with occasional chilliness, pains in the back and loins, great
prostration, languor, dulness, and even delirium, with cold sweats,
anxiety, dyspnoea, and at times muscular spasms. As in beasts, there
are the dusky skin and mucous membranes, petechiæ, and cyanosis, and
in bad cases there may be sudden collapse and death. The symptoms vary
much, however, according to the extent of the local lesion, to the
amount of poisonous chemical products thrown into the blood, to the
degree of the invasion of the blood by the bacillus, and to the
complication (not infrequent) of the affection with septicæmia. In the
very mildest cases the affection never proceeds beyond a local slough,
the size of a quarter or half dollar, the germs do not enter the blood
in sufficient numbers to survive, the constitutional symptoms are few
or absent, and the sore heals by granulation.
The disease usually lasts from six to ten days, and for the first
forty-eight hours the symptoms are generally purely local.
Malignant anthrax oedema (oedeme maligne) was first observed by
Bourgeois as occurring in the eyelid, and has since been recognized in
other parts of the body (arm, forearm, head). It differs mainly from
malignant pustule in the absence of the preliminary vesicle, of the
hard nodule (parent nucleus), and of the early circumscribed gangrene.
It has this further peculiarity, that the local disease often appears
as a {941} sequel rather than a precursor of the constitutional
disturbance. It corresponds in the main to the diffuse erysipelatoid
anthrax of the lower animals, and has been attributed to the anthrax
poison introduced by inhalation. It has been observed to follow eating
of anthrax flesh (Leube, Müller). Inasmuch as the active disease is
often delayed a week or ten days after exposure to infection, it may
reasonably be supposed that the bacillus has been imprisoned on the
mucous membrane, or, entering the blood in small quantity only, has
been held in check by the antagonism of the blood-globules until some
elements, escaping into the connective tissue, have started the local
disease. The symptoms are usually first languor, sleeplessness,
restlessness, with some sense of chill, debility, and headache, and
finally, after a few days, the formation of the specific oedema at one
point or more. This has a pale, semi-translucent, slightly yellowish
or greenish aspect, pits on pressure nearly equally at all points, and
tends to a rapid extension, with concomitant aggravation of the
constitutional symptoms, and in many cases nausea and vomiting.
Gangrene sets in--not progressively, as in malignant pustule, but
simultaneously over a more extensive surface--and is followed by great
prostration, stupor, dyspnoea, cyanosis, collapse, and death.
Anthrax intestinalis may be looked upon as the counterpart of the
internal anthrax or anthrax fever of animals, described above. As in
animals, the constitutional symptoms may result early in a fatal
issue, with scarcely any local lesion save in the blood and spleen
(Carganico, Leube, Müller, Winkler, Lorinser). As in animals too, the
sanguineous engorgement of the spleen and the intestinal anthrax are
often complicated by external anthrax oedema or malignant pustule
(Heussinger, Virchow, Buhl, Waldeyer, etc.). In this form pyrexia and
other constitutional disturbances are first seen. There is a general
feeling of languor and depression, with some chilliness, fever, pains
in the limbs, back, and head, vertigo, and ringing in the ears. Even
at this early stage there is noticed a dusky hue of the skin and
visible mucous membranes, which goes on increasing to a brown or
yellow tinge, to petechiæ, or, with the supervention of dyspnoea, to
cyanosis. Digestive derangement is early shown in abdominal pain,
nausea, vomiting, tenderness, some swelling, and finally diarrhoea,
often bloody and sometimes profuse and exhausting. In acute cases the
symptoms become rapidly worse, and then follow discharge from the
mouth and nose of uncoagulable blood, dyspnoea, cyanosis, small pulse,
dilated pupils, great anxiety or drowsiness, and stupor, or there may
be tonic spasms of the trunk or extremities. Death usually results
from asphyxia or collapse, as in animals. These cases are almost
invariably fatal within a period of thirty-six hours, though some
linger six or seven days.
