Chapter XII

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_Treatment_.--The various treatments adopted for the cure of sub-horny quittor offer the veterinary surgeon a large number to select from. We will describe them in the order in which they are, perhaps, most commonly practised.

_Poultices and Hot Baths_.--As in cutaneous quittor, and as in coronitis, when the pus formation is only suspected, and has not yet broken out at the coronet or elsewhere, then the first indication in treatment is the use of warm poultices or of hot baths. Their application is in most cases productive of pointing at the coronet.

Directly this appears it is a wise plan to thin the wall down with the rasp immediately below the swelling. To some extent it relieves the pressure of the inflammatory products within, and at the same time paves the way for operative measures which may be necessary later on.

With the breaking of the abscess and the discharging of its contents, we may in some measure ascertain the condition we have to deal with. The probe is used, and the abscess cavity explored. The size of the wound, its depth below the upper margin of the wall, the structures involved, and other information, may be thus obtained.

At first, however, the nature of the wound, and the character of the discharges, must largely guide us as to the treatment we adopt. In many cases, even where the abscess cavity is far below the upper margin of the wall, and is presumably in an unfit position to drain and heal, a a regular application of an astringent and antiseptic dressing is sufficient to bring about resolution. If, however, the discharge from the wound continues to be liquid, and the wound itself at one spot refuses to heal, it may be judged that a portion of necrotic tissue is situated under the wall, and affecting the laminæ, the cartilage, or ligament, as the case may be. If this is so, then operative measures must be determined on (see Removal of the Wall, p. 349).

_Blisters_.--Instead of the poultice and hot baths, the pointing of the abscess and the casting off of the slough may be brought about by the application of a sharp cantharides blister. We have, in fact, seen many cases where this treatment was adopted prior to the formation of a fistula, and also in cases where one or more fistulous openings already existed, where repeated blisters to the coronet have alone been sufficient to effect a cure.

We are bound to admit, however, that the treatments of poulticing and blistering are only expectant--we might almost say empirical. At any rate, we admit to ourselves that what we have advised and carried out is not in itself curative, but only a means of assisting Nature to satisfactorily work her own ends. Empirical or not, however, we believe that in every case of quittor it is wise in practice to at first adopt some such simple measure, for in nearly every instance where operative measures are practised, the patient must be laid aside for at least several weeks, whereas in this way he may be kept at work and a cure effected at the same time.

_The Actual Cautery_.--Largely of the same empirical nature, yet doing something a little more calculated to destroy necrotic tissue and bring about its sloughing is the use of the cautery, both actual and potential.

The actual cautery may be beneficially employed for the relief of sub-horny quittor in at least two ways.

In the first place, it is often used--a blunt 'point-firing' iron being the instrument--instead of the knife as a means of evacuating the contents of the coronary abscess. Those who use it for this purpose are able to say this in its favour: it brings about the opening of the abscess without the unsightly hæmorrhage attending the use of the knife, and at the same time just as effectually empties it. The opening made is not nearly so likely to close prematurely--that is, before a proper course of treatment of the wound has been carried out--and so leave necrotic tissue at its bottom. The intense tissue reaction it sets up is productive of a large slough, cast off by highly active inflammatory phenomena, which means that the remaining wound is one in which no dead tissue is left, and which is more amenable to treatment.

We have also seen the actual cautery used in sub-horny quittor, where that disease has reached a chronic fistulous stage, as a means of cauterizing the whole length of the lining of each fistulous passage.

At the present day this method is regarded as barbarous, and savouring too largely of the methods and practice of the old empirics. There is no denying the fact, however, that it is at times followed by a speedy and complete cure of what has for months been an intractable and apparently incurable quittor; and, honestly speaking, we ourselves can see nothing very greatly against the operation in certain cases save its appearance. In that it is certainly rough, and is not calculated to favourably impress the more critical of our clientele. With the animal chloroformed, however, much of what can really be urged against it disappears, and on farms and other places where a skilled and competent dressing of an operation wound cannot be looked for, it is sometimes wise to advise this method of treatment in preference to more advanced methods of operating. So far as we can judge, the after-effects are very little worse than those following other operative measures, more especially when a suitable case has been chosen.

