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Laparotomy or Abdominal Section

LAPAROTOMY OR ABDOMINAL SECTION It is said that Henon (1800), professor at Lyons Veterinary School, frequently performed this operation, but particulars of his cases have not been published. In England laparotomy was performed on a mare by King, of Stanmore, in 1829. The mare had been affected with abdominal pain for thirteen days, during which time she had been bled, purged, and clystered without benefit. King secured the animal in the erect position, incised the left flank, intro duced his hand, and soon found a portion—about twelve inches—of the small intestine stuffed full and quite hard, and the gut in front of the obstruction full of fluid. He grasped the obstructed bowel, pressed it gently, and mixed its contents with the fluid. Having softened the mass in the bowel, he closed and dressed the wound in the flank. The mare died six hours after operation. Three years later, Gaullet operated on a moribund ass in which he had diagnosed obstruction of the pelvic flexure of the colon. He opened the flank, incised the gut— which was almost black—extracted a concretion, and closed the wounds with coarse sutures. The patient died in twenty-four hours. The next, and to this day the only successful laparotomy performed on a horse affected with intestinal obstruction, is that recorded by Felizet, of Elbceuf. In June 1849, Felizet was called by a miller to see a horse, about nine years old, that had been affected with colic for about sixteen hours. Two or three times within four months the horse had shown symptoms of constipation. Clysters had been given, but no other remedy. Rectal examination discovered a concretion, as large as a child's head, at the beginning of the floating colon. Felizet was positive of the existence of the calculus. As death seemed the only possible result, the miller was informed that his horse could not live much longer. But a conversation between Felizet and a farmer probably saved the animal's life. Five days before, the farmer's colt in jumping a hedge had opened the abdomen and torn the point of the cmcum. Felizet treated the wounds, but gave no hope of recovery. The farmer now told him that the colt had made wonderful progress; and on learning this, Felizet was struck with an idea as bold as it proved to be fortunate. At once he decided to return to his patient, the miller's horse, open the flank, and extract the calculus. Unaided by anaesthetics and antiseptics, he per formed laparo - enterotomy. The horse was thrown on the left side; the upper hind leg, unhobbled, was drawn backwards and lashed to a stout pole. The skin of the right flank was incised longitudinally, the muscles were divided with forefinger and thumb, and the peritoneum was opened with the point of a bistoury. The left hand with fingers extended within the abdomen prevented protrusion of bowels, while the right hand in the rectum pushed the obstruc tion towards the flank. Acting together, the hands passed the tumour through the wound. The right hand was now withdrawn, and cleansed by an assistant. The distended bowel was gently wiped, and incised two fingers' breadth from the mesentery. To facilitate extraction the concretion was reduced by separating its faecal crust. A furrier's suture was used for the wound in the gut, the muscles were stitched in layers, and a strong quilled suture closed the wound in the skin. Sweating profusely, the horse was allowed to rise. He was poulticed on the loins and bled six times at intervals of three hours, twenty-one pints altogether being with drawn. During the next four days he drank from twelve to eighteen pints of water every twenty-four hours, but he refused to eat either hay or grass. He groaned when moved, was dull and very stiff. Two days later his appetite returned, and by the ninth day he fed well, looked bright, and moved freely. The wound healed rapidly. In about a fortnight he was put to work on the land, and in September of the same year he was bought for 1100 francs by a Paris merchant, who was very much pleased with his purchase.

It is to be regretted that the report does not contain particulars of the length of the incision, and of the material used in stitching the bowel. A furrier's suture implies the passage of the silk or other thread through the whole thickness of the gut, and as a consequence considerable risk of leakage.

To relieve obstructed bowel in the horse, laparo-enterotomy was performed by F. Smith in 1889, by Dollar, Rickards, and Rogers, and by Garry in 1894. These cases did not recover, and the reports show that death was mainly attribut able to the operation having been too long delayed. Woodruff, in 1911, performed colotomy in a hackney mare and, five weeks later, entero anastomosis, but the mare died two days after the second operation.

Before Charlier made known his method of spaying per vaginam, mares were always cas trated through the flank, and occasionally, even now, as a successful case recently reported by Martin goes to prove, the older operation is preferred.

