[Footnote A: Journal of Comparative Pathology and Therapeutics, vol. iv., p. 24.]

Treated in this way, the horse with cankered feet may be usually kept at work during the whole time that treatment is carried out, and a cure is obtainable in periods varying from six weeks to six or even twelve months.

The same essentials in treatment—namely, removal of diseased horn, antiseptic dressings, and pressure—are insisted on by other writers. Bermbach,[A] in 1888, treats canker as follows: The horse having been cast, the undermined hoof-horn is removed with the knife, and the hypertrophied sensitive structures, if necessary, reduced in the same manner. The chief difficulty in removing the latter is experienced in the lateral lacunae of the frog, where it is most conveniently scraped away with a spoon or sharp curette. Professors Hoffmann and Imminger also operate in the same way, applying an Esmarch's haemostatic bandage, and using the knife and curette freely.[B]

[Footnote A: Ibid., vol. ii., p. 68.]

[Footnote B: Veterinary Journal, vol. xxxv., p. 433.]

Haemorrhage is afterwards arrested, and a dressing of perchloride of mercury (a solution, 1/2 per cent., in equal parts of alcohol and water) applied. The after-dressings succeeding best are those of slightly caustic and astringent agents, preferably in the form of a powder, and held in position by carbol-jute pads and linen bandages applied with a certain amount of pressure.

The same author draws attention to the fact that caustic agents such as nitrate of lead, chloride of zinc, etc., act too powerfully if the bleeding has been arrested and the wound disinfected. They then form a thick crust, under which profuse suppuration takes place. The same agents are likewise contra-indicated when haemorrhage is still present. In this latter case they combine with the blood to form metallic albuminates, which lie as an impenetrable layer on the surface of the wound, and so hinder the action of drugs on the tissue below.

During his after-treatment, Bermbach advocates removal of the dressings every second day, all cheesy material to be scraped away with the knife, and the sublimate lotion to be used again. He also insists on the animal being kept standing in a dry stable,—nothing but a stone pavement kept clean—and put to regular work in a plate shoe after the first or second week. Cure of advanced cases is said to be obtainable in from four to six weeks.

As illustrative of the value of pressure in the treatment of canker, we may also draw attention to a treatment advocated by Lieutenant Rose.[A] This observer holds that adequate pressure is unobtainable by packing the foot, and, to obtain it, removes the wall from heel to heel, much after the manner of preparing the foot for the Charlier shoe, so that the whole of the weight is taken by the sole and the frog. Tar and tow is then lightly applied, the foot placed in a boot, and the patient turned into a loose-box. The dressing is repeated at intervals of four or five days until the animal is cured.

[Footnote A: Veterinary Record, vol. xi., p. 435.]

Those who have followed this method of treatment have modified it by actually shoeing the animal Charlier fashion, and keeping him at work, attention, of course, being at the same time given to a proper antiseptic dressing.

Reported Cases.—1. (Malcolm's Treatment[A]). The subject was a five-year old horse belonging to a client of Mr. Giver's, of Tamworth. The case was an exceptionally bad one, for not only was the whole of the frog and sole of the near hind-foot cankered, but the disease on the outside quarter extended to within 1/2 inch of the coronet, and on the inside quarter to within 2 inches of it. As the owner, a farmer, had not proper convenience for Mr. Olver to treat the case, the latter asked me, while visiting him, if I would care to undertake the treatment, saying at the time it would be a very good test-case, as the disease was so far advanced. I readily agreed, and, after the necessary arrangements, had the horse removed to Birmingham on July 2. In this case it was found necessary to cast the animal and cauterize the foot a second time before a healthy granulating surface was secured; but after this the progress towards recovery was uninterrupted, although necessarily slow, on account of the large amount of new secreting surface which had to be formed.

[Footnote A: Journal of Comparative Pathology and Therapeutics, vol. v., p. 48.]

The horse was finally discharged, after inspection by Mr. Olver, absolutely cured and free from canker, on January 7.

The illustration (Fig. 135, p. 312) is from a photograph, and it gives a somewhat imperfect representation of the state of the foot two months after it came under my care.

2. (Rose's Treatment.[A]) This was a bad case of canker, which had been for two or three months treated in the ordinary manner, with but little sign of ultimate success. Commenced in June and carried on until the end of September, the ordinary treatment consisted in burning down the fungus growth with the hot iron, and dressing with copper sulphate, zinc sulphate, and boracic acid. The cauterization was repeated every five days.

[Footnote A: Veterinary Record, vol. xi., p. 435.]

The treatment of Lieutenant Rose was commenced at about the end of September, at which date the disease extended from the toe on one side of the foot right back to the heel, involving the sole, half of the frog, and the bulb of the heel. One week after treatment the diseased surface was drier, and granulations were more healthy. At the expiration of a fortnight the new horn had commenced to grow from the wall, and also from the frog, right round the diseased surface, the diseased part of the bulb of the heel being divided from the sole by new horn.

Three to four weeks later the diseased surface was gradually getting smaller, while in about six weeks it was quite healed up, the last place to heal being a strip outside the bar, between it and the wall, and a smaller spot on the bulb of the heel. These healed up simultaneously, and left the animal sound.

3. (Treatment by Pressure, H. Leeney [A]). I was consulted in the early part of last summer, before the dry weather had begun, as to a farm-horse with canker in three feet. Her shoes were in the 'disgruntle' condition we so often find on farms, that, to give her a level bearing until I should call another day with a farrier to help me to pack the foot up in the old-fashioned way, I had the remaining shoes pulled off. The case somehow dropped out of my list, and I neglected to call, until asked one day to see something else.

