TREATMENT OF INFLAMMATION AND FEVER.
Treatment will be guided very largely by the type of the attendant fever. If that is of a high type, with a hard, full, rapid pulse, bright red mucous membranes, a clear eye, and well sustained strength in a strong, vigorous animal, what is known as antiphlogistic (depleting, depressing) treatment is admissible at the outset. But in many cases with a low type of fever, a weak, rapid pulse, pallid, yellow, or livid mucous membranes, a coated tongue, a dull or sunken eye, much depression and prostration, swaying on the limbs in walking, pendant head, ears, eyelids and lips, and varying and irregular temperature of the limbs, etc., such measures are forbidden from the first, and tonics and stimulants are demanded from the outset. Between the two extremes there are many grades, which demand a judiciously adjusted intermediate treatment. The general principles only of each characteristic form of treatment can be here formulated, it being understood that no two cases can be most advantageously treated in precisely the same way, but that according to its special grade each case will demand its own specific management applied according to the skill of the physician.
Regimen. An antiphlogistic diet will consist in a moderate or very sparing amount of non-stimulating food of easy digestion (wheat bran or oil meal in warm, sloppy mash, carrots, turnips, beets, potatoes, apples, pumpkins; fresh, tender, green grass or in winter a little scalded hay, may be taken as examples). Ruminants should have no food necessitating chewing of the cud; thus the roots, etc., should be pulped or boiled, and hay and even grass must be interdicted until rumination is re-established. When food is absolutely refused for days in succession well-boiled gruels of oatmeal, barley-meal, linseed meal, bran, etc., may be given from a bottle or by injection. Dogs and cats should have only vegetable mush (unbolted flour, barley, or oatmeal) with just enough beef-juice to tempt the animal to eat a little. Milk with an admixture of oxide of magnesia, or even lime water is often at once palatable and cooling. Drink should be pure water, cool, if kept constantly fresh before the animal, but warmed to something less than tepid if supplied only at long intervals, so that the thirsty patient is not tempted to drink to excess and chill himself. Rest in a clean, well-aired building, free from draughts of cold air and with a southern exposure, is desirable, especially in winter. The best temperature is usually sixty degrees to seventy degrees, especially in inflammations in the chest, and extremes of temperature are to be avoided. Clothing will depend on the weather. In warm weather it may be often discarded, while in winter it should always be sufficient to obviate the access of chill and consequent aggravation of the disease. Whenever the atmosphere can be kept warm only at the expense of impurity it is better to secure the comfort of the patient by the requisite clothing than to subject him to impure air. As the extremities are the first to suffer from cold, loose flannel bandages to the limbs are often imperative.
Remedies. General bleeding, a great resort of our fore-fathers, has been long all but discarded from modern practice. Today it is rarely resorted to, except to save from an urgent and extreme danger, as in the plethoric cow merging into parturient apoplexy, or the fat and overdriven horse, gasping for breath and life, in general acute congestion of the lungs. There are other cases of extensive acute and dangerous congestions, especially in a strong, vigorous, and plethoric patient, in which general bleeding in beneficial in warding off threatened death; but sound, discriminating judgment is necessary to its safe employment. When resorted to at all, the blood should be drawn from a large orifice, in a full stream, to secure the desired depressant effect with the smallest loss of blood, and the patient should be kept especially quiet and apart from all excitement which would tend to counteract the sedative action.
Local bleeding is more extensively applicable than general, as it usually effects the same purpose without the permanently weakening effect. It acts in two ways, first, by emptying and contracting the vessels in the skin over the inflamed organ, it solicits a sympathetic contraction of the capillary vessels in that organ itself, and thus inaugurates a progress toward recovery; and second, by so much as it draws blood to the surface it diminishes the blood pressure on the deeper inflamed organ, and affords a better opportunity for the restoration of the healthy circulation and function. Local bleeding may be practiced by simple scarification or leeches, or better, by cupping with or without scarification. To apply leeches, the skin must first be shaved. To cup, it must at least be greased. As a cup, an ordinary large drinking-glass may be used, the air contained in it being driven out by a lighted taper, and then the taper being withdrawn, the mouth of the cup is instantly and accurately applied on the skin and held there, until, as it cools, it draws up the skin within it and clings like a sucker. A number of these may be applied according to the extent of the inflammation, and, if desired, they may be removed, the part scarified, and the cup reapplied. The cupping usually effects more than a mere local attraction of blood; it very commonly causes a free circulation in the whole skin, a generally diffused warmth, and even perspiration. Thus we may secure the derivation of blood from the inflamed part, the cooling of a large mass of blood in the extensive cutaneous circulation, the cooling of the entire system by the return of this blood internally, the elimination of injurious waste matters through the skin, the lowering of the febrile heat and tension, and a better functional activity of all the organs of the body.