This method of treatment is particularly applicable to cases of chronic sub-horny quittor in the more posterior parts of the foot. Here, if one or more fistulas exist, their openings are probed and the direction of the sinuses determined. In all probability they are burrowing down along-side the wall to the sole, where, for want of outlet, they are invading the substance of the plantar cushion or the plantar aponeurosis.

Should this preliminary probing demonstrate that neither of the fistulas run dangerously near the joint, then the operation may be decided on.

The animal is cast and chloroformed, the foot firmly fixed, and the horn of the quarter rasped away quite thin. The sole of the same side is also pared with the knife until the horn of both the quarter and the sole yields easily to pressure of the thumb. All that is then needed is three or four long, round, and pointed irons (about 1/4 to 3/8 inch in diameter) heated to redness. These are inserted into the fistulas, and the false mucous coat of these passages thus destroyed. When the iron, on being directed into the fistulous opening at the coronet, is found to travel alongside the wall, and to easily reach the sole, it should be made to go further still. The sole is penetrated, and a dependent opening thus made for the escape of the discharge that afterwards accumulates.

What happens now, of course, is that an intense and acute inflammation is set up along the whole track of the fistula, in which position the inflammatory changes were heretofore chronic. The whole lining of the fistula, and with it, we hope, all necrotic tissue, is cast as a slough, leaving nothing but healthy tissue behind. This, with a suitable dressing, heals and gives no further trouble.

The after-treatment consists in the application of hot poultices. These tend to greatly ease the pain, and at the same time to facilitate the removal of the slough. The poulticing should be continued, therefore, until the sloughing comes about, which happens, as a rule, at about the fifth or seventh day.

Immediately the slough is cast off, the poultices may be discontinued and dressing of the wound carried out. This consists of injections of solutions of zinc chloride 1 in 200, perchloride of mercury 1 in 1,000, carbolic acid 1 in 20, of Villate's solution, or of such other antiseptic as the surgeon may think fit. The dependent orifice at the sole should be kept open for as long as possible, being occasionally trimmed round with the drawing-knife, and scooped out with a sharp-edged director.

Directly a healthy and pink-looking granulation is observed along the track of the iron, and the discharge therefrom takes on a thick and yellow appearance, the strength of the antiseptic solutions should be gradually diminished. This point, in fact, is of great importance in treating all wounds of the foot. There is a great temptation, on account of the known excessive liability of the parts to septic infection, to use an antiseptic solution unduly strong. What must be remembered is that used _too_ strong they themselves give rise to dead tissue, or to impermeable layers consisting of compounds of the discharges with themselves, and so create substances that prove a source of irritation and subsequent trouble.

_The Potential Cautery_.--This is employed in the treatment of sub-horny quittor, either in the solid form (in sticks, in lumps, or in the powder), or in the liquid form, when it is injected with a quittor syringe.

In the former method such drugs as perchloride of mercury in the lump, or nitrate of silver, chloride of zinc, and caustic potash or soda in the stick, are introduced into each of the sinuses present. This is done by means of a director or a probe.

A better method, however, when the dressing lends itself to the purpose, is to use it in the form of a powder, wrapped in the form of small cubes in extremely thin paper, such, for instance, as is used for rolling cigarettes. It is then conveniently inserted into each fistula. Introduced in this more finely divided form the drug is, perhaps, a little more active in bringing about the desired result.

This method of 'plugging,' although practised by many, we cannot recommend in preference to the use of the hot iron or of liquid injections. Our reasons are these: the action of the drug is a protracted one. Almost immediately after its introduction into the fistula there is formed about it an almost impermeable layer of a metallic albuminate, which effectively prevents further rapid action of the caustic. In addition to thus preventing further action of the dressing, this combination of the tissue albumin with the metal of the salt, together with much necrotic tissue that it has caused, is extremely hard to remove from the healthy tissues. This we explain by pointing out that the action of the caustic, prolonged as it is, sets up a tissue reaction which partakes largely of the type of a chronic rather than an acute inflammation. With a chronic inflammation there is sooner a tendency to the production of fibrous tissue (and thus the firmer attachment of the necrosed portions) rather than an active phagocytosis and the casting-off of a slough. Again, careful though we may be with the probe, it is extremely difficult to be certain that we have discovered the whole extent of any fistula. An equal difficulty, therefore, exists in being certain that we have placed the caustic in the position in which it is most wanted--namely, at the furthermost end of the fistula where the necrotic tissue is to be found.

