Part 139

Many cases with a more favorable issue are recorded. Bellenger had a patient who had been bitten by his cat, and manifested violent paroxysms of hydrophobia, but was instantly cured by the sight of the animal in good health. Bouardel records that a man was bitten by his dog, which afterward disappeared. He was seized with severe hydrophobia, which continued for two days, when the lost dog was found and presented to him, and the symptoms disappeared. Trousseau speaks of a magistrate whose hand had been licked by his hound, which immediately after attacked a flock of sheep, so that many of them died of rabies. The master then manifested hydrophobia, but as death was deferred beyond the usual time, he concluded it was not genuine and recovered. Prof. Dick was called to visit a man who had been bitten by a favorite dog while suffering from distemper, had manifested severe hydrophobic symptoms, and had been given up by the attending physicians. He succeeded in convincing the subject that as the dog had had distemper, and as no two great diseases could coexist in the same system, it could not have had rabies. In spite of the false premises, this reasoning had the desired effect and the patient recovered. A few years ago a boy twelve years old in Ithaca, N.Y., was bitten by a dog supposed to be rabid, and in due time manifested hydrophobia, which advanced rapidly until he was having a violent paroxysm every half hour, and it was pronounced impossible for him to survive another day. At this time I saw him, observed that he {902} had a nervous organization, and was somewhat lacking in the hyperæsthesia of rabies, learned that he had recently been gorging himself with Christmas delicacies, and was now very costive; and, as there was no satisfactory history of the dog, I at once suspected lyssophobia. The friends and strangers who had come to condole with the parents and feast on the horror were excluded, and the boy's attention fully engaged in amusing pictures and conversation; the paroxysms were omitted, and in two hours the patient, overcome by weariness, went to sleep. Next morning he was still kept secluded and quiet, and two enthusiastic students took up the rôle of keeping his attention constantly engaged on whatever would interest him. The prima viæ was relieved by medicine, and under a course of tonics the boy quickly recruited, and at the end of a week went back to school.

In doubtful cases the test by inoculation may be tried. Inoculation with the saliva of a man suffering from hydrophobia is manifestly useless, since he must die before we can hope for the development of the disease. But in the case of a dog having bitten one or more people the inoculation of the virus on the brain of one or two other dogs would ensure the development of the affection in the course of one or two weeks, provided the first was rabid. The non-success of this operation when practised on two dogs would provide the best possible medicine for the diseased mind of the person bitten.

PATHOLOGICAL ANATOMY.--Post-mortem lesions are rather remarkable for their inconstancy than for their specific characters. Hardly a single lesion can be specified which may not be absent in particular cases, yet some are so characteristic that, when taken along with the symptoms during life, they very materially assist in diagnosing the disease. Of the pathological appearances common to man, dog, and other animals the following may be named: The body is greatly emaciated; the rigor mortis is normal or nearly so; decomposition usually sets in early; a white skin is livid, cyanotic, or petechial; the cicatrix is often hardly noticeable even after the animal has been shaved; the superficial veins, especially those of the neck and head, are filled with black inspissated blood; the external mucous membranes are of a dark livid hue, those of the mouth and nose being covered by a tenacious mucous or muco-purulent secretion (in dogs they are usually covered with earth or dust); the fauces, pharynx, and tonsils are usually of a dark livid hue, and sometimes swollen; in other cases the dark red hue and manifest swelling that obtained during life disappear after death; similar lesions are found in the larynx, and I have seen extensive erosions; the bronchial mucous membrane is reddened and coated with a muco-purulent secretion (and in dogs with earth and foreign bodies); the lungs are usually congested, often to the extent of showing death by asphyxia; the heart and large blood-vessels are filled with a black thick, venous blood, and the muscles, charged with the same blood, have a dark reddish-brown hue; the stomach is usually congested, sometimes to a port-wine hue, and is the seat of blood-extravasations and even erosions; this congestion is often present, though to a less degree, in the intestines; the mesenteric glands and those in the vicinity of the pharynx are not unfrequently enlarged and congested; a very constant feature is the entire absence of proper food in the stomach and of chyme in the small intestine; the liver is usually hyperæmic, {903} exuding on pressure the characteristic dark blood, and it may be the seat of some granular degeneration, but it usually retains its normal consistency; the spleen is normal; the kidneys are hyperæmic and leaden or bluish gray, and slightly cloudy on the surface (in dogs fatty degeneration of the inner cortical layer is common even in health); the urinary bladder is usually empty or contains a little turbid, yellowish, slightly albuminous urine, while the mucous membrane is often covered with dark reddish-brown petechial spots; the brain is usually hyperæmic, and, together with its membranes, slightly oedematous, yet the lesions are not constant either in kind or degree; the medulla oblongata usually shows a similar condition, and even minute points of acute congestion, but neither these nor the hyperæmia and oedema of the spinal cord can be found in every case.