[Footnote A: Veterinary Records, vol. xi., p. 447]

I then found that, under a pressure of work, the animal had been used in the shafts of a farm-cart on tolerably level ground, and when the dry weather had already set in. There was a distinct improvement in all the diseased feet, and as she was badly wanted I contented myself with rasping off some broken crust, and supplied some caustic dressing for use at night. Without shoes she worked continuously on the dry and hard meadow-land for several weeks, and was practically cured in something less than three months. My astringent or caustic lotion may have had something to do with the cure of the deep-seated parts, but the bare recital of the case should be sufficient to show that it is all a question of bearing, or nearly so.

7. SPECIFIC CORONITIS.

Definition.—In describing this condition under the above heading, we are following the lead of Mr. Malcolm. We may define it as a chronic inflammatory condition of the keratogenous membrane, usually confined to that of the coronary cushion, the ergots and the chestnuts, but sometimes extending to that of the frog and the sole, characterized by a malsecretion of the affected membrane similar to that observed in canker.

Causes.—The cause which we have indicated for canker—namely, a local specific one, is in all probability the one operating here. Apparently there is a variance of opinion as to whether the condition is actually canker or not. We think, however, that the character of the secretion of the affected membranes, the appearance of the growths, the manner in which they react to the hot iron, the comparative absence of pain, and other points of similarity, point to the fact that the two conditions are actually identical. In other words, the cause is precisely the same, and the only point of difference is the alteration in the point of attack.

Symptoms.—Like canker, the disease is insidious in onset. In precisely similar manner the horn, and in this case the skin of the coronet, is underrun. Later there is the partial shedding and fissuring of the undermined horn and the exuding of the characteristic discharge—in this case not so watery as that of canker. The caseous material of canker is also present, as is a disposition to hypertrophy of the exposed sensitive structures. What horn is left becomes rough and irregularly fissured, and has been likened by some observers to deeply-wrinkled bark of an old tree. A peculiar characteristic of this condition is the state of the ergots and chestnuts. Here the keratogenous membrane participates in the diseased process, and their horn becomes dry and brittle, and readily splits into small fibrous bundles very similar to the fibroid growth described in canker. These excrescences are easily separated from the sensitive structures beneath, and the exposed surface is seen to be more or less moist, or even exhibiting a slight oozing of blood.

Again, as in canker, the deeper layers of the sensitive structures appear to be normal, the horn-secreting layers being the only ones affected. According to Malcolm, the disease is in its nature equally as inveterate as canker, but it is easier to treat, on account of its more exposed position.

Treatment.—This is exactly that as described for canker.



Recorded Case.—The subject of this case was a young black cart gelding. The disease is reported as having begun as thrush, and then extended to the coronet. When I saw him he had been in a similar condition to that depicted in Fig. 137 for, it was said, two or three months, the driver of the horse meanwhile endeavouring to effect a cure by some potent drug of his own. The animal was in good condition, but walked with difficulty owing to the pain. The coronary bands were swollen to two or three times their natural size, and this caused the hair immediately above to curl upwards. Just below the coronary bands there was a line of separation between them and the wall. They themselves were covered with the cheesy substance typical of canker, and they bled on friction. Down the wall of the off fore-foot some blood had trickled, which may be seen in Fig. 138. The frogs of all four feet bulged backwards, and were badly affected. The soles were covered with normal horn, but I did not resort to paring to see if they were affected. One very curious feature about the case was the fact that all the callosities (ergots and chestnuts) seemed to participate in the morbid process, and they, too, were covered with a thin layer of soft cheesy horn. The animal used to bite at his coronets and also the callosities above the knees and hocks until they bled, which they did quite easily. The owner would not go to the expense of having him treated, so he was destroyed.[A]

[Footnote A: Henry Taylor, Veterinary Record, vol. xvii., p. 311.]



CHAPTER X

DISEASES OF THE LATERAL CARTILAGES

A. WOUNDS OF THE CARTILAGES.

To a consideration of this we shall devote but little space. It is sufficient to say that any wound in the region of the coronet should always be given the most careful attention. More particularly should this be so when it is ascertained that the wound has involved one of the lateral cartilages. Wounds of non-vascular bodies such as these are always slow to heal, and, by reason of their slowness, invite septic infection. In many cases, in fact, it happens that they do not heal at all. Instead, the injured part becomes necrotic, is unable to cast itself off, and remains as a centre of infection in the depths of the wound, thus constituting what is known as a quittor.

Apart from this, it will be remembered that the internal face of the cartilage is in intimate contact with the pedal articulation, especially anteriorly. Wounds in this situation are, therefore, likely to penetrate the joint, giving us as a complication of the injury the conditions of synovitis and arthritis.

Immediately a wound is inflicted in this position, attempts should be made to insure thorough asepsis of the part. When possible, by far the better way of accomplishing this will be to wholly immerse the foot in a tub of cold antiseptic solution, and keep it there for an hour three times daily. During the time the foot is out of the solution the wound should be protected with a pad of carbolized tow or other suitable dressing, and wrapped in a linen bandage or clean bag. If unable to use the bath, then antiseptic solutions of more than moderate strength should be freely applied to the wound and the adjacent parts, a carbolized or other antiseptic pad placed over it, and the bandage adjusted as before. Repeated injuries to the cartilages, even if not attended with an actual wound, are apt to bring about their ossification and end in the formation of side-bones.

B. QUITTOR.

Definition.—A fistulous wound of the foot, usually opening at the coronet, and variously complicated according to the structures invaded by its contained pus. For the reason that quittor is in every-day veterinary nomenclature usually associated with necrosis or other abnormal condition of the lateral cartilage, we include its description in this chapter.

Classification.—It has been customary with Continental authors to classify quittor according to the extent and position of the diseased process. There were thus distinguished:

(a) The Simple or Cutaneous Quittor, in which had occurred nothing more than necrosis of a portion of the coronary skin and the structures immediately underlying it—that is, the superficial portion of the coronary cushion.

