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John Idikula,

C'-fASci-

M.S., DIP.N.B., Booshanam V. Moses, M.S., F.I.C.S., David Sadhu, M.S.,

Sunil Agarwal, M.S., Gauhar Jahan, M.B.B.S., andJoy Thomas, M.B.B.S., Vellore,India
Bull horn injury is not uncommon, and during a 12 year penad Jrom 1977 lo 1988, 101 patients required inpatimt treatrnent at the Christian Medical CollegeHospital, ,a teaching hospital at Vellore South in India. The ages oJ these patients ranged Jrom two years to 90 years and the mate to Jemale ratio was 4:1. Sixty-oneper ceneoJ the injuries occurred either to the penneum or abdornenand wounds were directed obliquelyupward. Thirl)'five per cent requiredextensive surgical intervention. The over-all wound inJection Tale was 12.9 perocent. OJ wounds that were primarily closed,42.9 per cenehad wound inJection, while only. 6.3 per cmt that wer-esecondarily closed develop~d injection. TlVOpatient.s diRd as a consequence the oJ injury. Basedon t/IRresul1s this study, we recommend oJ that a careJul evaluation oJ the injury and timely and abfJrofJriate managernentoJ each batient must be

the computer coded record keeping system of the Medical Records Department of the hospital. The files pertaining to all these instances \\'ere retrieved and studied to obtain the desired information. /nclusion criteria. AlI patients who sustained injuries from contact with the horns of bulls, oxen or cows were included in this studv. Exclusion criteria. Patients \\1th injuri~s from horns of other animals (for example, goats and buffaloes), animal inflicted injuries other than bull horn injuries and patients who were managed in casualty or as outpatients \\'ere excluded from the study.
RESULTS

During the 12 year period from 1977 to 1988, 101 patients with bull horn injuries \\'ere treated as inpatients. Patients were admitted under various specialty departments depending on the THE Bl'LL, OX and cow are domesticated animals that are normally docile. Rarely, the animal mar site of the injury or the age of the patient. Sixty become aggressi\'e and attack man either to per cent were admitted under general surgery, se\'en per cent each under thoracic surgery and defend itself or its young or"to ward off intruders. Injuries mar be sustained from the horns of these plastic surgery, six per cen t each under pediatric animals either accidentally or as the result of surgery, neurosurgery and g'y'l1ecology and the an attack (1). The term bull horn injury, although remaining eight per cent under urolog'y', orthonot a medical subject heading term, is generally pedics and ear, nose and throat. used to indicate injuries sustained from the horns The data depicting the age and gender disof the bull, ox or CO\\7. tribution is illustrated in Figure l. The age of The results of a few other series also indicate these patients ranged from t\IJOto 90 years \\!ith that this is not an uncommon type of injury, a mean of 32 years (S.E. of mean, 2.04 )'ears) although the pre\'alence is not accurately deter- and the male to female ratio was 4: l. In Table mined (2-5). Extensive injuries do occur that 1, the distribution of injury according to anatomical sites is given. Injuries to the perineum and require specialized care (6-7). This presentation highlights various aspects of the 101 bull horn abdomen were significantly higher than other sites injuries that \\'e have encountered. (p<0.05). Bull horn injuries occurred throughout the year, although it was more frequent in the MATERIALS A""D :\IETHODS quarter from January to April (44 patients). During a 12 year period from 1977 to 1988, "'Tounds were graded for severity based on the all consecutive instances of bull horn injuries extent of the injury (Table II). No patient had that required inpatient treatment at the Christian more than one primary injury indicating that Medical College Hospital, which is a tertiary care the animal gored the patient only once. Three hospital in a tO\\7nin the southern part of India, patients had a second injury on account of being were studied. These injuries were identified from thrown clown or being trampled opon after the horn injury. From the Deparunent of General Surgery Unit 3, Christian Medical ('.ollege Hospital, Vellore, India. The treatments administered are classified as

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222 SURGERY, Gynecology& Obstetncs.MaTch 1991. Volume 172


TABlE m-ffiThfARY 1REA1MENr ADMINl5IERED FOR 101 PA~

Patient nu~
Treat1lU'nt
Less extensive Nonsurgical Extensive surgicaJ treaunent ..