Some conditions are especially pathognomonic in the dog. In nearly all cases of furious rabies the stomach is gorged with foreign bodies, such as hay, straw, wood, coal, leather, portions of textile fabrics, fæces, earth, sand, stones, pieces of iron, lead, etc., and the same materials are usually found in the small intestine, while the large intestines are empty. Portions of these foreign bodies are often found in the bronchia as well, giving rise to circumscribed lobular pneumonia. The significance of such matters when found in large amount in the stomach of a dog which has been given to biting or other symptom of rabies is very great, and if the stomach contains none of the natural food of the animal and the duodenum no chyme, it may be held pathognomonic of rabies. If, however, the materials are small in quantity and mingled with natural food, and if the duodenum contains chyme, the dog was probably not rabid. Dogs frequently chew and swallow fresh leaves of grass, and those in detention gnaw and swallow pieces of wood, cloth, horn, etc.; but these are used either as an emetic or a teething-ring, and virtually imply that digestion is not entirely abolished. Their presence, therefore, along with food does not indicate rabies.

PROPHYLAXIS.--In view of the almost or quite constantly fatal issue of rabies in man and animals, the main attention should be given to the question of prevention. As the disease is perhaps never in our time developed except as the result of contagion, we have the most perfect guarantee that by suitably devised measures it may be absolutely suppressed and excluded from any country. Even if we allow that a rare case is at long intervals developed spontaneously, it is none the less certain that the disease can be practically abolished, as nothing can be easier than to nip the disease in the bud in the locality where it first shows itself. Thus in Australia, Tasmania, and New Zealand rabies has not yet appeared, though prevailing in the same latitude and climate in both hemispheres. It reached Mauritius in 1813, and has prevailed uninterruptedly since, while in Bourbon, immediately adjacent and almost identical in geology, climate, flora, and fauna, it is still unknown. The same truth is told in the entire extinction of rabies in Berlin by the universal muzzling of dogs, as recorded above. The immunity lasted for nine years, during which muzzling was enforced. A more recent example of the same kind is found in Holland. In 1875 universal muzzling was made obligatory in all communes where rabid animals had been and in adjoining communes. From 1877 on the disease was unknown save on the borders of {904} Belgium and Prussia and in a very few dogs recently imported. Nearly all cases of hydrophobia in man and animals being due to bites by rabid members of the canine fraternity, a fundamental condition of all success in prevention is the prohibition of its diffusion by dogs. For this reason the following measures are requisite: 1st. All dogs should be registered and heavily taxed. The number of useless dogs kept in every community affords the greatest opportunity for the speedy diffusion of the rabid germ whenever that has been introduced. Whatever tends to reduce this number directly tends to the restriction and extinction of rabies. 2d. Every dog should be made to wear a collar with plate bearing the name and residence of his owner. All stray dogs without such badge should be summarily shot by the police. This will secure the payment of the taxes and the destruction of superfluous and dangerous dogs. 3d. In all cities and counties where rabies has existed within a year, and in the counties adjoining them, every dog should be muzzled except when securely shut up or tied. All dogs found at large without a muzzle should be promptly shot by the police. The objection to muzzles is satisfactorily met by the use of the wire muzzle, which impedes neither breathing nor drinking. 4th. Dogs and cats suspected or known to have been bitten by rabid animals should be at once destroyed, or if considered sufficiently valuable may be confined in a secure cage for six months under veterinary supervision. 5th. Dogs which have bitten and are supposed to be rabid should be similarly caged and placed under veterinary supervision. If rabid, the symptoms will be fully developed in a few days, whereas if destroyed at once the bitten party is liable to develop lyssophobia. 6th. Dogs imported from countries where hydrophobia is known to exist should be subjected to a period of quarantine of six months. 7th. Foxes, wolves, badgers, martens, skunks, must be indiscriminately destroyed in localities where they have become infected with rabies. 8th. The disinfection or burning of the kennels where rabid dogs have been is a natural corollary of the above.

