WOUNDS OF SPECIAL REGIONS.
Wounds of Joints. Open Joint. Traumatic Arthritis. Open Arthritis. - A wound which in other regions of the body would be considered as comparatively trivial, is likely to have serious if not disastrous results if it penetrates the capsule of a joint. As compared with a similar injury in man, open joint in the horse is always a condition of the greatest gravity, owing to the following reasons: (a) The difficulty of prevent ing infection; moreover, in the majority of instances the part is infected before professional attendance is sought. (b) The impossibility of securing and maintaining perfect rest of the part. Owing to the acute pain of the joint the animal is constantly moving the limb, and thus interferes with the process of repair. (c) The tendency to the formation of a stiff or immovable joint. This sequel is unfortunately very common and is the cause of much disappointment after a long, tedious, and expensive course of treatment. Obviously, a horse with a stiff or immovable joint when the articulation is one in which free movement is essential is of little value. Not uncommonly complications set in during the course of the case, such as a high degree of fever, accompanied by extreme pain, abscess formation, emaciation, nervous symptoms, and exhaustion, which render the destruction of the animal a necessity. Here it is desirable to point out that the injury or wound per se is not the main factor in causing the serious effects associated with an open joint. The extensive lesions produced in the joint and the severe constitutional symptoms observed are in reality due to infection, either at the time of accident or subsequently, owing to unfavourable sur roundings and the impossibility of carrying out aseptic treatment.
If infection could be eliminated from an open joint the effects of the injury would be limited to simple inflammation of the synovial mem brane and the wound in the overlying structures, both of which conditions would recover under suitable treatment. When, however, as is usually the case in veterinary practice, micro organisms have entered the joint, an acute septic arthritis (septic inflammation of the joint) occurs, which leads to destruction and disin tegration of the joint. It is necessary to state, however, that occasionally wounds of joints in animals escape serious infection, and provided suitable treatment be adopted, successful results are obtained.
In order to gain an accurate idea of the patho logical changes produced in a joint by a wound associated with infection it is necessary to be acquainted with the anatomy of the structure in a general way. Usually the joints which are liable to suffer from injuries leading to an open arthritis are those of the limbs.
We shall point out briefly the structures entering into a joint which possesses free move ment (termed a diarthrodial joint); the modifi cations occurring in certain articulations will be considered later, when they are of sufficient surgical importance to merit attention.
A joint is composed of the articular ends of the bones which enter into its formation. The articular surfaces are covered by a thin layer of what is known as hyaline cartilage. The bones forming the joint are kept in apposi tion by binding or restraining ligaments which pass from one bone to the other. A capsular ligament encloses the cavity of the joint and gives support to the synovial membrane which lines its internal surface. The synovial mem brane secretes synovia which is popularly known as"joint-oil"and serves to lubricate the joint.
Normal synovia is a glairy, straw-coloured fluid, which is somewhat oily, in appearance but in reality only contains traces of fat. Its glairy character is due to the presence of mucin and albumin.
The synovial membrane has a basis of vas cular connective tissue which is adherent to the inner surface of the capsular ligament. At the margin of the articular surfaces this connective tissue blends with the articular cartilage. Here also the synovial membrane may take the form of finger-like or villous processes projecting into the joint cavity; these serve to distribute the synovia in the joint.
Causes of Open Joints. - Penetrating wounds arising from kicks, a stab from a stable fork, a puncture from barbed wire, injuries in the hunting field such as wounds from a sharp pro jecting stone, or from a pointed branch of gorse; falls, such as result from stumbling, where a horse's knee comes in contact with a sharp stone and opens one of the joints of the knee. The coffin-joint may be punctured by a picked up nail. In some instances the injury may be inflicted at some distance from the joint and the septic inflammation may extend upwards by way of the tendon sheaths and reach the synovial membrane, as in the case of a septic wound of the forearm ultimately involving the elbow joint.
Again, a wound directly over a joint may not primarily puncture the capsular ligament, but should sloughing occur the articulation becomes involved. Meddlesome probing of a wound over a joint not infrequently leads to the capsule being opened.
Morbid Alterations as the result of Open Joint. - When infection has gained entranceto a joint, serious structural alterations are produced. The synovial membrane becomes acutely inflamed, the primary effect being to check the secretion of synovia; but this is soon followed by exuda tion or increased secretion, which is of a thin, turbid character and rapidly becomes purulent. During the movement of the joint the altered synovia may be expelled forcibly from the wound in a fine stream, and even while at rest it is discharged and coagulates around the lips of the wound. The entire joint becomes tense, swollen, and extremely painful, and little or no weight can be borne by the limb. The sup purative process extends deeply into the joint, and abscesses may also form in the vicinity of the wound. The ligaments become sodden and relaxed, and ultimately the synovial membrane is replaced by granulation tissue. The arti cular cartilages become softened, eroded, and finally destroyed. Suppuration extends beneath these cartilages and separates them from the bones, and portions of the necrosed cartilage may be found free within the joint. The ends of the bones forming the joint undergo acute ostitis (inflammation of bone) resulting in the transformation of the medulla into granulation tissue and absorption of the bony cancelli. The ultimate result, should the patient survive, is anchylosis of the articulation, i.e. the union of the opposing surfaces of the bone with immo bility of the joint.
Symptoms. - In addition to the local symp toms just mentioned there are marked consti tutional disturbances and much pain, which seems out of all proportion to the extent of the injury. As a rule these symptoms are not manifested immediately after the infliction of the wound, but are usually deferred until the second or third day, or even later, and their severity depends on the degree of infection that occurs. When open joint is complicated by fracture of one of the bones forming the articula tion the pain and lameness are observed shortly after the accident. The pulse is increased in frequency and soon assumes a hard and wiry character, respiration is much accelerated, and the temperature may rise to 104° or 105°. Muscular tremors and sweating are observed in severe cases, also loss of appetite. Owing to the severe and continuous pain there is constant movement of the limb. Unless relief be obtained and the suppurative process can be checked by treatment the animal gradually becomes exhausted, or various complications set in and prove fatal. Even if one is so fortunate as to check the discharge of synovia and to obtain healing by granulation, it not infre quently happens that anchylosis of the joint results and renders the horse of little value.
gnosis. - This is based on the situation of the wound, on the discharge of synovia, and on the constitutional disturbance. In severe cases the opening into the joint is plainly visible. It must be remembered that an in fected open synovial bursa in the vicinity of a joint may give rise to considerable pain and lameness, with discharge of synovia, hence dis cretion is necessary in forming a diagnosis, especially as exploration of the part with a probe cannot be practised without extreme danger to the patient.
Prognosis. - In many instances it is extremely difficult to foretell the result of open joint. The presence of blood in the discharge is an indication that the vascular ends of the bone are exposed and that anchylosis is likely to result. Should this take place in a joint where free movement is essential to the utility of the horse, the outlook is distinctly unfavourable. If one of the principal knee-joints or the true hock-joint be exposed by the injury, the chances of a useful recovery are very remote. If early treatment be carried out, and if the joint in volved be one in which free movement is not essential to locomotion, the prognosis is more favourable. But under the best conditions open joint in veterinary patients must be regarded as a very serious injury, because of the difficulty of maintaining asepsis and preventing move ment of the articulation.
Treatment. - Various methods of treatment have been advocated from time to time for open joint, and if we are to accept the views and statistics of some practitioners as correct, we can only assume that they have been singu larly fortunate in the cases they have treated, or that the patients have possessed marked powers of resistance to pathogenic micro organisms which have gained entrance to a joint. It is customary to discuss treatment under two headings, viz. (a) cases in which infection has not taken place; and (b) cases which are already infected.
With regard to non-infected cases we must point out that even if the penetrating wound were inflicted by an aseptic object - a very rare occurrence - the probability is that infec tion would be carried inwards from the skin. The instructions to suture the wound after cleansing it, and to apply a dressing of iodo f orm collodion, etc., so as to seal the part, are ideal in theory, but the difficulty in practice is to ascertain at this stage whether the interior of the joint is aseptic or infected. If, as usually happens, infection has already occurred, the practice of sealing the wound is likely to do more harm than good.
Experience has taught that, after removal of the hair around the wound and carefully cleans ing the part with an antiseptic solution and removing any foreign bodies present, the best treatment is to place the animal in slings and to apply a blister to the joint. The blister may be composed of cantharides (1 part to 8 of lard) or of biniodide of mercury (1 part to 8 of lard). Some practitioners prefer to irrigate the part continuously with cold water (by attaching a rubber pipe connected with a barrel of water above the wound) and claim good results, but this treatment has not proved successful in our hands. In cases where suppuration has occurred - and we may remark that these will form the large majority - drainage should be provided if necessary, and the joint cavity should be carefully washed out with an anti septic solution such as one composed of corrosive sublimate 1 part, water 1000 parts. After this is carried out, a blister should be applied to the whole surface of the joint. Experience has proved that the counter-irritant relieves pain, limits movement, causes approximation of the lips of the wound, and tends to stimulate reparative action.