(b) The Tendinous Quittor, in which not only the immediately subcutaneous tissues were attacked, but also portions of tendon and of ligament.

(c) The Sub-horny Quittor, in which the diseased process had invaded the deeper portions of the coronary cushion, and continued a downward course until the laminal tissue below the upper margin of the wall was involved, or any other case, no matter what the starting-point, in which pus existed within the horny box and was discharging itself by a fistulous opening.

(d) The Cartilaginous Quittor, in which a portion of the lateral cartilage had become attacked and rendered necrotic.

We believe that—in this country, at any rate—the word 'quittor' is usually held to indicate one or other of the two latter conditions, and probably the last of these; and that the two first are held of small account, or hardly of sufficient gravity to allow of the word 'quittor' being applied to them. In fact, by defining quittor as a 'fistula,' or little pipe, we have ourselves already indirectly restricted the use of the word to the two latter conditions, for in those varieties known as Simple or Cutaneous and Tendinous, the wound is generally broad and open, or, at any rate, superficial, and can scarcely be strictly described as 'fistulous.' In the two latter, however, a true fistula exists. These, however, have only one essential difference, and that consists simply in the position of the lesion and the structures it has attacked. In the main the symptoms will be the same, the disease in each case about equally serious, and in each the same essentials of treatment will have to be regarded.

In our opinion, therefore, a lengthy classification serves no useful end, and we think matters will be simplified by considering quittor under two headings only—namely, 'Simple or Cutaneous' and 'Sub-horny,' and discussing the other varieties as simply complications of either of these two.

1. SIMPLE OR CUTANEOUS QUITTOR.

Definition.—This condition is simply a sloughing of a portion of the skin of the coronet, together with a portion of the immediately underlying soft structures.

Causes.—This form of quittor has its origin more often than not in contusions, punctures, or wounds of the region severe enough to cause death of a small portion of the tissues. In this case the low vitality of the parts does not allow of the dead portion being removed piecemeal by a process of phagacytosis, as is usually the case with similar injuries elsewhere. Instead, the tissues around, aided by a process of suppuration, cast the offending portion off as a slough. It is the wound remaining after the slough which we may really regard as a quittor. In this connection may be considered as causes blows from falling shafts, self-inflicted treads, or treads from other horses, overreach, etc. On the other hand, simple or cutaneous quittor may occur without ascertainable cause. In this case we can only explain its appearance, as we did that of simple coronitis (see p. 231), by attributing it to septic infection through a wound or a blow that is able to inoculate the skin, yet which is insufficient to cause pain, or in any other way attract the attendant's notice. Meanwhile, the spot of infection thus started spreads, and the end result is an abscess in the coronary region, again accompanied with necrosis and sloughing of more or less skin and other tissue, which terminates by discharging its contents and leaving behind a wound which again constitutes a cutaneous quittor. Thus, as with simple coronitis, anything lowering the vitality of the parts, and so favouring infection of the skin, may bring about a quittor. Walking through much water in the winter months, through the dirt and mud of our streets, through melting ice and snow, or through anything in the nature of a chemical irritant, may be looked upon as a cause.

Symptoms.—Whether commencing from an ascertainable injury, or beginning at first unnoticed, cutaneous quittor is characterized sooner or later by the appearance of an inflammatory swelling, usually confined to the seat of injury. Heat and tenderness are present, and the animal is lame.

Later the inflammatory swelling becomes more profuse, the animal is fevered, and the symptoms of lameness increased. Poulticing is at this stage perhaps resorted to. By its means the process of suppuration is aided, and the swelling (at first tense and hard) either becomes gradually softened, its contents discharged, and a simple abscess cavity left behind, or the suppuration runs immediately round the necrosed structures, and casts them off bodily as a slough. This latter condition is always manifested, where the hair does not hide it, by the colour of the skin. At first this is only red in colour—the angry red of an inflamed spot. As its intention to slough away becomes evident, the red gradually gives way to a gray, or even blue-black appearance, while from around it oozes a slight discharge of pus, yellow in colour and non-offensive, or blood-stained and dark in appearance, and foetid to the smell.

Almost invariably these symptoms are added to by a more or less diffuse and oedematous swelling of the lower portion of the limb, extending in some cases to as high as the fetlock or the upper third of the cannon.

With the casting off of the slough the phenomena of inflammation to a great extent subside, the pain ceases, and the case under ordinary conditions commences to mend.

Pathological Anatomy.—In its early stages the condition of simple or cutaneous quittor is really a condition of acute coronitis (see p. 229), and consists in an inflammation of the subcutaneous tissue, and the more superficial portions of the coronary cushion. The tissues implicated are destroyed outright, become infiltrated with the inflammatory exudate and escaped blood, and act as a source of irritation to the still living tissues around. Under the irritation the latter, as we have said before, cast the necrosed portion away by a process of sloughing.

Always, however, it is found that the portion to be sloughed off, while easily separated from the tissues adjacent to its sides, is closely connected on its lowermost or deeper face with the structures below, and cannot be torn away without haemorrhage and the causing of acute pain.

Prognosis.—With wounds about the feet our forecast should always be guarded. Even with this, the most simple form of quittor, no decided opinion should be given until the progress of the case warrants one in reasonably assuming that complications are absent. Once this point is decided, a favourable prognosis may be given.

Complications.—With cutaneous quittor various complications may arise, according to the extent of the invasion of the septic matter. Necrosis of tendon, of ligament, or of cartilage, caries of the bone, or a condition of synovitis and arthritis may be met with. As these complications are equally common to sub-horny quittor, we shall reserve their description until dealing with that condition. Treatment (Preventive).—Immediately after the infliction of an injury in this position, more especially if it is such as to lead one to judge that necrosis will follow to any large extent, the patient should be rested. Ill effects may then be probably warded off by having the foot immersed in a cold antiseptic solution, and afterwards bound with an antiseptic pad and bandage.

