plained : the section of the sciatic above the hock removes all sensibility
in the lower part of the leg, while that of the median leaves a certain
amount of it, due to the cubital nerve, which co-operates to the formation
of the external plantar.

VII.

KNUCKLING.

Knuckling is congenital or acquired, essential or symptomatic. It is
specially common on the fore extremities. In adults, the deviation of
the fetlock is either essential, connected with tendinous lesions, or again
symptomatic, secondary to one of the numerous painful diseases of the
anterior extremity ; more particularly those of the feet or of the digital
region. Young horses are subject to an essential form of knuckling, or-
dinarily differently marked on both legs (fig. 75).

The remarkable extensibility of tendons in colts permits the easy cure
of this knuckling of youth. Numerous examples of it are recorded (Ehrle,
Friebel, Brunet, Ostertag, Easy, MoUer). When the deviation of the
phalanges is not great, the cutting away of the heels, an elongated toe
shoe raised at its point, will be sufficient, if the animal is turned loose in
a field. If the ailment is more marked, it may be reduced with the hinged
splints, by which the fetlock is pushed backwards. The orthosome of
Brogniez is useful here (fig. 76).

In the Recucil oi 1881, Brunet has described an apparatus which has
given him good results. It is applied as follows : A shoe, the branches of
which are elongated backwards and united by a crosspiece, is put on the
shoe. From the crosspiece rises a metallic upright which carries a plate
of sufficient height to reach the back of the knee in a fore leg or the
chestnut of a hind leg, and about 2 centimeters in thickness. This plate,
hollowed and padded, carries two leather straps, one near the superior ex-
tremity of the canon, the other a little above the fetlock ; they allow
regulated traction on the deviated levers and permit of them being grad-
ually brought back in their normal position. The filly treated by Brunet
was much knuckled on the left fore leg and rested on the toe ; she was
straight in twenty-two days (no relapse). Another was affected on the right
hind leg to such extent that the entire anterior face of the wall of the foot
rested on the ground, from the toe to the coronet. In five weeks the
animal had recovered, and her fetlock was straight.



ICNUCKLINCJ.



317



The application of splints and plaster dressings have also been recom-
mended after a forced extension of the phalanges on the canon, made
while the animal was secured in cubital position. Recovery has been
obtained in several weeks. The dressing has to be changed at various
times, as the leg resumes its proper function. Tenotomy of one or both
legs is performed, if the other treatments fail. Generally the section of
the perforans is sufficient.

Knuckling of adults is a common complication of tendinitis and of the




Fig. 76. — Orthosome of Brogniez (Peuch and Toussaint).

various affections met with in the inferior regions of the extremities.
According to the cases, the tendons are simply retracted, or, on the con-
trary, inflamed and swollen. The fetlock is carried forward so much
more if the lesion is serious and old. The first indication of a rational
treatment consists in treating the cause: tendinitis, navicular diseases,
seams, exostosis. When the retraction is slight -in cases of knuckling of



3i8



VETERINARY SURGICAL THERAPEUTICS.



the first degree — and the actions of the animal are again free, the trouble
may disappear by exercise. If already the deviation is more accused, the
overtaxed bony levers become inflamed ; the tendons, carrying no longer
their share of the weight of the body, retract more and more, and thus,
generally speaking, tenotomy must be resorted to. By turn highly recom-
mended and again objected to severely, this operation often gives imme-
diate and remarkable results, but quite as often the results are far from
satisfactory. Exposed tenotomy is no longer performed. The subcutane-
ous method is used in our day. The animal is first shod properly. If
the perforans alone is to be divided, the foot, with the heels pared away,
should have a shoe with an elongated toe, so as to throw the weight of the
body upon the posterior parts of the foot. In double tenotomy, to avoid
the dropping of the fetlock backwards, the orthosomes of Brogniez and of
Defays, or, better, the immovable bandages (Didot, Delwart), are recom-
mended. (See Tendinous Woinids^

Whether a fore or hind leg is to be operated, the animal is cast on the
opposite side, the leg left in the hobble. A rope is placed round the foot,

another above the knee or
the hock. The skin is wash-
ed, shaved, asepsized on the
middle third of the external
face of the canon. Two in-
struments, straight and curv-
ed tenotomes, are necessary.
Instead of the straight teno-
tome, a narrow scalpel or
bistoury can be used (fig. 77.)
Placed in front of the knee
or near the hock, by careful
exploration of the tendons
the separation which exists
between them is readily made
out ; when the tendons are
surrounded by indurated tis-
sue, this separation is not so
readily made out. On the
hind leg the middle of the
canon is the spot of elec-
Fig. 77.— Knuckling and phalangeal perios- tion, on the fore leg a trifle
tosis. (From a photograph.) above it(i or 2 centimeters.)