The coagulum of synovia which forms on the lips of the wound should not be removed. If, in spite of this treatment, abscesses form in the vicinity of the joint, the discharge con tinues and is blood-stained, and the constitu tional disturbance shows no signs of abatement, and especially if the joint is one in which free movement is essential to utility, the case will not repay further treatment and destruction of the animal is advisable.
Of late years American practitioners claim success from adopting treatment which differs from that just mentioned. Frost (American Journal of Veterinary Medicine) shaves the hair from the area surrounding the wound thoroughly, and injects into the joint cavity 1 part of Lugol's solution of iodine in 4 parts of glycerine two or three times a day, using sufficient to fill the joint capsule (Lugol's solu tion of iodine is composed of iodine, 1 part; potassium iodide, 3 parts; water, 40 parts).
In the case of open joints where bandages can be applied, a dressing composed of anti septic gauze should be employed.
Steffen (Special Equine Therapy) advises, after thoroughly cleaning the wound, irrigation of the joint cavity for at least ten minutes with a solution of corrosive sublimate (1 part of sublimate to 3000 of water) at body temperature. This is followed by irrigation with physiological salt solution. The irrigations are continued until the fluid returns clear and free from pus, flakes, etc.
The interior of the joint is then injected with the following preparation: Biniodide of mercury, ounce; pure olive oil, 4 ounces; mix and shake before using.
This amount is injected slowly, and then the entire joint is enveloped in cotton-wool and a suitable bandage applied, or other retain ing appliance in cases where bandaging is not practicable. The dressing is allowed to remain in place for two weeks. Steffen claims that in nine out of ten cases a complete cure will have been effected when the dressing is removed at the end of the period mentioned, and in rare instances only will it be necessary to repeat the treatment.
Wounds of the Lips. - Falls on hard ground, bites, kicks, tears from nails fixed in the vicinity of the manger. Bruising of the lips may be produced by the first three of the factors mentioned, and also by the rough and severe application of a twitch.
Lacerated wounds vary in extent and depth, and in some instances the lip may be"split,"so that the internal mucous surface is severed as well as the skin.
Treatment. - Owing to the great mobility of the lips in the horse, and the fact that during prehension of food contamination of the wound is inevitable, considerable difficulty is often ex perienced in securing satisfactory healing. Con servative surgery should, however, be the rule so as to avoid permanent blemish. The general principles of wound treatment should be applied, viz. the removal of loose shreds of tissue, thorough cleansing with an antiseptic solution, and the employment of interrupted sutures to bring the edges of the wound together. Some practitioners prefer pin-sutures, as they tend to support the wound edges and are less likely to be disturbed by the movement of the lip. In cases where the edges of the wound have become dry owing to delay in treatment, they should be freshened by gentle scraping with a knife prior to suturing. When the lip is split through it is sometimes necessary to apply sutures to the internal mucous surface as well as to the external wound. Keeping the animal on sloppy food is advisable in order to limit the movement of the lips as much as possible.
Wounds of the Cheeks. - The most trouble some of these are deep wounds in the corner of the mouth, with severing of the mucous mem brane and lengthening of the opening of the mouth so that some of the molar teeth may be exposed. Unless healing can be brought about a serious blemish results, which interferes with feeding and drinking.
Treatment. - The lips of the wound should be thoroughly cleansed and freshened. Deep sutures are inserted, first through the internal or mucous surface, and then another layer through the skin and underlying tissues. The suture material should be sufficiently strong yet soft in texture. The horse should be fed on milk and gruel until healing takes place. If the sutures slough out, fresh suturing should be attempted, and may prove successful. We have seen a case in a foal in which two attempts had failed and the third brought about satisfactory healing.
Other wounds of the cheek are to be treated on ordinary surgical principles.
Stenson's duct (the duct of the parotid gland) may be divided as the result of a punctured wound of the cheek in the vicinity of the third upper molar tooth, and salivary fistula may follow. For the treatment of this condition the reader is referred to the special article on salivary fistula.
Wounds of the internal surface or mucous membrane of the cheeks are common as the result of contact with the sharp edges of the molar teeth during mastication. They heal rapidly when the teeth receive surgical attention, i.e. removal of the sharp edges by means of the tooth rasp.
Wounds of the Nostril. - These are usually caused by the horse catching the nostril on a projecting hook or nail in the stable, and occa sionally result from the bite of another horse. A common injury is a lacerated wound which lays open the false nostril. The cartilaginous portion of the nostril is sometimes wounded and may prove a troublesome condition owing to difficulty in healing and the danger of stenosis (narrowing) of the nostril as a result.
Treatment. - Thorough cleansing of the wound and freshening of its lips; sutures are then inserted and the part painted with a solution of iodoform in collodion. When the cartilage is divided pin-sutures are preferable. The horse should be put on the pillar-reins to prevent his rubbing the part and thus displacing the sutures.
Occasionally much difficulty in obtaining heal ing may be found when immediate treatment has not been applied.
Wounds of the Tongue. - These vary from a trivial injury to an extensive laceration of the organ.
Wounds of the tongue may be produced by a severe bit and a rough driver; also by rough handling of the organ when giving a ball or filing the teeth, and injury is more likely to occur if the horse rears up during the pro cedure. A serious wound is also caused by the reprehensible practice of passing a rope or cord around the tongue in attempting to control nervous or vicious horses. The tongue may also be wounded in its lateral aspect by sharp edges on the molar teeth.
Treatment. - Trivial wounds of the tongue heal rapidly; all that is required is an antiseptic and emollient mouth-wash, such as one composed of borax, honey, and water. Soft food should be ordered for the patient. In more extensive wounds suturing may be necessary, though often healing takes place without sutures. The best suture material for the purpose is silk, and the stitches should be inserted deeply and close together. Sloppy food should be ordered and a mouth-wash used at intervals.
When extensive bruising and laceration of the tongue are present, sloughing is liable to occur, and it is necessary to remove surgically the necrosed portion - amputating through sound tissue.
Wounds of the Hard Palate. - foreign bodies in the food may wound the hard palate, but such wounds usually heal rapidly. If, however, the palatine artery be wounded surgical attention is necessary, as serious haemorrhage is likely to result. This accident has occasionally occurred when an amateur, in lancing the palate for the imaginary affection called"lampas,"has made incisions towards the side of the palate instead of in the centre, and severed one of the palatine arteries.
Treatment. - The haemorrhage is often very difficult to control, as owing to the constant movement of the tongue blood is prevented from clotting in the arterial opening. Pressure applied by means of a tampon of tow and a tape bandage fixed around the upper jaw beneath the lip is preferable to a bandage applied over the nose. In placid horses the actual cautery may be used, or a suture may be passed through the lips of the wound by means of a curved needle, and this checks the bleeding. In nervous or vicious horses it may be necessary to resort to casting before the bleeding can be stopped.
Wounds of the Soft Palate. - The commonest cause is injury inflicted by the attendant in attempting to administer a ball by means of a pointed stick. Considerable inflammation re sults from such a wound, which is likely to extend to the pharynx and to produce septic pharyngitis.
The symptoms observed are: difficulty in swallowing, quidding of food, flow of saliva from the mouth; in some cases the saliva is fcetid and streaked with blood. When the inflamma tion extends to the pharynx the head is"poked out"and there is considerable swelling in the external pharyngeal region, swallowing even of fluids may be impossible, fluid food, water, etc., being returned by the nostrils.
Treatment consists in the administration of an electuary composed of belladonna, chlorate of potash, borax, honey, and glycerine. This is placed as far back as possible on the tongue by means of a wooden spoon, three times daily. Should acute pharyngitis exist, a hot cataplasm of thermofuge should be applied to the throat. In severe cases the application of a blister is indicated. The food should be restricted to oat meal gruels, linseed-tea, barley-water, milk, etc.
Wounds of the Cranial Region and of the Orbit. - These result from injuries such as occur when a horse running away comes into violent contact with a wall or a gate-post, and may also arise during the struggles of an animal suffering from"megrims."In some cases the skin carrying the forelock is torn in the form of a flap. A contused wound of the orbit may appear insignificant at the time of infliction, but owing to the bruising of the tissues and their infection an extensive swelling results and involves the eyelids and surrounding parts.
Wounds in this region must always be re garded as serious, and special precautions should be adopted to prevent or overcome infection. Septic cellulitis or erysipelas is not uncommon as a complication, which extends to the struc tures within the orbit, and the inflammation may spread to the coverings of the brain (meninges) owing to the fact that one of these coverings, viz. the dura mater, is continuous with the periosteum of the orbit through foram ina by which the nerves and blood-vessels gain entry and exit.
