CHAPTER VIII

.

SURGICAL DISEASES COMMON TO MAN AND DOMESTIC ANIMALS.

TETANUS.

Synonyms: _Trismus_, _Lockjaw_.

Tetanus is an _acute infectious disease_, of relatively infrequent occurrence, _invariably of microbic origin, characterized by more or less tonic muscle spasm with clonic exacerbations_, which, for the most part, occurs first in the muscles of the jaw and neck, involving progressively, in fatal cases, nearly the entire musculature of the body. Certain _races_ of people seem predisposed, and in certain climates and geographical areas the disease is exceedingly prevalent. Negroes, Hindoos, and many of the South Sea Islanders show a peculiar racial predisposition, and, in a general way, inhabitants of warm countries are less resistant. This is shown partly by the fact that in various European wars the Italians and French have suffered more than the soldiers of more northern climes. Tetanus is by no means confined to adult life, since infants are far from exempt, and in the _tropics_ the _trismus of the newborn_ is the cause of a high mortality rate. In Jamaica one-fourth of the newborn negroes succumb within eight days after birth, and in various other hot countries the proportion is at times equally great. One plantation owner states that fully three-fourths of the colored children born upon his plantation succumbed to the disease. The peculiar reason for this infection will appear later when speaking of _tetanus neonatorum_. Men seem more commonly affected than women, probably because of their occupations, by which they are more exposed. Military surgeons have had to contend with the disease in its most virulent form, and it has been noted that soldiers when worn out by fatigue or suffering from the disaster of defeat seemed more liable to the disease. In 1813 the English soldiers in Spain suffered from tetanus in the proportion of 1 case to 80 wounded men. In the East Indies, in 1782, this proportion was doubled. Quick variations of heat and cold, such as warm days and cold nights, coupled with the other exposures incidental to military life, seem to exert a great effect. Curiously enough, the wounded in many campaigns who have been cared for in churches have suffered more from the disease than those cared for in any other way. Tetanus, however, is by no means necessarily confined to any one clime or race, but may be met with anywhere, at any time, providing only that infection has occurred. A celebrated Belgian surgeon lost by tetanus ten cases of major operations before he discovered that the source of the infection was his hemostatic forceps. As soon as these were thoroughly sterilized by heat he had no further undesirable complications. If the disease can be conveyed by the instruments of a careful surgeon, how much more so by the dirty scissors of a careless midwife, etc.

It is true, also, that the popular notions of the laity concerning the liability to tetanus after certain forms of injury are not ill-founded. Small, ragged wounds of the hands and feet are those which ordinarily receive little or no attention, and are among those most likely to be followed by this disease. The _toy pistol_, which, a few years ago, was such a prevalent and widely sold children’s toy, was the cause of many a small laceration of the hand, due to careless handling and the peculiar injury produced by the explosion of a small charge of fulminating powder in a paper or other cap. It was not the character of the laceration or injury thereby produced, but the fact that such injuries occurred in the dirty hands of dirty children, which were most likely to become infected, that has caused the so-called _toy-pistol tetanus_ to be raised almost to the dignity of a special form of this disease. During the month of July, 1881, in Chicago alone, there were over 60 deaths from tetanus among children who had been injured in this way by these little toys. This led to their sale being suppressed by law.

=Etiology.=--Two theories have had strong advocates, one being that which would account for the disease by irritation of nerves; while the second, the humoral, would explain the disease by alterations in the blood. Each has had its most ardent defenders, but both have now completely yielded to the investigations of a few observers, among whom Kitasato and Nicolaier are the most prominent. These ardent workers were, in 1885, able to clearly establish the _parasitic_ nature of this disease, and to isolate and investigate the organisms by which it is produced.

[Illustration: FIG. 17

Tetanus bacilli, showing spore formation. (Kitasato.)]

The bacillus of tetanus is a somewhat slender, rod-shaped organism, with a peculiar tendency to spore formation at one end, which gives it a drumstick appearance. It is essentially an anaërobic organism, and can never be cultivated in contact with the air. In laboratory experiments it is grown in the depths of a solid culture medium or else in fluids and on surfaces in an atmosphere of hydrogen gas. It is one of the apparent contradictions of bacteriology that this organism, which can only be grown as an anaërobe, nevertheless abounds in earth,

## particularly the rich, black loam which best supports luxuriant

vegetable life, and that it practically inhabits the upper layers of the soil, which accounts for the fact that so many contaminations and infections have occurred from stepping upon planks or boards with nails projecting, or from introduction of splinters, or from lacerations of the hands and feet which are so often followed by contact with such materials. There is nothing about a rusty nail wound which, by itself, predisposes to tetanus, but the rusty nail upon which a person steps is either itself infected or leaves a rent or wound which may become infected within the next few moments, and which is not likely to receive the careful attention which it should. Verneuil has of late laid stress upon the fact that in localities where horses are kept tetanus is more prevalent, and that the infectious organism abounds in and upon stable floors, about barn-yards, and wherever the excretions of a horse may be found. Bacteriologists are aware that in the intestines of herbivorous animals the bacilli (anaërobic) of tetanus and malignant edema are often found. Verneuil has further shown that almost the only instances of tetanus which occur on shipboard are upon those ships which are used for transportation of horses and cattle. His statements are at least interesting, if not absolutely well-founded. At all events, tetanus is certainly of telluric origin.