Other measures less thorough and efficient are often advocated and resorted to, but should be discarded whenever it is possible to practise a method of absolute extermination. Among these may be named the flattening of the teeth, and especially of the canines, with a file, as advocated by Bourrel, and later by Fleming. While this is a measure of protection, it does not remove the desire to bite, nor the power of wounding the skin when that is delicate or tender. Another method is to hang a block of wood from the neck, so that it may impede the movements of the forelegs and prevent a rush and sudden attack. The futility of such a resort need hardly be remarked upon. The emasculation of dogs is another preventive measure advocated. The single advantage of this is that it does away with the host of suitors that follow a rutting bitch, and the mutual worrying and biting that ensue. But it is not yet proved that the disease is produced by privation of the generative act, while if it were it is still certain that cases of spontaneous rabies are extremely rare; that the rabid dog bites the castrated one as readily as the perfect male; that the emasculated one contracts rabies as readily as others when bitten, and that he communicates it no less persistently. Galtier's method of intravenous injection of the rabic saliva, which seems to have proved effectual in sheep and rabbits, utterly failed in the hands of Lussana and {905} Pasteur in dogs. Besides this objection, that it is useless for the animal which is beyond all comparison the main propagator of rabies, it has the serious disadvantages that its practice would necessitate the maintenance of a constant succession of cases of rabies, that great danger attends this production and handling of the virus, and the expense and risk of a general application of the measure must absolutely forbid it.

More recently Pasteur has found that the virus when transmitted through several monkeys in succession becomes so weak as to be harmless to the animal inoculated, and yet protects the animal against the more virulent poison. This fact he utilizes by inoculating this mitigated ape-virus on the brain of the animal just bitten, so as to render that refractory to the disease when the poison from the bitten wound shall reach it by its ordinary slow channel. At the time of writing, the method is being attempted on a man bitten by a mad dog.

Another precautionary measure which is always in place is the diffusion among dog-owners of correct information as to the premonitory symptoms of rabies, and the necessity for careful seclusion when any such symptoms are manifested.

TREATMENT OF BITES.--The treatment of bites by animals supposed to be rabid consists mainly in seeking the elimination of the poison or its destruction by caustic. The first object should be to prevent absorption of the poison. If the bite has been on a limb, a tourniquet should be instantly placed above it. A stout cord or handkerchief is always at hand, and may be tied around the limb and twisted with a piece of wood until circulation is arrested. Sucking the wound is usually effective in withdrawing the poison, and can convey no additional danger to the person bitten. If the patient cannot reach the wound with his own mouth, another may volunteer to suck it, though in these days of diseased teeth and gums the act is pregnant of danger. This may be largely obviated by alternately sucking and rinsing the mouth with a solution of carbolic acid, or, better, by applying such a solution to the wound before sucking, or finally by sucking through a tube. Cupping over the wound is highly commendable, though less effective than sucking. When cupping can be combined with wringing of the wound, there is an approximation to sucking. Cupping is especially valuable in wounds of the trunk, where a tourniquet cannot be applied. Intermittent squeezing and wringing of the part and steeping in warm water is an excellent resort when no better measure can be had. Cutting the wound open to its depth, while it may in certain cases be necessary to allow of the thorough application of a caustic, is objectionable as multiplying the points of infection and absorption. Drinking of liquids to excess temporarily retards absorption by overfilling the vascular system. Ammoniacal, alcoholic, and other stimulants are resorted to for the same purpose, being held to cause plenitude, not only by quantity, but by rarefying the animal fluids.