Similar good results are obtained from all remedies that induce surface warmth and vascularity and a free secretion from the skin.
Warm baths, for animals to which they can be applied, abstract blood temporarily from the inflamed internal organs, diminish the blood pressure, and really cool the system, beside securing elimination from the skin and other secreting surfaces. They may be commenced warm (80° F.) and gradually cooled down to 65° F. after the skin has become freely active. In the larger quadrupeds, in which the warm bath is too often practically impossible, the same revulsion of blood and warmth to the skin may be secured by rags wrung out of hot (almost scalding) water, wrapped tightly round the body, covered with two or more dry blankets, and kept tightly applied against the surface by elastic circingles. The legs may be rubbed with straw wisps till warm, and then loosely bandaged, or applications of red pepper, ammonia, or mustard, may be made prior to bandaging. In place of hot water rugs, bags loosely filled with bran, chaff, or other light agent, heated to 110° F., may be applied round the body, or, where it is available, a Turkish or steam bath may be resorted to. These hot cutaneous applications, to produce glow and perspiration, are especially valuable in the chill that heralds a violent inflammation, and if that can be suddenly checked by this means the inflammation will often be warded off, or at least rendered slight and easily controllable. After perspiring for half an hour the patient may be gradually uncovered, rubbed dry, and covered with a dry, warm blanket. If the skin is still glowing, a slight sponging with cool or cold water may beneficially precede the rubbing and drying.
Cold Baths. In cases of very high fever a full cold bath (68° F.) may be employed for fifteen minutes, and repeated as often as the temperature rises. In many cases of parturition fever in cows great benefit accrues from sponging the body with cold water and allowing it to evaporate from the burning skin. In the extreme fever of heat apoplexy (sunstroke), with a temperature of 110° F. and upward, a strong current of cold water from a hose directed on the head and body often gives the best results. In ordinary fevers in large animals the cold pack will often serve a good purpose. Wring a blanket out of water (cold or tepid, according to the height of the fever and the strength and power of reaction of the patient), wrap it round the body, cover it with several dry blankets so that no part is exposed, and keep the whole in close contact with the skin by elastic circingles. In fifteen minutes the skin should be glowing and perspiring, and in half an hour the wrappings should be removed, a little at a time, the parts rubbed dry and covered with a dry woolen blanket. It may be repeated as often as the fever rises.
Diaphoretics. Besides these remedial methods of inducing a revulsion and glow in the skin with perspiration, medicinal diaphoretics may be resorted to. Among these may be included copious drinks and injections of warm water, acetate of ammonia, antimony, ipecacuan, or pilocarpin, or one of the sedatives, aconite, veratrum, or opium, etc. Many a threatened acute inflammation has been to a great extent cut short and nipped in the bud—the stage of chill—by warm clothing, active hand rubbing, and such an apparently unscientific nauseant as tobacco.
When the preliminary stage has passed and the hot stage of the fever has set in, cooling and eliminating agents are especially called for.
Laxatives. In many cases, and especially in those with marked constipation or bowels loaded with indigestible materials, a laxative is beneficial. For the horse, aloes, or, often better, sulphate of soda, and for cattle or sheep, the latter, or Epsom salts, will at once remove an irritant, cool the general system, draw off much blood and nervous energy to the bowels, and secure a considerable depletion and elimination from the intestines. For swine, dogs, and cats castor oil or salts may be used, and for fowls castor oil. If the mucous membranes are yellow, the tongue furred, and feces scanty, hard, and fœtid, a dose of calomel (horse or ox, one drachm; sheep or pig, one scruple; dog, three grains; chicken, one-half grain) with tartar emetic (horse or ox, two drachms; sheep, twenty grains; swine, one-half grain; dog, one-fourth grain; chicken, one-eighth grain) may be given and followed in ten hours by one of the laxatives named above.
Diuretics. In the absence of any manifest disorder of the digestive organs, the laxative may be omitted and refrigerant diuretics resorted to. Acetate of ammonia or potassa, nitre, tartrate of potassa, carbonates of potassa or soda, may be used along with sedatives.
In cases of infectious disease with poisoning by ptomaines and toxins the elimination of these by the bowels and kidneys is of the greatest importance.
Sedatives. Of the sedatives, aconite, bromide of potassium, veratrum, hyoscyamus, or chloral hydrate may be used according to the special indications.