Frequently cryptorchid horses have been castrated through the flank, and it may be said that the usual operation for abdominal crypt orchidism is effected by laparotomy slightly modified.

Laparotomy has been performed oftener on cattle than on horses. Few fatalities have been recorded. In oxen invaginations have been reduced, herniae liberated, and the bowel has been resected. Probably the earliest operation is a laparo-enterectomy or resection performed by Thomas Brayn, a cattle-doctor of Yeaton, Salop, in 1730. Brayn was called to an ox suffering with obstinate constipation. He opened the flank, searched for the obstruction, and found"the gut was about the stoppage putrefied for about three-quarters of a yard."This part he excised, then drew and stitched the ends of the sound gut together upon"a hollow keck"three or four inches long, and closed the hole in the flank. The ox passed the keck, recovered, and served its owner usefully for several years.

Intussusception was successfully reduced in 1839 by Anker of Berne, who had operated frequently in cases of pelvic hernia.

Meyer opened the right flank of a cow, brought the invaginated bowel outside, and failing to effect reduction, excised about six feet of gut which was becoming gangrenous. To facilitate anastomosis, Meyer inserted into the bowel a piece of paper rolled up and greased. The edge of the posterior gut was inverted, and the anterior end passed into it for about an inch and a half. The serous surfaces were united by a continuous suture of well-waxed thread passed through the serous and muscular coats.

Taccoen operated on two cows. From one he removed ten inches of gut. The external wound healed in thirty-five days. In the other cow an artificial anus formed, but this did not impair her health.

Riedinger treated ten cases of invagination in oxen. Seven had to be slaughtered; and in three the invagination was reduced, but only two recovered completely.

Degive diagnosed invagination in a cow. He incised the flank, brought the intestine outside, and, after considerable difficulty, effected reduc tion. The cow recovered in three weeks. Riis reports a similar case. He found the volvulus with ease and drew it to the opening in the flank. The gut was swollen and congested. It was bathed with weak sublimate solution, gently pressed for fifteen minutes, and reduced. The cutaneous wound was closed with fifteen button stitches. The animal fed in the evening and completely recovered.

Diagnosis. Abdominal diseases amenable to surgical treatment may be diagnosed in dogs by manipulation, in cattle by rectal exploration or by rumenotomy, but in horses diagnosis is extremely difficult because of the size, disposi tion, and relations of the viscera and the common symptoms they provoke when diseased. The history of the patient; the character of the pain, whether intense and continuous or sub acute and intermittent; distension, local or general; constipation, persistent or interrupted; the action of eserine; the posture of the patient; backing; straining; the quantity of urine passed; the rejection of clysters; expulsion of flatus; and the symptoms sometimes afforded by palpation, percussion, and auscultation, merely suggest a possible cause—all are fallacious and unreliable in the diagnosis of abdominal diseases. If examination per rectum gives more assistance, it does not always yield satisfaction. The height of the operator and the length of his arm should be considered as well as the state of the home's bowels. In a healthy horse, fifteen hands high and of medium coupling, the hand may reach the coeliac axis and the last rib. In a long loined, sixteen-hands carriage horse, lying on his right side, the border of the spleen, the last rib, and the left kidney can be felt, but in the standing horse the spleen cannot be reached. Experiment warrants the assertion that an imaginary vertical plane falling from the first lumbar vertebra to midway between the xiphoid and umbilicus represents the forward limit of rectal exploration. Employing the left hand for the right half and the right for the left half of the abdomen, all the viscera behind this boundary may be examined more or less satisfactorily — in the healthy horse. In abdominal disease, especially in obstruction, the intestines are often crowded towards the pelvis, and frequently the hand cannot pass onwards in consequence of straining and pressure from distended bowels. But when the hand has reached the flank it may, and sometimes does, discover displacements, volvulus, or invagination; recognize and remove con cretions; ascertain the condition of the contents of the colon, csecum, floating colon, and small intestine; and in herniae distinguish and liberate omentum and bowel. Cases that give no sign to exploration are uncommon, and without this precious aid diagnosis, whether positive or negative, is doubtful. In this, as in other diagnostic efforts, the spirit of the practitioner dominates procedure. With faith in possibilities, rectal exploration may be tried again and again, and information may be gained at every investigation.