For a wound in this region which shows contusion suturing should not be practised. Thorough cleansing with an antiseptic solution is essential, and all necrotic tissue should be removed with dressing - forceps and scissors. On the first appearance of cellulitis a dose of polyvalent anti-streptococcic serum ought to be administered. Similar remarks apply to wounds in any part of the cranial region. If, however, a long incised wound exist, suturing is desirable, care being taken to provide sufficient drainage and to remove the stitches on the first appear ance of suppuration.
When a wound involves the skin carrying the forelock the hair should be closely removed, including the forelock itself, and the deep parts of the wound thoroughly irrigated with Dakin's solution until the part is as clean as possible. Suturing is then carried out, taking care to provide sufficient drainage. Daily attention is necessary in order to detect as early as possible the advent of suppuration and to remove a few of the sutures so as to permit of thorough irri gation and free drainage. As a rule this type of wound is difficult to heal.
Wounds of the Eyelid. - These are of common occurrence and usually result from contact with a nail or other sharp body in the stable. The eyelid may be torn so that it only remains attached by one extremity.
The edges should be freshened and the part thoroughly cleansed. Interrupted sutures of fine silkworm gut are then inserted, taking care to get the parts into perfect apposition. The wound is then dried with absorbent cotton-wool, and painted with iodoform collodion. The horse should be put on the pillar-reins for four or five days to prevent him rubbing the part and disturbing the sutures. As a rule primary union takes place provided sufficient care be bestowed on the disinfection of the wound.
Wounds of the Eye. - Wounds and injuries of the eye will only be mentioned here, and for further information regarding their nature and treatment the reader is referred to the article entitled"Diseases of the Eye and its Append ages." Punctured wounds of the eye are of compara tively common occurrence in veterinary practice, and may result from contact with a sharp pointed body, and, in hunters, from a thorn or sharp twig penetrating the cornea. The result ing injury varies according to the depth of the puncture and the amount of damage done to the interior of the eye, while the degree and virulence of the infection which may complicate the injury have an important influence on the gravity of the case.
A small puncture of the cornea may heal after the resulting inflammation of the cornea (kera titis) has subsided, but a common sequel is the formation of a cicatrix at the site of injury, which is at first of a bluish colour and later becomes white, forming what is known as a nebula.
In more extensive punctures of the cornea, associated with infection, the eye may become completely disorganized. A blow from a stick may cause extensive laceration of the cornea, with escape of the aqueous humour and luxation of the lens.
In the treatment of wounds of the eye it is advisable to employ a lotion having sedative and antiseptic properties, when acute inflam mation is present. For this purpose the follow ing may be applied twice daily: extract of belladonna, 1 ounce; boric acid, 4 drachms; cherry-laurel water, 4 ounces; and water to make 1 pint. Lint soaked in this lotion may be placed over the eye and secured by means of tape fixed to the head-collar.
For an incised wound of the cornea sutures of very fine silkworm gut may be employed to bring the edges together. In order to carry this out with facility a local anaesthetic such as a 10 per cent solution of cocaine combined with a solution of adrenalin should be applied to the eye.
In serious wounds of the eye accompanied by collapse of the globe, treatment should be directed to allaying inflammatory action and the prevention of infection. The remaining portion of the eye will shrink, and usually it gives no further trouble. It is only in rare instances that excision of the eyeball is neces sary, and operative measures should be delayed until it is found that a suppurative condition is likely to persist. From an aesthetic point of view a shrunken eyeball is preferable to an empty socket.
Wounds of the External Ear. - These in the horse may be caused by nails or hooks and occasionally as the result of bites. In the dog, especially in the long-eared variety, wounds of the ear are of common occurrence, being usually due to bites sustained in fighting.
In the horse, if the wound is confined to the skin, it usually heals satisfactorily when the edges are sutured. When the cartilage is slit by the injury there is considerable difficulty in obtaining union. The edges should be freshened and the part thoroughly cleansed with an anti septic solution; interrupted sutures are then inserted through both skin and cartilage on the internal and external surface. In some cases a portion of the cartilage may be torn off by the injury, and a permanent blemish then results.
In long-eared dogs the cartilage does not extend to the point of the ear, and in the latter region it is replaced by a fascia-like tissue. Wounds of the tip of the ear in such dogs are often very difficult to heal in consequence of the animal constantly shaking the head, and thus causing continuous irritation of the part. Not uncommonly the edges of the wound become thickened, and even ulceration may occur. In such cases it is necessary to prevent movement of the ears by applying a bandage round the head or a special cap to cover the head and ears.
Wounds of the Lower Jaw. - These are usually the result of a kick from another horse. Occa sionally the submaxillary artery or vein may be severed and will require ligation. The sali vary duct may also be wounded and a salivary fistula established.
In some cases a circumscribed fracture of the lower jaw may be produced, and in this event the wound should be enlarged and the loose pieces of bone removed.
Wounds of the Poll. - Wounds of the poll are usually caused by the animal striking its head against a sharp projecting body in the stable. The great danger in such cases is the formation of sinuses, and the production of the condition known as Poll-Evil (see article"Poll-Evil").
In the treatment of wounds of the poll it is essential to provide proper drainage and, as far as possible, to prevent infection of the bursa which lies between the funicular portion of the ligamentum nuchae and the second cervical vertebra. If, owing to a punctured wound, infection of this bursa occurs, free incision is necessary and treatment similar to that pre scribed for poll-evil is indicated. In treating wounds associated with contusions of this region, care should be taken to search for and remove loose portions of bone.
Wounds of the Neck. - Wounds in the region of the ligamentum nuchae are apt to give con siderable trouble, as pyogenic infection often extends to the ligament and induces necrosis.
Special attention to drainage is necessary in the treatment of such wounds, and frequently free incisions are required. Should any evidence of necrosis be present the part should be thoroughly curetted. As a result of a wound in the vicinity of the jugular furrow the jugular vein may be punctured or severed, or the carotid artery may be wounded. The latter is, of course, the more serious condition, as death from haemorrhage may rapidly ensue unless the vessel be ligatured. When the jugular vein is wounded or severed, it should be ligatured not only at the upper end of the wound but also at the lower end, the reason for the latter pre caution being to prevent the entrance of air into the vein.
In a wound with exposure of the jugular vein which is unwounded, it is advisable to ligature the vessel, as owing to it being subjected to stretching during the movements of the neck it may rupture and cause fatal haemorrhage - an accident that occurred in our experience. When the carotid artery is wounded, immediate steps should be taken to apply a ligature to it. Even when the wound in the skin is small, ligation is necessary. The skin wound should be enlarged, and the vessel sought for with the fingers, and artery forceps temporarily applied above the bleeding - point if the wound is a punctured one. The vessel is then drawn forward and separated from the nerves which accompany it, and ligatured on each side of the puncture. Some authors advise that the vessel should now be divided between the two ligatures so as to avoid its giving way at the point of ligature, owing to the tension which is normally present. In cases where the artery is completely severed by the injury, the lower end should be sought for, secured by artery forceps, and a ligature applied. The upper end should also be ligated, but owing to retraction either end may not be within reach. The reason for ligating both ends when practicable is on account of the collateral circulation, and bleed ing would follow from the upper (peripheral) end of the vessel if this precaution were not taken.
The injury may cause division of the vagus and recurrent nerves, and thus produce roaring.
A wound caused by the shaft of a car may per forate the trachea, and mechanical pneumonia may result owing to blood gaining entrance to the lungs. The symptoms pointing to perfora tion of the trachea are: blood - stained dis charge from the nostrils, an emphysematous condition of the skin in the region of the wound (the presence of air under the skin), and frothy discharge from the wound. Fits of coughing, marked difficulty in breathing, and a blood stained nasal discharge are suggestive of the entrance of blood into the lungs.
The treatment of wounds involving the trachea is to be conducted on ordinary surgical principles. Bleeding vessels should be liga tured, and in cases where extensive swelling of the neck occurs, causing compression of the trachea and interfering with respiration, a tracheotomy tube must be inserted below the seat of the injury. If, however, the wound is situated very low down, the tracheotomy tube must be secured in the tracheal opening so that it cannot get displaced.
The esophagus may be penetrated by a punc tured wound inflicted by the horn of a cow, in the vicinity of the jugular furrow of the neck. As a rule the injury producing it is situated in the lower third of the region. The charac teristic symptom of the lesion is the presence of masticated food and saliva in the wound. With regard to treatment, the wound in the gullet should be sutured, after careful cleansing has been carried out. If the skin wound is exten sive, the edges should be brought together by sutures, taking care to provide proper drainage. The animal should be fed on fluid foods until the wound in the gullet heals.
Wounds of the lower region of the neck, close to the scapula, are not uncommon as the result of penetration by a shaft of a car during a collision. In such cases the wound may extend deeply between the scapula and the thorax and prove very serious, as efficient drainage is diffi cult to obtain, and there is much laceration of muscular tissue. In some cases the injury produces fracture of a rib - a very grave con dition.
