a kind of hygroma, a chronic dropsical con- dition of the sheath. In the interior of this are also to be found fibrous bands, running from the tendon to the bone. If the dis- ease is older, erosions are found upon the diarthrodial surface of the navicular varying in number and in size, and the tendon is roughened on its anterior face with longitudinal fissures. At times, it becomes atrophied and thin, dry and brittle; and has been found, it is said, ruptured transversely. In many cases, the cartilage covering the bone has disappeared and the bone is ex- posed, hoUowed and affected with osteojDorosis. The union of the bone with the tendon has also been found among the varieties of determination. IV. Diagnosis. — This disease is at first easily mistaken for some form of rheumatic afi'ection. Where pain is the main symp- tom it is easily detected, but where there are no other signs of in- flammation, it is just the lack of proportion between the intensity of the lameness and the serious symjstoms, such as the absence of heat ; of special sensibility ; of pulsations in the digits, which distinguishes navicular disease from other affections of the feet. The error with contracted heels is easier, as here the change of form of the foot being primitive, at once attracts the attention of the practitioner ; while this alteration in the foot is absent in navicularthritis at the outset of the disease. V. Prognosis. — Generally, it is unfavorable, as most com- monly the veterinarian is called only when the disease has already made serious progress and passed into the chronic stage ; and again, because of the difficulty of reaching the disease by reason of its peculiar location. YI. Etiology. — To properly understand the etiology of this disease, one must bear in mind the part played by the anterior legs in the action of locomotion. Columns of support more than of impulsion, it is their office to sustain the weight of the body when it is thrown forward by the extension of the hind legs. The reaction of the ground is first felt at the shoulders, through the DISEASES. 699 muscular slings which attach them to the trunk, but it is partly diminished in the scapulo-humeral joint, which closes, notwith- standing the resistance of the muscles implanted on its apex. The remaining force is transmitted to the vertical column, represented by the union of the radius, the carpus and the metacarpus. Reach- ing the digital region, this force is there decomposed. Part of it, passing on the phalanx, loses itself and disappears in front of the horny box of the foot, the other being thrown upon the flexor tendons, and finally upon the perforans, which distributes it to the posterior parts of the foot, and to the navicular bone. It must be observed that in this complex action of decomposition of the shock, the os sesamoid, though pushed from before backward by the OS coronse is, however, supported by the resistance of the per- forans tendon. Consequently, both the bone and the tendon are pressing upon each other, when the feet are placed on the ground, throwing the body forward by the impulse of the hinder parts, and thus press powerfully against each other. When this pressure takes place in an animal going full speed, and a good and high stepper, it may commence by becoming merely a sHght confusion, but, if often repeated, the result may be some lesion upon the corresponding surface of the bone and of the tendon, or of the synovial which facilitates theii' move- ments. But the energy of action in the animal cannot be con- sidered the only producing cause of these lesions, as a vice of conformation in the foot, a want of elasticity in its posterior parts where the resisting power is diminished, may also produce it. The disease, then, is observed in animals whose plantar cushion, covered by a small, dry and atrophied frog, is itself badly devel- oped, from being compressed between the bars, which are more vertical, or the heels, which are more contracted; all these be- ing conditions which diminish the flexibiUty of the back of the foot. Two principal causes, then, co-operate in the genesis of navi- cular disease, and are almost always present in animals thus affected. On the one hand, it will appear among well-bred ani- mals, especially those of English breeds, those from Hanover, Mecklenburg and Normandy, which will be more affected. Loiset and Lafosse, however, have seen it in common breeds, in animals with flat feet and soft horns. Lafosse says he has seen it in mules. But besides this influence of the breed, there is the effect of what 700 OPEBATIONS ON THE FOOT. we may denominate the hygiene of the foot ; the too dry bedding, certain wrong modes of shoeing and all the predisposing causes of contracted heels. Let us add also, as a cause, the effect of changing the animals from marshy fields, where they were walk- ing on soft, damp ground, to stables with dry bedding — a cause commonly present in horses transported from northern Germany to the south. Hard work and excessive exercise are also causes of this affection — for example, jumping fences with a heavy rider, slipping in steeple-chases, racing, a sudden stop on the fore feet, especially on stony, hard, frozen or rough ground. All these are fruitful cases of navicular disease. Traumatic causes, such as punctured wounds, involving the sesamoideal sheath, are also productive causes which may origin- ate navicular disease. We do not believe in internal causes, nor admit, with Loiset, that visceral inflammation, sudden arrest of perspiration, especially of the lower part of the legs, can produce the disease. We should rather anticipate that these metastases would affect more the more important serous structure. Neither can we admit, with Lafosse, that this affection can also follow a sudden arrest of the milky secretion. VII. Treatment. — We have seen, in speaking of the termina- tions of these lesion, that in certain peculiar circumstances which may be accounted favorable to the I'eturn of the elasticity of the foot, a spontaneous recovery is possible. This leads us to the measure of the prophylactic means proper to be used; and it seems evident that by a better hygiene of the feet, by rational shoeing, sometimes educating young horses only gradually to fast work, one may in many cases avoid navicular disease. While it is in its first stages, one may, with care and patience, sometimes reheve the patient. In this case, absolute rest is coun- ter-indicated, but on the contrary, moderate exercise, upon even and not too hard ground; or, if the lameness is great, walking exercise only, at a moderate gait. The absorption of the serosity present is made easier by a little exercise than by absolute rest. Bleeding from the toe, or the veins of the affected legs, is also, at least, superfluous, the disease becoming chronic almost at the outset. It is also a good practice to shoe the horse, and above all, to remove the shoe frequently. The best shoeing is that which allows for the natural expansion of the hoof. The Charlier shoe has proved useful, while the bar shoe, which is heavier, and DISEASES. 701 presses upon the frog, is counter-indicated. It is important to en- courage the suppleness of the hoof by proper ointment, especially the aj)plication of glycerine, and to have under the feet a bed- ding always sUghtly damp and soft. The bedding of moist saw- dust is very convenient ; we prefer it to poultices, and even to the tepid alkaline baths mentioned by Hertwig. At times, at inter- vals of about eight days, and then during two consecutive days, a good friction with blister ointment above the coronet is advan- tageous, as well as one with Lebas' ointment. English practi- tioners prefer salines; the better treatment would be to turn the animal to grass. Brauell advises iodine internally, and says he has found it work well. Others recommend diuretics. Setons in the shoulder or chest seems to us inexpedient. We prefer the ad- ministration of a purgative ball every eight days. Sewell and BraueU advise a seton, running from the hollow of the coronet thi'ough the plantar cushion, a little behind the tendon of the perforans, and within a short distance, therefore, of the diseased capsule, making its exit at the anterior third of the frog. This drain is to be maintained for two, three, and even four weeks ; Sewell, Brauell, Hertwig, and several other veterinarians, English especially, claiming much benefit from it. This seton is intro- duced by means of a curved frog seton-needle ; it has been used but little in France. Bruner has recently proposed the puncture of the sesamoideal capsule with a trochar, introduced into the hollow of the coronet, an operation only practicable if the serous collection can be felt outward. After the puncture, he recommends an injection of iodine. Lafosse proposes after the removal of the sole, the transversal incision of the plantar cushion, with removal of a part of it, down to the tendon, following the axis of the sesamoid; then the cau- terization of the bone and its cartilage, in imitation of what is sometimes done in punctured wounds of the foot. Brauell recom- mended as a useful surgical operation, the section of the perforans tendon in the metacarpal region, in order to prevent friction against the sesamoid groove, and to allow an easier adhesion be- tween the tendon and the bone. But it is to be feared that this section, supposing that it proves successful, might so weaken the tendon as to render the animal unfit for fast work. If navictdar disease should be accompanied with deviation of the wall, and contraction, true or false, the treatment will be that 702 OPERATIONS ON THE FOOT. of this affection in its simple form. An operation, often recom- mended, has been that of neurotomy, upon the posterior branches of the plantar nerves, repeated at intervals of at least fifteen days, in order to remove the lameness wholly, without entirely depriv- ing the foot of the sensibihty of feeling. Berger, Brauell, Bou- ley, Gross, Mandel, and others, have obtained real success by it; but it is attended with serious dangers ; at any rate the benefit is not of long duration, or about one year. The animal then stumbles more readily, and is more exposed to traumatic lesions, etc., and it is probable from this cause that double neurotomy is seen to be followed by softening of the deep parts of the foot, suppuration, sloughing of the foot, while the animal has previously shown no signs of pain. Consequently, neurotomy is an operation which finds its application only in peculiar and exceptional cases, and animals thus operated upon remain fit for light work only. QUITTOR. Synonyms. — Fesselgeschwur, German ; giarda, ItaHan ; gialarrs, Spanish ; javart, French. A name of unknown etymology, by which old hippiatrics desig- nate various affections of the inferior regions of the legs of the horse, donkey and mule, and even of bovines. These possess the common character of a degeneration of a portion of the tissues, that is expelled by the efforts of nature under the form of a slough {hourhillon). There is a softening of the mortified structures, and an elimination by suppuration. In several old works, these sloughs are called quittors {javars), and this name has been ex- tended to the disease itself. This name having been preserved by use, notwithstanding the efforts of Vatel in opposition, we shall also employ it, and with Girard, recognize : 1st. The simple or cutaneous quittor, which is only the furuncle which occui's in the thickness of the dermoid structure nearest to the coronary band. 2d. The tendinous quit- tor, which greatly resembles the felon of man, where a portion of the sub-cutaneous cellular tissue, and of a tendon sloughs out. 3d. The sub-horny quittor, the furuncle of the cutidura of the coronary band itself, the slough involving the superior portion of laminated tissue. 4th. The cartilaginous quittor, or the limited caries of the lateral fibro-cartilage of the os pedis, and which old writers compounded with the horny quittor. "We might join to DISEASES, 703 those the furuncle of the frog. We beheve it useless, at present, to enter upon a general consideration of quittor, and will pro- ceed to examine the pathological phenomena presented by each variety. A. Cutaneous Quittok. — This is a simple furuncle of the coronary region of the foot, in that part of the dermis nearest to the coronary band, having, however, a special character on account of the extraordinary thickness and inelasticity of the dermis of the region it occupies, the result being a kind of strangulation of the inflamed tissue beneath, and a very painful compression It is through error that some authors have designated by the same name, the furuncle of the canon, of the fetlock, and of the co- ronet. The hind feet are more subject to it than the fore, and it is more frequent at the heels, at the flexure of the fetlock, though it is also observed on the sides and front of the coronet, in which case it is much more painful. Cutaneous quittor has also been observed in bovines, where, however, as we shall see as we pro- ceed, it is generally comphcated with the tendinous variety, and becomes a true felon. I. Symptoms. — Cutaneous quittor is characterized by an in- flammatory tumor or swelling, warm, painfid, and tense, of the coronary region of the foot, the color of the skin being but little changed, if it is dark, but if the skin is light then the redness is well marked. This swelling is accompanied with a diffused sedema, extending to the fetlock, or even to the hock. We often find angeioleucites, or rather what we call leucophlegmasiae. The lameness is generally extreme, and the animal frequently can scarcely rest on the diseased leg. The pain is sometimes so great as to induce general fever and loss of ajDpetite, and the animal becomes dull and depressed. After acquu'ing certain dimensions, the tumor shows a tendency to soften at its summit, its base, however, remaining hard for a considerable time. Rising more and more, it soon ulcerates at a point from which flows a small quantity of bloody pus, followed by the appearance of the slough, {bourbillon). An abscess is now formed in the tumor, which, as it opens, carries with it a portion of the skin, sometimes Umited, at others measuring from four to ten centimeters, and there is a slough formed of the subcutaneous cellular tissue which separates by the suppuration with the portion of dead skin. This comes 704 OPEKATIONS ON THE FOOT. out by degrees. It is still adherent by its base and cannot be pulled out with the forceps unless by tearing and with acute pain, and this is often followed by slight hemorrhage. A few days later it will, however, become entirely loose, and in its place there will remain a cylindroid open cavity extending through the tu- mor, from its summit to its bottom, and from this a deep wound results, followed by a sero-bloody secretion, mingled with pus. As soon as the slough has taken place, or when it begins, the lameness subsides, as well as all the other phenomena of the pain. The wound heals up rapidly if there is no complication. Cutaneous may easily be complicated with tendinous quittor if the disease or process of sloughing of the mortified tissues ex- tends to the tendons or ligaments of the region involved. This complication is specially common in bovines, where cutaneous quittor generally gives rise to more swelling and greater suffering than in the horse. The quittor has quite a rapid progress, and may last from eight to fifteen days ; very seldom longer. At times, it seems to be a single furuncle ; at other times, there are several existing to- gether. Often again, they come in succession, the first one treated being soon followed by others. This is said to take place princi- pally when the diseased part remains exposed to the action of ir- ritating substances, and relapses are prevented .by protecting the part from the effects of these occasional causes. II. Pathological Anatomy. — It is an inflammation of the very abundant sub-cutaneous cellular tissue of the region, spread- ing from a starting point ; the inflamed tissues are mortified and becomes gangrenous, and by a process of suppuration, the econ- omy attempts to eliminate them. The slough represents more particularly the inflamed ceUxilar tissue, which is thickened, and which has become filamentous and hard and much impregnated with purulent serosity. III. Etiology. — Contusions of the region, bruises and punc- tured wounds are quite frequent causes of cutaneous quittor, but it may also take place without evidence of determining causes. Mud, manure, urine, all filth in which animals have to walk or re- main, are also considered as causes. For this reason the disease is more common in the fall and winter, on account of the action of cold at times, and frozen mud. It is also more frequent in cities than in the country. Ray observes that the mud of cities is al- DISEASES. 705 ways more irritating and contains mineral substances, especially lime, alkalines, and salts, and other substances. The gutters of some industrial estabhshments have also a direct irritating action. D'Arboval has observed that the mud of places where mineral springs exist, is more irritating, as also are calcareous soils, where cutaneous quittor is more frequent than in any other. Common, large horses, notwithstanding their thick skins — or, rather on that account and on account of the hair which covers it — are more commonly affected than private horses. Towing horses are much more exposed to the disease than those otherwise employed. IV. Treatment. — As a first direction, during the covirse of the treatment it is always a prudent rule not to work the animal and to keep it in the stable, the feet being kept dry on a good bedding. An internal treatment is seldom necessary to control the general symptoms ; if any is requh'ed, ordinary salines will generally be sufficient. It is necessary to assist the process of suppuration of the abscess by emolients, warm baths, poultices of flaxseed or of marshmallows, with melted lard, applied quite warm, or by the appHcation of a mixture of honey and bran or flour. We have apphed a coating of blister ointment to the tu- mor, covered with a warm poultice ; the maturing effect is then very rapid. It is often necessary to lance the tumor to reduce the pain and prevent the mortification of a large piece of skin. This operation is recommended by D'Arboval and H. Bouley, and is specially indicated when the tumor is much developed. It is then important to incise in the entire thickness of the dermis and to a sufficient length, and if necessary to make severel parallel in- cisions which will give rise to a copious flow of blood. In this mode, the parts are reheved, the pressure of the tumefaction is reduced and the gangrene diminished, if not entirely prevented. It is necessary — and we insist on this point — to incise so deeply that the tumefied skin is divided in its entire thickness. We have seen blacksmiths thus operate by the introduction of points of cauterization in the summit of the abscess ; but this mode, though facilitating the sloughing of the strangulated part and reducing the compression, ought not to be preferred to the incision with a sharp instrument — cauterization is more painful. When gangrene exists and the abscess is open, the incision is certainly less efficacious than at the outset, but it is not for that reason useless, as it reUeves the pain and prevents excessive com- 706 OPERATIONS ON THE FOOT. pression. "We do not by it attempt to loosen the slough, which it is advantageous to have detaching loose itself when it holds only by its base. If the abscess, once formed, is slow to ulcerate, making a point of cauterization is a good way to stimulate the escape of the matter of the slough. This mode of opening pro- duces in the part an increase of vital action and forms a sore of benign character, which falls off by the effect of the suppuration formed underneath, and which is nearly always followed by a comparatively speedy recovery. To obtain this radical cure, it remains to continue the use of the ordinary means to facilitate suppuration and bring on resolution. If the wound is pale and covered at the bottom with large granulations, it must be dressed first with basilicon ointment and afterward with alcoholic liquids, as spirits of camphor, tincture of aloes, or simply an aromatic in- fusion ; at times, baths of sulphate of iron, with a little sulphate of copper, are indicated ; or, when the wound has become red, the granulations vascular and of healthy character, a simple dressing of cegyptiacum ointment, diluted in vinegar, is enough. If proud flesh develops itself, it must be cut off. It is important to have the wound covered with a protecting dressing, which must be re- newed daily if the suppuration is very abundant, or it may some- times be left on for two days. B. Tendinous Quittor. — Synonym: Hornwurne (Germ.) — It is the nervous quittor of hippiatres, and the analogue of the felon of man. It is again a furuncle, different from the preceding, only because instead of being limited to the skin and subcutane- ous cellular tissue, there is caries of a portion of the tendons (especially the flexors), or of the Hgaments of the region, and also, at times, necrosis of the bone with sjTiovitis and arthritis. By extension, though we think, improperly, the name has also been given to the felon of the region of the cannon, while the applica- tion ought to be confined to that of the digital region, situated in the fold of the fetlock. The quittor may be superficial or deep-seated when it affects only the subcutaneous cellular tissue, uniting the skin to the ten- dons, or where the inflammation extends to the phalangeal sheath, and the pus accumulates into it. Differing from cutaneous quit- tor, this form, generally less common, is more frequently seen in the anterior than the posterior extremities. It may also be seen in cattle. DISEASES. 