Curative.—When the condition has gone undiscovered until commencing necrosis and suppuration are plainly discernible, then the wisest course we can follow is to do all we can to hasten removal of the necrosed portion.

This is best done by promoting the suppurative process by means of warmth or stimulant applications.

To this end hot poultices, or, better still, hot baths, should be resorted to. Under their influence a greater supply of blood is directed to the still healthy tissues enabling them to actively continue the inflammatory processes necessary to the detaching of the portion necrosed, while, at the same time, the pus organisms, stimulated by the heat, are stirred into greater activity, and the readier accomplish their purpose of destroying the adhesion still existing between the necrotic portion and the surrounding living tissues.

When prolonged poulticing or bathing cannot be practised, then the swelling should be stimulated with a sharp cantharides blister, repeated, if the case demands it, at intervals of a few days.

Should the swelling show distinct signs of pointing, and an abscess is plainly the condition to be dealt with, its contents should be liberated by a free use of the knife. In this connection it is important to insist on the fact that the opening should be made large enough. One bold incision from the uppermost limit of the swelling down to the coronary margin of the wall is usually sufficient.

Even when pointing is not very evident, and suppuration is plainly more or less diffuse, benefit may still be derived from the use of the knife. In this case a deep scarification of the part is indicated. Three, four, or more vertical incisions are made in the swelling, and from them obtained a flow of blood mingled with a small quantity of pus from several different centres. By this means sloughing of the diseased portion is quickly obtained, and nothing but an ordinary open wound left for treatment. It should be mentioned, however, that when sloughing can be in any way induced to take place naturally it is better to allow this to take place. Even when the necrosed portion is freely movable, and only adherent by its base, it should not be forcibly removed, but left to the slower but more effectual action of the tissue reactions. If torn forcibly away, we in all probability leave in the bottom of the wound remnants of the dead tissue, which, being small and consequently less productive of inflammatory phenomena, are not so readily sloughed as the larger portion. These remain as centres of infection, and prolong the case.

Once a suitable slough has occurred, the after-treatment is simple. It consists in dressing the wound with reliable antiseptics, and maintaining the parts in a healthy condition until Nature completes the cure by repairing the breach. Solutions of carbolic acid, of perchloride of mercury, of zinc chloride, or of moderately strong solutions of copper sulphate, are all of them useful (see also treatment of coronitis on p. 236).

It is sometimes found that even with careful attention the wound left by the removal of the slough shows a marked disinclination to heal. The greater portion of the cavity becomes filled with granulation tissue, and the epidermis gradually closes round until all is covered except a spot of perhaps the size of half a crown or a crown piece. Here the regenerative process stops, and the wound obstinately refuses to effectually close.

In such cases we have derived excellent results with the actual cautery. The animal is cast, the foot firmly secured by fastening it upon the cannon of another limb, and the animal chloroformed. A practical point to be remembered in this connection is that all necessary fixing of the limb is easier performed if the chloroform is administered first. With the patient thus secured we first of all ascertain by means of the probe whether or no the non-healing of the wound is due to the presence of a fistula. Decided in the negative, we take an ordinary flat firing-iron, and with it cut away a portion of the skin immediately around the still open wound, carrying our incisions deep enough to 'scoop' out a large portion of the new inflammatory tissue beneath. With the loss of pressure from beneath, occasioned by the removal of so much of the cicatricial tissue, the epidermis the more readily closes over the wound. To a large extent also this new growth of epidermis is helped by the renewal of the inflammatory phenomena brought into being with the cauterization.

2. SUB-HORNY QUITTOR.

Definition.—A fistulous wound of the foot in which the lower and blind end of the fistula is situated below the level of the coronary margin of the wall.

Causes.—These, again, will be practically the same as those mentioned in the cause of cutaneous quittor—namely, bruises, punctures, wounds—in fact, any injury upon the coronet severe enough to cause death of tissue and a suppurating wound. We may thus expect sub-horny quittor to follow upon treads, overreach, accidental injuries with the stable-fork, and kicks from other animals.

Sub-horny quittor may also arise without original injury at all to the coronet. Either from a violent blow upon the hoof, or from the animal himself kicking violently against a wall, death of a portion of the sensitive structures takes place within the hoof, suppuration ensues, and the formation of quittor commences. With the escape of the pus at the coronet the quittor is fully formed.

Any other diseased condition of the foot in which suppuration is present may in like manner terminate in quittor. In complicated sand-crack, suppurating corn, or in ordinary pricked foot quittor may be a sequel. In these conditions the pus formation either goes unnoticed or is neglected, and after seriously invading the sensitive structures within the hoof, breaks out at the coronet. Again, too, as with the simpler form of quittor, and as with coronitis, we may always regard as a predisposing cause the action of excessive cold in promoting septic infection of the wound when occurring at the coronet.

Symptoms and Diagnosis.—Where the fistulous wound has had its starting-point in an injury to the coronet diagnosis is, of course, easy. The history of the case explains it. Nothing in this instance remains but to probe the opening, and ascertain its direction, depth, and extent.

An animal with the wound thus open at the coronet, and freely discharging its contents, may, if no serious complications exist, walk tolerably sound. It is only when put to the trot that symptoms of lameness are apparent.

It may so happen, however, that we first see the case when the symptoms are wholly those arising from a painful suppuration within the horny box. This occurs when the original injury has taken place at a more dependent position than the coronet. Either from violent blows upon the hoof, puncture from below, from corn or from sand-crack, or any other causes we have enumerated, suppuration is occurring deeply within the hoof, with as yet no opening upon the coronet.

