Chapter 40

_Symptoms._--The incomplete variety may be unaccompanied with any special symptoms, but in the complete kind one of the bony plates may be so far detached as to press upon the cerebral substance with sufficient force to produce serious nervous complications. When the injury occurs at the base of the cranium hemorrhage may be looked for, with paralytic symptoms, and when these are present the usual termination is death. It may happen, however, that the symptoms of an apparently very severe concussion may disappear, resulting in an early and complete recovery, and the surgeon will therefore do well to avoid undue haste in venturing upon a prognosis. In fractures of the orbital or the zygomatic bones the danger is less pressing than with injuries otherwise located about the head.

_Treatment._--The treatment of cranial fractures is simple, though involving the best skill of an experienced surgeon. When incomplete hardly any interference is needed; even plain bandaging may usually be dispensed with. In the complete variety the danger to be combated is compression of the brain, and attention to this indication must not be delayed. The means to be employed are the trephining of the skull over the seat of the fracture and the elevation of the depressed bone or the removal of the portion which is causing the trouble. Fragments of bone in comminuted cases, bony exfoliations, collections of fluid, or even protruding portions of the brain substance must be carefully cleansed away and a simple bandage so applied as to facilitate the application of subsequent dressings.

FRACTURES OF THE BONES OF THE FACE.

In respect to their origin--usually traumatic--these injuries rank with the preceding, and are commonly of the incomplete variety. They may easily be overlooked, and may even sometimes escape recognition until the reparative process has been well established and the wound is discovered owing to the prominence caused by the presence of the provisional callus which marks its cure. When the fracture is complete it will be marked by local deformity, mobility of the fragments, and crepitation. Nasal hemorrhage, roaring, frequent sneezing, loosening or loss of teeth, difficulty of mastication, and inflammation of the cavities of the sinuses are varying complications of these accidents. The object of the treatment should be the restoration of the depressed bones as nearly as possible to their normal position and their retention in place by protecting splints, which should cover the entire facial region. Special precautions should be observed to prevent the patient from disturbing the dressing by rubbing his head against surrounding objects, such as the stall, manger, rack, etc. Clots of blood in the nasal passages must be washed out, collections of pus removed from the sinuses, and, if the teeth are loosened and liable to fall out, they should be removed. If roaring is threatened, tracheotomy is indicated.

FRACTURES OF THE PREMAXILLARY BONE.

These are mentioned by continental authors and are usually encountered in connection with fractures of the nasal bone, and may take place either in the width or the length of the bone.

The deformity of the upper lip, which is drawn sidewise in this lesion, renders it easy of diagnosis. The abnormal mobility and the crepitation, with the pain manifested by the patient when undergoing examination, are concurrent symptoms. Looseness of the teeth, abundant salivation, and entire inability to grasp the feed complete the symptomatology of these accidents. In the treatment splints of gutta-percha or leather are sometimes used, but they are of difficult application. Our own judgment and practice are in favor of the union of the bones by means of metallic sutures.

FRACTURES OF THE LOWER JAW.

A fracture here is not an injury of infrequent occurrence. It involves the body of the bone, at its symphysis, or back of it, and includes one or both of its branches, either more or less forward, or at the posterior part near the temporomaxillary articulation, at the coronoid process.

Falls, blows, or other external violence, or powerful muscular contractions during the use of the speculum, may be mentioned among the causes of this lesion. The fracture of the neck, or that portion formed by the juncture of the two opposite sides, and of the branches in front of the cheeks, causes the lower jaw, the true dental arch, to drop, without the ability to raise it again to the upper, and the result is a peculiar and characteristic physiognomy. The prehension and mastication of feed become impossible; there is an abundant escape of fetid and sometimes bloody saliva, especially if the gums have been wounded; there is excessive mobility of the lower end of the jawbone; and there is crepitation, and frequently paralysis of the under lip. Although an animal suffering with a complete and often compound and comminuted fracture of the submaxilla presents at times a serious aspect, the prognosis of the case is comparatively favorable, and recovery is usually only a question of time. The severity of the lesion corresponds in degree to that of the violence to which it is due, also to the resulting complications and the situation of the wound. It is simple when at the symphysis, but becomes more serious when it affects one of the branches, and most aggravated when both are involved. Fracture of the coronoid process becomes important principally as an evidence of the existence of a morbid diathesis, such as osteoporosis, or the like.