Allied to the intestinal anthrax is anthrax angina, a not unknown
occurrence in man. This begins as a bad sore throat, with an
especially dark-red hue of the pharyngeal mucous membrane. As it
advances the shade becomes increasingly darker, the power of
deglutition is lost, serous phlyctenæ with gangrene and deep
ulceration set in, but without any tendency to the formation of false
membrane as in diphtheria. There are early superadded the
constitutional symptoms above described, and the patient dies in a
state of collapse or asphyxia.
MORBID ANATOMY.--The lesions closely agree with those already {942}
described for animals in general. The blood presents the same dark-red
or black, tarry, incoagulable, or only slightly coagulable condition
in the worst cases, yet this is less constant in man, as the bacteria
are less constant or numerous in the blood, in keeping with the more
prolonged localization of the external anthrax in man, and the more
pronounced antagonism between the blood and the bacillus which results
from feeding exclusively or largely on flesh. The red globules do not
tend to adhere together, and the white globules are in excess and very
granular. The spleen is less extensively enlarged than in animals, but
is highly charged with blood, bacilli, and micrococci. The lymphatic
glands too are enlarged, hyperæmic, cloudy, hemorrhagic at points, of
a dark grayish, deep red, or blackish color, and highly charged with
the bacillus. The surface of the skin and mucous membranes (mouth)
presents hemorrhagic spots and patches, with serous vesicles and
eschars. The malignant pustule when cut into presents a central slough
and a surrounding hard indurated mass, both of a dark blood-red, with
similar prolongations downward into the adipose tissue, and around all
the characteristic oedematous infiltration, often streaked with blood.
The bacillus is found in tufts or dense groups at intervals in the
rete mucosum, the dermis, and the subcutaneous connective tissue. The
serous membranes present the same general lesions as in animals. The
walls of the stomach and bowels are the seat of cloudy red
infiltration, with at intervals small hemorrhagic foci, and on the
mucous surface distinct sloughs. Jelly-like exudations are also found
in these membranes in the mesentery and in the retro-peritoneal
tissue. The liver and kidneys are usually congested or are infiltrated
with an oedematous exudate, and in these, as in all the local anthrax
lesions, the characteristic bacilli are found.
DIAGNOSIS.--Malignant pustule is distinguished by its commencing from
a minute red point with dark centre, and by its progressive extension
from this point by a dark-red, puffy, and vesicular areola, with
steadily advancing induration and gangrene. The bites of insects have
a yellowish central point with red areola. A boil lacks the dark
centre and the rapidly rising elevated red areola. Carbuncles and
plague-boils tend to appear on clothed parts of the body, respectively
on the back of the neck and shoulders and on the trunk and
extremities. In carbuncle several boils rise and burst simultaneously,
though they may finally slough into one sore, while in anthrax the
extension is from one point. The plague-boil is usually multiple and
much more painful than anthrax. The glanderous nodule is usually
multiple, situated at intervals on the course of a lymphatic, the
intervening portion of which is inflamed, hard, and cord-like. It is
also usually associated with the specific glairy discharge from the
nose, the nasal ulcers and nodules, and the enlarged painless,
nodular, and indolent submaxillary lymphatic glands. As a last resort
the detection of the bacillus in the indurated nucleus and the
inoculability of the disease on the lower animals (rabbit,
guinea-pig), may be appealed to.
Malignant anthrax oedema is less easily recognized, but may be
inferred from the sudden swelling with a dusky yellow or greenish hue
and a tendency to vesiculation and gangrene, the whole preceded and
attended by the constitutional symptoms of anthrax, and, above all,
from the presence of the bacillus in the exudate.
{943} In both of these forms much may be deduced from the known
liability of the district to anthrax, from the occupation of the
subject as being exposed to infection (worker in hair, wool, bristles,
hides, catgut, etc.), or from his having eaten meat which was open to
suspicion.