Even when an opening has already occurred on the coronet, the same condition of sub-horny suppuration may be met with in cases when the opening of the fistula has by some means or other become occluded. Granulation tissue, for instance, may have temporarily closed the mouth of the fistula. The pus, instead of continuing its discharge thereat, is made to burrow in other directions.

In either of these cases pain is excessive, the animal walks on three legs, the foot is painful to percussion, and grave constitutional disturbance is noticeable. The presence of pus is immediately suspected, and, in the absence of any indication of an opening having existed at the coronet, searched for at the sole. It may or may not be found. If found it is given exit, and the case ends as one of ordinary pricked foot, of suppurating corn, or some other condition equally simple when compared with quittor. In those cases where the pus is not discovered at the sole, one adopts the expectant treatment of poulticing. This, if pus is present, is followed by a painful swelling of the coronet. At one point there forms a hot and tender enlargement, with the hairs on it standing straight up from the skin, which latter is seen below red and inflamed in appearance.

Later, the abscess—for abscess it is—discharges its contents, the opening is explored, and we find that in extent it is not confined to the coronary region, but that it is deep enough to constitute a true sub-horny quittor.

This discharge of the abscess contents may take place at a well-defined spot on the coronet, or it may ooze out at the junction of the wall with the skin. In appearance the discharged pus varies. When the softer structures only are attacked it is thick, and yellow or white in colour; when bone is involved it is ichorous; and when attacking the horn itself black or gray. It may or may not be extremely foetid, and often it is mingled with blood.

When evidence of a previous opening upon the coronet is plain, then it is not considered wise to attempt a paring of the sole. Instead, poulticing is at once resorted to, to induce the discharge of the pus through its original channel. Once this has occurred a fistulous wound remains, which is open for treatment upon one or other of the lines we shall afterwards indicate.

COMPLICATIONS—(a) Necrosis of the Lateral Cartilage.—This is the so-called 'cartilaginous quittor' of other writers. In all probability it is the condition generally understood when the word 'quittor' is used by one practitioner to the other. Its tendency to keep the disease existing in a chronic form renders it of grave importance, and for that reason we give it first mention among the complications.

It may occur as a sequel either of cutaneous or of sub-horny quittor, and may result either from actual wounding and infection of the cartilage, or from an attack on it of septic matter originating elsewhere.

Unless there has been discovered a fistula, which on probing is seen to lead direct to the position in which we know the cartilage to be, we know of no precise means by which the existence of this condition may be diagnosed. When free from other complications, the horse with his foot in this state may travel fairly sound. This is so when the necrosis is situate in the posterior half of the cartilage, in which case the irritation set up by the disease is confined to the comparatively non-sensitive tissues of the cartilage itself and the fibrous mass of the plantar cushion. When attacking the anterior half of the cartilage, the close contiguity of the joint renders the disease of a more serious nature. It is then that we have acute pain, and with it extreme lameness, for in this position it is more than likely that we have involved either the synovial membrane of the articulation or the tops of the sensitive laminae. It will be remembered that here the synovial membrane protrudes as a small sac between the antero- and postero-lateral ligaments of the joint. More or less easily then it is bound to come into intimate contact with the septic matter attending the necrosis of the cartilage, and so share in the inflammatory processes, afterwards communicating them to the interior of the articulation.

With necrosis of the lateral cartilage is always swelling and thickening of the skin and subcutaneous structures of the coronet. This is the greater the longer the disease has been in existence. Upon the swelling is seen the mouth of the fistula, or it may be the mouths of several, and from them all a discharge of pus.

The mouth of each fistula is generally filled with a mulberry-like granulation tissue, standing above the level of the skin, and bleeding easily if touched. The exuding pus is thin and pale gray in appearance, gritty to the touch, and generally free from pronounced smell. At other times its colour is reddened with contained blood, and floating in it are tiny particles of a pale-green substance, which when picked up and rubbed between the fingers are seen to be small fragments of the diseased cartilage.

Should the mouth of a fistula become occluded with the granulations filling it, and the discharge prevented from escaping, it soon happens that we have close to the fistula that has closed a tender fluctuating swelling. This points and breaks, and pus is again discharged from another opening. In this manner is accounted for the multiplicity of scars and fistulas seen on the swelling of an old-standing quittor.

The continued, inflammation thus kept in existence has the effect of rendering the skin and subcutaneous tissues in the neighbourhood greatly thickened and indurated. This in time leads to a tumour-like enlargement, and causes the structures of the coronet to greatly overhang the hoof. At the same time the constant inflammation has made its stimulant effects noted in a great increase in the growth of the horn of the wall.

Although more abundant, however, the quality of the horn is deteriorated. The perioplic ring has become obliterated, and the varnish-like appearance of the healthy wall destroyed. Cracks and fissures in its surface are numerous, and sometimes deep enough to lead to exposure of the sensitive structures beneath, complicating the quittor with a sand-crack of a peculiarly objectionable type.

Pathological Anatomy of the Diseased Cartilage.—The bulk of observers appear to agree in the statement that in quittor the necrotic cartilage is pea-green in colour, and recognise it by that characteristic. In size the necrotic portion thus recognisable varies from the tiniest speck to a portion the size of a horse-bean. Commonly, however, it is about as large only as a pea. It is seen to be more or less detached from the rest of the cartilage, to which it is adherent by one of its extremities only. In general appearance we can best liken it to the split half of a green pea, whilst others have compared it with the green sprouting of a seed. The portions of cartilage nearest the necrotic piece are also slightly green in colour, thus indicating that here also the diseased process has commenced. This peculiar change of colour in the affected cartilage is of great importance to the surgeon. It enables him when operating to distinguish with some degree of certainty those portions of the cartilage which are healthy and those which are not.