A French veterinary surgeon of twenty-five years’ experience had not seen a single case of tetanus until 1884, when he “removed a tumefied testicle from a horse, with the _ecraseur_, and it died of tetanus; in the following six months he castrated five, and all died; another castrated fifteen in one day, and all died but one; another in ten days castrated six bulls and operated on three fillies for umbilical hernia, when five of the bulls and one of the fillies died.” This will illustrate how the infectious agent may be conveyed by instruments, etc.

The tetanus bacillus manifests other peculiar properties, for some of which it is most difficult to account. Upon susceptible animals it is violently infectious, but is rarely found at any distance from the tissues in which it has first lodged. In laboratory investigations the period of incubation is seldom longer than forty-eight hours. Another peculiarity of the organism is that it generates certain poisons of

## active properties which may be separated from pure cultures, by whose

injection the peculiar spasms of the disease itself may be reproduced. These have been isolated, especially by Brieger, who has given to them the names of _tetanin_, _tetanotoxin_, _spasmotoxin_, etc. It has been estimated that about ¹⁄₃₀₀ Gm. of the pure toxin of tetanus would be a fatal dose for a man. This toxin seems to have a specific affinity for the ganglion cells of the anterior horn of the spinal cord, with which it unites with great force. Herein lies the secret of its disturbing power.

It is peculiar that some time may elapse after its injection before the appearance of the first symptoms. Diphtheria toxins appear to be prompt in their action, and thus display quite opposite characteristics. Experiment would seem to show, moreover, that the tetanus toxins do not reach the cord through the blood stream, but appear to slowly pass along the axis cylinders. Sensory nerves do not transport the toxins to the cord. The toxin enters the nerve termination, first of all, at the site of the infection, where it is most concentrated, which will explain why the spasms most frequently begin in the vicinity of the infection, or are the most marked there. Most of the toxin is taken up by the blood and lymph and distributed all over the body, and then passing along the motor fibers it enters the cord and leads to general convulsion. When the toxin is injected directly into the cord the symptoms begin at once. Therefore, for protective purposes, much may be expected from the administration of the antitoxin in cases of suspicious injury or those where experiment has shown there is reason to fear the development of tetanus. There does not appear to be on record a single instance in which a person who had been given antitoxin soon after receiving such a wound has developed tetanus, nor does the antitoxin by itself seem to have done any harm. Obviously, then, the earlier antitoxin is used in the case the better. It may be recalled that there are no diagnostic symptoms of tetanus until the first spasm develops, usually after the expiration of from five to twelve days. By this time the nerve cells are thoroughly saturated with the poison and considerable time may elapse before the antitoxin can reach these cells by a more indirect route.

=Tetanus Neonatorum.=--Tetanus neonatorum, or _tetanus of the newborn_, a condition already alluded to, is a remarkably fatal affection, very prevalent among the negro race, especially in hot climates. It nowise differs from traumatic tetanus, but is such in effect, since the infection in these instances always follows the _division of the umbilical cord_, which is usually effected with dirty scissors in the hands of a dirty midwife, while the thread with which the cord is tied is itself a possible source of infection, as well as the rags which are used to cover the umbilicus in the first dressing. It is generally fatal, because of the weakness and lack of resistance of these little patients. It occurs usually within a week after birth, if at all.

=Tetanus Cephalicus.=--Tetanus cephalicus, called also _tetanus hydrophobicus_ and _head tetanus_, is only a peculiar manifestation of this same affection, confined mainly to the head and usually following injuries to this region. The muscle spasms are mostly confined to the facial, pharyngeal, and cervical muscles, sometimes extending to the abdominal. These manifestations may be reproduced in animals by inoculating them on the head rather than upon the extremities. It is the least fatal form of the disease.

=Symptoms.=--There is always a _period of incubation_, usually three or four days, occasionally a week in length, but rarely longer.

It is generally held that the longer the period of incubation the more hopeful the prognosis. While for the great part the disease assumes an acute type, a chronic tetanus is described and occasionally seen. The _first warning_ of the disease usually comes as more or less _stiffness_ of the _cervical_ and maxillary _muscles_, which is likely to be referred to by the patient as a “sore throat,” because of the consequent difficulty in deglutition. A complaint to this effect should be regarded as a warning, especially if on inspection no visible reason for it can be detected in the pharynx. This complaint is usually made in the morning after an ordinary night’s rest. This muscle stiffness will be followed by increasing _tonic spasm_ in the _muscles of the jaw_, making it difficult to open the mouth, while the head and neck gradually become stiffened and fixed by spasm of the cervical muscles. These muscles may now be felt more or less rigidly contracted, as if by voluntary effort, and the condition, which is at first not painful, becomes after some hours a source of discomfort, perhaps of actual pain, to the patient. If the disease pursues the usual course, the other muscles of the body become gradually affected, usually in the order of their proximity, but not necessarily so. The _abdominal muscles_ are _firm_ and board-like, and the dorsal muscles more or less contracted, sometimes to an extent which causes arching of the spine. Should the original wound or port of entry for infectious germs have been in the hand or foot, the muscles of this limb become contracted, more or less rigidly, holding it in a position which is not easily changed, even by efforts of the attendant. Sensation is also often more or less perverted. In this condition of tonic rigidity the muscles remain, to relax usually only with death.