707 I. Symptoms. — The first symptom is an excessive lameness, manifesting itself even where no visible change exists ia the af- fected leg. The animal e\'idently suffers great pain, while his actions do not aid us in localizing it accurately, though the foot is always examined as being the probable seat of it, the animal raising it more rapidly than the other from the ground, and rest- on it with much caution and hesitation. After from two to five days, a phlegmonous tumor appears at the coronet, above the heel. It is extremely warm, and much more painful than that in cutaneous quittor, the hoof and the skin preventing the free de- velopment of the inflammation by strangulating it. The foot almost ceases to rest on the ground, but is flexed and raised from it, feeling in the parts being very' painful. The swelling of the leg extends to the fetlock, or to the cannons, and even to the knee. The animal has more or less fever, and when there is a deep quittor, he loses all his appetite, and ordiaarily lies do^vn and continues in the recumbent position. Generally, much time is required for the phlegmon to assvmie the character of an abscess, as the slough, being in this case no longer formed by the cellular tissue, is slower to define itself. This process of suppm-ation is not so well localized ; there is, on the contrary, a kind of deep abscess, which probably becomes complicated by the resistance opposed to the ulcerative inflamma- tion by the aponeurosis of the sheath and the thickness of the skin. However this may be, it is always very difficult to recog- nize the presence of one or several of these abscesses, even when they form in the subcutaneous cellular tissue, and so much the more if the purnilent gathering is deeply seated. After the opening of the abscess and exfoliation of the slough, either with or without the di'opping of a portion of the skin, there does not remain the simple wound of the cutaneous quittor, but on the contrary, a persistent fistula, running down a necrosed point of the tendons or of the fibrous sheaths. At times, almost from the outset, we may observe in the fold of the coronet numer- ous httle pimples, which terminate in as many deep fistulse, from which ooze a more or less thick humor, foetid, puriform and bloody. In frequent cases, the disease in unaccompanied with suppiu'ation, and there is a swelling, more or less hard, with a gradual diminution of the pain and other inflammatory symptoms. A more frequent compHcation is the suppurative inflammation of 708 OPEKATIONS ON THE FOOT. the tendiaous sheaths, or even of the digital articulations. There may also be a diffused gangrene with separation of the hoof and purulent infiltration under the horny box — periostitis, and caries of the cartilage. This is the deep tendinous quittor in the most severe form. In this last case, especially if there is an accumula- tion of pus in the tendinous sheath, the tumor is very painful, the sHghtest touch giving rise to the manifestation of extremely acute suffering, the hoof being constantly raised from the grovmd. The fever is violent, there is a complete anorexia, and the exercise of all functions is more or less disturbed. The compulsory resting upon the healthy legs may give rise to swelling of the hocks, and even to laminitis. In cattle, tendinous quittor becomes more painful than in the horse, and is always accompanied by a swelling which may extend to the knee. Rumination stops, and the animal endures great an- guish. The slough is followed by a wound of varying depth, which often exposes the diseased articular surfaces of the phalanges. If this remains too long, the pus may aifect the interdigital ligament, complicate the disease, and even make it incurable. In this case, the amputation of one of the digits may sometimes be performed. II. Progress, Duration and Termination. — The duration is generally pi'otracted; the disease often gives rise to chronic lesions difficult to remove. This will be easily understood, if we remem- ber that the region affected is composed, between the skin and the bones, of synovial capsules, ligaments, tendons and aponeu- roses, more or less cellular tissue, and of very strong nervous ramifications. If the disease is not very deeply seated or unilat- eral, complete recovery may be looked for; but if there are chronic lesions, if the articular surfaces become affected; espe- cially if particles of bones are sloughing, if the animal recovers it will be but imperfectly, and it will usually be accompanied by anchylosis of the joint, and diffused gangrene is also a complica- tion to be looked for. III. Diagnosis. — We said at the beginning that tendinous quittor is a very obscure disease ; the lameness is very great, but not characteristic ; in proceeding, we referred to the acute local pains at the side of the tendinous cord of the cannon, the inflam- matory swelling, the increase of local pains, and the general reac- tive fever. IV. Prognosis. — It is a very serious disease, on account of DISEASES. 709 the possible complications and sequelae. The loss, or the deform- ity of a phalanx, which are sometimes arr ,ong the sequelae of the felon of man, are in him accidents which never give rise to serious comj)lications, or are quickly forgotten, while in the horse such comphcations are equivalent to the death of the animal. V. Etiology. — The causes are the same as those of a simple quittor, which is complicated with the tendinovis kind ; this is also observed after the subcutaneous abscesses, frequently resulting from bruises, or even from punctered wounds. It is most com- monly met with in low-bred horses, and Fisher says that it is more frequent, and less malignant, in young than in adult ani- mals ; according to this writer, it is a common manifestation of distemper. Irritating muds favor its development in the same manner in active as in simple quittor. It often appears without appreciable causes. VI. Treatment. — When tendinous quittor is superficial, it re- quires about the same treatment as the simple kind, excej)t that, in this case, the counter openings must be made early to prevent the sloughs, migrations of the pus and the gangrene. The sur- geon must not foi'get that the inflammation in this affection must ordinarily terminate by suppuration, and he must bear in mind that there is a possibility of the modification of the inflamed cell- ular tissue, and that the mortified portion of that tissue must slough out, as their presence, too long continued, may be very dangerous. The general indication is to prevent, as much as pos- sible, the accumulation of the pus, an indication which will be best fulfilled by making openings for its escape, even before the formation of the abscess. As the tissues which surround the pus are very resisting, nature will not be able, or if so, only with great difficulty, to efi'ect the expulsion of these matters. It is for this reason that it is necessary to assist her operations by making an opening for the escape of the pus and of the slough. The opera- tion is without danger ; but if it is not performed in good time, lesions will be likely to spread, the disease cease to remain a local trouble, and the life of the animal become compromised. It is also more necessary to make an opening when the puru- lent secretion is established, for in this case it is important to avoid delay and to facilitate its escape. A simj)le longitudinal in- cision, four or five centimeters long, is sufficient, when the collec- tion lies immediately under the cutaneous organ. This incision 710 OPEEATIONS ON THE FOOT. must involve the whole thickness of the skin, as far as the ten- dons, and should be made in the middle of the coronet region, as near the foot as possible. It gives rise to an abundant hemor- rhage, which reheves the part, and warm poultices and baths, to accelerate the suppuration, are then indicated. When the product of suppuration has passed in the tendinous sheath, a longitudinal opening of this part towards the most de- pendent points, is indicated. To do this, a canulated directory is introduced to guide the bistoury ; when the incision is made, the pus flows freely, and by this mode the large blood vessels and the various ligaments of the region are avoided in the operation. Notwithstanding the incision, or if the suppuration had already accumulated before it was made, the pus may also accumulate in the j)ouch formed by the tendinous sheath behind the tendons. It is then very difficult to prevent its collection in those deep jDarts, and it may extend to the smaU sesamoid. It is because the pus cannot run toward the skin that it filtrates along the tendon. It is only by pressure and by injections that the indications presented can be fulfilled. After making free incisions, one may try by jjres- sure to remove the pus accumulated between the tendons and their sheaths, following it by cleansing injections, which must be re- peated as often as possible. The wounds which remain after the slough, in the superficial tendinous quittor, and that which follows the opening of the simple or multiple abscesses when it is deeper, are always charac- terized by the presence of fistulas running down to some necrotic spot of the tendons or of their sheaths. For these, an injection is recommended of tincture of aloes, tinctiu'e of iodine, and some- times of Villate's solution; lately, dressings with petroleum or phenic acid have been used. Phenicated baths, those of suljDhate of iron and lotions of permanganate of potash have also proved useful. At times, when the fistulas are persistent, it is necessary, after enlarging them, to have recourse to actual cauterization with a pointed cautery introduced, while at a white heat, down to the bottom of the tract. A general dressing of the wound follows, with tincture of aloes, sometimes with egyptiacum. The dress- ings should be more or less frequent, according to the quantity of the pus discharged. We must dress it until the wound is entirely healed, and it must, moreover, be carefully watched for fear of another infiltration of pus, or the formation of other fistulas. DISEASES. 711 Superficial cauterization is necessary in order to remove the induration and swellings likely to follow, and to stimidate the resolution. The action of the firing may be stimulated by blister- ing, or by an alterative ointment of iodide of merciuy, of sulphur, etc. C. SuB-HoKNY Qtjittor. — This is the inflammation of the su- perior part of the keratogenous appai'atus of the cutidura; or even of the superior parts of the sensitive laminge. This quittor is, therefore, located under the hoi'uy box, and is more like the cartilaginous kind, which old hippiatrics, and especially Solleysel and Garsault, describe with it. It generally takes jDlace on the quarter, and more seldom at the toe, or at the mammae. Some- times it is observed at the heels, but it is then of small conse- quence. I. Symptoms. — The lameness is very great. The animal walks on three legs, and there is strong reactive fever, due to the excessive pain — this form of the disease being more painful than the others, in consequence of the pressure of the horny structure upon the inflamed tissues. At the origin of the nail a warm and very painful tumor is found; the foot is hot and the haii*s staring on the site of the injury. If the disease has existed for some time, there is a separation of the hoof at its origin, due to a sero- purulent exudation, and under the hoof suppuration and mortifi- cation of a more or less extensive portion of the coronary band, or of the laminae will be found. The suppnration which there exudes varies, being in rare instances blackish, as it is usually found in traumatic injuries of the hoof; or, again, it is white and unctuous, with the odor of decajong cheese ; while more commonly it consists of a bloody or greyish matter, mixed with pus. If the mortified portion is not deeply seated, so that the slough can take place readily, the quittor is quite simple, since as soon as it has dropped off there is a well marked improvement. The pain then ceases almost instantaneously^ and the wound at once progresses toward cicatrization. But it is not rare, even when the mortification is somewhat superficial, to find the sub-ungueal suppuration extending so that the matter runs under the hoof, producing at times more or less serious fistula, or a separation of the sensitive and insensitive laminae. Girard says it has been seen to extend downward to the sole, and to separate it from the vel- vety tissue. The deep, sub-horny quittor may be complicated. 712 OPEKATIONS ON THE FOOT. forward, with necrosis of the tendon of the extensor muscle; with the inflammation of the joint ; with caries of the os pedis, and even to assume the cartilaginous form of the disease by its exten- sion to the cartilages of the foot. After the recovery of the sub-horny quit tor, if the coronary band has been mortified in its entire depth, the foot may present permanent longitudinal fissures, or seams, or transversal grooves, presenting evidences of the existence of a cicatricial tissue when the quittor was in progress. II. JPrognosis. — The gravity of this quittor depends upon the depth of the disease. When superficial and affecting only the siu-face of the tissue, it is easy to cure, but if deeply seated it is more serious, on account of the possibility of complications. III. Etiology. — Bruises and violent blows are the ordinary causes of sub-homy quittor. It is commonly due to overreach- ing, or to the wounds occurring when animals are wearing long caulks, as in winter. The irritating effect of frozen mud has also been admitted as a cause. IV. Treatynent. — The superficial quittor requires a simple treatment. Emollient baths and maturating poultices are then indicated. It is a good jslan to thin the wall with the rasp or the sage knife over the whole extent of the furuncular tumor to a height of about two fingers. A compress of chloroformed oil, while it alleviates the pain, is also indicated to soften the wall. It frequently becomes necessary to puncture the tumor, but we prefer to cauterize it with a pointed iron, following the cauteriza- tion with a poultice of honey with Venice turpentine or camphor. Some authors recommend astringent baths, as oak bark, or of sulphate of iron. It is often the case that after some interval fol- lowing sloughing of the bourbillon, the wound continues to dis- charge a liquid secretion, which is an evidence that there is a ten- dency to accumulation of matter toward the lateral cartilage, or under the wall, in the laminse ; or that there is some carious spot existing. In the first, if probing horizontally, a cavity is de- tected, it is convincing evidence that a cartilaginous quittor is in course of development; in the second case, the pressure and col- lection of the matter increases the inflammation of the laminse, separates the wall, and complicates the disease, necessitating the operation of the siih-horny quittor. The removal of the portion of the hoof which covers the lesion, DISEASES. 713 must, however, include more than the purulent center, so tnat the diseased tissues may be well exposed and the suppurative process detach them readily. This removal, always proportioned to the internal lesions, is made either lengthwise, following the direction of the hoi'ny fibres, or crosswise. In that case, it will attack only a portion of the wall toward its point of union with the skin. This latter method, it is true, requires less cutting, but it has sev- eral quite serious objections and often necessitates a second oper- ation. Even in cases where the growth of the granulations can be controlled, and where a good return of the horse is obtained, the horse only recuperates its perfect integrity by the slow growth downward of the wall. In some cii-cumstances the operation is completed by the removal of a portion, or even of the entire mass of the sole, when it is separated from the velvety tissue. The removal of a portion of the wall must be accomplished in the manner which will be indicated for cartilaginous quittor, in carefully avoiding the injirry of the coronary band and of the podophyllous tissue. The diseased tissue being exposed, all that is of bad appearance is removed, the carious portion being freely taken off. An ordinary dressing of oakum with diluted alcohol, or any other drug, kept in place with a light shoe or sHpper, en- tire or ti-uncated, as the case requires, is then appHed. As for all wounds of the foot, the dressing needs only to be changed when the pus accumulated under the oakum, or other peculiar conditions indicate it. It is true that changing the dress- ing is an effective means of cleansing the wound, but it has the inconvenience of also irritating it, and especially at the begin- ning may tend to interrupt the natural process of repair. It is of advantage, after the first dressings, to change them as infrequently as possible. In this way hemorrhages, which may always be looked for, are avoided. This is a point of the first importance. It has been proved that even in operations where a portion of the wall has been removed, a dressing left on for from fifteen to twenty days without removal, was followed by rapid recovery, the new hoof growing under the oakum without suppuration. It is useless to probe or wipe out the surface of the wound. On the second dressing, that is, after a few days, the parts begin to be covered with numerous white points, which are so many rudi- ments of hoof. These, which at first are soft, white, and isolated, gather together by degrees, and first unite into a thin layer, soft 714 OPEKATIONS ON THE FOOT. and yellowish, which becomes hard and thick ; it is the hoof secret- ed by the laminse, which, Httle by little, unites with that coming from the coronary band. Excessive granulations or proud flesh are removed in the ordinary way. D. Caktilaginous Quittor. — HufJcnorjyeJflster (German) — {improperly called siib-horny quittor^ by Lafosse, Jr., coronary quittor of Vitet;^6ro chrondritis of the third phalanx, by Vatel; sub-horny cartilaginous quittor of Girard ; quittor proper of Del- wart). This form of quittor is peculiar to solipeds, they being the only animals which have fibro-cartilage on the os pedis. Fig. 533.— Cartilaginous Apparatus of the Hrrse's Foot, a.— Lateral flbro cartilage. 6.— The superior bordor. c— Its posterior border, d. — Anterior lateral ligament, e. — Flexor tendons. /.—Extensor tendon, g. — Os pedis. h. — Retrorsal process. These fibro-cartilages (Fig. 523) are two pieces, which, with the plantar cushion, complete the os pedis and form the base of the heels, each representing a piece flattened sidewise, a parallelo- gram in shape, and extending posteriorly to the coffin bone. Their external face is convex and pierced with foramina for the passage of veins, and slightly overlies the surface of the bone of the foot. It is separated from the skin by a very rich vascular plexus. The internal face, concave, is hollowed by vascular grooves, and covers (forward) the articulation of the foot and the cul-de-sac of the synovial sac which protrudes between the two lateral ligaments of that joint. Downward and backward it is united to the plantar cushion, either by continuity of tissue, as DISEASES. 715 near the inferior border, or by fibrous bands running from one to the other. The superior border, either convex or straight, is thin and separated from the posterior by an obtuse angle in front of which it presents a deep notch for the passage of the blood ves- sels and nerves. The inferior border is attached, forward, to the basilar and retrosal processes of the os pedis. Behind this it re- flects inward, to continue to the inferior face of the plantar cush- ion. The posterior border, oblique, backward and downward, is slightly convex and unites with the preceding. The anterior border, obHque in the same direction, is more intimately vmited to the anterior lateral ligament of the articulation and can be sepa- rated from it only by artificial dissection. It sends upon this ligament and upon the anterior extensor of the phalanx, a fibrous extension, which unites with that of the opposite side. In their structure, the fibro-cartilages comprehend a mixture of fibrous and cartilaginous tissue, a mixture which is far from being homogeneous and even in the various parts. The more it is examined forward and near the base, the more its substance is seen to resemble that of cartilages proper, being white, flexible, brittle, and homogeneous. Toward its posterior part it loses its character of homogenity, becomes less brittle and presents in its thickness a greater amount of fibrous texture. More posteriorly again, the fibro-cartilagiaous structure is more marked. By close attention it seems to show cartilaginous nuclei, isolated, and sur- rounded with an entu'ely fibrous substance ; and again, at its pos- terior extremity it becomes fibro-greasy with much cellular tissue and unites with the plantar cushion. The vitality of the cartilage is in inverse ratio with its density and consequently is greater in its jDOsterior part than toward the base and its anterior extremity. This fibro-cartilage may easily and more or less comi^letely be- come ossified; old horses are those which most commonly present this condition, and draught horses are more subject to it than those used to the saddle. It assumes various forms. At times it occupies the entire extent of the cartilage, and at others only at its base ; sometimes the external surface is ossified, while the internal remains in its normal structure ; then again, the ossification exists only anteriorly while the posterior is cartilaginous, and it more rarely happens that the process consists in bony lamellae, which, starting from the base, spread toward various points of its cir- cumference. 716 OPERATIONS ON THE FOOT. These fibro-cartilages are generally more developed in the an- terior than the posterior extremities. They also present, in one foot, this slight difference, that the internal stands a little higher than the external. Cartilaginous quittor is a serious affection, characterized by the partial caries of one of the fibro-cartilages ; it is a partial gan- grene whose character is to slowly spread into the cartilaginous structure upon which it starts. To be treated with success, it re- quires a very regular attendance, and often an operation, which consists in the removal of the cartilage. Sometimes this opera- tion is indispensable, and its study is interesting, especially be- cause, though not as commonly performed as at the beginning of this century, it is one which requires a high degree of surgical skill for its success. I. Symptoms. — A division has been made of an acute and chronic form of this disease. Under the first name, is considered the earlier period of the affection, that in which there is inflam- mation of the cartilage and painful swelling of the part, and when the caries or necrosis of the fibro-cartilage is not yet established ; or if there is a wound, when it does not yet granulate, and the suppuration, if it exists, is very slight. Chronic javart would be that in which the partial and progressive mortification of the fibro-cartilage exists; for, as Renault has said, it is the ordinary termination of fibro-chondritis. When free from serious compHcation, the disease is generally accompanied with but little lameness ; sometimes there is almost none, and animals can be kept at work, especially at a slow gait; but if made to trot, the horse will show lameness. It is especially when the quittor exists in the posterior parts, that the inflamma- tion and the pain are not excessive, because there is then an abundance of soft, fatty tissue. But when the caries is more for- ward, and is situated more deej^ly, in a point nearer the articular surface, the lesion then affects the fibrous tissues and the pain is greater. It is sometimes excessively acute. Upon the lateral part of the coronet, toward the heels or the quarters, more or less tumefaction appears, more or less painful, according to the duration of the disease, and in this case more or less indurated. In the centre there exists a granulating fistu- lous wound. There are one or several fistulse (Figs. 524, 525, 526) whose openings show granulations, bleeding easily, their course DISEASES. 717 ^^^m/as, '^s^^A '■mi Figs 524, 525, 526.— Cartilaginous Quittor. Various Spots of Necrosis. 718 OPERATIONS ON THE FOOT. always forward, running at times in straight lines, at others ir- regularly. The tracts frequently communicate and discharge a granular, serous and thin pus, of pale greyish color, generally odorless, or slightly sanious, containing greenish particles, which are but pieces of diseased fibro-cartilage. The pus dries up on the surface and adheres to the hoof and to the hair, and some- times irritates the surface of the skin. If one of these fistula be- come cicatrized, a fluctuating tumor soon appears, close to it, which rapidly ulcerates, and then gives rise to another fistula. If the disease is quite old, the hoof of the quarter corresponding to the necrosed cartilage, loses its perioplic band, becoming rough, ramy and cracked, and the wall is thickened, because the irritation of the coronary band has stimulated its growth. This change in the condition of the wall varies with the length of time the dis- ease has existed, and consequentl}', it indicates its duration quite accurately, when one remembers that the hoof grows downward about one centimeter in each month. When cartilaginous quittor is the sequelae or complication of the suppurative corn, of a punctured wound by a nail of the shoe, or any other affection of the foot, the symptoms proper to these diseases are first observed, though the lameness is greater, and the fistulse of the quittor is evident. Often, however, this, instead of being external and on the coronet, is situated at the in- ferior part of the foot, at the internal face of the inferior border of the wall, upon the sole, and sometimes connected with the wound of some of those affections of the foot. II. Pathological Anatomy. — When one examines the cartil- age affected with the necrosis proper of quittor, he always finds lesions in proportion to the intensity and the age of the disease. It is seldom, however, that the portions of the cartilage which have undergone the green degeneration, constituting the caries, reaches more than one centimeter in extent; they have the form of a small plate, of a green color, ordinarily elongated, and adhe- rent to the healthy parts of the cartilage by one of its extremities, that which is more forward and the deepest. Others have com- pared it to the green growth of a seed in germination. The points of the fibro-cartilage which are in immediate contact with the carious portion, have also a slightly pale greenish hue. These are already diseased; there is already a beginning of necrosis; in the remainder of its extent the exfoliation is separated from the DISEASES. 