In the first step of the operation, the right hand, holding the straight
tenotome, is thrust between the tendons undl the point is felt under the




RNUCKLlNG. 519

skin of the opposite side ; while there slowly pull it away from the tract it
has made ; the curved tenotome is then introduced in its place and its
sharp edge brought in contact with the perforans. Taking a point of
support with the thumb on the anterior face of the canon, the section of
the tendon is made by a very limited sea-saw motion of the hand, while at
the moment of the division the assistants are pulling on the ropes at the
foot and at the knee in different directions, that of the foot forward, the
other backward. With care, the skin is seldom cut more than the point
of introduction of the tenotome. If double tenotomy is performed,
divide the perforans first, then pass the tenotome behind the perforatus
and divide it as the perforans was. The division from forward backwards
exposes a large incision of the skin ; clean up the region, close the cuta-
neous wound with collodion and apply a slightly compressive bandage. A
bloody extravasation fills up the space left between the extremities of the
tendon, the surrounding connective tissue becomes inflamed and a piece
of embryonic tissue is soon formed. The swelling, first warm and painful,
gradually diminishes and indurates. After two months, the newly formed
tissue has obtained sufficient resistance to allow resuming work. After-
wards, like all cicatricial tissue, a more or less marked retraction takes
place and for a long time it is the seat of an abnormal sensibility which
interferes with the motions of the animal or lames the horse.

The accidental section of one of the nerves of the canon is of no im-
portance ; wound of the artery, very rare, demands the application of a
compressive bandage. More serious is the opening of the carpal, tarsal
or sesamoid sacs — which can occur only with those lacking anatomical
knowledge. Simple cleanliness prevents the suppuration at the traumatic
center.

As remarked by Bouley, the work of cicatrization of one or the other of
the tendons is always followed by their intimate and lasting union. The
perforans and perforatus are solidarized, the mechanism of the ring of the
perforatus is destroyed ; now the phalanges, almost immobile upon each
other, do not flex any more, and the horse is always liable to stumble
and fall. He can no longer be utilized to fast gait, so much go that the
neoformed structure remains always more vascular, more sensitive and
more exposed to dilacerations than the normal fibrous tissue. However,
tenotomy allows some horses to be used which otherwise would have
remained unfit for work.

It is not the case, however, that successful results obtained by tenotomy
remain always lasting, even where the cause of the knuckling has been
properly treated. Against relapse, blistering and firing applied on the
retracted cicatricial tissue have been recommended. A second tenotomy
is the only thing to replace the leg in its proper position j but, from an
economical point of view, it is not advisablei



320 VETERINARY SURGICAL THERAPEUTICS.



VIII.
SPRUNG KNEES.

The deviation of the knee forward of the plumb-line, produced by the
obliquity of the bones of the fore arm and of the canon, is most com-
monly the result of excessive work, an indication of wearing of an extre-
mity : the horse suffering with it is called " sprung-kneed." Sometimes,
however, the conformation is observed in young animals as a congetiifal
malformation, or again occurring in the first days of life. These are called
" brassiconrts " by the French.

The treatment is indicated in animals with which this conformation is
congenital or occurring during the first years of life. When it is due to
overwork, to wearing, the subject is not worth intervention.

Sometimes the deformity is much marked. Brachet has related the
case of a filly which, perfect at birth, was, towards the third month of her
life, so severely affected on both fore legs, that both heels nearly touched
the elbows ; the animal was walking on her knees, almost as fast as other
sound subjects of the same age. Strong pulling on the lower end of the
leg was not sufficient to open the radio-metacarpal angle, so powerful was
the retraction of the flexors of the canon. Other authors have men-
tioned similar cases. Suykerbuyck has seen an eight day colt whose
right anterior leg was sprung and knuckled to such a point that the leg was
resting on the metacarpo-phalangeal joint. When the deviation is not
much marked, it may be removed by proper splints. Brogniez has in-
vented an orthosome which can be used in such cases or applied after
carpal tenotomy. SoUeysel and Lafosse, thinking that sprung knees were
due to shortening of the coraco-radial aponeurosis, proposed its subcuta-
neous division. The operation has given some success (Brogniez, Chas-
saing), but the result is doubtful.