The most _characteristic features_ of the disease, however, are the peculiar _clonic exacerbations_, which _convert spastic rigidity_ into _violent and convulsive muscle activity_, so that the limbs and even the frame of the patient are more or less contorted, the muscle exertion being sometimes painful to witness. Notable effects are thus produced; the mouth is peculiarly puckered, and its corners drawn upward and backward by the risorius muscles, giving to the face that peculiar expression known as the “_sardonic grin_.” When the abdominal and flexor muscles of the thighs are involved, and the body is more or less curved forward, this condition is known as _emprosthotonos_; when the muscles of the back especially are involved, with the extensor muscles of the thighs, as _opisthotonos_; and when the body is bent to one side or to the other it is called _pleurosthotonos_. It is said that opisthotonic convulsions occur to such an extent in some instances that the heels touch the head. At all events, the patient’s body is frequently raised from the bed, so that he rests upon the head and feet.

Another characteristic feature of the disease is the _reflex irritability_, or _hyperesthesia_, by which these convulsive attacks apparently are produced. Into this condition the patient falls more or less rapidly within the first day after the inception of the disease, and to such a height may it be augmented that the slightest movement in the room, jarring of the bed, or displacement of clothing, even noise or a flash of light, may immediately bring on a convulsion. Rupture of muscles has been reported during some of these violent convulsions.

[Illustration: FIG. 18

Characteristic tetanic spasm in a rabbit twenty-six hours after inoculation with pure culture of tetanus bacilli. (Tizzoni and Cattani.)]

During the course of this disease the jaws are so fixed that patients speak with extreme difficulty and the tongue cannot be protruded. The mind is clear until the end. The pain is rather the acute soreness due to intense muscle strain. There is spasm of the sphincters, by which urine and feces are often retained. There is nothing characteristic about the temperature, which is seldom much augmented. Attempts to swallow give pain, and are resisted because of the renewed muscle spasm which is likely to follow the irritation inseparable from the

## act itself. As the result of spasm of the glottis peculiar respiratory

sounds may be noted.

Until the last only the voluntary muscles are involved. Finally, however, there are spasms of the accessory respiratory muscles and of the diaphragm. Death is usually produced by involvement of these muscles analogous to those of the others, and results usually from _apnea_ or _suffocation_. During the last hour or two perspiration may be copious and the temperature may rise.

_Chronic tetanus_ is characterized throughout by a milder and much more prolonged series of symptoms. The period of incubation is much longer, and, while the general program of the acute form is adhered to, it is of less severe degree and is spread over a longer time; in fact, cases covering two months or more are reported. In chronic tetanus the prognosis is much more hopeful than in the acute form.

The wound is but slightly, if at all, affected. In some cases it will be found to have healed before the onset of the disease. If suppurating or open, its evidences of repair will be found unsatisfactory and some indications of septic infection may be noted. Pricking or needle sensations may be subjective phenomena.

=Prognosis.=--Prognosis is almost invariably bad; if patients live more than five or six days it is thereby improved.

=Postmortem Appearances.=--These are rarely distinctive. In most instances there are evidences at least of hyperemia, if not of more

## active changes, in the upper portions of the cord. Less often slight

changes have been noted in the brain, consisting, in some measure, of disintegration and softening. Evidences of ascending neuritis in the nerve trunks leading to the injured area have been claimed in some instances. Few if any distinctive postmortem changes can be described as due to this disease.

=Diagnosis.=--The diagnosis should be made as between _strychnine poisoning_, _hysteria_, _hydrophobia_, _tetany_, and, in the beginning, from pharyngitis, tonsillitis, etc. When the disease is fully developed it is not likely to be mistaken for anything else.

Tetanus may be simulated by _hysteria_, but in this event the phenomena will be so uncertain, and the evidences of organic disease so essentially lacking, that it is not likely that mistake can occur.

=Treatment.=--If any case can be imagined in which efficient treatment is most urgently demanded it is one of tetanus. In scarcely any disease, however, is drug treatment so unsatisfactory. In the rare instances in which patients have recovered it is questionable whether it is not due to individual resistance rather than to medication. Treatment may be subdivided into _local_, _constitutional_, and _specific_. If there is still an _open suppurating or discharging wound_, it is, of course, essential to cleanse this out, basing this advice in some measure upon general principles--largely upon the fact, already stated, that ordinarily only the immediate surroundings of such a wound are found infected by the bacilli themselves. Consequently thorough _scraping_, _excising_, and _cauterization_, either with powerful caustics or the actual cautery, are indicated. Since the specific germ is an anaërobe, hydrogen dioxide may be used locally with great advantage, mainly because it oxidizes the albuminous material upon which the bacilli thrive. If it is in a finger or toe, amputation may be the simplest method of eradicating the local lesions.

_Constitutional treatment_ may be divided into _nutrition_ and medication. The tendency too often in these cases is to be careless or indefinite with regard to the excretions and the nutrition of the patient. If, for instance, each attempt at catheterization throws him into convulsions, the bladder may become overdistended and burst. So, too, there is apprehension usually in regard to fecal evacuations. At the same time these patients are allowed to almost starve because of the difficulty of feeding them. It is advisable to resort to chloroform to permit the introduction of the stomach tube--through the nostrils, if necessary--by which nutrition may be introduced into the stomach without causing the violent convulsions that would occur without an anesthetic. At the same time the catheter may be used.