The particular seat of the injury, with its special features, will, of course, determine the treatment. For a simple fracture, without displacement, provided there is no laceration of the periosteum, an ordinary supporting bandage will usually be sufficient, but when there is displacement the reduction of the fracture must first be accomplished, and for this special splints are necessary. In a fracture of the symphysis or of the branches the adjustment of the fragments by securing them with metallic sutures is the first step necessary, to be followed by the application of supports, consisting of splints of leather or sheets of metal, the entire front of the head being then covered with bandages prepared with adhesive mixtures. During the entire course of treatment a special method of feeding becomes necessary. The inability of the patient to appreciate the situation, of course, necessitates a resort to an artificial mode of introducing the necessary feed into his stomach; this is accomplished by forcing between the commissures of the lips, in a liquid form, by means of a syringe, the milk or nutritive gruels selected for his sustenance until the consolidation is sufficiently advanced to permit the ingestion of feed of a more solid consistency. The callus will usually be sufficiently hardened in two or three weeks to allow of a change of diet to mashes of cut hay and scalded grain, until the removal of the dressing restores the animal to its old habit of mastication.

FRACTURES OF VERTEBRÆ.

These are not very common, but when they do occur the bones most frequently injured are those of the back and loins.

_Causes._--The ordinary causes of fracture are responsible here as elsewhere, such as heavy blows on the spinal column, severe falls while conveying heavy loads, and especially violent efforts in resisting the process of casting. Although occurring more or less frequently under the latter circumstances, the accident is not always attributable to carelessness or error in the management. It may, of course, sometimes result from such a cause as a badly prepared bed, or the accidental presence of a hard body concealed in the straw, or to a heavy fall when the movements of the patient have not been sufficiently controlled by an effective apparatus and its skillful adaptation, but it is quite as liable to be caused by the violent resistance and the consequent powerful muscular contraction by the frightened patient. The simple fact of the overarching of the vertebral column, with excessive pressure against it from the intestinal mass, owing to the spasmodic action of the abdominal muscles, may account for it, and so also may the struggles of the animal to escape from the restraint of the hobbles while frantic under the pain of an operation without anesthesia. In these cases the fracture usually occurs in the body or the annular part, or both, of the posterior dorsal or the anterior lumbar vertebra. When the transverse processes of the last-named bones are injured, it is probably in consequence of the heavy concussion incident to striking the ground when cast. The diagnosis of a fracture of the body of a vertebra is not always easy, especially when quite recent, and more especially when there is no accompanying displacement.

_Symptoms._--There are certain peculiar signs accompanying the occurrence of the accident while an operation is in progress which should at once excite the suspicion of the surgeon. In the midst of a violent struggle the patient becomes suddenly quiet; the movement of a sharp instrument, which at first excited his resistance, fails to give rise to any further evidence of sensation; perhaps a general trembling, lasting for a few minutes, will follow, succeeded by a cold, profuse perspiration, particularly between the hind legs, and frequently there will be micturition and defecation. Careful examination of the vertebral column may then detect a slight depression or irregularity in the direction of the spine, and there may be a diminution or loss of sensation in the posterior part of the trunk, while the anterior portion continues to be as sensitive as before. In making an attempt to get upon his feet, however, upon the removal of the hobbles, only the fore part of the body will respond to the effort, a degree of paraplegia being present, and while the head, neck, and fore part of the body will be raised, the hind quarters and hind legs will remain inert. The animal may perhaps succeed in rising and probably may be removed to his stall, but the displacement of the bone will follow, converting the fracture into one of the complete kind, either through the exertion of walking or by a renewed attempt to rise after another fall before reaching his stall. By this time the paralysis is complete, and the extension of the meningitis, which has become established, is a consummation soon reached.

To say that the prognosis of fracture of the body of the vertebra is always serious is to speak very mildly. It would be better, perhaps, to say that _occasionally_ a case _may_ recover. Fractures of the transverse processes are less serious.

_Treatment._--Instead of stating the indication in this class of cases as if assuming them to be amenable to treatment, the question naturally would be: Can any treatment be recommended in a fracture of the body of a vertebra? The only indication in such a case, in our opinion, is to reach the true diagnosis in the shortest possible time and to act accordingly. If there is displacement, and the existence of serious lesions may be inferred from the nervous symptoms, the destruction of the suffering animal appears to suggest itself as the one conclusion in which considerations of policy, humanity, and science at once unite.

If, however, it is fairly evident that no displacement exists; that pressure upon the spinal cord is not yet present; that the animal with a little assistance is able to rise upon his feet and to walk a short distance--it may be well to experiment upon the case to the extent of placing the patient in the most favorable circumstances for recovery and allow nature to operate without further interference. This may be accomplished by obtaining immobility of the whole body as much as possible, and especially of the suspected region, by placing the patient in slings, in a stall sufficiently narrow to preclude lateral motion, and covering the loins with a thick coat of agglutinative mixture. Developments should be watched and awaited.