719 cartilage by a reddish, soft tissue, which also lines the inside of the fistulous tract. This fistula, which extends from the necrosed spot to the skin, is but the hollow tract left by the diseased proc- ess upon the cartilage, while gradually destroying its substance. Always lined with a pseudo-mucous membrane, by a true p3'ro- genic ajjparatus, the fistula is often narrow, sinuous, irregular in its course and extent, especially if the disease is of some standing. Renault, and after him Lafosse, have mentioned a special al- teration of the fibro-cartilage which is sometimes met, and which Lafosse looks uj)on as a step toward recovery. It is a softening of the tissue, anatomically characterized by a loss of the consist- ency of the cartilage, resembling the case of the cellular tissue becoming indurated, or that of bones deprived of their earthly salts after soaking in weak acids ; its yellowish color is then char- acteristic. It may be noticed during life, and is recognized by a softening in the region of the cartilage, which then yields, giving easily to the pressure of the finger; besides this, ^ a probe intx-o- duced into the fistulous tract readily penetrates into the softened substance. But the true way to diagnosticate this change con- sists in raising the coronary band or after thinning the wall ; then one wiU see and may feel the true nature of the transformation. Lafosse adds that, in presence of this alteration, the removal of the cartilage is no more necessary, for then the cicatrization is readily obtained by stimulating the sloughing of the necrosed tis- sue or by removing it. With cartilaginous quittor there is always plastic infiltration of the cellular tissue suiTounding the cartilage. Very often the wall of the synovial capsule of the articulation of the foot is some- what thickened, and in that case there is less risk of injuring it during the operation. — (Rey.) III. Progress, Duration and Termination. — Left to itself, the caries of the fibro-cartilage may last for a long time, through difficulty in determining its true nature. Spontaneous cure, how- ever, is not impossible, as Renault proved it, and as many practi- tioners have seen it, esj)ecially in young and healthy subjects, when the disease is mild at its outset and effects parts of the or- gans where the fibrous element ^predominates, as in the posterior portion of the cartilage. This fortunate result follows the slough- ing of the " boiU'biUon " which makes its appearance under the shape of a greenish particle. 720 OPERATIONS ON THE FOOT. But, ordinarily, the disease progresses slowly, destroying the cartilage by degrees, and the diseased process ceases only when the caries has reached the ligament of the joint, which it some- times also attacks. The tissue of the fibro-cartilages has not the force of reaction possessed by other inflamed structures, and which is so well marked in cellular tissue. A process of suppura- tion, such as rapidly eliminates the mortified structure, cannot very readily take place in it, and when by natural forces the cari- ous sjDot is eliminated and pushed outward, the surrounding tis- sues are most commonly already affected. These undergo the same alterations, and are eliminated in the same manner until the entire cartilage is destroyed. This process of caries by repe- tition may last a year. In its progressive stage, the disease may spread to surround- ing parts, such as the os pedis, the j)lantar aponeurosis, the liga- ment of the joint, or the sesamoid sheath, all of which may be- come the seat of inflammation. They are diagnosticated by the greater pain and more marked lameness, symptoms which are comparatively light in the simple necrosis of the cartilage. Finally, as a possible complication of cartilaginous quittor, one may observe an entire emaciation of the animal, an alteration of the fluids due to a j^utrid or purulent infection; some authors claim to have even seen glanders and farcy follow it ; this is inad- missible. IV. Diagnosis. — Cartilaginous quittor is recognized only when there is a wound from which escapes the product of the suppuration and of the necrosis. This pus has nothing charac- teristic, notwithstanding what has been said. If it is thinner than that of a simple solution of continuity of the region, or that of simple quittor ; if it is less foetid than that of bony caries, it has, however, of itself some special characters, vaiying according to the subject and the degree of the disease, and especially resem- bling much that of sub-horny quittor. If the escape of the pus is slow, and it is desired to carefully examine it, a simple pad of oakum, kept by a few turns of bandages on the fistulous opening, will, when removed, give a sufficient opportunity to recognize its nature. The probing will often assist in distinguishing the cartilagin- ous from the simple or sub-horny quittor. In these last, the fis- tula is less profound, and does not reach the thickness of the DISEASES. 721 uouf Til ^« "^^ cartilaginous disease, tte flstiUa is often sin- uous, It IS better to use a soft, ijexible instrument, such as a fine probe made of lead. Tbe iniection of liquid maytX the plac cUrectly, whUe in deeper and uregdar iistute, it will penetrate more readUy. The indm-ation of the coronet, th rough ZTll appearance of the hoof of the quarter corresponding t^h fis tula, mdicate generally a necrosis of the fiL-eartila.e these characters ai-e missing m the furuncle. " ' V. J^roffuosis.-T^ consequence of the tenacity of the disease this form of quittor is always serious; though this gravity has i^ our days, greatly diminished, on account o? the meanTof trlT ment now in use, which were unknown some thirty 111:0 most mcurable and which more recently was treated by au opera- tion which rendered the animal unfit for work for seveii molZ can m the majority of cases be cured in about fifteen days fion meftr"' ''°'''™'' ™™'' ™'' '^*P''"'^^ "^ the complica- ^LJ f*rf "'"■"'' °' """ l'S'«"«'^te. inflammation of the articulation of the foot, or of the sesamoid sheath, the extirpation of tlie cai-flage itself, done with the greatest dexterity, fs Tot e«n a warranty of recovery. It remedies only the nec^'osis o he cartilage, but leaves the other diseased processes to pZ resf m such a manner that the animal remains worthless if he has not to succumb to them. The pain is, besides the other igns one " the most important points to consider: very acute, it is generX ^ht^C"" °"™' ""' '"^'^ *° *^^ ^^'^'-- »f -"ou-:m' fe„7f' -^'''°%y— Heavy draught horses are more frequently af- fected, on account of their, peculiar work. The most common cartUage, it is most common m horses di-awing trucks loaded cartUage The same cause exists for horses workin.^ in extensive works of buildings, in the construction of railroadlld tZ shops of mechanic construction. u m tne Owixig to these concUtions, it is also more common in lar^e cities than m the country, and more £i-equent in stony an" tT po^ roads than in those which are smooth and tiat. Flat fee" with low heels, ai-e more exposed than others, as weU ^thot 722 OPEEATIONS ON THE FOOT. whose hoofs are soft. Quittor is more frequent in the fore than the hind feet, the fibro-cartilages of the fore feet being more de- veloped and more flexible, and because their heels are generally lower than in the hind legs. In some, it is more common on the internal than the external quarters, while with us, it has been the contrary. It is often a compHcation of suppurative com ; of punctured wounds of the foot, of canker, of simple and sub-homy quittor, of grease, etc., which are then the determining causes of the disease. VII. Treatment. — "When the disease is recent and the quittor acute, and antiphlogistic treatment may be attempted and resolu- tion looked for, baths and emollients are generally beneficial. A good blister has sometimes proved advantageous, and when it is used, Hmited suppuration, with the formation of a simple slough, may take place. If necrosis is well estabhshed, it is an indication of the neces- sity of a recourse to more energetic treatment, in which case sev- eral measures are recommended, including the actual and poten- tial cautery and the removal of the cartilage. In actual cauterization, the necrosed spot is destroyed by a cautery brought to a white heat, applied directly upon it, after it has been exposed by a free incision. It is a simple treatment, and one that has been successful in cases of posterior necrosis where ^ much fibrous tissue was diseased, and principally in young and well-conditioned animals (Lafosse, Sr., Girard, Vatel, Mangin, Renault). Still, this treatment not only often fails, but may even become a means of irritation of the fibro-cartilage, and cause an extension of the necrosis. (Hurtral, D'Arboval, Lafosse). In our day, this treatment is almost entirely ignored by good practition- ers, and the potential cautery more generally adopted. This had already been employed by hippiatrics. SoUeysel principally recommended the use of corrosive sublimate mixed with aloes ; Girard, Barreyre and Bernard also mentioning it. English veterinarians recommended their use very strongly. (White, Blaine, Riding, etc.). These practitioners all used the solid caustic, either in the form of trochiscus or in powder, and if they obtained good results, it required a much longer time than that reqmred in our day by the use of the liquid forms of caustics which are at our command. With the solid form, the action was of limited extent, and scarcely more effective than that obtained DISEASES. ' ' 723 by the actual cautery; moreover, tliey frequently injured the healthy structures by irritating them and increasing the inflam- mation, and thus resulting in serious complications. As we have said, liquid caustics are largely used to arrest the spread of the caries ; they modify the process of decomposition, dry up the suppuration and stimulate the tissues without injuring the healthy structures. This mode of treatment must be credited to Manage, who in 1847 established the unfailing efficacy of re- peated injections of Villate's solution; one of sulphate of copj)er and sulphate of zinc, 64 grammes of each in 1 liter of Aonegar, and decomposed by 125 grammes of Goulard's extract. It is really simply a solution in vinegar of acetate of copper and zinc, holding sulphate of lead in suspension. Villate himself had al- ready used his solution with success by injecting it in cartilagin- ous quittor as early as 1829, since which time Burgniet, Verrier, Sr., CoUignon and others have recognized the benefit of liquid escharotics in the treatment of the same disease. Villate's solu- tion is not a specific, and cartilaginous quittor has been cured by the injection of tincture of sublimate with solution of nitrate of silver (Bernard), with the perchloride of iron, chloride of coj^per, sulphate of copper and zinc, nitrate of lead, more or less concen- trated mineral acids, and especially the Eabel water (ColHgnon). It is difiicult to say which is the more useful of these drugs and which has been more successful. Success has also been ob- tained with injections of tincture of iodine, phenic acid and even petroleum. It is less the nature of the drug that insures the ef- fect than the mode of using it. We ought also to say that, ad- vantageous as this mode of treatment is, it is not infalHble, though Mariage and others so consider it. It is not to be preferred to the extirpation of the cartilage, an operation which proves suc- cessful when all other means have failed. To obtain a cure by the use of liquid applications it is essen- tial to make injections every day, and even several times daily. These are made with a sjainge, carefuUy adapted in respect to size, with a small canula. The injection must be pushed well in, but must be allowed to escape freely after coming in contact with all the diseased surfaces which it is designed to modify. To effect this, it becomes necessary, as the fistulae are sometimes very nar- row, and even irregular, to enlarge them, or to make counter openings. Mariage had originally insisted that these precautions 724 • OPERATIONS ON THE FOOT. were essential to the success of the treatment. H. Bouley and Viseur also strongly insisted uj)on the same point, viz., that of en- larging the iistula in order that the liquid should not be allowed to remain at the bottom of the fistulous tracts, by which aU possi- bility of the extension of the disease from that cause might be avoided. These enlargements of the fistulas, or covinter openings, close, however, very rapidly; as a remedy to which, Hivernat has suggested the introduction into the tracts of little wedges of wood pointed like pencils, for the purj)ose of lacerating the walls of the fistula, followed by the insertion in them of small setons, moist- ened with ViUate's solution. Guerrapain introduced a fine meche of oakum, a seton in the tract, by means of a curved needle. If the fistula runs downward its bottom is under the wall, and he thins this down and makes a counter opening through the hoof thus thinned. This seton prevents the closing of the counter opening, and enables the operator to push through the injection regularly. Other precautions are also necessary. One, especially, is rest. The animal must not be put to work. Lafosse says that these liquid caustics act with regularity and cure with certainty. A bar shoe, not pressing on the diseased quarter, is also useful. Emol- lient poultices are sometimes necessary after the injection, to diminish the irritation. Mariage also recommends them. If the fistula extends under the coronary band, or the podophyllous tis- sue, it becomes necessary to thin, or to remove altogether, the hoof of the diseased quarter. After fifteen days of this treatment, the exfoliation often takes place, and recovery follows. Often, however, twice this length of time is necessary. After the first eight days the pus becomes more abundant, white and laudable ; the tumor softens and dimin- ishes, as the pain subsides. Later, the injections penetrate with greater difficulty, which is a good sign. The injections constantly attack the germ of the disease and leave it without chance to re- form or to spread; the gangrenous structure which develops in the cartilage is changed into an inert substance ; the pyogenic membrane of the fistulous tract is stimulated; the process of granulation becomes more rapid ; the wound becomes more and more healthy, and the diseased process ceases. If, however, it continues, the wound changes its character, large granulations develop themselves, and in their center the openings of the fistu- DISEASES. 725 lous tracts, which open on the cartilage, make their appearance. At times the wound closes ; but, after a short interval, opens agaia, or another forms at another point. There is then a repetition of the same course of treatment by caustic applications — but gener- ally this indicates a complication, and suggests the propriety of an operation. The injections are generally successful, however, and most certainly so if the caries occupies the posterior parts of the cartilage. They may even succeed in the anterior parts, when the animal is young and of good constitution. But if the cartil- age has already become partly ossified, the caustic is irregular in its action, and the result becomes doubtful. If the caries is deej) and extensive, and especially if the necrosis extends through and through to a point corresponding to the synovial capsule of the articulation of the last phalanx; or if the necrosis exists on the internal face of the cartilage, where it covers that structure, then the repeated injections of Villate's, or of any other caustic, may be followed by serious complications. An old or complicated caries will offer an increased resistance to the treatment by liquid caus- tics, in proportion as there is more or less difficulty in bringing them in direct contact with the necrotic points. The third method of treatment is that of the removal of the cartilage. This operation, first recommended by Lafosse, Sr., in 1754, was often performed by his son, and may be considered one of the most valuable results of the application of anatomical knowledge to the practice of veterinary surgery. This operation was also performed by Bourgelat and his students, by Girard, Hurtrel, D'Ai'boval, and was principally studied and described by Kenault. In Germany, notwithstanding the writings of Langen- bacher, Dieterichs and Hertwig, it did not meet with approval, and Enghsh veterinarians seldom, if ever, resorted to it. At pres- ent, even in France, it is seldom performed, except in case of fail- ure by the caustic injection treatment, and this is often the case where the disease is situated in the anterior part of the fibro- cartilage, where the cartilaginous tissue predominates, or where the vitality is diminished, and above all, where ossification has taken place. It is an operation of the greatest delicacy, and ac- companied with great risks on account of the proximity of the joint of the foot, and it requires an experienced operator and thorough practitioner to justify a hope of successful results. It consists in the excision, by layers, of the diseased cartilage, and 726 OPERATIONS ON THE FOOT. in avoiding injury to the coronary band, and to the podophyllous tissue, which are essential elements of the organization of the foot. It is also essential to avoid injury of the lateral ligament of the foot joint, which is close to the cartilage, and above all, of the synovial capsule of the joint, which is directly covered by the cartilage. The partial or entire extirpation of the cartilage can be performed. In the first case, only a portion of the necrosed fibro-cartilage is removed. Vatel, Sanstas, Renault, Bell and La- fosse have reported many cases of recovery by this mode of oper- ation, but it is not likely to be thoroughly successful, unless in cu-cumstances as favorable as those accompanying the treatment by liquid caustics. It is generally much better when the operation is decided upon to perform it by excising the entire structure, and removing all the carious elements. The partial removal is to-day entirely abandoned, and entire extirpation accepted as the true and only operative procedure. The best method of performing it is that recommended by Renault and adopted in our colleges. We shall make it the subject of description with all necessary details, and with various modifications as performed by other practitioners; we shall also offer some observations upon various other modes of performing the operation in question. The operation includes two principal steps : first the removal of the part, or the whole of the waU corresponding to the diseased cartilage ; and second, the extirpation of the cartilage itself. The opinions of surgeons vary as to the amount of hoof which should be removed, and the extent of horny tissue to be taken off. In respect to the length of the superior border of the portion requir- ing removal, it is genei-ally agreed that it must extend from the anterior extremity of the cartils,ge backward, that is, the two pos- terior thirds of the space reaching from the toe to the heels, or one-third of the circumference at the coronary band. But opinion continues divided as to the lower border (Fig. 527). Lafosse, Sr., left it longer than the superior, and made the direction of the division of the groove correspond to that of the fibres of the hoof. Lafosse, Jr., accepting the idea of Solleysel and of Dieterichs, did not reach the sole with its groove, and removed only a portion of hoof parallel to the coronary band. Renault prefers crossing the fibres of the hoof with the groove, and brings the lower end of it to one-half the dimensions of the upper border, its groove running backward. Rey considers this to be running too far back and DISEASES. 727 C if Fig. 527.— Direction the Groove should take to remove the Quarter in the Operation for Cartilaginous Quittor. .-1 B. — According to LafoBse. A C— According to Rey. A D. —According to Renault. A £.— According to Lafosse and Dietericths. too near the heel, and recommends the groove to be so made that the lower border will have the same length as the ujpper, and for that reason advises that it be as nearly parallel as possible with the line of the heels. Lafosse, Sr., removes too large a portion of the hoof. Lafosse, Jr., leaves a portion of hoof which not only is useless, but which interferes with certain steps of the operation, when with the double sage knife, the skin is separated from the external surface of the cartilage, and also, when this is removed ; and again, there is a separation between the severed portions of the quarters much greater than occurs in the process of Renault, which, hke that of Rey, exposes the entire cartilage, and greatly facihtates the operation. It is to be understood that the foot has been prepared ; that the hair has been clipped over the skin covering the cartilage; that the sole has been pared thin, down to the blood, as well as the bar corresponding to the diseased cartUage, so that the quarter has been allowed to project below the sole, to facilitate its e ver- sion. The foot has been, moreover, well prepared by two or three days of poulticing, to render the hoof easier to be cut by the in- strument, and the operation easier to perform, and therefore shorter in its various steps, beside jDlacing the patient in the best condition for the endurance of so serious an operation. After casting the animal upon a good bed, and fixing the feet, placing a temporary hemostasis, by the use of a strong cord, simi- lar to a tourniquet, aroimd the coronet, a groove is made, using various-sized drawing-knives, running from the anterior angle of the lower border of the cartUage downward to the sole, following 728 OPEBATIONS ON THE FOOT. the direction recommended by Lafosse, Sr., Rey, or Renault. This groove, made first with the widest, and finished with the narrow- est of the drawing knives, must not touch the podophyllous tissue, and still must run through the entire thickness of the wall, with- out producing hemorrhage. In this step of the operation, as Girard correctly observes, short cuts of the knife are always bet- ter and quicker than those made by scraping or dragging with the instrument. It is also important to come down to the soft tissue at the coronary band first, and successively downward to the inferior border of the waU, as otherwise, as the instrument is moved from above downward, with a certain amount of force, it might slip and cause a serious division or laceration of the podo- phyllous tissue. The separation is then made of the wall from the sole by another groove, extending from the end of the groove already made, on the quarter, back to the heels. This is done without difficulty, with a small drawing-knife, when the foot has been properly prepared. There is, however, one point which usually offers more or less resistance when the quarter is removed. It is that where the wall is continued to the bars. This resistance is sometimes so considerable that if much traction is made, the wall will break more or less in front of the heels, where it is com- paratively thin, and it may consequently become necessary to re_ move, by itself, the portion which has remained attached. This little accident, however, can be avoided by ascertaining certainly before the extraction of the wall is effected, that the continuity of the wall and bars has been cut off. This being the case, the com- plete separation of the wall from the sole is made by running the sharp edges of the double sage knife through the structure of the living tissue underneath. The resection of the quarter can then be proceeded with. For this purpose, a properly constructed lever is carefully in- troduced into the groove before mentioned, at the wall and sole of the foot. The inferior and anterior angle of the hoof at this point being then carefully raised, an assistant grasps it with the nippers, turns it back and tears it slowly, while the surgeon, with such a motion of the lever as may be necessary, assists in the tearing off of the portion of the quarter requiring removal. If adhesions remain, interfering with this manipulation, they are removed by cutting with a sharp instrument. As this separation of the wall reaches about to the coronary band, the separation is very easy, DISEASES. 