ations, less commonly after ovariotomy, the operation for inguinal or for
umbilical hernia, caudal myotomy, amputations of the tail, removal of
tumor, firing, the application of a blister, puncture of the caecum.
Insignificant superficial traumatisms are sufficient for its apposition ;
sometimes it follows venesection, a simple cutaneous puncture, even
from an hypodermic injection.
In females, more commonly in cows, it is observed after parturition
or abortion {puerperal tetanus). Most of the cases related in bovines
have been observed in cows after difficult labor, wounds of the vagina,
uterus, or imperfect delivery.
In young-borns, principally colts and lambs, tetanus may be a com-
plication of umbilical phlebitis, especially when it is purulent, gangrenous
or septic (tetanus of new-borns). In lambs it is not rare to see the
disease become enzootic.
Tetanus generally makes its appearance from the third to the fifteenth
day of the wound, sometimes the second, or even the first ; at others
more lately, during the third or fourth week, in some cases only when
the wound is already cicatrized. The difficulty in moving, stiffness of
the extremities, extension of the head on the neck, are the first troubles
noticed. Sometimes the contractions are generalized from the start,
in others they began on the head and neck, on the hindquarters, or the
yiiuscles in the neighborhood of the wound and gradually extend to
1 88 VETERINARY SURGICAL TIIERAFEUTICS.
the trunk or tlie extremities. The nostrils are dilated, lips contracted,
ears erected and stiff, eyes partly covered by the nictitans, tail more or
less elevated and stiff. Contraction of the masseters — trismus — is
more or less marked, prehension of food and mastication are difffcult
or impossible ; saliva slobbers from the mouth. In most patients the
muscles of the tongue, pharynx, and larynx are also contracted.
Ordinarily the neck is elevated and the dorso-lumbar regions slightly
ciirved downwards {opisthotonos) ; in other cases the vertebral column
forms a straight horizontal line {orthotonos) ; exceptionally it is curved
one side or the other (^plcnrosthonos). Contractions are continuous, with
spasms at certain times. Various causes of excitement produce in-
creased convulsions. Respiration is difficult, more or less rapid ;
during the access it increases three or four times the normal number.
At the outset, circulation is not disturbed, nor in the periods of calm, but
it increases at the time of the access. Temperature remains normal or
only a few tenths higher in benignant cases ; in general serious cases
are characterized by a rise of two or three degrees ; however, they may
also develop without great elevation of temperature. In the few hours
preceding death it may rise to 42° C. and above. However, numerous
causes exist to produce this hyperthermia.
In acute tetanus the invasion is rapid, the contractions are severe
and generalized, trismus great, prehension of food and deglutition
impossible, respiration very difficult and accelerated, pulse quick,,
paroxysms frequent, temperature elevated.
Death occurs generally from the second to the fourth day.
In chronic tetanus, incubation is generally longer, contractions slight,
trismus weak, disphagia little marked, respiration and circulation not
much disturbed, paroxysms rare, temperature normal or raised only a
few tenths. There are cases where this condition remains stationary
for two or three weeks ; thus by degrees the contractions subside and
disappear ; in others the disease presents alternate conditions of im-
provement and of relapse until resolution takes place ; finally, sometimes-
after a variable length of time, most ordinarily towards the end of the
first week, the severity of the contraction increases, tetanus becomes
acute, and death takes place within a few days. Even when the stiff-
ness seems mild, the disease may last for weeks, and an increase, a
relapse or complications ought to be always looked for. Pneumonia by
foreign bodies is possible during the entire disease ; it may occur during
convalescence, the fourth week, or even the second month.
The principal symptoms of tetanus are the same in all species. In
cattle the movements are less rapid than in horses and the contractions
are less severe. On the contrary, in sheep and dogs the evolution of
the disease is rapid. Death ordinarily takes place from the sixth to.
the eighth day.
TETANUS. 189
Some authors believe that the mortality is not as high in our day as
in the past, that acute cases are less common, which would be due to an
attenuation of the pathogenous agent, or a more rational therapeuty.
But in horses it seems to have preserved all its severity; only that
which is observed is the predominance of acute or chronic cases, accord-
ing to years or periods of times.
