Part 8

=Healing by Second Intention. Granulation.= When a wound has caused destruction of tissue, or when a simple incision is left exposed to the air, the breach is filled up by new tissue through the process known as granulation. The superficial layer of lymph thrown out on the raw surface becomes oxidized and degenerates into pus, while the deeper layers become solid, fibrillated, the seat of cell growth, and are finally transformed into a fibrous structure. New bloodvessels form in loops in the developing lymph and constitute the bright red granulation-points which cover the raw surface. The fibrous tissue into which the lymph is transformed undergoes gradual contraction in development, and thus, day by day, the edges of the adjacent healthy skin are drawn in, so as to cover the wound more or less perfectly, and a slight scar only is left when healing has been accomplished.

=Granule Corpuscles and Masses.= This is another degenerative transformation in lymph and, is seen mainly in inflamed glands and brain and lung tissue. The cells found in the exuded lymph are made up of granules ¹⁄₁₀₀₀₀ inch in diameter, and besides these, large, irregularly shaped masses of granules are extended along the capillary bloodvessels. After the lymph has coagulated these granular masses soften and liquefy preliminary to reabsorption and removal, and the restoration of the tissue to a healthy condition. When in excess this softens and disintegrates the tissues, leading to permanent loss of substance. See granular degeneration.

=Interstitial Development of Lymph into Tissue.= This is equivalent to what takes place in the formation of the sac of the abscess or of granulation-tissue. The liquid lymph in coagulating, becomes fibrillar, and the cells and nuclei of the adjacent tissue, having an abundant supply of blood and nutriment, multiply first as simple, rounded embryonic cells, then deposit around them new tissue, becoming elongated, spindle-shaped, branching, etc., and thus get imbedded in a fibrous material of their own formation. These new formations are usually of a low type of organization, like white fibrous tissue or bone, and hence, although breaches in the higher structures like muscle, nerve, gland, skill, are filled up, it is usually only by the drawing together of the remaining healthy parts by these new formations without the restoration of any of the original tissue which has been destroyed. The cicatrix (scar), alone is made up of new material.

Lymph developing in this way may undergo any degeneration to which normal tissues are subject. Thus it may undergo black pigmentary (melanotic) degeneration, it may become impregnated with lime-salts (calcified), it may wither up into a hard gelatiniform or horny mass, or it may undergo fatty degeneration.

=Fatty degeneration= is the most common form, and consists in the excessive deposit of fatty granules, first in the cells which are in excess or badly nourished, and next in the adjacent tissue, the normal elements of which are replaced by fatty granules.

=Softening= is an almost constant result of inflammation. The exudate infiltrates and separates the tissue elements, destroying their cohesion; the liquefaction of these elements impairs this still further, and the more or less perfect transformation of the tissue into embryonic tissue entails the loss of its rigidity and power of resistance. Thus the inflamed brain-tissue may become a mere pulp, and the inflamed bone may be cut with a knife.

=Ulceration= is closely allied to softening. On the surface of a sore there is an excessive exudation of lymph, which loosens and disintegrates the layer of lymph that is already in process of development, and also a part of the tissue beneath. The cells in these parts fail to develop naturally and to build up good tissue; they become fatty, die, and together with the tissue in which they lie, break down and pass off as a pulpy debris. Thus the sore constantly deepens and widens, or at least refuses to contract and heal. It is usually the result of bacterial infection.

=Gangrene= or =death of a part= is another effect of inflammation. It results usually from the cutting off of the blood supply through the obstruction of the bloodvessels; by the pressure of excessive exudation in unyielding structures, as in bone, or under the hoof; by implication of the inner coats of the bloodvessels in the inflammation, when the contained blood will clot and obstruct them; or by blocking with the blood clots that have been formed at a distance and washed on in the blood current to be arrested when they reach vessels too small to admit them. Like suppuration, gangrene is associated with and often caused by a bacterial growth. The dead mass remains as an irritant, and is slowly separated by the formation around it of embryonal tissue, granulations and pus. A second form is molecular gangrene, in which the cells and minute elements of the tissue die, and are cast off, leading to phagedenic (eating, extending) sores, as noted above under Ulceration. When gangrene occurs on an exposed surface, that may be altered from the normal color into shades of yellow, brown, green, red, or black, according to the amount of blood and the stage of decomposition, and may be cut without pain, if the subjacent parts are not pressed upon; it may be soft, may pit on pressure, may crackle under the hand from the evolved gases of decomposition, and may be covered with blisters (phlyctenæ) with red, grumous liquid contents (moist gangrene); again, it may be white, as after freezing, or it may be dark colored, dry, and horny, as from ergotism (dry gangrene).

FEVER.

Definition. Symptomatic. Idiopathic. Symptoms. Contagion. Incubation. Premonitory symptoms. Chill, rigor. Reaction, hot stage. Defervescence. Crisis. Lysis. Natural temperature. Fever temperature. Retention of water in the system. Production of waste materials. Typhoid condition. High fever, low, hectic. Treatment in vigorous subject, in weak one. Regimen. Solipedes. Ruminants. Carnivora. Drink. Rest. Clothing. Air. General and local bleeding. Cupping. Warm baths, tepid, compresses, derivatives. Cold. Diaphoretics. Laxatives. Diuretics. Sedatives. Alkalies. Antipyretics. Stimulants. Tonic refrigerants. Tonics. In low fever. No depletion. Judicious elimination. Stimulants. Refrigerants. Antiseptics. Diet. Local treatment of inflammation. Cold. Astringents. Antiseptics. Warm applications. Stimulating embrocations. Blisters. Firing. Massage. Suppuration.