In the way of _active medication_ there is no agent so efficacious for controlling the tetanic spasms as _chloroform_, which may be administered occasionally, or more or less continuously, according to the wishes of the attendant. By its use the severest spasms can be kept in abeyance, and the horrible character of the disease somewhat mitigated. Of the other medicaments used, most of them are of the nature of nerve sedatives, such as _chloral_, the _bromides_, _Calabar bean_, _cannabis indica_, _opium_, etc. Hot-air baths or diaphoretics, by which copious perspiration may be induced, have yielded good results.

_Specific treatment_ means in these instances taking advantage of the well-known properties which the _blood serum of an animal artificially immunized_ against the disease possesses. This is in accordance with experimental labors with a number of different diseases, of which tetanus is one. It is, in effect, similar to the serum therapy of diphtheria.

The most hopeful of remedies is _antitoxin_. More lives can be saved by this preparation, if used _early_ and freely, than by any other known remedy. Moschcowitz, in 1900, collected 338 cases, with a mortality of 40 per cent. In many of these cases it was not used early. It is of importance, however, to use it at the very outset, and to repeat its use as soon or as often as may be indicated by any exacerbation of symptoms. In one instance under my observation twenty-three phials of antitoxin were used before muscle rigidity subsided; in another case double this amount was used. Without quoting figures it is safe to say that the former great mortality rate of tetanus has been _reduced at least 50 per cent._ by its use, and that further reduction can be effected by its early and prolonged use.

The use of antitoxin nowise takes away the necessity for proper physical care of the laceration or the wound. Every particle of affected tissue should be cut away, all the principles of physical cleanliness adhered to, and proper antiseptics used.

When the antitoxin is used in the presence of the disease it should be injected into the spinal canal, as it is known that the cerebrospinal fluid may contain a considerable amount of the toxin and is of itself highly poisonous. Therefore after inserting the needle into the canal it is well to withdraw a considerable amount of the fluid before injecting the antitoxin. If this method is pursued the material is brought into more immediate contact with the anterior horns of the cord than could be effected in any other way. After withdrawing all the fluid that will run through the needle without applying the syringe--probably 150 to 200 Gm.--10 to 15 Cc. of the antitoxin may be slowly injected, the process consuming from three to five minutes. Then a further injection should be made along some of the large nerve trunks, preferably those leading to the part involved. This injection should be made with a finer needle, such as that with which cocaine solution is injected during anesthesia for the prevention of shock. This is a more effective and less serious matter than trephining the skull for the injection of fluid upon the surface of the brain. This may be done while the patient is under the influence of the anesthetic administered for the purpose of giving proper attention to the wound. The antitoxin should be injected into the nerve trunks after their exposure. At the same time it is well to make intravenous saline injections at more than one point. After from twelve to fifteen hours the injection of antitoxin and perhaps of saline solution should be repeated, if necessary, under such light anesthesia as can be produced by ethyl chloride. Recently a substitute for antitoxin has been suggested in an emulsion of brain tissue which has been shown to have a specific affinity for the tetanus toxin. It has been seen that when these two substances have been thoroughly shaken together the toxin is removed from the fluid and confined in harmless form within the brain-tissue cells.

In injecting the antitoxin into the spinal canal no harm will ensue if a little blood flow through the needle, showing that the cord itself has been touched.

When there is need to employ this material the brain of a freshly killed small animal should be removed under antiseptic precautions. 10 Gm. or 15 Gm. should be emulsified in about 30 Cc. of sterile salt solution, which should then be strained through a sterile cloth under light pressure. This is then injected as near the wound as possible and the procedure repeated every day as long as indicated. This method can only be expected to neutralize toxin that has not yet entered the nerve cells. Nevertheless, Russian observers have reported thirteen recoveries out of sixteen instances in which the method was practised.

When no other means are at hand a 1 per cent. carbolic acid solution may be injected after the same fashion, using such an amount that about five grains are administered during twenty-four hours to an adult. This is the method especially favored by the Italians, and is due especially to Baccelli.

Matthews has devised a method which seems quite effective in experimental animals. It consists of the use of a solution of the following: Sodium chloride 4 Gm., sodium sulphate 10 Gm., sodium nitrate 3 Gm., calcium chloride 14 Cgm., water 1000 Cc. This is intended for intravenous injection, and must be introduced very slowly. The performance should be repeated twice during the first twenty-four hours and once each succeeding twenty-four hours. It produces profound diuresis, _i. e._, a washing out of tissue cells, as he calls it.

HYDROPHOBIA.

Hydrophobia is _an acute specific or infectious disease_, as far as known _never originating in man, but transmitted to him, usually through the bite_ or by inoculation from the saliva of a _rabid animal_--in this country usually the dog, although the wolf, the cat, the skunk, and even certain of the domestic poultry, are capable of conveying the disease. Chickens are said to be immune save when their vital resistance is lowered by starvation. Chicken blood injected into other animals seems to antidote the virulence of the virus. It can also be inoculated in other animals, like rabbits. The _virus_ is ordinarily conveyed in the _saliva_ of the rabid animal. This may be wiped off as the teeth of the animal pass through the clothing of the injured individual; consequently, infection does not certainly follow such bites. But those upon exposed portions of the body, where animals generally bite, are almost invariably followed by infection. Hydrophobia is frequently spoken of as _rabies_, sometimes as _lyssa_. While rare in this country, it is by no means uncommon in Central Europe, especially perhaps in Russia, where bites from infuriated wolves are common. In the United States infection comes almost invariably from the rabid dog, in which this disease presents two types.