The diagnosis of tetanus offers no difficulties. In some light cases,
one might, at first sight, mistake it for laminitis ; but the generalized
stiffness, the tension of the muscles, the attitude of the conical rod and
of the head, the protruding of the membrana nictitans upon the eye,
and the tail stiff and extended, are signs permitting the differentiation.
In all species of animals, the prognosis is most serious. In horses,
the average mortality is 751^. Out of 30 horses affected with tetanus in
our wards, from 1888 to 1894, 21 died — a mortality of ^o^fc. Seventeen
of those affected with acute tetanus died : i the day of its admission,
4. the second, 4 the third, 3 the fourth, 2 the fifth, i the sixth, 2 the
eighth. Four others, in which the symptoms were less marked, died :
I the tenth day, i the thirteenth, i the twentieth, i the twenty-sixth.
Sudden attack, rapid extension of the contractions to all the muscular
groups, complete trismus, sweating, great acceleration of respiratioti
and circulation, and hyperthermia, are manifestations to be dreaded.
The greater the dyspnoea, the more death is to be feared. A recumbent
position is a bad sign. Almost all creatures affected with tetanus that
dropdown in a fit or through exhaustion, die quickly. At all periods of
ihe disease, but especially in the first, death may be the consequence of
pneumonia by foreign bodies. After the second septenary, the chances
»'or recovery are great.
The prophylaxy of tetanus includes: 1st, the means belonging to
surgery and hygiene ; 2d, the injection of antitoxic serum. With the
first, a treble indication is fulfilled : prevent the infection of the wounds
of operations, disinfect accidental traumas, protect the operated and
Ihe wounded from the effect of cold.
Animals operated upon should be protected from tetanus by observ-
ing the rules of asepsis and antisepsis. The lips of aseptic wounds
should be held together by sutures, covered with a dressing, or occluded
with an impermeable substance (collodion); the latter dressing should
be made at long intervals, as this renewal exposes the wounds to in-
fection. Wounds of operation soiled during the interference should be
minutely disinfected ; if they are left open and exposed, they should be
frequently dressed with antiseptic solutions. .Ml suspected wounds,
accidental or of operation, soiled by matter ordinarily tetaniferous
(manure, ground), should be cleansed with a warm antiseptic liquid
(a strong solution of carbolic acid), carefully washing every part
and corner of them ; all foreign bodies that they may contain should
IQO VETERINARY SURGICAL THERAPEUTICS.
be removed, without disturbing the parts any more than necessary,
without enlarging the wound, and without exeresies. The bistoury,
curette, or cautery should be used only in cases where portions of
tissues are seriously bruised, crushed, and destined to gangrene, or
are already necrosed. The purification of the traumatic center should
be completed by a fresh irrigation, by balneation, or by atomization,
according to the case. Afterwards it should be covered by a protective
or isolating coat (carbolated or iodoformed vaseline). Finally the
patients shall be removed from etiological influences which promote
the action of tetanigenous elements: cold, rain, dampness. Under
ordinary circumstances, veterinarians cannot realize in their practice
the conditions of asepsis necessary to prevent tetanus entirely, but it
is always possible to avoid those tetanic enzootia, which are so com-
monly reported ; for this, it is sufficient to take stringent measures for
disinfection, and see that there is perfect asepsis of the hands, instru-
ments, and objects which come in contact with the wound.
Injections of antitetanic serum give a temporary immunity lasting at
least fifteen days, but ordinarily remains from three to five weeks.
First advocated for man by Vaillard, recommended by Nocard, they are
absolutely efficacious, providing they are repeated at intervals of ten
days, as long as tetaniferous or suspect centers are existing. Out of
more than 2,000 wounded or operated which have been immunized by
this serum, only one took lockjaw. In the practices where these facts
have been observed and during the time the serum was used, nearly
200 cases of tetanus were observed in horses that were not injected
(Nocard). To wounded or operated large animals, as early as
possible an injection of 10 Cc. is made under the skin and renewed
after ten days. When the trauma is extensive, complicated, sup-
purating for a long time, it may be necessary to make two or three
other injections at intervals of twelve or fifteen days. With small
animals, two doses of 5 Cc. are made. As long as the blood contains
a sufficient quantity of antitoxine, the animals are protected. The
serum is delivered in vials of 10-20 Cc. ; it keeps its properties for
several months. Let us remark that preventive serotherapy is practi-
cally applicable only to animals affected of wounds of operation or by
accident, which have a' certain gravity. But tetanus occurs quite
frequently after slight wounds of the extremities, or after lesions which
are overlooked.