When a caustic is used at all, it is far better to employ it in the liquid form, when either of the drugs we have just mentioned may again be used. In the first place, the liquid is far more likely to be brought into contact with the diseased structures than is the solid salt. Also, its action may be regulated by altering the strength of the solution, and the liability to form impermeable albuminates thus diminished.

Probably the best solution for use in this way is the old-fashioned Villate's solution (see p. 199).

This liquid should be injected at least every day, and, in a bad case, even two or three times daily. Practical hints to be borne in mind when attempting to cure quittor by means of injections are these:

If the fistulas are numerous, the fluid should be injected into their various orifices.

In order to force the fluid to the bottom of each diseased track, it is necessary, when injecting one opening, to firmly close all others.

Several injections should be made at each time of injection. In other words, we must not be content with just forcing fluid in. It must be forced in, and again forced out by a further syringeful. The fistulous tracks must, in fact, be washed in the liquid.

The effect of the injection during the first eight or ten days is to render suppuration more abundant and whiter. After two weeks of the treatment sloughing of the inside of the sinuses occurs, and healing of the wound commences. Signs that this is occurring are--slight hæmorrhage at the end of each injection, and a gradually increasing difficulty in forcing in the fluid.

_The Making of Counter-openings to the Fistulas_.--Although Villate's solution or any other caustic used in the manner we have described often effects a cure, many practitioners insist on the fact that a counter-opening to the fistula must also be made.

The probe is used and the direction and depth of the fistula ascertained. Through the wall is then made an opening at exactly opposite the lowest point found by the probe, or through the sole if the probe should there lead us. This opening is best made with a sharp-pointed iron, and may afterwards be kept large enough by an occasional trimming with the knife. Many of the older authors, and with them writers of the present day, declare that unless this is done the ordinary injection is likely to fail in a great many instances where it would otherwise have been successful.

Where a counter-opening is thus made it is found that it very readily closes with granulation tissue, and the purpose for which it was made defeated. This may be avoided by the use of a seton. In preference to the seton, however, we ourselves would advise that the opening be kept free by the occasional use of a sharp-edged director or a fine scalpel.

An interesting modification of the practice of making a counter-opening is that related by Veterinary-Captain S.M. Smith.[A] In point of severity it runs a middle course between the making of a simple counter-opening and the removal of a wedge-shaped portion of the coronary band and the wall, a method which we shall later describe.

[Footnote A: _Veterinary Record_, vol ii., p. 157.]

To perform this operation, the animal is cast and chloroformed. The foot is fixed and the parts thoroughly cleansed. The horn of the wall is then sawed through in a direct line from the coronary margin to the solar edge, the saw-line running exactly over the seat of the sinus.

A strong scalpel is now introduced at the coronary opening, with its cutting-edge outwards, and is gradually passed down the opening made by the saw. In this way the sinus is completely destroyed, and from end to end converted into an open wound. The parts are then washed in a perchloride of mercury solution, covered with a mixture of powdered iodoform and boracic acid, over which a pledget of carbolized tow is placed, and then a bandage over the whole. This dressing should be left on three or four days, after which the injury should be treated as an ordinary wound. In conclusion, the author says: 'I can safely recommend this line of treatment to any practitioner having an obstinate case under treatment.'

_Removal of the Wall and Excision of the Necrotic Tissue_.--This we may term the radical operation for sub-horny quittor, for it is often productive of a successful issue when all other means have failed. No matter in what position the sinus is, whether at the extreme anterior portion of the coronet, or whether in the region of the heels, it is to be thoroughly opened up. To do this, the fistula is carefully explored with the probe and a knowledge of its exact dimensions arrived at. This is carefully noted, and the horn of the wall for some little distance around it then rasped down quite thin. Immediately over the sinus, and for a short distance on either side of it, the horn is stripped away to the sensitive structures. The cavity of the fistula is then opened up with a scalpel, and every particle of diseased tissue removed with this instrument and a pair of forceps. After-dressing consists simply in the application of suitable antiseptics.