729 and no fear of lacerating the soft structures need be entertained. Care is necessary at this step, however, to avoid injuring the cor- onary baud, and the podophyllous tissue ; to prevent which it will be prudent on the part of the assistant to press upon the band as the separation takes place. This being accomphshed, the edges of the wound are carefully examined; any projections remaining are removed, and the blood is sponged off. The double sage knife is then carefully plunged, with the convexity turned upward (that is, toward the skin), be- tween the external surface of the cartilage and the internal face of the skin, below the border of the coronary band, and then carried forward and backward, or as required, until the separation of the skin and the cartilage is completed and the external surface of the cartilage is exposed. In moving the iastrument backward, it is necessary to be very cautious, especially while carrying the sharp edges downward and inward, in order to avoid injury to the cor- onary band and the skin, of which, however, there can be but little danger, when the knife is carefiilly held and properly directed. The succeeding step is to separate the skin from the cartilage ; it is to be carefully raised and separated from its attachments under- neath, which is sometimes a process quite difficult to accomplish, as the skin has always become more or less tumefied, and there- fore has lost much of its natural flexibility and suppleness. Some operators, in order to avoid these difficulties, and overlooking the functions of the coronary band, cut it, and remove it, with those portions of the skin which cover the cartilage. Others, more con- servative (Herting, for example) cut it only through the middle, until they reach the superior border of the cartilage, and then, raising the two flaps of the skin, accomplish the same result with less cutting. The destruction of the principal organ of the secretions of the hoof having been involved in the first method, and having now taken place, it can never be restored to a healthy condition, and the animal continues to be exposed to the frequently serious com- plications of "false quarter." By the second method, the produc- tion of a new wall is nearly always accompanied with the forma- tion of a "quarter crack." The recovery is slow in either case, and more or less deformity is likely to follow. It is, then, the better and wiser plan to separate the skin from below, and to avoid the division of the coronary bands or of the teguments. 730 OPERATIONS ON THE FOOT. The next step is the removal of the cartilage altogether. This is done with the single sage knife, held firmly in the hand, either the left or the right, always, however, that corresjjonding to the side of the heel to be operated upon. Taking a point of rest with the flat of the thumb upon the plantar surface of the foot, the in- strument is pushed between the skin and the cartilage, and the sharp edge turned backward, with a firm rotary motion, down- ward and forward. The detached portion of cartilage is then seized with a pair of bull-dog forceps, and brought outward, and the sage knife is brought forward, downward and outward, from under the cartilage. It is a good plan, in order to make more room for working, to raise the skin and coronary band with a blunt tenaculum. The operation should always be commenced at the posterior part, in order to avoid the articular synovial cap- sule, which might be opened if the removal of the cartilage was begun forward. As the operator reaches the anterior part of the cartilage, which is situated almost over this capsule, it is prudent to hold the foot in excessive extension, and thus avoid injury to the capsule. This is an important point to consider in the oper- ation. The sharp instrument being carefully handled, every por- tion of the cartilage is taken off, either at once, or better by layers successively, until the whole is removed. It is thus accomplished in three or four pieces. In some instances the anterior portion is cut off by a longitudinal incision, made with a straight bistoury, following the direction of the posterior face of the coronet, the object, in this case, being simply to render the operation easier. The cartilage is thus removed, great care being taken to avoid opening the capsular articular bursae. It is essentially necessary to remove the whole of the diseased tissues, in order to bring the parts into the condition of a simple wound. Still, there need be no alarm if some small portions remain, more fibrous than cartilag- inous, which, deep as they are, may protect the synovial capsules or the ligament ; and moreover, they often slough off by them- selves, with the abundant suppuration which follows. To operate with the greater facility, it is well to have two forms of sage knife, one right and one left-handed, and some of extra strength, with which to remove the larger particles of cartilage, the others being small, thin and light, being adapted to the more careful dissection necessaiy toward the lateral ligament, and about the synovial bur see of the joint. DISEASES. 731 Toward the end of the operation, the surgeon will, with the finger, carefully exj)lore the condition of the parts, to insure him- self that the cartilage is entirely removed ; that the articular syn- ovial sac has been preserved intact; that the hgament of the joint remains perfect, and that the parts are well washed, and ready for the dressings. Although in the absence of possible compHcations, the operation is now finished, it may yet be followed by some serious sequelse, which we will next consider. The operation may become complicated by a variety of atten- dant and accessory circumstances. Among these are, the opening of the articular capsules; the wounding of the anterior lateral ligament of the articulation; the ossification of the fibro-cartilage ; caries of the os pedis ; and the alteration of the coronary band and of the reticular tissue. The opening of the articular capsule, either during the oper- ation, or by ulcerative process, is not so serious an accident as it was originally thought to be. Still, however, it requires some at- tention. It only becomes dangerous when the ulceration is ac- companied by serious disorganization, and especially when it is associated with purulent arthritis. (Renault, Hurtrel, D'Arboval, Bernard). It is treated by simple pressure, camphorated paste, a little corrosive sublimate mixed with starch, or better, with Egyptiacum ointment. The u^ound of the ligaments has also been considered a very serious accident, which, according to Girard, cripples an animal permanently. But Lafosse thinks this an exaggerated notion, and claims to have witnessed the radical recovery of animals after the necrosis and sloughing of the ligament. If ossification of the cartilage is discovered during the opera- tion, the removal of all the unossified portion is first proceeded with, in order to prevent a recurrence of the disease. The extii'- pation of the osteo-cartilaginous portion is then effected, either with a small drawing-knife, or the gouge, or the bone forceps. The removal is made as far as the ossification is found to be com- plete, the operator making svire that every portion of cartilage is thoroughly destroyed. If the ossification is but partial or irregu- lar, the surgeon must be guided by the condition of the parts. When the entire cartilage has undergone ossification, its suscepti- bility to caries has ceased. When caries of the os pedis exists, the part must be destroyed 732 OPERATIONS ON THE FOOT. with tlie sage knife, the gouge, or the chisel, according to the existing conditions. But in this case, portions of the reticular structure require removal, of which, however, as little as possible should be destroyed. It may happen that the portion of the coronary band covering the cartilage may be destroyed, either wholly or in part, either as an effect of the disease, or by accident during the operation. In the first case, if the entire band has been destroyed, there is noth- ing to be done. But in the other case, if any portions of it re- main, care must be taken to ins\u-e their preservation, as they may supply the necessary elements for a new, healthy secretion of hoof, and the quarter may grow again, more soUd and less de- formed. If the wound of the coronary band consists merely in a simple division of limited extent, the wisest course will be to at- tempt to obtain union by immediate adhesion, or first intention, by bringing the edges of the incision together and maintaining the contact by careful dressing. When the alteration of the re- ticular tissue alone, is present, it is very essential to avoid the ex- cision of the injured laminae. It is, in fact, the better course to avoid wholly the use of sharp instruments, and to leave to the natural process of suppuration the removal of the disorganized parts. Renault having observed how their removal interfered with the reparative process, has often left them undisturbed, even when their dark color and softened condition indicated the small- ness of their chance of conservation. The success of the opera- tion after a first dressing, has shown the wisdom of the plan of non-interference ; they were found covered with a new layer of yellowish hoof; and D'Arboval has on several occasions observed the same result. The dressing must be methodically and carefully applied. Done well, a dressing greatly assists in the recovery, while many, when badly performed, have been the cause of serious complica- tions, which have greatly hindered the repairing process, and of- ten, indeed, rendered a disease incurable, which need not have been beyond remedy. In the application of the dressing, two points are important to consider: first, Ave must dress the subcu- taneous wound, resulting from the separation of the skin and the extraction of the fibro-cartilage ; the other, that of the sub-horny wound, produced by the removal of the portion of the quarter. Both are important, but the second requires the greater care, and DISEASES. 733 is more difficult and more important than the former ; any excess in the sanguineous circulation must be prevented, and excessive granulations must be kept under control. The dressing, then, must be somewhat compressive, vdthout being excessively rigid, in order to obviate possible danger of excessive inflammation ; not too loose or so soft as to allow hemorrhage, or the undue pro- liferation of granulations. It must be both supple and firm, and of an even and uniform pressure. The proper material is balls of- oakum for the subcutaneous wound, and pads of the same mate- rial for the sub-horny, the first being moistened with alcohol, while the others are made dry. It is in question whether we should aim to obtain immediate adhesive union of the wound resxilting from the removal of the cartilage, or in other words, whether it is good treatment to in- troduce some material of dressing between the skin and the bot- tom of the wound. Here opinions vary. Our behef is, that this union is by no means easy to secure ; and that the removal of the cartilage, more or less altered, prevents it at various points. Still, we must not raise the skin too much, and choosing a middle course between, only a small, soft ball of oakum is now placed in the deepest part of the wound, or a thin pad is placed between the two parts, sufficient to represent about the natural form of the part, being enough, however, to prevent the immediate reunion from taking place. A Hght, thin shoe having been prepared (Figure 528), adapted to assist the application of the dressing and its holding prop- erly, it is put on with one of its branches cut off short on the side where the operation has been l^erf ormed, while the other branch projects backward beyond the heel, to support the rollers of the bandage of the dressing. Des- plas had thought to turn up that long branch of the shoe (Fig. 529) • /i 1 „j! 1 1, j.^ „„ • I ■„ Fig. 528.— Truncated Shoe for Dressing m the shape of a hook to assist m .^ ^^^^ ^^ cartilaginous Quittor or Com. holding the dressings. This is plicated Corn. 734 OPERATIONS ON THE FOOT. Fig. 529.— Desplas' Shoe for Dressing after Operation of Cartilaginous (^uittor and Complicated Corns. useless. Some veterinarians leave the animal unshod, but the bandage is more likely to slip off. The shoe must be put on while the animal is down, and before the appHcation of the dressing. With some practitioners, that is the moment for the removal of the tourniquet or cord, which had been apphed at the beginning of the operation in order to prevent the bleeding. This is an un- necessary precaution, and only renders the application of the dressing more difficult. First, balls of oakum are placed over the coronary band, then, upon the points of union of the preserved wall and of the podophyllous tissue, and then all over the wound. We must endeavor, as Renault says, to give the dressing a cylin- drical form, or rather, according to Rey, hemispherical, after which the whole is covered with pads and rollers. These must be put on in abundance, the rollers passing over the branch of the shoe on the soimd side, and running successively from above down- ward, and generally from before backward (Figs. 530, 531, 532, 533). Flat feet require special care in dressing, and the fore feet are generally more difficult to dress than the hinder. When all is finished, the animal has to be watched for several days. Ordi- narily, after the operation, there is abundant hemorrhage, occur- ring within some fifteen minutes, and oozing through the dress- ings. This requires no special attention, and generally ceases spontaneously, or by the pressure of the dressing, or by the use of the cold bath. If the dressing seems to be too tight, and the animal shows signs of acute pain, with strong reactive fever, it is not therefore necessary to remove the dressing, but may be suffi- cient simply to loosen the bandage. The animal should be placed in a wide stall, or box, if possible, where he may move freely, and DISEASES, 735 VARIOUS STEPS IN THE APPLICATION OF THE DRESSING AFTER OPERA- TION FOR CARTILAGINOUS QUITTOR. Fig. 532.— 3d Step. Fig. 533.— Dressing Completed. lie down easily ; and lie must be jorevented from tearing off the dressing by the application of a neck cradle. A low diet is neces- sary for several days, in some instances mashes being the only food allowed. Still, a good appetite and lively condition are always good signs. The interval of time which should be allowed to elapse be- tween the operation and the removal of the first dressing, should be judged by the amount of pain which the animal seems to suf- fer ; by the temperature of the atmosphere ; and by the amount of liquid discharge found oozing from the wound and moistening the dressing which covers and protects it. Generally, the dress- ings should be disturbed as late and as seldom as possible. Cir- cumstances will sometimes occur, however, which necessitate their removal earlier, as for example, the extreme heat of the weather; 736 OPEBATIONS ON THE FOOT. the extremely offensive odor proceeding from the diseased parts ; and a sudden and evident increase of pain in the wound, without any known cause. Under these circumstances, which, however, are of rather infrequent occurrence, it is sometimes necessary to remove the dressing as early as the third day, although at this time, as suj)puration is not yet well estabUshed, the operation is quite painfid, and may be accompanied by free hemorrhage. But if the weather is not excessive ; or the dressing remains dry on the outside, and matters seem to be generally in good condition, the better course is to wait from eight to ten days, before the dressing is renewed. Indeed, numerous cases are on record when a still longer period has been allowed to elapse, and the re-dress- ing has been deferred to the extent of three weeks, or longer. In any event, great caution must be exercised in the removal of the dressings, and the surgeon should be careful to have all his ap- pUances ready in advance, in order that the wound may be ex- posed to the air for the shortest possible space of time. When exposed, the wound should be of a red color, with commencing granulations, and a temporary hoof, soft and whitish in appear- ance, should be visible on the podophyllous tissue. A dressing is then applied of tincture of aloes, or a weak solution of iodine. At a later period the dressings are changed at intervals of about eight days, and an application is made of pulverized sulphate of copper, in order to facilitate the drying and hardening of the soft hoof. Baths of sulphate of iron, with a small portion of sulphate of copper are of service in promoting and hastening the cicatriza- tion. About the thirtieth or fortieth day after the extirpation of the cartilage, the animal may be put to hght work. But three or four months, if not a longer period, must elapse, before it wUl be safe to task him with heavy labor. Toward the end of the assigned term he should be fitted with a bar shoe, shortened on the side where the quittor has existed. If the dressing is skillfully applied and proper care is exercised, the diseased foot may be sufficiently protected, and the animal made to resume his work with safety. In time, the portion of hoof secreted by the coronary band unites with that of the podophyllous tissue, and after a few months, no remains of the operation are visible. But if the cor- onary band has ulcerated; if the skin has been divided; if by contact of the firing iron, or application of caustics, it has been DISEASES. 737 destroyed; the quarter then presents irregularities, and some- times divisions, which may be of long continuance, and give rise to a lameness which may, perhaps, become permanent. This danger indicates the necessity of exercising the utmost skill and caution in operating, in order to avoid possible injuries to the coronary band. Several modifications of the ordinary mode of operation have been proposed. Some have had for their principal object, the prevention of the extraction of the hoof, with a view of thus re- turning the animals to their work at the earliest period practic- able. It is thus that Hazard, Jr., proposed to make a crucial incision upon the skin covering the fibro-cartilage ; the four flaps being so dissected as to expose it, and then removing it with the sage knife. In this process, the extirpation of the entire cartilage becomes extremely difficidt without inflicting injury vipon the lat- eral ligaments and the synovial capsules. Pagnier has proposed to merely thin down the quarter, to make an incision in the skin along the sujDerior border of the car- tilage, and through this to remove the organ. But in this opera- tion, however thin the hoof may be, it always interferes with the entire extirpation of the cartilage. Bernard, following the idea of Lafosse junior, who only re- moved the superior border of the wall, proposed a mode of j)ro- ceeding which is principally useful in cases of separation of the hoof. Instead of removing the band of hoof parallel with the coronary bourrelet, Bernard pared it down with the drawing- knife, the sage-knife, or the rasp, in order to make it as thin as possible, while avoiding the injury to the sensitive laminae. This done, an incision is made along the coronary band, below it, de- stroying its union with the laminae. At this step of the operation, the indications are the same as in the ordinary modus operandi, except that the coronary band being covered with a certain thick- ness of hoof, is less flexible. This, however, is easily removed, as soon as it becomes softened. The remaining steps of the opera- tion are the same as in the ordinary, old way. That is to say, the posterior part of the cartilage being well defined, the sage-knife is used in the same manner. In this method, however, as the sage-knife works more flat-wise, there is less danger of wounding the ligaments or the synovial capsules. If any part of the car- tilage remains near these organs, some care must be used in 738 OPKKATIONS ON THE FOOT. removing it, and it must be done by degrees, and in very small portions. The advantages of this process are: 1st, the avoidance of ex- tensive wounds, and of the extreme pain produced by the extirpa- tion of the quarter. 2d, to keep the foot shod, and to allow the animal to resume his work as soon as the first pain has subsided, which may occur at quite a considerable interval in advance of the perfect cicatrization of the wojind. 3d, to avoid long and fre- quently-repeated dressings. In this method, however, the quarter left intact sometimes in- terferes vnth the operation, and the excision of the cartilage is more difficult, being only practicable, indeed, in cases where there is a separation of the wall. Maillet has modified the method of Bernard, so that, instead of thinning down the band of hoof, he only appHes the rasp upon the quarter, and thins down with it all that portion which is ex- tirj)ated in the process of Eenault, and availing himself also, of the drawing and sage-knives. The remaining details of the oper- ation are like those of the ordinary processes. An objection to this mode is that it can be put in practice only in cases where there is already a separation of the wall. It is objectionable from its tendency to weaken the foot too much, by interfering with the firm and soHd adjustment of the shoe, as well as retarding its application to the hoof. CHAPTER XIV. OPERATIONS UPON THE EYE AND EAR. ON THE EYE. OplitKalmology, though it has made appreciable progress in vet- erinary practice within a few years, has not yet reached a position corresponding with that which it occupies in human surgery, and probably will not for years to come, if ever. The difference in value and importance between the functions of the organ of sight in the man and in the horse is too measureless to induce or re- quire an equal amoimt of interest and study in the optical path- ology of the two animals, the human and the equine. It is in- deed, a fact that many of the forms of disease which affect the eye of the horse have not yet been recognized and investigated by students of veterinary medicine. For these reasons the contents of the present chapter will be limited to those affections in which, strictly speaking, special sur- gical interference has been so imperatively needed as to compel the attention of scientific veterinarians, by considerations of both duty and interest. We shall consider the subject ujider two principal divisions, or heads, viz., operations, performed on the accessory, and those pertaining to the essential organs of the ocular apparatus. 