No such measures should, however, be allowed to delay for an instant the use of caustics. This is the one effectual means of destroying the poison, and the choice of caustic is of less consequence than its thorough application. The hot iron in the form of a skewer, nail, poker, or other available instrument, at a white heat, may be brought in contact with all parts of the wound to its utmost recesses.

Of chemical caustics, solid sticks of nitrate of silver, chloride of zinc, {906} and potassa, or the crystals of cupric or ferric sulphate, are to be preferred to the liquid forms (mineral acids, butter of antimony, etc.), because of the greater thoroughness with which they can be brought into contact with all parts of the wound. Lastly, the galvano-cautery may be used if within reach. If the liquid caustics are employed, they may be introduced into the depth of the wound by means of a pipette, a piece of porous wood, or a pledget of tow. For a great number of small wounds a bath of corrosive sublimate has been recommended.

In some cases the amputation of a badly-lacerated member or one with a compound fracture offers the only measure of protection.

But although nothing should be allowed to delay cauterization, yet the impossibility of an immediate application should not be accepted as a reason for its neglect at a later date. On the presumption that the virus is localized in the seat of inoculation until it has increased largely and is poured into the blood in sufficient quantity to subjugate the blood-globules to its influence, it is logical to excise the cicatrix and cauterize the wound, though days or even weeks have elapsed.

If it should be shown by further experiment that Galtier's intravenous injection of virulent saliva is harmless and protective to sheep, rabbits, and it may be other Herbivora, it would be logical to employ this in these animals just after they have been bitten, as there will be ample time to establish the systemic influence of the intravenous injection before the poison shall have accomplished its recrudescence in the cicatrix. The constantly fatal result of rabid bites in these animals would at least warrant such an attempt, the main precaution being that the liquid shall be most carefully preserved from contact with any of the tissues, including even the coats of the injected vein.

In addition to the local treatment of the sore, certain general medication has usually been resorted to, though its real value may well be questioned. Thus, the elimination of the poison has been sought by profuse perspiration induced by warm, Turkish, and Roman baths, and by the use of medicinal agents, sudorifics, sialogogues (mercury), laxatives, and diuretics (cantharides). The neutralization of the poison has been attempted by ammonia, the sulphites and hyposulphites, chlorine, etc. Besides these are used nerve-sedatives and tonics, such as venesection, belladonna, prussic acid, tartar emetic, sulphates of copper and zinc, arsenic, strychnia, etc.

What is probably of greater importance is a sound hygiene. Stimulating food eaten to excess is injurious alike to man and beast, and by inducing digestive disorder and cerebral congestion will tend at least to precipitate the attack. Costiveness or biliousness from sedentary habits and lack of exercise in the outer air and sunshine, exposure to intense heat or cold and over-exertion, are all to be guarded against.

Finally, psychical treatment is of the highest importance. Those about the person who has been bitten should preserve a calm, equable, and cheerful demeanor and avoid all allusion to the occurrence. The patient should be protected against all sources of excitement, and should not be allowed to see that he is an object of solicitude. If the matter is referred to incidentally, he should be impressed with a conviction of the efficacy of the treatment adopted.

THERAPEUTIC TREATMENT.--Almost every agent in the {907} Pharmacopoeia has been employed as a remedy for hydrophobia, but, up to the present, it must be acknowledged, with no measure of success. The agents supposed to be prophylactics are those also resorted to as therapeutic remedies. To these may be added the potent nerve-sedatives and anti-spasmodics--chloroform, chloral hydrate, ether, bromides of potassium, sodium, and ammonium, curare, Calabar bean, and the sialogogue diaphoretic pilocarpine.

Chloroform is one of the most appropriate, as it may be taken by inhalation, though with much excitement to the patient, and it at once relieves the oppressed breathing and pharyngeal and other spasms, while it acts as a cerebral sedative and anæsthetic; and if it cannot be held up as a curative agent, it at least secures euthanasia. Chloral given as an injection, so as to induce its soporific action, is equally soothing, though nothing more. Curare injected hypodermically overcomes the spasms, but does not usually, if ever, retard death. Three cases of hydrophobia in man treated in this way recovered, but we have no proof that even these exceptional cases were rabies. Pilocarpine has been used in a number of cases, but, with the exceptional case of a young man reported by Denis Dumont, all terminated fatally. The committee of the Paris Academy of Medicine reported in 1874 that in three experimental cases "it hastened death by the fits it brought on." Morphia is often of great value in calming the excitement and giving rest and sleep during the intervals of the paroxysms. Daturia and atropia, administered hypodermically, are somewhat less effectual. Inhalation of oxygen is said to arrest the convulsions and delirium, but not to retard death. Vaccine virus and the venom of the viper have each been tried, but with no good effect.

