PETECHIAL FEVER. ACUTE HÆMORRHAGIC—ANASARCOUS—TOXÆMIA.
Synonyms. Definition. Causes, obscure, bacteria variable, pus microbes no active contagion, toxic products, any toxin causing vaso-dilatation, examples, toxins from fermenting ingesta, debility; impaired innervation, nutrition and function; gravitation; primary and secondary forms: predisposing diseases. Lesions: petechiæ and slight blood extravasations in skin, subcutis, mucosa, submucosa, serosæ, and solid tissues, largest in soft tissues; round cutaneous swellings one to two inches across, patches, cracks, oozing, fissures, sloughs, section shows yellow serous and blood infiltrations, capillaries greatly dilated, infiltrated thickened mucosæ, blocked nasal passages, ulcers, serous and bloody discharges, pharynx, larynx, lungs, stomach, intestines, kidneys, blood firm or diffluent. Symptoms: Hyperthermia, nasal petechiæ, extravasation, pink or yellow oozing, swellings on nose, lips, face, limbs, oozing, cracks, sloughs, turning up of toe from detachment of the flexors, metastasis from skin to lungs, or abdomen, dyspnœa, colics, serous or bloody diarrhœa. Course. Duration: acute two days, average one to three weeks, tardy one to two months, Diagnosis: from glanders, anthrax, urticaria, malignant œdema, horse pox. Mortality. Prognosis: 50 per cent.: hopeless and grave indications. Sudden retrocession. Treatment: excellent sanitary conditions, cleanliness, air, light, green food or mashes, pure water, laxative food, or salts, diuretics, alkaline diuretics, vaso-motor contractors, antiseptics, quinine, strychnine, phenic acid, lysol, ichthyol, sulphites, etc.; locally aluminium acetate, cold water, scarification, nasal injections and tubes, tracheal iodine injections, argentum colloidale intravenously, antistreptococcic serum subcutem, Menveux’s solution.
Synonyms. Purpura Hæmorrhagica; Morbus Maculosus; Anasarca (Fr.); Typhus: Anthrax; Dropsy of Connective Tissue; Mal de Tete de Contagion; Coryza Gangrenosa; Malleus Gangrenosa; Charbon Blanc; Diastashemia; Leucophlegmasia.
Definition. An acute (or subacute), toxæmic, generally secondary disease, manifested by capillary dilatation and petechiæ on the mucosæ, skin, serosæ and elsewhere, and attended by extensive effusions of lymph and blood into the skin and connective tissue, to form hot, tender, nodular, diffused, or general swellings.
Causes. The causes of petechial fever are not clearly made out. Bacteria are found in the early exudate, but these are not constant in kind and it is not unreasonable to suspect that these may be results rather than causes of the lesions. On the other hand there may be an as yet undiscovered organism present, the products of which are capable of producing the disorder. Or the latter may be due to a combination of the toxins of two or more. Among the bacteria found may be named: The pus microbes, cocci, streptococci, staphylococci, and bacilli, have been found and adduced as causes, also diplococci, the bacillus hæmorrhagicus of Kolb, the streptococcus of strangles, the microörganism of contagious pneumonia and that of influenza, with a variety of others too great and too inconstant to be accepted as proof of cause. The fact that rarely more than one animal suffers in the same stable at the same time might be held to oppose the idea of contagion and of a definite organized germ.
Hence the theory of its causation by the presence in the system of the toxic products of bacteria rather than the bacteria themselves. (Dieckerhoff.) Cadeac supposes that any toxin which causes capillary dilatation may determine the disease, and calls attention to the fact that the injection of mallein (a vaso-dilator) aggravates the phenomena of petechial fever and determines enormous local exudations and engorgements. He notes further the potent vaso-dilator action of the products of strangles, contagious pneumonia, and influenza which are among the most frequent antecedents of petechial fever. Dieckerhoff also looks on the phenomena as the result of poisoning by the absorbed toxins of the microbes of suppuration, which modify the nutritive changes in the walls of the capillaries and determine exudations and hæmorrhages. Zschokke thinks that there is infection of the intima of the capillaries, with the formation of coagula. Clots are not found, however, apart from hæmorrhages.
The toxin theory receives indirect support from the absence of the same specific lesions in simple mechanical congestion of the capillaries and veins. Ranvier had no such results from tying the veins of a rabbit’s ear. Roger tied the auricular veins of the rabbit, and then cut the sensory nerves without effect: he then destroyed the cervical sympathetic ganglion, when there supervened marked exudation, lasting for three days. The complete blocking of veins by pressure or aseptic ligature, does not produce a spreading œdema, whereas in ordinary suppurative phlebitis, with abundance of toxins in the tissues this is a constant result.
The toxin theory does not fully account for those cases that occur suddenly, without any manifest pre-existing disease, and as the result apparently of cold and chill. On the other hand, it is only a very small proportion of horses exposed to the same degree of cold and chill that contract petechial fever, and it might well be surmised that in these few an unknown focus of suppuration or other lesion existed prior to the chill or that toxins having the requisite devitalizing and vaso-dilating properties had been absorbed from fermentations in the bowels or elsewhere. The mere exposure is harmless to the very great majority of subjects.
In any case it must be accepted that the debility and impaired local innervation, nutrition and function, that attend on the exposure to cold and toxins must be looked on as potent contributing causes. The predilection of the swellings for dependent parts (limbs, venter, face) shows the influence of gravitation and congestion. Whether there is present any special microbe which has yet eluded discovery, but which is the main pathogenic factor, must be left to the future to decide.
In cases that appear to be due to cold or chill alone, the disease is held to be primary; in those following on another affection, secondary.
Among the diseases on which petechial fever supervenes as a secondary affection contagious inflammatory affections of the lungs and air passages hold a bad preëminence. Strangles, influenza and contagious pneumonia, about in the order named, are especially causative factors or occasions of petechial fever. Among the other affections on which it supervenes may be named pharyngitis, abscess of the nasal sinuses, hepatic, renal and other internal abscesses, acute coryza, laryngitis, or bronchitis, enteritis, abortion, aggravated grease, suppurating wounds of the skin, infective abrasions by harness, suppurating sores after firing, infective arthritis with open joint, amputation of the tail, and castration.
Lesions. In certain cases these may be largely confined to petechiæ and slight blood extravasations, which are distributed very generally throughout the tissues, but show especially in the skin, subcutis, mucosa and submucosa of the nose, eyes, pharynx, guttural pouches, larynx, trachea, bronchia, mouth, stomach, intestine, bladder, vagina and womb; also in and on the lungs, pleura, pericardium, heart, liver, spleen, kidneys, peritoneum, pancreas, ovaries, bones, lymph glands, brain and nerves. The largest extravasations are liable to be in the softest tissues, and in the lungs they may reach the size of the closed fist, though usually they vary from a mere spot up to this. The spleen is sometimes engorged even to rupture. Beside the extravasations, and associated with them in position, and probably largely as an effect of them, there is more or less serous effusion infiltrating the tissues, congestions, suppurations, degenerations, and necrotic changes.
The skin, if white, and the dark skins on section, are seen to be marked by petechiæ. The cutaneous swellings may appear on any part, commencing with nodular thickenings varying in size from a pea to a walnut, and merging together into extensive elevated areas terminating abruptly at their margins in the smooth skin. The larger and more persistent engorgements settle on the lower aspect of the body and other dependent parts like the limbs and face. Cracks, oozing, deep fissure, and extensive sloughs are not uncommon. When the skin is incised it shows serous infiltration and thickening, with spots and patches of blood extravasation. The subcutaneous connective tissue is similarly infiltrated and discolored, and often in the limbs, face, and under the breast, sternum and abdomen so as to form a tremulous gelatinoid cushion of several inches in thickness. The capillaries may be distended to more than 20 times their normal calibre. The exudate may extend deeply between the muscles, and sloughs may lay these freely open and invade their substance. The muscular tissue is mottled with petechiæ, and apart from these it is pale, yellow, or grayish, having to some extent undergone granular or fatty degeneration. Detachment of the perforans and perforatus from their insertions is occasionally met with.
The nasal mucosa may show only petechiæ and circumscribed blood staining, but in fatal cases it is more likely to present extensive blood extravasations involving it may be the whole mucosa, and narrowing the lumen almost to complete occlusion. Sloughing is not rare, and the resulting ulcers may extend into the subjacent tissues, so as to penetrate the septum nasi or the thin plate of the turbinated bone.
The buccal mucosa and submucosa are often involved in common with the skin of the lips, cheeks, and intermaxillary space, the tissues being involved in one common infiltration of blood and serum. In some cases circumscribed necrosis and ulcerations are formed.
In the pharynx and larynx infiltration of the mucosa and adjacent parts of a deep blood red, with or without ulceration, causes serious narrowing of the passage, that on the vocal cords threatening suffocation. Suppuration of the pharyngeal glands and guttural pouches is not uncommon. Alimentary matters are frequently found in the larynx, and bronchia.
Beside the petechiæ and hæmorrhages in the lungs, œdematous infiltration in dependent parts, hepatization, abscess, and limited areas of necrosis are met with. The pleural sacs often contain a sanguineous effusion.
The stomach and intestines are usually more or less mottled with petechiæ involving mucosa, serosa or muscular coat; they are raised in rounded or irregular elevations by œdemas; or they are the seats of more or less extensive and even perforating ulcers. The contents of the bowels may be deeply discolored by the escaping blood.
The kidneys may be pale except where blood stained and œdematous infiltration of the surrounding tissue may be marked. Serous effusion into the peritoneum is not rare.
The eyelids are often implicated, infiltrated thickened, and rigid, and the conjunctiva, bulbar and palpebral, the seat of extensive petechiæ.
Barreau mentions extravasations on the divisions of the lumbosacral plexus causing sudden paraplegia.
Petechiæ and hæmorrhages mark endocardium, pericardium and cardiac muscle, otherwise the muscle is pale. The blood is sometimes in firm clot, at others diffluent or nearly incoagulable.
Symptoms. If hyperthermia is not already present as a feature of the pre-existing malady it usually shows itself early, at first slight, it may be (101° F.), and afterward rising in some cases to 104° to 106° F., or even higher. The general symptoms are usually those of the pre-existing disease (strangles, contagious pneumonia, influenza, nasal catarrh, pharyngitis, bronchitis, etc.), pursuing, it may be, a persistent course, or attended by special toxæmic symptoms of prostration and other signs of depression of vital functions. In some cases the hyperthermia is either absent at this stage or overlooked. On the prostration supervene the petechiæ on the visible mucosæ, and often also the swellings of the skin and subcutis. One of these may be seen before the other and it is difficult to decide whether the petechiæ always appear first as has been claimed. Cadeac claims that when œdema is first seen it has been preceded by petechiæ in that tissue (skin).
The petechiæ are usually first noticed on the nasal mucosa as fine red points, pin’s heads, or up to half an inch in diameter, or a number of these have coalesced to form extensive patches, and by and by to cover the entire wall. At first the mucosa is spotted with purple, without any marked elevation of the surface, but as the lesions extend it becomes swollen and raised at the points of extravasation and immediately around them and oozes a serous, sometimes a pinkish or yellow fluid. Even in the smallest petechiæ the color is persistent and does not disappear on pressure like the blush of the adjacent mucosa.
Usually cutaneous swellings coincide with the petechiæ, or appear within two days thereafter. The first manifestation is in the form of rounded abruptly elevated nodules, about 1½ inch to 3 inches in diameter, strongly resembling the eruption of urticaria. These show a certain predilection for the more dependent parts of the body,—limbs, abdomen, sheath, mammæ, sternal or pectoral region, nose, lips, face, etc.,—but they may develop on any part or on the whole surface. Neither tenderness nor heat is usually excessive. The swellings tend to run together so as to form extended elevations enveloping the entire limb up to a given point, forming a great pad under the chest and abdomen, or distending the whole face or head so that it seems more like that of a hippopotamus than of a horse. In such cases the lips and nostrils become so thick and rigid that prehension is impossible, and breathing if it can be accomplished at all is accompanied with a marked snuffling. The swollen eyelids are closed, and the general turgid surface of the face is hard and resistant and no longer pits on pressure.
Under the chest and abdomen the swellings show as a continuous pad or cushion, on one side mainly or extending across continuously on both sides, and from the breast to between the thighs. It usually pits on pressure, and may shed the hair and become rough and scabby or ooze a serous fluid from the surface.
On the limbs the swelling usually shows first on the fetlock or pastern and gradually extends upward until it reaches the body.
As the disease advances chaps, cracks and fissures tend to form on the swellings, showing about the head, on the lips or on the nose and maxilla where the noseband of the halter crosses; on the lower part of the body where the circingle crosses, or where the part is pressed upon in lying down, and in the limbs in the flexure of the joints—behind the pastern, or knee or in front of the hock. In many cases the skin and connective tissue sloughs, and drops off exposing the muscles, the tendons or the ligaments of the joints. In other cases the tendons are involved in the degenerative process or necrosis and become detached from their lower insertions so that the toe may be turned up or the fetlock pad may come to the ground. The matrix of the hoof wall (coronary band) may separate from the horn, leaving a gaping opening which exudes liquid freely, and if the animal survives, the entire hoof may be shed.
In other cases, and often quite early in the disease, the swellings may suddenly subside and disappear, with it may be, a recovery, or, in other cases, with an exudation into the lungs or chest, the digestive organs or abdomen. In case the lungs are attacked, there is hurried oppressed breathing merging into dyspnœa or asphyxia. In case the bowels suffer there are colicy pains more or less acute, with much constitutional disturbance, marked prostration and serous or bloody diarrhœa. These mostly prove speedily fatal. Less redoubtable are those cases in which the swellings alternately subside or moderate, and reappear or increase, without implication of the internal organs. The absence of internal lesions and the moderation and intermissions, of the external ones, give good hope of the preservation of the vitality of the tissues and of recovery.
Course and Duration. These vary much with the severity of the case. In subacute and tardy cases with few petechiæ and restricted swelling in the limbs, the symptoms become remittent and recovery finally takes place after one or two months. In other cases the morbid phenomena which developed rapidly may subside as quickly and recovery occurs in a few days. In the more typical case the visible lesions may encrease or remain stationary for one, two or three weeks and then terminate in death or recovery. In the most violent types death may occur within forty-eight hours. The average duration of the affection is found to be about 16 days.
Differential Diagnosis. In typical cases of petechial fever, diagnosis is easy. The supervention on a protracted or debilitating disease of the respiratory passages of an access of hyperthermia, and marked prostration, with the appearance on the nasal or other mucosa of petechiæ and swellings of a dark red color throughout, and of cutaneous swellings in the form of nodular elevations and more extended salient patches, having a tendency to ooze blood or serum, to crack and fissure is virtually pathognomonic.
Acute glanders may resemble it but lacks the extended sloughs of petechial fever, and the nasal ulcers that form in glanders are on a yellowish base and periphery, whereas the purpura ulcer is on an uniformly dark red base, and without the elevated margin seen in glanders. In cases of doubt the mallein test is not available as the purpuric patient is already fevered, or liable to be so at any moment, and any wound in such a subject will give rise to extensive swelling.
In glanders the nodular submaxillary enlargement is almost pathognomonic and still more so if the facial lymphatic vessels are thickened (corded) and both symptoms fail in purpura. In cutaneous glanders with swollen joints or limbs the attendant pain is much more severe, and the farcy buds, forming on the thickened and indurated lymph vessels, bursting and discharging an albuminoid fluid like oil have no counterpart in petechial fever. In cases of doubt the search for the glander bacillus, and above all the inoculation of a male Guinea pig in the flank and the discovery of the bacillus mallei in the resulting exudate and diseased testicle will decide.
From anthrax and emphysematous anthrax petechial fever is distinguished by the absence of the large bacilli of these respective diseases from the exudate. It is not communicable, like anthrax, to the sheep, Guinea pig and rabbit, and does not crackle on manipulation, like emphysematous anthrax. The swellings are much more generally diffused than in anthrax and the hyperthermia much less.
Urticaria furnishes a skin eruption which may be indistinguishable from the earlier skin lesions of petechial fever, but these lesions are not associated with the petechiæ in the nasal and other mucosæ, and the swellings do not advance to great sanguineous engorgements, cracks, fissures, necrosis, and deep and extensive sores as in purpura. Urticaria is, moreover, usually traceable to some digestive disturbance and fault in feeding.
Malignant œdema is usually confined to the seat of the inoculation wound and an extension around that, the exudate is very watery and may be mixed with fetid gas bubbles, so as to crepitate slightly, and it contains an abundance of its specific, round ended bacillus, often in chain form. The carcass putrefies with great rapidity.
Horse pox affecting the pastern and limb with attendant swelling is distinguished by the absence of petechiæ on the mucosæ, and by the formation on the affected part of little pea-like papules, which early exude an abundant liquid, the concretion of which on the hairs forms a remarkable yellowish encrustation, embedded in the angry red sores beneath.
Mortality. Prognosis. The mortality has generally averaged about 50 per cent. Much, however, depends on the violence of the attack, and the reduced and worn out condition of the patient. The most hopeful cases are those in which the temperature remains near the normal, the strength and appetite are well sustained, the swellings are comparatively slight, and there is no indication of any internal complication. The unpromising symptoms are: persistent high temperature; complete anorexia; great dulness and prostration; excessive swellings not only cutaneous but in the nose and throat as well; a marked oozing from the swellings with a tendency to form cracks, fissures and sloughs; the serious obstruction of breathing and prevention of hæmatosis by blocking of the nose, pharynx or larynx by sanguineous and serous exudate; the appearance of oppressed breathing and other indications of exudate with the lungs and chest, or of colics, diarrhœa, and other suggestions of effusion on the bowels or in the abdomen. Extreme fetor of the expired air and of the fæces is a bad symptom, though not always a fatal one. Sudden retrocession of the cutaneous swellings, may be the precursor of internal exudations and death, yet in the absence of marked acceleration of the pulse, and of the objective symptoms of disease of the chest or abdomen, it is rather to be taken as a herald of recovery.
Treatment. Whatever may be the precise cause of petechial fever it is largely connected with and maintained by an unhealthy condition of the blood, and especially with the presence of toxins and waste products in that liquid. The first consideration is to secure for the patient the best possible sanitary conditions. A roomy loose box, dry, clean, well lighted and well aired, nourishing, easily digested food—green food, carrots, turnips, or mashes—and pure water are desiderata. A sunny exposure is desirable especially in winter, and everything like chill should be guarded against. Blanketing may be called for in cold weather, but the circingle like the halter should be avoided as being calculated to cause indentation, cracking or sloughing of the swellings.
A moderate action of the bowels should be secured by the nature of the food (linseed meal or tea), or by small doses of saline laxatives (sodium sulphate) or calomel. Suppression of the urine too, must be counteracted by diuretics (saltpeter, oil of turpentine) when necessary.
Further internal medication has been aimed to correct the dilatation of the capillaries, and to prove antidotal to or to eliminate the poisons present in the blood.
As vaso-motor stimulants have been employed ergot, belladonna, tannic, sulphuric and hydrochloric acids, oil of turpentine, iron sulphate, potassium bichromate and chlorate, quinia sulphate, and strychnia sulphate and arsenate. The value of any one of these is dependent on its early employment, the slight character of the lesions and the remissions that so often occur even in severe attacks. None are of much account in a violent attack at its worst.
In the slighter cases ergotin, 5 grains daily in two doses, has been apparently useful. An objection is that its continued action on the nerve centres and digestive organs is liable to prove depressing and injurious. Of the acids, tannic is liable to engender constipation, locking up the injurious products to which, however, it acts to some extent as an antiseptic. Sulphuric and hydrochloric acids have a tonic effect, and the latter is a stomachic under ordinary conditions. The same may be said of the iron salts and to some extent of oil of turpentine, which have both proved useful in favorable cases. Cadeac condemns ol. terebinth as calculated to abolish kidney secretions. The potash salts, bichromate and chlorate, and quinia sulphate are decided antiseptics and though the admissible dose would not ensure the destruction of bacteria, yet, acting in the system, with leucocytes and leucomaines, they may serve by keeping them in check. The chlorate of potash is given to the extent of an ounce the first day, and of half an ounce on succeeding days. The quinine salt is given in half ounce doses once or twice daily. In combination with bitters they seem to be of material value. Nux vomica (1 dram) or strychnia sulphate or arsenate (2 grains) given twice daily has seemed to be among the most promising agents of this class. As a potent vaso-motor stimulant, a bitter tonic and stomachic, strychnia has seemed at times to rouse the vitality and enable the system to throw off the load of poison that depresses it. The wonderful power of adrenalin chloride as a vaso-motor stimulant more than warrants its use both locally and generally. In using any one of these agents, we should not neglect concurrent attention to the bowels and kidneys, to antisepsis internally and externally, to hygienic and tonic measures generally.
Antiseptic agents have been given by the alimentary canal, the skin, the subcutis, and the air passages.
By the stomach the following have proved more or less useful in checking gastro-intestinal fermentations, and perhaps in hindering absorption of toxins from the specific lesions on this track: phenic acid, creolin, lysol, ichthyol, boric acid, salicylic acid, sodium salicylate and hyposulphite, and calomel.
To the superficial swellings, fissures and sores the same agents may be freely applied, alone, or combined with astringents, such as alum, lead acetate, aluminum acetate. In the hot season they may be applied cold, whereas in the cold weather hot applications are often preferable. Aruch claims excellent results from covering the engorged head with a woolen cloth and irrigating it with cold water.
The question of drainage of the worst cutaneous swellings by scarification, has been variously dealt with, Dieckerhoff advocating deep incisions, while Friedberger and others forbid them as encreasing the tendency to necrotic infection and sloughing. In the slighter cases it can well be omitted, but in extensive swellings the disintegrating and debilitating action on the tissues is so great as to well warrant its prevention by incisions and drainage. It is well to first give the surface a soapy wash, then apply a mercuric chloride or carbolic acid lotion and lance it in the prominent and tense portions. As a further precaution against septic infection it may then be covered by cotton soaked in one of the above lotions and covered with a bandage. For swellings beneath the abdomen or chest this may be held in place by loose circingles. Scarifying becomes imperative in case of paraphymosis arresting the flow of urine. Deep fissures and sores following sloughing may be treated with mercuric chloride solution, (1:1000), creolin or phenic acid (2:100), iodoform, dermatin, naphthalin or salol.
Disinfection of the nasal passages has been attempted by pervading the air with carbolic acid, creolin, cresyl, lysol, or naphthalin, by hanging saturated cloths in the stall, or spreading them on the floor. Perhaps a better method is to flush out the nose, by injecting each chamber in turn with a piece of rubber tubing, one end of which is introduced into the nose, and the other raised four feet and furnished with a funnel. The injection may be 1 dram creolin to 2 quarts water, or carbolic acid or alum may be substituted or alternated.
The swelling of the nostrils may be so great that it becomes requisite to hold them open mechanically. The suture of the two altogether, across above the nose has been practiced, or a tube of light wood or aluminum can be inserted in each nostril.
Injection of the trachea and bronchia with a solution of iodine 1 part, potassium iodide 5 parts, and water 100 or 200 parts, was advocated by Dieckerhoff and met with a fair measure of success in mild cases. In some cases, however, granular tracheitis and bronchitis followed, and in others necrotic tracheitis and pulmonary gangrene, so that the method has not been widely accepted. If resorted to, the weaker solution is to be preferred, and may be injected through a tracheal ring, or the membrane between two rings twice a day in doses of 3 to 5 centigrammes (45 to 75 drops).
Injection into the veins of Argentum Colloidale, 1 per cent solution in doses of 1⅔ oz. (50 grammes) at intervals of 2 hours has been very strongly advocated by Dieckerhoff who in four successive cases had complete recoveries in from three to six days. After disinfection of the skin a small trochar and cannula, or a hypodermic needle is introduced into the jugular and the injection made. Local treatment for the swellings was also applied.
Injection subcutem of the antistreptococcic serum of Marmorec, has been lauded as promptly overcoming the capillary dilatation, and enabling the leucocytes to neutralize the toxins.
Finally Menveux recommends an artificial compound as possessing all the good qualities of the antistreptococcic serum. This is composed of sodium chloride 5 grammes, sodium phosphate 1 gramme, sodium sulphate 20 centigrammes, sodium carbonate 1 gramme, caffein chlorhydrate 10 grammes, boiled filtered water 100 grammes. Inject daily in three doses 135 grammes.