1 Trelut.— Journ. des Vet. du Midi, 1865, p. 4S6.
2 Burck. — Recueil de Med. Vet., 1892, p. 341.
3 Drouet. — Journ. de Med. Vet. 1S92, p. 6S4.
20
306 VETERINARY SURGICAL THERAPEUTICS.
ing weight when the annual is at rest by the use of strong splints or by the
apparatus of Relier. In that region, no suture will resist the weight of
the body. In the majority of cases, a blistering friction on both faces of
the hock will be proper; the walking, difificult at first, will regulate itself
later ; after six weeks or two months, light work will be possible.
Guittard and Furlanetto have observed in cattle the displacement of the
tendon of the infraspinatus. To take place, such accident requires the
rupture of the synovia and of the fibrous bands which hold it over the
torochiter. In the patients treated by Guittard, the moving of the cord
was little shown, the flexion taking place in two steps ; the walking was
difficult and the movements of the leg slow and hesitating. In the obser-
vation of Furlanetto, the accident had occurred on both legs after a violent
effort. At rest, no symptom indicated the injury, but when the animal
raised the leg, the tendon could be seen slipping backwards from the
trochiterian convexity; this displacement could also be produced with
pressure by the hand. Absolute rest and repeated blistering frictions
were followed by recovery in a month.
VI.
SPRAINS OF TENDONS.— NERF-F£RURE.—TEN0SITIS.
Produced by powerful muscular contractions, by efforts which stretch the
tendinous cords and rupture more or less a great number of their constitu-
ting fibres, this affection, observed in all animals used as motors, is very
common in horses. Though a great number of tendons may be " forced,"
the denomination of sprain (effort) of tendons is applied, in ordinary lan-
guage, to lesions of this kind which involve the tendons of the flexors of
the phalanges, their reenforcing bands and the suspensory ligament.
The general belief, that old hippiatres did not know the true effort of
tendons, is erroneous. Lafosse, in his Dictionary, recognizes: (i) the
tendinous alterations produced by bruises (the nerf-ferure) ; (2) the
extension of the tendon, the " distension of its fibres " occurring outside of
all traumatism, during the actions of locomotion. But there was an
error made in relation to the frequency of the tendinous lesions resulting
from traumatic causes ; in most cases, indeed, the subcutaneous inflam-
mations of the tendons of the flexors of the foot have for cause an effort,
and not a bruise of the tendons.
To the expression of " nerf-fe'rure," used then to designate the lesions
which were believed to be of traumatic nature, a wider denomination has
been given, which has been confirmed by use. Indeed to-day both ex-
pressions are indifferently employed.
SPRAINS OF TENDONS.— NERF-FERURE.—TENOSITIS. 307
For a long time, in classical language, " powerful and repeated efforts
of locomotion " were mentioned as causes of those injuries. The mode
of action of these causes has been closely studied of late by Barrier and
Siedamgrotzky. With the assistance of instantaneous chromo-photographs
taken in series, these authors have given a new pathology of the altera-
tions of the disease. It is summarized as follows :
Let us suppose a leg, in which the metacarpal and phalangeal levers
flex normally : at the moment when the leg in motion comes to the
ground, the phalanges are in the long axis of the canon ; as soon as the
resting of the foot to the ground takes place, the phalangeal lever, formed
by the first and second pasterns, operates a movement of flexion upon the
immobile hoof, which has for effect to bring closer to each other the
semi-lunar crest and the sesamoid pulley, and also to relax the perforans.
A slight flexion of the first phalange also takes place on the second, con-
tributing to the relaxation of the perforatus and of the perforans. The
fetlock, no longer supported by the tendons, drops, the sesamoid pulley
slides over the anterior face of the deep flexor, and at this moment the
suspensory ligament is alone preventing the dropping of the fetlock back-
wards. If the reactions are powerful, or if the suspensory ligament is
diseased, it may tear. When a slight downward motion takes place, the
perforatus comes to the assistance of the suspensor ; and, for Barrier and
Siedamgrotzky, the lesions of the superficial flexor takes place at the first
step of the rest of the foot on the ground. On the contrary, the perfor-
ans, more relaxed, is seldom lacerated. But at the time preceding the
raising of the foot, when the leg is in hyperextension, the angle of the fet-
lock is bent forward, the phalanges become upright, the canon is oblique
from forward backward, the perforans is powerfully stretched by the pro-
jecting behind of the sesamoid and glenoid pulleys, and it is the less
resisting — the reenfoixing hand {la bride) — which generally gives way.
