recognized. Then Lorin, a French surgeon, published a case of the kind
in which inflammation of the hand was induced by inoculation from a
horse suffering from farcy, and Waldinger and Weith drew attention to
the dangers of infection about the same time. In 1821, Muscroft in
England and Schilling in Germany simultaneously reported cases of
infection from the horse in which the true symptoms of glanders in man
were recognized. Rust, Sedow, and Weiss soon followed with additional
cases; then Forozzi (1822), Seidler (1823), Wolff, Grossheim, Eck,
Brunslow, Lesser, Travers (1826), Kries, Grubb, Brown (1829), Neumann
(1830), Vogeli (1831), Alexander (1832), and Elliotson (1833). Though
the disease was now well recognized, yet its nature has been
elucidated by a series of later writers, including especially Rayer,
Tardieu, Virchow, Leisering, Gerlach, and Korányi.
ETIOLOGY.--Man is rarely infected from any other source than the
horse. In a very few instances the contagion has been derived from
infected men. The modes of infection, immediate and mediate, are the
main points to notice in this connection. Those employed about horses
are usually infected by direct contact of the poisonous discharges,
blood, or tissues with abrasions on the skin or mucous membranes. The
inoculation received in giving medicine, examining the nose,
performing operations with effusion of blood, dressing cutaneous
ulcers, slaughtering, {920} skinning, making a necropsy, burying,
etc., is not uncommon. Again, direct infection is sustained through
snorting of the horse, so that particles of the virulent discharge are
lodged on the mucous membrane of the eye or nose. Closely allied to
this is infection by inhaling the exhalations of glandered horses, and
this doubtless accounts for some few cases which have been recorded as
communicated through the unbroken skin. The bite of the glandered
horse is a rare means of infection. From infection by eating glandered
animals man is usually saved by the cooking of his food and by his
inherent power of resistance, yet with instances of this kind on
record, as recorded by Ringheim, and the well-known conveyance of the
disease to animals in this way, it would be folly to ignore the risk
to man from eating the flesh of glandered horses, sheep, goats, and
rabbits.
Among the mediate forms of contagion may be named drinking from the
same pail or trough after a glandered horse, using a knife that has
been employed to open a glanderous abscess, wiping a wound with an
infected blanket or handkerchief, handling infected harness,
wagon-pole, or manger with wounded hands, sleeping over glandered
horses or in a stall or on litter previously used by such horses.
Conveyance of glanders from man to man has taken place through using
or handling the same dishes, towels, or handkerchiefs, through
dressing the wounds, or, as in the case of the veterinarian Gerard,
through making an autopsy of a victim of the disease.
Fortunately, the susceptibility of man is slight, but few out of the
multitudes handling glandered horses becoming infected. It is
essentially an industrial disease, 114 cases being distributed as
follows among the different occupations: hostlers, 42; farmers and
horse-owners, 19; horse-butchers, 13; coachmen and drivers, 11;
veterinary surgeons and students, 10; soldiers, 5; surgeons, 4;
gardeners, 3; horse-dealers, 2; policemen, shepherds, blacksmiths,
employés at veterinary school, and washerwomen, 1 of each.
A condition of ill-health doubtless predisposes to this as to other
invasions of infectious disease, yet men in apparently the most
vigorous health have succumbed to the poison.