In the majority of cases, volvulus, invagina tion, internal herniae, and obstruction by con cretions, bands, or pedunculated tumours cannot be definitely diagnosed without resorting to exploratory laparotomy. With anaesthetics to suspend the movements of the patient and antiseptics to prevent infection of the wound, exploratory incision is justifiable in any linger ing case of bowel obstruction. Volvulus or twisted small intestine in the horse is never likely to be successfully reduced because of the intricacy of the condition, but obstruction due to concretions, intussusception, or torsion of the pelvic flexure of the colon is within the range of the operating veterinary surgeon.

Laparo-enterotomy. Materials, etc., required: Aseptic cotton-wool or small sponges for use inside the abdomen and about the bowel. Pieces of aseptic gauze, tarlatan, or fine muslin for packing round the bowel brought outside the abdomen. Enamelled trays for instruments, ligatures, and needles. Zinc pails for saline solution, carbolic lotions, etc. Some 20 per cent carbolic or other antiseptic soap for wash ing hands and horse's flank and for shaving the skin. One aseptic scalpel and a razor. Two elbowed scissors, sharp- and blunt-pointed, to divide muscles, open peritoneum and bowel. Two sponge-holding forceps. Two Thornton's T-shaped forceps to stop bleeding from skin or muscle. Two Wells's catch forceps, and one or two spring and dressing forceps. A few straight and curved suture needles. Twenty milliners' needles, straws No. 5, for stitching the gut. Prepared Chinese twist for all sutures —No. 1 for the gut, No. 3 for muscles, and No. 6 for the skin. A fine trocar and cannula, to puncture, if necessary, distended bowel. A convenient supply of hot water, and a piece of fine muslin several layers thick for use as a filter for water to be used for lotions or for irrigation. Chloroform and an inhaler with sponge; and some pure carbolic acid in a graduated bottle. A quantity of pure sodium chloride for making normal saline solution (one dram to the pint of boiled water). For dressing the wound the following should. be ready: Iodoform and tannin, 1 to 3; antiseptic cotton-wool and tow; carbolized gauze; a piece of calico, six yards by nine inches; roller bandages; and a few safety-pins.

Preparation for Operation. Before casting the horse, the flank from spine to groin and from haunch to sixteenth rib is clipped and washed. When the horse is under chloroform, the flank, within two or three inches of the boundary marked by clipping, is shaved and disinfected. While these preliminaries are proceeding, the pails and trays are arranged and filled. All the solutions must be warm, and the water used in their preparation passed through muslin.

Abdominal Incision. The linea alba offers the least vascular and shortest route to the interior of the abdomen. Through an incision of the white line any organ within the cavity can be felt, the small and large intestines in part can be seen, and to some extent portions of these viscera can be withdrawn; but the colic mesentery is too short to permit the first part of the floating colon to pass through the wound. Besides, if the incision is made at this point the wound does not heal rapidly, and adhesion between its peritoneal surface and omentuin or bowel is a probable complication. In the horse, incision of the abdomen an inch or two to the right or left of the linea alba is equally objectionable. When the floating colon has to be opened, the bowel can be reached most conveniently through the flank. In opening the flank three wounds are made before b touching the peritoneum. The first divides the skin, fascia, and external oblique muscle; the second the internal oblique; and the third the transversalis. The first starts at a point four inches below the lumbar transverse processes, midway between the angle of the haunch and the last rib, and passes downwards and forwards for seven or eight inches. The forward direction of this incision is opposed to all teaching, but its advantage is conceivable. The upper hind limb is unhobbled and drawn backwards. The wound gapes and exposes the internal oblique muscle, which is then cut with scissors in the direction of its fibres. A similar opening is made in the transversalis. The third wound exposes a layer of fat which is lined by peri toneum; this is pierced with the finger, and the opening is enlarged with scissors in the direction of the transversalis wound. Bleeding must be stopped before the peritoneum is punctured.

Incision and Suture of the Bowe/. - , - In Felizet's case the gut was opened two fingers' breadth from the mesentery. But the bowel should be opened at the middle of the longitudinal band —where the wall appears strongest and most capable of supporting sutures. With sharp pointed elbowed scissors the gut can be punctured and the wound extended without the slightest difficulty. The wound is closed with sutures of prepared Chinese twist No. 1.