Of non-medicinal therapeutic measures the following are among the most promising: Perfect seclusion, quiet, and darkness serve to abate the hyperæsthesia, the painful acuteness of the senses, and the convulsive and delirious paroxysms. It can no longer be doubted that a very few cases of genuine rabies recover, but those that do so have almost all had special advantages in the way of quiet and seclusion, and few have had the excitement of medicinal treatment. Eight cases of the recovery of rabid dogs are reported by Menecier, Decroix, Laquerriere, Rey, Harold Leiney, and Pasteur. The two first were attested by successful inoculation on other animals; Decroix's second case was caused by inoculation with the saliva of a hydrophobous man; the next three had been bitten by dogs undoubtedly mad; while Pasteur's was inoculated with the brain-matter of a rabid cow. All in due time presented the characteristic symptoms of rabies, yet all recovered, without any record of medicinal treatment. Pasteur's case, when again inoculated, resisted the disease. A certain number of recoveries of men from pronounced hydrophobia under medicine and without it are on record, but in the absence of successful inoculations it is impossible to tell how many were cases of infecting rabies. The parallel between rabies and tetanus in the intensity of the reflex excitability would demand darkness and quiet as a sine quâ non of any rational treatment. Faradization has produced a temporary relief, but no permanent improvement. Warm baths, steam baths, and hot-air baths serve to abate excitability and spasm, and have been lauded as specific in hydrophobia, but have proved useless in the lower animals.

{908} Intravenous injection of warm water (two pints) in a hydrophobous man reduced the pulse from 150 to 86 and restored the power of deglutition. Life was prolonged for nine days, but in great agony, from the supervention of suppurative arthritis (Majendie). In another case the dread of water disappeared, but death ensued in fifty-four hours. In the hands of Youatt and Mayo it proved equally unsuccessful in dogs. A cold bath with submersion to unconsciousness is an old remedy now abandoned. Venesection to fainting, with or without mercury, mitigated the symptoms, but seemed to hasten paralysis and death. The excision and cauterization of the cicatrix, or the cutting of the nerves proceeding from it, has been useful in delaying, or even absolutely preventing, the paroxysms. When, therefore, the premonitory symptoms of hydrophobia have set in, and when an aura or shooting pain is felt proceeding from the seat of the wound toward the heart, one or other of these measures may serve to prevent the immediate occurrence of reflex convulsions. When the poison has actually invaded the brain, this can be looked on as a palliative measure only, but in the many cases of lyssophobia it may put an instant stop to the affection.

{909}

GLANDERS (EQUINIA GRAVIOR, FARCY).

BY JAMES LAW, F.R.C.V.S.

SYNONYMS.--Greek, [Greek: malis]. Latin, Malleus, Equinia Nasalis, E. Apostimatos, Farcinia. French, Morve, Farcin. German, Rotz, Lungenrotz, Hautrotz, Wurm, Hautwurm. Italian, Morva, Moccis, Cimurro. Spanish, Cimorro, Lamparones.

DEFINITION.--An infectious, bacteridian disease occurring in the horse, ass, or mule, and communicated by inoculation to various other animals, including man. It is usually ushered in by rigors, followed by articular pains, lameness, and the formation of a specific deposit in the lymphatic system of some part of the body, with a tendency to destructive degeneration and ulceration. In the form known as glanders these deposits and ulcers take place mainly in the nasal mucosa, in the lungs, and in adjacent glands, while in that known as farcy the deposits occur in the cutaneous and subcutaneous lymphatic plexuses and the dependent glands.