_When the Complication of Necrosed Tendon or Ligament exists_.--We may take it as an axiom that wherever this exists, whether it is in the extensor pedis, in the lateral ligaments of the joint, or in portions of the flexors, all diseased structures should, where possible, be removed. This is done either with a scalpel or with a curette.

When septic matter has gained the sheath of the perforans, and the formation of pus therein is indicated by inflammatory swellings in the hollow of the heel, it is sometimes advisable to lay the sheath open for 1 to 2 inches along the course of the tendons. This, if a fistula is present, may be best done with a blunt-pointed bistoury, or with a cannulated director and a scalpel. With the pus thus given exit, and an antiseptic dressing regularly applied, the case sometimes ends in rapid resolution. More often than not, however, it is found that the pus has been liberated too late, and that it has gravitated in the sheath to the extent of affecting the plantar aponeurosis. Or it may be, of course, that it was in the plantar aponeurosis the disease commenced. Whichever may have been the case, we have in the hollow of the heel one or more fistulous openings, or an opening we have made ourselves, leading down to a necrosed portion of the terminal expansion of the perforans.

In such cases we ourselves have derived benefit from a regular flushing of the sinuses with a 1 in 2,000 solution of perchloride of mercury, introduced by means of a glass syringe, followed later by flushing in the same manner with a 1 in 40 solution of carbolic acid, the hollow of the heel meanwhile being kept clean with an antiseptic pad and bandage, or by liberal applications of an antiseptic powder.

The septic materials are in this way destroyed, and the wound heals without further complication. We must admit, however, that the cure of the lesion is generally at the expense of slight lameness, due, in all probability, to inflammatory tissue adhesions between the flexor perforans and the perforatus, and to a partial destruction of the synovial membrane of the sheath.

If, in spite of the antiseptic irrigations, the fistula persists, then nothing remains but to resort to excision of the aponeurosis, as described on p. 222.

_When Necrosis of the Lateral Cartilage is present_.--In this case we may at first try the ordinary treatments of poulticing; and blistering, of antiseptic caustic injections, and of plugging. In some cases a cure is effected. Should these fail, however, and we intend to see the finish of our case, then operative measures must be determined on. This means cutting down upon the diseased cartilage, and either removing the necrosed portion, or excising the cartilage in its entirety.

The latter method is seldom practised in this country. As it is the most radical of the two, however, we shall describe it here first.

_Extirpation of the Lateral Cartilage_.--The operation of extirpating the lateral cartilage is by no means a new one, being introduced, according to Zundel, by the senior Lafosse in 1754. It consisted in removing a portion of the wall by grooving and stripping it, and of excising the exposed cartilage by means of a sage-knife.

As to what portion of, and how much of the horn of, the quarter should first be removed, and as to what particular direction each groove should take, opinion among the older writers varied considerably. This we know now is not an important matter, and it is sufficient to say that the first preliminary is a thinning down of the horn of the quarter with the rasp over the position occupied by the cartilage. At the present time there are two or three modifications of the operation as originally introduced. In all, however, the preliminary steps are the same. We shall therefore describe them collectively, as applying correctly to either of the three methods of operating we are about to show.

_Preparation of the Subject and Preliminary Steps in the Operation_.--On the day previous to the operation the horn of the wall immediately over the cartilage must be so thinned with a rasp as to yield readily to pressure of the thumb in any position. It should be so thin as to only just avoid wounding the sensitive structures below.

The whole of the foot must then be thoroughly cleansed, and rendered as nearly aseptic as possible. The use of warm water, soap, and a stiff brush is the readiest means of removing the surface dirt. Afterwards the foot should be soaked for some time in a reliable antiseptic solution, a 1 in 1,000 solution of perchloride of mercury being the most suitable. When removed from the solution the foot must be packed round with wool or tow impregnated with corrosive sublimate, and then bandaged, the whole afterwards wrapped in a thick cloth, or protected with a boot.

On the following day the animal is brought out and cast, and the foot desired to be operated on firmly secured, after the manner described on p. 81. The bandages and sublimate pads are then removed, and the skin of the coronet over the seat of operation shaved of hair. An Esmarch rubber bandage is next run up the limb, and the tourniquet applied, thus rendering the operation a nearly bloodless one.