(b) Necrosis of Tendon and of Ligament.—This complication of quittor is, as we have said before, treated by other writers as a distinct form of the disease, and described by them under the heading of Tendinous Quittor.

This simply means, of course, that the diseased process has extended to either of the flexor tendons, to the tendon of the extensor pedis, or, perhaps, to the ligaments of the pedal articulation.

Of the flexor tendons, the perforans is the one commonly attacked, by reason, of course, of its more superficial position. At times, however, especially when its aponeurotic expansion is diseased, the necrosis of the perforans spreads until the aponeurosis is eaten through and the phalangeal sheath penetrated. Septic materials gain entrance thereto, and commence to multiply. In this way the flexor perforatus is invaded, and comes to share in the diseased process.

The extensor pedis is usually attacked by extension of the disease from a necrotic cartilage, or results from the infliction of a severe tread in a hind-foot. In this case the diseased structure has nothing between it and the articulation, the synovial membrane in one position actually lining its inner face. The result is that a condition of synovitis is easily set up, and the case aggravated by that and by arthritis.

With the flexor tendons attacked pain is always very great, and lameness is excessive. This, however, is not sufficiently characteristic to enable us to determine the precise seat of the necrotic changes. Later, however, a tender but hard enlargement made its appearance in the hollow of the heel, which enlargement, later still, became soft and fluctuating. At this stage there is also considerable swelling along the whole course of the tendons, as high up as the knee or the hock. The foot is carried forward with all the phalangeal articulations flexed, and in many cases the limb is unable to take weight at all. Manipulated after the manner of examining the tendons for sprain, this swelling is found to be extremely painful. The animal flinches from the hand, and shows every sign of acute suffering. This condition may, in fact, be mistaken for sprain, and is only to be distinguished from it by carefully noting the history of the case—first, the appearance of the swelling in the hollow of the heel, and, secondly, the after-swelling of the upper portions of the tendons.

The formation of the abscess, the after-discharge of its contents, and the final establishing of a fistula, are processes greatly prolonged in this form of quittor. It will readily be understood why this should be so when one remembers the depth at which the suppurative process is going on, the thickness of the metacarpo-phalangeal sheath, and the resistant nature of the material of which this latter is made, and which must be penetrated before the condition becomes observable.

After the opening of the abscess, which usually takes place in the hollow of the heel, there is left the fistulous wound which obstinately refuses to heal. Or it may be, again, that there are several of these fistulas, each opening in the heel, and the mouth of each marked by a small, ulcer-like projection. The discharge continually oozing from these keeps the heel constantly wet with a thick purulent discharge, which is nearly always blood-stained, and very often foetid.

This constitutes what is known as tendinous quittor in its worst form, for more often than not there is associated with it inflammation of the navicular bursa, caries of the bones, or arthritis of the pedal articulation.

With the extensor pedis attacked matters are not quite so grave, in spite of the fact that the articulation is closely situated thereto, for in this case the more superficial position of the diseased structure allows both of readier exit of the discharges and of easier removal of the necrosed portion and after-treatment of the wound.

(c) Caries of the Bones.—Portions of the os pedis, more especially of its wings, and therefore usually occurring in conjunction with necrosed cartilage, become carious in quittor. In many cases it is impossible to say with certainty when this has occurred. In a few instances, however, the exuding discharge gives evidence of what has happened. It is thin, but extremely offensive, with the characteristic odour of decayed bone or tooth, and with a feel that is gritty with contained particles of broken-up bone. If, with a discharge of this nature present, the probe also conveys to the fingers the sensation that bone is reached, then diagnosis may be sure.

(d) Ossification of the Cartilage.—This may take place in part or in whole. It, of course, constitutes Side-bone, a fuller description of which will be found in a later portion of this chapter.

(e) Penetration of the Articulation.—This may occur either as a result of the suppurative changes or as an accident in excision of the diseased cartilage. Unless it is followed by a severe purulent arthritis, it is not so grave a complication as at first sight it would appear.

(f) Synovitis and Arthritis (Purulent).—Should this complication arise, the case is a most serious one. Beyond here mentioning the fact that it may occur, we shall not dwell on it. Fuller consideration is given to it in Chapter XII.

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 laminae, 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 haemorrhage 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 haemorrhage 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 laminae 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 laminae (see Fig. 139).

The flaps (Fig. 139, a, a) are now held back by tenaculae, 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).



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 laminae (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.]



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 laminae, 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 laminae 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.



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 anaesthetic. 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 laminae, 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.



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 laminae 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 laminae 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 Chapter XII.

Surgical Shoeing in Quittor.—In the case of simple or cutaneous quittor, no alteration in the shoeing is necessary.

When the condition becomes sub-horny, however, and particularly when it is situated in the region of the quarters, ease is afforded to the diseased parts by removing the bearing of the shoe in that position.

Should there be no dependent opening at the sole, then the best shoe for the purpose is an ordinary bar shoe (Fig. 68), with the bearing eased under the affected quarter.

If, however, there is a dependent orifice, or one is expected, then it will be necessary either to leave the animal unshod or to provide him with a shoe that admits of dressing the lesion. In the latter case the most suitable shoe will be found to be either a three-quarter shoe (Fig. 102) or a three-quarter bar shoe (Fig. 103). Many operators, however, keep the animal unshod. We must say ourselves that we consider a shoe useful after either of the operations for removal of the cartilage, if only to assist in maintaining the bandages and dressings in position.

In this case a very useful shoe will be the three-quarter bar shoe. With a little manipulation the bandages are easily run under the bar portion of the shoe, and a few of their turns every now and again wrapped round the bar in order to keep the whole firmly in position.