Sutures applied by Lembert's method pass through both the serous and muscular coats; the mucous membrane must not be punctured. The needle enters one-quarter inch from wound, passes through muscle for one-eighth inch, then pierces serous one-eighth inch from the edge of the wound. It is then carried across the wound, reinserted one-eighth inch from edge, passed through muscle for one-eighth inch, and brought out one-quarter inch from the wound. A glance at the diagram will enable any one to under stand the course of the needle. The sutures are placed one-eighth inch apart and tied separately. The ends are shortened to within one-quarter inch from the knots.

Operation. Cast the horse on left side, and give chloroform. Wash, shave, and disinfect the flank. Spread sponge cloths, wrung out of carbolic lotion (5 per cent), in front and behind area of incision. Incise skin and external oblique; unhobble upper hind limb, draw it backwards, and fix to a post or wall. Douche wound with warm carbolic lotion (2i per cent) and stop bleeding from skin and muscle. With elbowed scissors slit internal oblique muscle in the direction of its fibres, trim the edges, and stop bleeding. Snip transversalis with scissors, and extend opening with finger, taking care not to puncture fatty layer or peritoneum. Ex amine wound and check bleeding. Sponge with warm carbolic lotion (2i per cent) and remove excess of fluid. When satisfied that the wound is"dry,"rinse the hands, push the finger through fat and peritoneum, and enlarge opening with blunt-pointed elbowed scissors.

Pass a large sponge, wrung out of (2i per cent) warm carbolic solution into abdomen, and get tarlatan ready. Pass the hand into abdomen, bring out the bowel, and hold it gently until the assistant has placed pieces of tarlatan, moistened with warm carbolic lotion (2i per cent), round the wound. This done, let the assist ant take the bowel between his fingers applied like clamps, the hands resting one in front, the other behind the wound. Incline the bowel towards the horse's thigh, and slit the free border with scissors. Remove contents, and wash its mucous lining. With a fresh sponge clean the edges of the wound, and apply Lem bert's sutures. Place the stitches one-eighth inch apart, and insert two or three beyond the wound at each extremity. Pass all the sutures before tying any. Wipe the edges as tying proceeds, and shorten the suture ends to one quarter inch from the knot. When the wound has been closed, pull the bowel well out of abdomen, and let assistant renew his hold. Carefully sponge off clots, hairs,, and suture ends, and douche with normal saline solution in boiled water that has been allowed to cool to about 106° F. Remove packing from round the wound, let the bowel slip into abdomen, and withdraw the sponge. Look inside, and, if necessary, pass in a fresh sponge to take up clots or fluid. Adjust the edges of transversalis wound, and excise protruding fat. Pass two or three sutures (twist No. 3) through internal oblique muscle, and sponge the surface with carbolic lotion. Rehobble upper hind limb, and bring edges of external oblique together with a few fine sutures. Close the external wound with strong (No. 6) twist sutures passed through skin and muscle, tied in front or behind the line of union. Then slit skin and fascia downwards and backwards to two inches from lower end of first incision. This will drain the operation wound. Sponge the surface with carbolic lotion, and let the horse rise. Dust the flank with iodoform and tannin, insert aseptic tow in drainage wound, and cover the whole with carbolized cotton, protected with four layers of gauze. Support the dressing by winding calico round the body, and roller bandages secured with safety-pins. Muzzle the horse for five or six hours, but leave his head loose. Encourage, but do not force, exercise. For a few days restrict his diet, which ought to be somewhat laxative. Dressings shop d not be renewed until oozing occurs; then redress, but do not plug the drainage wound. The dressings might be substituted with advantage by a pitch plaster or a mild blister.

Enterectomy (excision of part of the intes tine). This operation is indicated in some cases of invagination,"twist"or strangulation that cannot be reduced. Successful operations in cattle have been recorded by Brayn, Meyer, and Taccoen; and in dogs resection of the bowel experimentally has frequently been per formed.