Among the numerous curative treatments recommended, including
the most recent, none has shown a great superiority over the others or
succeeded in establishing itself. There have been recommended as
surgical means, bleeding, cauterization, free excision of peritraumatic
tissues, amputation, neurotomy, neurotripsy, polyneurotomy, stretching
of nerves, even castration for horses; and cases of recovery imve
TETANUS. 191
been mentioned to prove the efficacy of all these treatments. But the
facts reported were only those of benign cases of the slow form of infec-
tion of chronic tetanus, which, as Teissier says, recovers ivith everything
and often loithoitt anything. Knowing the nature of the disease and the
disposition of the tetanigenous agents on the wound, the only means
which deserve any confidence are cauterization, excision and amputation.
The favorable results obtained by amputation in the case of mankind
(Larrey, Berger), and the affirmation of bacteriologists that the Nicolaier
bacillus remain confined to the vicinity of the wound of inoculation, have
induced us to try, without very encouraging results, the free incision
and cauterization of the infected region, with a certain number of ani-
mals suffering from traumatic tetanus, which have been under our treat-
ment during the last few years. In a general way, the free removal of
the tissues of the peritraumatic zone — eradication — has shown itself
much less advantageous than the simple disinfection and careful
cleansing of the virulent wound. For man, Verneuil objected to the
eradication of the toxic center, when it necessitates mutilation ; and
Chauvel opposed to this treatment the experimental results of A^ail-
lard, proving that the extirpation of a m.uscle in which a few drops of
tetanic poison have been injected does not prevent the development
of the disease. The rapidity of diffusion of the toxic agent goes
counter, generally speaking, to free ablations.
As to the medical treatment, it counts agents without number, some
harmless, others somewhat injurious, all of an indifferent value. Those
that have been principally used are opium and morphine, belladonna and
atropine, hyoscyamus, stramonium, alcohol, ether, chloroform, chloral,
curare, Calaborbean, eserine, jaborandi, and pilocarpine, spirits of tur-
pentine, with oil, iodine, salicylic acid, and quinine in intratrachial in-
jections, bromide and iodide of potassium, and inhalations of oxygen,
bichloride of mercury and phenic acid in intravenous injections,
bromhydrate of quinine and antipyrine in intratrachial injections, and
finally the antitetanic serum in cutaneous or intravenous injections.
All those agents have given more failures than successes. None can
overcome the tetanic spasm. Medicamental substances, however,
which reduce the hyperexcitability of the spinal cord have a beneficial
action and attest towards recovery : two especially, chloral and mor-
phine, are advantageous and constitute the medicaments to be preferred.
Morphine has the disadvantage of provoking phenomena of excitement
in the horse; it should be used only in small repeated doses ; in large
or even medium doses, it has always shown itself to us more injurious
than beneficial.* Chloral can be administered through the rectum by
intravenous injections. If it is introduced into the digestive canal it
* C. D. Norris claims to have had good results by subcutaneous injections of sul-
phate of eserinic and dilute hydrocyanic acid. (Am. Vet. Rev. Vol. 15, p. 3S6.) (T.)
192 VETERINARY SURGICAL THERAPEUTICS.
must be well diluted. We i^refer giving it in lavements, 100 to 150
grammes a day and in solution of i in 50. The intravenous injections
(Poitevin, Poret, Jacobin) must be considered as a last resource ;
20 or 25 grammes of chloral are injected in the jugular, according to
patients ; often a temporary relief is obtained ; the injection is repeated
when the contractions return.
Let us present a curative treatment, according to the data already
established.
Whatever may be the form of tetanus, one must, first of all, look for
the wound, which has served as means of entrance to the bacilli.
Cleanse it well with hot water, evacuate the recesses of the wound,
disinfect it with care with strong antiseptic solutions (sublimate in acid
solution, phenol, tincture of iodine or chloride of zinc), remove all
foreign bodies, if there are any; in some cases enlarge the wound,
excise the grangrenous or necrotic parts as as well the fungous granula-
tions. After another antiseptic irrigation, the wound should be dusted
with iodoform and covered with vaseline or wadding. If there are
several wounds all should be treated with the same care. Some fist-
ulous or anfractuous wounds require the ablation of a wide and thick
layer of tissues to remove the toxi-infectuous center.