Alkalies. Resolvents. When the organ inflamed is a serous membrane in which dangerous adhesions or other functional disorders are likely to occur from newly formed false membranes, their formation should be counteracted as far as possible by the free use of alkalies (carbonates of soda, potash, or ammonia, nitre, iodide of potassium, muriate of ammonia, etc.), and in the same conditions excessive effusion should be controlled by free action on the kidneys.
Antipyretics. To reduce the febrile temperature and especially, when caused by the ptomaines and toxins of bacterial infection, agents like acetanilid, antipyrin, exalgin, analgene, benzanilide, salicylate of soda, and quinine have been largely employed and will usually lower the temperature several degrees in a few hours. They nearly all depress the vital forces, or hinder reparatory processes, so that their use is to be carefully guarded. Quinine which is less depressing than the others hinders migration of the leucocytes and thus stands in the way of successful phagocytosis. With a dangerously high temperature they may be temporarily admissible, but they should be suspended as soon as possible. In all ordinary cases they are probably better avoided. A judicious use of the cold or tepid bath, or of wet compresses is incomparably safer and more generally applicable.
Stimulants. When the disease results in great prostration or when symptoms of septic or ptomaine poisoning set in stimulants are often required to sustain the flagging heart and circulation. These may be alcoholic, ammoniacal, etherial, camphor, digitalis, etc.
Tonic Refrigerants. Later, when both inflammation and fever have been somewhat reduced, temperature, breathing, and pulse rendered more moderate, eye clearer, and even appetite perhaps slightly improved, the sedatives may give place to refrigerating tonics, such as mineral acids (nitric, muriatic, sulphuric, or phosphoric), in combination with bitters (quassia, cascarilla, calumba, gentian, salicin), without as yet the suspension of refrigerant diuretics. Thus for the horse the following Recipe: Pharmaceutical nitric acid, two drams; infusion of gentian, ten ounces; nitrate of potassa, two ounces. Dissolve. Give one ounce every six hours.
In Convalescence. When convalescence has fairly set in, the fever has subsided, and there remains merely some debility with a remnant of the inflammatory exudation to be removed or organized into tissue, or when an abscess has developed and burst, the tonics must be even more freely given, the mineral acids may even give place to preparations of iron or cod-liver oil, and the diet must be made increasingly liberal. But throughout the whole progress of the disease the bowels should be carefully watched. Costiveness may quickly undo all that has been gained, hence any indication of this should be met by laxative food (boiled flaxseed, etc.), or, this failing, by injections or laxatives. Similarly, if a freer action of the kidneys seems to be necessary for elimination of waste matters or to reduce fever, diuretics should be continuously kept up.
Treatment of Adynamic Inflammation and Fever. In treating low asthenic or adynamic inflammation all depression and depletion is to be carefully avoided. Even laxatives must be employed with extreme caution. If absolutely necessary it is best to give them in small (half) doses and supplement their action by liberal injections of hot water. Elimination of waste matter from the blood and system is still to be sought, but it must be by stimulating diuretics (sweet spirits of nitre, carbonate, acetate, or muriate of ammonia, digitalis), and direct stimulants and tonics must be given from the first (ammonia, wine, strong ale, whisky, brandy, ether, gentian, calumba, nux vomica). For the horse the following may serve as an example: Recipe: Sweet spirits of nitre, four ounces; sulphuric ether, two ounces; tincture of gentian, ten ounces; digitalis, one dram. Mix. Dose, two ounces in a pint of cool water four times a day. When there is great debility and prostration ammoniacal and alcoholic stimulants must be given freely, while if the fever heat rises very unduly the cooling diuretics (citrate, tartrate, or acetate of potassa, or nitre, etc.), and even sedatives (bromide of potassium, hydrobromic acid, chloral hydrate, salicin, salicylate of soda), must be resorted to. If there is any indication of a special depressing poison in the system, or of the absorption of septic or other noxious matter from a wound, antiseptics (hydrochloric acid, or salicylic acid, sulphite of soda, quinia, or chlorate of potassa) may be advantageously added to the prescription.
In these cases of asthenic inflammation, as in the advanced and debilitated stages of sthenic inflammation, the diet should be as good as the patient can digest. Boiled oats, barley, or flaxseed, rich, well-boiled gruels, and beef-tea (even for herbivora,) may frequently be resorted to with advantage.