The so-called _furious form_ is that which is marked by frenzy and canine madness, the objective symptoms being more pronounced and alarming, though not less dangerous than the other variety. After the period of incubation, which varies considerably, these animals show depression and uneasiness, and even thus early their saliva is infectious. Their sense of hunger becomes perverted; they exhibit unusual tastes, secrete saliva abundantly, which becomes very tenacious and even frothy, exhibit a dry and edematous condition of the faucial mucous membranes; the character of the bark is altered, while they are usually infuriated at the sight of other dogs. In this stage there is usually insensibility to pain. Finally, come more or less paralysis of deglutition, quickened respiration, dilated pupils, and frenzy and madness of manner, by which they attack indiscriminately men and other animals. To this stage of furious excitation succeeds one of paralysis, and death follows from exhaustion. These manifestations usually last about a week.

_Dumb hydrophobia_ is the more common form. Here paralysis appears much earlier and involves especially the lower jaw; the tongue falls out of the mouth; and the posterior extremities are quickly paralyzed. This form is much more quickly fatal than the other.

Animals thought to have hydrophobia should be kept by themselves in a secure enclosure and carefully watched, especially those known to have bitten men or other animals. If a suspected dog have been killed before the suspicion has been confirmed, the head and upper part of the neck should be removed for examination. Veterinarians claim that what they call the plexiform ganglion permits an almost certain diagnosis to be made. The presence of foreign bodies in the stomach of the animal is a corroborative feature. Diagnosis by subdural inoculation requires two or three weeks, and in at least one case a human patient died while waiting for diagnosis to be thus established.

_Hydrophobia in man_ is rare in this country, yet is occasionally observed. Its etiology is as yet obscure. That a _contagion vivum_ is present is positive, but its nature is uncertain. Negri, of Pavia, has recently described certain bodies observed in the nervous system of animals dead of hydrophobia which may offer the solution of the problem that has so long been sought. They are found in the protoplasm of nerve cells, but not in their nuclei. They are round or oval in shape, vary in size from 25 microns down to those which can be barely seen with the highest powers. They take ordinary stains.

Negri maintains that these bodies are parasites and he has invariably failed to find them in animals which did not have rabies. His work has been confirmed by a number of his colleagues, and bids fair to furnish a reliable and rapid means of diagnosis. The fact that the virus of hydrophobia will pass through a porcelain filter nowise contradicts the view that these bodies may be parasitic, for it is quite possible that they undergo different stages of development, in some of which they are small enough to pass even barriers of porcelain.

In fact it seems to have been positively demonstrated that these bodies described by Negri, in 1903, are diagnostic for rabies. They are most likely to be found in the horns of Ammon or the cerebellum. When found here, careful examination must be made of the Gasserian ganglion, where may be found the lesions first described by Van Gehuchten and Nelis, which consist of a proliferation of the endothelial cells to such an extent that the ganglion cells are first invaded and then destroyed, their places being taken by the new cells.

The Negri bodies have been generally regarded as protozoa and the specific cause of the disease. At all events, it seems possible always to successfully reproduce the disease in rabbits or guinea-pigs by inoculation with these bodies.

If examination shows neither the Negri bodies nor the lesions in the ganglion the presence of the disease can scarcely be suspected, and could only be proved by animal inoculations, which, however, would be advisable in doubtful cases where human beings have been bitten.

=Symptoms.=--The _period of incubation_ in man is variable, ten weeks being perhaps the average. It is shorter in children, as also when the bites are numerous. It is even stated that it may be as long as a year or more, during which time the poison seems to lie latent. When the active symptoms supervene there are, locally, discomfort about the wound, itching, heat, and peculiar unpleasant sensations. It is said also that vesicles may make their appearance in the neighborhood of the original lesion. _As in animals, so in man_, the disease may assume either the _furious_ or the _paralytic_ type. These cases are nearly all marked by mental depression and apathy, with complete loss of courage. The earlier symptoms are connected perhaps with the respiration, which is infrequent, while inspiration is halting and speech is interfered with. The facial appearance is often changed to one of anxiety, even despair. The muscles of deglutition are next involved in a combination of spasm and paralysis, and the act of swallowing is interfered with, sometimes made almost impossible. Although patients can swallow their own saliva, they find it difficult to swallow any foreign substances, such as water, etc. This is _not due to the fear of water_, as the term “hydrophobia” would imply--this being an absolute misnomer--but is due to reflex spasm excited by the attempt. It is accompanied by more or less sense of suffocation and palpitation of the heart. Indeed, a paroxysm of this kind may be precipitated by the attempt to swallow, so that the patient instinctively refuses water or any other fluid. _Reflex excitability_ is also very great, and a breath of air or a trifling disturbance may precipitate a paroxysm, almost as in extreme cases of tetanus. As the case progresses the saliva becomes more tenacious and viscid, faucial irritation more marked, and the attempts to expel the secretion, along with the disturbed respiratory efforts, have given rise to the foolish lay notion that these patients bark like dogs. The paroxysms, as the case progresses, become more marked, the patient more restless, until, later, furious mania or muttering delirium is present, to be followed by prostration and paralytic phenomena, muscle tremor, etc., and death.