1. — Operations Perfoemed on the Accessory Ocular Organs. On the Eyelids. — These constitute the two cutaneo or mu- cous veUs, which are situated in front of the organ, and are divided into superior and inferior, uniting at their extremities to form the angles or commissures of the eye. Besides these, there is a pecu- liar apparatus situated on the internal or nasal angle, known as a third eyeUd, or menhrana nictitans. This is a small cartilage, thinned out on its free border, continued on its posterior portion with the adipose cushion of the eye, and covering it in front, wiping, as it were, its corneal surface, whenever the ocular globe 740 OPERATIONS UPON THE EYE AND EAR. is drawn back into the orbital cavity. On the internal commis- sure are found the caruncula lachrymalis, showing on the upper and lower lids the lachrymal pimcta, both of which empty into the lachrymal sac, which is itself continuous with the lachrymal canal, and through the lachrymal duct empties at the lower com- missure of the nostril by the lachrymal opening. Among the surgical diseases of the eyelids must be mentioned traumatic lesions, pathological growths, defective congenital con- formations, and specific diseases of their elements. A. — Traumatic Lesions. JBruises of the eyelids are specially common in horses after kicks and blows in that region, and may also be the resvdt of fric- tion and chafing from the harness. If the cause has been severe, oedema of the lid is the result, as well as more or less flow of tears, and, possibly, irritation of the cornea. These accidents are generally of no great severity so long as the globe of the eye re- mains intact, but if this is injured serious complications ensue. The indications of treatment are those of all similar injuries of a local character, consisting of cooling astringents, with local bleeding, which generally bring rapid rehef. B. — Solutions of Continuity. These are very common with all our animals. They are sel- dom simple, but are more commonly complicated with lacerations of the tissues, by nails, hooks, etc., or even the teeth of other animals Clean wounds by sharp instruments are rare, and are easier to treat than those having torn and irregular edges. They may be superficial, and may involve the thickness of the lid alone, but they may also be deep and complicated with wounds of the globe of the eye itself. The condition of the wound in this re- spect is important to know, and should be ascertained as early as possible. The raising of the eye with the elevator palpoebrum (Fig. 534) greatly facilitates this examination, and the animal sel- dom offers any serious resistance to it. Fig. 534.— Eyelids Elevator. SOLUTIONS OF CONTINUITY. 741 Simple lacerations of tlie lids commonly heal without any treat- ment beyond mere cleanliness — a soft sponge and a little clean water. But the application of the pin or twisted sutui-e, in con- nection with antiseptic measures will greatly promote cicatrization by the first intention. Care must be taken to confine the animal's head in such a manner as to prevent him from rubbing the wound until cicatrization is weU estabUshed. C. — Defective Congenital Confoemations. Under this head we shall consider the deviation of the hds, either outwardly or inwardly, from the convex lines of the cornea, with which they should be parallel. A deviation in the growth of the eyelashes, or cihse, is another annoying ii-regularity of the same region. The outward deviation of the eyelid is called ectro- pion; the inward, entropion. The deviation of the eyelash is known as trichiasis. 1. Ectropion. — The two principal causes of this abnormal condition are an excess of mucous membrane or deficiency of skin. Again, the ectropion depending upon paralysis of the orbic- ularis palpcebrum, is of a different nature. Ectropion occurs more frequently in the lower than in the upper hd When depending on a want of skin, it is generally the result of a wound or a burn, or possibly of an abscess, and is a cicatricial ectropion, in which the retraction of the cicatricial tissue has carried the lid with it. Paralytic ectropion is the result of age, and is more or less peculiar to old animals. It may also result from a diseased condi- tion of the conjunctiva, or of some of the organs of the orbital cavity. The treatment of a case of this afiection should be modified by the nature of its cause. If it is due to excess in the mucous membrane, the redundancy must be reduced. If caused by want of cutaneous surface, the remedy must be applied to that surface. If a hyphertrophied, mucous membrane is the trouble, astrin- gents, caustics, and scarifications must be employed; or even the removal of portions of the conjunctival mucous membrane, with the scissors or the bistoury. If, on the contrary, the deformity results from the condition of the skin, hlepharoplasty or hlep)ha- rortapy must be resorted to. The simplest manner of operating consists in amputating a V-shaj)e jDortion of the eyehd and uniting the edges with stitches. 742 OPERATIONS UPON THE EYE AND EAR. 2. Entropion. — This is a malformation in which the border of the lid is turned inward. While in an ectropion the skin is in excess, the reverse condition is discovered here, where it is defi- cient. It is often the result of ophthalmic attacks, and it may also follow a loss of substance ia the conjunctiva, after ulceration, or the removal of foreign growths. According to Leblanc and D'Arboval it may follow some eruptive fevers, or parasitic dis- eases. In entropion there is an increased flow of tears, abundant muco-purulent secretion, keratitis, which may become ulcerative, and loss of sight. The treatment consists in the excision of all the inverted por- tion of the deformed lid, which is accomplished by raising it from the globe with a forceps, and separating it with a single cut of the curved scissors, the protruding portion being then amputated. The hemorrhage is stopjjed with cooling lotions. Another mode of operating consists in cutting off only a por- tion of the skin of the lid, and unfolding it by passing the finger under the inverted border. Then a fold of skin is amputated near the free border of the lid, and the edges brought together by twisted pin suture. 3d. The deformity of trichiasis, or abnormal growth of the lashes has been observed by Leblanc in sheep, but in our domestic animals is a rare disease. Amputation of a portion of the skin ; pulling out the eyelashes, followed by cauterization, and extirpation of the free border of the Hds, have all been recommended against this abnormality of cutaneous secretion. D. — Pathological Growth and Caries of the Membrana NiCTITANS. Acute inflammation of the third eyelid, either as a symptom of ophthalmia, or resulting from direct traumatism, such as blows, or the presence of foreign bodies, terminating in caries of the constituent cartilage of this delicate organ, or the formation and development of epithelioma of the mucous membrane, are condi- tions often seen in our domestic animals, principally in horses and dogs. We have often noticed this peculiar affection, so easily recognized by the presence at the nasal angle of the eye, of granu- lating masses of various sizes, protruding at their internal commis- sure of the hds, and over the surface of the cornea, accompanied DISEASES OF THE MEMBRANA NICTITANS. 743 with more or less suppuration, lacrymation and ectropion of the lower Ud. The epithelial growths, when small, will sometimes disappear under the appHcation of caustics, or can be removed with the Hgature, or by direct amputation with fine scissors. In some cases they assume very large dimensions, the mucous membrane becoming more or less ulcerated, and the cartilage itself diseased, and amputation of the entire cartilage becoming necessary. This operation is not of recent origin, having been per- formed, within our knowledge, some years ago, though entirely upon emj)irical grounds, in tetanic cases, from the fact that the protrusion of the membrana nictitans over the inner side of the external surface of the ocular globe, qmte out of its nor- mal position, had often been noticed among the symptoms of lock-jaw. The removal of the '•'• haxcck^'' as the operation was then called, has never, however, for the reasons which were them ac- cepted, become legitimized among the theraj)eutics of the scien- tific veterinarian. The removal of part, or what is more effectual, of the whole of the membrana nictitans requires three instru- ments, a speculum ocuh, a special forceps, like that of Snellen, and a pair of curved blunt scissors. The animal must be thrown, and the eye being anestheticised with cocaine, and the lids kept weU apart with the specvilum, the organ, with the mucous membrane which covers it, is drawn out with the Snellen forceps, and by degrees severed in its continuity. "WTien it is loosened sufficiently to be brought entirely out of the orbital cavity, it is separated with the scissors from all its attach- ments. The adipose mass which was then slightly protruding re- turns to its position and the operation is concluded. There is always a Httle hemorrhage accompanying the dissec- tion, which, however, is readily subdued by means of a simple compress of cold water. No special subsequent attention is neces- sary. n. — Operations on the Lachrymal Apparatus. A. — On the Caruncula Apparatus. The caruncula lachrymalis is sometimes the seat of hypertro- phy, as commonly seen in cattle, the vague designation of Encarh- this being given to all such lesions of the caruncula lachrymaHs, whatever may be their origin or nature. 744 OPEKATIONS UPON THE EYE AND EAR. It is an affection which is quite frequent in dogs, as the result of localized chronic conjunctivitis. It is characterized by a tume- faction of the organ, more or less developed, pedimculated, pro- truding in the inner commissure of the lids, and accompanied by lachrymation, caused by the obstruction of the lachrymal punctse. While at the outset anodynes and astringent collyria may some- times control its development, there are many cases in which its removal by ligature or excision is indicated. SUk is recommended by Leblanc as the best material for a ligature, but elastic thread is in our judgement much to be preferred. Excision is far preferable. The operation is a simple one, con- sisting in merely severing the peduncle with a curved scissors or Fig. 535.— Bistoury for the Excision of the Encanthis. a bistoury (Fig, 535), ad hoc. The comparative abundant hemor- rhage that follows is controlled by cold water applications. The woimd which remains is treated on general principles. H. — On the Lachryinal Ducts. The occlusion or obliteration of these little canals by foreign bodies, or as the result of inflammation of their mucous membrane, sometimes occurs in horses. Its characteristic symptom is an abundant and continual lachrymation, and it is only by careful examination of the condition of the orifices of the lachrymal pamc- tse, that a correct diagnosis can be assured; a thick, muco-puru- lent discharge sometimes oozing from them. Though this diffi- culty often subsides by resolution of the inflammation, or the use of washes and collyria, there are cases where surgical interfer- ence, of the nature of a true catheterism of the duct, with possi- bly an enlargement of its canal with the bistoury, cannot be dis- pensed with. The probe of Bowmann (Fig. 536), and the knife of Weber (Fig. 537), answer the purpose very well. The animal is placed in the decubital position, the grooved probe introduced into the duct, and its wall divided with the knife, guided by the groove of the probe. ON THE LACHBYMAL APPABATUS. 745 Fig. 536.— Probe of Bowmann. FiG. 537.— Knife of Weber. C. — On the Lachrymal Canal. The obliteration of the lachrymal canal may become necessary in consequence of changes in the structure of its walls, or the pressure made upon it by the surrounding parts. In the first case, it occurs as the result of traumatic lesions, or of inflamma- tion of the mucous membrane, the exudates accompanying it, and the accumulation of thick secretions in the channel of the canal. In the second case, it is due to severe rhinitis, swelling of the in- flamed mucous membrane of the nasal cavities, polypi, bony growth of any kind, or in cases of dental caries. The symptoms are : Lachrymation, filling up of the canal, its inflammation, and arrest of the flow of the tears through the lachrymal opening at the nose. According to Professor Leclainche, there are four modes of treatment for the relief of this trouble. 1st. Opening of the natural tract and reinoving the cause of the obstruction. — This is done by the catheterism of the canal by means of fine probes, or by detersive injections forced through the inferior opening in the nostrils; or, again, as practiced by Director Trasbot, by insufflation. 2d. Making an Artificial Tract. — If the point of obliteration is situated near the lower opening of the canal, an artificial open- ing can be made above it. To do this, Leblanc recommends the in- troduction of a whalebone probe through the superior lachrymal opening into the canal until the place of obstruction is reached when a counter opening is made with a fine bistoury through the walls of the canal. Two or three silk threads are then introduced into the new passage between the two openings and left in place for about twenty days. If the obliteration is in the bony portion of the canal, and cannot be overcome with the silver probe, the perforation of the lachrymal bone and an artificial fistula must be made. 746 OPERATIONS UPON THE EYE AND EAR. Neither of these operations is often followed by successful re- sults, although the perforation of the bone enables the tears still to escape in the nasal cavities. The formation of a fistula fur- nishes a channel for the flow of the tears over the lachrymal sur- face of the face. 3d. Obliteration of the Natural Tract. — The intention of this operation is to effect the entire obHteration of the duct from the lachrymal puncta and the lachrymal duct down. It is obtained by the cauterization of these parts, either alone or inclusive of the obliteration of the lachrymal sac. Tincture of iodine often pro- duces the same effect. As the result of this treatment, the flow of the tears takes place over the face. 4th. Extirpation of the Lachrymal Gland. — This is not re- ferred to as a practicable measure, but only because it is some- times mentioned in the way of theorizing. The situation of the gland in our domestic animals renders the ojoeration an impossi- bihty. III. — Operations on the Essential Organs of Sight. On the Globe. — The essential organ of vision, or ocular globe, is a membranous ball, comj)letely closed, and filled with transpar- ent fluids of different densities, and popularly known as the humors (or media) of the eye. This ball, nearly spherical, flattened from backwards in front, has its greater convexity in front, where it is closed by the cornea, a transparent expansion, thick and resisting ; the glass of the eye. Posteriorly, it is composed of three capsular, concentrical sheaths, proceeding from without inward. These are the fibrous sclerotic, the choroid and the retina (Fig. 538). In the cavity of the globe one of these membranes — the cho- roid — throws out, perpendicularly to the great axis of the organ, a septum, the iris, a kind of contractile diaphragm, perforated in its center by the pupil. The retina is a membrane of special nature, being an expan- sion of the optic nerve, and performs the function of receiving the impressions of hght, and transmitting its impressions and images to the brain. The humors of the eye are three, considered from before back- ward, the most anterior being the aqueous, the most posterior the vitreous, with the crystalline lens in the intermediate position. ox THE ESSENTIAL ORGANS OF SIGHT. 747 Fig. 538. —Theoretical Section of the Horse's Eye. a.— Optic nerve. 6. —Sclerotic, c— Choroid.— rf.— Retina, e —Cornea. /.— Iris.— p/t.— Ciliary circle i,or ligament) and processes given off by the choroid, though repre- sented as isolateJ from it, in order to indicate their limits more ck-arly. 1— Insertion of the ciliary iirocesscs on the crystalline lens. J.— Crystalline lens, fc.— Crystalline capsule. Z.— Vitreous hody. «i.»i.— Anterior and posterior chambers, o.— Theoretical indication of the membrane of the aqueous humor, pp. — Tarsi. (77— Fibrous mem- brane of the eyelids, r— Elevator muscle of the upper eyelid, ss.— Orbicularis muscle of the eyelids. <.— Skin of the eyelids, v —Conjunctiva. 1;.— Epidermic layer of this membrane covering the cornea, x — Posterior rectus muscle. 2/.— Superior rectus muscle, z —Inferior rectus muscle, w —Fibrous sheath of the orbit (or orbital mem- brane). To this essential organ are added as accessories, first, a mus- cular aipparatus, constituted by seven muscles — ^.posterior straight or retractor^ four others, also straight, the superior, inferior, ex- ternal and internal; and two oblique, or rotators, the great and small, or external and internal oblique; second, an adipose ptad; third, an apparatus of lubrication, composed of the lachrymal gland and its means of conducting the tears, the j^roduct of its secretion, viz., the hygrophthahnic canals, i\\ep>uncta lachrymalis, the caruncula lachrymalis, the lachrymal ducts, the lachrymal sac, and the lachrymal canal. The whole mass of this apparatus is enclosed in a conical fibrous sac, the ocular sheath, which forms a membranous lining, as it were, to the orbital canity, or bony box, which is anteriorly open, except when closed by the eyelids. Our design in the present chapter is to confine our considera- tion entirely to such portions of surgical ophthalmology as are likely to demand the careful and practical attention of the vet- erinarian. 748 OPERATIONS UPON THE EYE AND EAR. A. — The Extraction of Foreign Bodies on the Surface OF THE Globe. The presence of a foreign body between the lids and the globe of the eye is just as painful to animals as to man, and may, if allowed to remain, give rise to symptoms of irritation and inflam- mation which, unless promptly relieved, may induce severe attacks of diseases which may compromise the usefulness of the organ. Dust, insects, and small seeds of various kinds may indeed find a lodgment in the eye, and resist the efforts made for their removal, notwithstanding the excited function of the membrana nictitans, or the super-excited flood of tears stimulated by their presence. Immediate removal is the first indication. This may some- times be effected by bringing the lids together and keej)ing them temporarily closed until the stimulated collection of tears washes out the offending substance. If this fails, cocaine must be applied upon the eye, and when its full effect is obtained, careful examination must be made, if necessary, with the assistance of a loup, by everting the lids, in order to bring the entire surface of the cornea into view The irritating body may be wiped out with the finger, a piece of cloth, or a soft camel hair brush, or when the object is hard and angu- lar, as a particle of metal or stone, which has become partly im- bedded in the cornea, the forceps may be necessary. B. — Puncture, or Paracentesis of the Cornea. The object of this operation is to empty the anterior chamber of the eye of its aqueous humor, of a collection of pus, or to effect a release of a living intruder from the cavity of the eye, as, for example, the parasitic ,/^Yar^a oculi. The operation is simjDle, but the use of cocaine cannot be omitted. The instruments necessary are a cataract knife, or a lanceolated bistoury (Fig. 539). It is introduced obliquely through the cornea, at a very short distance from the sclerotic, and its in- FiG. 539 —Lanceolated Bistoury. ON THE ESSENTIAL ORGANS OF SIGHT. 749 troduction of course causes the immediate evacuation of the fluid contained in the anterior chamber, and the dropping or collapsing of the cornea, which assumes a rough and shrunken appearance. In a few hours, however, it resumes its normal condition, the secretion of the humor having taken place, and the wound of the cornea being closed. Compresses of cold water, and the application of a weak solu- tion of atropine will obviate severe symptoms. C. — Staphyloma. This designation applies to a deformity or distension of the cornea, consisting in its protrusion beyond its normal and sym- metrical convexity. It varies in shape, and may be round or pointed. It is very common in dogs, especially in young ones, and if not discovered and attended to in its first stage becomes very rebellious to treatment. If overlooked and neglected ulcera- tion of the cornea and destruction of the eye is certain. Cauterization, with nitrate of silver, the Hgature, and complete excision with the scissors are recommended, but the chances of success depend on the length of time it has existed and the size it has attained. D. — Cataract. The opacity of the crystalline lens, or that of its capsule, or that of the humor of Morgagni, or of these three conjointly, pro- duces loss of sight, and for its re-estabUshment the operation called "of the cataract" is, in some exceptional cases, attempted on horses and dogs. The object in view is the extraction of the opaque lens; its di\ision into fragments that may be resorbed ; or its dislocation from its normal position. It is not often performed in veterinary practice, but successful attempts have been credited to Vatel, La- fosse and others, while still others, as Gohier, Brogniez, H. Le- blanc, Haubner, Hertwig and Hering have reported their results as sometimes successful and sometimes otherwise. The animal is to be placed in the decubital position, and the dilatation of the pupil is to be obtained by the application of a solution of sulphate of atropia or extract of belladonna. Among the difficulties connected with this operation is the peculiar anatomy of the globe of the eye, which by the action of 750 OPERATIONS UPON THE EYE AND EAR. the posterior rectus muscle is drawn back in the orbital cavity, a displacement which not only renders the action of the instruments more difficult, but also stimulates the motion forward, over the cornea, of the membrana nictitans. The immobility of the eye is one of the first points to be secured. There are two ways of securing it, one fixing it from the front, the other from behind. It can also be fixed from the front in two ways — that of Le- blanc and that of Brogniez. Leblanc uses a tricuspid stylet (Fig. 540), which has three branches, two of which are applied on the Fig. 540.— Tricuspid Stylet of Leblanc. sclerotic at the internal angle of the eye, the third, which is mov- able, resting also on the same membrane at its inferior part. The first two keeps the membrana nictitans from the cornea, and all three, implanted into the sclerotic, keep the globe immovable. Brogniez uses a special instrument, which he calls a " diapta- tor" (Fig. 541), which is a metallic rod, having three or four Pig. 341.— Brogniez Diaptator. points, twisted like those of a cork-screw, which by a sUght pressure, combined with a little twist of the instrument, com- pletely fixes the ocular globe. To fix the globe from behind, Hayne, Dieterichs, Prinz and Bleiweiss make an incision through the skin behind the orbital arch, and an assistant, with one of his fingers passed through it, keeps it in place by direct pressure. General anesthesia is always indicated. Peuch and Toussaint recommend the use of the Waldon forceps (Fig. 542) to immobil- 'F»""'"""»"""""|'flM Fig. 548.— Forceps of Waldon. ON THE ESSENTIAX, ORGANS OF SIGHT. 751 ize the eye. It operates by grasping tlie conjunctiva on the inner angle of the organ, and keeping it motionless by a shght pres- sure. The Hds are kept widely separated by means of the specu- lum ocuh akeady mentioned. There are three principal modes of operation besides these, which are used in human surgery, which result in the union of these principal methods. 1st. Method. Dislocation of the Lens. — It is intended to displace the cataract en masse from the pupilar focus, and to fix it in a dependent part of the chamber, behind the iris, where it will no longer intercept the light. It is generally performed in two ways — through a punctui-e of the sclerotic (Scleroticonyxis), or by puncture through the cornea (Keratonyxis). The instrument used is called Scarpa's needle (Fig. 543). This is either straight or curved. The eye being fixed, Fig. 543.