Retraction of the external and oblique flexors of the mecatarpus seems
to be the great cause of sprung knees. Numerous authors, and among
them Dieterichs, Hering, Brogniez, Bassi, Brachet, Chassaing, have pub-
lished the successes they have obtained by the section of those tendons.

Miquel, on an animal sprung on both knees, cut the tendons on one
leg first, and several days later on the other : the animal recovered its
plumb-standing. A ten-year-old horse, not so severely affected, was
operated on both legs at one sitting. The wounds were closed with pinned



SPRUNG KNEES.



321



sutures ; cicatrization took place without suppuration ; twelve days after
the callus formed by the union of the tendinous stumps was as hard and as
big as a French nut. From that time he had walking exercise, a month
later did light work, and afterwards resumed his ordinary life, all cured.

In a filly, Brachet first made on the level of the tendons an incision (3
centimeters long) parallel to the fore arm, and
divided them with a concaved bistoury. The
result not being sufficiently satisfactory, he
made " another section of the epicondilo me-
tacarpal (internal flexor of the metacarpus),
which prevented the complete extensions of
the leg." The knee straightened almost en-
tirely and there remained very little deviation.
The separation of the ends of the tendons was
about seven centimeters. The knee was placed
in a padded splint held in place with a wide
bandage. After a month the animal was free
from pain and in one year had as good, firm
action as others of her age (fig. 78).

Like plantar tenotomy, the suscarpal must
be performed subcutaneously. â–  'Lafosse, Gour-
don, Peuch, have described ''the operation,
which includes two steps : t^f, Section of the
external flexor j 2nd, that ofeth"^ oblique.

The animal is thrown oil' We' sound side;
one rope is secured on the ii|DJ)er portion of Fig- 78.— Part of the fore
the fore arm, and puUed^'backwaftis ; another, ^"^"^ and knee (posterior
attached to the canon or to thef6ot, is pulled f^c^) - ^^' ^^^1^^"^ flexor
forward. "'

The operator places himself in front of the
knee. The region prepared, a narrow puncture is made through the skin
and the subcutaneous aponeurosis, about 5 centimeters above the suscar-
pal bone, on the anterior border of the external flexor. Then the curved
tenotome is introduced under the tendon, as far as its posterior border,
and with it the tendon is divided, from forward backward, while the assist-
ants are pulling on their ropes. The section of the oblique flexor is done
in the same maniier, the puncture of the skin being made on its anterior
border and the division done as before.

By cutting the tendons from backwards forwards, as in plantar tenotomy,

there is more danger to cut the arterial divisions situated between the per-

foratus and the perforans ; if the operation is performed too near the knee,

there is danger of injuring the articular svnovial sac or the carpal bursa.

21




nietacarpis ; Fe, external
flexor nietacarpis.



322 VETERINARY SURGICAL THERAPEUTICS.

There is sometimes an abundant hemorrhage, but a simple ligature or a
compressive bandage are sufficient to stop it.

According to Chassaing, the section of the tendon of the external flexor
is all that is required in the majority of cases. But if the bend of the
knee is great, double tenotomy is preferable.

Sometimes the straightening of the knee takes place immediately, at
others it requires some time. In the cases where the knee has a tendency
to bend backwards, the padded apparatus of Brachet or the orthosome of
Brogniez can be used with advantage. In this way the articulation is kept
in normal condition until the cicatrization is completed, and when the
apparatus is removed, after about twenty days, the knee keeps the position
which it has received.

When the deviation seems due to a simultaneous retraction of the
flexors of the metacarpus and of those of the phalanges, it is, as suggested
by Lafosse, proper to complete the suscarpal tenotomy by that of the
perforans. In a twelve-days old colt, Chassaing made the section of ex-
ternal flexor, and a month later double plantar tenotomy. Recovery was
not complete until four months after the operation.