HISTORY AND GEOGRAPHICAL DISTRIBUTION.--Under the name of malis Aristotle describes a fatal disease of asses, supposed to have been identical with the malleus humidus of Vegetius Renatus and other writers of early Christian times, and with the cymoira of other early Roman writers. This malady was characterized by swelling of the submaxillary glands and discharge from nose and mouth. From the fourteenth century onward glanders is reported from different parts of Europe at frequent intervals; thus in 1320 in England (Rogers); in 1640 in Badajoz, brought by Portugese horses (Villalba); in 1686 at Treves (Eggerdes); again in 1776 in Southern France (Lafosse); in 1794 in Bavaria (Plank); in 1796 in Franconia (Laubender); and in 1798 in Piedmont (Toggia). At the beginning of the present century this affection was very widely prevalent in Great Britain, the chronic cases being habitually worked in stage-coaches, but of recent years, when it has been made criminal to expose or use a glandered horse, the malady has to a great extent disappeared. To-day glanders is almost coexistent with the distribution of the domesticated equine family, yet its prevalence bears a direct relation to the facilities for infection (horse-traffic, war, preservation of the diseased, confinement in close stables, ships, etc.), and some countries appear to be entirely free from the affection. Thus, Krabbe gives the yearly losses per 100,000 horses for the principal countries of Europe and Algiers as follows: Norway, 6; Denmark, 8.5; England, 14; Sweden, 57; Wurtenberg, 77; Prussia, 78; Saxony, 95; Belgium, 138; {910} France (army), 1130; Algeria (army), 1548. The losses in Prussia more than doubled after the Franco-German War; thus, in 1869-70 they were 966, and in 1873-74, 2058. In Bavaria they rose in the same period from 173 to 390 (Hahn). In Lisbon, Portugal, glanders was unknown for the thirty years preceding the Peninsular War, whereas after the war it proved a veritable scourge (Saunier). Charles Percivall, during an eight years' residence at Meerut and Cawnpore, Hindostan, saw not a single case of glanders, and so late as 1275, Fleming claims an entire immunity for India; yet in 1877 complaints were numerous of the very general prevalence of the disease in Upper India especially, while in 1879 the campaign in Afghanistan was seriously affected by its ravages. Climate appears to have little influence. The disease is virtually unknown in the island of Bornholm with 7000 horses, and in the Faroes and Iceland with 35,000, while it is quite frequent in Sweden. It is unknown in Australia, but is very prevalent in China, South Africa, Abyssinia, and Algiers, and but little known in Asia Minor, Arabia, and Egypt.

In the United States as in Europe the disease has mainly concentrated itself in the large cities in times of peace, and spread widely on the advent of war. It is alleged that it first entered Mexico in 1847 with the American cavalry, though with the horses kept in the open air it failed to gain a wide extension. The horses and mules drawn into the Union armies in 1861 brought infection with them, and soon the disease was most prevalent and destructive, not only in the ranks, but in every State in which the armies operated. John R. Page says the first case he saw in the Confederate army was a captured Federal troop-horse on the retreat from Manassas, and that the breaking down of the Confederate cavalry in the last two years of the war was mainly due to glanders. At the close of the war the sale of army horses distributed the infection widely through all the States, North as well as South. Every year in a country district in Western New York I see several cases of glanders, and occasionally a whole stud is carried off through an infected purchase. In other States the case is no better. In Pennsylvania, Ohio, Illinois, and Michigan cases are constantly seen in the country districts, and in the three last-named States five human victims have been reported within a short period. In Connecticut the same is true, and the disease made one human victim in Waterbury in 1879. In the large cities the case is still worse. Liautard of New York in 1878, in a single visit to one car-stable, condemned 8 horses, in another stable 18, and in a third, at two visits, 45, while a fourth had lost no fewer than 200 horses in the course of one year from glanders. In the Troy (N.Y.) car-stables the malady prevailed from 1875-77, most of the subjects suffering from chronic farcy, until in the latter year, by my advice, these propagators of contagion were destroyed. In Springfield, Mass., in 1879, the disease assumed such alarming proportions that it was vigorously suppressed by a city ordinance enjoining summary slaughter. These are but indications of what is happening all over the country, entailing losses of many hundreds of thousands yearly as well as an enormous risk to humanity.