In operating on the small intestine of the horse, the abdomen may be opened at the flank or near the linea alba. The bowel is brought out and clamped in front and behind the obstruction, care being taken to apply the clamps over sound bowel two or three inches from the strangulated part. Within two inches of the clamps, along a line near to the attach ment of the diseased segment, the mesenteric vessels are tied; the bowel is then detached from its mesentery, divided at two places, and removed. The continuity of the gut is restored by continuous or interrupted sutures passed through serous and muscular coats of the inturned ends. The mesentery from which the bowel has been separated is carefully folded to the right or left, and secured by sutures of fine twist placed at the borders of the fold, or a piece of mesentery can be excised and the edges united by continuous suture; but whether folded or excised no gap should be left between mesentery and bowel. If clamps are not employed, the ends of the gut should be drawn over a piece of trachea or decalcified femur, and the edges inverted before applying the sutures. To protect the wound and support the sutures, Senn suggested that a bit of omentum should be applied and stitched to the bowel. But stitches are unnecessary, as the omentum readily adheres to the wound. In the human sub ject, continuity can be attained by lateral im plantation and by lateral apposition as well as by end-to-end approximation. In the first the posterior end is closed by continuous suture, and a hole is cut in the side of the bowel. The

anterior end is then passed for an inch into the open ing, and fixed by sutures. In the second, anastomosis is effected by means of Senn's perforated bone plates, or slices of raw turnip. The ends of the gut are turned in and closed; each is then slit open at the side about two inches from the end, and a bone plate or a slice of turnip to which sutures have been attached is in serted through the opening. The sutures are then passed through the wall of the gut and tied together to maintain the serous surfaces in apposition.

Caesarean Section extraction of the fcetus through wounds made in the abdominal and uterine walls. This operation is indicated, though not always per formed, when delivery by the natural channel is impossible in consequence of insurmountable maternal or fcetal difficulty. Introduced with the object of saving the young, the operation at first was only carried out on the dead female. Improved methods and increased confidence, as well as the desire to relieve suffering, suggested the operation on the living with the hope of saving both mother and young.

Recommended by Brugnone and Bourgelat, Caesarean section has occupied a place in veterinary practice since the early part of last century. The operation as recorded has been performed fifty-one times altogether—on five mares, twenty-one cows, seven sows, two ewes, and seventeen bitches. Of the mares three were killed, one died, and one survived. Eight of the cows died, seven were killed immediately or soon after operation, and six recovered. Six of the seven sows recovered, and of the bitches four died and thirteen recovered from the operation. Franck, quoted by Fleming, men tions forty-eight cases, twenty-five of which were unsuccessful; and St. Cyr and Violet give a summary of forty-one cases with twenty-eight deaths. These statistics, it must be confessed, are not encouraging, and at first view tend to hinder rather than promote confidence in the operation; but closer examination will show that most of the reports belong to a time antecedent to the employment of antiseptics in veterinary practice.

Recently Ccesarean Ovaro-hysterectomy — or extirpation of the uterus with its appendages —has replaced to a large extent the older operation in human surgery. In 1768 the possibility of removing the gravid uterus in animals was proved experimentally by Cavallini of Florence, who operated on dogs and sheep; and similar experiments were performed by Dr. Blundell, Fogliata, Porro, and Rein. In veterinary practice in England the uterus in pregnant bitches is frequently excised. (See"Ab dominal Diseases of Dog and Cat,"pp. 738-42.) In performing Caesarean section, chloroform should be given, and the flank should be pre pared and incised as in laparotomy. The incision should measure, according to the case, from five to sixteen inches. Having exposed the womb, it should be incised on its upper surface, and the wound extended by probe pointed scissors. The foetal membranes if still intact should be ruptured; and to prevent soiling of the peritoneum a piece of mackintosh cloth should be spread over the lower part of the abdominal and uterine wounds. If the cord can be reached it should be tied and divided before the fcetus is removed. In the bitch, as suggested by Degive, advantage will be gained by bringing the womb as far as possible out of the abdomen before incising the horn. After extracting the fcetus the membranes should be separated and withdrawn through the vagina if possible. The uterine wound should be closed by Lembert's sutures; this done, the womb and adjacent viscera should be douched with warm saline solution. Excess of fluid is then removed by aseptic cotton-wool or sponges, and sutures are placed in the abdominal wound, which is subsequently dressed and bandaged in the usual way.

In hysterectomy, excision has been effected by the ecraseur and by the knife, with ligature of strong twist secured by a Staffordshire knot. The stump may be allowed to drop back into the abdomen, or it can be sutured with the wound of the flank, and a few days afterwards set free.