In the treatment of such wounds the first consideration is the suppression of should a blood-vessel be severed. In conse quence of the position and depth of the wound great difficulty is experienced in securing the vessel, and it may be necessary to enlarge the orifice before ligation can be carried out. Plugging the wound with carbolized tow soaked in compound tincture of benzoin will succeed in the case of haemorrhage from small vessels, but will fail if a large artery is involved. The next step in treatment is to provide proper drainage for the wound. A wound extending behind the scapula presents the greatest diffi culty in the way of efficient drainage, and owing to the constant movement of the shoulder blade healing is interfered with. It must not be forgotten that in the attempts to provide drainage a large blood-vessel may be cut, and may be very difficult to ligate owing to its situation. Another point of importance is that prognosis in wounds of this kind should be guarded, as it is impossible in the early stages to ascertain the amount and extent of the injury inflicted on deep-seated structures.
No hard and fast rule can be laid down with regard to the technique of providing drainage; each case will require special measures depend ing on the direction of the wound.
Having made every effort to secure a depend ent opening, the wound should be thoroughly irrigated with an antiseptic solution by means of a continuous-flow pump and rubber-tubing. This is to be carried out daily, but in the case of a wound which is deeply infected the pro cedure ought to be repeated three times daily. If a hosepipe attached to a water - main be convenient, the preliminary daily cleansing should be carried out by this means, and the irrigation completed with an antiseptic solution. For efficiency and cheapness Dakin's solution can be recommended. In spite of all precau tions sinus formation may occur as a sequel and prove very obstinate to treatment. Should free incision and curetting of the sinus fail to bring about healing, a strong solution of sul phate of zinc (4 ounces to 1 pint of water) may be injected daily, and frequently it succeeds in effecting closure. As an auxiliary to surgical treatment an autogenous vaccine (i.e. one pre pared from the pus that issues from the sinus) should be employed.
In the treatment of shaft wounds of the breast the principles are similar to those mentioned under"Wounds of the Lower Region of the Neck."By the exercise of a little ingenuity it is possible in some cases to provide a dependent opening for drainage. Irrigation with an antiseptic solution, repeated at frequent intervals, is of great importance. A careful watch for the early evidences of sinus formation is very desirable. Constant discharge of pus and the presence of a smooth-walled channel associated with lack of healing should indicate the need for a free incision so as to enlarge the opening at the surface and to curette the interior of the wound. Sinuses in this region may persist for an indefinite period in spite of treatment. In adopting surgical measures to bring about healing it is necessary to be very thorough in the technique, and to endeavour if possible to reach the depth of the sinus, then provide drainage, seek for the presence of a foreign body or a portion of necrotic tissue, remove it, and then use the curette freely.
Sinuses in the vicinity of the sternum are amongst the most troublesome conditions en countered by the veterinary surgeon. Here, too, the knife should be freely used, but the risks of from deep-seated vessels being severed must be remembered. In some instances a portion of the sternum may have become necrotic and must be removed by a strong curette.
In carrying out operative measures for the above conditions the horse should be cast and chloroformed, as it is impossible to control haemorrhage with the animal in the standing position.
In cases which resist the treatment men tioned, we have seen good results follow the daily injection into the sinus of a strong solu tion of sulphate of zinc (1 part of zinc sulphate to 5 parts of water).
Instances occur in which a sinus between the shoulder and the thorax heals at its anterior extremity and a new opening forms in the vicinity behind the elbow.
Open - This condition is not of common occurrence, owing to the fact that the joint is fairly well protected from injury.
The treatment of open shoulder-joint is - to be conducted on similar lines to those already advised. The injury must be regarded as a very serious one, and if suppurative arthritis occurs permanent lameness is likely to result.
Wounds of the Axillary Region. - The axillary region is situated between the inner and upper aspect of the elbow and the sternum. It con tains much loose cellular tissue. A frequent complication of a punctured wound in this region is surgical emphysema. This is a condi tion in which air gains access via the wound to the cellular tissue and spreads rapidly to the shoulder, neck, and even to the head. The affected parts appear distended, and on mani pulation they feel like an air-cushion. When, as sometimes occurs in hunters that are wounded in the axillary region, the animals are walked some distance home, the emphysema tous process may extend even to the hind quarters.
Another point in connection with such wounds is that, in consequence of their situation, healing is difficult to promote owing to the movement of the limb.
Surgical emphysema requires no special treat ment, as the air disappears gradually after a few days.
A punctured wound in the region mentioned should, after being thoroughly cleansed and dis infected, be plugged with a tampon of gauze soaked in an antiseptic solution. This treat ment should be carried out daily. The animal should be left in the stable so as to give the part as much rest as possible.
Wounds of the Forearm. - Punctured or lacer ated wounds of the upper region of the forearm either on the inside or outside of the limb must always be regarded as serious, in consequence of the tendency for infection to extend under the fascia and reach the elbow-joint.
The synovial membrane at the posterior aspect of the elbow-joint lines the tendons or origin of the flexor muscles of the limb. This explains the facility with which infection of the tendon sheaths in the case of septic wounds in this region spreads to the -elbow-joint, causing suppurative arthritis.
In the treatment of wounds of the forearm it is of the greatest importance to provide efficient drainage early and to carry out thorough disin fection. Even in the case of a small punctured wound such as that caused by a prod with a stable-fork, a free longitudinal incision should be made so as to enable the part to be efficiently disinfected and prevent the spread of infection under the fascia or along the tendon sheaths.
We ma point out that in the treatment of wounds 01 the forearm, with the exception of those only involving the skin and subcutaneous tissue, sutures should not be employed.
Open - This condition may arise from a kick or a puncture from a stable-fork. Suppurative arthritis usually results, accom panied by very acute pain and lameness and extensive swelling of the joint. The other phenomena are similar to those mentioned under the heading of"Open Joint."Although early treatment be adopted, it is seldom that the part can be rendered aseptic. The usual experi ence with regard to suppurative arthritis of the elbow-joint is that treatment of any kind is useless, as even if the suppurative condition be overcome, a stiff joint with permanent lameness results.
As already mentioned, suppurative arthritis of the elbow may occur as the result of a septic wound of the forearm.
A wound at the posterior part of the elbow may, by sloughing, extend to the joint, as at this point there is no ligament, and the muscles directly support the synovial membrane.
Wounds of the Knee. - These are of very frequent occurrence in the horse. The term"Broken Knee"is applied to abrasions or wounds of the front of the knee, resulting from a fall on a hard surface or on a sharp stone.
Wounds of the knee at any part of the joint are common in hunters, and may be inflicted by sharp stones or a sharp-pointed branch of gorse. Barb wire and a prod from a stable-fork are not infrequently causes of wounds of the knee, also a kick from another horse may inflict a very severe injury in this region.
Dealing first with"broken knee"we may remark that the term includes injuries which vary much in extent and gravity.
In the least serious type the skin in front of the knee is abraded but not cut through, and a slight oozing of bloOd occurs. The treatment of such a case is simple. All mud, dirt, etc., should be carefully removed by irrigation with an antiseptic solution, and a dry dressing, com posed of equal parts of boric acid and oxide of zinc, dusted over the wound. The horse should be prevented from lying down until the part is healed, as unless this precaution be taken, the pressure to which the knee is subjected while the animal is in the recumbent position is likely to cause further injury to the skin and to damage the hair roots, and so lead to a permanent blemish. Should the knee swell to any extent, the application of cold water is indicated.
A more serious form of broken knee is that in which the skin is cut through. As a rule the part is bruised to a greater or less extent and the subcutaneous tissue is exposed.
Mud, gravel, etc., gain entrance to the wound, and in carrying out treatment the first essential is to remove all foreign bodies by irrigation and the use of dressing-forceps. The initial cleansing of the wound is of supreme importance, and should be carried out very thoroughly. If, as not uncommonly happens, a pouch or pocket of skin is formed at the lower aspect of the wound, the judicious use of the knife is necessary in order to provide drainage and prevent an accumulation of discharge from the wound.
Having thoroughly cleansed the part by irri gation with an antiseptic solution, the knee should be enclosed in a layer of double cyanide gauze soaked in Dakin's solution, and a thick layer of cotton-wool applied over this and kept in place by a bandage. The periods at which the dressings should be changed will depend on the amount of discharge, and when the latter soaks through the wool and bandage the wound should be re-dressed.
In the case of a more severe injury the tendons passing over the front of the knee are exposed and much damage is done to the skin and underlying tissues. The bursa of the large extensor tendon is opened, and synovia appears in the discharge from the wound. Considerable pain, swelling, and lameness are present, and the case may be mistaken for one of open joint.
The swelling extends both above and below the knee, the limb is kept in a semi-flexed position, and movement is performed with difficulty.
The treatment in such cases is to provide proper drainage, to remove foreign bodies and all shreds of injured fascia, and to irrigate the wound thoroughly with an antiseptic solution. The knee should then be enveloped with gauze and cotton-wool, as already described, and the animal placed in slings. Irrigation with Dakin's solution should be carried out daily. If the discharge of synovia from the open bursa be profuse, it is advisable to inject for a few days the following: Lugol's solution of iodine 1 part, glycerine 4 parts.