Mate Female Total


20":. 30 3 13 23 43

surgicaJ

treaunent

Total.

30 80

5 21

35 101

capabIe of inflicting horn injuries by attack or by accident to humans who co~e within its range. It is not uncommon in pIaceswere cattIe rearing is common, especialIywhen they are aIIowed to roam about freeIy on the roads or other crowded places and where buII fighting is a common sport. Injuries mar occur in any age group. Injuries to fue abdomen and perineum accounted for 61 per cent of alI injuries and wounds are directed obIiqueIy upward. The reason for this mar be that, when fue buII attacks, it charges with its head heId Iow and the horn Ieading. At the time of goring, it tends to extend its head upward so that fue horn traces an arco The part of fue body most IikeIy to be injured in a person either facing the buII or running awayis fue abdomen or the perineum. A carefuI assessment the injury is of to institute This was seen in 19 of fue patients we .An extreme example of this occurred in one patient in whom fue hom had entered the anal canal \\'thout any external injury, entered the peritoneal ca~ty by penetrating the anterior rectal wall and had transected the distal part of the ileum. The only e~dence of injury at fue time of admission (which was less than two hours after injury) was blood staining of the finger stall on rectal examination. The patient did well after emergency laparotomy, resection and anastomosisof the injured intestine and sigmoid colostomy (defunctioning), which was closed later. Wound infection was common (12.9 per cent), especially for wounds that were primarily closed. However, in wounds closed secondarily, the in-

fection was low (6.3 per cent). Therefore, it mar be recommended that these ",'ounds should be closed by secondary or delayed primary closure even when injury is less than six hours old. The morbidity and mortality rate from bull horn injuries can be kept low only by correct assessment and timely management. Personnel at the primary care level who have to deal with bull horn injuries will do well to evaluate carefully all instances and refer those with extensive injuries to a tertiary care center. With appropriate and timely intervention, the mortality and morbidity rate from bull horn injuries Cal} be kept low.
SUM~fARY

ti

.
: i

A series involving 101 patients ",ho sustained injuries from the horns of domesticated bulls, oxen or cows is reported from a teaching hospital in south India. The ages of these patients ranged from two to 90 years. There were 21 female and 80 male patients. The anatomic site, nature and se\'erity of injury are highlighted. Il1juries to the perineum and abdomen were significan tI)' higher than in other regions. Thirty-five of the patients required extensive surgical treatnlent. The overall mortality rate was 2 per cent. Wound infection was significantly lower in those who had secondary closure of the wound. The results of this study reveal that, with appropriate and timely inter\'ention, mortality and morbidity from bull hom injuries can be kept low.
REFERE~CES l. Shattock, F. M. Injuries caused by wild animals. Lancet, 1968, 1: 412-413.

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2. Shukla, H. S.., Mittal, D. K., and Naithani, Y: P. Bull hom injury: a clinical study. Injury, 1977, 9: 164-167. 3. Rau J. B. V. Bull gafe injuries iri rural afeas. Indian J. Surg., 1982, 44: 664-671. 4. Prusty,G. K., and Nagaraj, T. Bull gafe craniocerebellar injury. Indian J. Surg., 1986, 48: 361-362. 5. Sekhon, M. S., Khutri, H. L., Grewal, S. S., and Maf)'a, S. K. S. Indian J. Surg., 1983, 45: 486-488.
6. Gonzalez Ulloa, M. Severe avulsion of the scrotum, in bullfighter: reconstructive procedure. Br. J. Plast. Surg., 1963, 16: 154-159.

7. Hughes, L. E. Penetrating injuries of the extraperitoneal rectum. Br. J. Surg., 1969, 56: 169-172.