This done, the animal is chloroformed, and an antiseptic douche played over the foot.

So far, the steps in the operation are common to all methods. There are now, however, three slightly differing modes of extirpating the cartilage, which modes vary simply according to the structures severed by the knife.

_First Method_.--This is the oldest method of the three, and consists in making (1) a horizontal incision through the sensitive laminæ along the lower border of the cartilage, and (2) a vertical incision through the skin of the coronet, the coronary cushion, and a portion of the sensitive laminæ (see Fig. 139).

The flaps (Fig. 139, _a, a_) are now held back by tenaculæ, and the whole of the cartilage, or only the necrosed portion, carefully excised by means of right- and left-handed sage-knives. Fistulous openings in either of the flaps _a, a_ must now be carefully curetted and dressed, and the flaps allowed to fall into position. They are then sutured with carbolized gut, and the wound finally dressed as to be described later (p. 357).

[Illustration: FIG. 139.--EXCISION OF THE LATERAL CARTILAGE (OLD METHOD). The wall covering the lateral cartilage first thinned and stripped off; the two flaps (_a, a_) of skin and the coronary cushion made by the vertical incision turned back. _a_, The operation flaps; _b_, the exposed cartilage; _c_, the sensitive laminæ; _d_, the coronary cushion.]

_Second Method (after Holler and Frick_[A]).--These operators deem it wise to leave untouched the skin of the coronet and the coronary cushion. They therefore make their first incision along the lower border of the coronary cushion (see Fig. 140), afterwards exposing the lower half of the cartilage by removing a half-moon-shaped portion of the thinned horn and underlying sensitive laminæ (see Fig. 140, _b_).

[Footnote A: Two cases of quittor successfully treated by this method are reported by R. Paine, M.R.C.V.S., in the _Journal of Comparative Pathology and Therapeutics_, vol. xv., p. 81.]

[Illustration: FIG. 140.--EXCISION OF THE LATERAL CARTILAGE. (AFTER MOLLER AND FRICK.) _a_, The thinned horny wall covering the coronary cushion; _b_, the lateral cartilage exposed by stripping off the thinned wall; _c_, the sensitive laminæ.]

This done, the external face of the cartilage is separated from the skin of the coronet. To do this a double sage-knife is run flatwise between the coronary cushion and the cartilage, with the convex surface of the blade towards the skin. The knife is then passed backwards and forwards until the necessary separation is accomplished. During these movements of the knife a finger of the unoccupied hand should follow the knife, and guard the coronary cushion against injury.

Following this, the inner surface of the cartilage must be also separated from the structures lying beneath it. To this end a sage-knife (right- or left-handed, according as to whether the anterior or posterior portion of the cartilage is to be first removed) is again passed into the incision. With the cutting-edge of the knife forward, it is gradually reached round and under the hindermost end of the cartilage, and theposterior half of the cartilage separated from underlying structures, and at the same time excised by one clean cut forwards. Using the second sage-knife in a similar manner, the cutting-edge this time backwards, it is reached in front of the cartilage, whose anterior half is then excised by a careful cut backwards. Any small portions of cartilage remaining after this are sought for with the finger, and carefully removed by means of a scalpel and a tenaculum.

The fistulous opening or openings in the skin of the coronet should now be thoroughly curetted, and the whole of the wound dressed as to be described later.

In removing the anterior half of the cartilage it is highly important to remember the close contiguity to it of the synovial membrane of the pedal articulation. This projects as a small sac between the antero- and postero-lateral ligaments of the joint. Risks of injury to it may be diminished by having the foot secured with a line, and pulled forward by an assistant while the cut is being made.

_Third Method (after Bayer)_.--This operator recommends that, after stripping a half-moon-shaped piece of horn from the seat of operation, instead of raising the skin of the coronet and the attached coronary cushion in two flaps (as Fig. 139, a, a), that the cartilage be exposed by raising up one flap only (Fig. 141, a), consisting of a portion of the sensitive laminæ, the coronary cushion, and the skin and underlying structures of the coronet.

