Part 77

=Mild Cases.= In the mildest cases there is stiffness and lameness in one, or less frequently in both hind limbs, coming on when put to work after a period of idleness, and not associated with any appreciable lesion of the limb in question. There may or may not be hardness and swelling of the gluteal or other muscles of the quarter or loins. This has the appearance of rigidity or spasm but may be primarily due to œdema or exudation into the substance of the muscle. In some instances the muscles of the breast, shoulder, or forearm are the seat of the trouble. Muscular trembling and perspiration may be present and if the urine is examined, it is often found to be glairy, or charged with urea, and allied nitrogenous products. These cases are not benefited by local applications, but they recover (temporarily) under rest and above all under active eliminating treatment. Under gentle and progressive exercise too they improve and get well. They recur, however, with great readiness under a rich nitrogenous diet and a temporary rest followed by sudden exertion.

Between the mildest and gravest cases there are infinite gradations of severity, one-third to one-half of the worst cases usually terminating fatally, whereas the mildest are always amenable to treatment.

Progress. The course of the disease depends on the severity of the attack but also, in no small degree, on the good judgment of the driver. Cases that develop with great suddenness, and apparently with extreme severity may subside spontaneously if the animal is placed in a condition of absolute rest. If, however, we can secure rest of the muscles of progression only, while the breathing remains rapid and labored, improvement is unlikely, as the system continues to receive large accessions of the toxic products. When the patient is down and unable to rise, the enforced rest may be beneficial, but too commonly, the greater effort with which breathing is carried on in the recumbent position, and the frequent ineffectual struggles of the limbs prevent the requisite muscular quietude.

In some cases, and especially in the mildest, recovery may seem to have been effected in a few hours, and in others it will be seen in twenty-four or forty-eight hours, while in still others the paresis and helplessness may continue for a week and yet be followed by recovery. In these cases appetite may be retained in greater or less degree, but the intestinal peristalsis is usually weak and imperfect, the fæces small in quantity and dry, and the bladder atonic so that the urine may have to be drawn off with the catheter. It usually retains the deep red color, or improvement may be heralded by a change to a dirty grayish hue. If, however, it shows an excess of albumen, cylindroid casts entangling renal epithelium and white or red globules it will indicate the access of diffuse nephritis and a prolonged or even a fatal illness.

When control of the limbs is not restored at the end of a week, the paretic muscles usually undergo marked and rapid wasting, which may last for months or years. This is especially common in the case of the patellar muscles (muscle of the fascia lata, triceps extensor cruris) in which the atrophy may become so extreme that the skin covering the inner and outer sides of the thigh may be brought virtually in contact in front of the femur. This entails an almost complete inability to sustain the body on the hind limbs. When atrophy is less extreme, there is only a weakness, stiffness, or swaying or staggering on the hind limbs in progression.

In fatal cases death may occur early in connection with the violent struggles, the excited breathing, pulmonary hypostasis and congestion, a cyanotic hue of the visible mucous membranes and a gradual increase of stupor. Though delayed for several days, there is a continuation of the muscular struggles, and the labored breathing; the red or glairy character of the urine persists or is exaggerated; the nervous irritability increases, with muscular trembling; and cyanosis, or stupor increases until death.

The mortality is always high in the severe forms of the disease, the deaths ranging from 20 per cent. upward.

After a first attack there is a strong predisposition to a second under similar exciting conditions.

Diagnosis. The peculiar symptoms of this disease and the circumstances attending its onset, are usually sufficient to distinguish it from all others. There may be danger of confounding certain cases with thrombosis of the posterior aorta, or of the iliac arteries or their branches, but the absence, in such cases, of the special history of the attack and of the morbid state of the urine, and the absence of pulsation in the arteries distal to the thrombosis will serve to prevent confusion. Spinal myelitis will be distinguished by the gradual nature of the onset, by the absence of the conditions attending on the attack of hæmoglobinæmia, and usually by the absence of hæmoglobin, urea and other nitrogenous products in excess in the urine.