It is shown that, according to the new theory, the suspensory ligament
and the perforatus are liable to injuries at the beginning of the period of
rest of the foot, while it is the perforans and its reenforcing bands, the
lateral ligament of the phalangeal joints, the digital ligaments, which are
threatened at the end of the rest, when the leg ready to leave the ground
is in hyperextension. Barrier has specially insisted upon the secondary
" nei-f -fern res y He has shown that the false ankylosis of the first and
second interphalangeal articulations predispose to the lesions of the per-
forans, of the carpal and tarsal bands and of the perforatus ; with Petit,
he has observed that the chronic great sesamoideal synovitis, in prevent-
ing the functions of the pedal pulley, brings on atrophical lesions of the
perforans, well accused, and, by that alone, predisposes to the disease of
the perforatus. In fact, the lesions of the carpal band occur frequently
?o8
VETERINARY SURGICAL THERAPEUTICS.
•with phalangeal periostosis, which seem to have existed before them.
But the primitive " neff-/erure" is often observed in animals with rapid
gait, whose phalangeal structure is free from lesion. In these animals, it
is exclusively produced by the excessive distension of the tendinous cords
under the action of the weight of the body and with the force of the im-
pression. And if phalangeal periostosis predisposes to " nerf-ferure,"
the latter predisposes to the former.
In a paper presented in 1844, before the Soci^t^ Centrale de Medecine
Vet^rinaire, Prudhomme, from a number of observations gathered at the
Alfort clinics, defended the statement
that the carpal band was affected
in two-thirds of the cases, and that the
tendinous lesions were observed only in
the other third. Bouley and all of his
day accepted the opinion of Prudhomme.
For them, the suspensory ligament
was never afifected, on account of its
great elasticity. It was said that,
when the leg returns to rest on the
ground, the force, representing the
weight of the body, transmitted to the
summit of the os suffraginis had for
result to lower the phalangeal lever;
the suspensory ligament, very elastic,
thanks to the muscular fibres that it
contains, could yield without being
injured ; but the tendons, inextensible,
would tear if the reactions were too
powerful, and the thinner band, less
resisting than the tendons, would be
most frequently injured. Carefully
studied observations (Barrier, Siedam-
grotzky, Com^ny, Jacoulet, Poy) have
shown that the alterations of the sus-
pensory ligament are not as rare as
they were thought to be. Indeed,
the lesions of " nerf-f^rure " may occur
in all the desmo-tendinous parts of the cannon, fetlock, and coronet — that is^
upon the suspensory ligament, the perforans, perforatus, the carpal, tarsal
radial and calcanean bands, the metacarpo-phalangeal sheath, the reen-
forcing bands sent by the suspensory ligament to the anterior extensor of
the phalanges, the inferior sesamoid ligaments, the inserting branches of
Fig. 72. — Suspensory ligament, car
pal band, perforans and perforatus.
SPRAINS OF TENDONS. — NERF-FERURE. — TENOSITIS. 309
the glenoid cartilage, the reenforcing aponeurosis of the perforans
(fig. 72).
Which of these lesions is most frequent ? We have just seen the pro-
portion mentioned by Prudhomme. According to Siedamgrotzky, the
lesions of the carpal band are far the most common. Out of eleven cases,
Barrier has found five on the suspensory ligament. According to Jacoulet
and Poy, this ligament would be diseased in 50 per cent, of the cases,
while the carpal band would be only in 12 percent. (Poy). The great
difference between these figures is due to numerous conditions, specially
to the difference of conformation and work of the animals under the ob-
servation of those authors. The professor from Dresden insisted on that
point. He has shown that the lesions of the suspensor and of the inferior
sesamoid were met specially in saddle, hunting or steeple-chase horses and
in fast trotters. Long and weak pasterns, high heels, high heeled shoes,
high action, fast gait with heavy load, misteps, jumps— all of those favor
their development. Alterations of the perforans, of the carpal band, of
the ligaments and bands of the fetlock and coronet are more particularly
seen in heavy draught horses, exposed to violent and sudden hyperexten-
sions. Low heels, feet improperly pared, work on uneven ground, and
heavy loads predispose to them. This we observed in our clinics at
Alfort among the draught horses which form the best part of our patients ;
as in the days of Prudhomme, lesions of the carpal band are those that we
have most commonly to treat. But if the carpal band and the reenforcing
aponeurosis are more commonly affected than the deep flexor, the lacera-
tions of this tendon are not rare. According to Siedamgrotzky, they most
commonly occur between the sesamoid pulley and the glenoid cartilage ;
they are due to the chronic inflammation of the sesamoid, carpal or tarsal
sheath. Barrier, on the contrary, sees specially in those alterations of the
deep flexor, atrophic and degenerating lesions, due to chronic synovitis.
