Chapter 3

Acute bursitis and thecitis is of frequent occurrence in horses because of direct injury from contusion, punctures and other forms of traumatism. These synovial membranes, with few exceptions, when inflamed occasion a synovitis that may be very acute, yet there is less manifestation of pain than in arthritis.

It is only in structures such as the bursa intertubercularis or in the sheath of the deep digital flexor that an inflammation causes much pain and is apt to result in permanent lameness. This is due to the peculiar character of the function of such structures.

An acute inflammation of a small bursa may even result in the destruction of such synovial apparatus without serious inconvenience to the subject, either at the time of destruction or thereafter. Obliteration of the superficial bursa over the summit of the os calcis is not likely to cause serious inconvenience or distress to the subject unless it be due to an infected wound. Even then, with reasonably good care given the animal, recovery is almost certain. Complete return of function of the member and cessation of lameness takes place within a few weeks in the average case.

Where an infectious synovitis involves a structure such as the sheath of the tendon of the deep digital flexor (perforans) the condition is grave and because of the location of this theca the prognosis is not much more favorable than in an articular synovitis.

Inflammation of bursae and thecae may be classified on a chronological basis with propriety because the duration of such affections, in many cases, materially modifies the result. A chronic inflammatory involvement of a theca through which an important tendon plays may cause adhesions to form. Or there may occur erosions of the parts with eventual hypertrophy and loss of function, partial or complete.

However, in general practice a classification on an etiological basis is probably more practical and we shall consider inflammation of bursae and thecae as _infectious_ and _noninfectious_.

_Infectious_ bursitis and thecitis is usually the result of direct introduction of septic material into the synovial structure by means of injuries. Infection by contiguous extension occurs and also metastatic involvement is met with occasionally.

The noninfectious inflammation of bursae and thecae usually result from contusions or strains and generally run their course without becoming infective in character, where vitality and resistance of the subject are normal.

In a general way, inflammation and other affections of bursae and thecae are considered very similar to like affections of joints.

AFFECTIONS OF MUSCLES AND TENDONS.

Muscles and tendons having to do with locomotion are more frequently injured than are any of the other structures whose function is to propel the body or sustain weight. This is due in part to the exposed position of muscles and tendons. They serve as a protection to the underlying structures and in this manner receive many blows the force and violence of which are spent before injury extends beyond these tissues.

Muscles of the breast, shoulder and rump are most frequently the recipient of injuries of various kinds. The abductors of the thigh are subjected to bruising when horses are thrown astride of wagon poles or similar objects. Thus in one way or another muscle injuries are occasioned and cause lameness.

Traumatic affection of muscles of locomotion may be surface or subsurface--subsurface with little injury done the skin and fascia, but with subsurface extravasation of blood and masceration of tissue. Puncture wounds wherein the vulnerant body is of small diameter, are observed, and they occasion deep seated infectious inflammation of the parts affected, with surface wounds that are often unnoticeable. Such injuries--puncture wounds--are always serious, and because of the fact that, there exists little evidence of injury at the time of their infliction, treatment is usually deferred several days and often infection has become quite extensive when the practitioner is consulted.

Where infective wounds of muscles of locomotion occur, the course and gravity of the affection are directly influenced by the proximity of the injury to lymph plexuses. For instance, injuries causing an infectious inflammatory involvement of the adductors of the thigh may result in a generalization of the infection by way of the inguinal lymph glands.

Large open wounds that extend deep into muscles, render inactive such structures, and even where division is not complete, the pain occasioned causes the subject to favor the part in every way possible. Contraction of muscular fibers of such parts increases pain and because of this fact groups of muscles are at times disabled because of injury done to one muscle. Instances of this kind are frequently seen where shoulder injuries, which affect but one muscle, exist; yet because of such injury a marked swinging-leg lameness is present.

Tendons, because of their inelasticity, are subjected to injuries peculiar to themselves. In addition to being affected as are muscles, wounds of many kinds are found to affect tendons--contusions, interference wounds, penetrant wounds, incised wounds and lacerations.

However, the commoner form of injury done tendons, is strain or sprain. Because of the sudden tensile strain brought to bear upon tendons in the shocks of concussion, as well as in propulsion of the body, there frequently occurs a rupture of fibers and this we know as sprain.

Sprains may be considered as fibrillary fractures of soft structures and since this form of injury is subsurface, and limited to fractional portions of tendons, the inflammation occasioned usually remains an aseptic one. Reaction to this form of injury is characterized by inflammation, the course of which is erratic and variable. In chronic inflammation of tendons, where animals are continued in service, the usual sequel is contraction, or shortening of these structures.

The degree of contraction as well as its import varies in different subjects and in the various tendons which may be affected. Contraction is a slow-going process that is progressive, gradually causing a decrease in the length of the affected structure and eventually rendering the animal useless.

