SITES IIT SIS Nad ee aA ea es. Lele Pues poh? A oe Abe foe SOs - a aS ey A ARRAS Cees RAL AALS AM on te, aKa AAS —— 144 hbss SADA a sa a, oA e OG SA ae (e sx » » eb > ‘*. Satasas > a eaea sas as (4 on ad 4 ry i fk ae fy See ; $f * oc oP. Keke hat aiak< > PEE eyo aP Sata sehatchal Sate satcsete: a ees ie eee P rv tay: OLS ERE LE San Get oa PE EELS ae Lh ELS OTT REN SSI eK 2 ewe ee Pree a esas 6 4 Aat sea rhe ah, : Oren yee > 7 : tits 4 TP APPL LE Lees ; : 4 7 ; 4. J Py) 4 AA. aa ORY ; ; + eee OR 4 eas LEILA ESS , rarer i AAPL S ES ESS ALS abe ‘ } > eb eS ; . 5 oe ae : : ga ee $44 ce ae hore ee : eee es ee ar Rte . . a's $Ait/ Porat ees Er SF RO se Para er Paar ie oe ew Tor Ce he 4 2 Secs ‘ on) a wat as Pe ee) Eo ADD De es ae 4 Aa de Are , i" ¢ 7 AA, ( lass JE T// Hook fp 7 Copnghi X° CTMOMMLTT UP Pers Cr at ee : A a ae eS ee ell OD ed abe Nee ir hae . 7 if : i ae HAND-BOOK OF VETERINARY SURGERY AND OBSTE VRS WITH CO-OPERATION OF ProF. Dr. ALBRECHT (MUNICH), STAFF VETERINARIAN BARTKE (STETTIN), PROF. DE BRUIN (UTRECHT), PROF. CADIOT (ALFORT), Pror. DR. EBERLEIN (BERLIN), PROF. DR. GMELIN (STUTTGART}, STAFF VETERINARIAN HELL (ALTona), PROF. HENDRICKX (Brus- SELS), PRoF. DR. HESS (BERN), PROF. Dr. HIRZEL (ZURICH), STAFF VETERINARIAN KONIG (KONIGSBERG), PROF. LANZILLOTTI-BUON- SANTI (Minan), Docent LUNGWITZ (DRESDEN), PROF. DR. OSTERTAG (BERLIN), PROF. DR, PFEIFFER (GIESSEN), PROF. DR. SCHINDELKA (VIENNA), DR. SCHMIDT (VIENNA), LATE PROF. Dr. SIEDAMGROTZKY (DRESDEN), PROF. DR. VENNERHOLM (STOCKHOLM), PRoF. Dr. ZSCHOKKE (Zitrich). EDITED BY PROFESSOR Dr. JOS. BAYER and Prorrssor Dr. EUG. FROHNER VIENNA BERLIN WAOP Ee JOE GENERAL SURGEI< Dr. EUGEN FROHNER THIRD EDITION 1905 GENERAL SURGERY BY DR. EUGEN FROHNER PROFESSOR IN THE ROYAL VETERINARY COLLEGE IN BERLIN Authorized Translation From THE THIRD REVISED EDITION BY D. HAMMOND UDALL, B.S.A., D.V.M. ASSOCIATE PROFESSOR OF SURGERY AND OBSTETRICS COLLEGE OF VETERINARY MEDICINE OHIO STATE UNIVERSITY Columbus. TAYLOR & CARPENTER ITHACA, N. Y. 1906 Copyright, 1904 BY TAYLOR & CARPENTER Registered at Stationers’ Hall LONDON, ENGLAND ‘ ote PREPACH TO “THE FIRST EDITION. In the following hand-book of veterinary surgery and ob- stetrics the general surgery, as well as the operative surgery, forms a separate, independent work. In a sense they serve as an introduction to the following third and fourth volumes of special surgery of the different organs. Any text-book of general veterinary surgery must depend on the investigations and text-books of human medicine. While I have kept this point in view in the development of the following plan, I think I have clearly drawn the relations between the general surgery of man and animals. I also admit that in the writing of this book I have followed princi- pally the plans which Billroth, and recently Tillman, have used in their text-books of human and general surgery. The reader will readily note that the following work is nota mere compilation of the books mentioned on human medicine. In many particulars veterinary surgery, like pathology, phar- macology and therapy, has developed independent lines. Many chapters on humaa surgery have no connection with veterinary surgery ; other divisions that are very important in human surgery are of little or no importance in veterinary science. Tuberculosis of the bones and joints, for example, belongs to one of the most important divisions of human surgery ; in veterinary surgery it is practically never the occasion for surgical interference. Conversely, actinomycosis and botryomycosis is of great importance in veterinary surgery, the latter is almost unknown in man. In man osteomyelitis is the most important form of inflammation of the bones ; in the horse periostitis is the most important form. Erysipelas, so frequent in man, appears to be very rare in animals. It is obvious that resection of joints, as well as most amputations of limbs, cannot be employed on cy) VI PREFACE. domestic animals. The aseptic method, which is so important in human surgery, seems to be of little importance in veteri- nary science because of purely external causes. Even bone- fractures present an entirely different surgical problem in large animals than in men. Firing, and the application of blisters for chronic inflammations of bones, tendons, and joints, are special surgical methods of veterinarians. On the other hand, the following work is not a compen- dium of other surgical text-books on veterinary surgery. On the basis of many years of surgical and clinical activity, I think I have had sufficient experience to elucidate the follow- ing subject from my own point of view. In many chapters, namely, those on fractures and tumors, I was in a position to insert my own investigations. I was also careful to arrange the material purely from a veterinary standpoint, and only for the object of veterinary practice. On this basis the reader will find, for example, many references in this book to forensic veterinary science (age of wounds, fractures, fissures, muscular atrophy; curability or non-curability of bomne-fractures in horses and cattle; abnormal fragility of bones ; prophylaxis of bone-fractures, etc.). Foreign bodies, parasites, and con- genital new-formations, which are of great surgical import- ance, have been given special attention. General surgery has numerous and important relations to general pathology and pathological anatomy. Unfortunately we have no text-book of general pathology in our veterinary literature. On the other hand we have recently come into the possession of a very important hand-book of veterinary pathological anatomy. I am under great obligations to this excellent book of Kitt’s for valuable suggestions and informa- tion. General surgery is also closely related tu anatomy. I have found a deficiency in the descriptions of tendon-sheaths and fasciz in most veterinary text-books on anatomy ; these are very important from a surgical standpoint, the descriptions are usually incomplete and indistinct. With reference to the relation of general surgery to bacteriology, it must be acknowl- edged that the latter has contributed largely to the problem of suppuration and inflammation, as well as to the combating of PREFACE. VII these processes by means of antiseptics, from a standpoint of both scientific and practical surgery. On the other hand, one must not overestimate the importance of bacteriology to general surgery and overlook everything else for bacteria. Many surgical inflammations have nothing to do with bacteria ; this is especially true of the purely traumatic, aseptic inflammations of bones, joints, tendons, tendon-sheaths, and muscles. At suitable places I have considered it my duty to repeatedly refer to this obligation. From a diagnostic standpoint also, bacteriology should not be given too great weight in surgery. Pus-cocci, in particular, are of little practical diagnostic impor- tance ; this is especially true where the candidate, unfortu- nately, is overenthusiastic concerning the significance of a bacteriological examination, to him the presence of pus-forming bacteria in pus from bones may form the principal evidence for the presence of a bone-fistula. The bacteriological confusions that have occurred concerning wound-erysipelas receive atten- tion in the chapter on this subject. There is no claim of completeness for the bibliography at the end of each chapter. My principal object was to divide the literature on human medicine from that of veterinary sci- ence and, above all, also to indicate to students the funda- mental investigations that have been made in human medi- cine; only the most important and recent works have been mentioned. The book contains no illustrations. I am opposed to the usual custom in veterinary science of appropriating illus- trations from works on human medicine, either unchanged or specially modified. I maintain that it is not admissible. KISSINGEN, August, 1896. PREFACE “CO. PEE (bern DE Di-DlG ine The new, third edition of general surgery is improved and enlarged in many respects. The individual changes are as follows: The chapter on the etiology of tumors has been re- written, and many additions have been made to the casuistry ~ of this group; unfortunately the recent etiological works on tumors are largely speculations. The chapter on botryomy- cosis has been newly written to harmonize with the most re- cent investigations on this subject; there is hardly a doubt that in this wound infection we have to deal, not with staphy- lococci, but with an infectious disease sui generis. Regardless of the objections of critics, the chapter on tuberculosis has been retained and even enlarged ; the motive for following this plan is explained in that chapter. I have supplemented the important chapter on chronic deforming arthritis with the re- sults of recent investigations made in my clinic upon ringbones chronic gonitis, and omarthritis. This is also true of primary infectious osteomyelitis the occurrence of which in the horse, according to our recent investigations, can be no longer doubted. Recent investigations on myositis, neuritis, healing of fractures, necrosis bacilli, pseudo-edema bacilli, and foal- lameness have also been considered. On the subject of asepsis against antisepsis it may be definitely stated that now, even in human therapeutics, all have returned to antisepsis. In the first edition of this book I recommended antisepsis for the vet- erinary surgeon. Even for the disinfection of fresh wounds the application of pure carbolic acid, as well as the hot iron, has been recently recommended in human surgeries. What a change within one decade ! Berlin, December, 1904. Pror. Dr. FROHNER. (VIII) TRANSLATOR’S PREFACE The translation of the third edition of Frohners ‘‘ General Surgery ’’ has been undertaken to supply a well classified pre- sentation of the fundamental principles of surgery. It is hoped that it may assist the beginner in obtaining a clear perspective of the mass of surgical diseases with which he must come in contact. That portion of the text dealing with bibliography has been omitted in the translation as it is practically unavailable to most English readers. Otherwise the text has been closely followed, no additions or other changes having been made. The translator of this work is especially indebted to Pro- fessor David Stuart White who has rendered valuable assist- ance in reading the proof sheets. He is also indebted to Drs. A. D. Fitzgerald and James MclI. Phillips for suggestions that have materially reduced the list of errors. The translator wishes to express his gratitude to the firm of Taylor & Carpenter who have procured the authorization of this translation from the German publishers, assumed all financial responsibility, and shown every possible courtesy and assistance in furthering the progress of the work. Dene UDALL. Columbus, Ohio, July, 1906. (IX) PREFACE. 1@ THE] TEIRD EDITION: The new, third edition of general surgery is improved and enlarged in many respects. The individual changes are as follows: The chapter on the etiology of tumors has been re- written, and many additions have been made to the casuistry © of this group; unfortunately the recent etiological works on tumors are largely speculations. The chapter on botryomy- cosis has been newly written to harmonize with the most re- cent investigations on this subject; there is hardly a doubt that in this wound infection we have to deal, not with staphy- lococci, but with an infectious disease sui generis. Regardless of the objections of critics, the chapter on tuberculosis has been retained and even enlarged ; the motive for following this plan is explained in that chapter. I have supplemented the important chapter on chronic deforming arthritis with the re- sults of recent investigations made in my clinic upon singbones chronic gonitis, and omarthritis. This is also true of primary infectious osteomyelitis the occurrence of which in the horse, according to our recent investigations, can be no longer doubted. Recent investigations on myositis, neuritis, healing of fractures, necrosis bacilli, pseudo-edema bacilli, and foal- lameness have also been considered. Onthe subject of asepsis against antisepsis it may be definitely stated that now, even in human therapeutics, all have returned to antisepsis. In the first edition of this book I recommended antisepsis for the vet- erinary surgeon. Even for the disinfection of fresh wounds the application of pure carbolic acid, as well as the hot iron, has been recently recommended in human surgeries. What a change within one decade ! Berlin, December, 1904. ProFr. Dr. FROHNER. (VIII) TRANSLATOR’S PREFACE The translation of the third edition of Frohners ‘‘ General Surgery ’’ has been undertaken to supply a well classified pre- sentation of the fundamental principlesof surgery. It is hoped that it may assist the beginner in obtaining a clear perspective of the mass of surgical diseases with which he must come in contact. That portion of the text dealing with bibliography has been omitted in the translation as it is practically unavailable to most English readers. Otherwise the text has been closely followed, no additions or other changes having been made. The translator of this work is especially indebted to Pro- fessor David Stuart White who has rendered valuable assist- ance in reading the proof sheets. He is also indebted to Drs. A. D. Fitzgerald and James Mcl. Phillips for suggestions that have materially reduced the list of errors. The translator wishes to express his gratitude to the firm of Taylor & Carpenter who have procured the authorization of this translation from the German publishers, assumed all financial responsibility, and shown every possible courtesy and assistance in furthering the progress of the work. Deve, UDALL. Columbus, Ohio, July, 1906. (IX) CONTENTS ESRC Cone ene ee eee Me te ney ee eee gee ore @ontents' 2-222 ee at CAE We Le ee ah eee GOA grimy Weal Re epeL ee NAc Un ACLS IE Ee ce oe ah SL ee oe een ee a I. Definition, Classification, and Symptoms _________-___._-- Il. Incised, Stab, Contused, Shot, Lacerated, and Poisoned WaT Gm ener ka eee Fe Ue ee ti eacontroloteMemorshage, =o). see eee IV. Anatomical Changes in Wound Healing V. Wound Infection Diseases Suppuration neon one at ele 0 Ore eee aig ee ee ee Ibscesseeen = 2 = ae Pe oe EE os w= I ee ee ee ee \Wiv@ueaa! Tes ce Sn SP): Se EOS ey ees Septicemia Pyemia ~ WAKHEYH VI. Treatment of Wounds Subcutaneous Injuries of Soft Parts, (Contusion, Rupture) Ie eContusion 2. = II. Rupture Inflammation I. Nature and Causes II. Kinds, Symptoms, and Course of Inflammation Ill. Treatment of Inflammation Hip COre meres os ae ane 2 a Ee te a leh istwlay ses Page ee ve aya 8S UI pe eee ees A del cs Ill. Gangrene XIi CONTE NEES Avigioma..2< 23. 3a NS ss Lymphoma Sarcoma COI AREY YH 4 ml “J E i) Lani iS) B. Epithelial New Formations Tee Carcinomas 2. Papilloma 3. -Adenomay. 2222025) Ao eee ee Co CYSHIC TU O TS: a ot ae nS Se 2 D- Infecttous: TUMOTS = 2 ee I. Actinomycoma 2, Botry omy coma =) =) ee ee a= 7 Tuberciilosis, «oa eee Concrements and Foreign Bodies________________________________ i; ‘Goncrements:.. 295 U ee eee i “Horeign Bodies: i uGaie aes ee et he eee Hernia-and Prolapse: ... 2-525 4s See ee eee i MEP aS. 2 2 ee 5 Ii=eProlapse'ss 22 ss 4 hee ee eee Diseases\of (Bones ==...) 2 eee Tf WHractures 22 22. oa ee a ee ee II. Inflammation of Bone. Periostitis. Ostitis. Osteomyelitis 1. Inflammation of the Periosteum. Periostitis_________ 2. Inflammation of the Bone Substanee. Ostitis________ 3. Inflammation of the Bone Marrow. Osteomyelitis ____ III. Necrosis, Atrophy, and Hypertrophy of the Bones________ Ts, INECresis Of He iB o1res eeeeen ene ree ee cee ee 2... Atrophy of the Bones* 722 se eee A daly jelcimacay oleh Ont iio IXoyevoS Ls ek IVe, -Rachitistand: Osteomalaciass =e a eee anes eee eee Diseases: of: Joints... 5). 32 eee ee I. Inflammation of the Joints. Arthritis or Synovitis_______ Tt. Serous Inflammation. Arthritis Serosal=22= 292 o2222s5 2. Suppurative Inflammation. Arthritis Purulenta______ 3. Deforming Inflammation. Arthritis Deformans_____- 185 185 188 190 Igo 216 217 220 221 226 226 228 229 229 232 233 234 236 238 CONTENTS 4. Tubercular Inflammation. Arthritis Granulosa Il. Changes in Position of the Joints. Luxation, Distorsion, STS 10 1 eee ee ce ee ee i ee ee 1. Luxation or Dislocation Dee DISTOTSION TOG S Praline ee eee ee Se 3. Contusion or Bruise of the Joint Ill. Anchylosis and Contracture To AC hvlOSISHOLSUMneSSa ea ee 2. joint Contracture (Stilt-Foot) 9 -.-- 3.5 2 IV. Joint Bodies. Corpora Libera Diseases of the Tendons, Tendon-Sheaths, and Mucous Bursae ____ Ie DIScasectoltaticr Lend ons ss us a weeee oe eh Le 1. Inflammation of the Tendons. Tendinitis Zee nd OnmRTIpEITer we: 2 a hs en ee PmerLencdonsNecrosisye sso sek e es eee Fe Dive WDisedses of Tendon=Sheaths2 «250 (oe a es ek 1. Inflammation of Tendon-Sheaths. Tendo-Vaginitis__ 2. Distension of Tendon-Sheaths. Hydrops Dice Discases.ahk WWiticous bursaes = a.) - se eee ee Tt. Inflammation of Mucous Bursae. Bursitis 2. Hygroma of Mucous Bursae Diseases of the Muscles, Fasciae and Nerves ime ISeases Ofuthe mViuscleseaes - 2 21... [eee ee 1. Inflammation of Muscles. Myositis 2. Muscle Rupture 3. Muscle Atrophy ie OT Seases Of hascice- = eas Ov. Wt 5 ae ee IRemINECLOSIS0 Ol WMaSCice =a ae. o-oo ee nes A 2. Rupture of the Fascize De DISeAsesroriNervesi 6 Set 0 8.) xe I pt alte ie ip OAtesiq ands batalySigk 2. bo... . sane ea) 2. Inflammation of Nerves. Neuritis Diseases of Vessels lig JONGCERES Ghia Wace es) Pe eet Ay ed ee I. Inflammation of Arteries. Arteritis 2. Dilitation of Arteries. Aneurysm 3. Rupture of Large Arteries Pe ISCAS CemOL EV GIiG = see Ors ln") Sic ee eee. ete iqelitlanmmation or Viemns, Phlebitisues: 295) 22220 5” 2. Dilitation of Veins. Varix. Phlebectasis III. Diseases of Lymph-Vessels XIV CONTENTS I. Lntlamimationvotslyimipl-Wesselcmeess = 2. se | ae 2. Dilitation of Lymph-Vessels. Lymphangiectasis_____ Distases of (Glands = ee ee eee Ee ree ee I. Inflammation of Lymph-Glands. Lymphadenitis________ II. Inflammation of the Mammary Glands. Mastitis_________ Surgical Diseases of the Skin and Mucous Membranes _-_..________- I Surgical Diseasesiot: the Sling 5 22 5 22 eae ee ee I. Inflammation of the Skin. ‘Dermatitis: 222 = > ae ) Burns. Combustion 22-2 "- ie TU ee Le eee 4. JBreezing.. \Congelations=- <2. - 262. so 5 eee eee II. Surgical Diseases of the Subcutaneous Tissue___________- ts ctidemat..222ce. 2223) ee aCe oS ee ee 2. se mphy Seine. Voeeee eel. Pee eee ore ee ee III. Surgical Diseases of the Mucous Membranes_________-___ IV; ‘Surgical Diseasesiof the Pododerm =} “= 2=- 22. 2 ase Appendix. Congenital Malformations of Surgical Importance_____ Index’ 82-422 22.5 a Se ee al Se eee os WOUNDS I. GENERAL REMARKS CONCERNING THE NA- TURE, SYMPTOMS, AND CLASSIFICATION OF WOUNDS. DEFINITION.—A wound, in a restricted sense, indicates any injury accompanied by a breach in the continuity of the skin or mucous membrane. Wounds may also be defined as open, hemorrhagic injuries, in contrast to lacerations and fractures which occur in the subcutaneous tissues and are not characterized by a breach in the continuity of the outer cov- ering. The latter are closed.to the presence of air, they are aseptic; that is, protected against the entrance of infectious irritants. Wounds, on the other hand, are open to the entrance of septic infection. The symptoms, course, prognosis, and treatment for both are, therefore, extremely variable. For this reason the open and subcutaneous injuries must be considered under separate headings. An ulcer is differentiated from a wound by its tardiness in healing ; it may be considered as a wound which will not heal. GENERAL SyMpToMs OF WounpDs. The most important symptoms of fresh wounds are hemorrhage, pain, gaping, and disturbed function. 1. Hemorrhage varies according to the size and con- dition of the wounded vessels. One recognizes arterial, venous, parenchymatous, and capiliary hemorrhage. Arterial hem- orrhage is that which results from injuries to individual arteries, it spurts from the wound and is bright redincolor. In venous hemorrhage large veins are involved, dark red blood flows from the peripheral ends in a continual stream as from a spring. Parenchymatous hemorrhage includes both 2 WOUNDS arterial and venous (mixed hemorrhage) ; the incised vessels are small, the blood is medium-red in color and flows from all portions of the wound similar to being squeezed froma sponge (tumors, swollen parts, muscle). Capillary hemor- thage follows slight injuries to the skin and mucous mem- brane, the blood flows in drops from the incised capillaries. As a rule, transverse wounds to vessels bleed more freely than those in a longitudinal direction because the gaping is greater (therefore an incision should be longitudinal when operating). In contused wounds the hemorrhage is occasion- ally very slight, the adventia constricts, the intima and media are retracted inwards, this results in mechanical closure of the vessel similar to that which occurs in torsion (ecraseur, emasculator). Penetrating wounds of large vessels usually close spontaneously (penetrating injury of the jugular from intravenous injection, an occasional penetrating injury to the carotid during the same operation). In previous anastomosis formation vessels bleed from both ends (carotid, large veins, thyroid gland). The following symptoms are observed after severe hem- orrhage : general anaemia which is especially characterized by paleness of the visible mucous membranes ; coolness of the skin ; as well as weak pulse and heart-beat which results from sinking of the blood pressure and weakness of the heart. Death from hemorrhage is further preceded by general weak- ness, tottering, vertigo, loss of consciousness, dyspnoea, dili- tation of the pupils, disappearance of the corneal reflex action, involuntary urination and defecation, as well as convulsions. Death ismore certain when the loss of bloodis more than a third of the total amount. "The The total amount of blood in a horse is equal to about one fifteenth of the total body weight. A horse weighing 450 kg., for example, (blood contents= 1/15 = 30 kg. or litres) dies after a loss of more than 10 kg. (litres) of blood. Loss ofa third of the blood is followed by pronounced heart weakness and sinking of blood pressure, it is possible, however, for regeneration of the blood to take place from the parenchyma- tous fluids. Loss of a fourth of the total amount of blood is WOUNDS rx only followed by decreased blood pressure (phlebotomy). Regeneration occurs through the absorption of water from the lymph of the tissues as well as from the fluid contents of the stomach and intestines (hydraemia); this is followed by an increase in the formation of the white blood corpuscles (leuco- cytosis); finally the red blood corpuscles gradually increase in number. Injuries to large lymph vessels, joints, and tendon sheaths result in a discharge from the wound of lymph, synovia, and tendon-sheath fluid respectively ; saliva is dis- charged from wounds to the salivary glands, salivary ducts, and esophagus; food or feces from perforating injuries to the stomach or intestines; milk from wounds to the udder ; urine from lesions to the bladder or urethra. Hemorrhage is absent in corneal wounds. 2. Pain is due to cutting, bruising, or tearing the sen- sitive nerves. The so-called primary pain should be distin- guished from secondary wound pain due to inflammation (nailing!). The pain of wounds is in direct proportion to the nerve supply of the affected tissues. Wounds of the skin, pododerm, periosteum, mucous membranes, cornea, or peri- pheral nerve endings are more painful than those of bone, car- tilage and tendon, connective-tissue, or brain substance. ‘The blunter the cutting instrument, and the slower the separation of the tissue, the greater the apparent pain (experience in opera- tions). The sensitiveness of different animals varies according to the individual, age and sex, as well as the race and species. Many horses are very sensitive to neurectomy while others remain quiet during the operation. Many horses will stand without narcosis for trepanation and tra- cheotomy, as well as similar operations which require restraint, while others must be cast and restrained for operations that are far less painful. In general horses are more sensitive than cattle ; dogsand cats more than horses. Horses that belong to the warm blooded races frequently show more sensitiveness than those of the cold blooded race (e. g. castration). Mares and stallions are usually more sensitive than geldings. The 4 WOUNDS following appear least sensitive : old horses, phlegmatic horses, and those affected with blind staggers. In comparison to man, all domestic animals appear to be less sensitive to wounds. Many animals, after a severe in- jury, show a certain amount of resignation similar to man (trained dogs). Complete insensibility follows deep narcosis (chlo- roform, cocaine); is present in dead tissues; and occurs after neurectomy, so that nail puncture in the hoof, for example, does not cause pain. 3. Gaping of wounds depends on the character of the incised tissue, as well as upon the direction of the wound. Gaping is most pronounced in those places where the skin is widely separated as a result of transverse muscle and tendon wounds. 