Gastrocentesis. Piercing the rumen for the relief of tympanites in cattle and sheep has been practised in all countries since very early times. The operation performed with trocar and cannula through the left flank is familiar, simple, and generally successful. A few cases have been recorded in which puncture was followed by peritonitis induced by the escape of gastric contents into the peritoneal cavity.

In 1838 it was suggested that gastric tympany in the horse might be relieved by puncturing the stomach with a long curved trocar and cannula passed through the abdominal floor; but I have not been able to find the report of a single case treated by this method. Gastric flatulence is not a rare condition in horses, but I doubt if the stomach—even when distended and somewhat displaced—can be safely reached through the abdominal wall. In other operations with the trocar there is some degree of certainty that the instrument will directly pierce a cavity or a dilated viscus, but in attempting gastric puncture in the horse the flexures of the colon, and perhaps the spleen, would probably be encountered on the way. The danger of the operation lies not with the stomach, but with other viscera which might be transfixed by the penetrating trocar.

Paracentesis Abdominis. the ab domen for the evacuation of ascitic or other fluid. This operation, which is neither difficult nor dangerous, though rarely required in horses, cattle, or sheep, has been frequently performed on dogs. Palliative rather than curative, paracentesis gives the patient ease, and some times lengthens life. The puncture may be made inferiorly in either flank. An instrument of small calibre should be employed. In operating on the dog a many-tailed bandage will be found useful to supply counter-pressure as the fluid escapes. Having removed the hair and disinfected the skin, the bandage is applied, and a"window"cut at the seat of operation. The trocar or aspirating needle should be pushed slowly into the abdomen. There is little risk of wounding the bowel, which is generally anaemic and retracted. The escape of fluid may be interrupted by omentum, gut, or solid particles. Whether all or only a part of the fluid should be removed at one tapping is sometimes discussed, but the question is of little moment. With the bandage well adjusted all the fluid may be withdrawn—perhaps with advantage. When it is carefully secured, the bandage to some extent retards reaccumula tion, if it does not altogether prevent it. For this purpose, or to arrest the secreting power of the serous membrane, injections of a weak solution of iodine, as recommended by Leblanc more than ninety years ago, have been used successfully by St. Cyr and other veterinary surgeons.

In connection with paracentesis I should mention that uterine and ovarian dropsy has been relieved by tapping through the flank. Steel of Biggar removed 102 quarts of fluid from the uterus of a cow, and W. Field operated twice on a mare, and withdrew altogether 8 gallons from an ovarian cyst.

Enterocentesis — Puncturing the bowel in tympanites. Vegetius (4th century) recom mends abdominal puncture in the treatment of strophus or pain in the belly. Enterocentesis was mentioned by Markham in 1656, and was practised for the relief of tympanites in horses by Roem of DreSden in 1776. Bourgelat and Chabert (1781) operated through the rectum, and Barrier and Herouard—somewhat later— through the right flank. For many years after its introduction, enterocentesis was viewed with much apprehension because of the occur rence of abscesses between the muscles of the abdominal wall and of the frequent deaths, which were often attributed—rightly or wrongly —to the operation. Vatel expressed the fear that peritonitis might be induced by the use of the instrument; and Chabert warned intending operators of the danger of inhaling the mephitic gases, advising the injection into the rectum of antiputrid"substances—perhaps the earliest suggestion of the employment of antiseptics in veterinary practice. Somehow the operation lost ground and fell into desuetude until 1834, when it was revived by Bernard at Toulouse, and soon after by Rey at Lyons, and by Chabert in Paris. Numerous experiments were made to prove that the horse's bowel could be punctured without danger, and that the formation of abscesses at the seat of operation could be prevented by attention to cleanliness.

In this country the operation was revived— if not performed for the first time—by Stewart of Glasgow in 1836. But Stewart's limited experience, while it startled a failed to convince many. The old conservative methods of dealing with flatulent colic prevailed; but treatment must vary with advancing know ledge. Since 1850 enterocentesis has gradually gained the confidence of practitioners everywhere as a ready, harmless, and frequently successful means of relieving tympanites in the horse. The symptoms of the condition are familiar; but sometimes one meets with a case in which the abdomen is much distended, and yet no gas can be found with trocar and cannula. In torsion of the large intestine, when haemorrhage into the substance of the bowel has occurred, blood may escape from the cannula. The opera tion, if it fail to relieve distension, may assist diagnosis; more than once a horse has been promptly destroyed when blood instead of gas spurted from the cannula, and in every instance post-mortem examination revealed a hopeless condition of the large bowel.