Definition. Whether occurring as an accompaniment of inflammation or independently of it, fever is an unnatural elevation of the temperature of the body, the direct result of an excess of destructive chemical change in the blood and tissues, and more remotely of disordered nervous function.

Of all extensive inflammations fever is the constant result and accompaniment, rising as the inflammation rises or extends, and subsiding as the inflammation subsides. It also occurs as a distinct affection, as in all the infectious diseases, as the result of a specific irritating poison in the system, and then is the manifestation of the disease, while a local inflammation may or may not be present as a special secondary feature of the malady or as an accidental complication.

Symptoms of Fever. Fever is marked by certain definite stages, each of which has its own special manifestations. In the cases due to a specific disease germ, or contagium, these are, however, preceded by a period of latency or incubation in which no symptoms whatever are manifest, but during this time the germ is rapidly multiplying in the system, and it is only when it has gained a certain increase that it disorders the nervous system, wastes the tissues, raises the temperature of the body, and induces the other phenomena of fever. The same may be said to hold in the fever attending on inflammation. The slight and circumscribed inflammation is at first productive of no fever, and it is only when it gains a certain extent that the nerves and nutrition are disordered so as to bring about a feverish condition.

Premonitory Symptoms. These usually last but a few hours and are often entirely absent or unnoticed. There is a lack of the customary vigor and spirit, an indisposition to exertion, a loss of clearness and vivacity of the eye, a manifest dullness, with hanging of the head, and frequent shifting of the limbs as if fatigued. Appetite is less sharp and ruminants chew the cud less heartily or persistently.

Cold Stage. These are soon succeeded by the chill, rigor, or shivering fit, in which the hair, especially that along the back, stands erect (staring coat), the skin is cold and adherent to the structures beneath (hidebound), the extremities (legs, tail, ears, horns, nose) are cold, and the frame is agitated with slight tremors, or even a shivering so violent that a wooden floor or building is made to rattle. The back is arched, the legs brought nearer together (crouching), the mouth is cool and clammy, the breathing hurried, the pulse weak, and it may be rapid, but with a hard beat, the bowels costive, and the urine higher colored than natural. The temperature of the interior of the body, taken by a thermometer in the rectum, is already found above the normal, the excessive destruction of tissue having begun, and the blood driven from the cooler surface, and accumulating in the hot interior, at once favors tissue change and maintains the extra heat thereby produced. In cattle the end of the tail is soft and flaccid from this stage onward. The cold stage lasts a few minutes, or one or two days in different cases.

Hot Stage. The hot stage appears as a reaction from the chill, the contraction in the minute vessels of the skin giving place to dilatation, so that the whole surface, including the extremities, becomes hot and burning, but still dry and parched. The burning is especially noticeable in the more vascular parts, like the roots of the horns and ears, the muzzle or snout, the mouth, the hoofs, the bare parts of the paws in carnivora, and the mammæ (udder) in suckling animals. The mucous membranes lining the nose and mouth become hot and red, the breathing freer, but not less rapid, the pulse softer but accelerated, appetite (and rumination) greatly impaired or lost, thirst great, costiveness increased, urine diminished and of a higher color, the flow of milk greatly impaired or entirely arrested, and the dullness and prostration greatly increased.

The hot stage lasts longer than the cold one, usually persisting until death or convalescence. It may alternate with chills throughout the whole course of the illness, and in the fever of inflammation the interruption of the hot stage by a chill usually implies either a considerable extension of the inflammation or the occurrence of suppuration.

Defervescence. The decline of the fever may take place by a sudden reduction of the body temperature to the natural standard, or near it, and a sudden and general improvement in the symptoms (crisis), or by a slow improvement from day to day through a more or less tedious convalescence (lysis).

Fever Temperature. A temporary rise of one or two degrees is unimportant, but a permanent rise indicates fever. A rise of ten or twelve degrees is usually fatal. A sudden fall to or below the natural, unless with general improvement in the symptoms indicates sinking. A similar fall, with a free secretion (perspiration, urination, relaxed bowels) and general improvement in symptoms, betokens recovery. For normal and febrile temperature see Semeiology.

Retention of water in the fevered system is as significant as the elevated temperature. The patient drinks greedily but all the secretions are arrested or diminished, and liquids go on accumulating in the system. The sudden bursting forth of secretions (especially sweating) implies that the fever has, at least temporarily, given way.

The production of waste matters in the system is necessarily proportionate to the amount of tissue destroyed. This appears in the blood mainly as urea, the organic acid of urine (hippuric in herbivora, uric in carnivora), together with phosphates, sulphates, and chlorides. These thrown off by the urine give it its high density. If not thus thrown off they remain as poisons in the circulation and bring about that prostrate, sunken, debilitated condition which characterizes the advanced stages of all severe and continued fevers—the typhoid condition. This is not to be confounded with the specific typhoid fever, in which a special fever germ expends itself, mainly on the bowels, and that runs through a regular course. The typhoid condition is that state in which an animal system, already greatly weakened by a severe disease, and perhaps further prostrated by a specific disease-poison, is subjected to a species of poisoning by the retained chemical products of the waste of the tissues.

Types of Fever. These are as characteristic as the types of inflammation, and of the same kind. The strong type of fever which attends on an acute inflammation in an otherwise healthy vigorous system, is spoken of as a high or inflammatory fever. The weak type which occurs in a broken down or debilitated system, or in connection with the action of a specific disease germ, or with the saturation of the system by waste chemical products is known as low, typhoid (better typhous), or adynamic fever. That form which persists in the utterly debilitated system, where the power of assimilation is practically lost, is known as hectic.

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.