In some cases, where the injury to the tendon has been excessive, sloughing of this structure may occur, and even rupture. Such lesions are usually hopeless. Permanent enlargement of the knee, and stiffness of the joint due to adhesion of the tendon to the surrounding parts, are not uncommon results in broken knee com plicated by open bursa. In order to prevent this undesirable sequel it is advisable not to keep the animal in slings for too long a period, and prescribe gentle walking exercise as soon as possible. If, after the part has healed, it is found that flexion of the knee-joint is interfered with, the animal should be cast and chloro formed and the knee forcibly flexed so as to break down the adhesions.
Open Knee-joint. - This may occur from falls during which the knee comes into contact with a sharp stone. It is also met with as the result of a puncture received in the hunting-field, or from a prod with a stable-fork. Of the joints comprising the knee the most serious when opened is that between the lower end of the radius and the upper row of knee-bones (the radio-carpal joint), an open joint between the two rows of knee-bones (the intercarpal) is less serious, while the least serious is the joint between the lower row of knee-bones and the head of the metacarpus (the carpo-metacarpal joint).
It may be taken as a general rule that an extensive opening into the first two joints mentioned, except in the case of a valuable stallion or brood mare, seldom repays the cost of treatment, as a stiff and greatly enlarged knee is the usual result, and not uncommonly the animal succumbs to some complication or event ually has to be destroyed. Simple punctures without severe injury of the surrounding tissues are more hopeful.
The treatment to be adopted has already been mentioned under"Open Joint." Punctured wounds at the back of the knee are met with in hunters, and prove very tedious in consequence of the constant movement of the joint interfering with healing.
Punctured and lacerated wounds of the knee resulting from injuries sustained in the hunting field, or from kicks, are to be treated according to ordinary surgical principles. It is of the greatest importance to provide proper drainage, and to make a thorough search for foreign bodies.
Wounds from thorns are common in hunters, and, owing to the small size of the external opening, they are apt to be overlooked. Con siderable swelling and tenderness of the knee may result, accompanied by lameness. The thorn which has caused the injury may be embedded completely in the tissues, or the point only may be present, the remainder having been broken off either at the time of the acci dent, or subsequently by the owner or attendant in their efforts to remove the foreign body.
In the treatment of this injury, if any portion of the thorn can be located by manipulation, the small opening in the skin should be cautiously enlarged and the foreign body re moved by means of forceps; the wound is then to be treated in the ordinary manner. If, however, the thorn cannot be located, a thick hot layer of thermofuge should be applied to the knee and repeated daily. This may succeed in causing the thorn to approach the surface so that it can be removed. If this measure fails, the case must be left to nature, as it would not be rational treatment to explore for a foreign body without being certain of its location. At times a thorn comes to the surface of the skin long after its penetration, and makes its exit through a small abscess.
Wounds of the Metacarpal Region. - The most important of these are wounds involving the tendons and tendon sheaths in this region. Such wounds may occur from contact with sharp bodies, barb-wire, etc., and are not un common in hunters as the result of injuries inflicted by sharp-pointed stones in a wall. Wounds of the flexor tendons vary in extent and gravity. In very severe injuries either one or both flexor tendons may be severed. When the perforatus tendon alone is divided lameness may be trivial and the toe of the foot may be turned upwards to a very slight extent.
Division of the perforans tendon results in a well-marked turning up of the toe at every attempt of the animal to stand on the limb.
Wounds involving the sheath of the flexor tendons must always be regarded as very serious, as the suppurative inflammation of the tendon sheath is apt to result, and may terminate in disease of the tendon itself. An open tendon sheath is evidenced by severe lameness, acute pain, extensive swelling along the course of the tendon, and the presence of a synovial discharge from the wound.
The treatment of wounds of the tendons is to be conducted according to ordinary surgical principles. In the case of suppurative inflam mation of the tendon sheath which extends in an upward and downward direction it is advis able to enlarge the opening in the sheath by an incision so as to provide drainage and prevent extension of the infection to the fetlock. Thorough irrigation with Dakin's solution should then be carried out, and the part enveloped in gauze soaked in a similar solution, and covered with a thick layer of cotton-wool. Exuberant granulations must be checked by the judicious application of finely-powdered sulphate of copper. When the synovial discharge is per sistent it is advisable to inject the following every third day: Lugol's solution of iodine, 1 part; glycerine, 4 parts.
In the case of a tendon being divided, suturing should be attempted, although the chances of union taking place are rather uncertain. The best form of suture for the purpose is a variety of mattress suture (known as Le Furt's) which is passed through the entire thickness of each end of the tendon and may be reinforced by addi tional sutures. The horse should be placed in slings and a high-heeled shoe applied.
Similar remarks apply to division of the extensor tendons, but in this case the high heeled shoe is not required.
Contusions of the Inner Aspect of the Meta carpal Region. - This is a common injury re sulting from the inner edge of the shoe of the opposite foot, and is known as"Speedy Cut." The contusion may be situated just above the knee, or at the inner side of the joint, or further down the metacarpal region. In some cases the skin is broken, in others a swelling is pro duced which may contain serum or even blood. When the lesion has been in existence for some time and the animal continues to"strike"the part, an abscess may form with sloughing of the skin. Not infrequently a chronic enlargement of the part is produced. As regards treatment, in mild cases hot fomentations, or the applica tion of a cataplasm of thermofuge for a few days, reduces the swelling. In cases where a soft enlargement containing much serum is present, it is advisable to make a free incision and to remove the contents, the cavity is then packed with gauze soaked in solution of hydrogen peroxide, and the dressing changed daily. When pus formation takes place as the result of speedy cut, a free incision should be made and the cavity irrigated with an antiseptic solution. Attention to shoeing is necessary so as to prevent a recurrence of the injury. The shoe of the opposite foot should have a feather-edge on the inside and be nailed on the outside only.
In the treatment of this injury experience has taught that in order to cleanse the wound thoroughly and to provide drainage it is neces sary to enlarge the opening. Not infrequently a foreign body such as a small piece of stone may be present which, if not removed, will cause con tinuous suppuration and ultimately sinus forma tion. This bursa may also be punctured by a thorn, and not uncommonly a portion of the latter may become embedded in the part and give rise to chronic lameness.
In cases where acute pain and lameness are present, after enlarging the opening of the wound it is good practice to apply a cataplasm of thermofuge for a few days; this relieves pain and, in the event of a foreign body being present, has the effect of bringing it towards the surface, so that it can be removed. The treatment of more extensive wounds of the anterior aspect of the fetlock is conducted on similar lines to those just mentioned. Not infrequently wounds in this region appear to heal, but later swelling and suppuration occur. In such instances it is necessary to make a free incision and curette the interior of the wound. In cases where there is a persistent discharge of synovia a few injec tions composed of Lugol's solution of iodine, 1 part to 4 parts of glycerine, should be carried out. As a sequel to open fetlock bursa a chronic enlargement of the front of the fetlock is usual. This can be reduced to some extent by the application of a biniodide of mercury blister.
Wounds of the posterior aspect of the fetlock are also met with, and occur as the result of contact with a sharp stone. In some instances the sesamoid sheath may be punctured and serious consequences are likely to result.
The treatment of open fetlock-joint is to be conducted on similar lines to those advised under"Open Joint." Similar remarks apply to open pastern-joint.
Brushing is the term applied to contusion, abrasion, or wound caused on the inside of the fetlock owing to the part being struck by the shoe of the opposite foot. The lesion is to be treated on ordinary surgical principles. Preven tion consists in ascertaining which part of the shoe causes the injury, and taking steps to round off the shoe at this point. In obstinate cases a"preventing"boot should be worn.
Wounds of the Coronet. - The most common injury to this region is an open contused wound produced by the horse treading with the heel of one foot on the coronet of the opposite one. Cases of the kind are most frequently observed during frosty weather when a horse is"sharpened"so as to enable him to travel on slippery roads. The wound produced may involve either the coronary band, the skin and subcutaneous structures, the tendon of the extensor pedis, the lateral cartilage, and some times even the s3movial membrane of the coffin joint. Treads occurring in severe frosty weather (which is the most likely time for them to be met with) are to be regarded as serious, and are especially dangerous when horses have to work after snow has fallen, as the wound is subjected to the devitalizing influence of severe cold, and may become infected by slush. Not infrequently the result is extensive sloughing of the tissues, and in some instances the necrosing process may extend to the coffin-joint and prove fatal. When the injury is situated in front of the coronet over the pyramidal process of the os pedis, the tendon of the extensor pedis may be punctured, and the coffin-joint opened at this point. Injury to one of the lateral cartilages may terminate in"quittor."The necrotic process may extend to the sensitive laminae of the foot, and lead to separation of the horny and sensitive laminae Destruction of a portion of the coronary band may result in the formation of"false quarter." Serious injuries to the coronet may result from the wheel of a heavy float passing over this region. Some bruising of the tissues is produced, and this leads to extensive slough ing; not uncommonly a portion of the os pedis may be broken off, and occasionally a fracture of the navicular bone also results. Wounds of the coronet caused by a sharp body may sever one of the branches of the digital artery and give rise to considerable hemorrhage.