The antitetanic serum has not given the results that were first ex-
pected. Excellent to grant immunity, it is ordinarily powerless as soon,
as the poison has reached the nervous system. However, it may avert
the increase of the manifestations by presenting new quantities of toxine
reaching those centers.
The wounded should be put in a place where the temperature will
be moderate and regular, and protected from exciting causes, noise, or
strong light; if possible, this place should be isolated, spacious, dark,
with an abundant bedding of supple and short straw, to permit the
motions of the animal without his legs being entangled, as they might
be were the straw long. Cut straw may irritate by pricking the skin o£
the extremities. A box stall is always to be preferred, with the window
covered with a thick blanket, to make it as dark as possible. To be
alone is sometimes a cause of uneasiness to horses ; they get impatient
and restless. Instead of placing them alone, it is better to have them
standing in their own stalls, giving them quiet neighbors. Contagion
might not be impossible for these, if they had wounds on them on
which tetanic pus should be accidentally deposited; but direct con-
tagion is an exception, and can be prevented by simple means.
The opening and closing of doors, surrounding noises, strong light,
or touching with the hand, may promote exacerbations ; frequent visits
should be avoided ; changes, examinations, and explorations are useless ;
no one except those who care for the patient should approach it. Rest,
quiet, darkness, soothe muscular hyperexcitability ; the attacks occur
TETANUS. 193
further apart, the contractions diminish, the respiration is easier.
During summer one should see that the animal does not suffer from
excessive heat ; in winter, he should be sufficiently covered to keep the
skin slightly moist ; if perspiration is too abundant, blankets must be
changed. In severe cases, where there is danger of falling, slings are
advantageous.
The patient should be sustained with substantial food. It should
receive liquid food especially (mashes, farinaceous drinks, hay tea,
milk, soup), grass and cool water at will. If trismus and dysphagy do
not allow the swallowing of these substances, nutritive rectal injections
should be given four or five times a day. It is sometimes necessary
either to empty the rectum, or to help micturition, by pressing upon
the bladder through the rectum, or by the introduction of the catheter.
Besides this, injections of serum shall always be indicated to destroy
the toxine which still penetrates in the blood. As medications,
one should employ agents which can be used with food, drinks,
or lavements, or in hypodermic injections (purgatives, alkalines,
antiseptics, chlorhydric acid, iodine, morphine, chloral). The admin-
istration of drenches is sometimes impossible on account of the
trismus ; for us, these are always forbidden on account of the excite-
ment they give rise to, the danger of their passing in wrong directions,
and the severe complications following. One may, by giving daily
100 or 200 grammes of sulphate of soda in drinks, prevent constipation,
and 2 to 6 grammes of aqueous extract of belladonna, or opium, will
quiet the nervous irritation (Trasbot). In acute cases the hyperexcit-
ability should be controlled with chloral, administered by injections
through the rectum, and morphine in small doses by hypodermic in-
jections.
13
CHAPTER IV.
GRANULATIONS— CICATRICES.
In the cicatrization of traumas with loss of substance, as soon as the
granulations have reached the level of the skin, their growth generally
ceases; they become even; their structure is more dense ; connective
structure develops in them ; blood vessels are obliterated ; cellular elements
disappear by regression ; the purulent secretion diminishes more and more ;
and at the periphery of the wound, at the limit of the cutaneous borders
and of the newly formed tissue, there appears a slightly projecting circle,
a kind of reddish band, which progresses slowly toward the center of the
cicatrix, followed at a short distance by a very thin band of darker color.
This new layer, which ordinarily spreads evenly on the innodular tissue
from the periphery to the center of the solution of continuity, is the
regenerated epidermis. Sometimes in large wounds, when small pieces
of skin with the Malpighian layers have been preserved, the new forma-
tion of the epidermis takes place at several points. At the same time
that the cicatrization advances, the tumefaction and the morbid sensibility
gradually diminish and disappear.
But the repairing process does not always follow this normal progress.