SYMPTOMS.--The incubation of acute glanders in inoculated cases
usually varies from one to four days. In cases in which the mode of
entrance is not so manifest it may apparently extend over one, two, or
even three weeks. If the disease has occurred by external inoculation,
the seat of the wound shows the first symptoms, consisting of tense
swelling, pain, and a dark or yellowish erysipelatoid redness, while
the edges of the wound are puffy and everted, the matter escaping is
sanious, and the surrounding lymphatics are swollen and red and the
lymphatic glands enlarged and tender. After a few days constitutional
disorder sets in--languor, extreme weakness and prostration, aching in
the limbs (muscles and joints) and in the head, rigors alternating
with fever or a continued fever after the first violent chill, and in
some cases nausea, vomiting, and even diarrhoea. In cases not
resulting from external inoculation the febrile symptoms are the
earliest to be noticed, and the muscular and articular pains may be at
first mistaken for acute rheumatism. In other cases, in which the
gastric and intestinal disorders are the most prominent and the
prostration and weariness extreme, the symptoms at first strongly
{921} suggest typhoid fever. Soon, however, with a sense of
formication a local yellowish or livid erysipelatoid inflammation
appears, by preference on the softer parts of the face, the nose,
eyelids, cheeks, or on one of the principal joints, the shoulder,
elbow, or knee. In the midst of the phlegmonous swelling, or even
antecedent to it, there appear small firm red spots or nodules,
sometimes as small as those of variola, at others like a pea or as
large as a walnut or larger. These gradually blanch in the centre,
soften, and change into pustules or abscesses, and, bursting,
discharge a slimy, thick, sanguineous pus, often emitting a mawkish or
fetid odor. The sores thus formed are ulcerous and unhealthy, with
puffy, ragged, everted borders and a grayish or yellowish red base,
which often extends deeply between the muscles and exposes tendons and
bones. When several deposits of this kind are closely aggregated, they
tend to combine in one slough, which may involve a great extent of
tissue. In all cases there are the swollen, reddened, tender condition
of the connecting lymphatics and the tumefaction of the lymphatic
glands. At times the deposits and abscesses are deeply seated in the
interstices of the muscles, and at other times the joints are enlarged
by exudation.
In nearly one-half of the cases glanders supervenes on the cutaneous
symptoms. At first a viscid, whitish nasal catarrh appears from one or
both nostrils, mixed with striæ of blood; then upon the pituitary
membrane appear ulcers like those already described in the horse; the
same form on the buccal, pharyngeal, and laryngeal mucous membranes,
and by physical examination they may even be found to have invaded the
lungs. The margins of the nostrils become adherent through the drying
of the tenacious mucus; the meati are blocked or narrowed by the
swelling of the mucosa, the detachment of sloughs, and the
accumulation of the discharges; the breathing becomes snuffling and
difficult; the voice altered or lost; the cough weak, with a mucous
and bloody expectoration, and the breath offensively fetid. The
submaxillary lymphatic glands are inflamed and enlarged, and may even
go on to suppuration and ulceration. The conjunctiva is usually
involved, and at times the specific formation and ulceration extend to
the stomach and intestines, and nausea, vomiting, indigestion,
irregularity of the bowels, and fetid diarrhoea ensue. There is
complete anorexia, but thirst is ardent, especially with diarrhoea.
With the advance of the disease dyspnoea supervenes, and nervous
disorder is shown by the extreme weakness, anxiety, sleeplessness,
troubled dreams, nocturnal delirium, dilated pupils, and even coma.
The temperature, though at first unaltered, may later rise to 104° F.,
and the pulse to 110 to 120 beats per minute. The diagnosis is
confirmed by detection of the bacillus in the discharges, and, above
all, in the liquids of freshly-opened pustules (Wassilieff).
The duration of acute glanders in man may be no more than three days,
though usually it is protracted to fourteen or twenty-one, and
exceptionally to twenty-nine days. The almost constant termination of
this form of the disease is in death.