Treatment. - In all traumatic injuries to the coronet thorough cleansing and disinfection of the wound is of great importance. A careful search should be made for foreign bodies, and if present they must be removed. Any loose shreds of tissue should be excised by means of scissors. The entire foot is then thoroughly cleansed and washed with a strong antiseptic solution, and immersed to above the coronet in a bath of Dakin's solution for half an hour. A dressing of gauze soaked in the same solution is next applied, followed by a layer of cotton-wool, which is kept in place by means of a properly adjusted bandage. Daily dressing should be carried out. In cases accompanied by acute pain it is advisable to apply a cataplasm of thermofuge for a few days until inflammatory symptoms are reduced. If a portion of the horn of the wall close to the coronary band is detached it should be removed by a sharp dressing-knife. In cases where injury to the os pedis is suspected it is advisable to place the patient in slings, and to apply the cataplasm already mentioned over the foot and coronet. In the event of a small portion of the bone being chipped off it will find its way to the surface, and can be detected and removed after enlarging the wound by the employment of a sequestrum forceps. Injuries such as fracture of the os pedis extending to the articulation, or of the navicular bone or open coffin-joint, are hopeless.
In wounds of the coronet associated with division of one of the branches of the digital artery it is necessary to secure and ligate the severed vessel. Not infrequently this is diffi cult to carry out as the vessel retracts within the tissues. The application of a tourniquet above the fetlock assists procedure. In an emergency case, where artery forceps are not at hand, pressure by means of a pad of tow secured by a bandage will succeed in arresting the bleeding. In deep wounds of the coronet in the vicinity of the lateral cartilage, sinus forma tion is not uncommon. Care should be taken to examine the part so as to detect the early signs of this lesion, and adopt suitable treatment, which will consist in the free use of the curette and the provision of proper drainage. When, in spite of this, disease of the lateral cartilage sets in, surgical measures must be adopted (see article on"Quittor").
In the case of a punctured wound of the heel the sheath of the tendon may be involved, or the tendon itself may be implicated. The symptoms presented are: acute lameness, severe pain, swelling of the heel which tends to extend to the fetlock, and a discharge of synovia. The appropriate treatment is similar to that advised for wounds of tendons.
A fissured heel is best treated by applying a cataplasm of thermofuge for a few days, then the part should be thoroughly cleansed and the crack packed with dry dressing composed of iodoform an ounce, oxide of zinc 1 ounce, and boric acid 1 ounce, and covered with a layer of cotton - wool and a bandage. In some cases healing is hastened by the judicious application of nitrate of silver to the edges of the fissure.
Perfect rest should be ordered. A shoe slightly raised at the heels favours approximation of the edges of the crack.
In the treatment of"over-reach"the wound first be thoroughly cleansed and dis When a flap of slain and tissue includ ing the junction between it and the horny frog is almost completely detached, immediate excision is advisable, as there is no possibility of union taking place and an unsightly blemish will result if the part is left to itself. In cases of less extensive injury the ragged edges of the wound should be trimmed and an endeavour made to promote union by applying antiseptic dressings and a layer of cotton-wool. Exuberant granulations must be checked by the ton of powdered sulphate of copper. Wounds at the junction of the skin and coronary band are sometimes followed by a horny growth, which must be repressed or removed by a hoof-knife.
Injuries caused by"Picked - up Nails."- These are of very common occurrence in city practice in consequence of the careless manner in which packing-box nails are thrown on the street. Occasionally a puncture of the foot results from a shoe becoming loose and the horse treading on the toe-clip, or the animal may"pick-up"a shoeing nail on the floor of the forge. The gravity of a case of"picked-up nail"depends on the situation and depth of the puncture and on the nature and amount of infection introduced by the nail. The commonest seats of wounds caused by nails are: the point of the frog, the side of the frog at the junction of the latter with the sole, and the centre of the frog. Any part of the sole may, however, be punctured. The most danger ous location for the puncture is the centre of the frog, as the point of the nail may penetrate the perforans tendon and open the bursa or even injure the navicular bone. A puncture in the vicinity of the point of the frog may extend to the coffin-bone and cause necrosis. Not infrequently there is considerable difficulty in detecting the puncture caused by a nail, and unless a very careful examination be made of the sole and frog it will be overlooked in the diagnosis of a case of lameness.
Nail punctures of the foot may be superficial and simply wound the sensitive sole or sensitive frog, in which instances recovery takes place after simple treatment has been adopted. The shoe is removed and the horn should be care fully thinned in the vicinity of the puncture so as to bring the latter into view. With a French hoof-knife a circular portion of horn is removed around the puncture so as to afford drainage, a strong antiseptic is then applied to the wound, followed by a cataplasm of thermofuge kept in place by a layer of carbolized tow and a boot made of canvas. When pain and lameness increase, the foot should be well soaked in hot antiseptic solution twice daily. When lame ness and discharge diminish, dry dressing with a leather sole is applied.
In cases where a deep puncture exists, free removal of the horn is essential, otherwise in fection will extend, and ultimately find its way to the coronet. Poulticing with linseed meal must be condemned, although it is a popular method of treatment of wounds of the feet. It causes softening of the tissues, promotes infec tion, and increases pus formation. For the relief of pain and inflammation a cataplasm of thermofuge is preferable, and this can be alter nated with the prolonged use of an antiseptic foot-bath. Excessive granulations, which are so common in wounds of the foot, may be removed by the knife or curette. Here we may remark that it is always advisable to remove the shoe from the opposite foot at the first examination of the case. If this precaution be neglected laminitis may develop in the foot, as owing to the inability to bear weight on the injured limb it is borne by the sound limb.
Tetanus being a not uncommon complica tion of wounds of the foot, the administration of anti-tetanic serum as a preventive is a wise course to adopt.
In cases where the os pedis has been punc tured it is advisable to cast the horse, and to remove the sole around the seat of the puncture. The condition of the part can then be observed, and if necrosis of the sensitive sole exist, the diseased tissue must be removed by means of a curette. Necrotic changes in the os pedis at the site of the puncture should be sought for, and if present, should be curetted. In some instances a sequestrum forms and either ex foliates or has to be removed. These cases are always very serious, and in those that recover the course is slow.
When the nail punctures the tendon of the flexor pedis perforans the chances of recovery are very remote, and except in the case of a valuable horse the outlay in treatment is seldom justified. The extent of the injury varies from a septic inflammation of the bursa situated between the tendon and the inferior aspect of the navicular bone, to a puncture of the bone itself, followed by necrotic changes. Septic bursitis may lead to extensive disease of the tendon, and ultimately the suppurative process may extend upwards to the hollow of the heel and there find an outlet.
The only treatment likely to prove of any benefit in such cases is to expose the tendon, resect it, and remove all diseased tissues, includ ing the terminal necrotic portion of the tendon. The horse is cast and chloroformed and the horny and sensitive frog removed over the site of the affected tendon. This is accomplished by making a triangular incision, the base of which corresponds to the base of the frog. The diseased portion of tendon will be recog nized by its greenish or yellowish colour. It is removed after locating the navicular bone by making a transverse incision over the middle of this bone, followed by two lateral curved incisions. Care should be taken to avoid open ing the coffin-joint. If any roughened surface is detected on the navicular bone it should be scraped by a curette. The entire operation must be conducted under strictly aseptic con ditions. The part is then plugged with iodo form gauze and a layer of carbolized tow applied and kept in place by a properly constructed canvas boot. Needless to remark, this operation is one which can only be carried out in a properly equipped infirmary, and for economic reasons it has limitations, as we have already pointed out.
(2) Injuries caused by Treading on Sharp Bodies such as Glass, etc. - Broken glass may become embedded in the sole, especially in wet weather when the horn is soft and more easily punctured. The neck of a bottle when trodden on is capable of causing very extensive laceration of the frog, extending to the deep structures, and is often accompanied by severe haemo rrhage. In hunters it is not uncommon to find a small sharp bit of flint embedded in the sole or frog and causing severe lameness. A sharp pointed piece of gorse may penetrate the cleft of the frog and prove very serious.
In many cases the presence of a foreign body in the foot may easily be overlooked unless a very careful examination be made, and the lameness may be erroneously ascribed to other causes. The error is discovered when a dis charge of pus issues from the heel or coronet. Here we may point out that the pus in such cases is thin and of a greyish or blackish colour; it is of a similar character when the injury results from a"picked-up nail." Treatment. - In the treatment of the above injuries, the important point is to ensure that the foreign body is removed and efficient drain age provided. The after-treatment is similar to that advised for"picked-up nail": a pro phylactic dose of antitetanic serum is always advisable.