Often, especially with extensive lesions, the cicatrization is disturbed, the
new tissue assumes a peculiar aspect or character, due to various pathologi-
cal conditions of the granulations.
Sometimes, because of some disease or some general cause interfering,
the granulation relaxes and stops before the wound is entirely filled. It
must be stimulated by exciting preparations, strong antiseptic solutions or
superficial cauterization with the nitrate of silver.
More commonly, the granulations rise quite high above the cutaneous
layer, and are exuberant. Among horses and cattle, it is quite common
to observe, especially on wounds of the extremities, cicatrices more or
less protruding, which in their earlier stages can easily be controlled by the
use of drying powders, styptic applications, pressure, or dressings with
astringent preparations (tannin, white lotion).
Fungous granulations protruding much above the level of the skin,
and sometimes covering its edges, assume an aspect resembling that of
194
GRANULATIONS— CICATRICES. I95
mushrooms. Ordinarily soft, friable and bleeding, they secrete in various
quantities a thin and serous pus. They are almost always due to local
causes : sometimes the fungosities conceal or contain foreign bodies
(granular wounds) ; at others the cutaneous edges are indurated, callous,
or loosened for some distance ; or again the edges are irritating to the
granulations by their constant motion. In some circumstances, the cause
of the anomaly cannot be made out. When the cause is established, it
is simple to obtain the cicatrization by extending to it the treatment
required by that cause ; but it is necessary sometimes to excise the granu-
lations or to destroy them, either with caustics (alum, nitrate of silver) or
with the actual cautery.
Erethistic granulations are the seat of a well-marked morbid sensibility :
the slightest touch upon it gives rise to sharp pain, combined sometimes
with an alteration of the nervous fibers of the edges or of the bottom of
the wound. Ordinarily, the peritraumatic zone is much inflamed. The
anomaly may be due to the presence of foreign bodies ; and their re-
moval, the application of warm compresses or balneations, analgesical
vaseline, iodoform or cauterizations slight and repeated are ordinarily
successful. In some cases it is necessary to cauterize the entire granular
layer, or the most painful parts of it.
One observes sometimes, in cicatrizing wounds of all animals, the in-
fectious complication described under the name of diphtheria of granula-
tions. It is a mild form of hospital gangrene. From one day to the
next, the surface of the wound is covered with a diphtheritic yellowish
gray layer several millimeters thick. Under this false membrane the
granulations are softish, dark red in some places and yellowish or grayish
in others. When this complication occurs on recent wounds not entirely
protected by a granulating layer, it always is complicated with a serious
lymphangitis of rapid development. Sometimes the granulations disinte-
grate and ulcerate, and a putrid detritus collects on the wound. We have
observed this affection in horses and in dogs. Hoffmann has seen it in
the horse ; Moller in dogs and birds ; others have mentioned seeing it in
cattle. Cultures, on gelatine and gelose, of the products taken from the
surface of the granulations have given us colonies of streptococci.
This diphtheritic condition of the granulations is treated by a minute
disinfection of the wound with warm solutions of corrosive sublimate, car-
bolic acid or chloride of zinc. When it takes place upon an extremity,
balneation in an antiseptic solution at 45-50° and iodoform dressing are
very advantageous, especially if there is complication of lymphangitis.
If the trouble resists, the surface of the granulations must be destroyed
with the cautery or removed with the curette, and the wound must be
dressed with iodoform.
196
VETERINARY SURGICAL THERAPEUTICS.
The tissue of new formation which repairs solutions of continuity and
losses of substance is at first, we have said, exclusively formed of embryonal
elements and blood vessels ; as its organization becomes more complete it
sustains a retraction which gradually increases : the
hair, follicles, sudoriferous and sebaceous glands are
not reconstructed.
Cicatrices whose development is complete are glab-
rous, dry, ordinarily indolent, smooth or slightly rough,
marked with ridges and fissures little developed, some-
times with bands and grooves running in various di-
rections. With some there remains, even for a long
time, a great sensibility. When they are situated in
regions where there are frequent motions (those upon
which the harness is) or on the tissues of the foot,
they interfere with work and even prevent it, or impose
a more or less active interference, such as the removal
of the innodular part, the thinning of the new hoof,
or neurotomy. When the pain seems to be due to
the adherence of the cicatrix to the tissues underneath,