4. Disturbed function occurs after wounds of the hoof, tendons, joints, and muscles, where it is characterized by lameness ; wounds of the tongue result in deranged mastica- tion; blindness may follow corneal wounds; wounds to the motor or sensory nerves may produce paralysis or anesthesia. Very painful wounds in the horse result in a diminution or complete loss of appetite, this is frequently observed after horses have been operated under restraint. Genuine shock or wound shock (sudden paralysis of the vasomotor cen- ter with anemia of the mucous membranes, retardation and paralysis of the activity of the heart) is very rare in animals. Perforating abdominal wounds in the horse are frequently fol- lowed by colic (peritonitis). The following conditions fre- quently follow injuries to large nerve branches (neurectomy): stagnation edema, inflammatory conditions, ulcer formation and necrosis of the skin and pododerm, inflammation of the periosteum, bone, and joints, exungulation, atrophic changes, fractures, tendon ruptures, etc. (See chapter on diseases of the nerves.) Occasionally sudden death follows the introduction of air into the jugular vein (operation on shoulder abscess, phlebotomy); this is partly due to paralysis of the lungs (air emboli in the pulmonary capillaries), partly to paralysis of the heart (air in the chambers of the heart, air emboli in the WOUNDS 5 coronary arteries), partly to paralysis of the brain (air em- boli in the capillaries of the brain). The aspiration of air into the abdominal cavity (gurgling sound), sometimes ob- served in the castration of stallions, is usually harmless. Finally, any wound may be followed by wound fever. Two forms are recognized, aseptic and septic wound fever. Aseptic fever is due to the resorption of degenerated blood products without the presence of bacteria. It is characterized by a slight elevation of temperature without severe disturbances of the general system (see chapter on wound fever). Septic fever, on the other hand, depends on the presence of specific infectious material which gains entrance to the wound and finally enters the blood stream. It is characterized by a marked elevation of temperature and severe derangement of the general system (see chapter on septicaemia and pyaemia). CLASSIFICATION OF WounpDs.—According to the causes wounds are classified as follows: incised, punctured, lacerated, contused,stab, shot wounds, and bites. In addition to wounds due to mechanical force one must con- sider injuries produced by chemical irritants (caustics), and thermic influences (burns, freezing), which are classified as caustic wounds, necrotic wounds, etc. According to the condition of the wound they are classified as simple or non-contused (incised, punc- tured), and complicated or contused wounds (con- tusions, shot wounds, bites), wounds with and without loss of substance, flap or skin wounds, clean, unclean, (hair, dirt, dust), infected and poisoned, superficial, deep, and perforating or penetrat- ing (abdominal cavity, thorax, joints), slight, severe, and fatal, fresh and old, hemorrhagic, suppura- tive, granulating and cicatrized wounds. According to the seat and tissues involved they are classified as wounds of the head, thorax, throat, ab- domen, skin, mucous membranes, muscles, bones, cartilage, joints, tendons, brain, cor- nea, stomach and intestines. 6 INCISED AND STAB WOUNDS SHock IN ANIMALS.—Beck has observed one case of paralysis of the heart in a calf asa result of castration (Wochenschrift fir Tier. heilkunde. 1go1). The animal bellowed very loud after the remova- of the first testicle (pain, fear, terror), collapsed and died immediately. The results of a post mortem were negative. Il. |) INCISED; PUNCTURED;) CONTUSED, SHOT, LACERATED AND POISONED WOUNDS. INCISED AND STAB WouNps.—These are due to injur- ies from surgicaland ordinary knives, hay knives, hoof knives, butcher knives, case knives, shears, glass, pieces of iron, scythes, sickles, sabers, hatchets, etc. The characteristics of incised and thrust wounds consist in their straight dir- ection, longitudinal form, as wellas sharply de- fined, smooth, non-contused edges. Hemorrhage and retraction of edges are more pronounced than in the other forms. ‘They are most often seen in horses, dogs, and cattle on various parts of the body, especially the limbs. According to depth they may be termed wounds of the skin, muscle, tendon, bones, and perforating wounds. The prognosis is favourable when the skin only is involved (suture). Froma forensic standpoint it should be observed that many lacerat- ed and contused wounds present edges similar to those of in- cised wounds (wire, sharp edge of the hoof). PUNCTURED Wounbs.—Punctured wounds are caused by manure forks, hay forks, nails, needles, pointed knives, and shears, lances, bayonets, harrows, splinters of wood, etc. Penetrating wounds in horses are most often due to manure and hay forks, as well as treads on nails and nailing. In the German Army the lance is a frequent cause of wounds on ac- count of its wide use in the cavalry. During operations punctured wounds are often produced by means of the injection needle and the trochar (subcutaneous, intravenous, intra- peritoneal, parenchymatous, intraocular, subconjunctival, sub- dural, intracranial, and even intracerebral injections, paracen- tesis thoracis, paracentesis, abdominis, harpooning the udder, BITES, LACERATED AND CONTUSED WOUNDS 7 / lumbar puncture). Punctured wounds are usually small, round, slightly hemorrhagic, and frequently leadtoa fistulous canal. Perforations into joints, tendon sheaths, abdomen, thorax, eyes, etc., are common. Experience with injections and puncture has demonstrated that perforating wounds with sharp, clean instruments are harmless when they penetrate body cavities, the rumen, intestines, or a large blood vessel (jugular, carotid). All unclean objects, however, especially manure forks, unclean injection needles, old nails and harrow teeth, are liable to result in suppurative and septic infection (phlegmon, abscess, fistula formation, septicaemia, malignant edema, tetanus). Punctured wounds of the hoof (treading on nails, nailing) are frequently followed by tetanus. CoNTUSED Wounpbs.—Contused wounds are injuries caus- ed by blunt objects, treads on the coronet, kicks, falls, col- lisions, running into objects, being run over, falling into holes, remaining in a recumbent position for a long time. Con- tused, wounds are usually irregular in outline, possess jagged, unclean margins, areswollen, often havea loss of substance, and the contused tissue has a tend- ency to become necrosed. Occasionally hemorrhage is slight or fails entirely even in large contused wounds. One can differentiate superficial (excoriations, abrasions of the skin) and deep contusions, with and without loss of substance. (See chapter on contusions. ) LACERATED WounNDs.—Lacerated wounds have some of the characteristics of incised wounds, they are also similar to contused wounds. They are caused by catching on or getting against hooks and nails, by sharp calks, running into wagons, machinery, etc. In horses they are most often seen on the head (false nostril, eyelid), on the thorax, buttocks, and pos- terior limbs. Special lacerated wounds are observed on the cornea in dogs (scratches from cats). Lacerated wounds are frequently in the form of flap wounds with angular forma- tions, the margins of the wound may be regular or torn. BITES.—Injuries caused by bites from dogs, horses and other animals present various characteristics; they may be punctured, contused or lacerated. They most frequently 8 POISONED AND GUN SHOT WOUNDS occur in dogs and horses, seldom in cattle or other animals. Dog bites frequently result in severe phlegmon and com- plicated bone fractures; bites from horses in extensive necrosis of the skin on the sides and top of the neck (bites from animals standing in the same stall at night. ) POISONED Wounps.—Under this term are included injuries, especially to animals at pasture and hunting dogs, due to snake bites, bee and wasp stings, as well as infected wounds (rabies, anthrax, glanders, tetanus, septicaemia). With reference to the specific diseases thus produced one must consult text books on toxicology and infection (see chapter on wound infection diseases). SHotT Wounps.—These belong to a special type of con- tused wounds and may be termed contused-lacerated wounds. They are characterized by an external opening with smooth, contused, angular or lacerated margins, a tubular shot canal, and an exit opening. When the latter fails it is termed a blind shot canal. When the shot is fired near the seat of in- jury the wound edges are burned. Superficial, long, gutter- shaped injuries of the skin are observed in furrowed gun- shot wounds, contusions of the subcutaneous tissues without injury to the skin in gunshot contusions. Shots which per- forate only beneath the skin are termed seton shots. In the bones there exists either a shot hole, that is, a round, somewhat tube-shaped shot wound without splintering of the bones, or comminuted fractures, that is, comminuted bone frac- tures with splintering and crushing of the bones ; gun-shot con- tusions may be characterized by subcutaneous (simple) frac- tures. Unfortunately the literature of the German veterinary surgeries concerning gun shot wounds of horses in the earlier campaigns is worthless. According to the statistics of Jewse- jenko collected in the Russo-Turkish War, from a total of 211 horses shot, 41 involved injuries of the bone (equal to 20 per cent). Healing frequently follows encapsulation, especially small shot, the latter seldom change position (wandering). When other bodies, however, enter with the bullet; namely, dirt, hair, portions of the covering, of the tugs, etc., there develops a suppurative or ichoric inflammation in the vicinity GUN SHOT WOUNDS 9 of the shot canal. Shot woundsin horses are of importance in war ; otherwise they are seldom observed (hunting dogs, cats). GUNS AND PROJECTILES.—Shot injuries are produced, either by hand weapons (muskets, revolvers, pistols, small rifles), or cannon (shells, schrapnel, solid shot). Injuries caused by small shot are rela- tively slight, experience has demonstrated that in dogs they may heal without reaction. Injuries caused by musket balls are of more impor- tance. While these balls were formerly manufactured from lead, were round, and tolerably large in diameter, the bullets of modern weapons of war, especially the eight millimeter gun, have a very small diameter (eight millimeters), a cylindrical, long form, as well as a very hard steel jacket overacore of lead. On account of the steel jacket and small diameter these bullets retain their form, while the earlier bullets were flattened or shattered when they came in contact with a bone, causing severe injuries, especially to the soft tissues. Modern pro- jectiles exert, however, on hard bodies, especially bone, more active splintering force, and in addition to this an enormous penetration. According to Kocher (Zur Lehre von den Schusswunden durch Kleincalibergeschosse. 1895) the force of modern projectiles is a blow in the direction of their light (penetrating influence)on the oneside, and an explosive effect (lateral impaction) onthe other. Asaresult of the penetrating as well as the explosive effect the tissues involved are either lacerated or contused (explosive effect), or torn away (pene- trating force). The slower the speed of the bullet, the lighter the explosive effect; penetration and explosive effect stand, therefore, in an inverse ratio to each other. If the pro- jection force is less than the cohesion strength of the involved parts they become stretched and contused ; when both are equal there exists a wedge-shaped perforation ; if the force of the shot is greater than the cohesion of the parts the tissues are ruptured. In the first case the involved tissues are stretched; in the second they are pushed forward or to one side; in the third, lacerated. The degree of rupture depends on the diameter of the shot and the character of the tissues. An increase in the diameter of the missile is constantly occurring, this increases the surface of contact (oblique exit, change in the form of the shot). There exists a ‘“‘reciprocal”’ influence between the target and the shot, in which the increased resist- ance of the target increases the explosive effect of the bullet, the explosive effect is also intensified by increasing the speed of the bullet. With increased resistance and explosive force there is a parallel diminution in the speed of the bullet (heating, deformation). A decrease in calibre and increase in the strength of the jacket results in decreased explosive force for elastic bodies, muscle and epiphyses of bone. Small calibre shots 10 GUN SHOT WOUNDS from a short distance produce the following effect on cortical bone : laceration and contusion, splintering, and a bullet-shaped enlargement of the exit wound ; large calibers produce very severe lacerations with enlargement of the entrance wound ; with an increased velocity small bullets may produce the same results. Through international agreement a calibre of not more than six millimeters has been adopted, the bullets to be covered with a hard jacket, so that they do not become deformed by spreading, lacerations are prevented as much as possible and the prognosis from shot injuries very much improved. The effect of the German eight millimeter gun on men and animals has been demonstrated by experimental investigations (Preussisches Kriegsministerium, v. Bruns, Kocher, Kohler and others). According to the investigations of Ellenberger and Baum (Berliner Archiv. 1893) on the horse it has a very variable action on different parts of the body at a distance of 250 to 600 meters. I. The skin had, as a rule, a smooth-margined entrance wound which was usually smaller than the diameter of the bullet. The exit wound in the skin was always larger than the entrance wound. It was especially large when the shot had penetrated bones and the wound was torn by bone splinters. 2. Injuriesto muscle vary according to their thickness. Insmooth, stretched muscle the wounds are in the form of a slit, have smooth edges and are smaller than the diameter of the bullet; those in thick muscles are larger and more lacerated. The track of the bullet gradu- ally enlarges, thereby increasing the laceration so that the exit wound is about double the size of the entrance wound and severely lacerated. Spent bullets (rebounding shots), as well as bullets which have passed through bone, produce severe tearing of the muscles. It is remarkable that in such cases vessels and nerves sometimes remain intact. Wounds in the fascia and connective tissue are in the form of aslit, frequently they are recognized with difficulty. Tendons are split with a slight retraction of the edges. 3. The epiphyses of the long bones frequently pre- sent a shot hole, extensive laceration is constant; the epiphysis is less frequently disunited. Shots in the diaphyses, on the other hand, are usually characterized by complete fracture, or at least accompanied by pronounced splin- tering; even with grazing shots the bones, asa rule, are completely comminuted. Grazing shots on the epiphyses lead to splintering. Shots in the center of short bones (carpus, tarsus, vertebrae) usually result in comminution. Flat bones usually present a shot hole with a round, small entrance wound, and a larger wound of exit which produces fissures and slightsplintering. When the ribs are hit in the middle there exists a shot hole the size of the bullet’s diameter, with longitudinal laceration and slight splintering at the GUN SHOT WOUNDS 106 somewhat enlarged wound of exit. Grazing shots in the longitudinal direction of the body fracture the ribs. Transverse shots through the thorax penetrate the entire horse. When the bullet comes in contact with a rib at the entrance wound, one is also fractured at the wound of exit, it isa complete break in the continuity. On the bones of the skull there is produced a shot hole with splintering and sometimes crushing of the bones. The base of the skull is shattered. Gunshot wounds of the cartilage, on the other hand, are relatively small, they are often in the form of a smooth split. 4. The lungs are severely lacerated, the shot track usually contains splinters of bone, near the wound of exit the track increases in diameter. Also in the heart, one finds lacerated, flap, gaping wounds; seldom small round openings. In the small intestines there usually exists a small shot hole; in the large intestines, on the other hand,the wound is usually broad, flap-like and lacerated. The French Weapons, according to Gabeau (Recueil vét. 1895) in experiments on the cadaver of the horse, result in severe injuries which are always of acomplicated nature. At a distance of roo to 200 meters all bullets penetrated the body of the horse. In the skin the entrance wounds are circular, as though penetrated with a punch ; the skin itself is not changed. In soft parts the exit wound is oval in form; skin overlying bones on the other hand, is lacerated and notched. In muscles the wound canal is much larger than the diameter of the bullet; it contains fleshy, bloody masses and dilates in the direction of the exit wound. The muscle fibers appear to be torn in the direction of the rotation of the bullet. The aponeuroses and flat ligaments present linear wounds; tendon wounds are twice the width of the bullet, their ibersappearto be tornand lacerated. Long bones are broken or split and present oblique frac- tures with extensive splintering ; short bones are crushed into splinters ; the ribs present transverse fractures. The joints are commin- uted, their bones are crushed to pulp; sometimes fragments of the bone are torn away and thrown sev- eral meters. The exit wound of joint shots is very large, the skin is torn in shreds. The lungs have cylindrical shot canals. In the liver the entrance wound is much larger than the bullet, the wound canal is very wide, the tissue of the liver is ground to pulp fora distance of three or four centimeters. In the stomach and intestines the entrance and exit wound are seemingly equal in size. In the hoof the ‘entrance wound is hardly one mm. in diameter, almost invisible ; the penetration of the hoof is complete. The explosive effects of the so-called dum dum bullets is extremely active. These are small caliber bullets from which the steel point has been removed (expansive bullets). According to Walker (The Veter- 12 ARREST OF HEMORRHAGE inarian. 1899) the entrance and exit wounds are small ; the shot expands in the tissues and lacerates the bones and soft tissues. III. ARREST OF HEMORRHAGE. SPONTANEOUS ARREST OF HEMORRHAGE.—This is a cessation of hemorrhage of itself in contrast to artificial arrest by means of therapeutic agents. The so-called ‘‘stopping’’ of hemorrhage occurs in capillary and parenchymatous hem- orrhage, as well as from that due to injuries to small arteries and veins. The causes of spontaneous arrest of hemorrhage are, first of all, the small amount of blood, in addition one finds aretraction of the vascular walls with a narrow- ing of the lumina of the vessels. Coagulation of the exposed blood results in the formation of a thrombus which closes the opening and lies partly within the lumen of the blood vessel. Because of slight blood pressure in the capillaries and veins thrombi form in them in a very short time, thus arresting hemorrhage. In large vessels, on the other hand, especially in arteries, thrombus formation fails to occur, or exists only after the loss of a large amount of blood with resulting heart weakness and decrease of blood pressure, so that the blood coagulum is no longer forced away by the blood stream. After the loss of large quantities of blood it is made more coagulable by the addition of white blood corpuscles, thus aid- ing in the arrest of hemorrhage. ‘This explains, for example, a fact which has been demonstrated by experiment, that stal- lions castrated without any precautions finally recover after severe hemorrhage. In general, as already remarked, the loss of blood must not exceed a third of the total amount, oth- erwise, there occurs a fatal paralysis of the heart and brain. Quantitative regeneration of the blood seems to take place rapidly through resorption of lymph from the tissues, as well as fluids from the stomach and intestines. The newly formed blood is, however, at first, very rich in water, the red blood corpuscles, on the other hand, are deficient, they are formed only after a long time. ARREST OF HEMORRHAGE 13 The exact phenomena of thrombus formation are not fully understood. The principal factor in arrest of hem- orrhage is the formation of a so-called white thrombus, which is composed of white blood corpuscles and the blood plates discovered by Bizzozero. This must be differentiated from the fibrinous coagulum which is the ordinary pro- duct of coagulation within the cadaver or outside the body. In contrast to the white thrombi, which to a certain extent are the result of physiological processes in normal living bodies, the so-called red thrombi are formed asa pathological pro- cess. The latter are made up of red blood corpuscles and fibrin and are formed during life in the vessels of animals suffering from septic affections, as well as from a general marasmus (marasmatic thrombi). These red thrombi are formed by a process of coagulation and death, similar to the formation of blood coagula in cadavers, they possess, therefore, an essen- tially different composition and importance. When both white and red thrombi exist at the same time they are termed a mixed thrombi. The course of white thrombi varies according to the presence or absence of infectious material. When the throm- bus remains free from infection, so-called organization occurs ; that is, it develops into indurated, vascular, connective tissue, whereby the injured vessel contains a solid and perma- nent cicatricial obstruction. If infectious material gains en- trance to the thrombus, however, there occurs a suppurative and ichoric softening of the thrombus with subsequent emboli. 1. The so-called organization of the thrombus con- sists in a replacement of the same by connective tissue. ‘The cells of the thrombus itself do not undergo active division, the thrombus plays more of a passive role in that it is gradually pushed away by the newly formed tissue. The new con- nective tissue is produced by proliferation of the vascular epithelium. ‘The endothelial cellsof the intima of the vessels proliferate and are transformed into spindle-shaped and polymorphous formative cells, which advance towards the center of the thrombus, they penetrate and surround the same and are transformed later into fibrillar 14 ARREST OF HEMORRHAGE connective-tissue cells; so that the thrombus, under the influ- ence of the firm connective tissue, is finally pressed away and replaced. Vascularization of the thrombus oc- curs at the same time by means of a budding process from the vasa vasorum. In about four weeks the thrombus, when formed in small vessels, is made up of a cicatricial mass of connective tissue penetrated by capil- laries ; subsequently this becomes harder as a result of atrophy and retraction of the capillaries. Calcification or cretefaction of the thrombus is rare (so-called vein-stone or phlebolith). The re-establishment of the circulation, which was broken by the thrombus, is made possible by the formation of a collateral circulation, in which the central and per- ipheral branches of the artery given off at the thrombus, as well as the vasa vasorum, are dilated. Occasionally the blood stream afterwards passes through the center of the thrombus, which becomes pervious; or it may pass through dilated cicatricial vessels. _ 2. Softening of the thrombus is due to the entrance of bacteria, which produce a suppurative liquefaction and ichoric disintegration of the thrombic mass and thereby the danger of embolic processes and general infection of the body (compare with the chapter on pyaemia and phlebitis). DETERMINATION OF THE AGE OF A THROMBUS.—This is of impor- tance to the veterinarian from a forensic standpoint (thrombus of the arteries of the limbs and pelvis in the horse). Unfortunately, exact experimental investigations on the horse are wanting. In general thrombus formation is more rapid in small vessels than in large ; pro- ceeds more rapidly in young animals than in old. Thrombus formation in chronic endarteritis in the horse seems to take place especially slow. In dogsit has been demonstrated experimentally that the thrombus is vascularized in from seven to fourteen days after injuries to small ves- sels, it is also composed of soft tissues; after three to five weeksa complete vascular cicatrix is present. Occasionally organization of the thrombus requires a much longer time. In old age calcified thrombi are observed. In general the age is determined by the consistence and color of the thrombus, which finally becomes hard and clear, as well as by the changes in the vascular walls. ARTIFICIAL CONTROL OF HEMORRHAGE.