The _paralytic form in man_, as in dogs, is marked by the much earlier paretic phenomena, anesthesia, and, finally, respiratory paralysis which terminates the case. Curtis and others have insisted that the hydrophobic paroxysms are not convulsions in the ordinary sense of the term, but are due to temporary inhibitions of the most important respiratory and cardiac centres as the result of peripheral impressions. He likens them to the shock of a shower bath.

=Postmortem Changes.=--Postmortem changes are indistinct and only suggestive. They consist for the greater part of a sort of vacuolous degeneration of the ganglion cells of the nerve centres--most prominently in the medulla, next in the hemispheres, and then in the spinal cord. There is hyperemia, with minute ecchymoses, with infiltration of the adventitia of the vessels and perivascular extravasation. The changes met with in the other viscera bear no constant relation to symptoms. Nevertheless, Gowers holds that because of the location of the lesions and their intensity in the neighborhood of certain nerve nuclei we have here a distinguishing anatomical character of the disease.

The toxin (as we may call it for the lack of a better term) seems to be transmitted much as is that of tetanus (_q. v._), along the afferent nerves to the cells of the anterior horns of the cord.

=Diagnosis.=--As between hydrophobia and tetanus diagnosis is not difficult, as already described. In certain hysterical individuals nervous paroxysms, largely due to fright, may be precipitated by dog-bites and other incidents or accidents. In these cases there is rarely such a period of incubation, and in a true hysterical case there will be no such mimicry of this awful disease. A condition known as _lyssophobia_ (fear of hydrophobia) has been described. It is seen in hysterical subjects. It is said to have even been fatal, but this must have been from other complications.

=Treatment.=--There is no authenticated case on record of recovery after medication by drugs. It is probable that recovery has never followed anything but the modern inoculation treatment.

The only successful treatment for this disease has been elaborated as the result of the labors of that indefatigable French savant, Pasteur, and is among the glorious triumphs of laboratory research, against which it is so often charged that it is not practical in its results. It is in some respects a curious commentary on the study of infectious disease that we can secure and work with the peculiar virus of hydrophobia, and at the same time be utterly unacquainted with its true character. To this fact is due the modern cure. It is based upon the fact that the virus is not only in the saliva, but also in the nervous system of animals suffering from this disease, and that its effects are intensified and hastened by inoculation directly into the cerebral substance. Accordingly, when a diagnosis of hydrophobia can be reasonably well established, no time should be lost in sending the patient to one of the “Pasteur Institutes,” to be found now in most of the great centres, there to undergo a regular course of treatment. It was reported that in the Institute in Paris, between the years 1886 to 1894, there were treated a total of 13,817 cases, and that the mortality was 0.05 per cent. Of course but a small proportion of these really had or would have developed the disease.

Virus obtained from the brain or cord and inoculated into the dura of another animal quickly precipitates the disease. It is, moreover, modified in virulence as it passes through successive animals of certain species--for example, monkeys. It is increased by passage through rabbits, and the period of incubation thereby shortened. The weakest virus can by proper handling and manipulation in this way be so intensified as to produce disease within seven days after inoculation. Desiccation reduces the virulence, and preparations from the cord of an infected animal may be attenuated to almost any desired extent by drying. By inoculating a dog or a rabbit with virus prepared from this weakened source, and daily making injections from stronger and stronger preparations, it is in the course of a couple of weeks rendered practically immune to the disease. Animals thus made immune are trephined and the virus injected beneath the dura, by which more certain results are obtained. The treatment consists in using a section of a rabbit’s spinal cord, 0.5 Cm. in length, rubbed up in 6 Cc. of sterile salt solution. Half of this amount is injected each day into the flank of the patient. The cord first used is one that is thirteen or fourteen days old, which has been kept suspended in a sterile flask, over caustic potash, in order to assist in its desiccation. The next day a cord one day younger is used, and so on until by the twelfth day of treatment the cord is one only two days old, and at the end of two weeks a fresh cord can be used which would convey the disease had it been used first. If this course of treatment can be carried through before the first symptoms of the disease appear, the antidote has gained complete mastery over the infecting agent and the patient is saved.

GLANDERS AND FARCY.

Glanders as it is known in man is a _specific infectious disease, transmitted usually from the horse, characterized by rapid formation of specific granulomas_, particularly in the skin and mucous membranes, _which quickly break down into ulcers_, and by the general toxemia characteristic of any acute infection. In German it is known as _Rotz_, in French as _morve_, while its old Latin name was “malleus” (hence we speak of the _bacillus mallei_). It was also known in former days as _equinia_. In horses the disease has also been known as _farcy_, because of the peculiar subcutaneous nodules which farriers and hostlers, almost from time immemorial, have called “farcy buds.” The disease, while capable of transmission from man to man, is generally produced by contagion from some of the domestic animals, most commonly the horse, although sheep and goats are known to occasionally have it, and dogs are susceptible, though seldom showing manifestations of it.