The practice of applying shoes with extended toe-calks for the purpose of "stretching" contracted deep digital flexor tendons (flexor pedis perforans) cannot be too strongly condemned. While the addition of an extension such as is ordinarily employed to the toe of a shoe of this kind, prevents for a time, frequent stumbling in such cases, the increased tensile strain which is thus occasioned hastens further contraction and subjects animals so shod to much unnecessary pain.

AFFECTIONS OF NERVES.

Because of their being protected by other structures, nerve trunks, which supply muscles of locomotion, are not subjected to frequent injuries such as contusions. However, they do become injured at times and the result is lameness, more or less severe.

Lameness originating from nerve affection, may involve central structures as, for example, the spinal cord, medulla oblongata or parts of the brain. In making an examination of some lame animals it is necessary to distinguish between cases of lameness that are of central origin and marked by incoördination of movement, and disturbances caused by other affections. Tetanus in its incipiency should not be confused with laminitis involving all four feet, or with certain forms of pleuritis, when careful examination is made, yet, in a way, to one not trained, the clinical symptoms are similar.

Disturbances of nerve function are caused in a variety of ways. It is not within the scope of this work to discuss central nervous disturbances caused by ingestion of mouldy provender, or disturbances of the brain or cord occasioned by infectious diseases, but mention of the existence of such conditions is appropriate.

By direct injury the result of blows, certain nerves are injured and muscles supplied by such nerves are rendered inactive. Depending upon the nature and extent of an injury thus inflicted, so the manner in which the affection is manifested varies. The suprascapular nerve is rather frequently injured causing partial or complete loss of function of the structures supplied by this nerve, and abduction of the scapulohumeral joint naturally results.

In some cases of dystocia the obturator nerve, (or nerves, if the involvement is bilateral), becomes injured by being caught between the maternal pelvis and some dense part of the fetus. This results in paralysis of the adductors of the thigh if sufficient injury is done.

It is said that nerves become over-stretched and held tense, in certain positions in which animals are obliged to remain while cast in confinement such as in some instances where unusual methods of restraint are employed. When the fore feet are drawn backward in such manner that great strain is put upon the radial nerve, it suffers more or less injury, and this is followed by partial or complete paralysis which may be temporary or permanent.

Degenerative changes affecting nerves, as in other tissues, occur and more or less locomotory impediment will follow--this depending upon the nerve or nerves affected and the nature of such involvement. Tumors may surround nerves and eventually the nerve so exposed becomes implicated in the destructive process. Before degenerative changes take place in the nerve substance, in such cases, pressure may completely paralyze a nerve when it is so situated. Melanotic tumors in the paraproctal tissue in some cases, because of the large size of the new-growths, cause paralysis of the sciatic nerve. The author has seen one case of brachial paralysis occasioned by an enormous development of fibrous tissue involving the structures about the ulna.

AFFECTIONS OF BLOOD VESSELS.

Lameness caused by disturbances of circulation may be due to structural affection of vessels, or functional disorders of the heart, and in some instances, a combination of these causes may be active.

Direct involvement of vessels is the commoner form of circulatory disturbance which occasions lameness, and the most frequent cause is of parasitic origin. Sclerostomiasis with attendant arteritis, thrombus formation and subsequent lodgement of emboli in the iliac, femoral, or other arteries, causes sufficient obstruction to prevent free circulation of blood, and the characteristic lameness of thrombosis results.

Indirect injury to vessels may occur because of contused wounds and subsequent inflammation of tissues supplied by such vessels. If the injury be of sufficient extent, considerable extravasation of blood will take place and the painfully swollen parts necessarily impair locomotion. In such instances lymph vessels participate in the disturbance, and the condition then becomes one wherein lymphangitis is the predominant disturbing element.

Angiomatous tumors are occasionally found affecting horses' legs--usually the result of some injury; and because of their size or position, they mechanically interfere with function. Furthermore, when such tumors are located on the inner or flexor side of joints, enough pain is occasioned that affected animals show evidence of distress, usually by intermittent lameness.

Horses do not suffer from distension of veins as does man, that is, there is rarely to be seen a case wherein much disturbance from this source exists.

AFFECTIONS OF LYMPH VESSELS AND GLANDS.

Inflamed lymph vessels and glands, the result of various causes, is a rather common source of lameness of horses. When one considers the proportion of tissue that is composed of lymph vessels and glands, it is then obvious that inflammation of these structures should cause a painful affection of members, when so affected, and that marked lameness and, in some instances, general constitutional disturbance such as anorexia, hyperthermia and general circulatory disorder are to follow.

Lymphangitis is most frequently occasioned by the introduction of septic material into the tissues; consequently, infectious lymphangitis is more frequently observed than the non-infectious type.