In connection with tendinous quittor, when septic matter has gained the sheath of the flexor tendons, there is, for a long time after healing of the fistula, a marked tendency for the animal to go on his toe. To a large extent we judge this to be due to slight adhesions between the two tendons brought about by the growth of inflammatory fibrous tissue. In such cases benefit is sometimes derived from the application of a shoe with an extended toe-piece (see Figs. 84 and 108).

C. OSSIFICATION OF THE LATERAL CARTILAGES, OR SIDE-BONES.

Definition.—An abnormal condition of the lateral cartilages, in which the substance of the cartilage becomes gradually removed and bone formed in its place.



Symptoms and Diagnosis.—Side-bones are nearly always met with in heavy draught animals, and are rarely seen in the feet of nags. They are, moreover, nearly always confined to the fore-feet. In the ordinary way little need be said concerning their characteristics, and the way in which they may be detected. Neither need any concern be ordinarily manifested with regard to the effect they may have on the animal's gait and future usefulness. Seeing, however, that side-bone constitutes one of the recognised hereditary diseases, and that at the various agricultural and horse shows its existence or otherwise in a certain animal is a matter of great importance, some little attention must be given to these two points.

With a side-bone anywhere approaching full development, diagnosis is easy. The thumb is pressed into the coronet over the seat of the cartilage, when, in place of the elasticity we should normally meet with, we have the solid resistance offered by bone. In some instances diagnosis is even easier still. We refer to those cases in which the side-bone stands above the level of the coronet with such prominence as to be readily seen and recognised without manipulation, and where its growth has caused distinct enlargement and bulging of the wall of the affected quarter. It seems that in such cases the bone-forming process does not end with simply depositing bone in place of the removed cartilage, but that, after that is accomplished, the bone still continues to be produced, as in the case of an exostosis elsewhere.

Although diagnosis in cases such as these is easy, it becomes a very different matter when we are called upon to give an opinion in cases where ossification of the cartilage is only just commencing. Whether the result of our examination is to decide the sale or purchase of an animal, to determine his fitness or otherwise to enter the show-ring, or to merely advise a client as to whether or no a side-bone is in course of formation, our position is equally difficult, and in either case our examination must be searching.

Perhaps the best advice we can give is to say that the whole of the cartilage must be manipulated both with the foot on and off the ground. What the reason may be we do not pretend to say, but it is a well-known fact that in many instances the cartilage, with the foot bearing weight, is so rigid as to at once convey the impression that ossification has commenced or is even far advanced. And yet that same cartilage, with the foot removed from the ground, is as pleasantly yielding to pressure of the thumb as the most exacting of us could wish for. In any case, then, where doubt exists, the foot should be lifted to the knee, and the cartilage carefully examined with the foot in that position. If, then, at any spot above the normal contour of the os pedis we meet with hardness or rigidity, we are to look upon that foot with suspicion. Nevertheless, providing our conscience is sufficiently elastic, the animal may be passed sound so far as the existence of a side-bone is concerned. We know, however, that with commencing rigidity we may ere long expect one, and if our opinion is asked with regard to that particular, it must be admitted that with rigidity of the cartilage once commenced it is usually not long afterwards before a fully-developed side-bone makes its appearance.

As is only to be expected, the first noticeable hardening of the cartilage is to be found near the normal bone. We may thus look for it more particularly in the lower portions of the cartilage. We think we may say, too, that in the vast majority of cases the ossification of the cartilage commences in its anterior half. It is thus brought about that often we are called upon to examine and report on the condition when we have anteriorly a side-bone in course of formation, and posteriorly a perfectly normal cartilage. It is to the latter half of the cartilage that dealers and others mainly, if not wholly, devote their attention. A horse with the cartilage in this transition state will therefore pass muster, and a nice little point of ethics has again to be decided by the veterinary surgeon before giving his signature to a certificate of examination of an animal in this condition.

With regard to alteration in gait, we may say at once that side-bones in heavy animals are not often the cause of lameness. In fact, where the foot is well developed, when neither the foot as a whole nor the phalangeal bones give evidence of disease, and where the pasterns are fairly oblique and well formed, this alteration of the cartilages may be looked upon as of no serious import at all. Neither is the side-bone due to blows or other injuries likely to be productive of lameness—that is, always supposing, of course, that the foot in other respects is of good shape. If lameness is met with at all, then it is where we have a foot that is in other respects unsound, with badly contracted heels and upright 'stumpy' hoof, or where side-bones have occurred in a young animal, and have already reached a large size before the horse is put to labour. In this latter case, the added effects of concussion and the evil influences of shoeing are sufficient to turn the scale. Directly the animal, previously sound, is asked to work, lameness is the result.

It follows, therefore, that side-bone in the feet of young animals is of far more serious import than when occurring in older horses. In a nag animal they constitute a positive unsoundness, and lameness in this case is more often than not an accompanying symptom.

Causes.—To commence with, we may remark that, although met with sometimes in very early life, side-bones are seldom, if ever, congenital, and that more often than not they may be looked for in animals of three years old, or older, seldom earlier. They appear, in fact, only when the animal is shod and commences work.

This at once suggests two of the principal factors in their causation—namely, concussion and loss of normal function. Directly the horse is put to work he has for a great part of his time to travel upon roadways—either macadamized roads or town sets—where everything is calculated to bring concussion about. In addition to that he has the lateral cartilage itself thrown largely out of action by shoeing. We explained in Chapter III. (p. 66) that the chief function of the cartilage was to take concussion received by the plantar cushion and direct the greater part of it outwards and backwards. Now, with the animal shod, the plantar cushion does not itself, as normally it should, receive concussion. By the shoeing the frog is lifted from the ground, and the plantar cushion, together with the cartilage, taken largely out of active work. In other words, the normal outward and inward movements of the cartilage are enormously reduced.