Like some of the other infectious diseases glanders appears to be variable in its manifestations. While infection occurs probably through some superficial abrasion, it is almost certain that it may also occur through the unbroken mucous membrane of the respiratory organs. It is said to be also capable of transmission from mother to fetus _in utero_. So far as known in man, infection occurs practically invariably through some slight abrasion, either of the skin or the mucous membrane of the nose, the eye, or the mouth. The discharges from the nostrils of affected animals are extremely virulent, and infection comes usually from this source. It is said to have been communicated from one patient to another by eating from the same dish or by drinking from a pail used by a diseased horse.

Glanders is due to the specific bacillus known as the _bacillus mallei_. It is shorter and plumper than the tubercle bacillus, in length about one-third the diameter of a red corpuscle. It is a non-motile organism, occasionally spore-bearing, not very resistant, belonging to the facultative anaërobic forms, growing best at blood temperature, taking stains easily, and losing them in the same way.

=Symptoms.=--Glanders is seen usually in workers and hangers-on in stables. The _acute_--the common--form has a _period of incubation_ of from three to seven or eight days, after which both local and general symptoms supervene. About the infected region a form of cellulitis appears, assuming often a more or less phlegmonous type, with implication of the adjacent lymphatic nodes and evidences of periphlebitis and perilymphangitis. Over the affected area vesicles appear, which become hemorrhagic and later suppurate. A wound which has healed may reopen. Almost always there are accompanying constitutional disturbances of septic type, occasionally chills, pyrexia, etc. It is rather characteristic of glanders to have severe pain in the muscles and extremities, with epistaxis and formation of metastatic tumors and edematous swellings in various parts of the body. Frequently, later in the disease, appears a somewhat distinctive eruption, papular in character, merging into pustular. Hemorrhagic bullæ are also often seen. Pustulation and edema of the face change its appearance. There are also edema of the eyelids and _mucopurulent discharge from the conjunctivæ and the nose_. This latter discharge is often ozenous in character. Upon inspection of the nasopharynx and oropharynx a similar condition will be noted. In connection with these local signs more or less general furunculosis also will be observed. Obviously, as these local conditions intensify and multiply, septic disturbance will be increased, and the patient dying of acute glanders dies generally of septicemia or intoxication and exhaustion combined.

A chronic form is known, distinguished mainly by slowness or tardiness of lesions, though the local changes are not particularly different in character. There is perhaps more tendency to suppuration and less to lymphatic complications. The nodule which breaks down will leave a foul ulcer, the _discharge_ from these lesions being _extremely infectious_.

=Diagnosis.=--This is not always easy, but may be based in suspicious cases to some extent upon the occupation of the patient. The presence of multiple lymphatic lesions and subcutaneous nodes, especially when breaking down as above described, and accompanied by ozenous discharge from the nose, should at least be suggestive, and will serve to distinguish between this disease and, for instance, typhoid fever. The chronic type of glanders might be mistaken for syphilis, and here is where the real difficulty of diagnosis will probably occur. In doubtful cases the crucial tests are the microscopic examination of discharges, after staining for bacilli, and the cultivation test.

=Prognosis.=--A generalized attack of glanders is a matter of gravest import, especially when acute. Scarcely more than 10 or 15 per cent. of such cases recover. In the more chronic manifestations the prognosis is more favorable, half of the patients making a final recovery.

=Treatment.=--All infected animals should be isolated and destroyed, their carcasses being _burned_. If possible, the infected wound or abrasion should be induced to bleed freely, and then cauterized with an

## active caustic. By prompt interference with the first manifestations

it may be possible to cut short the disease. This would necessarily be done by _excision_, _cauterization_, _packing_, etc. Bayard Holmes has reported a case in which, during two and a half years of chronic manifestations of this disease, he anesthetized the patient twenty times for the purpose of opening new foci or scraping out old ones, finally obtaining a permanent cure. There is no specific treatment, but the septic symptoms should be combated as indicated in the chapter on Septicemia.

By making a _glycerin extract_ from the filtered and evaporated culture of the glanders bacillus it is possible to prepare a toxalbumin analogous to tuberculin, which reacts in a similar way. By it animals may be fortified against inoculation, and by its use a peculiar reaction is produced in those affected by the disease. It is known as _mallein_, and by it are tested all horses used for the preparation of the diphtheria antitoxin, in order that all possibility of glanders may be eliminated. It is probable that it might be made of therapeutic value in treating the disease when actively present in man.

ANTHRAX.

Anthrax is more commonly known as _splenic fever_, _malignant pustule_, or _woolsorters’ disease_; in Germany as _Milzbrand_, and in France as _charbon_. It is an infectious disease of cattle, which has devastated many parts of Central Europe, and has been frequently met with on the Continent among men, though but rarely in the United States. All the domestic and nearly all the experimental animals are subject to it. Gronin has stated that in the district of Novgorod, in Russia, during four years more than 56,000 cattle and 528 men perished from anthrax. Poultry and dogs are not strictly immune, but possess a low susceptibility to the disease. It generally prevails in low districts and in marshy grounds.

The disease is the result of the invasion of the _bacillus anthracis_, which is a relatively large-sized bacillus, varying in breadth from 1 to 1¹⁄₂ and in length from 5 to 20 microns. It is easily cultivated outside the body, and multiplies with great rapidity in the bodies of susceptible animals; it is the type of spore-bearing bacilli, and is so readily recognized and worked with that it is commonly used in laboratory investigations. The demonstration of its specificity we owe to Davaine, in 1873, although he had described it in 1850.