Chronic glanders occasionally appears in man, and is in most respects
the counterpart of that of the horse. The morbid process shows itself
in the integumental or other tissues of the body, and only attacks the
nose and air-passages later, when the constitutional symptoms become
more intense. The general malaise, languor, prostration, aching of
{922} limbs and joints, and inappetence are usually present,
complicated by a local swelling in the seat of inoculation (face,
hands, etc.), with small nodules progressing to pustules, congestion
of the lymphatics, and swelling of the lymphatic glands. These lesions
may subside even before suppuration, and the disease is manifested for
a week or two only by a general feeling of weariness and ill-health;
but sooner or later the local symptoms reappear in the same or another
seat, and the neoplasms, though indolent for an indefinite length of
time, finally degenerate, soften, burst, and form ulcers. These ulcers
have the general characters already described--a livid grayish or
yellowish hue, with red, puffy, irregular edges, and a viscid
greenish, yellowish, dirty white, or bloody discharge. They tend to
increase, or they may appear to heal by the peculiar firm cicatricial
formation, but on the swollen margins new deposits, abscesses, and
ulcers tend continually to form. Sometimes these are of considerable
size and seated deeply among the muscles, but when opened they show
the same unhealthy serous or bloody pus, and manifest a tendency to
extension rather than to healing. When the disease extends to the
respiratory organs, often two or three months after the onset, there
is cough and sore throat, blocking of the nose by the tenacious
discharges and swollen mucosa, and in the pharynx, fauces, and nose
the characteristic ulcer may be detected. The attendant constitutional
symptoms are also much more marked--indigestion, nausea, vomiting,
diarrhoea, rigors, profuse perspiration, high temperature, excited
breathing and pulse, a yellowish or earthy hue of the skin, rapid
emaciation, and great prostration. Though great emaciation, debility,
and hectic ensue on the indolent chronic processes, yet the disease
usually assumes all the characters of the acute type before
terminating fatally.
In cases that recover the fever diminishes, exacerbations cease,
ulcers granulate and cicatrize, vesicles dry up, the nodules and
enlarged glands diminish, the erysipelatoid swellings of skin and nose
subside, and a very tardy and imperfect convalescence is established.
The duration of chronic glanders, nasal or cutaneous (farcy), is
exceedingly indefinite, varying from three months to ten or eleven
years. One of the most protracted cases is that recorded by Bollinger
of a veterinarian who, after an eleven years' illness, recovered with
cicatricial contraction of the nose and larynx and a decided cachectic
appearance.
MORBID ANATOMY.--Besides the lesions above mentioned as occurring in
the skin and mucous membranes of the nose, mouth, and pharynx, the
frontal sinuses, the larynx, and less frequently the lungs, are the
seats of the specific glanderous processes. In the lungs there are
then the nodules, hard, caseous, or purulent according to their age,
and varying in size from a millet-seed and pea upward to the involving
of the greater part of a lobe. Beneath the pleuræ may be seen
ecchymoses, hard, fibrous nodules, and yellow elevations, which on
being incised furnish grumous pus. The spleen is usually enlarged,
gorged with blood, gray or black, and is the seat of suppuration. The
liver is enlarged, softened, and may be the seat of glanderous
processes, with ulcers in the bile-duct or gall-bladder. The joints,
like other serous cavities, become the seat of specific suppuration.
The bones are often implicated in adjacent deposits, especially in the
face, cranium, and hands, so that the compact tissue may become
reduced to the merest shell, while the medulla and periosteum {923}
abound in the specific products. The cerebral meninges and
brain-tissue are frequently the seat of specific growths and minute
abscesses. It is noticeable that the enlargement of the lymphatic
glands is usually less than it is in the horse, though they are never
entirely free from lesions. Indeed, the tendency in man to the
formation of considerable glanderous neoplasms is much less than in
the solipede.
The microscopy of the lesions is essentially the same as in the horse.
O. Wyss describes the cutaneous nodules as formed by a great
proliferation of round cells (like pus-cells) in the upper layer of
the corium just beneath the papillary layer. In a more advanced stage
the corium and papillæ are filled with pus-cells, and, becoming
disorganized, give rise to the formation of pustules and small
abscesses. Lagrange describes in a chronic ulcer of the palm, a layer
about 2 mm. in thickness of embryonic cells closely packed with an
amorphous intercellular substance. The nuclei appeared larger than in
ordinary ulcers or tubercles. Extending into this layer were capillary
vessels packed with red globules and with blind extremities, or in
some instances minute ruptures and hemorrhages. Beneath this
superficial cellular layer was a stratum of striated muscle,
especially noticeable for the excess of condensed connective tissue
making up the intermuscular septa, and the great multiplication of
nuclei with large, clearly-defined nucleoli, not only inside the
sarcolemma, but also between the fibrillæ and separating them widely.