—This consists of closure of the bleeding vessel either by means of pressure or ARREST OF HEMORRHAGE 15 coagulation. The following are the most important methods : 1. Ligation of the bleeding vessel. The ligature is the surest means of controlling hemorrhage from large arteries and veins. The bleeding vessel is grasped with a good pin- cette and then ligated with silk. When the isolation is not complete the surrounding tissue is also included (ligature en masse) after having passed around the parts with a needle. If none of these methods are applicable on account of the depth of the bleeding vessel the spurting artery must be ligated at a centripetal point (ligation in the continuity ), for example, the carotid is ligated after an injury to the internal carotid. 2. Compression of vessels by knots and band- ages is indicated in capillary and parenchymatous hemor- rhage. Occasionally strong pressure may be brought to bear on the bleeding vessel by means of a tampon in the wound. Momentary and provisional relief from hemorrhage may be.at- tained through pressure with the finger or hand (digital compression), the application of an elastic bandage (Es- march’s bandage), or a rubber bandage (Martin’s bandage); pressure should be applied between the wound and the heart. A special method employed by the veterina- rian for the control of hemorrhage consists in the application of clamps for the castration of stallions. The formerly em- ployed tourniquets (pad in the form of a girth) as well as the so-called acupressure are very seldom used at the present time. 3. Torsion of the bleeding vessels results in loosening and rolling up of the intima and media, as well as retraction of the adventia, thus closing the lumen of the injured vessel. Torsion is either applied to the bleeding vessel alone, when it is grasped with the pincette and twisted on its axis for a long time, or the surrounding soft tissues may be included (torsion of the spermatic cord). From many castrations of horses I am convinced that regular torsion of the spermatic cord is a surer means for the prevention of hemorrhage than either clamps or the ligature ; from a standpoint of simplicity or asepsis torsion and clamps, especially the latter, are not preferable. 16 ARREST OF HEMORRHAGE 4. Heat in the form of a red hot iron or cautery is effi- cient in many forms of parenchymatous hemorrhage. It forms an eschar over the ends of the bleeding vessels which performs the function of an aseptic bandage (searing the tail after amputation). The application of cold (ice-cold water, spray of ether) is less effective. Its action is due to the contraction and narrowing of small vessels. Hot water is employed at a temperature of 45-50 C. asa styptic for parenchymatous hemorrhage of the uterus. Even steam at a temperature of 100-120° has been employed recently in the human family for persistent cases of uterine hemorrhage (vaporization of the uterus, so-called atmocausis and zestocausis). 5. The following therapeutic agents exert astyp- tic influence, active only in capillary and parenchymatous hemorrage: liquor ferri chloridi, concentrated or com- bined with collodion, with surgeons cotton or in aqueous solution. This causes coagulation of the blood with simul- taneous constriction of the blood vessels. Other agents are alum, tannin, creolin, sugar of lead, nitrate of silver, oil of turpentine, gelatine (subcutaneous), ergot or hydrastis is employed to control hemorrhage that cannot be treated surgically. HEMOPHILIA.—Hemophilia (blood disease ) is a congenital tendency to hemorrhage (hemorrhagic diathesis) which presents the following characteristics in man: uncontrollable hemorrhage after very slight wounds. This disease also occurs in the horse (Kohne, Siedamgrotzky, Dreymann, Otto, Zschokke, and others). The following examples have been observed: after enlarging castration wounds, after the removal of setons, after splitting fistulous canals, after the extraction of teeth in dogs; hemorrhage has continued for hours and days regard- less of all preventatives. Not all reported observations from veterinary sources are free from exception ; I have never seen a case of hemophilia in the dog or horse. The real cause is unknown (abnormal condition of the blood? failure to coagulate ? deranged nourishment of the vas- cular walls?). According to Schindelka many descendants of the thor- oughbred stallion ‘‘Gunnersbury”’ suffer from a hemorrhagic diatheses (epistaxis) (transmission as in man ?). KINDS OF WOUND HEALING i Iv. ANATOMICAL CHANGES IN WOUND HEALING. Kinps OF .WouND HEALING.—The anatomical changes in the healing of wounds, which have been demonstrated by the exhaustive investigations of Thiersch, are extremely variable. They depend upon the following conditions : whether the wound is clean or infected, sutured or open, incised or contused, with or without loss of substance. The following forms of wound healing may be recognized : Po imealias biy\ferst intention: 2 ienlinc Dy second intention. Belle dlbinge by third intention: 40 lea lins, 1:der sica b. 5. Abnormal granulation and cicatrization HEALING BY PRIMARY INTENTION.—Healing by first intention consists of a direct union of the margins of the wound through immediate agglutina- tion without suppuration. Healing by primary union depends on the following conditions : fresh, non-infected (aseptic) wounds, fresh incised wounds with even margins and, when possible, without loss of substance ; when infection has occurred careful disinfection must be employed (antiseptic treatment); the margins of the wound must be brought in close apposition by means of sutures ; all foreign bodies (hair, dirt, blood, etc.) must be removed ; application of an aseptic bandage. In the domestic animals these conditions are usually applicable only to operation wounds, and then only when possible to afford protection by means of a bandage. Macroscopically healing by primary union first presents an agglutination of the edges of the wound with blood, afterwards a lymph-like plasmic fluid (so-called wound cement) exerts the same influence. The surface of the wound remains dry. About the second day the margins of the wound are slightly swollen, sensitive, and red. After about a week (four to eight days) definite union results with the formation of a small cicatrix. Microscopically one soon observes emi- gration of the white blood corpuscles from the neighboring blood vessels to the margins of the wound and to the wound 18 HEALING BY FIRST INTENTION cement: This, ceJilanlag ami liratiio non atypia wound with wandering white blood corpus- clesis considered aprocess of inflammation. Wandering of the white blood corpuscles is due to a traumatic irritant (traumatic, aseptic inflammation) and is to be consid- ered, therefore, as a reactive manifestation on the part of the injured tissue. According to recent investigations bacteria which gain entrance to a wound that heals by primary union are soon rendered harmless and partly resorbed ; this is prin- cipally due to the bactericidal properties of the blood serum (antitoxins, alexins) which is one of the constituents of wound secretions. The infiltration of the wandering cells (leuco- cytes) in the wound cement and margins of the wound reaches its height on the third day ; from that time they degenerate or return to the vessels. The wandering cells take no part in the formation of the definitive cicatrix, a former erroneous supposition. The cicatricial tissue develops from the so-called fibroblasts; these are round cells which arise from the proliferation @f the fixed (@utoenh- thonouws) connective tissue cells “and jane endothelium of the vessels. The fibroblasts gradu- ally enlarge; large epithelioid, as well as long, spindle, and club-shaped cells are formed ; these are afterwards transformed into fibrillar, connective tissue cells when they form genuine cicatricial tissue. Simultaneously there occurs a budding process from the walls of the incised capillaries, new vessels are thus formed be- tween the margins of the wound. The fibroblasts in combination with the newly formed vessels form the so-called germinal tissue (granulation tissue); this is a cellular and vascular new formation. After the transformation of the fibroblasts into connective tissue cells the granulation tissue contracts so that the newly formed vessels atrophy again; thus the formation of the genuine cicatricial tissue is com- plete. Finally the cicatricial tissue is com- pletely covered by proliferations fromthe epidermal cells (rete Malpighi, epithelium HEALING BY SECOND INTENTION 19 of the dermal glands) atthe margins of the wound. This completes the process of healing by primary union. HEALING BY SECOND INTENTION.—This mode of healing occurs with suppuration as a result Gare ction with ordinary pus cocci. It is characterized by the formation of an abun. dance of granulationtissue. One finds this form of healing in old wounds, wounds that have become infected, those that have not received aseptic treatment, contused wounds, wounds with a loss of substance, or those which can- not be sutured. ; Macroscopically, within the first twenty- four hours the individual tissues and blood may be readily differentiated on the surface of the wound. A serous, lym- phatic, reddish-yellow secretion is formed after one or two days, giving the surface of the wound a gelatinous appear- ance. From the second to the third day the sur- oe on the wound presents angranular aip- pearance (granulations), pus begins to form. During the course of the suppuration the necrosed tissue is sloughed off, the wound is ‘‘selfecleansing.’’ Later, the gran- ulating wound surface is gradually covered with epidermis from the margins of the wound, the newly-formed epidermis surrounds the margins of the granulations in the form of a light colored fringe. The granulation tissue contracts and is completely covered, there finally remains a broad, firm, tendonous cicatrix. The microscopic changes anevidentical with those whichioceur during healing by first intention. The only points of dif- ference are that in healing by second intention infection takes place. The wound is irritated by bacteria and ther products, which results in the forma- tion of large quantities of granulation tissue, this being the product of a suppurative inflammation it fur- nishes a purulent exudate. Healing, therefore, re- quires a much longer time (two or more weeks). Cellular in- filtration of the edges, formation of the fibroblasts, budding of 20 HEALING BY THIRD INTENTION the capillaries, and transformation of the fibroblasts into con- nective tissue proceeds exactly as in healing by first intention. Further, suppuration does not form an abso- lutely mecessary condition for healing by secondary union. The essential condition is the abund- ant formation of granulation tissue, which may occur without suppuration (aseptic granulations). Granulation tissue formed during healing per secundam serves principally as a com- pensation for the loss of substance. In ad= dition it form's ‘an’ important (protectios against the entrance of infectious irritants into the blood stream. The entrances to the lymph streams are mechanically closed by the granulation tissue, the pus also contains bactericidal properties (pus serum, like blood serum ; pus corpuscles, like white blood corpuscles). This explains the long known surgical fact, that with the formation of granulation tissue the danger from general infection is greatly diminished after the third day. Experimental inves- tigations upon sheep have also demonstrated that granulating wound surfaces are not permeable for anthrax bacilli or for the toxins of tetanus. The protective action of granulations is of great importance, therefore, in veterinary science, as healing by primary union is seldom attained. Above all, the granula- tions supply the loss of substance when healing by primary union is impossible. Many wounds cannot heal except through the formation of granulation tissue (wounds of the cartilage and cornea). HEALING BY THIRD INTENTION.—This consists in the artificial union of wound surfaces that are already granulating and suppurative. It sometimes follows careful disinfection and exact suturing of suppurative granulations. Healing by third intention should not be confused with scarification and suturing of granulating wounds (same as healing per prima). Healing by third in- tention is of considerable importance in veterinary surgery as certain forms of purulent lacerated wounds may be brought to rapid healing by this method. This is especially true of HEALING UNDER AN ESCHAR 21 those about the head (false nostril), permanent union result- ing in wounds a week or more old. Healing by third inten- tion should always be given a trial, especially in the horse, when healing per prima cannot be expected from scarification of the wound surfaces. HEALING UNDER AN EscHAR.—This is a form of pri- mary wound healing. The blood dries on the surface of the wound and leads to the formation of a protective coat. In small wounds cicatrization without suppuration takes place rapidly beneath the eschar, new epidermis is quickly replaced from the margins of the wound. In veterinary surgery this method of healing is of great importance as many wounds can be neither sutured nor bandaged, the dry scab taking the place of the latter. It may be applied artificially by means of a hot iron, production of a necrotic covering (wounds of the ear, tail, joints, extirpation of small tumors from the backs of dogs), or by the application of tannin, tanno- form, glutol, amyloform, argentum nitricum or other disinfecting agents that produce an eschar. ABNORMAL GRANULATION AND CICATRIZATION.— While the various forms of normal wound healing by the processes of granulation formation and cicatrization lead, asa rule, after more or less time, to the formation of a typical cicatrix, many wounds form an exception tothisrule. The granulation and cicatricial process appears abnormal. This is true when foreign bodies or necrosed pieces of tissue remain in the wound, when there is great loss of substance, when continued infection or irritation occurs in fresh or healing wounds, when the injured animal is suffering from certain infectious dis- eases (see below). 1. Granulations are especially abnormal when the granulation tissue forms too rapidly and in large quantities ; exuberant proliferations, fungus-like granulations (granuloma, caro luxurians, proud flesh). Excessive granu- lations are observed in treads on the coronet; fistulous withers or saddle galls when necrosed pieces of tissue are re- tained and act as a constant irritant to the part; in skin wounds on the flexor surfaces of the joints (carpus, tarsus) 22 ABNORMAL WOUND HEALING when continually irritated by flexion and extension move- ments of the limbs; in muscle prolapse as a result of con- striction and continued irritation of the exposed part after injury to the fascia of the limbs, in intensive suppurative infec- tion. Other diseased forms are: erethistic granulations, that is, sensitive, dark-red, easily hemorrhagic, and very pain- ful granulation tissue; atonic (torpid, asthenic) weak or deficient, as wellas unequal granulation, and gangren- ous degeneration of the granulation tissue (diphtheria of the granulations). 2. Cicatrization may become abnormal in various ways. Great loss of substance results in an incomplete cicatrix ; suppurative decomposition in the formation of an ulcerorfistula. In horses there is frequently observed on the cicatrix an abundant accumulation of horny epidermal cells (horny cicatrix). Occasionally one observes a tumor- like proliferation of the cicatricial tissue (cicatricial keloid, cicatricial hypertrophy). This is seen in horses in the flexor regions of the fetlock and coronet (compare with chapter on keloids, under tumors). So-called painful or sensitive cicatrices (neurectomy, throat, shoulder) are rare in the horse. A cicatricial contracture occasionally results from extensive destruction of the skin, that is, cicatricial con- traction of the neighboring skin leads to change in position of parts of the body (caput obstipum from contraction of the tissues of the neck ; stilt-foot in necrosis of the skin on the posterior surface of the carpus and metacarpus; ectropium from extensive wounds of the eyelids). The causes of atypical wound healing are both local and general. Under local causesare mechanical lesions of the tissues (contusions, constant irritation from foreign bodies, licking, rubbing, and movements); irritation of the wound through chemical irritants (antiseptics, decomposing secretions, necrosed particles of tissue); in fec- tion of the wound through specific inflammatory irritants (botryomyces fungi, glanders, necrosis bacillus), or by means of various other especially virulent, pus forming bacteria ; deranged circulation (anaemia, hyperaemia, throm- bosis). Neurectomy, asa local cause of deranged circula- WOUND HEALING IN DIFFERENT TISSUES 23 tion and nourishment, may influence normal wound healing (injuries to the hoof). General causes of disturbed wound healing aressfebrile seneral diseases; chloroform (reduced activity of the white blood corpus- eles; weakening of the activity of the heart); old age; general weakness and conditions of exhaustion; weak constitution; faulty breed- momcane and food: diseases of the kidney s; Pwdnracmias cancerous, cachexia; diabetis. Also the race and species, as well as the condition of the stable, temperature, season, climate, etc., all have an influence on the healing of wounds. Finally, many animals have idiosyncrasies which interfere with normal wound healing and favour the entrance and multiplication of infectious ma- terial. On the other hand, many animals appear to have congenital immunity against wound infection diseases ; wounds on native born Algerian horses, for example, heal without suppuration and without treatment. WOUND HEALING AND REGENERATIVE ABILITY OF DIFFERENT TissuES.—1. Wound healinginthe skin, pododerm and mucous membrane takes place according to the previously described methods. Regreneration is most rapid in the following tissues: epidermis, skin and pododerm (formation of horn), the epithelium of the mucous membranes, as well as the connective tissues. 2. Muscle wounds do not heal by regeneration of muscle fibers, but by means of a fibrillar, connective-tissue cicatrix. The regen- erative ability of muscle is very slight. Proliferation and enlargement of the muscle cells occurs only in the vicinity of con- nective tissue cicatrices, as well as in small, superficial injuries to the muscle, even here the formation of new muscle fibers is limited. 3. Tendon wounds heal principally through proliferation of the cells of the tendon sheath, of the paratendineum, and the interfascicular connective tissue, the genuine tendon cells of the tendon stump also take part. The granulation tissue that results from this proliferation unites both ends of the tendon and gradually changes into genuine tendon tissue (compare with the chapter on rupture of tendons). 4. Wounds of the bone heal in the same manner as fractures, through ossification of the granulation tissue (callus); this is formed from the periosteum and bone marrow, as well as the bone itself (periostitis, osteomyelitis, and ostitis ossificans) (compare with chapter on healing of bone fractures). 24 WOUND HEALING IN DIFFERENT TISSUES 5. Cartilage wounds that are covered with perichondrium (lateral cartilage, trachea, muscles of the ear) heal, similar to bone wounds, through proliferation of the perichondrium with the formation of a callus that is at first fibrous and afterwards ossified. The cartilage cells that fall directly into the cartilage wound undergo fatty degeneration. Synchronous with the prolifera- tion of the perichondrium there occurs a multiplication of the neigh- boring cartilage cells with a new formation of cartilage tissue. In non-vascular articular cartilage, however, the relation is very different. Aseptic, clean, cartilage wounds in the joint never heal, they remain as a permanent defect. Infected, articular- cartilage wounds, on the other hand, healcompletely. Severe irritation of the non-vascular tissue of the wound leads to the formation of granulations and a connective-tissue cicatrix. Afterwards the connective- tissue cicatrix may be even partly transformed to hyaline tissue. 6. The peripheral nerves, when injured, possess an ex- tremely active regenerative ability. Whenanerve suture is applied replacement takes place through new formation of nerve fibers from the old nerve fibers of the central stump; these new fibers grow into those of the per- ipheral stump. When the ends of the nerves, however, remain at least one centimeter apart (neurectomy) the peripheral portion of the incised nerve degenerates, while the central nerve stump anastomoses with neighboring nerves, in this manner the conductivity is again established. At the same time new nerve fibers sprout from the central stump, which fill in the defect between the ends, and extend along the course of the peripheral portion. In this manner the nerve is replaced, when degeneration was complete, or fusion may occur when the fibers are still intact (chemotatic influence of the products of degeneration of the old nerve fibers on the growing central nerve cylinder). Asa result of constant irritation (neuritis) the central nerve end undergoes a new formation of nerve fibers and con- nective tissue, this results in a club-shaped swelling (neuroma), 7. Inthe brain and spinal-marro w—in contrast to the per- ipheral nerves—regeneration of nerve substance does not occur; there is a formation of connective-tissue cicatrix similar to that which occurs in regeneration of muscle. 8. In the non-vascular cornea healing of wounds is similar to that in vascular tissues. One first finds migration of white blood cor- puscles from the neighboring conjunctiva and schlera, as well as a sub- sequent autochthonous cellular proliferation with the formation of fibroblasts and the successive transformation of these into fibrillar con- nective-tissue. The formation of new vessels in the cornea, however, does not take place in the corneal tissue, but proceeds from the margin of the sclera. WOUND INFECTION DISEASES 25 V. WOUND INFECTION DISEASES. DEFINITION.—The term wound infection dis- eases or accidental wound diseases embraces the general surgery of a long list of affections due to wounds which depend on the entrance of microorganisms or their products (toxins). The bacteria gain entrance to the wounds by contact or through the air. They maintain local disease processes in the wound or some form of general derangement. In a narrow sense the most important wound infection diseases are: 1. Suppuration, 2. Phlegmon, 3. Ab- scess, 4. Wound Fever, 5. Septicaemia, 6. Pyaemia. The following diseases may also result from the wound: inflam- mation of the lymph vessels (lymphangitis), inflammation of the veins (phlebitis), as well as erysipelas. In a broader sense wound infection includes tetanus, glanders, Fabies, botryomycosis, actinomycosis, tuber- culosis, malignant edema, strangles, anthrax, black leg, and Wildsewche. The following in- cludes a description of the wound diseases in the narrow sense. I. SUPPURATION OF WOUNDS. CausES.—Suppuration which accompanies healing by second intention is a product of inflammation caused by 1n fec- tion of the wound with pus cocci. The following have been found most often on bacteriological examination : staphylococcus and streptococcus (staphylomycosis, strepto- mycosis). The following are the most important pus forming bacteria : a) Staphylococctts pyogenes aureus is the most frequent pus coccus in animals, especially the horse. They are in the form of small, round, non-motile cocci; ar- ranged as lobules, clusters, or as diplococci; on potatoes, agar, and gelatine they form orange-yellow cultures. Hxperi- ments have demonstrated the fact that their action is due to the production of toxins which act as an irritant and produce inflammation. Subcutaneous injection of a pure culture usually results in the formation of an abscess; intra-abdominal 26 PUS-FORMING BACTERIA injection in fatal suppuration ; injection into the blood, pyae- mia as well as ulcerative endocarditis. Repeated injections have resulted in the seemingly rapid formation of amyloid degenerations (liver, kidneys). Staphylococcus pyogenes aureus is especially common in circumscribed, localized suppuration, in pyaemia, and in the pyaemic form of foal lameness. b) ‘Staphylococcus pyogenes albus: 1s dese common. It is distinguished from the preceding form by its less virulent pathogenic action, and white, varnish-like cul- tures. According to some, it is the cause of moon blind- ness (?). c) Staphylococeus pyogenes citreus isirare: It is characterized by the citron-yellow color of its cultures, otherwise it is identical with the preceding. d) Streptococcus pyogenes is next in importance to staphylococcus pyogenes aureus. It forms cocci arranged in the form of a chain; it does not grow on potatoes, on gelatine it forms very small white colonies. Streptococcus pyogenes is a special cause of progressive phlegmon- ous suppuration with subsequent septicaemia. It is found, therefore, in the septic form of foal lameness. It also appears to be identical with the streptococcus of erysip- elas, strangles, contagious pleuro pneumonia, acute articular rheumatism, and petechial fever (?). e) Bacillus pyogenes appears to be the most im- portant cause of pus formation in cattle and swine; see page 36. f) Bacillus pyocyaneus—the bacillus of blue and green pus—forms small, slim, very motile bacilli. They frequently possess four to six flagella. Through the decom- position of albumen they produce a blue and yellowish-green coloring material (pyocyanin, pyoxanthin) similar to the bacilli of blue milk. Chemically this is closely related to anthracine, it also belongs to the benzol group, and colors the pus and bandage blue or greenish-yellow. While the coloring material is harmless, the bacilli and their toxins have a patho- genic action towards experimental animals, producing an PROPERTIES OF PUS 27 edematous and suppurative inflammation at the point of in- jection. Bacilli with red coloring material are also found in pus. Coron BaciLLus.