Specific infectious forms of lymphangitis are seen in glanders and in strangles; infectious types of this disturbance are found in many instances where, initially, a localized or circumscribed infection has occurred--the contagium having been introduced by way of an injury. An example of this kind is to be seen in a wound perforating the tibial fascia, where the injury is inflicted by means of a horse being kicked by another animal shod with sharp shoe-calks. Cases of this kind invariably result in a septic lymphangitis, and frequently lymphadenitis also occurs, for the inguinal lymph glands are so situated that their becoming contaminated is almost certain.

The trite phrase that "the tissues are bathed in lymph" should make clear the reason for the frequent occurrence of infectious lymphangitis and lymphadenitis. Foreign substances, bacteria and their products, inorganic material and in fact, anything that is introduced into the tissues, if soluble or miscible, will be taken up and conveyed by the afferent lymph vessels and disseminated throughout the system--hence the constitutional disturbances so frequently thus caused.

A non-infectious type of lymphangitis is frequently seen in the heavy draft breeds of horses and in such cases one or both hind legs are involved--it is very seldom that the thoracic limbs become so affected. Law[3] refers to this ailment as "Acute Lymphangitis of Plethora in Horse." When one takes into consideration that these cases so frequently occur in heavy draft animals that are not worked regularly, that the pelvic limbs are the ones involved, and that the disorder often runs a short course (recovery often taking place within two or three days, with no treatment given other than a purge, circulatory stimulants and walking exercise) it is plausible to ascribe the condition to idiopathic factors.

Admitting the frequency of non-infectious lymphangitis, the practitioner must not confuse this type with similar lymphatic inflammation occasioned by nail punctures of the foot. It is very embarrassing indeed to make a diagnosis of lymphangitis--expecting that the disturbance will terminate favorably and uneventually--and later to discover a sub-solar abscess caused by a nail prick in the region of the heel.

Recurrent attacks of this disturbance cause hypertrophy of the lymph vessels and in some cases lymphangiectasis. In old subjects used for dissection or surgical purposes, it is very evident that in the ones which have suffered from chronic lymphangitis there exists an excessive amount of sub-facial connective tissue, making subcutaneous neurectomies quite difficult in some instances.

A sequel of chronic lymphangitis is a condition known as elephantiasis. In such cases there occurs a hyperplasia of the skin and subcutaneous tissues, resulting in some instances, in the affected member attaining an enormous size. Sporadic cases of this kind are to be seen occasionally, and are apparently caused by repeated attacks of lymphangitis. The affection is not benefited by treatment, and while a horse's leg may become so heavy and cumbersome as to mechanically impede its gait, as well as to fatigue the subject when made to do service even at a slow pace, elephantiasis causes no constitutional derangement. The hind legs, in elephantiasis, are affected and a unilateral involvement is more often seen than a bilateral one. The legs may be enlarged from the extremity to the body, but ordinarily the affection does not extend higher than the hock or the mid-tibial region.

A chronic, progressive, hyperplastic-degeneration exists in some cases and the subjects are in time rendered unserviceable because of the burden of getting about encumbered by the affected extremity. In other animals hyperplasia progresses for a time--until the parts become greatly enlarged and conditions apparently attain an immutable state. Nevertheless animals so affected may continue in service for years without being distressed.

AFFECTIONS OF THE FEET.

Lameness is very often due to affections of the feet, and in all foot diseases probably the most constant cause is injury inflicted in some manner. Resultant from injury, there frequently develops complications and the one most often seen is infection.

Because of the fact that the feet are constantly exposed to germ-laden soil and filth, if not actually bathed in such infectious materials, it naturally follows that septic infection of some part of the feet must be of frequent occurrence.

Subsequent to being obliged to stand in mud and other damp or wet media, exposure to desiccating influences such as stabling upon dry floors, or at service on hot and dry road surfaces causes the insensitive parts of the feet to become dry, hard and brittle. This favors "checking" of the protecting structures and it frequently results in the formation of large fissures which expose the underlying sensitive parts of the feet and lameness is the inevitable outcome.

The function of the feet--bearing the weight of the animal at all times when the subject is not recumbent, and in addition to this, the increased strain put upon them at heavy draft work, together with the concussion and buffeting occasioned by locomotion, make the feet susceptible to frequent affections of various kinds.

Being almost completely encased by a somewhat inexpansible and insensitive wall and sole, renders the foot subject to pathologic changes peculiar to itself. The very nature of the structure of the foot together with the function of the sensitive lamina is sufficient cause for an affection unlike that seen involving other tissues--laminitis.