At some points the muscular tissue had undergone a vitreous
degeneration, while at others were many fusiform cells. At one point,
where the ulcer extended to the phalanx, the compact layer of the bone
was attenuated to the thinnest shell and perforated, so that the
medulla was continuous with the ulcer. The medulla contained a great
number of white globules, medulla-cells, and minute embryonic nuclei.
The vessels were remarkable by the extensive fibroid thickening of
their coats. On section of the ulcer many orifices stood widely open
because of the rigidity of their walls. The internal coat was
plicated, as if too large for the lumen. The external fibrous layers
were at points abundantly interspersed with, and even replaced by,
groups of embryonic cells, the active proliferation of which meant the
destruction of the perivascular fibrous layer. These embryonic cells
even invaded the lumen of the vessel and partly blocked it, so that
the remnant of the tube remained as the centre of a disintegrating
mass, or later a caseous or purulent focus.
DIAGNOSIS.--Acute glanders, when well developed, is unmistakable. The
presence on or near the skin of the characteristic nodules, pustules,
phlyctenæ, and ulcers, the oedema or erysipelatoid condition of the
adjacent skin, the redness of the lymphatics, the presence of the
neoplasms and ulcers in the nose, and the sticky, fetid, variously
colored nasal discharge, with the acute fever, prostration, and pains
in the limbs and joints, make a tout ensemble that is pathognomonic.
In the initial stage only it may be confounded with rheumatism, but
the arthritic pains are not usually attended by the same amount of
redness and swelling of the joints, the prostration is far more
profound, and there are in most cases an irritable, unhealthy-looking
wound and a history of exposure to infection from glandered horses.
In chronic glanders, and especially in the external form (farcy), the
diagnosis is often more difficult. From pyæmia and septicæmia it is
{924} usually to be distinguished by the comparative absence or the
slightness of the chills, by the less healthy character of the pus,
and by the implication of the nasal mucosa, the larynx, and lungs.
When the nose, larynx, or lungs are but slightly affected, there may
be a strong resemblance to syphilis or miliary tuberculosis, but a
close attention to the character of the lesions, the absence of any
concomitant history or symptoms of syphilis, and deductions drawn from
the occupation of the patient and the presumptive exposure, will
greatly assist in reaching a diagnosis.
The detection of the bacillus is not conclusive, as in tuberculosis
and some forms of septicæmia there are similar organisms, agreeing
with the microbe of glanders even in the matter of size. In cases of
doubt a little delay will usually allow the development of new and
more characteristic symptoms.
The final resort, however, is to inoculation. Auto-inoculation, as
practised by Poland, is rarely satisfactory, as the system has
acquired a partial tolerance of the disease and local lesions are not
so certainly developed as in the healthy subject (St. Cyr).
Inoculation on a healthy goat, sheep, or rabbit can always be availed
of, and if practised on more than one subject can be relied upon, as
the virus loses nothing of its power in passing through the human
system, but usually determines an acute form of the disease in the
animal inoculated.
PROGNOSIS.--Acute glanders is almost constantly fatal to man. Of
chronic cases, and especially the external form (farcy), from
one-third to one-half of the subjects recover. When both internal and
external (farcy--glanders), the issue is usually fatal. Kütner claims
that cases caused by external inoculation are more favorable than
those caused by the inhaled poison. This accords with the general
principle, that a poison viable in the comparatively vitiated air of
the lungs or on the surface of the intestinal canal is better fitted
by its habit of life for survival in the blood and plasma, and is
consequently more redoubtable. The greater the duration of the disease
in any particular case, the more favorable is the prognosis.