—The colon bacillus (Bacillus coli communis, Bacterium coli commune) is found in various varieties in the normal intestinal canal. It is present in many species and races, and is usually _ a harmless organism because its very poisonous toxins are neutralized in healthy animals by the action of the gall. Under certain unknown con- ditions the colon bacillus in the intestinal canal becomes highly viru- lent (calf diarrhoea, calf septicaemia, enteritis, peritonitis, cystitis, pyelonephritis, hepatic abscesses, endometritis, septicaemia puerperalis, polyarthritis and omphalo-phlebitis in the calf, malignant head catarrh in cattle, croupous enteritis in cats, as well as various other ‘‘colon bacilli” infections). Inthe subcutaneous connective-tissue it causes suppura- tion with more or less serious phlegmons (septic and gas phlegmon). It is alleged to be identical with Bacterium phlegmasiae uberis, bacillus foetidus, neapolitanus and lactus aerogenes. The following microorganisms may also cause suppuration under certain conditions: actinomyces and botryomyces fungi; the bacillus of glanders; the streptococcus of strangles; the cocci of contagious pleuro pneumonia; the micrococcus pyogenes tenuis and tetragenes ; the capsule coccus (diplococcus); the bacillus pyogenes foetidus; the staphylococcus cereus, albus, flavus; proteus vulgaris, and others. Finally, the courses of many infectious diseases ; namely, suppurations of tuberculosis and actinomycosis are, frequently accompanied by mixed infections of ordinary pus bacteria. For further informa- tion on suppuration, in regard to pus bacteria found in individual do- mestic animals, as well as on the development of so-called aseptic inflammation (injections of oil of turpentine, sublimate, nitrate of silver) compare with the chapter on inflammation. PROPERTIES OF Pus.—Under ordinary conditions pus forms a thick, creamy, yellowish or greenish, non-odorous, non-coagulable fluid (pus bonum et laudible). Asa result of infection with bacteria which produce a colored secretion the pus may be green or blue, seldom yellow. Thin, mucous-like, frothy, odorous pus indicates the presence of decomposition as a result of colonization of septic bacteria in the wound. The condition and quantity of the pus varies with the size and age of the wound, the blood supply and consistence of the wound, the species, quantity and virulence of the bacteria, tempera- ture and season, climate, breed, etc. Pus from the horse is usually yellowish and cream-like; that of cattle and birds is often caseous ; that of swine tenacious and green. 28 PHLEGMON When pus remains for a long time in a vessel one observes two layers. The upper is athin, apparently clear, and yel- lowish fluid ; it forms the so-called pus-serum. Theunder layer is thick and straw-yellow ; it contains the pus-corpus- cles. The pus-corpuscles are formed princi- pally from the white blood-corpuscles that migrate from the blood vessels (Cohnheim). Part of them, however, are descendants of the fixed connec- tive-tissue cells, as well as the degenerated connective-tissue substance of the tissue. Upon microscopic examination one finds, in addition to the pus corpuscles, various forms of pus cocci which are occasionally enclosed within the pus corpus- cles. There are also observed various other bacteria, red blood-corpuscles, tissue cells, drops of fat, crystals of fatty acids and cholesterin. The recognition of cartilage cells and giant cells in the pus are of special importance in the diagnosis of cartilage and bone fistule. The peptone contents of the pus is due to the transformation of the fibrinogen through the activity of the pus forming microorganisms ; absence of fibri- nogen in the pus accounts for its non-coagulability. When the suppuration does not remain confined to the wound, but involves the neighboring tissues in a suppurative inflammation, it leads to the development of a diffuse suppu- rative inflammation of the subcutaneous and submucous cellu- lar tissue (Suppurative phlegmon), a circumscribed accumulation of pus (abscess), a suppurative inflammation of the lymph vessels (lymphangitis), lymph glands (lymphadenitis), and veins (phlebitis), as wellasthe entrance of pus cocci andtheir toxins into the blood (wound fever, septicaemia, pyaemia). Compare with the subsequent chapter. 2. THE PHLEGMONS. DEFINITION.—Phlegmon, phlegmonous inflam- mation, or inflammation of connective tissue are terms used to indicate an infectious, serous, or suppurative inflammation of the connective tissue and all its parts; namely, the subcutaneous, submucous, subfascial, intermuscular, peri- PHLEGMON 29 osteal, perichondral, tendo-vaginal, and interglandular connec- tive-tissue. One speaks, then, of a subfascial or intermuscu- lar phlegmon, of a phlegmon of the subcutis, the perichon- drium, the tendon-sheaths, the udder, etc. CAUSES AND Forms.—Phlegmonous inflammation is due to the same bacteria that are found in suppuration. The streptococcus pyogenes and staphylococcus pyogenes aureus are the most frequent causes of phleg- mons (phlegmone streptococcia or streptomycosis ; phlegmone staphylococcia or staphylomycosis). The pus cocci usually gain entrance to the connective tissue through wounds; punc- tured, contused, and lacerated wounds form the ordinary sources of phlegmons. Very often the previous wounds are very small or entirely healed so that they can no longer serve as a source of entrance to pus forming bacteria. Formerly, the erroneous term of so-called spontaneous phlegmon was given to this condition. Phlegmon may occur at a point more or less removed from the point where the pus cocci gain entrance ; they being carried to this point through the lymphatic circu- lation. It may also occur that the infection of the connective tissue proceeds, not from without, but from the blood stream (metastatic or symptomatic phlegmon of pyaemia, strangles, contagious pleuro pneumonia, glanders). Hemor- rhage and lacerations of connective tissue as a result of con- tusions predispose to phlegmons. Surgically there are various forms of phlegmon. Classified from an anatomical standpoint we have—subc u- taneous, submucous, subfascial, intermuscu- lar. Itisalso spoken of as superficial and deep (e.g. subfascial), orcircumscribed anddiffuse phlegmon. The circumscribed form confines itself to a phlegmonous swel- ling in the vicinity of the wound and frequently leads to the formation of an abscess (phlegmonous abscess). Diffuse phlegmon consists of an inflammatory infiltration of large areas of connective tissue and frequently results in necrosis of the skin, subcutem, fascia, tendons, tendon sheaths (gangrenous phlegmons), whereby other bacteria may also play a part (necrosis bacillus). 30 PHLEGMON Septic phlegmon, in contrast to the ordinary form, is especially virulent. Itis also termed progressive phleg- mon, progressive inflammation of the cellular tissue, or gan- grenouserysipelas. It is due toa mixed infection of pus cocci and specific septic bacteria (streptococcus septicus, micrococ- cus tetragenes, colon bacillus, and others). It is character- ized by a rapid, extensive, ichoric suppuration of the cellular tissue, with a severe, often fatal general infection. The so- called gas phlegmon is a mixed infection composed of gas- forming bacteria (bacillus phlegmonze emphysematosz, colon bacillus). The ordinary suppurative phlegmon is termed simple in contrast tothe specific phlegmons. The latter are not due to pus cocci, but to certain other bacteria, espec- ially the bacilli which cause malignant edema and ery- sipelas (compare with the chapter on these subjects). GENERAL SYMPTOMS OF PHLEGMON.-Circumscribed phlegmon is characterized by swelling, high temperature, and pain over a small area of the skin. At first the swelling has a well defined boundary ; on palpation it may be hard and firm, or soft and fluctuating. Asa result of the swelling and tension the skin cannot be raised. Circumscribed phlegmon- ous swellings frequently result in the formation of an abscess ; it is characterized by fluctuation, a reddish-blue or dark grey color of the skin, and fever. Spontaneous evacuation may occur after necrosis of a small portion of the overlying skin. Healing follows by the formation of granulation tissue, when not evacuated artificially it may result in burrowing of pus as well as in progressive phlegmon. Suppurative lym- phangitis, lymphadenitis, phlebitis, as well as pyaemia and septicaemia may also occur. Diffuse phlegmon is characterized by extensive swelling of the skin—especially on the limbs—fever, and pain (lameness). Subfascial phlegmon is accompanied by especially high fever and severe pain, when the deeper layers are affected the skin may remain unchanged, or presents a slight, edematous, doughy swelling. Intermuscular phlegmon issimilar in appearance. All diffuse phlegmons frequently lead to extensive necrosis of the skin, subcutem, PHLEGMON 31 fascia, muscle, etc. They often result in fatal septicaemia or pyaemia. Septic phlegmon is very acute, spreads rapidly, and usually terminates in death. It is characterized by a high septic fever, extensive gangrenous destruction of the subcutem and neighboring soft parts, namely, the muscles, which are transformed into a discolored, odorous, punk-like, fatty mass, or a thin, ichoric discharge. The diseased parts may crepitate as a result of the formation of foul gases (gas phlegmon, septic emphysema). TERMINATION.—The course of phlegmons varies ac- cording to their character and extent, as well as with the genus of the animal. 1. Circumscribed and diffuse phlegmons are followed by healing through resorption. The latter, especially, frequently heal without necrosis or abscess formation. 2. Abscess formation may result from any kind of phlegmon. The prognosis is more favourable when the phleg- monous inflammation is situated near the surface. Subfascial and intermuscular abscesses are a source of danger, they may be in the form of numerous, small pus foci, or converge to form a large abscess, general infection is liable to occur. Occasionally subfascial abscesses rupture spontaneously on the surface. 3. Necrosis may result from any form of phlegmon. It most often results from septic, subfascial, intermuscular, peri- osteal, and perichondral phlegmons, especially when there occurs a simultaneous influence of the necrosis bacillus (fistu- lous withers, poll evil, quittor, phlegmon of the planter cushion). Necrosis often forms the sourceof septicaemia and pyaemia. 4. Encapsulation of abscesses is most often ob- served in intermuscular phlegmon (shoulder abscess). In dif- fuse, subcutaneous phlegmons on the posterior limbs of the horse the phlegmonous process is occasionally suspended for a long time, healing is only apparent ; sooner or later the phleg- mon returns. Possibly this recurrence explains a previous encapsulation-isolation of individual disease foci, with a sub- 32 PHLEGMON sequent spreading of the inflammatory process as a result of rupture, laceration, or liquefaction of the capsule. 5. Chronic induration or schleroesisioe curs when a diffuse, suppurative phlegmon terminates in a chronic connective-tissue proliferation of subcutaneous, inter- muscular, subfascial, and perichondral tissue. Schlerosis oc- curs on the posterior limbs after phlegmons (elephant leg), grease, or on the head (glanders), and leads to pronounced thickening of the skin; it is termed elephantiasis, pachyderma, or schleroderma. Compare wom the chapter on elephantiasis. TREATMENT.— When there is no evidence of abscess for- mation and resorption is possible, treatment consists in the application of moist, hot fomentations (Prieznitz), or disinfecting bandages (spirits of camphor bandage); antiseptic lotions, warm baths oer cataplasms; ointments of camphor, iodoform, tar, ,carbolic. acid; jcneolin, grey mer ciunyeee well as subcutaneous injections of disinfec- tants. In subacute, and in chronic phlegmons especially, resolution or accumulation of the pus in a circumscribed cavity may be attained by the application of a severe counter- irritant in the form of tincture of 10di1neljonsum. guentum hydrargyri cinereum. Arecolin is a very good internal resorbent. All abscesses, on the other hand, should be treated early by meansofa free incision. Experimental investigations as well as practical experience have demonstrated that early evacuation. of the pus by means of open ince sions is the most satisfactory treatment (disinfectant activity of the oxygen of the air). One may also irrigate the abscess cavity with antiseptic fluids and provide drainage. All necrotic tissue must be removed (amputation of the tail and claws ; resection of the lateral cartilage and the flexor tendon at its point of attachment to the os pedis). The application of massage is contra-indicated, especially for acute phlegmons. OcCURRENCE. — Most phlegmons are subcutaneous. PHLEGMON 33 Phlegmonous inflammations of the subfascial, intermuscular, and perichondral connective tissues, as well as the tendon sheaths are common, especially in the horse. Septic phleg- mons are very common in horses and dogs. ‘The following phlegmons are of special practical importance : 1. Subcutaneous phlegmon of the soft parts of the head (lips, eyelids, zygomatic region, pharynx); throat, and shoulder (subcutaneous injections); 2. Submucous phlegmon of the mucous membranes or the mouth and throat (stomatitis, ¢lossitis, pharyngitis) ; 3. Subfascial phlegmon of the fasciae of the throat, shoulder, and back (poll-evil, fistulous withers); 4. Phlegmon of the muscles of the throat shoul- der, elbows, gluteal region, and abdomen in the horse (deep wounds); 5. Subcutaneous phlegmons of the posterior limbs of the horse in both forms: the ordinary simple and the rare, characterized by abscess formation; 6. Subcoronary and perichondral phlegmons at the coronet (treads on the coronet), and the lateral carti- lages (fistulae of the lateral cartilages), as well as phlegmon of the planter cushion in the horse (nail punctures) ; 7. So-called panaritium of the claws of cattle and dogs, corresponding to the subcoronary phlegmon of horses (see below); 8. Subfascial phlegmon of the fascia lata and the tibial fascia inthe horse (punctured injuries, wounds from blows); g. Phlegmon of the tendon-sheaths of the flexor tendons in the horse (traumatic, suppurative, and metastatic); 10. Subcutaneous and intermuscular phlegmon of the tail in cattle (lung plague injections, so-called tail worm), dogs (contusion), and horses (amputation); 11. Phlegmon of the sheath and scrotum in the horse (wounds, castration, glanders); 12. Phlegmon of the udder in cattle (small wounds, erysipelas, and furunculosis); 34 PANARITIUM 13. Puerpural phlegmon in cattle (septic gas-phleg- mon, so-called puerpural blackleg) from small contused wounds of the vulva and vagina at birth. PANARITIUM.—This name (derived from paronchium—inflammation of the bed of the nail—matrix unguis—) indicates a circumscribed phlegmon of the phalanges. In man, it applies to a special circumscribed, suppurative inflammation of the subcutaneous connec- tive tissue on t..e volar surface of the finger. The word is derived from human medicine, and in veterinary science the application is somewhat false. In man the anatomical structure of the subcutis predisposes to the existence of panaritium. The subcutaneous tissue on the volar surface of the finger is very thick, and its connective-tissue fibers are not parallel with the finger, but run perpendicular to it. Upon the entrance of pus cocci there first occurs a circumscribed inflammatory focus surrounded by fixed connective-tissue fibers (panaritium). The phlegmonous process extends from here to the tendon-sheaths, the periosteum, the joint, and the bone, there exists a progressive phleg- mon (panaritium tendonosum, periostale, articulare, osseum) which may lead to necrosis of the bones, suppurative inflammation of the joints and tendon-sheaths, to necrosis of the tendons, and death of the entire phalanges, even to fatal septicemia and pyemia. Very similar pro- cesses occur on the hoof of the horse, the claws of cattle, sheep, and dogs. All the above forms of panaritium can be observed in the sheep and dog especially. In cattle one can distinguish panaritium of the toes, panaritium between the claws and between the balls. The term phlegmon is more often employed. Subcoronary phlegmon of the horse is analagous to panaritium when it is complicated with phlegmon of the planter cushion, of the perichondrium, of the bursa of the navicular bone, as well as with necrosis of the flexor perforans, with fistula of the cartilage of the hoof, and suppurative inflammation of the pedal joint. 3. ABSCESS. DEFINITION AND CAuSES.—Abscess (abscessus, apos- tema) isan accumulation of pus which is usually the product of a syppurative inflammation; it may de- velop from sufpurative phlegmons, suppurative wounds, puru- lent hematomata, or metastatically through the blood. Pus bacteria, are the most frequent causes of abscess formation (staphylococcus and streptococcus pyogenes). Abscesses in horses are very often due tothe streptococcus of stran- gles and the botryomyces fungus. In other cases the abscesses contain diverse bacteria; occasionally the mi- ABSCESS 35 crococcus tenius, the bacillus pyogenes fetidis, the colon bacillus, and other bacteria are the causes of abscesses. Oc- casionally abscess formation is due toa mixed infection with various microorganisms (tubercular and actinomycotic abscesses). In addition to pyogenic bacteria gas-forming or- ganisms may gain entrance, for example, bacillus phlegmonae emphysematosae, thus the so-called gas abscesses exist. Pus BACTERIA IN DIFFERENT DOMESTIC ANIMALS.—In HORSES staphylococci and streptococci, as wellas botryomyces, are the most fre- quent causes of suppuration. According to Hell there are no positive differential characteristics between the coccus of contagious pleuro- pneumonia and pus cocci; the former may result in pus formation. Foth found streptococci of strangles and staphylococcus aureus in a strangles-abscess in the horse ; he is of the opinion, that under certain conditions, suppuration occurs in horses not affected with strangles, asa result of the activity of a streptococcus that cannot be differentiated from that of strangles by means of our present bacteriological methods. Schuemacher and Willach found a diplococcus in pus taken from a wound on a horse ; they were unable to discover any differential char- acteristics between this and the cause of contagious pleuro pneumonia. They thought that many suppurative processes were related, therefore, to contagious pleuro pneumonia. For shoulder abscess in the horse Bossi named a special pus-organism (micrococcus myositidis equi aureus and albus). According to Baldoni the cocci of shoulder abscess in the horse are identical with the pus cocci of man, except that they are more virulent. According to Jensen botryomyces fungi are the principal organisms in shoulder abscess. Schmidt found strangles cocci in a shoulder abscess. I, myself, found botryomyces fungi in 25-50% of shoulder abscesses ; ordinary pus cocci in 50-75%; occasionally strep- tococci of strangles were found. Lucet and Nocard maintain that abscesses in CATTLE are caused by special pus-organisms that have not yet been described, that they have demonstrated them bacterio- logically and given them special names as follows: streptococcus, staphylococcus, and bacillus pyogenes bovis; bacillus liquefaciens pyo- genes bovis, and bacillus crasus pyogenes bovis. The bacillus pyogenes bovis is identical with bacillus pyelonephritidis. In Swing, ac- cording to Grips, the bacillus pyogenes suis is a specific pus-forming bacterium that can be demonstrated in nearly all abscesses. Ktnneman found a special bacillus in 90% of all processes in cattle, which he named bacillus pyogenes bovis; this is not identical with Lucet’s bacillus. Pure cultures of this organism produce subcutaneous abscesses in cattle, in the vagina they cause a suppurative vaginitis. According to Glage the bacillus pyogenes suis and bovis are identical; it forms the most frequent pus-organism in swine and cattle, and is apparently transmitted 36 ABSCESS to swine through the milk of cattle suffering from disease of the udder. Jensen found the colon bacillus in prostatic abscesses in the DoG, he also found the same organism in suppurative peritonitis, cystitis, and pyelo- nephritis in the same animal. Forms or ApscEss.—The following forms of abscesses are recognized ; hot or cold (caused by acute or chronic suppurative inflammation). Cold abscesses are usually of tubercular, actinomycotic, and botryomycotic origin. Other classifications are: superficial and deep, primary and secondary, symptomatic or metastatire (strangles, pyaemia, tuberculosis, glanders), simple and multiple, congestive or wandering (wandering abscesses either pass downward from their own weight, or upward in the hoof, passing in the direction of least resist- ance), subcutaneous, subfascial, intermuscu- lar, strangles, bone, or hoof abscess. One vale speaks of a fecal or urinous abscess. OccURRENCE.—Abscesses occur in all domestic animals, especially in horses, dogs, and cattle. Avian abscesses have a peculiar, dry, caseous appearance. Abscesses are usually found in the subcutis, lymph glands, beneath fascia, in muscles, and in the mammae; bone-abscesses are rare. In the horse they are most often found in the following parts : pharynx (abscess of the lymph glands), at the coronet (coro- nary abscess), throat (subcutaneous injection), shoulder (shoulder abscess), saddle positions, gluteal region, the leg, the anterior surface of the carpus, and the inner surface of the metacarpus. In the dog their favorite seat is on the head and throat (bites). Abscesses in old cattle usually develop slowly (cold abscesses). Symptoms.—A subacute abscess has the appearance of a circumscribed, hot, painful swelling. It is fluctuating at the center and firm at the periphery. The skin is adherent over its surface. Inthe absence of pigment one observes a reddish-blue or grayish discoloration of the skin, it also has a glistening appearance. Fever often exists at the same time. Deep, or subfascial abscesses are characterized by a diffuse swelling without fluctuation. WOUND FEVER 37 In differential diagnosis one must distinguish between hematomata, phlegmons, galls, and new formations. An abscess is diagnosed as follows: it develops gradu- ally under inflammatory conditions, it fluctuates, the skin is moveable onthe surface, discoloration in white-skinned horses. Fever may alsoexist. To diagnose a deep or subfascial abscess it may be necessary to use an exploring needle. Sometimes deep abscesses are char- acterized by a high, septic, continuous fever, and by an intense, diffuse, very painful swelling. TREATMENT.—The treatment of abscesses is purely surcicala “It consists im early and complete ‘in: cision with subsequent antiseptic irrigation. The formerly used ‘‘expective’’ treatment—-waiting for spon- taneous discharge of pus—is no longer considered good surg- ery. The skin becomes necrotic, the process is prolonged, suppuration is more extensive, especially in subfascial abscesses, when the life of the patient is in danger. Very large abscesses, especially subfascial, should be drained. Caution is required when opening deep abscesses in the vicinity of the larynx; only the skin should be incised with a knife, then bore with the fingers or some blunt instrument (sound, blunt pointed scissors) to the depth of the abscess. The Opened abscess, should not be tamponed, but theated.as an open wound and drained. Cold abscesses may be treated with extirpation of their capsule (shoulder abscess), sutured, and then drained. Subfascial abscesses with pronounced extention, and necrosis of the neighboring fascia and muscle (fascia of the withers in the horse as aresult of fistulous withers) are occasionally incurable (septicaemia). 4. WouND FEVER. NATURE AND CausEsS.—The term fever indicates a role of symptoms that are complex in character ; they are the re- sult of various derangements of the generalsystem. The most important are: elevation of temperature, increased frequency of the pulse, derangement of the distribution of the 38 WOUND FEVER blood and blood pressure, as well as alteration in its composition. The digestive, respiratory, and nervous- system are also deranged. Elevation of temperature is not the only symptom of fever. The exact changes that take place during the existence of a fever are not yet fully understood. The most important changes, on the one side, seem to be increased assim- ilation, especially of albumen, as a result of changes in the blood ; on the other side, the heat center of the brain appears to play apart. This center regulates the distribution of the heat as well as the development of the heat in the body (caloric center). When the heat center is irritated, elevation of the temperature occurs ; when it is weakened or paralyzed, the body temperature becomes subnormal. Irritation of the heat center with a subsequent rise of temperature may be produced in various ways. Traumatic injuries from some instrument or asa result of otherinjuries (burns), or thermic through a high degree of heat (heatstroke, sunstroke), num- berless chemical agents (toxins, ferments, mallein, tuber- culin), reflex action asa result of pain (so-called nervous fever). Conversely, the heat center may become weakened or paralyzed with a subsequent fall of temperature. The factors which cause this condition may be traumatic (de- struction of the heat center), thermic (cold), chemical (antifebrin, antipyrin). In wound fever increased assimilation is combined with alterations in the blood, derangement of the heat regu- lators, and irritation of the heat centers. Apparently this is due to the resorption of dissolved bacterial toxins, as well as certain chemical agen found in the wound secretions. Wound fever may be termed a resorption fever. If the resorbed material is of bactericidal origin—bacteria or their toxins—it is termed a septic or bacterial fever (infection-fever, intoxication- fever, septicemia, pyemia). In a great many cases fever accompanies mild wounds, for example, after castration, or non-infected wounds, subcutaneous bone fractures, blood ex- travasations. ‘The fever is apparently caused by the resorption WOUND FEVER 39 of ferment-like products produced by degeneration of the blood and tissues. Their action on the blood and nervous system is similar to that of the toxinsof bacteria. Fever thus produced: ts called aseptic: or ferment fever, The chemical agents thus generated are ferments of the blood and tissues (fibrin-ferment, histozyme), organic material from the degeneration of cellular tissue (nuclein from the nuclei of white blood corpuscles, free hemaglobin), and occasionally glandular secretions. One observes aseptic fever after the transfusion of blood, as well as in horses that have been restrained. Symproms—Elevation of temperature in wound fever varies according to its intensity and course. In the dog and horse it is classified as mild (39.5° C); medium (40.5° C); high (41.5° C). Wound fever is sometimes continuous (sep- ticemia), sometimes remittent, usually however, atypical. It is seldom intermittent (pyemia). Aseptic wound fever is not characterized by pronounced general symptoms, for example, that following castration in the horse. In septic wound fever, on the other hand, one observes: eleva- tion of temperature, derangement of the appe- tite, digestion, and activity of the heart; ema- ciation; psychic derangements, etc. Septic wound fever is often followed by septicemia and pyemia. (See chapter that treats these subjects). TREATMENT.—The main therapeutic problem consists in the local treatment of the wound. In aseptic wound fever it is usually sufficient to change the band- age, thoroughly remove the pus, and disinfect the wound. . The drainage of wounds and incision of abscesses produces the same result. Septic wound fever, in addition to the above, should be treated internally with febrifuges. The most active surgical antipyretics (especially with synchronous weakness of the heart) are camphor and alcohol, they are best adminis- tered in the form of subcutaneous injections of spirits of camphor. 40 SEPTICEMIA 5. SEPTICEMIA. \ DEFINITION AND CAUSES.—Septicemia (sepsis, blood poisoning, putrid fever) isa severe wound infec- tion disease characterized by the presence of bacteria and their products of degeneration in the blood. Unlike pyemia, it is not accompanied by internal or external local affections (metastasis), but by general changes in the structure of the internal organs. Thisis especially character- ized by swelling of the spleen, and parenehg- matous inflammation of) the liver, the kidmeye the heart, and the other internal oo, cane often occurs that septicemia and pyemia are combined (sep- tico-pyemia, pyo-septicemia). From an etiological standpoint two principal forms of sep- ticemia are recognized: one due tothe action of bacteria, the other to that of chemical poisons (toxins). That due to bacteria is termed bacterial septicemia, bac- teriemia, or septic infection; that which results from toxinsis termed septic intoxication. The former may be transmitted through the blood to other animals, while the blood of the latter is not infectious. Between the two there are transitional forms and combinations (mixed in- fection). If no cause can be found for the existence of sep- ticemia, itistermed cryptogenic septicemia. I. Septic infection is caused by severalibactenar they may be cocci or bacilli. One can differentiate, therefore, between a coccidial and a bacterial septieemaua Some of the cocci which may produce septicemia are the streptococcus septicus and the micrococensame. tragenes; the cocci which produce pyemia, namely, strep- tococcus pyogenes and staphylococcus aureus are also able to cause septicemia. The experimental inves- tigations of Koch have demonstrated the pathogenic action of the following bacilli: the so-called bacillus of mouse septicemia, as well as the baciilus of rao speticemia, the group futher includes the colon bac- illus and the bacillus enteritidis. Specie SEPTICEMIA 4! speticemias, in contrast to the simple forms, may be caused by malignant edema, anthrax, blackleg, the organisin of erysipelas, and hog cholera, the septic form of so-called foal lameness, calf septicemia, septicemia hemorrhagica (wild- seuche), chicken cholera, and chicken plague. 2a oe ptic intoxication) 1s duerto the entrance of the poisonous products of bactericidal metabolism. These products aretermed toxins, ptomaines, putrid virus, Cadaver or septic poisons, and meat poisons, their chemical structure is extremely variable (toxalbumen ; albumoses, organic bases namely, amine and nuclein bases, fatty acids, and aromatic products). Usually these toxins are absorbed from a purulent focus on the surface of the body, or they may be absorbed from the uterus, intestines, lungs, or liver. As a rule it is the above named pathogenic bacteria that colonize in ichoric wounds, in retained decomposing sec- undines (puerpural septicemia), or in ichoric foci in the in- testines and lungs, and whose products of metabolsim are re- sorbed. Otherorganisms, especially the bacteria of put- refaction, can gain entrance to wounds and pus foci in the body. They result in putrid decomposition of animal tissues, from which are formed strong chemical poisons, which are resorbed and cause general intoxication. That form of septicemia due to the products of metabolism of putrefactive bacteria (saprophytes) is termed sapremia. Proteus vulgaris andtheclosely allied bacillus celluleformans (flesh poisoning) are especially dangerious in this connection. Migration of the saprophytes, themselves, to the blood, was formerly supposed to be a cause of septicemia ; according to recent investigations this appears to occasionally take place. PATHOLOGY.—On post mortem examination of animals that have died from septicemia, the following conditions are noted: The blood is of a tar-like consistence and has the appearance of varnish. ‘The blood as well as the solid organs of the body manifesta tendency to putrefy. In septic infection a microscopic examination of the blood reveals the concerned bacteria, which have led to a decomposition Cite white and red blood-corpuscles. ‘The 42 SEPTICEMIA white blood-corpuscles, in particular, are transformed to form- less colonies of bacteria as a result of the numberless organisms. that have gained entrance. Asa result of parenchymatous disease of the vascular walls, there occurs a hemorrhage into the mucous membrane, beneath the serous membranes— especially beneath the endocardium—into the mesome- trium and omentum, kidneys, spleen, and liver. The spleen, liver and kidneys usually show par- enchymatous swelling, the heart-muscle, and occasionally the skeletal muscles, havea cooked ap- pearance. In many cases there also exists an ulcerative endocarditis; a catarrhal, hemorrhagic, and even diph- theretic enteritis; as well as a parenchymatous and hem- orrhagic nephritis. In very acute cases of septicemia these changes are not pronounced. ‘This is especially true of the toxic form, where, similar to poisoning, post mortem may give negative results. (Caution in the inspection of meat !). SyMPpToMs.—Septicemia is the most important and the most frequent general wound infection disease. It is found in the horse after traumatic, pyo-ichoric inflammations of the joints (pedal joint, tarsal joint) and the tendon-sheaths, as well as in severe septic, subfascial and intermuscular phleg- mons. In the cow and bitch septicemia frequently follows parturition (puerperal septicemia). Comparatively speak- ing, swine are very resistant to septicemia (castration). Ac- cording to the seat of origin, the local changes are extremely variable. 1. Septicemia in the horse is characterized by a septic phlegmon around the margin of the wound. Sometimes local wound changes are absent (peracute cases). The general symptoms usually begin with severe febrile indications. The temperature may go to 42 C., and over, occasionally it is accompanied by chills, the pulse is frequent, small, and finally imperceptible, heart weakness is pronounced. In many forms of septicemia, elevation of temperature may fail. One occasionally observes severe general symp- toms: complete loss of appetite (occasionally horses eat a quarter or half ration to within a short time of their death), SEPTICEMIA 43 pronounced emaciation and weakness, heaviness of the sensorium, trembling, sometimes paralysis of the posterior limbs, profuse and continued perspiration, dirty-red or icteric coloration, and echymosis of the mucous membranes, discolored, albumenous urine, and towards the end, profuse diarrhea with symptoms of colic. The duration of the disease is extremely variable ; it may ter- minate fatally within twenty-four hours, it usually continues, however, several days, and may exist for several weeks (in- flammation of the pedal joint). 2 Unseatlie puerperal septicemia is the most frequent form (septic form of puerpural fever). Clinically, both forms of septicemia may be recognized ; infection and intoxication. Puerperal infection is characterized, either by a puerperal philegmon, a septic metritis (fever, straining, groaning, pain on pressure over the abdo- men, stinking, chocolate colored discharge from the uterus, diphtheretic changes on post mortem); or by an acute puerperal septicemia, which is differentiated from the preceding by general septic conditions (sudden loss of ap- petite and lacteal secretions, high fever, yellow mucous mem- branes, and weakness). As a rule it leads to death in from one to three days, and the post mortem changes are frequently slight or imperceptible. Puerperal intoxication ex- ists, either in the form of a parturient paresis (para- lytic calf fever, auto-intoxication), or slight symptoms of dis- ease (weakness, gastric derangement, normal temperature). Retemtion of the attér-birth; especially, is a cause of a mild form of sapremia; sudden paralytic conditions with death after a few hours are rare (De Bruin). TREATMENT.—As in a wound-fever, so in septicemia, local antiseptic treatment of the wound is of greatest importance. Apply powerful disinfectants, carefully remove stagnated wound-secretions, give thorough drainage, incise early all fluctuating spots. A puerperal uterus should be thoroughly irrigated and any retained placentae removed. The internal administration of febrifuges is of secondary im- portance. ‘Those agents which have been of greatest service 44 PYEMIA are: Camphor alcohol; and quinine: Argenta colloidale as wellas quicksilver in the form of small doses of calomel are employed internally. Antistrepto- coccic serum, on the other hand, has not proved satisfactory. 6. PYEMIA. DEFINITION AND CauSES.—Pyemia is a general wound- infection disease ; in contrast to septicemia it is characterized by the formation of suppurative foci of disease in the body (metastases). The bacteria of pyemia are ,essentially those of ‘septicemiay | Thejmosct frequent causes of pyemia are pus-cocci, especially, Staphylococcus pyogenes aureus, dud Strepite- coccus pyogenes. These are found in any abscess, and are the ones usually involved in metastasis (staphylomycosis multiplex, staphylohemia, pyemia metastatica). They enter the blood from a primary pus-focus, colonize in the various internal organs, where they multiply and cause suppuration. An acute or chronic pyemia depends on whether the pus cocci enter the blood ‘stream suddenly, and in large numbers ; or gradually, and in small numbers. In general, pyemia is much less common than septicemia. In the horse it is usually the result. of a septic, degenerating throne. phlebitis arising from wounds of the hoof, umbilicus, of the jugular vein, following injuries of the bone as well as from resorption of internal pus-foci (strangles). Pyemia of foals and calves which develops from a suppurative thrombo- phlebitis of the umbilical cord (pyemic form of the so-called foal lameness or calf lameness) is of practical importance ; these diseases possess no bacteriological individualities, in foal lameness, especially, staphylococci as well as streptococci have been demonstrated as a cause of the disease; in calf lameness the colon bacillus has been recognized. In cattle, pyemia usually develops from the internal organs, especially from the uterus (pyemic form of puerperperal fever), when it originates from a suppurative thrombo-phlebitis of the uterine veins, it seldom results from traumatic gastritis. Strangles in the horse isa specific type of pyemia; the same is true PYEMIA 45 of so-called dog distemper (suppurative folliculitis of the lips with secondary lymphangitis, lymphadenitis, and metastatic formations). Occasionally the origin of pyemia cannot be determined (cryptogenic pyemia). In many cases it is impossible to distinguish between sep- ticemia and pyemia, they both exist at the same time; one then speaks of a pyo-cepticemia. From a standpoint of practical surgery it is essential, however, to differentiate between cases of pure pyemia and septicemia. PATHOLOGY.——The anatomical characteristics of pyemia are a greater or lesser number of suppurative inflam- matory foci (metastatic processes) inthe internal and external organs (lungs, liver, spleen, kidneys, brain, heart, skeletal muscle, joints, tendon-sheaths, etc.). In foal lame- ness, suppurative inflammation of the synovial tissues of the joints is the main characteristic (polyarthritis pyemica). One also observes, suppurative inflammation of other serous membranes, the peritoneum, the pleura, the meninges; as well as suppurative inflammation of the eye (suppurative choroiditis and panophthalmia). Occasionally, one also observes, as in septicemia, an ulcerative endo- carditis and numerous circumscribed hemorrhages on the serous membranes, in the skin, in the eyes, and in the mus- cles. Anatomical changes characteristic of septicemia may also be present (septico-pyemia). Finally, the local changes are sometimes very characteristic ; forexample, asa result of the colonization of numerous bacteria in the venous walls of the wound (umbilical wound), there occurs a suppurative inflam- mation of the vascular walls with suppurative degeneration of the organized thrombus (suppurative thrombo-phle- bitis). This forms a source of the suppurative embolic foci within the body, as well as a point of origin for many bacteria that are present in the blood and inner organs (micrococci). Symproms.—Pyemic wound infection is ushered in with Mvanryine crequently intermittent; very ‘it- regular fever, and occasionally with chills. After this there develop symptoms of metastatic inflammation of the lungs, orsymptomsof abscess formation in 46 THE REMAINING WOUND INFECTION DISEASES the’ liver; kidneys, or brain, pyemic polyaa thritis, tendovaginitis, pleuritis, meningitis, etc. Occasionally, one further observes multiple, sub- cutaneous pus-foci, which often develop suddenly in large numbers in the form of phlegmonous swellings in various parts of the body. Pyemia usually runs a longer course than septicemia; usually from a few days to a few weeks, depending on the seat and course of the metastasis. It may develop into a chronic pyemia with pronounced emaciation of the animal. Recovery is more frequent than in septicemia, although it is uncommon, and convalesence oc- curs only after a long time. Puerperal pyemia (pyemic form of puerperal fever) is characterized by a febrile polyarthritis on the carpal and tarsal joints, mastitis, osteomyelitis, and tendovaginitis of the flexor tendons, as well as chronic parametritis (multiple abscess in the pelvic connnective tissue, chronic emaciation). It occurs in cattle, but is rare in horses. Strangles-pyemia (so-called wandering strangles) develops principally in the form of abscesses of the lymph glands in various parts of the body (superior, middle, in- ferior cervical glands, axillary glands, bronchial glands, omen- tal glands, pubic glands, lumbar glands, popliteal glands) as well as abscess formation in the brain, spinal marrow, omentum, udder, kidneys, pancreas, Orbit TREATMENT.—AsS In septicemia, the principal treatment consists in careful local disinfection, drainage, and incision. On account of its specific action as a febrifuge, quinine may be tried. 7. THE REMAINING WOUND INFECTION DISEASES ERYSIPELAS.—In man, this disease is a specific, infectious inflammation of the skin and subcutem; it involves the rete Malpighi and the papillary bodies. Through the medium of the lymph stream it rapidly spreads over large areas of the skin, and leads to severe general infection; the local changes, however, are usually slight. A superficial wound is usually the point of, origin of the infection. The bacteriological investigations with THE REMAINING WOUND INFECTION DISEASES 47 reference to the bacteria which cause erysipelas are very contradictory. It was formerly thought to be entirely due to the streptococcus erysipelatis, aspecific organism discovered by Fehleisen. Ac- cording to recent investigations (Baumgarten, Fraenkel, and others), the specific action of the coccus of erysipelas, on the other hand, is very doubtful; this organism appears to be identical with streptococcus pyogenes. The theory has been advanced, therefore, that erysipelas is not a specific wound infection disease, buta localized form of septicemia in the skin. According to its virulence, each strep- tococcus may cause suppuration, erysipelas, phlegmon, abscess forma- tion, pyemia, and septicemia (Marmorek). It is also claimed that erysipelas may be caused by staphylococci and typhus- bacilli. In man, therefore, according to the etiology, two forms of erysipelas are recognized: the primary, genuine type, due to strep- tococci; and the secondary type, which occurs during the course of various infectious diseases. The symptoms of erysipelas in man consist in the appearance of a diffuse red swelling in the vicinity of the wound; the swelling spreads very rapidly, and frequently along the course of the lymph streams (migrant erysipelas, ambulant erysipelas.) In other cases new inflammatory foci arise in several distant places, they are manifestly metastatic (erysipelas multiplex). Corresponding to the extension of the erysipelas, there is observed a rapidly developing, high grade fever. As the result of an active serous exudation, blisters are formed in many places on the surface of the skin (erysipelas bullosum). As a rule, the erysipelas heals with rapid sinking of the fever and desquama- tion of the skin. In typical cases the healing is as rapid as the develop- ment (simple, typical, non-complicated erysipelas). In other cases phlegmonous and gangrenous processes are present (erysipelas phleg- monosum and gangrenosum). Other complications are: erysipelatous pneumonia, pleuritis, endocarditis, pericarditis, myocarditis, diphtheria of the pharyngeal mucous membranes, enteritis, intestinal ulcers, nephritis, inflammation of the brain, neuritis, peripheral paralysis of the nerves, suppurative panophthalmia, otitis, parotitis, as well as septicae- mia, and pyaemia. In individual cases it has been observed that new formations (carcinoma, sarcoma, lymphoma, lupus) disappear after an accidental infection with erysipelas. Based on this experience, the un- safe experiment has been made of artificially producing erysipelas on the new formations mentioned by meaus of injections of erysipelatous cocci; the object being, to cause healing (erysipelas inoculation, cura- tive, artificial erysipelas). Treatment of erysipelas consists in epi- dermatic and endermatic (parenchymatous) applications of disinfectants (carbolic acid, creosote, creolin, lysol, tar, ichthyol, tincture of iodine, sublimate ), incisions of the skin, with antiseptic irrigation, application of pressure to the healthy margins (collodion, strips of sticking-plaster), 48 THE REMAINING WOUND INFECTION DISEASES as wellas cold. Recently the antistreptococcic serum has been applied. The fever is treated with camphor. Concerning the OCCURRENCE OF ERYSIPELAS IN ANIMALS def- inite knowledge is scarce. This is partly due to the fact, that the most characteristic symptom, the redness of the skin, is wanting in animals on account of the pigment formation and hair. On the other hand, genuine, typical erysipelas appears to be much less common in domestic animals than in man. For this and other reasons, it is better not to use the word erysipelas in vet- erinary surgery, but in general, to speak of inflammatory edema. In CATTLE, “erysipelas of the udder,” an erysipelatous, in- fections inflammation of the skin, is seen in the udder before and after parturition. The skin, on the posterior quarters of the udder in partic- ular, and occasionally on the inner surface of the tibia, is very red, painful, and swollen. It is alleged that this affection is frequently complicated with phlegmons of the subcutem, and either leads to desquamation and healing, or permanent schlerosis of the skin. A fatal termination is never observed. In the HorsE, phlegmon of the poster- ior limbs is considered erysipelas by many; Kitt, for example, defines it asa dermatitis erysipelatosa, while Schindelka classifies it with the phlegmons. It is very questionable if the so-called erysip- elatous form of scratches is genuine erysipelas. Malzew (Zur Aetio- logie der Mauke. Inaugeral-Disseration. Dorpat, 1899) sustains the theory, that with few exceptions, those inflammations of the fetlock region, known as scratches, are genuine erysipelas. In scratches of the horse he claimed to have found regular streptococci, which were identi- cal with those of erysipelas. Also, according to his experiments, erysipelas could be successfully transmitted from man and dog to the skin on the fetlock region of the horse. Considered from the stand- point ; that specific erysipelatous cocci do not exist (see above); that these cocci are found much more often in non-erysipelatous, simple, suppurative inflammations of the skin; that the disease is neither gen- eral, nor has a tendency to spread ; the erysipelatous nature of scratches is not a well supported fact. On the other hand, perhaps the case described by Semmer (Oesterreichische Monatshefte. 1895, S289) was one of genuine erysipelas. Three horses showed swelling of the lips after transportation in severe cold ; this spread rapidly to the region of the cheeks, the pharynx, the throat, and the anterior part of the thorax. All three horses died after a short time. Post mortem examinations revealed the following condition : an exudate in the swollen portions of the skin that was sero-fibrinous, partly fluid, and partly gelatinous in character; the pleura, pericardium, and peritoneum presented hemor- rhagic inflammations ; in the thoracic and abdominal cavities, as well as in the pericardial cavity, there was an abundance of dirty-red fluid ; on the omentum, and under the pleura of the lungs, there was anabundant MALIGNANT EDEMA 49 extravasate of blood; the spleen was enlarged. A pure culture of staphylococci were secured from the serous exudate of the swollen skin. Experimental cutaneous and subcutaneous injections of these in horses resulted in large, erysipelatous swellings at the point of injection (shoulder), which spread downwards to the carpus; fever and loss of appetite were also noted. In DoGs, among 70,000 cases of disease, I have observed symptoms referable to erysipelas in only four cases; I have described one case in the Wochenschrift fur Tierheilkunde (1894 ). Schindelka’s (Hautkrankheiten. 1903) experiences are identical with mine ; he has observed only three cases of erysipelas in the dog. Moller, also, (Lehrbuch der Chirurgie. 1893) has only occasionally observed typical erysipelas in the dog. In Swink, on the other hand, erysipelas is much more common in the form of erysipelas of the head ; it may also be transmitted by inoculation to other swine (Fehlei- sen). Nothing definite is known concerning genuine erysipelas in sheep, cats, and birds. MALIGNANT EDEMA.