With the horse cast and the preliminary steps over, the thinned horn of the quarter is incised in a semicircular fashion, and the half-moon-shaped piece thus separated from its surroundings stripped off. At about 1/4 inch from the incision in the horn, a second incision of similar shape is made through the sensitive structures, which incision is also carried up into the skin and structures of the coronet. This incision severs, from bottom to the top, (1) the sensitive laminæ covering a portion of the pedal bone and a portion of the lateral cartilage, (2) the coronary cushion, and (3) the skin of the coronet and such structures as lie between it and the cartilage.

[Illustration: FIG. 141.--EXCISION OF THE LATERAL CARTILAGE. (AFTER BAYER.) The horny wall is stripped off over the seat of operation. _a_, Semicircular flap of sensitive laminæ, coronary cushion, and skin; _b_, the lateral cartilage; _c_, the sensitive laminæ; _d_, the coronary cushion.]

That this incision of the sensitive structures should be kept at 1/4 inch from the one in the horn has a reason. It is that when this flap is again placed into position (as later it will have to be) we have round its circumference a rim of soft structures into which to place the sutures. And in this connection it is well to advise the operator that the thinness of the keratogenous membrane (the laminal portion of it) should warn him that the portion of it to be turned up--namely, that forming the tip of the flap--should be _scraped_ away quite close to the os pedis. Unless this is done, there will not be a sufficient thickness left to afterwards bring into position and suture.

The half-moon-shaped piece of tissue incised is now carefully dissected away from the external face of the cartilage, until it may be turned up as a flap (see Fig. 141, _a_), and held from off the cartilage by a tenaculum.

The exposed cartilage is now carefully removed by the aid of a sage-knife and a stout pair of forceps, the same precaution of holding the foot well forward being again taken in order to avoid wounding of the articular capsule.

At this stage in the operation considerable care is required. The operator must remember that close beneath him, and more particularly in front, is the pedal articulation. It is better, therefore, to excise the cartilage piecemeal, and to do it carefully, than to attempt, at the risk of injury to the joint, to make the operation 'showy.'

During removal of the cartilage, the terminal branches of the digital arteries are wounded, as also are the veins of the coronary plexus. Should either of these stand out with extra prominence from the others, it should be picked up with a pair of forceps, and ligatured with either carbolized gut or silk.

Attention should then be given to the flap of skin and coronary cushion. Wherever a sinus has existed in it, it is to be carefully scraped, and all dead portions of tissue removed. This done, the flap is allowed to fall into position, and is there carefully sutured, not only at the skin of the coronet, but along the whole circumference of the incision.

_Dressing of the Wound and After-Treatment_.--The whole secret of the success of this operation is in afterwards maintaining a strict asepsis of the wound. Unless there is reasonable room for belief that this may be done, the operation had far better not be advised, for if the wound is afterwards suffered to get into a suppurating and dirty condition, the last stage of the case may be worse than the first Synovitis and arthritis, with certain anchylosis of the joint, and a probable loss of our patient, is almost bound to follow.

We cannot, therefore, too strongly insist upon the advice that the whole of the preliminary antisepticising of the foot that we have described, and the after maintaining of asepsis that we are now about to relate, _must_ be methodically and thoroughly carried out. It is of even _more_ importance than little details in the operation itself.

In the first and second methods of operating, directly the actual operation is over, the surface of the wound and both surfaces of the skin-flaps should first be thoroughly douched with a 1 in 1,000 solution of perchloride of mercury. Bayer prefers a 1 in 5 solution of iodoform in ether.

Next, either iodoform or chinosol in the powder should be dusted over the whole surface, including again both inner and outer faces of the reverted skin-flaps. This done the flaps are allowed to fall into position and sutured there with carbolized silk or gut.

Another liberal application of an antiseptic dressing follows this. Iodoform, iodoform and boracic acid, or chinosol, is freely dusted over the wound and for some distance around it. Bayer, however, again prefers a dressing of the wound, and especially the moistening of the line of sutures with the 1 in 5 solution of iodoform in ether.

Over the wound is then placed a protective layer of gauze, impregnated either with boric acid, with a mercuric salt, or with iodoform.

Finally, numerous small and lightly-rolled balls of dry carbolized tow are packed regularly over the whole of the operation wound, and the foot bandaged.