In young dogs, it is quite frequent to observe a deformity of the anterior
legs, somewhat similar to the sprung knees of horses, an exaggeration of the
flexion of the metacarpals upon the fore-arm, due to the retraction of the
flexor tendons. This deformity may exist in one or both legs. Generally
suscarpal tenotomy succeeds. With the straight tenotome, introduced un-
der the external and oblique flexors of the metacarpus, these are divided.
Sometimes the division of the perforatus is necessary (Peuch). A dressing
with splints or pasteboard, extending from the lower end of the paw to
the superior extremity of the fore-arm, will keep the bones in their proper
position. After five or six days, the dressing can be taken ofl ; the wound
is cicatrized. The straightening of the leg takes place gradually.

IX.

TENDINOUS HELMINTHIASIS.

The reticulus spiroptere is found not only in connective tissue and
arterial walls, but also in tendinous and ligamentous tissues. The cervical
ligament, suspensory ligament, tendons of the perforans and perforatus
seem to be the most affected! When these exist on the legs, they give
rise to true tendinitis with lameness (Barrier, Mauri). Ordinarily the
deformity and sensibility of the affected organ permit the diagnosis ; but
there are cases where those are missing. The horse mentioned by Mauri
was very lame on the left fore leg ; the knee was constantly flexed ; by



TENDINO^^S HELMINTHIASIS. 323

pressure of the suspensory ligament, an acute sensibility was manifested,
but no deformity was visible " neither on the tendons nor on the carpal
bursae." Fine points firing applied twice did not remove the lameness.
The horse was destroyed. In such cases it would be well to try deep
penetrating points firing or median neurotomy.



CHAPTER V.

TENDINOUS SYNOVIAL SACS.

I.

TRAUMATIC LESIONS.

Contusions of tendinous synovials are not rare. Slight, they terminate
rapidly by resolution. When they are due to violent traumatic actions,
specially when the injured bursa is on the level with a distended cul de
sac, a bloody extravasation may take place in the sac ; or sometimes a
closed synovitis may follow. Their treatment is that indicated in the
chapter on contusions in general. Later, if indicated, that of acute
synovitis will be prescribed.

There is great analogy between wounds of tendinous and those of
articular synovials : same causes, same symptoms, same terminations.
At times, one may hesitate in the diagnosis. There is a deep wound on
the surface of the knee, of the hock, of the fetlock ; there is escape of
synovia; which sac is open? When there is no coexistence of tendinous
and articular lesions, the topography of the synovials and the seat of the
wound will solve the question. In doubtful cases, probing may give some
light, but it is a dangerous operation. The therapeutical indications being
the same in all cases, it is useless to expose a serous membrane, which
may be aseptic, to infection.

The treatment of penetrating wounds of tendinous synovials has varied
much with time. Antiphlogistic method (bleeding, poultices, emollient
lotions of all kinds) was abandoned long ago. Cold water and astringents
have been often used successfully. Arnal has treated with cold baths
and astringent lotions a steer wounded above the fetlock, by the prick of
a fork, which had entered the' sesamoid sheath ; the animal resumed
work in a week, the cicatrization taking place by first intention. On a
horse suffering with a punctured wound of the foot, in which the small
sesamoid synovial was injured, the result was as satisfactory : the foot
unshod, the sole thinned out, the wound was covered with pads kept in
place with a piece of leather, and the shoe secured with four nails ;
the horse was placed in running water in day time, and during the night
had Goulard extract lotions applied ; in six days, recovery was completed.
Trasbot has related a similar case : a nail had also penetrated the small
sesamoid sac, the sole was thinned out, the fistula enlarged, and the
wound irrigated with cold water; the 12th day, it was cicatrized.
324



TRAUMATIC LESIONS. 325

Some authors, balieving that the flowing of the synovia was the only
obstacle to the cicatrization of the trauma, have had recourse to coagulat-
ing agents. Causs^ and Peuch have recorded cases showing the ad-
vantages derived with tannin. Causs^ says he has cured with it four
cases of wounds of the sesamoid groove injured by nails and one of the
synovial of the tendon of the gastrocnemius. The horse treated by Peuch
was suffering with a penetrating wound of the tarsal sheath ; l)listering
frictions on the hock and cauterization of the wound with sublimate
having failed, with tannin recovery was quite rapid. Other practition-
ers have used successfully aegyptiacum ointment in dressings, as in cases
of wounds of articular synovials.