Prevention. The hard worked or systematically exercised horse, which is at the same time heavily fed must not be left in a state of absolute rest in his stall for twenty-four hours. A fair amount of exercise must be given on every day in the week, and at the same time, the food should be restricted in ratio with the restriction of exercise. Turning for an hour or two daily into a yard may be a sufficient precaution. When from any cause, rest is imperative, the diet must be materially reduced and given in part in a laxative form (bran, roots), or a slight laxative (Glauber salts) or diuretic (saltpeter) may be added. Cleanliness and a free ventilation of the stable, are also of value in obviating at once auto-intoxication and the admission of poison through the lungs. In the same way a free allowance of drinking water is beneficial as favoring a general elimination from the various emunctories, and a dilution of the plethoric blood.

These precautionary measures are especially important in the case of horses which have passed through a first attack and which are in consequence strongly predisposed to a second. Horses fed liberally on highly nitrogenous food (oats, beans, peas, cotton seed meal), will also require specially careful oversight when at rest for a day or two only.

Treatment. The first and perhaps the most important consideration is absolute rest. If the subject is stopped instantly on the appearance of the first symptoms, the disease may be often aborted. It is better to avoid the exercise of walking to a stable until such time as the severity of the attack has somewhat moderated and then to move the subject only in the slowest and quietest possible way. If the patient is already down and unable to rise, he may be carried to the nearest stable in an ambulance or on a stone-boat, and there helped to his feet and supported in slings. Though he may be unable to continue in the standing position without the sling, yet if he can use his limbs at all for support, and is prevented from lying down, the breathing will be rendered so much more free and quiet, that it may greatly lessen the transfer of the poisonous elements into the general circulation and materially contribute to recovery. If, however, he cannot stand on his limbs at all, but must settle in the slings, the compression of the chest will so excite the breathing that it will induce dyspnœa, pulmonary congestion and a rapidly fatal result. In such a case a good bed must be provided and the patient made as comfortable as possible in the recumbent position.

In some cases in the earliest stages a full dose of sweet spirits of nitre or even half a pint of whiskey has seemed to assist in aborting the disease though the urine was already of a deep red color. It probably acted by supporting the already oppressed heart, and securing a prompt elimination by the kidneys.

Friedberger and Fröhner strongly recommend bleeding in all cases of dyspnœa and excited heart action, and considering the plethoric condition of the animal it would equally commend itself in other cases as well. This is the most prompt sedative of the nervous and vascular excitement, and the most speedy and certain means of removing much of the poisons accumulated in the blood, and of diluting what remains by reason of the absorption of liquids from every available source. This will more than counterbalance any temporary increase of poisons drawn from the portal system to fill up the vacuum in the systemic veins caused by the emission of blood. When the thick tarry condition of the blood seriously hinders a speedy abstraction both jugulars may be opened at once.

In some cases of great nervous excitement bromides may be useful in moderating circulatory and respiratory movement, but on the whole the advantage is greater from an immediate resort to eliminating agents.

One of the most effective agents is water. If the patient is thirsty he should have all he will drink, and if not, it may even be given from a bottle, or thrown into the rectum. A still more effective resort would be to introduce water intravenously in the form of a normal saline solution, or even to pass it into the trachea through a small cannula or large hypodermic needle. This serves to dilute the over dense blood, to stimulate the kidneys and other emunctories to active secretion, and to retain in solution the hæmoglobin, urea and other products which would otherwise cause greater irritation. This would be especially applicable after the blood tension had been diminished by phlebotomy.

Warm fomentations to the loins or croup are not without their influence. They tend to soothe the irritated parts and to solicit the action of the kidneys more particularly. The old resort of a fresh sheep skin, with the fleshy side in, may be used as a substitute.