Internal anthrax is less certainly diagnosed because of the absence of
local symptoms until the constitutional disorder is well advanced. Yet
the reasonable suspicion of infection and the sudden and violent
eruption of the disease (headache, nausea, vomiting, bloody diarrhoea,
extreme anxiety, debility, dyspnoea, cyanosis, convulsions, collapse,
with petechiæ, and local discharges of diffluent blood) serve to
identify it. The bacillus is not always to be detected in the blood
under the microscope, but its presence can usually be demonstrated by
inoculation.
PROGNOSIS.--The prognosis of malignant pustule energetically treated
in its early stages is good. The disease is as yet a local one, and
the germs can be extinguished by local treatment. In anthrax
districts, where the disease is feared and early recognized, the
mortality may be from 5 per cent. (Nicolai) to 9 per cent. (Lengyel,
Koranyi). Even this mortality is mainly due to delay in treatment. In
districts, on the other hand, where the malady is infrequent, and
where efficient measures are applied too late, the mortality is often
30, 40, or even 50 per cent. After internal infection, and where local
symptoms only appear after general infection, the case is very
hopeless.
PROPHYLAXIS AND TREATMENT.--The prophylaxis of anthrax in man is to a
large extent identical with that for animals. All considerations as
regards soil, culture, drainage, sick and dead stock, cremation,
burial, disinfection, etc. have a most important if only a secondary
bearing on the protection of man. Still more important is the free use
of carbolic acid, chloride of lime, or tincture of iodine for the
hands of those dressing unhealthy sores in animals or handling
suspicious cases of sickness or cadavers, and of those working in
hides, wool, hair, horns, hoofs, guts, etc. Similarly, all products of
animals with anthrax should be withheld from general use.
In external anthrax of man, before the system has been contaminated,
the thorough destruction by caustic of the diseased part with its
contained poison is most effectual. Where there is as yet but the
preliminary papule it may be incised and thoroughly destroyed by a
stick of chloride of zinc, caustic potassa, or nitrate of silver, or,
if more convenient, by fuming nitric acid, muriatic or sulphuric acid,
or, perhaps preferably to all others, iodized phenol. Should the
parent nucleus have already formed, it should be excised with the
knife or deeply incised in a crucial direction, and then thoroughly
cauterized with one of the more potent escharotics (caustic potassa,
strong nitric acid) or with the iodized phenol. The latter agent may
be further applied on the sound skin adjacent, especially if there is
the slightest swelling or redness. Should the peripheral oedema
persist or reappear after the cauterization, the latter should be
repeated until this tendency is overcome. Hypodermic injections of a
solution of iodine and iodide of potassium may be made into the entire
swelling. After the caustic has done its work the eschar may be
softened and its separation favored by a warm poultice containing a
small amount of carbolic acid or iodized phenol. This treatment is
often highly beneficial, even after constitutional symptoms have set
in, by arresting the {944} propagation of the bacillus and checking
its introduction and that of its chemical products into the
circulation.
Constitutional treatment is not to be forgotten. Carbolic acid may be
profitably given to the extent of fifteen drops daily, iodide of
potassium ten to twenty grains thrice a day, and sulphate of quinia
ten grains at the same intervals. The strength should be sustained by
iron (tincture of the chloride) and wine or other alcoholic beverage,
both being, like the agents already named, calculated to retard if not
to limit the propagation of the bacillus. The diet throughout should
be nutritious and easily digested.
When a person is known to have eaten anthrax meat an emetic will be
indicated, followed by a smart oleaginous purgative combined with five
drops of carbolic acid, and subsequently by the constitutional
treatment above recommended. In case of extensive anthrax oedema,
incisions may be made into the part as far as the yellow exudate
extends, and a poultice containing carbolic acid may be applied. Or,
preferably, the swelling may be freely injected with a weak solution
of iodized phenol (1:100 water), and then painted with the same agent
or with tincture of iodine.
{945}
PYÆMIA AND SEPTICÆMIA.
BY B. A. WATSON, M.D.