On account of the obturating eschare that it produces, actual cauterization
or potential caustics has, for a long time, been considered by some as the
best treatment. Sublimate and nitrate of silver have specially been used.
In the observation of Knoll, the great sesamoid sac and the articulation of
the fetlock were open ; sublimate, used after several other treatments had
failed, brought on recovery. With sublimate collodion (15 parts in 30)
Francois has obtained the rapid closing of a wound of the tarsal sac.
In a horse affected with a wound of the small sesamoid sac due to a
fracture of the bone, Verlinde enlarged and cleaned the wound, cauterized
the fetlock with sublimate powder, and applied an antiseptic dressing.
No complication occurred.

Nitrate of silver has been praised by Barthe, Dangel, Ribaud. With
repeated cauterizations by this agent, synovial wounds close rapidly. The
mare of Barthe, which had an open sesamoid sac after a too severe firing,
recovered rapidly.

Many practitioners have combined vesicating, coagulating and cauter-
izing agents. The caustic tar (a tablespoonful of Norway tar, half a tea-
spoonful of sulphuric acid at 66°) has given Cagnat good results in the
treatment of wounds of the anterior face of the knee, involving the ex-
tensor tendons and their sheaths.

Though penetrating wounds of tendinous synovials may get well by the
use of so varied forms of treatment, to-day all those last, except con-
tinued irrigations, are with justice replaced by antisepsy. Pricks, after
careful disinfection of the skin, are covered with iodoformed collodion
and a wadding dressing. More extensive wounds should be first well
washed, carefully irrigated with a strong antiseptic solution, especially if
some hours have elapsed since they were received ; their edges should
be shaved ; stitches placed at their extremities will prevent their gaping
to excess ; and if asepsy is sure and complete they may be entirely closed
by stitches with or without drainage. A wadding iodoformed dressing
insures immobilization.



326 VETERINARY SURGICAL THERAPEUTICS.

II.

TRAUMATIC SYNOVITIS.

Whether traumatic synovitis succeeds infected synovial wounds or is
consecutive to a closed synovitis ending by suppuration, its symptoms are
in all cases very expressive: there is a fistula through which escapes a
yellowish, clotted, more or less purulent liquid; the region is warm, pain-
ful, oedematous ; lameness is great if it is the synovial of a leg; there is.-
more or less traumatic fever. One may hesitate between synovitis and
arthritis. In this last, however, the functional disturbances are more
marked ; the lameness greater ; the swelling, more extensive and diffuse,
spreading evenly on the whole periphery of the joint, while in synovitis it is
limited to the side of the leg where the synovial exists, or much more
marked there than on the opposite side.

According to Lafosse, synovitis would not be any more dangerous than
simple peri-articular phlegmons. With the great majority of authors,
we believe that suppurative inflammation of a tendinous synovial is always
a serious accident. Evidently the prognosis varies with the importance
of the synovial injured, the character of the wound, the length of time
it has existed. In some cases, the inflammation extends to the tendon,,
and with a suppurative teno-synovitis, the practitioner must be modest in
his opinions. Recovery is sometimes singularly favored through parti-
tions in the synovial by septum or bands ; the infection, instead of spread-
ing in the entire serous, remains localized on one point, sometimes one of
the cul de sacs. As a consequence of synovial inflammation, generally
strong adhesions take place between the walls of the sac, the sliding of
the tendon becomes difficult, the animal remains lame.

All the treatments indicated for synovial wounds have been recom-
mended against traumatic synovitis. The two therapeutic metliods that-
are favored by practitioners are hydrotherapy and antisepsy. If the
former is used, sometimes the wound and surrounding region are simply
irrigated with a rubber tube fixed above it; or again, by enlarging the
fistula and placing a drainage tube. Through the action of cool water,,
purulent secretion diminishes and recovery may be obtained. We prefer,
instead of cold water, antiseptic injections, following the necessary enlarge-
ment of the fistula. Sometimes a counter-opening and then a drainage.
Like Mauri and Labat, we generally use sublimate i in looo in injections
every two hours ; by degrees the discharge diminishes, the rational symptoms,
improve, the wound closes rapidly. Landreau has reported a case of syno-
vitis of the sheath of the anterior extensor of the phalanges, cured in four



CLOSED ACUTE SYNOVITIS. 327

'days. Sometimes the suppuration is slow to stop, and recovery demands
six weeks or two months to take place. Too often adhesions have taken
place ; the tendons do not move any longer in their sheath ; there re-
mains a marked stiffness, so much more that the suppuration has lasted
longer. Massage, warm water, moderate exercise, form the base of the