[Illustration: PLATE IV

FIG. 1

Anthrax Bacilli. Spore Formation. (Karg and Schmorl.)

From an agar culture twenty-four hours old. About the margin of the photograph are a number of free spores, × 600.

FIG. 2

Anthrax Pustule. Removed from Arm of Man. (Karg and Schmorl.)

Marked edema of the skin, causing elevation and separation of the papillæ. In the edematous exudate a large number of anthrax bacilli and leukocytes. × 50.]

_Anthrax bacilli_ may enter the body through the _respiratory organs_, through any _abraded surface_, and possibly even through the _alimentary canal_. They may also pass through the placenta and affect the fetus _in utero_. They are too large to pass through the walls of the capillaries of ordinary size; consequently they plug them and produce a mechanical stasis which is rapidly followed by gangrene. From the kidney structures and capillaries, however, they may escape, as bacilli are found in the urine in certain cases of anthrax. (See Plate IV.)

In _man_ the disease occurs usually as the so-called _malignant pustule_, or _woolsorters’ disease_, the latter name being given because of the liability of those individuals who come in contact with the carcasses and hides of diseased animals or their immediate products. The _period of incubation is brief_--on the average two or three days. The first lesion appears usually on the face, hands, or arms, and is characterized by local discomfort with formation of a small papule, which rapidly becomes a vesicle with an areola of cellulitis about it. This is rapidly followed by induration and infiltration, and these by local gangrene, the result being the separation of a core-like mass, similar to that of carbuncle. The affected area is usually discolored, often quite black. The process is not usually accompanied by suppuration, nor is there the pain of true carbuncle. The lesions tend to spread peripherally, but there is more or less vesication of the surrounding skin. On account of the local ischemia there will always be edema of the affected region, and sometimes the swelling and local disturbance become extreme. These peculiar lesions have given rise to the common name _malignant pustule_, which is well deserved. At last a line of demarcation becomes manifest, and if the disease progresses favorably the included area is sloughed out, leaving a surface which it is hoped will soon become covered with reasonably healthy granulations.

Absence of pain, and usually of pus, are significant features of anthrax. Should mixed infection occur, however, we are likely to see pus formation. When the disease partakes less of the characteristics of malignant pustule and more of a general infection, the local symptoms may not predominate, but, on the contrary, septic indications may become serious and even fatal. The evidence of more or less toxemia is usually at hand, however, and the toxin of anthrax is almost as destructive of muscle cell integrity as is that of diphtheria.

The local lesions may be single or multiple, but will be met with almost always upon exposed areas of the body.

=Postmortem Appearances.=--These will depend upon the clinical course of the disease. In the sloughing tissues the bacilli are very numerous, while around the margin more than one bacterial form will probably be met--_i. e._, mixed infection. Should saprophytic organisms complicate the case, they may have replaced the anthrax bacilli by the time the examination is made. The latter abound, however, in the blood, and may usually be found occluding the capillaries of the liver, spleen, kidney, etc. In intestinal infection, particularly in animals, the mesenteric nodes are involved. Inasmuch as septic features accompany all fatal cases, putrefaction will be found to begin early, and the changes in the blood and the gross changes in the other organs will resemble sepsis rather than anthrax.

=Prognosis.=--Prognosis for man is not usually unfavorable, the majority of cases recovering with more or less local destruction of tissue. Should, however, infection become generalized, the case will probably terminate fatally. Cases assuming the type of splenic fever are of much more serious character, and their prognosis graver.

=Treatment.=--This should be both local and constitutional. The former should consist of the most radical possible attack and include complete excision of the infected area, with the use of active caustics or the actual cautery. In fact, the latter instrument offers a most valuable means for combating the destructive tendency of the disease. Sloughing and separation of the cauterized mass may be hastened by warm antiseptic poultices. Subcutaneous injections of 5 per cent. carbolic solution have been given, with apparent benefit, in a number of cases, but should only be relied upon in the treatment of the milder manifestations.

Benefit will accrue from the use of the ichthyol-mercurial ointment whose formula was given under treatment of Erysipelas. It has been suggested to treat these cases by the employment of the bacillus pyocyaneus, since it is known that this organism when injected with the anthrax bacillus materially attenuates its effect.

=Prophylaxis.=--Prophylaxis is most important. The bodies of all infected animals should be burned, not buried, since the resistant bacilli are often brought to the surface of the soil by earth-worms. Every discoverable source or medium of infection should be destroyed or sterilized.

MALIGNANT EDEMA.

This disease has been recognized for some time, mainly by French and Continental clinicians, and under such names as _gangrène foudroyante_, _gangrène gazeuse_, _gangrenous septicemia_, and _gangrenous emphysema_. The name _malignant edema_ was given by Koch, who identified the infecting organism. It is one of the most dangerous forms of gangrenous inflammation, and occurs sometimes after serious injuries, and, again, after most trifling lesions, such as those inflicted by the dirty pointed implements of the gardener, etc., or even the stings of insects. Two cases are on record where the disease followed a puncture of the hypodermic needle for the administration of morphine. In one of these the organism was found in the solution; in the other it probably had been deposited upon the skin.

Malignant edema is essentially a specific form of _gangrene_ (see

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