It is fair, we think, to take it that the mere fact of the lateral cartilage persisting as cartilage is due in large measure to its constant movement. Directly, therefore, it is placed in a state of comparative idleness, then it commences to ossify, more particularly if there should at the same time be a tendency to a low type of inflammation of the parts.

Does this latter exist? We may safely say that it does. It is in this way: The secondary effect of loss of ground-pressure upon the frog and plantar cushion is to bring about contraction of the heels. With this we get compression of the parts within, with a certain amount of irritation and the exact low type of inflammatory phenomena calculated to assist in the bone-forming process.

The fact that concussion acts as a cause explains in great measure how it is that side-bones are more frequent in cart animals than in nags, and also why they should be more common in the fore-feet than in the hind. Taking, in both animals, a rough calculation as to the weight of body carried by feet of a certain size, we notice at once that the cart animal has proportionately more weight to carry than has the nag. Concussion to the foot is therefore greater. The greater part of the body-weight is borne by the fore-limbs. Concussion is therefore greater to the fore-feet than to the hind.

This, however, does not explain altogether the comparative immunity of the nag animal from this defect. He, too, must also be subject to the effects of concussion, especially when his higher and faster action is taken into account. To our minds there is only one explanation to be offered here. We point at once to the years of constant and judicious breeding of the nag. Compare that with the relatively few minutes that have been devoted to a more careful selection of the cart animal, and we at once see a possible explanation. That the explanation holds some amount of truth is borne out by the fact that, since a greater attention has been paid to the selection of our cart animals, side-bone has grown a great deal less common.

Is side-bone hereditary? We can best answer that by saying that, some several years ago, the Council of the Royal College of Veterinary Surgeons, at the request of the Royal Commission on Horse Breeding, drew up a list of those diseases 'which by heredity rendered stallions so affected unfit as breeding sires,' and that in that list was included side-bone.

Side-bones, therefore, are hereditary. We think, however, the statement needs qualifying. It is in this way: side-bones occur only at a certain, usually well-defined, time after birth, and we might say are never congenital. They occur only after the animal has been put to work, and are more or less plainly due to mechanical causes—namely, the ill effects of shoeing and concussion. The cause of their appearance, in short, is more plainly extrinsic than intrinsic, and side-bone in the horse is, as Professor McCall puts it, about as much due to heredity as is corn on the human foot.

Between these two opinions—that they are plainly hereditary, and that they just as plainly are not—it is well to strike a middle course. They are, we will say, hereditary in this way: So long as a cart animal is bred, to put it vulgarly, 'top-heavy' (that is, with a body out of reasonable proportion to the feet that have it to support), so long will the foot be subjected to a greater concussion, and so long will side-bones in such animals commence to make their appearance at about middle life.

In addition to the causes we have now mentioned, side-bones are often the result of other diseases of the foot. They thus occur as a sequel to sub-horny quittor, to suppurating corn, to complicated quarter sand-crack, or to the inflammation of the parts occasioned by a prick. They also arise in many instances from the effect of a prick or injury to the coronet. Among the latter we may mention treads from other animals, and treads inflicted by the animal himself with the calkin of an opposite shoe, or the repeated injury occasioned by the shafts being carelessly allowed to drop on to the foot. In severe cases of laminitis, too, the cartilages are nearly always affected. In this instance the inflammatory phenomena in the os pedis no doubt give rise to an abnormal activity of bone-forming cells. The cartilage is invaded, and the side-bone formed (see Fig. 118).

Treatment.—In the ordinary way the 'treatment' of side-bone is a thing but rarely mentioned. The explanation lies, of course, in the fact that side-bones are so rarely the cause of lameness. When lameness does occur with a side-bone, and we have reason to believe that the said side-bone is the cause of the lameness, it is well before talking of treatment to question ourselves thus: 'In what way does the side-bone cause lameness?' The now generally-accepted answer to that query is the explanation put forward several years ago by Colonel Fred Smith—namely, that the pain, and therefore the lameness, was due to the compression of the sensitive laminae between the ossified and enlarged cartilage and the non-yielding and often contracted wall of the quarters. That, in fact, constitutes the basis upon which Smith's operation for side-bone (that of grooving the wall of the quarters) is founded.

Before describing the operation, however, we may say that we are now able to understand that older operators who claimed success for other methods of treatment, were to a very great extent justified in so doing.

For instance, take the combined treatments of firing and blistering, and the use of a bar shoe. Here the beneficial action of the cautery and the blister may be largely problematical. The bar shoe, however, would be almost certain to give good results. Frog-pressure with the ground would be again restored, and the contraction of the heels removed. Pinching of the sensitive structures would be diminished, and the lameness cured.

Take, again, the treatment of 'unsoling.' It was barbarous, we know barbarous, because unnecessary and easily avoidable. It was practised, however, certainly very little more than two decades ago, and practised by men of standing in the profession. Without dragging the case to light again by mentioning the names of those concerned, we may mention that not many years ago a highly respected member of the profession was, at the instigation of the Royal Society for the Prevention of Cruelty to Animals, prosecuted for practising unsoling for the relief of side-bone. Practically only one other member of the profession was able to come forward and defend the operation on the score of its utility. We see now, however, that—as does Smith's operation—unsoling does permit of the greater expansion of the heels. The contraction is done away with, the pressure on the sensitive laminae again diminished, and the lameness relieved.

Not that we are attempting to defend the operation—far from it. We simply mention it as interesting, and quote this and the use of the bar shoe (with both of which methods older operators have claimed success) merely as evidence that the operation of Smith is based on a logical foundation.

When treatment is decided on, therefore, we may first advise blistering and the use of a bar shoe. After that, should the lameness continue, and should we still judge the side-bone to be the cause of it, the operation may be advised.