HISTORY.--There is little to be learned from existing literature of
the views which were maintained by the ancients, prior to the birth of
Christ, in regard to the morbid conditions now designated pyæmia and
septicæmia; although it is certain they were recognized by the "Father
of Medicine," who reports a well-marked case of puerperal fever
terminating fatally on the twentieth day of the disease, and also a
case in which death was unquestionably caused by septic poisoning, as
is clearly shown in the following:[1] "Criton, in Thasno, while still
on foot and going about, was seized with a violent pain in the great
toe; he took to his bed the same day, had rigors and nausea, recovered
his heat slightly; at night was delirious. On the second, swelling of
the whole foot, and about the ankle, erythema with distension and
small bullæ (phlyctænæ); acute fever; he became furiously deranged;
alvine discharges, bilious, unmixed, and rather frequent. He died on
the second day from commencement." Additional confirmation of the fact
that Hippocrates was familiar with the phenomena of these diseases may
be found in his dissertation on empyema and fevers. Prof. C. Heuter
says, under the head of septic fever,[2] "Hippocrates and Celsus
observed the fever in cases of injuries which proved so dangerous that
this danger could not have originated from the inflammation or from
the wound alone." Jacotius, a commentator of Hippocrates, has even
mentioned putrid fevers, the same as Adrianus Spigelius, who spoke of
fevers which arise from putrefaction; but both authors, as well as
their followers, did not discriminate between septicæmia arising from
the putrescence of wounds and pyæmia. In the mean time both varieties
were regarded as intermittent fever.
[Footnote 1: _Works of Hippocrates_, trans. by Adams, vol. i. p. 377.]
[Footnote 2: Pitha und Billroth, _Handbuch der Chirurgie_, 1 Band, 2
Abth., 1 Heft, 1 Liefg., S. 6.]
"Aretæus lived during the middle of the second century of the
Christian era. In his remarks on pneumonia he observes that the
subjects of this disease die mostly on the seventh day. 'In certain
cases,' he says, 'much pus is formed in the lungs, or there is a
metastasis from the side if a greater symptom of convalescence be at
hand. But if, indeed, the matter be translated from the side to the
intestine or bladder, the patients immediately recover from the
peripneumony.' He speaks of a metastasis to the kidneys and bladder
being peculiarly favorable in empyema. He ascribes suppuration of the
liver to intemperance and protracted disease, {946} especially
dysentery and colliquative wasting. The symptoms described by him
resemble those of chronic pyæmia."[3]
[Footnote 3: Braidwood on _Pyæmia_, p. 2.]
Galen and some of the other ancient physicians recognized the
existence of septic poisoning, as is shown by the opinions expressed
on the subject of putrid fevers. According to Galen, putrid fevers may
either arise from the conversion of ephemerals, or originally from
putrefaction of the fluids within the vessels.
Aetius states that they arise from constriction of the skin or
viscidity of the humors, whereby the perspiration is stopped, and the
quantity of vital heat so altered as to give rise to putrefaction,
first of the fluids, and afterward of the fat and solid parts. When
these corrupted fluids are contained within the vessels they occasion
synochous fevers, but when distributed over the body they give rise to
intermittents. Synesius and Constantinus Africanus give a similar
account. Alexander gives an interesting and ingenious disquisition on
the origin and nature of putrid fevers, one of the most common causes
of which he holds to be the conversion of ephemeral fevers, and the
inseparable symptoms being want of concoction in the urine and
quickness of the pulse with systoles. This is the account of them
given by most of the other authorities, both Greek and Arabian, so
that we need not enter into any circumstantial exposition of their
views. We shall merely give the brief account of those furnished by
Palladius. There are, he says, two kinds of synochous fevers, the one
being occasioned by effervescence, and the other by putrefaction of
the blood; of these the latter are the more protracted and dangerous.
In them the pulse is contracted, the heat pungent, and the urine white
and putrid.[4]
[Footnote 4: Paulus Ægineta, trans. by Adams, vol. i. p. 236 (Sydenham
Soc., 1844).]