— Scarpa's Needles. and the pupil dilated, the needle is introduced through the scle- rotic, on the outside, and lower part of the globe, a short distance back of the cornea (Fig. 544), pushing it in a direction first sUghtly obliquely upward, and then horizontally. The needle has thus Fig, 544.— Operation of Cataract by Displacement of the Lena. 752 OPERATIONS UPON THE EYE AND EAE. penetrated between the ciliary processes and the border of the lens, and presently becomes visible to the operator, passing be- yond the internal border of the pupil. By a slight motion up- ward and downward, the capsule is then opened and the lens depressed, first backward, then vertically, and pushed downward into the lower part of the vitreous humor. A gentle rotation of the instrument then releases it from the substance of the lens, and it is returned to its horizontal position. The instrument is not withdrawn until it is ascertained that the lens is established in its new position. When the puncture is made through the cornea the entrance into the eye takes place near the center of this membrane, and the access to the lens takes place through the opening of the pupil. In either case the wound of the globe is insignificant. 2d. Method. Extraction. — There are two principal modes of operation, one by extraction through a flap of the cornea upward, and another by a linear incision on the side of the globe. In the operation by the flap upioard, the knife of Richter, modified by Beer (Fig. 545), is introduced horizontally through Fig. 545.— Knife of Beers. the cornea, near the sclerotic border, a little above the horizontal diameter of the globe, with the edge turned upward, and as soon as the point of the instrument has entered the anterior chamber of the eye, it is pushed in a straight, horizontal direction, passing into the anterior chamber (Fig. 546), and when its point reaches the opposite side of the cornea, it is pushed through it in such a manner that its exit and its entrance occur at equal distances from the sclerotic border. The flap is completed by pushing the instrument directly out, when the aqueous humor escapes, and the cornea coUapses. The anterior wall of the crystalline cover is then divided with the kystitome (Fig. 547). The hook of which turns backward, and is made to tear the envelope by moving it from above down- ward and from within outward. The upper lid being raised with forceps, and a gentle pressure made with the finger at the lower ON THE ESSENTIAL ORGANS OF SIGHT. I 753 Fig. 546.— Operation of the Cataract toy Flap Upward. Fig. 547.— Kyetitome. border of the cornea, the lens presently falls out through the in- cision. If it becomes engaged in the wound it can be removed with the forceps or the curette of the kystitome. Unless care is taken at this point to avoid making too great a pressure upon the eye, there is danger of the escape of the vitreous humor. The Uds are then brought together and a light bandage applied, and as in other cases, the animal must be prevented from distvirbing the wound by rubbing or otherwise. The linear method consists in making a straight incision on the outside border of the cornea with the knife of Graafe (Fig. 548). It is principally employed in cases of soft cataract. Fia. 548.— Knife of Graafe. 754 OPERATIONS UPON THE ETE AND EAR. E. — Amputation or Extirpation of the Eye. This operation is only indicated in cases of degeneration of the globe, and after special traumatic lesions of the organ. It is comparatively a simple one, and not as dangerous nor as painful as it is generally supposed to be. It can easily be performed with a simple or a blunt bistoury. Hertwig recommends a sage- knife, and we have often performed it with only a pair of curved scissors. With the lids well separated, the eye, or what may remain of it, is secured with a pointed tenaculum, or a pair of forceps, and the conjunctiva divided in all its circumference with the knife. Then passing the bistoury into the orbital cavity, close to its walls, and cutting from the inside, and thence to the inferior part, the entire mass is detached, with the exception only of being held by the cord of the optic nerve. This last attachment is then severed with the scissors. The hemorrhage which always accompanies the operation is readily subdued by pressure. Simple cleanliness is all that is required in the subsequent treatment. Doctor E. Eolland describes his tnodus operandi for the enu- cleation of the eye as follows: The operation requires a specu- lum oculi, a hook such as is used in the operation for strabismus, curved blant scissors, forceps to fix the eye, and a pair of scissors curved on their flat for the section of the optic nerve. The lids being held apart with the speculum the operator grasps a fold of the conjunctiva, on the outside of the eye, and shts it near the border of the cornea. Then, with the scissors, the conjunctiva is entirely divided round its margin, near the corneal border. The sub-conjunctival cellular tissue being after- ward divided with the scissors, the muscles are brought out with the strabismus hook and divided, beginning with the external rectus. The speculum is then removed, and by pressing firmly on both Hds, the globe of the eye is pushed out of the orbital cavity. The curved scissors are passed behind the globe, and the optic nerve amputated at its point of entrance into the globe. The operation ended, the orbital cavity is washed out with cold sterilized water, and is then filled with pulverized and sifted bor- acic acid. This dressing is removed daily for five or six days, and the eye protected as in Fig. 549. ON THE ESSENTIAL ORGANS OF SIGHT. 755 Fig. 549.— How to Protect the Eye. Ocular Peothesis. The animal which has undergone the preceding operation is considerably deformed, but the difficulty is easily remedied by the insertion of an artificial eye. Artificial eyes for horses were first introduced by Schmidt in 1850. They were originally made of glass, but many varieties of material have since been used, and to-day all instrument-makers probably keep them in stock, of hard rubber and gutta-percha, etc. By the skillful use of pigments the artificial organ can now be made to so closely match its Hving companion as to be undis- tinguishable from that which the animal has always carried (Figs. 550 and 551). But the artificial organ must not be introduced into the orbital Figs. 550, 551.— Artificial Eye— side and full view. 756 OPERATIONS UPON THE EYE AND EAR. cavity until all granulations, suppuration and inflammatory proc- esses in and about the wound have ceased. To put the artificial eye in place the upper lid is raised and the the border of the artificial organ placed underneath it; in the meanwhile the lower lid is drawn downward and the correspond- ing border of the eye pushed on its internal face. The eye is in place, especially if after its introduction the animal makes a few motions with his lids, all the folds of which are soon removed. To remove the eye the lower lid is drawn downward, and it is dis- lodged by passing a blunt probe under it toward its posterior face. The artificial eye will not need removal of tener than once in eight or ten days. If worn too long there might be danger, with cer- tain materials, of softening. The advantage of having an alter- nate eye will, upon reflection, become obvious. ON THE EAR Amputation. Usually, only horses and dogs are subjected to this opera- tion. With the horse, the object is commonly either the correction of a deformity, or the cure of disease or injury. When performed upon the dog, it is principally as an opera- tion of fashion — so-called — or in compliance with some prevalent caprice relating to a supposed improvement in the appearance of the animal. Yet with these it must at times, of course, become necessary for the repair of an accident. It should be understood that the seat of the operation is in all cases the cartilage of the concha. Amputation in Horses. — The amputation may be either partial or complete. One ear may exceed the other in size, and it may become necessary to trim down the larger for the sake of estab- lishing symmetry between the mismatched pair with the knife. Or both may be similarly misshapen, and a partial amputation of both may be, therefore, indicated, for the same aesthetic reason as that which influenced ia the other case. This operation is seldom, if ever, performed at the present time. The complete amputation is indicated in cases where the cartilage is affected with pathological degenerations, and especially when these exist toward its base. AMPUTATION OF THE EAR. 757 Partial amputation may be performed with the patient in any postiu'e, and may be considerably simpHfied by using Brog- 3£ T Figs. 552, 553.— Brognlez Apparatus for Amputation of the Zar. Fig. 554.— Apparatus of Brog- nlez in Position. niez's apparatus. This consists of a wooden model of the inside of the cartilage (Fig, 552), and of metallic en- velopes or patterns of the outside (Fig. 553) of which there should be separate ones for each ear. Both the wooden model and the metallic pattern are held in place by a systematic screw (or wood screw) like those usen by cabinet-ma- kers in gluing wooden joints together. The ap- paratus is adjusted as shown in Fig. 554, and the excision of the protruding cartilage is made with the bistoury. Amputation with the nippers of Garsault (Fig. 555), or that with the bistoury do not give equally satisfactory results. Complete amputation, according to Peuch and Toussaint, is best performed with the ani- mal under complete anesthesia. We have had opportunities of operating without it, but it cannot be questioned that it furnishes power- ful assistance, when it becomes necessary to keep the head in place, as in this case. ^^''- ®S^7bS®™ *" 758 OPEEATIONS UPON THE EYE AND EAR. We consider the operation to be comparatively a simple one, though deUcate handling is required. A convex bistoury or scalpel, dissecting and artery forceps and needles and thread are the instruments required. A circular incision is made always, if possible, by one stroke of the knife, toward the base of the cartilage, beginning at about the lower commissure of the external opening of the concha; then carefully avoiding the division of the bifurcation of the parotid gland, the insertion of the muscles attached upon the concha is divided, the posterior and anterior auricular arteries are ligated, the adhesions with the surrounding cellular tissue are lacerated with the handle of the scalpel, and the Hgament which tmites the concha to the annular cartilage is severed, the Httle prolongation of the former can then be easily followed to its end, and the con- cha be readily extirpated by lacerating its cellular attachments. The wound is closed with sutures, and treated in the usual way. Amputation in Dogs. — Although, as we have remarked, this is principally an operation of fashion, there are still conditions in which it is rationally indicated. It is commonly performed with scissors, curved or straight, with which the requii'ed portions of the concha are amputated by a single cut of the instrument. Instruments have been invented to insure a more certain suc- cess in the operation, and a neater finish after the wounds have Fig. 556.— Nippers to Amputate Dogs' Ears, healed. The limitation forceps, represented in Figure 556, pos- sess some advantages in these respects. In any mode of operation, the flap of skin first excised be- comes the only true pattern by which to shape the second. The operation is generally followed by some hemorrhage, but this either subsides spontaneously, or by the application of local hemostatics, and the cicatrization proceeds without help under the scab, which after a day or two covers the edges of the wound. CHAPTEK XV. DISEASES OF THE WITHERS. The withers is the region of the body which, of all others, is most exposed to lesion, the injuries to which it is subject being of every form, nature and degree of severity. From its very loca- tion it is especially liable to all kinds of external traumatisms, and is pecuHarly apt to suffer from blows, bruises, bites, contusions, pressures and frictions by the harness, etc., and these give origin to bloody or serous tumors ; cold and warm oedemas, abscesses superficial or deep, and various wounds of the surface, with or without injuries of the subjacent tissues; and these again may be followed by necrosis of the dorso-cervical ligament, and of the apex of the dorsal vertebrae, accompanied with purulent filtrations, in various localities, the formation of fistulous tracts, and possibly the extenston of the diseased conditions to the ligamentum nuchse, ending with the disease of the neck, with aU its unfortunate sequelae. With the consideration of such a multipHcity of pathological evils before us, an orderly and systematic arrangement of topics is especially necessary, and we shall, therefore, in our treatment of the diseases of the withers, adopt the classification of Bouley ^d Nocard. And this introduces us successively to the study of excoriations, cedemas, hetnatoma, core or stickfasts, cysts, abscesses, wounds, and the "diseased toithers^^ proper, or what is generally understood as "the persisting lesion, fistulous in its character, and whose condition of formation and duration is due to the mortification of the fibrous, yellow or cartilaginous tissue of the apex of the spinous processes of the anterior dorsal vertebrae." Considered from an anatomical point of view, the withers form a very complex region. Its skeleton is formed by the superior spinous processes of the anterior dorsal vertebrae, and it is sur- rounded by muscles arranged in layers, intersected by fibrous 760 DISEASES OF THE WITHERS. aponeurotic bands or sheaths. The vertebrae give attachment by the cartilaginous nucleus, which is at their apex, to the pos- terior portion of the yellow, elastic cord, which is part of the funicular portion of the Hgamentum nuchse, and are also united by the interspinal ligament. The muscles which rest upon the ver- tebrae form six different planes, thus divided : 1st. The sMn, lined inside by cellular tissue, more condensed toward the median line than on the sides, where it is loose ; 2d. The trapezium muscle, thin and aponeurotic inferiorly, but thicker in its upper portion, Ccl Fig. 557.— 1st and 2d Layers of the Eegion of the Withers. P.— Skin folded down, pf.— Funicular portion of the cervical ligament, tc.— Cer- vical portion of the trapezium, td. — Dorsal portion of the same. ea. — ^Acromion spine which is muscular (Fig. 557), and lying over the external surface of the scapula and its cartilage of prolongation. 3d. The rhom- boideus muscle, which is separated from the second plane on its external surface by a layer of loose cellular tissue (Fig. 558), and is lined in its internal face, by a yellow elastic band, inserted on the inside face of the cartilage of prolongation of the scapula. DISEASES OF THE WITHEES. 761 Fig. 558.-3(1 Layer of the Eeglon of the Withers, ch. — Cartilage of the scapula, pf. — Funicular portion of the cervical ligament, rh. — Rhomboideus muscle, a.— Angularis of the scapulae. S. — Splenius. Fm 559.— 4th Layer of the Withera, BC— Section of the scapula and surrounding muscles, da. — Anterior small serratus. ap. — Its aponeurosis, gd.— Great serratus. pf. — Funicular portion of the cervical lig- ament, s. — Inferior attachment of the splenius. ad.— Ramifications of the dorsal artery, gc— Great complexus. pc— Small complexus. a.— Section of the angularis scapulse. 762 DISEASES OF THE WITHERS, This band is specially liable to attacks of necrosis. 4th. The su- perior portion of the anterior small serratus muscle, which is formed by a broad aponeurosis, attached to the superior extrem- ity of the spinous processes of the vertebrae (Fig. 559). 5th. The Fig. 560.— 5th Layer of the Withers, pi. — Lamellar portion of the cervical ligament, pf. — Funicular portion of the same, ac— Superior cervical artery, te. — Transversal spinous of the neck. bs. — Superior branch of the spinalis, bl. — Inferior branch of the same muscle, ic— Common inter- costal, ad. — Dorsal artery, gd. — Great serratus. si. — Inferior scalenus, it. — Inter- transversalis muscle. anterior portion of the ilio-spinalis muscle (Fig. 560). The 6th and the deepest of these planes, resting on the faces of the long spinous processes of the vertebrse, is formed by the transverse spinal muscle of the back. (Fig. 561). To these are to be added the posterior extremities of some of the muscles of the neck, covered by the internal face of the scapula, the ramification of the large blood vessels, branches of the anterior aorta, and the dorsal and superior cervical artery with the spinal nerves which are distributed in that portion of the body. If we map aU this distinctly in our minds, we shall have the material for forming an idea of the structure of the withers, and the intricate and inter- esting arrangement and disposition of its many parts, with their relation to the ailments which attack them. This wUl be facilitated by an inspection of the illustration (Fig. 562), representing a transverse section of the entire region involved. The drawing exhibits the obliquity of the direction of the various muscular layers, and demonstrates the tendency of the purulent gatherings, by gravitating and collecting between them, to contribute to the DISEASES OF THE WITHERS. 763 r- te jf ac i tc Fig. 561.— 6th Layer of the Withers. pi.— Lamellar portion of the cervical ligament, pf.— Funicular portion, te.— Trans- verse spinalis of the neck, ac— Spinous processes of the dorsal vertebrae, t.— Tuber- te.— Transverse spinalis of the back, ie.— Common intercostal, it,— Inter-transversalis. i.— Externai intercostal mus- csities of the same c. — Kibs. gd.— Great serratus. cle. l.—Inter-spinalis ligament. formation of the ailment recognized as a true " diseased withers," with the habitual severity which is its characteristic. The originating causes of the diseases of the withers may be divided into the predisjyosing and the occasional. Among the first are to be noted a defective anatomical conformation of the region ; the kind of work performed by the animal, and the degree of care he receives. For example, when the withers are low, thick and fleshy, as in heavy draught horses, the saddle of the harness has a tendency to slip forward and cause chafing and excoriation, an accident from which, however, animals with high, sharp withers are by no means exempt ; for though, for the reason stated, they are less liable than those of the other conformation, the advantage is ofi'set by the fact that the skin is exposed to a more unequal pressure, especially if that part of the harness is not properly padded and fitted, and presses irregularly on the soft tissues, upon which it rests. 764 DISEASES OF THE WITHEES. Fig. 562.— Transverse Section of the Eegion of the Withers, p.— Skin. fe. — Fibre elastic tissue. t.^Dorsal trapezium, r.— Rhomboid muscle, cp.— Cartilage of the scapula, is.— Ilio spinalis, v.— 5th dorsal vertebra, gd.— Great serratus. ss. — Sub-scapularis. s. — Scapula, se. — Antea-splnatus. sh.— Scapulo- humeral joint, pf.— Deep pectoral. pt.—Thoraciq walls. Saddle horses are for tlie same reason peculiarly apt to become sufferers from the lesion of which we are speaking. The self- inflicted bites and the scratching and rubbing of animals suffering from parasitic affections, in their efforts to relieve themselves, may also result in placing them in the category of the predisposed. To enumerate all the occasional causes would be to make a catalogue of casualties, which would be best done by coj)ying from the accident columns of the daily press, and we shall merely refer to a few of a kind which may possess some special characters and notable features, not too obvious or common and familiar Contusions of any kind, resulting from the causes stated, or even little abrasions from the simple misfit of a blanket kept in place by a surcingle too tightly buckled — anything, in fact, which may give rise either by its immediate effect or by its continuance, DISEASES OF THE WITHERS. 765 to the slightest form of pathological change, may serve as a spark which may kindle into the most serious case of fistulous, diseased withers. (a) JExeoriation. — This is the simplest of the lesions of the skin covering the withers, or any portion of the body. It is most com- mon in summer, when it appears in the form of a red spot, becom- ing rapidly covered with an abundant serous exudation, which rapidly forms a yellow or brownish crust, adherent to the under- lying tissues. This is always painful, especially in summer, when it excites a violent pruritis, which may degenerate into a lesion of a serious nature. Excoriations, however simple, ought never to be neglected, and precautions should always be taken against them. When they do occur, local heahng applications, usually simple ones, are sufficient, and should be made without delay. {!)) Warm (Edema. — This is the resvilt of the laceration of the subcutaneous cellular tissue and its subsequent inflammation. Saddle horses suffer from it, especially in summer and after long journeys. At such times, the skin becoming more or less adher- ent to the saddle, the motion of the animal, together with that of the skin, is communicated with every step to the subjacent cellular tissue (a sort of rubbing, to-and-fro motion) ; and this vio- lence, though slight, produces by its long continuance the natural effect of inducing an inflammatory state in the tissue. This oedema is characterized by a tumefaction of the parts, warm and pitting under pressure, more or less painful, and having a tendency to spread toward dependent structures. It disappears by resorp- tion in two or three days, but leaves a slight thickening of the cellular tissue, sometimes difficult to detect. This resorption takes place if the originating cause has, within a moderate period, ceased to operate ; but if, on the contrary, it has been permitted to keep up its irritating action, the oedema will increase, and in due time the condition will be changed to that of supjDuration, — a termination to be, if possible, by all means anticipated and pre- vented. The removal of the cause, sometimes accomphshed hy merely giving the patient a season of rest, is the most important item in the treatment. The resorption of the oedema can be accelerated by means of massage, cold compresses, astringent lotions, weak stimulating frictions of an alcoholic nature, or cold irrigations. 766 DISEASES OF THE WITHEBS. {c) Hematoma, or Bloody Tum,or. — This lesion is produced by a violent traumatism, such as a blow, a contusion, or a violent bite by some other animal. It develops immediately upon the oc- currence of the cause, resulting from the laceration of the super- ficial blood vessels. It is characterized by a swelling, varying in size according to the nature of the producing cause. It is at first somewhat warm and fluctuating, then becoming puffy, and when the blood has coagulated, hard, tense and crepitating. Ordinarily it is not very warm or painful, but it becomes so after a few hours, and then there is danger of its assuming a suppurative character. Yet in other cases it may maintain that condition for two or three weeks, undergoing the process of resolution, the resorption usually becoming complete in that period. The correct diagnosis of this condition, and of any occurrent changes, some of which it is im- portant to know, can be more satisfactorily estabhshed by explor- ation. Left without interference and in the absence of irritating causes, the hematoma will usually subside by spontaneous action. In their treatment, cold applications are indicated during the first days of its existence, but at a later period, when the tumefaction has be- come of a denser consistency, absorbent and stimulating local medication is indicated, such as blisters of cantharides, or of mer- curial preparations, or of the iodine compounds. These applica- tions, however, must not be too hastily resorted to, lest the exces- sive or premature stimulation should end in the formation of abscesses. Except when there is positive evidence of suppuration, pressure by bandaging and the opening of the tumor with the bistoury are always contra-indicated. (c?) Core, or Stickfast. — This is caused by the immediate mortification of a portion of the skin, and often of the deeper tissues. It is a hairless scab of a blackish color, having the ajD- pearance of tanned leather. It is at times superficial, and has a tendency to extend to the subjacent structures. It is rigid and inflexible, and its pressure upon the deeper tissues tends to in- crease mortification. The tissues surrounding it are inflamed and their sensibility increased, and at a later period a process of elim- ination by suppuration takes place all around its edges. But this pus does not very readily escape, and there is always a portion remaining in the bottom of the sloughing sui'face which becomes fistulated with the formation of collections. If the core should DISEASES OF THE WITHERS. 