Local Treatment of Inflammation. In all forms of superficial inflammation the local treatment occupies an important place. The persistent application of cold (cold water in a stream, icebags, freezing mixtures) will sometimes overcome the tendency to inflammation or arrest it. This is especially sought when a violent inflammation (as in a wounded joint) threatens to destroy an important organ. If adopted, it must be persisted in, as if it is suspended too soon the reaction is likely to make matters worse than ever. Cold astringent applications have a similar tendency. Sugar-of-lead, one-half ounce; laudanum, one ounce; water, one quart, may be kept applied by means of a linen bandage. The water may often be advantageously replaced by extract of witch-hazel. If the inflamed part is superficial the lotion may be made antiseptic (carbolic acid, one dram; or sulphurous acid solution, five ounces; water, one quart). Hot applications, fomentations, poultices are nearly always appropriate but they should be made antiseptic to prevent bacterial development. When adopted they should like cold ones be kept up as continuously as possible. These soothe alike the superficial and deeper parts, the latter through sympathy, producing first a relaxation of vessels and tissues, and later a contraction of the former attended by pallor of the surface. They greatly favor suppuration when that is already inevitable, though in other cases they may obviate it by checking at an early stage the acute inflammatory process on which it depends. Any bland agent that will retain heat and moisture will make an excellent poultice, though flaxseed-meal is the type of a soothing demulcent application. Very slight inflammation may be successfully treated at the outset with a stimulating embrocation (alcohol or camphorated spirit), yet in the more violent type of acute inflammation all local excitants tend to aggravate the disease. In these violent forms the activity of the disease should be first abated by local soothing and general sedative measures, and then the part over the inflamed organ may be safely treated with a stimulating liniment or even a blister. In such cases the liniment first acts as a derivative of blood and nervous energy from the inflamed part, and later and still more beneficially by securing in it a sympathetic healing process, like that set up in the skin. It is further probable that the absorbed albuminoids, which have been modified in the congested part often exercise a decided effect on the inflamed tissue. In raw sores where inflammation has been set up the granulations may become dropsical or excessive, bulging beyond the adjacent skin as proud flesh. This should be repressed by touching it gently with some mild caustic (lunar caustic), so as to produce a thin, white film, and the remote cause of the inflammation (often a local irritant) should be sought and removed. In some unhealthy sores tending to excessive granulation, the compound tincture of myrrh and aloes may be applied daily with great benefit. When the granulations become excessive they may be scraped down to the level of the skin and then treated with an antiseptic (iodoform, boric acid, acetanilid, aristol).
Blistering. In subacute and chronic inflammations and in those acute forms in which the violence of the inflammatory action has been already subdued by soothing measures, blisters and other counterirritants may be employed to counteract the remaining inflammatory action. These act primarily by drawing off blood and nervous energy from the inflamed organ to the skin, and secondarily, by establishing a sympathetic healing process in the diseased part, simultaneously with the work of recovery in the skin, when the blister has spent its action. But if applied above a part which is still violently inflamed, there is apt to be serious aggravation, through this same sympathy with the part suffering under the rising of the blister. In this way great and irreparable injury is often done through the laudations of particular blisters for the cure of given diseases, without any reference to the stage or grade of such disease. The value of a blister depends far more on the time of its application than on the ingredients of which it may be composed.
Firing. This acts in nearly the same manner as a blister, and demands similar caution in its application. It is especially available in subacute and chronic diseases of the joints, bones, and tendons, and may be made more or less severe according to the nature and obstinacy of the disease. It is applied in points or in lines at intervals of one-half to one inch, and penetrating one-third, one-half, or entirely through the skin. The hotter the iron the less the pain, but the greater the danger of destruction of the intervening skin by the excess of radiating heat. Hence the contact of the heated iron with any one part must be judiciously graduated to the heat of the iron and the delicacy of the skin, and should not exceed the fraction of a second.
Massage, Rubbing. In chronic inflammation and even in some acute forms, with considerable exudation, rubbing or massage is of great value. It hastens the progress of the blood through the veins, tends to restore the normal circulation in the stagnant or partially obstructed capillaries, moves on the exuded liquids in the lymphatic plexus, rendering the absorption more active, and at once prevents the process of disintegration of the tissues and obviates, the necessity for their solution and removal. This may be largely accomplished by the use of the brush or rubber, or by careful manipulation especially in the direction of the veins. If the inflammation is near the surface the use of antiseptic and deobstruent agents will heighten the good effect. Iodoform, iodide of potassium, boric acid may serve as examples.
Suppuration. Abscess. The great variety of the causes and forms of suppuration would forbid any extended notice of its treatment in this place. It seems preferable to refer the reader to the subject of pyæmid and the various surgical and medical diseases in which suppuration takes place.