TREATMENT.--In the treatment of glanders in man the same principles
must guide as in animals. In external, inoculated cases the wounded
tissues should be early destroyed by potent caustics--fuming nitric
acid, corrosive sublimate, iodized phenol, chlorine, sulphate of
copper, carbolic acid, or the hot iron. The erysipelatoid swellings
may be treated by leeching, followed by solutions of carbolic acid,
iodine, or chlorine-water, by ice, and internally by laxatives and
iodide of potassium. The first two antiseptics may be freely used by
hypodermic injection. Abscesses and tumors should be laid open and
cauterized as above, and then treated by weaker solutions of the same
agents. Nasal ulcers may be treated by insufflation of iodoform and
injections of creasote, carbolic acid, nitrate of silver, or
permanganate of potash solutions. Of the greatest importance is a
general tonic and stimulating regimen. A nutritious diet (including
beef-tea), abundance of pure air, alcoholic stimulants, quinia,
tincture of the chloride of iron, and, above all, arseniate of
strychnia, have been used with advantage. Various anti-ferments, such
as the bisulphites in full doses, carbolic acid, and iodide of
potassium, have apparently proved beneficial, and deserve a further
trial. As in the horse, a great {925} variety of other agents, mostly
of a tonic nature, have been employed, but with very variable results.
PREVENTION.--The first step toward the prevention of glanders in man
is the systematic restriction and extinction of the affection in
animals. This has been already sufficiently referred to above. Further
measures of prophylaxis embrace the following: the avoidance of
contact with glandered and suspected horses by all persons having any
wounds, abrasions, or ulcers on their skins; the cauterization with
nitrate of silver of all such sores on persons necessarily brought in
contact with glandered or suspected animals or their products; the
general diffusion of information as to the danger from glandered
animals; washing of hands and face in a solution of carbolic acid or
chloride of lime after handling infected or suspected animals or their
carcases or products; the thorough disinfection or destruction
(preferably by fire) of harness, clothing, racks, mangers,
wagon-poles, buckets, troughs, brushes, combs, litter, and fodder that
have been exposed to infection; and, finally, the exclusion from the
markets of all meat derived from suspected or infected animals. It is
generally held that the flesh of the horse alone demands inspection,
but with the known susceptibility of sheep, goats, and rabbits it can
easily be conceived how the infection may reach man through his food,
though horse-flesh is never consumed. That glanders has never been
recognized as arising from the consumption of diseased sheep or
rabbits does not prove that it has never reached man by this channel,
any more than the absence of all recognition of the infection of man
from the horse would prove the non-occurrence of such infection until
the beginning of the present century. The knowledge that the animals
used for food in this country are liable to contract and convey this
disease is an additional reason for the systematic and universal
suppression of the disease among the equine population.
{926}
ANTHRAX (MALIGNANT PUSTULE).
BY JAMES LAW, F.R.C.V.S.
SYNONYMS.--_Latin_, Ignis Sacer, Anthrax Epizoöticus, Pustula Maligna,
Pustula Pestifera, Erysipelas Carbunculosum, Carbunculo Contagioso,
Glossanthrax, Angina Carbunculosa, Anthrax Hæmorrhoidalis, Mycosis
Intestinalis, Apoplexia Splenitis, etc. _English_, Black Erysipelas,
Malignant Vesicle, Anthrax Fever, Splenic Apoplexy, Splenic Fever,
Inflammatory Fever, Carbuncular Fever, Black Quarter, Blood-Striking,
Bloody Murrain, Blain, etc. _French_, Pustule maligne, Charbon, Fièvre
putride, Typhohémie, Pélohémie, Mal de Rate, Splenite Gangréneusé,
etc. _German_, Karbunkelkrankheit, Contagiose Karbunkel, Milzbrand,
Milzseuche, Milzbrandfieber, Brandbeulenseuche, Rothlauf, etc.
_Russian_, Jaswa (boil-plague). _Italian_, Antrace. _Spanish_,
Carbunculo, Lobado. _Swedish_, Boskapssjukan. _Mexican_, Calentura del
piojo.
DEFINITION.--Anthrax is an acute, infectious, bacteridian disease,
occurring mostly in the Herbivora and Omnivora, but communicable to
other mammals (including man), to birds, and even fishes. Its local
manifestations are exceedingly varied in kind, but the malady is
characterized by the presence in the tissues or blood, or both, of
specific spherical and linear bacteria (micrococcus and bacillus
anthracis), leading to arrest of hæmatosis, to disintegration of the
blood-globules, to sanguineous engorgement of the spleen, to capillary
embolism, and to a spreading gangrenous inflammation.