Practical points to be remembered in this after-dressing are: (1) The balls[A] of tow should be numerous enough to exercise pressure upon the sutured flap when the foot is finally bandaged. (2) The bandage should be run on from the coronet downwards, in order to insure pressure being exerted in the exact position over the sutured flap. (3) Bandages should be used in abundance, commencing always from the coronet, and carefully applied so as to exert an even and uniform pressure. (4) The bandages should be of clean, unused linen.

[Footnote A: Bayer recommends that the tow be rolled into cylindrical tampons, each long enough to cross the wound. These are placed on the wound in alternate horizontal and vertical layers, so that when rolled round by a bandage they are pressed into an even and compact pad.]

Once the bandages are adjusted, the hobbles may be removed, and the tourniquet loosened. Directly the tourniquet is removed there is a steady oozing of blood through the bandages, no matter how many we have put on. This should occasion no alarm, as experience has taught that the careful attention to antiseptic measures observed throughout the operation has the effect of maintaining the lowermost dressings, those next to the wound, in a state of asepsis. The bandaged foot should now be wrapped in a piece of thick clean cloth or placed in a boot.

If our antiseptic precautions have been thorough, the dressings and bandages so adjusted may be allowed to remain without disturbance for from eight to fourteen days. In this, however, the veterinary surgeon must be largely guided by the symptoms of his patient. If, at the end of the first three or four days, the animal maintains a vigorous appetite, if he commences to place a little weight on the foot, and if the thermometer gives no indication of a rise beyond the one or two degrees of ordinary surgical fever, then the surgeon may know that things are proceeding satisfactorily. Pawing movements with the foot, inability to place weight upon it, loss of appetite, an increase in the number of respirations, and a serious rise of temperature, denote the opposite state of affairs. The wound is in all probability suppurating. The bandages and dressings should therefore be removed, and the wound either redressed and bandaged, or treated as an ordinary open wound.

Ordinarily, however, if the operation has been properly performed, healing takes place by first intention, and the wound when the bandages are removed at the end of the first or second week appears clean and _dry_.

Having assured ourselves that such is the case, we dress the foot in exactly the same manner as before, save that so many bandages are not put on. A similar dressing is repeated weekly until such time as the wound shows sufficient growth of horn--quite a thin pellicle--to act as a protective. It may then be left undressed, except for some simple hoof dressing and a bandage.

Complete healing of the wound takes from about four to eight weeks, at the end of which time the animal can be again gradually put into work. The labour, however, should be light, and quite three or four months should be allowed to elapse before any attempt is made to put him to heavy work.

Should the second method of operating have been the one adopted, then there is one slight difference in the after-dressing that needs attention calling to it. In this case we have more or less of a _hidden_ cavity left to deal with rather than the broad and _open_ wound left in either of the other methods. This cavity, left by the extirpation of the cartilage, must be thoroughly dressed with iodoform or chinosol, or with Bayer's iodoform in ether. The packing with carbolized tow and the bandaging may then be proceeded with as before.

In conclusion, we may say that the operation is one of some delicacy, and needs a good surgeon for its successful performance. Furthermore, no one of the antiseptic precautions we have advised can be omitted. It is, perhaps, these two considerations (and in justice to the English surgeon we should say most probably the latter of them) that have prevented this operation from being generally adopted.

That it is successful there is no gainsaying. Professor Bayer, of the Vienna School, with whose name is associated the last of the three methods of operating we have described, is enthusiastic in praise of the operation, and says: 'The favourable results that I have got by this operation have caused me wholly to abandon the medicinal treatment, and to prefer in all cases the surgical operation as being the best means to the end.'

_Partial Excision of the Lateral Cartilage_.--Discarding the somewhat elaborate methods we have just described, there are English operators who removed the necrosed portion only of the cartilage, and do so in what appears at first sight a comparatively rough-and-ready manner.

The apparent roughness is that they do not concern themselves with conserving the coronary cushion, and hesitate but little in cutting portions of it bodily away. One would imagine that in this case the quarter of the side operated on would be always more or less bare of horn. Such, however, is not the case.

To perform this operation the animal is again cast and chloroformed. Some operators, however, use the stocks and dispense with the anæsthetic. The foot is first well cleaned with soap and water and a stiff brush, and the hair of the coronet over the seat of operation shaved. Again, too, the horn of the affected quarter is rasped until it yields easily to pressure of the thumb, and the whole of the foot washed in an antiseptic solution.