—Malignant edema is a specific phleg- mon: it may be termeda sero-hemorrhagic infiltration of cellular tissue with gas formation. Apparently, the cause of the disease may be due to several bacteria. The most important is the malignant edema bacillus (bacillus edematis maligni) dis- covered by Koch. The bacilli of malignant edema form spores ; they are very motile; liquefy gelatine ; take Gram’s stain ; they are anaerobic rods 3 to 5 micro-millimeters in length, and one mirco-millimeter broad; they are four times as long as broad and a trifle slimmer than the anthrax bacillus. Several rods become adherent to form threads 10-40 micro-millimeters in length. After the death of the animal the edema bacilli increase rap- idly in length, and form threads which are partly straight, partly curved, and partly twisted; they are arranged in such a manner as to give one the impression of bacilli arranged upon one another in rows. Spores are afterwards formed from these threads. In cadavers of asphyxiated individuals that have been kept for 24 hours at a temperature of 38° C, large numbers of malignant edema bacilli are found in the blood, especially in that of the portal vein (migration from the intestines). By the same method, the so- called cadaver-bacilli are constant in the blood of the liver and in the spleen after 12-24 hours, in the general circulation of our domestic animal cadavers soon after, as the result of death due to dyspnea, especially from colics, when they remain} un- opened for some time in a warm place (confusion with anthrax bacil- lus!). There are also various forms of pseudo-edema bacilli (earth bacilli). The edema bacillus is extremely abundant in nature. It is especially numerous in the upper layers of the earth. If a small 50 MALIGNANT EDEMA amount of ordinary garden soil is brought beneath the skin of a rabbit, the animal dies from malignant edema in from 24-36 hours. The spores of malignant edema are also found in horses that are entirely normal, in the saliva andin the feces, so that infection may readily occur in the oral cavity and in the vicinity of the anus. For this reason, infec- tions are very common in the vagina and in the puerperal uterus. The infection results from an unclean condi- tion of wounds of the skin or mucous membrane; and may be conveyed by means of soil, feces, saliva, dust, etc.,it depends, however, on the entrance of the edema bacillu into the subcutaneous or submucous con- nective issue. The entrance of this organism into the circu- lating blood is comparatively harmless because the oxygen of the blood is fatal to anaerobic bacteria. Inoculation of the cutis also, produces no results (oxygen of theair). It is also difficult for the bacilli to enter granulating wounds. Moreover, the subcutaneous and submucous connective tissue must be previously weakened by means of previous contusions, the entrance of foreign bodies, ulceration, etc., before the edema bacilli gain entrance. This depends, first, on the existence of a nourishing media for the bacilli (serum, lymph, blood). Then the infectious material must be as free as possible from the oxygenated blood, as the oxygen of the blood is fatal to the bacilli. The greater the interruption of the circu- lation in the infected area, the more favorable are the conditions for the growth of the edema bacillus. According to recent investigation (Besson), genuine spores of the edema bacillus cannot develop in the healthy tissues of living animals (phagocytosis). Their development much more dependent on association with other bacteria (microbes favorisants) especially with staphylococci. This condition explains, as in tetanus, that, regardless of the frequency of the occurrence of the edema bacillus (ubiquity), cases of sickness from malignant edema are relatively uncommon in animals. Since Kitt has demonstrated that malignant edema could be ex- perimentally transmitted to domestic animals, numerous cases have been observed in cattle, horses, and sheep (Jenson and Sand, Reuter, Attinger, Elmenhoff, Nielson, Friis, Mesnard, Besson, Horne, de Bruin, Willach, Albrecht, Kitt, Gilruth, Reakes, personal observations). The causes are due to injuries, for example, subcutaneous injections of eserine, injuries of the tongue by means of food, foreign bodies, bites, and perforating wounds; injuriesto the uterus, the vagina, and the vulva (so-called puerperal blackleg which may also be caused by the pseudo- edema bacillus and the genuine blackleg bacillus), operations with un- clean instruments, castration of sheep and goats, amputation of the tail. In the Province of Brandenburg, in 1897, from 600 freshly shorn sheep, 50 died from malignant edema (Lembcken); in New Zealand, in 1900, TETANUS 51 among 4,000 shorn sheep, 300 died from malignant edema. In one case in a horse, I observed a twelve-hour period of incubation. Obviously, malignant edema has been known for a long time in veterinary science but under other names (flying necrosis, black necrosis, fire, progressive cellular inflammation), and formerly as blackleg, sometimes as anthrax and erysipelas, as well as wildseuche and cattle plague. The symptoms of malignant edema consist of a swelling in the vicinity of the point of infection. This develops suddenly, is.edematous, doughy,and very sensitive; it spreads rapidly to the neighboring tissues, and fre- quently crackles on palpation. The favorite seats of the edematous swellings are in the following places: the tongue, pharynx, laryngeal and parotid regions, the head, throat, and upper limbs, the lumbar and sacral regions. The center of the swelling is usually cool, relaxed and painless ; while the periphery is tense, hot, and sensitive. The subcutaneous and submucous connective and fatty tissue, as well as the neighboring muscular tissue, is filled with a gelatinous exudate, and a fou] smelling gas. The yellowish-red edematous fluid contains many characteristic edema bacilli and threads, which are not present in the blood during life, and are only occasionally found in the blocd after death. In many cases, however, the local symptoms are absent. One also notes high grade dyspnea (edema of the lungs), as well as severe gastric derangements (inflammation of the mucous membrane). The disease usually runs its course in a short time (one to three days), terminating fatally with severe febrile symptoms. When the disease is confined to the head, recovery sometimes occurs. On post mortem the spleen, liver, and kidneys are usually intact ; splenic tumors, in particular, are occasionally absent. The treatment, as inphlegmons, consists in making free incis- ions—admit the air—the most active opponent of anaerobic bacilli; provide drainage and apply antiseptics. According to an observa. tion of Attinger, warm fomentations appear to be contra-indicated ; they favour the extension of the edema. With reference to the liter- ature on malignant edema Cf: Friedberger and Frohner, ‘‘Spec- ial Pathology and Therapeutics’. Sixth Edition, 1904. Vol., II. Also Kitt: Monatshefte fiir praktische Tierheilkunde. Bd. VIII. TETANUS.—This was formerly considered a disease of the nerves characterized by trismus. As a result of the investigations of Nikolaier and Kitasato it was found to bea genuine wound- infection disease, caused by the bacillus of tetanus. It is most frequently observed in the horse after injuries to the hoof (nail pricks, nailing, treads on the coronet), the posterior limbs and the head, after castrations, after operations on the tail (amputation, setting up), subcutaneous injections, removal of setons, entrance of foreign bodies (kernels of grain) into the guttural pouches. It is also observed 52 TETANUS in cattle (tetanus puerperalis after injuries to the vagina and uterus, castration, umbilical wounds in calves), sheep and goats (castra- tion, inoculation, seton, umbilical wounds). In dogs, however, tetanus is extremely rare ; two cases have been observed by MOller. Among 70,000 diseased dogs, I have never seen a case of tetanus; the experimental inoculations of garden soil into dogs by Nikolaier also gave negative results. Kitt, on the other hand, was able to produce tetanus in dogs by injecting pure cultures. The tetanus bacillus (bacillus tetani) is in the form of a rod, shaped like a stick pin, music note, or cooking ladle ; the end contains a spore. It is found everywhere, especially in garden soil, as well as in earth that has been covered with horse manure, it is also found on the floors of horse stalls. As experimental inoculations with ordinary garden soil have proved, infection usually re- sults from the entrance of bacterial earth; -other ob- jects may act as intermediate carriers of the tetanus bacillus (horse-shoe nails, splinters of wood, instruments, dust of hay, manure, kernels of grain, cob webs). Conditions for the infection are made more favora- ble by the simultaneous existence of other microorganisms, especially the pus-forming bacteria (microbes favorisants). In contrast to the bacteria of septicemia and pyemia, the tetanus bacilli do not enter the blood, but remain at the point of infection where they develop a strychnine-like toxin (tetanotox-albumen), which is resorbed by the blood. Inthe form of tetanospasmin it produces convulsions as a result of its action on the spinal marrow. This toxin contains an un- precedented poisonous; a dose of 0.00025 grams, equal to 4 mg., equal to 1-200 of a minum, produces death in the horse ; it is a thousand times more poison than strychnine (lethal dose for the horse—o.25 grams). The toxin is absorbed by the substance of the axis cylinders of the peri- pheral nerves and carried to the central nervous system. Tetanus, therefore, is to be considered as an infectious disease, in which a general intoxication arises from the local point of infection. Occasionally one observes a seemingly long period of incubation, several days or even weeks (the usual period is from 4-20 days), in which tetanus occurs, for example, after careful disinfection and bandaging of the wound, even after healing and cicatrization are complete. I have ob- served a period of incubation of even forty days in a horse (Monatshefte fiir praktische Tierheilkunde. Igo2). The symptoms of tetanus consist in locking of the jaws (tris- mus) ; convulsive, stiff extension of the head, throat, and back (ortho- tonus); dorsal or lateral curvature of the throat (opisthotonus and pleurotonus) ; stilted, or sawbuck-like position of the limbs; stiff, extended position of the tail and ears ; pronounced contraction of the compressors of the abdomen ; dyspnoea (spasms of the inspiratory mus- cles); increased reflex irritability ; timidity; and perspiration. In horses, the course is either very rapid (death after one to three WOUND DIPHTHERIA 53 days), or acute (death after four to ten days); in other cases, espec- ially in the non-frequent cases of recovery, a subacute and even a chronic course is observed (many weeks). One occasionally observes a contagious-like outbreak of tetanus (experience with military horses and in clinics). The mortality in horses is from 50-80%. The post mortem is apparently negative. Treatment is not very satisfactory (local disinfection ; removal of the foci of infection, ampu- tation of the tail, forexample; removal of external excitants; diate- tics). Administration of chloral hydrate, bromide of potash, morphine. The treatment of horses suffering from tetanus with tetanus antitoxin has not proved satisfactory. Antitoxin, on the other hand, has proven useful as prophylactic previous to operations (Nocard, Labat). With reference to the literature on tetanus see: Friedberger and Frohner, ‘Special Pathology’’. Sixth Ed. 1904, Vol. II. Wounp DIPHTHERIA.—The name wound diphtheria (hospital gan- grene, gangrena nosocomialis) indicates a wound infection disease which was formerly very common, but which has become infrequent under the influence of modern antiseptics. It consisted of a coagu- lation necrosis of the granulations asa result of the action of specific bacteria (necrosis bacillus). The granulations are trans- formed into a yellowish-red, suppurative, ichorous pulp (croupous and diphtheritic form) ; or into a grey, pulpy, gangrenous mass (ulcerative form); or intoa stinking, putrid and soft mass similar to the pulp of a spleen (pulpy form). Treatment consists of burning early, or cauteri- zation of the wound with chloride of zinc. Bayer has described a case in the horse. The tissue in the region of the parotid glands was trans- formed into a greenish-brown, fetid mass; the process was accompa- nied with the formation of the gasses of degeneration, which had pro- duced an emphysematous condition of the neighboring tissues. I have observed similar cases in the horse. GLANDERS.—In rare cases, wounds in the horse become infected with the bacillus of glanders (primary glanders of the skin). This occurs, especially, on the extremities, abdomen, thorax, shoulders, and head. There then develops from the wound, a crater-like glanders ulcer; it is characterized by tenacious, discolored, frequently hemor- rhagicsecretions; from the ulcer, wreath-like swollen lymph vessels extend to lymph glands which are also swollen (glandular lymphangitis and lymphadenitis). Lameness exists according to the location of the glandular processes. Occasionally there also develops a chronic glandular phlegmon, whichmay finally leadto elephantiasis of the extremities and head (glandular pachyderma). I have described one case of this kind in the horse (Report 1883). Richter has described acase of glanders of the eye (glandular keratitis) (Zeit- schrift fur Veterinaerkunde. 1896). For further information concerning glanders, especially with reference to differential diagnosis of the same, refer to text-books on special pathology. 54 - RABIES RABIES.—Rabies is a genuine wound infection disease ; the cause of the infection has not yet been discovered ; infection gains entrance from the saliva through the medium of wounds caused by bites, and then passes into the body. The bites, themselves, present no special characteristics, as a rule they heal similar to the wounds of tetanus. The acquired virus is sufficient for the development of the disease, the appearance of the first visible symptoms may require weeks, and even months (long period of incubation). According to paragraph 35 of the government laws which refer to animal plagues, no attempts can be made to cure animals affected, or supposed to be affected, with rabies; animals affected with rabies must be killed immediately (paragraph 37); those supposed to be affected must be killed or confined (paragraph|34). In man, treatment consists in cauter- ization, cutting out the wound, as well as in the application of strong disinfectants (sublimate, creolin, aqua chlorata, calcium permanganate, etc., carbolic acid is unefficient). BLACKLEG.—This is also a wound infection disease in which the blackleg bacillus gains entrance to the wound only through inju- ries to the skin and mucous membranes (the subcutis and submucosa). Blackleg, therefore, may be considered as a specific phlegmon of cattle, similar to malignant edema. It is characterized by edema- tous swellings of the skin which develop rapidly and crepitate, the cen- ters of these swellings undergo necrotic degeneration, they are located on the upper parts of the limbs, the throat, the shoulders, the inferior surface of the thorax, etc., the motions of the animal are also deranged ; there are swellings in the regional lymph glands; severe general symptoms, and high fever are present. The course of the dis- ease is usually rapid, terminating fatally in from one to three days. Treatment of the area of infection is usually too late (incision, disinfec- tion amputation, ligature). The so-called puerperal blackleg of cattle is usually, not a case of genuine blackleg, but partly a gas phlegmon, partly a malignant edema (Carl); sporadic cases of genuine puerperal blackleg have been identified by Rievel, Olt, and Ostertag. For further information concerning blackleg see text- books on special pathology, as well as Kitt, Monatshefte fur praktische Tierhielkunde. VIII. ANTHRAX.—In contrast to man, anthrax is rarely a wound infection disease in animals. In addition to the ordinary infection through the intestines, one occasionally observes sporadic cases of entrance of anthrax bacilli through wounds in the skin and mucous mem- branes, after previous operations (castration), bites, or punctures from insects. There exists, first, a local inflammatory focus in the skin and mucous membranes (anthrax carbuncle, anthrax edema) this is followed by a rapid general infection, which usually has a fatal termination. Cases of anthrax of the skin and mucous mem- branes were formerly described under the names, carbuncle disease, boil TREATMENT OF WOUNDS 55 fever, anthrax of the tongue, anthrax of the gums, and morbus carbuncularis. WILDSEUCHE.—The so-called exanthematic form of wildseuche exists apparently through the entrance of infectious material into small wounds of the skin or mucous membranes (injuries from the twitch, accidental injuries), and is, therefore, considered a wound infection disease. It is characterized by pronounced edematous swelling of the skin and mucous membrane, as well as the subcutis and submucosa of the head, the oral cavity, the submaxillary region, throat, etc., there also develop symptoms of septicemia hemorrhagica. Death usually occurs after 12-36 hours. Details concerning wildseuche may be found in text-books on special pathology. STRANGLES.—Strangles usually develops from the mucous mem- branes of the respiratory and digestive apparatus. Occasionally there occurs a strangles infection from wounds, whereby the regional lymph glands are involved first. A case of this type has been described by Litfas (Berliner tierarztliche Wochenschrift. 1895). I myself, have observed two cases. With reference to other wound infection diseases (actinomy - cosis, botryomycosis, tuberculosis, lymphangitis, phlebitis, petechial fever) compare with the chapters on these subjects. WouUND INFECTION DISEASES OF THE VETERINARIAN.—The fol- lowing are the various wound infection diseases against which the vet- erinarian should be guarded: phlegmons, lymphangitis, and erysipelas, septicemia and pyemia, eczema on the hands and arms (obstetrics), anthrax, glanders, ra- bies, botryomycosis, tuberculosis. Among 365 officials in the Berlin Abbatoir and Stock Yards (veterinarians, butchers, etc.), 7 had inoculations with tuberculosis on the hands, 3 had questionable nodules (Lassar). ’ VI. TREATMENT OF WOUNDS. ANTISEPTIC AND ASEPTIC TREATMFNT OF WoUNDS.— Lister is the founder of the modern treatment of wounds. Working on the theory that wound infection might be pre- vented by the application of antiseptics, as well as careful bandaging, he employed, in 1867, carbolic acid with a band- age ; the latter being termed a Lister Bandage. This Lister bandage is applied as follows: irrigate the wound with a 2-5% solution of carbolic acid; spray the surrounding air 56 TREATMENT OF WOUNDS with the same solution ; cover the wound with a piece of carbolized silk or surgeons cotton (silk or cotton protective) ; place over this a thick layer of carbolized gauze or other car- bolized dressing ; over this is placed an impermeable layer of surgeons cotton (mackintosh ); the whole is retained by means of a moist, carbolized gauze bandage. Between the years 1872-1875 the Lister bandage was in general use in Germany. Later the use of the spray was dropped and the simple bandage applied. In 1880 the dry iodoform pack supplanted the use of the carbolic acid. Since then, other disinfectants have partially taken the place of iodoform (sublimate, creolin, lysol, tannoform, and other disinfectants). In recent times the use of antiseptics in human surgery has been restricted, in some cases even suspended. Schi m- melbusch and others claim that when a wound has been infected for no longer than one minute there is no certainty of destroying the bacteria with disinfectants. There is no ob- ject, then, in disinfecting the wound, it is even harmful, because the tissues are irritated and the wound secretions are increased. Antiseptic treatment has, therefore, given way to the aseptic method, whichis carried out as follows: the wound is made as dry as possible with the use of a sterilized towel, and without the application of antiseptic fluids; it is irrigated only with sterilized water, or sterilized physiological salt solution (0.6%), and then covered with a sterilized bandage. The material is sterilized in a specially prepared apparatus, it is exposed to steam of not less than 100° C., for a period of twenty to thirty minutes ; the instruments are sterilized in the same manner. Boiling for a long time in a one or two per cent soda solution is one of the surest methods of sterilization. Special care is taken with reference to disinfection of the hands of the operator. After the dirt has been thoroughly removed from the nails, the hands are brushed with soap and water, then washed in warm sublimate, carbolic, or creolin water, and finally rubbed in a fifty per cent alcoholic, or alcohol and soap solution. The following must also be rendered aseptic: the operating field, operating table, clothing of the patient, oper- ators, assistants and helpers, all utensils that are used, as well ANTISEPTICS 57 as the operating field in the vicinity of the wound. Even operating gloves, and masks for the mouth and nose are em- ployed as aseptic protectives. The aseptic treatment of wounds in human surgery has many advantages. Healing follows the natural self-pro- tection of the tissues (leucocytes, blood-serum), and there are only slight changes from external interference. Recently, many surgeons have changed from the purely aseptic method to the antiseptic; since Henle and others, contrary to the conclusions of Schimmelbusch, have demonstrated by means of statistics that local disinfection of the wound is possible within the first few hours, and that the results of the aseptic method are no more satisfactory than those of the antiseptic. Bruns even employed pure carbolic acid to disinfect the wounds, Kuster used the hot iron (Berlin Surgical Congress, 1go1). Antiseptic surgery involves the very difficult, or impossible, disinfection of the hands, which is not improved by the use of sterilized operating gloves ( Berlin Surgical Congress, 1898). ip ssombne present time aseptic suseeny ii veterinary science, has received a very lim- ited use. I have already mentioned this fact in the first edition of this book. The veterinarian deals mostly with old, infected wounds, in which, not asepsis, but thorough antisep- sis, is necessary. Even fresh operation wounds can seldom be given aseptic treatment, for example, in a clinic. Even in a well equipped veterinary hospital the aseptic surgical treatment of horses offers the greatest difficulties. Bandages can be applied only to a limited extent, in some cases it is almost impossible to prevent infection during the operation. When compared with human surgery, infection through the air plays a more important part (dust, hair), against which asepsis is of no use. For these reasons, the BMtisSe pte method),is to be —prefenredy tothe Dseptle in veterinary science. ANTISEPTICS.—In selecting and deciding upon the various therapeutic agents to be used in the treatment of wounds, a general point of view comes into consideration. In the first place, besides the disinfecting properties of the various ma- 58 ANTISEPTICS terials, we must consider the resistance of the organisms in the wound. ‘This resistance lies, as I have fully explained else- where (Lehrbuch der.allegemeinen Therapie), about midway between the very resistant anthrax spores, and blackleg bacilli at one extreme ; and the easily destroyed anthrax and swine erysipelas bacilli at the other. The streptococci and staphylococci, especially,should not be fought with weak disinfectants; their destruction re- quires stronger antisepties (suwbiimate, cred: lin, lysol, tannoform, carbolic acvdtjsolmtiion of aluminum acetate, nitrate of silver). The toxic action of the antiseptics must also be considered, their irritating action on the wound, their decomposition by the secretions of the wound, their strength and form, the price, and the state of healing. In general the following rule should be adopted: employ disinfectants which are ac tive, not too irritating, not easily decomposed, non-poisonous, reasonably active in aqueous solution, prompt in their action on the wound (tannoform). Actual disinfection should be preceded by careful irrigation. The following descriptions refer to the more important disinfectants (detailed descriptions are found in my Lehrbuch der Arzneimitellehre, 6. Aufl.). SUBLIMATE.