Perhaps the most important indication is to secure depletion from the overloaded portal system and liver. Where nothing better offers, a pint or quart of castor oil, or a pound of Glauber salts, or a half drachm of podophyllin and four drachms of aloes may be given. If available 1 to 1½ grains of eserine, or 7 grains of barium chloride may be given hypodermically in distilled water or that which has been raised to the boiling point. This may be supplemented by frequent injections of hot soap suds or even of laxative saline solutions. If the bowels can be roused to free secretion the removal of toxic matters from the portal blood and the delay in the progress of similar matters through the liver will go far toward securing a favorable result. When free purgation has been secured recovery can usually be counted on.

The action on the bowels must be followed up by diuretics to eliminate the offensive matters from the general system. Colchicum has been recommended because of its action in increasing the solids of the urine, and this may be combined with saltpeter or other diuretic, or the latter may be used alone and repeated twice a day. If, however, the patient can, by the free use of common salt or otherwise, be induced to drink freely of water, the elimination through the kidneys will be sufficiently secured.

The muscular weakness and paralysis that remain after the acute symptoms have subsided must be met by stimulating liniments and even blisters to the loins or affected muscles, by the internal use of strychnia (2 grs. twice daily) until the jerking of the muscles indicates that its physiological action has been secured, and by an electric current daily for ten minutes at a time through the affected nerves and muscles. Animals that have been helpless for weeks have, in our hands, recovered under such treatment, and even cases of several months’ standing, with the most extensive atrophy of the triceps, and in which the animal could barely stand, have made a satisfactory recovery.

Any remaining nephritis must be treated according to its indications.

During recovery and in the convalescent animal the diet should be laxative and non-stimulating. Bran mashes, turnips, beets, carrots, green fodder, ensilage and scalded hay may be allowed. Oats, corn, beans, peas, vetches, etc., must be carefully avoided. If the food fails to maintain the bowels in a gently relaxed condition one, two or more ounces of sulphate of soda may be added daily.

In the mild cases a good dose of purgative medicine succeeded by a course of diuretics will serve a good purpose.

In all cases alike work must be resumed very gradually. At first the animal may be walked a few hundred yards, and the pace or load and duration of exercise may be increased day by day until full work can be safely endured. In an animal that has once suffered the same gradual inuring to labor should be followed, after any short period of rest on a fairly good ration.

JAUNDICE, ICTERUS, THE YELLOWS.

Symptomatic. Causes: Mechanical obstruction of bile duct, gall-stones, hydatids, distomata, extraneous bodies, inflammation, stricture, obliteration, absence, ulceration, spasm, tumor, enlarged lymph glands, gastric tumors, pancreatic, kidney or omental tumor, aneurism, fæcal accumulation, pregnancy, ovarian tumor: Without mechanical obstruction, ptomaines and toxins, animal venoms, mineral poisons, hepatic atrophy, fear, other emotions, cerebral concussion, imperfect oxidation, excess of bile, hepatic inflammation, constipation and reabsorption of bile, experimental jaundice, balance of tension in gall ducts and blood vessels, duodenitis, compression of aorta, hæmatoidin and bilirubin, destruction of blood globules by hydroæmia, taurocholate of soda, chloroform, ether, freezing, heat, electricity, alkalies, nitrites. Hæmoglobin: Its solubility in horse. Bile acids and blood pigment. Summary of causes. Gravity of icterus. Symptoms: Coloration, yellow, orange, brown, of tissues and secretions: Tests, staining white paper, Gmelin’s test, nitric and sulphuric acids, rainbow hues: Pettenkofer’s test for bile acids, syrup and sulphuric acid, dark violet: Stranburg’s test syrupy paper and sulphuric acid, dark violet; clay colored fœtid stools; gravity.

The terms icterus and jaundice are applied to a yellowness of the mucosæ, urine, skin and tissues caused by the presence in them of the coloring matters of bile. The condition is a symptom of many different affections rather than a disease per se, yet the phenomenon is so characteristic that it has been hitherto accorded a special place and article in systematic works.

Jaundice is either associated with mechanical obstruction of the bile duct or ducts, or it is independent of such obstruction. The following enumeration of its causes slightly modified from Murchison, is equally applicable to the lower animals as to man: