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.