—This is our most powerful and poisonous dis- infectant. A I-ro0oo sublimate solution quickly destroys all bacteria involved in wound infection. With the ex- ception of ruminants it can be employed on all domestic animals. In cattle sublimate acts as a specific poison, for this reason one must be guarded in its use. When combined with albumenous wound secretions it partly precipitates in the form of an albumenate of mercury, partly decomposes (formation of oxychloride of mercury). The decomposition has no material influence on its antiseptic action ; decomposition may be prevented by the addition of sodium chloride (pastil of sublimate), The advantages of sublimate are: its strong antiseptic properties, non-odor, cost, convenience (sublimate tablets). The disadvantages of sublimate are: pronounced toxicity, espe- cially for cattle ; irritability, especially on the mucous membranes of the eye (ophthalmology), and the uterus (obstetrics); it also rapidly amalgamates the instruments. In France,in the place of sublimate, hydrargyrum biniodidum rubrum is employed ina solution of ANTISEPTICS 59 I: 10,000 to I: 20,000; it is more active and less irritating. Many also prefer hydrargyrun cyanatun to sublimate because it does not amalgamate the instruments. CREOLIN, LYSOL, BACILLOL, AND OTHER CRESOL COMBINATIONS. — The antiseptic action of the cresols is pronounced and rapid. A 3% solution destroys wound infection organisms. The dis- infectant properties of cresol are apparently stronger than those of carbolic acid. It further possesses deodorizing properties; it is relatively non-poisonous, and inexpensive, its disadvantages are: odor, irritating action of strong solutions on the mucous membranes, gradual destructive action on rubber tubes, cloudiness of the solutions. CARBOLIC ACID.—The action is relatively strong. Most bacteria die after a long time in a 3% solution. The official carbolic acid solution is mixed in a 4% solution. The action of carbolic acid seems to be slight towards the infectious material of tetanus, rabies, the tubercle bacillus, and the spores of anthrax. Castration clamps, for example, transmitted tetanus after eighteen months, notwithstanding the fact that they were placed in a 4% solution of carbolic acid for five minutes (Nocard). Advantages: its strength is constant and it does not decompose. Disadvantages: cost, odor, irritating and toxic action, especially the latter, for cats. IODOFORM.—This is an excellent, mild stimulator of granulations ; also used in etherial solutions 1:5-10). Disadvantages: odor, cost, toxicity for dogs (licking), insolubility in water. The following similar preparations from iodine are expensive ; for this reason they are not much employed in veterinary surgery: lorentin, losophan, iodo- phen, europhen, aristol, iodoformin, iodoformogen, iodol, iodtrichlorid (easily decomposed). In actinomycotic infections, iodine and iodide of potash in aqueous solution (Lugol’s solution) is a\specific for actinomycotic infection. TANNOFORM.—At the present time this isour best aseptic cov- ering and dry antiseptic. Applied early to cuts, it checks suppuration (healing under an eschar). In horses it is preferable to iodoform on account of being a more active and non-odorous antiseptic. Other formaldehyde preparations are: glutol, amyloform, and others ; they are more expensive and their action is less constant than that of tannoform. Formaldehyde, itself, in a 1 to 2% solution is a strong disinfectant, it irritates the wounds however ; it is very caustic when concentrated (caution!). NITRATE OF SILVER.—This is an excellent wound dress- ing. Itisastrong disinfectant (a 1: 100 solution is fatal to pus cocci). It is a valuable regulator of abnormal granulations, and leaves a pro- tective covering in the form of an eschar (eschar of silver). The same is true of the more recent but very expensive preparations of silver (argentum lacticum and citricum, actol, itrol, protargol, ichthargan). 60 ANTISEPTICS SOLUTION OF ALUMINUM ACETATE.—This is an excellent non- toxic antiseptic ina 2-8% aqueous solution (also contained in Bur- row’s solution); because of the expense it is preferable to the more costly substitutes: alumnol, tannal, gallal, sozal, boral, salumin, cutol, etc. BisMUTH SAL?Ts.—These are absorbing, astringent, dry antiseptics; their action is similar to tannoform, they seem to be more expensive, however. The following are most often employed : bismuth subnitricum, subsalicylicum, gallicum (dermatol), dithiosalicylicum (thioform), airol (iodid of dermatol). The latter in the form of AIROL PASTE is an excellent aseptic protective covering fo wounds ; it is non-irritating, easily applied, dries rapidly, and is very adherent. ALCOHOL.—This is an important agent for disinfecting the hands of the operator and the skin of the operating field. Itis best employed in the form of a 50% aqueous solution or aqueous solution of sublimate (absolute alcohol has only a weak anti- septic action). Alcoholic soaps are also employed. Alcoholic TINCTURE OF ALOES stimulates granulations on old wounds and is an active antiseptic. TINCTURE OF IODINE is an excellent disinfectant for infected wounds that have a tendency to necrosis. SALICYLic AcID.—A weak antiseptic,it is non-poison- ous however, odorless and non-irritating. It finds ap-- plication in ophthalmology, in irrigation of the internal organs of the body, and in the treatment of cats. Thioform (bismuth dithiosali- cylate) isa substitute for iodoform. It is especially employed because of its non-odor and non-toxicity (very expensive !). Boric Acip.—A mild, non-toxic, and odorless anti- septic; its action is slight (ophthalmology, irrigation of the uterus). The following, with other solutions of boric acid, possess a similar action: borax and borate of magnesia, boral, an- tipyonin, rotterin; antiseptin, borol. CHLORIDE OF ZINC.—A caustic antiseptic (2-8% solnu- tion), its action as an antiseptic is relatively weak (common agent for abnormal granulations). CALCIUM PERMANGANATE.—Weak antiseptic. Specific against snake bites and the toxin of rabies. CamMPHOR.—A powerful antiseptic, especially for torpid gran- ulations, phlegmons, and necrotic processes (spirits of eamphor bandage). Those agents which have a similar action are: oil of turpentine, turpentine (old hoof remedies), thymol oil of eucalyptus, balsam of Peru, and other etherial oils. Tar.—An excellent antiseptic, especially for wounds of the hoofs and claws. Wood tar is preferable to coal tar. AQuA CHLORATA.—Strong antiseptic. Specific for rabies- and snake bites. Employed in ophthalmology. OPEN WOUND TREATMENT AND BANDAGING 61 PYOCTANIN.—Active antiseptic. Disadvantages: blue color. HEAT.—By means of high temperature pus bacteria die in ten minutes at a temperature of 55-62°, the streptococcus of strangles at 60°, the tetanus bacillus at 75°, the spores of tetanus at 100°. OPEN WOUND TREATMENT AND BANDAGING.-—If a wound is aseptically or antiseptically handled, and eventually sutured, a bandage should be applied wherever possible. It protects the wound from the entrance of infection (air, and contact infection), as well as irritants. The bandage should be dry. Such a bandage is termed a dry, aseptic wound band- age. A moist antiseptic bandage is better for ex- tensive wounds, pronounced suppuration, phlegmons, prepa- ration of certain portions of the body for operating, ete. ‘The moist bandage combines protection with a continued antiseptic action ; it neutralizes the action of the wound secretions; the moist warmth assists granulation and cicatricial formation. Through maceration of the skin and horn it may occasionally become injurious.. When a bandage is not changed for a long time it is termed a permanent bandage. Other forms Gmebandages: aré: simple Lister) -pressuare, dry dressings, ointment and tar bandages, iodo- form bandages, antiseptic tampomade, -ete. ‘With referance to bandage materials and bandage technique see: Bayer, Operationslehre. Only the most important rules for bandaging are given here. These are: 1. Every wound, when possible, should be bandaged. 2. The bandage should, after aseptic operations, remain in position as long as possible (following resection of the lateral cartilage, for ex- ample, fourteen days). 3. The bandage must be changed, however ; (a) when it becomes saturated with pus, wound se- cretions, or filth; (b) when improperly applied; (c) when there is pain or pronounced swelling in the vicinity of the wound, or when fever exists. In) veterimary: practice the opem treatment of wounds must often replace bandaging. This is especially true of horses and cattle, in which the application of a bandage in various parts of the body is impossible (gluteal region, up- per limbs). In such wounds the oxygen of the air acts as a 62 TREATMENT OF DIFFERENT KINDS OF WOUNDS disinfectant ; it is of special value in malignant edema. For this reason, the suturing of old oreraee wounds is contra-indicated. The aseptic wound bandage is most readily applied to dogs. When a bandage cannot be applied healing under eschar may occur (dry or moist blood-eschar ; necrosed eschar ; one formed by tannoform, tannin, silver nitrate, dry dressings, etc.). Oint- ments may take the place of a bandage (boric acid, silver nitrate, decubital salve, etc.).. Adhesive remedies per- form the same function (airol paste, iodoform-colodion, zinc paste, bismuth paste, adhesive plaster). In many cases, as in human surgery, permanent irrigation is employed with good results, that is, the wound is irrigated for a long time with an antiseptic fluid. Immersion (water bath) has a very limited field of application (hoof baths, baths for mange). Antiseptic cataplasms are employed to encourage the sloughing of necrotic tissues in hoof injuries, fistulous withers, etc., (linseed meal bandage with creolin water). The appli- cation of linseed meal to any wound is not considered good surgery at the present time (Translator). TREATMENT OF THE DIFFERENT KINDS OF WOUNDS.—I. Fresh incised, punctured and lacerated wounds or bites are treated as follows: arrest the hemorrhage; irrigate; disinfect; and drain ; apply an aseptic tampon; suture as muchas possible; and when practical, apply a bandage. 2. Contused and old, especially suppurating wounds, are not sutured; otherwise they are treated as fresh incised wounds. In many cases of small, old, suppurating wounds, heal- ing by third intention is possible; the modus ope- randi is as follows: trim the margins, irrigate care- fully for along time; disinfect, remiove allio necromie portions, bring the margins of the wound in close apposition by means of sutures (wounds of the head in the horse). When removing foreign bodies or destroyed tissues from con- tused wounds care should be taken not to remove the sound tissue also. This is particularly true of flap wounds (treads on the coronet), where the retention of small flaps of skin is of greatest importance. Contused wounds with pronounced suppuration and tissue necrosis are best treated by meansof moist bandages; as open wounds; or with permanent irrigation. 3. Shot wounds are treated according to the same rules of asepsis and antisepsis as those employed for the treatment of ordinary wounds. TRANSPLANTATION 63 As experience in men has proved that bullets are frequently encapsuled, expective treatment should usually be followed, do -not favour extraction of the bullet (v. Bergman, Kocher). Probing of the wound is also superfluous ; when the finger or probe are not carefully disinfected it is even dangerous to life (keep the finger and probe away). Shot wounds are best treated as follows: anti- septic occlusion and tamponade; or drainage with- out suture followed by a bandage. If for certain reasons it seems necessary to extract the bullet (phlegmons, pain, high fever, etc.), a simple incision is often all that is necessary ; employ foreign- body forceps, curette, etc., in place of special bullet forceps. 4. Joint wounds, when fresh, should be carefully disin- fected; sutured; and when possible, covered with an aseptic occlusive bandage. It is not always possible to bandage perfo- rating joint wounds in horses and cattle; in those cases one may use iodoform-collodion, airol paste, and other adhesive materials, the cau- tery may be used to close the wound witha necrotic eschar, per- manent irrigation is alsoemployed. The earlier employed caustic ap- plications in the vicinity of the joint (closure of the wound by swell- ing) are of little value. Suppurating joint wounds in dogs may be drained, irrigated, incised if necessary, and packed with an antiseptic tampon. In horses and cattle they are frequeutly incurable. 5. Perforating abdominal wounds require careful antisepsis; reposition of the intestines after thorough disinfection ; ligation and removal of the prolapsed omentum, as well as a double suture. 6. Poisoned wounds (snake poison, rabies, etc.) may be ex- cised ; cauterized ; burned ; or treated with specific disinfectants ; po- tassium permanganate, aqua chlorata, liquor ferri chloridi, and calcium bichromate in the form of sub- cutaneous injections. 7, Wounds that are granulating abnormally are treated with the knife, curette, cautery, caustics (nitrate of silver and chloride of zinc), ointment bandages, tincture of aloes, etc. See treat- ment of ulcers. TRANSPLANTATION.—This was first employed by Reverdin, in the year 1870, It was employed in human surgery to provide a rapid covering for granulating wound surfaces. Thiersch also had a broad experience in the transplantation of epidermis. Formerly, pieces of skin, the entire thickness of the epidermis, were transplanted. At the present time the modus operandi is as follows: the rules of asepsis are very carefully observed ; very thin, superficial sections of the skin are removed with a razor, they extend, however, to the papillary bodies ; these sections are about the length and breadth of one’s finger, they are removed from the upper arm or limb, and are transferred from here to the granulations. The granulations have been previously freshened 64 SUBCUTANEOUS INJURIES OF THE SOFT PARTS with a curette, the flaps of skin are applied without coming in contact with any antiseptics (necrosis of the epidermis), they are carefully re- tained in position by means of sterilized tin foil, a dry or moist band- age (salt solution) is employed for protection. If the transplantation is successful the pieces of skin heal to the granulations by first intention ; about the third day they are vascularized by vessels from the granula- tion tissue; and the wound is covered through the formation of new epidermis from these artificial islands of skin. A simpler method con- sists in the removal of the epidermis only, from the healthy skin, this being placed on the granulations. It is also possible to transplant mucous membrane on mucous membrane, as well as pieces of bone with perios- teum and marrow from living young animals to man. On the other hand, the transplantation of nerves, muscles, and tendons, from animals to man has not yet been successful. The difficulties of transplantion consist in the prevention of death of the removed piece of skin on the one hand, and the difficulty of fixing it to the granulation tissue on the other. The latter is especially diffcnlt in animals. Mamadyschski has been successful in horses and dogs with Krause’s method of transplantation. Querruau has successfully treated saddle pressure in the horse by means of trans- plantation. Bayer, on the other hand, has repeatedly employed trans- plantation in horses without results; the great mobility of the skin of the horse hinders exact fixation of the flaps, while the firmness and non-vascularity of the same does not favour rapid growth. Bayer has even retained the flaps by means of sutures and needles without re- sults. Also, the hair on the skin of animals often retards growth. On the other hand, the transplantation of skin and mucous membrane from animals to man is successful; the same is true of the transplantation of spurs to the comb of a cock. SUBCUTANEOUS INJURIES OF THE SOFT PARTS (CONTUSION, LACERATION). I. CONTUSION. DEFINITION AND CAuSsES.—In contrast to wounds of the skin and mucous membrane, which are always accompa- nied by a breach in their continuity, a contusion is an injury to the soft parts without an external wound. It is caused by pressure from a blunt instrument, the skin, because of its elasticity, remaining uninjured, while the underlying soft parts, especially those covering bone are torn. Contused wounds and contusions are due to the same GRADE OF CONTUSION 65 causes. In every other way they are different, namely, symp- toms, course, treatment, and prognosis. This is due to the fact that contused wounds are open to infection, while in sub- cutaneous injuries of the soft tissues the paths of infection are closed. The causes of contusions in the domestic animals are various. In horses they are caused by pressure from the harness, saddle, bit, shoe, faulty nailing of shoes (corns, nailing), calks, kicks, blows, and falls, entering doors, self- inflicted injuries from treads on the coronet, decubitis, etc. In cattle they are caused by horn-thrusts. Bites and chastise- ments frequently produce contusions in dogs. GRADE oF ConTusion.—According to the severity and extent of subcutaneous injuries, different grades of contusions are recognized ; differentiation being based on the injuries to blood-vessels. The simplest division is that which separates a contusion with preservation of tissue from one that results in necrosis. According to the extent of hemorr- hage the first may be further subdivided into contusions with slight or severe hemorrhage. In general, therefore, three grades of contusion are recognized : I. Contusions of the first grade are character- ized by a slight amount of hemorrhage. The extravasate may be evenly distributed through the contused tissues (bloody infiltration), orit may occupy small circumscribed foci (ecchymosis, petechia),. 2. Contusions of the second grade lead either to large subcutaneous accumulations of blood (hema- . tomata ), there are also alleged to be circumscribed effu- sions of large quantities of lymph (lymph-extrava- sate), orto a superficial accumulation of a large amount of blood (suffusion). s ,Contusrons of the third grade result in gangrenous death ot the involved tissues (necrosis, mortifica- tion). The cause of death is due to the deranged circulation brought about by extensive injuries to the blood-vessels (pri- mary anzemic necrosis). Necrosis may also be due to en- trance of infection from without or through the blood-stream 66 SYMPTOMS (secondary septic necrosis). Experimental investigations have proved that the contusion of itself does not cause necrosis. Complete crushing of the contused parts is sometimes ‘termed a contusion of the fourth grade. Microscopic CHANGES IN ContTuSIONS.—The following condi- tions are found in contusions that are experimentally produced in ani- mals: In contusions of the first grade only a laceration of the loose connective tissue, that which is supplied by the smallest blood-vessels. In contusions of a severe grade there is also laceration of the intercellu- lar substance of the tissues, so that the cells are separated from one an- other. In the severest crushing of the tissues, however, the cells usually remain unimpaired. This explains the fact that crushing, alone, does not result in necrosis (Gussenbauer). SymptToms.—Swelling, due to hemorrhage, is the most important symptom (contusion swelling). In contusions of the first grade (bloody infiltration) the swelling is small and diffuse. Large circumscribed swellings characterize second grade contusions (hematomata). Hematomata on the hind limbs of horses become especially large (larger than one’s head); I observed one case in the region of the udder in a horse in which the hematoma contained 25 liters. - Contusions may occur in the following places: skin, mucous membrane, subcutem, subfascia, intermuscular tissues, in the vicinity of joints, within joints (hemarthrosis), in the tunica vaginalis (hematocele, etc.). Superficial excoriations sometimes occur on the skin over the contused area. As long as the contused swelling contains nothing but extravasate, without any mate- rial injury to the skin, and no infection from without, inflam- matory symptomsare absent. This is true of hematomata and is an accurate means of differentiating between a hematoma and an abscess. ‘The consistence of the swelling is usually softer, fluctuation is pronounced, on palpation crepitation may be noted (coagulum of blood). When the contused tissues are rich in nerves, pain may accompany the swelling. This causes lameness when the seat of injtiry is in the following regions or tissues: hoof, periosteum, muscles, and nerves. Severe contusions of the nerves, spinal cord, and brain lead to paralysis, insensibility, and unconsciousness. A reflex paraly- sis of the central nervous system may result from severe peri- COURSE 67 pheral contusions (so-called shock). General symptoms are usually absent. Symptoms of anzemia are observed only in rupture of large blood-vessels. Resorption of extravasate from severe contusions may be followed by febrille symptoms (asep- tic resorption fever), and swelling of the lymph-glands. Fat emboli of the lungs have occurred in man. Inflammation asa result of contusion may result in suppuration and necrosis, it may also assume the form of septicemia. CourRSE.—The termination of the blood-extravasate de- pends upon its size, the degree of contusion, and the infection or non-infection of the wound, it is, therefore, variable. The blood may become resorbed, or encapsuled, orga- nization, suppuration, or necrosis may also occur. 1. Resorption, that is, the absorption of the extra- vasate through the lymph-vessels, usually follows subcutane- ous contusions of the first grade; small hematomata are occa- sionally absorbed in the same manner. ‘The component parts are resorbed in the following order : the blood-serum, the dis- solved fibrin, the degenerated white blood-corpuscles, and finally the red blood-corpuscles ; the latter are resorbed partly in toto, partly in a degenerated condition. The resorbed red blood-corpuscles sometimes accumulate in the lymph-glands to such an extent that the latter have an appearance of dark- red swellings. Red blood-corpuscles which remain in the con- tused areas undergo granular degeneration and give off their coloring matter. The latter is diffused in the surrounding tissues and is transformed into a crystalline hematoiden or a soluble choleglobin out of which are developed color- ing matters similar to those found in the gall; green, red, blue, and black (melanin) (Latschenberger). These are visible only in unpigmented skin where they appear in the form of so- called black and blue spots. Later they are resorbed and dis- appear. 2. Organization and encapsulation, so-called, occur in relatively large hematomata. In the vicinity of the hemorrhagic focus there exists, as a result of proliferation of the autochthonous tissue cells, a cellular infiltration with the formation of fibrous connective tissue. This gradually dis- 68 DIFFERENTIAL DIAGNOSIS places the extravasate and, similar to the so-called organiza- tion of a thrombus, forms a connective-tissue indu- ration as the product of an aseptic, interstitial inflamma- tion (tumor fibrosus). When the connective-tissue mass does not displace the extravasate, but the inflammatory process runs a chronic aseptic course around its periphery, as around foreign bodies, the extravasate finally becomes encap- suled by a connective-tissue membrane (blood-cyst, hygroma). This process of cystic formation is frequently observed in dogs. I have observed one case in which the capsule developed in fourteen days. In the horse one occa- sionally finds small, moveable blood-cysts located subcutane- ously in the region of the withers, as well as subcutaneous hygromata with free bodies (corpora libera). Caseous in- crustations, even cartilaginous and osseous degenerations, may result from the organization of a hematoma (othematoma in dogs, subperiosteal hematomata). 3. Suppuration and ichorous ulceration in contused swellings is only the result of the entrance of infec- tious material into the blood-extravasate. A hematoma then, may terminate in an abscess, under certain conditions the abscess may become encapsuled (shoulder abscess). Diffuse bloody infiltrations terminate in phlegmons, necrosis may develop during the course of the latter and, in case of complications, pass into septicemia or pyemia. DIFFERENTIAL D1aGNosis.—Contusions run an ex- tremely variable course, they may become complicated with wound infection diseases, and they are often confused with other surgical affections. One must consider tumors, phlegmons, hernia, and fractures (crepitation). It is of great practical importance to differentiate between hematomata and abscesses. One must remember that hema- tomata develop suddenly over their entire area ; abscesses de- velop slowly. A genuine hematoma is not characterized by inflammatory symptoms nor general febrile conditions. The periphery of an abscess is hard, that of a hematoma is fluctu- ating. In doubtful cases one may use the exploratory probe. TREATMENT 69 TREATMENT.—The treatment of contused swellings is variable ; it depends on the degree of the contusion. 1. Slight, circumscribed blood- extrava- sates may be‘treated with massage, moist heat, and com- pression, as well as counter-irritants. The object being to bring about resorption. 2. Large hematomata are best treated by means of an incision, this should not be made tooearly. Extirpate encapsuled blood-cysts ; ‘aspiration, with a subsequent injec- tion of tincture of iodine is sometimes effectual. Encapsuled hematomata and hygromata may occasionally be ruptured with force. 