The frequency of the primitive lesion of the perforans is not doubtful ;
however, in many instances, those lesions of the perforans seem to be
brought on by primary synovitis, which prevents the action of the sesamoid
pulley.
Let us add, however, that all phlegmasies of the flexor tendons do not
follow efforts or traumatisms. No more than others, tendinous tissue is
not exempt from inflammatory process of infectious origin (pneumonia,
influenza, rheumatism).
The synnptoms of " nerf-f^rure " are generally well marked. At times
the swelling is large, diffuse, involving the whole leg; at others it is
limited to a portion of the tendon or of the carpal band ; there are cases
where in one day it assumes large dimensions (hemorrhage or extensive
310 VETERINARY SURGICAL THERAPEUTICS.
peri-tendinous infiltration). Tlie seat, dimensions, and condition of the
levelling permit the recognition of the locality of the disease. All that is
necessary is positive anatomical knowledge of the parts.
The prognosis, always serious and often very much so, varies with the
situation, extent, and serosity of the lesions. Sprains of the suspensory
ligament or of the perforatus are less serious than those of the perforans
or carpal band. With complete rupture of the suspensory, recovery may
be sufficiently perfect to permit the animal to resume work. When the
perforans and its band are simultaneously affected, the prognosis is very
serious. Distension, with or without tearing of the metacarpo-phalangeal
sheath, gets well almost always; the line of the tendons remains irregular,
but the lameness disappears. If both tendons are affected at the same time,
recovery is doubtful. Of course, the seriousness of the prognosis varies
with the severity of the lesions and the thickness of the altered fibrous
structure. Again, it has been observed that sprains of the tendon occur-
ring suddenly are often incurable, while the lameness due to a slow, gradual
and progressive inflammation of the tendons ordinarily disappears by proper
treatment. The prognosis is evidently aggravated when there are bony,
synovial or articular lesions already present, as well as by the complications
they may bring on (synovitis, periostosis, knuckling).
The new theories given upon the pathogeny of " nerf-f(^rure " leave the
prophylaxis doubtful and poor. For light legs, douches, massage and care-
ful shoeing are recommended ; thick heeled shoes are only indicated for
low heels. Long bracelets in glove-skin or flannel bandages are also ad-
visable. We must bear in mind that high heeled shoes and high heels
predispose to lesions of the suspensory, and that dry roads and speed are
the worst enemies of tendons.
The therapeutics of the disease includes numerous more or less active
indications ; but their results are uncertain ; quite often, the disease resists,
progresses and brings on complications. A first important indication,
common to all cases, is to place the tendon in conditions which will insure
it the most complete rest. To this end an appropriate shoe will be put
on, and the animal turned loose in a box stall. To immobilize the cannon
and the fetlock, plaster bandages have been recommended. If the in-
flammatory symptoms are severe, it is generally preferable to treat them
by cold water, white lotions, compresses and alum water frequently changed.
Ableitner advises to begin the treatment by the application of compresses
as cold as possible or by irrigation; if compresses are used, they are
changed for the night, by an application of wet clay alone or mixed up
with salt and vinegar. Some prefer cold baths, the patient being placed in
running water, three or four times a day, an hour at a time. Running
SPRAINS OF TENDONS.— NERF-FERURE. — TENOSITIS. 3II
water at 7-8 deg. C. is excellent. This treatment is stopped when the local
hyperthermia has subsided, occurring ordinarily after two or three weeks.
The cooling method is useful, especially at the onset, where there is great
pain and marked tumefaction : it reduces the phlogosis of the tendon,
arrests the interstitial hemorrhages and possesses a real sedative action.
We combine with it light pressure by the use of flannel bandages or very
thin rubber roller.
At a more advanced period, the resorption of the exudate and of the
extravasated blood must be stimulated. To this end, some practitioners
have recourse to mercurial ointment or that of iodide of potassium ;
others, more numerous, use blisters, red ointment, mercurial blisters, strong
liniments. Sometimes several frictions are made in succession and suffi-
ciently apart so as not to irritate the skin too much. In numerous cases,
after three weeks to a month, the lameness disappears. Nevertheless the
tissues preserve an exaggerated sensibility : any efforts may have for result
to start a new inflammation ; hence a rest of several weeks is necessary
after recovery. It is only by degrees and little by little that the anima
can be allowed to resume work.
Most of foreign authors prefer damp heat 2S\.^ pressure to blisters. Moller
recommends to wrap the leg in moist and warm wadding held in place by
a flannel bandage. The dressing is to be renewed every four or five hours.
This method has a remarkable action against the suffusion and paratendi-
nous infiltrations ; it prevents the secondary indurations. Ableitner, hav-
ing obtained only unsatisfactory results with vesicating preparations, has
given them up. After cooling applications used for a certain length of
time, varying according to cases, he, like Moller, uses damp and warm
compresses. The beneficial effects of this treatment, used when the in-
flammatory phenomena have subsided, are incontestable. Yet, blisters
count also many numerous successes ; they offer the advantage of being
easier to apply and demand less time. The secret of success depends,
however, on the long-continued rest given ; it is principally when the
animal resumes his work too early that the trouble returns, that the inflam-
mation of the tendon becomes chronic and that the leg knuckles.
If cooling applications, damp heat or blisters fail, we must have recourse
to fnassage, with or without hot affusions, or to cauterization. Recovery
can be completed by massage, in covering the region with a sheet of
parchment. The fingers, coated with vaseline, make light frictions on
that sheet from downwards upwards in the direction of the lymphatic cur-
rent ; in operating methodically the massage is done without changing the
direction of the hair. These applications will be made twice a day,
fifteen minutes at a time, and the treatment continued for several weeks.
In serious cases and when massage has given only incomplete results, cau-
312 VETERINARY SURGICAL THERAPEUTICS.
terization may be used. Firing in transverse lines, penetrating points or
in needles is preferred. Seldom is the superficial points cauterization, of
old technic, now used.
Some practitioners begin the treatment of light lesions by moist and
hot compresses. In serious cases, others use astringents first, and cold
for a week ; or, again, unmindful of the pain, make a vesicating friction
(spirit of turpentine loo, cantharidis powder loo, euphorbium powder
TOO, vaseline 400), and if necessary repeat it : when the scabs are off.
they cover the region with a coat of ointment of iodide of potassium and
immobilize it with a plastered bandage, which is changed after ten 01
twelve days. If some induration of the tendon remains, they complete th«
resolution with hot compresses and massage.
Hunting, in the Veterinary Record, has on several occasions recom-
mended the following treatment, which has given him good results : In
day time, application of a pad of cotton-laine kept in place with a linen
bandage ; during the night, pressure with a flannel roller ; besides massage
and walking exercise. When the disease is chronic, a plastered
bandage.
For old tendinous sprains, or those formed slowly, whose lesions become
marked gradually, as well as in all cases where the local sensibility and
hyperthermia are limited, cauterization had better be used at once.
When the disease is relatively recent, not subordinated to bony lesions
and free from comphcations, good treatment gives a good proportion of
successes. By his method, cold, moist heat and cauterization, Ableitner
has obtained the following results : Out of 287 cases, 263 recoveries
(among which a few incomplete), 24 failures. For 125 horses, recovery
was obtained in one month; for 97, in about two; for 41 it required a
little more than three.
A certain number of cases of tendinitis resist the most rational treat-
ment. Either the horse remains somewhat lame or again is entirely un-
able to work. Then tttedian neurotomy is indicated. Peters, Moller,
Goldmann, Blanchard, have shown the advantages to be derived from it
in old lesions of tendons, which have resisted local treatment. To per-
form it, the animal is cast on the lame side, the lame leg is drawn forward
with a rope or carried in that position with the side-bar hobbles, and the
other upper fore leg secured above the hock of the corresponding hind
leg, when the region to be operated is well exposed.
Then, exploring the internal face of the elbow with the fingers, by care-
ful motions from forward backward and vice versa, the thick cord formed
by the median nerve is readily detected (fig. 73). Oblique downwards
and backwards, it is a little more superficial than the radial artery, with
SPRAINS OP TENDONS.— NERF-FERURE.—TENOSITIS. 313
which it passes, below the elbow, under the radius and the mass of the
flexors muscles.
The skin shaved and disinfected ; according to the quantity of cellular
tissue and the thickness of the muscular layers, an incision 4 to 6 centi-
meters long is made, on the course of the nerve, on a level with the inferior
part of the articulation or immediately behind the superior extremity of
the radius. A second stroke of the bistoury divides in the same direction
and with the same length the sterno-aponeuroticus. If some hemorrhage
occurs, it is stopped with affusions of boiled water or by plugging, torsion
or ligatures being seldom required. The edges of the musculo- cutaneous
wound kept open with spreaders, the antibrachial aponeurosis is exposed
with a peculiar nacreous yellow coloration. Feehng the bottom of the
wound with the finger, be sure that the nerve is situated well on the line
of the incision ; in the contrary case, bring it there in carrying the leg
slightly forward and backward. Then the aponeurosis is divided, or,
Fig- 73-— Median neurotomy.— N, Median nerve ; A, radial artery ; V, one of
the posterior radial veins.
better still, a small incision is made through it on the lower -angle of the
wound, and a groove director introduced into it from downwards upwards ;
the bistoury, guided by the director, incises the aponeurosis from inwards
outwards. This incision can be made also with a blunt bistoury. By
cutting with the scissors a semi-elliptic piece of each edge of the aponeu-
rosis (Moller) the median is more widely exposed.
The nerve is isolated by dissection of the connective tissue or by tearing
it with the end of the director ; the vessels and radial artery are carefully
avoided. Should they be wounded, secure them with an hemostatic for-
ceps,
314
VETERINARY SURGICAL THERAPEUTICS.
The nerve being free, it is raised with forceps, an aneurism needle or a
piece of thread passed first underneath it, and a piece of it (about 2 cen-
timeters) is amputated, — the division of the nerve being made first at the
upper end of the incision. The wound is then washed with boiled water ;
the clots of blood that it may contain are cleaned away ; the edges of the
wound are dusted with iodoform or covered with iodoformed vaseline,
brought together with three stitches, including skin and muscle, and coated
with collodion. Cicatrization may occur by first intention. If suppura-
tion takes place, the stitches are cut off, the wound cleaned and treated
antiseptically. It will be closed in about two weeks.
Fig. 74. — Neurotomy of the sciatic— A, aponeurosis of the leg ; C, subcuta-
neous cellulo-adipous layer ; N, sciatic nerve.
This operation permits some animals to be used, for a variable length of
time, which had remained very lame notwithstanding repeated cauteriza-
tion ; still the operation cannot be considered as able to render the " im-
mense " services claimed by some enthusiasts.
Sprain of the flexor tendons is rare on the hind legs. Their treatment
is the same as for those of the anterior extremity. Cool applications,
moist heat, blistering or firing should be used. Should the lameness per-
sist, and work is impossible, neurotomy of the sciatic can be used. (Rous-
seau, Benjamin, MoUer, Vogel).
SPRAINS OF TENDONS. — NERF-FERURE. — TENOSITIS.
315
The operation is made on the inner side of the leg, a hand's-breadth
above the point of the hock. The horse laid on the lame leg, the super-
ficial leg is secured on the corresponding fore leg, and the region to be
operated is thus exposed. On the selected place the great sciatic is
situated almost immediately under the tibial aponeurosis (fig. 74). The
skin shaved and disinfected, make, 3 centimeters in front of the tendo
Achillis, an incision 4 or 5 centimeters long, parallel to it. If there is
hemorrhage, stop it as usual. Divide the tibial aponeurosis in the same
direction and with the same length. Moller recommends to excise a
Fig- 75- — Colt affected with knuckling on both fore legs (Moller).
semi-elliptic piece of the aponeurosis on each lip of the wound. To ex-
pose the sciatic nerve, it is good to use the groove director ; once isolated,
a piece of the nerve (2 centimeters) is inserted with the same care as
for the neurotomy of the median. The hemorrhage stopped, the wound
is washed and closed by two stitches of suture.
The cares required are those of all superficial wounds of operation :
antiseptic lotions twice a day, vaseline or antiseptic powder ; cicatrization
jS complete in two weeks, Benjamin has observed after this operation
3l6 VETERINARY SURGICAL THERAPEUTICS.
he elongation of the tendons, the fetlock touching the ground ; we have
seen the same accident, and one sloughing of the hoof. Sciatic neuro-
tomy seems more dangerous than median. This difference can be ex-