An exhaustive consideration of foot affections is a study in itself and one that comes within the realm of pathologic shoeing; nevertheless, a practical knowledge of diseases of the foot is indispensable in the diagnosis of lameness wherein the foot may be at fault.

The peculiar nature of foot affections renders them difficult of classification on any sort of basis that is helpful in the consideration of this subject. Injuries are the most constant cause of foot lameness, yet one must admit that there results complications because of infection in most instances; and that in some cases the injury is slight--just enough to permit the introduction of vulnerant organisms into the tissues. Therefore, one might well classify affections of the feet as infectious and non-infectious. There can be grouped in the class of infectious affections such conditions as nail pricks, calk wounds and canker. In the class of non-infectious affections one may consider conditions such as laminitis, strain and fractures.

FOOTNOTES:

[Footnote 1: A System of Veterinary Medicine by E. Wallis Hoare, F.R.C.V.S., Vol. I, page 519.]

[Footnote 2: Ibid, page 807.]

[Footnote 3: Vol. I, page 534, Veterinary Medicine, by James Law, F.R.C.V.S.]

SECTION II.

DIAGNOSTIC PRINCIPLES.

_To observe attentively is to remember distinctly._--_Poe_.

Before treatment is administered in constitutional disturbances resulting in disease, _cause_ is logically sought; so, in order to handle effectively any case of lameness, it is necessary first to discover the source of the trouble and contributing conditions affecting the structures. Hence, diagnostic ability is the prime requisite; and a thorough knowledge of pathologic anatomy or of surgical technic is of little value if this knowledge is not applied with the insight of the trained diagnostician.

The cruel and unnecessary methods employed by those untrained for diagnostics, cannot be too vigorously condemned. For instance, the application of an active and depilating vesicant upon a large area on the gluteal or crural region, in a case where the practitioner "guesses" the condition to be one of "hip lameness," constitutes an exposition of gross ignorance, and at once stamps the perpetrator as a crude bungler without scientific insight whose works are no credit to his profession. How much better it would be, if the practitioner does not see fit to call in a competent consultant, to prescribe a suitable agent to be given internally, and to recommend complete rest for the subject.

In establishing a diagnosis in such cases, the student or practitioner seldom has recourse to laboratory assistance, and his work is done by means of physical examination; therefore, a thorough knowledge and a clear conception of the physiology of locomotion are essential. Memorizing nosological facts without an understanding of underlying principles is of no more practical benefit for qualification as a diagnostician in cases of lameness, than is the employment of similar methods in the study of theory and practice. A knowledge of the dosage of drugs does not in itself qualify one as being competent to administer such therapeutic agents to a proper effect. How much is a practitioner benefited by the knowledge that a high temperature is usually present in septic intoxication, if he is not possessed of a scientific understanding of anatomy, physiology, bacteriology and pathology, as well as the principles of clinical diagnosis?

In order to determine the reasons for certain symptoms manifested by the subject, an analysis of these symptoms is the proper method of procedure, insofar as this is possible. If one may reason that an animal assumes a certain position while at rest to allow relaxation of an inflamed tendon or ligament, such a fact enables the diagnostician to recall that this is indicative of some specific ailment. In acute tendinitis, the subject while at rest, maintains the affected member in volar flexion because this position permits relaxation of the inhibitory apparatus, including the inflamed tendon. Likewise, the various abnormal positions assumed,--adduction, abduction, undue flexion or pointing--have their own significance and are taken into account by the trained diagnostician in the course of an examination.

In the examination of lame subjects, where the cause is not obvious, a systematic method of diagnosis is pursued even by the most expert practitioners. In all obscure cases of lameness a methodical and thoroughly practical examination of the animal according to an established procedure is necessary to determine the nature and source of the affliction.

Anamnesis.

The first thing to be given consideration in diagnosis is the fact that related history of the case is not always dependable, because of lack of accurate observation or wilful deceit on the part of the owner or attendant. The successful veterinarian soon acquires the faculty of obtaining information in a manner best adapted to his client,--either by direct interrogation or by subtle means of suggestion, and in this way he draws out evaded facts essential to his diagnosis. In time he learns to make allowance for misstatements made to shield the owner or driver and to hide the facts of apparent neglect or abuse that the subject may have experienced. A suppurating cartilaginous quittor, complicated by the presence of a large amount of hyperplastic tissue, cannot be successfully represented to be an acute and recently developed affection, where a trained practitioner is left to judge the validity of the statement.

In complicated conditions, where there is evident a chronic disturbance which could not be conceived as sufficient cause for a marked manifestation of lameness, accurate history of the case may be of great aid in arriving at a diagnosis. An aged animal, having recently become very lame, showing a small exostosis on the first phalanx, and with the history given that the osseous deposit was of long standing, should at once lead the veterinarian to seek the source of trouble elsewhere.

Visual Examination.