FRACTURE OF THE RIBS.

The different regions of the chest are not equally exposed to the violence that causes fractures of the ribs, and they are therefore either more common or more easily discovered during life at some points than at others. The more exposed regions are the middle and the posterior, while the front is largely covered and defended by the shoulder. A single rib may be the seat of fracture, or a number may be involved, and there may be injuries on both sides of the chest at the same time. It may take place lengthwise, in any part of the bone, though the middle, being the most exposed, is the most frequently hurt. Incomplete fractures are usually lengthwise, involving a portion only of the thickness of one or other of the surfaces. The complete kind may be either transverse or oblique, and are most commonly denticulated. The fracture may be comminuted, and a single bone may show one of the complete and one of the incomplete kind at different points. The extent of surface presented by the thoracic region, with its complete exposure at all points, explains the liability of the ribs to suffer from all the forms of external violence.

_Symptoms._--In many instances fractures, especially the incomplete variety, of these bones continue undiscovered, without displacement, though the evidences of local pain, a certain amount of swelling, and a degree of disturbance of the respiration, if noticed during the examination of a patient, may suggest a suspicion of their existence. Abnormal mobility and crepitation are difficult of detection, even when present, and they are not always present. When there is displacement the deformity which it occasions will betray the fact, and when such an injury exists the surgeon, in view of possible and probable complications of thoracic trouble, of course will become vigilant and prepare himself for an encounter with a case of traumatic pleuritis or pneumonia. Fatal injuries of the heart are recorded. Subcutaneous emphysema is a common accompaniment of broken ribs, and I recall the death, from this cause, of a patient of my own which had suffered a fracture of two ribs in the region of the withers, under the cartilages of the shoulder, and of which the diagnosis was made only after the fatal ending of the case.

These hurts are not often of a very serious character, though the union is never so solid and complete as in other fractures, the callus being usually imperfect and of a fibrous character, with an amphiarthrosis formation. Still, complications occur which may impart gravity to the prognosis.

_Treatment._--Fractures with but a slight or no displacement need no reduction. All that is necessary is a simple application of a blistering nature as a preventive of inflammation or for its subjugation when present, and in order to excite an exudation which will tend to aid in the support and immobilization of the parts. At times, however, a better effect is obtained by the application of a bandage placed firmly around the chest, although, while this limits the motion of the ribs, it is liable to render the respiration more labored.

If there is displacement, with much accompanying pain and evident irritation of the lungs, the fracture must be reduced without delay. The means of effecting this vary according to whether the displacement is outward or inward. In the first case the bone may be straightened by pressure from without, while in the second the end of it must be raised by a lever, for the introduction of which a small incision through the skin and intercostal spaces will be necessary. When coaptation has been effected it must be retained by the external application of an adhesive mixture, with splints and bandages around the chest.

FRACTURES OF THE BONES OF THE PELVIS.

These fractures will be considered under their separate denominations, as those of the sacrum and the os innominatum, or hip, which includes the subdivisions of the ilium, the pubes, and the ischium.

_The sacrum._--Fractures of this bone are rarely met with among solipeds. Among cattle, however, it is of common occurrence, being attributed not only to the usual varieties of violence, as blows and other external hurts, but to the act of coition and violent efforts in parturition. It is generally of the transverse kind and may be recognized by the deformity which it occasions. This is due to the dropping of the bone, with a change in its direction and a lower attachment of the tail, which also becomes more or less paralyzed. The natural and spontaneous relief which usually interposes in these cases has doubtless been observed by the extensive cattle breeders of the West, and their practice and example fully establish the inutility of interference. Still, cases may occur in which reduction may be indicated, and it then becomes a matter of no difficulty. It is effected by the introduction of a round, smooth piece of wood into the rectum as far as the fragment of bone and using it as a lever, resting upon another as a fulcrum placed under it outside. The bone, having been thus returned, may be kept in place by the ordinary external means in use.

_The os innominatum._--Fracture of the ilium may be observed either at the angle of the hip or at the neck of the bone; those of the pubes may take place at the symphysis, or in the body of the bone; those of the ischium on the floor of the bone, or at its posterior external angle. Or, again, the fracture may involve all three of these constituent parts of the hip bone by having its situation in the articular cavity--the acetabulum by which it joins the femur or thigh bone.