A probe is now inserted into the opening at the coronet, and the direction of the fistula noted, after which the foot is firmly secured, and an Esmarch bandage and tourniquet applied to the limb.

This done, a triangular or wedge-shaped portion of skin, coronary cushion, and thinned horn is removed with a strong sage-knife or scalpel.

The base of the wedge-shaped portion removed contains the opening of the fistula, and the apex of the wedge should reach to the bottom of the sinus (see Fig. 142).

After the horn is removed and the fistula followed up, it is sometimes found that what we at first thought was its end, it may now be continued in an altogether different direction.

It is again followed up with the probe, and the horn and sensitive structures excised until we are quite certain we have reached its furthest extent.

Attention should next be paid to the cartilage. Wherever spots of necrosis are found, as indicated by the pea-green colour of the affected parts, they must be _carefully_ excised. Care should be taken in so doing to carry the line of excision some little distance around the visibly affected parts. This is done that we may be quite certain nothing at all remains calculated to give rise to further trouble.

It goes without saying that, in addition to the necrosed cartilage, all other diseased and necrotic tissues should also be removed. The os pedis is occasionally found necrotic just where the cartilage joins it, or it may be that a small portion of the sensitive laminæ, by reason of its _liver-red_ or even gray coloration, gives evidence of death of the part.

The former must be well curetted, and the latter cleaned carefully with a scalpel and forceps.

[Illustration: FIG. 142.--PARTIAL EXCISION OF THE LATERAL CARTILAGE BY REMOVING A PORTION OF THE CORONARY CUSHION. The dotted lines show the outline of the wedge-shaped portion of structures to be removed, including skin, coronary cushion, horn, and sensitive laminæ. _a_, The opening of the fistula.]

The operation finished, the foot is again douched in an antiseptic solution, the wound mopped dry with carbolized tow, dressed with either of the dressings described on page 358, and finally bandaged. The dressing should be changed every three days only, unless in the meanwhile pawing movements and other symptoms of distress indicate their removal.

The length of coronary cushion removed in this operation is from 1/4 to 1/2 inch (we ourselves, however, have seen it more), and yet its loss seems to occasion no serious after-trouble beyond a slight deformity of the parts beneath. The sensitive structures become sufficiently covered with horn, and the animal in nearly every case is returned to work, while in a great many instances he may also trot perfectly sound.

Simple though the operation may appear, and apparently rough in its method, it is nevertheless successful in effecting a cure in cases where blisters, plugging, injections, and other means have failed.

Mr. W. Dacre, M.R.C.V.S.,[A] after reading an article on the operation before the members of the Lancashire Veterinary Medical Association, says: 'My observations have not been based on a single case, and having had nine of them, and all of them successful, I felt it to be my duty to bring this subject before the Society.'

[Footnote A: _Veterinary Record_, vol. v., p. 407.]

Mr. T.W. Thompson, M.R.C.V.S.,[A] says: 'In a great number of cases I have removed a 1/2 inch of the coronary band.... I have performed the operation a great number of times, and have never seen a foot that has been damaged by it.'

[Footnote A: _Ibid_.]

Professor Macqueen[A] says: 'I do not spare the coronary band or sensitive laminæ when I find those parts diseased. I do not unnecessarily damage those structures. At the same time, I am confident that excision of a piece of the coronary band or removal of a few sensitive laminæ has not the untoward consequences so much dreaded in former days.'

[Footnote A: _Ibid_., p. 714.]

Mr. John Davidson, M.E.C.V.S.,[A] says: 'The treatment described, if carefully carried out and details attended to, will be found a success in dealing with the majority of cases of quittor. If I may be permitted to say so, without being considered boastful, I have yet to see the first case that has resisted the treatment.'

[Footnote A: _Ibid_., vol. xiv., p. 769.]

Should our case of quittor be complicated by caries of the bone, this must, where possible, be scraped or curetted until the whole of the diseased portion is removed, and a healthy surface is left. After-dressing must then be carried out as in other cases.

The treatment of ossified cartilage will be found under treatment of side-bones, and the methods of dealing with penetrated articulation and purulent arthritis are treated of in