A new era in the literature of this subject dawned during the
sixteenth century. Ambrose Paré and Bartholomew Maggi each published a
work in which they pointed out the old errors and announced new
truths. Paré's _Treatise on Gunshot Wounds_ was published in Paris in
1551, while Maggi's treatise appeared a year later at Bologna. Paré
gained his first experience in the treatment of gunshot wounds in
1536, which is described as follows: "The storming of the small
mountain-fortress Villane, near Susa, probably gave him for the first
time full occupation, and he followed in all things the example of
older colleagues. Like them, although hesitatingly, he poured into the
gunshot wounds boiling oil of elder to destroy the poison, but the oil
fell short, and then he was compelled to dress the other wounded men
with an ointment of oil of roses and turpentine. Fearing that the
latter would soon become victims of the wound-poison, he passed a
sleepless night, got up early to see the ill consequences, but was
greatly surprised to find those that he had half given up free from
pain and without inflammation or swelling, while those who had been
treated with boiling oil lay in a state of fever, with great pain and
much swelling. He therefore determined, as he tells us, never again to
burn the poor subjects of gunshot wounds so cruelly."[5] It will be
seen that Paré's treatise on gunshot wounds was published fifteen
years after this impressive experience at the fortress of Villane. In
this work he sought to correct the prevailing idea that {947} gunshot
wounds were poisonous, and was ably supported in his effort by
Bartholomew Maggi; but it required all the respect which Paré enjoyed
in riper years to gradually obtain consideration for the new view. The
idea that gunshot wounds were poisonous is supposed to have originated
in the fact that in every war there are cases of acute sepsis,
developed after the infliction of these injuries, which agree in all
their essential points with the results of the bites of poisonous
snakes. We are even informed that during the late Franco-Prussian War
there were cases which even excited suspicion among the laymen that
the enemy had used poisoned missiles.
[Footnote 5: _German Clinical Lectures_, 2d series (New Sydenham Soc.,
1877), p. 65 _et seq._]
The nature of the error which Paré and Maggi endeavored to correct is
shown by the declaration made by Johannes de Vigo at the commencement
of the sixteenth century, who expressed in dogmatic form the views
then firmly held by physicians. "A gunshot wound is a contused wound,
he says, for the bullet is round; it is burnt, for the bullet is
heated; it is poisoned, for the powder is poisonous. The poisoning is
the essential condition; therefore the treatment must be directed
above all to counteract this."
The next step was that a poisonous substance may develop itself or
settle in the wound, and especially in gunshot wounds--a substance
which has nothing to do with powder or lead. Paré himself adopted this
view. When he took part in the siege of Rouen many wounds sloughed and
had a cadaverous smell, and on opening the bodies of those who died
numerous collections of pus were found in different parts full of
greenish ill-smelling ichor. Besiegers and besieged believed
themselves to be wounded with poisoned bullets. Paré looked for the
cause in a deterioration of the air by the large quantity of
decomposing substances, and he appears to have assumed, as is done at
this day, a direct action of the so-called deteriorated air upon the
wound itself.
The evil influence of air vitiated by the products of decomposition,
not upon wounds only, but upon the organism generally, has never been
lost sight of by physicians since that time. That rotten straw,
decomposing bodies of men and animals, surfaces saturated with
excrement, and overcrowding of badly-ventilated hospitals give rise to
infectious fevers and unhealthy state of wounds is not a result of
modern observation only. That it was a question of the processes of
fermentation which became communicated to the body by means of the
exciters of fermentation contained in the air was a view frequently
adopted. "To quote one only out of many; John Pringle, in his
_Observations on the Diseases of the Army_, published in 1775, devotes
a chapter especially to 'Diseases resulting from Bad Air,' and his
forty-eight experiments on septic and antiseptic substances contain
numerous hints at attempts resembling those made at the present day to
determine the antiseptic power of certain things. No advance was made,
however, beyond vague surmises concerning the nature of the exciters
of putrefaction, and they were for the most part looked for amongst
the volatile, ill-smelling products of decomposition, and were
believed to be extremely subtle gaseous matters."[6]
[Footnote 6: _German Clinical Lectures_, Second Series (New Sydenham
Soc., 1877), p. 67 _et seq._]