(3) Pricks or Stabs in Shoeing -"Nail-bound,"" Drawn Nail."- These are injuries associated with shoeing, in some instances being accidents and in others due to carelessness.
The point of the shoeing nail may enter the sensitive membrane when carelessly driven, or when the nail-holes in the shoe are punched too close to the inner border of the web, or inclined too much in an upward and inward direction. The terms"drawn nail"or"blind stab"is applied when the farrier, finding he has either driven the nail too close to the sensitive mem brane or wounded it, withdraws the nail and does not report the injury.
The term"nail-bound"signifies pressure exerted on the sensitive structures by one or more nails without actual penetration.
Treatment. - This will depend on the nature of the case. When pressure without actual penetration is present, removal of the shoe, soaking the foot in a tub of hot water, and the application of a linseed meal poultice will gener ally succeed in causing the lameness to dis appear provided early treatment be adopted. In a neglected case suppuration occurs, and free drainage must be provided by removing a sufficient amount of the sole around the nail hole. The foot is then soaked in hot antiseptic solution and a cataplasm of thermofuge applied. In cases of actual penetration of the sensitive membrane the nail- holes must be thoroughly opened up and similar after-treatment to that just mentioned should be carried out. When pus forms within the hoof, a free opening must be made in the sole, otherwise an abscess at the coronet, followed by quittor, may be the result. In the case of a"blind stab"a very careful examination of the foot is often necessary in order to detect the injury. For obvious reasons the smith who shod the animal should not be entrusted with the examination of the foot, unless under the personal supervision of the practitioner.
In the early stages swelling and tenderness of the withers are observed, and if the infiltra tion be slight and only affecting the skin, simple treatment will succeed in causing absorption of the serum in a few days. When, however, the extravasation of blood or lymph is sub cutaneous the case becomes more tedious, while subfascial extravasation must always be regarded as serious. Suppuration may occur as a complication and extend to the deep tissues, and unless early treatment be adopted the case may terminate in fistulous withers.
According to some authors the fluctuating swelling which not uncommonly results from a bruise of the withers is due to inflammatory action in the bursa mucosa which lies on the superior spinous processes of the fifth to the seventh dorsal vertebrae.
This swelling is found close to the middle line and may appear on one or on both sides of the withers. The contents consist at first of blood-stained serum, but later it alters to an amber-coloured viscid fluid which contains a number of flat or discoid masses. As compared with the swelling due to extravasation of serum or blood, that resulting from bursitis is slower in development and better defined.
Treatment. - In slight contusions of the withers associated with tenderness, swelling, and infiltration rest must be ordered, and the application of a compress of lint soaked in a lotion composed of equal parts of Goulard's extract and water.
In more severe cases a thick cataplasm of thermofuge should be applied and covered by a layer of cotton-wool.
If the case be one of bursitis in the early stages similar treatment is indicated, and when the inflammation is reduced strong tincture of iodine should be applied daily. When this treatment fails a free incision should be made into the swelling, the contents evacuated, drain age provided, the part thoroughly irrigated with an antiseptic solution, and packed with gauze soaked in a liniment composed of creosote 2 drachms, oil of turpentine 4 ounces, and olive oil 1 pint. This dressing should be changed after twenty-four hours. Treatment by aspira tion of the swellings is useless, as the part rapidly refills.
When, as the result of continued pressure from the saddle, an abrasion of the skin or an actual wound results, great care is essential in order to prevent deep-seated infection from occurring. If acute pain is present a cataplasm of thermofuge should be applied for a few days, succeeded by a dry dressing composed of iodo form ounce, boric acid 1 ounce, and zinc oxide 1 ounce. In the case of a wound the part must be explored with a probe, and if the wound extends in a downward direction with in the tissues, a free incision should be made so as to provide drainage and prevent sinus formation. Neglected cases may terminate in fistulous withers. For information on the latter condition the reader is referred to the special article on"Fistulous Withers." Saddle-Galls. - These consist of bruises and sometimes excoriations of the skin or subjacent tissues arising from uneven pressure of the saddle, or pressure on parts unfitted to bear it. The common seats of saddle-galls are: the withers, the middle line of the back, or on either side of the vertebral column, i.e. the surface on which the saddle rests. Similar lesions in the last - named region may be produced by the harness straddle. The nature of the swelling. produced is similar to that described as occur ring in bruises of the withers. The presence of a"warble,"originating from the grub of a variety of warble-fly, not infrequently is the starting-point of a saddle - gall, so also is an acne pustule, when subjected to pressure by the saddle.
The treatment of saddle-galls is to be con ducted on similar lines to those advised for bruises of the withers. In the case of those arising from"warbles"the part must be fomented for a few days and the"grub"then squeezed out.
A not uncommon complication of saddle-gall is the formation of what is known as a"sit-fast,"which is a circumscribed necrosis of the skin surrounded by a circular raw surface which suppurates. The affected skin assumes a tough leathery character, and is very firmly adherent to the subcutaneous tissue.
The only treatment likely to prove successful is to remove the necrosing portions of skin by careful dissection and to leave an open wound which heals by granulation. Unless this radical treatment be adopted, the lesion will persist and give constant trouble.
Collar-Galls. - Are similar in their nature to saddle-galls. They result from a badly-fitting collar, and should be treated on the same lines as those indicated for saddle-galls and bruises of the withers.
(2) Wounds which perforate the pleura and thoracic wall.
In both these classes of wound the usual causes are: injuries from a shaft occurring during a collision, kicks, punctures, or lacera tions arising from a splinter of wood or a sharp pointed stake or from barb -wire, and injuries from horned cattle. The wound may be situated on the side of the chest or may be sustained between the shoulder and the wall of the thorax, or it may penetrate through the caput muscles and enter the cavity of the chest.
For non - penetrating wounds of the thorax treatment must be conducted on ordinary surgical principles, the most important being the provision of efficient drainage and thorough irrigation with an antiseptic solution. The necessity for sutures will depend on the nature and extent of the wound. For an extensive lacerated wound the judicious employment of sutures, provided sufficient drainage be secured, will hasten healing and lessen resulting blemish. In many instances it is difficult to decide at the first examination of the case whether the thorax has been penetrated or not. Common sense will suggest the necessity to avoid the use of the probe in deciding the question, because of the risk of making an opening into the pleural cavity.
When dealing with penetrating wounds of the breast we pointed out the difficulties associated with cases in which the wound extended between the shoulder and the chest-wall. Apart from the immediate dangers such as fatal owing to injured blood-vessels, and from pene tration of the thoracic cavity, the impossibility of securing proper drainage must be considered. Another serious complication which is often associated with wounds of the thorax is injury to one of the ribs which may terminate in a costal fistula. Not infrequently this lesion proves most obstinate to treatment. The direction of the fistula must be ascertained by means of a probe, the part is then freely opened up, and the sequestrum, if present, removed. Thorough curetting is then carried out, and the part irrigated daily with an antiseptic solution. If the disease extends to the inner surface of the rib, treatment is rarely successful.
In every region of the thorax punctured wounds have a tendency to sinus formation, hence it is necessary to watch for the early signs of this complication, and to employ the curette freely when a purulent discharge persists and the interior of the wound shows the smooth lining characteristic of sinus.
Another point worthy of notice is that in the case of penetrating shaft wounds between the shoulder and the thorax or through the caput muscles important nerves may be injured, and various forms of local paralysis may result.
In the treatment of sinuses in this region the risks from haemorrhage occurring as the result of severing large vessels during the surgical procedure must not be overlooked. Recurring haemorrhage is not uncommon from the opera tion wound in such cases, when the animal is exercised, even within two weeks following the procedure, and when not due to infection is probably due to the movement and tension exerted on a vessel in which perfect occlusion by blood-clot has not taken place.
In cases where perforation of the thorax has occurred serious consequences may result, such as injury to the lung, haemorrhage, pneumo thorax, haemo-thorax, pleurisy, and pneumonia.
Pneumo-thorax signifies the presence of air in the pleural cavity. The air may enter through a wound in the thoracic wall, or may come from an injury to the lung. In the case of a wound of considerable size in the chest-wall air is drawn in through the opening during inspiration and ex pelled during expiration, and collapse of the lung usually takes place. In a wound of smaller extent the opening may be partly or entirely closed during expiration, and air is forced into the connective tissue in the vicinity, causing surgical emphysema.
Hcemo-thorax signifies the presence of blood in the pleural cavity. It may proceed from rupture of blood-vessels in the thoracic wall, or from injury to the lungs or even the heart. When extensive haemorrhage takes place death occurs rapidly from asphyxia due to compression of the lungs.
In cases of injury to the lung, a blood-stained discharge from the nostrils is generally observed. In the case of an extensive wound in the thoracic wall, a portion of the lung may protrude from the opening.