767 extend to the dorsal ligament or to the bones, the result will be necrosis and caries, and a true diseased ioither will be the conse- quence. With these conditions, lymphangitis, leucophlegmasia, and deep abscesses may be expected, and usually supervene. The sloughing of the mortified structure is always slow, espe- cially when the deeper tissues are involved, but the wound which remains after the casting off of the core is not uniform in its sub- sequent action. When it is superficial it heals quite rapidly, but recovers only with great dif&culty when it is deep-seated, and in- volves fibrous, cartilaginous and bony structures. The prognosis of this lesion of the withers varies according to the thickness of the tissues which are involved ; but it also varies according to its location, those which are situated on the lateral faces of the withers being less serious than those which occur on the median line. The treatment indicated is strictly local. The first indication is to discontinue, or obviate, the irritating cause, by changing the harness, by chambering it, or, what is better, by refraining from working the animal until he has entirely recovered. The second indication is to hasten the sloughing of the mortified tis- sue, and allay the irritability which the animal betrays upon the slightest touch of the hand, or other object, upon his back. Top- ical remedies in the form of ointments, lotions or povdtices, are in- dicated for this purpose. As soon as the process of sloughing begins it must be stimulated and encouraged. Warm comjjresses, antiseptic lotions, glycerine, phenial mixtures are then beneficial. The maintenance of simple moisture, by means of phenicated or creolined mixtures has, in our own experience, been of great ad- vantage. If during the process of the elimination of the core the suppuration seems to be abundant with a tendency to accumulate instead of escaping, care must be taken to facihtate its removal by means of oakum, absorbing cotton, sponges or drainage tubes. Sometimes the core is of unusual size, with roots reaching deeply into the tissues beneath, but although this may be the case, no attempt should ever be made to tear them forcibly away. They must be permitted to drop away by spontaneous action. If the edges are very wide they may be trimmed off with the scissors or bistoury, but interference beyond this is never permissible. When they have entirely sloughed away there remains but a simple granulating wound, which ordinarily requires but mild forms of 768 DISEASES OF THE WITHERS. treatment. The animal, however, ought not to be made to re- sume work until it is entirely healed. (e) Cyst, or Hygroma. — These terms designate a tumor which usually forms on either the middle or the lateral face of the withers, originating in the dropsical condition of a serous bursa. On whatever part of the withers it may make its appearance, the originating cause is the same, and it is the effect of friction, or of the slight but long-continued irritation produced by an ill-fitting harness, inflicted while the animal is suffering from parasitic dis- eases. In these cases the connective areolae of the bursa become the seat of an amount of secretion in excess of that which is re- moved by the act of resorption, and the accumulated hyper- secreted fluid gathers into the cavity, to form the serous cyst. When located in the median line, the hygroma constitutes a soft tumor, of varying size, from that of a pigeon's egg to that of a child's head — bilobulated, always soft, fluctuating, without heat, and painless ; even transparent, when the skin is pigmentless. It always presents the differential characters of being well defined in its outlines, and without inflammatory peripherical infiltra- tion. When the cyst is on the side of the withers it may present some similar characters, but when it is deep, under the apone- urosis of the trapezium, or even under the rhomboideus, an ex- ploration becomes necessary to establish the differential diagnosis from abscess, as upon the true nature of the tumor depends the immediate indications of treatment. Hygroma of the withers may retain their characteristics for a long time, but many change iu their nature under the influence of external irritations, bruises, contusions, improper treatment, etc. In that case the cyst is transformed into an abscess, or rather a suppurating cyst. In respect to the treatment of cystic withers, the first indica- tion is to remove the cause, and with this not only will the accu- mulation of the serosity cease, but the possibility of its trans- formation into the abscess form will be removed. When the cyst is small and of recent formation, resolvent treatment is in order, as cantharides ointment, bichloride or biniodide of mercury pomatums, etc. Actual cauterization, in lines or in points, has given satisfactory results in chronic cases. In- jections of tincture of iodine have also been recommended. Our DISEASES OF THE WITHERS. 769 own experience warns us that it is not without danger, from its liability to be followed by a severe form of diseased withei's. Bouley and Nocard, in relation to this mode of treatment, say "it is better to empty the cyst with a capilliary trocar, or by the aspirator, to wash its cavity with an antiseptic preparation, shghtly irritating (5 per cent, solution of phenic acid), to repeat this injec- tion several times, until the liquid taken out of the cyst is per- fectly limpid, and then apply over the entire surface of the skin a thick coat of blister." The purulent cyst is treated as an abscess. if) A bscess. — A phlegmon of the withers may rise suddenly under the influence of a severe traumatism, or become the sequel of a hematoma, or of a cyst. It appears most commonly on the superior part of the withers ; sometimes on the sides, as a tumor more or less warm and painful, first uniformly hard and tense, and afterward soft, with a fluctuating center, and surrounded by an oedematous infiltration, more or less developed. If the abscess is superficial, ulceration of the skin soon takes place, followed by the escape of thick, white and creamy pus. If, on the contrary (and this is often the case), the abscess is deep, developing itself under the the aponeurosis of the great dorsal, or of the rhomboideus muscle, or even deeper, under the cartilage of the scapula, or the thickness of the ilio-spinalis, the symptoms then, however, being less defined. The tumefaction is less characteristic, the heat less marked, the fluctuation not detect- able, and the only sign which guides the surgeon is the excessive pain manifested uj)on the slightest pressure on the tumor, and from which the animal shrinks in fear. This soreness is in fact so great that in some animals it interferes with the action of the leg on the side affected. The appearance of general febrile symptoms is not uncommon at this period, with elevation of temperature, increase in the circulation, anorexia, excessive thirst, etc. At this period, also, it becomes important to be certain of the diagnosis, or at least to be sure of the existence of the suppuration, and its loca- tion must be accurately made out, in order to prevent the severe disorders that may be caused by the presence of the pus ; a prob- lem which can be only solved by repeated capillary exploring punctures, made at various points, and at given depths, according to the dimensions of the phlegmonous enlargement. The prognosis of abscess of the withers depends altogether on 770 DISEASES OF THE WITHEES. the seat it occupies. If superficial, and on the lateral faces of the region, it is not serious, If on the median line, it assumes a more severe character. If deep, it is also of a dangerous nature, unless it is simple or Hmited ; but, on the contrary, if the quantity of the pus has continued to increase, and infiltration has taken place into the cellular tissue separating the muscular layers ; or the sup- puration has penetrated under the cartilage of the scapula; it will have assumed the most complicated form of the disease, with chances of recovery of a very doubtful character. When the pres- ence of the pus has been detected, the immediate indication is to assist its discharge by a free incision down to the bottom of the cavity. The incision must be made on the most dependent part of the tumor ; in such manner as to prevent the collection from settling in a cul-de-sac. A means of drainage must be provided, and the tube is preferred to the tent of oakum, or even to the seton, as more sure to reach all parts of the collection, and the more thoroughly to wash out the cavity. If, however, the sujDpuration has not been detected, the appli- cation of local stimulation is indicated by means of warm com- presses, hot poultices and the like ; a constant watchfulness being maintained, meanwhile, in order to detect the presence of the pus at the earhest moment of its formation ; when it must be immedi- ately evacuated. {g) Wounds. — Resulting from every variety of traumatic agencies, these injuries will necessarily vary in their extent and the nature of the tissues which are involved. They therefore extend from the most trifling hurt of the skin to the severest lacerations of the important ligamentous, cartila- ginous and bony structures contained in the region under con- sideration. With such a diversity in their form and nature there must also be a corresponding range in the character of the prog- nosis to be announced, from that of rapid spontaneous recovery, without interference, to the gravest of terminations. One of the principal indications in the treatment of wounds of the withers is to prevent as much as possible the filtration and deposit of pus through the various layers of the region, and facili- tate the cicatrization, by placing them in a state of immobility, and according to Bouley and Nocard, the best method of seciiring this suspension of movement is to apply a broad blister all around the wound, and to repeat the appHcation after a few days. The DISEASES OF THE WITHEKS. 771 pain caused by this compels the animal to abstain from all move- ment, and besides this the inflammatory swelling resulting from the bUster promotes the cicatrizing process by stimulating the proliferation of the cells of the repairing tissue. Aside from this special direction, the treatment of wounds of the withers involves no methods or indications different from those of similar hurts in other parts of the body. In most cases the surgeon must trust his experience and knowledge of general principles for guidance. (A) '■'■ Diseased 'Withers'''' proper : Fistulous Withers. — As we have before stated, this denomination belongs to "a persisting lesion, fistulous in character, due to the mortification of the tis- sues of the withers, fibrous, yellow, cartilaginous or bony." It is necrotic in its nature, and while it may attack but one, it may also exist in all of these organs. Whatever this condition may be, however, the necrosis is always manifested externally by an indicator, in the form of a fistula giv- ing exit to an abundant, thin pus, serous, sanious, grayish in color, adhering to the hair, and irritating and excoriating the skin upon which it flows. At first it is odorless, and nearly homogeneous, but it soon becomes foetid in odor and loaded with the detritus of necrotic tissues, more or less abundant, varying in thickness and in color, according to the nature of the tissue from which it is formed. One or several of these fistulous openings may exist on one or both sides of the withers leading from the same or from different necrotic centers. Their number is not limited. Several of them may be in existence at the same time, especially when the disease has maintained its hold on the system for a period of three or four months without being checked or cured ; a state of things not infrequently witnessed. Their formation is explained by the constant accumulation of the pus in the sinuosities of the original tract, which by degrees overcomes the resistance of the surrounding structures, and es- tablishes a channel for itself by the same process as that by which the first outlet was formed. It may sometimes happen that the opening of new canals becomes the cause of the closure, or perhaps only the constriction, of the original channel, and a new exploration becomes necessary to ascertain the new routes of the fluid. In this case their direction will be best made out by the injection of liquids through their open mouths. 772 DISEASES OF THE WITHERS. The presence of one of these canals at the bottom of a wound may sometimes be detected by the appearance of large, fleshy, cone-shaped granulations, of a purplish color, from which an ooz- ing of pus takes place upon the application of pressure. But in another case, the orifice of the fistula may be directly on the skin, surrounded with granulations, protruding, soft and bleeding upon the sHghtest touch, with an escape of sanious pus between them ; these granulations at a later period, flattening, as the wound contracts, until the thinned skin seems to be continu- ous with the smooth, reddish membrane which lines the internal face of the tract. It may even happen that a process of cicatriza- tion taking place around the opening will transform its external outlet into a narrow strait which opens in the bottom of a cavity formed by the skin drawn inwardly by the cicatricial retraction of the indurated peri-fistulous tissue. The direct exploration of the fistula is the best mode of ascer- taining its existence, direction, extent and depth, and also the lesion which gives rise to it. This exploration ought to be made by the taxis, since it is obvious that no instrument can communi- cate an impression such as can be obtained by the touch of the finger. By the hand, therefore, must be ascertained the course and sinuosities of the fistula, its diverticulum, the nature of the necrosed tissue, and the extent of the mortification. But this manual exploration is not always possible, either because of the deficient caliber of the passage, or of its sinuosity, or its length. Eesort must be had to the various probes and directors in use. When the necrosis occupies the apex of one or more of the spinous processes, and the fistula is superficial, a slight incision will expose the diseased spot to ocular inspection, and the condi- tion of things may be at once fully reaHzed. When the lesion is limited to the cervical ligament, the eschar or slough will have an olive-greenish color, and will be of soft, pultaceous consistency, with a pecTiliar foetid odor, from its maceration in the pus. If the necrosis has attacked the cartilages of the vertebrae, the morti- fied part assumes a yellow color, with a tint of pale green. In all cases, however, it is more or less loosened at its borders, and differs materially from that of the healthy tissue. And while at the point of separation it is covered with a layer of granulations, highly vascular, yet the continuity of the fibres between the healthy and the diseased tissues still exists in the parts which are DISEASES OF THE WITHEBS. 773 deeper and more central, where the connection is maintained by a sort of peduncle of varying size, through which the necrosis con- tinues to be propagated. If the disease is of sufficiently long standing the necrosis may involve the entire thickness of the carti- lage, lu this case the spongy tissue of the vertebrae is exposed, covered with the healthy granulations, which contribute to the cic- atrization. This, however, is a rare termination, the bone, ordi- narily, becoming necrosed or carious, the necrosis being indicated by its brownish color, its di-yness, its roughness and its sonority on percussion, while the caries is recognized by its friabihty, its red and yellowish color, the foetid suppuration which oozes from its areola and the facihty with which it yields to the edge of a sharp cutting instrument. This condition of mortification may affect but a single verte- bra, but it is not uncommon to find several, or possibly all, the spinous processes of the region affected. While the fistula may be considered as the essential physical symptom of this ailment there are other symptoms coexisting. There is accompanying it an external swelling, sometimes diffuse, sometimes compact, and more or less indurated, according to the duration of its existence ; very painful on pressure, and of which the form, direction and extent so perfectly correspond with those of the fistula, that it may be viewed as accurately representing the extent and limits of the lesion itself. This induration increases in consistency, and may with time become infiltrated with calcareous deposits, or even bony growths, attached to the spinous processes. The diagnostic and prognostical importance of this induration is very great. So long as there is no perceptible decrease in its dimensions, no apparent improvement in the external wound or modification in the nature and amount of the discharge can be of any favorable signification, and the surgeon may feel thoroughly assured that the disease continues unchanged in extent and char- acter. As it diminishes it indicates that the necrosis is also con- tracting its limits, and it becomes certain that the sloughing has taken place and the wound is once again assuming its character of original simplicity. And when the swelling disappears, and the tissues have resumed their normal integrity, questions as to the depth of the fistula, or the extent of its sinuosities, and abun- dance of the discharge will cease to be of any significance. 774 DISEASES OF THE WITHERS. In the beginning of the necrosis, while the parts are very sensitive, the exaggerated sensibility is not at aU in proportion to the apparent extent of the disease. The animal shrinks from the manipulations of the touch, and this is a symptom which should be carefully considered in its relation to the progress of the dis- ease, fi'om the fact that in these manifestations it is passing through the same phases as those which marked the progress of the induration, running a sort of parallel with the duration of the necrosis, and diminishing as the sloughing proceeds, the interior situation being interpreted by the exterior phenomena, with some exceptions For there are cases in which it diminishes, while the disease continues without change, to exhibit the same severe symptoms. One effect of the abundant suppiiration accom- panying diseased withers, and the febrile symptoms which accom- pany it, is a rapid loss of Hesh by the suffering animal. The disease is always of long duration, and even when treated in the most rational manner. Its persistency will naturally cor- respond with the slow process of the sloughs and repairs of the tissues involved, themselves of comparatively low vitality and slow of change. But as soon as the separation of the diseased parts has taken place, however deep the wound may have been, or whatever the number and depth of the fistulse, the cicatriza- tion proceeds rapidly, and is completed in a comparatively short time. The terminations, which are to be looked for, are classified by Bouley and Xocard under the following heads : 1st. Resolution. — This is very rare if the disease has been neglected, and only occiu's when it has been of a circumscribed extent and seated in a region favorably situated for the elimin- ation of the mortified tissue, as when it escapes through large openings, without lying long enough in the midst of the muscular substance to produce the effects of the long confinement of the pus in the deeply situated regions. 2d. Disease of the neck, when the necrosis has spread as far forward as the cervical portion of the ligamentum nuchae. This forms the more common termination, and is as serious and fatal as the original disease itself. It is too often met with, especially in low-bred animals of lymphatic constitution. 3d. Death, too frequently. 4th. Putrid infection, due to purulent fermentation and the absorption of septic principles. DISEASES OF THE WITHERS. 775 5th. Purulent infection^ i. e., consecutive with the caries of the vertebrae and with the phlebitis of the veins of the region. 6th. Purulent pleurisy, resulting from the passage of the pus into the thoracic cavity through the intercostal muscles. 7th. Exhaustion, in consequence of the uncompensated loss of substance by the abundant continued suppuration, and its ac- companying severe and persistent fever. Fistulous withers is always a serious disease, not only because of its progressive tendency, but also because, however intelligent and proper may be the treatment it receives, it can never be relied on to prevent the spreading of the necrosis, and assure a healthy cicatrization. The degrees of severity nevertheless vary, accord- ing to circumstances. It is less serious when the necrosis is on the median line, and the prognosis is still more favorable when it is on the posterior part of the region. When situated forward it seems more tenacious, and the danger of its extending to the neck is greater. But it is principally when its seat is in the an- terior part of the withers that the prognosis becomes alarming, as there the spinous processes are less prominent, the muscles thick- er and more complicated in their arrangements, and the cartilage of the scapula nearer, all these being conditions which render the discharge of the pus more difficult and the pui'ulent infiltrations more likely to take place, and where also counter-openings are made with more difi&culty, and indeed become almost impossible if the purulent accumulations are situated on the inside of the scapula or its cartilage of prolongation. It may be said, in fact, that the most important factor in the prognosis of this disease is the distance which separates the apex of the spinous processes of the vertebrae from the superior border of the cartilage of the scapula ; the chances of recovery being in the ratio of the distance between those two points. It is thus that it becomes less grave in well-bred animals, with elevated pro- jecting withers, than in low draught horses in which that region is depressed and thick, and the projection of the dorsal processes often replaced by a deep groove, bound on each side by the pro- jection of the muscles and of the border of the scapular cartilage. The disease is also of less gravity in young animals, except when they are under the influence of distemper. The treatment required in fistulous withers includes two prin- cipal indications : 1st. To facilitate the escape of the pus and 776 DISEASES OF THE WITHERS. obviate its action upon the tissues with which it comes in contact and prevent its necrosing influence, and second to accelerate the eHmination of the necrosed parts. The first indication is fulfilled in enlarging the fistulas to the greatest extent possible. This is done with the straight bistoury carried in the groove of the director or of the S probe, introduced into the tract as far as possible. But when the fistula runs ob- liquely downward and inward, and has become complicated with diverticulums which run into the depths of the tissues, this en- largement of the fistula is more difficult, inasmuch as it necessi- tates too extensive a division of tissues for safety. This difficulty is obviated by estabUshing counter-openings at points correspond- ing with the bottom or cul-de-sac of the fistula. The situation of these counter-openings must be carefully cal- culated in order to make the drainage perfect. The instruments most suitable are the dog seton needle, a curved trocar, or prefer- ably the S probe, and a straight bistoury. The openings must be liberal to assure the best results, and they must be prevented from contracting or too rapidly closing, and so checking the pur- ulent flow either by the introduction of a tent of oakum or other permeable foreign substance, or, and it is much the better method, by the use of a drainage tube similar to the India rubber irriga- tion tube. This implement, besides fulfilling all the other indica- tions desired, possesses the additional advantage of facilitating the injection of fluid detergents or curatives into the fistulous tract. When the drainage has become well established irrigations must be made two or three times daily as long as may be neces- sary. The fluids best adapted as being both detergent and cura- tive in their nature are pure tepid water, phenicated water (five per cent, solution), or permanganate of potash solution (one to two per cent.), or again simple alcoholic water. The irrigation can be made with an ordinary syringe. Peuch and Toussaint, however, say " that when the circumstances allow it cold water in continued irrigation constitutes the best medication and that which prevents most certainly all complications. On that account they cannot recommend it too strongly." While this form of treatment is usually successful in oases of lesser severity, there are many instances in which they become powerless, and other means become necessary for the removal of the necrosed part. In times gone by caustics, in both the solid DISEASES OF THE WITHERS. 