The seat of operation is the right flank, but the left may be punctured. Rectal puncture, abandoned soon after the decease of Chabert, has been revived by Fohringer and Immin„aer; against this method may be urged the risk of peritonitis from septic contamination, but with a small and clean trocar the objection may be disregarded. The flank operation, however, is simple and safe.

The complications which attended entero centesis many years ago were probably caused by want of care in selecting and cleansing the instrument. Trocars of excessive size and in all conditions were employed; and perhaps some of the unsatisfactory operations of the present day might be explained after examina tion of the instrument. The trocar and cannula, beyond the handle, should be somewhat flattened, and should measure roughly 6 inches by inch. It should be warmed and disinfected before, and cleansed and again disinfected after, the operation. In operating it is advisable to disinfect the skin and to remove the hair, but I must confess to having operated frequently without preparing the skin. To prevent the gut from slipping off the cannula, Broaniez, in 1843, designed an enterotome, which has, however, received little commendation. When employing a fine trocar and cannula I invariably first puncture the right upper-flank; and if no gas escape, reintroduce the trocar four to six inches below the first puncture. In many cases I have punctured both flanks at several places, and in one horse I punctured the right flank in seven places without complication. Beginning at the upper flank, the trocar may be safely introduced at intervals of a few inches down wards behind the last rib to the abdominal floor. I refrain from naming the bowel, because in flatulent colic sometimes one and sometimes another part of the gut is distended and in contact with the flank, and to wait until one can ascertain which bowel is most dilated is neither advisable nor advantageous.

The effects of the operation, when successful, are at once apparent: gas escapes, distension subsides, respiration becomes easier, pain dis appears, and the patient recovers.

Before withdrawing the cannula some practi tioners pour medicine into the bowel, but this practice is not always free from risk.

The neurectomies which are of practical value, and which are commonly performed in equine practice, are five in number, viz.: median, ulnar, plantar, and anterior and posterior tibial.

Of these the median and plantar are the operations which are done the most frequently.

Median neurectomy, originally introduced by Peters of Berlin, was first performed in England of lameness is definitely below the fetlock, as plantar neurectomy would serve the purpose equally well.

The operation can be performed under cocaine in the standing posture, but it is much better to cast and chloroform the patient. When the latter is done, the fore leg to be operated upon (the underneath one) is drawn forward and held out straight and in a forward direction by one or two men, being prevented from going too far in 1894, and is of especial value in obscure lame ness proceeding from chronic affections which cause pain on the inside of the limb; such, for example, as chronic periostitis or ostitis, the presence of a knee-splint or one passing under the tendon and causing pressure between the latter and the cannon bone, a sprained and thickened tendon, or an ostitis (or periostitis) of the inside of the fetlock - joint. There is, of course, no good object in depriving the whole of the inside of the leg of sensation when the cause forward by a loop of rope, one end of which is attached above the knee and the other above the hock; the top fore leg being fixed back out of the way. The operator then, after shaving and painting with iodine (or other antiseptic), feels for the position of the nerve immediately behind the radius and exactly over the thin fan shaped portion of the fascia of the superficial pectoral muscle. With a scalpel a longitudinal incision is made immediately over this, a very thin layer of it being cut through, and the glistening white fascia of the flexor muscles is exposed. This is quite a tough layer, and needs to be incised very carefully, as the radial vein and artery lie close underneath it, and if injured bleeding becomes troublesome. A careful in cision is made with the point of the scalpel and enlarged with the aid of a director to the size of about three-quarters of an inch or an inch. As a general rule the nerve is then in view, and can be exposed sufficiently to pass the tenaculum underneath it. This is then done, care being taken not to injure the vein which lies exactly alongside it, and the nerve is drawn into position for excision; the latter being done with a scalpel at the upper part. A pair of artery or other forceps is then applied to the distal end of the nerve and a piece about two inches excised. The wound is then sutured, and painted with iodine daily, healing up generally by primary union. Sometimes the animal will trot sound at once, and at other times will not be improved for ten days or a fortnight. If not improved in the amount of lameness it is well not to give a final opinion for three weeks or a month, until the animal has had a trial at work. The ultimate results of this operation, especially upon the heavy breeds and those used for slow work, are excellent. For hunters, or animals required to put sudden strain (such as in jumping) upon the flexor tendons, it should not be performed without first advising the owner clearly that the tendon may give way suddenly under violent exertion.