Even in wounds of small extent the prognosis must always be guarded, as septic pleurisy may develop.
Treatment. - Bleeding vessels must be liga tured, and the wound thoroughly disinfected and drained as far as is possible, care being taken that the antiseptic fluid does not enter the pleural cavity. The wound should be plugged with a tampon of gauze soaked in an antiseptic solution and the part covered with a thick layer of cotton wool, kept in place by a broad sheet fixed round the chest, and changed daily. Pneumo-thorax does not require any treatment, as in favour able cases the air becomes absorbed. Similar remarks apply to surgical emphysema.
Should septic pleurisy set in, the case may be regarded as hopeless.
The nature and gravity of the injury vary according to the character of the object by which it has been inflicted, and the force of the impact. Thus in some cases an extensive con tusion may result accompanied by extravasa tion of blood; in others the abdominal wall is ruptured, but the skin remains intact; while in others again both skin and muscles are perfor ated, with or without perforation of the peri toneal cavity and prolapse of intestine. In some instances the internal organs are injured.
Dealing first with contusions or bruises of the abdominal wall, we may point out that not infrequently the resulting swelling may be very extensive, and there may be considerable diffi culty in differentiating between it and a case of perforation of the abdominal cavity accompanied by prolapse of the bowel but without involving the skin, which lesion is termed ventral hernia.
As a recent ventral hernia is accompanied by a diffuse swelling, it is advisable to defer giving a definite opinion as to the nature of the case until the inflammatory symptoms have been reduced by fomenting. Even then it is wise, before venturing to make incision, to explore the swelling by means of a small trocar and cannula. If the case be one of hernia the presence of intestine can be detected after the fluid has been evacuated by the instrument. If a large amount of bowel be present the instrument will enter the viscus, and a flow of intestinal contents will issue from the cannula. Having determined that the case is not one of hernia, an incision should be made in the most dependent part of the swelling, and the contents evacuated. The cavity is then irrigated with an antiseptic solution, and a tampon of gauze inserted to facilitate drainage and prevent refilling. In cases where exploratory puncture with the trocar and cannula shows the contents to be blood, it is advisable to defer incision for some days so as to avoid the risk of profuse bleeding, as a ruptured blood-vessel is present.
In some instances an abscess develops as a sequel to contusion of the abdominal wall; the presence of pus is confirmed by an exploratory puncture with the trocar and cannula, and treatment is conducted on the usual lines, viz. free incision, thorough drainage, and irrigation.
Wounds of the Abdominal Wall with Perfora tion of the Peritoneal Cavity. - These from superficial laceration of the skin and subcu taneous tissues to deep wounds involving the various muscular layers forming the abdominal wall. In the treatment of superficial lacerated wounds ordinary surgical principles apply; strong silk sutures are necessary, and careful attention should be directed to providing effi cient drainage. In punctured wounds sutures should not be employed.
In the case of deep lacerated wounds there is a tendency to the formation of pockets between the muscular layers, and in order to prevent accumulation of pus it is necessary to make suitable incisions for drainage. The wound should then be carefully examined, all loose shreds of tissue removed, and bleeding vessels secured; thorough irrigation is next carried out, and finally suturing. It is advisable to suture the deep layer of muscles, first so as to afford support and thus prevent the subsequent occurrence of hernia. Strong silk forms the best suture material, and in carrying out the procedure attention should be directed to pro viding adequate drainage. The skin and super ficial layer of muscles are next sutured, and it is of advantage to insert as well a sufficient number of sutures of relaxation, or tension sutures (see p. 571).
The after-treatment is to be conducted on general surgical principles. Whenever possible it is of advantage to apply a large pad of cotton wool to the wound, and to secure it in position by means of a broad sheet of linen passed round the Wounds of the Abdominal Wall associated with Perforation of the Peritoneal Cavity. - Wounds coming under this heading vary in their character and extent. They may be of the punctured or lacerated type, and may be accompanied or not by prolapse of the bowel, and with injury to the latter or to other internal organs. Every wound which perforates the peritoneal cavity must be regarded as very serious, even though it be a puncture which may appear insignificant at first sight. The frequent occurrence of septic peritonitis in the horse as the result of accidental wounds of the peritoneum is well known. In cattle, on the other hand, the resistance to infection of the peritoneum is well marked. It must be re membered that infection gains entrance at the time the wound is inflicted, and the difficulty of carrying out disinfection and of providing efficient drainage is quite apparent.
In spite of the high mortality from penetrat ing wounds of the peritoneum in the horse treatment should be attempted, except in cases where extensive prolapse of bowel occurs, with injury of the walls of the viscus either caused by the struggles of the patient or by the original accident. Many cases are recorded in which recovery took place although the outlook was anything but favourable.
In cases not associated with prolapse of the bowel the wound should be disinfected as thor oughly as possible, and sutured in two layers, viz. a deep and a superficial. For details see article on"Surgical Technique."Support should be given by means of a large layer of cotton-wool and a linen sheet fixed round the body.
When prolapse of bowel has occurred, and treatment is deemed worth attempting, the extruded intestine should be protected from injury by enclosing it in a clean linen sheet fixed round the body. The horse is then carefully cast on a clean straw bed covered by a sheet, and chloroform administered. Except in cases where the wound is situated high up on the flank it is necessary to secure the animal on his back. The extruded intestine is then carefully cleansed and disinfected, the wound being previ ously packed with sterilized towels, so as to prevent the fluid from entering the peritoneal cavity. If a wound be detected in the bowel itself it must be closed by means of Lembert's sutures (see article on"Surgical Technique"for details of this procedure). If bruised or injured omentum be present a ligature is applied above the injured part, and the latter is excised. The sterilized towels are then removed and the intestine is then returned to the abdominal cavity, and the wound sutured according to the method already mentioned.
Should symptoms of peritonitis arise, viz. high fever, loss of appetite, a"drawn-up" condition of the abdominal walls succeeded by tympanites, a wiry pulse, accelerated respira tions, and a haggard expression of countenance, the animal should be destroyed as hopeless.
In some cases a local peritonitis is set up associated with adhesions between the bowel and the peritoneum in the vicinity of the wound, and generally with a fatal termination.
Treatment. - In the case of contusion accom panied by a serous swelling or a haematoma a free incision should be made at its lowest point, so as to empty the cavity of serum and blood clot and provide drainage. The part is then irrigated daily with an antiseptic solution and a tampon of gauze inserted to keep the sac from refilling.
In the treatment of open wounds of this region ordinary surgical principles should be adopted. Special care should be directed to affording proper drainage. In wounds extend ing in a downward direction there is often con siderable difficulty with reference to drainage, but free openings and counter-openings must be made when necessary, and thorough irrigation carried out. Sutures composed of a strong soft material or of tape must be employed with discretion, care being taken that drainage is not interfered with. The strong fascia which abounds in this region tends to form pockets in which pus accumulates, and these should be slit open with the knife.
Owing to the strong fascia which covers the tibial muscles complications are likely to be associated with wounds of this region, especially punctured wounds. Subfascial cellulitis, exten sive suppuration, and necrosis of fascia may occur, also a portion of the muscular tissue is apt to protrude through the opening in the fascia and to form exuberant granulations. Marked lameness is present, and a tense painful swelling extends up the limb. Unless early and free incisions are made, cellulitis may lead to exten sive necrosis and terminate in general septi caemia. Another complication which may be encountered in cases caused by severe kicks is periostitis of the tibia and even fracture of that bone.
Treatment. - The wound should be carefully examined and proper drainage provided. In most cases it will be necessary to divide the fascia freely in a longitudinal direction, so as to release tension and permit of thorough irriga tion of the wound. When marked swelling and pain are present, fomentations are indicated. Exuberant granulations should be checked by the application of powdered sulphate of copper. Sinus formation is not uncommon as the result of wounds in this region, hence the early evidences of this lesion should be looked for, and if present, a free incision and the use of the curette are imperative to prevent the occurrence of this troublesome sequel.
In some cases a small portion of bone is chipped off the tibia by the injury, and its presence is detected by digital examination of the wound. Until this is removed healing will not take place.
Here we may remark that, in the case of wounds due to kicks on the inner aspect of the tibial region, it is always advisable to place the horse in slings, as owing to the strong fascial covering of this bone a fracture without dis placement may occur at the time of injury and cannot be detected. If the animal is permitted to lie down or is put to work displacement occurs, and the patient will then have to be destroyed, whereas if placed in slings a useful recovery is more likely to follow.
In the case of lacerated wounds, which do not involve the joint, treatment is conducted on ordinary surgical principles. Wounds in front of the hock with much bruising of skin are difficult to heal in consequence of the con stant movement of the joint, and there is a tendency to the formation of exuberant granu lations. In such cases it is advisable to place the animal in slings, so as to ensure rest to the joint; the excessive granulations must be checked by the judicious application of powdered sulphate of copper.