777 and liquid form, were held in high repute, even in the form of actual cauterization, as recommended by Lafosse. In later times, however, the serious effects which followed theu' appUcation caused them to be ignored. Preparations of lesser severity were then recommended, among which were Villate's solution ; those of the sulphates of copper or of zinc, in various degrees of strength; of tincture of iodine, of spirits of turpentine, of nitrate of silver, and even of tartar emetic, and their use was followed by good results. Cantharides ointment, appHed externally over the swelling, and by injections into the fistulous tract, after being diluted with tincture of cantharides, is also recommended. "When the pus has filtrated inside of the shoulder, Bouley and Nocard suggest the propriety of " attempting to lacerate with a me- tallic rod the cellular tissue of the internal face of the shoulder, so as to produce an abscess by congestion, whose opening, which must be made wide, would allow the escape of the pus, and the possible frequent cleansing of the enormous fistula thus formed. By this process one might avoid the serious accidents likely to result from the sejoum of the pus, and its fermentation from the contact of the tissues." For cases like these Lafosse recommended the trephining of the scapula — a very serious operation. It is said to have been successful with him, but it must be a difficult matter to perform it properly in such a manner that the trephine is appHed at a point on the surface exactly corresponding to the bottom of the fis- tula. When all means of so stimulating the action of the parts as to effect the arrest of the necrosis, and the sloughing of the morti- fied structure have failed, there is but one alternative left, and that is the direct amputation of the apex of the spinous process, and the excision of the diseased portion of the ligament. But this operation, indicated by Lafosse, is possible only when the disease is limited to the apex of the most prominent spinous pro- cesses. It is positively contra indicated in low and thick withers, in which the wound left after the operation would be a hollow, cup-shaped depression, from which the pus would naturally gravi- tate and filtrate in all directions. The instruments necessary for this operation are : A grooved director, curved and straight bistouries, sage-knives, sharp draw- 778 DISEASES OF THE WITHEES. ing knives, bull-dog forceps, and an amputating saw; and with these the appliances usually needed in the way of hemostatics, and the necessary dressings, artery forceps, oakum, sponges, drainer-tubes, dog seton needles, etc. The various steps of the operation are thus described by Peuch and Toussaint : "Everything being ready, the operator enlarges the fistulous tract, simple or ramified as it may be, so as to expose the ne- crosis. In making this special attention must be taken to give the incision a direction favorable to the escape of the pus. This first step of the operation is accompanied with abundant hemor- rhage, which must first of all be arrested either by ligating the divided blood vessels, or by plugging the wound with oakum moistened with a solution of perchloride of iron. The hemor- rhage stopped, and the necrosis exposed, the second step, and the important one of the operation, is proceeded with. To effect this the necrosed surface is limited by a double incision, made with a sharp instrument, straight bistoui*y, or sage-knife. This incision involves the entire thickness of the cervical ligament and the fibro- cartilage covering the apex of the sj)inous process and passing under this cartilage. In making this incision the operator must be careful not to injure any of the other processes if they are not diseased. This done, with the sage-knife the deepest layers of the cartilage are excised, and then, with the drawing knife, the bony tissue underneath is resected so as not to leave the smallest particle of necrosed tissue. Here, as in some cases of foot opera- tion, not only must all the diseased tissue be removed, but some of the healthy structures. The resection of the apex of the ne- crosed processes can be made with the saw instead of the draw- ing knife. But this instrument is preferable, as it is easier to manipulate and it always leaves a smooth wound." The subsequent treatment is of the routine kind. The parts are, of course, thoroughly cleansed ; the hemorrhage is controlled by pressure, a drain tube is secured at the lower angle of the wound, and the edges are brought together by quilled sutures. Eepeated injections of phenicated water are passed through the drainage tubes, and the patient is watched in order to prevent him from injuring himself by rubbing. If the season and the circum- stances permit, continued irrigation is established. Toward the fourth or fifth day the sutures are removed and the dressing changed. The granulating process is carefully DISEASES OF THE WITHERS. 779 watched, and its progress kept under control by mild caustic ap- plications, or by pressure, to prevent an uneven and too rapid cicatrization During the treatment the animal must be kept quiet, and even in some cases it will be prudent to hobble his fore legs in order to limit his movements and prevent the filtration of the pus under the shoulder. He is to be kept on light and nutritive diet, to compensate for the losses resulting from the abiindant suppura- tion, and when the disease has disappeared, and there is only a superficial wound remaining, and no more fear of returning com- pHcations or relapses, the animal can be returned to his labors, but must make his adieus to the bulky collar which has weighed so heavily on his neck, and substitute for it the equally efficient and far more sightly Dutch coUar, which has never yet in any way contributed to bring upon its wearer the calamity of diseased withers. DISEASES OF THE POLL. This region of the neck is the seat of lesions, frequently occur- ring, and of varying nature. They include excoriations, oedema- tous swellings, cores, cysts, bloody tumors, abscesses, bruises, wounds, etc., any of which may become complicated, and termi- nate in 2^oll evil, or the necrosis of one of the fibrous, elastic, or bony elements which enter into the composition of that region. Li considering the anatomical structure of the portion of the neck in question we find on the to}) a mass of hair, separated from that of the superior border of the neck by a surface which has become callous by the constant frictions of the head-strap of the halter or of the bridle; the skin (Fig. 563), thick on the median line, thinner on the sides, but always loosely connected with the subjacent tissues; a thick layer of Connective tissue, more or less infiltrated with fat, and lardaceous in low-bred horses ; the cord of the ligamentum nuchse, which is attached to the occipital bone, and more or less covered by the cervico-auricularis muscles ; on each side, and on the same level, the terminal insertion of the splenitis muscles, and forming an elevation which is covered by the aponeurosis common to that muscle and the small complexus, which itself makes an apparatus of retention of great resistance to the organs of the region ; then another layer, composed of the large tendon of the great complexus, the small oblique muscle of 780 DISEASES OF THE POLL. Pig. 563.— Section of the Neck on a Level with the Poll, p.— The skin, tc— Lardaceous connective tissue on the top of cervical ligament, gc— Superior extremity of the great complexus and small oblique muscle of the head. Ic— Ligament nuchse. dp.— Posterior straight muscles of the head, lao.— Atloido- occlpital ligament. Is. — Superior part of the atlas, sm.— Rachidian dura mater, m.— Spinal marrow, ta.— Adipose tissue of the rachidian canal, a.— Atlas, ph.— Pharynx, go.— Section of the great oblique muscle of the head, ao.— Section of odon- toid process of the axis, p.— Parotid gland, sm.- Sub-maxillary gland, da.— Anterior Btraight of the head 00.— CEsophagus. the head, the great oblique, and under them, the posterior straight muscles of the head; a serous sac, assisting the gUding of the cord of the ligamentum nuchse over the atlas, which is very small in yoimg animals, assumes larges dimensions in old subjects ; and, finally, a skeleton of the region, the atlas, the axis and the occi- pito-atloid' and atloido-axoid articulations. Two large arteries are distributed throughout the locality, the occipito-museular and the atloido-muscular. The causes in which diseases of the poll originate are numer- ous. Among them may be mentioned first, bruises, from blows given with the handle of a whip, or of a fork; contusions and continued frictions against hard substances, as the manger; the pressure and rubbiag of the parts of the harness (the bridle, etc.), which pass over that region; the repeated rubbing which the ani- mal inflicts upon himself when he is aflfected with parasitic cuta- neous* disease; the blows which he receives when in tossing his head, he brings it in contact with the ceiling of his stable, when this is too low, and he has formed the habit of puUing back on the halter; the spreading of diseases of the neck by the extension of the necrosis of the cord of the cervical ligament, all these are DISEASES OF THE POLL. 781 considered to be so many active agencies in the etiology of poll evil. In cattle it is most commonly chargeable to the pressure and frictions of the yoke. Hertwig, with other German authors, con- siders it, and particularly the sus-atloid hygroma, as the local mani- festation of a diathesic condition, such as rheumatism and dis- temper. They also admit that the true poll evil may develop itself spontaneously, and independently of all other traumatic causes. In considering the various forms which the disease may assume in this locality we shall adopt the division sanctioned by Bouley, who has thus arranged them. A — Excoriations; B — (Edematous Swellings; C — Core; D — Bloody Tumors. Diseases of the poU, in horses, exhibit too close a resemblance in their type and general history to escape notice, and the ther- apeutic indications exhibited in them are the same. And it must be borne in mind that however slight they may appear to be, and whatever may be their nature, they always require immediate at- tention and careful watching, and in all cases the use of the bridle and the halter must be suspended. E. — Cyst. Cysts of the poll are divided into superjicial and deej). The former, which are of uncommon occurrence, have their seat in the subcutaneous cellular tissue, and possess features in common with those which appear at the withers. The latter is an abnormal dilatation of the serous sac which facihtates the gliding of the cervical cord upon the atlas ; it is also known as the atloid hy- groma. It generally begins suddenly, and is manifested by the presence of a soft tumor, fluctuating, spherical, or bilobulated by the median pressure of the cervical ligament. It is usually pain- less, except when it is the result of acute violence, in which case it may be accompanied with inflammatory symptoms, which may extend to suppuration, but in such cases, which, however, are in- frequent, there is also a degree of fever corresponding in intensity with the other features of the case. The fluctuation is at first uniform, and easily detected, but at a later period, as the secre- tion becomes more abundant, and the tension of the pouch be- 782 DISEASES OF THE POLL. comes greater, and the thickening of the walls progresses, it be- comes obscure. In the stable the animal is very quiet, standing with the neck extended and the head carried downward ; he moves with difficulty, without raising the head, and avoiding all movements of the muscles of the neck, and especially of the extensors. At times the distension of the walls of the cyst may be so extreme that the capsular hgament of the occipito-atloid joint is pushed in- ward in the rachidian canal, and when this occurs nervous symp- toms appear, caused by the pressure of the rachidian bulbs. If unremedied, it assumes a chronic condition, with progres- sive distension, which may end in death by pressxire uj)on the bulb. Purulent transformation, and poll evil proper, are also the possible terminations of the atloid hygroma; indeed, it is only in rare instances that it is known to subside by resolution or resorp- tion. In cases of doubtful diagnosis as to the formation of cystic or purulent collections, exploration wOl relieve the doubt, and at once settle the question of treatment. Blistering and absorbing appHcations, often repeated, and combined with aspiration, have often reheved the atloid hygroma. Cauterization in lines or points, both superficial and deep, are also recommended. Injections of tincture of iodine have also their supporters, but they are sometimes liable to give rise to vio- lent irritation, ending in purulent collections, and perhaps necrosis possibly of the cervical ligament. F. — Abscess. This is the most frequent lesion of the poll, forming at once, when the exciting cause is sufficiently active, or when originating in the manner already described. It consists at first, of a diffused, not well defined, swelling of the abundant cellular tissue which separates the muscles of the region, to coalesce at a later period, to form a single purulent gathering, but not until it has macerated and destroyed all the intermediate tissues into which it had become infiltrated, and this- destructive process advances so actively and persistently that when it reaches the surface, instead of closing up, the abscess has be- come transformed into a fistulous center, with a constant dis- charge of mortified, fibrous, elastic, or bony structure. DISEASES OF THE POLL. 783 The establishment of the suppurative process, even before any local symptoms have been manifested, is betrayed by the changed appearance of the animal. As described in the previous pages, he becomes Hstless and dull, standing qviietly with the neck extended and the head resting on the manger; refusing to move, or if doing so, never raising his head, and by grunts and moans betraying the great pain he is suffering. If his head be raised by force he rebels against it, struggles, goes backward, strikes with his fore feet, and perhaps rears. By bringing the animal imder control and restraint, as by throwing him, the abscess may be easily discovered, on one side of the neck, as a diffused swelling, tense, warm, and so excessively sensitive to the shghtest contact, that it is with the greatest diffi- culty that an obscure and deep fluctuation can be detected. The positive nature of this tumor must then be made out as early as possible, by repeated capillary explorations, since if discovered to be unmistakably of a suppurative nature, a free exit to the pus must be at once established, to avoid its necrotic tendency ; while if it be a cyst, there is danger in opening it, arising from its lia- bility to be followed by necrosis of the cervical ligament. The prognosis of this abscess will vary according to the length of time which may have elapsed between its incejation and its detection. The serious nature of this prognosis is explained by the fact of the incompressibUity of the pus and the inextensi- bihty of the aponeurosis of the splenius and complexus muscles, which resist the sweUing of the inflamed tissues, and by their compression and strangulation, become the cause of gangrene. If a diagnosis of abscess is made, and it is immediately opened, the cavity may assume the character of an ordinary abscess, and close entirely ; but this is a rare termination. More ordinarily, the incar- ceration of the infiltrated pus between the muscular layers is an obstacle to its free and complete discharge, and it remains infil- trated, gathering into cul-de-sacs, and migrating irregularly be- tween the muscles. Hence the formation of so many fistulous tracts, opening at diverse points on the skin, which are generally the result of the necrosis of the Hgamentum nuchse, or of the fibrous tissue of the tendons, or even of that of the atlas, or possibly of the occipital bone. All the dangers which are likely to follow the existence of an abscess at the poll, demonstrate the necessity for prompt surgi- 784 DISEASES OF THE POLL. cal interference. Whenever the presence of the pus is established the abscess must be opened, and opened very freely. This must be carefully done. The puncture must be made in the center of the tumor, and after the evacuation of the pus it must be ex- tended with the bistoury, introduced with the aid of a grooved director, and making, of course, a counter-opening at the most dependent point. This incision should be made parallel with the cervical ligament, and must be carefully made, in order to avoid wounding the capsular ligament of the joint, or the occipito-mus- cular artery. The hemorrhage which accompanies this operation is easily controlled by pressiire. Antiseptic dressings, with the use of a drainage tube constitute the after-treatment, which must be similar to that of the same diseases at the neck and at the withers, with the difference, perhaps, that the dressings and cleanings must be oftener renewed. If no complications arise the wound will heal without diffi- culty, and the animal may be able to resume work after two or three weeks' recuperation. Poll Evil. But if, on the contrary, the animal is suffering with the per- sistent and tenacious lesion which consists in the necrosis of the yellow or white fibrous tissue of the region, or a diseased condi- tion of the suiTounding bones, we are confronted with the very serious affection commonly known as poll evil. This disease originates, ordinarily, in one of those already con- sidered, and yet it may appear spontaneously, if the instigating traumatism from which it grew has been sufficiently severe or violent. And, again, it may be a sequelae or extension of a similar diseased process in the neck. Its characteristic appearance is that of a large induration, de- veloped around one or several fistulous tracts, from which escapes a thin, sanious pus, of foetid odor. Upon being exploi*ed these fistulas are found to vary in their direction, in their depth, and in the tissue on which they terminate. Exploring with the probe, or, more certain, with the finger, a cavity is found more or less filled with pus, with granulating walls, in the bottom of which the cervical ligament is felt, isolated, roughened and more or less escharrified, or, if this chord has remained intact, it will indicate DISEASES OF THE POLL. 785 that the seat of the lesions is the tendon common of the splenius, or of the complexus, or, perhaps, of the obUque or posterior straight muscles. At an advanced period, when the progress of the mortification has been for some time unchecked, and the bony insertions of the hgament, or of the tendons, have become affected, the surfaces of these bones also become affected and their roughened or possibly necrotic character is readily recognized by the exploring finger. It may also happen that the capsular ligament of the joint, constantly macerated in the pus, softens and yields, and the pene- tration of the discharge into the vertebral canal soon ends the case by the rapid development of suppurative cerebro-spinal men- ingitis. Hertwig and Lafosse have reported instances where anchylosis of the occipito-atloid joiat had taken place. There is in the museum of the American Veterinary College a preparation of an anchylosis of the occipito-atloid articulation which undoubtedly is the result of a case of chronic poll evil. The prognosis of this ailment is always serious. A sKght lesion may grow and develop into a case, with all its dangers. For this reason a cautious expression of opinion on the part of the siu'geon is equally due to considerations of policy as to the obHgations of truth. The treatment is essentially and exclusively surgical. In the simplest cases free openings and ample drainage of the wound, with plenty of washing and antiseptic attention will con- trol the trouble. In more severe cases, where the presence of the fistulous tracts is stimulated by the indm-ation of the parts, and the con- stant movements of theu' walls, the external apphcation of a strong bhster and the injection iato the fistulee of tinctui-e of iodine, or of cantharides, or of solutions, more or less concen- trated, of tartar emetic, nitrate of silver, chloride of ziac, etc., will contribute to immobihze the parts and stimulate the granu- lating and healing process. The section of the cord of the ligamentum nuchse is indicated when the tension of the region becomes too rigid, and the pain inor- dinate. This alleviating measure was first instituted by Langen- bacher and Hertwig in Germany ; then by Lafosse and Rey in France, and it has always given excellent results. It relieves the 786 DISEASES OF THE POLL. pressure and the pain, obviates the danger of gangrene, facilitates the examination of the wound, and greatly aids the excision of the soft, necrosed tissues, and the scraping of their bony attach- ments. The operation is simple. The patient is thrown, and a straight bistoury, or in preference, a bliuit curved tenotomy knife are the instruments. With the latter, the division of the skin is avoided. The hgamentous section is subcutaneous, the instrument being introduced under the cord, and the division made from within outward. When the section is made, the ends of the ligament draw apart. If it is necrosed, the anterior stump is removed down to its insertion in the occipital bone, which may also be scraped. The same treatment is applied to the tendons of the muscles. In fact, the opening is cleared from all mortified substances, and treated as a simple wound. After the operation, the animal carries his head low down and vertical, but when the wound becomes cicatrized, and continuity is re-established between the stump of the ligament and the cervi- cal tuberosity, the head becomes by degrees elevated, and is event- ually restored to its normal position and natural liberty of motion.