_Symptoms._--Some of these fractures are easily recognized, while others are difficult to identify. The ordinary deformity which characterizes a fracture of the external angle of the ilium, its dropping and the diminution of that side of the hip in width, unite in indicating the existence of the condition expressed by the term "hipped." An incomplete fracture, however, or one that is complete without displacement, or even one with displacement, often demands the closest scrutiny for its discovery. The lameness may be well marked, and an animal may show it but little while walking, though upon being urged into a trot will manifest it more and more, until presently it will cease to use the crippled limb altogether, and travel entirely on three legs. The acute character of the lameness will vary in degree as the seat of the lesion approximates the acetabulum. In walking, the motion at the hip is very limited, and the leg is dragged; while at rest it is relieved from bearing its share in sustaining the body. An intelligent opinion and correct conclusion will depend largely upon a knowledge of the history of the case, and while in some instances that will be but a report of the common etiology of fractures, such as blows, hurts, and other external violence, the simple fact of a fall may furnish in a single word a satisfactory solution of the whole matter.

With the exception of the deformity of the ilium in a fracture of its external angle, and unless there has been a serious laceration of tissues and infiltration of blood, or excessive displacement, there are no very definite external symptoms in a case of a fracture of the hip bone. There is one, however, which, in a majority of cases, will not fail--it is crepitation. This evidence is attainable by both external and internal examination--by manipulation of the gluteal surface and by rectal taxis. Very often a lateral motion, or balancing of the hinder parts by pressing the body from one side to the other, will be sufficient to render the crepitation more distinct--a slight sensation of grating, which may be perceived even through the thick coating of muscle which covers the bone--and the sensation may not only be felt, but to the expert may even become audible. This external manifestation is, however, not always sufficient in itself, and should invariably be associated with the rectal taxis for corroboration. It is true that this may fail to add to the evidence of fracture, but till then the simple testimony afforded by the detection of crepitation from the surface, though a strong confirmatory point, is scarcely sufficiently absolute to establish more than a reasonable probability or strong suspicion in the case.

In addition to the fact that the rectal examination brings the exploring hand of the surgeon into near proximity to the desired point of search, and to an accurate knowledge of the situation of parts, both pro and con as respects his own views, there is another advantage attendant upon it which is well entitled to appreciation. This is the facility with which he can avail himself of the help of an assistant, who can aid him by manipulating the implicated limb and placing it in various positions, so far as the patient will permit, while the surgeon himself is making explorations and studying the effect from within. By this method he can hardly fail to ascertain the character of the fracture and the condition of the bony ends. By the rectal taxis, as if with eyes in the finger ends, he will "see" what is the extent of the fracture of the ilium or of the neck of that bone; to what part of the central portion of the bone (the acetabulum) it reaches; whether this is free from disease or not, and in what location on the floor of the pelvis the lesion is situated. By this method we have frequently been able to detect a fracture at the symphysis, which, from its history and symptoms and an external examination, could only have been guessed at. Yet, with all its advantages, the rectal examination is not always necessary, as, for example, when the fracture is at the posterior and external angle of the ischium, when by friction of the bony ends the surgeon may discern the crepitation without it.

Every variety of complication, including muscular lacerations with the formation of deep abscesses and injuries to the organs of the pelvic cavity, the bladder, the rectum, and the uterus, may be associated with fractures of the hip bone.

_Prognosis._--The prognosis of these lesions will necessarily vary considerably. A fracture of the most superficial part of the bone of the ilium or of the ischium, especially if there is little displacement, will unite rapidly, leaving a comparatively sound animal often quite free from subsequent lameness. If there is much displacement, however, only a ligamentous union will take place, with much deformity and more or less irregularity in the gait. Other fractures may be followed by complete disability of the patient, as, for example, when the cotyloid cavity is involved, or when the reparatory process has left bony deposits in the pelvic cavity at the seat of the union, which may, in the case of the female, interfere with the steps of parturition, or induce some local paralysis by pressure upon the nerves which govern the muscles of the hind legs. This is a condition not infrequently observed when the callus has been formed on the floor of the pelvis near the obturator foramen, pressing upon the course or involving the obturator nerve.

_Treatment._--In our estimation, the treatment of all fractures of the hip bone should be of the simplest kind. Rendered comparatively immovable by the thickness of the muscles by which the region is enveloped, one essential indication suggests itself, and that is to place the animal in a position which, so far as possible, will be fixed and permanent. For the accomplishment of this purpose the best measure, as we consider it, is to place the horse in a stall of just sufficient width to admit him, and to apply a set of slings, snugly, but comfortably. (See Plate XXXI.) This will fulfill the essential conditions of recovery--rest and immobility. Blistering applications would be injurious, though the adhesive mixture might prove in some degree beneficial.