Gelatinous degeneration of the flexor tendons, characterized by a swollen condition of the back of the limb, is the chief sequel to be afraid of. Should this occur, the animal should be humanely destroyed.

Ulnar Neurectomy.

This nerve is found at the back and slightly on the outside of the ulnar region, about three or four inches above the back of the knee. An incision is made through the skin and fascia in this situation, and the nerve picked up with the aid of the tenaculum. It is then excised with a scalpel, a length of two inches or so being removed. The wound is then sutured, and treated anti septically until healing has taken place.

Plantar neurectomy

can be performed on any of the legs, but is most commonly used for ail ments of the fore feet. When properly per formed, the parts below the site of operation are completely deprived of sensation. It can be done in two situations, one above the fetlock (this is the one most usually performed) and one below.

The method of operating is the same whichever is chosen, and it can be done either under chloro form or by the aid of a local anesthetic. It can be done with the animal standing, but to cast and draw the leg forward is more convenient. For the higher operation the site selected is about one and a half inches above the fetlock joint, in the hollow just in front of the tendons, the operator recollecting the letters V.A.N.T., which express the order in which the parts are placed (Vein, Artery, Nerve, Tendon), and a useful guide can always be obtained by locating the artery and nerve with the finger at the place where they pass over the side of the fetlock -j oint.

With a tourniquet properly applied, especially if Esmarch's bandage is used, the operation is practically bloodless. The skin is shaved and cut through in the place indicated, the white connective tissue is delicately dissected through with the scalpel, and the nerve brought into view. This is then picked up with a tenaculum, cut through at the upper part, and about an inch removed. There is no pain below the incision after the nerve has been cut through.

The wound is then sutured, and bandaged or not at the will of the operator, and if it has been rendered aseptic before the operation, it can be made to heal within a week by primary union.

4 15 / With the lower operation the same method of procedure is adopted, and the situation chosen is just in front of the tendon about an inch or an inch and a half below the fetlock - joint. This operation is only preferable to the higher operation when one is absolutely certain that the cause of lameness lies in the posterior region of the foot.

Anterior Tibial Neurectomy.This is per for this nerve is made about an inch in front of the gastrocnemius tendon. and five or six inches above the point of the hock on the inside. The nerve can be felt by palpation and is almost as thick as an ordinary lead-pencil. Compara tively speaking it is superficial, as it only requires an incision to be made through the skin and one layer of fascia in order to expose it to view. The tenaculum is then formed on the outside of the tibia about six or eight inches above the hock, just behind and underneath the popliteal ridge. It is fairly superficial in this situation and can be felt from the outside. It is cut down upon, and separated out with the tenaculum, about one or two inches being removed. The wound is then sutured and treated in the usual way.

Posterior Tibial Neurectomy.The incision brought into use, and a piece about two inches long excised in the usual way. The wound is sutured and treated antiseptically, usually heal ing by first intention.

Sequelce. With all the neurectomies, one should always warn the owner of the animal of the sequelee which are apt to occur, and neurec tomy should never be performed until all other known methods have failed to effect a cure.

Gelatinous degeneration and consequent break ing down of the tendon occasionally occurs, and upon the first sign_pf this the animal should be humanely destroyed. The first symptom of this is a swollen condition of the part, followed by elevation of the toe of the foot. For animals which do slow, steady work and are not hammered violently along hard roads, neurec tomy is an operation well worthy of a trial in obstinate and chronic 'lameness, especially in navicular disease, sprained tendons, sesamoid itis, splints and periostitis of all kinds affecting the inside of the cannon bone. It should never be done in cases of laminitis. The average working life of a horse afterwards is about two years, but it is always uncertain. It may only last three or four weeks, or it may last for several years, depending upon the effects of work or wear and the re-establishment of sensation.

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