3. Necrosis, phlegmon and abscess forma- tion should not be treated with massage. Suppurative and necrotic inflammations are treated according to the rules of antisepsis ; incise, remove the necrotic tissue, drain, and dis- infect. THE MOST IMPORTANT CONTUSIONS OF DomEsTIC ANI- MALS.—The following affections are of special practical im- portance : 1. Contusion of the neck, withers, on the sad- dle position, point of the shoulder, on the ster- num, and in the vicinity of the shoulder in the horse (pol]l- evil, fistulous withers, saddle galls, sternal and shoulder abscess). 2..Contusions of the upper and under lips (twitch), the skin at the angle of the mouth (bit), and the mucous membrane of the interdental space of the infe- rior maxilla in the horse. 3. Contusions of the external angle of the ilium, orbital, process, zygomatic region, etc., especially in horses and cattle (decubitis). 4. Hematomata in the gluteal region, especially in the region of the buttocks, onthe anterior surface of the carpal joint, and on the inner surface of the metacar- pus in the horse. 5. Bursitis intertubercularis and trochan- terica in horses. 70 LACERATION (RUPTURE) 6. Contused swellings on the elbow in the horse and dog (shoe-boil). In dogs they may occur on the neck, or at the tuberosity of the ischium. 7. Contused swellings on the anterior surface of the car- pal joint in horses and cattle, especially in working oxen (knee tumor). 8. Contused swellings over the tuberosity of the os calcis. in horses (capped hock) ; the same on the posterior sur- face of the os calcis (curb). 9. Treads on the coronet, contusions of the pododerm at the angle of the sole (corns), as well as contusions of the balls of the hoof (sore heels). 10. Hematomata in the vicinity of the udder, anterior and posterior in cattle (milk-vein, posterior abdominal vein). 11. Hematomata and blood-cysts on the throat and back of dogs. 12. Hematomata on the inner surface of the ear muscles in dogs (othematoma, hematoma auris). LYMPH EXTRAVASATE.—This name applies to contused swellings which are not filled with blood, but with lymph; they are due to lacera- tion of large lymph-vessels (lymphorrhea). According to Gussenbauer they occur when, as the result of a contusion, the skin is raised from the underlying parts (fascia) and slides over the firm subcutaneous struc- tures. Incontrast to hematomata, lymph-extravasates result in swellings which develop slowly, so that growth is observed for weeks and even months. The effusion of lymph does not coagulate as long as the skin remains intact. On account of chronic development and inability of thrombus formation, as well as resorption, the prognosis is unfavorable. Hoffman has described two cases in the horse (buttocks) ; he also men- tions having observed one case in the cow and dog (ear). Hoffman further refers the so-called knee tumors in horses and cattle to extrava- sations of lymph. Moller and Bayer contradict the occurrence of pure lymph-extravasates on the posterior limbs of horses and on the ear muscles of dogs ; they point out the possibility of a confusion with hem- atomata. I, myself, have not yet observed a lymyh-extravasate in either the dog or horse. II. LACERATION (RUPTURE). MuscLE RuPTURE.—This term indicates a subcutaneous break in the continuity of individual muscles as a result of TENDON RUPTURE 71 severe stretching and tension of the muscles, it is due to blunt forces from without, or pronounced muscular contraction (spontaneous rupture): distinguish between this and open muscular wounds. The rupture may be complete or incom- plete. Diseased muscles are predisposed to rupture (idio- pathic muscle-rupture). The symptoms are deranged mobil- ity, the presence of a space or blood-extravasate at the point of rupture, and a hernia (abdominal muscles). Healing fol- lows through resorption of the blood-extravasate and the formation of a connective-tissue cicatrix; there frequently remains a shortening of the muscles (muscle-contracture). Ruptures of abdominal muscles in large animals are usually incurable (ventral hernia). Treatment consists in the applica- tion of a pressure bandage whenever possible. In dogsa skin incision may be made and the muscles sutured. Muscle-rup- tures are usually seen in horses and cattle. They most fre- quently occur in the following places: the tibialis anti- Gus, the rectus, obliquus and transversus ab- deminrs: the quadriceps femoris (especially male=wastivs lateralis) the gastrochnemius : piuteal. the biceps: brachii and femoris» the mMcoreds; the -lLeyator humeri; pectoralis MminoLs) longissimus dorsi; psoas: (eracillis; infraspinatus; and tensor fascia lata. TENDON RupTuRE.—Tendon-ruptures also, should be dis- tinguished from tendon-wounds, they are subcutaneous breaks in the continuity. The causes are identical with those which produce muscle-rupture. Asa rule they areof external origin (overextension). They may, however, be due to an inner predisposition, such as diseased tendon following inflamma- tion, deranged nutrition, or necrosis (idiopathic ruptures of tendons during the course of suppurative inflammations ot tendon-sheaths, or contagious pleuropneumonia). Complete and incomplete (partial, fibrillar) ruptures are recognized : with reference to the latter, see chapter on inflammation, this being the most frequent cause. Complete tendon-ruptures in the horse most frequently occur in the flexor pedis per- forans, flexor pedis perforatus, flexors of the 12 INFLAMMATION metatarsi, and suspensory ligament; the ex- tensor pedis and achilles tendon are seldom rup- tured. In cattle anddogs the flexor metatarsi and achilles tendon aremost oftenruptured. Thesymptoms of tendon-rupture consist in a peculiar lameness, as wellas the occurrence of a space between the ends of the ruptured tendon (this is not present in rupture of the tibialis, and flexor pedis tendon inthe hoof). On anatomical examination one finds a blood-extravasate in the vicinity of the rupture, the ends of the ruptured tendon are fibrous, and covered with blood. Healing follows resorption of the blood, through the formation of a connective-tissue cicatrix from the tendon-sheaths, the paratendineum, and the interfasicular connective tissue; this afterwards takes on the character of tendon-tissue and may finally lead to tendon-contracture. ‘Treatment consists in the application of a plaster-of-Paris bandage; in dogs a tendon- suture may be applied (compare with the chapter on diseases of the tendons). RUPTURE OF FAascrIA.—-Subcutaneous rupture of fascia may lead to the formation of a so-called muscle hernia, that is, to the protrusion of a portion of the muscle through the rent in the fascia. I have observed many cases in horses on the posterior limbs, on the neck, and on the shoulder (her- nia of the semimembranosus and levator humeri). With ref- erefice to rupture of vessels, nerves, and articular ligaments refer to the chapter on diseases of the vessels, nerves, and joints. INFLAMMATION. I. NATURE AND CAUSES. NATURE.—Inflammation is a highly complicated reac- tive process in irritated tissues. (According the investigations of Cohnheim, v. Recklinghausen, Pfeffer, Metchnikoff, and others, the principal changes are as follows : I. The irritation of peripheral centers iom circulation produces, reflexly, a vasodilitation THEORIES OF INFLAMMATION 73 (vasodilators) of the arteries, veins and capillaries of the in- volved tissues ; this is the first change that occurs. 2. Acceleration of the blood-stream occurs with the vaso- dilitation. This is soon followed by a diminished ve- locity in the flow of the blood; finally the flow of the blood is entirely suspended (stasis). 3. When retardation of the blood-stream occurs, the white blood-corpuscles are arranged next to the vessel walls, especially in the veins; while the red blood-corpuscles occupy the center of the stream. At this period the white blood-corpuscles pass through the walls of the vessels (Migration) in the direction of the irritant (che- motropismus, chemotaxis, phagocytosis), whereby cellular infiltration of the inflamed tissue occurs. 4. Asa result of changes in the vessel walls there occurs an active transudation of blood- serum through the diseased walls of the vessels (inflam- matory transudate, exudate), occasionally there is also a passage of red blood-corpuscles through the capillary walls (diapedesis). In this way the so- called inflammatory swelling is produced. 5. Finally, in addition to the emigrated white blood-cor- puscles, the fixed autochthonous connective- tissue cells proliferate (division, proliferation) and take part in the inflammatory process, especially in the cellular infiltration. THEORIES OF INFLAMMATION.—According to recent theories on inflammation the primary process is the irritation of the local vasomotor nerves; the secondary process is the migration of the white blood-corpuscles according to the law of chemotaxis, as wellas the changes which take place in the vassel walls (v. Reck- linghausen). The importance of chemotaxis for the process of emigration of the white blood-corpuscles has been clearly demonstrated by Pfeffer. Formerly the primary, essential processes were supposed to be the changes in the walls of the vessels, the inflammatory exuda- tion, and the migration of the white blood-corpuscles (emigration theory of Cohnheim). Metchnikoff demonstrated the phago- cytic theory whereby the white blood-corpuscles form a protection against the entrance of inflammatory irritants by migrating and de- 74 CAUSES OF INFLAMMATION stroying them (devouring cells). According to Metchnikoff inflamma- tion is merely a “phagocytic reaction’ with certain attendant symptoms. Among the old theories of inflammation, the humoral, cellular and neural theories are of historical interest. Virchow es- tablished the cellular theory of inflammation, according to which, the inflammatory stimuli irritate the cells of the tissues, these hypertrophy and proliferate thus drawing large quantities of fluid nourishment from the blood (attraction theory, nutritive stimuli). The humeral theory of inflammation accounts for the nature of inflammation in changed conditions of the blood (dyscrasia). According to the neural theory the nervous system plays the principal part in inflammation (paralytic and spasmodic theories of inflammation by Bricke, Stilling and others). CAUSES OF INFLAMMATION.—The inflammatory stimuli that are operative on animal tissues are extremely variable in their nature. Mechanical, chemical, thermic and infectious causes may prepare the tissues for inflammation. In general inflammation according to causes may be divided into two, practical, very important groups. One group may be termed an aseptic or non-bacterial (non-infec- tious) inflammation; it is caused, not through the action of bacteria, but as a result of mechanical, thermic, and chemical influences (traumatic inflammation, burning, acrids). The other group includes the septic or bacterial (infec- tious) inflammations; they are due to the activity of micro- organisms. ‘The following are the most important causes of inflammation : I. Mechanical irritants (wounds, pressure, con- tusions, strains, ruptures) produce the so-called traumatic inflammations: wound healing by first intention, healing of subcutaneous bone-fractures, muscie and tendon-ruptures, that form of inflammation of the pododerm known as laminitis, non-infectious inflammations of the joints (spavin, ringbone, chronic deforming gonitis, omarthritis and coxitis, chronic podotrochlitis), tendons, tendon-sheaths, mucous burs, and bones. A purely traumatic aseptic inflammation may combine with one that is bacterial and infectious in character (healing per secundam, healing of compound bone-fractures). 2. Thermic irritants in the form of heat and cold. Purely aseptic inflammations of this kind are burns (red- CAUSES OF INFLAMMATION 75 ness, vesicles) and rheumatic inflammations, especially mus- cular rheumatism (non-bacterial inflammation of mus- cle due, simply, to irritation from cold). These thermic aseptic inflammations may afterwards combine with one that is infectious in character (suppurative infection of blisters). 3. Chemical irritants may produce various kinds and grades of inflammation without the aid of bacteria, especially suppurative inflammations. Experimental subcutaneous in- jections of sterilized chemicals (oil of turpentine, creolin, nitrate of silver, ammonia, and legumin) under aseptic precau- tions, produce an acute suppurative inflammation in the ab- sence of bacteria (Grawitz, De Bary and others). Inflamma- tion due to chemical irritants is of practical importance in ther- apeutics: through the application of irritants to the skin various grades of inflammation are produced for the object of healing (rubefacients, vesicants, pustulants, suppurants). 4. Infectious inflammations are caused by the en- trance of microorganisms into the tissues. ‘There are a great many kinds of bacteria that may cause bacterial or septic in- flammations; namely, staphylococci, streptococci, edema bacillus, tubercle bacillus, glanders bacillus, anthrax bacillus, botryomyces and actinomyces. Examples of infectious in- flammations are: suppuration of wounds, phlegmons, suppu- rative arthritis, tendovaginitis and pododermatitis. None of these organisms are mechanical irritants; inflammation is due to their chemical pro- Mucts of metabolism (toxins): | Leber was. the first to discover that infectious inflammation was due to chem- ical irritants. From a culture of staphylococcus he isolated a crystalline chemical substance (phlogosin) that has the pro- perty of inducing inflammation. The so-called parasitic inflammations (sarcosporidia) are of slight significance from a surgical standpoint ; they also appear to be due to the action of chemical bodies (sarcozystin). Finally, certain factors of the disposition have an influence in the production of inflammation (constitution, idio- syncrasy, immunity). 76 KINDS OF INFLAMMATION II. KINDS, SYMPTOMS, AND COURSE OF INFLAMMATION. KINDS OF INFLAMMATION.—According to the character of the exudate various kinds of inflammation are recognized : I. Serous inflammation is characterized by a serous, watery, lymph-like exudate containing very few white and red blood-corpuscles. Itis the slightest grade of inflam- mation ; the blood-vessels are only slightly changed. It occurs intheskin and subcutum (inflammatory edema, blisters, dermatitis bullosa); on the serous membranes of the joints, tendon-sheaths, and mucous bursae (serous arthritis, tendovaginitis and bursitis ; hydrops of the joints, tendon-sheaths, and mucous bursz) ; as well as on the mucous membranes (catarrhal inflammation). 2. Fibrinous or croupous inflammation is char- acterized by the formation of an exudate that is very rich in fibrin and white blood-corpuscles. As a result of this, croupous membranes (so-called fibrinous pseudo-membranes) are deposited on the inflamed tissues; leucocytes and fibrin threads make up the essential composition of these mem- branes. If a serous exudate is present at the same time it is termed a sero-fibrinous inflammation. Fibrinous in- flammations most frequently occur on the serosa of the joints, tendon-sheaths, and mucous bursz (arthritis, tendovaginitis, bursitis fibrinosa), on the mucous membranes (membranous conjunctivitis, as well as on the iris (fibrinous iritis of moon- blindness). 3. Suppurative inflammation is a special form which is usually due to an infection with pus-forming bacteria (streptococcus and staphylococcus pyogenes). The suppura- tive exudate is composed partly of emigrated white blood-cor- puscles, partly of. proliferated fixed connective-tissue cells. A circumscribed collection of pus in a tissue is termed an abscess. A diffuse suppurative inflammation is termed a suppurative infiltration; an accumulation of pus in joints, or in the cavities of the head, is termed empyema; suppurative inflammation of the mucous membranes, sup pu- rative catarrh; of the mucuous membranes of the eye, SYMPTOMS OF INFLAMMATION TE blennorrhea ; the skin of the external auditory canal, otorr- hea; purulent vesicles on the skin are termed pustules. 4. Diptheritic inflammation consists of a coagula- tion necrosis of the mucous membranes ; that is, in a deposit of fibrin in the tissues with necrosis of the cells. It leads, either to the formation of a so-called diptheritic pseudo- membrane, or to a loss of substance (diptheritic ulcers). 5- Hemorrhagic inflammation is characterized by the presence of large numbers of red blood-corpuscles in the exudate, which have left the vessels either per diapedesis of per rhexin. This form of inflammation always involves severe alterations in the walls of the blood-vessels. 6. Necroticor gangrenous (ichorous, putrid) inflammation is characterized by a discolored exudate under- going putrid degeneration (mixed infections with septic bac- teria and putrefactive fungi. ) 7. Productive or proliferative (hyperplastic) inflammation runs a chronic course, and results in new forma- tions of tissue (thickenings, adhesions). According to the. character of the new tissue it is termed indurated, schlerotic, ossifying, deforming, adhesive, pannows, fungows, verrucose, ete. 8. Specific inflammations correspond to specific in- fectious diseases (tuberculosis, glanders, actinomycosis, botry- omycosis, strangles, anthrax). With reference to erysipela- tous and phlegmonous inflammations see pages 28 and 46. SyMPTOMS OF INFLAMMATION.—The cardinal symptoms of inflammation are: heat (calor), redness (rubor), swelling (tumor), and pain (dolor) ; disturbed function (functio laesa) may be added asa fifth symptom. 1. Increased heat is most pronounced in acute inflam- mations. In veterinary science it forms an important sign for the determination of the existence of inflammation, as the in- flammatory redness is frequently invisible. Heat is due to an increased blood-flow, not to an increase in the production of local warmth in the inflamed tissue. 2. Inflammatory redness, in most animals, is usually 78 TERMINATION OF INFLAMMATION invisible in the skin on account of the hairand pigment in that tissue, on the mucous membranes, however, it is readily ob- served. Redness is due to the dilitation and pronounced fullness of the vessels (inflammatory hyperemia). One distinguishes between injection redness, where only individual vessels ap- pear to be strongly injected, and diffuse inflammatory redness. 3. Swelling is the result of an increased blood-supply and an inflammatory transudate. According to the character of the exudate and the kind of tissue in which the disease is located, the consistence of the swelling on palpation is ex- tremely variable: soft, firm, fluctuating, (abscess, hydrops of the joints and tendon-sheaths), or crepitating (fibrinous arth- ritis and tendovaginitis). Swelling is most pronounced in the widely reticulated tissue of the subcutis, in inflammation of the tendon-sheaths, joints, and glands. 4. Pain is due, partly to the pressure of the inflamma- tory swelling on the nerves, partly to the involvement of the nerves in the inflammatory process (neuritis). Acute inflam- mations of organs that are provided with a rich nerve-supply are extremely painful: skin, pododerm, periosteum, joints, eyes ; chronic inflammations are usually less painful. Sudden relaxation of pain in an acute inflammation indicates a bad prognosis (necrosis of the pododerm). 5. Disturbed function is characterized by lame- ness, suspension of the glandular secretions, opacity of the cornea, etc. ‘There is also a disturbance of the general condi- tion ; this is partly due to the pain, partly to the absorption of febrile producing irritants. COURSE AND TERMINATION OF INFLAMMATION.—One recognizes an acute (existing for a few days), and a chronic course (longer duration, at least four weeks), occa- sionally a peracute (existing a few hours), and a su ba- cute (existing for one or two weeks). With reference to the extent of inflammations, they are classified as super fi- cial, and deep (parenchymatous, itnterstitiam local or circumscribed, and diffuse or progres- Sive. Finally we have inflammatory primary and secondary foci (metastatic, embolic, general- THERAPEUTIC METHODS 79 ized, that is, an inflammation spread over the entire body through the medium of the blood-stream). The following are the most important terminations of inflammation: 1. The inflammatory product gradually disappears (res- olution) asaresult of the resorption of the inflammatory product through the lymph-stream under the influence of the white blood-corpuscles (phagocytosis, hystolysis). 2. The retention of inflammatory new forma- tions in the form of thickenings, indurations, and adhesions (schlerosis, elephantiasis, tendon callus, exostosis, dermatitis verrucosa, etc. ). 3. Gangrene may result from severe disturbances in the circulation or complications with septic infection. With reference to inflammations of individual organs see chapters on inflammations of the bones, joints, muscles, ten- dons, nerves, vessels, glands, skin, etc. III. TREATMENT OF INFLAMMATION. THERAPEUTIC MrtTHODS.—Those processes which take place in the tissues under the name of inflammation are con- sidered necessary reactions of the body whereby external irri- tants are expelled, and the body again assumes its normal condition through the expulsion of these derangors of its func- Hou.) Therefore, the inflammatory! procesis, as such, should not be combatted. The essential problem of surgical therapeutics consists in the support of the body in its endeavors towards self-protection and natural ad- justment, rather than in derangement of natural healing by means of improper treatment. Direct etiological methods of treatment are possible only in cases of septic inflammation (antiseptics). In all aseptic inflammations—those not due to bacteria—indirect, symptomatic therapeutics are the only ones to be considered. These consist in the application of rest, heat and cold, massage and cutaneous in titat ion, REsT.—Rest for the affected part is the fundamental treatment for nearly all painful inflammatory conditions. 80 HEAT Mere rest is all that is:required for recovery from many inflammations. This is true of distor- sions of the joints, aseptic inflammations of the hoof, and all chronic deforming inflammations of the joints (spavin, ring- bone, gonitis, omarthritis). In any case, rest supports the action of other remedies. Motionisseldom indicated : chronic inflammation, for example, chronic muscular rheumatism. Rest, from a therapeutic standpoint, involves the removal of the cause of inflammation—the inflammatory irritant—the shoe or nail in inflammation of the pododerm ; the saddle, harness, and check-rein in inflammatory conditions of the withers, saddle position, and jaw; irritating foreign bodies from beneath the lid in conjunctivitis; removal of loose pieces of necrosed cartilage and bone in chronic inflam- matory processes (fistula of the lateral cartilage, bone-fistula). HrAT.—Heat is indicated in all aseptic forms of in- flammation, but especially forthe subacute and chronic inflammations. Heat favors resorption of the inflammatory exudate. This is due to stimulation of the circulation, diffu- sion and migration of the phagocytes, as well as to softening and breaking down of the inflammed tissue. Heat also re- lieves pain by means of relaxation. Moist heat is especially useful in the form of frequently renewed Prieznitz ban- dages. The bandage is applied cold, this produces at first an active contraction of the vessels which is soon followed by pronounced dilitation. Frequent application of this bandage— every three to six hours—regulates the deranged circulation and has a favorable influence on the disturbed general condi- tion (temperature, blood-pressure, activity of the heart, dis- tribution of the blood, and nervous system). Warm poultices (cataplasms) exert a similar action ; they are more difh- cult to apply to animals (antiseptic cataplasms in inflammation of the hoof). Recent methods of heat therapeutics in man are the hot-air treatment, the hot-engorge- ment (Bier), andthe therapeuticsof light (thermic action of red rays, chemical, bactericidal action of blue rays). A new heating apparatus with constant action has been in- vented by Ullman under the name hydro-thermo- ‘vas COLD 8I regulator; Bayer has recommended its use for thiewinomscwm ) we application of heat isi-con- tra-indueated an: all septic’ inflammations, especially in septic phlegmons, as well as Mmalieonant edéemas; it favors the extension of the process and the multiplication of the infectious material. CoL_p.—This is indicated only in septic, as well asin the first stages of acute and very painful inflammations (tendon, * joint, and hoof inflammations). Its action consists principally in a contraction of the dilated blood-vessels (anesthetic and hemostatic action) ; it also has an antiseptic action on the microorganisms that cause inflammation. Cold retards the motility of white blood-corpuscles and even stops their migra- muon | Lhe application of cold according to a sen of fixed rules is more harmful than use- fulin aseptic inflammations, because the nat- ural healing process of phagocytic reaction is destroyed. According to experiments made by Bayer with employed methods of application of cold, the most pronounced action resulted from permanent irrigation of a shaved area with cold flowing water (water tubes); at the end of one hour tHen temperature had fallen 20°: